The endometrium is not located. On what day of the cycle is it better to do an endometrial ultrasound, and when to do Doppler ultrasound for endometriosis and hyperplasia? What to do if the endometrium is thin

Article outline

Heterogeneous endometrium is alarm signal about the presence of various abnormalities in a woman’s body. So what does this mean? The endometrium is the tissue that covers inner layer uterus, and its heterogeneity confirms the presence of an inflammatory process or hormonal disorder. For doctors, such heterogeneity of the uterus signals a deviation not only in the female genital organs, but also in the body as a whole.

Features of the endometrium

The uterine mucosa, which is enriched blood vessels. The size of the inner layer of the uterus helps in determining the disease, which can even threaten a woman’s life. The thickness of the endometrium varies depending on various factors, but in some cases this may be the norm.

Normal indicators

For women of childbearing age normal endometrium at different phases of the cycle has its own characteristics:

• Phase 1 – Beginning of the cycle. The thickness of the endometrium varies from 5 to 9 mm. The sound comes through perfectly, and there are no separations into layers.
• Phase 2 – Middle of the cycle. The endometrium thickens. Echogenicity decreases, but sound transmission remains quite high.
• Phase 3 – End of the cycle. The endometrium is divided into layers with hyperechoic inclusions that reach 9-10 mm. It is also worth noting that this is the most favorable phase for conception.

And for women in the postmenopausal stage, the thickness of the inner lining of the uterus is considered to be at least 6 mm with an even structure.

In general, the endometrium normally has a somewhat homogeneous structure, that is, it is equally compacted and also approximately thickened depending on the phase of the cycle. However, it is worth noting that in rare cases, a heterogeneous inner layer of the uterus may be physiological norm, but basically this indicates dangerous violations in organism.

Reasons for deviations

Mainly when the endometrium heterogeneous structure- this is considered a physiological norm. It depends on what phase you are in now menstrual cycle there is a woman.

And the following deviations indicate problems with uneven endometrial thickness:

• When the heterogeneous inner layer of the uterus, regardless of the period of the menstrual cycle, is manifested by a change in the hormonal background of the female body.
• When a woman is pre- or postmenopausal, this condition may indicate the presence of cancer or about other serious pathological processes.

A significant factor in the heterogeneity of the endometrium is a violation of the blood supply to the internal mucous membrane of the uterus.

The main task before the gynecologist is to determine the exact cause of the deviation. To do this, the patient will have to undergo extensive examination, and sometimes even consult with specialists of a different profile.

On ultrasound, the specialist sees the structure and gives an opinion whether pathological changes are present or not.

Types

IN given time It is customary to divide this condition into two types, namely:

• Normal heterogeneous endometrium is when development occurs during the menstrual cycle or during pregnancy. This condition is normal, that is, natural, it does not cause discomfort and does not require medication.
• Pathological is when development occurs outside of bearing a child and outside the corresponding day of menstruation. This pathology must be subjected to drug treatment, but first you need to determine the cause of its occurrence. There can be many factors: hormone imbalance, trauma to the uterine mucosa, impaired blood supply, as well as microcirculation of the inner layer and the pelvic organs as a whole.

It is worth noting that there are cases of congenital heterogeneity of the endometrium due to underdevelopment or developmental features of the reproductive system.

Symptoms

Symptomatic manifestations in of this disease are not sufficiently definable, but both the doctor and the patient herself should be alert, firstly, to irregularities in the menstrual cycle and the presence pain during menstruation. These signs show heterogeneous endometrium in the initial stages.

The heterogeneous structure of the endometrium is diagnosed by a gynecologist based on the results of an ultrasound examination, and after additional examination It is possible to identify a number of other diseases. With timely consultation with a doctor, a woman can prevent the development of infertility, cancer, heavy bleeding, accumulation of blood in the uterine cavity, and endometrial rupture.

If a heterogeneous endometrium has already been diagnosed, this means that an inflammatory process has started in the body. It cannot be ignored, and even more so, self-medication, this will only worsen the situation.

Perhaps the gynecologist will prescribe curettage - this is a fairly simple procedure. It involves removing the top layer of the uterus, which then tends to recover. Usually, this procedure carried out some time before the onset of menstruation.

