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AJR 2002; 178:129-133
© American Roentgen Ray Society

False-Normal Appearance of the Endometrium on Conventional Transvaginal Sonography

Comparison with Saline Hysterosonography

Sherelle Laifer-Narin1, Nagesh Ragavendra1, Evelyn K. Parmenter1 and Edward G. Grant1,2

1 Department of Radiological Health Sciences, UCLA School of Medicine, 10833 LeConte Ave., Los Angeles, CA 90095.
2 Present address: Department of Radiology, West Los Angeles Veterans Administration Medical Center, 11301 Wilshire Blvd., Los Angeles, CA 90073.

Received February 21, 2001; accepted after revision July 16, 2001.

 
Address correspondence to S. Laifer-Narin.


Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
OBJECTIVE. The objective of this article is to assess the utility of transvaginal saline hysterosonography in patients presenting with a normal-appearing endometrium on conventional transvaginal pelvic sonography.

MATERIALS AND METHODS. Between August 1997 and October 1999, 180 patients underwent saline hysterosonography for abnormal vaginal bleeding. All patients had conventional transvaginal pelvic sonography before saline hysterosonography. On conventional transvaginal sonography, the sonographic appearance of the endometrium was classified according to the following parameters: normal or abnormal thickness, homogeneous or heterogeneous echogenicity, bulbous contour, discontinuous, or obscured. A comparison was performed between the endometrial appearance on conventional transvaginal sonography with that of the uterine cavity on saline hysterosonography.

RESULTS. Saline hysterosonography showed abnormalities in 114 patients. Polyps were identified in 53 patients, submucosal leiomyomas in 37 patients, uterine anomalies in two patients, a uterine anomaly and a submucosal leiomyoma in one patient, uterine synechiae in three patients, a synechia and a polyp in one patient, thick endometrial walls in six patients, nondistensible cavities in two patients, and polyps and submucosal leiomyomas in nine patients. Sixteen (14%) of 114 patients showed abnormalities (polyps and submucosal leiomyomas) on saline hysterosonography despite normal-appearing endometria on conventional transvaginal sonography.

CONCLUSION. 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.


Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Abnormal vaginal bleeding is the most common reason for women to undergo an interventional gynecologic procedure [1]. In the past 10 years, the treatment of dysfunctional uterine bleeding has evolved considerably. Although dilatation and curettage was once the procedure of choice, hysteroscopy has proved to be a more reliable method in evaluating the endometrium [2], and many cases that were considered dysfunctional are now known to have harbored previously unidentified lesions as a cause for the vaginal bleeding. As sonography has proved to be a safe and noninvasive method for evaluating the endometrial cavity, transvaginal sonography has become the accepted technique for depicting and differentiating normal from abnormal endometrium. Saline hysterosonography offers another, possibly more definitive, noninvasive method for evaluating the abnormal or obscured endometrium but has generally been used to further define abnormalities found on the conventional transvaginal scan.

Numerous articles have appeared in the literature comparing sonography or sonohysterography with diagnostic hysteroscopy in patients presenting with abnormal vaginal bleeding [1,2,3,4,5]. In all studies, normal thickness parameters were used in evaluating endometrial thickness, and below certain threshold values, the standard transvaginal sonogram was considered to show normal findings. The goal was to differentiate women with functional disorders [4, 5] from patients with anatomic lesions necessitating surgery. In four studies, it was reported that small polyps [1, 2, 6] and submucosal leiomyomas [3] were missed on transvaginal sonography and detected on hysterosonography or hysteroscopy. The purpose of this study is to assess the utility of transvaginal saline hysterosonography in patients presenting with an apparently normal appearing endometrium on conventional transvaginal pelvic sonography.


Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
The radiology information system was reviewed to identify all patients who underwent saline hysterosonography for abnormal vaginal bleeding between August 1997 and October 1999. All patients had conventional transvaginal pelvic sonography before saline hysterosonography. All patients were examined on an HDI 3000 (Advanced Technology Laboratories, Bothell, WA) with an intracavitary C8-4 transducer. These studies had to be performed within 48 hr of each other. Saline hysterosonography was attempted during days 6-14 of the menstrual cycle; however, the stage of the menstrual cycle was not always known to the patients who were experiencing ongoing abnormal vaginal bleeding. Despite a normal-appearing endometrium in some patients, saline hysterosonography was performed because of a history of abnormal vaginal bleeding. Conventional transvaginal sonography was performed by an experienced technologist and reviewed by the attending radiologist before undertaking the saline hysterosonography. Standard images obtained included a midline sagittal image of the uterus, parasagittal images through the right and left uterine body, and coronal images showing the superior, mid, and inferior portions of the uterus. Attending radiologists did not perform the conventional transvaginal sonography.

Saline hysterosonography was performed according to the following protocol: the patient was placed in the lithotomy position, a speculum was inserted into the vaginal introitus, the cervical os was localized and cleansed with povidone-iodine 10% solution (Betadine; Purdue Frederick, Norwalk, CT), and a 5- or 7-French hysterosalpingogram catheter (Ackrad Laboratories, Cranford, NJ), in which both the main port and the balloon port had been flushed and connected to syringes filled with saline, was inserted through the cervical os into the lower uterine segment. The catheter was anchored in place in the lower uterine segment by dilatation of the catheter balloon tip with 1-2 mL of saline. The speculum was removed and the transvaginal probe was inserted. Sterile saline (10-75 mL) was infused into the uterine cavity with simultaneous sonographic scanning of the uterus.

Normal thickness parameters for measuring the endometrium were set as follows: less than or equal to 14 mm full wall thickness in a premenopausal patient; less than or equal to 8 mm full wall thickness in a postmenopausal patient on hormone replacement therapy; and less than or equal to 5 mm full wall thickness in a postmenopausal patient not on hormone replacement therapy [7,8,9,10,11,12]. A comparison was performed between the endometrial appearance on conventional transvaginal sonography with that of the uterine cavity on saline hysterosonography.

Saline hysterosonography was considered the gold standard for this study. All saline hysterosonography reports were reviewed, and cases were divided into normal and abnormal groups. Patients with saline hysterosonograms that showed normal findings were eliminated from further consideration. Those with abnormalities found on saline hysterosonography comprised our study population. In this group, sonography reports were reviewed, and based on the results, patients were subdivided into two groups: those with normal findings on conventional sonograms and those with abnormal findings on conventional sonograms. Images from the former (normal findings on conventional sonogram, abnormal findings on saline hysterosonogram) group were rereviewed by two experienced sonologists. Cases in which there was a disagreement or a subtle abnormality were eliminated. The remaining cases were used for statistical calculation.


Results
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 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
One hundred eighty patients (age range, 16-68 years) who fit the inclusion criteria outlined previously underwent transvaginal pelvic sonography and saline hysterosonography. Of 180 patients, 151 (84%) were premenopausal and 29 (16%) were postmenopausal. Of 180 patients, 66 (37%) had normal findings on a saline hysterosonogram and 114 (63%) showed abnormalities on saline hysterosonography. Using established saline hysterosonographic criteria as described by Laifer-Narin et al. [13] and Dubinsky et al. [14], polyps were identified in 54 patients, submucosal leiomyomas in 38 patients, three uterine anomalies (one with a submucosal leiomyoma), four uterine synechiae (one with a polyp), thick endometrial walls in six patients, nondistensible uterine cavities in two patients, and polyps and submucosal leiomyomas in nine patients.

Of the 114 patients who showed abnormalities on saline hysterosonography, 23 had normal conventional sonography reports. Of the 23 patients with normal results on conventional sonography reports, although the maximal acceptable endometrial thickness in a premenopausal patient was set at 14 mm in our laboratory, the endometrial thickness ranged from 4 mm to a maximum of 10 mm. Seven of 23 patients were excluded because a subtle abnormality was identified on retrospective review of the conventional sonogram. Sixteen (14%) of 114 patients showed abnormalities (polyps and submucosal leiomyomas) on saline hysterosonography despite normal-appearing endometria on conventional transvaginal sonography. Thirteen patients had polyps (Figs. 1A,1B,2A,2B,3A,3B,3C), one patient had a submucosal leiomyoma, and two patients had both polyps and submucosal leiomyomas (Fig. 4A,4B,4C). Thirteen (81%) of 16 patients were premenopausal and three (19%) were postmenopausal. Polyps ranged in size from a maximum of 4 mm to 2 cm in greatest diameter. These masses were shorter in the other two dimensions and may therefore have been unrecognized on conventional transvaginal sonography resulting from a compression of the mass and resultant flattening, with conformation to the shape of the endometrial cavity. In the three patients with submucosal leiomyomas, maximal submucosal extension was 5 mm.



