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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Munro MG, Critchley HOD, Fraser IS, FIGO Menstrual Disorders Committee. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 143(3):393-408, 2018 Dec. Review/Other-Dx N/A To review, clarify, and, where appropriate, revise the previously published systems for nomenclature of symptoms of normal and abnormal uterine bleeding (AUB) in the reproductive years (FIGO AUB System 1) and for classification of causes of AUB. No results stated in abstract. 4
2. Munro MG, Critchley HO, Broder MS, Fraser IS, FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 113(1):3-13, 2011 Apr. Review/Other-Dx N/A To describe an ongoing process designed to achieve the goals of development of a classification system, on several levels, for the causes of AUB, which can be used by clinicians, investigators, and even patients to facilitate communication, clinical care, and research, and to present for consideration the PALM-COEIN (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified) classification system for AUB, which has been approved by the International Federation of Gynecology and Obstetrics (FIGO) Executive Board as a FIGO classification system. No results stated in abstract. 4
3. Valentin L.. Imaging techniques in the management of abnormal vaginal bleeding in non-pregnant women before and after menopause. Best Pract Res Clin Obstet Gynaecol. 28(5):637-54, 2014 Jul. Review/Other-Dx N/A To present ultrasound findings in women with endometrial cancer, endometrial polyps, endometrial hyperplasia, adenomyosis, uterine myomas, including submucous myomas and leiomyosarcoma, and describe ultrasound-based triage of women with postmenopausal bleeding. No results stated in abstract. 4
4. Dias DS, Bueloni-Dias FN, Dias R, et al. Usefulness of clinical, ultrasonographic, hysteroscopic, and immunohistochemical parameters in differentiating endometrial polyps from endometrial cancer. Journal of Minimally Invasive Gynecology. 21(2):296-302, 2014 Mar-Apr. Observational-Dx 102 Women To evaluate the usefulness of clinical, ultrasonographic, hysteroscopic, and immunohistochemical parameters in differentiating endometrial polyps from endometrial cancer. Among women with endometrial cancer and endometrial polyps, respectively, mean age was 63 and 57 years (p = .01), 89% and 67% were postmenopausal (p < .05), and 85% and 30.5% had postmenopausal bleeding (p < .01). No sonographic parameter enabled differentiation of endometrial polyp from cancer. Of patients with endometrial cancer, 72% exhibited signs suggestive of hyperplasia, and endometrial polyps were diagnosed during hysteroscopy. Estrogen receptors (= 2 vs = 1; p < .001) and progesterone receptors (= 3 vs = 2; p = .07) were greater in endometrial polyps. There was no significant difference in microvessel density (p > .05). 4
5. Goldstein RB, Bree RL, Benson CB, et al. Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored Consensus Conference statement. J Ultrasound Med. 2001; 20(10):1025-1036. Review/Other-Dx N/A To discuss the role of US in women with postmenopausal bleeding. Panelists agreed that either TVUS or endometrial biopsy could be used safely and effectively as the first diagnostic step. Whether US or endometrial biopsy is used initially depends on the physician’s assessment of patient risk, the nature of the physician’s practice, and the availability of high-quality US, and patient preference. 4
6. Bayer SR, DeCherney AH. Clinical manifestations and treatment of dysfunctional uterine bleeding. JAMA. 1993; 269(14):1823-1828. Review/Other-Tx N/A To review treatment of dysfunctional uterine bleeding. Goals of treatment are to stop acute bleeding, avert future episodes, and prevent long-term complications. 4
7. Sweet MG, Schmidt-Dalton TA, Weiss PM, Madsen KP. Evaluation and management of abnormal uterine bleeding in premenopausal women. Am Fam Physician. 2012; 85(1):35-43. Review/Other-Tx N/A To review evaluation and management of abnormal uterine bleeding in premenopausal women. TVUS or SIS may be used to evaluate menorrhagia. The levonorgestrel-releasing intrauterine system is an effective treatment for menorrhagia. Oral progesterone for 21 days per month and nonsteroidal anti-inflammatory drugs are also effective. Tranexamic acid is approved by the FDA for the treatment of ovulatory bleeding, but is expensive. When clear structural causes are identified or medical management is ineffective, polypectomy, fibroidectomy, uterine artery embolization, and endometrial ablation may be considered. Hysterectomy is the most definitive treatment. 4
8. Brown DL, Packard A, Maturen KE, et al. ACR Appropriateness Criteria® First Trimester Vaginal Bleeding. J Am Coll Radiol 2018;15:S69-S77. Review/Other-Dx N/A To assist referring physicians and other providers in making the most appropriate imaging or treatment decision for first trimester vaginal bleeding using evidence-based guidelines . No results stated in abstract. 4
9. American College of Radiology. ACR Appropriateness Criteria®: Second and Third Trimester Bleeding. Available at: https://acsearch.acr.org/docs/69465/Narrative/. Review/Other-Dx N/A To assist referring physicians and other providers in making the most appropriate imaging or treatment decision for second and third trimester bleeding using evidence-based guidelines. No abstract available. 4
10. ACOG Committee Opinion No. 734: The Role of Transvaginal Ultrasonography in Evaluating the Endometrium of Women With Postmenopausal Bleeding Review/Other-Dx N/A To review the role of transvaginal ultrasonography in evaluating the endometrium of women with postmenopausal bleeding. No results stated in abstract. 4
11. Ragupathy K, Cawley N, Ridout A, Iqbal P, Alloub M. Non-assessable endometrium in women with post-menopausal bleeding: to investigate or ignore. Archives of Gynecology & Obstetrics. 288(2):375-8, 2013 Aug. Observational-Dx 57 Women To study outcomes for women with post-menopausal bleeding (PMB) and endometrium not assessable on trans-vaginal scan (TVS). In our study period of 40 months, 671 women with post-menopausal bleeding were referred to the ultrasound department for TVS to assess endometrial thickness. 92 % (614/671) women had the assessment. In 57 women (8 %), endometrial thickness was not assessable and this formed our study group. 3/57 records were not retrievable and excluded from our study. 43/54 (79 %) had some form of endometrial sampling done. Among the 81 % adequate samples (35/43), 7 (20 %) had endometrial cancer; 1 (3 %) had CAH, 1 (3 %) was diagnosed with cervical cancer. In women who had thickened endometrium (>4 mm; n = 448), there were 29 cases of endometrial cancers detected giving an incidence of 6.4 %. In women with PMB and non-assessable endometrial thickness, there is increased incidence of endometrial cancer when compared to the group where endometrial thickness could be measured. (Odds ratio = 3.3 [95 % CI = 1.2-9]). This is a statistically (p = 0.017) and clinically significant finding. 4
