Radiology
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Bree, R. L.
Right arrow Articles by Punch, M. R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Bree, R. L.
Right arrow Articles by Punch, M. R.
(Radiology. 2000;216:260-264.)
© RSNA, 2000

Ultrasonography

US Evaluation of the Uterus in Patients with Postmenopausal Bleeding: A Positive Effect on Diagnostic Decision Making1

Robert L. Bree, MD, MHSA, Richard A. Bowerman, MD, Marcela Bohm-Velez, MD, Carol B. Benson, MD, Peter M. Doubilet, MD, PhD, Shar'Ron DeDreu, MS and Margaret R. Punch, MD

1 From the Department of Radiology, DC069.10, University of Missouri Health Sciences Center, One Hospital Dr, Columbia, MO 65212 (R.L.B.); the Departments of Radiology (R.A.B., S.D.) and Obstetrics and Gynecology (M.R.P.), University of Michigan, Ann Arbor, Mich; the Department of Radiology, Western Pennsylvania Hospital, Pittsburgh (M.B.V.); and the Department of Radiology, Harvard Medical School, Brigham and Women's Hospital, Boston, Mass (C.B.B., P.M.D.). Received June 11, 1999; revision requested August 9; revision received October 12; accepted October 26. Supported in part by a grant from the Society of Radiologists in Ultrasound Research and Education Fund. Address correspondence to R.L.B. (e-mail: breer@health.missouri.edu).


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE: To assess the accuracy of hysterosonography (HSG) and its role in diagnostic confidence and therapeutic clinical decision making among referring physicians caring for patients with postmenopausal bleeding (PMB).

MATERIALS AND METHODS: One hundred twenty-three patients with PMB underwent transvaginal ultrasonography (US) and HSG. They were examined for cancer, polyp, leiomyoma, and hyperplasia. Physicians assessed the effect of the studies on diagnostic confidence and care, including biopsy, dilation and curettage, hysteroscopy, hormone manipulation, and/or patient reassurance. Abnormality was proved with histopathologic evaluation, and normality, with 6-month follow-up.

RESULTS: In 10 patients, HSG was unsuccessful, and in 15, follow-up was incomplete; this left 98 patients. Endometrial polyps were seen in 46 (47%) patients; leiomyoma, in 11 (11%); cancer, in four (4%); hyperplasia, in eight (8%); and normal findings, in 29 (30%). Our calculations yielded a sensitivity of 98% and a specificity of 88%. In 86 (88%) patients, US added certainty to the diagnosis; in 78 (80%), it resulted in a change in patient treatment.

CONCLUSION: HSG and transvaginal US in patients with PMB improves diagnostic accuracy, clinical decision making, and the clinician's diagnostic certainty. In patients with benign causes of PMB, the absence of abnormality at HSG and a normal endometrial biopsy result may eliminate the need for further studies.

Index terms: Uterus, abnormalities, 854.1495, 854.315, 854.318, 854.3199, 854.33 • Uterus, endometrium • Uterus, US, 854.12981, 854.12983


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Postmenopausal vaginal bleeding is a common clinical problem. Postmenopausal bleeding (PMB) is caused by endometrial cancer in about 10% of patients, although in some patient populations, this percentage is as high as 30% (1,2). Most reports in the clinical literature indicate that endometrial atrophy is the most common cause of PMB; however, the results of recent studies with hysterosonography (HSG) indicate that anatomic abnormalities such as leiomyomata and polyps are much more common than has been generally believed (3–7).

There have been a number of studies to define the role of both transvaginal ultrasonography (US) and endometrial biopsy in patients with PMB (1,2,7–15). The results of studies have consistently shown that an ultrasonographically measured endometrial thickness of 4 or 5 mm or less almost completely excludes endometrial carcinoma. In most of the studies, endometrial biopsy was found to have a high sensitivity for the detection of endometrial cancer—approaching 95% when there was an adequate sample. However, Dubinsky et al (8) reported on 12 of 18 patients with endometrial cancer who had false-negative endometrial biopsy results. In most studies, a negative endometrial biopsy result or negative dilation and curettage result has been used as the criterion for the diagnosis of the cause of PMB. Unfortunately, tissue sampling from dilation and curettage is accurate for detecting endometrial cancer but relatively inaccurate for diagnosing or excluding other causes of PMB, such as endometrial polyps or leiomyomata (16).

