AJR 2001; 176:617-621
© American Roentgen Ray Society
Endometrial Polyps
Sonohysterographic Evaluation
Johanna R. Jorizzo1,
Michael Y. M. Chen and
Gioia J. Riccio
1
All authors: Department of Radiology, Wake Forest University School of
Medicine, Medical Center Blvd., Winston-Salem, NC 27157-1088.
Received June 5, 2000;
accepted after revision September 6, 2000.
Presented at the annual meeting of the American Roentgen Ray Society,
Washington, DC, May 2000.
Address correspondence to J. R. Jorizzo.
Introduction
Endometrial polyps are a common cause of bleeding in pre- and
postmenopausal women and are difficult to differentiate from other causes of
endometrial thickening using transvaginal sonography. Because treatment of the
various entities resulting in endometrial thickening differs, improved
evaluation of the abnormally thickened endometrium is helpful for patient
treatment. The identification of multiple polyps as opposed to a single polyp
is useful to the clinician performing subsequent hysteroscopic resection to
ensure removal of all masses. The additional identification of associated
endometrial thickening allows the gynecologist to perform dilatation and
curettage at the time of polyp resection.
Procedure
All 20 women with pathologically proven endometrial polyps were initially
scanned with transvaginal sonography (XP-10; Acuson, Mountainview, CA), which
showed an abnormally thickened endometrium of 8 mm or greater. For
premenopausal women, attempts were made to scan on days 4-6 of the cycle, when
the endometrium is at its thinnest phase. Subsequent sonohysterography was
performed as previously described
[1]. Briefly, after cleaning
the cervix, a sterile 5-French catheter that has been flushed with sterile
saline to eliminate the air is then guided into the endocervical canal. The
catheter is advanced past the external cervical os for a variable distance
(usually 2-7 cm). The speculum (one with an open sidearm works best) is then
carefully removed, allowing the catheter to remain in place. Transvaginal
scanning is then performed during the instillation of sterile saline solution.
With occlusive balloon catheters, a total of 5-10 mL of saline is usually
sufficient, whereas straight catheters, with which cervical leakage is common,
may require as much as 40 mL to keep the endometrial cavity distended long
enough to obtain the necessary images for diagnosis. The examination usually
lasts 5-10 min and is well tolerated by the patient. No complications were
encountered in our patients.
Clinical History
Patients were 30-71 years old; 10 patients were premenopausal, and 10 were
postmenopausal. Of the premenopausal patients, nine presented with abnormal
bleeding and one with pelvic pain. Seven postmenopausal women presented with
bleeding, one with pain, and one with abnormal findings on Papanicolaou's
smear suggestive of endometrial abnormality. One other postmenopausal woman
was asymptomatic but was scanned to establish baseline endometrial thickness
before initiation of hormonal replacement therapy.
Sonographic Findings
Transvaginal sonography revealed endometrial thicknesses of 8-29 mm, which
did not correlate with patient age or number of polyps subsequently revealed
at sonohysterography. Those with polyps plus additional hyperplasia shown on
sonohysterography showed endometrial thicknesses of 10-26 mm on initial
transvaginal sonography.
Sonohysterography revealed 10 cases of single polyps and 10 of multiple
polyps (Figs.
1A,1B
and
2A,2B).
Of the premenopausal women, four had multiple polyps and six had single
polyps. The post-menopausal group included six patients with multiple polyps
and four with single polyps. Polyp sizes ranged from 0.5 to 3.0 cm. The
location of 32 distinct polyps revealed at sonohysterography included 11
fundal, five anterior, nine posterior, three right lateral, and four left
lateral.
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Fig. 1B. —Single polyp in 44-year-old woman who presented with
excessive bleeding. Sagittal sonohysterogram shows single round 1.9-cm
echogenic polyp (arrow). Note otherwise thin endometrium (2 mm).
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Fig. 2B. —Multiple polyps in 41-year-old woman who presented with pain.
Sagittal sonohysterogram shows three small round echogenic polyps (two shown
by arrows). Polyps are 5, 6, and 7 mm in diameter.
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Most polyps were homogeneously echogenic, although five showed small cystic
components of 2-3 mm and one had a 1-cm central cyst Fig.
3A,3B).
The polyps imaged in this study revealed a variety of shapes, ranging from
round or oval to elongated and angular (Fig.
4A,4B),
conforming to the shape of the endometrial cavity. Board bases and thin stalks
were seen, all with smooth surfaces (Fig.
5A,5B).
The remaining endometria measured 1-4 mm in 14 cases and 5 mm in one case. The
polyps of four patients with pathologically proven endometrial hyperplasia had
measurements of 6, 8, 8, and 10 mm (Fig.
6A,6B).
The polyps of two (50%) of the four patients with polyps and diffuse
hyperplasia had cystic components.
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Fig. 3A. —Polyp with cystic appearance in 71-year-old woman who
presented with postmenopausal bleeding. Sagittal transvaginal sonogram shows
26-mm-thick endometrium with cystic appearance (arrow).
