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Clinical utility of saline solution infusion sonohysterography in a primary care obstetric-gynecologic practice
Clinical utility of saline solution infusion sonohysterography in a primary care obstetric-gynecologic practice Mafilyn It, Laughead, MD, and Lisa M. Stones, RDMS Phoenix, Arizona OBJECTIVE: The purpose of this study was to evaluate the role of saline solution infusion sonohysterography in clinical practice in patients with abnormal uterine bleeding. STUDY DESIGN: A prospective case-controlled study was conducted comparing two-dimensional transvaginal imaging with saline solution infusion sonohysterography, endometrial biopsies, and histologic evaluation after surgical procedures. One hundred twenty-four patients with abnormal uterine bleeding were scanned transabdominally and transvaginally. Patients with an increased endometrial thickness or a poorly defined endometrium underwent saline solution infusion sonohysterography. Sterile saline solution, 4 to 10 ml, was injected into the endometrial cavity under direct ultrasonographic visualization. Once the endometrium was expanded, the presence of polyps or myomas and the anterior and posterior endometrial thickness was assessed. RESULTS: Fifty-six patients were noted to have uterine leiomyomas. Eighteen patients had endometrial polyps. Five patients had simple endometrial hyperplasia. Two patients had atypical hyperplasia. No patients in this study had endometrial cancer. No complications occurred in this group of patients. CONCLUSION: Saline solution infusion sonohysterography is a procedure that aids the clinician in the management of abnormal uterine bleeding and may be more cost effective than traditional methods of evaluation. (Am J Obstet Gynecot 1997;176:1313-8.)
Key word,~: Abnormal uterine bleeding, saline solution infusion sonohysterography, ultrasonography
Abnormal uterine bleeding is a common presenting complain| of women seen in a gynecologist's office. It can occur at any age. It may be due to anovulation, pregnancy problems, hormonal factors, and benign or malign a n t pelvic lesions. Use of ultrasonography has been shown by several investigators to aid in the diagnosis of abnormal uterine bleeding |hrough the evaluation of the endometrium, a-6 In postmenopausal women studies have shown that no cancer was found in patients with an endometrial thickness of -<5 mm. 79 Nasri et al. 1° therefore proposed that in postmenopausal patients with an endometrial thickness -<5 ram that no further screening is necessary for endometrial cancer. To more adequately evaluate the endometrium, saline solution infusion sonohysterography was described by Parsons and Lense 11 in 1993. This technique was also found by Goldstein 12 to be beneficial for evaluation of perimenopausal patients with unexplained uterine bleedPresented at the Sixty-third Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Sunrive~; Oregon, October 2-6, 1996. Reprint requests: Marilyn K. Laughead, MD, 13737 N. 92nd St., Scottsdale, AZ 85260. Copyright © 1997 by Mosby-Year Book, Inc. 0002-9378/97 $5.00 + 0 6/6/80915
ing and by Dubinsky et al. 13 in evaluating postmenopausal patients with endometrial thickening. We therefore sought to evaluate this technique in patients with abnormal uterine bleeding seen in a primary care obstetrics-gynecology office. Material and m e t h o d s
Patients from a primary care obstetrics-gynecology office with complaints of abnormal uterine bleeding were eligible to be entered in the study. The abnormal bleeding consisted of patients with menorrhagia, metrorrhagia, intermenstrual, or postmenopausal bleeding; patients receiving sequential hormonal therapy bleeding at irregular intervals; and patients receiving continuous hormonal therapy having bleeding after 6 months of use. Between Jan. 1, 1994, and June 30, 1996, 124 patients met these criteria. Patients with pregnancy-related bleeding were excluded from the study, as were patients receiving oral contraceptives who had breakthrough bleeding. The patients in this study ranged from 36 to 70 years old with a mean age of 48 years. Twenty patients were premenopausal, 62 patients were perimenopausal, and 42 patients were postmenopausal. Of the 124 patients evaluated, t14 underwent saline solution infusion sonohysterography. 1313
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Fig. 1. Longitudinal view of endometrium after instillation of saline solution. This reveals submucous myoma distorting endometrial canal. Patients were evaluated in a standard fashion, including transabdominal and transvaginal ultrasonography. Scanning was performed with an Acoustic Imaging 5200 (Phoenix, Ariz.) 3.5 or 5.0 MHz abdominal curvilinear transducer and a 5.0 MHz vaginal probe. When possible, patients were scheduled for ultrasonographic evaluation during the early or midproliferative phase, after menses had ended. Initially the patients were evaluated with an abdominal transducer to measure the uterus and evaluate any potential pathologic conditions outside the focal length of the vaginal transducer. The uterus and endometrium were then more clearly defined with the vaginal probe. In 10 patients a thin stripe of endometrium measuring --<4 mm was clearly seen from cervix to fundus. These patients did not undergo saline solution infusion sonohysterography. The patients who underwent saline solution infusion sonohysterography were postmenopausal patients with an endometrial thickness >5 ram, premenopausal and perimenopausal patients with an endometrium > 8 mm, and those patients with an endometrium that could not be defined regardless of menstrual state. (The 8 mm endometrial thickness was based on the work of Fleisher et al., 1 who showed that an endometrial thickness of up to 8 m m in the late proliferative phase occurred in normal patients.) Next a speculum with a side opening was placed in the vagina. A sterile preparation of the cervix was done with povidone-iodine. A Soules 5.3F intrauterine insemination catheter (Cook Ob Gyn, Spencer, Ind.) was threaded into the cervix, after the size of the uterus was adjusted for, to place the catheter tip at the entrance of the endometrial cavity. The speculum was removed and the vaginal probe was reinserted posterior to the catheter. U n d e r direct ultrasonographic visualization and with use of a 20 ml syringe,
June 1997 AmJ Obstet Gynecol
sterile saline solution was injected to distend the endometrial cavity until the e n d o m e t r i a l cavity was clearly seen. A total of 4 to 10 ml of saline solution was usually instilled. In cases where the patency of the cervix allowed the saline solution to leak out without adequate distention, an Ackrad 5F hysterosalpingogram catheter with an inflatable balloon placed in the cervix (Cranford, NJ.) was used. The Soules catheter was used in 105 patients and the Ackrad catheter in 9 patients. The contours of the endometrial cavity were evaluated from os to fundus and from tubal ostia to tubal ostia in the longitudinal and transverse planes. The anterior and posterior endometrial thickness was measured in the longitudinal plane. If polyps or submucous myomas were present, the location was noted and the lesions were measured. Invasive endometrial sampling was done the following day with a ZSI endometrial curette except in those patients with endometrial polyps who instead underwent a curettage. Endometrial biopsy was done the following day instead of the same day because of concern regarding the adequacy of the sample as a result of saline solution dilution. The tissue samples obtained were evaluated and then correlated with the ultrasonographic findings.
