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Trémollieres FA, Chabbert-Buffet N, Plu-Bureau G, Rousset-Jablonski C, Lecerf JM, Duclos M, Pouilles JM, Gosset A, Boutet G, Hocke C, Maris E, Hugon-Rodin J, Maitrot-Mantelet L, Robin G, André G, Hamdaoui N, Mathelin C, Lopes P, Graesslin O, Fritel X. Management of postmenopausal women: Collège National des Gynécologues et Obstétriciens Français (CNGOF) and Groupe d'Etude sur la Ménopause et le Vieillissement (GEMVi) Clinical Practice Guidelines. Maturitas 2022; 163:62-81. [PMID: 35717745 DOI: 10.1016/j.maturitas.2022.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/23/2022] [Accepted: 05/17/2022] [Indexed: 12/26/2022]
Abstract
AIM The aim of these recommendations is to set forth an individualized approach to the management of early postmenopausal women (i.e., within the first 10 years after natural menopause) covering all aspects of lifestyle and therapeutic management, with or without menopause hormone therapy (MHT). MATERIALS AND METHODS Literature review and consensus of French expert opinion. Recommendations were graded according to the HAS methodology and levels of evidence derived from the international literature, except when there was no good-quality evidence. SUMMARY RECOMMENDATIONS The beginning of menopause is an ideal time for each woman to evaluate her health status by assessing her bone, cardiovascular, and cancer-related risk factors that may be amplified by postmenopausal estrogen deficiency and by reviewing her lifestyle habits. Improving lifestyle, including nutrition and physical activity, and avoiding risk factors (notably smoking), should be recommended to all women. MHT remains the most effective treatment for vasomotor symptoms but it could be also recommended as first-line treatment for the prevention of osteoporosis in early postmenopausal women at low to moderate risk for fracture. The risks of MHT differ depending on its type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used. There is reasonable evidence that using transdermal estradiol in association with micronized progesterone or dydrogesterone may limit both the venous thromboembolic risk associated with oral estrogens and the risk of breast cancer associated with synthetic progestins. Treatment should be individualized to each woman, by using the best available evidence to maximize benefits and minimize risks, with periodic reevaluation of its benefit-risk balance. For bothersome genitourinary syndrome of menopause (GSM) symptoms, vaginal treatment with lubricants and moisturizers is recommended as first-line treatment together with low-dose vaginal estrogen therapy, depending on the clinical course. No recommendation of an optimal duration of MHT can be made, but it must take into consideration the initial indication for MHT as well as each woman's benefit-risk balance. Management of gynecological side-effects of MHT is also examined. These recommendations are endorsed by the Groupe d'Etude sur la Ménopause et le Vieillissement hormonal (GEMVI) and the Collège National des Gynécologues-Obstétriciens Français (CNGOF).
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Affiliation(s)
- F A Trémollieres
- Centre de Ménopause et Maladies Osseuses Métaboliques, Hôpital Paule-de-Viguier, CHU Toulouse, 330, avenue de Grande-Bretagne, TSA 70034, 31059 Toulouse, France; Inserm U1048-I2MC-Equipe 9, Université Toulouse III Paul-Sabatier, 1, avenue du Professeur-Jean-Poulhes, BP 84225, 31432 Toulouse cedex 4, France.
| | - N Chabbert-Buffet
- Service de gynécologie obstétrique, médecine de la reproduction, APHP Sorbonne Universitaire, Site Tenon, 4, rue de la Chine, 75020 Paris, France
| | - G Plu-Bureau
- Unité de gynécologie médicale, Hôpital Port-Royal, 123 boulevard de Port-Royal, 75014 Paris, France; Université de Paris, Paris, France; Inserm U1153 Equipe EPOPEE, Paris, France
| | - C Rousset-Jablonski
- Département de chirurgie oncologique, Centre Léon Bérard, 28, Promenade Léa-et-Napoléon-Bullukian, 69008 Lyon, France; Département d'obstétrique et gynécologie, Hospices Civils de Lyon, CHU Lyon Sud, 165, Chemin du Grand-Revoyet, 69310 Pierre-Bénite, France; Université Lyon, EA 7425 HESPER-Health Services and Performance Research, 8, avenue Rockefeller, 69003 Lyon, France
| | - J M Lecerf
- Service de nutrition et activité physique, Institut Pasteur de Lille, 1, rue du Professeur-Calmette, 59019 Lille cedex, France; Service de médecine interne, CHRU Lille, 2, avenue Oscar-Lambret, 59000 Lille, France
| | - M Duclos
- Service de médecine du sport et des explorations fonctionnelles, CHU Clermont-Ferrand, 63003 Clermont-Ferrand, France; Clermont Université, Université d'Auvergne, UFR Médecine, BP 10448, 63000 Clermont-Ferrand, France; INRAE, UMR 1019, UNH, CRNH Auvergne, 63000 Clermont-Ferrand, France
| | - J M Pouilles
- Centre de Ménopause et Maladies Osseuses Métaboliques, Hôpital Paule-de-Viguier, CHU Toulouse, 330, avenue de Grande-Bretagne, TSA 70034, 31059 Toulouse, France
| | - A Gosset
- Centre de Ménopause et Maladies Osseuses Métaboliques, Hôpital Paule-de-Viguier, CHU Toulouse, 330, avenue de Grande-Bretagne, TSA 70034, 31059 Toulouse, France
| | - G Boutet
- AGREGA, Service de chirurgie gynécologique et médecine de la reproduction, Centre Aliénor d'Aquitaine, Hôpital Pellegrin, 33000 Bordeaux, France
| | - C Hocke
- Service de chirurgie gynécologique et médecine de la reproduction, Centre Aliénor d'Aquitaine, CHU de Bordeaux, Place Amélie-Raba-Léon, 33076 Bordeaux cedex, France
| | - E Maris
- Département d'obstétrique et gynécologie, CHU Montpellier, Université Montpellier, Montpellier, France
| | - J Hugon-Rodin
- Unité de gynécologie médicale, Hôpital Port-Royal, 123 boulevard de Port-Royal, 75014 Paris, France
| | - L Maitrot-Mantelet
- Unité de gynécologie médicale, Hôpital Port-Royal, 123 boulevard de Port-Royal, 75014 Paris, France
| | - G Robin
- Service de gynécologie médicale, orthogénie et sexologie, UF de gynécologie endocrinienne, Hôpital Jeanne-de-Flandre, CHU de Lille, avenue Eugène-Avinée, 59037 Lille cedex, France
