Peter Slamka, MD

home

authors

peter-slamka-md

 Assessment of diagnostic accuracy of transvaginal sonohysterography in comparison with transvaginal ultrasound, hysterosalpingography and hysteroscopy in predicting endometrial hyperplasia.

 A prospective study was performed at Al- Azhar University Hospital, Cairo, Egypt and Hadi Hospital, a private hospital in Kuwait. A total of 255 patients (160 Egyptian and 95 Kuwaiti) with abnormal uterine bleeding were enrolled (165 premenopausal,90 postmenopausal). All participants were evaluated with transvaginal sonography (TVS), transvaginal sonohysterography (TV-SH) and operative hysteroscopy (HSC). Hysterosalpingography (HSG) was performed only for 40 Egyptian and 10 Kuwaiti patients. Endometrial curettage and/or histopathology of hysterectomy specimen were considered the gold standard diagnostic procedures. 

 The mean age of patients with endometrial hyperplasia (EH) was 44.34 ±3.33 years. the level of pain experienced by patients at HSG procedure was significantly higher than during TV-SH (P <0.0001). EH was found in 70 patients. TV-SH clearly delineated the endometrial cavity and successfully differentiated between endometrial polyp, submucous myoma and hyperplasia. In all EH cases, TV-SH had sensitivity of 95.7%,specificity 96.8%,PPV 91.8%,NPV 98.35% and diagnostic accuracy 96.5% compared to TVS  (77%, 94.6%,84.4%, 91.6% & 89.8%), HSC (75.7%, 97.3%, 91.4%, 91.4% & 91.4%) and HSG (29.4%, 97%, 83.3%, 72.7% & 74%) respectively. In premenopausal patients the corresponding figures were, 67.4%, 94.3%, 80.6%, 89.2% & 87.3% for TVS, 95.5%, 95.9%, 89.1%, 98.3% & 95.8% for TV-SH and 67.4%, 96.7%, 87.9%, 89.4% & 89.1% for HSC and in postmenopausal patients, 89.1%, 95.2%, 89.3%, 95.2% & 93.3%, for TVS, 96.3%, 98.4%, 96.3%, 98.4% & 97.8%, for TV-SH and 88.9%, 98.4%, 96%, 95.4% & 95.6%, for HSC, respectively.



 TV-SH is an advanced enhancement of conventional TVS. It is an easy, safe, rapid and tolerable procedure. It has an excellent diagnostic accuracy in EH, but it cannot substitute tissue diagnosis.



Key words: Endometrial hyperplasia, transvaginal sonohysterography, hysterosalpingography, hysteroscopy.

Abnormal uterine bleeding (AUB) is a common reason for gynaecologic visits for both pre menopausal and postmenopausal women.

 Up to 33 % of women referred to gynaecological out patient clinics have AUB and this proportion rises to 69 % in a peri or post menopausal group.

Endometrial hyperplasia (EH) is considered to be a frequent cause of abnormal uterine bleeding

Traditionally, dilatation and curettage (D&C) has been the method of choice for obtaining an endometrial sample, however, in studies comprising both pre – and post menopausal women with AUB, 43–66 % of hyperplasia were missed by D&C.

Also D&C is an invasive procedure requiring inpatient and general anesthesia 

. Approximately 80 percent of all curettage procedures performed for post menopausal bleeding results in benign diagnosis.

 Therefore, if a non invasive modality can be accurately used to determine endometrial thickness measurements below which pathology is less likely, sampling may be avoided.

In this cost conscious era, other less expensive, outpatient, simpler and apparently safer investigations have been advocated

. These include: measurement of endometrial thickness by Transvaginal Sonography (TVS)

, and hysteroscopy (HSC) (with directed biopsy, if necessary)

The aim of this prospective comparative study was to evaluate the diagnostic accuracy of all these investigations (TVS, TV-SH, HSG &HSC) in the diagnosis of endometrial hyperplasia in women with abnormal uterine bleeding.



We conducted a prospective study in two centers: Department of Obstetrics and Gynecology, AL- Azhar University Hospital, Cairo, Egypt and Department of Obstetrics and Gynecology, Hadi Hospital, private hospital in Kuwait, during the period from March 1998 to March 2002. The study included 255 patients (160 Egyptians and 95 Kuwaiti). All were admitted for management of abnormal uterine bleeding (165 premenopausal and 90 postmenopausal).

Complete evaluation of patients included conventional transvaginal sonography (TVS), transvaginal sonohysterography (TV-SH), and inpatient day case hysteroscopy (HSC). X-ray hysterosalpingography (HSG) was performed only for 40 Egyptian and 10 Kuwaiti patients. Endometrial curettage and/or histopathology of hysterectomy specimens were considered the gold standard diagnostic procedures. In each center every physician performed the same procedure on each patient and recorded his results separately without knowledge of the other findings. The same physician performed each procedure throughout the study.

The study and procedures were explained to the patient and consent was obtained. Antibiotics or analgesics were not used prophylactically unless indicated by medical risk factors.


