Sonohysterography: a technique for endometrial evaluation.

Sonohysterography involves the instillation of sterile saline under continuous sonographic visualization to assess the endometrial cavity. The technique is most useful for evaluating women with fertility problems, postmenopausal bleeding, or an abnormal endometrial interface as seen at baseline sonography. The procedure is performed with saline instilled into the endometrial cavity through a 5-F pediatric feeding tube or a hysterosalpingography or insemination catheter. In the normal uterus, the endometrium appears symmetric, surrounding the anechoic, saline-distended endometrial cavity. Adhesions appear as bridging bands of tissue that distort the uterine cavity or as very thin, undulating membranes, best seen at real-time examination. An intracavitary polyp is seen surrounded by anechoic fluid, with the point of attachment and thickness of the stalk clearly demonstrated. The location of leiomyomas can be determined: Intramural lesions do not distort the endometrial cavity, whereas submucosal lesions often do, with the overlying normal layer of endometrium clearly seen. In women with abnormal bleeding, focal areas of asymmetric endometrial thickening can be identified. Sonohysterography allows differentiation of intracavitary, endometrial, and submucosal abnormalities without the use of ionizing radiation or contrast agents.

Serial assessment of adnexal masses with transvaginal color Doppler sonography.

Transvaginal color Doppler sonography (TV-CDS) was performed on 64 women with adnexal masses at 3, 6 and 12 weeks after initial presentation. In 47 (72% of patients studied), the pelvic mass demonstrated a decrease in size and increase in pulsatility index (PI) after 12 weeks. Of the patients undergoing surgery in this group, one had a tubo-ovarian abscess, one diverticular abscess and one hydrosalpinx. In seven patients (10%), there was no change in size or PI. Three in this group had an endometrioma, whereas two had a peritoneal cyst. In five (7%), there was no change in size and an increase in PI. One of these patients had a mucinous cystadenoma. In three (5%), there was a decrease in size and PI. Two of these patients had a tubo-ovarian abscess. In two (3%) patients studied, the mass showed an increase in size and decrease in PI; both had corpora luteum cysts with acute hemorrhage. Seventy-two percent of masses with high impedance underwent regression, whereas only 21% of lesions with low impedance did. Only 20% of masses demonstrating low impedance or morphologically complex structure regressed. Sixty-five percent of lesions that regressed had a significant drop in PI, whereas all the lesions that showed no change in size or enlargement had either no change or decrease in PI. Probability of regression was the greatest in young women (less than 40 years of age) and in masses < 5 cm. Ninety-three percent of women with persistent masses that underwent progestational suppression demonstrated regression with decrease of PI and peak systolic velocity.(ABSTRACT TRUNCATED AT 250 WORDS)

Conventional and color Doppler transvaginal sonography of pelvic masses: a comparison of relative histologic specificities.

The relative specificity of CDS versus conventional TVS was assessed in 96 women with surgically excised and pathologically examined pelvic masses. In general, CDS was more specific than TVS in 43% of cases, both were equally specific in 41%, neither was more specific in 10%, and TVS was more specific than CDS in 6%. In particular, CDS seemed to be most specific in detecting ovarian malignancies, ovarian torsion, and ectopic pregnancy. The positive and negative predictive values of CDS were higher in postmenopausal women than in premenopausal women. The use of CDS as an adjunct to TVS is supported by the data from this study.

Color Doppler sonography of ovarian masses: a multiparameter analysis.

This study analyzed vessel location, maximum systolic velocity, impedance, and waveform shape in 25 benign and 25 malignant surgically excised and pathologically examined ovarian masses as depicted by transvaginal or transabdominal color Doppler sonography, or both. Those parameters that achieved statistical significance (P > 0.05) between the two types of masses included vessel location, impedance, and waveform shape. Malignant masses typically were characterized by centrally located vessels that had low impedance without a diastolic "notch" in the waveform. Maximum systolic velocities are statistically similar in benign and malignant lesions. Multiparameter analysis may improve the diagnostic specificity and sensitivity of this technique in distinguishing benign from malignant ovarian masses.