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  		Fig. 1A. —Endometrial polyp in 55-year-old woman on hormone replacement therapy. Sagittal sonogram of uterus shows normal full wall endometrial thickness (cursors) of 5 mm.

 


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  		Fig. 1B. —Endometrial polyp in 55-year-old woman on hormone replacement therapy. Sonogram obtained after saline infusion shows homogenous echogenic mass (arrows) in endometrial canal.

 


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  		Fig. 2A. —Endometrial polyp in 34-year-old woman. Sagittal sonogram of uterus shows normal-appearing endometrium (straight arrows) measuring 8 mm and posterior uterine leiomyoma (curved arrows).

 


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  		Fig. 2B. —Endometrial polyp in 34-year-old woman. Sonogram obtained after saline infusion shows homogeneous echogenic mass (arrows) in endometrial cavity, and no submucosal involvement by posterior uterine leiomyoma is present.

 


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  		Fig. 3A. —Endometrial polyp in 36-year-old woman with retroverted uterus. Sagittal sonogram of uterus shows distal endometrium (cursors) to be normal in appearance measuring 4.5 mm. Note large intramural fibroid (arrows) with possibility of submucosal extension.

 


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  		Fig. 3B. —Endometrial polyp in 36-year-old woman with retroverted uterus. Sagittal sonogram of retroverted uterus after saline infusion shows homogeneous echogenic mass (arrows) in fundal portion of uterine cavity.

 


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  		Fig. 3C. —Endometrial polyp in 36-year-old woman with retroverted uterus. Sagittal sonogram obtained after withdrawal of hysterosonogram catheter shows no submucosal involvement by large intramural leiomyoma.

 


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  		Fig. 4A. —Endometrial polyp and submucosal leiomyoma in 43-year-old woman. Sagittal sonogram of uterus shows normal-appearing endometrium (cursors) measuring 4.4 mm and slight heterogeneity of posterior myometrium.

 


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  		Fig. 4B. —Endometrial polyp and submucosal leiomyoma in 43-year-old woman. Sagittal sonogram obtained after saline infusion shows small round echogenic mass (arrows) identified in endometrial cavity, consistent with polyp.

 


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  		Fig. 4C. —Endometrial polyp and submucosal leiomyoma in 43-year-old woman. Sagittal sonogram also shows submucosal leiomyomas (arrows) involving posterior endometrial wall and fundal uterine cavity.

 


Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Abnormal vaginal bleeding is a common presenting complaint in both pre- and postmenopausal women, and its management differs according to the presence or absence of identifiable uterine abnormalities. Although numerous articles in the literature point to using conventional transvaginal pelvic sonography as a screening procedure for triage patients who require further diagnostic evaluation [2, 4], our study suggests that a considerable number of patients with treatable abnormalities may be inadvertently directed away from further evaluations on the basis of normal-appearing endometrium on conventional transvaginal sonography.

In a study using saline hysterosonography to evaluate postmenopausal women before the initiation of hormone replacement therapy, Cohen et al. [15] discovered intracavitary abnormalities in 37% of patients with an endometrial thickness of less than or equal to 5 mm and concluded that an endometrial thickness of less than or equal to 5 mm excludes hyperplasia but does not eliminate other intrauterine abnormalities. They suggested that saline hysterosonography might be useful in identifying women with existing intrauterine abnormalities who may be at increased risk for developing abnormal vaginal bleeding with the initiation of hormone replacement therapy. Dijkhuizen et al. [6] report four cases in which the endometrium measured within normal limits, but hysteroscopy revealed polyps and these researchers concluded that transvaginal sonography is of limited use in premenopausal women with irregular bleeding. Transvaginal sonography accurately diagnosed endometrial hyperplasia; however, four (14.8%) of 27 patients in this study with endometrial polyps would have been missed using this technique alone. This finding reflects the percentage of patients in our study who showed abnormalities on saline hysterosonography with apparently normal findings on conventional transvaginal sonograms.