HSG has been shown to be useful for evaluating the endometrium, particularly in patients with PMB. Even when the endometrial thickness is 5 mm or less, HSG is accurate in identifying an anatomic cause of the bleeding in some cases (3,5,17–19). Alternatively, office hysteroscopy has been used to further examine patients with abnormal transvaginal ultrasonograms in an attempt to define an anatomic cause of the PMB (20). With these diagnostic issues in mind, we conducted a clinical trial to evaluate the accuracy of transvaginal saline-assisted HSG and assess the effect of this examination on diagnostic confidence and therapeutic clinical decision making among referring gynecologists and primary care physicians caring for patients with PMB.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
A multicenter clinical trial was conducted at two academic medical centers and one community medical center, and 123 women with PMB were enrolled. Postmenopause was defined as 6 months of amenorrhea or documentation of an elevated follicle-stimulating hormone level at least 6 months before the manifestation of abnormal bleeding. Abnormal bleeding was defined as any bleeding in a postmenopausal woman who was not receiving hormonal replacement therapy or bleeding during the first part of the cycle in a woman receiving sequential hormonal replacement therapy. To diminish any selection bias, we enrolled consecutive women referred for the clinical problem of PMB without regard for any other clinical factors. Patients were enrolled in the study following a discussion of the protocol. Each patient signed a study-specified informed consent document that was previously approved by each site's institutional review board.

Some patients presented after unsuccessful endometrial biopsy, which was often due to cervical stenosis. We did not exclude these patients from enrollment in the study, and in five of them, successful HSG was performed when cervical stenosis precluded endometrial biopsy.

The study protocol mandated that a patient either had to previously have undergone endometrial biopsy at least 7 days before the US examination or was scheduled to undergo biopsy within 1 month after the US examination. Not all patients underwent endometrial biopsy, primarily because of the unexpected number of abnormalities found on the hysterosonograms. In addition, each patient was required to be a candidate for a definitive therapeutic procedure such as dilation and curettage or surgical hysteroscopy.

The US examinations were performed by one of several authors with commercially available US machines (Siemens Medical Systems, Iselin, NJ; Advanced Technology Laboratory/Philips, Bothell, Wash; or Acuson, Sunnyvale, Calif). The examinations consisted of transvaginal US with or without color Doppler imaging and HSG with or without color Doppler imaging. Transvaginal US was used to examine both ovaries and the uterus. The uterus was examined for the presence of myometrial masses, and the endometrium was examined for an endometrial pathologic entity. The maximum thickness of the endometrium was measured at the fundus, body, and lower uterine segment on the sagittal view.

Saline-assisted HSG was performed after the insertion of a catheter through the cervix. Most of the catheterizations were performed with a 5-F catheter equipped with an inflatable balloon. Occasionally, a pediatric feeding tube was used. Sterile saline was injected into the endometrial cavity with real-time transvaginal US monitoring to evaluate the distention of the cavity. The endometrial cavity was examined for the presence of polyps, submucous leiomyomata, or other pathologic conditions. Color Doppler US was performed in most patients, particularly when abnormalities were identified. We carefully searched for a feeding vessel when a polypoid lesion was seen.

