What Causes Variation In Endometrium Thickness?

Posted on Sat, 8 Feb 2014

Question: Hi I contacted you recently as I had a small amount of spotting at the very end of my period. I had a cervical screening and HPV screening, which was negative. I then had an ultrasound scan. The endometrium was between 4mm and 6.5mm thick. I had the scan just over a week before my period was due. The scan also showed that there was some old menstral blood still in the uterus, with some partially retained blood. My gynaecologist thinks there is nothing to worry about. I have been under a lot of stress lately and he thinks my hormones are out of balance. I don't understand how the endometrium can vary in thickness, isn't it supposed to be the same thickness all the way round. My gynaecologist says the reason it is thicker in some points is due to the remaining blood and tissue and that this may come out at my next period, and I should have a scan after the period to check that everything has come out. The scan also revealed that there were leutal cysts on both ovaries that had recently collapsed. My gynaecologist said this was nothing to worry about and was a perfectly normal finding. I would be interested in your thoughts.

Answered by Dr. Aarti Abraham (6 hours later)

Brief Answer: EXPLAINED BELOW Detailed Answer: Hello Thanks for trusting me yet again with your health concern. Yes, you are right, the endometrial lining is uniformly thick. Partially retained blood and tissue however, is present in some particular location in the uterus, generally the fundus ( topmost portion ). SO this makes the lining thicker there , in that particular area. SO your doctor is right, the endometrium would measure slightly thicker in that zone. Also, sometimes, there are focal areas of thickening in the endometrium, again due to hormonal imbalance. There is a term for this - focal endometrial hyperplasia - in simple terms, thickening or overgrowth of the uterine lining in some foci, or some areas. So under normal conditions, the endometrium should be uniformly thick, but when hormonal imbalance exists, it can proliferate and get thicker in parts. This is what has happened, leading to the post menstrual spotting you once experienced. Luteal cysts - now once the period is over, a follicle ( egg ) grows in each ovary, and then if no fertilization ( pregnancy ) results, then that egg gets leutenized ( ingrown with blood vessels and fat ) and ultimately collapses and gets absorbed. Due to mild hormonal imbalances, the collapse gets delayed, and cysts form ( luteal cysts ) which are normal, and ultimately do collapse, as has happened. Yes, it is a perfectly normal finding. I do not think there is anything to worry about. After 40, per menopausal changes often begin to start subtly, leading to hormonal imbalance, also due to stress, this gets compounded. Unless the symptom ( post menstrual or pre menstrual or midcycle spotting ) recurs, nothing remains to be done. All the best. Please feel free to revert.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Aarti Abraham (2 hours later)

Thank you very much for your detailed and clear answer. I have read that endometrial hyperplasia can be a pre-cursor to cancer of the womb and needs to be treated. Should I be concerned about this? Thank you.

Answered by Dr. Aarti Abraham (3 hours later)

Brief Answer: EXPLAINED BELOW Detailed Answer: Thank you for the appreciation. Am glad I could be of some help. Yes, certain types of endometrial hyperplasias are associated with a higher risk of developing into endometrial ( uterine ) cancer. It depends on the histological variant of hyperplasia. Firstly, you do not have endometrial hyperplasia. Secondly, even if you do, most types are low risk for future carcinoma. In case endometrial hyperplasia DOES develop, what would tell you how much at risk you are , is an endometrial biopsy. If there is presence of a high risk type of endometrial biopsy ( would not inundate you with the technical terms ), then you need to be worried. So realistically speaking, you are a long way off from any kind of concern about uterine cancer. Obesity, being diabetic, having hypertension , smoking - these would increase your risk of harbouring such a malignancy. All the best. Will be happy to address any follow up questions. Wish you good health always.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Aarti Abraham (3 hours later)

