Original Research
Women's Imaging
April 2008

Sonohysterography: Do 3D Reconstructed Images Provide Additional Value?


OBJECTIVE. The purpose of this study was to retrospectively determine the value of adding 3D multiplanar sonography to 2D sonohysterography.
MATERIALS AND METHODS. Between September 2003 and April 2005, 80 women (mean age, 43.5 years; range, 26–78 years) underwent sonohysterography with both conventional 2D sonohysterography and 3D multiplanar imaging (volume of data acquired and reconstructed in the transverse, sagittal, and coronal planes). Three blinded readers interpreted the 2D scans alone and then the 2D and 3D images together. Visualization of endometrial abnormality (polyps, fibroids, or septations) and definition of fundal contour were scored by each reader on a three-point scale (1, visualized; 2, unsure; 3, not visualized). Wilcoxon's signed rank test was used to assess mean differences between findings. Reader agreement was determined with the kappa statistic. Pathologic correlation was performed when the findings were available.
RESULTS. Average (mean ± SD) reader scores for identification of endometrial abnormality were not significantly different: 1.70 ± 0.91 for 2D alone versus 1.69 ± 0.92 for 2D and 3D combined (p = 0.38). There also was no significant difference when polyps (2.14 ± 0.90 vs 2.12 ± 0.93), fibroids (2.57 ± 0.79 vs 2.53 ± 0.82), and septations (2.88 ± 0.39 vs 2.87 ± 0.42) were evaluated separately. Average scores for definition of fundal contour were significantly (p < 0.0001) different (2.93 ± 0.34 for 2D alone versus 1.45 ± 0.80 for 2D and 3D combined). Agreement between readers was found with average kappa values of 0.72 for 2D alone and 0.78 for 2D and 3D. For the 42 subjects for whom pathologic findings were available, readers identified 92% of the abnormalities.
CONCLUSION. Three-dimensional reformations improve visualization of the uterine fundus and aid in identification or exclusion of a fundal contour abnormality but do not add value in the detection of endometrial abnormalities.


Conventional 2D saline infusion sonohysterography (SIS) is the accepted diagnostic procedure for evaluation of abnormal uterine bleeding. SIS is less invasive, less expensive, and more comfortable for the patient than are traditional methods of diagnosis, such as dilation and curettage and hysteroscopy [14], and is as accurate as hysteroscopy for detection of intracavitary abnormalities [2, 5, 6]. For detection of endometrial abnormalities, SIS has had higher sensitivity (83–88%) than pelvic MRI (76%) and transvaginal sonography (60–69%) [2, 6, 79].
Three-dimensional sonographic technology has become more widely available in clinical practice. This technology entails acquisition of a volume of data and rapid reconstruction of images in the transverse, sagittal, and coronal planes. Three-dimensional sonography technology to date has been used for obstetric and gynecologic disease, but studies [1014] have shown that 3D combined with conventional 2D sonography enhances characterization of fetal facial and skeletal anomalies and improves evaluation of adnexal lesions. In addition, 3D multiplanar surface-rendered views may yield important information to assist in the diagnosis or exclusion of congenital uterine anomalies [1517]. Combined with conventional 2D SIS, 3D technology facilitates retrospective review of both the uterine contour and the fluid-filled endometrial cavity in any plane [18]. Findings with the combination of 3D sonographic technology with 2D SIS have had excellent correlation with those of hysteroscopy in the diagnosis of congenital uterine anomalies such as septate and bicornuate uterus [1517]. However, the clinical relevance of 3D sonography as an adjunct to 2D SIS in the detection of endometrial abnormalities remains controversial [8, 1822]. The purpose of our study was to retrospectively evaluate the value of addition of 3D reformatted images to conventional 2D SIS in examinations of patients referred because of abnormal uterine bleeding or infertility.

Materials and Methods


This retrospective study was approved by our institutional review board, and informed consent was waived. From September 1, 2003, to April 15, 2005, 122 women underwent SIS at our institution. Conventional transabdominal and transvaginal sono graphy was required for all patients within 6 months of the scheduled SIS procedure to determine orientation of the cervix and uterus and to evaluate the adnexa. All premenopausal patients were scheduled for SIS during the follicular phase of the menstrual cycle, and a negative result of a urine pregnancy test was required of all premenopausal patients before the procedure.
Imaging and interpretation were performed by one radiologist or by one of a group of four specialists in obstetrics and gynecology. Indications for referral included abnormal uterine bleeding, infertility, and recurrent abortion. Static sono graphic images from these studies were retrospectively reviewed by one author to determine whether both 2D and 3D sonography had been performed. Of the original 122 patients, 80 pa tients (mean age, 43.5 years; range, 26–78 years) had both 2D and 3D images (sagittal, transverse, and coronal reformatted images) for comparison and were included in the study.

