Correspondence

Role of Transvaginal Sonographyand Endometrial Biopsy in theEvaluation of DysfunctionalUterine Bleeding inPremenopausal WomenThe diagnostic evaluation of dysfunctional uter-ine bleeding (DUB) is more difficult in premeno-pausal women than in postmenopausal womenbecause of the larger number of possible etiolo-gies. Assuming that complications of pregnancyand bleeding disorders have been excluded, themost common etiologies for premenopausal DUBare endocrinologic. Endometritis, endometrialpolyps, and submucosal fibroids are the major re-maining differential considerations in DUB. En-dometrial biopsies (EMBs) are still performed onthese patients primarily to exclude endometrialmalignancies and hyperplasia.

In a recent study, we showed that transvaginalsonography (TVS) is a better method than EMBfor evaluating the endometrium in women withDUB.1 However, very little has been writtenregarding the utility of TVS and transvaginalhysterosonography in the evaluation of DUB inpremenopausal women.2 We retrospectively re-viewed all of the pathology reports for EMB, di-lation and curettage (D&C), and hysterectomyprocedures performed in premenopausal womenwith DUB and compared these results with thoseof TVS.

A total of 156 premenopausal women under-went EMB (mean age, 33.6 years; range, 16–45years). Of these, 5 patients had abnormal results:1 carcinoma, 2 hyperplasias, and 2 endometrialpolyps with adenomatous changes. The remain-ing 151 patients had proliferative (87) or secre-tory (64) endometria with no lesion.

Forty-three of these 151 women underwentTVS, which showed 11 submucosal fibroids(Figure 1), an endometrium 12 mm or greaterin thickness in 14 women, and an endometriumless than 12 mm thick in 18 women. Pathologicexamination of subsequent hysterectomy speci-mens confirmed the TVS diagnosis of submuco-sal fibroids in all 11 women. In the 14 womenwith endometrial thickening on TVS, D&C and/orhysteroscopy demonstrated 3 endoluminal fi-broids, 3 endometrial polyps, 2 cases of endome-tritis, 1 carcinoma, 3 secretory endometria, and 2proliferative endometria. In the 18 women with athin endometrium on TVS, all had a final diagno-sis of endometrial atrophy or tissue insufficientfor diagnosis. The remaining 108 women weresuccessfully treated with hormone therapy andwere free of symptoms 3–6 months following theirEMB.

The most common abnormality seen with TVSin premenopausal women was submucosal fi-broids, followed by polyps and endoluminal fi-broids. Carcinoma was in fact the least common

© 1998 John Wiley & Sons, Inc. CCC 0091-2751/98/030180-03

FIGURE 1. (A) Transverse sonogram of the uterus in a 25-year-old woman with a 2-year history of menorrhagia and increasing menometrorrhagia.This image was initially interpreted as a posterior submucosal fibroid with anterior endometrial displacement (arrows). (B) Transverse hystero-sonogram obtained after injection of saline into the endometrial cavity shows that the submucosal fibroid (calipers) is actually located anteriorly.The curvilinear echoes that were believed to represent the endometrium may be early calcifications at the periphery of the fibroid.

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etiology for bleeding, with a prevalence of 1.3%.As in postmenopausal women, EMB missed mostof the polyps and fibroids and 1 of 2 carcinomas.The low prevalence of carcinoma in the premeno-pausal population as well as the insensitivity ofEMB for the diagnosis of most causes of DUBmakes its use as the first diagnostic step in thesewomen questionable.

Theodore Dubinsky, MDUniversity of WashingtonHarborview Medical CenterSeattle, Washington 98104

Yaser Abu-Gazzeh, MDAmman HospitalAmman, Jordan

Kristine Stroehlein, MDThe University of Texas–Houston Medical SchoolHouston, Texas 77030

REFERENCES

1. Dubinsky TJ, Parvey R, Gormaz G, et al: Transvagi-nal hysterosonography: comparison with biopsy inthe evaluation of postmenopausal bleeding. J Ultra-sound Med 1993;14:887.

2. Indman PD: Abnormal uterine bleeding. Accuracy ofvaginal probe ultrasound in predicting abnormalhysteroscopic findings. J Reprod Med 1995;40:545.

