S. Granberg

Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding — a Nordic multicenter study

OBJECTIVE The purpose of this study was to use transvaginal ultrasonographic measurements to find the thickness of the endometrium below which the risk of endometrial abnormality in women with postmenopausal bleeding is low. STUDY DESIGN This multicenter study was carried out at eight clinics in four Nordic countries. The study included 1168 women with postmenopausal bleeding scheduled for curettage Before the curettage was performed, the thickness of the endometrium was measured with transvaginal ultrasonography. The measurement included both endometrial layers (double-layer technique). The transvaginal ultrasonographic measurement was compared with the histopathologic diagnosis of the curettage specimens. RESULTS In women with atrophic endometrium the mean endometrial thickness (+/- SD) was 3.9 +/- 2.5 mm. The corresponding figures for women with endometrial cancer were 21.1 +/- 11.8 mm. No malignant endometrium was thinner than 5 mm. In 30 women (2.8%) it was not possible to measure the thickness of the endometrium; one of these women had endometrial cancer. The 95% confidence limit for the probability of excluding endometrial abnormality was 5.5% when the endometrial thickness was < or = 4 mm as measured by transvaginal ultrasonography. CONCLUSION The risk of finding pathologic endometrium at curettage when the endometrium is < or = 4 mm as measured by transvaginal ultrasonography is 5.5%. Thus in women with postmenopausal bleeding and an endometrium < or = 4 mm it would seem justified to refrain from curettage.

Testicular ultrasonography and extended chromosome analysis in men with nonmosaic Klinefelter syndrome: a prospective study of possible predictive factors for successful sperm recovery.

OBJECTIVE To investigate whether extended chromosome analysis or testicular sonography, including flow Doppler imaging, before diagnostic testicular sperm extraction have predictive value for successful sperm retrieval in men with nonmosaic Klinefelter syndrome. DESIGN Prospective clinical study. SETTING IVF clinic and genetics laboratory at a university hospital. PATIENT(S) Nineteen patients with nonmosaic Klinefelter syndrome and azoospermia. INTERVENTION(S) Collection of blood samples; histopathologic examination of testicular tissue; fluorescence in situ hybridization; sonography, including Doppler imaging; and testicular sperm extraction. MAIN OUTCOME MEASURE(S) Testicular volume, serum FSH and serum testosterone levels, percentage of normal XY cells, ultrasound echogenicity, intratesticular blood flow resistance, and sperm recovery. RESULT(S) Testicular volume and levels of serum FSH and serum testosterone levels did not differ significantly. No differences in testicular echogenicity or intratesticular blood flow resistance were found between 47,XXY men in whom sperm recovery was successful and those in whom sperm recovery failed. Significant differences were seen between all patients with the Klinefelter syndrome and controls with normal sperm values. Fluorescence in situ hybridization of peripheral lymphocytes and buccal tissue showed no correlation between frequency of normal 46,XY cells and testicular spermatogenesis. CONCLUSION(S) In azoospermic men with the Klinefelter syndrome, histopathologic findings seem to be predictive for successful sperm recovery. Infertility work-up, including diagnostic testicular sperm recovery, is recommended, and, if possible, viable sperm should be cryopreserved.

The endometrium in breast cancer patients on tamoxifen.

Abstract We restudied histologically and immunohistochemically 17 endometrial carcinomas, 2 malignant mixed tumors and 180 endometria with benign changes during or after tamoxifen therapy. The carcinomas were subtyped according to the 1994 WHO-classification. Endometrial biopsies were taken only if the endometrial thickness was > 8 mm sonographically, when a polyp was seen, or for postmenopausal bleeding. About half of the endometrial specimens showed simple or cystic atrophy, 55–76% had cystic-atrophic polyps or regressive hyperplasia. Depending upon the dose of tamoxifen, 7–19% (30 mg) to 27– 36% (20 mg) showed moderate glandular proliferation. 20–33% had foci of mucinous, clear cell or serous-papillary metaplasia. 68–70% revealed diffuse extensive fibrosis of the endometrial stroma. None of 11 patients biopsied before starting tamoxifen therapy had advanced endometrial glandular proliferation in the second endometrial biopsy after tamoxifen treatment. None of the 19 endometrial neoplasms after tamoxifen therapy was of the endometrioid type: 11 were mucinous adenocarcinomas, 4 clear cell carcinomas, 2 serous-papillary carcinomas, one carcinosarcoma and one malignant Müllerian mixed tumor. The reasons for discrepancies between suspicious sonograms and endometrial atrophy are discussed.

