The Institute for Advanced Medical Education is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The Institute for Advanced Medical Education designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit(s) TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

These credits are accepted by the American Registry for Diagnostic Medical Sonography (ARDMS).

Faculty:
Lyndon M. Hill, MD
Professor Obstetrics and Gynecology
Medical Director Ultrasound
Magee Women's Hospital
Pittsburgh, PA

Course: Saline Infusion Sonohysterography

Target Audience: Physicians, sonographers and others who perform and/or interpret obstetrical ultrasound.

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For any questions or problems concerning this program or for problems related to the printing of the certificate please contact IAME at (914) 921-5700 or email us.

Estimated Time for Completion of tutorial: One hour
Date of Release and Review: April 24, 2006
Expiration Date: April 24, 2009

Disclosure: In compliance with the Essentials and Standards of the ACCME, the author of this CME tutorial is required to disclose any significant financial or other relationships they may have with the manufacturer(s) of any commercial product(s) or provider(s) of any commercial service(s) discussed in this program.

Dr. Lyndon Hill discloses no relevant financial relationships with commercial interests.

IAME discloses no relevant financial relationships with commercial interests. 

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Saline Infusion Sonohysterography
Lyndon M. Hill, MD
Professor Obstetrics and Gynecology
Medical Director Ultrasound
Magee Women's Hospital
Pittsburgh, PA

(DIRECT TO QUIZ)

Objectives
After completing this course, the participant should be able:

• Describe the indication for and the technique to perform saline infusion sonohysterography.
• Identify the advantages of sonohysterography over other methods to assess the endometrial cavity.
• Apply sonohysterography to triage patients with vaginal bleeding into those that can be treated medically and those that require surgery.

Introduction
In the premenopausal female, endometrial thickness and sonomorphology reflect the functional status of the ovaries. Transvaginal sonography without fluid contrast cannot adequately evaluate the echogenic endometrium of the secretory phase (Fig. 1). In the postmenopausal patient, transvaginal sonography (TVS) can be used to narrow the differential diagnosis of vaginal bleeding. By detecting an atrophic endometrium (<= 4 mm), TVS reduces the need for invasive diagnostic testing1. Sonohysterography enhances transvaginal sonographic imaging of the postmenopausal endometrial cavity if vaginal bleeding recurs.

Figure 1 - Transvaginal examination of a 9 mm secretory endometrium To view an enlargement, click on the image.

Technique
In premenopausal patients, saline infusion sonohysterography should be performed after menstrual bleeding, but before day 8 of the menstrual cycle. At the beginning of the menstrual cycle the endometrium has not grown sufficiently to have an irregular appearance that might result in a false positive diagnosis of endometrial pathology. In women with short or highly irregular cycles, it is best to use a form of birth control prior to the procedure in order to ensure that an early intrauterine pregnancy is not interrupted.

A speculum is inserted into the vagina and the cervix prepped with betadine or hibicleans in the iodine sensitive patient. A sonohysterographic catheter is filled with sterile normal saline prior to insertion into the endometrial cavity. This reduces the amount of air introduced into the endometrial cavity when the saline is instilled.

The catheter is threaded into the endometrial canal. Occasionally, cervical adhesions or the direction of the endocervical canal will prevent the insertion of the catheter. The introduction of the end of a sterile Q-tip into the cervical canal will break up any adhesions and also determine the appropriate angle for catheter placement. A 5.0 French pediatric feeding tube will provide an adequate bolus of saline to evaluate the endometrial cavity. Characteristically, the patient will note a slight cramping when the pediatric feeding tube reaches the uterine fundus. By measuring uterine length before the procedure, the examiner will know how far the catheter should be inserted to reach the fundus. The insertion of additional catheter will interfere with endometrial cavity visualization and may result in kinking of the catheter that obstructs flow. For infertility studies in which tubal patency must also be evaluated, a balloon tipped catheter is required.

Once the catheter is in place, the speculum is removed and the transvaginal transducer is inserted. A 20 ml syringe containing sterile normal saline is attached to the catheter. Instillation of the sterile normal saline is begun slowly under direct sonographic visualization. When the endometrial cavity remains filled with fluid, additional injections of sterile saline are not required (Fig. 2). If the endometrial canal collapses immediately upon instillation of normal saline then a larger bolus of fluid is required. In addition, the transvaginal transducer should be used to manipulate the uterus in an attempt to reduce the egress of fluid. The latter modifications to the technique will usually permit adequate visualization of the endometrial cavity. When visualization is still sub-optimal, the pediatric feeding tube should be removed and a balloon tipped catheter used in its place.

