Comparison of transvaginal sonography, saline infusion sonography, and office hysteroscopy in reproductive-aged women with or without abnormal uterine bleeding

Comparison of Endometrial Polyp Characteristics in Transvaginal Sonography and Hysteroscopy in Predicting Endometrial Malignancies in Premenopausal and Postmenopausal Women

Background

Hysteroscopy is known as the gold standard for endometrial polyps diagnosis and its findings on vascularity, size, and number of polyps can indicate malignancy, but it is a relatively expensive method with some complications. Ultrasound is a common part of the gynecological examination, and with technological advances, its ability to predict pathological outcomes has increased. This study aimed to determine the accuracy of ultrasound in diagnosing the characteristics of endometrial polyps.

Materials and Methods

This diagnostic value study was performed on 300 premenopausal and postmenopausal women over 40 years of age with endometrial polyps referred to Alzahra and Beheshti hospitals in Isfahan. The characteristics of endometrial polyps were evaluated by transvaginal ultrasonography and hysteroscopy and biopsy specimens were sent for pathological evaluations.

Results

In this study, 103 premenopausal women and 197 postmenopausal women were evaluated. Malignancy was confirmed by pathology in 4 premenopausal women (2%) and 2 postmenopausal women (2%). In both hysteroscopy and ultrasound methods, the frequency of vascularity was significantly different in postmenopausal and premenopausal women, but the other features of the polyp were not significantly different in them. Ultrasonic sensitivity in detecting the presence of vascularity, polyps larger than 1.5 mm, more than 1 polyp, and the presence of pedicle were 39.04, 57.38%, 91.93 and 94.95%, respectively, its specificity were 98.94, 36.47, 99.57 and 98.89% respectively.

Conclusion

A comparison of the characteristics of polyps in both ultrasound and hysteroscopy methods shows that hysteroscopy has been more effective in diagnosing malignancy and ultrasound has not have acceptable sensitivity in diagnosing size and vascularity.

Post-Menopausal Bleeding: Role of Imaging

Post-menopausal bleeding (PMB) accounts for 5% of gynecologic office visits and is the presenting symptom in 90% of women with endometrial cancer, which requires prompt evaluation. The most common etiology of PMB is vaginal or endometrial atrophy and endometrial polyps, while endometrial hyperplasia and carcinoma account for less than 10% of PMB. Transvaginal ultrasonography measurement of an endometrial thickness (EMT) less than or equal to 4 mm has a 99% negative predictive value for endometrial carcinoma. Endometrial sampling is required if EMT >4 mm or persistent bleeding occurs. Further evaluation can be accomplished with saline infusion sonography, magnetic resonance imaging, and hysteroscopy.

Using transvaginal ultrasounds for the identification of follicle-like structures ≥10 mm in a multi-center randomized contraceptive clinical trial of three 84-day oral ulipristal acetate regimens

PURPOSE

We examine the use of transvaginal sonography in imaging ovarian follicles among non-pregnant reproductive-aged women enrolled in a contraceptive clinical trial.

METHODS

Ten sites conducted a clinical trial comparing three oral ulipristal acetate regimens for ovulation inhibition. Enrollees underwent twice weekly transvaginal sonography and hormonal blood testing throughout treatment and until the second menses post-treatment. The primary outcome of the present analysis was success in identifying follicles ≥10 mm in a subgroup of sonograms performed at times of likely follicular activity (estradiol <100 pg/ml and progesterone >3 ng/ml). Secondarily, an overall analysis assessed all sonograms regardless of timing.

RESULTS

At times of likely follicular activity, 135 women underwent 969 sonograms. The proportion of sonograms without follicles ≥10 mm ranged from 8.3% to 46.3% when stratified by site (p = .01). The odds of no follicle among higher-body mass index (BMI) women were 1.91 times those among lower-BMI women after controlling for site and treatment arm (95% CI: 1.13, 3.22). Results were similar for the overall population.

CONCLUSION

Sonographers were less likely to identify follicles for higher-BMI women and results varied by site. Machine quality slightly impacted sonogram results, but did not sufficiently explain site differences.

Modern assessment of the uterine cavity and fallopian tubes in the era of high-efficacy assisted reproductive technology

The high efficacy of modern assisted reproductive technology (ART) and increase in the number of noninfertile patients who are using ART for family building in the United States call into question the relevance of the standard, one-size-fits-all infertility evaluation. Here, we explore whether all patients presenting for ART need uterine cavity and tubal assessment and what tests are most appropriate, efficient, and cost-effective in current times.

Patient and provider satisfaction with saline ultrasound versus office hysteroscopy for uterine cavity evaluation prior to in vitro fertilization: a randomized controlled trial

PURPOSE

To compare patient and provider satisfaction with saline ultrasound (SIS) versus office hysteroscopy for cavity evaluation prior to in vitro fertilization (IVF) and to assess the capability of hysteroscopy to manage pathology at time of diagnosis to reduce delays and supernumerary procedures.

METHODS

This was a randomized, controlled trial in a university fertility clinic. One hundred enrolled subjects undergoing routine uterine cavity evaluation prior to planned embryo transfer were randomized to SIS or office hysteroscopy without anesthesia. Subjects and providers completed surveys about their experience. Subjects with findings on SIS had a hysteroscopy performed or scheduled for further evaluation. Those with hysteroscopy findings had management attempted within the same procedure.

RESULTS

Overall patient satisfaction was high and did not differ between groups, while providers indicated that hysteroscopy provided a better cavity evaluation. There was no difference in time to complete procedures between groups. Pain score on a ten-scale was slightly higher in the hysteroscopy group compared to the SIS group (3.38 ± 1.85 vs. 2.44 ± 1.64, p < 0.01), but this did not impact satisfaction scores. Although pathology was found in a similar rate (22% vs. 36% for SIS and HSC groups, respectively), those in the SIS group all required secondary procedures, while only 1/17 did in the HSC group (p < 0.01).

CONCLUSION

Although the hysteroscopy group exhibited slightly higher pain scores, overall patient and provider satisfaction was high and similar between groups. There were significantly fewer secondary procedures and delays in the hysteroscopy group. Hysteroscopy is a reasonable first line screening tool for patients requiring cavity evaluation.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT04415489.

Comparative retrospective study on transvaginal sonography versus office hysteroscopy in the diagnosis of endometrial pathology among different subgroups

BACKGROUND

Transvaginal sonography (TVS) and office hysteroscopy are considered essential diagnostic tool for the gynecologic everyday practice. Through the years equipment developments in both techniques along with cumulative experience gained by the gynecologists result in a disunity among clinicians in choosing optimal diagnostic approach with regards to endometrial pathology.

AIM

To evaluate the diagnostic accuracy of TVS versus office hysteroscopy (OHSC) in detecting endometrial pathology. Results were compared to available scientific evidence available among similar published studies.

METHODS

Comparative Retrospective study performed at the Endoscopic Unit, Department of Gynecology, University Hospital of Ioannina, Greece. A total of 2675 cases were collected for this study from January 1997 until August 2019. All cases recruited underwent a TVS followed by office hysteroscopy (OHSC) for various indications according to the local protocol. Endometrial samples from all cases were obtained and histology confirmed the diagnosis. Sonographic and hysteroscopic results were correlated with histologic reports to assess the diagnostic accuracy of both techniques.

RESULTS

In a total of 2675 cases recruited for this study, 23.2% were postmenopausal while the majority (76.7%) was of reproductive age. The commonest indication for hysteroscopy was abnormal uterine bleeding (AUB) accounting for 29.7% of the cases. Overall, TVS demonstrated diagnostic accuracy of 84.7%% in detecting endometrial pathology, compared to 97.3% of OHSC. Sensitivity, specificity, positive prognostic value (PPV) and negative prognostic value (NPV) of TVS detecting endometrial pathology were 84.0, 86.8, 95.3 and 63.0%, respectively. The corresponding values for hysteroscopy were 98.9, 95.1, 98.4 and 93.9%, respectively. Diagnostic value of both techniques was estimated in 6 (six) additional subgroups: total sample with AUB, women of reproductive age, women of reproductive age with AUB, women of reproductive age with infertility issues, postmenopausal women and postmenopausal women suffering from postmenopausal bleeding (PMB). All values were calculated with regards to histologic findings as gold standard technique. All results were correlated with scientific evidence collected from the international literature.

CONCLUSION

Office hysteroscopy is a more reliable tool in detecting endometrial pathologies compared to TVS regardless of reproductive status or clinical presentation. TVS is likely to orientate and guide specialists on what to expect prior to an hysteroscopic intervention.

Two-dimensional transvaginal sonography vs saline contrast sonohysterography for diagnosing endometrial polyps: systematic review and meta-analysis

OBJECTIVE

To compare the diagnostic performance of two-dimensional transvaginal sonography (TVS) and saline contrast sonohysterography (SCSH) for the diagnosis of endometrial polyps in studies that used both tests in the same group of patients.

METHODS

This was a systematic review and meta-analysis. An extensive search was conducted of Medline (PubMed), Cochrane Library and Web of Science, for studies comparing the diagnostic performance of TVS and SCSH for identifying endometrial polyps, published between January 1990 and December 2019, that reported a definition of endometrial polyp on TVS and SCSH and used pathologic analysis as the reference standard. Quality of the included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. A random-effects model was used to determine pooled sensitivity, specificity and positive and negative likelihood ratios of TVS and SCSH in the detection of endometrial polyps. Subanalysis according to menopausal status was performed.

RESULTS

In total, 1278 citations were identified; after exclusions, 25 studies were included in the meta-analysis. In the included studies, the risk of bias evaluated using QUADAS-2 was low for most of the four domains, except for flow and timing, which had an unclear risk of bias in 13 studies. Pooled sensitivity, specificity and positive and negative likelihood ratios for TVS in the detection of endometrial polyps were 55.0% (95% CI, 46.0-64.0%), 91.0% (95% CI, 86.0-94.0%), 5.8 (95% CI, 3.9-8.7) and 0.5 (95% CI, 0.41-0.61), respectively. The corresponding values for SCSH were 92.0% (95% CI, 87.0-95.0%), 93.0% (95% CI, 91.0-95.0%), 13.9 (95% CI, 9.9-19.5) and 0.08 (95% CI, 0.05-0.14), respectively. Significant differences were found when comparing the methods in terms of sensitivity (P < 0.001), but not for specificity (P = 0.0918). Heterogeneity was high for TVS and moderate for SCSH. On subanalysis according to menopausal status, SCSH was found to have higher diagnostic accuracy in both pre- and postmenopausal women; sensitivity and specificity did not differ significantly between the groups for either TVS or SCSH.

CONCLUSION

Given that SCSH has better diagnostic positive and negative likelihood ratios than does TVS in both pre- and postmenopausal women, those with clinical suspicion of endometrial polyps should undergo SCSH if TVS findings are inconclusive. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Diagnostic Accuracy of Transvaginal Sonography in the Detection of Endometrial Polyps

Background:

Transvaginal sonography (TVS) is considered a simple and generally accepted method for detecting uterine anomalies. With TVS, the uterus can be clearly visualized, but so far, the diagnostic accuracy of TVS varies across different studies. This retrospective study was devised to evaluate the accuracy of a sonographic diagnosis of endometrial polyps in a Ukrainian hospital.

Methods:

This was a single-center retrospective study of woman who underwent TVS and had hysteroscopy or dilation and curettage for endometrial pathology. A cohort of 156 women were included in this yearlong study. A comparative analysis was based on the preoperative diagnosis, according to TVS, compared with the postoperative histopathology results.

Results:

The overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of TVS in diagnosing endometrial polyps were 69%, 51%, 73%, 46%, and 63%, respectively.

Conclusion:

This retrospective study provided data on the lack of accuracy for a sonographic diagnosis of endometrial polyps. This was based on 26% of women whose diagnosis was not confirmed by histology. A false-negative result occurred for 54% of women who had polyps that were not detected at the preoperative stage. These data raise the question of the feasibility of further invasive procedures based on a single TVS study.

Diagnostic value of saline infusion sonohysterography for detecting endometrial focal lesion

Introduction

Different diagnostic tools are available to evaluate endometrial focal lesion such as hysteroscopy, sonohystrography and transvaginal ultrasound. The present study aimed to determine the diagnostic value of saline infusion sonohystrography (SIS) in diagnosis of intrauterine lesions in women with Abnormal Uterine Bleeding (AUB).

Methods

This cross-sectional study recruited 100 married women with chief complain of AUB referred to gynecologic clinics at the Amir Al-Momenin hospital, Semnan, Iran from March 2014 to February 2016. All participants were in the reproductive age and post-menopausal period that showed abnormal endometrial thickness or endometrial focal lesions through transvaginal ultrasound. Participants underwent SIS, hysteroscopy plus focal lesion resection and endometrial biopsy in order. The gold standard was the histopathology of endometrial specimen reported by pathologist.

Results

Mean±SD age of women was 41.2±11.3 years. To diagnose the overall focal lesions, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the SIS were 79.6, 89.1, 89.6, and 78.8% respectively. These figures were 75.0, 87.5, 82.5 and 81.7%, respectively to diagnose polyps. The SIS sensitivity, specificity, PPV and NPV values to diagnose the myomas were 60.0, 97.8, 75.0, and 95.7% respectively.

Conclusion

Findings show that, SIS probably is a proper method for detecting endometrial focal lesion including polyps and myomas. Future studies may help to define further advantages of this procedure.

Comparison of endometrial assessment by transvaginal ultrasonography and hysteroscopy

OBJECTIVE

To compare transvaginal ultrasonography and hysteroscopy for the diagnosis of endometrial pathologies.

METHODS

In the present retrospective cohort study, data were reviewed from women with ultrasonography findings suggestive of endometrial lesions and/or abnormal uterine bleeding who underwent hysteroscopy at a single center in Campinas, Brazil, between January 2011 and December 2013; data were stratified based on reproductive-aged and postmenopausal groups. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ultrasonography and hysteroscopy for the diagnosis of endometrial lesions were determined. Histopathology was used as the gold standard.

RESULTS

There were 754 patients included (256 reproductive age, 498 postmenopausal). In the reproductive-age group, ultrasonography had a sensitivity of 96.0%, specificity of 58.0%, PPV of 94.4%, NPV of 66.6%, and accuracy of 91.5%, whereas hysteroscopy had a sensitivity of 91.8%, specificity of 76.6%, PPV of 96.0%, NPV of 60.5%, and accuracy of 89.7% for the diagnosis of endometrial disease. In the postmenopausal group, ultrasonography had a sensitivity of 99.0%, specificity of 19.0%, PPV of 96.1%, NPV of 50.0%, and accuracy of 95.3%, whereas hysteroscopy had a sensitivity of 96.7%, specificity of 86.9%, PPV of 99.2%, NPV of 58.8%, and accuracy of 96.2%.

CONCLUSION

Ultrasonography was found to be an effective method for the diagnosis of endometrial disease, especially among postmenopausal women.

Accuracy of Two-Dimensional Transvaginal Sonography and Office Hysteroscopy for Detection of Uterine Abnormalities in Patients with Repeated Implantation Failures or Recurrent Pregnancy Loss

Background

We sought to compare diagnostic values of two-dimensional transvaginal sonography (2D TVS) and office hysteroscopy (OH) for evaluation of endometrial pathologies in cases with repeated implantation failure (RIF) or recurrent pregnancy loss (RPL).

MATERIALS AND METHODS

This prospective study was performed at Royan Institute from December 2013 to January 2015. TVS was performed before hysteroscopy as part of the routine diagnostic work-up in 789 patients with RIF or RPL. Uterine biopsy was performed in cases with abnormal diagnosis in TVS and/or hysteroscopy. We compared the diagnostic accuracy values of TVS in detection of uterine abnormalities with OH by receiver operating characteristic (ROC) curve analysis.

RESULTS

TVS examination detected 545 (69%) normal cases and 244 (31%) pathologic cases, which included 84 (10.6%) endometrial polyps, 15 (1.6%) uterine fibroids, 10 (1.3%) Asherman's syndrome, 9 (1.1%) endometrial hypertrophy, and 126 (15.9%) septate and arcuate uterus. TVS and OH concurred in 163 pathologic cases, although TVS did not detect some pathology cases (n=120). OH had 94% sensitivity, 95% specificity, 62% positive predictive value (PPV), and 99% negative predictive value (NPV) for detection of endometrial polyps. In the diagnosis of myoma, sensitivity, specificity, PPV, and NPV were 100%. TVS had a sensitivity of 50% and specificity of 98% for the diagnosis of myoma. For polyps, TVS had a sensitivity of 54% and specificity of 80%. Area under the ROC curve (AUROC) was 70.69% for the accuracy of TVS compared to OH.

CONCLUSION

TVS had high specificity and low sensitivity for detection of uterine pathologies in patients with RIF or RPL compared with OH. OH should be considered as a workup method prior to treatment in patients with normal TVS findings.

A "See and Treat" Office Procedure for Retained Products of Conception Removal After Normal Vaginal Delivery Using Manual Vacuum Aspiration: Preliminary Efficacy and Reproductive Outcomes

STUDY OBJECTIVE

To compare the efficacy and reproductive outcomes of an ultrasound-guided manual vacuum aspiration (MVA) procedure with the widely accepted operative hysteroscopic (OH) procedure in the removal of retained products of conception (RPOCs) after normal vaginal delivery.

DESIGN

A retrospective cohort study (Canadian Task Force classification II-2).

SETTING

A university-affiliated tertiary medical center.

PATIENTS

Eighty-six patients after normal vaginal delivery diagnosed with RPOCs from 2005 through 2015. This study was approved by the local institutional review board.

INTERVENTIONS

Treatment with either MVA or OH for patients diagnosed with RPOCs.

MEASUREMENTS AND MAIN RESULTS

Of 86 patients, 23 underwent remnant removal by ultrasound-guided MVA using a 6- to 7-mm catheter in a "see and treat" office procedure. Sixty-three patients underwent remnant removal using the OH procedure. Follow-up included sonographic examination 3 to 5 weeks after the procedure and long-term follow-up on complications and reproductive outcomes. Successful remnant evacuation and the overall complications rates were similar when comparing the MVA group and the OH group (95.7% vs 96.8% and 4.3% vs 4.7%, respectively). Conception rates and miscarriage rates were comparable in the MVA and OH groups (78.6% vs 72.2% and 9.1% vs 14.8%, respectively).

CONCLUSION

Preliminary results from 23 patients suggest that MVA is an efficient procedure with low complication rates and satisfactory reproductive outcomes. It does not require anesthesia or operating room facilities, allowing an immediate and inexpensive "see and treat" option for RPOCs. Further larger controlled trials are required.

Premenopausal abnormal uterine bleeding and risk of endometrial cancer

BACKGROUND

Endometrial biopsies are undertaken in premenopausal women with abnormal uterine bleeding but the risk of endometrial cancer or atypical hyperplasia is unclear.

OBJECTIVES

To conduct a systematic literature review to establish the risk of endometrial cancer and atypical hyperplasia in premenopausal women with abnormal uterine bleeding.

SEARCH STRATEGY

Search of PubMed, Embase and the Cochrane Library from database inception to August 2015.

SELECTION CRITERIA

Studies reporting rates of endometrial cancer and/or atypical hyperplasia in women with premenopausal abnormal uterine bleeding.

DATA COLLECTION AND ANALYSIS

Data were independently extracted by two reviewers and cross-checked. For each outcome, the risk and a 95% CI were estimated using logistic regression with robust standard errors to account for clustering by study.

MAIN RESULTS

Sixty-five articles contributed to the analysis. Risk of endometrial cancer was 0.33% (95% CI 0.23-0.48%, n = 29 059; 97 cases) and risk of endometrial cancer or atypical hyperplasia was 1.31% (95% CI 0.96-1.80, n = 15 772; 207 cases). Risk of endometrial cancer was lower in women with heavy menstrual bleeding (HMB) (0.11%, 95% CI 0.04-0.32%, n = 8352; 9 cases) compared with inter-menstrual bleeding (IMB) (0.52%, 95% CI 0.23-1.16%, n = 3109; 14 cases). Of five studies reporting the rate of atypical hyperplasia in women with HMB, none identified any cases.

CONCLUSIONS

The risk of endometrial cancer or atypical hyperplasia in premenopausal women with abnormal uterine bleeding is low. Premenopausal women with abnormal uterine bleeding should first undergo conventional medical management. Where this fails, the presence of IMB and older age may be indicators for further investigation. Further research into the risks associated with age and the cumulative risk of co-morbidities is needed.

TWEETABLE ABSTRACT

Contrary to practice, premenopausal women with heavy periods or inter-menstrual bleeding rarely require biopsy.

Comparison between findings of saline infusion sonohysterography and office hysteroscopy in patients with recurrent implantation failure

AIM:

This study aims to determine the accuracy of saline infusion sonohysterography (SIS) in the diagnosis of intrauterine pathologies in women with recurrent implantation failure (RIF).

SETTINGS AND DESIGN:

This is a prospective cross-over study which was carried out during the period between December 2013 and July 2014.

MATERIALS AND METHODS:

The study involved sixty subfertile women with a history of RIF. All cases underwent a transvaginal ultrasonography, SIS and then an office hysteroscopy (1 day after SIS) during early follicular phase. SIS was carried out by same sonographer, and then hysteroscopy was carried out by same gynecologist who was kept blind to findings at SIS.

STATISTICAL ANALYSIS:

Was done using IBM^© SPSS^© Statistics version 22. The sensitivity of SIS was calculated as it equals: True positive by SIS/all positive (true cases by hysteroscopy) and specificity was calculated as it equals: True negative by SIS/all negatives (normal by hysteroscopy).

RESULTS:

Overall uterine abnormalities were significantly less likely to be identified with SIS compared to hysteroscopy (P = 0.002), but analysis of each finding separately demonstrated a comparable difference between SIS and hysteroscopy (P > 0.05). We found that the sensitivity, specificity, positive predictive value, and negative predictive value of SIS to detect intrauterine pathology is 41.2%, 100%, 100%, and 81.1%, respectively.

CONCLUSION:

Our findings suggest a good role of SIS in the workup for RIF saving more invasive procedure for selected cases.

The role of transvaginal power Doppler ultrasound in the differential diagnosis of benign intrauterine focal lesions

PURPOSE

The purpose of this prospective study was to assess the role of power Doppler imaging in the differential diagnosis of benign intrauterine focal lesions such as endometrial polyps and submucous myomas using the characteristics of power Doppler flow mapping.

METHODS

A total of 480 premenopausal patients with abnormal uterine bleeding were evaluated by transvaginal ultrasonography (TVS) searching for intrauterine pathology. Sixty-four patients with a suspicious focal endometrial lesion received saline infusion sonography (SIS) after TVS. Fifty-eight patients with focal endometrial lesions underwent power Doppler ultrasound (PDUS). Three different vascular flow patterns were defined: Single vessel pattern, multiple vessel pattern, and circular flow pattern. Finally, hysteroscopic resection was performed in all cases, and Doppler flow characteristics were then compared with the final histopathological findings.

RESULTS

Histopathological results were as follows: endometrial polyp: 40 (69 %), submucous myoma: 18 (31 %). Of the cases with endometrial polyps, 80 % demonstrated a single vessel pattern, 7.5 % a multiple vessel pattern, and 0 % a circular pattern. Vascularization was not observed in 12.5 % of patients with polyps. Of the cases with submucousal myomas, 72.2 % demonstrated a circular flow pattern, 27.8 % a multiple vessel pattern, and none of them showed a single vessel pattern. The sensitivity, specificity, and positive and negative predictive values of the single vessel pattern in diagnosing endometrial polyps were 80, 100, 100, and 69.2 %, respectively; and for the circular pattern in diagnosing submucous myoma, these were 72.2, 100, 100, and 88.9 %, respectively.

CONCLUSION

Power Doppler blood flow mapping is a useful, practical, and noninvasive diagnostic method for the differential diagnosis of benign intrauterine focal lesions. Especially in cases of recurrent abnormal uterine bleeding, recurrent abortion, and infertility, PDUS can be preferred as a first-line diagnostic method.

Transvaginal Ultrasonography and Hysteroscopy as Predictors of Endometrial Polyps in Postmenopause

The study compared ultrasound and ambulatorial hysteroscopy as diagnostic methods detecting endometrial polyps in postmenopause women. 281 women aged 41–82 years who underwent ambulatorial hysteroscopy were analyzed for presence of uterine bleeding and/or altered transvaginal ultrasound (endometrial thickness ≥5 mm). Ultrasonography detected endometrial polyps in 22.8% of patients and endometrial thickening in the other 59.8%. Hysteroscopy diagnosed endometrial polyps in 80.8%. Ultrasonography showed sensitivity of 88.7%, specificity of 25.4%, positive predictive value of 81.7%, negative predictive value of 37.5% and accuracy of 75.4% in diagnosing endometrial polyps. Hysteroscopy showed 96.4% sensitivity, 74.6% specificity, 93.4% positive predictive value, 84.6% negative predictive value and 91.8% accuracy. Hysteroscopy demonstrated more accuracy than ultrasonography, which is not sufficient for accurate diagnosis.

The evolving role of saline infusion sonography (SIS) in infertility

Saline infusion sonography (SIS) has become a valuable diagnostic modality in gynaecology over the last three decades. SIS is now commonly employed for detailed evaluation of the uterine cavity as part of pre-treatment assessment in infertile women. The objective of this paper is review the scientific literature on SIS in infertility. Medline, Ovid and Cochrane databases were searched for relevant articles. The indications, technical aspects and the potential advantages of SIS are discussed. The efficacy and sensitivity of SIS are compared to hysteroscopy in the evaluation of uterine polyps, fibroids, intrauterine adhesions and uterine anomalies. Increasing evidence suggests the use of SIS prior to an in-vitro fertilization (IVF) cycle as it has increased sensitivity in the detection of intrauterine pathology. SIS is cost-effective and results in better patient satisfaction scores than hysteroscopy.

Abnormal uterine bleeding in reproductive-aged women

Abnormal uterine bleeding is a common medical condition with several causes. The International Federation of Gynecology and Obstetrics published guidelines in 2011 to develop universally accepted nomenclature and a classification system. In addition, the American College of Obstetrics and Gynecology recently updated recommendations on evaluation of abnormal uterine bleeding and indications for endometrial biopsies. This article reviews both medical and surgical treatments, including meta-analysis reviews of the most effective treatment options.

Transvaginal sonographic evaluation at different menstrual cycle phases in diagnosis of uterine lesions

Purpose:

Intrauterine lesions (IULs) are a common finding in women of reproductive age, particularly infertile women. Transvaginal sonography (TVS) is a popular tool for IUL detection, but there are conflicting data with respect to its accuracy.

Methods:

Five hundred and six women were enrolled into the study. Of these, 496 underwent hysterosalpingography and subsequent TVS six different times during the course of their menstrual cycle. If a lesion was detected, it was further evaluated by sonohysterography (SHG) and hysteroscopy.

Results:

Of 496 women, 41 were shown to have IULs by TVS and those lesions were confirmed in 39 by SHG and hysteroscopy. All 39 lesions were detectable during the ovulatory and early luteal phase (days 16–19) of the menstrual cycle. Accuracy of TVS during different phases was largely dependent on the size of the lesion. TVS falsely detected two lesions and missed fine adhesions in two patients.

Conclusion:

Accuracy of TVS in detection of IULs is highly dependent on the menstrual cycle phase, with the ovulatory and early luteal phase being the optimal time for this examination.

Prevalence, 1-year regression rate, and clinical significance of asymptomatic endometrial polyps: cross-sectional study

STUDY OBJECTIVE

To estimate the prevalence, 1-year regression rate, and clinical significance of endometrial polyps in women aged 45 to 50 years.

DESIGN

Cross-sectional study (Canadian Task Force II-2).

SETTING

University teaching hospital.

PATIENTS

Two hundred fifty-seven of 1000 randomly selected women aged 45 to 50 years.

INTERVENTIONS

Transvaginal ultrasonography and saline infusion sonography were performed in all study participants and were repeated in women with endometrial polyps after 12 months. Polyps present at follow-up were removed by hysteroscopic polyp resection.

MEASUREMENTS AND MAIN RESULTS

Endometrial polyps were diagnosed in 31 women (12.1%). At 1 year, the polyp regression rate was 27%. Myomas occurred more often in women with endometrial polyps, and women with polyps experienced significantly heavier periodic bleeding compared with women without polyps.

CONCLUSION

Our study findings suggest that endometrial polyps are common in women aged 45 to 50 years and that women with such polyps experience heavier periodic bleeding. Although some polyps seem to regress spontaneously during 1-year follow-up, most seem to persist.

Prevalence and diagnosis of congenital uterine anomalies in women with reproductive failure: a critical appraisal

BACKGROUND

The prevalence of congenital uterine anomalies in women with reproductive failure remains unclear, largely due to methodological bias. The aim of this review is to assess the diagnostic accuracy of different methodologies and estimate the prevalence of congenital uterine anomalies in women with infertility and recurrent miscarriage (RM).

METHODS

Studies from 1950 to 2007 were identified through a MEDLINE search; all relevant references were further reviewed.

RESULTS

The most accurate diagnostic procedures are combined hysteroscopy and laparoscopy, sonohysterography (SHG) and possibly three-dimensional ultrasound (3D US). Two-dimensional ultrasound (2D US) and hysterosalpingography (HSG) are less accurate and are thus inadequate for diagnostic purposes. Preliminary studies (n = 24) suggest magnetic resonance imaging (MRI) is a relatively sensitive tool. A critical analysis of studies suggests that the prevalence of congenital uterine anomalies is approximately 6.7% [95% confidence interval (CI), 6.0-7.4] in the general population, approximately 7.3% (95% CI, 6.7-7.9) in the infertile population and approximately 16.7% (95% CI, 14.8-18.6) in the RM population. The arcuate uterus is the commonest anomaly in the general and RM population. In contrast, the septate uterus is the commonest anomaly in the infertile population, suggesting a possible association.

CONCLUSIONS

Women with RM have a high prevalence of congenital uterine anomalies and should be thoroughly investigated. HSG and/or 2D US can be used as an initial screening tool. Combined hysteroscopy and laparoscopy, SHG and 3D US can be used for a definitive diagnosis. The accuracy and practicality of MRI remains unclear.

What is the value of preoperative bimanual pelvic examination in women undergoing laparoscopic total hysterectomy?

OBJECTIVE STUDY: To estimate the value of preoperative bimanual examination of the pelvis in women undergoing total laparoscopic hysterectomy (TLH).

DESIGN

Prospective observational cohort study.

SETTING

Private hospitals and centre.

PATIENTS

One hundred fourteen consecutive women undergoing TLH.

INTERVENTION

All women who were scheduled to undergo TLH from May 2005 through June 2006 had a bimanual examination of the pelvis performed before surgery and the size of the uterus clinically estimated and recorded as gestational equivalents. The operating time, the estimated blood loss (EBL) during TLH, and the final weight of the uterus at histologic study were recorded. Spearman correlation coefficient analysis was used to determine whether there was a correlation between the estimated uterine size before surgery and actual uterine weight, operating time, and EBL.

