Abnormal Vaginal Bleeding

You are here:
< Back

Date of origin: 1996
Last review date: 2014

 

American College of Radiology

ACR Appropriateness Criteria®

 

Clinical Condition: Abnormal Vaginal Bleeding
Variant 1: Postmenopausal vaginal  bleeding.  First  study.  (Endometrial  sampling may  also  be
performed initially followed by imaging if results are inconclusive or symptoms persist
despite negative findings.)
Radiologic Procedure Rating Comments RRL*
3-D imaging may be a useful adjunct to
US pelvis transvaginal 9 2-D imaging to better characterize an O
intracavitary abnormality.
US pelvis transabdominal 8 O
3-D imaging may be a useful adjunct to
US saline infusion sonohysterography 6 standard 2-D imaging if intracavitary O
abnormality is suspected.
This procedure may be useful to better
US duplex Doppler pelvis 5 characterize a focal or diffuse endometrial O
abnormality.
CT pelvis with IV contrast 2 ☢☢☢
MRI pelvis without and with IV 2 O
contrast
CT pelvis without IV contrast 1 ☢☢☢
CT pelvis without and with IV 1 ☢☢☢☢
contrast
MRI pelvis without IV contrast 1 O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

 

Variant 2:                         Postmenopausal vaginal bleeding, endometrium ≤5 mm by transvaginal ultrasound. (Some centers may choose to use ≤4 mm rather than ≤5 mm. Please see narrative.) Follow-up study.

 

Radiologic Procedure Rating Comments RRL*
US pelvis transabdominal 4 O
Color-flow Doppler may be useful for
US duplex Doppler pelvis 4 interrogation of a heterogeneous O
endometrium in searching for a focal
versus diffuse abnormality.
US saline infusion sonohysterography 2 O
MRI pelvis without and with IV 2 O
contrast
CT pelvis with IV contrast 1 ☢☢☢
CT pelvis without IV contrast 1 ☢☢☢
CT pelvis without and with IV 1 ☢☢☢☢
contrast
MRI pelvis without IV contrast 1 O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

 

Clinical Condition:         Abnormal Vaginal Bleeding

 

Variant 3:                         Postmenopausal vaginal bleeding, endometrium >5 mm by transvaginal ultrasound. (Endometrial sampling would also be warranted in this clinical setting to evaluate for malignancy.) (Some centers may choose to use >4 mm. Please see narrative.) Follow-up study.

 

Radiologic Procedure Rating Comments RRL*
3-D imaging may be a useful adjunct to
US saline infusion sonohysterography 8 standard 2-D imaging if intracavitary O
abnormality is suspected.
This procedure may be useful to better
US duplex Doppler pelvis 6 characterize a focal or diffuse endometrial O
abnormality.
MRI pelvis without and with IV This procedure is appropriate when SIS is
5 not feasible or there is the need define O
contrast
extent of disease with endometrial cancer.
US pelvis transabdominal 4 O
MRI pelvis without IV contrast 2 O
CT pelvis with IV contrast 2 ☢☢☢
CT pelvis without IV contrast 1 ☢☢☢
CT pelvis without and with IV 1 ☢☢☢☢
contrast
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

 

Variant 4: Premenopausal vaginal bleeding. First study.
Radiologic Procedure Rating Comments RRL*
3-D imaging may be a useful adjunct to 2-
US pelvis transvaginal 9 D imaging to better characterize an O
intracavitary abnormality.
US pelvis transabdominal 8 O
This procedure may be useful to better
US duplex Doppler pelvis 5 characterize a focal or diffuse endometrial O
abnormality.
3-D imaging may be a useful adjunct to
US saline infusion sonohysterography 4 standard 2-D imaging if intracavitary O
abnormality is suspected.
CT pelvis with IV contrast 2 ☢☢☢
MRI pelvis without and with IV 2 O
contrast
CT pelvis without IV contrast 1 ☢☢☢
CT pelvis without and with IV 1 ☢☢☢☢
contrast
MRI pelvis without IV contrast 1 O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

 

 

Clinical Condition: Abnormal Vaginal Bleeding
Variant 5: Premenopausal vaginal bleeding, endometrium <16 mm by transvaginal ultrasound. Follow-
up study.
Radiologic Procedure Rating Comments RRL*
3-D imaging may be a useful adjunct to
US saline infusion sonohysterography 6 standard 2-D imaging if intracavitary O
abnormality is suspected.
US duplex Doppler pelvis 6 May be useful to better characterize a O
focal or diffuse endometrial abnormality.
US pelvis transabdominal 4 O
CT pelvis with IV contrast 2 ☢☢☢
MRI pelvis without and with IV 2 O
contrast
CT pelvis without IV contrast 1 ☢☢☢
CT pelvis without and with IV 1 ☢☢☢☢
contrast
MRI pelvis without IV contrast 1 O
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

 

Variant 6:                         Premenopausal vaginal bleeding, endometrium ≥16 mm by transvaginal ultrasound. Follow-up study. (Endometrial sampling may also be warranted in this clinical setting depending on patient risk factors for malignancy.)

