Sonohysterography and Sonosalpingography - SD

Introduction

Hi, I am Dr. Jim Schweder. I'm an associate professor at the University of Louisville School of Medicine and the director of gynecology and the fellowship of Minimally Invasive Surgery.

Today we're gonna talk about sonohysterography and its use in the management of gynecologic patients. We're gonna talk about the use of sonohysterography and sono phonography and the evaluation of gynecologic patients. In addition, I'm gonna discuss a newer concept called sono biopsy because it fits very well into both of these procedures.

Case Presentation

I always like to start with a case presentation to kind of set the mood, if you will, for our discussion. And this includes a postmenopausal woman who's 63, who comes in with complaints of postmenopausal bleeding for three days, about three weeks ago.

Evolution of Evaluation Methods

Now, in our traditional evaluation of this patient, it has actually transformed over the years. When I trained, certainly we did DNCs. As our initial evaluation, as the pipe or suction, piston biopsy instrument became available, we transitioned more to office-based endometrial biopsy. Actually, a blind procedure hysteroscopy then became very popular and is actually has been an office-based procedure since the early eighties and allows us to look directly inside the uterus. And this certainly has become the gold standard.

But what we've come to learn is vaginal ultrasound, saline infusion, sonar hysteroscopy, and the addition of 3D has greatly enhanced our ability to evaluate patients in a convenient, non-invasive manner.

Sensitivity of Endometrial Biopsy

Now, in the past when we did endometrial biopsy, it was interesting to note that when marketed the this study by Tom Stovall indicating a sensitivity of 97.5% in detecting endometrial cancer was the mainstay on its acceptance by the medical community. But we see other studies of equivalent evidence who indicate that the sensitivity in detecting cancer could be as low as 44%. And I always look to those that are somewhat in the middle, such as G***o study at 83% to see what is the reliability.

In the G***o study, they had 65 patients who'd already been diagnosed with endometrial cancer. These patients underwent an endometrial biopsy in the operating room while they were asleep just prior to hysterectomy. And what they determined was is that 97% of the time they could get tissue that was adequate for analysis, but malignancy was only detected 83% of the time. And what they discovered was that five of the cancers were on a polyp. All of those where the endometrial cancer was not detected involved less than 50% of the surface area of the endometrium. And in three patients it was less than 5%.

So what can be concluded from this is that an endometrial biopsy with a pipee may not be as effective as we thought it was. And this kind of comes down to this study by Rodriguez who compared from a pipee to a Vara aspirator. And let's look at Vara Aspirator. Many people don't know what that is. If we look at the bottom right, we have the Pipee suction biopsy instrument. The top right is a rigid biopsy instrument called a Novak Curette. This is actually what many of us used prior to the adoption of the pipee. But on the left we see the vara aspirator. It's actually a rigid curating instrument hooked up to a suction apparatus that gives very good tissue specimen.

But when you look at this comparison of patients, what we see is one of the liabilities of using a pipee is that it only samples 4% of the endometrial surface. And in fact, if you take the endometrium and anteriorly take four quadrants and posteriorly four quadrants, we see that in fact, you on the average only 2.4 sections are measured with the pipee. So their limitations are is that it is a relatively focal biopsy rather than a true global biopsy.

Ultrasound as a Screening Tool

So let's go back to this patient 63 spotting for three days. Three weeks ago. If we place an ultrasound and do an ultrasound, we saw this, her endometrium is 3.9 millimeters thick. Now the question becomes do we need to sample this patient or not? This is now a screening tool. And in fact, the question would be, what's your threshold for doing further evaluation?

Well, we now have some guidance on this. The American College of ob, GYN and a committee opinion dated August, 2009 looked at the role of transvaginal ultrasound in evaluating postmenopausal bleed. And with an endometrial thickness less than five millimeters, they indicated that the biopsy could be performed 82% of the time, but in the biopsies that they obtained, 27% of them had adequate tissue for analysis. But a full 73% had tissue and sufficient for diagnosis.

Now, if you're utilizing this in your clinical practice, if they have a very thin endometrium and you elect to do a biopsy once you'd counsel patients that they have a very high incidence of getting tissue insufficient for diagnosis, which is what you would expect. But what they determined was when they analyzed these studies, they determined that the risk for endometrial cancer if the endometrium was four millimeters or less in thickness, was approximately one in 1000.

So as a screening tool, using any cutoffs of four millimeters is quite safe with these patients. And their final conclusion was that in the initial evaluation, it could be either by endometrial biopsy or vaginal ultrasound, but if the endometrial thickness was over four millimeters, it should trigger further evaluation either with an endometrial biopsy, sonohysterography or hysteroscopy.

Now, they did indicate that an endometrial biopsy with tissue insufficient for diagnosis required additional evaluation. I would indicate that if it's a pipee done that shows that it does require further evaluation. But if you have a very thin endometrium and the pipee confirms that, then we don't have to move further.