Before patient enrollment, the referring physicians were asked to complete an initial clinical decision form. This form contained demographic data, an initial clinical impression of the cause of the PMB, and the initial treatment plan before the performance of transvaginal US and HSG. Treatment plan options included watchful waiting, hormone manipulation, dilation and curettage, dilation and curettage and hysteroscopy, and hysterectomy. After transvaginal US and HSG had been performed, the referring physicians were asked to complete a second decision form, on which they were asked (a) whether the HSG results had facilitated a change in the original clinical impression and (b) their level of confidence in the new diagnosis. The clinical decision information from the referring physician was analyzed in two areas: (a) We asked whether the US findings added any degree of certainty to the diagnostic and treatment plan, and this was answered by using the following four-degree scale: none, little, some, or much. (b) We asked whether the US findings facilitated a change in patient treatment, and this was answered by using the following three-degree scale: no change, modest change, or substantial change.

A final pathologic diagnosis was made by using the results of the surgical procedure—that is, dilation and curettage, hysteroscopy, or hysterectomy—and histopathologic analysis. In those patients who were not treated surgically, the final diagnosis was determined on the basis of the results of a 6-month follow-up clinical examination, which indicated either the cessation of symptoms or no evidence of further disease. By using surgical or 6-month follow-up information as the reference standard, the sensitivity, specificity, positive and negative predictive values, and accuracy of HSG were calculated. When there was no pathologic condition or the results of histopathologic analysis were negative at surgery, it was considered a negative result. Abnormal histopathologic findings included hyperplasia, polyps, leiomyoma, and carcinoma. We determined the accuracy of HSG for the detection of specific pathologic conditions in each positive case in which histopathologic confirmation was obtained.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
One hundred twenty-three women with PMB were enrolled in our study. Fifteen patients who underwent HSG (eight positive cases and seven negative cases) were excluded from the data analysis because of incomplete follow-up. Another 10 patients were excluded because HSG was unsuccessful.

The 98 study patients ranged in age from 41 to 85 years (mean age ± SD, 56.6 years ± 8.6). Seventy-one patients were receiving hormonal replacement therapy. Seventy-five patients underwent endometrial biopsy, which was negative for cancer or nondiagnostic in all but four patients, who had endometrial carcinoma. In another five patients, endometrial biopsy was unsuccessful, but HSG was successful.

The HSG results in the 98 patients were as follows: normal in 29 (30%) patients, polyps in 46 (47%), leiomyomata in 11 (11%), cancer in four (4%), and hyperplasia in eight (8%). At HSG, 69 (70%) patients were found to have a pathologic condition that was responsible for the PMB; in 65 of these women, this finding was histopathologically proved. Twenty-nine (30%) of the HSG studies were negative, and the findings in 28 of these cases were histopathologically proved. These findings yielded a sensitivity of 98%, specificity of 88%, positive predictive value of 94%, and negative predictive value of 97% (Table 1).


View this table:
[in this window]
[in a new window]

  		TABLE 1. Results of HSG versus Histopathologic Analysis in Patients with PMB
 
Among the 65 patients with abnormal HSG results, including polyp, leiomyoma, cancer, or hyperplasia, 53 (81%) had the correct diagnosis made by using HSG (Table 1). In three of the four patients with endometrial cancer, an accurate diagnosis was made with transvaginal US and HSG. The fourth patient with endometrial cancer, who had positive endometrial biopsy findings, had a small focus of carcinoma; however, only a large leiomyoma was seen on the hysterosonogram. The most common HSG finding associated with cancer was a thickened endometrium with poor distensibility. At HSG, the polyps appeared as polypoid masses with a stalk, and sometimes at color Doppler US, they appeared with a single feeding vessel (Fig 1). At HSG, the leiomyomas appeared as broad-based submucosal masses, and sometimes at color Doppler US, they appeared to have diffuse hypervascularity. Hyperplasia appeared as diffuse endometrial thickening and a distensible endometrial cavity (Fig 2).



View larger version (161K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1a. Endometrial polyps in a postmenopausal woman who had vaginal bleeding and was receiving hormonal replacement therapy. (a) Transvaginal US scan shows a mildly thickened heterogeneous endometrium. The cursors and A mark the area of the endometrial thickness measurement. (b) HSG scan shows three polypoid masses, which represent adenomatous polyps. (c) Color Doppler image through one of the polyps shows the characteristic single vessel.