12. Kim YJ, Kim KG, Lee SR, Lee SH, Kang BC. Preoperative 3-dimensional Magnetic Resonance Imaging of Uterine Myoma and Endometrium Before Myomectomy. J Minim Invasive Gynecol. 24(2):309-314, 2017 02. Review/Other-Dx 66 gynecologists To describe the use of 3D MRI to help gynecologic surgeons localize uterine myomas, endometria, and surrounding vessels using the following steps: (1) registration of magnetic resonance images that have different sequences using an image processing technique; (2) detection of myomas, endometria, and vessels; and (3) their 3D reconstruction. Furthermore, we assessed the clinical usefulness of 3D MRI for preoperative imaging before uterine myomectomy through a Web-based survey mailed to gynecologic surgeons. A Web-based survey was sent to 66 gynecologists concerning imaging techniques used before myomectomy. Twenty-eight of 36 responding gynecologists answered that the 3-dimensional image produced in the current study is preferred to conventional 2-dimensional magnetic resonance imaging in identifying precise locations of uterine myomas and endometria. The proposed 3-dimensional magnetic resonance imaging method successfully reconstructed uterine myomas, endometria, and adjacent vessels. 4
13. Abbott JA.. Adenomyosis and Abnormal Uterine Bleeding (AUB-A)-Pathogenesis, diagnosis, and management. [Review]. Best Pract Res Clin Obstet Gynaecol. 40:68-81, 2017 Apr. Review/Other-Dx N/A To review pathogenesis, diagnosis, and management of adenomyosis and abnormal uterine bleeding (AUB-A). No results stated in abstract. 4
14. Kierans AS, Bennett GL, Haghighi M, Rosenkrantz AB. Utility of conventional and diffusion-weighted MRI features in distinguishing benign from malignant endometrial lesions. Eur J Radiol. 83(4):726-32, 2014 Apr. Observational-Dx 52 Patients To evaluate the utility of conventional MRI and diffusion-weighted imaging (DWI) in differentiating benign from malignant endometrial lesions. Findings with significantly higher frequency in malignant abnormalities were: presence of irregularly marginated endometrial lesion (R1: 71% vs. 34%, R2: 94% vs. 26%), irregular endo-myometrial interface on T2WI (R1: 77% vs. 26%, R2: 94% vs. 29%), irregular endo-myometrial interface on post-contrast T1WI (R1: 82% vs. 23%, R2: 88% vs. 20%), increased signal on high b-value DWI (R1: 82% vs. 20%, R2: 94% vs. 20%), decreased ADC (R1: 88 vs. 40%, R2: 94% vs. 20%) (all p<0.001, both readers). Endometrial thickness, presence of any focal endometrial lesion regardless of contour, diameter of endometrial lesion, endometrial heterogeneity on T2WI, decreased T2 signal, and increased endometrial enhancement, failed to show significant differences between groups (all p=0.159, both readers). At multivariate analysis, for R1, irregular endo-myometrial interface on post-contrast T1WI and increased DWI signal were significant independent predictors of malignancy (AUC=0.89); for R2, only increased DWI signal was a significant independent predictor of malignancy (AUC=0.87). 3
15. Jha RC, Zanello PA, Ascher SM, Rajan S. Diffusion-weighted imaging (DWI) of adenomyosis and fibroids of the uterus. Abdom Imaging. 39(3):562-9, 2014 Jun. Observational-Dx 93 Patients To evaluate differences, if any, in the apparent diffusion coefficient (ADC) values of fibroids and adenomyosis. The ADC values of adenomyosis and fibroids were compared using Student's t test. The mean and the standard deviation of the ADC values of the control group were as follows: fibroid 0.64 ± 0.29, adenomyosis 0.86 ± 0.30, myometrium 1.39 ± 0.36, and urine 3.01 ± 0.2 × 10(-3) mm(2)/s. There was a statistically significant difference among the ADC values of normal myometrium and fibroids (p < 0.0001), normal myometrium and adenomyosis (p < 0.0001), and fibroids and adenomyosis (p < 0.001). Histogram analysis demonstrates less heterogeneity of adenomyosis as compared to fibroids. 4
16. Lin G, Yang LY, Huang YT, et al. Comparison of the diagnostic accuracy of contrast-enhanced MRI and diffusion-weighted MRI in the differentiation between uterine leiomyosarcoma / smooth muscle tumor with uncertain malignant potential and benign leiomyoma. J Magn Reson Imaging. 43(2):333-42, 2016 Feb. Observational-Dx 8 LMS/STUMP and 25 benign leiomyomas To compare the diagnostic accuracy of contrast-enhanced (CE) magnetic resonance imaging (MRI) and diffusion-weighted MRI (DWI) in the differentiation between uterine leiomyosarcoma (LMS) / smooth muscle tumor with uncertain malignant potential (STUMP) and benign leiomyoma. CE-MRI yielded a significantly superior diagnostic accuracy (0.94 vs. 0.52) and a significantly higher specificity (0.96 vs. 0.36) than DWI (P < 0.05 for both), and remained a comparably high sensitivity as DWI (0.88 vs. 1.00). A combination of DWI and ADC value <1.08 × 10(-3) mm2 /s (determined by receiver operating characteristic analysis) improved diagnostic accuracy, sensitivity, and specificity of DWI to 0.88, 0.88, and 0.88, respectively, by post-hoc analysis based on the same study cohort. 3
17. Lakhman Y, Veeraraghavan H, Chaim J, et al. Differentiation of Uterine Leiomyosarcoma from Atypical Leiomyoma: Diagnostic Accuracy of Qualitative MR Imaging Features and Feasibility of Texture Analysis. European Radiology. 27(7):2903-2915, 2017 Jul. Observational-Dx 41 Women To investigate whether qualitative magnetic resonance (MR) features can distinguish leiomyosarcoma (LMS) from atypical leiomyoma (ALM) and assess the feasibility of texture analysis (TA). Four qualitative MR features most strongly associated with LMS were nodular borders, haemorrhage, "T2 dark" area(s), and central unenhanced area(s) (p?=?0.0001 each feature/reader). The highest sensitivity [1.00 (95%CI:0.82-1.00)/0.95 (95%CI: 0.74-1.00)] and specificity [0.95 (95%CI:0.77-1.00)/1.00 (95%CI:0.85-1.00)] were achieved for R1/R2, respectively, when a lesion had =3 of these four features. Sixteen texture features differed significantly between LMS and ALM (p-values: <0.001-0.036). Unsupervised clustering achieved accuracy of 0.75 (sensitivity: 0.70; specificity: 0.79). 2
