The role of US in postmenopausal bleeding

13th October 2024, NIA Diagnostic Imaging

transvaginal US

Menopause is characterised by complete absence of menstrual cycle due to no ovarian follicles left in reserve and it is clinically diagnosed when a woman has amenorrhea for at least 1 year (Sung, 2023).
Any post-menopausal women with vaginal bleeding should be appropriately managed through comprehensive clinical examinations and diagnostic studies; these include diagnostic imaging and, in some cases, endometrial biopsies (Sung, 2023).

Some common causes of post-menopausal bleeding include:
● Endometrial hyperplasia
● Uterine fibroids
● Endometrial polyps
● Urogenital infections e.g. vaginitis, cystitis, endometrial tuberculosis or cervicitis
● Genitourinary atrophy
● Vaginal or endometrial atrophy (Sung, 2023).

One of the most common causes of post-menopausal bleeding is atrophy of the vagina or endometrium due to decreased estrogen and it is the presenting symptom for nearly 90% of women with endometrial cancer therefore post-menopausal bleeding is a common indication for ultrasound evaluation. It is very important to quickly and accurately diagnose or rule out neoplasia in patients presenting with this issue (Buckley & Kondagari, 2023). Ultrasound images showing thin endometrial lining (less than or equal to 4mm) has a greater than 99% negative predictive value for endometrial cancer (ACOG, 2018).

Figure 1. 39-year-old premenopausal woman with normal endometrium immediately following menses. Transvaginal sagittal ultrasound shows endometrium as a thin echogenic line that measures 3 mm (Sadro, 2016).

Endometrial hyperplasia covers pathological changes in the uterine glands and stroma. Hyperplasia can be simple or complex, with or without atypia. The presence of atypia is the most worrisome feature (Brand, 2007).
Appearance on ultrasound can include asymmetrical focal thickening with surface irregularity, heterogeneous, polypoid mass lesion, intrauterine fluid collection and myometrial invasion.

Figure 2. A 66-year-old woman with postmenopausal bleeding. Transvaginal sagittal ultrasound shows thickened heterogeneous endometrium measuring 6 mm (Sadro, 2016).
Endometrial polyps are estrogen sensitive and their incidence declines after menopause (Brand, 2007). They are associated with Tamoxifen use and appearance on ultrasound can include solitary homogenous and echogenic lesions, a stalk to the polyp with vascularity, bright edge sign and may be surrounded by endometrial fluid.

Figure 3. Transvaginal ultrasound with colour Doppler of the uterus demonstrates an endometrial mass with feeding vessels (arrowhead) consistent with an endometrial polyp (Hurtado & Mahesh,2017)

Ultrasound is the first imaging modality of choice for the female pelvis. It allows for real time, fast and portable imaging of the uterus, cervix, ovaries and adnexa without the use of ionising radiation (Buckley & Kondagari, 2023). At NIA Diagnostic Imaging, transabdominal and transvaginal ultrasound is used to measure and assess endometrial thickness and it is often recommended as a preliminary ‘non-invasive’ technique for assessing the endometrium in women with post-menopausal bleeding.

References
Buckley, E., & Kondagari, L. (2023, January 16). Sonography postmenopausal assessment, protocols, and interpretation. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK570641/#:~:text=Postmenopausal%20bleeding%20is%20a%20common,of%20women%20with%20endometrial%20cancer
Brand, A. (2007, March). The woman with postmenopausal bleeding. https://www.racgp.org.au/getattachment/f759bd34-1266-4d94-bf7c-4e80ce0c788f/attachment.aspx
Hurtado, S., & Mahesh, S. (2017). Endometrial polyp. Endometrial Polyp – an overview | ScienceDirect Topics. https://www.sciencedirect.com/topics/medicine-and-dentistry/endometrial-polyp
Sung, S. (2023, December 20). Postmenopausal bleeding. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK562188/
Sadro, C. (2016, April 15). Imaging the endometrium: A pictorial essay. Canadian Association of Radiologists Journal. https://www.sciencedirect.com/science/article/pii/S0846537115001345
The role of transvaginal ultrasonography in evaluating the endometrium of women with postmenopausal bleeding. ACOG. (2018, May). https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/the-role-of-transvaginal-ultrasonography-in-evaluating-the-endometrium-of-women-with-postmenopausal-bleeding

PFO Closure

Furlan AJ, Reisman M, Massaro J, et al. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012; 366: 991–

A multicenter, randomized, open-label trial of closure with a percutaneous device, as compared with medical therapy alone, in patients between 18 and 60 years of age who presented with a cryptogenic stroke or transient ischemic attack (TIA) and had a patent foramen ovale. The primary end point was a composite of stroke or transient ischemic attack during 2 years of follow-up, death from any cause during the first 30 days, or death from neurologic causes between 31 days and 2 years.

