Transcript
Ultrasound in Menopause
Jaideep MalhotraNarendra Malhotra
Ashok KhuranaKuldeep Singh
www.rainbowhospitals.org
When in Doubt, Cut it Out
“ A palpable postmenopausal ovary shouldnot be reevaluated or followed up but beinvestigated promptly by liberal indicationsof surgery”
Hugh Barber, 1971
In the Presidential Symposium of the North American Menopause Society Annual Meeting in 2011, it noted, that, the sensitivity of newer imaging technology has resulted in the delineation of findings that are much more common and far more clinically innocuous than appreciated .
• Has created a tricky situation where because of lack of information and guidelines, women are being put through unnecessary procedures.
• These procedures are being carried out consequent to the fear of missing a malignancy, both on the part of the treating physician and the patient.
At the outset it is important to mention that ultrasound remains the principal modality in assessing the pelvis in menopause and beyond, and that CT, MRI and PET-CT remain problem solving and cancer staging modalities as in other gynecologic scenarios.
• High frequency transvaginalscans
• Color flow mapping
• Duplex Doppler
• Power Doppler
• Three dimensional ultrasound
Ultrasound techniques
Ultrasound techniques
Complimentary techniques
• Power and color Doppler
• Saline infusion sonohysterography
• Positive contrast sonohysterography
• 3D & 4D (Real time 3D)
AIM
• TO IMPROVE RECOGNITION OF PELVIC LESION ANATOMY
• CHARACTERISATION OF SURFACE FEATURES
• DETECTION OF TUMOR INFILTRATION
• PRECISE DEPICTION OF SIZE AND VOLUME
INDICATIONS
• Endometrial evaluation in vaginal bleeding
• Evaluation of palpable pelvic mass
• Screening for endometrial and ovarian cancer in
high risk group
TECHNIQUES
• Transabdominal
• Transvaginal
• Transperineal
EVALUATION
• Uterus
• Ovaries
• Extra-ovarian adnexal areas
• Cervix
• Pouch of douglas
SYSTEMIC EVALUATION
• Pleura
• Peritoneum
• Retroperitoneum
• Liver
• Kidneys
• Bladder
Post menopausal woman
Uterus
Atrophy
Uterus
Measurements
XX
Uterus
Measurements
The Endometrium in Menopause
Norms
Endometrium
Measurements
Endometrial Thickness
Considerations
• Include the entire endometrial thickness and not justone leaf
• The thickest anteroposterior measurement is to beconsidered
• The extent of a fluid collection should not be included
Endometrium
Measurements
Endometrium
Abnormal morphology
Focal increased echogenecity, diffuse increased echogenecityand diffuse inhomogeneity increase the predictability of pathologic findings.
Endometrium
Abnormal morphology
Endometrium
Abnormal morphology
Endometrium
Abnormal morphology
Endometrium
Abnormal morphology
Endometrium
Abnormal morphology
Endometrial polyps
3D Power Doppler
Endometrium
Saline infusion sonohysterography
Single/orthogonal/TUI
3D Display Formats
Single plane Tomographic display
Cervical Polyps
Vascular Pedicle
Endometrial Thickness
Study
No.
Endometrial
Thickness
Cutoff (mm)
Number of
Cases Below
Cutoff
Histological Findings
Minimal
Thickness of
Endometrial
Carcinoma
09 < 8 46Negative : 32 (70%)
Hyperplasia or polyps: 14 (30%)-
10 < 5 11 Negative : 11 (100%) -
11 < 5 117 Negative : 117 (100%) 9
12 < 4 60 Negative : 60 (100%) -
13 < 5 150 Negative : 150 (100%) 9
14 < 5 58Negative : 57 (98%)
Endometrial Carcinoma : 01 (2%)5
15 < 4 54Not Malignant : 51 (94%)
Malignant : 03 (6%)2
16 < 5 11 Negative : 10 (91%), Polyp : 1 (9%) 10
17 < 4 46
Negative : 44 (96%), Endometrial
Polyp : 1 (2%), Endometrial
Carcinoma : 1 (2%)3
18 < 4 518
Negative : 491 (95%), Endometrial
Polyp : 6 (1%), Endometrial
Carcinoma : 6 (1%)3
Endometrium
• A 3 mm cutoff limit after 5 years or more since menopause greatly improves the specificity and false positive rate for endometrial pathology.
• For a specific diagnosis of endometrial cancer (and not the entire gamut of endometrial disease) a thickness of 5mm and 6mm respectively are appropriate cut offs for women post-15 years menopause and women who are 5-15 years post menopause.