 

Radiologic Procedure Rating Comments RRL*
Follow-up study performed in the early
US pelvis transvaginal 8 proliferative phase of the menstrual cycle O
or following administration of
progesterone.
3-D imaging may be a useful adjunct to
US saline infusion sonohysterography 7 standard 2-D imaging if intracavitary O
abnormality is suspected.
US duplex Doppler pelvis 5 May be useful to better characterize a O
focal or diffuse endometrial abnormality.
MRI pelvis without and with IV 5 O
contrast
This procedure may be helpful if the
US pelvis transabdominal 4 uterus is in a neutral position or if uterine O
penetration by TVUS is poor.
MRI pelvis without IV contrast 3 O
CT pelvis with IV contrast 2 ☢☢☢
CT pelvis without IV contrast 1 ☢☢☢
CT pelvis without and with IV 1 ☢☢☢☢
contrast
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

 

 

 

Clinical Condition: Abnormal Vaginal Bleeding
Variant 7: Heterogeneous endometrium or suspected focal abnormality at transvaginal ultrasound.
Follow-up study.
Radiologic Procedure Rating Comments RRL*
3-D imaging may be a useful adjunct to
US saline infusion sonohysterography 8 standard 2-D imaging if intracavitary O
abnormality is suspected.
This procedure may be useful to better
characterize a focal or diffuse endometrial
US duplex Doppler pelvis 7 abnormality and to evaluate for vascular O
pedicle flow or irregular vessels in
endometrial cavity.
MRI pelvis without and with IV 5 Consider this procedure if SIS is not O
contrast feasible.
MRI pelvis without IV contrast 4 O
This procedure may be helpful if the
US pelvis transabdominal 4 uterus is in a neutral position or if uterine O
penetration by TVUS is poor.
CT pelvis with IV contrast 2 ☢☢☢
CT pelvis without IV contrast 1 ☢☢☢
CT pelvis without and with IV 1 ☢☢☢☢
contrast
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level
Variant 8: Endometrium not adequately visualized at transvaginal ultrasound. Follow-up study.
Radiologic Procedure Rating Comments RRL*
US saline infusion sonohysterography 8 O
US pelvis transabdominal 6 O
Consider this procedure if SIS is not
MRI pelvis without and with IV 6 feasible. This procedure would be O
contrast preferred if underlying malignancy is
suspected.
MRI pelvis without IV contrast 4 O
US duplex Doppler pelvis 3 O
CT pelvis with IV contrast 2 ☢☢☢
CT pelvis without IV contrast 1 ☢☢☢
CT pelvis without and with IV 1 ☢☢☢☢
contrast
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative
Radiation Level

 

ABNORMAL VAGINAL BLEEDING

 

Expert Panel on Women’s Imaging: Nadia J. Khati, MD1; Phyllis Glanc, MD2; Priyadarshani R. Bhosale, MD3; Mukesh G. Harisinghani, MD4 ; Robert D. Harris, MD, MPH5; Young Bae Kim, MD6; Donald G. Mitchell, MD7; David A. Nyberg, MD8; Pari V. Pandharipande, MD, MPH9; Harpreet K. Pannu, MD10; Thomas D. Shipp, MD, RDMS11; Cary Lynn Siegel, MD12; Lynn Simpson, MD13; Darci J. Wall, MD14; Jade J. Wong-You-Cheong, MD15; Carolyn M. Zelop, MD16; Marcia C. Javitt, MD.17

 

Summary of Literature Review

 

Introduction/Background

 

Virtually every woman will, at some point in her lifetime, experience episodes of vaginal bleeding that will be perceived as abnormal. From menarche to menopause, the average menstrual cycle is 29 days long, with a range of 23–39 days [1]. Overall, the length of the menstrual cycle remains relatively constant throughout the reproductive years, but as a woman approaches menopause the cycle gradually shortens. Although blood loss is difficult to quantify, most loss occurs in the first few days of menses, and bleeding generally lasts from 2 to 7 days. The cycle length and the volume and duration of bleeding remain fairly constant for a woman throughout her reproductive years. After menopause, bleeding ceases completely. Abnormal vaginal bleeding may include noncyclic, excessive, or prolonged bleeding in the premenopausal patient or any vaginal bleeding in the postmenopausal patient. Differential considerations vary with patient age, hormonal status, and risk factors for endometrial carcinoma [2]. The perimenopausal patient with abnormal bleeding is a special clinical challenge since menstrual bleeding is less predictable in this age group. Vaginal bleeding may occasionally be misinterpreted as hematuria. The latter should be excluded by clinical history, catheterized urine specimen, and/or physical examination.

 

Endometrial carcinoma is the most common gynecologic cancer in the United States, with a mean age of 60 years at diagnosis [3]. Although 20% of cases are diagnosed in premenopausal women [2], most patients are postmenopausal. The most common presentation is abnormal vaginal bleeding, a finding that is seen in over 90% of postmenopausal women with endometrial carcinoma [4]. However, even in the postmenopausal patient, endometrial cancer accounts for only up to 10% of uterine bleeding, with endometrial atrophy being the most common etiology in 50% of the cases [5]. Only about 15% of cancers occur in women without bleeding [6,7]. The early diagnosis of endometrial carcinoma allows for the best opportunity for cure. Therefore, endometrial carcinoma should be rigorously sought and excluded in any postmenopausal or perimenopausal patient with abnormal bleeding, and in younger patients with significant risk factors, such as obesity and anovulation. Anovulatory bleeding is the most common etiology of abnormal bleeding in the premenopausal patient [8]. However, anatomic abnormalities such as endometrial and cervical polyps and submucosal fibroids may also be a cause and are found in up to 40% of premenopausal patients evaluated for this symptom [9]. Other abnormalities that may cause abnormal bleeding include endometrial hyperplasia, fibroids, adenomyosis, cervical and vaginal neoplasia, and other less common uterine tumors and coagulopathies (most commonly Von Willebrand disease). Pregnancy-related complications should always be excluded in any woman of reproductive age with abnormal bleeding.

