Volume 3, Issue 1, Pages 26-30 (May 2005)

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ABSTRACT

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Contrast-enhanced gynecologic ultrasound: When to use it, what it shows

Sonohysterography and sonohysterosalpingography offer a safe, effective, and minimally invasive alternative to conventional imaging studies of the female reproductive tract. These contrast- enhanced studies may be especially useful in evaluating infertility, abnormal uterine bleeding, and recurrent pregnancy loss.

Article Outline

• Abstract

• The uses of SHG

• Polyps and myomas

• Endometrial hyperplasia and carcinoma

• Congenital uterine anomalies

• The uses of SHSG

• Tubal patency testing and interpretation

• Comparative efficacy

• Advantages and disadvantages of SHG and SHSG

• Medically related

• Performance- and cost-related

• Two noteworthy recommendations

• On the horizon

• Acknowledgment

• REFERENCES

• Copyright

Key Points

▪Sonohysterography (SHG) and sonohysterosalpingography (SHSG) use contrast agents to generate enhanced sonographic images of the reproductive tract.

▪SHG is used to identify pathologies of the uterine cavity and endometrium, while SHSG is used to assess tubal patency, a key step in the evaluation of infertile women.

▪The diagnostic accuracies of these techniques are comparable to those of the more familiar gynecologic imaging modalities, including transvaginal ultrasound (TVUS), X-ray hysterosalpingography, hysteroscopy, and laparoscopy.

▪SHG may be more effective than TVUS in spotting intrauterine polyps, myomas, and congenital anomalies.

▪SHG and SHSG offer several advantages over conventional imaging methods. They are well tolerated, associated with few risks and complications, simple to perform, and minimally invasive.

Sonohysterography (SHG) and sonohysterosalpingography (SHSG) combine sonographic imaging of the pelvis with intrauterine instillation of contrast agents. Initial reports of both techniques appeared in the early 1980s.1, 2 During the past two decades, numerous publications have attested to their use as routine diagnostic imaging modalities.

SHG is used to evaluate the uterine cavity and endometrium and is also referred to as hysterosonography and saline infusion sonohysterography. SHSG is used to evaluate tubal patency and is also known as hysterosalpingo-contrast-sonography, or HyCoSy.

In this brief review, we will discuss the types of conditions SHG and SHSG can best identify, and compare their diagnostic pros and cons with more conventional methods of assessing pelvic anatomy. The most common indications and contraindications for contrast-enhanced gynecologic ultrasound are listed in Table 1.3, 4

TABLE 1.

Indications and contraindications for SHG and/or SHSG

	Indications
	Abnormal uterine bleeding
	Infertility
	Recurrent pregnancy loss
	Suspected anatomic variants of the uterine cavity
	Suspected uterine synechiae (Asherman's syndrome)
	Preoperative and postoperative evaluation of the uterine cavity
	Suspected abnormality on conventional transvaginal ultrasound
	Inadequate visualization on conventional transvaginal ultrasound
	Contraindications
	Pregnancy or possible pregnancy
	Pelvic infection

SHG, sonohysterography; SHSG, sonohysterosalpingography.

The uses of SHG

Polyps and myomas

In the detection of focal intracavitary abnormalities, several investigators have consistently shown improved diagnostic performance of SHG over conventional transvaginal ultrasound (TVUS).5, 6, 7, 8, 9, 10, 11, 12, 13 To identify abnormalities, TVUS relies on altered echo-texture of the uterine tissues and increased endometrial thickness. With SHG, visualization is improved because of the intrauterine instillation of anechoic saline, which creates a separation of the endometrial surfaces and outlines the intracavitary portions of lesions. As saline is sonographically invisible, sharp delineation with the adjacent endometrium is obtained. Figure 1, Figure 2 show these enhancements and enable side- by-side comparisons of the two imaging methods.

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Figure 1. Thickened endometrium (16 mm) seen with conventional transvaginal ultrasound (A) and after intracavitary instillation of saline (B). The use of saline as part of the sonohysterography has outlined an endometrial polyp (arrows).