Figure 2 - Sonohysterogram illustrating a normal endometrial cavity. To view an enlargement, click on the image.

Extreme obesity and impaired flexibility of the hips are factors that may prohibit a sonohysterogram 2 . The procedure cannot be performed in the presence of true cervical stenosis. In patients with significant uterine retroversion, partially filling the bladder or manipulating the uterus with the transvaginal transducer may straighten the uterus enough to permit catheter placement.

While minimal discomfort when the catheter reaches the uterine fundus or with saline instillation can occur, severe pelvic pain should not be experienced. Patients may occasionally become dizzy or nauseous during, or immediately after, the procedure.

Infection is an acknowledged, but rare, complication of sonohysterography 3 . The administration of prophylactic antibiotics is controversial3,4. Bonnamy et al 5 has recommended prophylactic antibiotics for all patients with infertility. The limited amount of fluid utilized to evaluate the endometrial cavity and low intrauterine pressures achieved when a non-occluding catheter is used minimizes the risk of infection. The utilization of a balloon tipped catheter to evaluate the fallopian tubes has a theoretically higher potential of tubal infection. I, therefore, utilize prophylactic antibiotics in these cases. If the endometrial cavity must be assessed in a patient with hydrosalpinges, prophylactic antibiotics are also recommended 4 .

Endometrial Polyps
Endometrial polyps are a common cause of menometrorrhagia. VanBogaert 6 has reported a 23.8% prevalence of polyps in patients with menometrorrhagia. The highest incidence of endometrial polyps in patients with menometrorrhagia is in the fifth decade of life (29.3%). Endometrial polyps are also associated with infertility. The prevalence of polyps in infertile patients ranges between 5% and 44% 7,8,9 . The prevalence of polyps in asymptomatic women is 1.2% 10 . There is an association between endocervical and endometrial polyps. Coeman et al 11 reported a 26.7% incidence of endometrial polyps in patients with cervical polyps.

The risk of malignant transformation of an endometrial polyp is approximately 0.5% 12 to 0.8% 13 . Older age, menopause, and polyps > 1.5 cm are associated with an increased of malignancy 13,14 . Smaller polyps have been reported to slough with menstruation 12 .

A heightened awareness of the sonographic appearance of endometrial polyps may result in their presumptive diagnosis without sonohysterography. Transvaginal sonography in the proliferative phase of the menstrual cycle should suggest the presence of a polyp when a hyperechoic density is noted in the endometrial stripe (Fig. 3) 15 . In addition to being echogenic, polyps may also have cystic components 12 . The bright edges of a sharp interface between the endometrium and polyp is a sonographic marker that permits the diagnosis of a polyp without sonohysterography (Fig. 4). Caspi et al 16 reported a sensitivity, specificity, and positive predictive value of 96%, 82%, and 93%, respectively for the "bright edge sign" of an endometrial polyp.

Figure 3 - A fundal endometrial polyp (two arrows) during the proliferative phase (one arrow) of the menstrual cycle.		Figure 4 - 4. The bright edges of a sharp interface between a 1.92 cm polyp (between the markers) and the endometrium are illustrated.
To view an enlargement, click on the image.

Since a secretory endometrium is hyperechoic, it tends to obscure endometrial polyps. Transvaginal sonography has a sensitivity of 33.3% 17 in the detection of endometrial polyps versus 84% for sonohysterography 18 (Fig 5).

Figure 5 - Sonohysterogram of a centrally located 1.26 x 0.91 cm polyp. To view an enlargement, click on the image.

Color Doppler is a useful adjunct to sonohysterography - polyps generally have a single feeding vessel (Fig 6), while uterine leiomyomas have several vessels 19 .

Figure 6 - Saline infusion sonohysterogram of a polyp. Power Doppler illustrates the feeding vessel to the polyp. To view an enlargement, click on the image.

Tamoxifen Therapy
Tamoxifen is used as adjunctive therapy for breast cancer in postmenopausal women. Most postmenopausal women treated with tamoxifen will have an endometrial thickness > 4 mm due to the estrogen agonist effect of the medication. In view of this known estrogenic effect of tamoxifen on the endometrium, an endometrial thickness <= 8 mm is considered within the normal range in postmenopausal women on this medication 20 .

