Sonohysterography - SD

Introduction

My name is Dr. Anna Lev Toof.

In the upcoming presentation I would like to discuss Sonohysterography a very important technique in the diagnostic evaluation and management of a variety of problems that present in women.

Sonohysterography is also known as Hyster, sonography and saline infusion Sonohysterography.

Why Sonohysterography?

Vaginal sonography is limited in its ability to distinguish endometrial from myometrial lesions.

For example, when a fibroid is adjacent to the uterine cavity, the endometrium can be difficult to see in some cases.

For example, with myomas, we may not know the exact location of the endometrium.

This can also occur in adenomyosis or when the position of the uterus is unfavorable.

Furthermore, endometrial and myometrial lesions are both common.

They often coexist, but their distinction is clinically significant.

Keep in mind that abnormal bleeding in the presence of fibroids or adenomyosis may in fact be due to an endometrial lesion such as polyps.

Indications for Sonohysterography

The indications for sonohysterography are listed in this slide.

Among the most common are abnormal bleeding and infertility and habitual abortion.

Other indications include the evaluation of myomas pre and post-op uterine malformations, postpartum problems such as retained products of conception, suspected placental polyp or asherman's, otherwise known as intrauterine signia, the abnormal transvaginal sonogram that requires further evaluation, the patient with the intrauterine device and prior to endometrial ablation or uterine artery Embolization.

Of note is the fact that when looking at women with that present with abnormal bleeding or infertility, habitual abortion, it has been shown that even when the transvaginal sonogram appears to be normal in those two groups of patients, there is a significant false negative rate of the transvaginal sonogram and one should consider performing sonohysterography even in the presence of a normal transvaginal sonogram in those two groups of women.

Technique

What is the technique?

We usually use a five or seven French balloon bearing catheter in the cervical canal because in many cases, occlusion of the uterus is important in order to maximize the amount of information obtained.

However, in postmenopausal patients or in patients with cervical stenosis or when cost is an issue, a simple Foley catheter or pediatric feeding tube can also be used.

The important point is to distend the cavity slowly with IV grade sterile saline or water.

We use agitated saline to evaluate the fallopian tubes in order to assess the fallopian tubes and the peritoneal cavity.

Real time sonography is required.

This can be recorded on videotape.

More recently, we use four D near real time sonography for this purpose.

When conventional 2D ultrasound is used, we assess multiple sagittal and coronal planes and take hard copy and occasionally videotape.

Color and power doppler imaging are used selectively.

Most recently, we use 3D ultrasound to perform sonohysterography most efficiently and we acquire several volumes rapidly, in the coronal and sagittal plane.

I will demonstrate both of these techniques.

In this lecture. I'd like to cover diagnostic and technical pointers.

Mention a few pitfalls.

We'll focus mostly on women that present with abnormal bleeding and the common lesions of fibroids pre and post-op and adenomyosis, we'll demonstrate endometrial lesions and adhesions, uterine malformations.

And finally, the evaluation of the infertile woman.

Looking at the tubes in the peritoneum, this is a typical tray that is prepared prior to sonohysterography.

The important things I'd like to highlight are the single hinged speculum which facilitate the procedure and these balloon bearing catheters.

Precautions

Here a few precautions when the possibility of malignancy is considered, especially in older women, we limit the amount of infused fluid.

Do not perform this procedure if there are signs of pelvic peritonitis or a questionable menstrual history.

And finally, in women with a history of pelvic infection or tubal disease, one should consider prophylactic antibiotics such as doxycycline.

3D Sonohysterography Examples

This is an example of three dimensional sonohysterography.

Here we have the multiplanar display.

This is the uterus in axial sagittal and in the reconstructed coronal plane demonstrating a normal shape, triangular uterine cavity, but a focal echogenic lesion arising from the endometrium.

This represents an endometrial polyp.

This is the balloon bearing catheter.

Here are some rendered images, which give us, a little bit more sense of depth in this cavity.

And finally, with current 3D equipment, one can truly obtain a virtual hysteroscopic image of the uterine cavity.