Now the caution is if the endometrium is say eight or nine millimeters and it says tissue insufficient for diagnosis, that's an inadequate evaluation, requires further exploration either with sonohysterography with further biopsy or hysteroscopy with directed biopsies.

Advantages of Ultrasound in Detecting Other Issues

Another potential advantage of ultrasound is demonstrated by this study which looked at 76 postmenopausal women. They were evaluated with three different methods, a pipee as an outpatient transvaginal ultrasound prior to outpatient hysteroscopy, DNC or hysteroscopy in DNC. And what they considered on ultrasound was abnormal is an endometrial thickness greater than five millimeters.

Now in this study of 76 women, keep that number in mind the pipee with both success, successful and sensitive. In 70% of cases, a vaginal ultrasound actually was better, both more sensitive and more specific. But what I looked at in this study that was critical was is that there were five ovarian tumors that were detected. And of these five, three were missed on clinical exam and two were malignant. That's two out of 76 patients or an incidence of malignancy of about two to 3%.

In patients who present with postmenopausal bleeding, one cannot evaluate the adexo with a hysteroscopy or a pipe biopsy. And this was brought home in this 61-year-old patient referred to me for postmenopausal bleeding. She'd had spotting for two months. And when I did her ultrasound, her endometrium is 3.5 millimeters thick. This would've rendered tissue insufficient for diagnosis in over 70% of cases. But in her Aden nexa was this complex mass with a papillation consistent with a papillary serous cyst adenocarcinoma.

So a great advantage of ultrasound is the ability to screen the adexo. In addition, this 70-year-old was referred for postmenopausal bleeding for SIS. Now I did an initial ultrasound, the endometrium as two millimeters. There was really no need for an SIS but had been requested by the physician, so I complied. And the SIS revealed no focal lesions within the cavity and very thin endometrium measuring 1.2 and 0.7 millimeters. So a total of 1.9 millimeters. As anticipated, her biopsy returns showing tissue insufficient for diagnosis.

But what's critical in this patient is when one looked at the bladder, there was a mass that was detected. Here we see this cystic mass on the posterior wall of the bladder. This represents a ureteral seal and next to it is a thickened area on the wall of the bladder. In this transverse view, we can again see the ureteral seal and the thickened area, but on the opposite wall is this irregular mass like effect. This is now the third case I've seen of this and is highly suspicious for a transitional cell carcinoma of the bladder. And in fact, on this patient the same day we got a CT scan which shows the ureteral seal. It shows the thickened area next to the ureteral seal and it shows the thickened area in the wall remote from the ureteral seal. This patient underwent urologic evaluation and is found to have a stage two transitional cell carcinoma of the bladder, which presented as postmenopausal bleeding.

So ultrasound adds that dimension of evaluating the ad nexa and even the bladder in patients who may present with postmenopausal bleeding.

Indications and Contraindications for Sonohysterography

Now sonohysterography, the addition of fluid inside the cavity is indicated when we have an abnormal bleeding with a thickened or indistinct endometrium. In other words, the ultrasound is inadequate and f formally determining the cause of bleeding and it requires further evaluation, particularly if we have an inadequate or abnormal ultrasound.

Now an infertility, it is used for recurrent pregnancy loss, congenital anomalies of the uterine cavity and even findings of suspected uterine syne eye.

Now there are a few contraindications. Obviously pregnancy and pelvic infection are contraindications.

Now, if you want to obtain a pathologic diagnosis with histology, that requires either an endometrial biopsy or DNC. Now things that are best diagnosed by tissue biopsy including hormonal dysregulation, endometritis, endometrial hyperplasia, diffuse malignancy. And I admit in those patients who have underlying polycystic ovarian disease, particularly if they're obese with longstanding oligomenorrhea or a amenorrhea, I resort to a pipe health biopsy very early on in evaluation because I'm concerned about endometrial cancer because longstanding oligomenorrhea with polycystic ovarian disease confers three times the risk of endometrial cancer, as does obesity with A BMI over 30.

If one, however wants to quote, look inside the uterus to help detect polyps, sub mucus, myomas, or even a focal malignancy. This is where hysteroscopy ultrasound, particularly with saline infusion and even the addition of 3D remarkably help us.

Evaluation in Younger Patients

Now one of the key things is if we're looking for polyps and we're looking for sub mucus myomas, is there age critical? Is there an age that says we shouldn't evaluate these patients? And a colleague of mine, Dr. William Brown, looked at this when I was in Denver. And what we found was in doing ultrasound in patients, all people who refer to us for abnormal bleeding, we looked at the number of abnormals. In other words, sub mucus myomas or endometrial polyps that were present on ultrasound was saline infusion. And overall the rate was about 35%. But even in the younger age group, under 30, 31% of those had an abnormality.