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Figure 2. A uterine myoma (arrows) imaged with conventional transvaginal ultrasound (A) and after intracavitary instillation of saline (B). The sonohysterography technique provides better visualization of the lesion, clearly demonstrating its submucosal location and extent of intracavitary protrusion.

Compared with diagnostic hysteroscopy, SHG has similarly high accuracy for the detection of intrauterine pathology.5, 14 In a systematic review, SHG had a sensitivity of 85% to 100% and a specificity of 50% to 100%.10 For hysteroscopy, the respective values were 90% to 97% and 62% to 93%. In the detection of isolated endometrial lesions, diagnostic hysteroscopy is slightly superior to SHG, although more invasive.10

Endometrial hyperplasia and carcinoma

For the detection of more generalized lesions, such as endometrial hyperplasia and carcinoma, SHG offers little improvement over TVUS.12, 15 These lesions do not generally project into the uterine cavity, thus their detection is not improved by the instillation of contrast.

Please note: If endometrial hyperplasia or carcinoma is suspected, an endometrial biopsy should be taken for histologic examination in any at-risk patient. The postmenopausal woman is at increased risk when the bi-layer endometrial thickness is ≥5 mm.16

Congenital uterine anomalies

SHG is superior to TVUS and X-ray hysterosalpingography (HSG) in the identification of congenital uterine anomalies.17, 18 However, of these three techniques, X-ray HSG is likely best at detecting unicornuate17 and (possibly) diethylstilbestrol-exposed uteri.

Traditionally, uterine malformations suspected on TVUS or X-ray HSG have required diagnostic confirmation using more reliable techniques such as hysteroscopy and laparoscopy or magnetic resonance imaging (MRI). Septate uteri are differentiated from bicornuate and didelphic anomalies through demonstration of the outer contour of the uterine fundus.19 Distinction among these entities will dictate whether surgical metroplasty is indicated and whether a hysteroscopic approach is possible. Although preliminary reports indicate SHG may be promising in this respect,17, 18 more accurate modalities must still be used to confirm a diagnosis.20

The uses of SHSG

The assessment of tubal patency using SHSG is a key step in the investigation of infertile women. Unlike SHG, in which sonographically invisible saline is necessary to preserve visualization of endometrial surface details, SHSG requires the use of highly visible, positive contrast agents. These agents produce strong ultrasound echoes and are commercially available (Echovist, a suspension of galactose particles in a galactose solution that forms air bubbles, is one example). However, a simple mixture of saline and air (agitated saline) serves as an acceptable substitute.

Tubal patency testing and interpretation

The assessment of tubal patency is often performed immediately following SHG. After complete evaluation of the uterine cavity and endometrium with saline, the interstitial portions of the fallopian tubes are localized and a positive contrast agent is instilled. Flow of echogenic contrast along the tubes confirms patency (Figure 3).

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Figure 3. Tubal patency is evident in this image, which was taken during sonohysterosalpingography with Echovist contrast. The uterine cavity (asterisk) and fallopian tubes (arrows) are visible.

If the entire length of the tubes cannot be visualized, detection of contrast moving around the ovary or in the posterior cul-de-sac can also be taken as evidence of patency.21 Distal tubal obstruction (hydrosalpinx) is suggested by the pooling of contrast agent in dilated adenexal structures.22 Bilateral proximal obstruction or tubal spasm should be suspected if flow of the contrast is not observed.

Comparative efficacy

Laparoscopic chromopertubation is the gold standard in assessing tubal patency but carries the risks and invasiveness of an operative procedure. As a result, X-ray HSG has generally replaced laparoscopic chromopertubation as the method of choice for the initial evaluation of tubal patency and the uterine cavity.

SHSG is a reliable alternative to X-ray HSG. Comparisons of SHSG and X-ray HSG have revealed similar diagnostic accuracy for the detection of tubal obstruction.21, 23, 24, 25, 26 However, compared with laparoscopic chromopertubation, SHSG has reduced diagnostic performance.21, 22, 23, 24, 25, 26, 27, 28 There is a general concordance of sensitivities, specificities, and predictive values whether Echovist or agitated saline is employed.