Endometrial Thickness
Patients without bleeding
• Old standard: 4-6 mm
• Positive predictive value of > 5mm is 10%for any disease and 4% for cancer orhyperplasia
• A sampling should be considered at > 8mm
• Age is, however important. At age 50 therisk at 8mm is 4.1% and at age 79, 9.3%
Endometrium
Increased thickness (IMS criteria)
Hormone replacement therapy
Combined continuous
regimen
+ 1 – 1.5 mm
Sequential regimen + 3 mm
Time since menopause 3 mm after 5
years
Hypertension
Asymptomatic on
medication
6.2 mm
Untreated hypertension 4.3 mm
Endometrium
Increased thickness
Tibolone 5.5 mm
Raloxifene 4.0 mm
Tamoxifen 8.0 mm
Endometrium
• Proliferative endometrium
• Hyperplasia
• Cancer
• Residual adenomyosis
Tamoxifen
Endometrium
• 6 mm or less + homogeneous :EXPECTANT MANAGEMENT
• Focal increased echogenecity / Diffuse inhomogeneity / Focal lesion (any thickness) : AGGRESSIVE EVALUATION
Thickness and morphology
Khurana A, Sheikh M et al. Acta Obstet Gynecol Scand 2000
• In a postmenopausal woman without vaginal bleeding, if the endometrium measures > 8 mm a biopsy should be considered as the risk of cancer is 6.7%, whereas if the endometrium measures < or = 8 mm the risk of cancer is extremely low.
• In the situation of a thickness of 11 mm or less in patients without bleeding the patient’s age is worth considering in deciding to sample an endometrium.
• As a woman's age increases, her risk of cancer increases at each endometrial thickness measurement.
• Non-gynecological: trauma, systemic & bleeding disorders,medication including hormone therapy (HT)
• Vaginal atrophy
• Endometrial hyperplasia; simple, complex, and atypical.
• Endometrial carcinoma
• Endometrial polyps or cervical polyps
• Carcinoma of cervix
• Uterine sarcoma, ovarian, vaginal, vulval, tubal cancers
Postmenopausal Bleeding
Causes
Post Menopausal Bleeding
A complete survey
Post Menopausal Bleeding
The atrophic endometrium
Post Menopausal Bleeding
Abnormal endometrial patterns
ENDOMETRIAL THICKNESS
5-8 mm > 8 mm< 4 mm
SequentialHormones
All otherhormones
Bleeding No Bleeding Bleeding No Bleeding
ProbablyAtrophy
Normal Biopsy Likely normal
No Biopsy
Rescan early or Late in cycle
Biopsy
Myometrium
• Myometrium atrophies gradually during & after menopause.• This results in a reduction of uterine size but no appreciable
change in echo pattern. • Arcuate arteries may calcify, particularly in the diabetic patient.• Fibroids undergo a reduction in size after menopause & variably
shrink and calcify.• Multiple fibroids may occasionally distort & obscure the
postmenopausal endometrium
Myometrium
Fibroids
Myometrium
Fibroids
Ovaries
Atrophy
8.6 + 2.3 ml in the 1st
year
2.2 + 1.4 ml after that
Ovarian Cancer
• 80% of ovarian cancers occur in womenover 50 years of age
• Cost of screening versus quality of life
• Annual pelvic exam + tumor markers +ultrasound scan (TVS + color Doppler +4D)
Considerations
Benign Versus Malignant Disease
• General wall thickness
• Focal wall thickening
• Septations
• Nodularity / solid areas
• Heteroechoic pattern
Grey scale criteria
• Peritoneal fluid
• Lymphnodeenlargement
• Metastases
Benign Versus Malignant Disease
Grey scale criteria
BENIGN VERSUS MALIGNANT DISEASE
TRADITIONAL MARKERS
Ovary in Menopause
• Women with unilocular cysts on transvaginalultrasound (TVS) and a normal CA-125 are monitored with repeat TVS at 3 to 6 months. Those with a complex mass <5 cm and normal CA-125 should have repeat TVS and CA-125 testing in 4 weeks.
• Surgery is recommended for any women with increasing morphologic complexity or a rising CA-125.
Benign vs malignant
• Malignant lesions usually produce a significant increase in color Doppler flow signals secondary to angiogenesis.
• The color content of the tumor probably reflects tumor vascularity better than any other Doppler parameter.
• A color score is used to describe the amount of blood flow for the tumor as a whole:
• color score 1, no detectable blood flow;
• score 2, minimal flow;
• score 3, moderate flow;
• and score 4, highly vascular.
• Malignancies often exhibit their increased flow signals not only at the periphery of the mass, as seen with benign lesions, but also in the central regions of the mass, including within septationsand solid tumor areas.
• The neovascularity within malignancies is made up of abnormal vessels, lacking smooth muscle within their walls and containing multiple arteriovenous shunts, resulting in low-impedance flow
• (pulsatility index < 1.0)
• and (resistance index < 0.4),
• high time-averaged maximum velocity (> 15 cm/s),
• and absence of a diastolic notch in such masses .
Ovarian masses
• Neoplastic ovarian masses have a wide pathological spectrum and vary in appearance from simple, thin walled, unilocular, avascular cysts to completely solid masses.
