Diagnostic ultrasound ( PDFDrive )

544 PART II Abdominal and Pelvic Sonography
Adenoma malignum, also termed minimal deviation adenocarcinoma,
is an uncommon type of cervical carcinoma that
has been associated with Peutz-Jeghers syndrome. Watery vaginal
discharge has been described as a common symptom. Sonographically
these are most oten multiloculated cystic masses with a
solid component or completely solid masses (Fig. 15.14F–G). 105
Multiple adjacent nabothian cysts might simulate this lesion,
but when a solid component is present, particularly with low
by Doppler imaging, one should consider this uncommon
neoplasm.
ABNORMALITIES OF
THE ENDOMETRIUM
Because of its improved resolution, TVS is better able to image
and depict subtle abnormalities within the endometrium and
clearly deine the endometrial/myometrial interface than is TAS. 106
Knowledge of the varied normal sonographic appearances of
the endometrium that vary with respect to time of the menstrual
cycle, patient menopausal status, and hormone use allows for
recognition of pathologic conditions manifested by endometrial
thickening because the expected upper limits of normal thickness
will vary with these factors. Many endometrial pathologies, such
as hyperplasia, polyps, and carcinoma, can cause abnormal
bleeding. Abnormal bleeding can be due to abnormally heavy
menstrual periods at the expected time of the menstrual cycle
(menorrhagia, for example due to ibroids or adenomyosis),
abnormal bleeding at an unexpected time of the cycle (metrorrhagia),
or both (menometrorrhagia).
Causes of Metrorrhagia
Pregnancy
Systemic disease (liver disease, blood dyscrasias)
Endometrial polyps or hyperplasia
Endometrial cancer
Intrauterine device (IUD) malposition
Cesarean section scar defect
Although heavy vaginal bleeding is typically from a myometrial
or endometrial cause, abnormal bleeding can at times arise from
other sources such as bleeding from the vulva or vagina (lacerations,
infection, or cancer), from the cervix (polyps, ibroids, or
cancer), from the fallopian tubes (salpingitis, tumors, or tubal
pregnancy), or be secondary to ovarian pathology (estrogenproducing
tumor, cancer, functional ovarian cysts).
SHG can be of great value in further evaluating the abnormally
thickened endometrium. 5,6,107-110 SHG can distinguish between
focal and difuse endometrial abnormalities and help guide further
management. If the abnormality is difuse, a blind, nondirected
biopsy can be done, but a focal process, such as a polyp, typically
requires hysteroscopy with directed biopsy or excision. 5,110 SHG
may also be able to help distinguish benign from malignant
endometrial processes. 111,112 Patients with endometrial cancer
may have poorly distensible endometrial cavities. 112
Causes of Endometrial Thickening
Pregnancy
Retained products of conception
Fibroids (submucosal or intracavitary)
Endometritis
Adhesions
Hyperplasia
Polyps
Cancer
Postmenopausal Endometrium
Hormone Use
When assessing the postmenopausal endometrium, it is important
to know if the patient is taking any exogenous hormones
(hormone replacement therapy). hese hormones used to be
given long term to prevent osteoporosis and alleviate menopausal
symptoms. Because unopposed estrogen replacement is associated
with an increased risk of endometrial hyperplasia and carcinoma,
estrogen therapy is frequently combined with progesterone in
continuous combined or in sequential regimens. However, these
hormones are no longer frequently used for long-term therapy
owing to the known increased risk of thromboembolism, breast
cancer, adverse cardiac events, and stroke (which are not ofset
by beneits of lower rates of colorectal cancer and hip fractures). 113
hey may be given for a short time around the time of menopause
to help alleviate menopausal symptoms. Use of continuous
combined estrogen should lead to a thin atrophic-appearing
endometrium. Use of sequential estrogen and progesterone may
lead to a changing appearance of the endometrium similar to
that of premenopausal women with increased thickness in the
latter half of the hormonal cycle. 114 Women who are taking
unopposed estrogen need to be monitored, given the known
increased risk of endometrial cancer.
Effects of Hormones on the Postmenopausal
Endometrium
Hormone Regimen
No hormones
Unopposed estrogen
Daily estrogen/progesterone
Sequential estrogen/
progesterone
Tamoxifen
Expected Endometrial
Appearance
Thin, atrophic
Thick, maybe heterogeneous
Thin, atrophic
Thickness varies with phase
of cycle
Thick, cystic spaces (some
changes are in the
myometrium)
Tamoxifen and other hormonal treatments for breast cancer
can have estrogenic efects in the uterus. An increased risk of
endometrial carcinoma has been reported in patients receiving
tamoxifen therapy, 115 as well as an increased risk of endometrial
hyperplasia and polyps. 116,117 A correlation exists between
increased endometrial thickness and cumulative dose of tamoxifen.
118 On sonography, tamoxifen-related endometrial changes
are nonspeciic and similar to those described in hyperplasia,