Comparison of diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography, and hysteroscopy in evaluating the endometrial polyps in women with abnormal uterine bleeding: a systematic review and meta-analysis

Abstract

Introduction: In women with abnormal uterine bleeding (AUB), endometrial polyps are a frequent finding, and the risk of a focal (pre)malignancy in a polyp is up to 6%. Because of this reported risk, the detection of polyps in these women is important.

Aim: To evaluate and compare the diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography, and hysteroscopy in detecting endometrial polyps in women with AUB.

Material and methods: The searches were conducted by two independent researchers to find the relevant studies published from 1/1/2009 until the end of 30/06/2019. We searched for published literature in English language in MEDLINE, EMBASETM, The Cochrane Library, and Trip database. For literature published in other languages, we searched national databases (Magiran and SID), KoreaMed, and LILACS. The risk of bias of every article was evaluated by using QUADAS-2.

Results: After selection and quality assessment, 11 studies were included. Based on the random effect model the total prevalence of endometrial polyps in women with abnormal uterine bleeding was 38%. The sensitivity and specificity of saline infusion sonohysterography in diagnosis of endometrial polyps were 0.87 and 0.86, respectively. The sensitivity and specificity of transvaginal ultrasonography were 0.62 and 0.73 and the sensitivity and specificity of hysteroscopy were 0.92 and 0.85, respectively.

Conclusions: Although that sonohysterography is a safe and relatively cheap method, which allows ruling out or confirming endometrial polyps, it cannot be replaced with hysteroscopy due to the fact that hysteroscopy combined with biopsy is the gold standard for ruling out malignancies in an endometrial polyp.

Keywords: abnormal uterine bleeding; saline infusion sonohysterography; sonohysterography; transvaginal sonography.

Figure 1

PRISMA flow diagram

Figure 2

The risk of bias in the studies conducted was measured by using QUADAS-2 tool. The risk of bias shown in Equation 2 of the above image model of each diagram indicates the number and percentage of studies with high (red), medium (yellow), and low (green) risk of bias in four groups of the QUADAS-2 tool

Figure 3

Hierarchical summary receiver (HSROC) curve for hysteroscopy (A), transvaginal ultrasonography (B), and saline infusion sonohysterography (C) for diagnosing endometrial polyps in women with abnormal uterine bleeding

Figure 4

Meta-analysis of the overall prevalence of endometrial polyps in women with abnormal uterine Bleeding

Figure 5

Pooled prevalence of endometrial polyps in women with abnormal uterine bleeding by country

Figure 6

Meta-regression between age (A), publication year of study (B), and prevalence of endometrial polyps in women with abnormal uterine bleeding

Figure 7

Fagan’s nomogram for the calculation of post-test probabilities. A pre-test probability of 50% for all three diagnostic tools was fixed, which was estimated by the number of symptomatic cases in selected studies. A – TVS had a post-test probability of 69.4%. For SIS (B) the post-test probability was 89.1%, and hysteroscopy (C) had a post-test probability of 85.9%. If this patient tests positive, the post-test probability that she truly has dengue would be 37.5% (A) or 14.4 (B) or 41.2 (C) (solid line in red). On the other hand, if patient tests negative, the post-test probability that she truly has endometrial polyp would be 69.4% (A) or 89.1% (B) or 85.9 (C) (blue dotted line). The results were obtained by the following calculations: pretest odds = prevalence/1 – prevalence; post-test odds = pretest odds × LR– (LR+); post-test probability = posttest odds/1 + post-test odds LR – likelihood ratio.