 


View larger version (159K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1b. Endometrial polyps in a postmenopausal woman who had vaginal bleeding and was receiving hormonal replacement therapy. (a) Transvaginal US scan shows a mildly thickened heterogeneous endometrium. The cursors and A mark the area of the endometrial thickness measurement. (b) HSG scan shows three polypoid masses, which represent adenomatous polyps. (c) Color Doppler image through one of the polyps shows the characteristic single vessel.

 


View larger version (85K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1c. Endometrial polyps in a postmenopausal woman who had vaginal bleeding and was receiving hormonal replacement therapy. (a) Transvaginal US scan shows a mildly thickened heterogeneous endometrium. The cursors and A mark the area of the endometrial thickness measurement. (b) HSG scan shows three polypoid masses, which represent adenomatous polyps. (c) Color Doppler image through one of the polyps shows the characteristic single vessel.

 


View larger version (147K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 2. HSG scan in a postmenopausal woman shows marked thickening of the endometrium, as well as a polypoid mass (outlined by cursors) that was histopathologically proved to be an adenomatous polyp.

 
There were 55 patients with adequate measurement data in whom HSG findings indicated a polyp or leiomyoma and endometrial thickness could be adequately measured on the transvaginal ultrasonograms. The mean thickness of the endometrium (± SD) was 7.2 mm ± 4.4 (range, 2–18 mm). In 22 of these patients, the thickness of the endometrium was 5 mm or less.

In 86 (88%) cases, the results of transvaginal US and HSG substantially influenced the diagnostic certainty for the referring physicians. In 78 (80%) cases, treatment decisions were influenced by the HSG results. In the patients with normal HSG results (n = 29), the degree of certainty was influenced to a notable degree in 25 (86%) cases, and treatment decisions were influenced in 18 (62%) cases (Table 2).


View this table:
[in this window]
[in a new window]

  		TABLE 2. Clinical Decision-Making Results
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Postmenopausal vaginal bleeding is an important and common problem. It can be the presenting symptom of endometrial cancer, the most common gynecologic malignancy. The data in older gynecology and radiology literature (21) suggest that anatomic reasons for bleeding are less common than endometrial atrophy, which is a diagnosis made when no anatomic cause is found. More recently, however, the results of several studies (3,5,6,8,18), including ours, have indicated that anatomic causes of PMB, such as polyps, leiomyoma, and hyperplasia, are more common than was previously thought. Grimes (16) contended that the conventional dilation and curettage procedure does not enable one to confirm the presence of benign disorders, although it is excellent for enabling the detection of endometrial carcinoma. With the recent availability of hysteroscopy and HSG, more anatomic abnormalities are being found in women with PMB.

Transvaginal saline-assisted HSG, which is also called sonohysterography or hydrosonography, is performed by inserting a catheter into the endometrial cavity and injecting sterile saline solution while scanning transvaginally. The technique has been extensively described, and results indicate that its accuracy far exceeds that achieved with transvaginal US alone (7,8,17,19,20). To understand the clinical importance of HSG, we undertook this clinical trial to attempt to determine the role of HSG in clinical decision making and for diagnostic confidence in patients with PMB.

From a patient treatment perspective, determination of the presence or absence of endometrial cancer is the most important short-term outcome of testing. On the other hand, up to 50% of patients who are given prescriptions for hormonal replacement therapy do not continue taking the medication after 12 months. There are many reasons for this noncompliance, but an important one is the fear of uterine cancer, a fear that is exacerbated by unwanted bleeding episodes that have heretofore been unexplained (22). With HSG, a patient can be examined, and should an anatomic reason for the PMB—for example, a polyp—be found, it can be removed. Other causes for the bleeding, such as leiomyomata, can be treated with ablative techniques, or the patient can be reassured that no malignancy is present (8).

Our study results indicate that the participating referring physicians—both gynecologists and family practitioners—had a high level of confidence in the results of the HSG examinations. In addition, gynecologists frequently changed their initial therapeutic plan after learning the results of HSG. This included changing a planned hysterectomy to watchful waiting, changing a dilation and curettage procedure to dilation and curettage plus hysteroscopy, and changing watchful waiting to hysterectomy.

