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1
Radiology Department, C.M.C. Beausoleil, 119 Ave. de Lodeve, 34000
Montpellier, France.
2
Radiology Department, Radio A, CHU Dupuytren, 2 Ave., Martin Luther King,
87042, Limoges cedex, France.
3
Radiology Department, Legacy Meridian Park Hospital, 19300 S.W. 65th Ave.,
Tualatin, OR 97062.
Received November 15, 1999;
accepted after revision February 21, 2000.
Address correspondence to A. J. Maubon
Introduction
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Over 2 months, we prospectively studied 10 women in whom an abnormality of the endometrium was suspected. Our patients ranged in age from 36 to 69 years (mean age, 50 ± 11 years); four had peri- or postmenopausal uterine bleeding, four had dysmenorrhea, and two were asymptomatic but had abnormal endometrium findings on sonography. All patients underwent endovaginal sonography followed by MR imaging within 8 days. After the procedure, all patients underwent hysteroscopy or surgery performed by a gynecologist, and pathologic specimens of the endometrium were obtained from all patients. MR imaging hysterographic examinations were then retrospectively compared with the results of sonography and pathologic analysis.
MR imaging was performed on a superconductive 0.5-T magnet (Gyroscan T5NT; Philips, Best, The Netherlands) with a body coil; no endocavitary or surface coils were used. All patients were given broad-spectrum antibiotic prophylaxis 2 days before and 3 days after the procedure.
Before undergoing MR hysterography, patients underwent a pelvic MR imaging examination with T2-weighted fast turbo spin-echo sequences (TR/TE, 1600/100; number of signal averages, six; slices, 15; thickness, 10 mm; slice gap, 10%; 2 min 14 sec) in the sagittal plane and perpendicular to the main axis of the uterus and sagittal T1-weighted MR sequences (535/12; number of signal averages, four; slices, 16; thickness, 10 mm; slice gap, 10%; 2 min 49 sec). Then the patients, who were lying in the supine position on the magnet bed, were positioned out of the magnet, and a cushion was placed under their buttocks to make them comfortable. MR hysterography was performed in the MR imaging suite by a radiologist. After exposing the cervix with a plastic speculum, the radiologist disinfected the cervix and inserted a hysterosalpingography balloon catheter (Soft Seal; Conceptus, San Carlos, CA) into the endocervical canal using an aseptic technique. Ten to 15 mL of saline was gently injected into the uterine cavity with a 20-mL syringe, under visual control to avoid reflux of saline into the vagina. The hysterographic catheter was obturated and left in place so that reinjections could be performed if necessary. The patient was then immediately repositioned in the center of the magnet, and FLAIR sequences were performed in the sagittal plane perpendicular to the main axis of the uterine cavity (8000/300; inversion time, 2000; number of signal averages, four; turbo spin-echo factor, 20; slice thickness, 6 mm; slice gap, 20%; 4 min 56 sec).
MR hysterography, including sequence acquisition, added an average of 19 ± 11 min to the classic pelvic MR imaging examination.
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MR hysterographic images were of diagnostic value in all patients. The quantity of saline visible in the uterine cavity was variable, and some patients had saline depicted in the peritoneum (n = 4). Compared with the T1-weighted MR sequence, a measurable uterine cavity distention (8 ± 4 mm) was noted on the hysterography FLAIR sequences.
The uterine cavity was well depicted in all patients, displaying four layers of anatomy: a very low signal intensity in the cavity (from the saline), high signal intensity in the endometrium, low signal intensity in the junctional zone, and intermediate signal intensity in the myometrium.
Mucous endometrial polyps (n = 4) appeared as high-signal-intensity lesions, projecting into the cavity from the endometrium with no myometrial component. They were conspicuously outlined by saline (Figs. 1A and 1B).
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Adenomyosis (n = 2) had a low signal intensity, appearing as a pseudothickening of the junctional zone (Fig. 1C). Active endometrial invaginations in the myometrium appeared as high-signal-intensity lesions penetrating the low-signal-intensity junctional zone (Fig. 1C).
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Endometrial atrophy (n = 2) appeared as a thinned endometrium without high signal intensity between saline and the junctional zone (Fig. 2A,2B).
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Endometrial hypertrophy (n = 1) appeared as a thickened endometrium, measuring from the attenuated fluid to the junctional zone of the myometrium (>6 mm in the follicular phase) [6].
No complications occurred during or up to 72 hr after the procedure.
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The FLAIR sequence has been thoroughly studied, especially in brain and spine examinations [8, 9]. It is invaluable with its ability to null the signal of fluids, thus increasing contrast between lesions and surrounding normal tissue [10]. Use of FLAIR sequences in everyday practice was made possible by the use of fast MR imaging techniques. We use a fast inversion-recovery turbo spin-echo technique with an echo train length of 20 that dramatically decreases imaging times (4 min 46 sec instead of 16 min). Nevertheless, there is a potential pitfall in this type of sequence because its structure includes a 20% gap between slices; therefore, millimeter-sized lesions may be overlooked. Sequences with no gaps would double imaging times.
MR hysterography could be performed using fast T1-weighted MR sequences and injected gadolinium, which would be bright relative to the endometrium. The use of gadolinium-containing contrast materials has been tested with MR hysterosalpingography in rabbits to assess tubal patency [11]. However, the myometrium and junctional zone are not well depicted on T1-weighted MR images. Also, gadolinium is expensive and has not been approved for injection into the female reproductive tract. Saline solution has been used extensively for hysterosonography without complications [4].
Relative to radiographic hysterosalpingography and sonohysterography, MR hysterography is potentially limited by a lack of real-time imaging and a delay between injection and the start of imaging; however, rapid scan times decrease the delay. MR imaging is superior to other imaging methods in its depiction of the endometrium relative to the junctional zone and myometrium, and we predict that in some patients this technique will be beneficial. Presumably, most patients with infertility will still undergo radiographic hysterosalpingography initially, and most patients with abnormal uterine bleeding will undergo hysterosonography as a first-line diagnostic tool.
In conclusion, MR hysterography with FLAIR sequences is a promising technique that enhances the depiction of pathologic processes affecting the uterus. It could be considered in the armamentarium of women's imaging centers. Further studies (specifically prospective comparative studies with hysterosonography) and results from other centers are warranted. The association of saline injection and MR imaging with FLAIR sequences could be contemplated in other body parts involving a virtual cavity or anatomic space.
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