Abnormal uterine bleeding in adolescents: ultrasound evaluation of uterine volume

OBJECTIVE

To evaluate ultrasonographic measurements of internal genitalia in girls suffering from abnormal uterine bleeding (AUB) and to compare the appearances with those of healthy girls. DESIGN Prospective case - control study.

METHODS

One hundred and five not sexually active adolescent girls were enrolled - 67 patients were suffering from AUB and there were 38 healthy peers. The groups did not differ in chronological age, or in postmenarcheal age. All girls underwent assessment of their history, clinical data and transabdominal pelvic ultrasound to evaluate their uterus and ovaries. In order to avoid the impact of endometrium cycle fluctuations, the uterine volume was calculated including and excluding its thickness.

RESULTS

The uterine volume among the girls suffering from AUB was significantly larger than in the control group. The mean uterine volume including endometrium in the study and control groups was 63.2 ± 24.8 and 47.8 ± 17.5 cm³, respectively (p=.001), and excluding the endometrium was 34.7 ± 13.1 and 29.1 ± 13.8 cm³ (p=.043). We did not find any significant difference in ovarian volume between the groups.

CONCLUSIONS

The girls in the AUB group have significantly larger uterine volume than healthy girls. This finding does not depend on endometrial thickness.

[Feasibility and diagnostic value of hysterosonography performed in bleeding time in the exploration of abnormal uterine bleeding]

OBJECTIVES

The aim of our study is to evaluate the feasibility, safety and diagnostic value of hysterosonography performed in an emergency setting among patients consulting for active abnormal uterine bleeding.

MATERIALS AND METHODS

In this prospective study, we included 216 patients visiting our emergency department for abnormal uterine bleeding. All patients had a transvaginal ultrasound with doppler study and an hysterosonography. Secondly, the patients, in whom we diagnosed a suspected organic lesion, were addressed to an endoscopic or surgical procedure with pathological examination. Initially, we evaluated the feasibility and the safety of hysterosonography and secondly, we compared the two techniques (EEV and hysterosonography), sensitivity, specificity, LHR+and LHR-.

RESULTS

The hysterosonography was performed in 98.1 % of patients and its realization has resulted in an additional period of 1.2minutes on average (extreme: 6-12) compared to ultrasound. The tolerance of the hysterosonographic examination was very good in 73.5 % of patients and good in 23.1 % of them. For the 167 patients who had been diagnosed with presumed organic lesions, pathological examination found an endometrial hyperplasia in 34.7 % of cases, polyps in 40.1 % of cases, sub-mucosal fibroids in 11.3 % of cases, endometrial cancer in 0.7 % of cases and other lesions in 13.2 % of cases. The diagnostic value of hysterosonography was superior to ultrasound in the detection of polyps (AUC: 0.894 vs 0.778, P=0.003) and fibromas (AUC: 1.000 vs 0.716, P=0.001) while the two methods showed no significant difference in the detection of hyperplasia.

CONCLUSION

The purpose of our study was to focus on a particular context of use of the hysterosonography consisting on hemorrhagic period and on its realization in the emergency room. We were able to demonstrate that hysterosonography is compatible with the emergency situation as to its feasibility and its diagnostic value and that its realization would contribute to the sorting of patients to guide them immediately to a surgical or endoscopic procedure if necessary.

Comparison of transvaginal 3D sonohysterography with outpatient hysteroscopy in the evaluation of abnormal uterine bleeding

OBJECTIVE

To compare transvaginal three-dimensional sonohysterography (3D SHSG) and outpatient hysteroscopy with regards to diagnostic accuracy, procedure time, and patient discomfort with a prospective randomized controlled cohort study in a teaching hospital in London. The study included a population group of 49 women with abnormal uterine bleeding from varied ethnic backgrounds, of which 44 completed the study. Subjects with pregnancies, pelvic infections, large uteruses, suspicious or diagnosed pelvic malignancies, and who did not meet the criteria for day surgery, were excluded.