The sonographic examinations were carried out using Creds (Combison) 410 plus. with multifrequency convex transvaginal probe and a frequency range of 5: 7.5 MHz transducer (for Egyptian patients) and Aloka Co., ltd SSD 1700 Dyna View II Tokyo-Japan (for Kuwaiti patients). Trained ultrasonographer performed the scans. The uterus was scanned in three major planes: longitudinal axis, an oblique plane, and short axis (transverse) view to obtain images in varying directions, planes and depths and using the diagnostic criteria described by previous investigator.

 We used endometrium thickness <5 mm as the cut off level for abnormality in postmenopausal patients and <15 mm in premenopausal patients.

 After imaging of the uterus, the parametrium and adnexa were imaged systematically in transverse, sagittal and oblique planes.


Immediately after the performance of TVS ,TV-SH was carried out. The cervix was inspected through a vaginal speculum and cleansed with bovidine iodine solution (Betadine). A polyethylene cannula of the type used for intrauterine inseminations (Unimar KDF-2.3 Intrauterine cannula: Prodimed, Neuily en Thelle, France) was introduced into the cervix. Traction of the cervix was rarely necessary. The speculum was then removed .Then, the sterile sheathed vaginal ultrasound probe was reintroduced. The sonographer adjusted the image so that all the endometrium and myometrium were visualized on the screen at the time of saline infusion to visualize immediately distension of uterine cavity in the longitudinal plane. Scanning was maintained during infusion and also repeated on transverse plane. Infusion was gradual, with a slow and sustained flow and air bubbles were allowed to disappear before depiction of endometrial cavity. In the case of a patulous cervix, when saline solution reversed its flow and back out of the uterus, more solution was continuously infused. The uterine cavity was re-evaluated in longitudinal oblique and transverse planes and selected pictures were taken.

Endometrial echo, regularity and shape were depicted and endometrial thickness surrounding the fluid was measured. During each study; pre and post instillation scans were recorded on hard copy photos for patients record using Sony Graphic Video printer. 

Sixty patients completed questionnaires on a four point scale by the investigator: 0 = no or minimal discomfort, 1 = mild discomfort (tolerable pain), 2 = moderate discomfort (intense pain) and 3 = severe discomfort (unreliable pain) in which they rated the pain they experienced (15).The four point scale assessed pain during application of the instruments and during injection of contrast media.

Post procedure complications were also recorded.

Thirty five patients were followed up 3 to 6 months after treatment by TVS and TV-SH.


It was performed one week after ultrasound examinations using a non-ionic, monomeric, triiodinated, water soluble,  x-ray contrast medium {IOHEXOL (OMNIPAQUE)} Nycomed Ireland Ltd. Patient pain rating was determined by the same way as that in TV-SH.


It was performed one week after X-ray HSG or after TV-SH in patients who did not perform HSG. All hysteroscopic examinations were done under anaesthesia for all cases using rigid panoramic type with a continuous irrigation and suction sheath (26 French gauge) and a 4 mm forward oblique telescope (Karl Storz, Tuttlingen, Germany). The distending medium used was 1.5% glycine solution. The technique was terminated by target hysteroscopic biopsy of suspected endoluminal masses. All patients underwent D&C after hysteroscopy. For cases scheduled for TAH, D&C only was done leaving endoluminal masses in situ till histopathological diagnosis of hysterectomy specimens.


The results were statistically analysed using the McNemar test and Chi-square test. Evaluation of predictive power was based on. sensitivity= true positive (TP) X 100/TP +false negatives (FN), specificity=true negatives (TN) X 100/TN+false positives (FP), positive predictive value (PPV)=TPX100/TP+FP, negative predictive value (NPV)=TN X100/TN +FN, diagnostic accuracy (DA) =TP +TN X 100/total, false negative rate = FN/TN+FNX100 and false positive rate = FP/TP+FPX100.Univariate analysis using t-test used for the quantitative variables. The probability level 0.05 ( p = 0.05) was used to test the significance of the tests.


An endometrial sample was obtained by D&C in all cases. Thirty one patients were dropped during the study because of incomplete investigations due to several reasons. They were not included in the statistical evaluation.

Conventional TVS failed in three cases; in one case because of severe vulval and vaginal atrophy, in other case because of third degree uterine prolapse and a third case could not withstand the vaginal probe, all of them were postmenopausal. ln six cases the TV-SH was contraindicated; three patients had acute cervicitis, one had cardiac disease and a two cases were suspected to be pregnant. TV-SH procedure failed in seven cases because of cervical stenosis in three cases, and multiple myoma obscuring visualization of the uterine cavity in two cases, severe Asherman's Syndrome in one case and, in one case for unknown reason.



 represents the characteristics of the study group. The mean age of patients with EH was 44.34 ±3.33 years. Simple hyperplasia was diagnosed in 54 patients (36 pre-&18 postmenopausal ),and complex hyperplasia without atypia was diagnosed in 16 patients (5 pre-&11 postmenopausal)

The mean operative time was 5 ±1.7 minutes for TVS, 9 ±2.1 minutes for TV-SH from insertion of the catheter to completion of the procedure. It usually took <15 minutes to complete TVS and TV-SH.

The average volume of saline needed for infusion was 10 to 30 cc. In this study only one patients developed mild endometritis after the procedure and did not complete the study. She had performed D&C 2 days prior to TV-SH.