Results O f the 114 patients who underwent saline solution infusion sonohysterography, 56 had uterine leiomyomas that ranged in size from 1 to 13.7 cm in diameter. The n u m b e r of myomas in a patient varied from one to six. The myomas were seen as hypoechoic or echogenic masses within the myometrium. Some of these masses caused uterine contour deformity, poor acoustic transmission, or distortion of the endometrium. Of these patients with leiomyomas, 48 had intramural myomas and 8 had submucous myomas. The intramural myomas were identified before saline solution infusion sonohysterography. None of the submucous myomas were defined as such until after the introduction of saline solution, when the relationship of the myoma to the endometrial cavity could be identified. The submucous myomas could be seen as echogenic masses distorting the endometrial cavity and originating in the myometrium with varying depths penetrating into the myometrium (Fig. 1). The surgical histologic findings of these 8 patients confirmed the diagnosis of leiomyoma. In patients with a thickened endometrium (>5 m m in postmenopausal patients and > 8 m m in premenopausal or perimenopausal patients) saline solution infusion sonohysterography outlined in 18 patients polyps that were not identified as such before instillation of the saline solution. The polyps were seen as echogenic masses contained within the endometrial cavity and
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Fig. 2. A, Longitudinal view of endometrium before instillation of saline solution. B, Longitudinal view of patient in A after instillation of saline solution. This now reveals endometrial polyp with endometrial thickness of 6 ram. C, Transverse view of patient in A after instillation of saline solution. s u r r o u n d e d by fluid with a narrow or b r o a d base (Fig. 2). T h e polyps varied from 6 to 32 m m in length. All 18 patients had a hysteroscopic evaluation before surgical excision, Polyps were c o n f i r m e d with the hysteroscope in each of these patients. T h e histologic characteristics of the surgical specimens were consistent with benign end o m e t r i a l polyp. In o n e patient the pathologic examination showed b e n i g n polyp with mild atypia. Forty-six patients with thickened e n d o m e t r i u m but otherwise n o r m a l - a p p e a r i n g e n d o m e t r i u m on the sonog r a m had b e n i g n e n d o m e t r i u m that was proliferative or secretory on e x a m i n a t i o n of the biopsy specimen. In two patients in this g r o u p the histologic e x a m i n a t i o n showed a polypoid pattern o f tissue. A polyp was n o t identified on s o n o g r a m in these two patients. In 19 patients with a t h i c k e n e d e n d o m e t r i u m on s o n o g r a m 11o polyps or myomas were seen. T h e e n d o m e trial thickness r a n g e d f r o m 10 to 16 mm. In these patients the pathologic e x a m i n a t i o n showed 2 with simple hyperplasia, 12 with d i s o r d e r e d e n d o m e t r i u m , and 2 with atypical a d e n o m a t o u s hyperplasia. In 20 patients the e n d o m e t r i u m could n o t be well d e f i n e d on sonogram. After saline solution infusion these patients were n o t e d to have an e n d o m e t r i u m of < 5 m m and all showed atrophic e n d o m e t r i u m on biopsy s p e c i m e n examination.
Patient response to the p r o c e d u r e was favorable. No patient r e q u i r e d analgesia for the p r o c e d u r e . O n e third o f the patients had mild c r a m p i n g while the saline solution was instilled, which lasted for 3 to 4 seconds. Even in the postmenopausal patients it was possible to insert the catheter without significant pain. Prophylactic antibiotics were n o t used. No patients had postprocedural infection or o t h e r complications f r o m this procedure.
Comment In patients with a b n o r m a l b l e e d i n g part o f the evaluation process in the past has i n c l u d e d invasive procedures such as e n d o m e t r i a l biopsy or curettage. Ultrasonography was i n t r o d u c e d as a noninvasive test. O u r studies indicate that with the addition o f saline solution infusion sonohysterography, a m o r e specific diagnosis can be o b t a i n e d in an office setting. In the evaluation process saline solution infusion sonohysterography may be c o m p l e m e n t a r y to diagnostic hysteroscopy and endometrial biopsy but can be d o n e as the initial diagnostic p r o c e d u r e . E m a n u e l et al. ~4 felt that transvaginal ultrasonography could be i m p l e m e n t e d as a routine first-step p r o c e d u r e in patients with a b n o r m a l uterine bleeding. T h e i r r e c o m m e n d a t i o n was to p r o c e e d with diagnostic hysteroscopy or o t h e r further studies in cases of an
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abnormal or inconclusive sonogram. Saline solution infusion sonohysterography offers a study that can more clearly visualize the endometrium and may potentially eliminate the need for other studies such as endometrial biopsy. In the 10 patients not evaluated with saline soludon infusion sonohysterography, the biopsy results were not particularly helpful in the management because these patients were treated hormonally. The sonogram alone was far more helpful, confirming the studies by several authors.7, 9, a0 In the future it is likely that many endometrial biopsies could be avoided in this group of patients. Saline solution infusion sonohysterography afforded better visualization of the endometrium in patients with leiomyomas. Being able to see the extent of the myomas and the penetration into the endometrial cavity made it possible to help identify those patients who could further be treated with hysteroscopic resection, which included 3 patients. It was also possible to identify those patients with polyps and proceed to a surgical and therapeutic procedure, bypassing the need for an endometrial biopsy. However, saline solution infusion sonohysterography cannot always be used alone. In the patients with simple hyperplasia or adenomatous hyperplasia the saline solution infusion sonohysterography helped to identify an abnormality, but histologic diagnosis was necessary in deciding the best treatment modality. In this study a comparison of hysteroscopy with saline solution infusion sonohysterography was not done. Widrich et al?5 compared saline solution infusion sonography with office hysteroscopy and concluded that there was no difference in the procedures in detecting endometrial polyps, myomas, synechiae, hyperplasia, endometrial cancer, or normal uterine cavities. Although endometrial biopsies were done the following day in this study, we now remove the saline solution through the catheter with the syringe after the ultrasonographic studies are completed. The endometrial biopsy is then done the same day, which is more cost effective and has better patient acceptance because the patient does not have to return to the office another day. Finally, one significant advantage of saline solution infusion sonohysterography not yet addressed is the ease and quickness with which this procedure can be learned by an individual already performing ultrasonography. This is particularly important in a private practice setting where competition for educational time is significant. In summary, fluid instillation into the endometrial cavity is a procedure rarely associated with infections or complications. It is minimally painful, requiring no analgesia, while enhancing the ability to make a diagnosis in patients with abnormal uterine b l e e d i n g . Clinical pathways that incorporate sonohysterography in this group of patients may not only enhance diagnostic ability