MATERIALS AND METHODS

Patients were randomized into two groups: group 1 had hysteroscopy followed by SHSG while group 2 had SHSG followed by hysteroscopy. Diagnostic accuracy, procedure time, and patient discomfort of SHSG in comparison to hysteroscopy were studied.

RESULTS

A total of 44 patients completed the study. The average age of the study population was 44.8 years and the mean parity was 1.8. Nulliparas represented 34.03% of the study population and the average duration of symptoms was 14.8 months.

CONCLUSION

In the investigation of women with abnormal bleeding in an outpatient setting, both hysteroscopy and SHSG are comparable in the diagnosis of intracavity lesions, pain rating, and procedure time. However patient acceptability of SHSG was significantly more when compared to outpatient hysteroscopy.

Diagnostic accuracy of sonohysterography and transvaginal sonography as compared with hysteroscopy and endometrial biopsy: a prospective study

AIM

The aim of the study was to compare the diagnostic accuracy between transvaginal sonography (TVS) and sonohysterography (SHG) versus hysteroscopy (Hys) plus endometrial biopsy (EB) to evaluate uterine cavity.

METHODS

One hundred and sixteen patients were enrolled. These presented with infertility and/or abnormal uterine bleeding and/or suspicious uterine cavity pathology. Women consecutively underwent during the same day, to TVS, SHG and Hys plus EB by three different operators.

RESULTS

TVS shows excellent specificity (95.7%) in uterine polyps detection, good sensitivity (85,7%) and specificity (89.2%) in investigating endometrial hyperplasia, and excellent NPV (92.2%) in the diagnosis of submucous myomas. Diagnostic accuracy of TVS for synechiae is not evaluable. SHG demonstrates high specificity (92.8%) in the detection of uterine polyps, and high sensitivity (92.9%) and specificity (96.8%) in the diagnosis of endometrial hyperplasia. In addition it shows high sensitivity (90%), specificity (99%), PPV (92.2%), and NPV (99%) for detection of submucous myomas. Finally, SHG shows high PPV (100%) and NPV (100%) for synechiae assessment.

CONCLUSION

TVS could be used as first step investigation to exclude uterine pathologies. TVS could reduce the number of diagnostic Hys normally performed in women with normal uterine cavity. Furthermore SHG should be useful to diagnose the pathologies and to decide between operative Hys in-office or resectoscopic treatment.

Ultrasound evaluation of the Cesarean scar: relation between a niche and postmenstrual spotting

OBJECTIVE

To evaluate the relationship between a niche and abnormal uterine bleeding, and to develop a sonographic classification of niches and evaluate its relationship to abnormal uterine bleeding.

METHODS

An observational prospective cohort study was performed between October 2007 and May 2009. All women who had a Cesarean section performed in our hospital were asked to participate. Two hundred and twenty-five women were included and examined with both transvaginal sonography (TVS) and gel instillation sonohysterography (GIS) 6-12 months after the Cesarean section. In case of a niche, the depth, volume and residual myometrium were measured, and the shape was assessed according to a specified classification. A questionnaire and pictorial blood loss assessment chart were filled in.

RESULTS

The prevalence of a niche on evaluation with TVS and GIS was 24.0% and 56.0%, respectively. A niche was considered to be present if the depth was at least 1 mm visualized with GIS. Postmenstrual spotting was reported by 33.6% of women with a niche and 15.2% of women without a niche (P = 0.002). The niche volume was significantly different between women with and without postmenstrual spotting (P = 0.02). Most niches had a semicircular (50.4%) or triangular shape (31.6%). No significant relationship was identified between the shape of the niche and postmenstrual spotting (P = 0.19).

CONCLUSIONS

A niche is present in 56.0% of women with a history of Cesarean section when examined by GIS and is associated with postmenstrual spotting. Semicircular and triangular niches are most common, but the shape is not related to postmenstrual spotting.

