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Home , Myometrium

Myometrial Disorders Myometrium Echogenicity

Mani Montazemi, RDMS Director of Ultrasound Education & Quality Assurancee Baylor College of Medicine Division of Maternal-Fetal Medicine Texas Children’s Hospital, Pavilion for Women Houston Texas & Clinical Instructor Thomas Jefferson University Hospital - Radiology Department Normal myometrium has a smooth even texture throughoutut Philadelphia, Pennsylvania Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Inhomogeneous Myometrium Myometrium Echogenicity

••TransientTransient ••RealReal

2 min later

5 min later

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Myometrium Echogenicity Myometrium Echogenicity

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•Arcuate artery •Radial artery •Spiral artery Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders Inhomogeneous Myometrium Focal Densities Sub-Endometrial ••DensitiesDensities Placental site nodule ––Small,Small, focal, well defined Myometrium Fibroid, Scar, IUD ••LucenciesorLucencies or holes ––VesselsVessels ––flow flow Outer myometrium Arcuate Calcification ––CystsCysts ––no no flow ••MassesMasses ––DiscreteDiscrete with a border ––fibroid fibroid ––Ill-definedIll-defined –– adenomyosis

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Endo/Subendometrial Densities Placental Site Nodules

••FocalFocal echodensityechodensityat at endo-myo junctionjunction ••ProbablyProbably persistent site of prior implantationimplantation ••FoundFound in women with at least 1 ••AA benign microscopic lesion of intermediateintermediate trophoblasttrophoblast ––NoNo reports of GTD or malignancy ––Microscopically:Microscopically: well-well-circumscribed circumscribed nodulesnodules

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Endo/Subendometrial Densities Endo/Subendometrial Densities

••MostMost are variants of normal ••MostMost are clinically insignificant

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders Myometrium Densities Myometrium Densities

Transabdominal Transvaginal

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Myometrium Densities Myometrium Densities

Normal

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

43 y/o G0P0 Outer Myometrium intermenstrual bleed + pain Arcuate Artery Calcifications

••MayMay be seen in older women as symmetric calcified punctate structures ••AssociatedAssociated with ––DiabetesDiabetes ––HypertensionHypertension

Right arm extends into the myometrium Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders Diagnostic Challenge Uterine Leiomyoma – US Findings

••DiscreteDiscrete solid mass ––singlesingle oror multiplemultiple •Variable•Variable echogenecityechogenecity –Hypoechoic,–Hypoechoic, hyperechoic,hyperechoic, isoechoicisoechoic •Sound-attenuating•Sound-attenuating •Contour-deforming•Contour-deforming •Can•Can distortdistort thethe endometrialendometrial canalcanal

Mani Montazemi, RDMS Myometrium Disorders

Uterine Leiomyoma – US Findings Uterine Leiomyoma – US Findings

•Discrete•Discrete solidsolid massmass •Discrete•Discrete solidsolid massmass –single–single oror multiplemultiple –single–single oror multiplemultiple ••VariableVariable echogenecity •Variable•Variable echogenecityechogenecity ––Hypoechoic,Hypoechoic, hyperechoic, –Hypoechoic,–Hypoechoic, hyperechoic,hyperechoic, isoechoicisoechoic isoechoicisoechoic •Sound-attenuating•Sound-attenuating ••Sound-attenuatingSound-attenuating •Contour-deforming•Contour-deforming •Contour-deforming•Contour-deforming •Can•Can distortdistort thethe endometrialendometrial •Can•Can distortdistort thethe endometrialendometrial canalcanal canalcanal

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Uterine Leiomyoma – US Findings Uterine Leiomyoma – US Findings

•Discrete•Discrete solidsolid massmass •Discrete•Discrete solidsolid massmass –single–single oror multiplemultiple –single–single oror multiplemultiple •Variable•Variable echogenecityechogenecity •Variable•Variable echogenecityechogenecity –Hypoechoic,–Hypoechoic, hyperechoic,hyperechoic, –Hypoechoic,–Hypoechoic, hyperechoic,hyperechoic, isoechoicisoechoic isoechoicisoechoic •Sound-attenuating•Sound-attenuating •Sound-attenuating•Sound-attenuating ••Contour-deformingContour-deforming •Contour-deforming•Contour-deforming •Can•Can distortdistort thethe endometrialendometrial ••CanCan distort the endometrial canal canalcanal •May•May undergoundergo fattyfatty degeneration, calcification, hemorrhage, and necrosis Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders Atypical Uterine Fibroids Atypical Uterine Fibroids