June 1997 Am J Obstet Gynecol
but also reduce the overall costs of care by eliminating unnecessary procedures. REFERENCES
1. Fleischer AC, Kalemeris GC, Machin JE, Entman SS, James AE. Sonographic depiction of normal and abnormal endometrium with histopathologic correlation. J Ultrasound Med 1986;5:445-52. 2. Fleischer AC, Mendelson EB, Bohm-Velez M, Entman SS. Transvaginal and transabdominal sonography of the endometrium. Semin Ultrasound CT MR 1988;9:81-101. 3. Mendelson EB, Bohm-Velez M, Joseph N, Neiman HL. Endometrial abnormalities: evaluation with transvaginal sonography. AJR Am J Roentgenol 1988;150:139-242. 4. Smith P, Bakos O, Heimer G, Ulmsten U. Transvaginal ultrasound for identifying endometrial abnormality. Acta Obstet Gynecol Scand 1991;70:591-4. 5. Dodson MG. Use of transvaginal ultrasound in diagnosing the etiology of menometrorrhagia. J Reprod Med 1994;39: 362-72. 6. Kupfer MC, Schiller VL, Hansen GC, Tessler FN. Transvaginal sonographic evaluation of endometrial polyps. J Ultrasound Med 1994;13:535-9. 7. Goldstein SR, Nachtigall M, Snyder JR, Nachtigall L. Endometrial assessment by vaginal ultrasonography before sampling in patients with postmenopausal bleeding. Am J Obstet Gynecol 1990;163:119-23. 8. Granberg S, Wikland M, Karlsson B, Norstrom A, Friberg L. Endometrial thickness as measured by endovaginal ultrasonography for identifying endometrial abnormality. Am J Obstet Gynecol 1991;164:47-52. 9. Karlsson B, Granberg S, Wikland M, Yl6stalo P, Torrid K, Marsal K, et al. Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding--a Nordic multicenter study. AmJ Obstet Gynecol 1995;172:148894. 10. Nasri MN, ShepherdJH, Setchell ME, Lowe DG, Chard T. The role of vaginal scan in measurement of endometrial thickness in postmenopausal women. Br J Obstet Gynaecol 1991;98:470-5. 11. Parsons AK, Lense ~. Sonohysterography for endometrial abnormalities: preliminary results. J Clin Ultrasound 1993; 21:87-95. 12. Goldstein S. Use of ultrasonohysterography for triage of perimenopausal patients with unexplained uterine bleeding. Am J Obstet Gynecol 1994;170:565-70. 13. Dubinsky TJ, Parvey HR, Gormay G, Maklad N. Transvaginal hysterosonography in the evaluation of small endoluminal masses. J Ultrasound Med 1995;14:1-6. 14. Emanuel MH, Verdel MJ, Wamsteker K, Lammes FB. A prospective comparison of transvaginal ultrasonography and diagnostic hysteroscopy in the evaluadon of patients with abnormal uterine bleeding: clinical implications. AmJ Obstet Gynecol 1995;172:547-52. 15. Widrich T, Bradley LD, Mitchinson AR, Collins RL. Comparison of saline infusion sonography with office hysteroscopy for the evaluation of the endometrium. Am J Obstet Gynecol 1996;174:1327-34.
Editors' note: This manuscript was revised after these
discussions were presented. Discussion
DR. KENNETHA. BtrRRV, Portland, Oregon. Dr. Laughead has presented her clinical experience with a minimally invasive ultrasonography technique in the evaluation of women with abnormal uterine bleeding. The evaluation of the endometrium by ultrasonography has
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been described in the literature over the past 15 years. In the early 1980s pathologic conditions were described by abdominal ultrasonography of the uterus and abnormal endometrial echos were defined. By the mid 1980s Fleischer et al.~ characterized changes in the endometrium of normal cycles and correlated ultrasonographic findings with histologic findings in both normal and abnormal cycles. They defined an endometrial thickness of > 5 mra as abnormal in postmenopausal women with uterine bleeding. During the late 1980s transvaginal ultrasonography was in general use and shown to be superior to abdominal uhrasonography for evaluating the pelvis, especially for endometrial abnormalities. By 1991 SmiLh et al. 2 reported their experience with transvaginal ul trasonography preoperatively in 45 women with postmenopausal bleeding. There were four women with adenocarcinomas that were all identified by ultrasonography. The sensitivity in diagnosing pathologic conditions was 100%; however, the specificity was only 61% with a positive predictive value of 39%. Smith et al. concluded that "with further experience transvaginal ultrasonography might be used in clinical routine for diagnosing endometrial pathology." The use of transvaginal ultrasonography to evaluate the endometrium in women with dysfunctional uterine bleeding has become commonplace. In many clinics this method has replaced the endometrial biopsy for the evaluation of abnormal bleeding. Over the past year several reports have raised questions concerning the efficacy of transvaginal ultrasonography in evaluating endometrial pathologic conditions. Conoscend et al. ~ concluded that endometrial thickness was not sensitive enough to exclude pathologic conditions. They also reported that neither transvaginal ultrasonography nor hysteroscopy were sufficiently reliable to replace curettage in the diagnosis of endometrial pathology. 4 Earlier this year Wolman et al. 5 also concluded that "at this time, the role of vaginal sonography as an aid in determini~cig which women with postmenopausal bleeding should undergo curettage has yet to be determined. ,,5 To improve the diagnostic sensitivity and specificity of transvaginal ultrasound, adjuvant procedures have been used. The use of fluid injected into the uterus during ultrasonographic assessment was reported in 1984 as a test for rabal patency. 6 More recently, Parsons and Lense 7 reported their experience with sonohysterography in 39 women. They were able to correctly identify polyps, myomas, synechiae, endometrial hyperplasia, and cancer and verify their findings at surgery. This simple, well-toleramd procedure enhanced the transvaginal ultrasonographic examination. This year Cullinan et al. s also reported their experience by describing normal and abnormal findings of the endometrium by the use of sonohysterography. They were able to correctly diagnose adhesions, polyps, and myomas as well as focal hyperplasia. Widrich et al. 9 have also reported this year that saline solution infusion sonography is more sensitive for the detection of hyperplasia than hysteroscopy is. They con-
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clude that this procedure may become a screening method for endometrial cancer. There have been significant advances in medical ultrasonography over the past 15 years in which the endometrium has been assessed by this technology. The role of color Doppler imaging as an adjuvant to the evaluation gynecologic patient is yet to be fully realized. Further experience in clinical practices will be essential for establishing the role of this ever-evolving technique. This current article has contributed to the literature the sonohysterographic findings of another 124 women with abnormal uterine bleeding. Curettage will continue to be used to diagnose endometrial cancer; however, other causes of uterine bleeding, such as polyps and submucous myomas, can be accurately diagnosed and appropriately managed in a cost-effective m a n n e r by use of saline solutions infusion sonohysterography in the office. I have the following questions. (1) In which patients do you currently perform an endometrial biopsy? (2) How many fewer biopsies do you now perform? (3) How much is the cost difference between this procedure and a standard biopsy? (4) Do you have any experience with color flow Dopplei" imaging as a adjuvant procedure in the evaluation of these patients? REFERENCES
1. Fleischer AC, Kalemeris GC, Machin JE, et al. Sonographic depiction of normal and abnormal endometrium with histopathologic correlation. J Ultrasound Med 1986;5:445-52. 2. Smith P, Bakos O, Heimer G, Utmsten U. Transvaginal ultrasound for identifying endometrial abnormality. Acta Obstet Gynecol Scand 1991;70:5914. 3. Conoscenti G, Meir YJ, Fischer-Tamaro L, et al. Endometrial assessment by transvaginal sonography and histological findings after D&C in women with postmenopausal bleeding. Ultrasound Obstet Gyuecol 1995;6:108-15. 4. Conoscenti G, Meir Y, Fiscber-Tamaro L, et al. The diagnostic capacities of transvaginal echography and hysteroscopy in the characterization of endometrial pathology. Minerva Ginecol 1995;47:293-300. 5. Wolman I; SagiJ, Ginat S, et al. The sensitivityand specificity of vaginal sonography in detecting endometrial abnormalities in women with postmenopausal bleeding. J Clin Ultrasound 1996;24:79-82. 6. Richman TS, Viscomi GN, deCherneyA, et al. Fallopian tubal patency assessed by ultrasound following fluid injection. Radiology 1984;152:507-i0. 7. Parsons AK, Lense ~. Sonohysterography for endometrial abnormalities: preliminary results. J Clin Ultrasound 1993; 21:87-95. 8. CullinanJA, Fleischer AC, Kepple DM, Arnold AL. Sonohysterography: a technique for endometrial evaluation. Radiographics 1995;15:501-14. 9. Widrich T, Bradley LD, Mitchinson AR, Collins RL. Comparison of saline infusion sonography with office hysteroscopy for the evaluation of the endometrium. AmJ Obstet Gynecol 1996;174:1327-34. DR. THOMASR. HOLBERT,Los Angeles, California. First, I do a lot of vaginal ultrasonography and frequently can see submucous myomas and endometrial polyps. How many times do you find something on sonohysterography that you did not suspect from the ultrasonography itself?, Second, with the instillation of saline solution in patients who may have endometrial cancer, do you have
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any concerns regarding the spread of cancer cells through the fallopian tubes? DR. FRANKR. GAMBERI)ELLA,Santa Barbara, California. Although sonohysterography seems valuable to delineate a cavitary defect, endometrial sampling for confirmation of histologic diagnosis would seem essential. An example is a case of a 40-year-old infertility patient, gravida 0, with normal menses. Sonohysterography demonstrated a pedunculated, submucous fibroid, as did a hysterosalpingogram, which also showed tubal occlusion. At minilaparotomy, to perform pelvic reconstructive surgery and myomectomy, the pedunculated lesion within the uterine cavity proved to be a well-differentiated adenocarcinoma in a polypoid mass. In light of this case, I would question the statement that endometrial sampling may not be indicated, even in young patients. DR. THOMAS W. POWFa~S,Arcadia, California. Do you perform office hysteroscopy? It is an inexpensive technique and very fast. A lot of expensive equipment is not required, only a 30-degree lens with a 5 m m sheath. Any standard hysteroscopic medium can be used for uterine distention. Most of the time visualization is excellent, and selective biopsies or a simple endometrial biopsy suction curettage can be done after hysteroscopy. More diagnostic information can be obtained and it is less likely that a serious lesion will be missed. DR. R. GLEN F. STEINI~, Fresno, California. Saline solution infusion ultrasonography, like hysteroscopy, is another way of visualizing the endometrial cavity. Do you s e e this procedure as being superior to hysteroscopy both in terms of visualization and in lower costs? DR. MALCOLML MARGOUN, Los Angeles, California. Because it is simpler and quicker, I have replaced initial office hysteroscopy with sonohysterography. When an abnormality is found, hysteroscopy can be performed in the office, or, with a major abnormality, in the operating room. DR. RA~OND J. JEt~rNETr, Phoenix, Arizona. Do you have any problems getting saline solution infusion sonohysterography authorized by the various health maintenance organizations? DR. I.aUCHE~m (Closing). Dr. Burry and Dr. Gamberdella, an endometrial biopsy is performed when a diagnosis is n e e d e d in patients with a thick endometrium who have abnormal bleeding and no other pathologic condition. However, saline solution infusion sonohysterography does reduce the number of biopsies performed.
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In our study 38 the 124 patients (29%) did not undergo endometrial biopsy. The 36 patients had either a thin endometrium, polyps, or submucous myomas. Regarding the cost differential between an endometrial biopsy and a saline solution infusion sonohysterography, in the Phoenix area the cost of peMc ultrasonography is $185 to $275. In our office it costs $75 more. An endometrial biopsy costs $80 plus $60 for the office visit plus the pathologist's charge of $85 to $120, so by cost comparison saline solution infusion sonohysterography and endometrial biopsy are equivalent. Although I have not used color flow Doppler imaging because of its cost, investigators who have used it have not found that it aids saline solution infusion sonohysterography. Dr. Holbert, unless the endometrium can be clearly defined, pelvic ultrasonography alone cannot predict the findings after saline solution infusion hysterography. Although there may be theoretic concerns regarding the spread of cancer cells through the fallopian tubes, several long-term studies after hysterosalpingography serve to allay those fears. Dr. Gamberdella, any patients, regardless of age, who have endometrial lesions found on saline solution infusion hysterography need to have histologic confirmation, which is usually done at curettage or hysteroscopic resection. Dr. Powers, I do not do office hysteroscopy, but I do use hysteroscopy in the operating room. Dr. Steinke, because I do no office hysteroscopy, I cannot say that saline solution infusion hysterography is superior to hysteroscopy. In the April 1996 issue of the AmericanJournal of Obstetricsand Gynecology,Widrich et a l / compared hysteroscopy with saline solution infusion sonohysterography, which was found to be the more beneficial in the diagnosis of endometrial hyperplasia and had less pain associated with it. Dr. Jennett, to have the procedure reimbursed by health plans, it is helpful to include a description of the procedure. In my office the same code is used for hysterosalpingograms. REFERENCE
1. Widrich T, Bradley LD, Mitchinson AR, Collins RL. Comparison of saline infusion sonography with office hysteroscopy for the evaluation of the endometrium. AmJ Obstet Gynecol :1996;174:1327-34.
Key word,~: Abnormal uterine bleeding, saline solution infusion sonohysterography, ultrasonography
Abnormal uterine bleeding is a common presenting complain| of women seen in a gynecologist's office. It can occur at any age. It may be due to anovulation, pregnancy problems, hormonal factors, and benign or malign a n t pelvic lesions. Use of ultrasonography has been shown by several investigators to aid in the diagnosis of abnormal uterine bleeding |hrough the evaluation of the endometrium, a-6 In postmenopausal women studies have shown that no cancer was found in patients with an endometrial thickness of -<5 mm. 79 Nasri et al. 1° therefore proposed that in postmenopausal patients with an endometrial thickness -<5 ram that no further screening is necessary for endometrial cancer. To more adequately evaluate the endometrium, saline solution infusion sonohysterography was described by Parsons and Lense 11 in 1993. This technique was also found by Goldstein 12 to be beneficial for evaluation of perimenopausal patients with unexplained uterine bleedPresented at the Sixty-third Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Sunrive~; Oregon, October 2-6, 1996. Reprint requests: Marilyn K. Laughead, MD, 13737 N. 92nd St., Scottsdale, AZ 85260. Copyright © 1997 by Mosby-Year Book, Inc. 0002-9378/97 $5.00 + 0 6/6/80915
ing and by Dubinsky et al. 13 in evaluating postmenopausal patients with endometrial thickening. We therefore sought to evaluate this technique in patients with abnormal uterine bleeding seen in a primary care obstetrics-gynecology office. Material and m e t h o d s
Patients from a primary care obstetrics-gynecology office with complaints of abnormal uterine bleeding were eligible to be entered in the study. The abnormal bleeding consisted of patients with menorrhagia, metrorrhagia, intermenstrual, or postmenopausal bleeding; patients receiving sequential hormonal therapy bleeding at irregular intervals; and patients receiving continuous hormonal therapy having bleeding after 6 months of use. Between Jan. 1, 1994, and June 30, 1996, 124 patients met these criteria. Patients with pregnancy-related bleeding were excluded from the study, as were patients receiving oral contraceptives who had breakthrough bleeding. The patients in this study ranged from 36 to 70 years old with a mean age of 48 years. Twenty patients were premenopausal, 62 patients were perimenopausal, and 42 patients were postmenopausal. Of the 124 patients evaluated, t14 underwent saline solution infusion sonohysterography. 1313
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Fig. 1. Longitudinal view of endometrium after instillation of saline solution. This reveals submucous myoma distorting endometrial canal. Patients were evaluated in a standard fashion, including transabdominal and transvaginal ultrasonography. Scanning was performed with an Acoustic Imaging 5200 (Phoenix, Ariz.) 3.5 or 5.0 MHz abdominal curvilinear transducer and a 5.0 MHz vaginal probe. When possible, patients were scheduled for ultrasonographic evaluation during the early or midproliferative phase, after menses had ended. Initially the patients were evaluated with an abdominal transducer to measure the uterus and evaluate any potential pathologic conditions outside the focal length of the vaginal transducer. The uterus and endometrium were then more clearly defined with the vaginal probe. In 10 patients a thin stripe of endometrium measuring --<4 mm was clearly seen from cervix to fundus. These patients did not undergo saline solution infusion sonohysterography. The patients who underwent saline solution infusion sonohysterography were postmenopausal patients with an endometrial thickness >5 ram, premenopausal and perimenopausal patients with an endometrium > 8 mm, and those patients with an endometrium that could not be defined regardless of menstrual state. (The 8 mm endometrial thickness was based on the work of Fleisher et al., 1 who showed that an endometrial thickness of up to 8 m m in the late proliferative phase occurred in normal patients.) Next a speculum with a side opening was placed in the vagina. A sterile preparation of the cervix was done with povidone-iodine. A Soules 5.3F intrauterine insemination catheter (Cook Ob Gyn, Spencer, Ind.) was threaded into the cervix, after the size of the uterus was adjusted for, to place the catheter tip at the entrance of the endometrial cavity. The speculum was removed and the vaginal probe was reinserted posterior to the catheter. U n d e r direct ultrasonographic visualization and with use of a 20 ml syringe,
June 1997 AmJ Obstet Gynecol
sterile saline solution was injected to distend the endometrial cavity until the e n d o m e t r i a l cavity was clearly seen. A total of 4 to 10 ml of saline solution was usually instilled. In cases where the patency of the cervix allowed the saline solution to leak out without adequate distention, an Ackrad 5F hysterosalpingogram catheter with an inflatable balloon placed in the cervix (Cranford, NJ.) was used. The Soules catheter was used in 105 patients and the Ackrad catheter in 9 patients. The contours of the endometrial cavity were evaluated from os to fundus and from tubal ostia to tubal ostia in the longitudinal and transverse planes. The anterior and posterior endometrial thickness was measured in the longitudinal plane. If polyps or submucous myomas were present, the location was noted and the lesions were measured. Invasive endometrial sampling was done the following day with a ZSI endometrial curette except in those patients with endometrial polyps who instead underwent a curettage. Endometrial biopsy was done the following day instead of the same day because of concern regarding the adequacy of the sample as a result of saline solution dilution. The tissue samples obtained were evaluated and then correlated with the ultrasonographic findings.
