Ultrasound Appearance of the Endometrium Post-Radiofrequency Ablation

OBJECTIVE

To describe the ultrasonographic appearance of the post-ablative endometrium to improve knowledge of its sonographic findings.

METHODS

This was an Institutional Review Board approved prospective study of patients who underwent second-generation endometrial ablation from 2016 to 2019 at a single health system. Patients had postoperative transvaginal ultrasounds at 2, 6, and 12 months. Ultrasound reports were analyzed for endometrial thickness, description of the endometrium and myometrium, presence of uterine fibroids, and uterine size. Statistical tests for repeated measures were utilized.

RESULTS

There were 68 patients with the average age of 42 (SD 6) years and a BMI of 33 (SD 8). Preoperatively the average endometrial thickness was 10 mm, uterine length was 9.7 cm, and 38.2% had leiomyoma. The average endometrial thickness decreased at each ultrasound: 8.4 mm (SD 3.4), 7.2 mm (SD 3.0), and 5.8 mm (SD 2.5) at 2, 6, and 12 months, respectively. When comparing endometrial thickness postoperatively there was a significant difference at 2 and 12 months (P = .041), and 6 and 12 months (P = .031). There was no change during the postoperative period in the presence of leiomyoma, hyperechoic endometrium, hypoechoic endometrium, heterogeneous endometrium, and cystic endometrium on the ultrasounds.

CONCLUSION

After ablation with a second-generation device, the endometrial thickness on ultrasound decreases with time following surgery. Additional studies correlating these findings to clinical outcomes would be useful.

Ultrasound-guided percutaneous microwave ablation for adenomyosis with abnormal uterine bleeding: clinical outcome and associated factors

OBJECTIVE

To investigate the factors affecting the efficacy of ultrasound (US)-guided percutaneous microwave ablation (PMWA) for adenomyosis with abnormal uterine bleeding (AUB-A).

METHODS

Baseline data of patients with AUB-A who underwent US-guided PMWA treatment between October 2020 and October 2021, including demography characteristics, laboratory and imaging examination results were retrospectively analyzed. 3D reconstruction of magnetic resonance imaging (MRI) was applied to quantitatively assess the local treatment responses, including ratio of non-perfusion volume to adenomyosis volume (NPVr), ablation rate of the endometrial-myometrial junction (EMJ), and surface area (SA) of the ablated part of the EMJ. Patients were followed up at 3, 6, and 12 months after treatment, and divided into two groups: group with complete relief (CR), and group with partial relief (PR) or no relief (NR). Data were compared between them.

RESULTS

Thirty-one patients were analyzed with a mean age of 38.7 ± 6.8 years (range: 24-48): 48.4% (15/31), 63.3% (19/30), and 65.5% (19/29) achieved CR at 3, 6, and 12 months, respectively. In univariate analysis, compared with the PR/NR group, serum CA125 levels were significantly lower in CR group at 3 months, while ablation rates of EMJ and SA of the ablated part of the EMJ were significantly higher at the three time points. Other baseline characteristics and NPVr did not differ between the two groups.

CONCLUSION

Baseline CA125 and ablation rate of the EMJ and SA of the ablated part of the EMJ are associated with the outcome of AUB-A patients after US-guided PMWA treatment.

A Rare Case of Recurrent Hematometra of Unknown Etiology

An abnormal blood collection in the uterus is referred to as hematometra. Obstruction of the genitourinary outflow system caused by earlier surgeries or congenital defects is most frequently related to this rare disorder. The symptoms of hematometra include acute pelvic pain and a history of absent menarche. Here is a case of a 42-year-old female who presented with complaints of severe lower abdominal pain, and pain during urination that was accompanied by vulval itching in June 2021. She had undergone two Caesarean sections and a myomectomy in the past. She was given three monthly injections of gonadotropin-releasing hormone (GnRH) analogue after receiving USG-guided drainage because of a diagnosis of hematometra in January 2021. However, in June 2021, she experienced a recurrence of the same symptoms, necessitating a total abdominal hysterectomy and bilateral salpingo-oophorectomy, which completely resolved the patient's complaints. For a deeper understanding of this issue, further case reporting is necessary.

A study of pregnancy after endometrial ablation using linked population data

INTRODUCTION

Endometrial ablation encapsulates a range of procedures undertaken to destroy the endometrial lining of the uterus as a treatment for heavy menstrual bleeding in women who no longer wish to bear children. Pregnancy following ablation, while unlikely, can occur and may carry higher rates of complications. The aim of this study was to identify factors associated with post-endometrial ablation pregnancy and to describe pregnancy and birth outcomes for post-endometrial ablation pregnancies.