Now I emphasize these were filling defects, abnormalities at sono saline infusion sonohysterography if we took the patients to hysteroscopy or hysterectomy for definitive diagnosis. So even though the number is only 26%, that means one out of four patients who present with abnormal bleeding under the age of 30 have a filling defect. And the youngest patient I've seen for this was out of our pediatric adolescent group and a patient who was refractory to medical therapy and she was referred for evaluation. She was found to have a two centimeter, a 20 millimeter endometrium, and I was able to perform a sonar histogram in this patient. And what it reveals is a polyp that's approximately 1.6 by 0.8 centimeters in size. And in fact, we can see multiple polyps within within the uterus that was confirmed on operative hysteroscopy.

So even in this young age group, polyps can be an etiology for abnormal bleeding.

Perimenopausal Evaluation

Now what a more typical patient we might see is someone with menometrorrhagia whose perimenopausal this 45-year-old presents with omera for 16 months. She's on no birth control, her HGS negative, always check a pregnancy test in the reproductive age group. But the question is, how best should we evaluate this patient? Should it be a pipe or should it be an ultrasound?

Steve Goldstein looked at this in his practice with over 430 perimenopausal patients patients, and he did an ultrasound on day four to six of their cycle and set his cutoff at five millimeters as being dysfunctional uterine bleeding. So if the endometrium was less than five millimeters or five millimeters thick, no biopsy was required greater than that. The patient underwent SIS. If she had a thin endometrium which was uniform, he determined this was dysfunctional uterine bleeding. If there was a focal lesion, he did hysteroscopy D and C. And if there was global thickening, he would perform an endometrial biopsy.

And the summary of his findings were is that the non-directed office biopsy without imaging potentially missed polyps, sub mucus myomas and focal hyperplasia in 18.5% of patients. So he advocated that the blind biopsy in these patients should be augmented, certainly with ultrasound, to determine if there was further evaluation necessary.

Now, Dan Breal looked at the number five millimeters and said, okay, five millimeters or less could there be filling defects even with the thin and endometrium. So he took patients with an endometrium less than five millimeters and determined that in fact almost 8% of those patients had either an endometrial polyp or a sub mucus myoma perhaps contributing to their abnormal bleeding.

So the cutoff that I recommend is four millimeters for no biopsy in postmenopausal women. If you decide to use five millimeters, recognize that even if they have a five millimeter endometrium, some of those patients can have filling defects present. And the caveat is, is that if you elect not to perform a biopsy and the patient continues to bleed abnormally, they require further workup either with sonohysterography or with hysteroscopy.

Performing Sonohysterography

So let's talk about sonohysterography and how to do it. Timing is best done on round day five through 10 of the menstrual cycle. The reason is in the luteal phase, when you have secretory endometrium, that may mimic many, many abnormalities.

Now you can schedule some patients anytime the postmenopausal patient people on long-acting reversible contraception, Depo-Provera or perhaps continuous oral contraceptive. Certainly you can schedule them at any time.

Now I like to do an ultrasound prior to SIS because it allows mapping of the cavity. In other words, is the uterus markedly inflexed or retroflexed? This also gives me the ability that in anticipation of sonohysterography, I may not have to use a tenaculum because I can divert the catheter into the proper orientation. It gives me the availability to assess the adex in the bladder. And in some cases I can evaluate the cavity quite adequately with an unenhanced or without saline infusion.

Now one thing I like to do is to measure the cavity length including the cervix because some of the biopsy instruments I use and some of the sono hyster sonohysterography catheters I use have an acorn. And you wanna know how and what location do you wanna place that acorn.

So let's look at this. This is a patient who has a significantly retroflexed uterus. Now many patients are sent to me for evaluation of abnormal bleeding with the anticipation of having an endometrial ablation. With that in mind, some of the DI devices that are used for endometrial ablation requires certain dimensions be present in the uterus such that they could be used. So I will give these physicians the cervical length, I will give 'em the length of the endometrial cavity, and in a transverse view I will measure the endometrium transversely. This will allow them to know if the uterine cavity is adequate in size to use these devices.

Catheters and Setup

Now what catheters do I use? There are a number that are available. I tend to have preferences of my own. One thing I find is a shepherd catheter has a small stylet present. Right here we can see the tip of it. That's a little internal metal stylet that does have an opening but allows one to bend that catheter, which is less than two millimeters in diameter, such that if there is a relatively stenotic cervix or very small opening, I can usually insert this into a cavity fairly comfortably.

The sono biopsy catheter, uh, it can certainly be used for SIS, but I reserve that for patients who I'm gonna perform a biopsy in particularly if they have a patula cervix. Again, if they have a small noris appearing cervix or very small opening, one can do a biopsy with a shepherd. The Seuss catheter and Goldstein catheter are used by many people. They tend to be more flexible than the others and one can use things such as a Tampa catheter. These are various balloon catheters that are very helpful. If one has a very patch of cervix or if one plans on doing sono phonography, one needs to use a balloon catheter. And I will give you tips on how to use that uh, throughout our discussion.