 

In the nonpregnant premenopausal patient without risk factors for endometrial carcinoma, a trial of medical therapy may initially be undertaken if anovulatory cycles are suspected [2]. In the postmenopausal patient or for persistent bleeding despite medical therapy in the premenopausal patient, endometrial sampling or imaging is warranted. Although imaging procedures cannot replace definitive histologic diagnosis, they play an important role in screening, further characterizing anatomic abnormalities as focal or diffuse, and directing appropriate patient care, often preventing unnecessary diagnostic procedures. For further evaluation of the patient with inconclusive biopsy results or persistent bleeding despite negative biopsy findings, imaging can be essential.

 

In the setting of abnormal vaginal bleeding, office endometrial sampling now has largely replaced dilatation and curettage (D&C); however, issues of access to the endometrial cavity and sampling error limit the clinical value of a negative result. Furthermore, only about 60% of the endometrial cavity is curetted with D&C, and many focal lesions may be missed, making the detection of focal structural causes for bleeding a vital role of imaging in this clinical setting [10]. In their prospective study, Epstein et al [10] evaluated 105 postmenopausal women presenting with vaginal bleeding. Patients underwent D&C followed by hysteroscopic examination. Ninety eight percent of women were found to have a focal growth pattern at hysteroscopy and of those D&C failed to diagnose 58% of polyps, 50% of hyperplasia, 60% of atypical hyperplasia, and 11% of endometrial cancers. In a retrospective study evaluating 311 women with abnormal vaginal bleeding, D&C failed to detect intrauterine disorders in 52.7% of patients who were subsequently diagnosed at hysterectomy [11].

 

Transvaginal Ultrasound

 

Transvaginal ultrasound (TVUS) is generally the initial imaging procedure of choice for evaluating abnormal vaginal bleeding due to its high sensitivity for depiction of endometrial pathology, its widespread availability, and its excellent safety profile and cost-effectiveness [12 -16]. In the postmenopausal patient, endometrial thickness is a well-established predictor of endometrial disease, and TVUS is the mainstay in detecting and characterizing abnormal endometrial thickening with highly reproducible measurements [17-19]. Endometrial thickness refers to the double thickness measurement (sum of the thickness of the 2 endometrial layers excluding any intracavitary fluid). In order to obtain accurate endometrial measurements, it is crucial to perform the TVUS on days 4–10 of the menstrual cycle after the endometrium is sloughed in premenopausal women. For postmenopausal women on hormone replacement therapy (HRT), imaging is time-sensitive and will depend on the type of hormonal regimen (continuous combined vs cyclic hormones). If an abnormally thickened endometrium is identified, nonfocal endometrial biopsy is generally advocated as the next diagnostic step to exclude diffuse endometrial pathology, including carcinoma and hyperplasia [20,21]. Alternatively, saline infusion sonohysterography (SIS) may be obtained to differentiate between focal and diffuse abnormalities and to guide hysteroscopic biopsy.

 

In a meta-analysis of 35 studies including 5,892 postmenopausal women, using 5 mm as the upper threshold for normal endometrial thickness, the sensitivity of TVUS for detecting endometrial cancer was 96% [16]. An endometrial thickness ≤5 mm was associated with a less than 1% probability of endometrial cancer. Sensitivity for the detection of cancer did not differ for women taking HRT compared to those not taking HRT. Many additional studies have further demonstrated that with an endometrial thickness <5 mm, the risk of endometrial cancer is very low [19,22,23]. An expert panel for the evaluation of postmenopausal bleeding concluded that if US shows a normal -appearing endometrium with a double thickness measurement of ≤5 mm, the test can be considered negative for endometrial carcinoma [24]. A similar criterion can be used for women taking HRT, tamoxifen, or other selective estrogen receptor modulator therapy. Recent guidelines from the American College of Obstetrics and Gynecology advocate using 4 mm as the endometrial thickness cutoff that reasonably excludes endometrial carcinoma [25]. However, this threshold may be associated with lower specificity and more false-positive US examinations [16].

 

In the asymptomatic postmenopausal patient without bleeding, the use of TVUS for screening is controversial. There is lack of consensus regarding what endometrial thickness best separates those with from those without endometrial pathology, and further validation is necessary. Upper threshold values ranging from 4 mm to 11 mm have been suggested [7,26]. In addition to endometrial thickness, individual patient parameters such as age, hormonal therapy, and other risk factors for endometrial carcinoma must also be considered in patient management decisions.

 

The value of endometrial thickness as an indicator for endometrial pathology in the premenopausal patient is unreliable, as it may vary widely depending on the phase of the menstrual cycle. The optimum threshold level of endometrial thickness that should prompt further evaluation in this age group remains the subject of debate. The examination should ideally be performed during the early proliferative phase of the menstrual cycle when the endometrium is at its thinnest. A thickness >16 mm in a symptomatic premenopausal patient may be considered abnormal but with suboptimal sensitivity (67%) and specificity (75%) [14]. A recent study suggests that an endometrial thickness of 8 mm yields a higher sensitivity of 83.6% but with a lower specificity of 56.4% [27].

 

Focal heterogeneity or eccentric thickening of the endometrium detected at TVUS always should be further investigated regardless of endometrial thickness to exclude endometrial pathology [24]. TVUS can help to identify focal lesions within the endometrium such as polyps and submucosal fibroids, which may lead to sampling error and a negative biopsy result.