18. Tanaka T, Terai Y, Ono YJ, et al. Preoperative MRI and intraoperative frozen section diagnosis of myometrial invasion in patients with endometrial cancer. International Journal of Gynecological Cancer. 25(5):879-83, 2015 Jun. Observational-Dx 378 Patients To evaluate the diagnostic accuracy of myometrial invasion (MI) on preoperative magnetic resonance imaging (MRI) and intraoperative frozen sections (FSs). The sensitivity, specificity, positive predictive value, and negative predictive value for deep MI (= 50%) on MRI were 57.8%, 92.0%, 69.3%, and 87.5%, respectively, with a kappa value of 0.53. These figures on FSs were 66.7%, 97.9%, 90.9%, and 90.4%, with a kappa value of 0.71. When grade 3 endometrioid adenocarcinoma, serous carcinoma, clear cell carcinoma, and carcinosarcoma were considered high-grade tumors, the grade evaluation at the time of FSs was 70.2%, 99.0%, 96.1%, and 89.7%, with a kappa value of 0.75. In the patients with low-grade tumors, including grade 1 or 2 endometrioid adenocarcinoma on preoperative endometrial curettage, the rate of unexpected lymph node metastasis did not differ significantly between the patients who had a diagnosis of MI and lymph node metastasis by MRI and those with diagnosis of MI and histological grade by FSs (4.0% vs 2.6%; P > 0.05). 3
19. Mitamura T, Watari H, Todo Y, et al. Lymphadenectomy can be omitted for low-risk endometrial cancer based on preoperative assessments. Journal of Gynecologic Oncology. 25(4):301-5, 2014 Oct. Observational-Dx 56 Patients To investigate whether preoperative assessment is useful to select the patients in whom lymphadenectomy can be safely omitted. Fifty-one patients underwent surgery without lymphadenectomy. Five (8.9%) who had obvious myometrial invasion intraoperatively underwent systematic lymphadenectomy. One (1.8%) with endometrial cancer which was considered to arise from adenomyosis had para-aortic LNM. Negative predictive value of deep myometrial invasion was 96.4% (54/56). During the mean follow-up period of 55 months, one patient with deep myometrial invasion who refused an adjuvant therapy had tumor recurrence. The overall survival rate was 100% during the study period. 4
20. Li HM, Liu J, Qiang JW, Zhang H, Zhang GF, Ma F. Diffusion-Weighted Imaging for Differentiating Uterine Leiomyosarcoma From Degenerated Leiomyoma. J Comput Assist Tomogr. 41(4):599-606, 2017 Jul/Aug. Observational-Dx 42 Patients To investigate magnetic resonance diffusion-weighted imaging (DWI) in the differentiation of uterine leiomyosarcoma (ULMS) from degenerated leiomyoma (DLM). The mean ADC value in ULMSs (0.81 ± 0.14 × 10mm/s [ADC1], 0.90 ± 0.11 × 10mm/s [ADC2]) was significantly lower than that in DLMs (1.22 ± 0.22 × 10mm/s [ADC1], 1.50 ± 0.22 × 10mm/s [ADC2]) (P < 0.001, <0.001, respectively). The sensitivity, specificity, accuracy, and positive and negative predictive values for characterizing ULMS were 100%, 90%, 93%, and 83% and 100% [ADC1] and 100%, 93%, 96%, and 90% and 100% [ADC2]; respectively. Intraobserver and interobserver reproducibilities were excellent (intraclass correlation coefficient = 0.967-0.988; small variability and 95% limits of agreement). 4
21. Sato K, Yuasa N, Fujita M, Fukushima Y. Clinical application of diffusion-weighted imaging for preoperative differentiation between uterine leiomyoma and leiomyosarcoma. Am J Obstet Gynecol. 210(4):368.e1-368.e8, 2014 Apr. Observational-Dx 5 Patients To investigate the clinical usefulness of diffusion-weighted imaging (DWI) and the apparent diffusion coefficient (ADC) value for preoperative differentiation between uterine leiomyoma and leiomyosarcoma. The leiomyosarcoma lesions were readily apparent via DWI, presenting as an intermediate- to high-intensity area in the uterine wall. All low-intensity areas presented as leiomyoma nodules. The mean ADC value for the 10 leiomyosarcoma lesions was 0.791 ± 0.145 (×10(-3) mm(2)/s), significantly lower than that of the leiomyoma nodules that presented with intermediate-intensity areas, 1.472 ± 0.285 (×10(-3) mm(2)/s) (n = 41) (P < .001), and high-intensity areas (1.100 ± 0.343) (n = 9) (P = .03). Additionally, in this study, the highest ADC value for a leiomyosarcoma was 1.095, with an intermediate DWI intensity. Based on these results, we classified the patients into 2 groups: low-risk group (barely any leiomyosarcoma risk) and high-risk group. Analyses comparing the 2 groups yielded the following: sensitivity, 100%; specificity, 94.0%; positive predictive value, 66.7%; negative predictive value, 100%; and accuracy, 94.6%. 4
22. Gaetke-Udager K, McLean K, Sciallis AP, et al. Diagnostic Accuracy of Ultrasound, Contrast-enhanced CT, and Conventional MRI for Differentiating Leiomyoma From Leiomyosarcoma. Acad Radiol. 23(10):1290-7, 2016 10. Observational-Dx 28 Patients To determine whether uterine leiomyoma can be distinguished from uterine leiomyosarcoma on ultrasound (US), computed tomography (CT), and/or magnetic resonance imaging (MRI) without diffusion-weighted imaging. Mean suspicion scores were 2.5?±?1.2 (attendings) and 2.4?±?1.3 (residents) for leiomyoma, and 2.7?±?1.3 (attendings) and 2.7?±?1.4 (residents) for leiomyosarcoma. The areas under the receiver operating characteristic curves (range: 0.330-0.685) were not significantly different from chance, either overall (P?=?.36-.88) or by any modality (P?=?.28-.96), for any reader. Reader experience had no effect on diagnostic accuracy. No morphologic parameter was significantly predictive of malignancy (P?=?.10-.97). 3
23. Thomassin-Naggara I, Dechoux S, Bonneau C, et al. How to differentiate benign from malignant myometrial tumours using MR imaging. Eur Radiol. 23(8):2306-14, 2013 Aug. Observational-Dx 51 patients To retrospectively evaluate the ability of magnetic resonance imaging (MRI) to differentiate malignant from benign myometrial tumours. The significant criteria for prediction of malignancy were high b 1,000 signal intensity (OR = +infinity), intermediate T2-weighted signal intensity (OR = +infinity), mean ADC (OR = 25.1), patient age (OR = 20.1), intra-tumoral haemorrhage (OR = 21.35), endometrial thickening (OR = 11), T2-weighted signal heterogeneity (OR = 10.2), menopausal status (OR = 9.7), heterogeneous enhancement (OR = 8) and non-myometrial origin on MRI (OR = 4.9). In the recursive partitioning model, using b 1,000 signal intensity, T2 signal intensity, mean ADC, and patient age, the model correctly classified benign and malignant tumours in 47 of the 51 cases (92.4 %). 3