There is an increased prevalence of the following endometrial lesions with tamoxifen use: endometrial hyperplasia; polyps; adenocarcinoma; and subendometrial sonolucencies in the proximal myometrium. Since the junctional area is not clearly defined, the intramyometrial cysts may be erroneously included in the measurement of the endometrial thickness (Fig. 7). Sonohysterography is particularly helpful in differentiating between intramyometrial cysts and possible endometrial pathology. In the 8% of patients on tamoxifen with an atrophic endometrium and subendometrial sonolucencies, additional invasive testing is not required 20 .

Figure 7 - Sonohysterogram. There is a cyst (markers) below the endometrial lining consistent with tamoxifen therapy. To view an enlargement, click on the image.

If a patient on tamoxifen has vaginal bleeding, sonohysterography should be considered, regardless of the endometrial thickness. Saline infusion sonohysterography should also be performed in patients on tamoxifen with vaginal bleeding and a negative endometrial biopsy. Hann et al 20 found endometrial pathology in 12 of 19 (63%) sonohysterograms performed on women on tamoxifen with a negative endometrial biopsy.

Sonohysterography is more effective and acceptable than office hysteroscopy for detecting endometrial pathology in postmenopausal women who are on tamoxifen. In a study by Timmerman et al 21 19% of office hysteroscopies failed, accounting for the low sensitivity of this technique in the evaluation of the endometrium.

Figure 8 - Sonohysterogram of an intracavitary leiomyoma. To view an enlargement, click on the image.

Sonohysterography is equivalent to hysteroscopy in detecting submucous leiomyomas 22,23 . An advantage of sonohysterography is that this technique can determine the intramural component of submucous leiomyomas. If a leiomyoma is entirely intracavitary or extends into the myometrium < 50% (Fig. 9), the patient is a candidate for hysteroscopic resection. For leiomyomas that extend > 50% into the myometrium, transcervical resection should only be attempted in specific cases 24 .

Figure 9 - Sonohysterogram of a submucosal leiomyoma (arrow). To view an enlargement, click on the image.

The addition of saline to the endometrial cavity improves visualization of an endometrium obscured by leiomyomas 25 and improves interobserver agreement with respect to describing the location of leiomyomas 26 .

Rapid growth of leiomyomas due to tamoxifen therapy has been described 27 .

Figure 10 - Endometrial hyperplasia. The endometrial lining is thickened and contains multiple small cysts. To view an enlargement, click on the image.

Sonohysterography has been found to be as accurate as hysteroscopy in the detection of endometrial hyperplasia 30 .

Endometrial carcinoma
Figure 11a - The endometrial lining (1.16 cm) is thickened for a postmenopausal female		Figure 11b - Power Doppler reveals multiple vessels to the endometrial carcinoma.
To view an enlargement, click on the image.

There has been some concern about the theoretical risk of transporting malignant cells into the peritoneal cavity during saline infusion. Alcázar et al 32 performed saline infusion sonohysterography with an 8-French pediatric Foley in 14 patients with Stage I endometrial carcinoma at the time of laparotomy. There was not any spillage of fluid from the fallopian tubes in 9 patients. Malignant cells were detected in the fluid obtained from the peritoneal cavity of 1 of the remaining 5 patients (1 in 14; 7.1%). The viability of the cells that were flushed through the tubes was not assessed. The lower pressure infusion of saline with a patent cervix (i.e., utilization of a pediatric feeding tube) should carry a lower theoretical risk of cell dissemination to the peritoneal cavity 33 .

Figure 12 - Sonohysterogram of an anterior to posterior uterine adhesion. To view an enlargement, click on the image.

Uterine Malformations
While sonohysterography is an improvement over the traditional two-dimensional technique, 3-D has a higher sensitivity and specificity for the delineation of specific uterine anomalies (Fig. 13a and b) 37 . 3-D ultrasound also reduces the interobserver variability in the diagnosis of uterine anomalies 38 .

Bicornuate uterus
Figure 13a - Transverse 2-D image illustrating two distinct endometrial cavities (arrows).		Figure 13b - Cornual 3-D image. The serosal indentation indicates that this is a bicornuate, not a partially septated, uterus.
To view an enlargement, click on the image.

3-D Sonohysterography
Three-dimensional sonohysterography improves the overall evaluation of the uterine cavity. This technique also better delineates the location of endometrial pathology 39 . The coronal plane is the most useful for displaying the location of a lesion in the endometrial cavity (Fig. 14) 40 .

Figure 14 - A submucosal leiomyoma and a polyp are illustrated on this 3-D image. To view an enlargement, click on the image.