With the diagnostic confidence levels and therapeutic decisions influenced by HSG results in the normal and abnormal groups in this study, we have proved that this examination has an important role in the evaluation and treatment of patients with PMB. In addition, although the reference standard in the literature is that endometrial thickness of 5 mm or less generally excludes carcinoma and other endometrial abnormalities, 22% of our study patients with polyps or leiomyomata had an endometrial thickness that was 5 mm or less (1) (Fig 3).



View larger version (164K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 3a. Polyp and thin endometrium in a woman with PMB. (a) Transvaginal US scan shows a 3-mm endometrium (between cursors). (b) HSG scan demonstrates a small polyp (arrowhead), which was the source of the bleeding.

 


View larger version (149K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 3b. Polyp and thin endometrium in a woman with PMB. (a) Transvaginal US scan shows a 3-mm endometrium (between cursors). (b) HSG scan demonstrates a small polyp (arrowhead), which was the source of the bleeding.

 
The main procedure in competition with HSG is office hysteroscopy, which is performed by a minority of gynecologists. Timmerman et al (20), in a randomized crossover trial, found that HSG had a higher accuracy rate and was better accepted by patients than was office hysteroscopy. In addition, the incremental professional cost for office hysteroscopy is at least twice that for HSG (23). In our practice, if a patient has PMB, we routinely perform HSG at the time of the transvaginal US examination and thus eliminate the need for a return visit.

In our series, the sensitivity, specificity, and positive and negative predictive values were very high. This suggests that HSG should become the reference standard method with which other technologies are compared. At analysis of the four false-positive cases in our study, we found that at least two patients were bleeding at the time of diagnostic hysteroscopy and dilation and curettage, and the gynecologist reported that no pathologic entity was found, although it seemed highly probable at HSG.

A pitfall that was responsible for at least one false-positive study was the presence of an endometrial blood clot, which was mistaken for a polyp (Fig 4).



View larger version (173K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 4. False-positive polyp in a postmenopausal woman. HSG scan demonstrates an irregular polypoid mass. The polyp was not detected at dilation and curettage and hysteroscopy (not shown); this indicates that it probably was a blood clot. To avoid this type of error, HSG is best performed when there is no active bleeding.

 
We were accurate in determining the exact cause of the bleeding in many cases. The more difficult differential diagnoses were those of pedunculated leiomyomata that mimicked polyps and flattened adherent polyps that mimicked focal hyperplasia or leiomyomata (Fig 5). Using the color Doppler criteria of a single central vessel for a polyp and generalized hypervascularity for a leiomyoma helped in establishing these sometimes difficult differential diagnoses (2,17) (Fig 1).



View larger version (170K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 5. Adherent polyp in a postmenopausal woman. HSG scan shows a hyperechoic mass (cursors) that appears to be focal thickening or a broad-based endometrial mass. At hysteroscopy (not shown), a flattened adherent polyp was discovered.

 
Our study was performed to assess the patient and physician outcomes with a new technology in a large and diverse patient population (24). On the basis of our study results, we suggest that HSG become an important diagnostic procedure for examining patients with PMB who have negative endometrial biopsy results. In some cases in which the bleeding is minor and intermittent, hormone levels can be manipulated, but if bleeding persists, HSG is warranted, regardless of the results of transvaginal US. If the HSG study is positive, a definitive therapeutic procedure, selected on the basis of HSG results, can be performed. If the HSG study is negative, the patient can either be reassured that there is no substantial pathologic condition and urged to continue hormonal replacement therapy or have her prescription changed to one of the newer estrogens that have fewer side effects.


