Clinical assessment of sonohysterography in the diagnosis and management of abnormal uterine bleeding

OVERVIEW: Abnormal uterine bleeding is a common gynecological symptom. The curettage can asses only 50-60% of endometrium surface, thereby leaving some changes unrevealed. Sonohysterography (SHG), which combines the distention of the uterine cavity trough saline solution and ultrasound examination, allows a more exact evaluation of uterine cavity abnormalities. OBJECTIVES: To assess the value of sonohysterography in the diagnosis and management of abnormal uterine bleeding. MATERIALS AND METHODS: 67 women with abnormal uterine bleeding and uterine cavity abnormalities confirmed by transvaginal ultrasound were examined with sonohysterography. RESULTS: Sonohysterography revealed 21 cases of submucous myomas, 22 endometrial polyps and 24 cases of endometrial hyperplasia. All patients underwent diagnostic hysteroscopy to verify the results. The sensitivity and specificity for sonohysterography were both 93%. The positive and negative predictive values were 96% and 93%, respectively. CONCLUSIONS: Sonohysterography is a sensitive and specific method for diagnosis of abnormal uterine bleeding. It allows faster and less invasive diagnosis. Given the low costs of examination sonhysterography can be used as an ambulatory procedure reducing delay of treatment.     

Endometrial polyps: prevalence, detection, and malignant potential in women with abnormal uterine bleeding

PURPOSE OF INVESTIGATION: To report our evaluation of the prevalence and malignant potentiality of endometrial polyps in women with abnormal uterine bleeding, as well as the efficacy of transvaginal ultrasonography and sonohysterography as diagnostic techniques. METHODS: Fractional dilatation and curettage (D&C) was performed in 1,415 patients aged 23-85 years treated in our clinic for abnormal uterine bleeding from 1986 to 1998. Transvaginal ultrasonography was performed prior to D&C on all patients. Sonohysterography was performed only on 157 patients. Diagnostic efficacy for both techniques was evaluated for the detection of endometrial polyps combined with hyperplasia due to sonographic and histologic difficulties in distinguishing them. RESULTS: The prevalence of endometrial polyps was 8.9% (126/1,415). From all 126 endometrial polyps found, 94 were benign, 30 (23.8%) were found with premalignant changes (complex and atypical hyperplasias) and two (1.5%) had undergone malignant degeneration. Transvaginal ultrasonography was of limited diagnostic value for polyps and hyperplasia in premenopausal women, while in postmenopausal women the method provided a greater yield. Sonohysterography was found to be a more effective diagnostic tool. CONCLUSION: Endometrial polyp prevalence rises by age and/or menopause. Malignant degeneration of endometrial polyps was observed only in postmenopausal women. Sonohysterography represents an improvement over conventional ultrasonography and both methods could be used for screening purposes especially when hysteroscopy can not be performed.     

Transvaginal endometrial sonography in postmenopausal women taking tamoxifen

OBJECTIVE: To evaluate sonographic measurements of endometrial thickness in postmenopausal women taking adjuvant tamoxifen therapy for breast cancer, and to correlate sonographic and pathologic findings to symptoms and duration of tamoxifen therapy. METHODS: Medical records and sonograms of 80 postmenopausal women treated for breast cancer with adjuvant tamoxifen therapy were reviewed retrospectively. Endometrial thickness was recorded as a single-layer thickness and considered abnormal when greater than 2.5 mm for postmenopausal women. Sonographic endometrial thickness was correlated to histologic findings, symptoms, and duration of tamoxifen therapy. RESULTS: Fifty-seven of 80 postmenopausal women (69%) had single-layer endometrial thicknesses of 2.5 mm or greater, measured by transvaginal sonography, and 55 of 57 had endometrial biopsies or dilatations and curettage. Biopsies detected 24 cases of abnormal endometria, including endometrial carcinoma (two), breast carcinoma metastatic to the endometrium (one), endometrial polyps (13), tubal metaplasia (three), and benign endometrial hyperplasia (five). Using a single-layer endometrial thickness greater than 2.5 mm by transvaginal ultrasound, 21 of 24 (87.5%) women with abnormal endometria were detected. Women with abnormal pathologic findings had a significantly thicker mean single-layer endometrial thickness than those with normal findings, 7 mm versus 4 mm (P < .01). Twelve women had postmenopausal bleeding, all of whom had a single-layer endometrial thickness greater than 2.5 mm on transvaginal sonography. CONCLUSION: With a sensitivity of detecting endometrial abnormalities of 84%, transvaginal sonography was useful for studying postmenopausal tamoxifen-treated women.     

