Sonography & Sonohysterography of the Non-Gravid Uterus

Selecting Biopsy Technique with Ultrasound

One of the questions is, if a woman is gonna have a biopsy, can ultrasound help pick the best biopsy technique?

The answer here is, yes, a sonohysterogram in a woman. If a woman has a thickened endometrium and is gonna have a biopsy, a sonohysterogram can help select the appropriate biopsy technique.

In particular, if a woman with thickened endometrium has a sonohysterogram, and it shows that the endometrium is diffusely thick, a blind biopsy would be appropriate.

If it's focally thick, a hysteroscopic biopsy would usually be appropriate.

And I'll show you some examples shortly.

Performing Sonohysterography

How do we do a sonohysterogram?

A speculum is inserted into the vagina. A catheter is put through the cervix. A balloon may or may not be used. We usually use them in our department, but it's optional.

The speculum is removed. Transvaginal transducer is inserted. You scan and insert saline to outline the endometrium.

As in this case, you can see here saline is being instilled into the uterine cavity.

In this normal sonohysterogram, you see a nice thin, uniformly thin, smooth endometrium all the way around.

Role of Sonohysterography

The role of sonohysterography is if ultrasound shows a thick endometrium greater than four millimeters, or it's distorted or unmeasurable on the conventional scan, you can do a sonohysterogram.

And then if it is thin, which is less than or equal to two millimeters, uniformly single layer, which corresponds to a four millimeter double layer, the diagnosis is endometrial atrophy.

If the endometrium is diffusely thick, a blind biopsy would be appropriate.

Focally thick. A hysteroscopic biopsy would generally be needed.

And if you see a focal, I mean a submucosal fibroid excising, it would be may be considered a few examples.

Examples of Sonohysterography Findings

This is a conventional transvaginal ultrasound prior to sonohysterogram. You can see 12.8 millimeter or quite a thick endometrium in this woman with bleeding.

Does she need a biopsy? Yes. What kind of biopsy?

Well, we put saline in, as you can see here, and you can see it's pretty diffusely thick everywhere, all around, which means that a blind biopsy should be appropriate.

On the other hand, here's another woman with a thick endometrium measuring about 10 millimeters, so it's thick.

Does she need a biopsy? Yes. What kind to answer that when instill saline.

And you can see that the reason it's thick is because there's a pretty large polyp.

So she needs a hysteroscopic biopsy to make sure that the polyp is either biopsied or actually totally removed during the procedure.

Answering Key Questions

So we asked two questions earlier.

Is there an ultrasound finding that indicates biopsy is unnecessary? The answer is yes. A thin endometrium less than four millimeters.

Second question. Can ultrasound identify an appropriate biopsy technique? The answer again, is yes, sonohysterography can, depending on whether it's diffuse or focal, indicating a blind biopsy or a hysteroscopic biopsy is needed.

Diagnostic Approaches for Postmenopausal Bleeding

What the diagnosis of post-menopausal bleeding? There are really two approaches. One is ultrasound first, and the other is biopsy first.

With the ultrasound first criterion, we start out with a woman with transvaginal postmenopausal bleeding.

The first thing we do in the ultrasound first algorithm is a transvaginal ultrasound.

If the endometrium is thin, we diagnose atrophy.

If it's at least four millimeters or distorted or unmeasurable, do a sonohysterogram and pick the appropriate biopsy technique if needed, based on the sonohysterogram.

So that's the ultrasound first approach.

Another equally good approach is a biopsy first approach.

A woman presents with postmenopausal bleeding. The first thing that's done is an office biopsy.

If the diagnosis is complete conclusive, the workup is complete.

And if the biopsy is inconclusive or inadequate, there's an inadequate diagnosis based on it, you do a transvaginal ultrasound and then you proceed as in the prior algorithm, either biopsy first or biopsy.

Either ultrasound first or biopsy first is fine.

The key thing is to use them both in conjunction to reach a diagnosis.

Conclusion

Conclude this part of the talk.

Any woman with post-menopausal bleeding should undergo diagnostic evaluation to diagnose or exclude malignancy.

Either endometrial biopsy or transvaginal ultrasound is an acceptable first test.

If the endometrial biopsy is done and tissue is insufficient for diagnosis, transvaginal ultrasound should be performed.

An endometrial thickness of four millimeters or less, or some use five millimeters on a transvaginal ultrasound indicates a very low likelihood of cancer. An endometrial biopsy is not needed.

If the endometrial thickness is greater than four millimeters, sonohysterogram can identify the best biopsy technique.

And if the initial test is negative and bleeding persists, then additional evaluation is usually indicated.

So I've come to the end of the tour of ultrasound and sonography and sonohysterography of the non-gravid uterus considering congenital anomalies, myometrial lesions, and endometrial pathology.

I certainly hope it's been useful to you. Thank you.