Treatment after surgery is prescribed with antibiotics. Over a short period of time, there may be bloody issues or slight bleeding.

A heterogeneous structure of the inner layer of the uterus occurs after medical abortion. IN in this case Due to the thin layer of the endometrium, curettage is not prescribed.

The recovery process lasts for a month, but doctors are trying to speed up the process.

Treatment

Depending on the gender pathological process and the condition of the mucous membrane a certain drug therapy. In cases of inflammation, treatment is carried out with antibiotics that have a wide spectrum of action, namely:

• Ceftriaxone;
• Amoxicillin.

Drugs are also prescribed to increase immune system. In some cases, non-steroidal anti-inflammatory drugs are prescribed in addition:

• Ibuprofen;
• Diclofenac.

In cases of hormonal imbalance, treatment is carried out using hormones:

• Quite often with the use of combined, oral contraceptives, such as Regulon, Yarina;
• Estrogen, for example, Estrogel;
• Progesterone, for example, Utrozhestan, Nokolut.

Prevention

In order to prevent this disease, the following recommendations should be taken into account.

Firstly, it is appropriate to start with an ultrasound and preventive examination see a gynecologist at intervals of once every six months. You should also pass necessary tests and smears, especially for women of reproductive age, as hormone levels need to be regularly monitored.

During sexual intercourse, you should pay attention to the use of barrier methods of contraception, which can prevent the onset of unwanted conception. This is also one of the methods of preventing infection with sexually transmitted diseases.

A mandatory requirement is to undergo a preventive examination and ultrasound once a year for women who are in a state of menopause, since these women are at risk.

When the first alarming symptoms or pain in the pelvic organs, you should urgently contact your treating gynecologist. This condition may indicate the presence of infection or development pathological abnormalities. If you are attentive to your health and take care of it, you can prevent the occurrence of various kinds diseases or quickly cure them at an early stage.

The endometrium is the inner mucous membrane of the uterine body, which has two layers: functional and basal. The basal layer has a constant thickness and structure. The stem cells included in its composition are responsible for the restoration (regeneration) of the endometrial layers. The functional layer has different dynamics and is sensitive to concentration female hormones. Thanks to the changes occurring in the functional layer, menstruation occurs every month. It is she who is the indicator women's health. If any pathology of the endometrium occurs, disruptions in the menstrual cycle often occur.

Endometrial thickness

To put it figuratively, the endometrium can be compared to a cradle, which at a certain period is ready to receive a fertilized egg. If this does not happen, then rejection of the functional layer occurs, which is reborn again after menstruation.

The endometrium, the thickness of which varies, has different indicators according to the days of the cycle:

• 5-7 days. In the early proliferation phase, the thickness of the endometrium does not exceed 5 mm.
• 8-10 days. The endometrium thickens to 8 mm.
• 11-14 days. In the late proliferation phase, the thickness reaches 11 mm.

After this, the secretion phase begins. During this period, if there is no endometrial pathology, the layer becomes looser and thickens.

• 15-18 days. The thickness reaches 11-12 mm.
• 19-23 days. Maximum endometrial thickness. Average is 14 mm, but can reach a maximum of 18 mm. The layer becomes more loose, “fluffy”.
• 24-27 days. The thickness begins to decrease slightly, becoming from 10 to 17 mm.

These are the phases of the endometrium. During menstruation, the thickness of the endometrium decreases, reaching only 0.3-0.9 mm.

If a woman is going through menopause, what should her endometrium look like? The standard layer thickness is 5 mm. The slightest deviation of 1.5 or 2 mm should cause caution. In this case, it is better to see a gynecologist.

What to do if the endometrium is thin?

Very often, thin endometrium is the cause female infertility. It is quite possible to cure this, you just need to persistently pursue your goal. Treatment can be carried out in several ways alternative ways: hormonal drugs, herbal decoctions, pseudohormones.

Herbal treatment

Some women do not want to resort to drug treatment for thin endometrium and use folk remedies in this case.

