Transabdominal sonohysterography, transvaginal sonography, and hysteroscopy in the evaluation of submucous myomas

Effectiveness of sonohysterography in infertile patient work-up: a comparison with transvaginal ultrasonography and hysteroscopy

OBJECTIVE

The aim of this comparative study was to evaluate the accuracy of transvaginal ultrasonography (TVU), sonohysterography (SHG) with sterile saline solution compared to hysteroscopy in the diagnosis of intrauterine pathology in a population of infertile patients before an in vitro fertilization (IVF) program.

PATIENTS/METHODS

98 infertile patients with a mean age of 33.9 years (range 27-41) underwent TVU assessment and SHG with sterile saline solution immediately followed by hysteroscopy.

RESULTS

The clinical findings obtained by TVU, SHG and hysteroscopy were compared. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of TVU and SHG compared to hysteroscopy were calculated. The TVU sensitivity and specificity compared with hysteroscopy were 91 and 83% respectively. Using TVU, a 9.2% false positive rate (9 cases) and a 5.1% false negative rate (5 cases) were detected compared to hysteroscopy. The TVU PPV and NPV were 85.4 and 90% respectively. SHG yielded better results: sensitivity and specificity when compared to hysteroscopy were 98 and 94% respectively. The SHG PPV and NPV were 95 and 98% respectively. Accuracy of SHG was significantly better than TVU considering all intrauterine pathologies and polyps.

CONCLUSION

In experienced hands, SHG is an easy, safe, and well-tolerated alternative to diagnostic hysteroscopy in the initial evaluation of uterine cavity infertile patients.

Comparison of transvaginal sonography, saline infusion sonography and hysteroscopy in the evaluation of uterine cavity pathologies

AIMS

To determine whether performing transvaginal sonography (TVS) and saline infusion sonography (SIS) before hysteroscopy could reduce the number of diagnostic hysteroscopies performed for the evaluation of uterine cavity abnormalities.

METHODS

Two hundred and twenty three women with suspected uterine cavity abnormalities were prospectively evaluated by TVS, SIS and hysteroscopy, and had histological evaluation of the endometrium with hysteroscopic biopsy or dilatation and curettage (D&C). One hundred and sixty five patients (74%) were premenopausal and 58 patients (26%) were postmenopausal.

RESULTS

The positive predictive value (PPV) for endometrial polyps was 69% for TVS, 78% for SIS and 81% for hysteroscopy in premenopausal patients. In the postmenopausal group, TVS and SIS could detect only 24% of endometrial polyps, whereas 70% were diagnosed by hysteroscopy. The PPV for submucous fibroids was 47% for TVS, 81% for SIS and 77% for hysteroscopy in the premenopausal group.

CONCLUSIONS

In premenopausal patients, SIS and hysteroscopy are equally accurate in the diagnosis of endometrial polyps and submucous fibroids. Hysteroscopy is the most accurate test for polypoid lesions in the postmenopausal group. Performing TVS, SIS and D&C could reduce the number of diagnostic hysteroscopies performed for the evaluation of uterine cavity abnormalities by 71.5% in premenopausal patients. However, this rate decreases to 40% in the postmenopausal group.

A comparative study of three-dimensional saline infusion sonohysterography and diagnostic hysteroscopy for the classification of submucous fibroids

BACKGROUND

The purpose of this study was to compare three-dimensional saline infusion sonohysterography (3D SIS) and diagnostic hysteroscopy for the diagnosis and classification of submucous uterine fibroids.

METHODS

This was a prospective double-blind study of 49 women who presented with a history of menorrhagia, diagnosed on non-enhanced two-dimensional ultrasonography with submucous fibroids. Fibroids were classified on 3D SIS according to the proportion of fibroid contained within the endometrial cavity, using the European Society of Hysteroscopy Classification of Submucous Fibroids. These results were then compared with the findings at diagnostic hysteroscopy.

RESULTS

A total of 61 submucous fibroids was identified in 49 symptomatic women. Diagnostic hysteroscopy confirmed these findings in all cases. There was agreement between the two methods in 11/12 cases of Type 0 fibroids (92%), 34/37 (92%) of Type I fibroids and 9/12 (75%) of Type II fibroids. The overall level of agreement was good with a kappa value of 0.80.

CONCLUSIONS

There is a good overall agreement between 3D SIS and diagnostic hysteroscopy in classification of submucous fibroids. Agreement is better in cases where a greater proportion of the fibroid is contained within the uterine cavity.

The clinical value of 3-dimensional saline infusion sonography in addition to 2-dimensional saline infusion sonography in women with abnormal uterine bleeding: work in progress

OBJECTIVE

To evaluate the clinical relevance of 3-dimensional saline infusion sonography (3D-SIS) in addition to conventional SIS in women with abnormal uterine bleeding suspected of having intrauterine abnormalities.

METHODS

All women suspected of having intrauterine abnormalities were eligible. Before 3D-SIS, conventional SIS was performed. The results of these techniques were compared with the "combined method reference standard" (hysteroscopy, endometrial sampling, and clinical follow-up in cases with normal SIS findings). Diagnostic characteristics (with 95% confidence intervals [CIs]) of 3D-SIS and SIS were calculated as well as their respective accuracy in evaluating the histologic nature, the intrauterine extension, and the location of intrauterine abnormalities. Moreover, the reliability (kappa value) and clinical relevance of 3D-SIS were assessed.

RESULTS

A total of 49 women were included, and 4 women were excluded. The positive predictive values of 3D-SIS and SIS were, respectively, 1.00 and 0.86 (95% CI, 0.72-0.99; P = .15), and the diagnostic accuracy values were 0.98 (95% CI, 0.94-1.0) and 0.91 (95% CI, 0.83-0.99; P = .08). Saline infusion sonography and 3D-SIS were equally accurate in evaluating the histologic nature, intrauterine extent, and location of intrauterine abnormalities (respective kappa values: 0.85 versus 0.93; P = .88; 0.83 versus 0.83; and 0.77 versus 0.80; P = .81). The reliability of 3D-SIS was good: intraobserver and interobserver agreement (kappa) were 0.78 and 0.72. Three women (6.7%) had the benefit of additional 3D-SIS: in these women, SIS wrongly led to a diagnosis of intrauterine abnormalities (P = .08).

CONCLUSIONS

Three-dimensional saline infusion sonography is valid and reliable in women suspected of having intrauterine abnormalities and may indeed have relevant clinical value in addition to conventional SIS.

Sonohysterography: a valuable tool in evaluating the female pelvis

A number of medical conditions, including abnormal uterine bleeding, endometrial cancer, monitoring tamoxifen therapy, infertility, and recurrent abortion, warrant investigation of the female genital tract. Diagnostic studies including hysterosalpingogram, ultrasound, and sonohysterography have proved useful in the investigation of these gynecologic conditions. This article discusses each of these tests with particular emphasis on sonohysterography and their current and potential contributions in both diagnostic and therapeutic applications. The utility of each as well as their comparative value to each other and existing gold standards is reviewed.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to outline the current screening methods for uterine cavity and pelvic abnormalities, to list the advantages of sonohysterography, and to describe the clinical situations where sonohysterography can be used.

