Transvaginal sonography combined with saline contrast sonohysterography to evaluate the uterine cavity in patients with abnormal uterine bleeding and postmenopausal endometrium more than 5 mm

Objectives: To determine whether saline contrast sonohysterography (SCSH) gives additional information to that obtained by transvaginal sonography (TVS) for predicting endometrial abnormality in premenopausal, menopausal and postmenopausal patients with abnormal uterine bleeding and postmenopausal patients with endometrial thickness > 5 mm.

Methods: This was a prospective study at the Ege University Obstetrics and Gynecology Clinic in Izmir, Turkey. Patients presenting with abnormal bleeding related to uterine pathologies, postmenopausal patients with endometrial thickness more than 5 mm and scheduled for surgical treatment were prospectively included in our study conducted between 1 July, 2000 and 31 January, 2002. The uterine cavity was first evaluated with TVS in 53 premenopausal, menopausal, postmenopausal patients with abnormal uterine bleeding and postmenopausal patients whose endometrial thickness was > 5 mm measured by conventional ultrasound examination. SCSH was carried out later with the intention of establishing further surgical management (hysterectomy). Twenty of the patients had operative hysterectomy within the 1.5 year period of time. The presence of focally growing lesions and the type of lesion (endometrial polyp, submucous myoma, malignancy or unclear focal lesion) were noted at ultrasound examination and at hysteroscopy, and then hysterectomy material was examined by Ege University's Pathology Department which provided a detailed evaluation of the uterine cavity.

Results: Based on normal endometrial morphology alone, the results for detection of an abnormal uterine cavity were as follows: sensitivity of TVS 0.94, SCSH 0.97; specificity of TVS 0.56, SCSH 0.62; positive predictive value of TVS 0.79, SCSH 0.81; negative predictive value of TVS 0.83, SCSH 0.93. Transvaginal sonography combined with SCSH was superior to TVS for detection of intracavitary abnormalities. When normal endometrial morphology was combined with an endometrial thickness of < 12 mm for evaluation of all abnormalities including hyperplasia, the diagnostic potential of TVS or SCSH was almost unchanged. Transvaginal sonography missed 24% of the polyps.

Conclusions: Sonohysterography was a sensitive tool and was superior to TVS used alone for evaluation of the uterine cavity in patients who underwent operative surgery for abnormal uterine bleeding.

Saline contrast sonohysterography; Transvaginal sonography; Abnormal uterine cavity

[1] Fleischer A. C., Kalemeris G. C., Machin J.E. et al.: "Sonographic depiction of normal and abnormal endometrium with histopathologic correlation". Ultrasound Med., 1986, 5, 445.

[2] Narayan R., Goswamy R. K.: "Transvaginal sonography of the uterine cavity with hysteroscopic correlation in the investigation of infertility". Ultrasound Obstet. Gynecol., 1993, 3, 129.

[3] Granberg S．Wiklond M., Karlsson B. et al.: "Endometrial thickness as measured by endovaginal ultrasonography for identifying endometrial abnormality". Am. J. Obstet. Gynecol., 1991 , 164, 47.

[4] Bernard J.P., Lecuru F., Darles C., Robin F., de Bievre P., Taurelle R.: "Saline contrast sono-hysterography as first-line investigation for women with uterine bleeding". Ultrasound Obstet. Gynecol., 1997, 10, 121.

[5] Fleischer A. C., Kepple D. M.: "Benign conditions of the uterus, cervix and endometrium". In: Nyberg D. A., Hill L. M., BohmVelez M. et al. (eds). Transvaginal Ultrasound. St. Louis: MosbyYear Book, 1992, 35.

[6] Lewit N., Thaler I., Rottem S.: "The uterus: A new look with transvaginal sonography". Clin. Ultrasound., 1990, 18, 331.

[7] Deichert V.: "Vaginal hysterokontrastsonographie zur differentialdiagnostischen Abklarung eines Pseudogestations-sackes". Ultraschall Klin, 1987, 2, 245.

[8] Mitri F. F.: "A clinical comparison of sonographic hydrotuballon and hysterosalpingography". Br. J. Obstet. Gynecol., 1991, 98, 1031.