Scanning Procedure

The SIS protocol was as follows. A speculum was placed in the vaginal canal, and the cervical canal was identified and prepared with 4% chlorhexidine gluconate solution (Scrubcare, Exidine). A 5-French flexible catheter was introduced into the cervical canal, and a balloon at the catheter tip was inflated in the lower uterine segment. The speculum was removed, and a vaginal probe was placed. Under sonographic guidance, the balloon was pulled back slightly to occlude the cervical canal. Sterile normal saline solution (5–10 mL) was slowly introduced in the retrograde direction, just enough to distend the endometrial canal. Endovaginal imaging was performed with both transverse and sagittal imaging, and the resulting static images were recorded on a magnetooptical disk. An additional 5–10 mL of sterile normal saline solution was sometimes required before 3D volume acquisition.
When optimal distention of the endometrial canal was achieved, an adequately sized volume region-of-interest box was selected, and volume mode was activated. A volume sweep was performed with the automated transducer in the sagittal plane, and a second sweep was made in the transverse plane. All volume data were stored on a magnetooptical disk. Images in the three orthogonal planes (sagittal, transverse, and reformatted coronal) were later reviewed. Both 2D and 3D endovaginal images were acquired with a dedicated vaginal probe (RIC 5-9H, Voluson Expert 730, GE Healthcare).

Scan Evaluation

Static sonographic images of all subjects were loaded in an anonymously coded format onto a workstation (HP Compaq DWS-220, McKesson Inform ation Systems) for review. All patient identifiers were masked. A panel of three independent subspecialists, one in women's imaging, one in abdominal imaging, and one in obstetrics and gynecology, with 1–11 years of experience in pelvic sonography reviewed the 2D images and immediately compared 2D and 3D images of the same subject. Readers were blinded to the final outcome. Readers interpreted the 2D images followed by the combined 2D and 3D images for visualization and characterization of endometrial abnormalities such as polyps, fibroids, and septations and for definition of the uterine fundal contour. Each finding was marked as yes (visualized), unsure, or no (not visualized) by each reader on a data sheet. Readers then subjectively determined whether 3D images contained information additional to that on the 2D images for identification of an endometrial cavity abnormality or a uterine contour anomaly and for exclusion of uterine contour abnormalities. These responses also were marked yes, unsure, or no on a data sheet. For data entry, each yes, unsure, and no response was assigned a score of 1, 2, or 3, respectively, and entered into a computerized spread sheet for data analysis.

Statistical Analysis

Statistical analysis was performed with SAS software (version 8.2, SAS Institute). For detection of endometrial abnormality and for definition of fundal contour for both 2D and combined 2D and 3D scans, the average scores for responses from the three readers were determined. The probability comparisons of the average scores were calculated with Wilcoxon's signed rank test. A value of p < 0.05 indicated a statistically significant difference. Agreement between readers on the pre sence of endometrial abnormality or the diagnosis of a uterine contour abnormality for 2D and combined 2D and 3D imaging was determined with Cohen's weighted kappa coefficient.

Pathologic Correlation

Pathology reports were available for 42 of the 80 patients. Pathologic correlation was determined by review of the subjects' medical records. The available findings reported by pathologists at hysteroscopy, dilatation and curettage, or examination of a hysterectomy specimen were compared with the 2D and 3D SIS findings. Pathologists had no knowledge of the SIS results. The accuracy and positive predictive value for each reader for intracavitary abnormalities were determined.