Uterine cavity findings and hysteroscopic interventions in patients undergoing in vitro fertilization–embryo transfer who repeatedly cannot conceive

OBJECTIVE

To assess hysteroscopic findings in patients undergoing IVF-ET who repeatedly failed to conceive despite transfer of good-quality embryos.

DESIGN

Prospective, observational study.

SETTING

Clinical research unit for reproductive medicine in a private clinic.

PATIENT(S)

Fifty-five patients with a normal uterine cavity on hysterosalpingography before the initial IVF-ET cycle and two previous failed IVF-ET attempts despite transfer of a minimum of two good-quality embryos on each occasion.

INTERVENTION(S)

Standard transvaginal ultrasonography and diagnostic and therapeutic hysteroscopy.

MAIN OUTCOME MEASURE(S)

Endometrial findings on transvaginal ultrasonography and hysteroscopy and outcome of the cycles after surgical hysteroscopy and antibiotic therapy.

RESULT(S)

Twenty-five (45%) patients had abnormal endometrial findings and underwent treatment to correct the lesions. All patients underwent a third IVF-ET cycle. Pregnancy (50% vs. 20%) and implantation (19% vs. 5.5%) rates were significantly higher in patients who were treated for uterine abnormalities than in patients who had normal uterine cavities on hysteroscopy.

CONCLUSION(S)

The incidence of pathologic findings on hysteroscopy is high in patients with repeated failures of IVF-ET. Evaluation of endometrial integrity by hysteroscopy is highly valuable and should be applied to all such cases.

Saline contrast hysterosonography in abnormal uterine bleeding: a systematic review and meta-analysis

OBJECTIVE

To assess the diagnostic accuracy of saline contrast hysterosonography in the evaluation of the uterine cavity in women complaining of abnormal uterine bleeding.

DESIGN

A systematic review and meta-analysis of diagnostic studies that compared saline contrast hysterosonography to a gold standard diagnosis based on either hysteroscopy with or without histological sampling or to hysterectomy.

SETTING

University Hospital.

SAMPLE

Twenty-four studies (including 2278 procedures).

METHODS

Electronic databases were searched for relevant studies and references were cross checked. Validity was assessed and data were extracted independently by two authors. Heterogeneity was calculated, studies were plotted in an ROC area and data were pooled. Subgroup analysis was performed according to the validity area.

MAIN OUTCOME MEASURES

The success rate of saline contrast hysterosonography. The pooled sensitivity, specificity, likelihood ratio's and post-test probabilities of saline contrast hysterosonography on the prediction of uterine cavity abnormality.

RESULTS

The largest population of homogeneous data were the studies with complete verification. In these studies, the pooled sensitivity and pooled specificity of saline contrast hysterosonography in uterine cavity evaluation were respectively 0.95 (95% CI 0.93 to 0.97) and 0.88 (95% CI 0.85 to 0.92), the likelihood ratios were respectively 8.23 (95% CI 6.2 to 11) and 0.06 (95% CI 0.04 to 0.09) and the post-test probabilities were respectively 0.91 (95% CI 0.89 to 0.94) and 0.07 (95% CI 0.04 to 0.10). The overall success rate of saline contrast hysterosonography was 93% (95% CI 92% to 94%). The feasibility of saline contrast hysterosonography in postmenopausal women (success rate 86.5%, 95% CI 83.2 to 89.8) is significantly lower (P < 0.01) compared with premenopausal women (success rate 95%, 95% CI 94% to 96%).

CONCLUSION

Saline contrast hysterosonography is accurate in the evaluation of the uterine cavity in pre- and postmenopausal women suffering from abnormal uterine bleeding. The feasibility of saline contrast hysterosonography is high, although significantly better in premenopausal women compared with postmenopausal women. We conclude that saline contrast hysterosonography, in combination with an endometrium aspiration if necessary, can become the standard diagnostic procedure in women with abnormal uterine bleeding.

A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women

BACKGROUND

To determine the accuracy of transvaginal ultrasonography, sonohysterography and diagnostic hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women.

DESIGN

Systematic review of common diagnostic imaging tests.

DATA SOURCES

Relevant papers were identified through electronic searching of MEDLINE (1980 to July 2001) and EMBASE (1980 to July 2001) and manual searching of a bibliography of primary and review articles.

REVIEW METHODS

Studies were selected if accuracy of transvaginal ultrasonography, sonohysterography and diagnostic hysteroscopy was compared with a reference standard and included data that could be abstracted into a two-by-two table in order to calculate sensitivity and specificity. Quality assessment and data extraction were performed by at least two independent reviewers. Diagnostic accuracy was determined by calculating positive and negative likelihood ratios for all intrauterine pathologies, submucous fibroids and endometrial hyperplasia.

RESULTS

Nineteen studies met the inclusion criteria. Statistically significant heterogeneity was present between the likelihood ratios for studies of transvaginal ultrasound. A positive test result with sonohysterography diagnosed submucous fibroids with a pooled likelihood ratio of 29.7 (17.8, 49.6). A positive test result with hysteroscopy diagnosed submucous fibroids with a pooled likelihood ratio of 29.4 (13.4, 65.3), and any intrauterine pathology with a pooled likelihood ratio of 7.7 (4.3, 13.7). A negative test result with hysteroscopy for diagnosing any intrauterine pathology had a pooled likelihood ratio of 0.07 (0.04, 0.15).

CONCLUSION

Although there was considerable variability present between the studies, all three diagnostic tests were moderately accurate in detecting intrauterine pathology. However, sonohysterography and hysteroscopy performed better than transvaginal ultrasound in detecting submucous fibroids.

Technology assessment of saline contrast hysterosonography

OBJECTIVE

The purpose of our study was to evaluate to which extent saline contrast hysterosonography (SCHS) is able to replace diagnostic hysteroscopy in uterine cavity evaluation in women suspected of intrauterine abnormalities.

STUDY DESIGN

In this prospective observational study we performed SCHS instead of diagnostic hysteroscopy. Diagnostic hysteroscopy was performed in case of failed or inconclusive SCHS. Univariate and multivariate analyses were used to assess subgroups for their risk of failure and inconclusiveness.

RESULTS

Two hundred fourteen women were included consecutively. SCHS was conclusive in 180 cases (84.1%), failed in 12 (5.6%), and inconclusive in 22 (10.3%). Uterine size above 600 cm(3) was the best predictor of failure and/or inconclusiveness (positive predictive value 0.42).

CONCLUSION

SCHS was able to replace 84% of the outpatient diagnostic hysteroscopies in uterine cavity evaluation in women suspected of intrauterine abnormalities. Our study showed that diagnostic hysteroscopy can be restricted to inconclusive or failed SCHS.

High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence

OBJECTIVE

Uterine leiomyoma, or fibroid tumors, are the leading indication for hysterectomy in the United States, but the proportion of women in whom fibroid tumors develop is not known. This study screened for fibroid tumors, independently of clinical symptoms, to estimate the age-specific proportion of black and white women in whom fibroid tumors develop.