EH were found in 70 patients,(43 premenopausal & 27 postmenopausal). EH was associated with endometrial polyp (EP) in 9 cases (fig. 1) and with submucous myoma in 8 cases (fig. 2).TV-SH clearly delineated the endometrial cavity and successfully differentiated between EP, submucous myoma and EH (Fig 1,2&3) .The thickened hyperplastic endometrium around the sonolucent infused saline takes different unique shapes while the myometrial junction is intact except when there is subendometrial cyst, polypoid like shape, cryptiform shape, a homogenous hyperechoic thick band and a velvety shape which was confused with secretory endometium. Hyperplastic endometriurn may be found in patches or in one wall rather than the other. Myometrial sonolucent small cysts were found associated with polypoid and cryptiform types where histopathology revealed associated adenomyosis in 3 patients.

The level of pain experienced by patients at HSG procedure was significantly higher than during TV-SH (P <0.0001). At the TV-SH procedure, , 90% of patients experienced no discomfort,7% had mild and 3% had moderate discomfort during application of the catheters, while during infusion of saline,80% had no discomfort 13% had mild,5% had moderate and 2% had severe discomfort. While at HSG procedure,40% had no discomfort,45% had mild and 15% had moderate discomfort during application of instruments, while during infusion of contrast material,20% had mild,35% had moderate and 40% had severe discomfort. 

In table 2 the agreement between TV-SH and pathologic diagnosis of endometrial hyperplasia was almost perfect (diagnostic accuracy 96.5%),TV-SH was more superior than other procedures with marked difference compared to HSG and HSC, while TV-SH showed superiority to TVS. In all EH cases the false positive rate (FPR) was 15.7% in TVS,8.2% in TV-SH,16.7% in HSG and 8.6% in HSC. The false negative rate (FNR) was 8.3% in TVS,1.6% in TV-SH,27.3% in HSG and 8.6% in HSC. In premenopausal patients, the FNR & FPR were 10.9% &19.4%in TVS,1.7%&10.9% in TV-SH,10.6% & 12.1% in HSC. In postmenopausal were,4.8% &10.7% in TVS,1.6% &3.7% in TV-SH, and 4.6% &4.0% in HSC.

The response to progestin therapy was evaluated in subsequent sonographic examinations In 35 cases, proved to have simple EH and after 5 months treatment, the sagittal endometrial image at TVS regressed to a line less than 5 mm in thickness prior to infusion. After infusion (TV-SH), the endometrium became thinner with a smooth line that reverted to secretory endometrium at histopathology, (


This study assessed the use of TVS, TV-SH, HSG and hysteroscopy (HSC) in the evaluation of pre- and post menopausal bleeding. Clinicians have long hoped for an accurate & non-invasive screening tool for endometrial pathology.

 There are several non invasive methods for the evaluation of the endometrial cavity, TVS, TV-SH, HSG and HSC are such methods.

In the present study high false positive rate (16.7%) was observed with HSG in the diagnosis of EH. This finding is in agreement with many authors 

Accurate positive findings is essential as it directs the patient to a more beneficial procedure and correct management whereas, false positive findings exhaust normal patients and expose them to hazards of unindicated operative intervention. False negative results (27.3% for HSG) have the problem of directing the patient who has an organic lesion to medical treatment with its failure and recurrence to a more progressed state.

Hysterosalpingography delineates the uterine and tubal lumen. Therefore, disease processes that do not cause a filling defect or abnormality in the luminal contour have no hysterosalpingographic expression 

.Ultrasonography is a safe, readily available modality for non-invasive imaging of the endometrial cavity. It can allow visualization similar to hysteroscopy. especially if one resorts to saline infusion sonohysterography.

In the present study, for TVS, the sensitivity, specificity, PPV, NPV and DA in all EH cases were 77%, 94.6%, 84.4%, 91.6% & 89.8%,in premenopausal patients the corresponding figures were, 67.4%, 94.3%, 80.6%, 89.2% & 87.3%,and in postmenopausal patients were, 89.1%, 95.2%, 89.3%, 95.2% & 93.3%, respectively.

TVS had a sensitivity of 88% in premenopausal and 96% in postmenopausal women in diagnosing endometrial abnormalities 

, and a sensitivity of 88% and specificity of 68% in premenopausal women 

, reported a sensitivity of 97.4%, specificity 75.7%, PPV 23.8% &NPV 99.7% for detection of endometrial pathology in postmenopausal women, while, Sousa et al. 2001

, reported, 77.8%, 93.3%, 88.9% & 98.3%, Krampl et al 2001

, reported 33.3 %, 88.6 %, 25 % and 92.1 % respectively. Giorda et al. 

, reported 96% &8% for NPV &PPV for TVS in detecting EH in postmenopausal patients. 

This study and previous studies reveal the inability of traditional TVS alone, to identify true endometrial abnormalities

. In the present study evaluation of pain rating revealed that the level of pain experienced by patients at TV-SH was significantly lower than HSG. This is in agreement with most investigators 

On the other hand, some investigators reported higher pain ratings with TV-SH 

. This may be due to the need for more injections and other contrast media which may be more painful. 