Color Doppler sonography of benign and malignant ovarian masses.

The use of transvaginal and transabdominal color Doppler sonography for the assessment of ovarian tumor vascularity was investigated in 62 cases of surgically excised and histologically examined ovarian masses. The modality was used to differentiate tumor neovascularity from normal arterioles (which contain smooth muscle in their media) on the basis of differences in the pulsatility observed in Doppler waveforms. Of the 25 malignant tumors in the series, 20 had low-impedance flow (pulsatility index of less than 1.0), and none had the diastolic notch seen in vessels in normal tissue. Three benign lesions, including two dermoid cysts and one tubo-ovarian abscess, also had low-impedance flow. The negative predictive value of color Doppler sonography was 98%, whereas the positive predictive value was 83%. Color Doppler sonography seems to be accurate for excluding malignancy, but some misdiagnosis may occur in cases of inflammatory and metabolically active benign masses.

Transvaginal color Doppler sonography in the prenatal diagnosis of placenta accreta.

In a case of placenta accreta diagnosed antepartum, the sonographic findings included absence of the normal retroplacental clear space and presence of multiple dilated blood vessels beneath the placenta. Transvaginal color Doppler sonography was particularly useful in identifying these features.

Conventional and color Doppler transvaginal sonography in gynecologic infertility. Current clinical applications.

TVS affords accurate follicular monitoring and guidance for follicular aspiration. The role of TVS in assessing the adequacy of the endometrium is still undergoing investigation. Our studies suggest that there is a statistically significant difference in the pregnancy rate when the endometrium has a multilayered appearance. Infertility patients who successfully achieve pregnancy should be monitored with TVS because of a higher incidence of ectopic pregnancy, anembryonic gestation, and spontaneous abortion. TVS has a secondary role in evaluating certain uterine malformations and tubal disorders. With TV-CDS it is also possible to evaluate physiologic parameters such as adnexal and uterine blood flow. The role of TV-CDS in the anatomic and physiologic evaluation of early pregnancy is now being established.

Transvaginal color duplex sonography: clinical potentials and limitations.

This overview describes our preliminary experience in the application of transvaginal color Doppler sonography in evaluation of the uterus and ovaries. The main indications for this type of sonography include evaluation for ovarian torsion, differentiation of benign from malignant ovarian masses, diagnosis of pelvic congestion, and assessment of utero-ovarian perfusion. Obstetric applications include evaluation of complicated early pregnancy and evaluation of placental disorders such as placenta accreta. No doubt future applications will arise soon from active investigation with this new technique.

Assessment of ovarian tumor vascularity with transvaginal color Doppler sonography.

This report describes the results of transvaginal color Doppler sonography (TV-CDS) of 43 surgically proved ovarian masses. Waveform analyses of the signals arising from specific vessels (i.e., peripheral, central, septal) adjacent to and within these masses were correlated to those seen on macroscopic pathologic evaluation. The mean and standard deviation of the pulsatility indices (PI) of 32 benign lesions (1.8 +/- 0.8) were higher than 11 malignant ones (0.8 +/- 0.6) (P = 0.03). However, the range of benign (4.0 to 0.7) and malignant (1.5 to 0.4) lesions did overlap. Low PIs (less than 1.0) were found in five relatively benign lesions (one case each of dermoid cyst, cystadenoma containing a dermoid cyst, endometrioma, benign sclerosing stromal tumor, and thecoma), but also in all 11 malignant or borderline malignant lesions (nine cystadenocarcinomas, two germ cell tumors), causing an overlap between the PIs of some benign and malignant masses. With a 100% negative predictive value, our preliminary data suggest that TV-CDS can effectively exclude malignancy. However, with a positive predictive value of 73%, one in four malignant lesions diagnosed by TV-CDS will be benign.

Transvaginal color Doppler sonography of ovarian masses with pathological correlation.