Diagnosis of Endometrial Cavity Abnormalities and Definition of Fundal Contour

There was no statistically significant difference in average scores between 2D and the combination of 2D and 3D sonohystero g-raphy for identification of any endometrial abnormality (p = 0.38) (Figs. 1A, 1B, and 1C). There also was no significant difference in average reader scores when polyps, fibroids, and septations were evaluated separately (Table 1). Numbers of abnormalities identified by each reader are shown in Table 2. The median scores for fundal contour definition (Figs. 2A and 2B) were 3 for 2D imaging alone (mean, 2.93 ± 0.34) and 1 for the combination of 2D and 3D imaging (mean, 1.45 ± 0.80) with no significant difference between the groups. The numbers for each reader are shown in Table 3.
TABLE 1: Average Scores for Three Readers for Endometrial Cavity Abnormality
Abnormality2D2D + 3D
Any1.70 ± 0.901.69 ± 0.92
Polyps2.14 ± 0.902.12 ± 0.93
Fibroids2.57 ± 0.792.53 ± 0.82
2.88 ± 0.39
2.87 ± 0.42
Note—Scores are mean ± SD (1 = present, 2 = unsure, 3 = absent)
TABLE 2: Reader Identification of Endometrial Cavity Abnormality (n = 80)
Reader2D2D + 3D
145 (56)48 (60)
250 (63)53 (66)
49 (61)
49 (61)
Note—Data are number of patients with percentages in parentheses
TABLE 3: Reader Definition of Fundal Contour (n = 80)
Reader2D2D + 3D
13 (4)50 (63)
21 (1)60 (75)
2 (3)
67 (84)
Note—Data are number of patients with percentages in parentheses

Reader Agreement

In the diagnosis of intracavitary abnormalities, good agreement was found between readers for 2D imaging alone (κ = 0.69–0.74). For 2D and 3D imaging together, the agreement was slightly stronger (κ = 0.74–0.81). The differences, however, were not statistically significant (p = 0.09) (Table 4).
TABLE 4: Reader Agreement for Endometrial Cavity Abnormality
Readers2D2D + 3D
1 and 20.750.80
2 and 30.720.80
1 and 30.690.74
Note—Data are mean kappa value. There was no statistically significant difference (p = 0.10)

Added Value of 3D Imaging

All three readers found that combined 2D with 3D imaging subjectively enhanced confidence in exclusion of congenital uterine anomaly compared with 2D imaging alone but did not enhance confidence in identification of uterine cavity abnormalities (Table 5). There was one exception. In one subject, septum was diagnosed by the three readers, who suspected the septum might have been acquired rather than congenital because of clinical suspicion of Asherman's syndrome, which was later validated at hysteroscopy. In this subject, the readers found enhanced visualization and char acterization of the septum on the coronal re formatted images (Figs. 3A, 3B, and 3C).
TABLE 5: Reader's Subjective Assessment of Added Value of Coronal Scans (n = 80)
ReaderIdentification of Endometrial AbnormalityExclusion of Fundal Abnormality
115 (19)47 (59)
211 (14)58 (73)
310 (13)65 (81)
12 (15)
57 (71)
Note—Data are number of patients with percentages in parentheses except as indicated
Fig. 1A 45-year-old woman who presented with abnormal uterine bleeding. Static 2D transverse saline infusion sonohysterographic image shows homogeneous echogenic mass along posterior fundus (arrows). Findings are consistent with polyp.
Fig. 1B 45-year-old woman who presented with abnormal uterine bleeding. Transverse saline infusion sonohysterographic image of midbody of uterus shows second hypoechoic mass (arrows) along posterior wall with heterogeneous shadowing. Broad-based attachment and echogenicity suggest submucosal fibroid with greater than 50% protrusion into endometrial canal.
Fig. 1C 45-year-old woman who presented with abnormal uterine bleeding. Three-dimensional coronal reformation shows both polyp (arrows) and fibroid (arrowheads) and their relation to each other. All readers were able to identify and characterize both lesions equally with 2D imaging alone and combined 2D and 3D imaging.