| | - G André
- 15, boulevard Ohmacht, 67000 Strasbourg, France
| | - N Hamdaoui
- Centre Hospitalier Universitaire Nord, Assistance publique-Hôpitaux de Marseille, Chemin des Bourrely, 13015 Marseille, France
| | - C Mathelin
- Institut de cancérologie Strasbourg Europe, 17, rue Albert-Calmette, 67200 Strasbourg, France; Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67200 Strasbourg, France; Institut de génétique et de biologie moléculaire et cellulaire (IGBMC), CNRS UMR7104 Inserm U964, 1, rue Laurent-Fries, 67400 Illkirch-Graffenstaden, France
| | - P Lopes
- Nantes, France Polyclinique de l'Atlantique Saint Herblain, 44819 St Herblain, France; Université ́de Nantes, 44093 Nantes cedex, France
| | - O Graesslin
- Département de gynécologie-obstétrique, Institut Mère-Enfant Alix de Champagne, Centre Hospitalier Universitaire, 45, rue Cognacq-Jay, 51092 Reims cedex, France
| | - X Fritel
- Service de gynécologie-obstétrique et médecine de la reproduction, CHU de Poitiers, 2, rue de la Milétrie, 86000 Poitiers, France
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Hamdaoui N, Boubli L. [Management of side effects under hormonal replacement therapy in menopausal women: Abnormal uterine bleeding. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2021; 49:474-484. [PMID: 33757921 DOI: 10.1016/j.gofs.2021.03.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To publish, under the aegis of the French National College of Gynecologists and Obstetricians (CNGOF) and the Study Group on Menopause and Hormonal Aging (GEMVi), recommendations based on the evidence available in the literature for the management of abnormal uterine bleeding (AUB) in women taking hormonal replacement therapy (HRT). A review of the literature was performed by consulting Medline, Cochrane Library data as well as international recommendations in French and English up to September 1, 2020. RESULTS AUB occurring in a woman taking HRT (FIGO 2011) is one of the main factors of poor adherence to the HRT. AUB must seek an organic cause including endometrial cancer. The main functional causes of AUB in a woman taking HRT are resumption of ovarian activity, poor compliance, and trophic disorders of the endometrium. AUB are dependent on the type of HRT. In the event of AUB under HRT, it is suggested to perform a pelvic ultrasound at the end of the progestational sequence in the event of sequential HRT. In a single episode of AUB and when the ultrasound estimates the endometrial thickness less than or equal to 4mm, it is possible to postpone further uterine exploration. In case of recurrent AUB or when the endometrium thickness is greater than 4mm in a postmenopausal woman, additional uterine investigations (hysteroscopy and histology) are recommended. CONCLUSION AUB under HRT must seek an organic cause. The measurement of endometrial thickness by pelvic ultrasound is relevant for screening for endometrial cancer.
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Affiliation(s)
- N Hamdaoui
- Centre hospitalier universitaire Nord, Assistance publique-Hôpitaux de Marseille, chemin des Bourrely, 13015 Marseille, France.
| | - L Boubli
- Centre hospitalier universitaire Nord, Assistance publique-Hôpitaux de Marseille, chemin des Bourrely, 13015 Marseille, France
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Diagnostic efficacy of gel infusion sonography in post-menopausal bleeding. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00308-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Our purpose was to evaluate the diagnostic performance of two-dimensional transvaginal ultrasound (2D-TVUS) and gel infusion sonography (GIS) at offline analysis for endometrial characterization compared with real-time evaluation during scanning.
One hundred fifty women presented with PMB. At TVUS, endometrial thickness was ≥ 4 mm in 122 (81.3%) women and < 4 mm in 28 (18.72%). Among 122 women with endometrial thickness > 4 mm, GIS was successfully performed in 117 (95.9%). Examinations were stored as video clips for later evaluation (offline analysis) by two less experienced radiologists. Endometrial lesions were classified into four categories: no endometrial abnormality, hyperplasia, polyps, and cancer. Diagnostic efficiency of real-time and offline analysis for diagnosis of each category was calculated and compared, and inter-observer agreement for offline analysis was calculated.
Results
All patients underwent hysteroscopy and/or hysterectomy. Histopathological results confirmed no endometrial abnormality in (27.3%, 41/150), endometrial hyperplasia in (12.7%, 19/150), endometrial polyps in (17.3%, 26/150), and endometrial cancer in (42.7%, 64/150).
Overall diagnostic accuracy of real-time imaging was 89.7% (CI 84–91%)). The highest accuracy 92.7% (CI 88–98%) was seen in the diagnosis of cancer, and polyps 91.5% (CI 86–97%). The lowest accuracy 75% (CI 69–82%) was seen in hyperplasia.
Overall diagnostic accuracy of offline analysis was 81%, and it increased to 88% (CI 83–92%) after a restricted analysis of good quality clips. The highest accuracy 90.7% (CI 83–95%) was seen in the diagnosis of polyps, and cancer 90.4% (CI 83–96%). The lowest accuracy 71% (CI 69–75%) was seen in hyperplasia.
At offline analysis, the inter-observer agreement was substantial k = 0.77 (CI 71–84) in the evaluation of four endometrial categories after the exclusion of bad quality videos. It was excellent in exclusion of endometrial abnormalities k = 0.85 (0.78–0.90), substantial in the diagnosis of polyps k = 0.71 (0.69–0.88), cancer k = 0.61 (0.61–0.77), and moderate in the diagnosis of hyperplasia k = 0.41 (0.30–0.41).
Conclusion
Offline 2D analysis with a good image quality has comparable accuracy to a real-time evaluation during scanning in the diagnosis of endometrial lesions. It can increase the accuracy of sonography in ruling out endometrial abnormalities and diagnose non-hyperplastic endometrial pathologies. High NPV and substantial reproducibility can make it an efficient initial screening method in a post-menopausal bleeding.