Thank you very much for your reply. I wished I had emailed you and few days ago, and I wouldn't have spent the last few days thinking about it. It's all very well the consultant saying not to worry, but I do like to have an understanding of everything. The consultant did take a biopsy, mainly to stop me from worrying about it further, as he said he was not concerned and thought what had happened was due to a hormonal imbalance, due to stress etc. Hyperplaysia was unlilely. At the time of the biopsy he did say that the lining did appear to be very thin still, even though by that time my period was already 2 days late. It has not appeared yet (3 days after the biopsy) even though I had a very small amount of spotting yesterday. Hardly enough to notice if you weren't specifically looking. It does seem as though my cycle is still messed up. Is there anything I should be perscribed to bring on the period and then ongoingly to make sure the cycle stays as it should? Forgot to mention that I am not diabetic, overweight, do not have hyper tension and do not smoke.

Answered by Dr. Aarti Abraham (1 hour later)

Brief Answer: DETAILED BELOW Detailed Answer: Yes, in future, do feel free to discuss any issue, however trivial or complex it might seem to you. Sounding it out always helps more than fretting or imagining about it. Good that a biopsy was taken, it will reassure you. Yes, the lining was thin, and a biopsy was taken. THat means it is very likely that you might not have a full fledged period, this is because, the endometrial lining was already aspirated and removed while being biopsied. YOu might very well just have erratic spotting after the biopsy. In a period, this very lining gets naturally shed off, which was stripped off while taking a biopsy, which is why the period did not result. You can take 2 - 3 months of cyclical hormonal therapy, this will jumpstart your cycle to normal. Oral contraceptive pills beginning today for a month, or progesterone tablets taken from cycle day 15 - 25 for 3 months, will help. Ask your doctor if possible to scan you again. If the lining is almost absent ( most likely scenario after a biopsy ) you can start the pills from the same day, or count that day as day 1 and taken 10 days of progesterone from CD 15 - CD 25 as I mentioned. All the best. Please do share the biopsy report also. Take care.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Aarti Abraham (19 minutes later)

Thank you very much again for your detailed response. My consultant did mention that the period may be delayed but did not explain the reasons, which is quite frustrating for a control freak like me. I will share with you the results of the biopsy. I am being very neurotic, but I did ask my consultant if I could already have uterine cancer, and he said "N0". Do you share this view? I will ask for another scan.

Answered by Dr. Aarti Abraham (15 minutes later)

Brief Answer: DETAILED BELOW Detailed Answer: Yes, the period would be delayed because it will take time for the lining to grow back and get shed off. Will await the biopsy results. The answer to that question - could you already have uterine cancer - is a big NO. Since you love reason and logic, here are the reasons - 1. You do not have any symptoms - heavy bleeding with clots, pain, weight loss. 2. You did NOT have any features suggestive of carcinoma, even hyperplasia, in the ultrasound scan. 3. You do not have any risk factors for endometrial cancer. The biopsy will only prove this. ANd being a control freak is alright, just proves you care for yourself and your body. Take care. Keep interacting !

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Aarti Abraham (17 minutes later)

Hello again The scan did say there were no high risk vascular changes. It did mention something about multiple localised foci of calcification within the XXXXXXX layer, which were unlikely to be of any significance. When I asked my consultant about this he said it was something to be expected due to my age. The scan also said that I had reduced antral follicles, which my consultant also said this was to be expected at my age. Can you please explain both? Thank you.

Answered by Dr. Aarti Abraham (27 minutes later)

