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Usg in menopause JAIDEEP MALHOTRA
Ultrasound is essential for evaluating pelvic conditions in postmenopausal women, offering techniques such as transvaginal scans and 3D imaging to detect abnormalities and assess endometrial and ovarian health. The document highlights that ultrasound can reduce unnecessary procedures stemming from fear of malignancy, emphasizing the importance of appropriate cutoff measurements for endometrial pathology diagnosis. Advances in imaging technology have improved the accuracy of identifying benign versus malignant conditions, making ultrasound a valuable tool in managing menopausal health.
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Introduction to the role of ultrasound in assessing menopause-related conditions and comparisons with other modalities.
Detailing ultrasound techniques such as 3D and Doppler techniques optimal for pelvic assessments.
Goals include recognizing pelvic lesions, characterizing features, and evaluating potential tumors.
Describes methods for evaluating the uterus, ovaries, and related systems in postmenopausal women.
Assessment of uterine atrophy and endometrial thickness along with morphological abnormalities.
Discusses endometrial polyps and various abnormal morphological findings related to cancer risks.
Discussion on changes in myometrium and the significance of early detection of ovarian cancer.
Criteria for differentiating benign from malignant diseases through imaging techniques and Doppler parameters.
Guidelines for evaluating adnexal masses, including follow-up strategies based on size and vascularity.
Concludes the presentation emphasizing ultrasound as essential for managing menopause issues effectively.
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- 1. Ultrasound in Menopause JaideepMalhotra Narendra Malhotra Ashok Khurana Kuldeep Singh www.rainbowhospitals.org
- 2. When in Doubt,Cut it Out “ A palpable postmenopausal ovary should not be reevaluated or followed up but be investigated promptly by liberal indications of surgery” Hugh Barber, 1971
- 3. In the PresidentialSymposium 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.
- 4. At the outsetit 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.
- 5. • High frequencytransvaginal scans • Color flow mapping • Duplex Doppler • Power Doppler • Three dimensional ultrasound Ultrasound techniques
- 6. Ultrasound techniques Complimentary techniques •Power and color Doppler • Saline infusion sonohysterography • Positive contrast sonohysterography • 3D & 4D (Real time 3D)
- 7. AIM • TO IMPROVERECOGNITION OF PELVIC LESION ANATOMY • CHARACTERISATION OF SURFACE FEATURES • DETECTION OF TUMOR INFILTRATION • PRECISE DEPICTION OF SIZE AND VOLUME
- 8. INDICATIONS • Endometrial evaluationin vaginal bleeding • Evaluation of palpable pelvic mass • Screening for endometrial and ovarian cancer in high risk group
- 9. TECHNIQUES • Transabdominal • Transvaginal •Transperineal
- 10. EVALUATION • Uterus • Ovaries •Extra-ovarian adnexal areas • Cervix • Pouch of douglas
- 11. SYSTEMIC EVALUATION • Pleura •Peritoneum • Retroperitoneum • Liver • Kidneys • Bladder
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- 16. The Endometrium inMenopause Norms
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- 18. Endometrial Thickness Considerations • Includethe entire endometrial thickness and not just one leaf • The thickest anteroposterior measurement is to be considered • The extent of a fluid collection should not be included
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- 20. Endometrium Abnormal morphology Focal increasedechogenecity, diffuse increased echogenecity and diffuse inhomogeneity increase the predictability of pathologic findings.
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- 26. Endometrial polyps 3D PowerDoppler
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- 28. Single/orthogonal/TUI 3D Display Formats Singleplane Tomographic display
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- 30. Endometrial Thickness Study No. Endometrial Thickness Cutoff (mm) Numberof Cases Below Cutoff Histological Findings Minimal Thickness of Endometrial Carcinoma 09 < 8 46 Negative : 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 58 Negative : 57 (98%) Endometrial Carcinoma : 01 (2%) 5 15 < 4 54 Not 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 Negative : 491 (95%), Endometrial Polyp : 6 (1%), Endometrial
- 31. Endometrium • A 3mm 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.