Tubal Patency
Infertility investigations have traditionally included x-ray hysterosalpingography (HSG) or laparoscopy for the assessment of tubal patency. Sonohysterography is an alternative technique.

When tubal patency is evaluated, a balloon tipped catheter is required to appropriately distend the endometrial cavity and to force fluid out of the fallopian tubes into the cul-de-sac. The infused saline should be shaken in the syringe - the bubbles that result are easier to see passing through the fallopian tubes. Color Doppler assessment of the fallopian tubes has also been used to document tubal patency (Fig. 15). More recently, ultrasound contrast agents have been employed to assess tubal patency 41 .

Figure 15 - Color Doppler illustration of right fallopian tube patency. To view an enlargement, click on the image.

In the presence of bilaterally occluded fallopian tubes, the uterine cavity will expand with only a limited instillation of saline and will not decompress. Patients will invariably complain of discomfort from the uterine pressure. The demonstration of true unilateral occlusion, in contrast to cornual spasm, cannot be determined during sonohysterography. The rapid egress of fluid through the fallopian tube with the least resistance can be interpreted as a unilateral occlusion 42 .

The advantages of sonohysterography over other methods to assess the endometrial cavity include improved sensitivity/specificity in the detection of pathology. When compared to other modalities (hysterosalpingogram in the premenopausal patient or office hysteroscopy in the postmenopausal patient), the advantages of sonohysterography include: cost; avoidance of radiation; and patient comfort.

The determination that endometrial disease is focal or global improves the accuracy of subsequent biopsy. While diffuse endometrial disease can be biopsied blindly, focal abnormalities require a visually guided biopsy.

Sonohysterography not only assists in determining the diagnosis or therapeutic approach, it may also reduce or eliminate the need for surgical intervention.