Results O f the 114 patients who underwent saline solution infusion sonohysterography, 56 had uterine leiomyomas that ranged in size from 1 to 13.7 cm in diameter. The n u m b e r of myomas in a patient varied from one to six. The myomas were seen as hypoechoic or echogenic masses within the myometrium. Some of these masses caused uterine contour deformity, poor acoustic transmission, or distortion of the endometrium. Of these patients with leiomyomas, 48 had intramural myomas and 8 had submucous myomas. The intramural myomas were identified before saline solution infusion sonohysterography. None of the submucous myomas were defined as such until after the introduction of saline solution, when the relationship of the myoma to the endometrial cavity could be identified. The submucous myomas could be seen as echogenic masses distorting the endometrial cavity and originating in the myometrium with varying depths penetrating into the myometrium (Fig. 1). The surgical histologic findings of these 8 patients confirmed the diagnosis of leiomyoma. In patients with a thickened endometrium (>5 m m in postmenopausal patients and > 8 m m in premenopausal or perimenopausal patients) saline solution infusion sonohysterography outlined in 18 patients polyps that were not identified as such before instillation of the saline solution. The polyps were seen as echogenic masses contained within the endometrial cavity and
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Fig. 2. A, Longitudinal view of endometrium before instillation of saline solution. B, Longitudinal view of patient in A after instillation of saline solution. This now reveals endometrial polyp with endometrial thickness of 6 ram. C, Transverse view of patient in A after instillation of saline solution. s u r r o u n d e d by fluid with a narrow or b r o a d base (Fig. 2). T h e polyps varied from 6 to 32 m m in length. All 18 patients had a hysteroscopic evaluation before surgical excision, Polyps were c o n f i r m e d with the hysteroscope in each of these patients. T h e histologic characteristics of the surgical specimens were consistent with benign end o m e t r i a l polyp. In o n e patient the pathologic examination showed b e n i g n polyp with mild atypia. Forty-six patients with thickened e n d o m e t r i u m but otherwise n o r m a l - a p p e a r i n g e n d o m e t r i u m on the sonog r a m had b e n i g n e n d o m e t r i u m that was proliferative or secretory on e x a m i n a t i o n of the biopsy specimen. In two patients in this g r o u p the histologic e x a m i n a t i o n showed a polypoid pattern o f tissue. A polyp was n o t identified on s o n o g r a m in these two patients. In 19 patients with a t h i c k e n e d e n d o m e t r i u m on s o n o g r a m 11o polyps or myomas were seen. T h e e n d o m e trial thickness r a n g e d f r o m 10 to 16 mm. In these patients the pathologic e x a m i n a t i o n showed 2 with simple hyperplasia, 12 with d i s o r d e r e d e n d o m e t r i u m , and 2 with atypical a d e n o m a t o u s hyperplasia. In 20 patients the e n d o m e t r i u m could n o t be well d e f i n e d on sonogram. After saline solution infusion these patients were n o t e d to have an e n d o m e t r i u m of < 5 m m and all showed atrophic e n d o m e t r i u m on biopsy s p e c i m e n examination.
Patient response to the p r o c e d u r e was favorable. No patient r e q u i r e d analgesia for the p r o c e d u r e . O n e third o f the patients had mild c r a m p i n g while the saline solution was instilled, which lasted for 3 to 4 seconds. Even in the postmenopausal patients it was possible to insert the catheter without significant pain. Prophylactic antibiotics were n o t used. No patients had postprocedural infection or o t h e r complications f r o m this procedure.
Comment In patients with a b n o r m a l b l e e d i n g part o f the evaluation process in the past has i n c l u d e d invasive procedures such as e n d o m e t r i a l biopsy or curettage. Ultrasonography was i n t r o d u c e d as a noninvasive test. O u r studies indicate that with the addition o f saline solution infusion sonohysterography, a m o r e specific diagnosis can be o b t a i n e d in an office setting. In the evaluation process saline solution infusion sonohysterography may be c o m p l e m e n t a r y to diagnostic hysteroscopy and endometrial biopsy but can be d o n e as the initial diagnostic p r o c e d u r e . E m a n u e l et al. ~4 felt that transvaginal ultrasonography could be i m p l e m e n t e d as a routine first-step p r o c e d u r e in patients with a b n o r m a l uterine bleeding. T h e i r r e c o m m e n d a t i o n was to p r o c e e d with diagnostic hysteroscopy or o t h e r further studies in cases of an
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abnormal or inconclusive sonogram. Saline solution infusion sonohysterography offers a study that can more clearly visualize the endometrium and may potentially eliminate the need for other studies such as endometrial biopsy. In the 10 patients not evaluated with saline soludon infusion sonohysterography, the biopsy results were not particularly helpful in the management because these patients were treated hormonally. The sonogram alone was far more helpful, confirming the studies by several authors.7, 9, a0 In the future it is likely that many endometrial biopsies could be avoided in this group of patients. Saline solution infusion sonohysterography afforded better visualization of the endometrium in patients with leiomyomas. Being able to see the extent of the myomas and the penetration into the endometrial cavity made it possible to help identify those patients who could further be treated with hysteroscopic resection, which included 3 patients. It was also possible to identify those patients with polyps and proceed to a surgical and therapeutic procedure, bypassing the need for an endometrial biopsy. However, saline solution infusion sonohysterography cannot always be used alone. In the patients with simple hyperplasia or adenomatous hyperplasia the saline solution infusion sonohysterography helped to identify an abnormality, but histologic diagnosis was necessary in deciding the best treatment modality. In this study a comparison of hysteroscopy with saline solution infusion sonohysterography was not done. Widrich et al?5 compared saline solution infusion sonography with office hysteroscopy and concluded that there was no difference in the procedures in detecting endometrial polyps, myomas, synechiae, hyperplasia, endometrial cancer, or normal uterine cavities. Although endometrial biopsies were done the following day in this study, we now remove the saline solution through the catheter with the syringe after the ultrasonographic studies are completed. The endometrial biopsy is then done the same day, which is more cost effective and has better patient acceptance because the patient does not have to return to the office another day. Finally, one significant advantage of saline solution infusion sonohysterography not yet addressed is the ease and quickness with which this procedure can be learned by an individual already performing ultrasonography. This is particularly important in a private practice setting where competition for educational time is significant. In summary, fluid instillation into the endometrial cavity is a procedure rarely associated with infections or complications. It is minimally painful, requiring no analgesia, while enhancing the ability to make a diagnosis in patients with abnormal uterine b l e e d i n g . Clinical pathways that incorporate sonohysterography in this group of patients may not only enhance diagnostic ability
