by Jeffrey Dach MD
A 56 year old female patient had an episode of abnormal post-menopausal vaginal bleeding for which a pelvic sonogram was recommended. The sonogram showed a cystic swiss cheese appearance of the endometrium which looked like the left image at (red arrows). The abnormal endometrium is located between the three red arrows. Notice the small black areas which indicates small fluid collections.
Left Image: Ultrasound Machine Courtesy of Wikimedia.
The abnormal endometrium required two procedures. First, an endometrial biopsy and later, a D and C (Dilatation and Curettage) which was done for a complete removal of the abnormal endometrial tissue. Fortunately, the pathology report showed only benign endometrial hyperplasia and polyps. There was no endometrial cancer.
Diagram on the left shows the uterine outer muscular layer also called the myometrium. On right, diagram shows the inner uterus, also called the endometrium. This is the layer that is shed every month during the bleeding period.
Why Get a Baseline Pelvic Sonogram?
Dr. Uzzi Reiss’s reasons for a baseline pelvic sonogram:
1) A pelvic sonogram should be added to the manual pelvic exam because the old gyne pelvic exam is a 1950’s standard of care. The new standard of care for the year 2000 is a pelvic sonogram.
2) The annual pelvic exam is a useful exam, but is incomplete. It provides a pap smear, visualization of the cervix, and vaginal mucosa. It cannot provide much information about the uterus and ovaries unless these organs are grossly enlarged.
3) The pelvic sonogram provides much more detailed information about the uterine size, shape and consistency, endometrial thickness, and presence or absence of fibroids, masses, or polyps in the uterus. Small masses and abnormalities can be seen on pelvic sonogram which would never be detected on manual pelvic exam.
4) If endometrial thickness is greater than 5 mm, then endometrial biopsy is usually performed to rule out endometrial cancer.
The small image on the lower left (below) is a normal uterine cavity, and the larger image shows a white cauliflower mass growing into the endometrial cavity. This is endometrial cancer.
5) Pelvic sonogram is more sensitive than pelvic exam for detection and evaluation of ovarian, adnexal masses, cysts, and free fluid in the pelvis.
The image on the left shows a tubo-ovarian abscess. These findings would be difficult or impossible to detect with manual pelvic exam.
6) Post-menopausal bleeding may occur from fluctuating hormone levels when first starting a bio-identical hormone program. Abnormal vaginal bleeding requires a pelvic sonogram to evaluate the cause of the bleeding. Having a prior baseline sonogram for comparison aids in the interpretation, and can avoid unnecessary procedures.
The sonogram can easily determine the cause of abnormal vaginal bleeding:
Causes of Abnormal Vaginal Bleeding:
Diffuse Endometrial hyperplasia (overgrowth)
Diffuse Endometrial cancer
Focal Endometrial hyperplasia
Focal Endometrial cancer
Simply endometrial atrophy (undergrowth)
Uterine fibroids can cause bleeding and this is what uterine fibroids look like:
Fibroids on MRI .
On the MRI scan shown at left, the sacrum is at the right, and the anterior abdominal wall is at the left. The triangular shaped bladder contains fluid (white urine) below and to the left of the enlarged fibroid uterus. Fibroids the dark rounded lesions inside the enlarged uterus.
Sometimes bleeding can be caused by benign endometrial polyps as shown here.
If endometrial thickening (greater than 5 mm) or other abnormality is seen on a sonogram, then endometrial biopsy is usually done. The pelvic sonogram below illustrates the endometrial stripe which is outlined with the yellow line , and the blue line outlines the uterus. The Endometrial stripe should be less than 5 mm in thickness.
Here two images showing examples of a thickened endometrial stripe suspicious for cancer which requires endometrial biopsy for diagnosis:
Above left is a trans-abdominal sonogram, and below is a trans-vaginal sonogram showing thickening of the endometrium detail.
The endometrial biopsy is a 10 minute gyne office procedure in which an instrument is inserted through the endocervical canal and a small sample of the endometrial lining is obtained for pathology analysis. If the pathology is abnormal, a follow up procedure called a D and C (dilatation and curettage) is done to obtain a larger sample, and to remove the entire lesion which is also sent for pathology analysis.
Is Pelvic Ultrasound Safe?
There are no known harmful effects associated with the medical use of sonography which has not been shown to cause any harm or any adverse outcomes.
Trans-Abdominal Sonogram vs. Trans-Vaginal Sonogram
The transabdominal sonogram is usually the initial exam. This is done with a full bladder to provide an acoustic window for the transducer which is placed on the abdomen to obtain images of the uterus and ovaries. If needed, a more sensitive transvaginal sonogram is done with a special transvaginal transducer. This provides high resolution images of the uterine contents and ovaries.
Why You Need A Pelvic Sonogram
I hope the above discussion has convinced you of the importance of the pelvic sonogram, and why we ask that all post Menopausal women have a Baseline Pelvic Sonogram before starting our Bio-Identical Hormone Program.
A pelvic exam is 1950’s standard of care. A pelvic sonogram is newer technology and current standard of care for 2000-2008.
Call Us to Schedule Your Pelvic Sonogram
Still haven’t had your pelvic sonogram? To schedule your pelvic sonogram, call the office and we will arrange it for you.
Call Us if you Need a Gyne Doctor Referral
Are you in between doctors, and looking for a good gyne doctor? We know most of the gyne doctors in the community and can refer you to someone suitable for your needs. Call the office and you can select a gyne doctor from our own list of top doctors.
Jeffrey Dach MD
7450 Griffin Road Suite 190
Davie, Florida 33314
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Ultrasound in the Evaluation of Abnormal Vaginal Bleeding Massachusetts General Hospital Department of Radiology
Ultrasound of ovarian cancer Massachusetts General Hospital Department of Radiology
Uterine Fibroid Embolization Massachusetts General Hospital
Department of Radiology