 

Abnormalities within the myometrium such as fibroids and adenomyosis also may be a cause of abnormal vaginal bleeding. Fibroids are readily demonstrated at sonography and can be characterized as submucosal, intramural, subserosal, or cervical in location [28]. In a meta-analysis of 14 studies including 1,898 women who had US for uterine pathology, the pooled sensitivity and specificity for TVUS for the diagnosis of adenomyosis were 82.5% and 84.6%, respectively [29]. However, detection of adenomyosis at TVUS may be limited if there is coexisting uterine pathology, such as fibroids. In one study, the sensitivity and specificity of TVUS for diagnosing adenomyosis in patients with and without fibroids were 33.3% and 78% and 97.8% and 97.1%, respectively [30].

 

Saline Infusion Sonohysterography

 

SIS (also referred to as sonohysterography or hysterosonography) consists of the instillation of sterile saline into the uterine cavity via a small catheter under TVUS guidance. This allows for better delineation of the endometrial lining when it is not clearly delineated on TVUS, which may occur in 5%–10% of patients [31]. This technique also allows for differentiation of focal lesions such as polyps from diffuse abnormalities such as endometrial hyperplasia. More recently, the use of gel instead of saline to fill the uterine cavity (gel-instillation sonography [GIS]) has shown some promising results, with sensitivity of 77.8% and 85% and specificity of 80.7% and 85% for SIS and GIS, respectively, for detecting intracavitary lesions [32]. Because of its higher viscosity, a smaller amount of gel is required to adequately distend the uterine cavity, resulting is less patient discomfort/pain and better technical results. As an advantage, this technique does not affect power Doppler signal in women with endometrial polyps, a phenomenon that had been reported previously when using saline [33].

 

Conventional 2-D SIS and hysteroscopy show similar performance characteristics, with sensitivity of 95%–96% and specificity of 88%–90% for detecting/characterizing focal endometrial abnormalities [34,35]. However, hysteroscopy allows for directed tissue sampling. SIS before hysteroscopy permits identification of a focal mass, prompting triage to a hysteroscopically directed biopsy procedure. SIS may also be used to further evaluate the endometrium in patients with negative TVUS and biopsy with persistent bleeding, allowing for detection of small intracavitary abnormalities, such as polyps or focal hyperplasia, not detectable by TVUS [9,36]. In a study by Erdem et al [37] the sensitivity and specificity of SIS were 97.7% and 82.4%, respectively, versus 83.0% and 70.6%, respectively, for TVUS for detection of endometrial abnormalities such as polyps, submucosal fibroids, and endometrial hyperplasia in patients with abnormal vaginal bleeding. Differentiation of endometrial from subendometrial abnormalities, particularly in patients treated with tamoxifen, is also an important role for this technique with significant implications for patient management [38,39]. Some investigators have compared the diagnostic accuracy of 3-D SIS and that of conventional SIS. Although the 2 methods may show comparable or slightly higher sensitivity and specificity in diagnosing intrauterine lesions, 3-D SIS correlates better with hysteroscopy findings in premenopausal and postmenopausal patients with abnormal vaginal bleeding [40,41].

 

Transabdominal Ultrasound

 

Transabdominal pelvic US is usually performed in conjunction with TVUS, and the 2 techniques are complementary. Transabdominal scanning offers a wider field of view, increased depth of penetration, and an ability to evaluate adjacent organs. A transabdominal approach is particularly helpful for evaluating a markedly enlarged fibroid uterus, especially if there is extension of subserosal or pedunculated fibroids out of the pelvis. However, optimum evaluation of the endometrium generally requires TVUS, which allows for higher-resolution imaging [18,42]. If the transvaginal probe cannot be tolerated, as is often the case in a prepubertal or virginal patient, transabdominal US using the urinary bladder as an acoustic window becomes essential.

 

Doppler Ultrasound

 

Color and duplex Doppler US allow for the assessment of uterine and endometrial vascularization and may be of added value in further characterizing an endometrial abnormality detected at TVUS. Demonstration of blood flow in an intracavitary lesion excludes the possibility of a retained blood clot. Endometrial polyps often demonstrate a feeding vessel, which can aid in detection at TVUS [43]. A recent study by Cil et al [44] compared the mapping characteristics of power Doppler for the diagnosis of endometrial polyps versus submucosal fibroids. They found that the single vessel pattern had a sensitivity and specificity of 81.2% and 88.2%, respectively, for the diagnosis of endometrial polyps, whereas the rim-like pattern had a sensitivity and specificity of 70.6% and 100%, respectively, for the diagnosis of submucosal fibroids. However, the clinical usefulness of using intratumoral resistive indices and Doppler velocimetry of the uterine arteries in distinguishing benign from malignant processes remains under investigation [45,46].

 

Three-Dimensional Sonography

 

3-D sonography can be a useful adjunct to TVUS and SIS in the characterization of abnormalities within the endometrial cavity, including localization of focal abnormalities prior to directed biopsy. It allows the ability to reconstruct any plane of section in orientations that cannot be obtained directly using standard 2-D sonography and SIS [47,48]. In a study by Benacerraf et al [49] 3-D coronal view of the uterus was of added value to the standard 2-D pelvic sonogram in 24% of all patients referred for gynecologic sonography and in up to 39% of patients with an endometrial thickness ≥5 mm. Recently, 3-D power Doppler angiography combined with 3-D TVUS has become a new diagnostic tool to evaluate vascular patterns in the abnormal endometrium and endometrial volume. Although some advocate its potential usefulness in allowing for differentiation between benign and malignant causes of a thickened endometrium [50,51], others do not find it superior to the diagnostic capabilities of 2-D US [52].