Ultrasonographic endometrial thickness for diagnosing endometrial pathology in postmenopausal bleeding

We conducted this retrospective analysis of our clinical data to identify the incidence of benign endometrial abnormalities, endometrial carcinoma and to find out the endometrial thickness (ET) cut-off point using trans-vaginal ultrasonography for patients with postmenopausal bleeding (PMB) referred to the Rapid Access Clinic in Northampton General Hospital. All women referred between April 2004 and April 2005 with PMB were included in this analysis. Final diagnostic outcome was classified into benign endometrial polyp, endometrial hyperplasia, endometrial carcinoma or normal (by excluding these pathologies). A total of 142 patients were included in this survey. The incidence of abnormal endometrial pathology was found to be 23.9% and 5% for endometrial carcinoma. Our results suggested that benign endometrial pathology is the most common cause of postmenopausal bleeding. Lowering the endometrial thickness cut-off point from 5 mm to 3 mm will not improve the diagnostic accuracy of endometrial carcinoma.

TV sonographic assessment in postmenopausal women with bleeding

The aim of this study was to evaluate retrospectively the usefulness of transvaginal sonography for the detection of endometrial disease in postmenopausal women with bleeding. This study involved 275 postmenopausal women aged 47-81 years (median 62). None of them were on hormone replacement therapy and all had had amenorrhea for more than one year. Concerning the age of the study patients, we confirm that endometrial cancer occurs at any age, but more commonly in ages above 58 years. Transvaginal sonography was performed in all women. About 89.2% of malignant diseases were discovered in the study women whose endometrial thickness was above 4 mm, but we also found endometrial cancer in 10.2% of the cases in women whose endometrial thickness was below 4 mm. In postmenopausal symptomatic women premalignant or malignant causes of bleeding can not be excluded with just transvaginal ultrasound.

Abnormal uterine bleeding: imaging techniques for evaluation of the uterine cavity and endometrium before minimally invasive surgery--the case for transvaginal ultrasonography

Transvaginal ultrasound has been utilized for first line evaluation of abnormal uterine bleeding since its development in the early 1980's. The benefits and diagnostic effectiveness of transvaginal ultrasound in assessing the uterus, unlike hysteroscopy, extends to the complete pelvis. The ease of application, patient acceptance, and immediacy of results are rapidly apparent. Comparisons with hysteroscopic evaluation are discussed. While tissue diagnosis is still the gold standard, transvaginal sonography lets one know what surgical procedure to plan for from hysteroscopy to Endoscopy or laparotomy, including when no further surgical evaluation is necessary.

In the management of abnormal uterine bleeding, is office hysteroscopy preferable to sonography? The case for hysteroscopy

Office hysteroscopy for the diagnosis and management of abnormal uterine bleeding has developed into an easily performed procedure, with minimal discomfort and significantly reduced risks and expense. Miniaturization of instruments and safer liquid distention media, along with effective local analgesia, have made the procedure a fast, effective, and much more precise way to detect intrauterine abnormalities, as well as to better define the correct plan for any proposed operative management. In addition to the above, hysteroscopy is considered the "gold standard" for evaluating the uterine cavity. Numerous studies comparing hysteroscopy to sonography, with or without saline solution infusion are cited, along with other studies comparing hysteroscopy to blind biopsy and curettage, all indicating that hysteroscopy is more accurate, with fewer false-positive and false-negative results.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Levonorgestrel-releasing intrauterine system vs. transcervical endometrial resection for dysfunctional uterine bleeding

OBJECTIVE

To compare the acceptability, efficacy, adverse effects, and user satisfaction of a levonorgestrel intrauterine system (LNG-IUS) and transcervical resection of the endometrium (TCRE) for the treatment of dysfunctional uterine bleeding.

METHOD

Of 50 women with a pictoral blood loss assessment chart (PBAC) score of 100 or greater, 25 had a LNG-IUS inserted (Mirena; Schering, Berlin, Germany) and 25 underwent TCRE. Procedure-related complications, PBAC score, hemoglobin levels, adverse effects, and rates of acceptability and satisfaction were recorded at 3-month intervals for a period of 12 months.

