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Key Terms

  1. Endometrial “stripe”: interface representing endometrial bilayer thickness as seen in long axis.

  2. “Bilayer” thickness: measurement in millimeters of thickest measurement both layers of endometrium in anteroposterior dimension (usually taken in fundal portion of endometrium).

  3. Endometrial “width”: measurement in millimeters of distance of endometrium in thickest coronal dimension.

  4. Sonohysterography (SHG): assessment of endometrial surfaces using infused saline.


Over the past several years, transvaginal sonography (TVS) of the endometrium has assumed an integral role in the evaluation of women with possible endometrial disorders.1,2 TVS allows detailed delineation of endometrial thickness and texture in most patients. The sonographic findings have important implications in determining which patients need endometrial biopsy or dilatation and curettage, observation, or alteration of medication. The more extensive use of sonohysterography (SHG) (fluid instillation into the endometrial lumen) has also greatly enhanced sonographic evaluation of patients with endometrial disorders related to subfertility (please refer to Chapter 35) and polyps. Similarly, the use of 3D and color Doppler sonography has enhanced the evaluation of endometrial disorders such as those associated with polyps, distortion due to fibroids, or pathologic process such as adenomyosis, which can disrupt the inner myometrial/basal layer of endometrium interface or be associated with textural changes such as punctate cysts.

This chapter discusses and illustrates the clinically important applications of TVS in the evaluation of the endometrium. It emphasizes the technical and operator dependent factors as well as presenting the limitations of the technique.


One of the most common disorders evaluated by gynecologists is unexpected or excessive uterine bleeding. It should be emphasized that only 10% to 15% of women who present with irregular bleeding have endometrial cancer; the vast majority have bleeding secondary to benign disorders such as atrophy or hyperplasia.3 The role of sonography is to determine which patients can forgo endometrial biopsy and to monitor endometrial changes in patients receiving tamoxifen or other forms of hormone therapy (HT). Approximately 30% of women receiving combined HT experience bleeding. It is the role of TVS to determine which patients need biopsy, dilatation and curettage, alteration in their medicines, or observation.

Although endometrial cancer is more common than ovarian cancer, this disease is associated with far less mortality. This is clearly related to the fact that one of the earliest signs of endometrial cancer is vaginal bleeding. In addition, endometrial cancer is usually still confined to the uterus when the patient presents, whereas two-thirds of patients with ovarian cancer have extensive disease at time of presentation (see Chapter 36 on early detection of ovarian and endometrial cancer).

It is important conceptually to differentiate causes of uterine bleeding in the premenopausal from the peri- or postmenopausal woman. In the woman of child-bearing age, bleeding is usually associated with anovulation. It may also be related to ...

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