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Robbins JB, Sadowski EA, Maturen KE, Akin EA, Ascher SM, Brook OR, Cassella CR, Dassel M, Henrichsen TL, Learman LA, Patlas MN, Saphier C, Wasnik AP, Glanc P. ACR Appropriateness Criteria® Abnormal Uterine Bleeding. J Am Coll Radiol 2020; 17:S336-S345. [PMID: 33153547 DOI: 10.1016/j.jacr.2020.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 09/01/2020] [Indexed: 12/11/2022]
Abstract
This publication summarizes the relevant literature for the imaging of patients with symptoms of abnormal uterine bleeding, including initial imaging, follow-up imaging when the original ultrasound is inconclusive, and follow-up imaging when surveillance is appropriate. For patients with abnormal uterine bleeding, combined transabdominal and transvaginal ultrasound of the pelvis with Doppler is the most appropriate initial imaging study. If the uterus is incompletely visualized with the initial ultrasou2nd, MRI of the pelvis without and with contrast is the next appropriate imaging study, unless a polyp is suspected on the original ultrasound, then sonohysterography can be performed. If the patient continues to experience abnormal uterine bleeding, assessment with ultrasound of the pelvis, sonohysterography, and MRI of the pelvis without and with contrast would be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | | | | | - Esma A Akin
- George Washington University Hospital, Washington, District of Columbia
| | - Susan M Ascher
- Georgetown University Hospital, Washington, District of Columbia
| | - Olga R Brook
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Courtney R Cassella
- Reading Hospital, Reading, Pennsylvania; American College of Emergency Physicians
| | - Mark Dassel
- Cleveland Clinic, Cleveland, Ohio; American College of Obstetricians and Gynecologists
| | | | - Lee A Learman
- Virginia Tech Carilion School of Medicine, Roanoke, Virginia; American College of Obstetricians and Gynecologists
| | | | - Carl Saphier
- Women's Ultrasound, LLC, Englewood, New Jersey; American College of Obstetricians and Gynecologists
| | | | - Phyllis Glanc
- Specialty Chair, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Sanin-Ramirez D, Carriles I, Graupera B, Ajossa S, Neri M, Rodriguez I, Pascual MÁ, Guerriero S, Alcázar JL. Two-dimensional transvaginal sonography vs saline contrast sonohysterography for diagnosing endometrial polyps: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 56:506-515. [PMID: 32730635 DOI: 10.1002/uog.22161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/07/2020] [Accepted: 07/10/2020] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- D Sanin-Ramirez
- Department of Obstetrics and Gynecology, Universidad Pontificia Bolivariana, Medellin, Colombia
| | - I Carriles
- Department of Obstetrics and Gynecology, Clinica Universidad de Navarra, Pamplona, Spain
| | - B Graupera
- Department of Obstetrics, Gynecology, and Reproduction, Hospital Universitario Dexeus, Barcelona, Spain
| | - S Ajossa
- Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Cagliari, Italy
| | - M Neri
- Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Cagliari, Italy
| | - I Rodriguez
- Biostatistics and Epidemiology Unit, Department of Obstetrics, Gynecology, and Reproduction, Hospital Universitario Dexeus, Barcelona, Spain
| | - M Á Pascual
- Department of Obstetrics, Gynecology, and Reproduction, Hospital Universitario Dexeus, Barcelona, Spain
| | - S Guerriero
- Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Cagliari, Italy
| | - J L Alcázar
- Department of Obstetrics and Gynecology, Clinica Universidad de Navarra, Pamplona, Spain
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Thijssen SG, G Heremans RR, Nderlita M, Froyman WJG, Housmans S, Poppe WAJ, Timmerman D, den Bosch TV. Intrauterine Fluid Instillation and Transtubal Flow: A Randomized Controlled In vitro Trial Comparing Gel and Water. J Med Ultrasound 2020; 28:35-40. [PMID: 32368448 PMCID: PMC7194417 DOI: 10.4103/jmu.jmu_29_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/01/2019] [Accepted: 05/07/2019] [Indexed: 11/21/2022] Open
Abstract
Background: Possible transtubal spillage of malignant cells is a major concern in fluid instillation sonography, as it is in hysteroscopy. This study aims to compare the transtubal flow of gel and saline and validate the clinical hypothesis that application of fluids with higher viscosity causes less spillage. Methods: Randomized controlled in vitro trial comparing gel and saline infusion on 15 tissue specimens after hysterectomy with bilateral salpingectomy. Instillations are performed with saline and gel dyed with a 1% ink solution. Qualitative assessment of tubal spill is investigated as primary outcome. Secondary outcomes are instillation-volume and -pressure, assessed by measuring endometrial cavity dilation at in vitro ultrasound examination and subjective numeric 10-point scoring of the instillation pressure by a dedicated examiner. Results: Tubal flow was more often observed during saline instillation (odds ratio 4.88, P = 0.008). Median subjectively assessed instillation pressures were nine arbitrary units for gel and three for saline (P < 0.001). Tubal flow occurred from 2 cc onward in the saline group versus five cc in the gel instillation group. Cavitary dilation did not differ between both groups. Conclusion: Gel instillation sonography is in vitro associated with less tubal flow and therefore could be a safer diagnostic test compared to saline infusion sonography or hysteroscopy. In vivo studies are necessary to confirm these results.
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Affiliation(s)
- Soetkin G Thijssen
- Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, Leuven, Belgium
| | - Ruben R G Heremans
- Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, Leuven, Belgium
| | - Meri Nderlita
- Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, Leuven, Belgium
| | - Wouter J G Froyman
- Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, Leuven, Belgium
| | - Susanne Housmans
- Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, Leuven, Belgium
| | - Willy A J Poppe
- Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, Leuven, Belgium
| | - Dirk Timmerman
- Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, Leuven, Belgium
| | - Thierry Van den Bosch
- Department of Obstetrics and Gynaecology, University Hospitals KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, RZ Tienen, Tienen, Belgium
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Stepniewska AK, Verrazzo P, Savelli L, Trivella G, Signori C, Clarizia R, Guerriero M, Mollo A, De Placido G, Ceccaroni M. Comparison of Virtual Ultrasonographic Hysteroscopy with Conventional Hysteroscopy in the Workup of Patients Who Are Infertile. J Minim Invasive Gynecol 2020; 28:63-74. [PMID: 32197993 DOI: 10.1016/j.jmig.2020.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 03/08/2020] [Accepted: 03/11/2020] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE To compare the tolerability and diagnostic accuracy of virtual ultrasonographic hysteroscopy (VUH) with that of conventional diagnostic outpatient hysteroscopy in the workup of patients who are infertile. DESIGN A single-center, retrospective cohort study. SETTING Department of Obstetrics and Gynecology, Gynecologic Oncology, and Minimally Invasive Pelvic Surgery Unit of Sacred Heart Hospital Don Calabria in Negrar, Italy. PATIENTS A total of 120 consecutive women who underwent hysterosalpingosonography and subsequent VUH and conventional hysteroscopy for infertility evaluation were included. The inclusion criterion was infertility for at least 1 year, with evaluation in the early or intermediate follicular phase of the menstrual cycle. INTERVENTIONS After the placement of an intracervical catheter, a Ringer Lactate solution was injected into the uterine cavity and fallopian tubes, and a 3D volume was obtained. The ultrasound volume acquired was successively elaborated offline, and a VUH was performed. Subsequently, a variable amount of air was introduced into the uterine cavity, and the patency of the salpinges was evaluated. MEASUREMENTS AND MAIN RESULTS The VUH findings were compared with those of conventional hysteroscopy performed in the subsequent month. For the detection of endometrial pathology in the overall pool, the sensitivity and specificity of VUH in comparison with conventional hysteroscopy were 100% (95% confidence interval [CI], 84.6%-100%) and 100% (95% CI, 96.3%-100%), respectively. For the detection of uterine cavity pathology and uterine malformations in the overall pool, the sensitivities of VUH were 80% (95% CI, 28.4%-99.5%) and 100% (95% CI, 75.3%-100%), respectively, with specificities of 100% (95% CI, 96.8%-100%) and 100% (95% CI, 96.6%-100%), respectively, when compared with conventional hysteroscopy. The positive predictive values for endometrial pathology, uterine cavity alterations, and uterine malformations were 100% (95% CI, 84.6%-100%), 100% (95% CI, 39.8%-100%), and 100% (95% CI, 75.3%-100%), respectively, with a receiver operating characteristic area of 100%, 90% (95% CI, 70%-100%), and 100%, respectively. There were no cases of severe vasovagal reactions or other complications. Most patients (67%, 81 of 120 women) described the examination as "less painful than expected," 25% (30 of 120 women) "just as expected," and only 7% (9 of 120 women) as "more painful than expected." CONCLUSION VUH was well tolerated and showed a high accuracy (100%) in the study of the uterine cavity when compared with conventional hysteroscopy.