Sonographic Pitfall in DiagnosingBreast Cysts:Pseudomural Projections

Although the sonographic diagnosis of a simplebreast cyst is frequently straightforward, somepitfalls may be encountered. We describe a com-mon pitfall, pseudomural projections, which mayoccur in patients with multiple cysts.

To verify that apparent intramural noduleswere not due to solid masses, we aspirated cystsand performed pneumocystography on 18 pa-tients whose ages ranged from 36 to 52 years(mean, 42 years). Lobulated cysts were aspiratedwith a 21-gauge needle under sonographic guid-ance (7.5-MHz transducer), and then air equal involume to the aspirated material was insufflatedinto the cyst. Pneumocystograms were obtainedin craniocaudal and mediolateral oblique projec-tions. The pneumocystograms were correlatedwith the sonograms to confirm the presence orabsence of true intracystic masses.

A partial volume effect due to bulging of sur-rounding breast tissue into the cyst was respon-

sible for the pseudomural projections in 13 pa-tients. In 5 patients, the separation betweenadjacent cysts was responsible for this effect (Fig-ure 1).

FIGURE 1. Pseudomural projection due to neighboring cyst. (A) Sono-gram shows a questionable, well-defined, hypoechoic mass (arrows)within the cyst. (B) Pneumocystogram demonstrates inward lobula-tion of the inferior cyst wall (arrows) caused by compression by anadjacent cyst. The cyst wall is smooth and regular, and there is nosign of an intracystic mass.

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The sonographic demonstration of an echo-genic mass projecting from the wall of a breastcyst into its lumen can indicate an intracystic car-cinoma, although such tumors are rare, account-ing for less than 1% of all breast cancers.1 Thedifferential diagnosis includes an intracystic pap-illoma, a cyst containing a blood clot, a focus ofapocrine metaplasia and epithelial hyperplasia,and various forms of debris including inflamma-tory cells and sloughed lining cells, proteinaceousdebris, and cholesterol crystals.2,3 Occasionally,septa within a cyst mimic a mural nodule andmay be misdiagnosed as an intracystic mass.2

It is very important to apply strict criteria inthe sonographic diagnosis of a simple cyst. If in-ternal echoes, thickened walls, or mural projec-tions are present, aspiration or excision is indi-cated. For that reason, knowledge of somepotential sonographic pitfalls will help avoid un-necessary interventions. Artifactual internal ech-oes due to an incorrect power setting or time-gaincompensation and echoes restricted to the ante-rior part of the cyst due to artifactual reverbera-tions are common pitfalls that should be differen-tiated from true internal echoes.2,3 Anotherpotential pitfall, as we demonstrated, is the pres-ence of pseudomural projections that may affectsimple breast cysts, particularly multiple, clus-tered cysts. During sonographic examination, thispitfall can be identified easily by compressing thecyst or examining the cyst from different angles toshow changes in the shape or disappearance of

the pseudomural projection. Furthermore, trueintracystic masses often have a detectable bloodsupply, and thus color Doppler imaging may aidin their diagnosis.4

Radiologists should be aware of the describedpitfall in the evaluation of lobulated cysts to beable to exclude true intracystic masses. Althoughit is generally easy to identify this pitfall, fine-needle aspiration should be performed if the tech-niques mentioned above do not resolve the is-sue.

Ahmet N. Tenekeci, MDIstanbul University, Institute of Oncology34390 Capa–Istanbul, Turkey

Gokhan Pekindil, MDTrakya University22030-1 Edirne, Turkey

REFERENCES

1. Reuter K, D’Orsi C, Reale F: Intracystic carcinomaof the breast: the role of ultrasonography. Radiology1984;153:233.

2. Basset LW, Kimme-Smith C: Breast sonography.AJR Am J Roentgenol 1991;156:449.

3. Khaleghian R: Breast cysts: pitfalls in sonographicdiagnosis. Australas Radiol 1993;37:192.

4. Fornage BD: Role of color Doppler imaging in differ-entiating between pseudocystic malignant tumorsand fluid collections. J Ultrasound Med 1995;14:125.

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