Imaging of the Endometrium:

Physiologic Changes and

Diseases

Akshya Gupta, MD, Amit Desai, MD, Shweta Bhatt, MD

Department of Imaging Sciences, University of Rochester, 601
Elmwood Ave, PO Box 648, Rochester NY 14642. Address
correspondence to A.G. (e-mail: agupta@uwhealth.org).

Presented as an education exhibit at the 2016 RSNA Annual Meeting

All authors have disclosed no relevant relationships.

Acknowledgment.—The authors thank Nadezhda D. Kiriyak, BFA, for the

medical illustrations in the online presentation.
 Introduction
 Transvaginal ultrasonography (US) is the initial imaging modality of choice in
evaluating the endometrium.

 Radiologists must have an understanding of the wide spectrum of normal and

abnormal appearances of the endometrium, which can vary on the basis of the
patient’s age and clinical presentation.

 Initial transvaginal US also helps guide further imaging and clinical management.
The necessity for saline sonohysterography, computed tomography, or magnetic
resonance (MR) imaging is often determined by the results of the initial US.

 Topics reviewed include

Normal prepubertal and pubertal appearance of the endometrium at
transvaginal US

Normal appearance of the endometrium in both pre- and postmenopausal

patients

Pathologic conditions involving the endometrium in both pre- and

postmenopausal patients
 Learning Objectives

 Recognize the various physiologic changes of the endometrium.

 Identify the normal imaging appearance of the endometrium in premenopausal

and postmenopausal patients.

 Describe the various benign and neoplastic diseases affecting the endometrium,
with an emphasis on their US appearance.

 Review the Society of Radiologists in Ultrasound (SRU) guidelines for patients with
postmenopausal bleeding.
 Normal Appearance—Childhood

Neonatal Prepubertal

Sagittal transabdominal gray-scale US image

As the influence of maternal stimulation
demonstrates the more prominent neonatal
decreases, the endometrium appears as a
endometrium (arrow) due to maternal
thin echogenic line (arrow) as depicted in
hormonal stimulation. Fluid within the
this sagittal gray-scale US image.
endometrial and cervical canal is common.
 Normal Appearance—Menstrual Cycle

C
D

A B

A: Endometrium
B: Myometrium
C: Ovary
D: Fallopian tube
The endometrium consists of two distinct layers

Basal (stratum basale) (arrow): This is the supporting layer that adheres to the myometrium and comprises the
lower one-third of the endometrial lining. After losing the outer two-thirds of the endometrium (functional layer)
during menstruation, the basal layer remains and starts regenerating the endometrium for the next cycle.

Functional (stratum functionale) (arrow): This overlies the basal layer and responds to hormonal stimulation during
the menstrual cycle to prepare for implantation. This is the site of proliferation, secretion, and ultimately sloughing
of the endometrial lining during menses in the absence of pregnancy.
(Image courtesy of Nadezhda D. Kiriyak, BFA, University of Rochester, Rochester, NY.)
 Normal Appearance—Menstrual Cycle
Menstrual phase: The normal endometrium undergoes
tremendous change throughout the menstrual cycle in
response to hormonal stimulation.

 Initially appears as an echogenic line usually measuring

between 1 and 4 mm during days 1–4 of the cycle. The
endometrium is thinnest during this phase.

 This sagittal transvaginal US image demonstrates the

relatively thin endometrium (arrow), hyperechoic
compared with the adjacent myometrium.

Menstrual
phase

Early
Secretory
proliferative
phase
phase

Late
proliferative
phase
 Normal Appearance—Menstrual Cycle
Early proliferative phase: Increased estradiol secretion during
days 5–13 results in proliferation of the basal layer with
development of blood vessels and glandular tissue.

 This sagittal US image demonstrates the corresponding

thickened (arrow) and more echogenic appearance of the
endometrium, relative to the myometrium.
 Normal thickness is typically between 5 and 7 mm.

