3D US Best images possible U2lity? IUD

3D US Best images possible U2lity? IUD

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Current 3D reconstruction
1. A plane - Acquisition
2. B plane - 90° to A plane
3. C plane - 90° to B plane
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SIS=Saline infusion sonohysterography
Sterile saline infused into uterine cavity
Permits uterine distension
Allows endometrium to be imaged
Compared with TVUS more accurate in detection of focal
endometrial lesions
•  Similar performance to hysteroscopy
•  Erdem et al sensitivity and specificity between 98% and 82%
respectively (67% on TVUS)
•  Hyperplastic endometrium
• 
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–  Non directed sampling may miss focal lesion
–  D&C missed 58% polyps,50% hyperplasia,60% complex atypical
hyperplasia and 11 % carcinoma
–  24% of polyps seen on SIS not seen on TVUS
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Role of sono HSG
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•  Evaluating abnormally thickened endometrium
–  Can distinguish focal vs. diffuse endometrial thickening
–  Can discriminate between lesions of endometrial and
myometrial origin
•  Diffuse
–  Endometrial biopsy
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•  Focal
–  50% of AUB caused by focal lesions
–  Hysteroscopy with targeted biopsy and excision
Timing
•  Post menstrual or early proliferative phase ,
prior day 10
•  Irregular cycles : negative pregnancy test
•  Irregular bleeding
–  Medical curettage
•  Progestin ( 10 mg x 10 days) and then time the
procedure to the withdrawal bleed
•  Post menopausal
–  Unopposed estrogen – any time
–  Progestin 6 days after last pill when endometrium is
thinnest
Consent
•  Written consent
–  Discomfort similar to menstrual cramping
–  Risk of infection, bleeding
•  Post procedural Instructions
–  Self-monitor for signs of infection
•  Fever, pain, foul-smelling vaginal discharge
–  Abnormal bleeding
–  avoidance of intercourse for 48 hrs to minimize risk of
infection
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•  Assess size and position of the uterus
–  Orientation of the cervix
•  Pathology often co-exists
•  Do not assume fibroids etiology for bleeding
•  Nor assume fibroids will obscure visualization of the
endometrium
–  Lower frequency trans-abdominal probe
–  Trans-abdominal images at time of instillation may provide
diagnostic information
•  Apparently “normal “endometrium may mask pathology
–  Infertility/recurrent abortion
Contraindications
•  Pregnancy
•  Current pelvic infection
–  Bilateral tubal occlusion
–  Risk of PID ≈1 %
•  IUCD
•  Malignancy?
–  Potential risk of tubal dissemination(1/14)
•  Ongoing vaginal bleeding diminishes accuracy
–  Clot or blood products in cavity
Alcazar et al Obs Gynae Scan 2000
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Adverse effects
• 
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Inability to complete test (7%)
Pelvic pain (3.8%)
Vagal symptoms (3.5%)
Nausea(1%)
Post procedure fever (0.8%)
Endometritis(<1%)
•  Obscuration of area of interest by air
–  Fastidious attention to technique
–  Insufflate balloon with saline and not air
•  Perform in proliferative phase
–  Endometrium is thin and hypoechoic
•  Patients with continuous vaginal bleeding
•  Discriminate blood products from true endometrial
pathology
–  Flush endometrium
–  Dislodge at time of catheter withdrawal
–  Look for presence of a feeding vessel
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•  Helps anchor the catheter in the
endometrium
•  May help to occlude the cervix if fluid is
leaking back
•  Balloon can however obscure pathology in
the lower uterine segment so should be
deflated prior to imaging this region
•  Rapid acquisition of images with cine or
volume
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•  Deflating balloon at end of procedure
•  Injecting saline as catheter is withdrawn OR
•  Distend balloon close to external os and
distend saline gently to better opacify
cervical canal
•  Lesions that protrude into vagina typically
seen when residual fluid in vagina opacifies
them
