Saline infusion sonohysterography
- Steven R Goldstein, MD
Steven R Goldstein, MD
- Professor of Obstetrics and Gynecology
- New York University School of Medicine
- Section Editors
- Robert L Barbieri, MD
Robert L Barbieri, MD
- Editor-in-Chief — Obstetrics, Gynecology and Women's Health
- Section Editor — General Gynecology and Female Reproductive Endocrinology
- Kate Macy Ladd Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
- Deborah Levine, MD
Deborah Levine, MD
- Section Editor — Imaging
- Professor of Radiology
- Director of Ob/Gyn Ultrasound
- Department of Radiology
- Beth Israel Deaconess Medical Center
Saline infusion sonohysterography refers to a procedure in which fluid is instilled into the uterine cavity transcervically to provide enhanced endometrial visualization during transvaginal ultrasound examination [1,2]. The technique improves sonographic detection of endometrial pathology, such as polyps, hyperplasia, cancer, leiomyomas, and adhesions. In addition, it can help avoid invasive diagnostic procedures in some patients as well as optimize the preoperative triage process for those women who require therapeutic intervention. It is easily and rapidly performed at minimal cost, well-tolerated by patients, and is virtually devoid of complications. The American College of Obstetricians and Gynecologists, in conjunction with the American College of Radiology and the American Institute of Ultrasound in Medicine, developed a technology assessment document for saline infusion sonohysterography [3,4].
There are a number of situations where fluid enhanced endovaginal scanning will aid evaluation of the uterine cavity. The American Institute for Ultrasound in Medicine's standard indications and contraindications to this procedure are shown in the table (table 1).
Unscheduled uterine bleeding — Unexpected uterine bleeding accounts for a large proportion of gynecologic patient visits. Endometrial biopsy and/or office hysteroscopy are often used as initial diagnostic procedures; in hospital dilation and curettage is no longer considered an appropriate initial diagnostic test in most women .
Transvaginal ultrasound is used increasingly as an initial triage for patients with abnormal uterine bleeding. Sonohysterography is a subset of transvaginal sonography that is used when it is difficult to visualize the endometrium or the endometrium is thickened.
Sonohysterography is particularly useful for finding focal endometrial abnormalities or confirming that a focal abnormality diagnosed by transabdominal or transvaginal ultrasound is present and better defining the nature of the abnormality [6,7]. As an example, one study performed both transvaginal ultrasonographic examination and sonohysterography on 106 patients with menometrorrhagia . The sensitivity and specificity of saline infusion sonohysterography for detection of polyps were significantly higher than for transvaginal ultrasound alone (93 and 94 versus 75 and 76 percent for TVS) and were comparable to hysteroscopy, a finding confirmed by others [9-12].
- Parsons AK, Lense JJ. Sonohysterography for endometrial abnormalities: preliminary results. J Clin Ultrasound 1993; 21:87.
- Syrop CH, Sahakian V. Transvaginal sonographic detection of endometrial polyps with fluid contrast augmentation. Obstet Gynecol 1992; 79:1041.
- American College of Obstetricians and Gynecologists. ACOG Technology Assessment in Obstetrics and Gynecology No. 5: sonohysterography. Obstet Gynecol 2008; 112:1467.
- American Institute of Ultrasound in Medicine, American College of Radiology, American College of Obstetricians and Gynecologists, Society of Radiologists in Ultrasound. AIUM practice guideline for the performance of sonohysterography. J Ultrasound Med 2012; 31:165.
- APGO educational series on women's health issues. Clinical management of abnormal uterine bleeding. Association of Professors of Gynecology and Obstetrics, 2006.
- Goldstein RB, Bree RL, Benson CB, et al. Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored Consensus Conference statement. J Ultrasound Med 2001; 20:1025.
- La Sala GB, Blasi I, Gallinelli A, et al. Diagnostic accuracy of sonohysterography and transvaginal sonography as compared with hysteroscopy and endometrial biopsy: a prospective study. Minerva Ginecol 2011; 63:421.
- Kamel HS, Darwish AM, Mohamed SA. Comparison of transvaginal ultrasonography and vaginal sonohysterography in the detection of endometrial polyps. Acta Obstet Gynecol Scand 2000; 79:60.
