DOI: 10.1097/gme.0b013e318136e1c6
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PMID: 17693897
Issn Print: 1072-3714
Publication Date: 2007/09/01
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Excerpt
As a radiologist who interacts with large numbers of these patients daily during focused encounters of what will often evolve into long courses of medical testing, one cannot help but think that there must be ways to make this workup more efficient, less costly, and more comfortable without missing the important diagnoses. There must be an easier way.
In this month's issue, Erdem and colleagues argue that saline-infusion sonohysterography should be added to this diagnostic armamentarium because it is more accurate then endovaginal ultrasonography in diagnosing endometrial pathology.1 In a prospective analysis of 122 women with abnormal uterine bleeding, they demonstrate that the sensitivity and specificity for sonohysterography are 97.7% and 82.4%, respectively, whereas for ultrasonography, they are 83.0% and 70.6%, respectively. The final histologic diagnoses included 34 patients with normal endometrium, 61with endometrial polyps, 19 with submucosal fibroids, four with fibroids unrelated to the endometrial cavity, and four with endometrial hyperplasia. Their findings confirm previous reports that find that sonohysterography performs better than ultrasonography for this purpose. However, is this sufficient to justify a role for sonohysterography in evaluating women with abnormal bleeding? Perhaps.
Histology constitutes the definitive diagnosis in all women with abnormal uterine bleeding unresponsive to medical or hormonal therapy. Imaging is used to identify mural abnormalities, such as fibroids and adenomyosis, and to define endometrial targets for biopsy. The reason for such a rigorous histologic standard is simple: we do not want to miss cancer. Abnormal uterine bleeding is the most common presentation of endometrial cancer. Moreover, if diagnosed early and resected, endometrial cancer is curable. If the diagnosis is missed, it can kill. In the United States, 7,400 women will die of endometrial cancer this year.2
Because endometrial cancer is a relatively uncommon cause of abnormal uterine bleeding, the diagnosis may be missed or delayed. In postmenopausal women, endometrial cancer accounts for only 10% of uterine bleeding.3 In premenopausal women with bleeding, the incidence is estimated to be at least an order of magnitude lower. Benign causes, eg, endometrial polyps, atrophy, and fibroids, comprise the majority of the structural abnormalities. Thus, finding the rare endometrial cancer in a population of women with abnormal uterine bleeding becomes, in essence, a screening problem.
From a screening perspective, endovaginal ultrasonography has many of the properties of the ideal first test (Fig. 1). The technology is widely accessible, well tolerated, and inexpensive. Most importantly, it demonstrates very high sensitivity (96%) for detecting endometrial cancer in postmenopausal women when an endometrial thickness cutoff of >5 mm is used.1 It outperforms the more invasive and costly technologies such as sonohysterography, nonfocal endometrial biopsy, and hysteroscopy that demonstrate sensitivities of 89%, 87%, and 86%, respectively.2-4 (The latter two methods are hampered by issues of insufficient tissue sampling.) Thus, in patients with postmenopausal bleeding, a normal endometrial thickness on endovaginal ultrasonography reduces the risk of cancer from 10% to 1%. It is a powerful first step.
Should the endometrial thickness be abnormal, the next step in the workup is a nonfocal endometrial biopsy.
