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Correspondence
Endometrial Changes Assessed by
Transvaginal Sonography
The article “Transvaginal sonographic assessment of premalignant and malignant changes in
the endometrium in postmenopausal bleeding” by
Fistonic et al1 discusses a subject in which I have
long been interested. I would like to offer the following comments.
In patients whose diagnosis was atrophy, the
mean endometrial measurement was 6.2 mm,
with a minimum of 3 mm and a maximum of 14
mm. The authors did not give us any further
breakdown or scattergram. How do the authors
explain that what they are measuring, that on
sonography is up to 14 mm thick, is still supposedly associated with atrophic inactive endometrium, especially since such tissue would be merely
1 cell layer thick? Other studies utilizing saline
infusion sonohysterography have demonstrated
that focal lesions, such as polyps, will increase the
apparent endometrial thickness, which is probably better referred to as “central uterine echoes”
rather than “endometrium.”
I believe that the study by Fistonic et al does
support the fact that the main value of sonography in postmenopausal women with vaginal
bleeding is its very high negative predictive
value. It is interesting that only 16.5% of their
patients with postmenopausal bleeding had endometrial thickness measurements below 5 mm.
This is in contradistinction to Goldstein et al,2
who had a 37% incidence of such a finding, and
Granberg et al,3 who had a 70% incidence. However, like all the mentioned studies except that of
Varner et al,4 Fistonic et al also found that endometrial thickness below 5 mm was always associated with a lack of malignancy.
As a final note, it is important to remember
that the endometrium is a 3-dimensional structure and that a single long-axis measurement is
not necessarily indicative of the entire structure.
I would have liked to have seen the authors acknowledge this fact. Strict regard for the fact that
the endometrium is a 3-dimensional structure
will only serve to enhance the accuracy of the ultrasound technique.
Steven R. Goldstein, MD
New York University School of Medicine
New York, New York 10016
© 1998 John Wiley & Sons, Inc.
280
CCC 0091-2751/98/050280-02
REFERENCES
1. Fistonic I, Hodek B, Klaric P, et al: Transvaginal
sonographic assessment of premalignant and malignant changes in the endometrium in postmenopausal bleeding. J Clin Ultrasound 1997;25:431.
2. Goldstein SR, Nachtigall M, Snyder JR, et al: Endometrial assessment by vaginal ultrasonography before endometrial sampling in patients with postmenopausal bleeding. Am J Obstet Gynecol 1990;
163:119.
3. Granberg S, Wikland M, Karlson B, et al: Endometrial thickness as measured by endovaginal ultrasonography for identifying endometrial abnormality.
Am J Obstet Gynecol 1991;164:47.
4. Varner RE, Sparks JM, Cameron CD, et al: Transvaginal sonography of the endometrium in postmenopausal women. Obstet Gynecol 1991;78:195.
The authors reply:
Goldstein addresses the issue of atrophic endometrium that appears thickened on transvaginal sonography (TVS). Although we did not supply a
scattergram, the box-and-whiskers plots in Figure 4 of our article1 present the distributions of all
the endometrial thickness measurements. Only
one endometrium diagnosed as atrophic on a dilatation and curettage (D&C) specimen was 14
mm thick on TVS.
As the histologic appearance and thickness of
the endometrium depend on hormonal status, if
an irregular proliferation or a glandular cystic hyperplasia (simple hyperplasia) precedes the decrease in the level of estrogen, an entity called
“cystic atrophy” results.2 The appearance of an
atrophic endometrium is different in hysterectomy and biopsy specimens. In hysterectomy
specimens, under low magnification, the cystically dilated glands may be confused with simple
hyperplasia.3 This implies that a cystically atrophic endometrium can be as thick as a hyperplastic one. In specimens provided by aspiration or
D&C, atrophic endometrium appears typically
scant, consisting of a small amount of mucoid material with a few fragments and strips of glands.
Intact glands are not usually found, and stroma is
frequently absent.3,4 Our specimens were obtained by biopsy, so the pathologist could not differentiate between “endometrial atrophy” and
“cystic endometrial atrophy.”
We also want to address the issue of the atroJOURNAL OF CLINICAL ULTRASOUND
CORRESPONDENCE
phic endometrium being merely 1 cell layer thick.
Only the epithelial lining of the atrophic glands is
1 cell layer thick; it lacks mitotic activity, indicating that no proliferation takes place. The thickness of the endometrium, which can be readily
distinguished into the basal and functional layers
before menopause, declines after the physiologic
cessation of ovarian function. However, the endometrium itself is never 1 cell layer thick. That
would mean that no glandular lumens are seen
and that the stroma has disappeared completely.
It is true, though, that toward the end of reproductive life, the endometrium is no longer differentiated into functional and basal layers.5
In our cohort, only 16.5% of patients with postmenopausal bleeding had endometrial thickness
measurements below 5 mm. This percentage is
significantly less than the percentages reported
by others. As there are no data from “Eastern”
countries, we can compare our results only with
those reported in Central European and AngloSaxon papers. Maybe the answer is in the demographic and ethnic differences. Larger study
populations should provide more precise results.
VOL. 26, NO. 5, JUNE 1998
Ivan Fistonic, MD, MSc
Branko Hodek, MD, PhD
Petar Klaric, MD, PhD
University Hospital Sestre Milosrdnice
10000 Zagreb, Croatia
REFERENCES
1. Fistonic I, Hodek B, Klaric P, et al: Transvaginal
sonographic assessment of premalignant changes in
the endometrium in postmenopausal bleeding. J
Clin Ultrasound 1997;25:431.
2. Dallenbach Hellweg G, Poulsen H: Atlas of Endometrial Histopathology. Berlin, Springer Verlag, 1996,
p. 38.
3. Mazur MT, Kurman RJ: Diagnosis of Endometrial
Biopsies and Curettings: A Practical Approach. New
York, Springer Verlag, 1994.
4. Kurman RJ, Mazur MT: Benign diseases of the endometrium. In Kurman RJ, ed: Blaustein’s Pathology of the Female Genital Tract, 4th edn. New York,
Springer Verlag, 1994, p. 383.
5. More JAR: The normal human endometrium. In Fox
H, ed: Haines & Taylor Obstetrical and Gynaecological Pathology, vol. 1, 4th edn. New York, Churchill
Livingstone, 1995, p. 365.
281
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