Post-menopausal women diagnosed with Endometriosis and "Imaging"

Imaging of Endometriosis in the Postmenopausal Patient

Key Points

Importance:

• While premenopausal women most often get diagnosed with endometriosis due to the onset of significant symptoms, other women can develop -or be diagnosed endometriosis, after menopause.
• The image interpretation of these women is important as the differentiation of other entities such as occult cancer needs to be investigated.

Highlights:

• There are several important image findings on MRI that may suggest Endometriosis' involvement in deep pelvic structures, ovaries, or the superficial peritoneal surface.
• These findings are presenting in the following article. 

What’s done here:

• A case-based article on the image interpretation of postmenopausal with women is presented in order to highlight suggestive findings of endometriosis that should be assessed in women suspected of having endometriosis.

Key Results:

• MRI is a useful tool to differentiate endometriosis from other pathologies that may mimic its clinical presentation. It is also utilized for preoperative work-up for patients suspected of having deeply-infiltrating endometriosis or occult malignancy.
• On T2W images, endometriomas have a variable appearance due to the variable amount of blood within the cyst. 
• In the case of superficial endometriosis, MRI has been shown to be less useful than in the assessment of endometriomas. 
• Patients should be followed in individualized intervals depending on the degree of suspicion for malignancy for continued close surveillance.

Lay Summary

Postmenopausal endometriosis is an underrecognized clinical entity that may present similarly to those of younger patients with endometriosis. Radiologists have an important role in the diagnosis of these patients as they recommend which imaging study should be used to differentiate endometriosis from other possible entities.

Authors from the Department of Radiology and Obstetrics and Gynecology at Mayo Clinic recently wrote an article titled, “Endometriosis in the postmenopausal female: clinical presentation, imaging features, and management” in the Journal of Abdominal Radiology in order to shed light on how postmenopausal women may be diagnosed with endometriosis and display several MR images of postmenopausal patients with findings that were later found to be endometriosis. A significant risk factor for the diagnosis of endometriosis in this period is a history of endometriosis that was either clinically indolent or was not diagnosed until later during the postmenopausal period. Alternatively, these patients can be diagnosed with endometriosis through imaging for some other reason or during surgery.

The typical MR appearance of pelvic endometriosis is varied depending on the characteristics of the endometriotic lesions themselves. Ovarian endometriomas are usually solitary and are characterized as homogenous and hyperintense on T1W images. On T2W images, endometriomas have a variable appearance due to the variable amount of blood within the cyst. The presence of a thick, T2 hypointense capsule or a T2 “dark spot” within the mass can suggest a chronic endometrioma versus a hemorrhagic ovarian cyst. In the case of superficial endometriosis, MRI has been shown to be less useful than in the assessment of endometriomas. Due to their small size, most peritoneal lesions are not simple to identify unless they have bled. In these cases, an associated T1 hyperintensity may be seen. For deeply infiltrating endometriosis, solid nodules, plaque-like thickening, or stellate soft tissue with intermediate T1 signal intensity and low T2 signal intensity may be seen.

Due to the common appearance of cul-de-sac and bowel involvement in patients with DIE, the presence of endometriosis should be assessed with MRI in order to define the extent of disease and guide surgical intervention that may be warranted. Due to the increased risk of ovarian cancer in women with endometrioma, patients suspected of having endometriosis in the postmenopausal period should be assessed for the presence of malignancy. On MRI, an intermediate T2 signal with early enhancement and restricted diffusion. It is important that these patients should be followed in individualized intervals depending on the degree of suspicion and results for continued close surveillance.

Endometriosis is a complex disease with a very heterogeneous clinical presentation. Thus, there are ongoing efforts to see how and when pre and post-menopausal women should be images for screening, evaluation, or post-intervention purposes. 

Research Source: https://www.ncbi.nlm.nih.gov/pubmed/31701193