Hysteroscopic evaluation of the endometrium in postmenopausal women taking tamoxifen

STUDY OBJECTIVE: To evaluate hysteroscopic endometrial changes due to tamoxifen therapy in postmenopausal women with breast cancer. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. Patients. Eighty-eight postmenopausal women (or with iatrogenic amenorrhea) receiving tamoxifen 20 mg/day for at least 1 year for breast cancer. INTERVENTION: Record review of patients undergoing transvaginal sonography (TVS) and office hysteroscopy with eye-directed biopsy specimens obtained with a 5-mm, continuous-flow, operative hysteroscope. MEASUREMENTS AND MAIN RESULTS: Patients with thickened endometrium and pathologic findings at hysteroscopy had taken tamoxifen for significantly longer times than those without such findings (p < 0.05). CONCLUSION: Our findings confirm the estrogenic effect of tamoxifen on endometrium. Endometrial evaluation by TVS suggests further diagnostic procedures, but only hysteroscopy allows the surgeon to visualize endometrial lesions and obtain eye-directed biopsy tissue.     

Limited Value of Sonohysterography for Endometrial Screening in Asymptomatic, Postmenopausal Patients Treated with Tamoxifen

Objectives. Sonohysterography (SHG) has been proposed as a useful tool for the surveillance of the endometrium in patients receiving tamoxifen. This study aimed to assess the value of SHG in asymptomatic patients who would have been biopsy candidates because of abnormal transvaginal ultrasound (TVUS) results.Methods. The study population included postmenopausal breast cancer patients receiving adjuvant tamoxifen who had asymptomatic abnormalities at TVUS (endometrial thickness ≥8 mm or endometrial echo not adequately visualized). SHG was performed with an Aloka SSD 680 system using a 5-MHz vaginal probe, with sterile saline solution as contrast medium.Results. Forty-one patients entered the study. A regular endometrial echo was identified by SHG in 9 patients (21.9%). Histology was obtained in the remaining 32 patients with positive (n = 27, 65.8%) or unsuccessful (n = 5, 12.2%) SHG. Benign polyps (n = 15, 36.6%) and endometrial atrophy (n = 14, 34.1%) were the most common findings; 3 patients (7.3%) had simple hyperplasia.Conclusions. Breast cancer patients with asymptomatic, tamoxifen-associated TVUS abnormalities have little additional benefit from SHG. More than remain candidates for biopsy, which usually yields benign or insignificant findings.     

Value of Sonohysterography in Asymptomatic Postmenopausal Tamoxifen-Treated Patients

A prospective study was performed to assess the efficacy of sonohysterography (SHG) in identifying endometrial pathologies among asymptomatic, postmenopausal breast cancer patients treated with tamoxifen. In this study the uterine cavity of 68 such patients with endometrial thickness of ≥8 mm was prospectively evaluated by SHG. Forty-six (67.6%) patients in whom SHG did not identify any findings in the uterine cavity (negative group) were followed by diagnostic hysteroscopy. Another 22 (32.4%) who were identified by SHG to have abnormal endometrial findings, such as an echogenic or polypoid mass (positive group), were followed by operative hysteroscopy and by postoperative SHG. In the positive group the basal transvaginal sonogram revealed an endometrial echogenic mass in only 10 (45.5%). In the remaining 12 (54.5%) patients, the transvaginal sonogram identified only thick endometrium. In these latter 12 patients, histological assessment confirmed endometrial polyps in 8 (66.7%) and fibroid in 1 (8.3%). Four (18.2%) patients in the positive group had no histological endometrial pathology. Two (50%) of them had a uterine septum as diagnosed during hysteroscopy, in one (25%) operative hysteroscopy failed to resect the endometrial polyp, and in another (25%) there was a false-positive SHG diagnosis. Overall, SHG accurately diagnosed endometrial and/or other intrauterine pathology in 95.5% of these patients. In the 46 patients with “negative” basal SHG features, diagnostic hysteroscopy confirmed this diagnosis. Thus, there was no SHG false-negative diagnosis. Comparing the results of the basal SHG with those of operative hysteroscopy and/or the histopathological findings in the positive group, the sensitivity of SHG was 1.0, the specificity 0.0, positive predictive value 95.5%, and negative predictive value 0.0. It is suggested that SHG is a useful diagnostic tool for the assessment of specific endometrial pathologies in asymptomatic postmenopausal breast cancer patients treated with tamoxifen who were diagnosed by transvaginal sonography to have thick endometrium.     