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Fig. 3B. —Polyp with cystic appearance in 71-year-old woman who
presented with postmenopausal bleeding. Sagittal sonohysterogram shows large
broad-based polyp with cysts (arrow) and 8-mm associated endometrial
thickening (arrowheads) caused by hyperplasia.
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Fig. 4B. —Elongated polyp in 55-year-old woman who presented with
postmenopausal bleeding. Sagittal sonohysterogram shows 2.3-cm elongated
angular polyp (arrow) with 0.8-cm stalk and small 0.7-cm polyp
(arrowhead).
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Fig. 6A. —Polyp and diffuse endometrial thickening in 44-year-old woman
who presented with excessive bleeding. Sagittal transvaginal sonogram shows
endometrium (cursors) with focal thickness of 10 mm.
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Fig. 6B. —Polyp and diffuse endometrial thickening in 44-year-old woman
who presented with excessive bleeding. Sagittal sonohysterogram shows 11-mm
polyp (arrow) and diffuse endometrial thickening
(arrowheads) caused by hyperplasia.
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Differential Diagnosis
Endometrial hyperplasia cannot be distinguished from an endometrial polyp
on the basis of the transvaginal sonography findings alone because both
entities are hyperechoic and may contain cystic components
[2]. Sonohysterography is
necessary to show the focal nature of the polyp as opposed to the diffuse
endometrial thickening of endometrial hyperplasia although, occasionally, a
polypoid appearance may be due to hyperplasia alone (Fig.
7A,7B).
Differentiation of endometrial polyp from submucosal fibroid (Fig.
8A,8B)
at sonohysterography is most effectively done by echotexture assessment and
identification of an overlying echogenic endometrium. The classic submucosal
fibroid is hypoechoic with shadowing and similar in texture to the myometrium
with an overlying echogenic endometrium defining the subendometrial location.
Because a submucosal fibroid may present almost completely within the
endometrial cavity as does a polyp, location is not a reliable distinguishing
feature.
Subendometrial pathology caused by diffuse adenomyosis or focal adenomyoma
may be confused with endometrial polyp on transvaginal sonography alone (Fig.
9A,9B).
The increasing number of patients on tamoxifen citrate therapy for treatment
and prevention of breast cancer has resulted in an increasing incidence of
endometrial polyps, carcinoma, and adenomyosis
[3]. Sonohysterography is the
most useful modality for visualizing the site of abnormality (subendometrial
versus endometrial) by revealing the overlying endometrium with subendometrial
cysts or, in the cases of adenomyoma, focal mass.
Blood clots may be quite difficult to distinguish from polyps because they
may also be echogenic (Fig.
10A,10B).
Attempts should be made to flush blood clots from the endometrial cavity
during sonohysterography, although these attempts may be unsuccessful. Clots
are often seen as multiple strands crossing the canal but also can be
masslike. If possible, sonohysterography should not be performed when the
patient is bleeding excessively because of difficulties in differential
diagnosis; however, this may not be practical in patients who have been
bleeding continuously for extensive periods of time. Synechiae may also be
echogenic but extend from wall to wall without a focal mass and usually can be
identified on sonohysterography without confusion with endometrial polyp
(Fig. 11).
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Fig. 10B. —Blood clot in 69-year-old woman who presented with
postmenopausal bleeding. Sagittal sonohysterogram shows polypoid mass
(arrow). Pathologic diagnosis was blood clot. This may be difficult
to differentiate from polyp if it cannot be flushed during procedure.
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Fig. 11. —Synechiae in 46-year-old woman who presented with excessive
bleeding. Sagittal sonohysterogram shows echogenic strands
(arrowhead) traversing endometrial canal consistent with synechiae.
Note that anterior myometrial fibroid was also seen.
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Although none of the polyps in our study showed malignant foci, a small
percentage (0.5-3%) [4] may
contain adenocarcinoma (Fig.
12A,12B),
and removal of polyps is therefore necessary for exclusion of malignancy as
well as treatment of bleeding. Polyps may be difficult to distinguish from
well-differentiated endometrial carcinoma. Obvious invasion of the underlying
endometrium is consistent with malignancy, but less obvious invasion may not
be appreciated on transvaginal sonography or sonohysterography. Endometrial
carcinoma may be focal (versus polyp) or diffuse (versus hyperplasia) and may
be quite inhomogeneous in echotexture. One recent study suggested that lack of
distensibility of the endometrial canal during sonohysterography may be a sign
of endometrial carcinoma [5].
Good technique using a balloon catheter to occlude the cervical os would
therefore be essential in the differentiation of a nondistensible endometrial
canal caused by carcinoma from poor distention caused by incomplete occlusion
of a patulous cervical os.
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Fig. 12B. —Endometrial adenocarcinoma in 37-year-old woman who presented
with excessive bleeding. Sagittal sonohysterogram shows 4-cm polypoid mass
(arrow). Pathologic diagnosis was endometrial adenocarcinoma.
Difficulty in adequately distending endometrial canal despite use of occlusive
balloon may have been sign of carcinoma.
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Ascher SM, Imaoka I, Lage JM. Tamoxifen-induced uterine
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Robboy SR, Duggan MA, Kurman RJ. Gynecologic pathology. In: Rubin
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