MATERIAL AND METHODS

This population-based data linkage study included all female residents of New South Wales, Australia, aged 15-50 years with a hospital admission between July 2001 to June 2014 who birthed between July 2001 and June 2015. Cox proportional hazard regression was used to estimate associations between women's characteristics and post-endometrial ablation pregnancy of at least 20 weeks' gestation. Descriptive statistics were used to characterize pregnancy and birth outcomes.

RESULTS

Of 18 559 women with an endometrial ablation, 575 (3.1%) had a post-ablation pregnancy of at least 20 weeks' gestation. Nulliparity (adjusted hazard ratio [aHR] 12.2, 95% confidence interval [CI] 9.1-16.2), older age (35-39 years: aHR 0.39, 95% CI 0.29-0.51; 40-44 years: aHR 0.06, 95% CI 0.04-0.11), marital status (single: aHR 0.67, 95% CI 0.55-0.83; widowed/divorced/separated: aHR 0.58, 95% CI 0.36-0.94) and a diagnosis of heavy menstrual bleeding (aHR 0.09, 95% CI 0.07-0.13) were associated with post-ablation pregnancy. There were high rates of cesarean delivery (43%), preterm birth (13%), twin or higher order pregnancies (9%) and stillbirth (13.3/1000 births) among these post-ablation pregnancies.

CONCLUSIONS

Nulliparity at the time of endometrial ablation is associated with increased risk of post-ablation pregnancy, highlighting the importance of careful discussion and consideration of treatment options for heavy menstrual bleeding.

More Than Just 2 Layers: A Comprehensive Multimodality Imaging Review of Endometrial Abnormalities

Endometrial abnormalities develop in female patients of all ages. Symptoms related to endometrial pathologies are among the most common causes of gynecologist office visits, with the radiologists playing an important role in endometrial evaluation. In some instances, the radiologist may be the first physician to note endometrial pathology. In this article, we will provide a comprehensive review of radiologic modalities utilized in the evaluation of the endometrium, as well as the imaging appearance of various endometrial disease processes.

Feasibility and safety assessment of magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU)-mediated mild hyperthermia in pelvic targets evaluated using an in vivo porcine model

Purpose: To evaluate the feasibility and assess safety parameters of magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU)-mediated hyperthermia (HT; heating to 40-45 °C) in various pelvic targets in a porcine model in vivo.Methods: Thirteen HT treatments were performed in six pigs with a commercial MRgHIFU system (Sonalleve V2, Profound Medical Inc., Mississauga, Canada) to muscle adjacent to the ventral/dorsal bladder wall and uterus to administer 42 °C (±1°) for 30 min (±5%) using an 18-mm target diameter and 100 W power. Feasibility was assessed using accuracy, uniformity, and MR-thermometry performance-based metrics. Safety parameters were assessed for tissues in the targets and beam-path by contrast-enhanced MRI, gross-pathology and histopathology.Results: Across all HT sessions, the mean difference between average temperature (Tavg) and the target temperature within the target region-of-interest (tROI, the cross-section of the heated volume at focal depth) was 0.51 ± 0.33 °C. Within the tROI, the temperature standard deviation averaged 1.55 ± 0.31 °C, the average 30-min Tavg variation was 0.80 ± 0.17 °C, and the maximum difference between Tavg and the 10th- or 90th-percentile temperature averaged 2.01 ± 0.44 °C. The average time to reach ≥41 °C and cool to ≤40 °C within the tROI at the beginning and end of treatment was 47.25 ± 27.47 s and 66.37 ± 62.68 s, respectively. Compared to unheated controls, no abnormally-perfused tissue or permanent damage was evident in the MR images, gross pathology or histological analysis.Conclusions: MRgHIFU-mediated HT is feasible and safety assessment is satisfactory for treating an array of clinically-mimicking pelvic geometries in a porcine model in vivo, implying the technique may have utility in treating pelvic targets in human patients.

