What is your Diagnosis of this Female Patient with Polymenorrhea?

In this case we will discuss a 27 year old female patient with a history of polymenorrhea. She has been treated with medication.

History and Symptoms: This young woman came in for a routine ultrasound examination after 6 months of medication with an estrogen agonist after prolonged polymenorrhea. She had normal menstrual cycles before this episode and did not have any history of major illness. She had a history of lower segment caesarean section (LSCS) during the first pregnancy.

Family History: She has 1 healthy child, who was delivered at full term by LSCS. This mother (the patient) was one of 2 children.

Present History: The patient had prolonged and sometimes painful menses for which she underwent medical treatment. She had a history of occasional bleeding per vagina (P/V). The medication was stopped a few days before the ultrasound study.

Clinical Examination: Her blood pressure was normal (BP: 116/ 80 mm. of Hg); her other vital signs were also normal. On abdominal examination, she had no tenderness or palpable lesions in the pelvis.

Imaging Studies: This patient underwent routine transabdominal and transvaginal ultrasound imaging to study the pelvic organs.

Image 1: Sagittal section of uterus (transabdominal image)

Image 2: Transvaginal sonographic image of the left ovary

The transabdominal image of the uterus in sagittal section shows a remarkable finding, but let's look at the myometrium first. It shows normal echogenicity and echotexture. The cervix appears grossly normal.  The thickness of the endometrium measures 18 mm. Is this normal?

The transvaginal image of the left ovary shows a simple cyst of 3.6 cms. Is this related to the findings of the uterus?

Let's look at an additional image.

Image 3: Transvaginal sagittal section image of the uterus

Observe the central part of the uterus. Is this a mass inside the uterus?  The endometrial region definitely appears abnormal. In fact the actual thickness of the endometrium is 21 mm. Could that be due to a fibroid or mass in the endometrial cavity or is there something more to the central echoes? Do you notice anything in the echo texture of the “endometrium”?

Yes, there are minute cystic lesions filling the entire endometrial area. Is this a submucosal fibroid filling the endometrial cavity? Do you have a diagnosis now?

Let's look at the final images in this case.

Image 4: Color Doppler image of the uterus

Image 5: Spectral Doppler trace

There is significant vascularity within the central region of the endometrium with low resistance flow on Spectral Doppler trace.

The history of the patient is important. She stated that she underwent medical treatment for heavy menstrual bleeding for 6 months prior to the sonography. What type of drugs are used to control polymenorrhea in a woman?

Discussion and final diagnosis

Discussion: The drugs used to treat polymenorrhea are usually estrogen agonists or estrogen receptor modulators. The appearance of the endometrium seen in these images is akin to those seen after tamoxifen therapy for breast cancer in women. The similarity between the effects of tamoxifen and the estrogenic drugs are that both have profound estrogenic effects on the uterus and specifically on the endometrium. The cystic changes in the endometrium are the result of this long term exposure to the drug.

Final Diagnosis: Cystic Endometrial Hyperplasia

Endometrial hyperplasia is considered when the endometrial thickness exceeds 10 mm. in pre-menopausal women. This diagnosis can be reliably excluded when the endometrial thickness is less than 6 mm. There are 3 subtypes of hyperplasia of the endometrium: cystic, adenomatous and atypical.

Cystic hyperplasia is characterized by endometrial thickening with multiple minute cysts scattered throughout the hyperplastic endometrium. This type of cystic hyperplasia that is seen after exposure to estrogen agonists is usually reversible after ceasing the use of the drug. The other forms of hyperplasia of the endometrium are considered pre-cancerous and pathological correlation is mandatory in all such cases.

Differential Diagnosis

1) Cystic changes in endometrial polyp may also produce a strikingly similar appearance and here sonohysterography and hysteroscopy can prove to be diagnostic. Besides histopathological examination is also very helpful in distinguishing the two entities.

2) Submucous fibroid can also produce a mass effect inside the endometrial cavity. However, micro -cystic changes of the type seen in this case are not evident.

References:

References:

Images fromwww.ultrasound-images.com,Cystic hyperplasia of the endometrium
Callen, PW. Ultrasonography in Obstetrics and Gynecology
Rumack, C. Diagnostic Ultrasound
Nagamani, P., Levine, D.Sonographic evaluation of the endometrium in patients with a history or an appearance of polycystic ovarian syndrome", J Ultrasound Med.J Ultrasound Med 2007; 26:55–58