Sonohysterography

1. Mahmoud meleis MD
SONOHYSTEROGR
APHY
IN ABNORMAL
UTERINE BLEEDING

2. Using sterile saline solution as a
negative contrast medium in
conjunction with traditional TVUS.
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. Abd/ TV US can identify myomas &endometrial
morphology but is unable to differentiate between
the potential etiologies of thichened end. As:
polyps, submucous myomas and bomogenous
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
Tvu endometrial thichned

6. The Thickened endometrium may be a
polyp
catheter

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

8. The Thickened endometrium may
be a polyp
endometrium

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

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

11. A
B
Endometrium thickness = A-B
diffuse thickening of the echogenic
endometrial stripe without focal
abnormality
The Thickened endometrium may be an
endometrial hyperplasia

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

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

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 when
there is a nonspecific thickened central
endometrial complex,sonohysterography
can provide additional information and can
be used to directto directthe patient to athe patient to a visuallyvisually
guided hysteroscopic procedureguided hysteroscopic procedure
ratherratherthan a potentiallythan a potentially
unsuccessful blind biopsyunsuccessful blind biopsy
procedure.procedure.

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

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

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

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. 85100502000Dijkhuizen
85100391998Williams
91871041998Schwarzler
76991091997Bernard
100100341997Keltz
10096471996Wolman
100961301995Widrich
94100581993Parsons
100100141993Syrop
9796961992Bonilla-Musoles
Specificity %Sensitivity %nYearAuthor

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

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 beVarious catheter types may be
used, includingused, 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 the
endocervical canal.
The speculum was then
carefully removedwhile the
catheter was left in place.

30. the covered transvaginal
probe 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. The most common indication
for SIS is abnormal bleeding
in pre- and postmenopausal
patients.

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

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

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

37. 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. 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. 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. 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. 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. 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. 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