An interesting finding elicited in the present study was the marked superiority of TV-SH in demonstration of EH and superiority was higher in postmenopausal compared to premenopausal women (

). The superiority of TV-SH in diagnosis of EH compared with TVS was consistent with findings of many authors 

. The sensitivity and specificity were 97.9% and 33.2%,with an accuracy of 52.3% in postmenopausal women

. TV-SH has become the standard test in evaluation of AUB because it allows reliable differentiation between focal and diffuse endometrial and subendometrial lesions

. Because TV-SH allows distinction between diffuse or focal abnormalities, it provides physicians with a cost-effective way to plan the next step in case management

. For instance, when sonographic characteristics suggest diffuse hyperplasia and not polyp or myoma, an office biopsy to exclude cancer is quite sufficient. It can be simply performed nowadays with small flexible biopsy instruments which are very popular with physicians despite the tendency to sample less than 15% of the endometrial cavity 

. When there is a focal lesion or asymmetry a hysteroscopically directed biopsy is necessary to ensure removal for diagnosis as well as remission of symptoms 

. EH usually appears as diffuse thickening of the echogenic endometrial stripe without focal abnormality, but occasionally focal EH, can be seen

In this series, TV-SH clearly delineated the endometrial cavity, provided accurate measuring of single layer endometrial thickness and excellently differentiated endometrial hyperplasia from submucous myoma (

).Thus, it can change the classic concept of further investigations for hyperplasia and a less invasive interference by aspiration biopsy to exclude cancer would likely be sufficient. In the present study, TV-SH was able to demonstrate focal or patchy endometrial thickness and presence of EH on one wall rather than the other (

).Accordingly, it can assist the gynecologist to direct the curette properly to the desirable site.

Consequently, it increased the potential to convert the blind curettage to a directed one contracting the expected high false negative results with the blind procedures.

Regression of endometrial thickness at TV-SH after three to six months progestin therapy is an additional advantage. Follow-up of the endometrium by TV-SH after progestin therapy can help track the response of EH to medical treatment. Unfortunately, TV-SH could not provide specific criteria to different histopathological types of hyperplasia; and thus, it could not substitute tissue diagnosis. 

The demonstration of subendometrial and myometrial microcysts associated with polypoid and cryptiform endometrium, together with the pathological finding of associated adenomyosis ,is an additional advantage of TV-SH. Demonstration of combined EH with submucous myoma or EP is one of the important indices required for endometrial resection, 

 In this study, TV-SH clearly delineated these lesions that were missing at conventional scanning.

A great variation had been reported by many authors regarding diagnostic potential of HSC in diagnosis of EH .The DA was 43% by Widrich et al., 1996

 and also the sensitivity of HSC was 54% by Motashaw and Dave 1990

, 71.8 % in premenopausal and 85.1% in postmenopausal women by Torrejon et al., 1997

.HSC showed a sensitivity of 95.8% and 93.9% specificity for detecting endometrial pathology, in postmenopausal women

. Sensitivity, specificity, and NPV of HSC accounted for 98%, 95% and 99%, PPV was higher in postmenopausal patients compared to women in the fertile age (72 vs.58%)

. HSC revealed sensitivity of 88.9%, specificity 98.3%, PPV 88.9% and NPV 98.3% in postmenopausal patients with AUB

.The great variability could be explained by the fact that all hysteroscopic findings are not yet internationally standardized to allow all hysteroscopists to speak the same language. We still find a great similarity between endometrial hyperplasia and late normal secretory endometrium in agreement with the findings of previous investigators

 TV-SH is an advanced enhancement of conventional TVS. It is an easy, safe, rapid and tolerable procedure. It has an excellent diagnostic accuracy in EH. It can evaluate the endoluminal abnormalities more definitely. Hence, it may then direct biopsy procedures and minimize false negative results, but it cannot substitute tissue diagnosis.

[Click images to open larger view in separate window]

 A-TVS of the uterus in long plane. Thickened hyperechoic endometrium measuring 23.1 mm (callipers). Pathology revealed simple hyperplasia without atypia. B-TV-SH in the same plane. Thickened hyperechoic homogeneous endometrium surrounding a sonolucent distended cavity. The single layer endometrial thickness measured 8.4 and 9.6 mm, respectively (callipers). The summation (18 mm) is less than the total thickness at TVS. C- TV-SH at oblique plane. It demonstrates corporofundal small endometrial polyp 5 mm in diameter. This explains the difference in endometrial thickness at both procedures. 

 A-TVS of the uterus in the long plane. Central ovoid endometrial thickening suggesting a submucous myoma (arrows). The endometrial mass is hyperechoic with intact E-M junction. Hyperplasia is also considered. B- TV-SH in the same plane. Markedly thickened endometrium with polypoid appearance and intact E-M interface. Note the associated anterior wall corporeal small submucous myoma. Also, note anechoic polypoid structure which was stable during infusion. It represents the intrauterine insemination cannula. C-TV-SH of the same patient in the same plane. Myometrial microcystic spaces representing reactivation of foci of adenomyosis. C-HSG of the same patient. Wide endometrial cavity with irregular endometrial contour. The small submucous myoma was missed.