   FOOTNOTES
 
Abbreviations: HSG = hysterosonography PMB = postmenopausal bleeding

Author contributions: Guarantor of integrity of entire study, R.L.B.; study concepts, R.L.B.; study design, all authors; definition of intellectual content, R.L.B.; literature research, R.L.B.; clinical studies, C.B.B., R.L.B., R.A.B., M.B.V., P.M.D.; data acquisition and analysis, all authors; statistical analysis, R.L.B.; manuscript preparation, S.D., R.L.B., R.A.B., C.B.B., M.B.V.; manuscript editing and review, R.L.B., R.A.B., C.B.B., M.B.V.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Smith-Bindman R, Kerlikowske K, Feldstein VA, et al. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA 1998; 280:1510-1517.[Abstract/Free Full Text]
  2. Atri M, Nazarnia S, Aldis AE, et al. Transvaginal US appearance of endometrial abnormalities. RadioGraphics 1994; 14:483-492.[Abstract]
  3. Bronz T, Suter T, Rusca T. The value of transvaginal sonography with and without saline instillation in the diagnosis of uterine pathology in pre- and postmenopausal women with abnormal bleeding or suspect sonographic findings. Ultrasound Obstet Gynecol 1997; 9:53-58.[Medline]
  4. Karlsson B, Granberg S, Wikland M, et al. Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding: a Nordic multicenter study. Am J Obstet Gynecol 1995; 172:1488-1494.[Medline]
  5. O'Connell LP, Fries MH, Zeringue E, et al. Triage of abnormal postmenopausal bleeding: a comparison of endometrial biopsy and transvaginal sonohysterography versus fractional curettage with hysteroscopy. Am J Obstet Gynecol 1998; 178:956-961.[Medline]
  6. Saidi MH, Sadler RK, Theis VD, et al. Comparison of sonography, sonohysterography, and hysteroscopy for evaluation of abnormal uterine bleeding. J Ultrasound Med 1997; 16:587-591.[Abstract]
  7. Cullinan JA, Fleischer AC, Kepple DM, Arnold AL. Sonohysterography: a technique for endometrial evaluation. RadioGraphics 1995; 15:501-514.[Abstract]
  8. Dubinsky TJ, Parvey HR, Maklad N. The role of transvaginal sonography and endometrial biopsy in the evaluation of peri- and postmenopausal bleeding. AJR Am J Roentgenol 1997; 169:145-149.[Abstract]
  9. Granberg S, Bourne TH. Transvaginal ultrasonography of endometrial disorders in postmenopausal women. Ultrasound Quarterly 1995; 13:61-74.
  10. Lewit N, Thaler I, Rottem S. The uterus: a new look with transvaginal sonography. J Clin Ultrasound 1990; 18:331-336.[Medline]
  11. Mogavero G, Sheth S, Hamper UM. Endovaginal sonography of the nongravid uterus. RadioGraphics 1993; 13:969-981.[Abstract/Free Full Text]
  12. Parsons AK, Lense JJ. Sonohysterography for endometrial abnormalities: preliminary results. J Clin Ultrasound 1993; 21:87-95.[Medline]
  13. Van Den Bosch T, Vandendael A, Van Schoubroeck D, et al. Combining vaginal ultrasonography and office endometrial sampling in the diagnosis of endometrial disease in postmenopausal women. Obstet Gynecol 1995; 85:349-352.[Medline]
  14. Varner RE, Sparks JM, Cameron DC, et al. Transvaginal sonography of the endometrium in postmenopausal women. Obstet Gynecol 1991; 78:195-199.[Medline]
  15. Wolman I, Jaffa AJ, Hartoov J, et al. Sensitivity and specificity of sonohysterography for the evaluation of sonohysterography for the evaluation of the uterine cavity in perimenopausal patients. J Ultrasound Med 1996; 15:285-288.[Abstract]
  16. Grimes DA. Diagnostic dilation and curettage: a reappraisal. Am J Obstet Gynecol 1982; 142:1-6.[Medline]
  17. Bree RL. Ultrasound of the endometrium: facts, controversies, and future trends. Abdom Imaging 1997; 22:557-569.[Medline]
  18. Schwarzler P, Concin H, Bosch H, et al. An evaluation of sonohysterography and diagnostic hysteroscopy for the assessment of intrauterine pathology. Ultrasound Obstet Gynecol 1998; 11:337-342.[Medline]
  19. Williams CD, Marshburn PB. A prospective study of transvaginal hydrosonography in the evaluation of abnormal uterine bleeding. Am J Obstet Gynecol 1998; 179:292-298.[Medline]
  20. Timmerman D, Deprest J, Bourne T, Van den Berghe I, Collins WP, Vergote I. A randomized trial on the use of ultrasonography or office hysteroscopy for endometrial assessment in postmenopausal patients with breast cancer who were treated with tamoxifen. Am J Obstet Gynecol 1999; 179:62-70.
  21. Lidor A, Ismajovich B, Confino E, David MP. Histopathological findings in 226 women with post-menopausal uterine bleeding. Acta Obstset Gynecol Scand 1986; 65:41-43.
  22. Samsioe G. Hormone replacement therapy: aspects of bleeding problems and compliance. Int J Fertil Menopausal Studies 1996; 41:11-15.
  23. Hildebaugh D. A comparison of clinical outcomes and cost of office vs hospital hysteroscopy. J Am Assoc Diagn Laparocs 1998; 4:39-45.
  24. Thornbury JR. Clinical efficacy of diagnostic imaging: love it or leave it. AJR Am J Roentgenol 1994; 162:1-8.[Abstract/Free Full Text]



