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.