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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