Multiple polyps in a 52-year-old woman with abnorma

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Saline Infusion Sonohysterography
Robert D. Auerbach, M.D. FACOG Senior Vice
President Chief Medical Officer CooperSurgical,
Inc. Associate Clinical Professor Yale University
School of Medicine
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Introduction

• Saline Infusion Sonohysterography (SIS)
• Transcervical introduction of fluid
• Provides enhanced endometrial visualization
  during TV U/S examination
• Benefits
• Easy to perform
• Minimal cost
• Well tolerated by patients
• Few complications

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Indications Contraindications

• Indications
• Abnormal Uterine Bleeding
• Infertility and habitual abortion
• Congenital abnormalities of the uterus
• Pre or postoperative evaluation of uterine
  myomas, polyps, cysts
• Suspected uterine cavity synechiae
• Inadequate TV U/S

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Indications Contraindications

• Contraindications
• Pregnancy
• Pelvic infection

AIUM standard for the performance of Saline
Infusion Sonohysterography www.aium.org/consumer/s
tandards/saline.pdf
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Indications - AUB

• Abnormal Uterine Bleeding (AUB)
• Accounts for many patients visits
• Diagnostic procedures
• TV U/S
• Endometrial Biopsy
• Hysteroscopy
• DC no longer considered an initial diagnostic
  test

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Indications - AUB

• SIS is useful for finding focal lesions in AUB
• 106 patients with menometrorrhagia

Significant difference and comparable to
hysteroscopy Dx rates
Kamel, HS, Darwish, AM, Mohamed, SA. Comparison
of transvaginal ultrasonography and vaginal
sonohysterography in the detection of endometrial
polyps. Acta Obstet Gynecol Scand 2000 7960.
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Indications - AUB

• De Kroon, CD, Jansen, FW, Louwe, LA, et al.
  Technology assessment of saline contrast
  hysterosonography. Am J Obstet Gynecol 2003
  188945.
• Prospective series of 214 consecutive pre- and
  postmenopausal women with AUB
• Suspected uterine abnormality on TV U/S
• SIS followed by hysteroscopy preferable to
  hysteroscopy initially
• Hysteroscopy could be avoided 84 of patients

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Indications - AUB

• SIS can help distinguish
• Anatomic AUB from anovulatory bleeding
• Postmenopausal bleeding from atrophy
• May help select appropriate candidates for
  endometrial sampling
• Differentiate focal lesions that need biopsy
  under direct vision versus a global process that
  can be sampled blindly

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Indication - Infertility

• Assessing the endometrium is part of the routine
  infertility recurrent pregnancy loss work-up
• SIS can Dx anatomic causes of infertility
• Submucous myomas
• Endometrial polyps
• Uterine anomalies
• Intrauterine adhesions

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Indication - Infertility

• SIS is comparable or better than HSG
• Salle, B, Gaucherand, P, de Saint, Hilaire P,
  Rudigoz, RC. Transvaginal sonohysterographic
  evaluation of intrauterine adhesions. J Clin
  Ultrasound 1999 27131.
• Darwish, AM, Youssef, AA. Screening
  sonohysterography in infertility. Gynecol Obstet
  Invest 1999 4843.
• Alborzi, S, Dehbashi, S, Parsanezhad, ME.
  Differential diagnosis of septate and bicornuate
  uterus by sonohysterography eliminates the need
  for laparoscopy. Fertil Steril 2002 78176.
• Alatas, C, Aksoy, E, Akarsu, C, et al. Evaluation
  of intrauterine abnormalities in infertile
  patients by sonohysterography. Hum Reprod 1997
  12487.
• HSG better at outlining fallopian tubes

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Indication - Tamoxifen

• Tamoxifen is used extensively as adjunctive
  chemotherapy in women with estrogen
  receptor-positive breast cancer
• May thicken the uterine wall in some women when
  viewed by TV U/S
• May be polyps or abnormal endometrial tissue

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Indication - Tamoxifen

• SIS has shown these changes are often microcysts
  of the basalis (focal adenomyosis reactivation)
• Hann, LE, Gretz, EM, Bach, AM, Francis, SM.
  Sonohysterography for evaluation of the
  endometrium in women treated with tamoxifen. AJR
  Am J Roentgenol 2001 177337.
• Elhelw, B, Ghorab, MN, Farrag, SH. Saline
  sonohysterography for monitoring asymptomatic
  postmenopausal breast cancer patients taking
  tamoxifen. Int J Gynaecol Obstet 1999 6781.
• Routine sonographic screening of the endometrium
  of asymptomatic women taking Tamoxefen has not
  been recommended by ACOG

