isuog basic training · guerriero et al. ultrasound obstet gynecol 2016; 48: 318–332 . basic...
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ISUOG Basic Training Examining the Uterus: Cervix & Endometrium
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Learning objectives
At the end of the lecture you will be able to:
• Recognize the typical ultrasound appearances of a
normal cervix and endometrium
• Recognize the typical ultrasound appearances of
abnormalities in the cervix and endometrium
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Key questions
• What are the typical ultrasound findings of a normal
cervix and endometrium?
• What are the typical ultrasound findings of common
abnormalities in the cervix and endometrium?
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Key points
• Understand the typical ultrasound features of a normal
cervix and endometrium
• Understand the typical ultrasound features of common
abnormalities in the cervix and endometrium
• Know when to refer for a specialist opinion
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Vagina
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Rectovaginal nodule of endometriosis
• You don’t need to know how to recognize this
• It is just a reminder to not forget to look at the vagina when you start your TV US
• The more you see ‘normal’ the easier it will be to recognize abnormalities
Guerriero et al. Ultrasound Obstet Gynecol 2016; 48: 318–332
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Cervix
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Cervical findings
• Nabothian follicle
• Cervical polyp
• Cancer
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Nabothian follicle • Mucus-filled cyst on surface of
cervix
• Caused by squamous epithelium of the ectocervix growing over the columnar epithelium of the endocervix
• This tissue growth can block the cervical crypts
• On US:
- Anechoic
- Avascular
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Cervical polyps • Sessile or pedunculated well-
circumscribed masses within
endocervical canal
• Hypo or hyper-echogenic
• Identifying the stalk attaching
to the cervical wall helps
differentiate it from an
endometrial polyp
• May have feeding vessel
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Cervical cancer • Heterogeneous mass involving the cervix
• May show increased vascularity on color
Doppler
• Ultrasound can be useful to evaluate:
– size (<4 cm or ≥4 cm)
– parametrial invasion
– tumor invasion into the vagina
– tumor invasion into adjacent organs
– hydronephrosis (implies stage IIIB tumour)
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Endometrium
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Describing the endometrium
Hyperechogenic
Isoechogenic
Hypoechogenic
Leone et al. Ultrasound Obstet Gynecol 2010; 35: 103–112
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Normal ultrasound findings
• Differ between women before and after menopause
• Change throughout the menstrual cycle
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The endometrium changes
throughout the menstrual cycle
Shortly after
menstruation
Proliferative phase Proliferative phase Secretory phase
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Changes during menstrual cycle
Shortly after
menstruation
Proliferative phase
3 days before ovulation
Proliferative phase
1 day before ovulation
Secretory phase
6 days after ovulation
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The endometrium in postmenopausal
women
• Median ET = 3mm
• 10th & 90th percentile: 2 – 5mm
• ET >5mm is NOT necessarily pathological
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The IETA consensus statement How to describe
• Endometrial echogencitiy
• Endometrial midline
• Endometrial-myometrial junction
If fluid in the cavity
• Fluid echogenictiy
• Endometrial outline
• Intracavitary lesion
On colour/power Doppler
• Colour content
• Morphology of endometrial vessels
Anything that protrudes into a fluid-filled uterine cavity
Pedunculated Sessile
Leone et al. Ultrasound Obstet Gynecol 2010; 35: 103–112
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How to measure endometrial thickness
(ET)
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How to measure endometrial thickness
(ET) 1. When intracavitary fluid is
present, measure thickness of
both single layers and add
together to give ET
2. When intracavitary pathology is
present measure total ET
including the lesion (unless it’s a
well defined myoma that can be
measured separately)
Leone et al. Ultrasound Obstet Gynecol 2010; 35: 103–112
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Most common endometrial pathology
• Polyp
• Submucous myoma
• Endometrial thickening
• Cancer
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Typical ultrasound features of
endometrial polyp
Regular cysts
Bright edge
Hyperechogenic
Feeding vessel
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Typical ultrasound features of
submucuous myoma
• Solid tumor protruding into uterine cavity
• Same echogencicity as myometrium
Courtesy Dirk Timmerman
• Color Doppler: ring of color
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Typical ultrasound features of
endometrial cancer
• Richly vascularized on color Doppler
• Thick endometrium
• Inhomogenous echogenicity
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Diffuse vs focal endometrial thickening
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color score 1
= no color color score 2
= minimal color color score 3
= moderate color
color score 4
= abundant color
IETA consensus statement Doppler ultrasound examination of the endometrium
Quantification of the color content of the endometrial scan
Adjust settings: maximize detection of flow without artefacts
(pulse repetition frequency (PRF): 0.3-0.6 KHz, 3-6 cm/s velocity scale)
Leone et al. Ultrasound Obstet Gynecol 2010; 35: 103–112
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Benefits of fluid instillation
Leone et al. Ultrasound Obstet Gynecol 2010; 35: 103–112
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Intrauterine adhesions
Leone et al. Ultrasound Obstet Gynecol 2010; 35: 103–112
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Correct position of copper IUCD
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Correct position of hormonal IUD
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IUD and 3D ultrasound Correct placement
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Too low
Incorrect position of IUCD
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Which patients should I refer for
specialist opinion?
• Those in whom you are uncertain about the
diagnosis (especially if you suspect malignancy)
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Key points
We should use a standardized terminology when
we describe ultrasound images of:
• Adnexal lesions (IOTA)
• The endometrium/uterine cavity (IETA)
• The myometrium (MUSA)
• Deep infiltrating endometriosis (IDEA)
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Key points
When in doubt:
refer for second opinion
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Acknowledgements These slides were created by:
• Shabnam Bobdiwala
• Maya Al-Memar
• Lil Valentin
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ISUOG Basic Training Examining the Uterus: Cervix & Endometrium