Accuracy of Saline Contrast Sonohysterography in Detection of Endometrial Polyps and Submucosal Leiomyomas in Women with

1. UOG Journal Club: July 2017 Accuracy of saline contrast sonohysterography in detection of endometrial polyps and submucosal leimyomas in women of reproductive age with abnormal uterine bleeding: systematic review and meta-analysis C. A. Bittencourt, R. dos Santos Simões, W.M. Bernardo, L. F. P. Fuchs,J. M. Soares Júnior, A.R. Pastore and E.C. Baracat Volume 50, Issue 1, Date: July Pages: 32–39 Journal Club slides prepared by Dr Joel Naftalin (UOG Editor for Trainees)

2. Accuracy of saline contrast sonohysterography in detection of endometrial polyps and submucosal leiomyomas in women of reproductive age with abnormal uterine bleeding: systematic review and meta-analysis C. A. Bittencourt et al., 2017 Background • Abnormal uterine bleeding (AUB) is a significant problem in women of reproductive age • Endometrial polyps and submucosal leiomyomas are common etiologies • Current diagnostic modalities include transvaginal ultrasound, two-dimensional (2D) and three-dimensional (3D) saline contrast sonohysterography (SCSH), hysteroscopy and uterine curettage • Hysteroscopy remains the gold standard for uterine cavity assessment but requires qualified professionals and more equipment than does SCSH and is therefore more expensive • SCSH is less invasive, well-tolerated with reasonable costs and rare complications.

3. Accuracy of saline contrast sonohysterography in detection of endometrial polyps and submucosal leiomyomas in women of reproductive age with abnormal uterine bleeding: systematic review and meta-analysis C. A. Bittencourt et al., 2017 Objective To analyze the diagnostic accuracy of 2D and 3D-SCSH in the detection of endometrial polyps and submucosal leiomyomas in women of reproductive age with AUB, compared with gold standard hysteroscopy

4. Accuracy of saline contrast sonohysterography in detection of endometrial polyps and submucosal leiomyomas in women of reproductive age with abnormal uterine bleeding: systematic review and meta-analysis C. A. Bittencourt et al., 2017 Methods • The systematic review included only studies with an observational design that compared 2D- and/or 3D-SCSH with hysteroscopy and histopathology in the evaluation of uterine cavity abnormalities • The methodology of the included studies was analysed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) • The review was carried out in accordance with PRISMA and SEDATE guidelines • MEDLINE, EMBASE and The Cochrane Library databases were searched between Dec 2015 and Mar 2016 with no restriction on publication year or language • Retrospective baseline studies and those for which the authors did not have access to the full text were excluded

5. Accuracy of saline contrast sonohysterography in detection of endometrial polyps and submucosal leiomyomas in women of reproductive age with abnormal uterine bleeding: systematic review and meta-analysis C. A. Bittencourt et al., 2017 Results

6. Accuracy of saline contrast sonohysterography in detection of endometrial polyps and submucosal leiomyomas in women of reproductive age with abnormal uterine bleeding: systematic review and meta-analysis C. A. Bittencourt et al., 2017 Results Sensitivity (a) and specificity (b) of 2D-SCSH in detecting endometrial polyps in women of reproductive age with AUB

7. Accuracy of saline contrast sonohysterography in detection of endometrial polyps and submucosal leiomyomas in women of reproductive age with abnormal uterine bleeding: systematic review and meta-analysis C. A. Bittencourt et al., 2017 Results Sensitivity (a) and specificity (b) of 2D-SCSH in detecting submucosal uterine leiomyomas in women of reproductive age with AUB

8. Accuracy of saline contrast sonohysterography in detection of endometrial polyps and submucosal leiomyomas in women of reproductive age with abnormal uterine bleeding: systematic review and meta-analysis C. A. Bittencourt et al., 2017 Results Summary receiver–operating characteristics curves for 2D-SCSH in detecting endometrial polyps (a) and submucosal uterine leiomyomas (b) in women of reproductive age with AUB. (a) Area under the curve (AUC) = 0.968 + 0.128; (b) AUC = 0.967 + 0.072

9. Accuracy of saline contrast sonohysterography in detection of endometrial polyps and submucosal leiomyomas in women of reproductive age with abnormal uterine bleeding: systematic review and meta-analysis C. A. Bittencourt et al., 2017 Conclusion • 2D-SCSH had high sensitivity for the detection of endometrial polyps and submucosal uterine leiomyomas in women of reproductive age with AUB • 2D-SCSH can be considered as an alternative diagnostic modality to hysteroscopy, especially in detecting submucosal uterine leiomyomas, with values close to the gold standard • More studies are needed on 3D-SCSH in this population of women

10. Accuracy of saline contrast sonohysterography in detection of endometrial polyps and submucosal leiomyomas in women of reproductive age with abnormal uterine bleeding: systematic review and meta-analysis C. A. Bittencourt et al., 2017 Strengths • Studies included in the meta-analysis were evaluated rigorously for their methodology using the well-established QUADAS-2 tool • The strict selection of studies, particularly with regards to population selection • The comprehensive review of the literature Limitations • Some studies that assessed women of reproductive age with AUB alongside other populations, e.g. menopausal women, were excluded • There was no standardization of the stage of the menstrual cycle in which the tests were performed • There was a high risk of bias, mainly related to the index test and reference standard, in two of the studies • There was an unclear risk of bias due to a lack of information in most studies regarding the time between completion of the index test and the reference standard

11. Accuracy of saline contrast sonohysterography in detection of endometrial polyps and submucosal leiomyomas in women of reproductive age with abnormal uterine bleeding: systematic review and meta-analysis C. A. Bittencourt et al., 2017 Discussion points • How much more sensitive and specific would SCSH have to be, compared to 2D transvaginal ultrasound, before it could be considered the first-line diagnostic method? • Are these results applicable to other populations, e.g. women with post-menopausal bleeding and women undergoing fertility investigations? • As operative outpatient hysteroscopic equipment becomes smaller, will SCSH become redundant as hysteroscopy offering both diagnosis and treatment becomes increasingly well-tolerated? • Is 3D-SCSH likely to be more accurate than 2D-SCSH? • Studies comparing 2D- and 3D-SCSH have practical challenges. If each test is performed by the same person, bias is introduced as one test informs the other. If the tests are performed by different people, you introduce interobserver variability. How might these challenges be overcome?