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SIS Technique

• Usually scheduled between day 5 10 of the
  menstrual cycle
• No routine anesthesia or analgesia needed
• Bimanual exam
• Place speculum
• Aseptic prep of the cervix
• SIS
• Flush catheter
• Insert catheter
• May be accomplished without the need for a
  tenaculum

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SIS Technique

• Fill balloon and snug catheter against the
  internal os
• Remove speculum
• Attach 10ml syringe of sterile saline
• Insert TV U/S probe

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SIS Technique

• Fluid is instilled while the probe is shifted to
  each cornual region
• Long axis plane
• Turn probe 90 degrees and instill more fluid
• Coronal plane
• Fan from the endocerival canal to the fundus

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Findings - Normal
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Normal SIS with Balloon Inflated
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Findings - Polyp
TV US for abnormal bleeding revealed an
ill-defined mass
SIS demonstrates fundal polyp
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Polyp - Removal
Polyp removed under U/S guidance leaving a normal
endometrial cavity (left)
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Multiple Polyps
Multiple polyps in a 52-year-old woman with
abnormal bleeding. Saline infusion
sonohysterography shows multiple polypoid masses
(arrows) outlined by the anechoic saline.
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Cancerous Polyps
Papillary serous carcinoma in a 71-year-old woman
with postmenopausal bleeding. Findings from blind
endometrial biopsy performed before the SIS were
negative.
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Findings Submucosal Myoma
TV US shows myoma with non-distinct borders
SIS shows myoma protruding into endometrial cavity
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Findings - Tamoxifen
TV US showing irregular endometrium and cysts
SIS showing thin endometrium and sub-basalis cysts
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Endometrial Hyperplasia
Saline infusion sonohysterography shows diffuse
endometrial thickening and multiple cystic areas
(arrowheads). Pathologic examination showed
simple endometrial hyperplasia.
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Endometrial Hyperplasia
Endometrial hyperplasia in a 54-year-old woman
with menorrhagia showing areas of focal
thickening of the endometrium. Pathologic
examination revealed complex endometrial
hyperplasia without atypia.
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Findings Endometrial Cancer
TV US shows 7mm endometrium after menses should
be no gt than 4mm
SIS demonstrates inapprop. thick endometrium
biopsy reveals well differentiated adenocarcinoma
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Metastatic Cancer
Mass in a 71-year-old woman with a history of
breast cancer treated with tamoxifen for
approximately 2 years who had PMP bleeding. SIS
shows an inhomogeneous focal mass (arrows).
Pathologic examination revealed metastatic breast
cancer to the uterus.
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Findings - Adhesions
Intrauterine adhesions in a 33-year-old woman
undergoing a fertility workup with a history of 2
dilation and curettage procedures. Saline
infusion sonohysterography shows a poorly
distensible endometrial cavity with adhesions
(arrows).
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Technical Difficulties Complications

• Passing the catheter
• Cervical stenosis
• Uterine position
• Uterine abnormality
• Poor visualization
• Unable to retain fluid (patulous cervix)
• Infection
• Same risk as HSG
• Obtain cultures and Rx with AB based on risk
  factors

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Technical Difficulties Complications

• Cancer dissemination positive cytology equals
  at least Stage IIIA
• Theoretic concerns
• HSG study with spill survival rates unchanged
• Devore, GR, Schwartz, PE, Morris, JM.
  Hysterography a 5-year follow-up in patients
  with endometrial carcinoma. Obstet Gynecol 1982
  60369.
• False positive
• Attributed to blood clots, intrauterine debris,
  mucus, shearing of the endometrium and thickened
  endometrial folds

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Getting Fooled
Inadvertent injection of a small amount of air.
The air appears as a bright echogenic focus in
the fundal region of the endometrial cavity
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Getting Fooled
Blood clot mimicking a mass. The patient had
postmenopausal bleeding. Initial images (A and B)
show an echogenic mass in the endometrial cavity
(arrow). Color Doppler imaging (C) shows no color
flow within the mass. During the examination, the
mass was dislodged with the catheter, and the
final image (D) shows a normal thin endometrium.
C
A
D
B
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Technical Difficulties Complications

• Prospective study of 1153 women age 23-64
  undergoing SIS
• Failure to complete procedure 7
• Pelvic pain 3.8
• Vagal response 3.5
• Nausea 1
• Post procedure fever 0.8

Dessole, S, Farina, M, Rubattu, G, et al. Side
effects and complications of sonohysterosalpingogr
aphy. Fertil Steril 2003 80620.
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Summary

• SIS provides enhanced endometrial visualization
• Improves sonographic detection of polyps,
  hyperplasia, cancer, myomas and adhesions
• Can help avoid invasive procedures
• May optimize preoperative evaluation who require
  therapeutic intervention