Practice Issues

What Is New in
Gynecologic Ultrasonography?
Best Articles From the Past Year
James M. Shwayder, MD, JD

T his month we focus

on current research
in gynecologic ultraso-
Box 1. Abstracts Discussed in This Commentary
1. Billingsley CC, Kenne KA, Cansino CD, Backes FJ,
Cohn DE, OMalley DM, et al. The use of transvaginal
nography. Dr. Shwayder
ultrasound in type II endometrial cancer. Int J Gyne-
discusses four recent col Cancer 2015;25:85862. Available at: http://dx.
publications, which are doi.org/10.1097/IGC.0000000000000423.
concluded with a bot-
tom line that is the 2. Rotenberg O, Renz M, Reimers L, Doulaveris G,
take-home message. The Gebb J, Goldberg, GL, et al. Simultaneous endome-
trial aspiration and sonohysterography for the eval-
complete reference for
uation of endometrial pathology in women aged 50
each can be found in years and older. Obstet Gynecol 2015;125:41423.
Box 1 on this page, along Available at: http://dx.doi.org/10.1097/AOG.
with direct links to the 0000000000000631.
abstracts.
3. Frates MC, Doubilet PM, Peters HE, Benson CB.
Adnexal sonographic findings in ectopic pregnancy
(Obstet Gynecol 2015;126:66971) and their correlation with tubal rupture and human
DOI: 10.1097/AOG.0000000000001010 chorionic gonadotropin levels. J Ultrasound Med
2014;33:697703. Available at: http://dx.doi.org/
10.7863/ultra.33.4.697.
4. Sayasneh A, Kaijser J, Preisler J, Smith AA, Raslan F,
The Use of Transvaginal Ultrasound in Type II Johnson S, et al. Accuracy of ultrasonography per-
Endometrial Cancer formed by examiners with varied training and experi-
This retrospective review of 173 women diagnosed ence in predicting specific pathology of adnexal
with type II endometrial cancer, which included 58 who masses. Ultrasound Obstet Gynecol 2015;45:605
12. Available at: http://dx.doi.org/10.1002/uog.14675.
had documented endometrial thickness measurements
preoperatively, continues the controversy surrounding
the use of ultrasonography in screening patients with
postmenopausal bleeding. The authors reviewed pa- that 72.4% of these patients had an endometrial
tients with type II endometrial cancer using an endo- thickness of more than 5 mm. Conversely 27.6% had
metrial thickness of more than 5 mm as the threshold an endometrium that was less than 5 mm or indistinct.
for further evaluation. Type II cancers included endo- Of these patients, 8.6% had no visualized uterine
metrioid, serous, and clear cell carcinomas. They found abnormalities. They concluded that endometrial sam-
pling should be included in all women with post-
Dr. Shwayder is from the Department of Obstetrics and Gynecology at the menopausal bleeding regardless of endometrial
University of Mississippi Medical Center, Jackson, Mississippi; e-mail: thickness.
jshwayder@umc.edu.
Financial Disclosure Bottom Line: Endometrial thickness may not be a reli-
Dr. Shwayder receives royalties from Cook Womens Health for a catheter used
for sonohysterography. able screening method in patients with type II endo-
2015 by The American College of Obstetricians and Gynecologists. Published
metrial cancer. The American College of
by Wolters Kluwer Health, Inc. All rights reserved. Obstetricians and Gynecologists recommends that
ISSN: 0029-7844/15 all patients with postmenopausal bleeding and an