Accuracy of transvaginal sonography,sonohysterography and hysteroscopy in diagnosis of intrauterine pathology

OBJECTIVES: Sonohysterography (SHG) is a relatively new technique in evaluation of intrauterine disorders. We compared the diagnostic accuracy of this method with that of transvaginal sonography(TVS) and diagnostic hysteroscopy (DH) in diagnosis of intracavitary abnormalities in women with abnormal uterine bleeding, inconclusive endometrial view at TVS and thickened endometrium. METHODS: In prospective study, pre- and postmenopausal women underwent TVS, SHG, and DH. The findings at TVS and SHG were compared with hysteroscopic and histologic findings (obtained from operative hysteroscopy, hysterectomy and d&c). Sensitivity, specificity, positive and negative predictive values were calculated for focally growing lesions. RESULTS: 150 patients were included in the study. There was very good agreement between SHG and DH in the diagnosis of focally growing lesions. SHG was more sufficient in detecting intracavitary abnormalities than TVS. Problems with distention of the uterine cavity were due to cervical stenosis and endometrial carcinoma. CONCLUSION: SHG is more accurate in the diagnosis of intracavitary abnormalities than is TVS. SHG is almost as good as DH at detecting focally growing lesions in the uterine cavity.     

The effect of tamoxifen on the endometrium, serum lipids and hypothalamus pituitary axis in the postmenopausal breast cancer patients

BACKGROUND: There is still no cost-effective endometrial screening method for asymptomatic postmenopausal breast cancer patients using tamoxifen. We investigated the effectivity of transvaginal ultrasonography and endometrial sampling as a screening method for asymptomatic patients. Additionally the effect of tamoxifen on hypothalamus-pituitary axis and serum lipid profiles were investigated. METHODS: Sixty-seven gynecologically asymptomatic postmenopausal breast cancer patients were enrolled in this randomized crossover study. Endometrial thickness was determined by transvaginal ultrasonography, endometrial biopsy was obtained by Pipelle or fractional curettage, hormone and lipid profiles were compared in the two groups which consisted of forty-seven tamoxifen user (cases) and twenty nonuser (controls) patients. RESULTS: The mean endometrial thickness measured by transvaginal sonography was 7.8 mm (3-20 mm) versus 3.7 mm respectively. The difference was significant in tamoxifen users. The most common histopathologic finding was endometrial polyp, detected in five patients. In the control group there was no endometrial polyp. The positive histopathologic findings were present in twenty-two patients in the case group but there were only two patients with positive histopathologic findings in the control group. Ultrasound findings did not correlate with the presence of endometrial abnormalities on biopsy and no endometrial cancer or hyperplasia were detected. In tamoxifen users serum FSH and LH levels were significantly lower than in nonusers. Serum HDL levels were significantly higher in the case group. CONCLUSION: Ultrasonographic imaging of the endometrium in asymptomatic postmenopausal breast cancer patients using tamoxifen should be interpreted with caution. Other imaging techniques should be used for more specific information about the endometrium.     

Diagnostic accuracy of sonohysterography in the evaluation of uterine cavities in tamoxifen administered asymptomatic postmenopausal breast cancer patients with endometrial thickness ≥5 mm

To evaluate diagnostic efficacy of transvaginal saline infusion sonohysterography (TV-SHG) in the evaluation of uterine cavities in tamoxifen (TAM) administered asymptomatic postmenopausal breast cancer patients with increased endometrial thickness, sixty asymptomatic postmenopausal breast cancer women receiving adjuvant TAM treatment for at least 6 months and with endometrial thickness’ ≥5 mm measured in transvaginal ultrasonography (TVS) were enrolled. Each patient underwent TV-SHG, followed by outpatient hysteroscopy (HYS) with endometrial biopsy. TV-SHG application was accepted as unsuccessful in four cases (6.7%). When office HYS combined biopsy was considered as gold standard, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of TV-SHG were estimated as 90%, 100%, 100%, and 95%, respectively. Our findings showed that TV-SHG was a valuable diagnostic tool in the evaluation of uterine cavities of TAM administered asymptomatic postmenopausal patients having an increased endometrial thickness.     