So this is a saline infusion sonogram. The uterus was retroverted. There were no internal filling effects. And we see that the endometrium is uniform and symmetric measuring 3.8 and 3.8 millimeters. In this situation, one can do an endometrial biopsy anywhere on the lining, and this is gonna be representative of what the pathologic findings are overall once you do both the sagittal and transverse view to make sure that there are no irregularities that are missed on either view.

Now how one does this can be somewhat technically oriented. It's actually very simple. Here I'm demonstrating a Goldstein catheter. We can see an acorn present. I do measure from the cervix to the fundus. A key thing I like to do is to set this little acorn a little closer to the tip than I measure. And the reason is you want it to semi occlude the O preventing some of the backflow that occurs. But you don't want the tip of the catheter at the top of the fundus, which can be very uncomfortable for patients.

I inserted through a regular speculum. I don't even use an open sided speculum. I'll tell you how that works. I, this is after I've examined the cervix and prepped it with either a Betadine or hebe cleanse type of solution. I then stabilize the catheter as I open the speculum up so that the, the top and bottom blades don't compress the cervix and cause more discomfort. I watch as it comes out. And what I do is use a 10 cc syringe that allows me to place this through the speculum without requiring an open sided speculum.

So if we look at this, this is a patient who has an endometrium that we can easily see. And what we'll do is see how it looks. We're inserting this, this is using a shepherd catheter. I can tell because it's got this bright echo right here. When we insert this, this takes about two ccs of fluid. You can see again excellent dis distinction of the cavity. Very easy, very simple to do. We can take our picture and take our measurements.

Now this is a little more difficult 'cause as I look at this uterus, the cervix is here, here's the fundus, and here is the endometrium, which appears to have multiple cystic areas, a very heterogeneous appearance. I'm not even sure how thick it should be. If we do an SIS on this patient, what we'll see is the fluid indu, the cavity, it distends the cavity and we can see a polypoid appearance. An asymmetric appearance to the endometrium here, a global biopsy, a blind biopsy would not be appropriate because this is not a global process. This is a focal process that requires either guided biopsy with ultrasound or hysteroscopically guided biopsies.

Now there are limitations to the devices I use here. We're using a shepherd catheter. One can see that the fluid is almost flowing out as quickly as it goes in. This is a patch list type of cervix. I would require changing this to either a catheter with an acorn on it or one with a balloon on it to get adequate distension.

Now this happens to use a balloon catheter. We can see because there's fluid within the balloon, that is one of my tips if you will, is to put fluid in the balloon rather than air. And we see a large sub mucus myoma, approximately 3.71 millimeters in diameter. The surrounding endometrium is actually quite thin in this circumstance. And what we see is this venetian blind effect with loss of through transmission consistent with a myoma.

Now there are many kits available for saline infusion. This is just demonstrating some of the kits available. They can include speculums, the sanitizing solution, sterilizing solution, the various catheters, et cetera. To be honest with you, I don't use these kits. I use a fairly simple setup. I have a reusable speculum. I have three large swabs. I have either the HE cleanse or Betadine available. The blue device is actually a OS finder. I don't use that and have it open on every case, but I do have one in the room in the case. I have difficulty finding, particularly the internal O. We have a 10 cc syringe with sterile saline available. And then one of the catheters that I use, I don't open the catheters up until I actually am looking at the cervix to know what type of catheter I want to use.

Here we see the setup for the balloon catheter exactly the same. So all I have to do is change out the catheter that I'm gonna use.

Now I use Satan infusion, a great deal of time in the preoperative evaluation of patients. For instance, if we look at this case, this patient has a retroverted uterus, a very thick endometrium in the sagittal view. Now I will tell you that I made a mistake on this. This is a transverse view and I would not recommend measuring the endometrium in the transverse view because if it's a markedly retroverted or retroflexed uterus or inflexed uterus, you can get an oblique angle that will give you a endometrium that appears thicker than anticipated. So always measure the endometrium in the sagittal view.

But we can see when we put saline in on this patient that we see marked abnormalities on the posterior wall. We see polypoid appearance, a diffusely thickened endometrium. This is abnormal. Now in this case, if we do 3D rendering, we can see that there are certainly multiple polyps within the cavity. And what this allows me to do is to prepare for operative hysteroscopy. 'cause I anticipate I'm gonna find multiple polyps. And in that regard, I will tell the patient two things. One is we may have to do this as a staged procedure or I will likely leave either a Foley catheter, a balloon type of device, or even an IUD in the uterus following your procedure. And here we see on hysteroscopy the multiple polyps that are present. And here we see towards the end of her procedure where the cavity is being restored to normal.

So it allows me to predict what I'm gonna see at surgery and plan appropriately.

Examples of Findings

Now with sonohysterography, if you're doing straight 2D, don't have 3D available. I like to observe the infusion of fluid under real time because people often say, well, how much fluid do you put in? I put in only what's necessary. It could be as little as one cc. It could be much as 23 Cs ccs. What I do is I capture a sagittal and transverse view and I measure the endometrium in the sagittal view.

