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

Executive Summary of the Uterine Cancer Evidence Review Conference

Evidence for uterine cancer prevention, diagnosis, and special issues from the Uterine Cancer Evidence Review Conference is summarized.

The Centers for Disease Control and Prevention recognized the need for educational materials for clinicians on the prevention and early diagnosis of gynecologic cancers. The American College of Obstetricians and Gynecologists convened a panel of experts in evidence review from the Society for Academic Specialists in General Obstetrics and Gynecology and content experts from the Society of Gynecologic Oncology to review relevant literature, best practices, and existing practice guidelines as a first step toward developing evidence-based educational materials for women's health care clinicians about uterine cancer. Panel members conducted structured literature reviews, which were then reviewed by other panel members and discussed at a virtual meeting of stakeholder professional and patient advocacy organizations in January 2021. This article is the evidence summary of the relevant literature and existing recommendations to guide clinicians in the prevention, early diagnosis, and special considerations of uterine cancer. Substantive knowledge gaps are noted and summarized to provide guidance for future research.

Diagnostic value of saline infusion sonohysterography for detecting endometrial focal lesion

Introduction

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

Methods

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

Results

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

Conclusion

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

Ultrasound-guided sialo-irrigation with a saline-air mixture as the contrast medium

Ultrasound (US)-guided salivary gland irrigation is a popular conservative treatment method that improves the success rate and reduces complications of the sialo-irrigation procedure. US is routinely used for evaluation of various salivary gland diseases because of its easy accessibility and absence of ionizing radiation. US also allows dynamic studies with real-time imaging during diagnostic or surgical procedures. However, conventional US images have limitations in salivary duct visualization. Although US images acquired with saline irrigation have improved visualization because of ductal system dilation by the pulling effect, the resultant image quality remains insufficient for diagnosis. Therefore, contrast agents are required during US-guided sialo-irrigation procedures to produce diagnostic image quality. Air bubbles in saline solution have high echogenicity and enhance image quality by acting as a US contrast agent. The aim of this study was to assess the clinical significance of US-guided sialo-irrigation with a saline-air contrast medium, to estimate its diagnostic and treatment efficacy, and to examine the procedure in two patients. In the study, two patients underwent US-guided salivary gland irrigation with air-bubble mixed saline solution. During the procedure, we were able to visualize the salivary gland duct and subsequently irrigate and clean the inside of the duct. As a result, the patients' symptoms were relieved and saline solution mixed with air bubbles was confirmed to be an effective contrast agent.

Role of 3-Dimensional Sonography in the Assessment of Submucous Fibroids: A Pilot Study

OBJECTIVES

To investigate the accuracy and reliability of 3-dimensional (3D) transvaginal sonography in classifying submucous fibroids using the International Federation of Gynecology and Obstetrics PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) classification and protrusion (percent) compared to 2-dimensional (2D) transvaginal sonography, 2D saline infusion sonography, and 3D saline infusion sonography, using hysteroscopy as a reference test.

METHODS

A prospective cohort pilot study was performed among 14 consecutive patients undergoing hysteroscopic surgery, preceded by routine sonography (2D transvaginal sonography, 2D saline infusion sonography, 3D transvaginal sonography, and 3D saline infusion sonography).

RESULTS

The intraclass correlation coefficient (ICC) for 2D transvaginal sonography versus hysteroscopy was 0.69 (95% confidence interval [CI], 0.06, 0.90) compared to 0.94 (95% CI, 0.83, 0.98) for 2D saline infusion sonography. The ICCs for 3D transvaginal sonography versus hysteroscopy were 0.69 (95% CI, 0.03, 0.90 [investigator A]) and 0.55 (95% CI, -0.48, 0.86 [investigator B]). The ICCs for 3D saline infusion sonography versus hysteroscopy were 0.94 (95% CI, 0.81, 0.98 [investigator A]) and 0.87 (95% CI, 0.60, 0.96 [investigator B]). Interobserver agreement of 3D transvaginal sonography was 0.81 (95% CI, 0.43, 0.94) compared to 0.86 (95% CI, 0.56, 0.96) for 3D saline infusion sonography.

CONCLUSIONS

In these preliminary data, 3D transvaginal sonography was not as accurate as 2D or 3D saline infusion sonography and was not more accurate than 2D transvaginal sonography. There was moderate interobserver agreement for 3D transvaginal sonography. There might be room for improvement, as 3D transvaginal sonography is more accurate when endometrial thickness increases. Further study is warranted to evaluate in which patients saline infusion sonography eventually can be obviated.