24. Gupta A, Grunhagen T. Live MR angiographic roadmapping for uterine artery embolization: a feasibility study. J Vasc Interv Radiol. 24(11):1690-7, 2013 Nov. Observational-Dx 20 Patients To assess the feasibility of live magnetic resonance (MR) angiography roadmapping guidance for uterine artery (UA) embolization (UAE) for fibroid tumors. In all 20 patients (40 UAs), the MR angiography overlay on live fluoroscopy was accurate and allowed for successful catheterization of the UA, resulting in a technical success rate of 100%. In the subset of the initial 20 UAs (ie, the first 10 patients) in which this data point was recorded, 17 (85%) were successfully catheterized with no iodinated contrast medium at all, by purely relying on the MR angiography roadmap. Mean procedure time was 45 minutes (range, 30–99 min), mean contrast agent dose was 75 mL (range, 46–199 mL), and mean DAP was 155 Gy·cm2 (range, 37–501 Gy·cm2). 4
25. Kubik-Huch RA, Weston M, Nougaret S, et al. European Society of Urogenital Radiology (ESUR) Guidelines: MR Imaging of Leiomyomas. Eur Radiol. 28(8):3125-3137, 2018 Aug. Review/Other-Dx 25 questionnaires To develop imaging guidelines for MR work-up in patients with known or suspected uterine leiomyomas. The 25 returned questionnaires as well as the expert consensus meeting have shown reasonable homogeneity of practice among institutions. Expert consensus and literature review lead to an optimized MRI protocol to image uterine leiomyomas. Recommendations include indications for imaging, patient preparation, MR protocols and reporting criteria. The incremental value of functional imaging (DWI, DCE) is highlighted and the role of MR angiography discussed. 4
26. Canverenler E, Buke B, Canverneler S. The Up to Date Status of Three-Dimensional Ultrasonography in Postmenopausal Bleeding. J Gynecol Neonatal 2017;1:101. Review/Other-Dx N/A To review current evidence about the use of three-dimensional ultrasound for assessing postmenopausal bleeding. No results stated in abstract. 4
27. El-Sherbiny W, El-Mazny A, Abou-Salem N, Mostafa WS. The diagnostic accuracy of two- vs three-dimensional sonohysterography for evaluation of the uterine cavity in the reproductive age. Journal of Minimally Invasive Gynecology. 22(1):127-31, 2015 Jan. Observational-Dx 120 women To compare 2-dimensional sonohysterography (2D SHG) vs 3-dimensional sonohysterography (3D SHG) using saline solution infusion, with outpatient hysteroscopy as the gold standard, for evaluation of the uterine cavity in women of reproductive age. For 2D SHG, sensitivity was 71.2%; specificity, 94.1%; positive predictive value, 90.2%; negative predictive value, 81.0%; and overall accuracy, 84.2%. For 3D SHG, sensitivity was 94.2%; specificity, 98.5%; positive predictive value, 98.0%; negative predictive value, 95.7%; and overall accuracy, 96.7%. Thus, 3D SHG was superior to 2D SHG (p = .02) and comparable with outpatient hysteroscopy (p = .12) for diagnosis of intrauterine lesions. 3
28. Nergiz S, Demircan-Sezer S, Kucuk M, Yuksel H, Odabasi AR, Altinkaya SO. Comparison of diagnostic methods for evaluation of postmenopausal bleeding. European Journal of Gynaecological Oncology. 35(3):292-7, 2014. Observational-Dx 47 Patients To determine and compare diagnostic accuracy parameters of saline infusion sonohysterography (SIS), transvaginal ultrasonography (TVUSG), and hysteroscopy (H/S) based on histopathologic results which are accepted to be the gold standard in patients with postmenopausal bleeding (PMB). Specificity and sensitivity values calculated based on histopathologic results for all endometrial cavity lesions were found, respectively: 44.4% and 25% for TVUSG, 88.8% and 60.7% for sonohysterography (SIS), and 100% and 77.7% for hysteroscopy (HIS). 3
29. Nieuwenhuis LL, Bij de Vaate MA, Hehenkamp WJ, et al. Reproducibility of three-dimensional gel installation sonohysterography in the assessment and classification of intrauterine abnormalities. Eur J Obstet Gynecol Reprod Biol. 179:141-6, 2014 Aug. Observational-Dx 45 3-D volumes To determine the interobserver and intraobserver variability of 3D GIS in the assessment of intrauterine abnormalities. Cohen's kappa for interobserver variability for type of abnormalities (none, polyp, fibroid, other) was 0.64 and for presence of a fibroid (fibroid yes/no) 0.77. Agreement on type of fibroid was 0.59. Intraobserver agreement was almost perfect for type of abnormality (Cohen's kappa of 1.0) and good for fibroid diameter. Quality of the 3D volumes was poor in 11 out of 45 cases. Reproducibility increased when poor quality images were excluded. 4
30. Fang L, Su Y, Guo Y, Sun Y. Value of 3-dimensional and power Doppler sonography for diagnosis of endometrial polyps. Journal of Ultrasound in Medicine. 32(2):247-55, 2013 Feb. Observational-Dx 426 Patients To investigate whether the endometrial thickness, endometrial volume, and endometrial and subendometrial vascularization index, flow index, and vascularization-flow index were useful for diagnosing endometrial polyps in infertility. A total of 426 patients were enrolled in the final analysis. Significantly higher endometrial thickness and volume were found in groups C and D compared with groups A and B (P < .05). There were no significant differences among the 4 groups in terms of the endometrial and subendometrial vascularization index, flow index, and vascularization-flow index (P > .05). The sensitivity, specificity, and positive and negative predictive values of endometrial thickness and volume in predicting endometrial polyps were 62.7%, 69.8%, 26.9%, and 91.9% and 39.3%, 88.2%, 35.8%, and 89.7%, respectively. Combined sonographic evaluation (sonographic echogenicity, endometrial thickness, and endometrial volume) showed higher sensitivity, specificity, and positive and negative predictive values (65.6%, 89.0%, 50.0%, and 93.9%) compared with a single indicator. 3
31. Inoue T, Kitajima M, Taniguchi K, Masuzaki H. Three-dimensional saline-infusion sonohysterography is useful for the identification of endometrial polyp. Journal of Obstetrics & Gynaecology Research. 42(7):855-9, 2016 Jul. Observational-Dx 16 Women To determine whether three-dimensional saline infusion sonohysterography (3D-SISH) is useful for the detection of endometrial polyps and whether it can accurately identify the site of attachment within the uterine cavity. Endometrial polyps could only be identified in 37.5% of women using MRI, but could be identified in all women using 3D-SISH. The accuracy rate of the attachment site of endometrial polyps was 87.5% on 3D-SISH and 18.8% (in all patients) or 50.0% (in polyp-detected patients) on MRI, indicating a higher accuracy rate using 3D-SISH. 4