STUDY DESIGN

Randomly selected members of an urban health plan who were 35 to 49 years old participated (n = 1364 women). Medical records and self-report were used to assess fibroid status for those women who were no longer menstruating (most of whom had had hysterectomies). Premenopausal women were screened by ultrasonography. We estimated the age-specific cumulative incidence of fibroid tumors for black and white women.

RESULTS

Thirty-five percent of premenopausal women had a previous diagnosis of fibroid tumors. Fifty-one percent of the premenopausal women who had no previous diagnosis had ultrasound evidence of fibroid tumors. The estimated cumulative incidence of tumors by age 50 was >80% for black women and nearly 70% for white women. The difference between the age-specific cumulative incidence curves for black and white women was highly significant (odds ratio, 2.9; 95% CI, 2.5-3.4; P <.001).

CONCLUSION

The results of this study suggest that most black and white women in the United States develop uterine fibroid tumors before menopause and that uterine fibroid tumors develop in black women at earlier ages than in white women.

Transvaginal sonography and saline infusion sonohysterography in the evaluation of abnormal uterine bleeding

OBJECTIVE

To evaluate the accuracy of transvaginal sonography (TVS) and saline infusion sonohysterography (SIS) in diagnosing submucous fibroids and endometrial polyps in the patients of abnormal uterine bleeding (AUB).

DESIGN

Prospective, comparative study.

SETTING

Postgraduate Institute of Medical Sciences, Rohtak.

POPULATION

Fifty patients with AUB underwent TVS and SIS prior to hysterectomy.

MAIN OUTCOME MEASURES

Comparison of diagnosis of submucous fibroids and endometrial polyps at TVS and SIS with the final diagnosis at hysterectomy ie 'gold standard'.

RESULTS

Both procedures were helpful in detecting submucous fibroids and endometrial polyps. However, SIS was found to be more useful (sensitivity 89.5%, specificity 100%, likelihood ratios of the presence and absence of submucous fibroids of infinity and 0.1 respectively) than TVS (sensitivity 70% and specificity 96.6% and likelihood ratios of 21.2 and 0.3 respectively) for submucous polyps. Saline infusion sonohysterography was also more accurate for endometrial polyps (sensitivity 100%, specificity 97.8%) than TVS (sensitivity 66.6%, specificity 100%). With SIS and TVS, the post-test probability with negative test was 0% and 4%, respectively, thus suggesting that no endometrial polyp would be missed on SIS.

CONCLUSION

Saline infusion sonohysterography is more accurate in diagnosing submucous fibroids and endometrial polyps in the patients of abnormal uterine bleeding than is TVS. TVS should be included in the standard protocol for the management of AUB. Saline infusion sonohysterography should be reserved for those patients who have centrally located fibroids as they may be submucous.

Comparison of sonohysterography and hysteroscopy: lessons learned and avoiding pitfalls

We compared ultrasound images of the uterine cavity obtained by sonohysterography (SHG) with those of hysteroscopy in an attempt to avoid inaccurate interpretations. Women referred for abnormal bleeding or infertility underwent SHG before treatment. Those with an abnormal study underwent hysteroscopy for confirmation and treatment. Abnormal SHG studies are frequent, with false positive images including blood clots, mucus plugs, and shearing of normal endometrium relatively common. Uterine pathology generally seen on SHG, including anomalies, polyps, and myomas, is consistent with that seen at hysteroscopy. Performing intraoperative SHG concomitantly with hysteroscopy adds value due to SHG's three-dimensional images to confirm depth of pathology and false negative hysteroscopy findings.

Color Doppler imaging in the sonohysterographic diagnosis of residual trophoblastic tissue

PURPOSE

The purpose of this study was to evaluate the role of color Doppler imaging during sonohysterography in the diagnosis of residual trophoblastic tissue.

METHODS

This prospective cohort study involved 25 consecutive women with clinical and sonographic signs of an echogenic intrauterine mass who were referred to the sonography unit of our institution for evaluation. All women underwent saline infusion sonohysterography with color Doppler sonographic evaluation. An operative hysteroscopy with histologic examination was performed in 17 cases.

RESULTS

Thirteen women (group A) had sonohysterographic features suggestive of residual trophoblastic tissue (ie, an echogenic intrauterine lesion not detached from the uterine wall after introduction of saline). The initial diagnosis was confirmed by histologic analysis in all cases. Blood flow was detected within the intrauterine mass in 6 (46%) of these 13 women; the resistance indices were low in all 6 cases (mean +/- standard error, 0.38 +/- 0.01). Twelve women (group B) had sonohysterographic findings negative for retained tissue, and no blood flow was detected within any of the intrauterine masses in this group (p < 0.05).

CONCLUSIONS

Our results confirm the potential role of color Doppler sonography in the initial diagnosis of residual trophoblastic tissue. The detection of color Doppler signals, especially with low-resistance flow, within an intrauterine lesion should increase the confidence of the sonologist in the diagnosis of residual trophoblastic tissue.

Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis, mapping, and measurement of uterine myomas

OBJECTIVE

The purpose of this study was to evaluate and compare the accuracy of magnetic resonance imaging and transvaginal ultrasonography in myoma diagnosis, mapping, and measurement.

STUDY DESIGN

This was a double-blind study of 106 consecutive premenopausal women who underwent hysterectomy for benign reasons. Myomas (total, 257) were exactly mapped by magnetic resonance imaging and transvaginal ultrasonography; in each patient, we counted correctly identified myomas with pathologic position as true value.

RESULTS

The presence of myomas was detected with the same high level of precision by both methods (magnetic resonance imaging: sensitivity, 0.99; specificity, 0.86; transvaginal ultrasonography: sensitivity, 0.99; specificity, 0.91). The mean number of correctly identified myomas was significantly higher by magnetic resonance imaging than by transvaginal ultrasonography (mean difference, 0.51 +/- 1.03; P <.001), a difference that narrowed to 0.08 +/- 0.76 (P =.60) in 26 patients with 1 to 4 myomas and uterine volumes <375 mL. Magnetic resonance imaging and transvaginal ultrasonography myoma diameter measurements had equal and high accuracies in patients with 1 to 4 myomas.

CONCLUSION

Transvaginal ultrasonography is as efficient as magnetic resonance imaging in detecting myoma presence, but its capacity for exact myoma mapping falls short of that of magnetic resonance imaging, especially in large (>375 mL) multiple-myoma (>4) uteri.

Imaging the endometrium: disease and normal variants

The endometrium demonstrates a wide spectrum of normal and pathologic appearances throughout menarche as well as during the prepubertal and postmenopausal years and the first trimester of pregnancy. Disease entities include hydrocolpos, hydrometrocolpos, and ovarian cysts in pediatric patients; gestational trophoblastic disease during pregnancy; endometritis and retained products of conception in the postpartum period; and bleeding caused by polyps, submucosal fibroids, endometrial hyperplasia, or endometrial adenocarcinoma. Other findings include tamoxifen-associated changes, intrauterine fluid collections, and endometrial adhesions. Although ultrasound (US) is almost always the first modality used in the radiologic work-up of endometrial disease, findings at sonohysterography, hysterosalpingography, magnetic resonance imaging, and computed tomography are often correlated with US findings. It is important to understand that the appearance of the endometrium is related to multiple factors, including the patient's age, stage in the menstrual cycle, and pregnancy status and whether she has undergone hormonal replacement therapy or tamoxifen therapy. Accurate diagnosis requires that these factors be taken into account in addition to clinical history and physical examination findings.