One can look beyond a large lesion and one can see how this could be valuable in, surgical planning.

This clip demonstrates the technique of 3D sonohysterography.

The balloon ca bearing catheter has been placed into the lower uterine segment.

We have instilled some saline. This is the volume box.

We are now acquiring the volume in the sagittal plane.

This occurs in a matter of seconds.

Typically, we acquire several more acquisitions and the examination is complete.

In this video clip, we see the use of four D Sonohysterography, and here we have the ability in near real time to manipulate the images.

During the procedure, we have the three planes here, the axial, the sagittal, and the coronal, and we see a normal uterine cavity with a very mild arcuate deformity in this uterus.

And in this case, we see the four D multiplanar display in an abnormal examination here in the coronal plane.

We see the fluid coming in.

The fluid is being pulsed in in order to actually break up the blood clot, which is adherent to this sub mucus myoma.

This is the normal shape of the uterus in the mid coronal plane and the normal triangular uterine cavity.

In this patient with a history of pregnancy loss, we have performed sonohysterography and we see here that the cavity is normal except for the shape of the uterus.

This demonstrates a mild malformation.

This is an arcuate uterus.

Diagnostic Criteria

The diagnostic criteria for interpreting sonohysterography are rather straightforward.

In general, polyps and other endometrial lesions have the appearance of the endometrium.

In other words, they are echogenic.

Fibroids are myomas tend to be hypoechoic, although they may be heterogeneous in echo texture.

But an important distinction is that there is attenuation of the sound posterior to the lesion.

Finally, adhesions are usually manifested as echogenic bands, but occasionally adhesions are simply seen as a uterine cavity that will not distend globally.

It is important when doing sonohysterography to assess the endometrial myometrial junction and to assess the degree of cavity diss extensibility.

Here we see, two examples of endoluminal lesions.

They both appear somewhat echogenic here and here.

The reason that this is a myoma, and this is an endometrial polyp, is that there is attenuation of sound posterior to this myoma.

This myoma is most likely undergone some degenerative change, which is why it's relatively more echogenic than most myomas.

Notice that there is no attenuation of sound posterior to this endometrial polyp.

Finally, another example of an intracavitary lesion.

This is hypoechoic similar, slightly more hypoechoic or similar to the myometrium.

There's a small, koic focus and notice that there is, an overlying layer of increased echogenicity.

This represents an intracavitary myoma.

Notice that there is posterior acoustic shadowing and it is simply covered by a layer of endometrium.

The use of color or power doppler can be helpful when one encounters an unusual, endoluminal findings, such as in this case we see a hypoechoic mass and then attached to it a more echogenic lesion.

In this case, we see a more echogenic lesion and then a hypoechoic component.

When we use the color of power doppler, we see that this is vascularized and this is not.

So this represents an intracavitary myoma with an attached with organizing blood clot.

Here is another example of a mass iso coic with the myometrium with abundant, internal flow.

This is another intracavitary myoma.

Here are two multiplanar displays of another endo cavitary abnormality.

This is the balloon bearing catheter.

And here in the right cornal region, we see a small this time echogenic nodule.

Here it is again, we demonstrated it in all three planes of this multiplanar display.

This represents by our previous criteria a small endometrial polyp.

Role in Evaluation of Myomas

Sonohysterography has a very important role in the evaluation of some women with myomas.

As the treatment, of myomas, becomes more, tailored and varied, preoperative evaluation can be, very important.

Hysteroscopic resection is increasingly being used to treat, sub mucus and intracavitary myomas because the degree of surgical difficulty in the selective removal of these tumors depends on the intramural extent.

Preoperative evaluation is particularly important.

What do we need to tell the clinician regarding a woman with myomas?

On sonohysterography?

We need to define the precise relationship between each fibroid and the uterine cavity.

This information is critical in planning the type of myomectomy.

We can also use sonohysterography in the post myomectomy assessment of the uterine cavity.

The European Society of Hysteroscopy has presented this classification of the sub mucus myoma.

The T zero lesion is pedunculated and is entirely within the cavity without any component in the wall of the uterus.

