Endometrial thickness is a commonly measured parameter on routine gynaecological ultrasound and MR imaging. The appearance, as well as the thickness of the endometrium, will depend on whether the patient is of reproductive age or post-menopausal and, if of reproductive age, at what point in the menstrual cycle they are examined.
The endometrium should be measured in the long axis or sagittal plane, ideally on transvaginal scanning. The measurement is of the thickest echogenic area from one basal endometrial interface across the endometrial canal to the other basal surface. Care should be taken not to include the hypoechoic myometrium in this measurement.
The normal endometrium changes in appearance as well as in thickness throughout the menstrual cycle:
- in the menstrual and early proliferative phase it is a thin, brightly echogenic stripe comprising of the basal layer (figure 1). Minimal fluid can be appreciated endovaginally within the endometrium in the menstrual phase.
- in the late proliferative phase it develops a trilaminar appearance: outer echogenic basal layer, middle hypoechoic functional layer, and an inner echogenic stripe at the central interface.
- in the secretory phase it is at its thickest and becomes uniformly echogenic, as the functional layer becomes oedematous and isoechoic to the basal layer (Figure 2). There is through transmission and posterior acoustic enhancement noted.
The postmenopausal endometrium should be smooth and homogeneous.
Normal range of endometrial thickness
The designation of normal limits of endometrial thickness rests on determining at which thickness the risk of endometrial carcinoma is significantly increased.
Whilst quantitative assessment is important, endometrial morphology and the presence of risk factors for endometrial malignancy should also be taken into account when deciding whether or not endometrial sampling is indicated.
Commonly accepted endovaginal ultrasound values are as follows.
In premenopausal patients, there is significant variation at different stages of the menstrual cycle.
- during menstruation 1,4: 2-4 mm
- early proliferative phase (day 6-14): 5-7 mm
- late proliferative-pre ovulatory phase: up to 11 mm
- secretory phase: 7-16 mm
- following dilatation and curettage or spontaneous abortion: <5 mm, if it is thicker consider retained products of conception.
Will depend on the whether or not there is a history of vaginal bleeding, and on the use of hormonal therapy / tamoxifen.
- vaginal bleeding (and not on tamoxifen):
- suggested upper limit of normal is <5 mm 5
- the risk of carcinoma is ~7% if the endometrium is >5 mm and 0.07% if the endometrium is <5 mm 8
- on hormonal replacement therapy: upper limit is 5 mm
- no history of vaginal bleeding:
- the acceptable range of endometrial thickness is less well established in this group, cut-off values of 8-11 mm have been suggested.
- the risk of carcinoma is ~7% if the endometrium is >11 mm, and 0.002% if the endometrium is <11 mm 8
- if on tamoxifen 3: <6 mm (although ~50% of those receiving tamoxifen have been reported to have a thickness of >8 mm 7)
Endometrial thickness is well assessed on MRI. Measurement should be taken at a midsagittal slice, similar to the US assessment plane.
The normal endometrium is homogeneously hyperintense on T2WI, regardless of the phase of the menstrual cycle or menopausal status and well outlined by the low signal myometrial junctional zone.
- tamoxifen-associated endometrial changes
- endometrial hyperplasia
- endometrial atrophy
- abnormally thickened endometrium
Ultrasound - gynaecology
- ultrasound (introduction)
- acute pelvic pain
- chronic pelvic pain
- Mullerian duct anomalies
- ovarian follicle
- ovarian torsion
- pelvic inflammatory disease
- ovarian cysts and masses
- ovarian cyst
- corpus luteum
- haemorrhagic ovarian cyst
- ruptured ovarian cyst
- ovarian epithelial tumours
- granulosa cell tumours of the ovary
- paraovarian cyst
- polycystic ovaries
- ovarian hyperstimulation syndrome
- post-hysterectomy ovary
- fallopian tube
- 1. Nalaboff KM, Pellerito JS, Ben-levi E. Imaging the endometrium: disease and normal variants. Radiographics. 21 (6): 1409-24. Radiographics (full text) - Pubmed citation
- 2. Lin MC, Gosink BB, Wolf SI et-al. Endometrial thickness after menopause: effect of hormone replacement. Radiology. 1991;180 (2): 427-32. Radiology (abstract) - Pubmed citation
- 3. Fong K, Kung R, Lytwyn A et-al. Endometrial evaluation with transvaginal US and hysterosonography in asymptomatic postmenopausal women with breast cancer receiving tamoxifen. Radiology. 2001;220 (3): 765-73. doi:10.1148/radiol.2203010011 - Pubmed citation
- 4. Williams PL, Laifer-narin SL, Ragavendra N. US of abnormal uterine bleeding. Radiographics. 23 (3): 703-18. doi:10.1148/rg.233025150 - Pubmed citation
- 5. Sahdev A. Imaging the endometrium in postmenopausal bleeding. BMJ. 2007;334 (7594): 635-6. doi:10.1136/bmj.39126.628924.BE - Free text at pubmed - Pubmed citation
- 6. Hulka CA, Hall DA, Mccarthy K et-al. Endometrial polyps, hyperplasia, and carcinoma in postmenopausal women: differentiation with endovaginal sonography. Radiology. 1994;191 (3): 755-8. Radiology (abstract) - Pubmed citation
- 7. Hann LE, Giess CS, Bach AM et-al. Endometrial thickness in tamoxifen-treated patients: correlation with clinical and pathologic findings. AJR Am J Roentgenol. 1997;168 (3): 657-61. AJR Am J Roentgenol (abstract) - Pubmed citation
- 8. 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): 558-65. doi:10.1002/uog.1704 - Pubmed citation