Radiographic imaging techniques for the diagnosis of abnormal uterine bleeding.

The introduction of SIS has been a significant advance in TVUS evaluation of the endometrial cavity in the 1990s. SIS provides an unparalleled, clear, enhanced view of the endomyometrial complex that cannot be obtained with TVUS alone. Focal and global endometrial pathology can be differentiated with SIS. Saline infusion improves the sensitivity for the detection of endometrial abnormalities. The continuing challenge for gynecologists is to provide patients with cost-effective, minimally invasive evaluation and directed therapy for menstrual dysfunction. SIS targets patients needing biopsy, directs the surgical approach, and minimizes office diagnostic hysteroscopy--all with a quick office procedure. For patients, the benefits include minimal and brief discomfort and a better understanding of intrauterine pathology through viewing the ultrasound monitor. Patients also appreciate the ease of scheduling, the minimal time away from work, and that no escort is needed after the procedure. SIS provides an extension of the pelvic gynecologic examination. SIS is the most important imaging modality for evaluating endometrial pathology. Although there is no perfect test to evaluate the endometrium, overall, SIS is superior to other imaging and diagnostic procedures. It is less expensive than D&C or hysteroscopy. It is a safe, efficient, convenient, and well-tolerated procedure. In some instances, however, neither TVUS nor SIS is definitive in determining the location of fibroids or able to discern adenomyosis. In these instances, MR imaging triage is helpful. MR imaging is gaining widespread acceptance and, in many instances, is a cost-effective tool in the evaluation of abnormal uterine bleeding. It is noninvasive, differentiates uterine anatomy in response to exogenous hormones or the normal menstrual cycle, and reliably localizes pelvic pathology and size of lesions. When uterine conservation is desired in women with fibroids and TVUS or SIS is indeterminate in localizing depth of myometrial involvement of a fibroid, MR imaging should be considered as a part of the clinical algorithm. The precision of MR imaging localization of submucosal fibroids can obviate the need for hysterectomy and permit a skilled surgeon to hysteroscopically resect the fibroids. If the clinical examination is suspicious for adenomyosis and the US is nondiagnostic, the clinician should consider MR imaging strongly. When the results of the imaging study would influence surgical route and planning, MR imaging should be considered in the preoperative evaluation.

Accuracy of preoperative diagnostic tools and outcome of hysteroscopic management of menstrual dysfunction.

STUDY OBJECTIVES: To review diagnoses, complications, and surgical findings in women treated for abnormal uterine bleeding by operative hysteroscopy, and to assess the accuracy of preoperative transvaginal ultrasound (TVS), saline-infusion sonography (SIS), diagnostic hysteroscopy, and endometrial biopsy. DESIGN: Retrospective study (Canadian task force classification II-2). SETTING: Tertiary care academic medical center. PATIENTS: Three hundred seventy-five women. Intervention. Operative hysteroscopy for abnormal uterine bleeding. MEASUREMENTS AND MAIN RESULTS: Main indications for hysteroscopy were postmenopausal bleeding (164 patients, 43.7%) and abnormal premenopausal uterine bleeding (211, 56.3%). Main pathology findings were endometrial polyps (172, 45.9%) and submucous myomas (105, 28%). Polyps had histologic abnormalities in 18 patients. Sensitivity of preoperative diagnostic tools for all intrauterine abnormalities and specifically for myomas and polyps was TVS 74% and 39%, SIS 96% and 96%, hysteroscopy 100% and 99%, and Pipelle biopsy 24% and 10%. The complication rate was 1.3%. Postmenopausal women felt significantly more improvement in symptoms (p = 0.02), and were more satisfied (p

Vaginal ultrasonography versus endometrial biopsy in women with postmenopausal bleeding.

OBJECTIVE: Our goal was to compare the predicted outcomes and costs of two diagnostic algorithms for postmenopausal bleeding. STUDY DESIGN: Two algorithms for postmenopausal bleeding were developed, one with vaginal ultrasonography and the other with office endometrial biopsy as the first test. Literature review was performed to estimate the probability of either an abnormal result of ultrasonography or a nondiagnostic biopsy, or both. Cost and sensitivity analyses were performed. RESULTS: Estimated probability of a nondiagnostic endometrial biopsy was 28%, and estimated probability of an abnormal result of vaginal ultrasonography (either inconclusive or endometrial thickness > 4 mm) was 55%. Cost analysis showed that vaginal ultrasonography as the first diagnostic test cost $230 per patient on average compared with $244 for endometrial biopsy, with savings ranging from $14 to $20 per patient over a wide range of possible values for estimated parameters. CONCLUSION: Vaginal ultrasonography costs slightly less than office endometrial biopsy as the first test in the diagnostic evaluation of women with postmenopausal bleeding.

Comparison of saline infusion sonography with office hysteroscopy for the evaluation of the endometrium.

OBJECTIVE: Intrauterine infusion of saline solution during transvaginal ultrasonography enhances visualization of the endometrium. We compared the accuracy and pain rating of saline infusion sonography with those of flexible office hysteroscopy. STUDY DESIGN: The uterine cavities of 130 patients with abnormal bleeding were evaluated by two physicians in an office setting. Findings of endometrial polyps, submucous myomas, synechiae, endometrial hyperplasia, or cancer were recorded independently and subsequently compared. Patients rated their pain after each procedure. RESULTS: Both procedures were performed in 113 of 130 patients. With saline infusion sonography pathologic findings were identified in 61 patients (54%). For all findings combined, sensitivity was 0.96 and specificity was 0.88, compared with hysteroscopy. The results of saline infusion sonography and hysteroscopy did not differ significantly (p = 0.18). The former was less painful for patients than hysteroscopy (p < 0.0001). CONCLUSION: Saline infusion sonography is an accurate and well-tolerated method to evaluate abnormal uterine bleeding, compared with hysteroscopy.