Late proliferative phase: This proliferation culminates in the

triple line or multilayered appearance on days 14–16.

 Hypoechoic functional and hyperechoic central and outer

basal layers (arrow), as demonstrated on this sagittal US
image of a retroverted uterus. Note the thin central echogenic
line that represents the two coapted endometrial layers.
 This periovulatory appearance has a normal endometrial
thickness typically less than 11 mm.

Secretory phase: The final portion of the cycle involves increased

stromal edema, as well as glandular distention with mucus and
glycogen.

 This occurs approximately in days 16–28, where sagittal US

images will demonstrate a thickened, echogenic
endometrium (arrow) that typically measures up to 16 mm.
 Normal Appearance—After Menopause

The endometrium is uniformly thin, measuring

up to 5 mm. The hypoestrogenic state causes
atrophy of the functional layer, leaving only the
thin basal layer, which is visualized as a smooth
thin echogenic stripe (arrow), as seen on this
sagittal gray-scale US image.
 Measuring the Endometrial Lining
Endometrial measurements should be obtained
in the midsagittal plane. The entirety of the
endometrial lining (double-headed arrow),
extending to the endocervical canal, should be in
profile.

Measuring in an oblique plane leads to

inaccurate values for endometrial thickness.
Here, there are limited views of the
endometrium at the lower uterine segment
because of the obliquity.

Endometrial fluid should not be included in the

measurement. If the patient has fluid in the
uterine cavity, two separate measurements
(double-headed arrows) for each endometrial
layer should be added to determine the
endometrial thickness.
 Endometrial Polyp

• Hyperplastic growth of endometrial glands

and stroma Pedunculated polyp
• Can be pedunculated or sessile
• Most are asymptomatic but are a common
source of bleeding in both pre- and
postmenopausal women.
• More common in patients taking tamoxifen

Myometrium
Sessile polyp

Differential Diagnosis
Endometrium

• Submucosal fibroid—Typically larger with

broad attachment. Continuous with
myometrium.
• Endometrial carcinoma—Early stage can be
difficult to differentiate. Later stages may
have myometrial invasion or necrosis.

(Image courtesy of Nadezhda D. Kiriyak, BFA, University of

Rochester, Rochester, NY.)
 Endometrial Polyp
• Transverse gray-scale US images demonstrate
endometrial thickening secondary to a polyp. Focal cystic
changes (arrows) occur secondary to dilated glands.
Sonohysterography can help differentiate a polyp with
cystic changes from endometrial hyperplasia with cystic
changes (mimic).
• Polyps can range in size from small focal masses to diffuse
endometrial thickening that encompasses the entire
uterine cavity, such as the examples shown above.
• Transverse color Doppler US images demonstrate the vascular
pedicle sign (arrow on top image). Identifying the vascular
pedicle has 95% specificity and 76% sensitivity for
endometrial polyps.
• Saline sonohysterography helps differentiate focal
endometrial lesions (arrow on bottom image) involving less
than 25% of the endometrial surface from diffuse processes.
This determines whether a blind biopsy or hysteroscopically
guided biopsy is necessary.
 Endometrial Polyp
Gray-scale US image demonstrates a
sessile polyp (arrow), well visualized
in the proliferative phase. Color
Doppler US image demonstrates a
pedunculated polyp (arrow).

Intracavitary saline may be necessary

to visualize the stalk
(sonohysterogram).

Polyps can be missed in the

secretory phase because of the Sessile Pedunculated
background thickened echogenic
endometrium.

Note the oval shape. Submucosal

fibroids are more likely to be round
and broad based.