Adenomyosis: A Sonographic Diagnosis

Adenomyosis is a common benign uterine condition and a frequent cause of pelvic pain in premenopausal women. Transvaginal US is now considered the primary imaging modality for the diagnosis of adenomyosis, and thus radiologists should be familiar with its sonographic appearance. US findings can be divided into three categories, which parallel the histology of adenomyosis: (a) ectopic endometrial glands and stroma, (b) muscular hyperplasia/hypertrophy, and (c) increased vascularity. Ectopic endometrial glands manifest as echogenic nodules and striations, radiating from the endometrium into the myometrium. When the glands contain fluid, myometrial cysts and fluid-filled striations may be visible at US. Muscular hyperplasia and hypertrophy cause focal or diffuse myometrial thickening and globular uterine enlargement, often with thin "venetian blind" shadows. The combination of these findings results in a heterogeneous myometrium, with blurring of the endometrial border. Adenomyosis increases uterine vascularity, depicted as a pattern of penetrating vessels at color Doppler US. Other US techniques that are helpful in the diagnosis of adenomyosis include obtaining cine clips and coronal reformatted images, both of which can survey the entire endometrial-myometrial border, and performing saline-infusion sonohysterography, during which ectopic glands frequently fill with either air or fluid. While most cases of adenomyosis develop spontaneously, there are specific inciting causes that include tamoxifen use, postendometrial ablation syndrome, and deep-infiltrating endometriosis. Mimics of adenomyosis include leiomyomas, uterine contractions, neoplasms, and vascular malformations. This article reviews the pathophysiology of adenomyosis and correlates it with the US findings, highlights specific causes of adenomyosis, and describes how to distinguish this common diagnosis from a variety of mimics. Online supplemental material is available for this article. ^©RSNA, 2018.

Endometrial ablation: normal appearance and complications

Global endometrial ablation is a commonly performed, minimally invasive technique aimed at improving/resolving abnormal uterine bleeding and menorrhagia in women. As non-resectoscopic techniques have come into existence, endometrial ablation performance continues to increase due to accessibility and decreased requirements for operating room time and advanced technical training. The increased utilization of this method translates into increased imaging of patients who have undergone the procedure. An understanding of the expected imaging appearances of endometrial ablation using different modalities is important for the abdominal radiologist. In addition, the frequent usage of the technique naturally comes with complications requiring appropriate imaging work-up. We review the expected appearance of the post-endometrial ablated uterus on multiple imaging modalities and demonstrate the more common and rare complications seen in the immediate post-procedural time period and remotely.

Histopathologic Features of Postablation Tubal Sterilization Syndrome

Postablation tubal sterilization syndrome (PATSS) is an uncommon complication of endometrial ablation in patients with antecedent tubal ligation characterized by cyclic pelvic pain. Recurrent tubal distention resulting from retrograde menstruation into occluded proximal fallopian tube segments by residual/regenerated cornual endometrial tissue is postulated to be the cause. Reports of PATSS have largely focused on the clinicoradiologic and operative findings. Detailed descriptions of the gross pathologic findings of PATSS are sparse and rarer still are examples in which the histologic manifestations are discussed. Three patients with a history of tubal ligation and subsequent endometrial ablation who underwent hysterectomy and bilateral salpingo-oophorectomy for pelvic pain were identified. A clinical suspicion of PATSS was conveyed to the pathologist at the time of initial pathologic examination in only 2 of the 3 cases. Pathologic findings in all 3 cases were similar and included hematosalpinx of the proximal fallopian tubes, intraluminal hemosiderotic material, mural hemosiderosis, and pseudoxanthomatous salpingitis featuring plical and mural lipofuscin-laden macrophages, along with inactive to attenuated endometrium with variable submucosal myometrial hyalinization/scarring compatible with postablative changes. The pathologic features, in conjunction with the appropriate clinicoradiologic findings, were interpreted as consistent with PATSS. PATSS complicates an estimated 5% to 10% of endometrial ablations, but is likely underreported due to a lack of awareness. Pathologists should consider PATSS in hysterectomy specimens that show postablative endometrial changes accompanied by hematosalpinx and pseudoxanthomatous salpingitis of the proximal segments of ligated fallopian tubes. To our knowledge, this is the first study to depict the histopathologic features of PATSS.

Through thick and thin: a pictorial review of the endometrium

The purpose of this pictorial review is to describe the normal appearance of the endometrium and to provide radiologists with an overview of endometrial pathology utilizing case examples. The normal appearance of the endometrium varies by age, menstrual phase, and hormonal status with differing degrees of acceptable endometrial thickness. Endometrial pathology most often manifests as either focal or diffuse endometrial thickening, and patients frequently present with abnormal vaginal bleeding. Endovaginal ultrasound (US) is the first-line modality for imaging the endometrium. This article will discuss the endometrial measurements used to direct management and workup of symptomatic patients and will discuss when additional imaging may be appropriate. Three-dimensional US is complementary to two-dimensional ultrasound and can be used as a problem-solving technique. Saline-infused sonohysterogram is a useful adjunct to delineate and detect focal intracavitary abnormalities, such as polyps and submucosal fibroids. Magnetic resonance imaging is the preferred imaging modality for staging endometrial cancer because it best depicts the depth of myometrial invasion and cervical stromal involvement. Unique imaging features and complications of endometrial ablation will be introduced. At the completion of this article, the reader will understand the spectrum of normal endometrial findings and will understand the workup of common endometrial pathology.