AJR 2002; 179:385-389
© American Roentgen Ray Society
Spectrum of Endometrial Hyperplasia and Its Mimics on Saline Hysterosonography
Johanna R. Jorizzo1,
Michael Y. M. Chen,
Deena Martin,
Raymond B. Dyer and
Therese M. Weber
1 All authors: Department of Radiology, Wake Forest University School of
Medicine, Winston-Salem, NC 27157-1088.
Received July 27, 2001;
accepted after revision February 8, 2002.
Presented at the annual meeting of the American Roentgen Ray Society,
Seattle, April—May 2001.
Address correspondence to J. R. Jorizzo.
Introduction
Endometrial hyperplasia is a proliferative endometrial disorder that
results from unopposed estrogen stimulation and is a common cause of vaginal
bleeding in both pre- and postmenopausal women
[1]. Routine transvaginal
sonography of patients with endometrial hyperplasia shows endometrial
thickening that cannot be differentiated from other causes, including
endometrial cancer. With the use of saline hysterosonography, the diffuse
nature of endometrial hyperplasia can be shown and blind endometrial biopsy
should be adequate in the outpatient setting for cost-effective management
[2].
Clinical History and Procedure
Our study population consisted of 23 women who ranged in age from 35 to 71
years (mean age, 50 years). Two patients were premenopausal (<40 years
old), 16 were perimenopausal (40-55 years old), and five were postmenopausal
(>55 years old). Our study population included 18 patients with endometrial
hyperplasia and five patients with endometrial metaplasia.
Symptoms and sonographic findings in all patients were similar. All women
presented with abnormal vaginal bleeding. Patients were initially examined on
transvaginal sonography (model XP-10; Acuson, Mountain View, CA). Sonographic
findings in all patients showed an abnormally thick endometrium, ranging from
6 to 28 mm (both walls).
Saline hysterosonography was performed by a radiologist as described in a
previous report [2]. The cervix
was localized using a speculum with an open side arm to facilitate removal
without dislodging the catheter. After the cervix was cleansed with an iodine
swab, a sterile 5-French catheter, usually one with an occlusive balloon, that
had previously been flushed with sterile saline was advanced into the
endocervical canal. Once the balloon was inflated with approximately 2 mL of
saline, the speculum was carefully removed and the transvaginal sonography
probe was reinserted. Scanning was then performed during the slow infusion of
sterile saline (typically 5-10 mL or more if needed) into the endometrial
cavity. The examination was well tolerated by all patients, and no
complications were recorded at follow-up clinical visits.
Pathology
Endometrial hyperplasia is a pathologic term used to describe a group of
proliferative disorders of the endometrium usually resulting from unopposed
estrogenic stimulation. Endometrial hyperplasia is subdivided into hyperplasia
with or without cytologic atypia
[3,
4]. Simple and complex forms
refer to the degree of glandular complexity and crowding encountered
[1]. Because endometrial
proliferative disorders range from simple endometrial hyperplasia without
cytologic atypia at one end of a biologic continuum to endometrial
adenocarcinoma at the other, this classification is useful in predicting
progression of endometrial hyperplasia to carcinoma in a given patient. Less
than 2% of the cases of endometrial hyperplasia without atypia progress to
endometrial carcinoma, whereas approximately 23% of the cases of atypical
endometrial hyperplasia progress to carcinoma. The greater the complexity of
architecture (complex endometrial hyperplasia), the greater the likelihood of
cancer development.
Endometrial metaplasia refers to endometrial cellular changes often
associated with endometrial hyperplasia and also thought to result from excess
estrogen [1]. Five cases of
simple endometrial hyperplasia plus metaplasia (squamous and ciliated cell
tubal types) and five cases of metaplasia alone (squamous cell, ciliated cell,
and papillary syncytial change) were included in our study. All are benign
pathologic entities that refer to a change in the endometrial cells to
resemble, respectively, squamous cells; epithelium of the fallopian tube, in
cases of ciliated cell tubal metaplasia; or eosinophils, in cases of papillary
syncytial change.
Patients with endometrial hyperplasia and metaplasia usually present with
abnormal bleeding, as was seen in all 23 of our patients. Endometrial
thickening is diffuse but does not necessarily involve the entire endometrium
in patients with both conditions. Lobular thickening may resemble endometrial
polyps or carcinoma, both of which may coexist with endometrial
hyperplasia.