Thin endometrium is well restored with the help of sage. They drink it in the first phase of the cycle. 1 teaspoon should be brewed in 200 g of water and taken throughout the day.

The boron uterus is transformed as a pseudohormone in the woman’s body. In addition, it has an anti-inflammatory effect.

Drops "Tazalok" from the homeopathy series help normalize the menstrual cycle and are a regulator of the synthesis of endogenous gonadotropic hormones.

Increasing thin endometrium with the help of drugs

How to grow thin endometrium, the thickness of which varies depending on the different phases cycle? In the first phase of the cycle, doctors prescribe the drug "Proginova", "Femoston", etc. For the second phase of the cycle, "Duphaston" is suitable. This drug promotes the formation of the endometrial structure; it acts like synthetic progesterone.

Before using all these synthetic drugs, you should definitely consult a gynecologist and assess the risk yourself, since they all have some contraindications.

There are cases when thin endometrium is detected after taking oral contraceptives. Quitting them and taking Regulon tablets for two months often gives positive result and helps restore the thin endometrium.

Anatomical certificate

A healthy endometrium is the key to the successful onset and development of pregnancy. Currently, many women are faced with some kind of endometrial disease and, as a result, suffer from infertility. What does the term “endometrial pathology” mean, what consequences does this phenomenon lead to, how to overcome this problem? First things first.

The main function of the endometrium is female body is a successful, safe embryo implantation. For pregnancy to occur, it must attach to the endometrial wall. That is why, with various pathologies of the endometrium, infertility can occur, and successful implantation of the embryo becomes simply impossible. But pathologies are different; there are several endometrial diseases. Which one should be determined by a specialist in each specific case.

Deviations from the norm

Based on the nature of the disease, gynecologists-endocrinologists distinguish two benign disorders. The pathology of the endometrium of the uterus is inflammatory in nature, this includes endometritis. Non-inflammatory - these are hyperplastic processes. These include endometrial polyps, hyperplasia, and endometriosis.

It happens that several pathologies are combined in the female body. What is the reason for this? First of all, disruption endocrine system or genetic predisposition. In many cases after successful treatment pregnancy becomes possible.

Endometritis

Inflammatory disease of the mucous membrane (endometrium) of the uterus. What causes the disease? Penetration of various pathogenic microorganisms into the uterine mucosa. There are several basic factors contributing to the disease:

• Any infectious processes existing in the body.
• Complete sexual intercourse without protection.
• Erosion of the uterus.
• Examination of the uterus and tubes using hysterosalpinography.
• Chronic gynecological diseases.
• Unsterile instrument during a gynecological examination.
• C-section.
• Endometrial scraping.
  

Typical symptoms of endometritis:

If endometritis is discovered during pregnancy, it requires immediate treatment. The disease can affect the membranes of the embryo and lead to its death.

Hypoplasia - thinning

If on certain days of the cycle the thickness of the endometrium is underestimated, gynecologists diagnose hypoplasia. The cause of the disease is hormonal disorders, poor blood supply, inflammatory processes. Such endometrial pathology can occur as a result of frequent abortions, infectious diseases, long-term use of an intrauterine device. The main task in curing hypoplasia is thickening the endometrium.

Hyperplasia - thickening

The cause of the disease is most often hormonal imbalances in the body or hereditary factors. With hyperplasia, the layers of the endometrium change their structure.

There are several types of hyperplasia:

• Glandular hyperplasia.
• Atypical fibrous hyperplasia (precancerous condition).
• Glandular cystic hyperplasia.

Glandular endometrium is often found in diseases of the adrenal glands, ovaries, and thyroid gland. Most often, hyperplasia affects women with diabetes mellitus, polyps in the uterus, fibroids, arterial hypertension.

Why is hyperplasia dangerous? Uncontrolled cell growth, which can lead to dire consequences - endometrial cancer. Hyperplasia is treated as using medications, and surgical intervention.

