Journal of Obstetrics and Gynaecology, February 2009; 29(2): 132134

GYNAECOLOGY

A pilot evaluation of saline sonohysterography for postmenopausal bleeding with thickened endometrium

S. I. M. F. ISMAIL1, D. H. O. PUGH1, K. GOWER-THOMAS2 & C. DAVIES2

Departments of 1Obstetrics and Gynaecology and 2Radiology, Royal Glamorgan Hospital, Wales, UK

Summary The aim of this study was to assess the clinical and cost implications of pilot introduction of saline sonohysterography for postmenopausal bleeding with thickened endometrium (5 mm), at the Royal Glamorgan Hospital. The investigation was attempted in 48 patients who were found to have a thickened endometrium (5 mm) on transvaginal ultrasound scanning. The attempt was successful in 45 patients (93.8%). Failures were due to (1) cervical stenosis and (2) leakage of saline from the cervix. Difcult catheterisation of the cervix causing pain was encountered in a minority of cases. Two-thirds of patients were found have focal lesions and were booked for hysteroscopic resection. These patients included 30 with polyps, which were precisely described in all of them. In view of this low complication rate and high accuracy, the technique was integrated as a standard method of investigation for postmenopausal bleeding at the hospital. Keywords Postmenopausal bleeding, saline sonohysterography, ultrasound

Introduction
Postmenopausal bleeding is a common gynaecological presentation (Reinhold and Khalili 2002). Traditional methods of investigation include transvaginal ultrasound scan and endometrial sampling as well as outpatient or inpatient hysteroscopy and biopsy (Guruwadayarhalli et al. 2007; Timmermans et al. 2007). The introduction of saline into the endometrial cavity in patients with thickened endometrium increases the diagnostic value of transvaginal ultrasound by delineating patients with focal lesions, who would benet from an operative hysteroscopy, from those without such lesion, for whom an endometrial sample would be sufcient (Ismail 2005). The technique has been shown to be as accurate as outpatient hysteroscopy in identifying focal lesions (Widrich et al. 1996) including polyps and broids (Senoh et al. 1999). However, there is limited information about the clinical impact and cost implications of using such technique in clinical practice as part of the patient pathway. This study looks at these aspects in a pilot evaluation that was carried out at the Royal Glamorgan Hospital.

ultrasound scan, a Cuscos speculum was inserted into the vagina, the cervix was cleaned with an antiseptic solution and a 5F hysterosalpingography catheter, already primed with saline using a 20 mm syringe, was introduced into the cervix and the balloon of the catheter inated. The rigid manipulation handle was removed to make it easier to re-introduce the transvaginal probe and saline was injected through the catheter. The thickness of each wall of the endometrium and the presence and nature of focal thickening were noted. At the end, the transvaginal prove was removed and the balloon of the catheter deated to enable its withdrawal from the cervix (Ismail 2005).

Results
The investigation was attempted in a total of 48 patients and was successful in 45 cases (93.8%). Three failures were encountered: one (2.1%) was due to cervical stenosis and two (4.2%) were due to leakage of saline. A total of 31 cases (65%) were direct referrals from general practitioners and 17 (35%) were referred by gynaecologists. Difcult catheterisation of the cervix was noted in six patients (12.5%), and two patients (4.2%) experienced signicant pain. Polyps were noted in 30 patients (62.5%), four (8.3%) of whom had broad base, and focal lesions were noted in another two (4.2%). It was possible to measure all polyps and describe their number and location. All 32 patients were booked for inpatient hysteroscopic resection. Endometrial carcinoma was reported in one and the rest

Materials and methods

Saline sonohysterography was offered to patients with postmenopausal bleeding with thickened endometrium (5 mm) on transvaginal ultrasound scans carried out in the radiology department. After standard transvaginal

Correspondence: S. I. M. F. Ismail, Department of Obstetrics and Gynaecology, Yeovil District Hospital, Yeovil BA21 4AT, UK. E-mail: sharif212121@yahoo.co.uk ISSN 0144-3615 print/ISSN 1364-6893 online 2009 Informa Healthcare USA, Inc. DOI: 10.1080/01443610802667088

Gynaecology, gynaecological ultrasound, menopause

were all benign. No syncopal attacks or subsequent infection were encountered. The features of the patients included in this series are shown in Table I. An illustration of a polyp becoming visible on the introduction of saline is shown in Figures 1 and 2.

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Discussion
The technique was successful in 45 out of 48 patients (93.8%), with no complications, apart from the cases that

Table I. Features of the patients who had saline sonohysterography attempted. n Age (years) (median, interquartile range) Referral source GP Gynaecology Problem Pain Difcult catheterisation Poor image Findings Polyps Focal lesion 55 31 17 2 6 5 30 2 (%) 52.562 64.6 35.4 4.2 12.5 10.4 62.5 4.2

had pain. One failure was due to cervical stenosis that could have been overcome with cervical dilatation under local anaesthesia. Two cases had poor visualisation of the endometrial cavity due to excessive cervical dilatation. All three failures happened at an early stage and represent part of the learning curve (Epstein et al. 2001). These features demonstrate the safety of the technique and the ease with which it can be integrated in the postmenopausal bleeding investigation pathway. They also match published reports on safety (Goldstein 1996) and the success of the technique (Bronz et al. 1997). The investigation was very accurate, providing ample detail about polyps and focal lesions that guided their subsequent resection. With prior knowledge of the location, side and number of polyps and whether they had a thick pedicle or not, it was not only possible to proceed to hysteroscopic resection of these lesions, but to plan the instrument to be used and check for complete resection of all polyps as well. In addition to avoiding diagnostic hysteroscopy, on outpatient or inpatient basis, which spared patients having repeat investigations and saved clinic appointments, it also reduced time waste in theatre. These features concur with published studies that describe the additional information the technique provides in describing polyps (Cicinelli et al. 1994), illustrate its diagnostic accuracy (Cullinan et al. 1995) and costeffectiveness (Bronz et al. 1997). Two-thirds of the patients included in this series were found to have polyps or focal lesions that required operative hysteroscopy. Similar rates were reported in other studies (Bronz et al. 1997), which further demonstrates the cost-effectiveness of the technique. Saline sonohysterography adds a few minutes to a standard ultrasound scan and requires relatively inexpensive equipment. There is no need for admission to hospital or any additional staff. The avoidance of diagnostic hysteroscopy also further reduces the waiting time between referral and denitive investigation. The investigation was carried out by radiologists in this series. With the introduction of the College Advanced Skills Module on gynaecological ultrasound, it is possible now for gynaecologists to perform this investigation as part of a one-stop clinic, where polyps could be removed using outpatient operative hysteroscopy, further reducing the need for patient admission.

Figure 1. Ultrasound scan showing thickened endometrium.

Conclusion
Saline sonohysterography is a safe, effective and valuable method of investigation that can be easily integrated into the investigation for postmenopausal bleeding. Since this pilot, the technique has been introduced as a standard investigation at the Royal Glamorgan Hospital. Declaration of interest: The authors report no conicts of interest. The authors alone are responsible for the content and writing of the paper.

References
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Figure 2. A polyp is noted on the introduction of saline.

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