VOL. 126, NO. 3, SEPTEMBER 2015 OBSTETRICS & GYNECOLOGY 669

Copyright by The American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
endometrial thickness of more than 4 mm (rather than
5 mm) should have further evaluation.1 Failure to
identify a thin, distinct endometrium also should trig-
ger further evaluation. Patients with persistent bleed-
ing after initial screening should undergo further
evaluation with a method not previously used, such
as sonohysterography or hysteroscopy with endome-
trial sampling.
Simultaneous Endometrial Aspiration and
Sonohysterography for the Evaluation of Endometrial
Pathology in Women Aged 50 Years and Older
This is a retrospective cohort study of 603 patients
with postmenopausal bleeding who underwent saline-
infusion sonohysterography followed by endometrial
sampling with the same 2.3-mm catheter used for the
saline-infusion sonohysterography. The authors were
able to obtain endometrial tissue in 94.0% of patients.
Outcome data were available in 540 patients. Thirty
patients (5.6%) had cancer or endometrial hyperpla-
sia. The authors compared saline-infusion sonohyster-
ography only, saline-infusion sonohysterography with
endometrial aspiration, and endometrial biopsy only.
The sensitivity in detecting endometrial hyperplasia
or cancer based on an abnormal result was 100%,
86.7%, and 50%, respectively. The specificity was
27.8%, 100%, and 99.6%, respectively. Saline-infusion
sonohysterography with endometrial sampling yields
cumulative sensitivities and specificities approaching
100%. The authors describe a one-stop method of
endometrial evaluation with high sensitivity and
specificity.
Bottom Line: This novel technique combines the aug-
mented visualization of saline-infusion sonohysterogra-
phy with endometrial sampling using the same catheter
used for the saline-infusion sonohysterography proce-
dure. This essentially puts to rest the controversy of
which should be done firstultrasonography or endo-
metrial biopsy. This technique combines both methods
in a one-stop method of evaluating patients with post-
menopausal bleeding. Further study will be necessary
to validate these findings.
Adnexal Sonographic Findings in Ectopic Pregnancy
and Their Correlation With Tubal Rupture and
Human Chorionic Gonadotropin Levels
This retrospective study included 231 patients with
ectopic pregnancy, with and without tubal rupture.
The authors evaluated several ultrasound findings,
correlating them with tubal rupture. These included
the nature of the adnexal mass, free fluid in the
670 Shwayder Whats New in Gynecologic Ultrasonography?
Copyright by The American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
peritoneum, color Doppler flow in an adnexal mass,
and human chorionic gonadotropin (hCG) levels. A
moderate-to-large amount of free fluid was the only
finding significantly associated with tubal rupture. Of
note, 41.2% of patients with tubal rupture had hCG
levels less than 1,000 milli-international units/mL.
The authors concluded that neither ultrasonographic
findings nor hCG levels were useful predictors of
tubal rupture.
Bottom Line: Ultrasonography should be considered
for the initial evaluation of all patients with suspected
ectopic pregnancy. The two most common ap-
proaches in evaluating patients with suspected
ectopic pregnancy include serial hCG levels, defer-
ring ultrasonography until a level of 1,0001,500
milli-international units/mL is reached; or ultraso-
nography first, with hCG levels if the ultrasonogra-
phy is not diagnostic. The current study found that
41.2% of patients had ruptured ectopic pregnancy
when the hCG level was less than 1,000 milli-
international units/mL. Significant morbidity associ-
ated with tubal rupture can be avoided by performing
ultrasonography first, even if the hCG level is below
the threshold level.
Accuracy of Ultrasonography Performed by
Examiners With Varied Training and Experience in
Predicting Specific Pathology of Adnexal Masses
This prospective multicenter cohort study, conducted
in the United Kingdom by members of the Interna-
tional Ovarian Tumor Analysis group, evaluated the
ability of nonconsultant ultrasound examiners to
classify adnexal masses as benign or malignant and
to predict the final histology based on subjective
assessment. A total of 1,279 women underwent trans-
vaginal ultrasonography, 364 of whom were treated
surgically. After excluding cases of torsion, 313 cases
were available for review. These examiners were able
to classify adnexal pathology as benign or malignant
by subjective assessment with a sensitivity of 90% and
a specificity of 92%. Physicians performed slightly
better than ultrasonographers. Predicting histology
was highest with simple cysts (100%), hydrosalpinges
(100%), mature teratomas (88%), endometriomas
(75%), ovarian fibromas (88%), and tubo-ovarian
abscess infections (88%). These diagnostic sensitivities
were essentially equivalent to those reported by
experienced ultrasound examiners in previous Inter-
national Ovarian Tumor Analysis studies2 (75% com-
pared with 77% for endometriomas, 88% compared
with 86% for mature teratomas, and 60% compared
with 54% for serous cystadenomas).
OBSTETRICS & GYNECOLOGY
 Bottom line: Ultrasound examiners who are
not expert, consultant ultrasonographers are
able to predict the specific histopathology in
a majority of adnexal masses, with diagnostic
sensitivities equivalent to experienced examiners.
The current examiners had at least 1 year of expe-
rience undertaking at least 600 ultrasound
examinations.
REFERENCES
1. The role of transvaginal ultrasonography in the evaluation of
postmenopausal bleeding. ACOG Committee Opinion No.
440. American College of Obstetricians and Gynecologists. Ob-
stet Gynecol 2009;114:40911.
2. Sokalska A, Timmerman D, Testa AC, van Holsbreke C,
Lissoni AA, Leone FPG, et al. Diagnostic accuracy of transvagi-
nal ultrasound examination for assigning a specific diagnosis to
adnexal masses. Ultrasound Obstet Gynecol 2009;34:46270.

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VOL. 126, NO. 3, SEPTEMBER 2015 Shwayder Whats New in Gynecologic Ultrasonography? 671

Copyright by The American College of Obstetricians

and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.