The T one lesion is a Cecile myoma with an intracavitary component of more than 50%.

T zero and T one lesions are readily amenable to hysteroscopic resection.

The T two lesion has less than 50% within the, cavity of the uterus and can be a problem for hysteroscopic resection.

Several examples.

This is a sagittal and a axial image of a myoma here seen slightly hypoechoic to the myometrium.

When we look carefully in all three planes here on this multiplanar display, we see that although this lesion in dense, the uterine cavity and projects slightly within the uterine cavity, in fact, most of this myoma is mural and this patient would not be a candidate for hysteroscopic resection.

Here, this, myoma has a predominantly mural component with a small sub mucus component.

Again, not likely to be amenable to hysteroscopic resection.

This is a typical T zero lesion.

This myoma is entirely within the uterine cavity and is a candidate for hysteroscopic resection.

Uterine Anomalies and Other Endometrial Lesions

Moving on to uterine anomalies and other endometrial lesions.

In this multiplanar display, we see an anomalous uterus.

The external uterine contour is normal, however, the uterine cavity is divided by a septum.

The septum reaches down to the upper lower uterine segment.

This is a sub septate uterus.

We can delineate the exact extent, the exact width and length of the uterine septum, and we can also delineate the fact that there is nearly diffuse end endometrial thickening.

In this postmenopausal patient, this woman had a hissing igram.

And on hissing we can see that there's an abnormality of the uterine cavity, but we cannot distinguish between a bco with uterus and a septate uterus.

On 3D sonohysterography, we see that the external contour is normal.

This in fact represents a sub septate uterus.

In addition, there is an endometrial polyp in this location.

This is an example of a pedunculated intracavitary myoma here in the coronal view, this represents the balloon.

This is also the balloon.

Here we've instilled some sterile, saline.

We see the inferior portion of this intracavitary mass, and then we've placed the balloon a little bit higher in the uterine cavity and we can now clearly see the pedicle.

This myoma has undergone central necrosis, which is why it is more hypoechoic.

On the, on the inside,

this case demonstrates the value of sonohysterography in women with abnormal bleeding, even when the transvaginal sonogram does not suggest a focal abnormality.

And this woman, the uterus is bulky.

The anterior corpus is thicker than the posterior.

This was thought to possibly represent adenomyosis or myomas, but the endometrial cavity, the endometrial echo complex was thought to be normal.

But in fact, when fluid is placed into the uterine cavity, we see that there is a small echogenic nodule here in Sagittal and here in axial on color flow imaging, we're able to demonstrate a feeding vessel and this represents an endometrial polyp which could explain this woman's inter menstrual bleeding and is much more readily treated, than, a major surgical procedure on the uterus.

Postpartum and Post-Surgical Evaluation

In the postpartum or post-surgical situation, sonohysterography can be very helpful to demonstrate the presence of sinia or intrauterine adhesions.

This woman was post hysteroscopic myomectomy.

We see a somewhat capacious uterine cavity, but the cavity is preserved.

There is a single thin bridging adhesion in the lower uterine segment, not likely to be of clinical significance.

In contrast, in this woman, there are thick bands traversing the uterus, indicating severe intrauterine adhesions.

Here is another hy ofs picogram to be compared with sonohysterography.

We see an abnormal uterine cavity.

It was unclear on this examination whether this represented a uterine anomaly or some other intrauterine lesion.

Here on three dimensional multiplanar sonohysterography, we see that the cavity is in fact compromised and distorted by the presence of adhesions on the left side of the uterus.

The uterus itself is normal in shape.

Technical Pointers

A few technical pointers.

We tried to make the patients comfortable during this procedure by suggesting the ibuprofen typically four to 600 milligrams an hour before the procedure.

Topical lidocaine gel can be used in selected patients.

It's important to have specular in various sizes and shapes.

We use chlorhexidine or Betadine to prep the cervix.

Another point is that in some women, a balloon bearing catheter will not be appropriate, and in these cases we may use a pediatric feeding tube.

A Foley catheter can also be used as can an intrauterine insemination catheter.