 A-TVS in the long plane. Central echogenic mass with its cranial part thicker than the slippered caudal part and an intact E-M junction. TVS suggested large endometrial polyp. B-TV-SH revealed thickened endometrium with single layer thickness 7.6 and 7.5 mm respectively and intact E-M junction. The endometrial surface irregularity showed cryptiform appearance surrounding a sonolucent cavity. Note small microcystic spaces representing reactivation of foci of adenomyosis. C-HSG of the same patient. Wide endometrial cavity with irregular endometrial contour. D-HSC of the same patient. Irregularly thick heaped up endometrium with increased vascularity. It is difficult to distinguish it from late secretory endometrium.

 A-TV-SH in the standard longitudinal view revealed thickened endometrium only at the posterior and fundal walls with velvety appearance like brush border while the anterior endometrium is smooth and thin. Target biopsy revealed hyperplastic endometrium without atypia in the thickened areas while the smooth anterior endometrium was proliferative. B-TV-SH of the same plane after 3 months progestin therapy. The thickened areas contracted to a small thickened fundal patch. Targeted biopsy revealed fundal hyperplasia while the remaining endometrium was proliferative. C-TV-SH after another two months progestin therapy. The residual hyperplastic fundal patch reverted to secretory endometrium at target biopsy. The secretory endometrium shows also a velvety appearance.


1. Karampl E, Bourne T, Hurlen – Solbakken H, Istre O. Transvaginal ultrasonography, sonohysterography and operative Hysteroscopy for the evaluation of abnormal uterine bleeding. Acta Obstet. Gynaecol Scand 2001 ; 80 (7) : 616 – 22.
2. Mencaglia L, Perino A, Hamou J. Hysteroscopy in peri menopausal and post menopausal women with abnormal uterine bleeding. J Reprod Med 1987 ; 32 : 577 – 582.
3. Loverro G, Bettocchi S, Pansini N, Porreca MR, Selvaggi L. Hyperplastic human endometrium. J Am Assoc Gynaecol Laparosc 1996; 3(4, supplement) : S 27.
4. Epstein E, Ramirez A, Skoog L, Valentin L. Dilatation and curettage fails to detect most focal lesions in the uterine cavity in women with post menopausal bleeding. Acta Obstet Gynaecol Scand 2001 ; 80 : 1131 – 36.
5. Buyuk E, Durmusoglu F, Erenus M, Karakoc B. Endometrial disease diagnosed by Transvaginal ultrasound and dilatation and currettage. Acta Obstet Gynaecol Scand 1999; 78:419 – 22.
6. Sousa R, Silvestre M, Sousa L A, Falcao F, Dias I, Silva T, Oliveira C. Transvaginal ultrasonography and hysteroscopy in post menopausal bleeding : a prospective study. Acta Obstet Gynaecol Scand 2001; 80 : 856 – 862.
7. Lerner JP, Timor – Tritsch IE, Monteagudo A. Use of transvaginal sonography in the evaluation of endometrial hyperplasia and carcinoma. Obstet and Gynaecol Survey 1996; 51 (12) : 718-25).
8. Goupta JK, Wilsom S, Desia P, Hau C. How should we investigate women with post menopausal bleeding? Acta Obstet Gynaecol Scand 1996 ; 75 : 475 – 79.
9. Mortakis A, Mavrelos K. Transvaginal ultrasonography and hysteroscopy in the diagnosis of endometrial abnormalities. J Am Assoc Gynecol Laparosc 1996;3(4,supplement):S32.
10. Davis PC, O’Neill MJ, Yoder IC, Lee SI, Mueller PR. Sonohysterographic findings of endometrial and subendometrial conditions. Radiographics 2002 ; 22 (4) : 803 – 816.
11. Gaucherand P, Piacenza JM, Salle B, Rudigoz RC. Sonohysterography of the uterine cavity :preliminary investigations. J Clin Ultrasound 1995;23:339-348.
12. Tahir MM, Bigrigg MA, Browning JJ, Brookes ST, Smith PA. A randomised controlled trial comparing transvaginal ultrasound, outpatient hysteroscopy and endometrial biopsy with inpatient hysteroscopy and curettage. Br J Obstet Gynaecol 1999 ; 106 : 1259 – 1264.
13. Emanuel MH, Verdel MJ, Wamsteker K, Lammes FB. A prospective comparison of transvaginal ultrasonography and diagnostic hysteroscopy in evaluation of patient with abnormal uterine bleeding: clinical implications. Am J Obstet Gynecol 1995;172:547-552.
14. Towbin NA, Gviazda IM, March CM. Office hysteroscopy versus transvaginal ultrasonography in the evaluation of patients with excessive uterine bleeding. Am J Obstet Gynecol 1996;174:1678-1682.
15. Battaglia C, Genazzani AD, Artini PG et al. Colour doppler hysterosalpingography in the diagnosis of tubal patency. Fertil Steril 1996 :65(2): 317 - 322.
16. Yoder IC, Hall DA. Hysterosalpingography in the 1990s.A J R, Am J Roentgenol. 1991;157(4):675-83.
17. Goldstein SR, Zeltser I, Horan CK, Snyder JR, Schwartz LB: Ultrasonography based triage for perimenopausal patients with abnormal uterine bleeding. Am J Obstet Gynecol 1997;:177:102-108.
18. Dijkhuizen FP, Brolmann HA, Potters AE, Bongers MY, Heinz AP. The accuracy of transvaginal ultrasonography in the diagnosis of endometrial abnormalities. Obstet Gynecol 1996;87 (3):345-9.
19. Tsuda H, Kawabata M, Yamamoto K, Inoue T, Umesaki N. Prospective study to compare endometrial cytology and transvaginal ultrasonography for identification of endometrial malignancies.Gynecol Oncol 1997;65 (3):383-6.
20. Giorda G, Crivellari D, Verones A, Perin T, Campagunutta E, Carbone A, Scarabelli C. Comparison of ultrasonography, hysteroscopy and biopsy in the diagnosis of endometrial lesions in postmenopausal Tamoxifen-treated patients. Acta Obstet Gynecol Scand 2002;81(10):975.
21. Bourne T. Evaluating the endometrium of post menopausal women with transvaginal ultrasound (opinion). Ultrasound Obstet Gynaecol 1995 ; 6 : 75–80.
22. Widrich T, Bradley LD, Mitchinson AR, Collins RL. Comparison of saline infusion sonography with office hysteroscopy for evaluation of the endometrium. Am J Obstet Gynecol 1996;174:1327-1334.
23. Session DR, Lee GS, Kelly AC. A comparison of pain tolerance during x-ray hysterosalpingography and sonohysterography. Gynecol Obstet Invest 1996;43:116-119.
24. Heikkinen H, Hartikainen H, Takay A, Jouppila P, Volpi E. Transvaginal salpingosonography for assessment of tubal patency in infertile women: methodological and clinical experiences Fertil Steril 1995; 64(2): 293 – 298.
25. Randelzhofer B, Prompeler HJ, Sauerbrei W, Madjar H, Emons G. Value of sonomorphological criteria of endometrium in women with postmenopausal bleeding:a multivariate analysis. Ultrasound Obstet Gynecol 2002;19 (1):62-8.
26. Jorizzo JR, Riccio GJ, Chen MY, Carr JJ. Sonohysterography: the next step in the evaluation of the abnormal endometrium. Radiographics 1999;19 Spec No:S117-30.
27. Donnez J, Nisolle M, Clercka F, Roux FC et al.,: Advanced endoscopic techniques used in dysfunctional bleeding, fibroids and endometriosis, and the role of gonadotrophin – releasing hormone agonist treatment. Br J Obstet Gynaecol 1994; 101: 2-9.
28. Embaby KAM, and El-sheriff: Hysteroscopic and histopathological assessment of recurrent perimenopausal bleeding. J Egyp Soc Obstet & Gynecol 1992; 11:55.
29. Motashaw ND, Dave S: Diagnostic and therapeutic hysteroscopy in the management of abnormal uterine bleeding. J Repr Med 1990; 23: 99-103.
30. Abou El-Khair YO, Allam M, Shalan H et al.,: Correlation between transvaginal sonography, hysteroscopy and histopathology of patients with perimenopausal bleeding. J Egyp Soc Obstet & Gynecol 1992; 18 (3) : 21-32.
31. Torrejan R, Fernandez – Alba JJ, Carnicer I et al.,: The value of hysteroscopic exploration for abnormal uterine bleeding. J Am Assoc Gynaecol Laparosc 1997; 4 (4): 453-456.
32. Haller H, Matecjcic N, Rukavina B, Krasevic M, Rupcic S, Mozetic D. Transvaginal sonography and hysteroscopy in women with postmenopausal bleeding. Int J Gynecol Obstet 1996;54 (2):155-9.