RESULTS

At the end of 1 year there were a 97% and a 94% reduction in menstrual blood loss in the LNG-IUS and TCRE groups, respectively, and hemoglobin concentration had increased by 5.5% in the LNG-IUS group and 5.2% in the TCRE group. Adverse effects were similar in both groups except for systemic effects, which were seen only in the LNG-IUS group. Satisfaction rates were about 80% in the 2 groups.

CONCLUSION

Both treatments were found to be equally effective but LNG-IUS placement requires less operator skill and entails no operative hazards, and the device provides effective contraception.

Malformation artérioveineuse utérine. Une cause rare de métrorragies récidivantes

Uterine arteriovenous malformation is a rare condition. We report a case with acquired arteriovenous malformation arising from the left uterine artery. She was diagnosed by color Doppler ultrasound and treated with a selective uterine artery embolization.

Correlation of endometrial thickness, cycle day and histopathology in women with abnormal uterine bleeding

OBJECTIVE

To correlate the endometrial thickness measured by transvaginal sonography (TVS), cycle day and menstrual status with histopathology in women with abnormal uterine bleeding and to evaluate the accuracy of transvaginal sonography in detecting intrauterine abnormalities as compared to hysteroscopy.

METHODS

This prospective study was conducted in the Department of Obstetrics and Gynecology, Sultan Qaboos University Hospital between January 1998 and July 2002. Transvaginal sonography was performed in 160 women with abnormal uterine bleeding, followed within 48 hours by hysteroscopy and endometrial biopsy. Statistical analysis was performed by MacNamar's chi-square test and the various correlations were calculated.

RESULTS

No statistically significant association was found between endometrial thickness and cycle day with histopathology. None of the women with endometrial thickness of <5 mm had atypia or malignancy. There was a highly significant association between menstrual status and histology. Transvaginal sonography and hysteroscopy were in agreement in 73.7% of the patients.

CONCLUSION

An endometrial thickness of <5 mm in women with postmenopausal bleeding could mean that curettage can be avoided. No definite cut-off value could be assigned for the menstruating women. Transvaginal sonography is a good initial screening tool in the evaluation of women with abnormal uterine bleeding. Hysteroscopy and histological examination is indicated in cases of abnormal or inconclusive sonograms or if complaints persist after a normal sonogram. Transvaginal sonography seems to be an effective procedure to exclude endometrial and intrauterine abnormalities.

Sonohysterography: a prospective survey of results and complications in 81 patients

PURPOSE

To evaluate the sonohysterography (SHG) for the diagnosis of intrauterine abnormalities and describe complications and failure rate.

STUDY DESIGN

A prospective survey on 81 patients, (44 patients with menometrorrhagia, 30 with postmenopausal bleeding and 7 with infertility) was conducted. Histopathology and clinical survey, if sonohysterography was normal, were the gold standards.

RESULTS

Pathology has been performed in 55 cases. There were four failures (cervical stenosis), one severe complication (endometritis), one pelvic pain. Sensitivity and specificity of sonography were 56 and 83%; for sonohysterography 88 and 98%; and for hysteroscopy 78 and 97%. Sonohysterography was accurate for the diagnosis of the submucous myoma component.

CONCLUSION

Sonohysterography is available in uterine pathology, easy, safe and cheap, but sonographists and patients should be informed of the little risks of such examination technique.

Vaginoscopic hysteroscopy and transvaginal sonography in the evaluation of patients with abnormal uterine bleeding

STUDY OBJECTIVE

To compare accuracy of vaginoscopic hysteroscopy, a new method of outpatient hysteroscopy, with that of transvaginal sonography in diagnosing intracavitary pathology in women with abnormal uterine bleeding.

DESIGN

Retrospective comparative study (Canadian Task Force classification II-2).

SETTING

Department of gynecology in a tertiary care university hospital.

PATIENTS

Three hundred ninety-seven consecutive patients.

INTERVENTIONS

Vaginoscopic hysteroscopy, transvaginal sonography, and histologic evaluation of endometrium.

MEASUREMENTS AND MAIN RESULTS

Findings at hysteroscopy and sonography were compared with histopathologic results, considered the gold standard diagnosis. Sensitivity, specificity, and positive and negative likelihood ratios were 92%, 95%, 18.4, and 0.08 for vaginoscopic hysteroscopy and 67%, 87%, 5.15, and 0.38 for transvaginal sonography, respectively.