The value of sonohysterography in detecting intracavitary benign abnormalities

The aim of this retrospective study was to assess the diagnostic value and the usefulness of sonohysterography in the detection of uterine intracavitary benign abnormalities, compared with other diagnostic methods (transvaginal ultrasonography and diagnostic hysteroscopy). From January 2003 to December 2003, a total of 73 patients (47 premenopausal (middle age 38.9) and 26 postmenopausal women (middle age 60.5)) underwent transvaginal ultrasonography (TVS) and sonohysterography (SHG), consisting of an intrauterine infusion of saline solution during transvaginal ultrasound. The women referred to our Ultrasonography Center because of intermenstrual (38) or postmenopausal bleeding (19), or an abnormal or a poorly defined endometrial interface (16) as seen as baseline ultrasonography. The findings at TVS and SHG were compared with hysteroscopy (HS). In one case, the SHG was technically impossible to perform. In premenopausal group the sensitivity of SHG had been 100% in detecting submucosal fibroids, endometrial polyps and hyperplasia and 75% in detecting normal uterus. The specificity had been always 100%. In postmenopausal group the sensitivity of SHG had been 75% in detecting submucosal fibroids, 93.8% in endometrial polyps and 100% in hyperplasia and normal uterus. The specificity had been 100% in submucosal fibroids and hyperplasia and had been 90.0 and 95.5% in endometrial polyps and normal uterus, respectively. SHG allows to obtain a precise diagnosis of benign uterine pathology and it is more accurate in the diagnosis of intracavitary abnormalities than that obtained by TVS. Preoperative use of SHG may assist in choosing the best surgical treatment for the patient.     

Prospective study of saline infusion sonohysterography in evaluation of perimenopausal and postmenopausal women with abnormal uterine bleeding

AIM: To evaluate saline infusion sonohysterography as an investigative modality in abnormal uterine bleeding in perimenopausal and postmenopausal women. METHODS: Fifty-eight patients, 52 perimenopausal and six postmenopausal women, with abnormal uterine bleeding were selected from the department of Obstetrics and Gynecology of Shrimati Sucheta Kriplani Hospital. After complete work-ups, transvaginal examinations were performed followed by sonohysterographies. The sensitivity, specificity, positive predictive values and negative predictive values were calculated for transvaginal sonography (TVS) and saline infusion sonohysterography as compared with findings of hysteroscopy/hysterectomy. RESULTS: Saline infusion sonohysterography was performed in 56 cases. It could not be done in one perimenopausal and one postmenopausal woman. Cavity was normal in 41 perimenopausal and five postmenopausal women. Ten women displayed abnormalities. Two had submucosal fibroids, two had intramural fibroids, one had fibroid polyp, three had endometrial polyps and two patients had endometrial growths. We found that TVS missed three endometrial polyps and one endometrial growth and led to mislabeling two intramural fibroids as submucosal. On comparing the sonohysterographic findings with those of hysteroscopy or hysterectomy, one endometrial polyp and one endocervical polyp was missed on sonohysterography, and one false positive growth was observed on sonohysterography. The sensitivity, specificity, positive predictive value and the negative predictive value of TVS were 84.8%, 79%, 82.4% and 82%, respectively. The sensitivity, specificity, positive predictive value and the negative predictive value of saline infusion sonohysterography were 94.1%, 88.5%, 91.4% and 92%, respectively. CONCLUSION: Saline infusion sonohysterography is a safe, convenient, time conserving, cost effective, easily accessible and acceptable investigative modality. It definitely enhances the diagnostic potential of TVS in assessment of endometrium and intracavitary pathologies.     

Sonographic, hysteroscopic, and histologic evaluation of the endometrium in postmenopausal women with breast cancer receiving tamoxifen

STUDY OBJECTIVE: To evaluate the estrogenic effects of tamoxifen on the endometrium in postmenopausal women with breast cancer. DESIGN: Consecutive study (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Thirty-three women. Interventions. All patients underwent transvaginal sonography (TVS) and color flow Doppler of endometrial vessels, hysteroscopy, and, if necessary, endometrial biopsy or other operative hysteroscopic procedures. MEASUREMENTS AND MAIN RESULTS: In four women the endometrium was thin on TVS and atrophic at hysteroscopic assessment. In 29 women with thick endometrium on TVS, hysteroscopy and endometrial biopsy showed atrophy (11 patients), hyperplasia (5), polyps (11), and well-differentiated adenocarcinoma (2). The two endometrial cancers were present in women with uterine bleeding. In women with positive histologic findings, the endometrium was significantly thicker (p = 0.04) and duration of tamoxifen therapy longer than in those with negative findings, although this was not statistically significant (p = 0.067). CONCLUSION: We believe regular assessment of the endometrium by TVS should be performed in postmenopausal patients at the start of the tamoxifen therapy, and hysteroscopy in women with a thick endometrium or postmenopausal bleeding. We believe that patients with thin endometrium on TVS at the beginning of tamoxifen therapy, who have no abnormal uterine bleeding should be screened with these examinations for 2 years.     