Uterine transplantation, abdominal trachelectomy, and other reproductive options for cancer patients

More and more women with cancer issues are now raising fertility concerns as survival improves and childbearing is delayed. Pregnancy is no longer contraindicated in cancer patients including breast and endometrial cancer survivors. In fact, survival in patients treated for breast cancer who subsequently become pregnant is actually higher than that in patients who do not become pregnant. "Therapeutic" abortions are no longer recommended. Assisted reproductive technology (ART) have been associated with ovarian neoplasms, but the association is probably not causal. Neither ART nor hormone replacement is contraindicated in cancer patients. Our institution is very supportive of patients and the difficult decisions cancer survivors face. Using a program of counseling and close collaboration between oncologists, perinatologists, and reproductive endocrinologists, informed patients are offered every possible option, including ART and uterine transplantation, to achieve their family planning objectives.

Evaluation of the uterine cavity with magnetic resonance imaging, transvaginal sonography, hysterosonographic examination, and diagnostic hysteroscopy

OBJECTIVE

To evaluate and compare the diagnostic accuracy of magnetic resonance imaging (MRI), transvaginal ultrasonography (TVS), hysterosonographic examination (HSE), and hysteroscopy in the evaluation of the uterine cavity.

DESIGN

Independent double-blind study.

SETTING

University medical hospital.

PATIENT(S)

One hundred six consecutive premenopausal women who underwent hysterectomy for benign diseases.

INTERVENTION(S)

Results of MRI, TVS, HSE, and hysteroscopy were compared with the results of histopathologic examination at hysterectomy (the gold standard).

RESULT(S)

The overall sensitivity was MRI 0.76, TVS 0.69, HSE 0.83, and hysteroscopy 0.84. The specificity was MRI 0.92, TVS 0.83, HSE 0.90, and hysteroscopy 0.88 (MRI, HSE, hysteroscopy vs. TVS <0.05). Polyps were missed in 9 of 12 cases at MRI, 7 at TVS, 4 at HSE, and 2 at hysteroscopy (MRI vs. hysteroscopy, and TVS vs. hysteroscopy <0.05). The sensitivity for identification of submucous myomas was MRI 1.0, TVS 0.83, HSE 0.90, and hysteroscopy 0.82; the specificity was MRI 0.91, TVS 0.90, HSE 0.89, and hysteroscopy 0.87 (MRI vs. TVS, and MRI vs. hysteroscopy). Magnetic resonance imaging was significantly more precise than TVS, HSE, and hysteroscopy in determining submucous myoma in-growth (2-way ANOVA <0.05).

CONCLUSION(S)

For exclusion of abnormalities in the uterine cavity, MRI, HSE, and hysteroscopy were equally effective and slightly superior to TVS. Magnetic resonance imaging and TVS missed endometrial abnormalities such as polyps, but MRI and HSE were most accurate for the evaluation of submucous myomas, and MRI was superior in evaluation of exact submucous myoma in-growth.

Fibroids and infertility: a systematic review of the evidence

A systematic literature review was performed to determine whether leiomyomata are associated with decreased fertility rates, and whether surgical removal increases fertility rates postoperatively. Meta-analysis was conducted when multiple studies addressed a single issue and were sufficiently homogeneous. Data were analyzed for effect of any fibroid upon fertility, as well as specific fibroid location. Results of studies comparing women with infertility and fibroids versus infertile controls showed widely disparate results. Subgroup analysis failed to indicate any effect on fertility of fibroids that did not have a submucous component. Conversely, women with submucous myomas demonstrated lower pregnancy rates (RR 0.30; 95% confidence interval [CI] 0.13--0.70) and implantation rates (RR 0.28; 95% CI 0.10--0.72) than infertile controls. Results of surgical intervention were similar. When all fibroid locations were considered together, myomectomy results were again widely disparate. However, when women with submucous myomas were considered separately, pregnancy was increased after myomectomy compared with infertile controls (RR 1.72; 95% CI 1.13--2.58) and delivery rates were now equivalent to infertile women without fibroids (RR 0.98; 95% CI 0.45--2.41). The current data suggest that only those fibroids with a submucosal or an intracavitary component are associated with decreased reproductive outcomes, and that hysteroscopic myomectomy may be of benefit.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to summarize the data on the role of fibroids and infertility, describe the effect of myomectomy on fertility, and list the methods used to evaluate intracavitary fibroids.

Transvaginal sonography combined with saline contrast sonohysterography in evaluating the uterine cavity in premenopausal patients with abnormal uterine bleeding

OBJECTIVES

To evaluate whether saline contrast sonohysterography (SCSH) adds additional information to that obtained by transvaginal sonography (TVS) for predicting endometrial abnormality in premenopausal patients with abnormal uterine bleeding.

PATIENTS AND METHODS

This was a two-center prospective study at a university clinic and a central hospital in Denmark. The uterine cavity was evaluated with TVS and SCSH in 470 premenopausal patients with abnormal uterine bleeding. One hundred and eighty-nine of the patients had operative hysteroscopy or hysterectomy within 4 months which provided a detailed description of the uterine cavity and was used as the true value for exclusion of polyps and submucous myomas.

RESULTS

Based on normal endometrial morphology alone, the results for detection of an abnormal uterine cavity were as follows: sensitivities of TVS 0.92, SCSH 0.99; specificities of TVS 0.62, SCSH 0.72; positive predictive values of TVS 0.80, SCSH 0.85; negative predictive values of TVS 0.82, SCSH 0.98. Transvaginal sonography combined with SCSH was superior to TVS for detection of intracavitary abnormalities (McNemar test, P = 0.008). The post-test probability of there being an abnormal cavity after normal findings on TVS alone was 0.18 (0.10-0.32) and after TVS and SCSH it was 0.02 (0.01-0.11). When normal endometrial morphology was combined with an endometrial thickness of < 12 mm for evaluation of all abnormalities including hyperplasia, the diagnostic potential of TVS or SCSH was almost unchanged except for specificities, which were markedly lower (TVS 0.54; SCSH 0.57). In all the patients referred, TVS had a negative predictive value of 0.94 for identification of polyps and myomas when findings at subsequent SCSH were accepted as the true value. Transvaginal sonography reduced the pretest probability of polyps or submucous myomas from 0.35 to a post-test probability of 0.06, but missed 21% of the polyps.

CONCLUSIONS

Sonohysterography was a sensitive tool and was superior to TVS used alone for evaluation of the uterine cavity in patients who underwent operative surgery for abnormal uterine bleeding. All abnormalities except one were found at SCSH, while TVS alone missed polyps and had almost one in four equivocal findings. The use of TVS, without saline contrast, left one in five of the polyps undiagnosed in referred patients with abnormal bleeding.