These are plastic graduated dilators, that can be used to gently dilate the cervix prior to sonohysterography in women with cervical stenosis.

Finally, in occasional cases, we will, instill 1% lidocaine using a 22 gauge spinal needle into the exo cervix, to provide local anesthesia prior to doing cervical dilatation.

It is important to recognize that the lidocaine should be instilled at the 12 and six o'clock position on the exo cervix and not at the three or nine o'clock position where the uterine arteries come in.

Finally, when we're finished evaluating the uterine cavity, important to remove the sonohysterography catheter very slowly so as to evaluate the lower uterine segment as well as the cervical canal.

This takes a little bit of, doing and patience to do.

You don't wanna just deflate the balloon and immediately pull out the catheter because lesions, important lesions that cause patient's symptoms can be located in this location.

So on this video clip here, we see a evaluation of the uterine cavity, and then when we remove the catheter, we do it slowly and we're able to visualize the entire lower uterine segment and cervical canal.

In this case, the uterine cavity was unremarkable in this patient with postal bleeding, but when we evaluate the cervix, we see here that there's an endo cervical mass.

This represents an a both end cyst, which is not clinically significant, but here is the sizable endo cervical mass.

We put power doppler on it and we see that there is a feeding vessel.

This is in the sagittal projection,

And here in the axial projection, we've confirmed that this represents a true endocervical lesion.

This is an endocervical polyp.

Additional Examples of Lesions

In this example, we have another echogenic nodule within the uterine cavity.

This represents an endometrial polyp.

Notice that the remainder of the endometrium is nice and thin.

She has an arcuate uterus as well.

In this example, there were two endometrial polyps as well as diffuse thickening of the endometrium that proved to represent endometrial hyperplasia.

This is an image from a postmenopausal woman who presented with what was thought to be a very worrisome endometrial lesion.

Certainly in a postmenopausal woman, this amount of echogenic material centrally within the uterus would raise concern for the possibility of endometrial cancer.

But in fact, we see by installation of a small amount of fluid into the uterine cavity that this is not an endometrial lesion, but a, an unusual myometrial lesion.

This represents an unusual variant of a myoma most likely echogenic because of a fatty component, a so-called lipo myoma.

And in fact, she has no endometrial lesion and there is no longer a concern for malignancy.

Here on a hys pangram, we see a definite intrauterine filling defect, but on histography, we are unable to distinguish between a myoma and a polyp.

This represents the sonohysterogram on the same patient, and we clearly see a lesion that is similar in echo texture to the myometrium representing an intracavitary myoma.

This lesion would be amenable to hysteroscopic resection.

Two examples of hysters pergram showing uterine anomalies.

Again, our experience shows that hyalin is limited in the evaluation of the exact type of anomaly.

However, sonohysterography, especially when combined with 3D ultrasound, can clearly delineate the precise morphology.

In this case, the external contour is normal.

This is again a sub septate uterus.

This patient also has multiple echogenic nodules on both sides of the septum, representing multiple endometrial polyps.

Another 3D sonohysterogram, and a woman with infertility.

The cavity is normal except for an arcuate uterus, which does not require surgical intervention.

On these preliminary transvaginal sonograms, we see a small hypoechoic nodule representing a myoma, but the exact location with respect to the uterine cavity was difficult to assess.

On sonohysterography, though we see that in fact this represents a, tiny but strategically located sub mucus intracavitary myoma that is in the left corneal region.

Adenomyosis

A significant number of patients will present with abnormal bleeding and or an endometrium that is difficult to evaluate.

On transvaginal sonography, we have found that in many cases with the installation of fluid, it becomes clear that these women have adenomyosis.

This woman was thought to have a grossly thickened endometrial, echo complex.

But in fact, what we saw when we put fluid in was that the endometrial myometrial junction is indistinct because of the invasion of the myometrium by endometrial glands.

Notice how thick the posterior myometrium is compared to the anterior myometrium.

So this is an example of adenomyosis involving predominantly the posterior wall of the uterus.

In fact, there are no endometrial lesions in this case.

