Transvaginal sonography study of choice for initial work-up of abnormal vaginal bleeding

Endometrial thickening: Focal more suspicious than diffuse

Polypoid masses with internal color flow

Mixed echogenicity, ± necrosis

Can invade myometrium, cervix, parametrial structures

Disruption of endometrial-myometrial interface and subendometrial halo suggests myometrial invasion

Hematometros if tumor obstructs cavity or cervix

Multiple feeding vessels on color Doppler

Saline-infusion sonohysterography useful to differentiate focal from diffuse endometrial pathology

High-resolution T2 and C+ MR for local staging

CECT or MR (contrast enhanced and diffusion weighted) to evaluate for lymphadenopathy, metastatic disease

Endometrial hyperplasia or polyp

Submucosal fibroid

Uterine sarcoma

Adenomyosis

Majority are adenocarcinoma, 75% endometrioid type (associated with estrogen stimulation)

Papillary serous and clear cell types also occur

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  Not associated with estrogen stimulation

Atypical hyperplasia: Confers 25% risk of developing endometrial cancer

Most common gynecologic malignancy; 75% postmenopausal

Abnormal bleeding in 90%: Postmenopausal, menorrhagia, intermenstrual bleeding

Risk factors: Obesity, diabetes, hypertension, chronic anovulation, polycystic ovarian syndrome, unopposed estrogen stimulation, Tamoxifen

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  Early menarche and late menopause

  
  
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  Hormone replacement therapy without progestins

  
  
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  Estrogen-secreting tumors

Thickness of endometrium should be correlated with menopausal status and timing in menstrual cycle

Imaging alone cannot differentiate hyperplasia from carcinoma

In postmenopausal patients, presence of vaginal bleeding is helpful in risk stratification

> 5 mm bilayer thickness in postmenopausal patient with vaginal bleeding → biopsy

Without bleeding, higher threshold for bilayer thickness

Both transabdominal and transvaginal probes may be required due to uterine size; evaluate endometrial-myometrial interface carefully