Dr. Mohammed Abdalla Egypt, Domiat Hospital

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Dr. Mohammed AbdallaEgypt, Domiat Hospital

• Sonohysterographyin abnormal uterine bleeding

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• using sterile saline solution as a negative
  contrast medium in conjunction with traditional
  transvaginal ultrasound .
• you can image the uterine cavity and evaluate the
  tubal patency.

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• it is advantageous over hysteroscopy that it can
  scan the uterus, ovaries and pelvis at the same
  time imaging the uterine cavity.

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• Abdominal or transvaginal sonography can identify
  myomas and thickened endometrium but is unable to
  differentiate between the potential etiologies of
  thickened endometrium,, polyps, submucous myomas,
  and homogenously thickened endometrium.
• In combination with endometrial biopsy, it can
  identify anatomic problems and abnormal
  pathologic findings.

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• At transvaginal ultrasonography , the finding of
  a thickened central endometrial complex, with or
  without cystic changes, is often nonspecific.

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The Thickened endometrium may be a polyp
catheter
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The Thickened endometrium may be a polyp
CYST
POLYP
With polyps the endometrial-myometrial interface
is preserved
well-defined, homogeneous, isoechoic to the
endometrium
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The Thickened endometrium may be a polyp
endometrium
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The Thickened endometrium may be a Submucosal
leiomyomas
With myomas the endometrial-myometrial interface
is distorted
broad-based, hypoechoic,
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sonohysterography can accurately depict the
percentage of the fibroid that projects into the
endometrial cavity
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The Thickened endometrium may be an endometrial
hyperplasia
Endometrium thickness A-B
A
B
diffuse thickening of the echogenic endometrial
stripe without focal abnormality
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The Thickened endometrium may be a Secretory
endometrium


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Endometrial cancer
Endometrial cancer is typically a diffuse
process, but early cases can appear as a polypoid
mass
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• sonohysterography, allows identification of
  intracavitary lesions and focal or diffuse
  endometrial abnormalities and helps determine
  whether an abnormality is endometrial or
  subendometrial.

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• At transvaginal US, when the endometrium cannot
  be accurately measured or when there is a
  nonspecific thickened central endometrial
  complex, sonohysterography can provide additional
  information and can be used to direct the patient
  to a visually guided hysteroscopic procedure
  rather than a potentially unsuccessful blind
  biopsy procedure.

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New Zealand Guidelines Group

• Transvaginal ultrasound and transvaginal
  sonohysterogram are both more accurate in
  diagnosing the location of fibroids than
  hysteroscopy A.

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SIS

• low-tech

low-cost
Well tolerable
no radiation exposure
Effective
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Adverse Events

• Discomfort
• Cramping( minor ) 33.3 Laughheadstones
• Pain (menstrual like )
• (sever pain ) 11.5 Cecinilli et al
• Infection 2.5 Dubinsky et al

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Effectiveness
To compare the effectiveness of an Investigatory
procedure assessing the endometrium. Hysteroscopy
with biopsy is regarded as the "gold standard"
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Effectiveness

• In 10 studies where sonohysterographic findings
  were compared with surgical findings and
  histological assessment (hysteroscopy biopsy OR
  hysterectomy ) it was found that SIS has high
  Sensitivity and specificity for evaluation of
  abnormal uterine bleeding.
• Sensitivity 94.9
• Specificity 89.3

(level II evidence)
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Effectiveness
Specificity
Sensitivity
n
Year
Author
97
96
96
1992
Bonilla-Musoles
100
100
14
1993
Syrop
94
100
58
1993
Parsons
100
96
130
1995
Widrich
100
96
47
1996
Wolman
Keltz
100
100
34
1997
76
99
109
1997
Bernard
91
87
104
1998
Schwarzler
85
100
39
1998
Williams
85
100
50
2000
Dijkhuizen
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Effectiveness
It benefits clinical decision making, as up to
40 of patients will avoid diagnostic
hysteroscopy.
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How it works
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How it works

• only preparation necessary was for the patient to
  empty the bladder.