32. Czuczwar P, Wozniak S, Szkodziak P, Kudla MJ, Pyra K, Paszkowski T. Elastography Improves the Diagnostic Accuracy of Sonography in Differentiating Endometrial Polyps and Submucosal Fibroids. J Ultrasound Med. 35(11):2389-2395, 2016 Nov. Observational-Dx 47 Patients To assess whether strain elastography may be used to visualize the different stiffness of endometrial polyps and submucosal fibroids. Forty-seven patients were included and underwent hysteroscopy. In 29 cases, endometrial polyps were found, and in 18, submucosal fibroids were found. The diagnostic accuracy rates for B-mode sonography, power Doppler imaging, and strain elastography in distinguishing endometrial polyps and submucosal fibroids were 70.2%, 65.9%, and 89.4%, respectively. The proportion of correct findings was significantly higher for strain elastography than for B-mode sonography (P = .0265) and power Doppler imaging (P = .0153). 3
33. Stoelinga B, Hehenkamp WJ, Brolmann HA, Huirne JA. Real-time elastography for assessment of uterine disorders. Ultrasound Obstet Gynecol. 43(2):218-26, 2014 Feb. Review/Other-Dx 218 Women To define, in a systematic manner, specific sonoelastographic characteristics of the myometrium, fibroids and adenomyosis, to evaluate the feasibility of sonoelastography in patients with suspected gynecological pathology and to compare the results with histology and/or magnetic resonance imaging (MRI)-based diagnoses. With elastography, the uterus was well delineated from the surrounding bowel. The myometrium was uniform in color in 49% of the cases, with a main color of purple or dark blue, indicating stiffer tissue. Fibroids and adenomyosis had different elastographic characteristics and different color patterns. In general, fibroids were darker and adenomyosis was brighter than adjacent myometrium. The agreement between elastography-based diagnosis of fibroids and adenomyosis with MRI-based diagnosis was excellent; with histology-based diagnosis, agreement was substantial for fibroids and adenomyosis. 4
34. Kabil Kucur S, Temizkan O, Atis A, et al. Role of endometrial power Doppler ultrasound using the international endometrial tumor analysis group classification in predicting intrauterine pathology. Archives of Gynecology & Obstetrics. 288(3):649-54, 2013 Sep. Observational-Dx 97 Patients To assess the contribution of the terms and definitions recently described by international endometrial tumor analysis (IETA) group when evaluating endometrial lesions on power Doppler imaging. Ninety-seven patients were included in the study. The histopathological diagnoses were as follows: endometrial polyp: 39 cases (40.2 %), endometrial hyperplasia: 9 cases (9.3 %), submucous myoma: 10 cases (10.3 %), endometrium cancer: 7 cases (7.2 %), non-specific findings: 32 cases (33 %). The sensitivity, specificity and positive and negative predictive values for single dominant or branching single dominant vessel pattern in diagnosing endometrial polyps were 66.67, 98.28, 96.3 and 81.43 %; for multiple vessels with focal origin pattern in diagnosing endometrial cancer, they were 42.86, 91.11, 27.27 and 95.35 %; for multifocal origin at the myometrial-endometrial junction in diagnosing other non-specific endometria, they were 81.25, 89.23, 78.79 and 90.62 %; for scattered vessel pattern in diagnosing endometrial hyperplasia, they were 88.89, 88.64, 44.4 and 98.73 % and for circular flow pattern in diagnosing submucosal fibroids, they were 80, 100, 100 and 97.75 %, respectively. The color score of the endometrium was not statistically different among different endometrial pathologies (P value >0.05). 4
35. Timmerman D, Verguts J, Konstantinovic ML, et al. The pedicle artery sign based on sonography with color Doppler imaging can replace second-stage tests in women with abnormal vaginal bleeding. Ultrasound Obstet Gynecol. 2003; 22(2):166-171. Observational-Dx 3,099 patients To determine accuracy of pedicle artery test in detecting endometrial polyps. Of the 3,099 women, no gold standard was available in 2,230. Only 28/199 patients who were test-positive did not have a gold standard. In the 869 patients in whom a gold standard was available, 182 had one or more endometrial polyps. The pedicle artery test had an apparent sensitivity for detection of endometrial polyps of 76.4%, specificity of 95.3%, PPV of 81.3%, and NPV of 93.8%. When extending the test to the prediction of any focal intracavitary pathology the PPV was 94.2%. 3
36. Kamaya A, Yu PC, Lloyd CR, Chen BH, Desser TS, Maturen KE. Sonographic Evaluation for Endometrial Polyps: The Interrupted Mucosa Sign. Journal of Ultrasound in Medicine. 35(11):2381-2387, 2016 Nov. Observational-Dx 82 Patients To evaluate the interrupted mucosa sign for identification of endometrial polyps, using pathologic confirmation as the reference standard, compared to other accepted sonographic findings. The mean age of the patients was 44.99 (SD, 9.88) years, 79.1% of whom were premenopausal. Pathologic diagnosis confirmed polyps in 58 (70.73%). A single feeding vessel was visualized in 36 patients with polyps (62.07%), whereas the interrupted mucosa sign was visualized in 34 (58.62%). The presence of a feeding vessel, the interrupted mucosa sign, or both detected 48 (82.76%) of the polyps. In the multivariate analysis, only the interrupted mucosa sign was a statistically significant predictor of pathologic diagnosis of a polyp (P= .035), with an odds ratio of 3.83 (95% confidence interval, 1.10-13.29). Other sonographic findings were not independent predictors of a polyp: mass (P = .35), single feeding vessel (P = .31), endometrial thickness (P = .88), and endometrial echogenicity (P = .45). The sensitivity, specificity, and positive predictive value of the interrupted mucosa sign were 59%, 75%, and 85%, respectively. 4
