Dr. A.Tabatabai

1. Dr. A.Tabatabai Sonohysterographyin abnormal uterine bleeding

2. 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.

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

4. 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.

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

6. The Thickened endometrium may be a polyp catheter

7. The Thickened endometrium may be a polyp CYST POLYP With polyps the endometrial-myometrialinterface is preserved well-defined, homogeneous, isoechoic to the endometrium

8. The Thickened endometrium may be a polyp endometrium

9. The Thickened endometrium may be a Submucosal leiomyomas With myomas the endometrial-myometrialinterface is distorted broad-based, hypoechoic,

10. sonohysterography can accurately depict the percentage of the fibroid that projectsinto the endometrial cavity

11. The Thickened endometrium may be an endometrial hyperplasia Endometrium thickness = A-B A B diffuse thickening of the echogenic endometrial stripewithout focal abnormality

12. The Thickened endometrium may be a Secretory endometrium + +

13. Endometrial cancer Endometrial cancer is typically a diffuse process,but early cases can appear as a polypoid mass

14. sonohysterography, allows identification of intracavitary lesions and focalor diffuse endometrial abnormalities and helps determine whetheran abnormality is endometrial or subendometrial.

15. At transvaginalUS, when the endometrium cannot be accurately measured or whenthere is a nonspecific thickened central endometrial complex,sonohysterography can provide additional information and can be used to directthe patient to a visually guided hysteroscopic procedure ratherthan a potentially unsuccessful blind biopsy procedure.

16. New Zealand Guidelines Group Transvaginal ultrasound and transvaginal sonohysterogram are both more accurate in diagnosing the location of fibroids than hysteroscopy [A].

17. SIS low-tech low-cost Well tolerable no radiation exposure Effective

18. Adverse Events • Discomfort • Cramping( minor ) 33.3% Laughhead&stones • Pain (menstrual like ) (sever pain ) 11.5% Cecinilli et al • Infection 2.5%Dubinsky et al

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

20. 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)

21. Effectiveness Author Year n Sensitivity % Specificity % Bonilla-Musoles 1992 96 96 97 Syrop 1993 14 100 100 Parsons 1993 58 100 94 Widrich 1995 130 96 100 Wolman 1996 47 96 100 Keltz 1997 34 100 100 Bernard 1997 109 99 76 Schwarzler 1998 104 87 91 Williams 1998 39 100 85 Dijkhuizen 2000 50 100 85

22. Effectiveness It benefits clinical decision making, as up to 40% of patients will avoid diagnostic hysteroscopy.

23. How it works

24. How it works onlypreparation necessary was for the patient to empty the bladder.

25. A speculum, is used to exposethe cervix, which was then cleansed with an iodine swab

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

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

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

29. 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 theendocervical canal. The speculum was then carefully removedwhile the catheter was left in place.

30. the covered transvaginalprobe was inserted into the vagina, and continuous scanningin the Sagittal and coronal or transverse planes was performedduring instillation of sterile saline solution. only 2–5 mLare actually needed to distend the cavity adequately

31. Cervicalleakage is common, and it is helpful to have two 20-mL syringesof saline solution available for the procedure.

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

34. Take home SIS delineates masses or defects in the uterine cavity.

35. Take home SIS distinguishes between focal lesions and global endometrial thickening.

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

37. 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.

38. 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.

39. 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.

40. 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, 1997;16(9):587-591.

41. 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

42. 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

43. 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

44. Thank you