This article has been cited by other articles:


Home page
 J Ultrasound MedHome page
AIUM Practice Guideline for Ultrasonography in Reproductive Medicine
J. Ultrasound Med., January 1, 2009; 28(1): 128 - 137.
[Full Text] [PDF]

Home page
 J Ultrasound MedHome page
D. L. Berridge and T. C. Winter
Saline Infusion Sonohysterography: Technique, Indications, and Imaging Findings
J. Ultrasound Med., January 1, 2004; 23(1): 97 - 112.
[Abstract] [Full Text] [PDF]

Home page
 RadioGraphicsHome page
P. C. Davis, M. J. O'Neill, I. C. Yoder, S. I. Lee, and P. R. Mueller
Sonohysterographic Findings of Endometrial and Subendometrial Conditions
RadioGraphics, July 1, 2002; 22(4): 803 - 816.
[Abstract] [Full Text] [PDF]

Home page
 J Ultrasound MedHome page
E. Becker Jr, A. S. Lev-Toaff, E. P. Kaufman, E. J. Halpern, M. I. Edelweiss, and A. B. Kurtz
The Added Value of Transvaginal Sonohysterography Over Transvaginal Sonography Alone in Women With Known or Suspected Leiomyoma
J. Ultrasound Med., March 1, 2002; 21(3): 237 - 247.
[Abstract] [Full Text] [PDF]

Home page
 RadiologyHome page
R. L. Bree and R. C. Carlos
US for Postmenopausal Bleeding: Consensus Development and Patient-centered Outcomes
Radiology, March 1, 2002; 222(3): 595 - 598.
[Full Text] [PDF]

Home page
 Am. J. Roentgenol.Home page
L. E. Hann, E. M. Gretz, A. M. Bach, and S. M. Francis
Sonohysterography for Evaluation of the Endometrium in Women Treated with Tamoxifen
Am. J. Roentgenol., August 1, 2001; 177(2): 337 - 342.
[Abstract] [Full Text] [PDF]

Home page
 RadiologyHome page
J. R. Medverd and T. J. Dubinsky
Cost Analysis Model: US versus Endometrial Biopsy in Evaluation of Peri- and Postmenopausal Abnormal Vaginal Bleeding
Radiology, March 1, 2002; 222(3): 619 - 627.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Figures Only
Right arrow Full Text (PDF)
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Bree, R. L.
Right arrow Articles by Punch, M. R.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Bree, R. L.
Right arrow Articles by Punch, M. R.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
RADIOLOGY RADIOGRAPHICS RSNA JOURNALS ONLINE