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• A speculum, is used to expose the cervix, which
  was then cleansed with an iodine swab

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• Various catheter types may be used, including
• 5-F catheter, with or without an occlusive
  balloon
• pediatric feeding tubes,
• insemination catheters,
• Goldstein sonohysterography catheter

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• A catheter, is important to be flushed with
  sterile saline solution before being inserted to
  prevent the introduction of echogenic air
  bubbles.

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• The catheter can be inserted through the side of
  a standard speculum, rather than down the
  channel, for easier removal of the speculum.

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• Advancement of the catheter was aided by grasping
  the end of the catheter 2 to 3 cm from the tip
  with a ring forceps and gently feeding it through
  the cervical os to position the tip beyond the
  endocervical canal.
• The speculum was then carefully removed while the
  catheter was left in place.

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• the covered transvaginal probe was inserted into
  the vagina, and continuous scanning in the
  Sagittal and coronal or transverse planes was
  performed during instillation of sterile saline
  solution.
• only 25 mL are actually needed to distend the
  cavity adequately

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• Cervical leakage is common, and it is helpful to
  have two 20-mL syringes of saline solution
  available for the procedure.

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Take home

• The most common indication for SIS is abnormal
  bleeding in pre- and postmenopausal patients.

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Take home

• SIS delineates masses or defects in the uterine
  cavity.

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Take home

• SIS distinguishes between focal lesions and
  global endometrial thickening.

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Take home

• There is no contraindication to SIS in
  Non-pregnant, non-infected women who are
  bleeding.

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Take home

• Steps should be taken to avoid uterine lavage
  propelling cancer cells into the peritoneal
  cavity.
• using low pressure infusion by avoiding the use
• of balloons in women at risk for cancer.

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Take home

• The studies show that the use of SIS will benefit
  clinical decision making, with up to 40 of
  patients avoiding diagnostic hysteroscopy.
• Hysteroscopy is a more invasive procedure, and
  is associated with significant financial cost, as
  well as physical discomfort.

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Take home

• MSAC (The Medicare Services Advisory Committee)
• recommended that on the strength of evidence
  pertaining to saline infusion sonohysterography,
  public funding should be supported for this
  procedure as a second-line diagnostic procedure
  for abnormal uterine bleeding, when findings from
  transvaginal ultrasound are inconclusive.

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Take home

• TVS and SHG offer a cost-effective alternative to
  diagnostic hysteroscopy in the evaluation of
  patients aged 40 years or older with abnormal
  uterine bleeding. The authors concluded that
  their study suggests that SIS is a more
  sensitive test than diagnostic hysteroscopy for
  evaluating abnormal uterine bleeding.

Saidi M H, Sadler R K, Theis V D, Akright B D,
Farhart S A, Villanueva G R. Comparison of
sonography, sonohysterography, and hysteroscopy
for evaluation of abnormal uterine bleeding.
Journal of Ultrasound in Medicine,
199716(9)587-591.
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Take home

• Sonohysterography was in general the most
  accurate test. Its diagnostic accuracy was
  markedly superior for polypoid lesions and EH,
  with total agreement with the gold standard.
• In diagnosis of intrauterine adhesions, SHG had
  limited accuracy, similar to that obtained by
  HSG, with a high false-positive diagnosis rate.

Fertil Steril. 2000 Feb
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Take home

• Saline infusion sonohysterography is more
  accurate in diagnosing submucous fibroids and
  endometrial polyps in the patients of abnormal
  uterine bleeding than is TVS. TVS should be
  included in the standard protocol for the
  management of AUB. Saline infusion
  sonohysterography should be reserved for those
  patients who have centrally located fibroids as
  they may be submucous.

Aust N Z J Obstet Gynaecol. 2002 Nov
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Take home

• Conventional transvaginal pelvic sonography does
  not appear to be a screening procedure of
  sufficient diagnostic value in the symptomatic
  patient with abnormal vaginal bleeding.
• In patients presenting with the chief complaint
  of abnormal vaginal bleeding, diagnostic
  evaluation with a saline hysterosonogram may be
  warranted despite normal findings on a
  transvaginal pelvic sonogram.

AJR Am J Roentgenol. 2002 Jan
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Thank you