References

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2. Epstein E, Ramirez A, Skoog L, Valentin L. Transvaginal sonography, saline contrast sonohysterography and hysteroscopy for the investigation of women with postmenopausal bleeding and endometrium > 5 mm. Ultrasound Obstet Gynecol 2001;18:157-162.
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5. Bonnamy L, Marret H, Perrotin F, Body G, Berger C, Lansac J. Sonohysterography: a prospective survey of results and complications in 81 patients. Eur J Obstet Gynecol Reprod Biol 2002;102:42-47.
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9. Valle RF. Hysteroscopy in the evaluation of female infertility. Am J Obstet Gynecol 1980;137:425-31.
10. Cooper JM, Houck RM Rigberg HS. Incidence of intrauterine abnormalities found at hysteroscopy in patients undergoing elective hysteroscopic sterilization. J Reprod Med 1983;28:659-61.
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15. Syrop CH, Sahakian V. Transvaginal sonographic detection of endometrial polyps with fluid contrast augmentation. Obstet Gynecol 1992;79:1041-43.
16. Caspi B, Appelman Z, Goldsmith R, Ashkenazi M, Haruvy Y, Hagay Z. The bright edges of the endometrial polyp. Ultrasound Obstet Gynecol 2000;15:327-30.
17. Cicinelli E, Romano F, Anastasio PS, Blasi N, Parisi C. Sonohysterography versus hysteroscopy in the diagnosis of endouterine polyps. Gynecol Obstet Invest 1994;38:266-71.
18. 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.
19. Fleischer AC, Shappell HW. Color Doppler sonohysterography of endometrial polyps and submucosal fibroids. J Ultrasound Med 2003;22:601-04.
20. Hann LE, Gretz EM, Bach AM, Francis SM. Sonohysterography for evaluation of the endometrium in women treated with tamoxifen. AJR 2001;177:337-42.
21. Timmerman D, Deprest J, Bourne T, Van den Berghe I, Collins WP, Vergote I. A randomized trial on the use of ultrasonography or office hysterscopy for endometrial assessment in postmenopausal patients with breast cancer who were treated with tamoxifen. Am J Obstet Gynecol 1998;179:62-70.
22. Gaucherand P, Piacenza JM, Salle B, Rudigoz R Ch. Sonohysterography of the uterine cavity: preliminary investigations. J Clin Ultrasound 1995;23:339-48.
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24. Wamsteker K, Emanuel MH, de Kruif JH. Transcervical hysterocopic resection of submucosal fibroids for abnormal uterine bleeding: Results regarding the degree of intramural extension. Obstet Gynecol 1993;82:736-40.
25. Cicinelli E, Romano F, Anastasio PS, Blasi N, Parisi C, Galantino P. Transabdominal sonohysterography, transvaginal sonography, and hysteroscopy in the evaluation of submucous myomas. Obstet Gynecol 1995;85:42-47.
26. Becker E, Lev-Toaff AS, Kaufman EP, Halpern EJ, Edelweiss MI, Kurtz AB. The added value of transvaginal sonohysterography over transvaginal sonography alone in women with known or suspected leiomyoma. J Ultrasound Med 2002;21:237-47.
27. Schwartz LB, Rutkowski N, Horan C, Nachtigall LE, Synder J, Goldstein SR. Use of transvaginal ultrasonography to monitor the effects of tamoxifen on uterine leiomyoma size and ovarian cyst formation. J Ultrasound Med 1998;17:699-703.
28. Parsons AK, Lense JJ. Sonohysterography for endometrial abnormalities: preliminary results. J Clin Ultrasound 1993;21:87-95.
29. Bonilla-Musoles F, Simón C, Serra V, Sampaio M, Pellicer A. An assessment of hysterosalpingosonography (HSSG) as a diagnostic tool for uterine cavity defects and tubal patency. J Clin Ultrasound 1992;20:175-181.
30. Soares SR, dos Reis MMBB, Camargos AF. Diagnostic accuracy of sonohysterography, transvaginal sonography, and hysterosalpingography in patients with uterine cavity diseases. Fertil Steril 2000;73:406-11.
31. Laifer-Narin SL, Ragavendra N, Lu DSK, Sayre J, Perrella RR, Grant EG. Transvaginal saline hysterosonography: characteristics distinguishing malignant and various benign conditions. AJR 1999;172:1513-20.
32. Alcázar JL, Errasti T, Zornoza A. Saline infusion sonohysterography in endometrial cancer: assessment of malignant cell dissemination risk. Acta Obstet Gynecol Scand 2000;79:321-322.
33. Alatas C, Aksoy E, Akarsu C, Yakin K, Aksoy S, Hayran M. Evaluation of intrauterine abnormalities in infertile patients by sonohysterography. Hum Reprod 1997;12:487-90.
34. Romano F, Cicinelli E, Anastasio PS, Epifani S, Fanelli F, Galantino P. Sonohysterography versus hysteroscopy for diagnosing endouterine abnormalities in fertile women. Int J Gynecol Obstet 1994;45:253-60.
35. Berridge DL, Winter TC. Saline infusion sonohysterography. Technique, indications, and image findings. J Ultrasound Med 2004;23:97-112.
36. Stadtmauer L, Grunfeld L. The significance of endometrial filling defects detected on routine transvaginal sonography. J Ultrasound Med 1995;14:169-172.
37. Jurkovic D, Geipel A, Gruboeck K, Jauniaux E, Natucci M, Campbell S. Three-dimensional ultrasound in the assessment of uterine anatomy and detection of congenital anomalies: a comparison with hysterosalpingography and two-dimensional sonography. Ultrasound Obstet Gynecol 1995;5:233-237.
38. Salim R, Woelfer B, Backos M, Regan L, Jurkovic D. Reproducibility of three-dimensional ultrasound diagnosis of congenital uterine anomalies. Ultrasound Obstet Gynecol 2003;21:578-82.
39. Sylvestre C, Child TJ, Tulandi T, Tan SL. A prospective study to evaluate the efficacy of two- and three-dimensional sonohysterography in women with intrauterine lesions. Fertil Steril 2003;75:1222-25.
40. Lev-Toaff AS , Pinheiro LW, Bega G, Kurtz AB , Goldberg BB. Three-dimensional multiplanar sonohysterography. Comparison with conventional two-dimensional sonohysterography and x-ray hysterosalpingography. J Ultrasound Med 2001;20:295-306.
41. Strandell A, Bourne T, Bergh C, Granberg S, Asztely M, Thorburn J. The assessment of endometrial pathology and tubal patency: a comparison between the use of ultrasonography and x-ray hysterosalpingography for the investigation of infertility patients. Ultrasound Obstet Gynecol 1999;14:200-204.
42. Spalding H, Martikainen H, Tekay A, Jouppila P. Transvaginal salpingosonography for assessing tubal patency in women previously treated for pelvic inflammatory disease and benign ovarian tumors. Ultrasound Obstet Gynecol 1999;14:205-9.
43. Bree RL, Bowerman RA, Bohem-Velez M, Benson CB, Doubilet PM, DeDreu S, Punch MR. US evaluation of the uterus in patients with postmenopausal bleeding: a positive effect on diagnostic decision making. Radiology 2000;216:260-264.

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