- 32. Endometrial Thickness Patients withoutbleeding • Old standard: 4-6 mm • Positive predictive value of > 5mm is 10% for any disease and 4% for cancer or hyperplasia • A sampling should be considered at > 8mm • Age is, however important. At age 50 the risk at 8mm is 4.1% and at age 79, 9.3%
- 33. Endometrium Increased thickness (IMScriteria) 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
- 34. Endometrium Increased thickness Tibolone 5.5mm Raloxifene 4.0 mm Tamoxifen 8.0 mm
- 35. Endometrium • Proliferative endometrium •Hyperplasia • Cancer • Residual adenomyosis Tamoxifen
- 36. Endometrium • 6 mmor 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
- 37. • In apostmenopausal 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.
- 38. • 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
- 39. Post Menopausal Bleeding Acomplete survey
- 40. Post Menopausal Bleeding Theatrophic endometrium
- 41. Post Menopausal Bleeding Abnormalendometrial patterns
- 42. ENDOMETRIAL THICKNESS 5-8 mm> 8 mm< 4 mm Sequential Hormones All other hormones Bleeding No Bleeding Bleeding No Bleeding Probably Atrophy Normal Biopsy Likely normal No Biopsy Rescan early or Late in cycle Biopsy
- 43. Myometrium • Myometrium atrophiesgradually 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
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- 46. Ovaries Atrophy 8.6 + 2.3ml in the 1st year 2.2 + 1.4 ml after that
- 47. Ovarian Cancer • 80%of ovarian cancers occur in women over 50 years of age • Cost of screening versus quality of life • Annual pelvic exam + tumor markers + ultrasound scan (TVS + color Doppler + 4D) Considerations
- 48. Benign Versus MalignantDisease • General wall thickness • Focal wall thickening • Septations • Nodularity / solid areas • Heteroechoic pattern Grey scale criteria • Peritoneal fluid • Lymphnode enlargement • Metastases
- 49. Benign Versus MalignantDisease Grey scale criteria
- 50. BENIGN VERSUS MALIGNANTDISEASE TRADITIONAL MARKERS
- 51. Ovary in Menopause •Women with unilocular cysts on transvaginal ultrasound (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.
- 52. 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.
- 53. • A colorscore 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.
- 54. • Malignancies oftenexhibit 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 septations and 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 .
- 55. Ovarian masses • Neoplasticovarian 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
- 56. • The criteriafor 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.
- 57. • Color flowand 3D vascular reconstruction criteria include • abnormal calibration of vessels, • dichotomous branches, • elongation, coiling, aneurysms, • vascular lakes, • arteriovenous anastamoses • and veno-venous anastomoses
- 58. Benign Versus MalignantDisease • 40% - 90% accuracy • Non universal selection of parameters • Highest, lowest or mean impedance values • Selection of vessels • Operator variance • System sensitivity Color flow criteria Doppler parameters
- 59. BENIGN VERSUS MALIGNANTDISEASE COLOR FLOW MAPPING
- 60. BENIGN VERSUS MALIGNANTDISEASE NEWER MARKERS (!) IMPEDANCE VALUES
- 61. Benign Versus MalignantDisease • Dilated, saccular and tortuous • Elongation and coiling • Dichotomous branching • No decrease in diameter of higher order branches 3D color flow criteria
- 62. Benign Versus MalignantDisease • 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
- 63. Benign Versus MalignantDisease • Arteriovenous anastamoses - Low global flow resistance - High global blood flow - Hypoperfused areas 3D color flow criteria
- 64. Benign Versus MalignantDisease 3D color flow criteria
- 65. Benign Versus MalignantDisease 3D color flow criteria
- 66. Benign Versus MalignantDisease 3D color flow criteria
- 67. Benign Versus MalignantDisease 3D color flow criteria
- 68. Adnexal Masses (ACRCriteria) 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 - - - -
- 69. Adnexal masses • Thesecriteria 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.
- 70. Adnexal Masses Extra ovarianlesions
- 71. Adnexal Masses Extra ovarianlesions
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- 74. Urinary Evaluation D • Dynamicassessment 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
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- 78. Breast Sonography D • Densebreasts • Palpable lesions • Synchronous lesions • Interval cancers
- 79. Proposed Time Table D •Pretreatment baseline • After 6 months of treatment • Annual exam • Three / six monthly exam after change of regimen • After a bleed • ? Six weeks / ? Three month after finding of abnormal morphology
- 80. UAE is an effectiveand 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
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- 82. MRIgFUS represents anew, safe and effective method for the ablation of adenomyotic tissue
- 83. • Ultrasound isthe 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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