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  • Original Article
  • Open Access

Hysterohydrosonoscopy—an integrated modality for uterine imaging

  • 1, 2Email author,
  • 2,
  • 1,
  • 1 and
  • 1
Gynecological SurgeryEndoscopic Imaging and Allied Techniques20107:576

  • Received: 28 January 2010
  • Accepted: 20 February 2010
  • Published:


Office hysteroscopy and hydrosonography have long been viewed as competitive methods. This study was aimed to find out whether a combined approach of hysteroscopy followed by hydrosonography could provide more accurate information about the uterine lumen. Consecutive patients referred for diagnostic hysteroscopy were recruited to the study. Each patient had a transvaginal ultrasound scan, hysteroscopy, and immediately thereafter hydrosonography. Additional information retrieved by hydrosonography was recorded. When hysteroscopy revealed a normal uterine cavity, no further information was gained from hydrosonography. However, in 80% of the cases where hysteroscopy showed an abnormal uterine cavity (e.g., septum, adhesions, fibroid, endometrial polyp), hydrosonography added significant information regarding the size of the lesion, degree of fibroid encroachment, or luminal contour. We conclude that a combination of diagnostic hysteroscopy and hydrosonography could serve as a simple “one-stop” approach for full evaluation of the uterine cavity.


  • Hysteroscopy
  • Hysterosonography
  • Imaging
  • Uterine cavity


Office hysteroscopy (HS) and hydrosonography (HSG) have long been viewed as competitive methods for visualization of the uterine cavity. Both are performed in order to visualize the uterine cavity and are carried out in an office setting by a single operator; they share the same indications, have similar diagnostic accuracy and safety record, and are equally tolerated by the patients. In spite of same diagnostic accuracy, each method has its own strengths and weaknesses. HS enables direct visualization of the uterine cavity whereas HSG is an indirect technique. On the other hand, HSG allows measurements of intracavitary lesions while HS does not. Currently, after initial assessment of the uterine cavity by transvaginal ultrasound scan (TVUS), HS is employed as a first-line procedure by endoscopists, whereas HSG is preferred by US experts. After either method, in case of an abnormal finding, an operative HS is performed as a treatment.

Since early publications, these procedures were compared with each other for diagnostic accuracy for various indications in different patient populations; however, they had rarely been considered complementary [111].

The aim of this study was to find out whether HSG immediately after HS could provide further and more complete information about the uterine cavity.

Materials and methods

This was a prospective cohort study performed between January 2007 and January 2010 in the Women’s Health Center of the Maccabi Health Services, affiliated with Hadassah Hebrew University Medical Center. The study included patients referred for diagnostic HS. Each patient gave informed consent prior to the procedure according to institutional guidelines. The patients underwent a three-step procedure: (1) a TVUS, (2) HS, and immediately afterward (3) HSG with the residual saline. TVUS of the uterus was performed in both sagittal and oblique transverse planes with a 6.5-MHz probe (LOGIQ 200, SUMSUNG GE Medical System, South Korea). Subsequently, the vagina and cervix were disinfected with betadine solution, and HS was performed by a rigid 5-mm hysteroscope (Karl Storz, Tuttlingen, Germany) with a 30° angle view at the distal end. During the procedure, the uterus was visualized with an infusion of 0.9% saline solution. The uterine cavity was considered abnormal if an endometrial polyp, submucous myoma, uterine septum, or adhesions were seen. Immediately after removing the hysteroscope, HSG of the uterus was performed with the residual distension fluid left inside the uterine cavity and without the additional insertion of a balloon catheter into the cervical canal. The added information provided by the HSG was recorded.


A total of 64 patients were recruited for the study. Patients’ characteristics and the indications for the procedure are detailed in Table 1. Five patients were excluded because of the inability to complete the HSG due to escape of saline from the uterine cavity immediately after HS. Three excluded patients were 2 to 3 months after cervical dilatation either naturally by a normal delivery or surgically prior to a curettage for missed abortion.
Table 1

Patients’ characteristics and indications for HS


Age mean ± SD (range) years

35 ± 10.9 (21–68)

Parity mean ± SD (range)

2.6 ± 1.8 (0–7)

Menopausal status


Indications for HS

Menorrhagia/metrorrhagia (n = 18)


Postpartum bleeding (n = 12)


Hypomenorrhea (n = 2)


Suspected uterine deformation (n = 7)


Uterine cavity check up prior to IVF (n = 10)


Asymptomatic finding on TVUS (n = 12)


Postmenopausal bleeding (n = 3)


TVUS transvaginal ultrasound

HS revealed a normal cavity in 59% of patients (n = 35). In these cases, there was full agreement between HS and HSG and the HSG did not add further information about the cavity. In 24 patients (41%), an abnormal uterine cavity was detected by HS: endometrial polyps (n = 14), submucous fibroids (n = 2), intrauterine adhesions (n = 4), and Mullerian duct anomalies (n = 4). In 20 out of 24 (83%) of these cases, HSG provided additional information by enabling measurements of the intracavitary lesions whether a polyp (Fig. 1), a fibroid, or a septum, the degree of fibroid encroachment, and better delineation of luminal contour in case of coarse uterine adhesions (Fig. 2). The HSG did not add further information in cases of delicate intrauterine adhesions and arcuate uterine cavity.
Fig. 1
Fig. 1

a Preprocedure transvaginal ultrasound scan of the uterus. b Hysteroscopic evaluation of the uterine cavity revealing a thick isthmal adhesion obliterating further access to the cavity. c Hydrosonography immediately after hysteroscopy revealing uterine cavity distal to the adhesion