37. Dueholm M, Christensen JW, Rydbjerg S, Hansen ES, Ortoft G. Two- and three-dimensional transvaginal ultrasound with power Doppler angiography and gel infusion sonography for diagnosis of endometrial malignancy. Ultrasound in Obstetrics & Gynecology. 45(6):734-43, 2015 Jun. Observational-Dx 169 Women To evaluate the diagnostic efficiency of two-dimensional (2D) and three-dimensional (3D) transvaginal ultrasonography, power Doppler angiography (PDA) and gel infusion sonography (GIS) at offline analysis for recognition of malignant endometrium compared with real-time evaluation during scanning, and to determine optimal image parameters at 3D analysis. Offline 2D and 3D analysis were equivalent, but had lower diagnostic performance compared with real-time evaluation during scanning. Their diagnostic performance was not markedly improved by the addition of PDA or GIS, but their efficiency was comparable with that of real-time 2D-GIS in offline examinations of good image quality. On logistic regression, the 3D parameters from the REC-score system had the highest diagnostic efficiency. The area under the curve of the REC-score system at 3D-GIS (0.89) was not improved by inclusion of vascular indices or endometrial volume calculations. 2
38. Kara Bozkurt D, Bozkurt M, Cil AS, Barut MU, Ersahin AA, Caliskan E. Concomitant use of transvaginal sonography and Doppler indices improve diagnosis of adenomyosis. Journal of Obstetrics & Gynaecology. 37(7):888-895, 2017 Oct. Observational-Dx N/A To investigate whether measuring of Doppler indices with TV-DUS improved the diagnosis of adenomyosis. Sensitivity, specificity, PPV and NPV and positive and negative likelihood ratios (LR+) and (LR-) of TV-US in the diagnosis of adenomyosis were found to be 70.8%, 62.1%, 40.4%, 85.4%, 1.96 and 0.47, respectively. Sensitivity, specificity, PPV, NPV, LR?+?and LR?-?in the diagnosis of adenomyosis following the addition of TV-DUS were found to be 90%, 94.2%, 81.8%, 97%, 15.5 and 0.10, respectively. 4
39. Dubinsky TJ. Value of sonography in the diagnosis of abnormal vaginal bleeding. J Clin Ultrasound. 2004; 32(7):348-353. Review/Other-Dx N/A To determine whether US or biopsy is more effective in evaluating women with abnormal vaginal bleeding. Endometrial biopsy and TVUS have equal sensitivities for carcinoma, but US is far more effective in diagnosing benign disease. 4
40. Smith-Bindman R, Kerlikowske K, Feldstein VA, et al. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA. 1998; 280(17):1510-1517. Meta-analysis 35 studies; 5,892 women To determine accuracy of EVUS in detecting endometrial disease in postmenopausal women with vaginal bleeding according to hormone replacement use. In women not using hormone replacement therapy, 593 (8%) with normal histological findings had an abnormal EVUS result (specificity, 92%; 95% CI, 90%-94%), whereas 1,544 (23%) using hormone replacement therapy had an abnormal EVUS result (specificity, 77%; 95% CI, 75%-79%). EVUS has a high sensitivity. Inadequate
41. Meredith SM, Sanchez-Ramos L, Kaunitz AM. Diagnostic accuracy of transvaginal sonography for the diagnosis of adenomyosis: systematic review and metaanalysis. Am J Obstet Gynecol. 2009; 201(1):107 e101-106. Meta-analysis 14 trials with 1,895 aggregate participants To critically appraise the diagnostic accuracy of TVUS for diagnosing adenomyosis. TVUS predicted adenomyosis with a likelihood ratio of 4.67 (95% CI, 3.13-6.17). The overall prevalence of adenomyosis was 27.9% (95% CI, 25.5-30.3). The probability of adenomyosis with an abnormal TVUS was 66.2% (95% CI, 61.6- 70.6). The probability of adenomyosis with a normal TVUS was 9.1% (95% CI, 7.3-11.1). M
42. Wong AS, Lao TT, Cheung CW, et al. Reappraisal of endometrial thickness for the detection of endometrial cancer in postmenopausal bleeding: a retrospective cohort study. BJOG: An International Journal of Obstetrics & Gynaecology. 123(3):439-46, 2016 Feb. Observational-Dx 4383 women To estimate the accuracy of transvaginal ultrasound (TVS) measurement of endometrial thickness (ET) in diagnosing endometrial cancer in postmenopausal women with vaginal bleeding (PMB). Endometrial cancer was diagnosed in 3.8% of women. The median ET in those with endometrial cancer was significantly higher than those with benign conditions (15.7 versus 3.2 mm, P < 0.001). The area under the ROC curve was 0.92 (95% CI 0.89-0.94). The sensitivity for the detection of endometrial cancer at 3-, 4-, and 5-mm cut-offs were 97.0% (95% CI 94.5-99.6%), 94.1% (95% CI 90.5-97.6%), and 93.5% (95% CI 89.7-97.2%), respectively. The corresponding estimates of specificity at these thresholds were 45.3% (95% CI 43.8-46.8%), 66.8% (65.4-68.2%), and 74.0% (72.7-75.4%). 3
43. Breitkopf DM, Frederickson RA, Snyder RR. Detection of benign endometrial masses by endometrial stripe measurement in premenopausal women. Obstetrics & Gynecology. 104(1):120-5, 2004 Jul. Observational-Dx 206 sonohysterograms To estimate whether a transvaginal endometrial stripe of less than 5 mm in premenopausal women would exclude endometrial polyps and intracavitary leiomyomata, thereby eliminating the need for sonohysterography. Endometrial stripe measurements were obtained before sonohysterography in 200 of the 206 consecutive exams in premenopausal subjects. Of the 80 subjects with an endometrial stripe measurement less than 5 mm, 11 had endometrial polyps and 5 had submucosal fibroids on sonohysterography. With an endometrial stripe thickness of less than 5 mm, the sensitivity was 74% (95% confidence interval 62-84), the specificity was 46% (95% confidence interval 38-54), the positive predictive value was 37%, and the negative predictive value was 80%. The detection of pathology was not improved by excluding cases with an abnormal-appearing endometrial stripe on the baseline transvaginal images. The use of other endometrial stripe cutoff values did not improve the diagnostic accuracy. 3
44. Farquhar C, Ekeroma A, Furness S, Arroll B. A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women. Acta Obstet Gynecol. Scand. 2003; 82(6):493-504. Review/Other-Dx 19 studies Systematic review to determine the accuracy of TVUS, sonohysterography and diagnostic hysteroscopy for examining abnormal uterine bleeding in premenopausal women. A positive test result with sonohysterography diagnosed submucous fibroids with a pooled likelihood ratio of 29.7 (17.8, 49.6). A positive test result with hysteroscopy diagnosed submucous fibroids with a pooled likelihood ratio of 29.4 (13.4, 65.3), and any intrauterine pathology with a pooled likelihood ratio of 7.7 (4.3, 13.7). A negative test result with hysteroscopy for diagnosing any intrauterine pathology had a pooled likelihood ratio of 0.07 (0.04, 0.15). All three diagnostic tests were moderately accurate in detecting intrauterine pathology. However, sonohysterography and hysteroscopy performed better than TVUS in detecting submucous fibroids. 4
45. Ozdemir S, Celik C, Gezginc K, Kiresi D, Esen H. Evaluation of endometrial thickness with transvaginal ultrasonography and histopathology in premenopausal women with abnormal vaginal bleeding. Arch Gynecol Obstet. 2010; 282(4):395-399. Observational-Dx 144 women To examine cut-off value of the endometrial thickness by TVUS and to detect the accuracy of preoperative Pipelle biopsy in premenopausal women with abnormal vaginal bleeding. 113 (78.4%) women had normal and 31 (21.6%) had abnormal endometrium. With endometrial thickness of 8 mm, sensitivity was 83.6%, specificity 56.4% and NPV 95.6%. Accuracy rate of preoperative Pipelle biopsy was 94.7% in 57 women. 2
46. Hulka CA, Hall DA, McCarthy K, Simeone JF. Endometrial polyps, hyperplasia, and carcinoma in postmenopausal women: differentiation with endovaginal sonography. Radiology. 1994; 191(3):755-758. Observational-Dx 68 women Retrospective study to determine whether endometrial hyperplasia, polyps, and carcinoma can be differentiated on the basis of their US appearance. Pathologic and US findings were correlated. 30 sonograms showed hyperechoic endometria in women with hyperplasia (n=8), polyps (n=4), polyps and hyperplasia (n=2), or atrophy, proliferative change, mild atypia, or normal endometria (n=16); 27 sonograms showed cystic spaces in women with polyps (n=21), carcinoma (n=1), polyps and hyperplasia (n=2), or atrophy (n=3); and 11 sonograms showed heterogeneous endometria in women with endometrial carcinoma (n=7), atrophy (n=2), proliferative endometrium (n=1), or secretory endometrium (n=1). Cystic spaces were predictive of polyps (P=1.19 x 10(-10)). 3
47. Bazot M, Cortez A, Darai E, et al. Ultrasonography compared with magnetic resonance imaging for the diagnosis of adenomyosis: correlation with histopathology. Hum Reprod. 2001; 16(11):2427-2433. Observational-Dx 120 consecutive patients To prospectively compare the accuracy of TAUS and TVUS and MRI for the diagnosis of adenomyosis, and to correlate imaging with histological findings. Results of these examinations were interpreted blindly to histopathological findings. Sensitivity, specificity, PPV and NPV values of TAUS and TVUS were 32.5% and 65.0%, 95.0% and 97.5%, 76.4% and 92.8%, and 73.8% and 88.8% respectively. Sensitivity, specificity, PPV and NPV values of MRI were 77.5%, 92.5%, 83.8% and 89.2% respectively. No difference in accuracy was found between TVUS and MRI, but sensitivity was lower with US in women with associated myomas. TVUS is as efficient as MRI for the diagnosis of adenomyosis in women without myoma, while MRI could be recommended for women with associated leiomyoma. 2
48. Guideline developed in collaboration with the American College of Radiology, American College of Obstetricians and Gynecologists, Society of Radiologists in Ultrasound. AIUM Practice Guideline for the Performance of Sonohysterography. Journal of Ultrasound in Medicine. 34(8):1-6, 2015 Aug. Review/Other-Dx N/A To provide guidelines to assist physicians performing sonohysterography. No abstract available. 4
49. American College of Obstetricians and Gynecologists' Committee on Gynecologic Practice.. Technology Assessment No. 12: Sonohysterography. Obstetrics & Gynecology. 128(2):e38-42, 2016 08. Review/Other-Dx N/A To explain the sonohysterography procedure, including benefits and risks. No results stated in abstract. 4
50. Bhaduri M, Tomlinson G, Glanc P. Likelihood ratio of sonohysterographic findings for discriminating endometrial polyps from submucosal fibroids. J Ultrasound Med. 33(1):149-54, 2014 Jan. Observational-Dx 200 Patients To determine which combination of sonohysterographic features has the highest likelihood ratios (LRs) in discriminating polyps from submucosal fibroids. The LR of 13.4 was achieved for polyps when there was a combination of an intact endometrial-myometrial interface, a single vessel, an acute angle, and homogeneous echogenicity. The highest LR of 27.8 was achieved for submucosal fibroids when the combination of sonographic features included an absent endometrial-myometrial interface, an arborized/multiple vascular pattern, an obtuse angle, and heterogeneous echogenicity. 3
51. Bittencourt CA, Dos Santos Simoes R, Bernardo WM, et al. 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. [Review]. Ultrasound Obstet Gynecol. 50(1):32-39, 2017 Jul. Meta-analysis 5 Studies To analyze the diagnostic accuracy of two- (2D) and three- (3D) dimensional saline contrast sonohysterography (SCSH) in the detection of endometrial polyps and submucosal uterine leiomyomas in women of reproductive age with abnormal uterine bleeding compared with gold standard hysteroscopy. A total of 1398 citations were identified and five studies were included in the systematic review and meta-analysis. Pooled sensitivity and specificity of 2D-SCSH in detecting endometrial polyps were 93% (95% CI, 89–96%) and 81% (95% CI, 76–86%), respectively, with pooled LR+ of 5.41 (95% CI, 2.60–11.28) and LR– of 0.10 (95% CI, 0.06–0.17). In the detection of submucosal uterine leiomyomas, pooled sensitivity and specificity were 94% (95% CI, 89–97%) and 81% (95% CI, 76–86%), respectively, with pooled LR+ of 4.25 (95% CI, 2.20–8.21) and LR– of 0.11 (95% CI, 0.05–0.22). 2D-SCSH had good accuracy in detecting endometrial polyps and submucosal uterine leiomyomas, with areas under the SROC curves of 0.97?±?0.02 and 0.97?±?0.03, respectively. Studies that analyzed the diagnostic accuracy of 3D-SCSH could not be compared due to high heterogeneity related to menopausal status, type of technique used and primary outcome being investigation of infertility. Good
52. American College of Radiology. Manual on Contrast Media. Available at: https://www.acr.org/Clinical-Resources/Contrast-Manual. Review/Other-Dx N/A To assist radiologists in recognizing and managing risks associated with the use of contrast media. No abstract available. 4