CONCLUSION

Vaginoscopic hysteroscopy is quick and well tolerated, and more accurate in detecting intracavitary uterine pathology than transvaginal sonography. More research is required to determine its place in patients with abnormal uterine bleeding, especially premenopausal women.

Determining the best catheter for sonohysterography

OBJECTIVE

To compare the characteristics of six different catheters for performing sonohysterography (SHG) to identify those that offer the best compromise between reliability, tolerability, and cost.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENT(S)

Six hundred ten women undergoing SHG.

INTERVENTION(S)

We performed SHG with six different types of catheters: Foleycath (Wembley Rubber Products, Sepang, Malaysia), Hysca Hysterosalpingography Catheter (GTA International Medical Devices S.A., La Caleta D.N., Dominican Republic), H/S Catheter Set (Ackrad Laboratories, Cranford, NJ), PBN Balloon Hystero-Salpingography Catheter (PBN Medicals, Stenloese, Denmark), ZUI-2.0 Catheter (Zinnanti Uterine Injection; BEI Medical System International, Gembloux, Belgium), and Goldstein Catheter (Cook, Spencer, IN).

MAIN OUTCOME MEASURE(S)

We assessed the reliability, the physician's ease of use, the time requested for the insertion of the catheter, the volume of contrast medium used, the tolerability for the patients, and the cost of the catheters.

RESULT(S)

In 568 (93%) correctly performed procedures, no statistically significant differences were found among the catheters. The Foleycath was the most difficult for the physician to use and required significantly more time to position correctly. The Goldstein catheter was the best tolerated by the patients. The Foleycath was the cheapest whereas the PBN Balloon was the most expensive.

CONCLUSION(S)

The choice of the catheter must be targeted to achieving a good balance between tolerability for the patients, efficacy, cost, and the personal preference of the operator.

The feasibility of a 'one stop' ultrasound-based clinic for the diagnosis and management of abnormal uterine bleeding

OBJECTIVES

We have established a 'one stop' clinic for the management of women with abnormal uterine bleeding based on transvaginal sonography and saline contrast sonohysterography. This report reviews our experience with the first 93 patients attending the clinic.

DESIGN AND METHODS

Patients were seen with the intention of performing a transvaginal scan, saline contrast sonohysterography, endometrial biopsy, full blood count and thyroid function tests. The findings were prospectively recorded on a computer database and a management plan formulated.

RESULTS

A transvaginal scan was performed on 89 (95.7%) women, 70 (75.3%) also undergoing saline contrast sonohysterography. An endometrial biopsy was carried out in 67 (72%) women aged 40 years and above, and 79 (84.9%) had blood tests. The median age of patients was 44 (range, 21-78) years. The majority of women presented with menstrual disorders. Uterine pathology was detected on transvaginal scan in 42 (47.2%) cases. Adnexal pathology was detected in 12 (13.5%) of the patients. Endometrial biopsy detected three (4.5%) cases of endometrial atypia, and three (4.5%) cases of adenocarcinoma. A hemoglobin level of < 10 g/dL was detected in 3 (3.4%) patients. A single clinic visit was thought sufficient for 83 (89.2%) women. Medical therapy was started in 47 (50.5%) patients, 15 (16.3%) were brought back for inpatient diagnostic hysteroscopy, and nine (9.7%) were booked for operative endoscopy, while six (6.5%) had conventional surgery; the remainder were reassured.

CONCLUSIONS

This study demonstrates that a 'one stop' management philosophy based on pelvic ultrasound is feasible. Our data suggest that diagnostic hysteroscopy can be decreased using this approach, and challenge the use of hysteroscopy as the first stage test.

[Role of diagnostic hysteroscopy in the exploration of postmenopausal metrorrhagia]

DIAGNOSIS

Diagnostic hysteroscopy is an effective method for identifying the causes of postmenopausal bleeding. It evaluates the uterine cavity and visualizes pathologic conditions such as endometrial polyps, submucous fibroids, and focal endometrial abnormalities including adenocarcinoma and its precursors.