 

Magnetic Resonance Imaging

 

Magnetic resonance imaging (MRI) of the pelvis may be a useful problem-solving tool when US findings are not definitive. Uterine anatomy is well-delineated at MRI secondary to inherent soft-tissue contrast of uterine tissues. Although not a first-line test, MRI may be considered for evaluating the endometrium when TVUS is not possible or when the endometrium cannot be well visualized due to uterine orientation or coexisting abnormalities such as adenomyosis or leiomyomas. MRI may provide additional important information regarding fibroid number, size, and location prior to intervention such as embolization or myomectomy. MRI may also help to confirm the diagnosis of adenomyosis, which may be difficult at TVUS when there are coexisting fibroids. In a recent study evaluating the diagnostic performance of MRI in the detection for adenomyosis and fibroids, MRI had a positive predictive value of 92.3% and 95.7%, respectively [53].

 

In a woman with an enlarging or an abnormally enlarged uterus where underlying malignancy is a concern and US does not delineate the endometrium, MRI may assist in identification of a thickened endometrial lining or of morphological lesions such as fibroids or adenomyosis. Although MRI-detected features of benign endometrial polyps overlap with those of carcinoma, most polyps are benign. The prevalence of malignancy in endometrial polyps increases with patient age but is generally less than 3% in postmenopausal patients and less than 1% in women of childbearing age [54]. Histologic confirmation remains necessary when an endometrial mass is identified at MRI [55]. However, evidence of an endometrial lesion invading the myometrium is suggestive of malignancy. In a recent study assessing the diagnostic accuracy of MRI in local staging of endometrial carcinoma, contrast-enhanced MRI showed a 90% sensitivity and 80% specificity for evaluating deep myometrial invasion

 

  • Also, demonstration of enhancement of an intracavitary abnormality with gadolinium contrast agents confirms the presence of a mass and excludes the possibility of a retained blood clot or debris. Results of initial studies investigating the added value of diffusion-weighted imaging in differentiating benign from malignant endometrial lesions show promise, but further investigation is necessary before this technique can be applied to clinical practice [57,58]. A recent prospective study showed that apparent diffusion coefficient (ADC) values were significantly lower in endometrial cancers compared to those of normal endometrium and normal myometrium [59]. The investigators, however, concluded that there was no correlation between ADC values and depth of myometrial invasion, histologic tumor grading, and presence of metastatic lymphadenopathy.

 

Computed Tomography

 

Computed tomography (CT) is generally not warranted for evaluating vaginal bleeding since uterine anatomy is not well characterized due to limited soft-tissue contrast resolution. For detection of endometrial thickening using TVUS as the reference standard, the sensitivity, specificity, and positive and negative predictive values of multidetector CT were 53.1%, 93.5%, 66.7%, and 89.1%, respectively, in one recent study [60]. Multiplanar reformation may be a helpful addition to standard axial images when evaluating the endometrium at multidetector CT [61], with reconstructed images in the sagittal plane being particularly useful in determining the degree of myometrial invasion in patients with endometrial carcinoma. However, an abnormal endometrium incidentally detected at CT should be referred to TVUS for further evaluation.

 

Positron Emission Tomography/Computed Tomography

 

Positron emission tomography (PET) with CT (PET/CT) is not warranted for evaluating vaginal bleeding. In premenopausal patients, normal endometrial uptake of fluorine -18-2-fluoro-2deoxy-D -glucose (FDG) changes cyclically, increasing during the ovulatory and menstrual phases. This variation requires that the evaluation of the endometrium be correlated with the menstrual history. In postmenopausal women, increased tracer uptake is considered abnormal [62]. Neither use of contraceptives nor hormonal therapy is associated with a significant increase in endometrial tracer uptake. Abnormal endometrial tracer uptake incidentally detected on PET should be referred for TVUS evaluation.

 

Summary

 

Imaging can play an important role in screening, characterization of structural abnormalities, and directing appropriate patient care, often preventing inappropriate diagnostic procedures. However, imaging procedures cannot replace definitive histologic diagnosis.

 

TVUS is generally the initial imaging procedure of choice for evaluating abnormal vaginal bleeding, and endometrial thickness is a well-established predictor of endometrial disease in postmenopausal women. Endometrial thickness measurements ≤5 mm [16,22,24] and ≤4 mm [19,23,25] have been advocated as appropriate threshold values to reasonably exclude endometrial carcinoma in the postmenopausal age group [22-25]. However, the most appropriate value for upper limits normal for the asymptomatic postmenopausal patient without bleeding remains the subject of debate. An upper threshold value of 16 mm has been suggested for the premenopausal patient with abnormal bleeding, although it remains controversial as endometrial thickness varies greatly in this patient age group [14,27].

 

Transabdominal US is generally an adjunct to TVUS and is most helpful when TVUS cannot be performed or when there is poor visualization of the endometrium secondary to uterine position or poor penetration due to associated uterine pathology such as fibroids or adenomyosis.

 

Tissue sampling may be the most appropriate initial step in the evaluation of abnormal vaginal bleeding.

 

SIS after TVUS allows for identification of focal abnormalities within the endometrial cavity, which may then guide hysteroscopic biopsy or resection [34,35]. GIS may represent an adequate substitute to SIS in the future [32,33].

 

Color and duplex Doppler allow for assessment of uterine and endometrial vascularization and may be of added value in further characterizing an endometrial abnormality detected at TVUS. Endometrial polyps will often have a feeding vessel, which aids in their detection [43,44].

 

Pelvic MRI is an important problem-solving tool and adjunct to TVUS, particularly when SIS cannot be performed for technical reasons or to better define extent of disease if endometrial carcinoma is suspected. Adding diffusion-weighted sequences may improve preoperative assessment of patients with endometrial carcinoma.