• Advances in transducer technology, color Doppler, power Doppler and 3D studies have greatly enhanced the accuracy of histological prediction of benign and malignant adnexal lesions
• The criteria for a diagnosis of a malignant mass include grey scale observations of
• a solid mass,
• a cystic mass with solid areas,
• focal or diffusely thick walls or septations,
• mural nodules
• and heterogeneous internal echoes.
• Pelvic and paraaortic lymph nodes enlargement, ascites, suprarenal and liver metastases and pleural effusions can be elucidated by transabdominal ultrasound.
• Color flow and 3D vascular reconstruction criteria include
• abnormal calibration of vessels,
• dichotomous branches,
• elongation, coiling, aneurysms,
• vascular lakes,
• arteriovenous anastamoses
• and veno-venous anastomoses
Benign Versus Malignant Disease
• 40% - 90% accuracy
• Non universal selection of parameters
• Highest, lowest or mean impedance values
• Selection of vessels
• Operator variance
• System sensitivity
Color flow criteriaDoppler parameters
BENIGN VERSUS MALIGNANT DISEASE
COLOR FLOW MAPPING
BENIGN VERSUS MALIGNANT DISEASE
NEWER MARKERS (!)
IMPEDANCE VALUES
Benign Versus Malignant Disease
• Dilated, saccular and tortuous
• Elongation and coiling
• Dichotomous branching
• No decrease in diameter of higherorder branches
3D color flow criteria
Benign Versus Malignant Disease
• No normal precapillary architecture
- Arteriovenous anastamoses
- Venovenous shunts
• Vascular lakes
- Incomplete vascular walls
- Increased interstitial pressure
- Increased vascular permeability
- Poor lymphatic drainage
3D color flow criteria
Benign Versus Malignant Disease
• Arteriovenous anastamoses
- Low global flow resistance
- High global blood flow
- Hypoperfused areas
3D color flow criteria
Benign Versus Malignant Disease
3D color flow criteria
Benign Versus Malignant Disease
3D color flow criteria
Benign Versus Malignant Disease
3D color flow criteria
Benign Versus Malignant Disease
3D color flow criteria
Adnexal Masses (ACR Criteria)Radiologic exam
procedure
Low risk
female +
no mass
on US
High risk
female +
no mass
on US
Clinical
mass +
simple
ovarian
cyst < 30
mm
Clinical
mass +
simple
ovarian
cyst 30-50
mm
Clinical
mass +
simple
ovarian
cyst > 50
mm
Clinical mass
+ complex/
solid mass
on US
Ultrasound
Color Flow 2 4 3 4 6 8
Doppler PI/RI 2 4 2 4 6 8
Follow up Ultrasound
06 weeks - - 2 2 6 2
12 weeks 2 2 4 ? 2 2
06 months 2 2 4 7 2 2
12 months 2 8 7 7 2 2
Image-guided - - 2 4 4 2
Aspiration
CT 2 2 2 2 4 4
MRI 2 2 2 2 2 4
CA125 2 2 - - - -
Adnexal masses
• These criteria and conclusions of other workers suggest that a cystic structure less than 30 mm in size, unilateral, unilocular and with no internal echoes, solid areas or nodules, which is avascular on color flow mapping may be re-evaluated 06 and 12 weeks later and then annually if it does not increase or change in morphology or vascularity.
• Any mass with abnormal vascularity and all masses greater than 50 mm in size warrant surgical evaluation.
• Aspirates obtained even under ultrasound guidance do not contain an adequate representation of cells from the tissue of origin to justify the technique.
• All masses associated with a rising Ca 125 level warrant surgical evaluation.
Adnexal Masses
Extra ovarian lesions
Adnexal Masses
Extra ovarian lesions
Adnexal Masses
Tuberculosis
Adnexal Masses
Dermoids
Urinary Evaluation
D
• Dynamic assessment in a sitting position
• Observation during Valsalva
• Pre and post surgical evaluation
- Anterior suspensory mechanism
- Suburethral endopelvic fascia
- Uterosacral complex
• Bladder wall thickness
• Bladder wall vascularisation
Urinary Evaluation
D
Urinary Evaluation
D
Urinary Evaluation
D
Breast Sonography
D
• Dense breasts
• Palpable lesions
• Synchronous lesions
• Interval cancers
Proposed Time Table
D
• Pretreatment baseline
• After 6 months of treatment
• Annual exam
• Three / six monthly exam after change ofregimen
• After a bleed
• ? Six weeks / ? Three month after finding ofabnormal morphology
UAE is an effective and
safe method in the treatment of
fibroids and adenomyosis.
BUT the recurrence rate
is not yet evaluated.
Uterine arterial embolization in the
treatment of fibroids and adenomyosis
MRI-guided Focused Ultrasound Surgery
MRIgFUS represents a new, safe and effective method for the
ablation of adenomyotic tissue
• Ultrasound is the mainstay of diagnosis and follow up of various problems associated with menopause and is indeed a boon.
• It saves from many unnecessary surgical procedures.
• Close monitoring and addition of 3D/4D and color doppler have added immense value .
Conclusion
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