This was another patient that came with a suspected endometrial polyp because of this island of echogenic tissue here in the upper uterus, this was in fact a patch of adenomyosis.

So when we do sonohysterography and notice that some of the echogenic, bubbles that are invariably present in the fluid that we instill that appear to be in the myometrium, this is at the beginning of the procedure and toward the end of the procedure, we see that there is some air in the myometrium.

This can be a clue to the presence of adenomyosis because in adenomyosis, the endometrial glands that are in the myometrium may communicate with a uterine cavity.

And when we instill fluid, air bubbles may in fact sate into the myometrium.

Evaluation in Infertile Women

Sonohysterography can be performed in lieu of the X-ray hy Pergram in screening the infertile woman.

We are not at the point where we are going to pick up very, tiny lesions, such as sitis Isa Noosa as demonstrated in this hyster of sapen igram.

However, at a minimum we can look at the cul-de-sac prior to the installation of any fluid.

And if this examination is performed before day 10, there should be no fluid or minimal fluid in the cul-de-sac.

Here we have a sagittal image of the cervix.

There was some bowel and some fluid that appeared during the sonohysterogram.

Another examination of the adnexal regions demonstrates that we can actually see the normal fallopian tube surrounded by fluid.

So if fluid is not present in the cul-de-sac at the onset of the examination and is demonstrated in the cul-de-sac or in the adnexal regions during or after the examination, this indicates at least unilateral tubal patency.

This is the appearance on 3D imaging of the tubal FIA that become apparent once fluid has been spilled into the uterine into the, peritoneal cavity.

If we want to image a tubal spill directly, we can use agitated saline.

So this is an image of the saline distended uterine cavity.

And when we're finished evaluating the uterine cavity, we can agitate saline and look how echogenic it is, and we can actually follow the echogenic saline going through the isthmic portion of the fallopian tube and spilling.

In this case, it spilled into a contained cavity.

This was a hydro cell. Pinks we're looking for free spill.

In this case, the echogenic bubbles remained around the ovary suggesting peri tubal adhesions.

On this video clip, we see that the balloon bearing catheter has been placed.

We're putting the volume box over the uterus.

Fluid is being instilled. We see that there is a myoma.

The cavity is distended.

We will acquire, once we're happy with the distension, we will acquire several volumes.

We'll come back later and evaluate the exact location of this myoma with respect to the uterine cavity.

But now we will proceed to evaluate tubal spill with echogenic saline demonstrated here in the uterine cavity.

And we will follow this, these echogenic bubbles out through the corneal regions and look for spill that will indicate tubal patency.

So this is the ovary with a mature follicle in it.

Release the pressure of the cath of the vaginal probe, and here is the echogenic saline spilling out of the fallopian tube.

So here we have a way of evaluating tubal patency without x-ray and without contrast.

Final Cases

A few final cases this woman presented in 2003 was thought to have a fibroid follow-up, was obtained in 2005, and the fibroid was noted to be larger.

Her clinical problem was abnormal bleeding.

In fact, sonohysterography demonstrated that the myoma was most likely not the cause of her bleeding.

Her myoma is remote from the cavity.

In fact, she has multiple endometrial lesions, multiple endometrial polyps that were the cause of her bleeding.

Finally, we, in women that have had previous cesarean sections, we may notice a deformity in the lower uterine segment.

This is the very commonly seen cesarean section defect.

It has been shown that in some women, this defect can be larger and may actually accumulate blood and be a cause of inter menstrual bleeding.

Again, sonohysterography is ideal for evaluation of this possibility.

Conclusion

In conclusion, the value of sonohysterography is widely accepted.

This technique is safe, less expensive, less painful, and less invasive than DNC endometrial biopsy and hysteroscopy.

The findings on sonohysterography can obviate endometrial sampling in many cases can take the place of the x-ray.

Hys. Picogram can assist in determining the therapeutic approach and often reduces the level of intervention.

Attention to detail is very important, and the use of 3D ultrasound facilitates a rapid study and extends the diagnostic ability of this examination.

Thank you.