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

AIM:

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

SETTINGS AND DESIGN:

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

MATERIALS AND METHODS:

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

STATISTICAL ANALYSIS:

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

RESULTS:

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

CONCLUSION:

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

Transvaginal Ultrasonography and Hysteroscopy as Predictors of Endometrial Polyps in Postmenopause

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

Sonohysterography: Principles, technique and role in diagnosis of endometrial pathology

Sonohysterography (SHG), which provides enhanced endometrial visualization during standard transvaginal ultrasonography, is a relatively safe procedure for the evaluation of endometrial pathology. It can be used to evaluate patients with abnormal vaginal bleeding or infertility. This modality offers real time imaging of the endometrium without exposure to ionizing radiation. SHG is typically used in patients for whom standard transvaginal ultrasonography does not show the endometrium well, show a potential abnormality for which further imaging is required, or in patients without endometrial pathology defined on routine transvaginal imaging but in whom there is a strong clinical suspicion of an abnormality. This article will discuss the utility of the sonohysterogram in evaluation of various endometrial pathologies. Imaging examples of these pathological entities will be illustrated as well.

Is it possible to obtain a presurgical Lasmar score for hysteroscopic myomectomy by ultrasound alone?

OBJECTIVE

To determine whether a Lasmar score obtained entirely by the use of two-dimensional (2D) and three-dimensional (3D) ultrasound provides results similar to those obtained using the original hysteroscopic technique.

METHODS

This was a prospective study performed on a series of patients presenting with symptomatic submucous fibroids and scheduled for hysteroscopic myomectomy. Ultrasound Lasmar scores were obtained by a single physician, a specialist in ultrasonography, in the luteal phase of the menstrual cycle. 3D images were evaluated by offline examination using multiplanar analysis. Classical Lasmar scores were obtained by a different physician, a specialist in hysteroscopy, during the follicular phase of the subsequent cycle. Surgery was performed by a third physician in the follicular phase who also reported a Lasmar score, which we considered as the gold standard. The concordance between group classifications (I-III, relating to difficulty of hysteroscopic resection) according to the three methods used to obtain the Lasmar score (ultrasound, classical and surgery) was calculated using Cohen's κ statistic.

RESULTS

Thirty-four women, with a mean age of 43 ± 4.9 years, were enrolled in the study. Thirty-six submucous fibroids were identified by both ultrasound and diagnostic hysteroscopy. The mean diameter of fibroids evaluated was 28 ± 13.2 mm. The concordance between the three methods of classifying patients according to Lasmar score was high: classical vs. surgery, κ = 0.88; ultrasound vs. surgery, κ = 0.93; and classical vs. ultrasound, κ = 0.77.

CONCLUSION

The Lasmar score can be obtained solely by ultrasound examination performed in the luteal phase of the menstrual cycle, avoiding office hysteroscopy without a loss of diagnostic accuracy.

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

Purpose:

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

Methods:

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

Results:

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

Conclusion:

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

Saline instillation sonohysterography test after normal baseline transvaginal sonography results in infertility patients. Is it justified?

PURPOSE

To investigate whether there is additional value for saline instillation sonohysterography (SIS) as a routine screening tool when baseline transvaginal sonography (TVS) is normal.

METHODS

Two-hundred ninety four infertility patients underwent baseline TVS and were categorised according to the results. TVS findings were negative in study group (n = 124) and positive (any abnormalities) in control group (n = 170). All the patients were further investigated by SIS. Hysteroscopy was performed whenever SIS results were suspicious. Our main outcome measure was accuracy of SIS in detecting intracavitary lesions using pathology reports as gold standard.

RESULTS

In the study group, out of 124 SIS tests, 13 (10.4%) showed positive findings and were further investigated by hysteroscopy. Three out of the 13 (23.0%) had subsequent positive hysteroscopy findings, however, no (0.0%) abnormality was found on pathologic examination. In the control group, out of 170 SIS tests, 62 (36.4%) showed positive findings, and were further investigated by hysteroscopy. Forty-two cases out of the 62 (67.7%) had subsequent positive hysteroscopic findings. Pathological examination was positive in 35 out of the 42 (83.3%) positive hysteroscopies.

CONCLUSION

Routine SIS for patients with normal TVS did not contribute additional findings. However, in patients with any suspicious findings on TVS (including extracavitary lesions), SIS was beneficial.

Comparison of diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography and hysteroscopy in postmenopausal bleeding

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.