Endometrial polyps

Benign proliferation of endometrial cells. Polyps can be located not only in the uterus itself, but also on its cervix. The reasons for their formation are hormonal disorders, the consequences of surgical interventions, abortions, and genitourinary infections. Polyps most often form in the endometrium. There are several types of polyps:

• Ferrous. They are formed in the tissues of the glands and are usually diagnosed at a young age.
• Fibrous. Formed in connective tissue. More often observed in older women.
• Glandular-fibrous. Consists of both connective and glandular tissue.

You can get rid of polyps only with the help of surgical intervention. This must be done as soon as possible, since the cells can degenerate into malignant ones. Modern equipment allows you to perform operations quickly, efficiently, and painlessly.

Endometriosis

A female disease in which nodes form outside the uterus, similar in structure to the endometrial layer. Nodules may appear on nearby organs. It happens that when the uterine tissues are rejected, they are not completely removed with menstruation, penetrate into the tubes and begin to grow there. Endometriosis develops.

The main causes of the disease:

• Excess weight.
• Frequent stress.
• Bad habits.
• Disruptions in the menstrual cycle.
• Inflammation in the genitals.
• Operations on the uterus.
• Heredity.
• Hormonal imbalances.
• Problems with the thyroid gland.

Symptomatic indicators of endometriosis include:

• Infertility.
• Painful urination and bowel movements.
• "Spotting" discharge in the middle of the cycle.
• Pain before the onset of menstruation.
• Pain during sexual intercourse.

Endometrial removal - ablation

Currently, an increasing percentage of women suffer from various endometrial pathologies. They suffer from prolonged, abundant, painful menstruation, hyperplastic processes, polyposis. Unfortunately, it is not always possible to achieve effective treatment hormone therapy or curettage of the uterine body. An alternative in this case is ablation, or removal of the endometrium. This is a minimally invasive procedure that destroys or completely removes the lining of the uterus (endometrium).

Indications for the operation:

• Massive, repeated, prolonged bleeding. However, the treatment is not effective. The presence of malignant processes in the genital area in women over 35 years of age.
• Relapses of hyperplastic processes during premenopause or postmenopause.
• Impossibility hormonal treatment proliferative processes during the postmenopausal period.

What factors need to be considered when performing ablation?

• Impossibility complete removal uterus or refusal of this type of surgical intervention.
• Reluctance to preserve reproductive function.
• Dimensions of the uterus.

Endometrial biopsy

For diagnostic purposes, small volumes of tissue are taken from the body using special methods. To make a correct diagnosis based on the results of a biopsy, the doctor must follow a number of rules when performing the procedure: necessary conditions. Based on the results of scraping examination, the pathologist assesses the functional and morphological state of the endometrium. The results of the study directly depend on how the endometrial biopsy was performed and what material was received. If heavily crushed pieces of tissue are obtained for research, it is difficult, sometimes impossible, for a specialist to restore the structure. When performing curettage, it is very important to try to obtain uncrushed, larger strips of the endometrium.

How is an endometrial biopsy performed?

• How complete diagnostic curettage body of the uterus with dilation of the cervical canal. The procedure begins with the cervical canal, then the uterine cavity is scraped out. In case of bleeding, curettage should be carried out with a small curette, it is necessary to pay Special attention pipe angles uterus, where polypous growths often form. If, during the first curettage, crumb-like tissue appears from the cervical canal, the procedure is stopped due to suspicion of carcinoma.
• Line scrapings (train technique). The goal is to find out the causes of infertility and monitor the results of hormone therapy. This technique cannot be used for bleeding.
• Aspiration biopsy. Suctioning pieces of endometrial mucous tissue. The method is most often used for mass examinations, the goal is to identify cancer cells.

If any endometrial pathology is detected in a woman’s body, treatment must begin immediately. Timely initiation of the treatment process gives the most promising prognosis. Even such a sentence as infertility may not be terrible if you consult a gynecologist in a timely manner and undergo full examination, a course of treatment. Watch your health!

According to V.N. Demidov and A.I. Gusa, ultrasonography endometrial testing should be carried out in the first three days after the end of menstruation; normally, at this time the endometrium should be completely homogeneous and hypoechoic.