Traditional surgical approaches to uterine fibroids: abdominal myomectomy and hysterectomy

Abdominal myomectomy and hysterectomy remain the traditional treatment of large symptomatic uterine myomas. The preoperative indications for abdominal myomectomy or hysterectomy must be clearly evaluated and delineated avoid unnecessary intervention. There appears to be an increasing trend toward expectant management for asymptomatic uterine myomas. Women should consider the options of myomectomy and hysterectomy when their symptoms are severe enough to warrant intervention and the benefits of intervention outweigh the risks. The advantages and disadvantages of preoperative medical also must be addressed before intervention. The factors influencing the choice of therapy seem to be strongly dependent on both the patient and physician preferences. A clinical approach to abdominal myomectomy in patients with infertility and repetitive miscarriage has been presented in this chapter. The rapid development and use of minimally invasive innovations and adjunctive medical therapies has provided clinicians with a wealth of alternatives. A practical and cost-effective approach based on the data currently available have been presented; however, there remains a paucity of prospective randomized data to evaluate and compare the effectiveness and safety of these alternative treatments to abdominal myomectomy and hysterectomy. Future studies should help define the optimal candidates for traditional surgical treatment with abdominal myomectomy and hysterectomy.

Impact of intramural leiomyomata in patients with a normal endometrial cavity on in vitro fertilization-embryo transfer cycle outcome

OBJECTIVE

Assess the impact of intramural uterine leiomyomata and a normal endometrial cavity on IVF-ET cycle outcome.

DESIGN

Retrospective case-controlled analysis.

SETTING

Tertiary-care-assisted reproductive technology program.

PATIENT(S)

Three hundred ninety-nine consecutive fresh IVF-ET cycles were performed in patients with a normal precycle diagnostic hysteroscopy; patients were divided into four groups. Group 1: positive leiomyomata, age <40 years (n = 51 cycles); group 2: negative leiomyomata, age <40 years (n = 57 cycles); group 3: positive leiomyomata, age > or =40 years (n = 22 cycles); group 4: negative leiomyomata, age > or =40 years (n = 59 cycles). A subgroup of all group 2 patients aged 35-39 (group 2A, n = 113 cycles) was also evaluated as an additional control.

INTERVENTION(S)

Controlled ovarian hyperstimulation, IVF-ET.

MAIN OUTCOME MEASURE(S)

Implantation (IR), live birth (LBR) rates.

RESULT(S)

There were no significant differences in LBR among age-matched controls: group 1 (49%) versus 2 (57.5%) or 2A (57%) and group 3 (40.9%) versus 4 (32.2%). IR was significantly lower in group 1 (21.4%) versus 2 (33.3%) or 2A (33.9%) but not in group 3 (17.5%) versus 4 (11.6%). Implantation did not correlate with either mean leiomyoma diameter or volume.

CONCLUSION(S)

[1] LBR was not affected by the presence of intramural leiomyoma in IVF-ET patients with hysteroscopically normal endometrial cavities. [2] A significant decrease in IR was only noted in patients <40 years old. [3] Given the relatively high LBR in all groups, prophylactic surgical intervention cannot be justified, but precycle hysteroscopy evaluation is recommended.

Radiographic imaging techniques for the diagnosis of abnormal uterine bleeding

The introduction of SIS has been a significant advance in TVUS evaluation of the endometrial cavity in the 1990s. SIS provides an unparalleled, clear, enhanced view of the endomyometrial complex that cannot be obtained with TVUS alone. Focal and global endometrial pathology can be differentiated with SIS. Saline infusion improves the sensitivity for the detection of endometrial abnormalities. The continuing challenge for gynecologists is to provide patients with cost-effective, minimally invasive evaluation and directed therapy for menstrual dysfunction. SIS targets patients needing biopsy, directs the surgical approach, and minimizes office diagnostic hysteroscopy--all with a quick office procedure. For patients, the benefits include minimal and brief discomfort and a better understanding of intrauterine pathology through viewing the ultrasound monitor. Patients also appreciate the ease of scheduling, the minimal time away from work, and that no escort is needed after the procedure. SIS provides an extension of the pelvic gynecologic examination. SIS is the most important imaging modality for evaluating endometrial pathology. Although there is no perfect test to evaluate the endometrium, overall, SIS is superior to other imaging and diagnostic procedures. It is less expensive than D&C or hysteroscopy. It is a safe, efficient, convenient, and well-tolerated procedure. In some instances, however, neither TVUS nor SIS is definitive in determining the location of fibroids or able to discern adenomyosis. In these instances, MR imaging triage is helpful. MR imaging is gaining widespread acceptance and, in many instances, is a cost-effective tool in the evaluation of abnormal uterine bleeding. It is noninvasive, differentiates uterine anatomy in response to exogenous hormones or the normal menstrual cycle, and reliably localizes pelvic pathology and size of lesions. When uterine conservation is desired in women with fibroids and TVUS or SIS is indeterminate in localizing depth of myometrial involvement of a fibroid, MR imaging should be considered as a part of the clinical algorithm. The precision of MR imaging localization of submucosal fibroids can obviate the need for hysterectomy and permit a skilled surgeon to hysteroscopically resect the fibroids. If the clinical examination is suspicious for adenomyosis and the US is nondiagnostic, the clinician should consider MR imaging strongly. When the results of the imaging study would influence surgical route and planning, MR imaging should be considered in the preoperative evaluation.

Accuracy of preoperative diagnostic tools and outcome of hysteroscopic management of menstrual dysfunction

STUDY OBJECTIVES

To review diagnoses, complications, and surgical findings in women treated for abnormal uterine bleeding by operative hysteroscopy, and to assess the accuracy of preoperative transvaginal ultrasound (TVS), saline-infusion sonography (SIS), diagnostic hysteroscopy, and endometrial biopsy.

DESIGN

Retrospective study (Canadian task force classification II-2).

SETTING

Tertiary care academic medical center.

PATIENTS

Three hundred seventy-five women. Intervention. Operative hysteroscopy for abnormal uterine bleeding.

MEASUREMENTS AND MAIN RESULTS

Main indications for hysteroscopy were postmenopausal bleeding (164 patients, 43.7%) and abnormal premenopausal uterine bleeding (211, 56.3%). Main pathology findings were endometrial polyps (172, 45.9%) and submucous myomas (105, 28%). Polyps had histologic abnormalities in 18 patients. Sensitivity of preoperative diagnostic tools for all intrauterine abnormalities and specifically for myomas and polyps was TVS 74% and 39%, SIS 96% and 96%, hysteroscopy 100% and 99%, and Pipelle biopsy 24% and 10%. The complication rate was 1.3%. Postmenopausal women felt significantly more improvement in symptoms (p = 0.02), and were more satisfied (p </=0.001) than premenopausal women. Only 10 women had repeat surgery for the problem.

CONCLUSION

Operative hysteroscopy is a safe outpatient procedure and is associated with high satisfaction in carefully selected patients. Hysteroscopy and SIS are better diagnostic tests for intracavitary abnormalities than TVS and endometrial biopsy.