FURTHER INFORMATION

With directed biopsy, diagnostic hysteroscopy also ensures the recognition of these lesions.

Ultrasonography-based triage for perimenopausal patients with abnormal uterine bleeding

OBJECTIVE

Abnormal perimenopausal bleeding is common and accounts for much medical and surgical intervention. This study was undertaken to evaluate an ultrasonography-based triage paradigm for perimenopausal patients with abnormal uterine bleeding.

STUDY DESIGN

Four hundred thirty-three perimenopausal patients with abnormal uterine bleeding (either metrorrhagia, menorrhagia, or both) were evaluated. In lieu of undergoing a sampling procedure they were brought back on days 4 to 6 of the subsequent bleeding cycle, when the endometrium was expected to be its thinnest. If a distinct endometrial echo < or = 5 mm (double layer) was imaged by endovaginal ultrasonography, dysfunctional uterine bleeding was diagnosed. If a thickened endometrial echo > 5 mm or no endometrial echo was reliably visualized, a saline infusion sonohysterography was performed. If saline infusion sonohysterography revealed a symmetric single-layer endometrial thickness < 3 mm, dysfunctional uterine bleeding was diagnosed. If focal lesions were noted (polyps, submucous myomas, focal thickening), the patient was scheduled for curettage with hysteroscopy. If the endometrium was globally thickened, nondirected office biopsy was performed.

RESULTS

A total of 341 patients (79%) had ultrasonographic evidence of no anatomic abnormality, and dysfunctional uterine bleeding requiring no further studies was diagnosed. Fifty-eight patients (13%) had focal polypold masses, all of which were removed hysteroscopically and confirmed pathologically. Twenty-two patients (5%) had submucous myomas; 10 patients (23%) had globally thickened endometrium on saline infusion sonohysterography, and then nondirected office sampling revealed hyperplasia in 5 and proliferation in 5. Two patients had technically inadequate saline infusion sonohysterography, and thus we proceeded to hysteroscopy with curettage.

CONCLUSION

Nondirected office biopsy alone without imaging would have potentially missed the diagnosis of focal lesions such as polyps, submucous myomas, and focal hyperplasia in up to 80 patients (18%). Our clinical algorithm for perimenopausal patients with abnormal uterine bleeding used unenhanced endovaginal ultrasonography followed by saline infusion sonohysterography for selected patients. This approach allowed for no endometrial sampling, nondirected sampling, or directed sampling depending on whether the ultrasonography-based triage revealed no anatomic abnormalities, globally thickened endometrial tissue, or focal abnormalities, respectively.

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

In this prospective study, 139 patients, 83 premenopausal patients with abnormal uterine bleeding and 56 postmenopausal patients either with metrorrhagia (33) or a suspect sonographic finding (23), were examined preoperatively with transvaginal sonography (TVS) and saline contrast hysterosonography (SCHS). The histological results, obtained by hysteroscopy, were compared with the preoperative findings. Uterine pathology (benign polyps, submucous fibroids, endometrial hyperplasia and carcinoma) was found in 74.7% and 76.8% of the pre- and postmenopausal patients, respectively. TVS and SCHS are very sensitive at diagnosing uterine pathology, the latter being more specific and enabling better surgical management and a reduction in unnecessary interventions.

How should we investigate women with postmenopausal bleeding?

OBJECTIVE

To evaluate the optimum method(s) of investigating women with postmenopausal bleeding.

DESIGN

Prospective study of 76 postmenopausal women.

SETTING

Teaching Hospital. Interventions. All women had pipelle endometrial biopsy in outpatient clinic. Prior to inpatient hysteroscopy and uterine curettage, each woman had pelvic ultrasonography to measure the endometrial thickness and to exclude ovarian pathology.