 

CT is generally not warranted for evaluating a patient with abnormal vaginal bleeding. An abnormal endometrium incidentally detected at CT should be referred to TVUS for further evaluation.

 

Relative Radiation Level Information

 

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, both because of organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared to those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria® Radiation Dose Assessment Introduction document.

 

Relative Radiation Level Designations

 

Relative Radiation Level* Adult Effective Dose Estimate Pediatric Effective Dose Estimate
Range Range
O 0 mSv 0 mSv
<0.1 mSv <0.03 mSv
☢☢ 0.1-1 mSv 0.03-0.3 mSv
☢☢☢ 1-10 mSv 0.3-3 mSv
☢☢☢☢ 10-30 mSv 3-10 mSv
☢☢☢☢☢ 30-100 mSv 10-30 mSv

 

*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (eg, region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies”.

 

Supporting Documents

 

For additional information on the Appropriateness Criteria methodology and other supporting documents go to www.acr.org/ac.

 

References

  1. Bayer SR, DeCherney AH. Clinical manifestations and treatment of dysfunctional uterine bleeding. 1993;269(14):1823-1828.
  2. Sweet MG, Schmidt-Dalton TA, Weiss PM, Madsen KP. Evaluation and management of abnormal uterine bleeding in premenopausal women. Am Fam Physician. 2012;85(1):35-43.
  3. National Cancer Institute. Comprehensive Cancer Information. 2012; http://seer.cancer.gov/ statfacts/html/ovary.html. Accessed 27 November 2012.
  4. Dimitraki M, Tsikouras P, Bouchlariotou S, et al. Clinical evaluation of women with PMB. Is it always necessary an endometrial biopsy to be performed? A review of the literature. Arch Gynecol Obstet. 2011;283(2):261-266.
  5. Doubilet PM. Diagnosis of abnormal uterine bleeding with imaging. 2011;18(4):421-424.
  6. Hofmeister FJ. Endometrial biopsy: another look. Am J Obstet Gynecol. 1974;118(6):773-777.
  7. Smith-Bindman R, Weiss E, Feldstein V. How thick is too thick? When endometrial thickness should prompt biopsy in postmenopausal women without vaginal bleeding. Ultrasound Obstet Gynecol. 2004;24(5):558-565.
  8. ACOG practice bulletin: management of anovulatory bleeding. Int J Gynaecol Obstet. 2001;72(3):263-271.
  9. Farquhar C, Ekeroma A, Furness S, Arroll B. A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women. Acta Obstet Gynecol Scand. 2003;82(6):493-504.
  10. Epstein E, Ramirez A, Skoog L, Valentin L. Dilatation and curettage fails to detect most focal lesions in the uterine cavity in women with postmenopausal bleeding. Acta Obstet Gynecol Scand. 2001;80(12):1131-1136.
  11. Yarandi F, Izadi-Mood N, Eftekhar Z, Shojaei H, Sarmadi S. Diagnostic accuracy of dilatation and curettage for abnormal uterine bleeding. J Obstet Gynaecol Res. 2010;36(5):1049-1052.
  12. Dijkhuizen FP, Mol BW, Brolmann HA, Heintz AP. Cost-effectiveness of the use of transvaginal sonography in the evaluation of postmenopausal bleeding. 2003;45(4):275-282.
  13. Dubinsky TJ. Value of sonography in the diagnosis of abnormal vaginal bleeding. J Clin Ultrasound. 2004;32(7):348-353.
  14. Hulka CA, Hall DA, McCarthy K, Simeone JF. Endometrial polyps, hyperplasia, and carcinoma in postmenopausal women: differentiation with endovaginal sonography. 1994;191(3):755-758.
  15. Smith P, Bakos O, Heimer G, Ulmsten U. Transvaginal ultrasound for identifying endometrial abnormality. Acta Obstet Gynecol Scand. 1991;70(7-8):591-594.
  16. Smith-Bindman R, Kerlikowske K, Feldstein VA, et al. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. 1998;280(17):1510-1517.
  17. Delisle MF, Villeneuve M, Boulvain M. Measurement of endometrial thickness with transvaginal ultrasonography: is it reproducible? J Ultrasound Med. 1998;17(8):481-484; quiz 485-486.
  18. Dueholm M, Lundorf E, Olesen F. Imaging techniques for evaluation of the uterine cavity and endometrium in premenopausal patients before minimally invasive surgery. Obstet Gynecol Surv. 2002;57(6):388-403.
  19. Gull B, Karlsson B, Milsom I, Granberg S. Can ultrasound replace dilation and curettage? A longitudinal evaluation of postmenopausal bleeding and transvaginal sonographic measurement of the endometrium as predictors of endometrial cancer. Am J Obstet Gynecol. 2003;188(2):401-408.
  20. Moodley M, Roberts C. Clinical pathway for the evaluation of postmenopausal bleeding with an emphasis on endometrial cancer detection. J Obstet Gynaecol. 2004;24(7):736-741.
  21. Shi AA, Lee SI. Radiological reasoning: algorithmic workup of abnormal vaginal bleeding with endovaginal sonography and sonohysterography. AJR Am J Roentgenol. 2008;191(6 Suppl):S68-73.
  22. Gupta JK, Chien PF, Voit D, Clark TJ, Khan KS. Ultrasonographic endometrial thickness for diagnosing endometrial pathology in women with postmenopausal bleeding: a meta-analysis. Acta Obstet Gynecol Scand. 2002;81(9):799-816.
  23. Karlsson B, Granberg S, Wikland M, et al. Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding–a Nordic multicenter study. Am J Obstet Gynecol. 1995;172(5):1488-1494.
  24. Goldstein RB, Bree RL, Benson CB, et al. Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored Consensus Conference statement. J Ultrasound Med. 2001;20(10):1025-1036.
  25. ACOG Committee Opinion No. 426: The role of transvaginal ultrasonography in the evaluation of postmenopausal bleeding. Obstet Gynecol. 2009;113(2 Pt 1):462-464.
  26. Dreisler E, Sorensen SS, Ibsen PH, Lose G. Value of endometrial thickness measurement for diagnosing focal intrauterine pathology in women without abnormal uterine bleeding. Ultrasound Obstet Gynecol. 2009;33(3):344-348.
  27. Ozdemir S, Celik C, Gezginc K, Kiresi D, Esen H. Evaluation of endometrial thickness with transvaginal ultrasonography and histopathology in premenopausal women with abnormal vaginal bleeding. Arch Gynecol 2010;282(4):395-399.
  28. McLucas B. Diagnosis, imaging and anatomical classification of uterine fibroids. Best Pract Res Clin Obstet 2008;22(4):627-642.
  29. Meredith SM, Sanchez-Ramos L, Kaunitz AM. Diagnostic accuracy of transvaginal sonography for the diagnosis of adenomyosis: systematic review and metaanalysis. Am J Obstet Gynecol. 2009;201(1):107 e101-106.
  30. Bazot M, Cortez A, Darai E, et al. Ultrasonography compared with magnetic resonance imaging for the diagnosis of adenomyosis: correlation with histopathology. Hum Reprod. 2001;16(11):2427-2433.
  31. Goldstein SR. Use of ultrasonohysterography for triage of perimenopausal patients with unexplained uterine bleeding. Am J Obstet Gynecol. 1994;170(2):565-570.
