March 2007 Vol 7 Isuue 1 FINAL without suicide .indd ABSTRACT Objective: Transvaginal Sonography (TVS) is being used in the investigation of postmenopausal bleeding (PMB). The bleeding could be the result of a number of factors; endometrial polyps are one of the common findings in these patients. The aim was to compare the findings of TVS and hysteroscopy to determine the sensitivity of each method in detecting endometrial polyps. Methods: This was a retrospective study, designed to investigate the sensitivity and specificity of transvaginal sonography in the detection of endometrial polyps. This study was conducted from July 992 to July 999 and identified from the record 37 patients with PMB referred for transvaginal sonography, hysteroscopy and biopsy investigations. Results: Thirty-seven patients with PMB were scanned using TVS and hysteroscopy. The result was not specific or sensitive when using TVS alone. TVS showed 3.52 % sensitivity, hysteroscopy/biopsy showed 00% sensitivity. TVS p>0.06 was not significant. Conclusion: Using TVS alone to diagnose polyps in PMB patients is not sensitive, especially when the polyps are smaller than 6 mm. If it is combined with hysterscopy, the reliability and s sensitivity are significantly improved. Keywords: Endometrial polyps, Transvaginal Sonography, Postmenopausal bleeding, Hysteroscopy The Relationship between Hysteroscopy, Endometrial Biopsy andThe Results of Transvaginal Sonography in Assessing Endometrial Polyps *Saad R I Al-Kubaisi *Ultrasound Supervisor, High Level General Hospital, P O Box 1462, Hight Level, Alberta, Canada, TOH 1Z0 Canada Email: saa3d@hotmail.com طيطٌ ونتائج َالتخْ بطانة الرحم ة زْعَ الرحم، خَ بني تنظير العالقة يَّة مِ الرَحِ البِطانَّةٌ الَئِلُ سَ تقييم في املهبل عبر اتِيِّ وَ التَصْ الكبيسي سعد البطانة ــالئل س منها عدة، لعوامل والذي يكون لليأس، التالي النزف ــقصاء اس في املهبل وَاتِيِّ عبر التَصْ طيطٌ َالتخْ ــتعمل امللخص: الهدف: يس ــية والقيمة احلساس لتحديد تنظير الرحم، الطريقة مع نتائج نتائج تلك مقارنة هو ــة الدراس من الهدف عند املريضات. توجد بكثرة ــي الت ــة الرحمي التخطيط التصواتي ونوعية حساسية لدراسة صممت ــة استعادية دراس الطريقة: هذه الرحم. بطانة ــالئل س ــاف اكتش في طريقة لكل التنبؤية للتخطيط احيلت ،1999 سنة 1992 الى من سنة التالي لليأس من النزف 37 حالة تعاني دراسة مت الرحم. بطانة ــالئل س ــاف اكتش في املهبل عبر التصواتي بالتخطيط لليأس التالي النزف من تعاني 37 مريضة فحص النتائج: مت الرحم. بطانة خزعة وفحص الرحم وتنظير املهبل عبر التصواتي لديها احلاالت كان %82.85 من مبفرده. التصواتي التخطيط فحص ــتخدم اس ــة حني حساس أو نوعية ــت ليس النتيجة . الرحم وتنظير املهبل عبر لوحده، بينما املهبل عبر التصواتي التخطيط بواسطة تشخيصها يتم لم (62.8%) السالئل 22 من 4 ملم). من (أكثر العام الرحم بطانة تضخم املهبل عبر التصواتي التخطيط استعمال يكفي اخلالصة: ال .(100%) سالئل بطانة الرحم قاطبة حااالت كل اكتشاف من الرحم تنظير استطاع ، وعندما ترفق 6 ملم من أقل السليلة تكون عندما خاصة لليأس، التالي النزف من املريضات الالتي يعانني عند الرحم بطانة سالئل حاالت لتشخيص ملموس. بشكل واحلساسية املعولية تتحسن تنظير الرحم مع التالي لليأس، تنظير الرحم. النزف املهبل، عبر التصواتي التخطيط الرحم، بطانة الكلمات: سالئل مفتاح SULTAN QABOOS UNIVERSITY MEDICAL JOURNAL APRIL 2007 VOL 7, NO. 1 SULTAN QABOOS UNIVERSITY© C L I N I C A L & B A S I C R E S E A R C H POSTMENOPAUSAL BLEEDING (PMB) IS A relatively common presentation that can be a source of anxiety because it is a symptom com- mon to both benign and malignant conditions. Men-opause is the permanent cessation of menstruation resulting from the loss of follicular ovarian activity.1 S A A D R I A L - K U B A I S I 52 Generally, PMB is regarded as bleeding from the geni- tal tract one or many years following the cessation of menses.2 PMB has no organic cause and some form of further investigation is required in order to exclude the possibility of malignancy3 or to identify the exist- ence of benign conditions such as endometrial hyper- plasia or polyps. PMB is regarded as an indicator to perform invasive procedures to obtain histological samples for diagnosis, such as hysteroscopy, endome- trial biopsy 4 or dilation and curettage (D&C). 5, 6 TVS is a non-invasive technique that can be assessed for this purpose. Endometrial polyps are common find- ing in 10% of pre and postmenopausal women and it is important they are diagnosed as the main source for the bleeding and the presence of any malignant lesion excluded.7 Histologically, the endometrial polyps are composed of a fine fibrous core of stroma and glands and are invariably benign. They may be asymptomatic and cause abnormal uterine bleeding.8 Malignant en- dometrial conditions are diagnosed only in a minor- ity of women with PMB. The risk remains sufficiently high, however, that the patients require further inves- tigation. Therefore, there is a need for a less invasive test, which is well tolerated by patients and relatively inexpensive.8, 9 The identification or exclusion of an en- dometrial malignancy is the primary goal of scanning this group of PMB patients. 