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Affiliation(s)
- Anna Katarzyna Stepniewska
- Department of Obstetrics and Gynecology, Gynecologic Oncology, and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS Sacred Heart Hospital Don Calabria, Negrar, Verona (Drs. Stepniewska, Trivella, Signori, Clarizia, and Ceccaroni).
| | - Paolo Verrazzo
- University Department of Neuroscience, Reproductive Medicine, and Odontostomatology, University of Naples Federico II, Naples (Drs. Verrazzo, Mollo, and De Placido)
| | - Luca Savelli
- Department of Obstetrics and Gynecology (Dr. Savelli) University of Bologna, Bologna
| | - Giamberto Trivella
- Department of Obstetrics and Gynecology, Gynecologic Oncology, and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS Sacred Heart Hospital Don Calabria, Negrar, Verona (Drs. Stepniewska, Trivella, Signori, Clarizia, and Ceccaroni)
| | - Chiara Signori
- Department of Obstetrics and Gynecology, Gynecologic Oncology, and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS Sacred Heart Hospital Don Calabria, Negrar, Verona (Drs. Stepniewska, Trivella, Signori, Clarizia, and Ceccaroni)
| | - Roberto Clarizia
- Department of Obstetrics and Gynecology, Gynecologic Oncology, and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS Sacred Heart Hospital Don Calabria, Negrar, Verona (Drs. Stepniewska, Trivella, Signori, Clarizia, and Ceccaroni)
| | - Massimo Guerriero
- Department of Computer Science (Dr. Guerriero), University of Verona, Verona, Italy; Clinical Research Unit (Dr. Guerriero), IRCCS Sacred Heart Hospital Don Calabria, Negrar, Verona
| | - Antonio Mollo
- University Department of Neuroscience, Reproductive Medicine, and Odontostomatology, University of Naples Federico II, Naples (Drs. Verrazzo, Mollo, and De Placido)
| | - Giuseppe De Placido
- University Department of Neuroscience, Reproductive Medicine, and Odontostomatology, University of Naples Federico II, Naples (Drs. Verrazzo, Mollo, and De Placido)
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecologic Oncology, and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS Sacred Heart Hospital Don Calabria, Negrar, Verona (Drs. Stepniewska, Trivella, Signori, Clarizia, and Ceccaroni)
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Diagnostic value of three-dimensional saline infusion sonohysterography in the evaluation of the uterus and uterine cavity lesions. Pol J Radiol 2019; 83:e482-e490. [PMID: 30655928 PMCID: PMC6334128 DOI: 10.5114/pjr.2018.80132] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 09/13/2018] [Indexed: 11/17/2022] Open
Abstract
Purpose The purpose of this review is to illustrate and discuss the seldom used technique of three-dimensional (3D) saline infusion sonohysterography (SIS) based on instillation of sterile saline through a catheter into the uterus under real-time vaginal transducer observation for assessment of the endometrial cavity. Material and methods The cases for this pictorial review were selected from the imaging material collected at the Ultrasound Unit, Clinical Imaging Department, Women’s Hospital of Hamad Medical Corporation during a seven-year period from 2011 to 2017. This was a retrospective collection of 216 consecutive cases that underwent two-dimensional (2D) and 3D SIS for evaluation of the uterine cavity, followed by verification of results with histopathology. An open-sided speculum is inserted into the vagina. An intrauterine catheter is then threaded into the endometrial cavity. After that, the speculum is removed carefully, and a vaginal transducer is inserted. Using a 60-ml syringe attached to the catheter, saline solution is instilled under direct real-time observation (2D SIS). Subsequently, reconstruction of the three-dimensional anatomy of the intrauterine cavity is performed. Pictorial review The review presents the most common indication for SIS, like abnormal bleeding in pre- and postmenopausal patients. SIS allows us to distinguish between focal lesions and global endometrial thickening. SIS should be supported as a second-line diagnostic procedure for abnormal uterine bleeding, when findings from transvaginal ultrasound are inconclusive. Conclusions The addition of 3D techniques to SIS procedure helps in the distinction between endometrial and myometrial lesions, also it facilitates delineation of uterine anatomy, resulting in more precise and accurate diagnosis.
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Abstract
Pelvic ultrasound examination is the primary imaging modality for evaluating a wide range of female pelvic symptomatology, and is often the first imaging test to detect a gynecologic malignancy. Ultrasound imaging is particularly useful for evaluating the thickness and appearance of the endometrium in patients with abnormal bleeding, and in detecting and characterizing ovarian lesions. This article reviews the ultrasound appearance of gynecologic neoplasms grouped by anatomic site of origin, the ultrasound appearance of select benign pelvic pathology not to be misinterpreted as malignancy, as well as available ultrasound imaging-based guidelines for managing potential gynecologic neoplasms.
