Transvaginal Saline Contrast Sonohystography to Investigate Postmenopausal Bleeding: A Systematic Review.

Farshad Tahmasebi,Sarah Stewart,Anita Mitra,Mridula Morje,Ahmad Sayasneh

doi:10.7759/cureus.10094

Abstract

Transvaginal ultrasound (TVUS) is the initial investigation of choice for postmenopausal bleeding (PMB), followed by diagnostic hysteroscopy and endometrial sampling if abnormalities are detected. Saline contrast sonohysterography (SCSH) - injection of saline through the cervix into the uterine cavity prior to TVUS - allowed increased diagnostic accuracy in women with PMB in several small, heterogeneous studies.The objectives of the current study were to evaluate the diagnostic accuracy of SCSH in women with PMB, comparing findings with surgical and pathological reports, highlight the necessity of SCSH in guiding clinical decision-making, and establish if there is an increase/decrease in the number of hysteroscopies performed for PMB and, hence, the adherence of clinicians to imaging referral guidelines.The search strategy included formulating search terms identifying all synonyms of SCSH and postmenopause. The databases searched were MEDLINE, Embase, and the Cochrane Library.Only studies comparing SCSH to an alternative method were selected. The studies were screened and data analysis performed using content analysis. Data reduction was performed through systematic coding and the generation of themesWe identified 18 studies, comprising 974 women, using SCSH to evaluate the endometrial cavity in women with PMB; most support SCSH improving diagnostic accuracy through delineating intracavitary structures.In effect, SCSH could be a first-line investigative modality to assess the uterine cavity once a larger, well-designed study has been conducted to clarify its specificity, sensitivity, and positive predictive value (PPV). Owing to its relatively non-invasive nature and potentially high diagnostic accuracy, SCSH could allow for more accurate decisions regarding the need for further investigation and subsequent management.Tweetable abstract"Saline contrast sonohysterography improves the diagnostic accuracy of the endometrium in postmenopausal bleeding."

Highlights

BackgroundTransvaginal ultrasonography (TVUS) significantly improved the accurate diagnosis of intrauterine abnormalities
One study argued that the feasibility of using Saline contrast sonohysterography (SCSH) as compared with diagnostic hysteroscopy is low in postmenopausal women [24]
Takac et al argued that SCSH is not a superior diagnostic tool to Transvaginal ultrasound (TVUS), a conclusion which contradicts other studies [31]

Summary

Introduction

Transvaginal ultrasonography (TVUS) significantly improved the accurate diagnosis of intrauterine abnormalities. In women with postmenopausal bleeding (PMB), a measurement of endometrial thickness (ET) reliably distinguishes a women’s risk of endometrial cancer. An ET of ≤4 mm decreases the likelihood of endometrial cancer by 10-fold in users and non-users of hormone replacement therapy [1,2]. In high‐risk women (ET > 5 mm), the evaluation of endometrial morphology and vascularisation using gray‐scale and Doppler ultrasound imaging refines endometrial cancer risk [3,4]. Most studies reporting on ultrasonography of the uterine cavity are small, with sometimes conflicting results regarding sonohysterography, potentially due to heterogeneity in study design and population. Large multicentre studies are necessary to clarify the role of sonohysterography in the assessment of endometrial morphology and vascularisation to differentiate endometrial and intracavitary pathologies

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