- Epstein E, Ramirez A, Skoog L, Valentin L. Transvaginal sonography, saline contrast sonohysterography and hysteroscopy for the investigation of women with postmenopausal bleeding and endometrium > 5 mm. Ultrasound Obstet Gynecol 2001; 18:157.
- Schwärzler P, Concin H, Bösch H, et al. An evaluation of sonohysterography and diagnostic hysteroscopy for the assessment of intrauterine pathology. Ultrasound Obstet Gynecol 1998; 11:337.
- Krampl E, Bourne T, Hurlen-Solbakken H, Istre O. Transvaginal ultrasonography sonohysterography and operative hysteroscopy for the evaluation of abnormal uterine bleeding. Acta Obstet Gynecol Scand 2001; 80:616.
- Soares SR, Barbosa dos Reis MM, Camargos AF. Diagnostic accuracy of sonohysterography, transvaginal sonography, and hysterosalpingography in patients with uterine cavity diseases. Fertil Steril 2000; 73:406.
- de Kroon CD, Jansen FW, Louwé LA, et al. Technology assessment of saline contrast hysterosonography. Am J Obstet Gynecol 2003; 188:945.
- Goldstein SR, Zeltser I, Horan CK, et al. Ultrasonography-based triage for perimenopausal patients with abnormal uterine bleeding. Am J Obstet Gynecol 1997; 177:102.
- Salle B, Gaucherand P, de Saint Hilaire P, Rudigoz RC. Transvaginal sonohysterographic evaluation of intrauterine adhesions. J Clin Ultrasound 1999; 27:131.
- Darwish AM, Youssef AA. Screening sonohysterography in infertility. Gynecol Obstet Invest 1999; 48:43.
- Ludwin A, Ludwin I, Banas T, et al. Diagnostic accuracy of sonohysterography, hysterosalpingography and diagnostic hysteroscopy in diagnosis of arcuate, septate and bicornuate uterus. J Obstet Gynaecol Res 2011; 37:178.
- Luciano DE, Exacoustos C, Johns DA, Luciano AA. Can hysterosalpingo-contrast sonography replace hysterosalpingography in confirming tubal blockage after hysteroscopic sterilization and in the evaluation of the uterus and tubes in infertile patients? Am J Obstet Gynecol 2011; 204:79.e1.
- Goldstein SR. Unusual ultrasonographic appearance of the uterus in patients receiving tamoxifen. Am J Obstet Gynecol 1994; 170:447.
- Hann LE, Gretz EM, Bach AM, Francis SM. Sonohysterography for evaluation of the endometrium in women treated with tamoxifen. AJR Am J Roentgenol 2001; 177:337.
- Elhelw B, Ghorab MN, Farrag SH. Saline sonohysterography for monitoring asymptomatic postmenopausal breast cancer patients taking tamoxifen. Int J Gynaecol Obstet 1999; 67:81.
- Schwartz LB, Snyder J, Horan C, et al. The use of transvaginal ultrasound and saline infusion sonohysterography for the evaluation of asymptomatic postmenopausal breast cancer patients on tamoxifen. Ultrasound Obstet Gynecol 1998; 11:48.
- Committee Opinion No. 601: Tamoxifen and uterine cancer. Obstet Gynecol 2014; 123:1394.
- Goldstein SR. Controversy about uterine effects and safety of SERMs: the saga continues. Menopause 2002; 9:381.
- Wolman I, Groutz A, Gordon D, et al. Timing of sonohysterography in menstruating women. Gynecol Obstet Invest 1999; 48:254.
- Yung SS, Lai SF, Lam MT, et al. Randomized, controlled, double-blind trial of topical lidocaine gel and intrauterine lidocaine infusion for pain relief during saline contrast sonohysterography. Ultrasound Obstet Gynecol 2016; 47:17.
- Dessole S, Farina M, Capobianco G, et al. Determining the best catheter for sonohysterography. Fertil Steril 2001; 76:605.
- Spieldoch RL, Winter TC, Schouweiler C, et al. Optimal catheter placement during sonohysterography: a randomized controlled trial comparing cervical to uterine placement. Obstet Gynecol 2008; 111:15.
- Sylvestre C, Child TJ, Tulandi T, Tan SL. A prospective study to evaluate the efficacy of two- and three-dimensional sonohysterography in women with intrauterine lesions. Fertil Steril 2003; 79:1222.
