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 Slides prepared by Dr Joel Naftalin (UOG Editor-for-Trainees) Read the free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.17352/full

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. 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
Objective
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

4. 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
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

5. Results
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

6. Results
Sensitivity (a) and specificity (b) of
2D-SCSH in detecting endometrial
polyps in women of reproductive age
with AUB
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

7. Results
Sensitivity (a) and specificity (b) of
2D-SCSH in detecting
submucosal uterine leiomyomas
in women of reproductive age with
AUB
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

8. 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
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

9. 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
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

10. 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
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
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. 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?
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