RESULTS

Pipelle biopsy was successful in 70% of cases and has a sensitivity of 70%. Hysteroscopy has superior diagnostic capabilities allowing direct visualisation of the endometrial cavity with directed biopsies. Endometrial thickness of > 5 mm used as an indicator of endometrial pathology compared to uterine curettage has a sensitivity of 83%, a specificity of 77%, and a positive predictive value of 54%. Ultrasound also detected five ovarian tumors, two of which were malignant and three missed by pelvic examination alone.

CONCLUSIONS

We recommend the routine use of pelvic ultrasonography in all women with postmenopausal bleeding as it is an invaluable diagnostic tool in excluding ovarian pathology. In addition, sampling of the endometrial cavity, preferably with outpatient hysteroscopy, is mandatory for histological diagnosis. Overall, the combination of ultrasound and outpatient endometrial sampling would spare hospital admission for at least 60% of women with postmenopausal bleeding.

A prospective comparison of transvaginal ultrasonography and diagnostic hysteroscopy in the evaluation of patients with abnormal uterine bleeding: clinical implications

OBJECTIVE

We determined the diagnostic value of transvaginal ultrasonography for endometrial and intrauterine abnormalities in patients with abnormal uterine bleeding.

STUDY DESIGN

Between June 1, 1992, and June 1, 1993, 279 consecutive patients underwent transvaginal ultrasonography. Findings were compared with the final diagnosis established by diagnostic hysteroscopy and histologic examination.

RESULTS

Transvaginal ultrasonography demonstrated a sensitivity of 0.96 and a specificity of 0.89. With a pretest probability (prevalence) of 0.42, this resulted in posttest probabilities of 0.03 in the case of a normal sonogram and 0.87 for an abnormal sonogram. The corresponding likelihood ratios were 0.04 and 9.09, respectively.

CONCLUSION

Transvaginal ultrasonography seems to be an effective procedure to exclude endometrial and intrauterine abnormalities. Its use could be implemented as a routine first-step procedure in patients with abnormal uterine bleeding, and it selects those in need of further diagnostic evaluation in the case of an abnormal or inconclusive sonogram.

[How to investigate menometrorrhagias at the time of menopause?]

Metromenorrhagia is common around the time of the menopause. Following a careful history and full gynecological examination, vaginal ultrasonography and hysteroscopy combined with biopsies enable the investigation of such genital bleeding. Vaginal ultrasonography can be used to visualise the uterine cavity and measure the thickness of the endometrium. The term atrophy is used if the latter is less than 5 mm. If, on the contrary, the endometrium is thick or if there is a more notable intracavitary lesion, hysteroscopy and the collection of biopsy material guided by it will provide the diagnosis.

[Experience with transvaginal ultrasonic examination in patients with metrorrhagia]

Transvaginal ultrasound examinations were performed just before D + C. at 61 patients suffering from metrorrhagia. Histological findings were compared to the endometrial thickness. There were 6 adenocarcinoma among the examined patients. The endometrium thickness was more than 10 mms in all of the cases. Five of the patients having malignant disease were postmenopausal. Based on these results it seems to be that the transvaginal sonography could be an useful additional test in the oncological examination for the postmenopausal women.

Use of transvaginal ultrasound in diagnosing the etiology of menometrorrhagia

Forty-five women with a chief complaint of abnormal vaginal bleeding from a few days' duration (spotting) to three to six months of bleeding (average, 4.5 months) were evaluated using a standard clinical approach followed by transvaginal ultrasound (US). Serum estradiol (E2), progesterone and/or endometrial biopsy was used to further clarify the etiology of the bleeding and confirm the clinical or ultrasound diagnosis. Anatomic findings were present in 31% of patients by US examination as compared to only 9% by clinical evaluation. An additional 9% of patients had polycystic ovary disease. Of the 16% of study patients on oral contraceptives with a clinical diagnosis of breakthrough bleeding, 33% had anatomic findings associated with the bleeding on US. The ultrasound image of the endometrium predicted the endometrial biopsy findings in all three patients with postmenopausal bleeding. In the remaining patients with a diagnosis of dysfunctional uterine bleeding (DUB) (a diagnosis usually made clinically by excluding other etiologies), US was helpful in excluding many patients with anatomic findings not detected by physical examination and in evaluating the endometrium, helping differentiate anovulatory from ovulatory DUB. US was helpful in predicting the hormonal and histologic endometrial status of the patients. Patients with more severe and prolonged DUB had low serum E2 with US findings of a single-line endometrium (consistent with low serum E2 and anovulation). US can be a valuable aid in evaluating women presenting with a complaint of abnormal vaginal bleeding by demonstrating anatomic findings frequently not discernible on pelvic examination, such as small cysts and leiomyomas and even endometrial carcinoma, and in evaluating the endometrium in terms of its thickness and, indirectly, the endometrial histology and the ovulatory and hormonal status of the patient. US can also be of value in confirming some diagnoses that are generally made clinically by exclusion, such as breakthrough bleeding from oral contraceptive use and DUB.

