0:01

Our next case is of a 50-year-old patient who's

0:03

premenopausal and is coming in for evaluation

0:05

of her dysfunctional uterine bleeding.

0:07

She had her LMP or last menstrual

0:09

period approximately one month before.

0:12

In our sagittal imaging here, we can already see

0:15

a classic appearing fibroid up here with areas

0:18

of heterogeneity and shadowing calcification.

0:21

Make this a little bit bigger.

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And then we have our endometrium.

0:25

Our endometrium does look a little bit

0:28

thickened, but there is something focal within

0:30

it right here, and you can kind of see it because

0:33

not only is it a little bit brighter than

0:34

the endometrium around it, but you have these

0:37

tiny cystic spaces within it that we don't

0:39

have anywhere else in the endometrial canal.

0:42

Just this one focal kind of area right here.

0:45

Then, of course, as we go through, you can

0:46

see another large fibroid back here.

0:51

Looking at our color Doppler images.

0:56

You can see some flow out here to the fibroid.

1:00

Endometrium itself is not that

1:01

vascular, nor should it be.

1:03

Might see little dots of flow

1:05

here and there, but it shouldn't

1:06

have that much color Doppler flow.

1:08

But we're already seeing right here

1:09

what looks like it might be a feeding

1:11

vessel and flow within the structure.

1:15

And hard to tell here, is it one feeding

1:16

vessel or multiple feeding vessels?

1:19

But what you can argue is we definitely have

1:21

an echogenic structure with cystic spaces.

1:23

It has color Doppler flow

1:24

leading out to it directly.

1:26

It is within the endometrium.

1:28

It is not a classic appearance for a fibroid.

1:31

So this case would be a differential case.

1:33

She is not postmenopausal; she's considered

1:36

premenopausal with an LMP of one month

1:38

prior, but she's nearing that age where you

1:41

could consider more of a differential than

1:43

you would in, say, a 24-year-old.

1:46

So with her, your differential is going

1:48

to be an atypical polyp because polyps can

1:50

occasionally have internal cystic spaces

1:53

like this one does.

1:54

It could also be hyperplasia or

1:56

it could be a focal malignancy.

1:59

Again, these are going to be hard to diagnose

2:01

or to differentiate on an ultrasound.

2:04

If you weren't sure if this was real or not,

2:05

you could have repeat ultrasound imaging.

2:08

She's in a secretory phase at this

2:09

point, so it's going to be maximal

2:10

thickness of her endometrium.

2:12

You could repeat it, you know, 5 to 7

2:15

or even 10 days after her LMP to try

2:17

and figure out if this is real or not.

2:19

However, in this case, with the internal cystic

2:21

spaces, we knew this was real, and she needed

2:22

to have this biopsy and/or removed.

2:25

So in this case, she did end up going to

2:27

surgery, and this ended up being atypical polyps.

2:30

So it's not hyperplasia or cancer,

2:31

just a polyp, but it was the cause of

2:33

her dysfunctional uterine bleeding.