Endometrial pathology of 104 postmenopausal breast cancer patients treated with tamoxifen

OBJECTIVE: To investigate the effects of tamoxifen on the endometrium in postmenopausal breast cancer patients. METHODS: Endometrial thickness was measured by transvaginal sonography and endometrial biopsies were done in 104 postmenopausal breast cancer cases who were treated with tamoxifen. Histopathologic findings were discussed. RESULTS: Mean endometrial thickness was 11.7+/-5.9 mm and duration of tamoxifen administration was 35.3 months. Four endometrial cancers, 17 endometrial hyperplasias, 25 proliferative endometrium, 5 endometrial polyps in the endometrial biopsies. We observed atrophic endometrium in 53 of the cases. Only one case with endometrial polyps was observed as a premalignant lesion when the endometrium was less than 5 mm, 51% of the cases had thicker endometrium (more than 10 mm) and 32% of these cases had malignant and premalignant endometrium. We found a significant correlation with the duration of tamoxifen and age (p<0.05). One hundred and two of our cases were asymptomatic; only 2 out of 4 endometrial cancer cases had vaginal spotting. A significant relation was noticed between endometrial thickness and duration of tamoxifen treatment (p=0.025). CONCLUSION: It was concluded that positive endometrial findings and endometrial thickness were due to continuous unopposed tamoxifen treatment and our findings support the hypothesis that tamoxifen increases the risk of endometrial carcinoma and premalignant changes.     

Endometrial disease diagnosed by transvaginal ultrasound and dilatation and curettage.

BACKGROUND: This study is designed to compare endometrial thickness measured by transvaginal ultrasound with endometrial pathology by dilatation and curettage. METHODS: Fifty-four women with postmenopausal bleeding were evaluated. Endometrial thickness, including both layers of the endometrium, was measured by transvaginal ultrasound after which fractional curettage was performed and samples taken were then dispatched for histologic examination. RESULTS: Median endometrial thicknesses of 5 mm, 8.5 mm and 6 mm were found for benign, hyperplastic and carcinomatous endometrium, respectively. Of the eight hyperplastic samples, two cases had 4 mm, and one case had 3mm endometrial thickness. Similarly, of the nine malignant samples, three cases had an endometrial thickness of 3 mm. Three mm has been found to be the best cut off point for endometrial abnormalities in postmenopausal bleeding with 100% sensitivity but low specificity (13%). CONCLUSION: Fractional curettage seems to be the best method for detecting endometrial abnormalities in women with postmenopausal bleeding.     

子宫声学造影对异常子宫出血的诊断价值

目的评价子宫声学造影对异常子宫出血的诊断价值.方法对78倒异常子宫出血患者进行子宫声学造影(SHG),根据不同的结果分别对患者进行诊断性刮宫或宫腔镜检查,或直接手术治疗,并将SHG结果与病理检查结果对照分析.结果SHG识别出子宫粘膜下肌瘤23例、内膜息肉14例、内膜癌8例、内膜增生过长17例,其诊断宫内病变的敏感性和特异性分别为96.7%和82.4%.本组病例造影后均未发生并发症.结论SHG是评价异常子宫出血、诊断宫内病变的简便、有效方法.     

Transvaginal ultrasound and lactate dehydrogenase isoenzyme activity profile in uterine aspirate for diagnosis of endometrial carcinoma in women with postmenopausal bleeding

Postmenopausal patients with vaginal bleeding (n = 72) were evaluated with the combination of transvaginal ultrasonography (TVS) and analysis of the lactate dehydrogenase (LD) isoenzyme activity profile in uterine fluid aspirates. TVS evaluation of the endometrium was classified as <5 mm, > or =5 mm, or poorly defined. The LD isoenzyme activity profile was characterized as abnormal or normal. Pathologic findings were further evaluated with diagnostic curettage. TVS found the endometrium to be > or =5 mm or poorly defined in 44 patients (61%). Endometrial carcinoma was found in 6 of 72 patients (8%). They appeared in the TVS groups endometrium >5 mm (n = 2) and endometrium poorly defined (n = 4) but not in the endometrium <5 mm. The LD isoenzyme activity profile was abnormal in the six malignant cases and in ten benign cases. Thus, the need for further evaluation with hysteroscopy and curettage was reduced to 16 cases. Since TVS had 100% sensitivity but only 42% specificity, it is suitable for first-level examination in patients with postmenopausal bleeding. The second-level method should have similarly high sensitivity but much higher specificity. The LD isoenzyme activity profile in uterine fluid aspirates had 100% sensitivity and 85% specificity. Another important feature is that the method is not sensitive to endometrial thickness, amount of sample, sampling device, or dilution. Thus, it is more reliable than aspiration histology. For every hysteroscopy or curettage that can be replaced by LD analysis, the cost is reduced by approximately EUR 720 or 540, respectively.     