4, 9 Studies have favoured the use of transvaginal ultrasound as an initial inves- tigation for women with PMB; this may raise the need for more invasive D&C, hystereroscopy or biopsy.4, 10 It is important to know which modality to use to find more diagnostic details. The aim of this study was to analyze the patients with PMB and compare the re- sults from TVS and hysteroscopy. Many sonographers will assert that the presence of polyps can be both confirmed and excluded using transvaginal sonogram. Various criteria have been hypothesized as indicat- ing the presence of polyps in the endometrium cavity, including endometrial thickness (ET), intracavitary fluid and the density of endometrial echoes. Studies have demonstrated the limited ability of the transvagi- nal sonogram to discriminate polyps in both pre- and postmenopausal women.9, 11&12 M E T H O D S This was a retrospective study. Thirty-seven patients with PMB were examined by TVS, followed by a hys- teroscopy and biopsy at three hospitals, in Canada and Brunei, without selection bias. Twenty patients were examined in Canada and 17 in Brunei. Various ultra- sound machines were used, such as ATL Ultra Mark 3000, HDI 5000, Diasonic 1000, Sonoline and Aligant 4500 scanning machines, with a 7.5 Mhz transvaginal and 3.5 Mhz trans-abdominal transducers. The ma- chines were top of the range and the differences did not influence the results, as TVS transducers with the same frequencies (5 to 10) MHz were used. The author did all the ultrasound examinations and meas- urements. The patients had signed a consent form approved by the hospitals’ ethics committees. The patients had attended outpatient clinics between July 1992 and July 1999 with post-menopausal bleeding and been referred for a TVS, followed by hysterosco- py and biopsy investigation. The patient ages ranged from 40 to 80 years (median was 60 years). TVS of the uterus were done in both sagittal and coronal planes. The American Institute of Ultrasound use in medicine criteria were used. The following criteria were record- ed: patient age at menopause, endometrial thickness (ET), the presence of abnormal echoes of fluid within the endometrium, the presence of any other uterine or ovarian pathology, whether the patient was taking hor- mone replacement therapy (HRT) or Tamoxifen. The results for the biopsies and hysteroscopy were collect- ed from the pathology departments. Any intracavitary fluid detected was subtracted from the overall thick- ness of the endometrium. The endometrial texture differentiation was homogeneous, heterogeneous or cystic. The presence of submucosal myomas (fibroids) or focal polyps was documented. The presence and position of myometrial myomas (fibroids) was noted. Any adnexal pathology such as dermoid was recorded. The ultrasound reports were then compared with hys- teroscopy and histology findings. The comparison was done by the departmental radiologist. Female nurses chaperones were asked to be in the ultrasound room when the TVS was conducted. R E S U L T S Thirty-seven patients with PMB were scanned using TVS. Hysteroscopy and histological results were ob- tained from the pathology departments upon request. Endometrium Thickness (ET) of 4 mm was found in eight cases using TVS with no sign of polyps, and us- ing hysteroscopy four polyps were detected. ET of 5 to 6 mm was found in 22 cases. Using TVS, 8 fibroids were suspected within the myometrium and one polyp noted. Hysteroscopy results confirmed the presence TH E R E L AT I O N S H I P B E T W E E N H Y S T E R O S C O P Y, E N D O M E T R I A L B I O P S Y A N D TH E R E S U LT S O F TR A N S VA G I N A L S O N O G R A P H Y I N A S S E S S I N G E N D O M E T R I A L P O LY P S 53 of 22 polyps and one fibroid was found. Seven cases measured an ET of 7 to 8 mm; TVS found four pol- yps and hysteroscopy results confirmed the presence of seven polyps. The results were tabulated according to the ET and the findings from TVS, hysterscopy, and biopsy results [Table 1]. D I S C U S S I O N When taking an endometrium thickness 5 to 8 mm the prevalence of polyps using TVS was 17.25 % as a positive diagnosis. The predictive value of TVS was less sensitive and less specific than the predic- tive value of hysteroscopy, especially in ET less than 6 mm. The ability of TVS to identify correctly the en- dometrial pathology can be affected by a number of factors. During TVS, sonographers often obtain