Advantages and disadvantages of SHG and SHSG

Medically related

In a series of 1,153 patients who underwent SHG or SHSG, 93% of the procedures were successfully completed.29 Of the failed procedures, 76% were completed without complication at a later date. The two most common reasons for failure were cervical stenosis and inadequate uterine cavity distension. Moderate to severe pain and vasovagal symptoms were experienced by 4% of patients and prevented the completion of less than 1% of the examinations.

It appears that SHG and SHSG are no less comfortable than, respectively, X-ray HSG and diagnostic hysteroscopy.11, 17, 23, 30, 31 Prophylactic use of nonsteroidal anti-inflammatory drugs is thus advisable and will help to reduce discomfort associated with the instillation of contrast.

Infective complications are reported in about 1% of women who undergo sonohysterographic imaging.5, 8, 10, 18, 27, 30 The majority of infections respond to oral antibiotics, but severe cases of infection requiring surgical management have been reported.29 The routine use of prophylactic antibiotics prior to SHG and SHSG can minimize this risk.

Performance- and cost-related

As ultrasound-based techniques, SHG and SHSG are readily available, inexpensive, and noninvasive. They also provide the opportunity for complete sonographic assessment of the pelvic organs within a single study. Moreover, although effective use of these techniques requires skilled operators,5, 9, 22, 23 competence in performing them is readily achieved.

Unlike X-ray HSG, both SHG and SHSG spare the patient exposure to ionizing radiation and iodinated contrast agents. Hysteroscopy and laparoscopy may afford direct visualization of intrauterine and pelvic structures, but they do so with the added expense of specialized equipment, advanced training, and an operating suite. Patients who undergo surgical techniques are also subjected to general anesthetics and potential operative complications.

Two noteworthy recommendations

Contrast-enhanced gynecologic ultrasound offers several advantages over existing modalities for examining the reproductive tract. We feel there are two instances in which these techniques may be especially useful. They are:

•For the evaluation of the infertile woman. A single ultrasound-based study using saline — alone for SHG and with air for SHSG — will generate an image of the ovaries, uterine cavity, and fallopian tubes, providing a comprehensive and timely evaluation of the pelvic anatomy in a single session.32, 33

•For the evaluation of patients with abnormal uterine bleeding or recurrent pregnancy loss. SHG specifically should play a central role in the assessment of the uterine cavity and endometrium. As mentioned earlier, the use of SHG will spare many patients without intracavitary and focal endometrial lesions the need to undergo hysteroscopy.6, 7, 8, 13

On the horizon

Contrast-enhanced gynecologic ultrasound has become well established and should be incorporated into existing investigatory algorithms for common gynecologic problems (Figure 4). Future investigations should focus on making continued improvements in diagnostic performance and developing innovative techniques.

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Figure 4. Investigating uterine and endometrial abnormalities

•One area that needs further evaluation is the ability of power and color Doppler imaging to enhance SHG and SHSG's diagnostic capabilities.

•SHG-directed biopsy has the potential to reduce the number of women requiring diagnostic hysteroscopy and thus calls for continued research.34, 35, 36

•For SHSG, studies should be conducted that directly compare the performance of commercially available positive contrast agents with that of agitated saline.

•Three-dimensional imaging deserves further evaluation of its ability to enhance the sonohysterographic detection of both intracavitary and structural uterine anomalies37, 38 and tubal patency.39

Acknowledgements

The authors wish to thank Dr. Jeff Haebe of the Division of Reproductive Medicine, University of Ottawa, and Dr. Douglas Black of Bank Ultrasound (Ottawa, Ontario) for their assistance in obtaining sonographic images.

REFERENCES

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a Division of Reproductive Medicine, Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada

Division of Reproductive Medicine, Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Ontario, Canada, 505-737 Parkdale Avenue, Ottawa, Ontario K1Y 4E9, Canada

PII: S1546-2501(05)00010-1

doi:10.1016/S1546-2501(05)00010-1

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