Brief Answer: EXPLAINED BELOW Detailed Answer: Hi again Yes I would be happy to explain both the phrases. Firstly the calcification bit. See, calcification is a part of ageing. As you grow older, the blood vessels of the body get multiple areas of calcium deposition within them. When this reaches a critical point, that vessel gets blocked ( thrombosed is the technical word ). That is how a stroke results, or a heart attack, when the vessels supplying that organ become blocked to a critical extent. Menopause occurs when you stop having periods, this is due to the stoppage of ovarian functions, and the absence of reproductive hormones. Also part of the peri menopausal spectrum is the gradual obliteration of vessels that supply the uterine lining, thus they slowly get blocked off and the lining itself atrophies and the menopause results. The endometrium or uterine lining has 3 zones, the deepest one, is the basal layer ( the base ). Then there are two more areas - the interim zone and the superficial topmost layer which gets shed off with each period. In your case, there are small multiple areas of calcification within the basal ( deepest ) layer. Truly this has no significance, and is an age related change. Gradually as all the 3 layers get calcified or obliterated, menopause would result, this sometimes does take years. Now for your ovaries - when any female is born, she carries a finite number of follicles ( eggs ). This is unlike males, where sperm production is a dynamic process, going on well into the seventies or eighties. In females, there is a fixed egg supply within the ovary. From this pool of follicles, each month, eggs are recruited, and one of them grows into a mature egg which ruptures ( ovulates ) and if fertilized, leads to pregnancy. Thus with age, the number of resting follicles ( antral follicles is the technical term ) gets depleted, until , at menopause, there are next to none, and even those of poor quality. Thus in your case, there are reduced antral follicles - indicating that the ovarian reserve is depleted, which is natural at 43. I hope both these things now make more sense than before ! If not, I would not mind doing better . See you .

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Aarti Abraham (5 minutes later)

I am going to switch off now and watch television. I truly appreciate your clear and helpful explanations. Now I really feel I can stop worrying and searching the Internet for explanations, which don't make any sense to me. You have been an absolutely massive help explaining these things in a way that I can understand - thank you.

Answered by Dr. Aarti Abraham (2 minutes later)

Brief Answer: TAKE CARE. Detailed Answer: Hey, thats a real compliment. Yes, do sit back and relax. I do NOT think you have cancer, or are going to have it at any point ( going by your history and current findings ). Do mail the biopsy report to me, that will objectify things further. Have a great weekend ! Will look forward to interacting with you always in future. Take care.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Aarti Abraham (28 hours later)

Hello again I just thought of something else. I am driving myself mad again. What would you expect to see on a scan if hyperplsia or cancer was present? Would you expect to see a much thicker endometrium? What does no high risk vascular changes mean? Sorry, I won't rest until I have the results. I have driven myself completely bonkers over this. It also said NAD with regards to the pelvis and the ovaries. Does this mean No Active Disease? Thank you so much.

Answered by Dr. Aarti Abraham (10 hours later)

Brief Answer: EXPLAINED BELOW Detailed Answer: Hello again. Its always good to hear from you, do not apologize, and feel free to talk anytime you wish to. If hyperplasia was present, the endometrium would be much thicker, and it would show internal echoes, sort of , a Swiss cheese appearance. In case of endometrial cancer , there would be thickening of the endometrium again, a discrete mass seen inside the uterine cavity which may entirely replace the endometrium, distortion of the shape of the uterine cavity itself, enlarged lymph nodes surrounding the uterus etc. High risk vascular changes would include - focal breaks in vessels, giant vessels, increased mitosis seen in the blood vessels, increased angiogenic factors etc. These are technical terms, and you should not worry about them, mainly because none of them are there in your case ! NAD means no appreciable disease, nothing abnormal detected. All the best And dont worry, no question is unwelcome !

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Aarti Abraham (35 hours later)

Hi Thanks again for your detailed answer. Would you have carried out a biopsy on someone with the scan findings I had? I do think that my consultant did the biopsy to stop me from worrying, but if you would expect to see a much thicker lining in case of hyperplasia I am now wondering why I put myself through the stress of having the biopsy. I should get the results this week. Thanks again.

Answered by Dr. Aarti Abraham (8 hours later)

Brief Answer: EXPLAINED BELOW Detailed Answer: Hi again. With the findings you had on the scan, I would not have gone for a biopsy. There was no hyperplasia or any indicator of it. But seeing your anxiety, I am sure if there had been no biopsy, you would have stressed yourself about that also, so I am sure we both can understand why the doctor did what he did. On second thoughts, if you introspect, had there been no biopsy, you would have worried much more about what COULD have been. Atleast, with the biopsy report, you will have it for you written in black and white. Wait it out, and try to divert yourself. Write in whenever you wish to. Take care.

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Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar