Saline contrast sonohysterography in the preoperative assessment of benign intrauterine disorders

Noninvasive Predictor for Premalignant and Cancerous Lesions in Endometrial Polyps Diagnosed by Ultrasound

Background

There was no consensus for management of asymptomatic endometrial polyps (EPs) up to date.

Objective

The aim of present study was to determine the risk factors of malignant lesions in EPs diagnosed by ultrasound and establish a noninvasive predictor to decrease unnecessary hysteroscopy for EPs.

Study Design

We reviewed the records of all consecutive patients who underwent hysteroscopy for EPs in the Women’s Hospital School of Medicine Zhejiang University between January 1, 2001 and December 31, 2018. The patients with histological diagnoses of atypical hyperplasia or cancer were defined as malignancy, while the patients with histological diagnoses of benign lesions were randomly selected as benign group according to the ratio of 1:4 (malignancy:benign), matching by age and year of hospitalization. Logistic regression analysis was used to analyze the clinical parameters for predicting malignancy of EPs. A Chi-squared automatic interaction detection (CHAID) decision tree analysis was performed to find a noninvasive predictor. The sensitivity, specificity, and the receiver operating characteristic curve (ROC) were used for assess the efficacy of the noninvasive predictor. New diagnosed EPs patients received in 2019 were used for verifying the accuracy of the noninvasive predictor.

Results

The age in 15,790 cases of benign lesions was significantly younger than that in 230 malignancy cases (41.97 ± 11.53 year vs 53.31 ± 11.61 years, p <0.001). AUB (OR 7.306, 95%CI 4.927–10.835), large EPs (OR 2.595, 95%CI 1.662–4.052), and blood flow signal in EPs (OR 2.690, 95%CI 1.872–3.866) were independent predictive factors of malignancy in all enrolled patients. A noninvasive predictor for malignancy of EPs was established, through combining with AUB, large polyps and blood flow signal. This predictor presented excellent sensitivity and NPV (91.3 and 95.8%), with acceptable specificity and AUC (0.801). Further validation in new diagnosed EPs also suggested excellent sensitivity and reasonable specificity (100 and 58.5%) of the predictor. Factors such as thickened endometrial thickness, menopause shorter than 10 years, hypertension, obesity and nulliparous were also validated as independent predictors of malignancy in different subgroup analysis.

Conclusions

The noninvasive predictor combined with other risk factors from subgroup analysis would be reliable to distinguish the benign lesions from malignancy for EPs diagnosed by ultrasound.

Transvaginal Saline Contrast Sonohystography to Investigate Postmenopausal Bleeding: A Systematic Review

Transvaginal ultrasound (TVUS) is the initial investigation of choice for postmenopausal bleeding (PMB), followed by diagnostic hysteroscopy and endometrial sampling if abnormalities are detected. Saline contrast sonohysterography (SCSH) - injection of saline through the cervix into the uterine cavity prior to TVUS - allowed increased diagnostic accuracy in women with PMB in several small, heterogeneous studies.

The objectives of the current study were to evaluate the diagnostic accuracy of SCSH in women with PMB, comparing findings with surgical and pathological reports, highlight the necessity of SCSH in guiding clinical decision-making, and establish if there is an increase/decrease in the number of hysteroscopies performed for PMB and, hence, the adherence of clinicians to imaging referral guidelines.

The search strategy included formulating search terms identifying all synonyms of SCSH and postmenopause. The databases searched were MEDLINE, Embase, and the Cochrane Library.

Only studies comparing SCSH to an alternative method were selected. The studies were screened and data analysis performed using content analysis. Data reduction was performed through systematic coding and the generation of themes

We identified 18 studies, comprising 974 women, using SCSH to evaluate the endometrial cavity in women with PMB; most support SCSH improving diagnostic accuracy through delineating intracavitary structures.

In effect, SCSH could be a first-line investigative modality to assess the uterine cavity once a larger, well-designed study has been conducted to clarify its specificity, sensitivity, and positive predictive value (PPV). Owing to its relatively non-invasive nature and potentially high diagnostic accuracy, SCSH could allow for more accurate decisions regarding the need for further investigation and subsequent management.

Tweetable abstract

"Saline contrast sonohysterography improves the diagnostic accuracy of the endometrium in postmenopausal bleeding."

Unravelling the endometrium: a pictorial review of saline infusion sonohysterography in the evaluation of abnormal uterine bleeding

This article describes the diagnosis of causes of abnormal uterine bleeding with experience of the biggest medical institute in Kashmir, India. We work in a low resource setting where unavailabity of hysteroscopy made us acknowledge the accuracy and efficacy of saline infusion sonohysterography in diagnosis of patients with AUB thus helping guide their management.

A randomised controlled trial of Outpatient versus inpatient Polyp Treatment (OPT) for abnormal uterine bleeding

BACKGROUND

Uterine polyps cause abnormal bleeding in women and conventional practice is to remove them in hospital under general anaesthetic. Advances in technology make it possible to perform polypectomy in an outpatient setting, yet evidence of effectiveness is limited.

OBJECTIVES

To test the hypothesis that in women with abnormal uterine bleeding (AUB) associated with benign uterine polyp(s), outpatient polyp treatment achieved as good, or no more than 25% worse, alleviation of bleeding symptoms at 6 months compared with standard inpatient treatment. The hypothesis that response to uterine polyp treatment differed according to the pattern of AUB, menopausal status and longer-term follow-up was tested. The cost-effectiveness and acceptability of outpatient polypectomy was examined.

DESIGN

A multicentre, non-inferiority, randomised controlled trial, incorporating a cost-effectiveness analysis and supplemented by a parallel patient preference study. Patient acceptability was evaluated by interview in a qualitative study.

SETTING

Outpatient hysteroscopy clinics and inpatient gynaecology departments within UK NHS hospitals.

PARTICIPANTS

Women with AUB - defined as heavy menstrual bleeding (formerly known as menorrhagia) (HMB), intermenstrual bleeding or postmenopausal bleeding - and hysteroscopically diagnosed uterine polyps.

INTERVENTIONS

We randomly assigned 507 women, using a minimisation algorithm, to outpatient polypectomy compared with conventional inpatient polypectomy as a day case in hospital under general anaesthesia.

MAIN OUTCOME MEASURES

The primary outcome was successful treatment at 6 months, determined by the woman's assessment of her bleeding. Secondary outcomes included quality of life, procedure feasibility, acceptability and cost per quality-adjusted life-year (QALY) gained.

RESULTS

At 6 months, 73% (166/228) of women who underwent outpatient polypectomy were successfully treated compared with 80% (168/211) following inpatient polypectomy [relative risk (RR) 0.91, 95% confidence interval (CI) 0.82 to 1.02]. The lower end of the CIs showed that outpatient polypectomy was at most 18% worse, in relative terms, than inpatient treatment, within the 25% margin of non-inferiority set at the outset of the study. By 1 and 2 years the corresponding proportions were similar producing RRs close to unity. There was no evidence that the treatment effect differed according to any of the predefined subgroups when treatments by variable interaction parameters were examined. Failure to completely remove polyps was higher (19% vs. 7%; RR 2.5, 95% CI 1.5 to 4.1) with outpatient polypectomy. Procedure acceptability was reduced with outpatient compared with inpatient polyp treatment (83% vs. 92%; RR 0.90, 95% CI 0.84 to 0.97). There were no significant differences in quality of life. The incremental cost-effectiveness ratios at 6 and 12 months for inpatient treatment were £1,099,167 and £668,800 per additional QALY, respectively.

CONCLUSIONS

When treating women with AUB associated with uterine polyps, outpatient polypectomy was non-inferior to inpatient polypectomy at 6 and 12 months, and relatively cost-effective. However, patients need to be aware that failure to remove a polyp is more likely with outpatient polypectomy and procedure acceptability lower.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 65868569.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 61. See the NIHR Journals Library website for further project information.

The prevalence of occult leiomyosarcoma at surgery for presumed uterine fibroids: a meta-analysis

There is a concern regarding the risk of occult leiomyosarcomas found at surgery for presumed benign fibroids. We sought to produce a comprehensive review of published data addressing this issue and provide high-quality prevalence estimates for clinical practice and future research. A comprehensive literature search using the PubMed/MEDLINE database and the Cochrane Library was performed. Inclusion criteria were human studies, peer-reviewed, with original data, involving cases for surgery in which fibroid-related indications were the primary reason for surgery, and histopathology was provided. Candidate studies (4864) were found; 3844 were excluded after review of the abstract. The remaining 1020 manuscripts were reviewed in their entirety, and 133 were included in the Bayesian binomial random effect meta-analysis. The estimated rate of leiomyosarcoma was 0.51 per 1000 procedures (95 % credible interval (CrI) 0.16–0.98) or approximately 1 in 2000. Restricting the meta-analysis to the 64 prospective studies resulted in a substantially lower estimate of 0.12 leiomyosarcomas per 1000 procedures (95 % CrI <0.01–0.75) or approximately 1 leiomyosarcoma per 8300 surgeries. Results suggest that the prevalence of occult leiomyosarcomas at surgery for presumed uterine fibroids is much less frequent than previously estimated. This rate should be incorporated into both clinical practice and future research.

Effect of hormone replacement therapy on postmenopausal endometrial bleeding

The aim of the study was to determine the effect of postmenopausal hormone replacement therapy (HRT) (treatment using estrogen only and sequential and continuous combined estrogen-progestogen treatment) on endometrial bleeding and histological changes of the endometrium. In a six-year period (2000-2005), 5893 patients were given care and the incidence of postmenopausal uterine bleeding was detected in groups of patients having and not having received hormonal treatment at the Menopause Outpatient Unit of the authors' department. In the case of bleeding, fractioned abrasion was performed and the samples were analyzed histologically. Among the postmenopausal patients who had not been given hormonal treatment, the incidence of bleeding episodes was significantly higher as among those having received hormonal treatment. In the samples, findings of proliferative endometrium occurred significantly more often in case of non-treated patients and those treated with sequential combined hormone therapy compared to patients receiving continuous combined hormone therapy. Although it was statistically not significant, hyperplasia simplex and complex together showed a tendency of reduced incidence in patients medicated by continuous combined treatment. These findings suggest that continuous combined hormonal treatment started at the right time (even before the menopause) may reduce the chances of the development of hyperplasia. A significantly higher incidence of hyperplasia was noted in patients using estrogen treatment only. It is possible that unopposed estrogen treatment further engraves an already diagnosed endometrial hyperplasia. In the group having received hormonal treatment, no complex hyperplasia accompanied by atypia occurred, only hyperplasia simplex was diagnosed in these cases. As a result of continuous reliance on combined preparations, the endometrium had become atrophied, therefore the chance of hyperplasia-related changes and of bleeding as a side effect decreased significantly. According to the authors' experience, hormonal treatment does not pose a risk to the development of endometrial carcinoma; on the contrary, continuous combined preparations appear to reduce the risk of hyperplasia and, indirectly, the chances of the development of adenocarcinoma.

The effect of postmenopausal hormone replacement therapy on endometrial bleeding

Cékitűzés: A vizsgálat célja meghatározni a postmenopausalis hormonterápia (kizárólagos ösztrogén-, szekvenciális és folyamatosan kombinált ösztrogén-progesztogén kezelés) hatását az endometrialis vérzésre és a méhnyálkahártya szövettani átalakulására. Beteganyag: Szerzők klinikájának Menopauza Ambulanciáján ötéves időszakban (2000–2005) 5893 beteget gondoztak, és vizsgálták a postmenopausalis méhvérzések előfordulását a hormonterápiában részesültek és nem részesültek csoportjában. Vérzés esetén mindig frakcionált abrasiót végeztek, és a mintákat szövettanilag feldolgozták. Eredmények: A postmenopausában lévő betegek hormonkezelésben nem részesítettek csoportjában több mint kétszer több vérzés fordult elő, mint a hormonkezelésben részesültek között. Anyagukban a proliferatiós és a hyperplasiás endometrium-leletek elsősorban a nem kezelt páciensek közül kerültek ki, ami amellett szól, hogy a megfelelő időben, akár már a menopausa előtt megkezdett hormonkezelés csökkentheti a hyperplasia és ezáltal közvetve az adenocarcinoma kialakulásának az esélyét. A kizárólag ösztrogént alkalmazó betegekben gyakoribb volt a hyperplasia. Elképzelhetőnek tartják, hogy az ellensúlyozatlan ösztrogénkezelés a már meglévő endometrium-hyperplasiát tovább súlyosbíthatja. A hormonkezeltek csoportjában atípiával járó komplex hyperplasia nem, csak simplex hyperplasia fordult elő. A folyamatosan kombinált készítmények alkalmazása mellett az esetek döntő részében a méhnyálkahártya atrófizálódott, így lényegesen csökkent a hyperplasiával járó eltérések s a mellékhatásként jelentkező vérzés esélye. A hormonkezeltek között gyakoribb volt az endometrium-polip, és nem tudják megmagyarázni, de a cervicalis polypusok aránya is. Következtetés: A szerzők tapasztalata szerint a hormonkezelés nem rizikótényezője az endometrium-karcinómának, hanem a kombinált készítmények a hyperplasia és ezen keresztül az adenocarcinoma eredeti esélyét csökkentik.

Risks and usefulness of sonohysterography in patients with endometrial carcinoma

OBJECTIVE

The purposes of this study were to assess the risk of malignant cell dissemination into the peritoneal cavity through the fallopian tubes in patients with endometrial carcinoma undergoing sonohysterography and to evaluate the accuracy of sonohysterography in the estimation of myometrial invasion by the tumor and its role in the preoperative staging.

STUDY DESIGN

This was a prospective study that was conducted at the Sassari University hospital. Thirty-two patients with endometrial carcinoma underwent sonohysterography during laparotomy for hysterectomy. The fluid that spilled from the fallopian tubes and was collected into graduated plastic tubes was analyzed by a pathologist. The presence of malignant endometrial cells in the fluid that was spilled from the fallopian tubes was assessed. The depth of myometrial invasion by tumor was assessed by gross and sonohysterographic examinations and compared with histopathologic findings.

RESULTS

Malignant cells were reported in the fluid that spilled from the fallopian tubes in 2 patients (6.25%). The occurrence of suspected cells in the fallopian fluid was reported in 6 women (18.75%); thus, the presence of malignant or suspicious cells in the fluid that spilled from the fallopian tubes was reported in 8 of 32 cases (25%). Sonohysterography correctly evaluated the depth of myometrial invasion in 27 of 32 cases (84.37%).

CONCLUSION

Sonohysterography was useful to assess the depth of myometrial invasion and may have a role in preoperative staging, but sonohysterography should not be performed in women with suspicious diagnosis of endometrial carcinoma.

The short-term clinical outcomes after saline infusion sonohysterography in women with postmenopausal bleeding

RATIONALE AND OBJECTIVE

To describe the short-term clinical outcomes of women with postmenopausal bleeding (PMB) who underwent saline-infused sonohysterography (SIS) and the impact of SIS results on clinical management.

MATERIALS AND METHODS

A retrospective review of the Radiology Information Systems database identified 786 women who underwent SIS between February 1998 and October 2002. Of this group, 144 women (mean age, 60; range, 42-83) presented with PMB. The following clinical data were extracted from the electronic medical record: date of birth, hormone replacement therapy (HRT) status, SIS results, and clinical management before and after the SIS procedure. We categorized post-SIS clinical management into three categories: additional diagnostic or therapeutic procedure performed; HRT change or addition; or no change in clinical management. Between-group comparisons were performed using a chi2 test.

RESULTS

Of the 144 women with postmenopausal bleeding who underwent SIS, 119 (82.6%) successfully completed the SIS. Eighty women (67.2%) had a positive SIS exam. Abnormalities detected including polyps (n = 42); submucosal fibroids (n = 6); endometrial thickening (n = 8); a combination of 2 or more of the above (n = 7), or other abnormalities (debris, adenomyosis, or indeterminate findings, n = 17). Of the women with a positive SIS exam, 58% received subsequent diagnostic/therapeutic procedures compared to 5% of women who had a negative SIS (P < 0.001). Conversely, 59% of women with a negative SIS had no change in clinical management compared to 17.5% who had a positive SIS (P < 0.001).

CONCLUSION

The trend in short-term clinical management is to pursue more aggressive subsequent diagnostic or treatment procedures if findings are positive on SIS. A negative SIS exam was associated with more conservative management.

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.

Sono-Guided Endometrial Biopsy: Comparison with Hysteroscopy Biopsy

OBJECTIVE

To assess the feasibility, tolerance and diagnostic accuracy of endometrial biopsy (EB) during sonohysterography (SH) compared to EB after hysteroscopy (HSC) in endometrial disorders.

METHODS

105 consecutive patients with irregular uterine bleeding were included prospectively in the calendar year 2001. SH and flexible HSC were performed in an office setting, subsequently and in a random order, by two different practitioners blind to the former experiment. SH-EB was performed using a 3.1-mm ultrasound-guided Bernard catheter in the uterine cavity still partly distended and with a gentle 20-ml syringe vacuum aspiration. The biopsy was directed on focal lesions or else randomly when no targets had previously been found. A Cornier Pipelle was used to perform EB after HSC. We investigated all patients by biopsy, independent of the endometrial thickness. HSC-EB was the gold standard.

RESULTS

For both methods, cervical catheterism was impossible in 20 patients, 75 of them successfully underwent both exams. Duration and tolerance were similar. SH was effective in the distinction between normal and pathologic cavities, as well as in the diagnosis of polyps. Endometrium appeared significantly thinner with HSC (1.8 mm) when compared to SH (2.9 mm, p < 0.05). Histological endometrial assessment failed in 30 cases of SH-EB and in 22 cases in HSC-EB (NS). There was a poor correlation of the histological results of both techniques. Hyperplasia has never been diagnosed by SH-EB, whereas 3 EB issued from HSC-EB brought up this diagnosis.

CONCLUSION

SH-EB with our technique did not improve the diagnostic potential of SH and severe diagnosis was missed. Histological assessment should fail less when we exclude endometrial atrophy. The diameter of the catheter and the aspiration technique must be revised and the learning curve must be considered. Our technique cannot replace EB by HSC.

Managing women with post-menopausal bleeding

Transvaginal ultrasound examination can reliably distinguish women with post-menopausal bleeding (PMB) who are at low risk of endometrial pathology (endometrial thickness < or =4 mm) from those who are at high risk (endometrium > or =5 mm) and can rule out focally growing lesions in the uterine cavity using saline infusion into the cavity as a negative contrast agent (hydrosonography). The 5 mm cut-off is applicable irrespective of the use of hormone replacement therapy. It is justified to refrain from endometrial sampling in women with PMB and an endometrial thickness of < or =4 mm because the risk of endometrial cancer in these women is low (0.1-1.0%). However, it is not known whether these women need follow-up. About 80% of women with PMB and an endometrium of > or =5 mm have focally growing pathological lesions in the uterine cavity. These should be removed by operative hysteroscopy because dilatation and curettage (D and C) will fail to diagnose and remove a large proportion of these lesions. However, D and C is a reliable diagnostic method for women without focal lesions in the uterine cavity. It is not known whether simple outpatient sampling devices (e.g. Pipelle) are as reliable as D and C in women without focal lesions. A measurement of endometrial thickness is a simple and accurate method for estimating the risk of endometrial cancer. The reliability of ultrasound evaluation of endometrial morphology and/or vascularization for risk estimation of endometrial malignancy remains to be determined.

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.

Side effects and complications of sonohysterosalpingography

OBJECTIVE

To evaluate the side effects and complications of, difficulties with, and possible solutions to the problems associated with sonohysterosalpingography.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENT(S)

One thousand, one hundred fifty-three patients who underwent sonohysterosalpingography to investigate abnormal uterine bleeding, infertility, thick endometrium at transvaginal ultrasonography, müllerian abnormalities, or the Asherman syndrome.

MAIN OUTCOME MEASURE(S)

Side effects and complications of and difficulties related to the procedure. Tolerance was assessed by using a pain-rating scale.

RESULT(S)

Ninety-three percent (1,074 of 1,153) procedures were performed correctly. Investigation was not completed in 79 (7%) women; a second attempt was successful in 60 of these patients. Side effects, such as moderate or severe pelvic pain, vasovagal symptoms, nausea, and vomiting, occurred in 102 (8.8%) women. Such complications as fever and peritonitis occurred in 0.95% of patients.

CONCLUSION(S)

Sonohysterosalpingography is a simple, safe, and well-tolerated technique that has a low rate of side effects and rare complications.

[Hysterosonography]

Hysterosonography, which consists in the injection of some cc of saline in the uterine cavity during sonography, allows an exploration of the uterine cavity and of the endometrium. Accuracy of hysterosonography is similar to that of office hysteroscopy. Hysterosonography distinguishes normal cavities from pathologic ones, endometrial atrophy from mucosal anomalies, polyps from myomas. Conversely, endometrial biopsy is still necessary for diagnosis of hyperplasia or cancer. Hysterosonography can also be proposed for first trimester bleedings, trophoblast retention or ectopic pregnancy. In the near future it could be applied to therapeutic goals such as sonographic section of polyps.

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.

Gynecologic problems of the perimenopause: evaluation and treatment

The gynecologic problems associated with the perimenopause and detailed in this review represent common and often vexing concerns for women during this transition. By heeding the evidence-based approaches to evaluation and treatment described herein, clinicians can improve the health and lives of their perimenopausal patients.

The added value of transvaginal sonohysterography over transvaginal sonography alone in women with known or suspected leiomyoma

OBJECTIVE

To assess whether sonohysterography provides added diagnostic value over transvaginal sonography in patients with suspected or known myomas by comparing diagnostic confidence, interobserver agreement, accuracy, and change in diagnoses when 2 independent observers interpreted transvaginal sonography alone and later interpreted transvaginal sonography and sonohysterography together.

METHODS

Hard copy images from 72 women were interpreted independently by 2 sonologists on separate occasions, rating parameters (abnormal uterus, myoma in any location, submucous myoma, classification of location of a submucous myoma with respect to the uterine cavity, myoma remote from the cavity, adenomyosis, and focal and diffuse endometrial lesions) on a scale of 1 to 5 (1 indicated definitely no; 2, probably no; 3, uncertain; 4, probably yes; and 5, definitely yes). Correlation was made with clinical and imaging follow-up, surgery, and pathologic examination.

RESULTS

The added information provided by sonohysterography resulted in improved diagnostic confidence for most parameters. Interobserver agreement was markedly improved for the diagnosis and location of submucous myomas and focal endometrial lesions. Sensitivity values for submucous myomas and focal endometrial lesions were 100% and 90% for transvaginal sonography and sonohysterography together and 100% and 70% for transvaginal sonography alone.

CONCLUSIONS

We found that sonohysterography does provide additional information over transvaginal sonography alone and is an important adjunct to transvaginal sonography in symptomatic women with known or suspected myomas, particularly before surgical or medical therapy.

Ultrasonographic assessment of endometrial thickness: a review

Measurement of endometrial thickness with ultrasonography is a modality commonly used today. Its clinical importance and applications extend throughout the phases of the reproductive lives of women. In premenopausal women, endometrial thickness is used to monitor infertility treatment, while in postmenopausal women with abnormal uterine bleeding it is useful as an initial investigation for endometrial hyperplasia or cancer. Moreover, endometrial thickness can vary with the menstrual cycle and with the use of hormone replacement therapy or selective estrogen receptor modulators. In this review, the use of ultrasound to measure both the premenopausal and postmenopausal endometrium is discussed.