We correlated the pathologic and sonographic findings and found that the
range of thicknesses of the endometrium showed considerable overlap and was
not predictive of the diagnosis. In patients with simple endometrial
hyperplasia, the endometrium ranged from 6 to 16 mm in thickness, whereas in
patients with simple endometrial hyperplasia and metaplasia, the endometrium
ranged from 10 to 20 mm. In patients with complex endometrial hyperplasia, the
endometrium ranged from 11 to 17 mm; in patients with complex endometrial
hyperplasia with atypia, from 8 to 20 mm; and in those with endometrial
metaplasia, from 5 to 12 mm.
Pathologic findings were confirmed at endometrial biopsy in 15 patients,
dilatation and curettage in five, and hysterectomy in three. Five cases of
simple endometrial hyperplasia without atypia, three cases of complex
endometrial hyperplasia without atypia, one case of simple endometrial
hyperplasia with cytologic atypia, and four cases of complex endometrial
hyperplasia with atypia were detected at pathology. In addition, five cases of
simple endometrial hyperplasia with metaplasia (squamous cell, ciliated cell
tubal) (Fig.
1A,1B)
and five cases of endometrial metaplasia alone were diagnosed.
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Fig. 1A. —Simple endometrial hyperplasia with no atypia and squamous
metaplasia in 51-year-old woman who presented with heavy bleeding. Sagittal
transvaginal sonogram shows 23-mm-thick endometrium (cursors).
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Fig. 1B. —Simple endometrial hyperplasia with no atypia and squamous
metaplasia in 51-year-old woman who presented with heavy bleeding. Sagittal
saline hysterosonogram shows 22-mm diffuse thickening (arrows) of
both walls.
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Sonographic Findings
On saline hysterosonography, the endometrial thicknesses (both walls)
ranged from 5 to 22 mm, with an average thickness of 12 mm. All of the
endometria were echogenic in texture. Lobular contours of the endometrium were
shown in two patients with endometrial hyperplasia (9%) (Fig.
2A,2B).
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Fig. 2A. —Complex endometrial hyperplasia with no atypia and
lobular-appearing endometrium in 48-year-old woman who presented with heavy
bleeding and cramps. Sagittal transvaginal sonogram shows 15-mm-thick
endometrium (cursors).
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Fig. 2B. —Complex endometrial hyperplasia with no atypia and
lobular-appearing endometrium in 48-year-old woman who presented with heavy
bleeding and cramps. Transverse saline hysterosonogram shows lobular
endometrium (arrow) with no polyps. No polyps were identified in
material submitted to pathology following dilatation and curettage.
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Cysts were contained in the thickened endometrium in 13 patients (57%). The
cysts were small (<5 mm) in 11 patients (48%) (Fig.
3A,3B)
and large (
5 mm) in two patients (9%).
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Fig. 3A. —Simple endometrial hyperplasia with no atypia and small cysts
in 45-year-old woman who presented with excessive bleeding and pain. Sagittal
transvaginal sonogram shows 20-mm-thick endometrium with small cysts
(arrow).
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Fig. 3B. —Simple endometrial hyperplasia with no atypia and small cysts
in 45-year-old woman who presented with excessive bleeding and pain. Sagittal
saline hysterosonogram shows 12-mm diffuse thickening (arrow) and
probable small blood clot centrally. No polyp was detected on hysteroscopy
(not shown).
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Concomitant endometrial polyps were present in six patients (26%); one
polyp contained multiple small calcifications
(Fig. 4). An associated blood
clot was discernible in five patients (22%) (Fig.
5A,5B,5C)
and synechia in one patient (4%) (Fig.
6A,6B).
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Fig. 4. —Complex endometrial hyperplasia with atypia and polyp with
calcifications in 48-year-old woman who presented with excessive bleeding and
abnormal findings on Pap (Papanicolaou) smear. Sagittal saline hysterosonogram
shows calcified polyp (solid arrow) on anterior wall and reveals that
endometrium is not covering polyp. Probable central blood clot (open
arrow) is visible.
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Fig. 5A. —Simple endometrial hyperplasia with no atypia and blood clot
in 45-year-old woman who presented with excessive bleeding. Sagittal
transvaginal sonogram shows 28-mm-thick endometrium (arrows).