53. McComiskey MH, McCluggage WG, Grey A, Harley I, Dobbs S, Nagar HA. Diagnostic accuracy of magnetic resonance imaging in endometrial cancer. Int J Gynecol Cancer. 22(6):1020-5, 2012 Jul. Observational-Dx 183 Women To investigate the accuracy of magnetic resonance imaging (MRI) in predicting the depth of myometrial invasion in the preoperative assessment of women with endometrial cancer and to quantify the impact of MRI as an adjunct to predicting patients requiring full surgical staging. For the detection of outer-half myometrial invasion, overall sensitivity of MRI was 0.73 (95% confidence interval [CI], 0.59-0.83), and specificity was 0.83 (95% CI, 0.76-0.89). The positive predictive value was 0.63 (95% CI, 0.50-0.74), and negative predictive value was 0.89 (95% CI, 0.82-0.93). Positive likelihood ratio was 4.35 (95% CI, 2.87-6.61), and negative likelihood ratio was 0.33 (95% CI, 0.21-0.52). Magnetic resonance imaging improved the sensitivity and negative predictive value of endometrial biopsy alone in predicting women with endometrial cancer who require full surgical staging (0.73 vs 0.65 and 0.80 vs 0.78, respectively). 3
54. American College of Radiology. ACR Appropriateness Criteria®: Pretreatment Evaluation and Follow-Up of Endometrial Cancer. Available at: https://acsearch.acr.org/docs/69459/Narrative/. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. No abstract available. 4
55. Hoyos LR, Benacerraf B, Puscheck EE. Imaging in Endometriosis and Adenomyosis. Clin Obstet Gynecol. 60(1):27-37, 2017 03. Review/Other-Dx N/A To review imaging in endometriosis and adenomyosis. No results stated in abstract. 4
56. Makled AK, Elmekkawi SF, El-Refaie TA, El-Sherbiny MA. Three-dimensional power Doppler and endometrial volume as predictors of malignancy in patients with postmenopausal bleeding. Journal of Obstetrics & Gynaecology Research. 39(5):1045-51, 2013 May. Observational-Dx 150 Women To evaluate the efficacy of 3D power Doppler angiography (3D-PDA) for distinguishing between benign endometrial lesions and endometrial carcinoma in patients with postmenopausal bleeding (PMB). Of the 150 women, 114 (76%) had benign endometrial lesions and 36 (24%) had endometrial carcinoma. Patients with endometrial carcinoma had significantly thicker endometrium (15.8?±?7.7 vs 9.9?±?5.9?mm; P?<?0.001), larger EV (9.1?±?4.7 vs 2.6?±?3.5?mL, P?<?0.001) and higher 3D-PDA indices (P?<?0.001) than patients with benign endometrial lesions. The best variable for distinguishing between benign and malignant endometrium was VI, with an area under the receiver operating characteristic curve (AUC) of 0.86. In contrast, the ET had an AUC of only 0.62. The best-fit logistic regression model for the diagnosis malignancy contained only VI as an independent factor (P?=?0.002). 4
57. El-Sharkawy M, El-Mazny A, Ramadan W, et al. Three-dimensional ultrasonography and power Doppler for discrimination between benign and malignant endometrium in premenopausal women with abnormal uterine bleeding. BMC Women's Health. 16:18, 2016 Mar 16. Observational-Dx 78 women To evaluate the efficacy of 3D ultrasonography and power Doppler for discrimination between benign and malignant endometrium in premenopausal women with abnormal uterine bleeding. The ET (P <0.001), EV (P <0.001), and endometrial VI (P <0.001) and VFI (P = 0.043) were significantly increased in patients with atypical endometrial hyperplasia and endometrial carcinoma (n = 10) than those with benign endometrium (n = 68); whereas, the uterine artery PI and RI and endometrial FI were not significantly different between the two groups. The best marker for discrimination between benign and malignant endometrium was the VI with an area under the ROC curve of 0.88 at a cutoff value of 0.81%. 4
58. Cogendez E, Eken MK, Bakal N, Gun I, Kaygusuz EI, Karateke A. The role of transvaginal power Doppler ultrasound in the differential diagnosis of benign intrauterine focal lesions. Journal of Medical Ultrasonics. 42(4):533-40, 2015 Oct. Observational-Dx 480 patients To assess the role of power Doppler imaging in the differential diagnosis of benign intrauterine focal lesions such as endometrial polyps and submucous myomas using the characteristics of power Doppler flow mapping. Histopathological results were as follows: endometrial polyp: 40 (69 %), submucous myoma: 18 (31 %). Of the cases with endometrial polyps, 80 % demonstrated a single vessel pattern, 7.5 % a multiple vessel pattern, and 0 % a circular pattern. Vascularization was not observed in 12.5 % of patients with polyps. Of the cases with submucousal myomas, 72.2 % demonstrated a circular flow pattern, 27.8 % a multiple vessel pattern, and none of them showed a single vessel pattern. The sensitivity, specificity, and positive and negative predictive values of the single vessel pattern in diagnosing endometrial polyps were 80, 100, 100, and 69.2 %, respectively; and for the circular pattern in diagnosing submucous myoma, these were 72.2, 100, 100, and 88.9 %, respectively. 4
59. Chandavarkar U, Kuperman JM, Muderspach LI, Opper N, Felix JC, Roman L. Endometrial echo complex thickness in postmenopausal endometrial cancer. Gynecologic Oncology. 131(1):109-12, 2013 Oct. Review/Other-Dx 250 Patients To determine the preoperative pelvic ultrasonographic characteristics of postmenopausal women diagnosed with endometrial cancer (EC) at our institution. Among 250 patients with postmenopausal EC, 156 had type 1 EC while 94 had type 2 EC. Thirty-six percent of the cohort had an EEC = 4 mm, including 37% of patients with type 1 EC and 34% of patients with type 2 EC (p=0.63). There were no significant differences between type 1 and type 2 ECs in any demographic characteristic, other than likelihood of postmenopausal bleeding. 4
60. Erdem M, Bilgin U, Bozkurt N, Erdem A. Comparison of transvaginal ultrasonography and saline infusion sonohysterography in evaluating the endometrial cavity in pre- and postmenopausal women with abnormal uterine bleeding. Menopause. 2007; 14(5):846-852. Observational-Dx 100 premenopausal and 33 postmenopausal women Prospective study to compare the diagnostic accuracy of TVUS and SIS of the endometrial cavity in pre- and postmenopausal women with abnormal uterine bleeding. When TVUS and SIS findings were compared with pathological results, the sensitivity and specificity of TVUS in diagnosing endometrial pathologies were 83% and 70.6%, respectively, whereas the sensitivity and specificity of SIS were 97.7% and 82.4%, respectively. The sensitivity and specificity of SIS in the diagnosis of endometrial polyps were 100% and 91.8%, respectively, and in the diagnosis of fibroids were 95% and 100%, respectively. SIS is more accurate than TVUS alone in the evaluation of the endometrial cavity in women with abnormal uterine bleeding. 2
61. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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