- Exalto N, Stappers C, van Raamsdonk LA, Emanuel MH. Gel instillation sonohysterography: first experience with a new technique. Fertil Steril 2007; 87:152.
- Davis PC, O'Neill MJ, Yoder IC, et al. Sonohysterographic findings of endometrial and subendometrial conditions. Radiographics 2002; 22:803.
- Bittencourt CA, Dos Santos Simões R, Bernardo WM, et al. Accuracy of saline contrast sonohysterography in detection of endometrial polyps and submucosal leiomyomas in women of reproductive age with abnormal uterine bleeding: systematic review and meta-analysis. Ultrasound Obstet Gynecol 2017; 50:32.
- Timmerman D, Verguts J, Konstantinovic ML, et al. The pedicle artery sign based on sonography with color Doppler imaging can replace second-stage tests in women with abnormal vaginal bleeding. Ultrasound Obstet Gynecol 2003; 22:166.
- Becker E Jr, Lev-Toaff AS, Kaufman EP, et al. The added value of transvaginal sonohysterography over transvaginal sonography alone in women with known or suspected leiomyoma. J Ultrasound Med 2002; 21:237.
- Reeves MF, Goldstein RB, Jones KD. Communication of adenomyosis with the endometrial cavity: visualization with saline contrast sonohysterography. Ultrasound Obstet Gynecol 2010; 36:115.
- Tocci A, Greco E, Ubaldi FM. Adenomyosis and 'endometrial-subendometrial myometrium unit disruption disease' are two different entities. Reprod Biomed Online 2008; 17:281.
- Ahonkallio SJ, Liakka AK, Martikainen HK, Santala MJ. Feasibility of endometrial assessment after thermal ablation. Eur J Obstet Gynecol Reprod Biol 2009; 147:69.
- Cooper JM, Brady RM. Intraoperative and early postoperative complications of operative hysteroscopy. Obstet Gynecol Clin North Am 2000; 27:347.
- Tuveng JM, Vold I, Jerve F, et al. Hysterosalpingography: value in estimating tubal function, and risk of infectious complications. Acta Eur Fertil 1985; 16:125.
- ACOG Committee on Practice Bulletins--Gynecology. ACOG practice bulletin No. 104: antibiotic prophylaxis for gynecologic procedures. Obstet Gynecol 2009; 113:1180. Reaffirmed 2016.
- Bese T, Demirkiran F, Guralp O, et al. Transtubal transport of carcinoma cells into the peritoneal cavity after saline infusion via transcervical route in patients with endometrial carcinoma. Int J Gynecol Cancer 2009; 19:682.
- Alcázar JL, Errasti T, Zornoza A. Saline infusion sonohysterography in endometrial cancer: assessment of malignant cells dissemination risk. Acta Obstet Gynecol Scand 2000; 79:321.
- Dessole S, Rubattu G, Farina M, et al. Risks and usefulness of sonohysterography in patients with endometrial carcinoma. Am J Obstet Gynecol 2006; 194:362.
- Lindheim SR, Morales AJ. Comparison of sonohysterography and hysteroscopy: lessons learned and avoiding pitfalls. J Am Assoc Gynecol Laparosc 2002; 9:223.
- Mihm LM, Quick VA, Brumfield JA, et al. The accuracy of endometrial biopsy and saline sonohysterography in the determination of the cause of abnormal uterine bleeding. Am J Obstet Gynecol 2002; 186:858.
- Dessole S, Farina M, Rubattu G, et al. Side effects and complications of sonohysterosalpingography. Fertil Steril 2003; 80:620.
- van Dongen H, de Kroon CD, van den Tillaart SA, et al. A randomised comparison of vaginoscopic office hysteroscopy and saline infusion sonography: a patient compliance study. BJOG 2008; 115:1232.
- Unscheduled uterine bleeding
- Tamoxifen-induced changes
- Hyperplasia and cancer
- Endometrial assessment after non-resectoscopicl endometrial ablation
- TECHNICAL CONCERNS
- Difficulty passing the catheter
- Poor visualization
- Dissemination of carcinoma
- False positive findings
- SIDE EFFECTS AND COMPLICATIONS
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS