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GYN ULTRASOUND EVALUATION OF ABNORMAL
UTERINE BLEEDINGAmy Boardman, MD
Director, division of gynecology
Department of obstetrics and gynecology
Carolinas Medical center
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LEARNING OBJECTIVES
• To be aware of the PALM-COEIN classification system for
causes of AUB in reproductive age women
• To identify the most common gynecologic ultrasound
findings
• To understand when to utilize vaginal ultrasound and
sonohysterography for evaluation of perimenopausal
abnormal bleeding.
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PALM-COEIN SYSTEM
• Universal system of nomenclature that classifies uterine
bleeding abnormalities and etiologies in reproductive aged
women.
• Introduced by FIGO in 2011 and supported by ACOG in 2012
• Abnormal uterine bleeding – specific descriptor terms
• Menorrhagia = Heavy menstrual bleeding (AUB-HMB)
• Metrorrhagia = Intermenstrual bleeding (AUB-IMB)
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PALM-COEIN SYSTEM
PALM (Structural Causes)
• Polyp (AUB-P)
• Adenomyosis (AUB-A)
• Leiomyoma (AUB-L)
• Submucosal (AUB-LSM)
• Other myoma (AUB-LO)
• Malignancy and Hyperplasia
(AUB-M)FIGO, 2011.
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PALM-COEIN SYSTEM
COEIN (Nonstructural Causes)
• Coagulopathy (AUB-C)
• Ovulatory dysfunction
(AUB-O)
• Endometrial (AUB-E)
• Iatrogenic (AUB-I)
• Not classified (AUB-N) FIGO, 2011.
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STRUCTURAL UTERINE PATHOLOGY
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ENDOMETRIAL POLYP
• Well-defined, homogeneous, polypoid lesion isoechoic to
endometrium
• Intact endometrial-myometrial interface
• Atypical features: cystic components, multiple polyps,
broad base, & hypoechogenicity or heterogeneity
Goldstein. Modern Evaluation of the Endometrium. Obstet Gynecol 2010.
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ADENOMYOSIS
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BRIGHT EDGE
Echo formed by
interface between
intracavitary lesion
and endometrium
Ultrasound Obstet Gynecol 2010;35:103-112.
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ENDOMETRIAL POLYPS
Slide courtesy of Linda Darlene Bradley, MD.
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ENDOMETRIAL POLYPS
Slide courtesy of Linda Darlene Bradley, MD.
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BROAD-BASED INTRACAVITARY POLYP
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HYSTEROSCOPIC VIEW BROAD-BASED INTRACAVITARY POLYP
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ADENOMYOSISFINDINGS ON IMAGING
• Globular, bulky uterus
• Heterogeneous myometrium
• Myometrial cysts
• Asymmetric myometrial thickness
• Loss of clarity of endo-myometrial interface
• Subendometrial echogenic linear striations
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ADENOMYOSISHISTOLOGIC CRITERIA
• Presence of endometrial glands & stroma 2.5 mm below basal layer of endometrium
• Prevalence varies from 31% to 61% depending on number of tissue sections
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ADENOMYOSIS
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ADENOMYOMA• Echogenic mass
• Ill-defined borders
• Uterine enlargement
• Heterogeneous
myometrium
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FOCAL ADENOMYOMA
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DIFFUSE ADENOMYOSIS
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ADENOMYOSISASYMMETRICAL WALL THICKENING
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ADENOMYOSISPOORLY DEFINED ENDOMETRIAL-MYOMETRIAL JUNCTION
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ADENOMYOSISLINEAR STRIATIONS/HETEROGENEOUS TEXTURE
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POLYPOID ADENOMYOSIS
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ADENOMYOSIS
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ADENOMYOSISMYOMETRIAL CYSTS
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ADENOMYOSIS
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ADENOMYOSIS
Stalnaker ML, Kaunitz AM. OBG Manag. 2014;26(6).
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Stalnaker ML, Kaunitz AM. OBG Manag. 2014;26(6).
ADENOMYOSIS
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Stalnaker ML, Kaunitz AM. OBG Manag. 2014;26(6).
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ADENOMYOSIS
Junctional zone
• Irregulary thickened
• Poorly marginated
• Hypoechoic
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Stalnaker ML, Kaunitz AM. OBG Manag. 2014;26(6).
ADENOMYOSIS
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Stalnaker ML, Kaunitz AM. OBG Manag. 2014;26(6).
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Stalnaker ML, Kaunitz AM. OBG Manag. 2014;26(6).
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Stalnaker ML, Kaunitz AM. OBG Manag. 2014;26(6).
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Stalnaker ML, Kaunitz AM. OBG Manag. 2014;26(6).
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Stalnaker ML, Kaunitz AM. OBG Manag. 2014;26(6).
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ADENOMYOSIS“VENETIAN BLIND” ACOUSTIC SHADOWING
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ADENOMYOSIS
• Increased
vascular flow
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ADENOMYOSIS
• Anechoic lacuna in
posterior myometrium
• Asymmetric
heterogeneity and
hypervascular flow
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SUBMUCOUS MYOMA
• Well-defined, broad-based,
hypoechoic, solid mass
• Posterior acoustic shadowing
• Overlying echogenic endometrium
• Distortion of endometrial-
myometrial interface
• Atypical features: pedunculation,
multilobulated surface
Goldstein. Modern Evaluation of the Endometrium. Obstet Gynecol 2010.
