Bioidentical Hormones 101 
The Book, by Jeffrey Dach MD

Importance of the Pe

Importance of the Sonogram Jeffrey Dach Bioidentical HormonesThe Importance of the Pelvic Sonogram

by Jeffrey Dach MD

A 56 year old female patient had an episode of abnormal post-menopausal vaginal bleeding for which a pelvic sonogram was recommended. The sonogram showed a cystic swiss cheese appearance of the endometrium which looked like the left image at  (red arrows).  The abnormal endometrium is located between the three red arrows. Notice the small black areas which indicates small fluid collections.

Left Image: Ultrasound Machine Courtesy of Wikimedia.

endometrial_hyperplasia and polyps on pelvic sonogram The abnormal endometrium required two procedures. First, an endometrial biopsy and later, a D and C (Dilatation and Curettage) which was done for a complete removal of the abnormal endometrial tissue. Fortunately, the pathology report showed only benign endometrial hyperplasia and polyps. There was no endometrial cancer.


Anatomy Lesson

Diagram on the left shows the uterine outer muscular layer also called the myometrium. On right, diagram shows the inner uterus, also called the endometrium. This is the layer that is shed every month during the bleeding period.


Left Image shows fibroid tumors involving the uterine wall in various locations.

Why Get a Baseline Pelvic Sonogram?

Uzzi Reiss MD, author of the book, Natural Hormone Balance for Women advises a pelvic sonogram exam for all new patients starting bio-identical hormones.  His new Book is The Natural Superwoman.

Dr. Uzzi Reiss’s reasons for a baseline pelvic sonogram:

1) A pelvic sonogram should be added to the manual pelvic exam because the old gyne pelvic exam is a 1950′s standard of care. The new standard of care for the year 2000 is a pelvic sonogram.

2) The annual pelvic exam is a useful exam, but is incomplete. It provides a pap smear, visualization of the cervix, and vaginal mucosa. It cannot provide much information about the uterus and ovaries unless these organs are grossly enlarged.

3) The pelvic sonogram provides much more detailed information about the uterine size, shape and consistency, endometrial thickness, and presence or absence of fibroids, masses, or polyps in the uterus. Small masses and abnormalities can be seen on pelvic sonogram which would never be detected on manual pelvic exam.

4) If endometrial thickness is greater than 5 mm, then endometrial biopsy is usually performed to rule out endometrial cancer.


endometrial_CA_2Endometrial Cancer.

The small image on the lower left (below) is a normal uterine cavity, and the larger image shows a white cauliflower mass growing into the endometrial cavity. This is endometrial cancer.

5) Pelvic sonogram is more sensitive than pelvic exam for detection and evaluation of ovarian, adnexal masses, cysts, and free fluid in the pelvis.

The sonogram image on the lower left shows small black spots along the outer margin of the ovary, these are multiple small benign ovarian cysts.


The image on the left shows a tubo-ovarian abscess. These findings would be difficult or impossible to detect with
manual pelvic exam.


6) Post-menopausal bleeding may occur from fluctuating hormone levels when first starting a bio-identical hormone program. Abnormal vaginal bleeding requires a pelvic sonogram to evaluate the cause of the bleeding. Having a prior baseline sonogram for comparison aids in the interpretation, and can avoid unnecessary procedures.

The sonogram can easily determine the cause of abnormal vaginal bleeding:

Causes of Abnormal Vaginal Bleeding:
Diffuse Endometrial hyperplasia (overgrowth)
Diffuse Endometrial cancer
Endometrial polyps
Submucosal fibroids
Focal Endometrial hyperplasia
Focal Endometrial cancer
Hormone imbalance
Simply endometrial atrophy (undergrowth)

Uterine fibroids can cause bleeding and this is what uterine fibroids look like:

On the left side is an anatomic diagram  showing uterine fibroids .





Fibroids on MRI .

On the MRI scan shown at left, the sacrum is at the right, and the anterior abdominal wall is at the left. The triangular shaped bladder contains fluid (white urine) below and to the left of the enlarged fibroid uterus.  Fibroids the dark rounded lesions  inside the enlarged uterus.


Sometimes bleeding can be caused by benign endometrial polyps as shown here.





If endometrial thickening (greater than 5 mm) or other abnormality is seen on a sonogram, then endometrial biopsy is usually done. The pelvic sonogram below illustrates the endometrial stripe which is outlined with the yellow line , and the blue line outlines the uterus.   The Endometrial stripe should be less than 5 mm in thickness.





Here two images showing examples of a thickened endometrial stripe suspicious for cancer which requires endometrial biopsy for diagnosis:

Above left  is a trans-abdominal sonogram, and below is a trans-vaginal sonogram showing thickening of the endometmore detail.



The endometrial biopsy is a 10 minute gyne office procedure in which an instrument is inserted through the endocervical canal and a small sample of the endometrial lining is obtained for pathology analysis. If the pathology is abnormal, a follow up procedure called a D and C (dilatation and curettage) is done to obtain a larger sample, and to remove the entire lesion which is also sent for pathology analysis.


This diagram shows the endometrial biopsy instrument in place inside the endometrial cavity performing a biopsy:

Is Pelvic Ultrasound Safe?

There are no known harmful effects associated with the medical use of sonography which has not been shown to cause any harm or any adverse outcomes.

Trans-Abdominal Sonogram vs. Trans-Vaginal Sonogram

The transabdominal sonogram is usually the initial exam. This is done with a full bladder to provide an acoustic window for the transducer which is placed on the abdomen to obtain images of the uterus and ovaries. If needed, a more sensitive transvaginal sonogram is done with a special transvaginal transducer. This provides high resolution images of the uterine contents and ovaries.

Why You Need A Pelvic Sonogram

I hope the above discussion has convinced you of the importance of the pelvic sonogram, and why we ask that all post Menopausal women have a Baseline Pelvic Sonogram before starting our Bio-Identical Hormone Program.

Articles With Related Interest:

Endometriosis Natural Treatmants

Jeffrey Dach MD

7450 Griffin Road Suite 190
Davie, Florida 33314

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