So here's an example, sanding infusion 2D that reveals an endometrial polyp, but the surrounding endometrium is 1.3 and 1.3 millimeters quite thin. If one did a biopsy and were to sample this area, it likely would be atrophic or tissue insufficient for diagnosis. But there is a polyp that is present that warrants removal.

Here is an ultrasound that that in screening is inconclusive. What we see is we see the cervix with an otium gland present. We see the fundus and then we see what appears to be a thickened endometrium, but it's difficult to tell if we should measure from here to here. Does it go further? It's just difficult to assess. Whereas if we put salient in, what you can see is this cavity dis descends very easily with less than two ccs. This surrounding endometrium is thin, but there's a large polyp and perhaps another mass present here. So now we can determine that the reason that this was a possibly thickened endometrium is the presence of an endometrial polyp and this patient can then be selected for appropriate removal.

3D Sonohysterography

Now how about 3D three D's? Wonderful in a couple of ways because even if you can't keep a lot of fluid in, if you can get a 3D sweep, you can reconstruct a uterus and see if there are any filling defects. Now I typically acquire one volume. In fact, the first thing I do with if I have a 3D machine available is as I infuse fluid, I take a 3D sweep, then I switch to 2D. But it appears to be a very convenient way to get this. And this is an example I mentioned. This is a sanding infusion done with a catheter. You're gonna see that the cavity will extend and then it tends to kind of bring down a little bit, kind of come down in size a little bit. Well, if I take a 3D sweep, I'm able to do a coronal reconstruction that actually shows that one side of the endometrium is perhaps a little bit thicker than the other oring. Further evaluation.

Now 3D is very valuable in looking at uterine anomalies. And the addition of SIS can certainly help. Here we see an SIS that's performed, and as we do multiplanar reconstruction and rendering, what we see is this actually RQ eight uterus. This is not quite a partial septum. I will go through the indications and the details behind that. But we can see here a somewhat abnormally shaped uterine cavity, but a normally shaped serosal surface to the endometrium.

Here we have a patient that has an arcuate uterus. We see it in the transverse view, the sagittal view. This is actually your acquisition plane. This is an orthogonal plane to that, and this is a coronal view. Now this area is 2.6 centimeters wide and 0.74 centimeters long. If this were greater than one centimeter, this would be called a sub septate uterus. The fact that it's less than one centimeter makes it an arcuate uterus. Again, we can see the serosal surface is normal and we can see the lower uterine segment is unified.

Now here we can see a nice demonstration of sonohysterography revealing a uniform endometrial thickness, but an endometrial polyp present arising from the anterior wall of the uterus. So one can tell the referring physician exactly what we have in the way of an intracavitary lesion, and in fact where it arises, this may even be applicable for ho uh, operative hysteroscopy or even office-based removal.

Now here's another patient. And one thing I would advocate particularly looking down at the bottom left of my image is something I put on all patient's records. This is on my first slide. I put on the ity in their parity, I discussed when their last menstrual period was. That may help me predict what I'm going to see at the time of surgery. Let me know if they're on any birth control, particularly if there's hormonal suppression involved. And then any surgical procedures. And you'll see this patient had an open myomectomy in April of oh nine. She had a hysteroscopic myomectomy in October of 2010, subsequently became pregnant and had a cesarean section done and then returns with some abnormal bleeding.

And as I look at this as we're moving through this, I can't see the endometrium clearly, but I can see this lucin area and I can't determine is that lucin area in the myometrium? Is it in the cavity? We're not sure. So the way we do this is now we put a balloon catheter in distend the cavity, and we can see this in fact, is a sub mucus myoma with an area of degeneration essentially filling the cavity. Now when we do this, what you can see is is that particularly with 3D reconstruction, you can see that this virtually fills the entire cavity on the coronal view.

So this patient was offered alternatives such as repeat hysteroscopy or perhaps even moving to hysterectomy. This patient elected to proceed with hysterectomy having had a successful outcome with pregnancy and hoping to avoid multiple surgical procedures in the future. So this allowed us to appropriately counsel this patient as to the underlying cause of her bleeding and the extent of planned surgery.

Identifying Abnormalities

So when we look at sonohysterography, this is what abnormalities look like. The sub mucus myoma is iso coic or hypo coic to the myometrium, it has some variable or perhaps even increased echogenicity. What you wanna look for is this posterior acoustic shadowing, oftentimes called the Venetian blind effect.

If we look at polyps, they tend to be closer in echo density to that of the MI endometrium. They tend to be brighter than the myometrium, and they may have some scattered cystic spaces, but we see polyps here, here and in this area, the small cystic spaces. And in fact, the other advantages, even in an unenhanced view, one could turn power doppler on with low pulse repetition frequency and could detect a flow within the endometrium, which would be indicative of a vessel that feeds the polyp.