Diagnostic accuracy of sonohysterography, transvaginal sonography, and hysterosalpingography in patients with uterine cavity diseases

OBJECTIVE

To evaluate the diagnostic accuracy of sonohysterography (SHG) in uterine cavity diseases in infertile patients, comparing its results with those of hysterosalpingography (HSG) and transvaginal sonography (TVS). Hysteroscopy was the gold standard.

DESIGN

Descriptive, prospective study.

SETTING

A tertiary university referral center.

PATIENT(S)

Sixty-five infertile women 19 to 43 years of age.

INTERVENTION(S)

Patients underwent SHG, conventional TVS, HSG, and hysteroscopy.

MAIN OUTCOME MEASURE(S)

The results of each examination were compared with those obtained by the gold standard. The following diagnoses were considered separately: polypoid lesions, uterine malformations, intrauterine adhesions, and endometrial hyperplasia (EH). Sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively), and 95% confidence intervals were calculated.

RESULT(S)

Sonohysterography had the same diagnostic accuracy as the gold standard for polypoid lesions and EH, with no equivocal diagnosis. Hysterosalpingography showed a sensitivity of 50% and a PPV of 28.6% for polypoid lesions and a sensitivity of 0% for EH. Transvaginal sonography had both sensitivity and PPV of 75% for polypoid lesions and EH. For uterine malformations, SHG had a sensitivity of 77.8%, whereas TVS and HSG both had a sensitivity of 44.4%. Sonohysterography and HSG had a sensitivity of 75% in the detection of intrauterine adhesions and respective PPVs of 42.9% and 50%. Transvaginal sonography showed sensitivity and PPV of 0% for this diagnosis.

CONCLUSION(S)

Sonohysterography was in general the most accurate test. Its diagnostic accuracy was markedly superior for polypoid lesions and EH, with total agreement with the gold standard. In diagnosis of intrauterine adhesions, SHG had limited accuracy, similar to that obtained by HSG, with a high false-positive diagnosis rate.

The use of chorionic villus biopsy catheters for saline infusion sonohysterography

BACKGROUND

Saline infusion sonohysterography is one of the recent refinements of ultrasonography that has the ability to enhance imaging of the uterine cavity in a safe, inexpensive and expedient manner. The technique can be difficult in women with a stenotic cervical os. This report describes a single-pass technique using chorionic villus sampling (CVS) catheters for saline infusion sonohysterography.

METHOD

Saline infusion sonohysterography requires the transcervical passage of a catheter, through which saline is infused. The subsequent distension of the uterine cavity enhances the ability to detect intrauterine pathology with ultrasonography. In women with cervical stenosis, a catheter can be used in place of the more conventional two-pass technique, which requires the use of a uterine sound or probe followed by a conventional catheter.

EXPERIENCE

We have used CVS catheters in women with cervical stenosis on 12 occasions. All have been successful and without significant discomfort to the patient.

CONCLUSION

The use of CVS catheters for saline infusion sonohysterography in women with cervical stenosis can alleviate the need to remove the cervical probe prior to introduction of the catheter.

A randomised controlled trial comparing transvaginal ultrasound, outpatient hysteroscopy and endometrial biopsy with inpatient hysteroscopy and curettage

OBJECTIVE

To compare the use of outpatient and inpatient procedures in the investigation of abnormal uterine bleeding.

DESIGN

A randomised controlled trial.

SETTING

Two university teaching hospitals.

PARTICIPANTS

Four hundred women with abnormal uterine bleeding (postmenopausal bleeding, menorrhagia, intermenstrual bleeding, postcoital bleeding, or irregular periods) above the age of 35 years, between June 1993 and January 1995.

MAIN OUTCOME MEASURES

1. Incidence of detection of abnormal pathology by vaginal ultrasound, outpatient hysteroscopy and endometrial biopsy compared with inpatient hysteroscopy and curettage; 2. Number of 'lesions' (e.g. fibroids, polyps, endometrial hyperplasia or malignancy) found by hysteroscopy that would have been missed by the combination of endometrial sampling and ultrasound; 3. Comparison of the quality of tissue obtained for histology by outpatient endometrial sampling and inpatient curettage; and 4. An evaluation of patient acceptability of outpatient and inpatient procedures.

RESULTS

1. A combination of transvaginal sonography, Pipelle endometrial biopsy and outpatient hysteroscopy has similar efficacy to inpatient hysteroscopy and curettage for the investigation of abnormal uterine bleeding; 2. Hysteroscopy will detect some fibroids and polyps missed by a combination of transvaginal ultrasound and Pipelle endometrial sampling; 3. The quality of histological samples obtained by outpatient Pipelle were comparable to those obtained by formal inpatient curettage; and 4. Outpatient procedures were well tolerated, with good patient acceptability.

CONCLUSION

Transvaginal sonography and endometrial biopsy can safely be used as the initial investigations in the management of abnormal uterine bleeding. Hysteroscopy can be used as a second line investigation. Outpatient hysteroscopy with local anaesthesia is well tolerated although general anesthesia may occasionally be necessary.

Sonohysterography: technique, endometrial findings, and clinical applications

Transvaginal ultrasound-guided saline infusion sonohysterography (SHG) is a relatively new technique for evaluation of the uterine cavity. As new studies declare the clinical usefulness of this technique, SHG may quickly become part of the routine ultrasound evaluation of the female pelvis. In this article, the SHG procedure is described and normal findings are discussed. Common endometrial pathological findings such as atrophy, polyps, fibroids, hyperplasia, and carcinoma are reviewed. The newly touted roles of SHG for screening patients on long-term tamoxifen therapy and for evaluating patients with infertility are introduced. Finally, we present a practical ultrasound-based flow chart for the workup of menopausal and perimenopausal patients with abnormal uterine bleeding.

Operative ultrasonography for upper genital tract pathology

PURPOSE

A procedure using transvaginal sonohysterography (SHG) to perform operative intrauterine biopsies and resections is described.

METHODS

Seven women, six with intrauterine pathology noted on diagnostic SHG and one with a thickened endometrium noted on transvaginal ultrasonography, underwent attempted operative SHG. The indications were peri- and postmenopausal bleeding (n = 4) and infertility requiring assisted reproduction (n = 3). Access to the uterine cavity was accomplished with a 9-F cervical access catheter (CAC) with a 3-ml balloon (BEI Medical Systems, ZSI Gynecology Products Division, Chatsworth, CA), which was placed in the cervical canal or lower uterine segment. Depending on the position of the noted uterine pathology, a 6-F uterine ostial access catheter (UOAC) (BEI Medical Systems, ZSI Gynecology Products Division) was placed through the CAC. The uterine cavity was distended with 5-10 ml of 1% Lidocaine and a 3-F loop grasper or finger-like biopsy grasper was then passed through the UOAC or a 5-F operative instrument directly within the CAC with attempted resection under ultrasound guidance. Biopsied samples were sent to pathology for definitive diagnosis. Office hysteroscopy was then performed to confirm adequate resection.