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Pennant ME, Mehta R, Moody P, Hackett G, Prentice A, Sharp SJ, Lakshman R. Premenopausal abnormal uterine bleeding and risk of endometrial cancer. BJOG 2017; 124:404-411. [PMID: 27766759 PMCID: PMC5297977 DOI: 10.1111/1471-0528.14385] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/04/2016] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- ME Pennant
- Public Health DirectorateCambridgeshire County CouncilCambridgeUK
| | - R Mehta
- Cambridge University Hospitals NHS Foundation trustCambridgeUK
| | - P Moody
- Cambridge University Hospitals NHS Foundation trustCambridgeUK
| | - G Hackett
- Cambridge University Hospitals NHS Foundation trustCambridgeUK
| | - A Prentice
- Cambridge University Hospitals NHS Foundation trustCambridgeUK
- Department of Obstetrics & GynaecologyUniversity of CambridgeCambridgeUK
| | - SJ Sharp
- Medical Research Council Epidemiology UnitUniversity of CambridgeCambridgeUK
| | - R Lakshman
- Public Health DirectorateCambridgeshire County CouncilCambridgeUK
- Medical Research Council Epidemiology UnitUniversity of CambridgeCambridgeUK
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Maheux-Lacroix S, Li F, Laberge PY, Abbott J. Imaging for Polyps and Leiomyomas in Women With Abnormal Uterine Bleeding. Obstet Gynecol 2016; 128:1425-1436. [DOI: 10.1097/aog.0000000000001776] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Short J, Sharp B, Elliot N, McEwing R, McGeoch G, Shand B, Holland K. Does the addition of saline infusion sonohysterography to transvaginal ultrasonography prevent unnecessary hysteroscopy in premenopausal women with abnormal uterine bleeding? Aust N Z J Obstet Gynaecol 2016; 56:432-5. [DOI: 10.1111/ajo.12490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 05/17/2016] [Indexed: 11/27/2022]
Affiliation(s)
- John Short
- Department of Obstetrics and Gynaecology; Christchurch Women's Hospital; Christchurch New Zealand
| | - Benjamin Sharp
- Department of Obstetrics and Gynaecology; Christchurch Women's Hospital; Christchurch New Zealand
| | - Nikki Elliot
- The Canterbury Initiative; Canterbury District Health Board; Christchurch New Zealand
| | - Rachael McEwing
- Department of Radiology; Christchurch Hospital; Christchurch New Zealand
| | - Graham McGeoch
- The Canterbury Initiative; Canterbury District Health Board; Christchurch New Zealand
| | - Brett Shand
- The Canterbury Initiative; Canterbury District Health Board; Christchurch New Zealand
| | - Kieran Holland
- The Canterbury Initiative; Canterbury District Health Board; Christchurch New Zealand
- The Canterbury Initiative and Community Referred Radiology; Canterbury District Health Board; Christchurch New Zealand
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Millet I, Badat N, Petit É, Cayrac M, Pages-Bouic E, Taourel P. Cancer de l’endomètre induit : quelle place pour l’échographie ? IMAGERIE DE LA FEMME 2016. [DOI: 10.1016/j.femme.2016.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Ogutcuoglu B, Karadag C, Inan C, Dolgun ZN, Yoldemir AT, Aslanova L. Diagnostic utility of saline infusion doppler sonohysterography in endometrial mass lesions. Pak J Med Sci 2016; 32:284-8. [PMID: 27182224 PMCID: PMC4859007 DOI: 10.12669/pjms.322.9452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the importance of saline infusion Doppler sonohysterography (SIS-D) in the assessment of transvaginal ultrasound (TVUSG)-suspected intrauterine mass lesions in women complaining about abnormal uterine bleeding with respect to hysteroscopy (H/S) and pathologic diagnosis. METHODS This study was conducted on patients, who visited to our clinic with abnormal uterine bleeding and whose TVUSGs indicated intrauterine masses. The study covered a total of 100 patients. SIS-D and hysteroscopy were performed on those 100 patients. SIS-D results were compared with hysteroscopy results. The relation between SIS-D findings and pathology results were evaluated. RESULTS For SIS; specificity was 96%, sensitivity was 60%, positive predictive value (PPV) was 87.8%, negative predictive value (NPV) was 83.3%, and the accuracy rate was 87%. For TVUSG; PPV was 75%. According to SIS-D, 92.2% of the lesions that had single-vessel feeding patterns were endometrial polyps, and this was statistically significant (p<0.0001). 57.1% of the lesions that had multiple-vessel feeding patterns were submucous myomas, and this was statistically significant (p<0.0001). CONCLUSION SIS should be performed in patients before hysteroscopy because it will protect a considerable number of patients from unnecessary invasive procedures. SIS-D gives an idea on the histopathology of the mass.
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Affiliation(s)
- Bilge Ogutcuoglu
- Dr. Bilge Ogutcuoglu, Medeniyet University Goztepe Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey
| | - Cihan Karadag
- Dr. Cihan Karadag, Marmara University Pendik Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey
| | - Cihan Inan
- Dr. Cihan Inan, Department of Obstetrics and Gynecology, Trakya University, Edirne, Turkey
| | - Zehra Nihal Dolgun
- Dr. Zehra Nihal Dolgun, Department of Obstetrics and Gynecology, Trakya University, Edirne, Turkey
| | - Ahmet Tevfik Yoldemir
- Dr. Ahmet Tevfik Yoldemir, Marmara University Pendik Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey
| | - Lale Aslanova
- Dr. Lale Aslanova, Marmara University Pendik Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey
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El-Faissal Y, El lithy A. Gel-instillation versus saline infusion during sonohysterography: Any advantages? MIDDLE EAST FERTILITY SOCIETY JOURNAL 2015. [DOI: 10.1016/j.mefs.2014.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Evaluation of sonohysterography in detecting endometrial polyps - 241 cases followed with office hysteroscopies combined with histopathological examination. Wideochir Inne Tech Maloinwazyjne 2014; 9:344-50. [PMID: 25337156 PMCID: PMC4198634 DOI: 10.5114/wiitm.2014.43024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 11/29/2013] [Accepted: 01/23/2014] [Indexed: 11/22/2022] Open
Abstract
Introduction Hysteroscopy is considered the ‘gold standard’ procedure in assessing uterine pathology however it is more expensive and invasive method than ultrasonography. An alternative to the diagnostic hysteroscopy is sonohysterography. Aim To evaluate the usefulness of sonohysterography in detecting endometrial polyps in female patients diagnosed with infertility. Material and methods We compared the results of sonohysterographic examinations with hysteroscopy combined with histopathological findings. Results All the 241 sonohysterography examinations were performed successfully. No complications were observed. Forty-three hysteroscopies (17.8%) and six sonohysterography examinations (2.5%) were performed in short total intravenous anesthesia because of a low pain threshold of the patients. After hysteroscopic resection polyps were diagnosed in 74 (30.7%) patients. In 72 cases both saline infusion sonography (sonohysterography, SIS) examination and hysteroscopy confirmed the occurrence of an endometrial polyp. In 7 examinations (4.2%) the diagnosed polyp was not confirmed in sonohysterography (false-positive results). Two SIS procedures (2.7%) did not confirm the occurrence of the polyp (false-negative results). Sensitivity, specificity accuracy and error of sonohysterography in detecting endometrial polyps were 97.3%, 95.8% 96.2% and 3.7%, respectively. Positive and negative predictive values were 91.1% (PPV) and 98.7% (NPV). The agreement between SIS and hysteroscopy combined with histopathological examination was very high (K = 0.91). Conclusions Sonohysterography is a safe and highly sensitive and specific method used in diagnostics of endometrial polyps. Its results closely correspond to those obtained in a hysteroscopic examination and histopathological analysis.