Here we see doppler directional doppler, which shows this flow of a large central vessel feeding the polyp.

Now, one of the questions that always arises, particularly if you're scanning a patient for reasons beyond abnormal bleeding, for instance, this patient has multiple cystic spaces in the endometrium, which looks, which looks thicker. We obtain power doppler and we can get a waveform present. And I draw your attention to the resistance index of 0.60.

A question that always arises is patients will ask, do I need to have the polyp removed? Because what's the chance of malignancy? It's a very difficult question. As I read the literature, the risk in an asymptomatic patient is probably between two to 3%. It is much greater in patients over 65 years of age, not so much in patients who are younger, but still a potential cause of concern.

The question is, how do I counsel patients, patients? Well, if we can get a waveform such as this, there's one study that was published in 2002 that looked at doppler and the prediction of malignancy in polyps. Now when you look at this, they were able to get doppler flow patterns in about 57% of patients with a measurable waveform in about one fourth of patients. But what they used as their abnormal range was a resistance index less than 0.5. And what they determined was is if the resistance index was less than 0.5, 23% of their patients had a malignancy in the polyp. If the resistance index was over 0.5, no patients had a malignancy.

So I augment my evaluation with this to either counsel my patients personally or advise the referring physician so they can counsel their patients appropriately.

Now, a little caveat is endometrial cancer. One of the things I'll say is certainly you have diffuse thickening, you may have abnormalities and homogeneous appearance to it. Certainly if you turn doppler on, you may have diffuse flow in the mass. The other thing is if one tries to do a sonohysterography and you find that the cavity is difficult to keep distended, that's one of my little hints for endometrial cancer. And just the other day, this exact situation happened, I told the resident I was working with that we couldn't keep the cavity distended. I was concerned we did a sono biopsy, which I'll discuss shortly, and she had endometrial cancer.

Pearls for Success in SIS

Now the best time to do SIS is day five through 10. If a patient has very irregular cycles, you can withdraw them with a progestin agent and base your evaluation on the timing of their withdrawal. This helps avoid artifacts if thicken endometrium found in the luteal phase. Although if a patient arrives in the luteal phase, sometimes you can do an ultrasound and even in its unenhanced version, you can see and easily see this endometrial polyp against the background of luteal phase endometrium.

Now, my pearls for success is avoid air in the syringe or catheter, which means you should purge them with the liquid before you insert them in the uterus. You can use a catheter periodically if necessary to break up clots and also even touch lesions to see if it's truly a clot or a true filling defect. And I don't pre pre-prepare the patients for pain unless they're coming in for say, a Sonos angiography.

So in general, most of my patients don't take anything for pain. But if they do, a nine steroidal certainly is quite adequate. And what I caution is, is I tell the patients about when I expect to have pain, and that is as the catheter passes the internal loss or if it abuts the fundus. And so what I do is it passes the internal loss. I slow down and be very careful not to abut the fundus.

If you use a balloon catheter, fill the balloon with fluid, not air, infuse the balloon very slowly because this can be uncomfortable, particularly for AUS patients, and in fact, could induce a vasovagal reaction and infuse the saline slowly, particularly in patients who had prior tubal because it only takes one to three ccs to distend a cavity normally. And if there's no flow out, the patients can get some significant cramping.

If you use a Goldstein catheter, I stabilize acorn before removing the speculum. Don't allow the speculum to close on the cervix as it comes out and always remove your vaginal ultrasound probe. Be before removing the catheter. 'cause occasionally the acorn can be pulled off.

The other hand is with balloon catheters. To evaluate the lower uterine segment is decrease the balloon and infuse saline as you withdraw the catheter. And in so doing, you may even detect a cervical polyp, which we can see here in rendering from a multiplanar reconstruction.

The other concept however, is if you have a midplane or axial uterus or fibroids, you may find an abdominal probe quite helpful in doing your SIS. So keep that in mind. I also, as I said, draw, obtain a 3D sweep at the very beginning of my study. In the event I cannot keep the cavity distended and then allow adequate time to perform, interpret, and document the procedure.

Accuracy of SIS

How accurate is it? SIS and hysteroscopy are very close. Excellent sensitivity and specificity with SIS surpassing regular ultrasound and certainly surpassing the pipee, particularly in detecting myomas and polyps.

Sono Biopsy

Now let's talk about sono biopsy. A concept most people may not know about, and this has to go with the ability to histologically evaluate the uterus. If I'm doing an ultrasound and see a very thickened endometrium, or if I'm taking to patient to the OR for a minimally invasive conservative procedure, I want to know what the pathology is before I go to the or. And I was always a little disturbed with the fact that when I finished an SISI would then have to re remove the catheter, reinsert the speculum, and obtain a biopsy. And I said, well, why don't we just use the same catheter that we used for the SIS for a biopsy, which generated this concept of sono biopsy as a one step procedure.