Sagittal T2-weighted MR image in

another patient demonstrates a focal
hypointense endometrial lesion
(arrow). There is corresponding
homogeneous enhancement (arrow)
on the sagittal postcontrast T1-
weighted MR image. Note that MR
imaging is a complementary but less
definitive modality compared with
US.
 Submucosal Fibroid

• Benign soft-tissue tumors are composed of smooth muscle Covering endometrial layer
and found in all age groups.
• Degeneration and calcification can cause variable
appearance.
• Distort the uterine cavity
• Fibroids that are greater than 50% within the endometrial
cavity can be hysteroscopically resected. Predominantly
intramural fibroids are usually approached
transabdominally.
Submucosal
fibroid
Differential Diagnosis
• Endometrial polyp—Typically has single feeding
vessel, compared with multiple vessels in a
submucosal fibroid.
• Adenomyoma—Borders are typically less well
defined.
• Leiomyosarcoma—Rare, rapidly growing. May
demonstrate signs of tumor spread.

(Image courtesy of Nadezhda D. Kiriyak, BFA, University

of Rochester, Rochester, NY.)
 Submucosal Fibroid
• More common in premenopausal
women and can continue to grow
until menopause. At this point can
degenerate and involute.

• Typically hypoechoic and well

circumscribed
• Can grow rapidly in pregnancy
• Posterior acoustic shadowing from
calcification and fibrous tissue
• Sonohysterogram will
demonstrate a broad-based
submucosal mass that distorts the
overlying echogenic endometrial
layer and allows determination of
intracavitary extension.
• Higher T2 signal on MR image if
there is cystic degeneration.
Higher T1 signal on MR image if
there is hemorrhage.
Sagittal color Doppler US image
shows irregular color flow with
Sagittal gray-scale US image multiple feeding vessels (arrows).
demonstrates a fibroid splaying
the endometrium (orange
arrow) with streaky acoustic
shadowing (yellow arrow).
Axial T2-weighted MR image
demonstrates a circumscribed
Sonohysterogram submucosal fibroid with
demonstrates a submucosal homogeneous low signal intensity
fibroid that distorts the uterine (arrow) at the fundus.
cavity and has a covering
endometrial layer (arrow).
 Adenomyosis
• Heterotopic endometrial glands within the
myometrium

• Majority of cases are in multiparous women.

• Can be diffuse, focal, superficial, or deep. Incites

muscular hypertrophy in the uterus.

• Common symptoms include abnormal uterine

bleeding, dysmenorrhea, and pelvic pain.

Differential Diagnosis Subendometrial

cysts
• Fibroid—Usually more well defined.

• Endometrial polyp—Look for single feeding vessel.

• Cystic glandular hypertrophy—Cystic changes are

in the endometrium as opposed to the
subendometrium.

(Image courtesy of Nadezhda D. Kiriyak, BFA, University of

Rochester, Rochester, NY.)
 Adenomyosis

Sagittal gray-scale US image demonstrates linear echogenic

Sagittal gray-scale US image demonstrates small
striations originating from the endometrium (arrow) and
subendometrial cysts (arrows). These are best visualized in
extending into the junctional zone, without focal mass
the end-secretory phase and are the most specific US sign for
(venetian blind appearance). Poorly defined endomyometrial
adenomyosis.
junction, limits exact measurement of the endometrium.

Sagittal gray-scale US image demonstrates the characteristic Color Doppler US image demonstrates increased vascularity
globular fundus (arrow). (arrow) relative to fibroids.
 Adenomyosis
A B

MR imaging is more sensitive and specific than US for diagnosis.

A: Sagittal T2-weighted MR image demonstrates a uniformly thickened junctional zone

(double-headed arrow). A junctional zone greater than 12 mm is abnormal and suggests
adenomyosis.

B: Axial T2-weighted MR image shows high T2 signal intensity foci within a thickened
junctional zone, correlating to heterotopic endometrial glands (arrow).
 Endometrial Hyperplasia

• Abnormal proliferation of stroma and glands,

which can be benign or neoplastic
• Defined as diffuse smooth hyperechoic thickening
of the endometrium greater than 10 mm

Differential Diagnosis
• Endometrial polyp—Can coexist. Look for Thick endometrium
vascular stalk and single feeding vessel. with underlying
• Secretory phase endometrium—Will glandular
proliferation
resolve at follow-up depending on phase of
menstrual cycle.
• Endometrial carcinoma—Can coexist. Look
for poorly defined margins or myometrial
invasion.