Pathologic Correlation

On combined 2D and 3D SIS, readers determined that an average of 24 (30%) of 80 subjects had no evidence of endometrial cavity abnormalities, 48 (60%) had definite abnormalities, and eight (10%) had possible abnormalities (four questionable polyps, four possible septations). In 51 subjects, one or more lesions (polyps, fibroids, or septa) were suspected at initial clinical interpretation of SIS images. Forty-two of these subjects underwent additional intervention, including dilation and curettage, hysteroscopy, and hysterectomy with pathologic analysis. Nine subjects had no additional intervention or pathologic correlation and were lost to follow-up. The three readers interpreting images of the 42 subjects with positive pathologic findings had no statistically significant difference in the accuracy values for the two scanning techniques (p = 0.32) (Table 6). The mean positive predictive value for 2D alone was 0.97 and for combined 2D and 3D was 0.98.
TABLE 6: Accuracy and Positive Predictive Value for Diagnosis of Endometrial Cavity Abnormality (n = 42)
2D2D + 3D
ReaderAccuracyaPositive Predictive ValueAccuracyaPositive Predictive Value
135 (83)0.9738 (90)0.97
239 (93)0.9741 (98)0.98
337 (88)0.9737 (88)1.00
37 (88)
39 (92)
Note—There was no statistically significant difference between the two groups (p = 0.32)
Number of patients with percentages in parentheses
Fig. 2A 35-year-old woman who presented with abnormal uterine bleeding. Static 2D sagittal saline infusion sonohysterographic image shows thin normal endometrium (arrows).
Fig. 2B 35-year-old woman who presented with abnormal uterine bleeding. Three-dimensional coronal reformation shows normal endometrium and defines complete fundal contour (arrows). Readers were more confident is excluding fundal contour abnormality with 3D reformation.