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Fig. 5B. —Simple endometrial hyperplasia with no atypia and blood clot
in 45-year-old woman who presented with excessive bleeding. Sagittal saline
hysterosonogram shows 20-mm diffuse thickening (arrows).
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Fig. 5C. —Simple endometrial hyperplasia with no atypia and blood clot
in 45-year-old woman who presented with excessive bleeding. Sagittal saline
hysterosonogram shows central mass (cursors) thought to represent
blood clot. No polyp was detected on hysteroscopy (not shown).
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Fig. 6A. —Complex endometrial hyperplasia with cytologic atypia and
synechia in 57-year-old woman who presented with postmenopausal bleeding.
Sagittal transvaginal sonogram shows retroverted uterus and 25-mm-thick
endometrium (cursors).
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Fig. 6B. —Complex endometrial hyperplasia with cytologic atypia and
synechia in 57-year-old woman who presented with postmenopausal bleeding.
Sagittal saline hysterosonogram shows 10-mm diffusely thickened endometrium
(cursors) and central synechia (arrow).
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Differential Diagnosis
Endometrial thickening can be diagnosed with transvaginal sonography, but
saline hysterosonography is necessary to determine the diffuse nature of the
abnormality [2,
5,
6]. The differential diagnosis
for diffuse thickening includes the various forms of endometrial hyperplasia
and endometrial metaplasia as well as endometrial carcinoma. Transvaginal
sonography and saline hysterosonography cannot differentiate among the various
forms of endometrial hyperplasia and metaplasia. The secretory phase of the
menstrual cycle is indistinguishable from other causes of diffuse endometrial
thickening on saline hysterosonography as are retained products of conception
and recent gestational state in some patients (Fig.
7A,7B).
Therefore, biopsy is necessary to identify those patients with cellular
atypia. Rare causes of diffuse endometrial thickening include endometrial
lymphoma and endometrial malacoplakia
[7] (Fig.
8A,8B).
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Fig. 7B. —Recent gestational state in 30-year-old woman who presented
with excessive bleeding. Sagittal saline hysterosonogram shows 12-mm diffuse
thickening (cursors) of both endometrial walls.
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Fig. 8A. —Endometrial malacoplakia in 55-year-old woman who presented
with postmenopausal bleeding. Sagittal saline hysterosonogram shows asymmetric
thickening of endometrium: Posterior wall (cursors) is 8 mm thick,
and anterior wall is 3 mm thick. (Reprinted with permission from
[7])
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Fig. 8B. —Endometrial malacoplakia in 55-year-old woman who presented
with postmenopausal bleeding. Transverse saline hysterosonogram shows 2-cm
masslike thickening (arrow) of fundal portion of endometrium
projecting into endometrial cavity.
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Saline hysterosonography can detect focal pathology and suggest the
diagnosis of an endometrial polyp (Fig.
9A,9B)
or a submucosal fibroid on the basis of the echotexture and, in cases of
fibroids or adenomyosis, the presence of overlying endometrium
(Fig. 10). Blood clots and
synechiae may also result in apparent endometrial thickening, but saline
hysterosonography can usually differentiate between these findings and diffuse
endometrial hyperplasia [8].
Color Doppler sonography may distinguish blood clots from polyps. When both
focal and diffuse processes coexist, visually directed biopsy of the focal
component and dilatation and curettage are warranted.
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Fig. 9B. —Endometrial polyp with cysts in 45-year-old woman who
presented with irregular bleeding. Sagittal saline hysterosonogram shows focal
polypoid mass (arrow). Posterior endometrium (arrowhead) is
thin (1 mm).
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Fig. 10. —Submucosal fibroid in 53-year-old woman who presented with
irregular bleeding. Sagittal saline hysterosonogram shows 2-cm anterior
submucosal fibroid (white arrows). Note hypoechoic texture and thin
overlying endometrium (black arrow).
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Conclusion
Abnormal uterine bleeding is a common disorder in pre- and postmenopausal
women and is often the result of endometrial hyperplasia. Patients with
endometrial hyperplasia showing cytologic atypia are at a significantly
increased risk of developing endometrial carcinoma.
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Introduction
Clinical History and Procedure