••NecrosisNecrosis ••CysticCystic degeneration • Calcification •Calcification Broad Pedunculated ••FattyFatty degeneration ••InfectionInfection ••SarcomatousdegenerationSarcomatous degeneration

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Atypical Uterine Fibroids Ovarian Carcinoma Metastases to

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Calcified Uterine Fibroids Uterine Fibroids

If large leiomyoma is located near the , vaginal delivery may be difficult or impossible

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders subserosal intramural Leiomyoma Locations

••SubmucosalSubmucosal ••SubserosalSubserosal ••IntramuralIntramural --95% 95% pedunculated submucosal ••PedunculatedPedunculated ••CervixCervix --3% 3% ••BroadBroad ligament

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Submucosal Fibroids Submucosal Fibroids

••IncompletelyIncompletely surroundedsurrounded Problem? by ••AcousticAcoustic shadowing Bleeding may be due to ••EchogenicendometriumEchogenic endometrium vascular engorgement or ––secretoryphasesecretory phase erosion of the overlying endometrial membrane

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Submucosal Fibroids Submucosal or Intramural Fibroids

may effect fertility by obstructing the movement of sperm or inhibiting normal implantation

Diffuse Blood Flow

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders Submucosal Fibroids Pedunculated Submucosal Fibroid

Associated with reproductive dysfunction ••HypoechoicmassHypoechoic mass that is completely endoluminal including:including: with a narrow base of ••RecurrentRecurrent miscarriages attachment ••EndometriumEndometrium covering ••PrematurePremature labor thethe fibroidfibroid isis thickenedthickened ••FetalFetal malpresentations & irregular ––ChronicChronic edema or ••ComplicationsComplications of labor inflammationinflammation relatedrelated toto irritationirritation fromfrom thethe massmass

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Intramural Leiomyoma Intramural Fibroids may distort the endometrial canal may displace the endometrial canal

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Intramural Fibroids may displace the endometrial canal Subserosal Fibroids

Will distort the uterine contour and may be difficult to distinguish from adnexal masses when pedunculated

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders Diagnostic Challenge Diagnostic Challenge

“probe” with the probe ! moves with uterus “probe” with the probe ! moves with uterus Color ! blood supply from uterus

Mani Montazemi, RDMS Mani Montazemi, RDMS Identify separate Myometrium Disorders Myometrium Disorders

Uterine Fibroids

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Uterine Fibroids RLQ Pain Post Partum

••AsAs cause of acute : ––InfarctionInfarction (usually associated with pregnancy) ••outout grow blood supply ––resulting resulting in ischemia ••nono longer support of blood supply then the vessels involuteinvolute quickly quickly ––TorsionTorsion

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders Acute Hemorrhagic RLQ Pain Post Partum Infarction of Fibroid

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Uterine Fibroids

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Pedunculated Fibroids

UT

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Fatty Tumors of the Uterus Lipoleiomyoma

••Rare,Rare, benign tumor of myometrium that contains fat ••AsymptomaticAsymptomatic ••HighlyHighly echogenic, solid myometrial mass that attenuates soundsound (diagnostic)(diagnostic) ••VariableVariable mixtures of fat, , fibrous tissue ••CT,CT, MRI to confirm fat

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Lipoleiomyoma vs. Cystic Teratoma Diagnostic Challenge

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders Diagnostic Challenge Leiomyosarcoma

••AccountsAccounts for only 1-3% of uterine malignancies ••BelievedBelieved to arise from existing leiomyomas ••IndistinguishableIndistinguishable from leiomyomaleiomyoma

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Leiomyosarcoma Premenopausal Cyst-What is it?