(Image courtesy of Nadezhda D. Kiriyak, BFA, University of

Rochester, Rochester, NY.)
 Endometrial Hyperplasia
A B

• Form or diffuse smooth endometrial thickening from

unopposed estrogen stimulation. Causes include
C
tamoxifen use, estrogen-secreting tumors, exogenous
estrogen use, and obesity.

• A: US image shows a well-defined myometrial interface

(arrows).

• B: US image shows cystic changes (arrow). Note this cystic

focus could also be secondary to an endometrial polyp.

• C: Sonohysterogram will demonstrate smooth

endometrial thickening (arrow) without a polypoid lesion.
 Endometrial Carcinoma

• Proliferation of abnormal irregular endometrial glands.

Majority of cases are adenocarcinoma.

• Abnormal postmenopausal bleeding is a presenting

symptom in 90% of patients.

• Most common gynecologic malignancy

Differential Diagnosis
• Endometrial hyperplasia—Imaging alone cannot
differentiate from early stage carcinoma. Irregular thick
endometrium
with myometrial
• Endometrial polyp—More likely focal. Cystic invasion
components are more commonly benign.

• Submucosal fibroid—Will distort but typically not

expand the endometrial cavity.

• Metastatic disease and lymphoma—Less common

but can also manifest as endometrial mass.
(Image courtesy of Nadezhda D. Kiriyak, BFA,
University of Rochester, Rochester, NY.)
 Endometrial Carcinoma

Sagittal gray-scale US image demonstrates Transverse gray-scale US image demonstrates a

heterogeneous irregular endometrial polypoid mass within the endometrial cavity
thickening (arrow). (arrow).

Sagittal (left) and transverse (right) US images demonstrate intrauterine fluid collections (arrows) in two
patients. The homogeneous internal echoes denote hemorrhage secondary to obstruction from an underlying
endometrial malignancy.
 Endometrial Carcinoma

Sagittal gray-scale US image demonstrates an

Sagittal color Doppler US image demonstrates
irregular interface of the endometrium with
a relative increase in vascularity (arrow). This
the myometrium (arrow). This is concerning
is a nonspecific finding.
for frank invasion into the myometrium.
 Endometrial Carcinoma

A B C

A: Sagittal T2-weighted MR image B: Sagittal T2-weighted MR image C: Sagittal T2-weighted MR

demonstrates a hypointense
mass of the uterine fundus. While
there is frank myometrial
extension, the areas where the
junctional zone becomes
indistinct (arrow) also suggest
myometrial invasion.
demonstrates an intermediate to
slightly hyperintense mass with
ill-defined lobulated borders
(arrows). Note the clear
myometrial invasion.
image again demonstrates an
endometrial mass with
intermediate to slightly high signal
intensity, with ill-defined borders
and myometrial invasion. Note the
extension into the lower uterine
segment and cervix (arrow).
 Tamoxifen-induced Changes

Sagittal gray-scale US image demonstrates a

Transverse color Doppler US image demonstrates
hyperechoic thickened endometrium
irregular cystic spaces (arrows).
(>8 mm) (double-headed arrow).

Sagittal T2-weighted MR image

• Proestrogenic effects causing proliferative response in the demonstrates endometrial thickening and
subendometrial cysts (arrow).
endometrium

• Results in endometrial thickening, cystic change,

endometrial polyps (most common), endometrial
hyperplasia, carcinoma, and cystic atrophy

• Clinical history of tamoxifen use in a patient with breast

cancer is paramount.
 Endometritis
• Polymicrobial ascending infection from the
cervix to uterus
• Most common cause of fever in a postpartum
patient
• Diagnosis is clinical because imaging findings
can be normal, particularly in uncomplicated
cases.
• However, increasing fluid and gas within the
endometrial canal is a key finding.
Differential Diagnosis
• Intrauterine clot—Complex appearance that
changes with time. Normal finding after
delivery.
• Retained products of conception—
Heterogeneous masslike appearance within
the endometrium.

Sagittal gray-scale US image illustrates echogenic foci with Sagittal (top) and transverse (bottom) gray-scale US images
reverberation artifact (arrow) representing intracavitary gas. demonstrate fluid and debris (arrows) within the endometrial
canal.
 Intrauterine Hematoma

Sagittal color Doppler US image demonstrates thickened and heterogeneous appearance of

the endometrium (arrow) compatible with postpartum intrauterine clot. Note there is no
associated vascularity within the uterine cavity.
 Retained Products of Conception
• Patients present with pain and bleeding after recent
miscarriage, abortion, or delivery.

• Elevated human chorionic gonadotropin (hCG) level

• US images typically demonstrate heterogeneous

echogenicity of the endometrium with increased
vascularity on color Doppler images.

Differential Diagnosis
• Endometrial clot—Should not have increased
vascularity.
• Gestational trophoblastic neoplasm—Markedly
elevated hCG level.

Top: Sagittal gray-scale US image demonstrates a

heterogeneous mass (arrow) within the endometrial
canal. Middle: Sagittal color Doppler US image
demonstrates increased vascularity (arrow).
Bottom: A high-flow low-resistance spectral
Sagittal postcontrast T1-weighted MR image in a patient
Doppler waveform helps confirm the diagnosis.
after an abortion with a serum hCG level of 51 mIU/mL
demonstrates a heterogeneous endometrial mass with
avid contrast enhancement (arrow).
 Uterine Arteriovenous Malformation

• Abnormal communications
between the intramural
arteries and myometrial venous
plexus

• Patients can present with

abnormal uterine bleeding.

• Can be congenital (rare) or

acquired (posttraumatic or
postinfectious)
Axial T1-weighted MR image
• Differential considerations demonstrates numerous flow
include gestational voids (arrow) within an enlarged
uterus. There is no T1
trophoblastic disease,
hyperintensity to suggest
endometrial carcinoma, and hemorrhage.
retained products of Sagittal gray-scale US image (top)
conception. demonstrates tubular anechoic
areas (arrowhead) within the
myometrium, with associated high
flow and color aliasing (arrow) on
color Doppler US image (bottom).
 Endometrial Pseudoaneurysm

• Result of trauma, typically iatrogenic

• Difficult to identify on gray-scale US

image, unless very large (rarely seen)

• Similar US imaging findings as seen in

pseudoaneurysms in other parts of the
body

Sagittal color Doppler US image (left) demonstrates a

small focus of color signal (arrow). Spectral Doppler US
image (above) demonstrates the characteristic to-and-fro
waveform (arrow) at the neck of the pseudoaneurysm.
 Hematometrocolpos
• Fluid-filled dilatation of the vagina and uterus
secondary to intrinsic obstruction, such as vaginal
stenosis, vaginal hypoplasia, and imperforate
hymen

• Hydro = Fluid
• Hemato = Blood products
• Metra = Uterine cavity
• Colpos = Vagina
Sagittal color Doppler US image above
T2 T1 demonstrates a fluid-filled distended endometrial
cavity (arrow). This same patient has congenital
absence of the right kidney on the gray-scale US
image below.

• Associated with anal, renal, vertebral, and

Sagittal T2- and T1-weighted MR images demonstrate
an endometrial cavity that is distended with T1 cardiac anomalies
hyperintense, T2 hypointense material (arrows) • Can also have associated mϋllerian duct
compatible with blood products. anomalies such as uterine didelphys
 Asherman Syndrome

• Endometrial scarring, typically from

prior pregnancy or dilation and
curettage, resulting in adhesion
formation

• Patients may present with infertility

and recurrent pregnancy loss.