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but also reduce the overall costs of care by eliminating unnecessary procedures. REFERENCES
1. Fleischer AC, Kalemeris GC, Machin JE, Entman SS, James AE. Sonographic depiction of normal and abnormal endometrium with histopathologic correlation. J Ultrasound Med 1986;5:445-52. 2. Fleischer AC, Mendelson EB, Bohm-Velez M, Entman SS. Transvaginal and transabdominal sonography of the endometrium. Semin Ultrasound CT MR 1988;9:81-101. 3. Mendelson EB, Bohm-Velez M, Joseph N, Neiman HL. Endometrial abnormalities: evaluation with transvaginal sonography. AJR Am J Roentgenol 1988;150:139-242. 4. Smith P, Bakos O, Heimer G, Ulmsten U. Transvaginal ultrasound for identifying endometrial abnormality. Acta Obstet Gynecol Scand 1991;70:591-4. 5. Dodson MG. Use of transvaginal ultrasound in diagnosing the etiology of menometrorrhagia. J Reprod Med 1994;39: 362-72. 6. Kupfer MC, Schiller VL, Hansen GC, Tessler FN. Transvaginal sonographic evaluation of endometrial polyps. J Ultrasound Med 1994;13:535-9. 7. Goldstein SR, Nachtigall M, Snyder JR, Nachtigall L. Endometrial assessment by vaginal ultrasonography before sampling in patients with postmenopausal bleeding. Am J Obstet Gynecol 1990;163:119-23. 8. Granberg S, Wikland M, Karlsson B, Norstrom A, Friberg L. Endometrial thickness as measured by endovaginal ultrasonography for identifying endometrial abnormality. Am J Obstet Gynecol 1991;164:47-52. 9. Karlsson B, Granberg S, Wikland M, Yl6stalo P, Torrid K, Marsal K, et al. Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding--a Nordic multicenter study. AmJ Obstet Gynecol 1995;172:148894. 10. Nasri MN, ShepherdJH, Setchell ME, Lowe DG, Chard T. The role of vaginal scan in measurement of endometrial thickness in postmenopausal women. Br J Obstet Gynaecol 1991;98:470-5. 11. Parsons AK, Lense ~. Sonohysterography for endometrial abnormalities: preliminary results. J Clin Ultrasound 1993; 21:87-95. 12. Goldstein S. Use of ultrasonohysterography for triage of perimenopausal patients with unexplained uterine bleeding. Am J Obstet Gynecol 1994;170:565-70. 13. Dubinsky TJ, Parvey HR, Gormay G, Maklad N. Transvaginal hysterosonography in the evaluation of small endoluminal masses. J Ultrasound Med 1995;14:1-6. 14. Emanuel MH, Verdel MJ, Wamsteker K, Lammes FB. A prospective comparison of transvaginal ultrasonography and diagnostic hysteroscopy in the evaluadon of patients with abnormal uterine bleeding: clinical implications. AmJ Obstet Gynecol 1995;172:547-52. 15. Widrich T, Bradley LD, Mitchinson AR, Collins RL. Comparison of saline infusion sonography with office hysteroscopy for the evaluation of the endometrium. Am J Obstet Gynecol 1996;174:1327-34.
Editors' note: This manuscript was revised after these
discussions were presented. Discussion
DR. KENNETHA. BtrRRV, Portland, Oregon. Dr. Laughead has presented her clinical experience with a minimally invasive ultrasonography technique in the evaluation of women with abnormal uterine bleeding. The evaluation of the endometrium by ultrasonography has
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been described in the literature over the past 15 years. In the early 1980s pathologic conditions were described by abdominal ultrasonography of the uterus and abnormal endometrial echos were defined. By the mid 1980s Fleischer et al.~ characterized changes in the endometrium of normal cycles and correlated ultrasonographic findings with histologic findings in both normal and abnormal cycles. They defined an endometrial thickness of > 5 mra as abnormal in postmenopausal women with uterine bleeding. During the late 1980s transvaginal ultrasonography was in general use and shown to be superior to abdominal uhrasonography for evaluating the pelvis, especially for endometrial abnormalities. By 1991 SmiLh et al. 2 reported their experience with transvaginal ul trasonography preoperatively in 45 women with postmenopausal bleeding. There were four women with adenocarcinomas that were all identified by ultrasonography. The sensitivity in diagnosing pathologic conditions was 100%; however, the specificity was only 61% with a positive predictive value of 39%. Smith et al. concluded that "with further experience transvaginal ultrasonography might be used in clinical routine for diagnosing endometrial pathology." The use of transvaginal ultrasonography to evaluate the endometrium in women with dysfunctional uterine bleeding has become commonplace. In many clinics this method has replaced the endometrial biopsy for the evaluation of abnormal bleeding. Over the past year several reports have raised questions concerning the efficacy of transvaginal ultrasonography in evaluating endometrial pathologic conditions. Conoscend et al. ~ concluded that endometrial thickness was not sensitive enough to exclude pathologic conditions. They also reported that neither transvaginal ultrasonography nor hysteroscopy were sufficiently reliable to replace curettage in the diagnosis of endometrial pathology. 4 Earlier this year Wolman et al. 5 also concluded that "at this time, the role of vaginal sonography as an aid in determini~cig which women with postmenopausal bleeding should undergo curettage has yet to be determined. ,,5 To improve the diagnostic sensitivity and specificity of transvaginal ultrasound, adjuvant procedures have been used. The use of fluid injected into the uterus during ultrasonographic assessment was reported in 1984 as a test for rabal patency. 6 More recently, Parsons and Lense 7 reported their experience with sonohysterography in 39 women. They were able to correctly identify polyps, myomas, synechiae, endometrial hyperplasia, and cancer and verify their findings at surgery. This simple, well-toleramd procedure enhanced the transvaginal ultrasonographic examination. This year Cullinan et al. s also reported their experience by describing normal and abnormal findings of the endometrium by the use of sonohysterography. They were able to correctly diagnose adhesions, polyps, and myomas as well as focal hyperplasia. Widrich et al. 9 have also reported this year that saline solution infusion sonography is more sensitive for the detection of hyperplasia than hysteroscopy is. They con-
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clude that this procedure may become a screening method for endometrial cancer. There have been significant advances in medical ultrasonography over the past 15 years in which the endometrium has been assessed by this technology. The role of color Doppler imaging as an adjuvant to the evaluation gynecologic patient is yet to be fully realized. Further experience in clinical practices will be essential for establishing the role of this ever-evolving technique. This current article has contributed to the literature the sonohysterographic findings of another 124 women with abnormal uterine bleeding. Curettage will continue to be used to diagnose endometrial cancer; however, other causes of uterine bleeding, such as polyps and submucous myomas, can be accurately diagnosed and appropriately managed in a cost-effective m a n n e r by use of saline solutions infusion sonohysterography in the office. I have the following questions. (1) In which patients do you currently perform an endometrial biopsy? (2) How many fewer biopsies do you now perform? (3) How much is the cost difference between this procedure and a standard biopsy? (4) Do you have any experience with color flow Dopplei" imaging as a adjuvant procedure in the evaluation of these patients? REFERENCES