Articles

Transvaginal Ultrasonography, Sonohysterography, Hysterosalpingography And Operative Hysteroscopy In Predicting Endometrial Hyperplasia

Transvaginal Ultrasonography, Sonohysterography, Hysterosalpingography And Operative Hysteroscopy

The aim of this study was to evaluate the role of TV-SH in the assessment of tubal patency and to compare these results with those obtained using HSG and laparoscopy.

A prospective study was performed at Al-Azhar University Hospital, Cairo, Egypt and Hadi Hospital, a private Hospital in Kuwait

of 200 infertile patients (150 Egyptian and 50 Kuwaiti). All women underwent HSG, TV-SH, and Diagnostic Laparoscopy. Patients were classified into 2 groups:

Group 2:100 patients had secondary infertility.

 The mean age was 27.6± 4.25 years for group 1 and 29.8±4.1 years for group 2.The mean duration of infertility was 4.6±2.1 years for group 1 and 5.2±1.9 years for group 2. On comparing the HSG findings with TV-SH and laparoscopic findings, there were no significant differences between the 3 methods of investigations. The total compatibility between the laparoscopic and HSG findings was 87%,and between the laparoscopic and TV-SH findings was 94.1%,the differences were statistically insignificant. According to the site of obstruction the sensitivity, specificity and diagnostic accuracy of TV-SH were insignificantly higher than that of HSG. TV-SH gave similar results as laparoscopy in diagnosing polycystic ovaries and did not detect the peritubal adhesions as HSG and laparoscopy. According to the site of obstruction and the presences or absences of hydrosalpingx, there was no significant difference between the sensitivity of TV-SH and HSG except in diagnosing corneal block (P<0.05).Also there were no significant differences between the specificity and diagnostic accuracy of the two methods.