At glandular hyperplasia(GE) endometrial thickness is 1-1.5 cm, rarely reaching 2.0 cm. The echogenicity of hyperplasia is increased, the echostructure is homogeneous, often with multiple small anechoic inclusions. Sometimes an acoustic amplification effect is observed distal to the GE (Fig. 1-4). When visualizing areas of increased echogenicity against the background of a practically unchanged endometrium, it is possible to conclude that focal hyperplasia endometrium (Fig.).

The situation with ultrasound diagnostics atypical endometrial hyperplasia (AHE). A number of authors indicate that there are no specific echographic criteria for diagnosing AGE. The thickness of the endometrium in this condition ranges from 1.5-2.0 cm, in some cases reaching 3.0 cm. The echogenicity of AGE is average, the echostructure is homogeneous (Fig. 5-6).

As rightly noted by V.N. Demidov and A.I. Gus, despite the significant morphological differences in endometrial polyps (glandular, glandular-fibrous, fibrous, adenomatous), their echographic image has much in common. A typical echo picture of an endometrial polyp (PE) is an oval or round formation of medium or increased echogenicity with a clear boundary between the polyp and surrounding tissues, usually in the form of an anechoic rim (Fig. 7-15).

The size of polyps can vary very significantly, from 0.5 cm to 4-6 cm (in the case of glandular fibrous and adenomatous PE). In the presence of small PE (<0.5 см) диагностика затруднена, и, как замечают В.Н. Демидов и А.И. Гус, единственным эхопризнаком может явиться деформация срединной линейной гиперэхогенной структуры М-эхо.

Dopplerography with hyperplastic processes of the endometrium. According to B.I. Zykin, with GE, blood flow inside the mucous membrane was either not recorded (in 75-80% of patients), or a few color loci were visualized (Fig. 16).

Color Dopplerography of endometrial polyps revealed a feeding vessel in the form of a “color bridge” between the sub- and endometrial zones (Fig. 17-18).

Blood flow indicators in benign hyperplastic processes of the endometrium were characterized by low speed and fairly high resistance (Fig. 19-21, Table 1). Similar data were obtained by other authors.

Table No. 1. Indicators of intraendometrial blood flow during hyperplastic processes (B.I. Zykin, 2001).

Endometrial cancer

A very large number of studies are devoted to trying to correlate the risk of endometrial cancer (EC) with the thickness of the M-echo, especially in postmenopause. Thus, A. Kurjak et al consider endometrial thickness >8 mm in perimenopause and >5 mm in postmenopause to be pathognomonic for EC. S. S. Suchocki et al. did not find a single case of cancer or hyperplasia with endometrial thickness. A number of authors pay special attention to the very low specificity of endometrial thickening as a criterion for endometrial endometrium. So, according to I. Fistonic et al. in patients with postmenopausal bleeding, the thickness of the endometrium was: 6.2 mm with endometrial atrophy, 12.4 mm with simple hyperplasia, 13.4 mm with complex hyperplasia, 14.1 mm with carcinoma. The authors did not find significant differences in endometrial thickness between the hyperplasia and carcinoma groups. Wherein average age of patients with carcinoma was significantly higher (62 years). Bakour et al. , using an endometrial thickness of 4 mm as a criterion for malignancy, were able to diagnose endometrial carcinoma with sensitivity, specificity, PCR, PCR of 92.9%, 50.0%, 24.1%, 97.6%. The authors conclude that in women with postmenopausal bleeding, endometrial thickness<4 мм позволяет с высокой вероятностью исключить вероятность карциномы, однако толщина 4 мм не добавляет значимой информации о наличии или отсутствии малигнизации.

When diagnosing EC, an assessment of the internal echo structure of the M-echo can play a significant role. According to T. Dubinsky et al. thin homogeneous endometrium is a prognostic sign of a benign finding, while visualization of a heterogeneous echostructure always requires histological examination to clarify the diagnosis. The combined use of three echographic criteria (thickness 5 mm, uneven contour, heterogeneous echo structure) allowed G. Weber et al. diagnose endometrial carcinoma with sensitivity, specificity, PCR, PCR 97%, 65%, 80%, 94%.