[9] Dorum A., Kristensen G. B., Langebrekke A. et al.: "Evaluation of endometrial thickness measured by endovaginal ultrasound in women with postmenopausal bleeding". Acta Obstet. Gynecol Scand., 1993, 72, 116.

[10] Rodriguez G. C.: "A comparison of the Pipelle device and the Vabra aspirator as measured by endometrial denudation in hysterectomy specimens: The pipelle device samples significantly less of the endometrial surface than the Vabra aspirator". Am. J. Obstet. Gynecol., 1993, 168, 55.

[11] Randolph J. R., Ying Y. K., Maier D. B. et al.: "Comparison of realtime ultrasonography, hysterosalpingography and laparoscopy/ hysteroscopy in the evaluation of uterine abnormalities and tubal patency". Fertil. Steril., 1986, 46, 828.

[12] Dodson M. G.: "Use of transvaginal ultrasound in diagnosing the etiology of menometrorrhagia". Reprod. Med., 1994, 39, 362. First presented at the 47th annual meeting of the American Fertility Society, 1991.

[13] Shipley C. F.: "Comparison of transvaginal sonography with endometrial biopsy in asymptomatic postmenopausal women". J Ultrasound Med., 1994, 13, 99.

[14] de Jong P., Doe! F., Falconer A.: "Outpatient diagnostic hysteroscopy". Br. J. Obstet. Gynaecol., 1990, 97, 299.

[15] Smith B. R., Kerlikowske K., Feldstein V. A., Subak L., Scheidler J., Segal M. et al.: "Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities". J.A.M.A., 1998, 280, 1510.

[16] Karlsson B., Granberg S., Wikland M., Ylostalo P., Torvid K., Marsal K.,Valentin L.: "Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding - a Nordic multicenter study". Am. J. Obstet. Gynecol., 1995, 172, 1488.

[17] Emanuel M. H., Verdel M. J., Wamsteker K., Lammes F. B.: "A prospective comparison of transvaginal ultrasonography and diagnostic hysteroscopy in the evaluation of patients with abnormal uterine bleeding:clinical implications [see comments]". Am. J. Obstet. Gynecol., 1995, 172, 547.

[18] Towbin N. A., Gviazda I. M., March C. M.: "Office hysteroscopy versus transvaginal ultrasonography in the evaluation of patients with excessive uterine bleeding". Am. J. Obstet. Gynecol., 1996, 174, 1678.

[19] F ukuda M., Shimizu T., F ukuda K., Yomura W., Shimizu S.: "Transvaginal hysterosonography for differential diagnosis between submucous and intramural myoma". Gynecol. Obstet. Invest., 1993, 35, 236.

[20] Cicinelli E., Romano F., Anastasio P. S., Blasi N., P arisi C., Galantino P.: "Transabdominal sonohysterography, transvaginal sonography, and hysteroscopy in the evaluation of submucous myomas". Obstet. Gynecol., 1995, 85, 42.

[21] Widrich T., Bradley L. D., Mitchinson A. R., Collins R. L.: "Comparison of saline infusion sono-graphy with office hysteroscopy for the evaluation of the endometrium". Am. J. Obstet. Gynecol., 1996, 174, 1327.

[22] Schwarzler P., Concin H., Bosch H., Berlinger A., Wohlgenannt K., Collins W. P., Bourne T. H.: "An evaluation of sonohysterography and diagnostic hysteroscopy for the assessment of intrauterine pathology". Ultrasound Obstet. Gynecol., 1998, 11, 337.

[23] Bronz L., Suter T., Rusca T.: "The value of transvaginal sonography with and without saline instillation in the diagnosis of uterine pathology in pre- and postmenopausal women with abnormal bleeding or suspect sonographic findings". Ultrasound Obstet. Gynecol., 1997, 9, 53.

[24] Dijkhuizen F. P., Brolman H. A., P otters A. E., Bongers M. Y., Heinz A. P.: "The accuracy of transvaginal ultrasonography in the diagnosis of endometrial abnom叫ities". Obstet. Gynecol., 1996, 87,345.