State-of-the-art flexible hysteroscopy for office gynecologic evaluation.

STUDY OBJECTIVE: To evaluate office flexible hysteroscopy without anesthesia with regard to pain, inconvenience and cost. DESIGN: A survey of patients to evaluate the level of pain they experienced during office hysteroscopy, and a comparison of costs for these procedures with those of hospital dilatation and curettage. SETTING: Office-based hysteroscopy suite in the outpatient building of a tertiary institution. PATIENTS: Women referred to this institution for gynecologic evaluation between February 1992 and December 1993. INTERVENTION: Diagnostic flexible hysteroscopy without anesthesia, cervical dilatation, or paracervical block. MEASUREMENTS AND MAIN RESULTS: A total of 417 women (mean age 42 yrs, range 16-84 yrs; 78 postmenopausal) were referred for evaluation during the study period. The most common indication for referral was abnormal uterine bleeding (86%). Hysteroscopy could not be completed in 29 women (7%), primarily because of cervical stenosis. Pain ratings obtained from 387 patients were as follows: easily acceptable discomfort, minimal discomfort during procedure, 133 (34.5%); acceptable discomfort, uncomfortable but easily bearable, 86 (22.2%); tolerable discomfort, equivalent to menstrual cramps and spasms, 106 (27.4%); barely tolerable pain, tolerable for short time only, 48 (12.4%); and intolerable pain, severe enough to stop the procedure before completion, 14 (3.6%). A single adverse event, a postprocedure temperature elevation, was easily treated with oral antibiotics. No pathology was identified in 183 (43%) of the women; 95 (22%) had polyps and 90 (21.5%) had fibroid tumors. The average duration of a procedure was 5 minutes. The charge for office hysteroscopy was $475. CONCLUSION: Flexible office hysteroscopy without anesthesia was well tolerated by the majority of the women. In addition, the procedure is far less expensive and time consuming than when it is performed in an operating room. We believe that it is a safe, well-tolerated, and cost-effective procedure of great diagnostic value.

Isolation and mapping of discrete DXS101 loci in Xq22 near the X-linked agammaglobulinaemia gene locus.

The X-linked agammaglobulinaemia (XLA) gene locus has previously been mapped to Xq22 in genetic linkage studies. The DXS101 locus has shown no recombinations with XLA in the ten informative meioses investigated so far. The DXS101 sequence, recognised by the cX52.5 plasmid, is moderately repeated in Xq22. We have isolated cosmids which contain this sequence; two copies of which have been found to lie near DXS178 and XLA, and a third copy which lies near the PLP gene, distal to these loci. We have used the cosmids to generate probes which should be of use for RFLP analysis, and thus in both prenatal diagnosis and carrier testing for XLA, and in constructing a genetic map of this region. These probes will also be used to complement the genetic map in the construction of a complete physical map of Xq22.

Genetic linkage analysis identifies new proximal and distal flanking markers for the X-linked agammaglobulinemia gene locus, refining its localization in Xq22.

Genetic linkage analysis has been instrumental in mapping the gene for X-linked agammaglobulinemia (XLA) to the proximal long arm of the human X chromosome, to Xq22. Due to the relative rarity of this disease the localization of the gene within Xq22 has remained imprecise. We have investigated twenty-nine families affected by XLA and have found no recombinants with the DXS178 locus in over 30 informative meioses. DXS178 is now the most reliable and informative locus for use in pre-natal diagnosis and carrier detection of XLA. In addition, we have identified new closely linked proximal and distal flanking markers for XLA, DXS442 and DXS101, respectively. These loci are separated by 2cM, considerably reducing the extent of DNA within which the XLA locus can be contained. This will open up the way for more directed positional cloning efforts for the isolation of the XLA gene.

Identification of species-specific and interspecies-specific polypeptides of Mycoplasma gallisepticum and Mycoplasma synoviae.

Temporal antisera (TA) prepared in susceptible Leg-horn-type chickens against Mycoplasma gallisepticum and M synoviae were evaluated to determine the extent of cross-reactivity in ELISA and hemagglutination inhibition tests. Species-specific and interspecies-specific polypeptides were identified after electrophoretic separation and protein immunoblotting with reference antisera, TA, and a monoclonal antibody specific for M gallisepticum. Mycoplasma gallisepticum antiserum cross-reacted with M synoviae polypeptides in ELISA and TA immunoblots. Two major M synoviae polypeptides (88 and 53 kilodaltons [kD]) cross-reacted with M gallisepticum antisera in TA immunoblots. An M gallisepticum polypeptide of 70 kD cross-reacted with M synoviae in TA immunoblots. In contrast, M gallisepticum and M synoviae reference antisera cross-reacted when immunoblotted with heterologous antigens. A monoclonal antibody specific for M gallisepticum bound to a 69-kD polypeptide in lectin-purified and whole-cell M gallisepticum protein fractions in immunoblot assays. The lectin-purified fraction hemagglutinated chicken RBC. Seemingly, the 69-kD polypeptide may constitute all or part of the M gallisepticum hemagglutinin.