••SignsSigns of malignancy: ––RapidlyRapidly growing, degenerating myoma, esp. in postmenopausal woman ––LocallyLocally invasive or distant metastases

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Endometrial Canal Outer Myometrium polyp Subendometrium gestational sac Deep Endometrium decidual cyst, ectopic or IUP Myometrium adenomyosis Mid Myometrium adenomyosis, fibroid, AVM Outer Myometrium arcuate vessels

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders Uterine Cysts Diagnostic Challenge

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Uterine Cysts – beta now 540 ? ectopic Adenomyosis

••EctopicEctopic endometrial glands and stromastromawithin within the myometrium surrounded by hypoechoic smooth muscle hyperplasia, hypertrophy

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Adenomyosis Adenomyosis – Clinical Presentations

••MostMost common > 30 y/oy/omultipara multipara ••Menorrhagia-oftenMenorrhagia - often have clots ••PelvicPelvic pain --unexplained, unexplained, throughout the cycle ••DysmenorrheaDysmenorrhea ••UterineUterine tenderness --, dyspareunia, tender on EV exam ––AdnexaAdnexa non-tender in adenomyosis (PID,(PID, )endometriosis)

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders Adenomyosis – Clinical Presentations Adenomyosis – US Findings

••MostMost commonly a woman with ••EnlargedEnlarged & tender (focal) thisthis conditioncondition experienceexperience thethe uterus symptomssymptoms likelike heavy, ••Ill-definedIll-defined heterogenousheterogenous myometrium prolonged or excessive ••AsymmetricAsymmetric myometrial bleeding during menstruation thickeningthickening -- posteriorly and periods with severe pain ••SmoothSmooth serosalserosalcontour contour ••DependingDepending on the severity of ••ThinThin pencil shadows disease and its levels of emanating from penetration into the uterine myometrium – streaky penetration into the uterine soundsound attenuationattenuation walls, the amount of cramps walls, the amount of cramps ••NoNo calcification and bleeding varies

By only conducting the biopsy of the uterine walls, Mani Montazemi, RDMS this condition can be diagnosed with certainty Myometrium Disorders

Diagnostic Challenge Adenomyosis – US Findings

••Small,Small, anechoic subendometrialsubendometrialcysts cysts ––SeenSeen best in end secretorysecretorystage stage ––MostMost specific US finding

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Adenomyosis – US Findings A Diagnostic Dilemma

••CysticCystic areas or abnormal echotexture within the ••AgeAge 45 myometrium 5 3 myometrium ••GG P ––(a.k.a.(a.k.a. “Swiss cheese”cheese”appearance) appearance) ••PainPain & tenderness ••MenorrhagiaMenorrhagia

Mani Montazemi, RDMS Myometrium Disorders Pelvic Pain & Cramps Myometrial Cyst Day 1 of Cycle

Day 20 Day 25

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Pelvic Pain & Cramps Pelvic Pain & Cramps Day 12 of Cycle Day 19 of Cycle

Still Nothing Seen

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Adenomyosis – US Findings Adenomyosis – US Findings

••SubendometrialechogeniclinearSubendometrial echogenic linear striations extending into myometrium ––MayMay also cause pseudo-widening

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders Poorly visualized endometrial echo at transvaginal US Adenomyosis – US Findings adenomyosis in a 66-year-old asymptomatic woman who had undergone tamoxifen therapy for 45 months Indistinct endometrial-myometrial border

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Diagnostic Challenge Adenomyosis – US Findings

••HeterogeneityHeterogeneity and assxassxwidening widening of subendometrial myometrium / subendometrial halo ––HypoechoicHypoechoic ––PoorlyPoorly marginated

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders

Adenomyosis – US Findings Adenomyosis – US Findings

••EchogenicislandsEchogenic islands of ectopic tissue ••Striated,Striated, linear shadowing w/o definite mass ••StreakyStreaky sound attenuation

52 Y/O with Menorrhagia

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders Ultrasound Evaluation of the Myometrium

Fibroids Adenomyosis ••WellWell defined mass ••IllIll defineddefined massmass ••VariousVarious locations ••AsymmetricAsymmetric thickening ••LocalizedLocalized attenuation ••StreakyStreaky attenuation Thank You ••CalcificationsCalcifications ••CystsCysts ••NulliperousNulliperous ••MultiparousMultiparous ••Rx:Rx: medical & other ••Rx:Rx:

Mani Montazemi, RDMS Mani Montazemi, RDMS Myometrium Disorders Myometrium Disorders