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Laganà AS, Ciancimino L, Mancuso A, Chiofalo B, Rizzo P, Triolo O. 3D sonohysterography vs hysteroscopy: a cross-sectional study for the evaluation of endouterine diseases. Arch Gynecol Obstet 2014; 290:1173-8. [PMID: 25022557 DOI: 10.1007/s00404-014-3366-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 07/08/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE To assess the concordance between the presumed diagnosis obtained with the 3D sonohysterography (SHG) and with the diagnostic hysteroscopy (HYS); to determine whether the 3D SHG has the accuracy needed to be considered as a diagnostic screening standard in cases of suspected endouterine pathology. METHODS We selected 224 patients who voluntarily decided to undergo 3D SHG from a population with suspected presence of endouterine disease at TVS. The patients underwent first 3D SHG and then diagnostic HYS. We recorded each patient's discomfort/pain during the two techniques. We used the "Bayes Theorem" to calculate the sensitivity and specificity of the 3D SHG as compared to HYS. RESULTS Overall the 3D SHG diagnosis was confirmed in 156/224 cases (69.64 %). Concordance for endometrial thickening was 0 %; for Asherman's syndrome was 50.00 %; for polyp was 77.78 %; and for myoma, mucus accumulation and Müllerian anomalies (arcuate uterus, septate and subseptate uterus) was 100.00 %. Furthermore, 3D SHG was better tolerated than HYS. CONCLUSION Despite the diagnostic accuracy and mini-invasiveness of 3D SHG, we suggest that it cannot be a substitute of HYS in endouterine disease diagnosis, but it could be considered as a good method of screening to address patients to hysteroscopic confirmation.
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Affiliation(s)
- Antonio Simone Laganà
- Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Via C. Valeria 1, 98125, Messina, Italy,
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Chawla I, Tripathi S, Vohra P, Singh P. To Evaluate the Accuracy of Saline Infusion Sonohysterography (SIS) for Evaluation of Uterine Cavity Abnormalities in Patients with Abnormal Uterine Bleeding. J Obstet Gynaecol India 2014; 64:197-201. [PMID: 24966505 PMCID: PMC4061335 DOI: 10.1007/s13224-013-0501-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Accepted: 12/11/2013] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate the accuracy of transvaginal sonography (TVS) and saline infusion sonohysterography (SIS) for detection of uterine cavity abnormalities in patients with abnormal uterine bleeding (AUB) taking hysteroscopy as the gold standard. METHODS This was a prospective study done in the department of Obstetrics and Gynecology of a tertiary care academic hospital. Sixty premenopausal and postmenopausal women who presented with AUB underwent TVS, SIS, and hysteroscopy. The presence of focal abnormality and the type of abnormality, i.e., polyp, submucous myoma, and endometrial hyperplasia, were noted. The results of TVS and SIS were compared with hysteroscopy. RESULTS On hysteroscopy, 76.67 % (n = 46) patients were diagnosed with intra cavity abnormalities. SIS showed sensitivity, specificity, PPV, and NPV of 89.1, 100, 100, and 73.7 %, respectively. In comparison, TVS showed sensitivity, specificity, PPV, and NPV of 43.48, 78.57, 86.96, and 29.73 %, respectively. CONCLUSIONS SIS was found to be more sensitive and specific than TVS in detection of intra cavity abnormalities.
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Affiliation(s)
- Indu Chawla
- />Department of Obstetrics and Gynecology PGIMER, Dr. RML Hospital, New Delhi, 110001 India
- />J-5/169, Rajouri Garden, New Delhi, 110027 India
| | - Suchita Tripathi
- />Department of Obstetrics and Gynecology PGIMER, Dr. RML Hospital, New Delhi, 110001 India
| | - Poonam Vohra
- />Department of Radiodiagnosis PGIMER, Dr. RML Hospital, New Delhi, 110001 India
| | - Pushpa Singh
- />Department of Obstetrics and Gynecology PGIMER, Dr. RML Hospital, New Delhi, 110001 India
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Vitner D, Filmer S, Goldstein I, Khatib N, Weiner Z. A comparison between ultrasonography and hysteroscopy in the diagnosis of uterine pathology. Eur J Obstet Gynecol Reprod Biol 2013; 171:143-5. [DOI: 10.1016/j.ejogrb.2013.08.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 07/09/2013] [Accepted: 08/12/2013] [Indexed: 10/26/2022]
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Bennett GL, Andreotti RF, Lee SI, Dejesus Allison SO, Brown DL, Dubinsky T, Glanc P, Mitchell DG, Podrasky AE, Shipp TD, Siegel CL, Wong-You-Cheong JJ, Zelop CM. ACR appropriateness criteria(®) on abnormal vaginal bleeding. J Am Coll Radiol 2011; 8:460-8. [PMID: 21723482 DOI: 10.1016/j.jacr.2011.03.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Accepted: 03/25/2011] [Indexed: 10/17/2022]
Abstract
In evaluating a woman with abnormal vaginal bleeding, imaging cannot replace definitive histologic diagnosis but often plays an important role in screening, characterization of structural abnormalities, and directing appropriate patient care. Transvaginal ultrasound (TVUS) is generally the initial imaging modality of choice, with endometrial thickness a well-established predictor of endometrial disease in postmenopausal women. Endometrial thickness measurements of ≤5 mm and ≤4 mm have been advocated as appropriate upper threshold values to reasonably exclude endometrial carcinoma in postmenopausal women with vaginal bleeding; however, the best upper threshold endometrial thickness in the asymptomatic postmenopausal patient remains a subject of debate. Endometrial thickness in a premenopausal patient is a less reliable indicator of endometrial pathology since this may vary widely depending on the phase of menstrual cycle, and an upper threshold value for normal has not been well-established. Transabdominal ultrasound is generally an adjunct to TVUS and is most helpful when TVUS is not feasible or there is poor visualization of the endometrium. Hysterosonography may also allow for better delineation of both the endometrium and focal abnormalities in the endometrial cavity, leading to hysteroscopically directed biopsy or resection. Color and pulsed Doppler may provide additional characterization of a focal endometrial abnormality by demonstrating vascularity. MRI may also serve as an important problem-solving tool if the endometrium cannot be visualized on TVUS and hysterosonography is not possible, as well as for pretreatment planning of patients with suspected endometrial carcinoma. CT is generally not warranted for the evaluation of patients with abnormal bleeding, and an abnormal endometrium incidentally detected on CT should be further evaluated with TVUS.
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Allison SJ, Horrow MM, Kim HY, Lev-Toaff AS. Saline-infused Sonohysterography: Tips for Achieving Greater Success. Radiographics 2011; 31:1991-2004. [PMID: 22084183 DOI: 10.1148/rg.317115074] [Citation(s) in RCA: 277] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sandra J Allison
- Department of Radiology, Divisions of Ultrasound and Neuroradiology, Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20007, USA
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Khan F, Jamaat S, Al-Jaroudi D. Saline infusion sonohysterography versus hysteroscopy for uterine cavity evaluation. Ann Saudi Med 2011; 31:387-92. [PMID: 21808116 PMCID: PMC3156516 DOI: 10.4103/0256-4947.83213] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The most frequent procedures performed on women with abnormal uterine bleeding are 2D and 3D ultrasound. The most common accepted approach for the management of abnormal uterine bleeding is 2D TV scan followed by therapeutic hysteroscopy. The purpose of this prospective study was to assess whether 3D saline infusion sonohysterography (3D SIS) could replace diagnostic hysteroscopy (DH) for the diagnosis of endometrial pathology, in patients with abnormal uterine bleeding. DESIGN AND SETTING A prospective study in the ultrasound department of the Women's Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia from January 2008 to February 2010. PATIENTS AND METHODS 0One hundred and one patients with abnormal uterine bleeding, suspected to have endometrial abnormality by 2D and 3D transvaginal scan, were prospectively studied. Of these, 55 patients had undergone both 3D SIS and DH, followed by verification of results with histopathology. RESULTS Upon comparison of 3D SIS and DH individually with histopathology, specificity and sensitivity for 3D SIS were 67% and 100%, respectively, and for hysteroscopy 67% and 98%, respectively. In addition, the positive predictive value and negative predictive value were 98% and 100%, respectively, for 3D SIS, while for DH they were 98% and 67%, respectively. CONCLUSION 3D SIS is a safe alternative to hysteroscopy. However, larger randomized controlled trials should be conducted to ascertain the validity and reliability of this advantageous, less-invasive procedure, for women with abnormal uterine bleeding, who require evaluation of the endometrial cavity.
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Affiliation(s)
- Faryal Khan
- Ultrasound Department, Women's Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
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Feitosa IMSD, Feitosa HN, Carvalho FHC, Pereira SM, Medeiros FDC. Comparação entre ultrassonografia transvaginal e histerossonografia na avaliação de pacientes com sangramento uterino anormal. Radiol Bras 2011. [DOI: 10.1590/s0100-39842011000300007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Avaliar a eficácia da ultrassonografia transvaginal (USTV) e da histerossonografia (HSG) e compará-las na avaliação de alterações endometriais em portadoras de sangramento uterino anormal. MATERIAIS E MÉTODOS: Estudo transversal com 30 pacientes, idade entre 29 e 71 anos, 21 delas (70%) na pré-menopausa e 9 (30%) na pós-menopausa. Utilizou-se solução salina a 0,9% para contraste na HSG. Foi considerado o achado histeroscópico e/ou histopatológico como método padrão. Utilizou-se o teste de MacNemar para comparação dos testes diagnósticos. RESULTADOS: A histeroscopia diagnosticou 18 casos (60%) de alterações intracavitárias, sendo 10 pólipos (33,3%). A USTV apresentou sensibilidade e especificidade de 83,3% e a HSG mostrou sensibilidade de 94,4% e especificidade de 91,6%. O teste de MacNemar evidenciou sensibilidade (p = 0,500) e especificidade (p = 1,000) semelhantes entre a USTV e a HSG para detecção de alterações endometriais. No diagnóstico de pólipo, a HSG apresentou maior sensibilidade (90,9% × 27,3%; p = 0,016), com especificidade semelhante (89,5% × 94,7%; p = 1,000). CONCLUSÃO: A HSG e a USTV apresentam boas taxas de predição para doenças endometriais em pacientes com sangramento uterino anormal. A HSG apresenta sensibilidade e especificidade semelhantes às da USTV na detecção dessas doenças, porém apresenta sensibilidade maior para pólipos.
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Bingol B, Gunenc Z, Gedikbasi A, Guner H, Tasdemir S, Tiras B. Comparison of diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography and hysteroscopy. J OBSTET GYNAECOL 2011; 31:54-8. [DOI: 10.3109/01443615.2010.532246] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Comparison of diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography and hysteroscopy in postmenopausal bleeding. Arch Gynecol Obstet 2010; 284:111-7. [PMID: 20665218 DOI: 10.1007/s00404-010-1604-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Accepted: 07/12/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To compare the diagnostic accuracy of transvaginal sonography (TVS), saline infusion sonohysterography (SIS) and hysteroscopy (HS) with respect to pathological diagnosis in the detection of uterine cavity abnormalities associated with abnormal uterine bleeding among postmenopausal women. METHODS Being a prospective, investigator-blind trial, the present study was conducted on 137 postmenopausal women, with abnormal uterine bleeding, admitted to the Department of Obstetrics and Gynecology of Istanbul Bilim University, Florence Nightingale Hospital and Fertigyn Woman Health and IVF Center. After TVS, all patients underwent SIS using Cook Soft 500 IVF transfer catheter and HS, consecutively. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated to compare the diagnostic accuracy of TVS, SIS and HS. RESULTS Most commonly encountered endometrial lesions were polypoid lesion (38.0%) and hyperplasia (28.4%) among our study population consisting of 137 women (mean age 61.6 ± 9.6 years) in their postmenopausal stage. Overall sensitivity rates were 70.0% for TVS, 89.6% for SIS and 92.3% for HS, while the overall specificity rates were 50.0, 77.3 and 80.7%, respectively. HS had PPV of 96.2% and NPV of 65.3%, whereas PPV was determined to be 80.9 versus 95.3% and NPV was 35.4 versus 58.3% for TVS and SIS, respectively. CONCLUSIONS As an easy to perform, safe and well-tolerated procedure yielding high diagnostic accuracy, saline infusion SIS via this catheter seems to be superior to TVS and very close to HS. It may be used as the primary method for the detection of uterine abnormalities among postmenopausal women with abnormal uterine bleeding.