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Ultrasound Obstet Gynecol 2010; 35: 103–12.
SUBMUCOUS MYOMA
Grade 0
(100% within cavity)
Grade 1
(≥50% into cavity)
Grade 2
(<50% into cavity)
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USE OF A CLASSIFICATION SYSTEM TO PREDICT COMPLETE HYSTEROSCOPIC RESECTION
Classification Type 0 Type I Type II
Location100% within
cavity
>50% into
cavity
<50% into
cavity
Hysteroscopic
Resection96-97% 86-90% 61-83%
Fluid
Absorption
Volume
450 mL 957 mL 1682 mL
*European Society of Hysteroscopy
Wamsteker K et al, 1993; Van Dongen H et al, 2006; Emanuel MH et al, 1997.
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SUBMUCOUS MYOMA
Submucosal
fibroid
Uterine myometrium
Endometrial
cavity
Slide courtesy of Raymond W. Ke, MD.
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GRADE 0 SUBMUCOSAL
MYOMA
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GRADE 1 SUBMUCOUS MYOMA
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POSTERIOR FIBROID
Slide courtesy of Linda Darlene Bradley, MD.
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POSTERIOR GRADE 2 FIBROID AFTER SIS
Slide courtesy of Linda Darlene Bradley, MD.
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DIAGNOSTIC HYSTEROSCOPY IN PATIENT WITH RECURRENT PREGNANCY LOSS
Slide courtesy of Linda Darlene Bradley, MD.
Tubal Ostia
Pedunculated Submucous
Myoma
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33 Y.O., SEVERE MENORRHAGIA & ANEMIA
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ENDOMETRIAL HYPERPLASIA
• Cannot be definitively diagnosed with SIS.
• Variable appearance
• Global or focal
• Localized to a polyp
• Uniformly hyperechoic, thickened endometrium
• Endometrial thickness, echogenicity, and appearance may
suggest need for biopsy or hysteroscopy.
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ENDOMETRIAL HYPERPLASIA
Moschos et al. Obstet Gynecol. 2009;113(4):881-887.
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ENDOMETRIAL HYPERPLASIA
Slide courtesy of Linda Darlene Bradley, MD.
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ENDOMETRIAL MOGULS
Small irregularities can
be mistaken for polyps
or focal hyperplasia.
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ENDOMETRIAL CARCINOMA
• Increased endometrial thickness on TVUS
• Myriad endometrial echo appearances
• Irregularly thickened, ill-defined
• Heterogeneous pattern
• Mixed echogenicity with variable hypoechoic texture
• Intact, irregular or disrupted endo-myometrial junction
• Enlarged or lobular uterus
• Distended or fluid-filled uterine cavity
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ENDOMETRIAL CANCER
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ENDOMETRIAL CANCER
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Uterine Evaluation
Perimenopausal AUB
Increased risk of structural anomaly
No
AUB-E or O
(presumptive)
Yes
TVUS
Normal Cavity?
Yes No
Hysteroscopy or SIS
Target Lesion?
No Yes
AUB-LSM, AUB-P, AUB-A
Indeterminate
Consider MRI
Adapted from Munro MG. Abnormal
Uterine Bleeding. Cambridge:
Cambridge University Press; 2010.
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Uterine Evaluation
Perimenopausal AUB
Increased risk of endometrial hyperplasia/cancer
No
AUB-E or O
(presumptive)
Yes
Office endometrial biopsy
Adequate specimen?
Yes
EH/CA?
No Yes
Management of AUB-M
No
Hysteroscopy or SIS
Target Lesion?
No Yes
AUB-LSM, AUB-P, AUB-A
Indeterminate
Consider MRI
Adapted from Munro MG. Abnormal Uterine Bleeding. Cambridge: Cambridge
University Press; 2010.
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CASES
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44 Y.O., 11 MONTHS AMENORRHEA THEN BLEEDING. TVUS -THIN ENDOMETRIUM SUGGESTIVE OF ATROPHY
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SIS: ENDOMETRIAL CAVITY FLUID & THIN WALLS
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58 Y.O., SCANT VAGINAL BLEEDINGNO SIS DUE TO CERVICAL STENOSIS
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40 Y.O. WITH MENORRHAGIATVUS - BENIGN ENDOMETRIAL POLYP
Hyperechoic line
Thickened central endometrial complex
with cystic spaces
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40 Y.O. WITH MENORRHAGIA SIS - BENIGN ENDOMETRIAL POLYP
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49 Y.O., HEAVY PERIMENOPAUSAL BLEEDING
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45 Y.O. PERIMENOPAUSAL, IRREGULAR, HEAVY BLEEDING FOR 20 DAYS
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56 Y.O., HEAVY POSTMENOPAUSAL BLEEDING WITH ET = 13.9 MM
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HYSTEROSCOPIC VIEWBENIGN POLYP AND ATROPHIC ENDOMETRIUM
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CONCLUSIONS
•Use of the FIGO Classification system provides a systematic ultrasound evaluation for AUB•Use TVUS and SIS to triage patients for endometrial
sampling with office biopsy versus hysteroscopy.•Consider the most common ultrasound findings for
the diagnosis of adenomyosis