 TV-SH is a simple procedure, it does not involve radiation exposure, it could be added to the usual conventional procedures to assess tubal patency as a new, easy and safe method and can be performed as an outpatient procedure in the routine infertility clinic.

Transvaginal Sonohysterography, Hysterosalpingography, Laparoscopy

Vaginal ultrasound has gained popularity with gynecologists and radiologists for evaluating many gynecologic problems

. Sonohysterography, a term coined in 1993 to describe the infusion of sterile saline through the cervix and into the uterus during vaginal sonography, is a simple and elegant technique for visualizing the endometrium during a routine vaginal ultrasound examination

. Sonohysterography may have many applications for infertility evaluation. It has been used to diagnose and locate endometrial polyps, intrauterine adhesions, and separated uteri, and has also been used to evaluate tubal patency

.Sonohysterography was as accurate as HSG in demonstrating tubal patency but less accurate in determining which tubes were patent

We conducted a prospective study in two centers: Department of Obstetrics and Gynecology, AL- Azhar University Hospitals, Cairo, Egypt and Department of Obstetrics and Gynecology, Hadi Hospital, private hospital in Kuwait, during the period from October 1996 and October 1999 .The study included 200 infertile patients (150 Egyptians and 50 Kuwaiti). All women underwent HSG, TV-SH, and diagnostic laparoscopy. Their ages ranged from 20 to 35 years. Patients were classified into 2 groups. Group 1:100 patients had primary

infertility and Group 2:100 patients had secondary infertility. The time period between the performance of the first and the last of the examinations was <2 months for each patient. Hysterosalpingography was conducted by the radiologists of the Hospitals. Laparoscopy, HSG, and TV-SH were conducted by specialized gynecologists of the departments of Gynecology of the Hospitals. The physicians performing the different examinations were blinded to the results of the other studies. Laparoscopy was considered the gold standard. The results of HSG, TV-SH were compared with those of laparoscopy.

Exclusion criteria were: ongoing or recent pelvic infection, late menses without confirmation of absence of pregnancy, and technical impairment in any of the examinations. The study was approved by the Ethics Committee of the Hospitals, and all patients gave informed consent.

The sonographic examinations were carried out using Creds (Combison) 410 plus. with multifrequency convex transvaginal probe and a frequency range of 5 : 7.5 MHz transducer (for Egyptian patients) and Aloka Co., ltd SSD 1700 Dyna View II Tokyo-Japan (for Kuwaiti patients). Trained ultrasonographer performed the scans.

Scanned in longitudinal and transverse planes, and any de­tected abnormality was described and measured. The adnexa were also evaluated. Immediately after the performance of TVS, TV-SH was carried out, always in the first half of the menstrual cycle. A standard bivalve vaginal speculum was put in place, and the cervix was cleansed with povidone-iodine. The upper cervical lip was grasped with a tenaculum, and a polyethylene cannula of the type used for intrauterine inseminations (Unimar KDF-2.3 Intrauterine cannula: Prodimed, Neuily en Thelle, France) was introduced into the cervix. After that, the tenaculum and the speculum were removed, and the TVS probe was reinserted in the posterior vaginal vault. With concomitant ultrasonographic examination, 5-15 mL of physiologic sa­line solution was slowly infused to distend the endometrial cavity. During the distension and by the end of it, the cavity was evaluated, with attention to the contour, dimension, thickness, and regularity of the endometrium and presence of polypoid lesions (polyps or myomas) or adhesions. At the end of the examination, the balloon was emptied and the injector was removed. During each study; pre and post instillation scans were recorded on hard copy photos for patients record using Sony Graphic Video printer. Prophylactic antibiotics-200 mg of Doxycycline 20 min­utes before the procedure-were given to patients with a history of pelvic inflammatory disease and cardiac disorders

. No analgesics or sedatives were used during the procedure. The patients were told to take an antispasmodic and an anti-inflammatory, agent 30 minutes before the procedure.

All HSGs were conducted under the supervision of the same radiologist. They were performed between the 5th and the 14th day of the menstrual cycle by using fluoroscopy and using a non-ionic, monomeric, triiodinated, water soluble, , x-ray contrast medium {IOHEXOL (OMNIPAQUE)} Nycomed Ireland Ltd.

This was done for each case, under general anaesthesia. Twenty ml of 0.5% methylene blue were injected using cervical cannula to test tubal patency by visualizing the bluish fluid staining the utenne cavity and tubes and coming out from the fimbrial end of both tubes.

The data obtained by transvaginal sonosalpingography, hystero­salpingography and laparoscopy for each case were recorded and tabulated for the comparative study.

For statistical analysis, Chi-square, the primary statistical test used for studying the relationship between variables, the sensitivity, specificity, and diagnostic accuracy of HSG and TV-SH were calculated by com­paring the results of each of the methods with those obtained by laparoscopy, the gold standard. The 95% CI for all parameters was also calculated.