Uterine findings by transvaginal sonography during percutaneous estrogen treatment in postmenopausal women

OBJECTIVES To evaluate the effect of hormone replacement treatment (HRT) with percutaneous estradiol and cyclical peroral medroxyprogesterone acetate (MPA) every month or every third month on the uterus and endometrium of postmenopausal women. METHODS Uterine size and endometrial thickness were measured by transvaginal sonography in 159 postmenopausal women before HRT, and after 6 and 12 months on HRT during 9-12 days of the MPA administration periods. RESULTS During HRT, uterine size and endometrial thickness increased. The percentage increase in uterine diameter varied between 3.8% and 19.6%, and endometrial thickness varied between 28.7% and 76.4%, being greater in the group receiving MPA every third month than in the groups receiving MPA every month. Myomas grew during the first 6 months on HRT but increased no further during the next 6 months on HRT. CONCLUSIONS The increases in uterine size, myomas and endometrial thickness during HRT were moderate and not problematic and occurred mainly during the first 6 months on HRT.

Endometrial thickness as measured by transvaginal sonography: interobserver variation

Transvaginal sonography of the uterus has become an important tool for diagnosing endometrial pathology in women with postmenopausal bleeding. One parameter that has been claimed to be important for curly detection of endometrial pathology in this group of women is the endometrial thickness. The purpose of this study was to evaluate the reproducibility of measurements of endometrial thickness as performed by five inexperienced doctors and one doctor experienced in the transvaginal sonography technique. The endometrial thickness as measured by the experienced doctor was regarded as the ‘true measurement’, and the mean discrepancy from this true measurement was 1.5 mm for the inexperienced doctors. No endometrial pathology was found at the histopathological examination after dilatation and curettage (D & C) when the endometrial thickness was measured as ≤ 4 mm by both the inexperienced and the experienced doctors. However, there were considerable differences between the results obtained by the five inexperienced doctors. If this method is to be used for identifying those women who will not have a D & C performed, based on the findings of a thin endometrium (≤ 4 mm), training is needed in order to minimize the error. We believe that this will make measurement more accurate and it may then be used to exclude endometrial abnormality in women with postmenopausal bleeding.

Factors influencing the presence of uterine cavity fluid in a random sample of asymptomatic postmenopausal women

AIMS To assess possible endometrial pathology and other factors influencing the presence of uterine cavity fluid in postmenopausal women. STUDY DESIGN A random sample of 559 asymptomatic postmenopausal women, recruited from the total population, were examined by transvaginal sonography (TVS) for the presence of uterine cavity fluid. Women with uterine cavity fluid who had an endometrial thickness of > or = 8 mm (including fluid) were admitted for hysteroscopy and a dilatation and curettage (D & C), and those with <8 mm underwent a new TVS examination one year later. A medical history, including details regarding previous minor gynecological surgery, was taken from the women and from an age-matched control-group of women from the same population. RESULTS Uterine cavity fluid was found in 8.9% (50/559) of the women. In four women with an endometrium measuring > or = 8 mm, curettage revealed polyps in three women and atrophy with a pyometra in one woman. At the one-year follow-up, 22 women who originally had an endometrial thickness<8 mm had an endometrial thickness of<5 mm; 11 women had no cavity fluid and in the remaining 11 the cavity fluid had decreased. In 17 women, endometrial thickness measured > or = 5 mm and subsequent histology showed 11 endometrial biopsies with atrophy, four endometrial polyps and two cervical polyps. The prevalence of uterine cavity fluid increased with increasing age (p<0.0001) and was increased in smokers (p<0.013) but was unaltered by the presence or absence of hormone replacement therapy (HRT). CONCLUSION There were no indications that uterine cavity fluid was associated with malignancy. The prevalence of uterine cavity fluid increased with increasing age and was higher in smokers. We could not demonstrate an increased prevalence of fluid in HRT-users.

Ultrasound in gynecology: endometrium

With the development and clinical application of transvaginal transducers/probes (TVS) the sonographic imaging of the endometrium was greatly enhanced compared with abdominal ultrasound. Also, the discomfort of a full bladder associated with abdominal ultrasound could be avoided. A shorter distance between probe and target allowed the use of higher frequency transducers, thereby achieving improved imaging. This review will only discuss the use of TVS, but it does not mean that abdominal ultrasound should not or cannot be used when dealing with the postmenopausal uterus. Transvaginal sonography (TVS) provides a valuable tool for the diagnosis of a wide range of gynecological disorders including those of the uterus and endometrium. The ability of TVS to depict the thickness and morphology of the endometrium has been established in both office and hospital settings. This article will discuss and illustrate the clinical and research applications of transvaginal sonography in relation to the endometrium in both symptomatic and asymptomatic postmenopausal women. The article is of particular relevance today given the number of women who are undergoing transvaginal ultrasonography in the absence of symptoms as a part of their routine check ups. There is a paucity of data relating to the management of apparent ultrasound abnormalities in such women. In symptomatic women or for women at risk of developing endometrial pathology, a technique that could reduce the number of biopsy procedures would be of value. Hysteroscopy, dilatation and curettage (D & C) as well as other endometrial sampling methods are all invasive, thus it would be of benefit if a way could be found to assess the endometrium using a relatively non‐invasive approach. Such a technique would need to be relatively easy to learn and perform, as well as being well accepted by the patients. We believe that transvaginal sonography fulfills many of these requirements, the following review will attempt to put forward some of the evidence to support this view.

A Simplified Ultrasound Based Infertility Investigation Protocol and Its Implications for Patient Management

AbstractPurpose: To evaluate whether a simplified infertilityinvestigation protocol, focusing on the use of hysterocontrastsonography (HyCoSy), one blood test, and a semen analysis,would be sufficient as an initial screening test to selectcouples for specific treatment. Methods: The infertile couples underwent gynaecologicalexamination, cervical sampling for cytology and Chlamydiatrachomatis culture, B-mode transvaginal ultrasonographyand basic hormonal analyses followed by a HyCoSy, and asemen analysis. A preliminary diagnosis was made for allpatients. A management plan for treatment was suggestedwhen possible; otherwise further examinations wererecommended. The data were stored for later analysis and theroutine investigation protocol was then adhered to and afinal diagnosis and treatment were decided upon. Results: Agreement between the diagnosis based on HyCoSyand our routine protocol was present in 74% of cases(N = 73). In 13% (N = 13) there was partial agreement. In36% the HyCoSy based protocol was considered sufficientto suggest treatment. Conclusions: A simplified approach may lead to asignificant reduction in both the time and cost of investigating aninfertile couple.

Factors associated with endometrial thickness and uterine size in a random sample of postmenopausal women

Objective:  To investigate factors possibly associated with endometrial thickness and uterine size in a random sample of postmenopausal women.

Ultrasonography in Reproductive Medicine and Infertility: Ultrasonography and hydrosalpinges in IVF

Hysterosalpingography (HSG) is the first diagnostic test used for patients with suspected mllerian anomalies. HSG can detect a two-chambered uterus and allow assessment of the size and extent of a septum. Two-dimensional (2D) ultrasonography was previously done by the transabdominal route, but transvaginal ultrasonography (TVS) is superior to the transabdominal route and is now the standard imaging technique for the uterus. The main advantage of three-dimensional (3D) ultrasonography over 2D is the ability to image the three orthogonal planes of the uterus, of which the coronal view is the most important. Sonohysterography is an ultrasound-aided technique that entails injection of normal saline into the uterine cavity. Many magnetic resonance imaging (MRI) studies have shown a very high sensitivity of 100%, and more recently values of 95% have been reported in cases of mllerian anomalies. Uterine mllerian anomalies have a high frequency of adverse obstetric implications.