The role of 3D sonography in gynecologic imaging continues to evolve, a number of studies showing potential advantages of 3D technology in clinical practice. For example, Benacerraf et al. [18] determined that storage of rapidly acquired real-time volume data may allow manipulation and review of the data in any plane after the patient has completed the examination, potentially increasing patient throughput and practice efficiency. This application would be useful to radiologists who interpret images acquired by sonographers, residents, and fellows and for review of studies transferred digitally from distant sites. For sonohysterography, Weinraub et al. [19] found that rapid acquisition of 3D volumes and subsequent interpretation of the saved volume data may reduce the amount of time the uterine cavity is distended with saline solution, decreasing patient discomfort.
An important advantage of 3D volume imaging over conventional 2D sonography is the ability to reconstruct images in any of the three orthogonal planes. Jurkovic et al. [17], Nicolini et al. [23], and Pellerito et al. [24] found that although 2D transvaginal sonography performed by experienced practitioners is sensitive for the diagnosis of major uterine anomalies, it also can lead to a large number of false-positive findings and cannot be used to differentiate the most frequently encountered uterine anomalies: arcuate, bicornuate, and septate uteri. Combined with SIS, 3D reconstructions in the coronal plane overcome the limitations by facilitating complete evaluation of the fundal contour, as with hysterosalpingography, and of the uterine cavity [17]. Differentiation of a bicornuate from a septate uterus is important because septate uterus is associated with early fetal loss but is surgically correctable [15, 17].
Our results show that compared with 2D SIS alone, 3D reconstructions added substantial value to the evaluation of the uterine fundus. Using 2D imaging alone, readers identified the complete fundal contour in only 3% of subjects, but with the addition of 3D images they identified the complete fundal contour in 74% of subjects. A probable explanation for the large difference is that during conventional 2D imaging of most women it is impossible to angle a transvaginal probe to completely visualize the entire uterus in the coronal plane. With 3D technique, the entirety of the uterus can be readily visualized in the coronal plane. Although we evaluated 3D sonohysterography, it seems likely that the fundal contour would also be well visualized with 3D transvaginal sonography. Our study included only one patient with acquired septum; however, we surmise that septum and subseptum can be much better evaluated with the introduction of saline solution into the endometrial cavity.
Fig. 3A 34-year-old woman who presented with multiple pregnancy losses and history of dilation and curettage. Static sagittal (A) and transverse (B) saline infusion sonohysterographic images suggest presence of septum (arrows).
Fig. 3B 34-year-old woman who presented with multiple pregnancy losses and history of dilation and curettage. Static sagittal (A) and transverse (B) saline infusion sonohysterographic images suggest presence of septum (arrows).
Fig. 3C 34-year-old woman who presented with multiple pregnancy losses and history of dilation and curettage. Three-dimensional coronal reformation defines and characterizes septum (arrows) better than do A and B. Irregularity suggests acquired rather than congenital septum.
For detection of intracavitary abnormalities, the use of 3D imaging as an adjunct to 2D SIS has had inconsistent results. In an early pilot study with 10 patients, Ayida et al. [20] found no added value for the addition of 3D technology to standard 2D sonohysterography in the detection and characterization of focal endometrial lesions. Bonilla-Musoles et al. [21] found in a study with 36 patients that 3D SIS was equivalent to 2D SIS for detection of endometrial atrophy (n = 11), polyps (n = 4), and malignancy (n = 11) but superior to 2D transvaginal sonography alone. Lev-Toaff et al. [22] found that in 13 of 20 patients who underwent both 2D and 3D SIS, the two procedures combined depicted most focal endometrial abnormalities, although 2D SIS alone did not depict one case of adhesions. In the other patients, improved subjective visualization of focal endometrial abnormalities was found with 3D SIS. In a prospective study with 49 patients, de Kroon et al. [8] found no statistically significant difference between 2D SIS and 3D SIS, but there was a trend toward improved accuracy with 3D SIS.
Our results showed no significant difference between combined 2D and 3D SIS and 2D SIS alone in the detection of focal endometrial abnormalities. The readers detected intracavitary lesions in 60% of cases with 2D SIS alone and 62% of cases with combined 2D and 3D SIS with no statistically significant difference in averaged confidence scores. The differences between our findings and those in some previous reports may be related to our study design. We evaluated a larger number of subjects and therefore had the statistical power to detect a difference. Our interobserver agreement among the three readers was very good with mean kappa values of 0.71 for 2D alone and 0.78 for combined 2D and 3D SIS with no statistically significant difference between the two groups.
We compared conventional 2D SIS with combined 2D and 3D SIS, rather than 3D SIS alone, to determine the added value of 3D technology. In our experience, 2D SIS is essential for evaluation of the entire pelvis, including the adnexa, and for real-time detection of subtle intracavitary abnormalities. Three-dimensional reformatted images, although much improved with current technology, lack the spatial resolution of conventional 2D images [18]. When the uterus is enlarged or acutely angulated, more than one volume sweep may be needed to optimally visualize the entire endometrium, resulting in reconstructed images that are difficult to interpret, which can lead to misinterpretation. In addition, the presence of anterior fibroids can produce shadowing, which obscures visualization on coronal reformations [17]. For these reasons, we believe 3D SIS cannot replace 2D SIS at this time but is valuable as an adjunct to 2D imaging, particularly for evaluation of the uterine contour.
An important limitation of our retrospective study was that only static 2D and 3D images were reviewed without the benefit of real-time imaging. Because real-time imaging can increase the sensitivity of detection of endometrial lesions with both techniques, the final comparison results would likely not have changed. A second limitation was that pathologic correlation was not available for all subjects, even when intracavitary abnormalities were suspected on SIS images. This limitation is unavoidable in clinical practice because some patients decline further intervention for a variety of reasons, including resolution of symptoms or other more urgent health concerns. Studies [7, 25] have shown equal diagnostic accuracy of SIS, hysteroscopy, and examination of hysterectomy specimens; therefore, additional invasive intervention is not indicated for patients with normal findings on SIS studies.
All three readers interpreted 2D with 3D images immediately after interpreting 2D images alone. Such a design might have biased the results in favor of the subsequent 3D interpretations because review of a case for a longer time can improve reader perception. For fundal contour abnormality, all three readers strongly favored 3D images. Although this bias might have been a small factor, it likely would not have changed the final results because the differences were substantial.
Since the time of this study, we have adopted routine use of 3D reconstructions in imaging of patients with infertility in whom a uterine congenital abnormality such as presence of a septum is suspected. Three-dimensional reformations are a helpful adjunct to 2D images alone for the evaluation and exclusion of uterine contour abnormalities. However, 3D combined with 2D transvaginal sonohysterography is not a significant improvement over 2D imaging alone for detection of endometrial abnormalities.


Address correspondence to S. V. Ghate.
This is a Web exclusive article.


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Information & Authors


Published In

American Journal of Roentgenology
Pages: W227 - W233
PubMed: 18356411


Submitted: May 14, 2007
Accepted: October 12, 2007


  1. pelvic sonography
  2. sonohysterography
  3. 3D sonography



Sujata V. Ghate
Department of Radiology, Duke University Medical Center, Duke South Hospital, Box 3808, Durham, NC 27710.
Michele M. Crockett
Radiology Associates, Monroe, LA.
Brita K. Boyd
Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Duke South Hospital, Durham, NC.
Erik K. Paulson
Department of Radiology, Duke University Medical Center, Duke South Hospital, Box 3808, Durham, NC 27710.

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