Fig. 2
Fig. 2

a Preprocedure transvaginal ultrasound scan of the uterus. b Hysteroscopic evaluation of the uterine cavity revealing an endometrial polyp. c Hydrosonography immediately after hysteroscopy enabled measurements of the lesion 10.2 × 12.2 mm


Competitive techniques

Many studies were published in the last two decades comparing the diagnostic accuracy of each method with comparable results: sensitivity of 90%, specificity of 80–85%, positive predictive value of 90%, and negative predictive value of 80% for both [16, 8, 9]. A systematic review of 19 publications between 1980 and 2001 assessing the diagnostic accuracy of TVUS, HSG, and HS for abnormal uterine bleeding in premenopausal women concluded that the performance of HSG and HS was comparable and superior to TVUS in detecting intrauterine abnormalities [10]. Only recently a new study design was published by two groups using HSG and HS sequentially. Makris et al. compared 3D HSG and HS done at a later stage in 242 cases of abnormal uterine bleeding [12]. Gumus et al. use a similar study design in 77 asymptomatic postmenopausal patients [7]. However, in contrast with our study, these authors employed the two methods on two separate occasions and still compared HSG and HS.

Complementary techniques

Our preliminary study is unique in its concept of performing HSG as complementary to HS in the diagnosis of an abnormal uterine cavity and in employing HSG immediately after HS using the residual distension medium left after the HS. By performing the sequence of luminal examination, TVUS–hysteroscopy–hysterosonography, more data could be retrieved from a single uterine imaging session. This modification has once been described by Cheng and Lin in a retrospective study investigating only submucous fibroids, but since then was unjustly neglected [13]. The new technology of 3DUS is now being credited of excellent view of the uterine cavity, but is still less available than 2DUS, more costly, and requires special expertise. The low technical failure rate of 7.8% (five out of 64) due to saline backflow through the cervix after removing the hysteroscope is surprising as the majority of our study group is women in their fertile years. We suggest that it could be attributed to the immediate insertion of the US vaginal probe right after the removal of the hysteroscope without changing the patient’s position.

Our modified technique, hysterohydrosonoscopy (HHSS), is simple and devoid of the cost and discomfort of a second procedure. With this method of imaging, the only modification needed to the set up of HS is a 2DUS machine with a TV transducer.


The data collected by the complementary HSG included measurements of the intracavitary lesion, transforming the nonquantitative hysteroscopic impression into a quantitative one. The size of a polyp and a fibroid as well as the length of a septum may have important clinical relevance. For example, the size of an asymptomatic endometrial polyp is considered a prognostic parameter for its malignancy potential [1416]; thus, a small size (<15 mm), asymptomatic polyp may just be followed as an alternative to its removal [1416]. Endometrial polyps may impact implantation and pregnancy rates after IVF depending on their size [17, 18].

The size of a submucous fibroid and its encroachment into the lumen may determine the surgical approach for its excision [1922]. The size of a submucous fibroid may also impact pregnancy rates in infertile women [23].

The length of the uterine septum (>1 cm) dictates the need for hysteroscopic septectomy in order to prevent unfavorable pregnancy outcome [2427].

Complementary HSG may also add valuable information where visualization of the cavity by HS is limited because of poor access into the uterus, e.g., retroverted uterus, or where thick isthmal adhesions are present. In these cases, further delineation of the luminal contour of the uterus can be achieved with complementary HSG. In the case of isthmal adhesions, neither HS nor HSG alone could reveal the true state of the uterine cavity as the integrated method HHSS does. In this way, a better planning of the operative procedure could be achieved.

This study should be addressed as pilot considering the small number of recruited patients, which limits the conclusions. Further investigation may be needed to confirm our findings in a larger series.

“Do two walk together unless they are agreed?” (Amos 3:3). We advocate that especially when the two are not agreed, they should go together. We suggest that HHSS, a combination of diagnostic HS followed by HSG, could serve as a simple “one-stop” approach for full evaluation of the uterine cavity.



The authors would like to thank Dr. Asher Shushan for the perusal and comments of this work.

Conflict of interest

No payment or support was received in kind for any aspect of the submitted work (including but not limited to grants, data monitoring board, study design, manuscript preparation, statistical analysis, etc.). There have been no financial relationships (regardless of amount of compensation) with any entities that have an interest related to the submitted work. There have been no nonfinancial associations or interests (personal, professional, political, institutional, religious, or other) that a reasonable reader would want to know about in relation to the submitted work.

Authors’ Affiliations

Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynaecology, Hadassah Hebrew University Medical Centre, Mt. Scopus, P.O. Box 24035, Jerusalem, 91240, Israel
Women’s Health Center, Maccabi Health Service, Modi’in Illit, Israel


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