The possibility of echographic assessment of malignant invasion into the myometrium is important. So according to F. Olaya et al. when diagnosing deep invasion of endometrial carcinoma into the myometrium (>50%), the sensitivity, specificity and accuracy of transvaginal echography were 94.1%, 84.8%, 88%. When differentiating the degree of invasion of endometrial carcinoma into the myometrium (no invasion, invasion of layers adjacent to the endometrium, deep invasion), the sensitivity, specificity and accuracy of transvaginal echography were 66.2%, 83.1%, 77.2%. The results obtained are comparable to the effectiveness of MRI without contrast, and slightly lower than the effectiveness of MRI with contrast.

Particularly noteworthy are the works whose authors describe cases of endometrial carcinoma in postmenopausal women with a thin or even non-visualized endometrium, or with a combination of the echo picture of endometrial atrophy and serometra (it is believed that the echo picture of fluid in the uterine cavity accompanies 50% of cases of endometrial cancer). So S. Li et al. found endometrial cancer in 3.9% of patients with endometrial thickness<5мм. По данным М. Briley и соавт. , при постменопаузальном кровотечении у 20% пациенток с невизуализируемым эндометрием имела место карцинома. Авторы считают, что у пациенток с постменопаузальным кровотечением при визуализации тонкого эндометрия (<6мм) биопсии можно избежать, однако утолщенный, и что важно - невизуализируемый эндометрий являются показанием для биопсии. H. Krissi и соавт. описали рак эндометрия при эхокартине атрофии в сочетании с серометрой, считая, что последняя может служить показанием для биопсии, поскольку компрессия стенок матки при серометре может скрывать патологические изменения эндометрия. В то же время R. Bedner и соавт. полагают, что небольшая серометра в постменопаузе (до 5 см3) вряд ли может ассоциироваться с карциномой эндометрия, описывая случай последней с объемом внутриматочной жидкости 12см3.

Moving on to detailing the echo signs of endometrial endometriosis, it is necessary to recall that the latter is divided into pathogenetic variant I (PE-I), which occurs against the background of endometrial hyperplasia, and pathogenetic variant II, which occurs against the background of endometrial atrophy (PE-II).

• Large M-echo thickness, more than half the thickness of the uterus
• Unevenness and blurred contours
• Increased echogenicity
• Increased sound conductivity
• Heterogeneous internal echo structure
• Internal liquid inclusions
• Uneven thinning of the myometrium, indicating invasion
• Fluid in the uterine cavity. The echo picture of RE-II is completely nonspecific, but this type should be suspected if the following echo signs are found in a woman with postmenopausal bleeding (Fig. 28)
• Unvisualized endometrium
• Fluid in the uterine cavity.

Figure 22 Endometrial cancer

Thus, summing up the section devoted to the echographic diagnosis of EC, one cannot but agree with B.I. Zykin, who believes that for the diagnosis of endometrial cancer, the thickness indicator is not decisive, and concludes that at the present stage, transvaginal echography (B-mode) has exhausted itself as a method for diagnosing endometrial cancer, having reached an accuracy ceiling of 75-85%.

Dopplerography for RE. As noted by B.I. Zykin, with RE-I, intraendometrial blood flow was detected in 100% of patients in the form of multiple, often chaotically located color loci (Fig. 24). Doppler indicators were characterized by high speed and low resistance of blood flow (Fig. 25-27, Table 2). Similar data have been obtained by most authors dealing with this problem.

Figure 26

Endometrial cancer (I pathogenetic variant) Low blood flow resistance

Figure 27

Endometrial cancer (I pathogenetic variant) High blood flow speed

In EC-II, color loci were not visualized in the projection of the atrophied mucosa, and cancer revealed itself only by a noticeable increase in blood flow in the subendometrial zones of the myometrium (Fig. 28). Thus, the only ultrasound criterion to suspect endometrial malignancy was not endometrial thickness, but abnormal color loci.

Table 2. Indicators of intraendometrial blood flow in endometrial carcinoma (B.I. Zykin, 2001).

There is no doubt that the widespread use of high-resolution transvaginal echography and Dopplerography will significantly increase the level of early detection of EC, and, possibly, reduce the frequency of unnecessary curettages in women with postmenopausal bleeding.

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