RESULTS

Three of six patients had adequate resection or biopsy of intrauterine pathology, while the seventh patient successfully had a directed biopsy of the fundal cavity under ultrasound guidance. In one case, the visualized lesion could not be grasped. In the other two cases, each patient had severe cervical stenosis and declined in-office cervical dilation precluding the procedure. Each procedure was well tolerated, with an average time from start to finish of about 25 min (range, 18-43 min) without complications.

CONCLUSIONS

Operative SHG makes it possible to resect and biopsy intrauterine pathology often missed on Pipelle sampling. If found to be as effective as hysteroscopy, operative SHG would provide a cost-effective alternative. Further study is ongoing to perfect the existing instruments to allow removal of larger lesions both safe and possible.

A prospective study of transvaginal hydrosonography in the evaluation of abnormal uterine bleeding

OBJECTIVE

The purpose of this study was to determine whether the intrauterine instillation of saline solution during transvaginal ultrasonographic imaging (hydrosonography) improves the diagnostic accuracy in detecting intrauterine abnormalities determined by direct visualization of the intrauterine cavity with either hysteroscopy or after hysterectomy.

STUDY DESIGN

This study was a prospective, blinded study of 39 women referred with the diagnosis of abnormal uterine bleeding after failing medical management. A routine vaginal probe ultrasonographic examination was followed by a blinded transvaginal hydrosonography in patients proceeding to either hysteroscopy or hysterectomy.

RESULTS

Twelve of the 39 patients had masses that impinged on the intrauterine cavity at hysteroscopy or hysterectomy. In 4 of the 12 patients with confirmed masses, an intrauterine lesion was detected by hydrosonography that was not seen on routine vaginal probe ultrasonography. In no case was an intrauterine mass detected by the hysteroscopy or after hysterectomy when hydrosonography indicated a normal intrauterine cavity. In 4 cases hydrosonography suggested that masses were present that were not confirmed at direct visualization. Although hydrosonography always recognized when intracavitary pathologic conditions existed in a patient, hydrosonography sometimes underestimated the number of intracavitary lesions present.

CONCLUSIONS

Hydrosonography is a simple, minimally invasive, and effective tool to use in the evaluation of patients with abnormal uterine bleeding who have not responded to medical treatment. In no case did hydrosonography fail to indicate when pathologic conditions existed in a given patient, and a normal hydrosonography always indicated a normal intrauterine cavity at hysteroscopy or after hysterectomy. For these reasons hydrosonography is a sensitive tool to triage women with abnormal uterine bleeding to operative or conservative management.

The role of transvaginal ultrasound in the investigation of women with post-menopausal bleeding

One-hundred and eighty-two women with post menopausal bleeding were examined with transvaginal ultrasound (TVUS) over a 16-month period. The imaging findings were correlated with the pathological specimens. One-hundred and forty had pipelle aspiration cytology and 35 hysteroscopy, dilatation and currettage and seven a hysterectomy. Endometrial thickness on TVUS was classified as either thin (equal to or less than 5 mm), thick (greater than 5 mm), or not seen. A thin endometrium was noted in 87 patients, in whom no pathological abnormality was found in 84 (negative predictive value 95%). There were three cases of hyperplasia or polyps but no carcinomas occurred in this group (negative predictive value for carcinoma 100%). A thickened endometrium was noted in 82 patients. In this group there were five carcinomas, nine polyps and eight cases of endometrial hyperplasia (positive predictive value 29%). In five patients the endometrium could not be identified. One carcinoma occurred in this group. There were an additional eight patients who were taking tamoxifen who were grouped separately. If a clear symmetrical endometrial stripe measuring less than or equal to 5 mm in thickness on TVUS is seen the probability of malignancy is extremely low and endometrial biopsy can probably be avoided in this group particularly in the context of an isolated episode of postmenopausal bleeding. If the endometrium is not seen or is thicker than 5 mm then endometrial biopsy is indicated.

Sonohysterographic screening before in vitro fertilization

OBJECTIVE

To evaluate the use of sonohysterography for uterine screening before IVF.

DESIGN

Prospective screening with sonohysterography and comparison with available hysterosalpingographic and hysteroscopic evaluations.

SETTING

Private practice.

PATIENT(S)

Seventy-two women undergoing IVF-ET using their own or donor eggs.

INTERVENTION(S)

Sonohysterography was performed by instilling saline into the uterine cavity through an intracervical balloon catheter; there was concurrent vaginal sonographic visualization in all cases.

MAIN OUTCOME MEASURE(S)

Sonohysterographic findings and pregnancy rates.

RESULT(S)

Cavitary lesions were detected in 8 (11.1%) of 72 sonohysterographic examinations. Six of 8 cases were confirmed and treated by hysteroscopy. After sonohysterographic evaluation, 35 (48.6%) of 72 patients conceived, resulting in 25 ongoing or delivered pregnancies, 5 chemical pregnancies, and 5 spontaneous abortions. No statistically significant difference was observed in the pregnancy outcome for patients undergoing IVF who had sonohysterography compared with that for patients undergoing IVF during the same period who previously had a uterine evaluation by a different method. The estimated cost savings per patient undergoing sonohysterography instead of in-office hysteroscopy was $275.

CONCLUSION(S)

Sonohysterography offers advantages over in-office hysteroscopy and hysterosalpingography for evaluation of the uterus before IVF.

A Review of Sonohysterograhy for Evaluation of Uterine Bleeding in the Postmenopausal Woman

Sonohysterography is a noninvasive procedure that uses fluid to artificially distend the uterine cavity. The fluid fills the endometrial cavity, allowing visualization of any pathology that might be present. Sonohysterography is not difficult to perform and is usually well-tolerated by the patient. It provides valuable information to the physician, and may prove other, more invasive, procedures unnecessary.

Upper genital-tract screening with hysterosonography in patients receiving donated oocytes

OBJECTIVE

To compare the results of sonohysterography (SHG) for imaging of the uterine cavity to hysterosalpingogram (HSG) and hysterscopy (HSC) in order to assess its clinical utility for recipients of donated oocyte.

METHOD

From January 1996 to December 1996, we evaluated all patients (n = 50) referred for ovum donation using SHG and compared the results with HSG obtained within 6 months of SHG. Patients having either an abnormal SHG of HSG underwent HSC for confirmation and treatment. SHG was routinely performed during the early follicular phase using 10 cc saline instilled through an intracervical H-S catheter with concurrent vaginal sonography.

RESULT

Pathology was observed and confirmed in 19 cases (38%) including polyps (n = 10, 52.6%), submucosal myomas (n = 7, 36.8%), intrauterine adhesions (n = 1, 5.3%) and bicornuate uterus (n = 1, 5.3%). SHG and HSG were concordant in 46 cases (95.8%) of which in 29 (60.4%) a normal cavity was observed, while four studies (8%) did not agree. Two polyps were missed on HSG, while two SHGs incorrectly diagnosed a calcified myoma and an endometrial fold. Using HSC for definitive identification, the accuracy of SHG was 90%, and similar to HSG.