Diagnostic value of sonohysterography in the evaluation of submucosal fibroids and endometrial polyps

AIMS: To evaluate the diagnostic value of sonohysterography in the evaluation of submucosal fibroids and endometrial polyps. METHODS: Thirty-two women whose preliminary transvaginal ultrasound suggested endometrial abnormality underwent sonohysterography. The findings were then compared with histopathological results. RESULTS: The sonohysterographic diagnosis was fibroid in seven patients, endometrial polyp in 23 patients and simple hyperplasia in two patients. Histopathological findings confirmed our diagnosis in all except three patients with endometrial polyps, who had normal secretory endometrium. Sonohysterography was found to have a sensitivity of 100%, a positive predictive value of 90% and diagnostic accuracy of 90.6%. CONCLUSION: Sonohysterography is a useful, minimally invasive and accurate technique to evaluate the pathologies involving endometrium and uterine cavity.     

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.     

Comparison of transvaginal sonography, saline infusion sonography and hysteroscopy in the evaluation of uterine cavity pathologies

AIMS: To determine whether performing transvaginal sonography (TVS) and saline infusion sonography (SIS) before hysteroscopy could reduce the number of diagnostic hysteroscopies performed for the evaluation of uterine cavity abnormalities. METHODS: Two hundred and twenty three women with suspected uterine cavity abnormalities were prospectively evaluated by TVS, SIS and hysteroscopy, and had histological evaluation of the endometrium with hysteroscopic biopsy or dilatation and curettage (D&C). One hundred and sixty five patients (74%) were premenopausal and 58 patients (26%) were postmenopausal. RESULTS: The positive predictive value (PPV) for endometrial polyps was 69% for TVS, 78% for SIS and 81% for hysteroscopy in premenopausal patients. In the postmenopausal group, TVS and SIS could detect only 24% of endometrial polyps, whereas 70% were diagnosed by hysteroscopy. The PPV for submucous fibroids was 47% for TVS, 81% for SIS and 77% for hysteroscopy in the premenopausal group. CONCLUSIONS: In premenopausal patients, SIS and hysteroscopy are equally accurate in the diagnosis of endometrial polyps and submucous fibroids. Hysteroscopy is the most accurate test for polypoid lesions in the postmenopausal group. Performing TVS, SIS and D&C could reduce the number of diagnostic hysteroscopies performed for the evaluation of uterine cavity abnormalities by 71.5% in premenopausal patients. However, this rate decreases to 40% in the postmenopausal group.     

Ovarian cysts in postmenopausal tamoxifen-treated breast cancer patients with endometrial thickening detected by transvaginal sonography

OBJECTIVE: To investigate the frequency of ovarian cysts in tamoxifen-treated postmenopausal breast cancer patients with endometrial thickening detected by transvaginal sonography. METHODS: Medical records and transvaginal sonographies of 38 postmenopausal women treated for breast cancer with adjuvant tamoxifen therapy who had undergone endometrial sampling due to abnormal endometrial thickness were reviewed retrospectively. RESULTS: During the study period five of 38 tamoxifen-treated postmenopausal patients (13.2%) had ovarian cysts. The mean tamoxifen treatment interval of the patients with an ovarian cyst was 22.4 +/- 18.4 months (p = 0.17). The mean endometrial thickness of the patients with an ovarian cyst was 12.6 +/- 5.9 mm (p = 0.17). Endometrial biopsy detected six cases of abnormal endometria, including endometrial carcinoma (n = 1), endometrial polyp (n = 1) and simple endometrial hyperplasia without atypia (n = 4). Three patients with ovarian cysts underwent laparatomy revealing simple cysts on histopathological examination. Two patients with ovarian cysts declined laparatomy and are currently under follow-up. CONCLUSION: Ovarian cysts a common side-effect of tamoxifen treatment in postmenopausal tamoxifen-treated breast cancer patients. Transvaginal sonography should be performed to detect any concomitant endometrial pathology.