Ultrasound, SIS advocated for abnormal bleeding. (Expert Opinion).

BOSTON -- When it comes to evaluation of abnormal uterine bleeding, ultrasound is the way to go, and if the endometrium looks suspicious, infuse a little saline into the uterus and do sonohysterography, said Dr. Steven R. Goldstein professor of ob.gyn. at New York University, New York.

Dr. Goldstein, a strong advocate for saline infusion sonohysterography (SIS), contends that by starting with conventional ultrasound and moving to SIS as necessary, clinicians can limit invasive procedures, such as endometrial biopsies, to only those patients who actually have anatomic abnormalities, not just hormonally mediated dysfunctional uterine bleeding.

"It is no longer appropriate to do blind office biopsy procedures unless you can first verify that the endometrial process is global. In all other scenarios, fluid instillation coupled with high-resolution endovaginal probes can offer tremendous diagnostic enhancement in a simple, inexpensive, well-tolerated office procedure," Dr. Goldstein said at an ultrasound meeting which was sponsored by Harvard Medical School and Brigham and Women's Hospital.

Dr. Goldstein supported his view with findings from a study he conducted of 433 patients evaluated with this stepwise triage protocol. The women were perimenopausal and were being evaluated for menorrhagia, metrorrhagia, or both.

All patients underwent unenhanced transvaginal ultrasound examination on day 4-6 of their cycles, even if they were still staining. If the endometrial echo was distinct, 5 mm or less in thickness, the investigators concluded there were no neoplasms or other suspicious lesions and made a diagnosis of dysfunctional uterine bleeding (DUB).

If the endometrium could not be visualized with unenhanced sonography or if the central uterine echoes were greater than 5 mm thick, the investigators went to SIS.

A total of 280 patients had thin endometrial echoes and were diagnosed with DUB, while 153 underwent SIS. Of these, 56 (13% of the total cohort) had focal thickening or polyps, which were removed via hysteroscopic surgery and confirmed pathologically. A total of 22 patients (5%) had submucous myomas; 9 of them were treated resectoscopically.