CONCLUSION

SHG appears both sensitive and highly predictive for evaluating pathology of the endometrial cavity and appears to be as effective as HSG. Advantages of SHG include improved imaging or uterine pathology, cost, greater patient comfort and the avoidance of radiation. Routine SHG of recipients uncovered a high incidence of abnormalities in older women and underscores the need to evaluate the uterine cavity prior to ovum donation.

Uterine myomas and factors associated with hysterectomy in premenopausal women

OBJECTIVE

Our purpose was to describe clinical characteristics in premenopausal women with uterine myomas and to identify factors associated with hysterectomy.

STUDY DESIGN

Data were collected by chart abstraction in 421 premenopausal women with myomas and analyzed by univariate and multivariable regression.

RESULTS

Over a median follow-up period of 29 months, 86% of women had symptoms associated with myomas and 40% had an increase in uterine size of > 2 gestational weeks. By multivariable regression, bleeding symptoms at presentation and previous surgical history of cholecystectomy and adhesiolysis were significantly associated with greater odds of hysterectomy. There was a significant interaction between age and uterine size, so that as age increased, uterine size had a greater impact on the likelihood of hysterectomy.

CONCLUSIONS

In this cohort of premenopausal women myomas were associated with symptoms in almost all women over the follow-up period. Hysterectomy was performed in 22% of women overall.

Three-dimensional hysterosonography for the study of endometrial tumors: comparison with conventional transvaginal sonography, hysterosalpingography, and hysteroscopy

We studied endometrial thickness and homogeneity in 36 patients with postmenopausal bleeding using three-dimensional ultrasound following distention of the uterine cavity with a sterile saline solution (3D-SHSG). Results with 3D-SHSG were compared with findings using transvaginal sonography, transvaginal sonohysterography, transvaginal color Doppler, and hysteroscopy. Sixteen patients (including three on tamoxifen) were undergoing hormone therapy at the time when they were studied. Visualization of the uterine cavity and of endometrial thickness was better with 3D-SHSG than with any of the other ultrasound techniques. The results with 3D-SHSG corresponded to the findings observed with hysteroscopy. Three-dimensional SHSG seems to improve ultrasound determination of myometrial and cervical invasion in cases of endometrial adenocarcinoma.

Saline infusion sonohysterosalpingography, an underutilized technique

Saline infusion sonohysterography (SIS) is an important gynaecological diagnostic tool which is little used in Australia. We herein report the findings in 60 women referred for SIS, the procedure being uneventfully performed in 55. Forty-nine of the 60 referrals were for investigation of abnormal uterine bleeding. The technique described allows examination of the uterine cavity and the Fallopian tubes. In 26 of the patients information was obtained which improved or altered the diagnosis made on B mode and colour Doppler ultrasound. Unlike hysteroscopy, SIS is always performed as an outpatient procedure, appropriate disinfection procedures are relatively simple to implement (1), and vasovagal reactions are rare. Hysteroscopy was avoided in 11 patients, there were other benefits in 4 patients, and in only 1 of 16 patients did the hysteroscopy findings differ with SIS. If diagnostic pitfalls are avoided by careful attention to detail, SIS offers a powerful new gynaecological investigative tool in the investigation of bleeding disorders (including menorrhagia, intermenstrual and postmenopausal bleeding), uncertain endometrial findings on vaginal ultrasound, infertility, and in the investigation of congenital and acquired uterine abnormalities.

Sonohysterography for screening in recurrent pregnancy loss

OBJECTIVE

To evaluate the role of sonohysterography for screening of the uterine cavity in patients with recurrent pregnancy loss.

DESIGN

Prospective evaluation of sonohysterography, including comparison with available hysterosalpingography and hysteroscopy.

SETTING

University referral center.

PATIENT(S)

Thirty-four reproductive-aged women with at least two consecutive pregnancy losses.

INTERVENTION(S)

Sonohysterography was performed on all patients, using saline instilled through an endocervically placed balloon catheter with concurrent vaginal sonography.

RESULT(S)

Seventeen of 34 sonohysterograms (50.0%) demonstrated intrauterine abnormalities. Eighteen of 34 cases have undergone hysteroscopy or, in 1 case, laparoscopy. All confirmed the positive or negative sonohysterographic finding, resulting in a sensitivity and specificity of 100%. Additionally, 100% (12/12) of the defects were diagnosed accurately at sonohysterography when confirmed by surgery. Twenty-seven of 34 patients also had a hysterosalpingogram that demonstrated a 90.0% sensitivity and 20.0% specificity based on hysteroscopic findings, yet only 5 of 11 (45.5%) defects were diagnosed accurately at hysterosalpingography when compared with surgery.

CONCLUSION(S)

Sonohysterography is a highly sensitive, specific, and accurate screening tool for the evaluation of uterine cavitary defects associated with recurrent pregnancy loss and offers several advantages over hysterosalpingography.

Ultrasound contrast media and their use in obstetrics and gynecology

Contrast media have gained acceptance to enhance ultrasonography in many fields of medicine; in particular, cardiology. Several agents have been described and many more are being manufactured and tested. By increasing the number of strong sound scatterers, these agents improve images by increasing the amount of echoes. This is true both for grey-scale and color or Doppler imaging. Their use in obstetrics is very limited at the moment because of safety issues. In a laboratory setup, they have been shown to markedly enhance placental imaging. In gynecology, imaging of the uterine cavity and Fallopian tubes is greatly improved. A potential area where ultrasound contrast may find a role is gynecological oncology. Vascularity is increased in many tumors, but usually vessel diameter is small and velocity low. One can therefore expect future use of the ultrasound contrast agents in ovarian or other gynecological neoplasms.

Hysteroscopic myomectomy

STUDY OBJECTIVE

To review the results of hysteroscopic myomectomy in 75 women with menorrhagia.

DESIGN

A retrospective analysis of 75 women who were evaluated and treated between November 1, 1988, and March 3, 1994.

SETTING

Private gynecologic practice.

PATIENTS

Seventy-five women with menorrhagia with confirmed hysteroscopic evidence of one or more submucous myomata.

INTERVENTIONS

Sixty-five women who had completed their childbearing underwent myomectomy and a concomitant procedure to destroy the endometrium. The remaining 10, who wished to retain their childbearing ability, underwent myomectomy alone. With two new techniques, large submucous myomata were removed rapidly and efficiently. Both laparoscopy and intraoperative ultrasound were performed when surgical guidance and control were thought to be necessary.

MEASUREMENTS AND MAIN RESULTS

Myomectomy was performed in 55 (73%) of women without intraoperative control, and in 10 (13.4%) with laparoscopic and ultrasound control. No serious complications occurred. Three patients had leiomyomas of uncertain malignant potential, the significance of which underscores the importance of having all the tissue that is excised evaluated histologically. The outcome of a single operation was satisfactory to 84% of women.

CONCLUSIONS

Hysteroscopic myomectomy to control menorrhagia appears to be a safe and effective procedure. Two new techniques should improve its efficiency. In addition, controlling with ultrasound may help to avoid perforation injuries and obviate the need for laparoscopic guidance.