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•  May be indicative of underlying pathology
–  Adhesions or synechiae(prior procedures or
infection)
–  Large polyps or submucosal fibroid
–  Endometrial carcinoma
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Cervical polyps
•  Early diagnosis as typically symptomatic
•  Rate of malignancy low around 0.3%
•  Association with endometrial polyps in 25%
–  40% if post menopausal
–  100% if on tamoxifen
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Fibroids
•  40% of women>35
•  Submucosal fibroids
cause bleeding by
increasing surface area of
the endometrium
•  Disrupt normal sloughing
process
•  Tendency to regression
with age unless hormonal
input
•  3D view integral to
management
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Determine if hysteroscopic resection
appropriate
Size < 5 cm
≥ 50% intracavitary
Assess thickness myometrium is behind the
fibroid (>1cm) at serosal surface
Post myomectomy assess endometrial cavity
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Endometrial atrophy
•  Atrophy exposes vessels
in underlying
myometrium
•  Functional layer ;inactive
and atrophic
•  Leaves shallow basalis
layer intact
•  Thin endometrium <
3mm
•  Early on there may be
cystic changes present=
Swiss cheese appearance
Hyperplasia
Endometrial hyperplasia
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•  Proliferation of glands
–  Irregular size and
shape
–  Increase gland/stroma
ratio
–  Usually diffuse but not
global
What do the studies show?
SYMPTOMATIC
•  Symptomatic PMB
–  Thin well seen
endometrium <4-5
mm
–  99% NPV and no
biopsy is advised
–  PPV for any disease
<10%
–  PPV for atypia or
malignancy <4%
Endometrial
thickness
Risk of
malignancy
>5 mm
7.3%
=5 mm
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ASYMPTOMATIC
Endometrial
thickness
Risk of maignancy
> 11mm
6.7%
= 11 mm
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PMB;Role of SIS
•  US shows thickness > 5 mm
–  Sonohysterogram can determine if thickening is focal or diffuse
•  Endometrial assessment precluded on US due to distortion
or limited visualization
–  SHG can optimally determine endometrium
–  Demonstrate sub-mucosal fibroid if present
•  65 patients with endometrial cancer(Guido et al 1995)
–  11 missed occupied <50% of surface area
–  11 cases in polyps ;pipelle missed 5
–  Only 46% of cancers occupied >50% of the uterine cavity
Smith-Bindman et al JAMA
1998
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Tamoxifen
•  Tamoxifen citrate
•  Anti-estrogenic agent in the breast
•  Estrogenic effect on the endometrium and
myometrium
•  Long term effects include
–  Endometrial proliferation,polyps,cystic atrophy
–  Adenomyosis,leiomyomas,endometrial ca and
sarcoma
–  Polyps 2-10% in malignant degeneration
–  Multiple processes can occur simultaneously
Recommendations on tamoxifen
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Risk factors
Endometrial carcinoma
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Most common gynecologic malignancy
Incidence in Canada 19/100,000
80% in post menopausal women
90% present with bleeding
–  10% of women with PMB have endometrial ca
•  72% have stage 1 disease at time of diagnosis
•  Overall 5 yr survival is 86%
•  Dependent on stage, grade and type of cancer.
Obesity
High fat diet
Nulliparity
PCOS
Early menarche
Late menopause
Tamoxifen use risk by 2.3 per 1000
HNPCC cumulative incidence of 20-60% by age
of 70 yrs
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Role in infertility
•  15-55% of recurrent pregnancy loss due to anatomic factors
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Synechiae
Sub mucosal fibroids
Mullerian anomalies
SIS in this context found abnormalities in 50%
SIS improved accuracy as compared with HSG and TVUS.
Retrospective review of 149 infertile patients comparing SIS with
HSG
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Adhesions
•  Baseline US often normal
•  Mobile thin echogenic
bands
•  Or bridging bands or
thick membranes that
preclude optimal
distension
•  Rarely obliteration of the
cavity
•  Rx hysteroscopic
resection
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