Usefulness of endovaginal ultrasound in the diagnosis of a premenopausal women with abnormal vaginal bleeding

Clinical History

A 38 year-old female consulting for abnormal vaginal bleeding.

Imaging Findings

A 38 year old woman (gravid 2, para 2) with previous regular menstrual cycles, consulted for a 4 months history of increased blood loss during menstruation and blood spotting between menstrual periods. General and genital examinations were normal. Pregnancy test was negative. Laboratory tests did not revealed significant anaemia or coagulation disorders. Transvaginal US showed the presence of a small ovoid mass of increased echogenicity when contrasted to the surrounding endometrium (Fig 1). Colour Doppler identified a vascular pedicle penetrating the endometrium from the myometrium to the polyp (Fig 2). Hysteroscopic polipectomy was carried out with subsequently cessation of abnormal vaginal bleeding. Hystological examination confirmed the diagnosis of a benign endometrial polyp.

Discussion

Endometrial polyps generally occur with abnormal vaginal bleeding, most commonly menometrorrhagia, from age 30-60, with the majority occurring in postmenopausal women. When abnormal vaginal bleeding occurs in a premenopausal women, differential diagnosis includes threatened abortion, retained products of conception, dysfunctional metrorrhagia, submucous fibroids, endometrial hyperplasia and malignancies as endometrial carcinoma and uterine sarcomas [1].
Endovaginal sonography plays a central role in the algorithm for differential diagnosis of endometrial disorders in women with abnormal vaginal bleeding. Endometrial polyps often demonstrate increased echogenicity compared with the endometrium and may contain punctuate cystic areas representing distended glands. Diagnosis of endometrial polyps by transvaginal ultrasound may be difficult in the second half of the cycle or when there is a coexisting endometrial hyperplasia due to increased thickening and more echogenic appearance of the endometrium. The identification of a vascular pedicle by means of Colour Doppler helps to corroborate the suspicion. Nevertheless, endovaginal sonography may yield highly false positive results of 20%, or more when used by inexperienced staff. In doubtful cases, sonohysterography serves as a useful tool to exclude focal abnormalities of the endometrial cavity, such as endometrial polyps or submucous fibroids [2].
Although endometrial polyps are usually benign, premenopausal women may beneficiate of an accurate diagnosis and adequate treatment because firstly, about 0.5% may progress to adenocarcinoma and secondly, they may lead to infertility. Hence, after suspicion of an endometrial polyp, a hysteroscopic procedure is required for confirmation and polipectomy. If not available, curettage is the traditional treatment option for the excision of the polyps. Patients should be advised that endometrial polyps tend to recur [3].

Differential Diagnosis List

Final Diagnosis

Benign endometrial polyp

URL:	https://eurorad.org/case/7602
DOI:	10.1594/EURORAD/CASE.7602
ISSN:	1563-4086