Results:

Primary end point was 5.5% in the closure group as compared with 6.8% in the medical-therapy group (adjusted hazard ratio, 0.78; 95% confidence interval, 0.45 to 1.35; P = 0.37)

Conclusion:

“In patients with cryptogenic stroke or TIA who had a patent foramen ovale, closure

with a device did not offer a greater benefit than medical therapy alone for the

prevention of recurrent stroke or TIA”

2 Saver JL, Carroll JD, Thaler DE, et al. Long-term outcomes of patent foramen ovale closure or medical therapy after stroke. N Engl J Med 2017; 377: 1022–

A multicenter, randomised, open-label trial ,randomly assigned patients 18 to 60 years of age who had a patent foramen ovale (PFO) and had had a cryptogenic ischemic stroke to undergo closure of the PFO (PFO closure group) or to receive medical therapy alone (aspirin, warfarin, clopidogrel, or aspirin combined with extended-release dipyridamole; medical-therapy group). The primary efficacy end point was a composite of recurrent nonfatal ischemic stroke, fatal ischemic stroke, or early death after randomisation.

Results:

Recurrent ischemic stroke occurred in 18 patients in the PFO closure group and in 28 patients in the medical-therapy group, resulting in rates of 0.58 events per 100 patient-years and 1.07 events per 100 patient years, respectively (hazard ratio 0.55; 0.31 – 0.999; P = 0.046)

Conclusion:

“Among adults who had had a cryptogenic ischemic stroke, closure of a PFO was associated with a lower rate of recurrent ischemic strokes than medical therapy alone during extended follow-up.”

Meier B, Kalesan B, Mattle HP, et al. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013; 368: 1083–

A prospective, multicenter, randomised, event-driven trial, randomly assigned patients to medical therapy alone (anti-platelet or warfarin therapy) or closure of the patent foramen ovale.

Results:

9 patients in the closure group and 16 in the medical-therapy group had a recurrence of stroke (hazard ratio with closure, 0.49; 0.22 – 1.11; P = 0.08). The primary analysis of the intentionto- treat cohort showed a nominal 51% hazard rate reduction with closure, but the reduction did not reach significance.

Conclusions:

” …there was no significant benefit associated with closure of a patent foramen ovale in adults who had had a cryptogenic ischaemic stroke.”

Sondergaard L, Kasner SE, Rhodes JF, et al. Patent foramen ovale closure or antiplatelet therapy for cryptogenic stroke. N Engl J Med 2017; 377: 1033–

Multinational trial involving patients with a PFO who had had a cryptogenic stroke, randomly assigned patients to undergo PFO closure plus antiplatelet therapy or to receive antiplatelet therapy alone.

Results:

During a median follow-up of 3.2 years, clinical ischemic stroke occurred in 6 of 441 patients (1.4%) in the PFO closure group and in 12 of 223 patients (5.4%) in the antiplatelet-only group (hazard ratio, 0.23; 0.09 to 0.62; P=0.002).

Conclusions:

“Among patients with a PFO who had had a cryptogenic stroke, the risk of subsequent ischemic stroke was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone; however, PFO closure was associated with higher rates of device complications and atrial fibrillation.”

Mas JL, Derumeaux G, Guillon B, et al. Patent foramen ovale closure or anticoagulation vs. antiplatelets after stroke. N Engl J Med 2017; 377: 1011–

In a multicenter, randomised, open-label trial patients 16-60 years of age who had had a recent stroke attributed to PFO, to transcatheter PFO closure plus long-term antiplatelet therapy, antiplatelet therapy alone or oral anticoagulation.

Results:

No stroke occurred among patients in the PFO closure group, whereas stroke occurred in 14 of the 235 patients in the antiplatelet- only group (hazard ratio, 0.03; 0 to 0.26; P<0.001). Large number of patients discontinued anti-coagulation in the anti-coagulant group and statistical significance was not analysed because the study was not adequately powered to compare outcomes.

Conclusion:

“Among patients who had had a recent cryptogenic stroke attributed to PFO with an associated atrial septal aneurysm or large interatrial shunt, the rate of stroke recurrence was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone. PFO closure was associated with an increased risk of atrial fibrillation.”

Lee PH, Song J-K, Kim JS, et al. Cryptogenic stroke and high-risk patent foramen ovale: the DEFENSE-PFO Trial. J Am Coll Cardiol 2018; 71: 2335–

Patients with cryptogenic stroke and high-risk PFO were divided between a transcatheter PFO closure and a medication-only group.

Results:

No events occurred in the PFO closure group. 12.9% of patients in the medication group had an event (p= 0.023).

Conclusion:

“PFO closure in patients with high-risk PFO characteristics resulted in a lower rate of the primary endpoint as well as stroke recurrence”