  32. Werbrouck E, Veldman J, Luts J, et al. Detection of endometrial pathology using saline infusion sonography versus gel instillation sonography: a prospective cohort study. Fertil Steril. 2011;95(1):285-288.
  33. Van Den Bosch T, Van Schoubroeck D, Luts J, et al. Effect of gel-instillation sonography on Doppler ultrasound findings in endometrial polyps. Ultrasound Obstet Gynecol. 2011;38(3):355-359.
  34. de Kroon CD, de Bock GH, Dieben SW, Jansen FW. Saline contrast hysterosonography in abnormal uterine bleeding: a systematic review and meta-analysis. 2003;110(10):938-947.
  35. van Dongen H, de Kroon CD, Jacobi CE, Trimbos JB, Jansen FW. Diagnostic hysteroscopy in abnormal uterine bleeding: a systematic review and meta-analysis. 2007;114(6):664-675.
  36. Laifer-Narin S, Ragavendra N, Parmenter EK, Grant EG. False-normal appearance of the endometrium on conventional transvaginal sonography: comparison with saline hysterosonography. AJR Am J Roentgenol. 2002;178(1):129-133.
  37. Erdem M, Bilgin U, Bozkurt N, Erdem A. Comparison of transvaginal ultrasonography and saline infusion sonohysterography in evaluating the endometrial cavity in pre- and postmenopausal women with abnormal uterine bleeding. 2007;14(5):846-852.
  38. Hann LE, Gretz EM, Bach AM, Francis SM. Sonohysterography for evaluation of the endometrium in women treated with tamoxifen. AJR Am J Roentgenol. 2001;177(2):337-342.
  39. Markovitch O, Tepper R, Aviram R, Fishman A, Shapira J, Cohen I. The value of sonohysterography in the prediction of endometrial pathologies in asymptomatic postmenopausal breast cancer tamoxifen-treated patients. Gynecol Oncol. 2004;94(3):754-759.
  40. Abou-Salem N, Elmazny A, El-Sherbiny W. Value of 3-dimensional sonohysterography for detection of intrauterine lesions in women with abnormal uterine bleeding. J Minim Invasive Gynecol. 2010;17(2):200-204.
  41. Terry S, Banks E, Harris K, Duvivier R, Dar P. Comparison of 3-dimensional with 2-dimensional saline infusion sonohysterograms for the evaluation of intrauterine abnormalities. J Clin Ultrasound. 2009;37(5):258-262.
  42. Coleman BG, Arger PH, Grumbach K, et al. Transvaginal and transabdominal sonography: prospective comparison. 1988;168(3):639-643.
  43. Timmerman D, Verguts J, Konstantinovic ML, et al. The pedicle artery sign based on sonography with color Doppler imaging can replace second-stage tests in women with abnormal vaginal bleeding. Ultrasound Obstet 2003;22(2):166-171.
  44. Cil AP, Tulunay G, Kose MF, Haberal A. Power Doppler properties of endometrial polyps and submucosal fibroids: a preliminary observational study in women with known intracavitary lesions. Ultrasound Obstet 2010;35(2):233-237.
  45. Bezircioglu I, Baloglu A, Cetinkaya B, Yigit S, Oziz E. The diagnostic value of the Doppler ultrasonography in distinguishing the endometrial malignancies in women with postmenopausal bleeding. Arch Gynecol 2012;285(5):1369-1374.
  46. Merce LT, Alcazar JL, Lopez C, et al. Clinical usefulness of 3-dimensional sonography and power Doppler angiography for diagnosis of endometrial carcinoma. J Ultrasound Med. 2007;26(10):1279-1287.
  47. Andreotti RF, Fleischer AC, Mason LE, Jr. Three-dimensional sonography of the endometrium and adjacent myometrium: preliminary observations. J Ultrasound Med. 2006;25(10):1313-1319.
  48. Lev-Toaff AS, Pinheiro LW, Bega G, Kurtz AB, Goldberg BB. Three-dimensional multiplanar sonohysterography: comparison with conventional two-dimensional sonohysterography and X-ray hysterosalpingography. J Ultrasound Med. 2001;20(4):295-306.
  49. Benacerraf BR, Shipp TD, Bromley B. Which patients benefit from a 3D reconstructed coronal view of the uterus added to standard routine 2D pelvic sonography? AJR Am J Roentgenol. 2008;190(3):626-629.
  50. Alcazar JL, Galvan R. Three-dimensional power Doppler ultrasound scanning for the prediction of endometrial cancer in women with postmenopausal bleeding and thickened endometrium. Am J Obstet 2009;200(1):44 e41-46.
  51. Odeh M, Vainerovsky I, Grinin V, Kais M, Ophir E, Bornstein J. Three-dimensional endometrial volume and 3-dimensional power Doppler analysis in predicting endometrial carcinoma and hyperplasia. Gynecol Oncol. 2007;106(2):348-353.
  52. Rossi A, Forzano L, Romanello I, Fachechi G, Marchesoni D. Assessment of endometrial volume and vascularization using transvaginal 3D power Doppler angiography in women with postmenopausal bleeding. Int J Gynaecol Obstet. 2012;119(1):14-17.
  53. Stamatopoulos CP, Mikos T, Grimbizis GF, et al. Value of magnetic resonance imaging in diagnosis of adenomyosis and myomas of the uterus. J Minim Invasive Gynecol. 2012;19(5):620-626.
  54. Costa-Paiva L, Godoy CE, Jr., Antunes A, Jr., Caseiro JD, Arthuso M, Pinto-Neto AM. Risk of malignancy in endometrial polyps in premenopausal and postmenopausal women according to clinicopathologic characteristics. 2011;18(12):1278-1282.
  55. Grasel RP, Outwater EK, Siegelman ES, Capuzzi D, Parker L, Hussain SM. Endometrial polyps: MR imaging features and distinction from endometrial carcinoma. 2000;214(1):47-52.
  56. Beddy P, Moyle P, Kataoka M, et al. Evaluation of depth of myometrial invasion and overall staging in endometrial cancer: comparison of diffusion-weighted and dynamic contrast-enhanced MR imaging. 2012;262(2):530-537.
  57. Fujii S, Matsusue E, Kigawa J, et al. Diagnostic accuracy of the apparent diffusion coefficient in differentiating benign from malignant uterine endometrial cavity lesions: initial results. Eur Radiol. 2008;18(2):384-389.
  58. Takeuchi M, Matsuzaki K, Nishitani H. Diffusion-weighted magnetic resonance imaging of endometrial cancer: differentiation from benign endometrial lesions and preoperative assessment of myometrial invasion. Acta Radiol. 2009;50(8):947-953.
  59. Rechichi G, Galimberti S, Signorelli M, et al. Endometrial cancer: correlation of apparent diffusion coefficient with tumor grade, depth of myometrial invasion, and presence of lymph node metastases. AJR Am J Roentgenol. 2011;197(1):256-262.
  60. Grossman J, Ricci ZJ, Rozenblit A, Freeman K, Mazzariol F, Stein MW. Efficacy of contrast-enhanced CT in assessing the endometrium. AJR Am J Roentgenol. 2008;191(3):664-669.
  61. Yitta S, Hecht EM, Slywotzky CM, Bennett GL. Added value of multiplanar reformation in the multidetector CT evaluation of the female pelvis: a pictorial review. 2009;29(7):1987-2003.
  62. Lerman H, Metser U, Grisaru D, Fishman A, Lievshitz G, Even-Sapir E. Normal and abnormal 18F-FDG endometrial and ovarian uptake in pre- and postmenopausal patients: assessment by PET/CT. J Nucl Med. 2004;45(2):266-271.