This report describes the correlation of pathological findings with transvaginal color Doppler sonography performed preoperatively on 26 ovarian masses. The pulsatility indices of benign lesions (1.9 +/- 0.7) were higher than those of malignant ones (0.7 +/- 0.2) (p = 0.03). Low pulsatility indices (< 1.0) were found in three relatively vascular benign lesions (one immature teratoma, one cystadenoma containing a dermoid cyst, one endometrioma), causing an overlap between the pulsatility indices of some benign and malignant masses. There appears to be significant potential for discrimination between benign and malignant ovarian masses with transvaginal color Doppler sonography.

Transvaginal sonography of the endometrium during induced cycles.

The thickness and texture of the endometrium as depicted by transvaginal sonography were assessed in 23 patients who underwent a similar ovulation induction protocol including a gonadotropin-releasing hormone analogue (Lupron) and human menopausal gonadotropin (Pergonal). In the 9 patients who conceived, a multilayered endometrium was more frequently present than in the 14 who did not, even though the number of mature follicles, oocytes retrieved and transferred, and estradiol values were similar.

Transvaginal sonography of postmenopausal ovaries with pathologic correlation.

The sonographic appearance of 67 ovaries in 34 postmenopausal women who underwent preoperative transvaginal sonography (TVS) was correlated to findings on pathologic examination. Both ovaries were detected by TVS in 60% of the women examined; in 85%, at least one ovary was detected. The size of the normal, sonographically visualized postmenopausal ovary was 2.2 +/- 0.7 cm in transverse, 1.2 +/- 0.3 cm in anteroposterior, and 1.1 +/- 0.6 cm in longitudinal axes, with an average volume of 2.6 +/- 2.0 cm3. The average size of ovaries that were not detected by TVS was 0.7 x 0.4 cm (range, 0.3 to 1.3 cm); most of these (five of six) were atrophic on pathologic exam. The difference between actual and sonographically measured size was negligible (TVS overestimated by 0.3 cm). Four simple cysts that ranged from 0.5 to 3.5 cm were found by TVS and confirmed pathologically, as were three benign serous cystadenomas that ranged from 2.5 to 3.5 cm, one 3 x 6-cm tubal carcinoma, and one 1 X 4-cm paratubal cyst. TVS missed a 6-cm dermoid, a 2.5-cm cystadenoma, a 0.8-cm Sertoli cell tumor, and a 0.5-cm fibrothecoma that were nonpalpable but that were found on pathologic examination. None of the missed lesions were palpable preoperatively. The positive predictive value was 94% for detection of an ovarian mass; the negative predictive value for exclusion of an ovarian lesion was 92%. It is concluded that TVS can accurately delineate the ovaries in most, but not all, postmenopausal women and that only rarely will pathologic lesions not be detected by TVS.

Transvaginal scanning of the endometrium.

Transvaginal sonography (TVS) can accurately depict the anteroposterior, width, and long axis of the endometrium. This article describes and illustrates normal and abnormal endometria as depicted by TVS.

Ectopic pregnancy: features at transvaginal sonography.

A retrospective review of the transvaginal sonograms of 50 women with laparoscopically confirmed ectopic pregnancy was performed to determine whether certain sonographic findings can be detected to confirm the diagnosis. Forty-seven of the 50 pregnancies were tubal. A tubal ring (a 1-3-cm mass consisting of a 2-4-mm concentric, echogenic rim of tissue surrounding a hypoechoic center) was seen in 23 of 34 (68%) ectopic pregnancies in which the fallopian tube had not ruptured, and the tubal ring could be distinguished from a corpus luteum cyst in most cases. Transvaginal sonography also depicted simple (n = 22) or particulate (bloody) (n = 13) peritoneal fluid associated with ectopic pregnancy. In each case in the series, at least one abnormal uterine, adnexal, or peritoneal finding was detected at transvaginal sonography. Because of its improved resolution of uterine and adnexal structures, transvaginal sonography is recommended as a means for detailed evaluation of patients suspected of having an ectopic pregnancy.

Transvaginal sonography (TVS) of the endometrium: current and potential clinical applications.

This review has discussed and illustrated the numerous applications of TVS for the sonographic detection of the endometrium. Its major applications are in early pregnancy evaluation and in evaluation of patients with endometrial carcinoma. As more clinical experience with this technique is gained, more extensive application of this technique will undoubtedly come about.