de- tailed images showing clearly defined polyps within the endometrium. This leads to the general idea that the majority of polyps can be detected by transvaginal sonogram. However, results from this study indicated that very few polyps could be detected in this way.9, 11, 12 Subsequent hysteroscopy examination identified sizeable and numerous small polyps less than 5 mm, which had not been noted sonographically. The use of saline contrast (sonohysterography) 12 may well im- prove the detection of endometrial polyps; however the widespread use of hysteroscopy has now gener- ally obviated the use of this technique. Essentially this comes down to how much reliability a gynecologist should place on a negative ultrasound report for en- dometrial polyps in a patient with postmenopausal bleeding. The predictive value of TVS for screening endometrial polyps is much lower than the use of hys- teroscopy. Ultrasound equipment has improved dra- matically over the past several years, particularly with the development of endo vaginal transducers with multi frequencies, harmonic imaging and 3D sonog- raphy. These features can increase the specificity and negative predictive value, thus decreasing the need for invasive procedures. Hysterscopy confirmed the pres- ence of endometrial lesions in 100% of cases in this study. TVS failed in 75.67 % of the case to confirm the presence of endometrial lesions. TVS was sensitive in 24.33 % of the cases. When the endometrium thicken- ing (ET) was 7 mm and larger, TVS was sensitive in 57.15 % of the cases. TVS was not sensitive in 95.45 % of the cases when ET was 5 to 6 mm. Using TVS alone it was difficult to differentiate between polyps and subserosal fibroids with false positive reporting. In ET 4mm and less, TVS missed four polyps, which were found by hysteroscopy and biopsy. The result of this study suggests that the diagnosis of endometrial polyps is not specific using TVS alone and it was not significant, (p>0.06), especially when the ET is 5 mm or less. While some polyps are readily identifiable, other polyps fail to present any specific features. 78.38 % of the cases presented with endometrial thickening. The sensitivity increased to 100% when a combination of TVS and hysteroscopy were used: p<0.01 and better than 95% confidence interval was obtained. TVS failed in 95.5 % of the cases to detect polyps in 5 to 6 mm ET. Therefore, the negative reports on the four cases done by TVS with an ET of 4 mm and less was coincidence and not reliable. TVS depends upon sonographer skills and training and the type of ultrasound equipment be- ing used. If the equipment and the TVS transducers were equipped with 3-D, harmonic fusion, angio col- our Doppler, gain suppression and focal strength ca- pabilities, the detection of these lesions might be more successful. L I M I T A T I O N S A prospective study would have greater validity be- cause all subjects would be required to have a hysteros- Number of Patients Endometrial Thickening (ET) T.V.S Finding Sensitivity Hysteroscopy Finding Sensitivity Biopsy Finding Sensitivity 8 4mm Normal Inconclusive 0% 4 polyps 4 normal 100% 4 polyps; Benign 100% 22 5 to 6 mm 8 fibroids 1 polyp 4.5% 1 fibroid 22 polyps 100% 22 polyps; 21 Benign, 1 Malignant 100% 7 7 to 8 mm 4 polyps, 3 normal 57.15% 7 polyps 100% 7 polyps Benign 100% TVS= Transvaginal sonography Table 1- The sensitivity of TVS versus Hysteroscopy and Biopsy to detect endometrial polyps. S A A D R I A L - K U B A I S I 54 copy regardless of the TVS findings, whereas in other cases, only those with abnormal TVS will be referred for hysteroscopy. In that case, those with endometrial lesion, but missed by TVS, would not be identified by hysteroscopy. It was difficult in some cases to obtain consent forms from the patients when they are older than 70 years. Most patients over the age of 70 asked their family members. They consented to the TVS af- ter the radiologist and their physician explained the benefit of this procedure to them. The advanced ul- trasound machines are expensive and required trained skillful sonographers to operate them. C O N C L U S I O N Using TVS alone to detect endometrial lesions is not sensitive and reliable enough. Using TVS with hyster- oscopy together with TVS increases the sensitivity to 100%. TVS was not sensitive and unreliable in 86.48 % of the cases in this study. Hysteroscopy is the method of choice to be used in PMB cases if the TVS shows a normal result, as it could be a false negative result. Advanced ultrasound equipment and multi frequency transducers are necessary to increase the sensitivity of the examination. R E F E R E N C E S 1. 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