J Menopausal Med.  2019 Dec;25(3):158-163. 10.6118/jmm.19015.

Thick “Swiss Cheese” Appearance of Uterine Endometrium in Postmenopausal Women with Different Gynecologic Conditions

  • 1Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea. leesr@amc.seoul.kr


To uncover gynecologic conditions with similar transvaginal sonographic findings of thick uterine endometrium with honeycomb appearance in pre-and postmenopausal women.
We retrospectively reviewed cases of patients with endometrial tissue biopsy from January 2010 to December 2016. We also collected office flexible hysteroscopic findings and surgical pathologic results. We analyzed data from 393 patients with confirmed endometrial pathology. Among these patients, 69 had transvaginal ultrasonographic images with thick uterine endometrium and honeycomb or "Swiss cheese" appearance.
We found gynecologic conditions such as submucosal leiomyoma with degeneration, endometrial polyp, pseudocystic endometrial change associated with tamoxifen use, progesterone associated endometrial change, pyometra, retained placenta, and uterine synechiae manifested with similar thick endometrium with "Swiss cheese" appearance in transvaginal sonographic images. The most common diagnosis in postmenopausal women was atrophic endometritis, followed by endometrial cancer and endometrial polyps. The most common diagnosis in premenopausal women was abnormal uterine bleeding without pathologic conditions.
Sonographic findings of thick uterine endometrium with "Swiss cheese" appearance need to be considered together with a thorough review of the patient's history and chief complaint before making a tentative diagnosis due to the various conditions sharing the feature.


Endometrium; Hyperplasia; Leiomyoma; Menopause; Polyps

MeSH Terms

Endometrial Neoplasms
Placenta, Retained
Retrospective Studies
Uterine Hemorrhage


  • Fig. 1 Gray-scale image, color Doppler sonographic image, and hysteroscopic image (from left to right) of patients with thick endometrium with “Swiss cheese” appearance on transvaginal sonography.

  • Fig. 2 The thorough examination of vaginal sonographic image can reveal space between normal appearing endometrium and “Swiss cheese” like endometrial mass. (A) Endometrial hyperplasia. (B) Endometrial cancer. (C) Submucosal leiomyoma with cystic degeneration.

  • Fig. 3 The magnetic resonance imaging (MRI) of progesterone associated endometrial change (PAEC). (A) T1-weighted image of MRI. (B) T2-weighted image of MRI. (C) Fat suppression image of MRI. The transvaginal sonographic image of PAEC before (D) and after (E) menstruation showed the “Swiss cheese” appearance of (D) is disappeared in (E) showing triple laminar feature of normal endometrium.

  • Fig. 4 Proposed diagnostic algorithm for managing thick uterine endometrium with “Swiss cheese” appearance. EM: endometrium, MP: menopause, D&C: dilatation and curettage.


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