• Sonohysterogram will demonstrate

the echogenic adhesions extending
along the uterine cavity.
Sagittal sonohysterogram demonstrates echogenic
adhesions (arrow) in this patient with prior dilation
and curettage.
 Endometrial Ablation

• Surgical ablation of the endometrial

lining to the level of the basal layer as
an alternative to hysterectomy for
treating patients with menorrhagia

• Sonohysterogram is used to evaluate

the uterine cavity preoperatively, while
routine pelvic US is the first-line
modality for evaluating patients after
ablation.

• Expected postoperative sonographic

findings include an indistinct
endometrial border and islands of
endometrial tissue.
• Complications include hemorrhage,
uterine perforation, and infection.
Long-term complications include
intrauterine adhesions or cervical
stenosis with subsequent hematometra
and adenomyosis.
Sagittal gray-scale US
image demonstrates the Top: Sagittal gray-scale US image
expected indistinct demonstrates a large amount of
endomyometrial junction echogenic material within the
(arrow) in this patient with endometrial cavity (arrow) in this
prior endometrial patient with prior endometrial
ablation. ablation, complicated by cervical
stenosis. Bottom: Axial T1-
weighted MR image demonstrates
T1 bright fluid distending the
uterus, confirming hematometra
(arrow).
 Gestational Trophoblastic Neoplasm

A
Spectrum of premalignant and
malignant placental lesions

• Premalignant lesions
• Complete hydatidiform mole: diploid,
usually no fetal tissue visible
• Partial hydatidiform mole: triploid, fetal
parts visible B
• Malignant lesions
• Invasive mole: molar pregnancy with
myometrial invasion
• Choriocarcinoma: abnormal proliferation
of trophoblastic tissue, often metastatic
at diagnosis
Sagittal gray-scale US images demonstrate
• Placental site trophoblastic tumor: focal
proliferation of trophoblasts in the A: Cystic endometrial mass with no fetal tissue (arrow)
myometrium at the site of placental compatible with complete hydatidiform mole.
insertion
B: Cystic endometrial mass with associated fetal tissue
(arrow) compatible with partial hydatidiform mole.
SRU Consensus on Postmenopausal Bleeding

• Either endometrial biopsy or transvaginal US is an appropriate

initial diagnostic procedure.

• This approach may depend on the physician’s experience,

availability of high-quality US, and patient preference.

• Biopsy may be indicated in higher risk patients: age older than

60 years, unopposed estrogen, obesity, and diabetes.

• The diagnostic criteria for US involve measuring endometrial

thickness and identifying heterogeneity or focal abnormalities.

• The endometrial stripe should be measured at its thickest

portion on the sagittal view.

• This double-thickness measurement should exclude central

fluid and the entire stripe should be visualized.
 SRU Consensus on Postmenopausal Bleeding

Transvaginal US US finding is also considered

suspicious if endometrial stripe
is incompletely visualized or if
there are indistinct endometrial
Endometrium less than 5 Endometrium greater than 5 mm (>8 margins.
mm mm in patients taking tamoxifen)

Atrophy Dilation and curettage or biopsy Sonohysterogram

Diffuse Focal
process lesion

Dilation and curettage Biopsy

 Conclusion

The normal endometrium has a wide spectrum of

appearances based on the patient’s age and phase
of menstruation.

Understanding this variability is essential in

differentiating normal entities from pathologic
processes that may require further workup. This
includes additional imaging with sonohysterography
or MR imaging or more invasive tissue sampling.

The SRU has published guidelines to help direct

management of patients with postmenopausal
bleeding. Patients with endometrial thickness
greater than 5 mm (8 mm if taking tamoxifen)
should undergo further investigation.
 Suggested Readings

1. 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.

2. Langer JE, Oliver ER, Lev-Toaff AS, Coleman BG. Imaging of the
female pelvis through the life cycle. RadioGraphics 2012;32(6):1575–
1597.
3. Nalaboff KM, Pellerito JS, Ben-Levi E. Imaging the endometrium:
disease and normal variants. RadioGraphics 2001;21(6):1409–1424.