DIFFICULTIES IN ENDOMETRIAL STRIPE MEASUREMENT The presence of multiple myomas, unusual orien- tation of the uterus or patient body habitus may prohibit optimal visualization of the endometrial stripe and accurate measurement of endometrial thickness. The presence of adenomyosis or endo- metrial cystic atrophy may lead to misleading endometrial measurements. In these instances, if abnormal is bleeding present, additional workup is warranted.
SUMMARY Appropriate triage of patients with abnormal vaginal bleeding begins with a history and physical examination. Imaging plays an integral part in the detection of endometrial disorders, and the algo- rithm in Fig. 15 summarizes a suggested workup of abnormal uterine bleeding (see Fig. 15). A similar algorithm to that proposed in this article has recently been suggested by Shi and Lee.48 The endometrium may be normal in thickness (% 18 mm in menstruating women and % 5 mm in postmenopausal women), in which case the bleeding is likely hormonal or caused by atrophy in the setting of normal physical examination. However, if clinical concern persists, SIS may reveal a small, otherwise occult lesion. In cases of endometrial thickening, determination of focal or diffuse disease may be best assessed with SIS, and appropriate hysteroscopic or undirected biopsy may follow, respectively. Alternatively, in patients who are at increased risk for endometrial cancer, such as those with morbid obesity, hypertension, diabetes, hormone replacement therapy, or tamoxifen use, endome- trial thickening on routine transvaginal sonography may prompt endometrial biopsy without SIS. SIS may be useful in the setting of negative undirected biopsy and persistent bleeding.
Fig. 15. Suggested algorithm for management of abnormal uterine bleeding in premenopausal, postmenopausal,and high-risk patients. In cases in which focality or diffusivity of endometrial thickening or better characterization of the endometrium is desired, SIS may be pursued after TVUS. In high-risk patients, undirected endometrial biopsy (EMBX) may be immediately undertaken. Also in patients with endometrial thickening and negative EMBX, SIS may be helpful for further assessment of possibly underlying pathology. 图15：对绝经前、绝经后及高危患者异常子宫出血的诊治步骤的演示。为了揭示内膜增厚是局灶性还是弥漫性或者更好显示内膜病变特异性，TVUS之后可以进行SIS。在高危病人，间接内膜活检（EMBX）可以立即进行。同样在内膜增厚的病人，EMBX提示为阴性，SIS可能会有助于评估潜在性的病理性改变。