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Value of 3-dimensional sonohysterography for detection of intrauterine lesions in women with abnormal uterine bleeding. J Minim Invasive Gynecol 2010; 17:200-4. [PMID: 20226408 DOI: 10.1016/j.jmig.2009.12.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 12/06/2009] [Accepted: 12/16/2009] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To compare 2-dimensional (2D) sonohysterography (SHG) and 3D-SHG with saline solution infusion vs diagnostic hysteroscopy for investigation of intrauterine lesions in perimenopausal and postmenopausal women with abnormal uterine bleeding. DESIGN Comparative observational cross-sectional study (Canadian Task Force classification II-1). SETTING University hospital. PATIENTS Fifty perimenopausal and 20 postmenopausal women with abnormal intrauterine bleeding with clinically or ultrasonically suspected intrauterine lesions. INTERVENTIONS Conventional 2D- and 3D ultrasonography and 2D- and 3D-SHG with saline solution infusion followed by diagnostic hysteroscopy, and endometrial curettage or subsequent operative treatment (e.g., hysterectomy, myomectomy, or polypectomy). Ultrasonographic and hysteroscopic findings were compared with histopathologic findings. MEASUREMENTS AND MAIN RESULTS For 2D-SHG, sensitivity, specificity, positive predictive value, negative predictive value, overall accuracy, likelihood ratio for a positive result, and likelihood ratio for a negative result were 79%, 72%, 89%, 54%, 76%, 2.82, and 0.29, respectively, and for 3D-SHG, were 92%, 89%, 96%, 80%, 91%, 8.36, and 0.09, respectively; and for diagnostic hysteroscopy, were 94%, 89%, 96%, 84%, 93%, 8.55, and 0.07, respectively. Thus, 3D-SHG was superior to 2D SHG (p = .02) and comparable to diagnostic hysteroscopy (p = .75) for diagnosis of intrauterine lesions. CONCLUSION 3D-SHG can be used in the initial investigation of intrauterine lesions in perimenopausal and postmenopausal women with abnormal uterine bleeding before resorting to invasive procedures such as diagnostic hysteroscopy. Further studies of computer-reconstructed 3D-SHG virtual hysteroscopy are recommended.
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Brasic N, Feldstein VA. Dysfunctional Uterine Bleeding: Diagnostic Approach and Therapeutic Options. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.cult.2010.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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The role of transvaginal ultrasound and sonohysterography in the evaluation of postmenopausal bleeding. Menopause 2010; 17:21-2. [DOI: 10.1097/gme.0b013e3181c4f37a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Elsayes KM, Pandya A, Platt JF, Bude RO. Technique and diagnostic utility of saline infusion sonohysterography. Int J Gynaecol Obstet 2009; 105:5-9. [DOI: 10.1016/j.ijgo.2008.11.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2008] [Revised: 11/07/2008] [Accepted: 11/17/2008] [Indexed: 11/29/2022]
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Yildizhan B, Yildizhan R, Ozkesici B, Suer N. Transvaginal Ultrasonography and Saline Infusion Sonohysterography for the Detection of Intra-Uterine Lesions in Pre- and Post-Menopausal Women with Abnormal Uterine Bleeding. J Int Med Res 2008; 36:1205-13. [DOI: 10.1177/147323000803600606] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This prospective study investigated 79 pre- and 25 post-menopausal women with abnormal uterine bleeding who underwent conventional transvaginal ultrasonography (TVS) and saline infusion sonohysterography (SIS) and compared the results with histopathological findings obtained by dilatation and curettage, hysteroscopy or hysterectomy. Histological examination revealed normal endometrial histology in 28 patients, intracavitary polyps in 46 patients, submucosal fibroids in 18 patients, intramural fibroids in six patients and endometrial hyperplasia in six patients. The sensitivity and specificity of TVS in detecting endometrial polyps were 65.2% and 87.9%, respectively, compared with 91.3% and 93.1% for SIS. The sensitivity and specificity of TVS in detecting uterine fibroids were 95.8% and 95.0%, respectively, versus 91.6% and 98.7% for SIS. These results show that SIS is a satisfactory method of identifying lesions and that it is easy and cost-effective, and improves on the diagnostic utility of TVS. SIS is also a less invasive alternative to hysteroscopy, so should result in less morbidity in the evaluation of abnormal uterine bleeding in women.
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Affiliation(s)
- B Yildizhan
- Department of Obstetrics and Gynaecology, School of Medicine, Marmara University, Istanbul, Turkey
| | - R Yildizhan
- Department of Obstetrics and Gynaecology, School of Medicine, Yuzuncu Yil University, Van, Turkey
| | - B Ozkesici
- Department of Obstetrics and Gynaecology, Göztepe Research and Training Hospital, Istanbul, Turkey
| | - N Suer
- Department of Obstetrics and Gynaecology, Göztepe Research and Training Hospital, Istanbul, Turkey
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Miller JC, Schiff I, Thrall JH, Lee SI. Ultrasound and Sonohysterography in the Evaluation of Abnormal Vaginal Bleeding. J Am Coll Radiol 2008; 5:1154-6. [DOI: 10.1016/j.jacr.2008.07.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2008] [Indexed: 10/21/2022]
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In reply. Menopause 2008. [DOI: 10.1097/gme.0b013e31816704e5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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In reply. Menopause 2008. [DOI: 10.1097/gme.0b013e31816704d5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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To the editor. Inability to make a correlation between levels of serum testosterone and scores derived from a 10-question screening tool known as the Androgen Deficiency in Aging Males questionnaire. Menopause 2008; 15:401; author reply 401-2. [PMID: 18327120 DOI: 10.1097/gme.0b013e31816704c5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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