So selection of patients, a thickened endometrium without, without a focal lesion or histologic evaluation prior to hysteroscopy, endometrial ablation or hysterectomy.

These are the two devices specifically designed for this. The first is a Bernard Leue, which is basically a pipe with a lure lock on it rather than a suction piston biopsy. And the Goldstein sono biopsy catheter, which is slightly thicker, a little stiffer with a larger opening than the traditional Goldstein catheter.

The setup is exactly the same as I use for every sono histogram. So no additional material is necessary. Here I've measured from the external loss to the fundus, it measures 6.3 centimeters. So when I move the acorn, I'll put my acorn about five and a half centimeters because I don't wanna abut the tip of the catheter at the fundus, I evacuate fluid from the catheter, place a syringe on, I do my sonohysterography first. I then withdraw fluid, expel any fluid that's remaining in the syringe. And then what I do is a biopsy by placing suction on the syringe and rotating the catheter 360 degrees.

A little hint, if you use a Goldstein catheter, just back the probe back a little bit. So the acorn has the ability to move in and out.

So here's an example. We do a Sona histogram. First, we see the cavity to stend very briefly. This is an excellent case for using 3D where I can take a sweep right now and get a full view. We have elected to do a biopsy because there's slight irregularity to the cavity and it is somewhat thicker than anticipated. So the 3D sweep that we took, here's a very quick 3D sweep, and what we can see is when you do multiplanar reconstruction, that this cavity has no focal lesions, intra cavitary lesion, such as a submucous myoma or endometrial polyp.

Here we can see now the catheter moving in and out when we do our biopsy. So under ultrasound guidance, you can actually determine that we're truly doing an in endometrial biopsy within the cavity and watching it for a 306 degree rotation.

Now here's another one. You've seen this SIS before, but we're also gonna do a biopsy this time with the shepherd catheter. And what you're gonna see is, as we do the biopsy, is you're gonna be able to see the catheter go in and out. So we'll see as we work here is that we're gonna see this catheter move in and out. We can see the bright echo from the internal stylet as we rotate it in and out, rotated 360 degrees, we can get an adequate sample.

Now in the work I've done, the shepherd gives a much smaller sample, but it is adequate for histologic analysis. The Goldstein catheter very equivalent to a regular suction piston biopsy instrument.

Now here's another thing that brought home the studies we've talked about previously. This patient has a sub mucus myoma that's being demonstrated on sonohysterography. We see it's a type one myoma, and that slightly more than 50% is exposed to the endometrial cavity. A type zero would be entirely exposed to type two would be, most of it would be in the endometrium. In the myometrium. We are now doing our biopsy. And what you see is this biopsy is going along the posterior wall of the endometrium. And despite being rotated 360 degrees, it is not sampling the entire endometrium.

And this brings home that study by Rodriguez. It said it only sampled 4% of the endometrium and only two and a half quadrants. So I think this is a fallacy that I have now come to realize that when I put a pipee or suction piston biopsy in blindly, I had the impression that I sampled the entire endometrial cavity. In fact, wherever it enters the cavity, if it buries itself into the endometrium, that's where you're gonna see its biopsy.

Here we have a patient who has an endometrial polyp, at least suspected because of the large number of cystic spaces that are present. We do a Sona histogram, which reveals a 3.3 by 1.9 millimeter endometrial polyp. And now when we do our biopsy, what you will see is along the anterior wall, you can see the movement of the catheter in and out. And despite being rotated 360 degrees, it's only biopsying one wall of the uterus. Again, one of the limitations of our blind biopsies with a suction piston biopsy instrument.

Pearls for Success in Sono Biopsy

Now what are the pearls for success? Measure the length from the external cervical loss to the top of the uterine fundus. Evacuate as much fluid as possible after your SIS before performing the biopsy. I use saline, not water, because saline does not affect histology water potentially. Could you reattach the syringe, apply negative pressure, rotate the catheter 360 degrees during the biopsy, and then rinse out the catheter after the biopsy with a formal and solution to assure you get all tissue specimen.

Sonosalpingography

Now, let's talk about sonography or what's often known as occi. This is really using saline infusion ultrasound to assess tubal patency basically for infertility. It allows you though also to evaluate the endometrial contour, assess tubal patency and look at the external contour of the uterus as well as looking at the adine exit.

Few CONT contraindications include acute pelvic infection or hydros, which is a relative contraindication. If during my initial ultrasound I detect the hydro soys, I will defer this procedure until a patient is on prophylactic antibiotics and I will warn her that it could reactivate underlying pelvic infection. So I typically treat these patients with five to 10 days of antibiotic therapy.

There are various mediums that are used in the United States. There is only saline and errors used. We do not use other high contrast agents as they do in Europe, but they have a very good concordance with other devices and other techniques.

This study by Katarina Exus looked at the various comparisons of occi to hyster, excuse me, occi to hying, agram, occi to laparoscopy and hying, agram to laparoscopy. And what we found was a concordance that's very equivalent across the board.

