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in Women's Health
November 2002
Case
A 31-year-old gravida 0 presents with vaginal spotting. She is
6’1”, 221.5 pounds, and has a blood pressure of 130/80.
At 19 years old, she was diagnosed with premature ovarian failure.
Her complete evaluation was negative. Since 19, she has been maintained
on hormone replacement therapy, which she takes about 50% of the
time. Her most recent laboratory studies done while she was off
hormonal therapy were FSH = 75.9 mIU/mL; estradiol = 8.6 pg/mL;
TSH = 2.01; fasting glucose = 82 mg/dL; hemoglobin = 13.6 g/dL;
hematocrit = 39.6%; and electrolytes were normal.
The patient was taking no medications and has no allergies. She
stopped her oral contraceptives when she had abnormal bleeding.
Her past medical history/past surgical history/family history were
not contributory.
Her gynecologic history was as follows: menarche age 11, regular
28-day cycles until age 19, then amenorrhea, and normal Pap tests.
Other examination results included the following: HEENT: no thyromegaly,
normocephalic/ atraumatic; abdomen: soft, nontender, nondistended,
no hepatosplenomegaly; pelvis: normal external genitalia; vagina:
moist without lesions and no discharge noted; cervix: no lesions
or discharge and nontender with motion; uterus: normal size, anteflexed,
anteverted, nontender, and mobile; and adnexae: nontender with no
palpable masses.
An initial ultrasound at another facility noted that the uterus
measured 7.8 x 2.7 x 4.6 cm. The endometrium measures 0.8 cm, which
appears heterogeneous in its echo texture and somewhat complex,
possibly due to blood products. The ovaries were normal in appearance
by ultrasound and measured 3.5 x 1.2 x 2.4 cm on the left and 3.6
x 1.5 x 3.1 cm on the right.
A saline infusion sonohysterogram was ordered and the images are
presented on the bottom of the page.
Utrasound Findings
These images of a saline infusion sonohysterogram demonstrate
a filling defect located in the anterior surface near the fundus
of the uterine cavity consistent with a polyp. At times it can be
difficult to distinguish a polyp on a standard transvaginal or transabdominal
2-dimensional ultrasound. However, the saline in the uterine cavity
shows clearly that the endometrium is very thin in all areas of
the endometrial cavity except where the filling defect is.
Polyps may be distinguished from leiomyomas of the uterine cavity
by a few characteristics demonstrated in these images. A polyp is
more likely to be hyperechoic in consistency. Typically, there is
not shadowing below the polyp as one would expect to see in a submucous
myoma. And lastly, a polyp will typically have a blood vessel or
two feeding the polyp. During the saline infusion sonohysterogram,
the color Doppler, or in this case, a Power Doppler may be used
to look for blood vessels feeding the polyp, as seen in the second
image. Leiomyomas typically do not have a central blood vessel;
instead, the blood vessels are displaced to the side.
OUTCOME
This patient was taken to the operating room for a hysteroscopic
polypectomy. Direct visualization through hysteroscopy confirmed
the presence of a polyp, which was removed under direct visualization.
This specimen was sent to pathology, which confirmed the presence
of a polyp.
A word of caution: A blind dilatation and curettage would likely
miss a polyp (particularly when it is on a longer stalk) and then
the patient would have the vaginal bleeding problem persist. If
one has difficulty doing a hysteroscopic polypectomy for whatever
reason and resorts to a dilatation and curettage, be sure to re-evaluate
the uterine cavity afterwards with the hysteroscope, to confirm
the complete removal of the polyp so the problem is resolved.
What is the diagnosis on these images?
Figure 1
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Figure
2
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