[Evaluation of intra-uterine pathology and tubal patency by contrast echography]

The contrast ultrasonography (CUS) is a new development of the pelvis ultrasounds. A contrast medium is injected through the cervix and is screened through the uterine cavity, the tubes and the peritoneal cavity. The contrast medium creates a new acoustic interface which improve the quality of the ultrasound imaging and the ability to diagnose endouterine pathologies. Further, tubal patency may be assessed by tracking fluid into the pouch of Douglas. The aim of this study was to assess the feasibility, the accuracy and the side effects of this technique when compared with the conventional procedures. Included were two groups of patients: the group 1 (10 cases) was of patients with menometrorrhagia before undergoing an hysteroscopy; the group II (11 cases) was of infertile patients before undergoing a laparoscopic tubal patency test. This technique, of low cost and without any radiation exposure, seems to be at least as accurate as the conventional methods for the intrauterine diagnostics. It is less effectiveness for the evaluation of the tubal patency. No side effect occurred in this study.

Doppler ultrasound assessment of endometrial pathology

In forty-five metrorrhagic patients, transvaginal Doppler ultrasound examinations were performed in order to test the correlation between the modified resistance index (RI) of the uterine and intramyometrial arteries and the histopathologic findings. Uterine volume (UV) and endometrial thickness (ET) were studied. The results were compared with 19 otherwise normal patients. UV and ET were found increased in metrorrhagic patients with abnormal histopathology. These showed a significant decrease in intramyometrial RI (66.7 +/- 15.9) and uterine RI (79.6 +/- 9.4) compared with a control group (intramyometrial RI: 78.8 +/- 16; uterine RI: 87.8 +/- 9.4). Uterine resistance was significantly greater in patients with normal histopathology (intramyometrial RI: 94.2 +/- 13.2; uterine RI: 89.1 +/- 9.3). Only three false-positive and three false-negative results were found upon analysing the predictive accuracy of intramyometrial Doppler examinations. However, the uterine resistance index was less specific. Although transvaginal Doppler velocimetry cannot replace histopathologic diagnosis, it does provide a high prognostic precision in cases of metrorrhagia.

Transvaginal ultrasound for identifying endometrial abnormality

Transvaginal ultrasound was used preoperatively to evaluate the endometrium in 96 patients referred for dilatation and curettage. The sonographic display was correlated to the histopathologic diagnosis. In 45 patients with postmenopausal bleeding, 4 patients had adenocarcinoma of the endometrium. All were identified by ultrasound. None of the 22 patients with a normal sonographic appearance had an abnormal histopathologic diagnosis. An endometrial thickness (single layer) cut-off point of greater than or equal to 4 mm precluded any missed malignancies but halves the number of dilatations and curettages in this postmenopausal group. The sensitivity of ultrasound in diagnosing endometrial pathology was 100% and the specificity was 61%. The positive and negative predictive values were 39% and 100% respectively. In 51 premenopausal women there was good agreement between histology and ultrasound. In this group a cut-off point of greater than or equal to 8 mm was used. The sensitivity in diagnosing endometrial pathology was 67% and the specificity 75%. The positive and negative predictive values were 14% and 97%. With further experience, transvaginal ultrasound might be used in clinical routine for diagnosing endometrial pathology.