This study comprised 200 infertile cases arranged in 2 groups. The mean age was 27.6± 4.25 years for group 1 and 29.8±4.1 years for group 2.The mean duration of infertility was 4.6±2.1 years for group 1 and 5.2±1.9 years for group 2.There were no significant differences between both groups and between the women of the two centers, regarding the means of ages and durations of infertility. 

 shows the HSG, TV-SH and laparoscopic findings in the studied cases. there was no significant difference between both groups. On comparing the HSG findings with TV-SH and laparoscopic findings, there were no significant differences between the 3 methods of investigations. The total compatibility between the laparoscopic and HSG findings was 87%,and between the laparoscopic and TV-SH findings was 94.1%,the differences were statistically insignificant. In cases with bilateral tubal block, compatibility was 87.1%,and incompatibility was 12.9% and in cases with unilateral tubal block,87.5% were compatible and 12.5% were incompatible, and the compatibility in bilateral tubal patency were 86.5% and incompatibility were 14.5%.

 represent the sensitivity, specificity and diagnostic accuracy of HSG and TV-SH according to the site of obstruction. The sensitivity, specificity and diagnostic accuracy of TV-SH were insignificantly higher than that of HSG.

Distribution of the 400 tubes studied according to the site of obstruction and to the presence or absence of hydrosalpingx , there were no significant differences between the 3 methods of investigations (

  shows the findings of HSG, Laparoscopy and TV-SH in the diagnosis of peritubal adhesions and polycystic ovaries (PCO). TV-SH gave similar results as laparoscopy in diagnosing PCO and did not detect the peritubal adhesions as HSG and laparoscopy.

 shows the sensitivity, specificity, and diagnostic accuracy of HSG and TV-SH according to the site of obstruction and the presences or absences of hydrosalpingx. There was no significant difference between the sensitivity of two methods except in diagnosing cornual block (P<0.05).Also there were no significant differences between the specificity and diagnostic accuracy of the two methods.

Ultrasonic evaluation of the fallopian tubes presents one of the greatest challenges for the sonographer.

 Hysterosalpingography is still an important diagnostic procedure to evaluate fallopian tube patency

. Hysterosalpingography allows documentation of tubal patency, enables detection of several tubal lesions and permits assessments of the fine intratubal architectural details, especially when an aqueous contrast medium is used

In the present study the HSG findings showed that the incidence of tubal block in primary infertility was 50% and in secondary infertility was 60%.These results were in agreement with the previous studies

 reported that HSG and laparoscopy were compatible in diagnosis of intratubal and distal tubal occlusion. The present study was in agreement with the previous studies

, regarding, the HSG findings confirmed by laparoscopy and revealed that the compatibility was found in 87% of cases while incompatibility was found in 13% of cases studied. On the other hand low figures for compatibility between the HSG and laparoscopy were reported by other investigators

In the present study the comparison between TV-SH results and the laparoscopic results show no significant difference between the two procedures. The compatibility of TV-SH for diagnosis of tubal patency or block was 94.1% when compared with laparoscopy.

The present study was in agreement with the results of previous studies by 

, who reported more than 90% compatibility between TV-SH and laparoscopy.

 reported that 88.7% of the cases of TV-SH were compatible when compared with that of laparoscopy. However Mitri et al in (1 991)

 reported only 72% compatibility. The present study was disagreement with the previous study due to the difference in technique and amount of injected saline. In the present study, the sensitivity, specificity and the diagnostic accuracy of TV-SH were insignificantly higher than that of HSG when both methods were compared. These results were in agreement with the previous studies

. Regarding the site of tubal obstruction and the presence or absence of hydrosalpingx, the 400 tubes were distributed in 5 groups: cornual block, midsegment block, fimbrial block, hydrosalpingx or patent tubes (table 3).

Comparing the results of TV-SH or HSG with that of laparoscopy revealed insignificant differences. TV-SH gave similar results with laparoscopy in diagnosing PCO and did not detect the peritubal adhesions as HSG and laparoscopy. these findings was in agreement with the result of previous study reported by 

reported in their studies similar conclusion regarding the accuracy of TV-SH in diagnosing the site of tubal obstruction. Mitri et al (1991)

 concluded that TV-SH is a simple technique and should replace the use of HSG. The disadvantage of the procedure is that it cannot demonstrate with accuracy the proximal part of the tube especially the cornual area. However Balen et al (1993)

 reported that TV-SH compared with HSG was insufficiently accurate in determining tubal pathology and it could not replace conventional HSG.

TV-SH is a simple procedure, it does not involve radiation exposure, it could be added to the usual conventional procedures to assess tubal patency as a new, easy and safe method and can be performed as an outpatient procedure in the routine infertility clinic.

Table 1: HSG, Laparoscopic and TV-SH Findings.         NO(%)

Table 2: Sensitivity, Specificity & Diagnostic         accuracy according to site of obstruction

Author | Peter Slamka, MD

Articles

Transvaginal Ultrasonography, Sonohysterography, Hysterosalpingography And Operative Hysteroscopy

Transvaginal Sonohysterography (Tv-Sh), Versus Hysterosalpingography (Hsg) And Laparoscopy