1. Fleischer AC, Kalemeris GC, Machin JE, et al. Sonographic depiction of normal and abnormal endometrium with histopathologic correlation. J Ultrasound Med 1986;5:445-52. 2. Smith P, Bakos O, Heimer G, Utmsten U. Transvaginal ultrasound for identifying endometrial abnormality. Acta Obstet Gynecol Scand 1991;70:5914. 3. Conoscenti G, Meir YJ, Fischer-Tamaro L, et al. Endometrial assessment by transvaginal sonography and histological findings after D&C in women with postmenopausal bleeding. Ultrasound Obstet Gyuecol 1995;6:108-15. 4. Conoscenti G, Meir Y, Fiscber-Tamaro L, et al. The diagnostic capacities of transvaginal echography and hysteroscopy in the characterization of endometrial pathology. Minerva Ginecol 1995;47:293-300. 5. Wolman I; SagiJ, Ginat S, et al. The sensitivityand specificity of vaginal sonography in detecting endometrial abnormalities in women with postmenopausal bleeding. J Clin Ultrasound 1996;24:79-82. 6. Richman TS, Viscomi GN, deCherneyA, et al. Fallopian tubal patency assessed by ultrasound following fluid injection. Radiology 1984;152:507-i0. 7. Parsons AK, Lense ~. Sonohysterography for endometrial abnormalities: preliminary results. J Clin Ultrasound 1993; 21:87-95. 8. CullinanJA, Fleischer AC, Kepple DM, Arnold AL. Sonohysterography: a technique for endometrial evaluation. Radiographics 1995;15:501-14. 9. Widrich T, Bradley LD, Mitchinson AR, Collins RL. Comparison of saline infusion sonography with office hysteroscopy for the evaluation of the endometrium. AmJ Obstet Gynecol 1996;174:1327-34. DR. THOMASR. HOLBERT,Los Angeles, California. First, I do a lot of vaginal ultrasonography and frequently can see submucous myomas and endometrial polyps. How many times do you find something on sonohysterography that you did not suspect from the ultrasonography itself?, Second, with the instillation of saline solution in patients who may have endometrial cancer, do you have
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any concerns regarding the spread of cancer cells through the fallopian tubes? DR. FRANKR. GAMBERI)ELLA,Santa Barbara, California. Although sonohysterography seems valuable to delineate a cavitary defect, endometrial sampling for confirmation of histologic diagnosis would seem essential. An example is a case of a 40-year-old infertility patient, gravida 0, with normal menses. Sonohysterography demonstrated a pedunculated, submucous fibroid, as did a hysterosalpingogram, which also showed tubal occlusion. At minilaparotomy, to perform pelvic reconstructive surgery and myomectomy, the pedunculated lesion within the uterine cavity proved to be a well-differentiated adenocarcinoma in a polypoid mass. In light of this case, I would question the statement that endometrial sampling may not be indicated, even in young patients. DR. THOMAS W. POWFa~S,Arcadia, California. Do you perform office hysteroscopy? It is an inexpensive technique and very fast. A lot of expensive equipment is not required, only a 30-degree lens with a 5 m m sheath. Any standard hysteroscopic medium can be used for uterine distention. Most of the time visualization is excellent, and selective biopsies or a simple endometrial biopsy suction curettage can be done after hysteroscopy. More diagnostic information can be obtained and it is less likely that a serious lesion will be missed. DR. R. GLEN F. STEINI~, Fresno, California. Saline solution infusion ultrasonography, like hysteroscopy, is another way of visualizing the endometrial cavity. Do you s e e this procedure as being superior to hysteroscopy both in terms of visualization and in lower costs? DR. MALCOLML MARGOUN, Los Angeles, California. Because it is simpler and quicker, I have replaced initial office hysteroscopy with sonohysterography. When an abnormality is found, hysteroscopy can be performed in the office, or, with a major abnormality, in the operating room. DR. RA~OND J. JEt~rNETr, Phoenix, Arizona. Do you have any problems getting saline solution infusion sonohysterography authorized by the various health maintenance organizations? DR. I.aUCHE~m (Closing). Dr. Burry and Dr. Gamberdella, an endometrial biopsy is performed when a diagnosis is n e e d e d in patients with a thick endometrium who have abnormal bleeding and no other pathologic condition. However, saline solution infusion sonohysterography does reduce the number of biopsies performed.
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In our study 38 the 124 patients (29%) did not undergo endometrial biopsy. The 36 patients had either a thin endometrium, polyps, or submucous myomas. Regarding the cost differential between an endometrial biopsy and a saline solution infusion sonohysterography, in the Phoenix area the cost of peMc ultrasonography is $185 to $275. In our office it costs $75 more. An endometrial biopsy costs $80 plus $60 for the office visit plus the pathologist's charge of $85 to $120, so by cost comparison saline solution infusion sonohysterography and endometrial biopsy are equivalent. Although I have not used color flow Doppler imaging because of its cost, investigators who have used it have not found that it aids saline solution infusion sonohysterography. Dr. Holbert, unless the endometrium can be clearly defined, pelvic ultrasonography alone cannot predict the findings after saline solution infusion hysterography. Although there may be theoretic concerns regarding the spread of cancer cells through the fallopian tubes, several long-term studies after hysterosalpingography serve to allay those fears. Dr. Gamberdella, any patients, regardless of age, who have endometrial lesions found on saline solution infusion hysterography need to have histologic confirmation, which is usually done at curettage or hysteroscopic resection. Dr. Powers, I do not do office hysteroscopy, but I do use hysteroscopy in the operating room. Dr. Steinke, because I do no office hysteroscopy, I cannot say that saline solution infusion hysterography is superior to hysteroscopy. In the April 1996 issue of the AmericanJournal of Obstetricsand Gynecology,Widrich et a l / compared hysteroscopy with saline solution infusion sonohysterography, which was found to be the more beneficial in the diagnosis of endometrial hyperplasia and had less pain associated with it. Dr. Jennett, to have the procedure reimbursed by health plans, it is helpful to include a description of the procedure. In my office the same code is used for hysterosalpingograms. REFERENCE
1. Widrich T, Bradley LD, Mitchinson AR, Collins RL. Comparison of saline infusion sonography with office hysteroscopy for the evaluation of the endometrium. AmJ Obstet Gynecol :1996;174:1327-34.