 

1Principal Author, George Washington University Hospital, Washington, District of Columbia. 2Panel Vice-chair, Sunnybrook Health Sciences Centre, Bayview Campus, Toronto, Ontario, Canada. 3University of Texas MD Anderson Cancer Center, Houston, Texas. 4 Massachusetts General Hospital, Boston Massachusetts. 5Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire. 6Tufts Medical Center, Boston, Massachusetts, Society of Gynecologic Oncologists. 7Thomas Jefferson University Hospital, Philadelphia, Pennsylvania. 8The Old Vicarage. Worcester Park, United Kingdom. 9Massachusetts General Hospital, Boston Massachusetts. 10Memorial Sloan Kettering Cancer Center, New York, New York. 11Brigham & Women’s Hospital, Boston, Massachusetts, American College of Obstetrics and Gynecology. 12Mallinckrodt Institute of Radiology, St. Louis, Missouri. 13Columbia University, New York, New York, American College of Obstetrics and Gynecology. 14Mayo Clinic, Rochester, Minnesota. 15University of Maryland School of Medicine, Baltimore, Maryland. 16 Valley Hospital, Ridgewood, New Jersey, American College of Obstetrics and Gynecology. 17Panel Chair, Uniformed Services University of the Health Sciences, Bethesda, Maryland.

The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through society representation on expert panels. Participation by representatives from collaborating societies on the expert panel does not necessarily imply individual or society endorsement of the final document.

Reprint requests to: publications@acr.org

 

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.