So one does an SIS initially, I then switch out that 10 cc syringe after I've done the SIS to a 30 cc syringe that contains half saline and half air. And then I assess tubal patency in the transverse orientation.

So the setup is very similar to before, except now I use have two saline bottles available. I fill it halfway with staining, then draw the syringe back so it's half air to affect the mixture rather than trying to shake the syringe and then attach it to the catheter. What I do is, is I orient the syringe towards the floor, which puts air in the upper portion of the syringe. When I insert that the air goes in first. If I then elevate the syringe towards the ceiling, the saline is the first thing that enters. So you just alternate floor ceiling for ceiling, and that'll alternate air and saline.

I do use a balloon catheter for this because you need to have pressure so that it does not return back through the cervix. If one wanted to be a little more sophisticated, you could use a three-way stop c**k with a connecting tubing, you open the stop c**k. So both syringes are open to the tubing, put saline in one syringe air in the other, and just have someone alternate saline and air. And that'll add, mix it. It works very well.

Now here's the saline infusion with the patient with coronal re construction shows a normal endometrial cavity. We then proceed with a sono iconography. We're in a transverse orientation and one can see is the air ad mixes with the saline that it causes scintillation. And we can see it easily flow through the left corneal region, out the left fallopian tube and into the peritoneal cavity. Note that it does not go through the right tube.

Here we look at another view. Again, we're putting some air in with saline going down the left fallopian tube. Scintillation is present. What I can do in this situation is tell the patient that we know you have a patent tube. I can't determine if the right tube is occluded or if there was just tubal spasm. Unfortunately, whatever you do when you put fluid in is it'll go the path of least resistance. But in a, if you will, gross fashion, we can now tell the patient she has patent tubes.

Now, what does it look like when the tubes are not patent? Here we have a situation where we're looking and we're now looking at the right fallopian tube And we can see the air ad mixes with the fluid and we can see there's no flow out. It looks like it starts to enter the right corneal region, but we see no flow out through that tube. If we go down and look at the left as well, What we see is again, we see fluid and error mixed together. We're looking towards the left side and we see no scintillation.

So in this instance, I cannot prove that this patient has patent fallopian tubes. I cannot tell you whether this is due to tubal spasm or true proximal tubal occlusion, but I can determine it's not patent.

Now the limitations of this procedure is it's a very gross procedure to say, are the tubes open? It does not tell me about intra tubal anatomy such as sitis osa.

Coding

Now, coding's important for the procedures we do. These are the codes one uses for sonohysterography. The 7 6 8 3 1 code involves the ultrasound interpretation and performance, whereas a 5 8 3 4 0 involves the procedure of placing contrast into the uterine cavity. So both of these codes apply for St. Satan infusion. I will caution you that if you look at S Satan infusion includes all elements of a transvaginal ultrasound. So you do not bill for that separately. And noting color flow doppler. If you've evaluated the adnexa, for instance with Doppler, you do not add on a doppler code with sono SAP angiography, you use exactly the same code.

Some people recommend using an HSG code as well that is not recommended by the American Society of Reproductive Medicine. Use the same codes as a sonohysterography. If one does sono biopsy, you use the codes for sono histogram, the two codes with that, and you add the code in for an endometrial biopsy, which is totally appropriate.

Conclusion

So in conclusion, sonohysterography is a simple technique with a low complication rate. It's well tolerated, tolerated by the patient. It's easily performed in the office with minimal equipment required with a high sensitivity and specificity, and certainly aids in preoperative counseling and triage.

So ultrasound compliments hysteroscopy. It determines on your initial screening if a biopsy is even necessary. It gives us the advantage of looking at the adnexa and bladder. It does help identify intracavitary lesions and then determines is the patient a more appropriate surgical candidate for hysteroscopy or hysterectomy With sonar hysteroscopy, it certainly gives you better delineation and characterization of the cavity than we do on transvaginal ultrasound. And I think actually may replace transvaginal ultrasound as a first line test in patients for abnormal bleeding. But the caveat that if you have a very thin endometrium, you don't need to proceed with sonohysterography.

It doesn't require a large capital investment because most people have ultrasounds with vaginal probes in their office and there is a low cost of disposables and reusables and one gets competitive reimbursement for the time spent with sono biopsy, it's a one step procedure. You do the sono histogram and the endometrial biopsy at one, sitting with one catheter. The sample appears to offer a diagnostic comparable to that of a pipee or suction piston biopsy instrument. And the addition of ultrasound with SIS helps detection of intracavitary and ovarian lesions and ultimately with Sonos angiography, it's equivalent to HSG. In assessing tubal patency, as I said, it does not reliably, however, demonstrate intra tubal abnormalities. It does allow evaluation of the external uterine contour and again, allows us to evaluate the adnexa, the ovaries, and the tubes.

I'd like to thank you very much for your attention.