MEASUREMENTS AND MAIN RESULTS

Of the one hundred fourteen consecutive women eligible for the study, 75 had complete data and therefore were included in the final analysis. The median age was 46 years (range 34-71 years); 22.7% (17/75) had a clinically estimated normal uterus, 10.7% (8/75) had an 8-10/40 uterus, 12% (9/75) had a 10-12/40 uterus, 14.6% (11/75) had a 12-14/40 uterus, 20.0% (15/75) had a 14-16/40 uterus, 9.3% (7/75) had a 16-18/40 uterus, and 10.7% (8/75) had an 18-20/40 uterus. The median operating time was 110 minutes (range 59-240 minutes); the median EBL was 80 mL (range 20-1000 mL); and the median weight of the uterus was 181 g (range 52-1080 g). Histologic diagnoses included leiomyomata in 64.0% (48/75), adenomyosis in 44.0% (33/75), endometriosis in 22.7% (17/75), endocervical polyp in 4.0% (3/75), and normal uterus in 8.0% (6/75). The Spearman correlations between clinical size of the uterus and the weight of the uterus, the EBL, and the operating time were 0.81, 0.33, and 0.29, respectively; that is, the 2 variables tended to increase together. These correlations were all significant (p <.0001, .0044, and .0114, respectively).

CONCLUSIONS

This study showed significant correlation between clinical estimate of uterine size and histologic weight of the uterus, operating time, and EBL in women undergoing laparoscopic hysterectomy. These findings are of great value in preoperative counseling in relation to the risk of bleeding and the potential need for blood transfusion, and in operating room planning.

Liquid-based endometrial cytology: its possible value in postmenopausal asymptomatic women

The incidence of endometrial adenocarcinoma in asymptomatic women is low. Nevertheless, some of these women might require endometrial surveillance. In this study, we evaluated the accuracy of liquid-based endometrial cytology compared to biopsy in asymptomatic postmenopausal women. Three hundred twenty women scheduled for hysteroscopy were enrolled for this study. After hysteroscopy, patients were submitted to endometrial cytology and to biopsy. Two hundred ninety-three (92%) women had sonographically thickened endometrium (>5 mm), 53 (17%) were on tamoxifen, and 16 (5%) were on hormonal substitutive treatment. The evaluation of the biopsies determined that six (2%) women had adenocarcinoma, one (<1%) had adenomatous atypical hyperplasia, and eight (3%) had simple nonatypical hyperplasia. Endometrial cytology evidenced 5 (2%) neoplastic cases, 2 (<1%) hyperplastic with atypia cases, and 25 (8%) hyperplastic without atypia cases. Two hundred twenty-two biopsies (69%) and 17 (5%) cytologies were inadequate. One adenocarcinoma and one simple nonatypical hyperplasia were underrated by cytology resulting, respectively, as atypical hyperplasia and as negative. Four cases were false positive (simple nonatypical hyperplasias on cytology, negative on biopsy). The sensitivity and specificity were estimated, respectively, at 94% and 95%; the positive and negative predictive value were estimated, respectively, at 80% and 99%. Endometrial cytology provided sufficient material more often than biopsy (P < 0.01). We suggest to introduce liquid-based endometrial cytology in the management of some subpopulations of asymptomatic postmenopausal women. Particularly, the combination of liquid-based endometrial cytology and transvaginal sonography may improve their diagnostic accuracy and reduce unnecessary more invasive and expensive procedures.

Sonohysterography versus transvaginal sonography for screening of patients with abnormal uterine bleeding

OBJECTIVES

To compare the accuracy of saline infusion sonohysterography (SIS) with transvaginal sonography (TVS) for the screening of causes of abnormal uterine bleeding (AUB) in out-patients.

METHODS

81 patients with AUB were studied. All cases who were examined with TVS, were further investigated with SIS using saline as contrast medium, finally hysteroscopy was used as the gold standard.

RESULTS

TVS had sensitivity of 72%, specificity of 92%, positive predictive value of 94% and negative predictive value of 65%, while SIS had sensitivity of 94.1%, specificity of 95%, positive predictive value of 96% and negative predictive value of 90%. TVS had kappa measure of agreement of 0.60 while 0.86 was reported for SIS.

CONCLUSIONS

In this study SIS was more sensitive and specific in diagnosing polyp, myoma and adenomyosis with high positive and negative predictive value. Furthermore, results obtained by SIS demonstrate more agreement with that obtained by hysteroscopy than TVS.