Other studies [3, 5] have discussed the ability of saline hysterosonography to visualize small masses not identified on conventional transvaginal sonography. Bernard et al. [5] advocate saline hysterosonography as a first-line investigation for patients with abnormal vaginal bleeding. They report a sensitivity and specificity of 98.9% and 76.4%, respectively, for the detection of uterine abnormalities using saline hysterosonography, with lesions as small as 3 mm in diameter being detected. Additionally, although the sensitivity rate for the detection of endometrial cancer was 40% (2/5 patients), sufficient abnormality was present on saline hysterosonography to warrant further evaluation, and no cancer was missed. In a comparison with saline hysterosonography and hysteroscopy, Schwarzler et al. [3] found the diagnostic accuracy of saline hysterosonography to approach that of diagnostic hysteroscopy. Moreover, additional information was obtained regarding the precise location of polyps and leiomyomas and the approximate intracavitary projection of leiomyomas.

Numerous published studies have set normal endometrial thickness measurements in both pre- and postmenopausal women [7,8,9,10,11,12]. Furthermore, studies have correlated sonography with findings on hysterosonography and hysteroscopy; however, these studies have been conducted mainly in peri- and postmenopausal women in which normal endometrial values are thin (<=5 mm). Our study population consisted of greater than 80% premenopausal patients. Because established parameters for normal endometrial thickness in the premenopausal patient are greater than in the postmenopausal patient, masses may be more difficult to define, and more lesions may be missed in the premenopausal patient than in the postmenopausal patient. Indeed, it has been shown that intracavitary abnormalities are prevalent in a substantial percentage of asymptomatic peri- and post-menopausal women and not revealed by the conventional transvaginal sonogram [15].

Goldstein et al. [4] stress the importance of viewing the uterus and endometrial cavity as a three-dimensional (3D) structure, and that failure to mentally re-create the three-dimensional anatomy may result in error. Although this is true, in our study, despite careful sonographic imaging by experienced technologists, attempts to perform saline hysterosonography during days 6-14 of the menstrual cycle, adherence to established cutoff values for normal endometrial thickness [7,8,9,10,11,12], and reliance on conventional transvaginal sonography would have considered 16 (14%) of 114 patients to have normal findings on sonography with a lack of considerable abnormality. Despite a retrospective review of the images with knowledge that an abnormality was present on saline hysterosonography, we failed to elucidate abnormalities in these patients. This group of patients would have been considered to have dysfunctional uterine bleeding, and further investigation for an intracavitary mass would not have been warranted.

The question has been raised about the clinical significance of these small lesions, which were missed on conventional transvaginal sonography. In our institution, masses were believed to be clinically significant if present in patients who were experiencing abnormal vaginal bleeding, despite the small size of the masses.

A potential question raised by our study is whether there might be an effect on results by performing a retrospective review of transvaginal sonography performed by a technologist and reviewed by a radiologist. Despite the fact that our technologists were experienced in the performance of transvaginal sonography, there is the possibility that closer prospective scrutiny (by a sonographer or sonologist) might improve results. Previous work by Tessler et al. [16] showed that, indeed, direct physician involvement in abdominal scanning showed abnormalities missed in a considerable number of scans obtained by technologists. The inherent scrutiny of a prospective study would likely produce closer evaluation of the endometrium and possibly improve results. Our retrospective analysis, however, approximates the scanning routine that occurs in most facilities, and we were conservative in that we eliminated any scan in which a possible abnormality was seen retrospectively. However, it is possible that images submitted by the technologist on the standard examination might not have been obtained from the region of abnormality because images are two-dimensional pictures of a three-dimensional structure.

Saline hysterosonography, hysteroscopy, and dilatation and curettage are invasive procedures that are more expensive than transvaginal sonography and have associated risks. Although we would like to identify patients who do not require further intervention and provide them with the cheapest and least invasive technique, it appears that findings on conventional transvaginal sonography may be subtle and difficult to diagnose in the average clinical setting. Conventional transvaginal pelvic sonography may not be a screening procedure of sufficient diagnostic value in the symptomatic patient with abnormal vaginal bleeding, and diagnostic evaluation with a saline hysterosonography may be warranted as a first-line study.


References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Bronz L, Suter T, Rusca T. The value of transvaginal sonography with and without saline instillation in the diagnosis of uterine pathology in pre- and postmenopausal women with abnormal bleeding or suspect sonographic findings. Ultrasound Obstet Gynecol 1997;9:53 -58[Medline]
  2. Emanuel MH, Verdel MJ, Wamsteker K, Lammes FB. A prospective comparison of transvaginal ultrasonography and diagnostic hysteroscopy in the evaluation of patients with abnormal uterine bleeding: clinical implications. Am J Obstet Gynecol 1995;172:547 -552[Medline]
  3. Schwarzler P, Concin H, Bosch H, et al. An evaluation of sonohysterography and diagnostic hysteroscopy for the assessment of intrauterine pathology. Ultrasound Obstet Gynecol 1998;11:337 -342[Medline]
  4. 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[Medline]
  5. Bernard JP, Lecuru F, Darles C, Robin F, de Bievre P, Taurelle R. Saline contrast sonohysterography as first-line investigation for women with uterine bleeding. Ultrasound Obstet Gynecol 1997;10:121 -125[Medline]
  6. Dijkhuizen FP, Brolmann HA, Potters AE, Bongers MY, Heinz AP. The accuracy of transvaginal ultrasonography in the diagnosis of endometrial abnormalities. Obstet Gynecol 1996;87:345 -349[Abstract]
  7. Goldstein SR, Nachtigall M, Snyder JR, Nachtigall L. Endometrial assessment by vaginal ultrasonography before endometrial sampling in patients with postmenopausal bleeding. Am J Obstet Gynecol 1990;163:119 -123[Medline]
  8. Granberg S, Wikland M, Karlsson B, Norstrom A, Friberg LG. Endometrial thickness as measured by endovaginal ultrasonography for identifying endometrial abnormality. Am J Obstet Gynecol 1991;164:47 -52[Medline]
  9. Karlsson B, Granberg S, Wikland M, et al. Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding: a Nordic multicenter study. Am J Obstet Gynecol 1995;172:1488 -1494[Medline]
  10. Levine D, Gosin BB, Johnson LA. Change in endometrial thickness in postmenopausal women undergoing hormone replacement therapy. Radiology 1995;197:603 -608[Abstract/Free Full Text]
  11. Lin MC, Gosink BB, Wolf SI, et al. Endometrial thickness after menopause: effect of hormone replacement. Radiology 1991;180:427 -432[Abstract/Free Full Text]
  12. Nasri MN, Shepherd JH, Setchell ME, Lowe DG, Chard T. The role of vaginal scan in measurement of endometrial thickness in postmenopausal women. Br J Obstet Gynaecol 1991;98:470 -475[Medline]
  13. Laifer-Narin SL, Ragavendra N, Lu DS, Sayre J, Perrella RR, Grant EG. Transvaginal saline hysterosonography: characteristics distinguishing malignant and various benign conditions. AJR 1999;172:1513 -1520[Abstract/Free Full Text]
  14. Dubinsky TJ, Stroehlein K, Abu-Ghazzeh Y, Parvey HR, Maklad N. Prediction of benign and malignant endometrial disease: hysterosonographic-pathologic correlation. Radiology 1999;210:393 -397[Abstract/Free Full Text]
  15. Cohen MA, Sauer MV, Keltz M, Lindheim SR. Utilizing routine sonohysterography to detect intrauterine pathology before initiating hormone replacement therapy. Menopause 1999;6:68 -70[Medline]
  16. Tessler FN, Tublin ME, Peters JC, Jie T, Peters TL. Value of selective second-look sonography by radiologists. Radiology 1996;199:551 -553[Abstract/Free Full Text]

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