OFFICE GYNECOLOGY
Loida S. Ponio, M.D., FPOGS, MHA
MPI-Medical Center Muntinlupa
OBJECTIVE

To refresh us with the different diagnostic
procedures, practical and cost effective that
can guide us in most of our office gynecology
practice

The diagnostic procedures that we should do
and request must be based on a working
impression gathered through a complete,
thoughtfully elicited and thorough history
and PE

In patients with no apparent symptoms referable to the
pelvic organs, the following information should be included:

Inquiry regarding abnormal bleeding or discharge
menstrual irregularities, pelvic discomfort, changes in or
abnormality of bowel or bladder function, pruritus or
lesions of the vulva.

Careful general exam should include survey of the neck,
breast, axilla, abdomen, groin, and legs.

Complete pelvic exams:

Inspection and palpation of the external genitalia

Bimanual and vaginal exam

Speculum exam of the cervix and vagina

Rectal exam including recto-vaginal exam
DIAGNOSTIC PROCEDURES
PAP SMEAR

Single diagnostic screening technique which
has had the longest impact into the
reduction of mortality in cervical cancer

Ideal Target population: Screening all
sexually active women and all women above
18 years.
PAP SMEAR

High Risk Group:
1. Early sexual activity
2. Early child bearing
3. Multiple sex partners
4. HPV and Herpes Simplex Virus II infection
5. Immunosuppressed patients
6. Smoking
7. Decreased dietary intake of vitamin A
CONVENTIONAL PAP SMEAR


Sampling of specimen:

1. Endocervix (transformation zone)

2. Lateral mid vaginal wall

3. Vaginal pool
Fixation use:

1. 95% alcohol

2. Ether and alcohol

3. Hair spray

4. Air drying
CONVENTIONAL PAP SMEAR

Factors that influence accuracy of PAP smear:

1. Appropriate volume of screening material

2. Adequate sampling of the epithelium at risk

3. Careful preparation of cytologic material

4. Accurate diagnostic methods in the
cytopathology laboratory
CONVENTIONAL PAP SMEAR

Information from PAP smear:

1. Diagnosis of cervical CA, dysplasia and CIN

2. Suggest carcinoma arising from other pelvic
organs and elsewhere in the peritoneal cavity.

3. Suggest etiology of cervico-vaginal infection

4. Quantitative assessment of estrogen status(MI)
CONVENTIONAL PAP SMEAR


Rough guide:
Superficial
Estrogen Effect
1-10%
slight
10-30%
moderate
30%
marked
Other basis for MI:
50% or more Basal
- low estrogen effect
90% or more Intermediate
- suppression of estrogen
by progesterone as in
pregnancy
CONVENTIONAL PAP SMEAR

Importance of MI:

1. Rough guide for HRT among menopausal
patients

2. Postmenopausal women without estrogen
supplement with increased estrogen effect may
suggest the possibility of existing estrogen
secreting granulosa cell or theca cell tumor of
origin.

3. Children with precocious puberty.
CONVENTIONAL PAP SMEAR

Limitations of MI:

1. Inflammation disturbs the cornification
pattern and render it unreliable as an index
of estrogen effect.

2. Postmenopausal women taking Digitalis
and related glycosides for more than 2 years
may increase MI.
LIQUID BASED CYTOLOGY OR
LIQUID-BASED PAP TESTING

A newer method called liquid-based cytology, or
liquid-based pap testing can remove some of the
mucus, bacteria, yeast, and pus cells in a sample and
can spread the cervical cells more evenly on the
slide.

Instead of being directly placed on a slide, the
sample is placed into a special preservative solution.

This new method, also known by brand names
ThinPrep or Autocyte, also prevents cells from
drying out and becoming distorted.
LIQUID BASED CYTOLOGY OR
LIQUID-BASED PAP TESTING

Recent studies show that liquid-based
testing can slightly improve detection of
precancers, and reduce the number of tests
that need to be repeated.

This method is more expensive than a usual
PAP smear.

HPV exam can be done simultaneously.
LIQUID BASED CYTOLOGY OR
LIQUID-BASED PAP TESTING

USA statistics
 At 50 years of age ~ 80% with (+) genital HPV
 5% of females of cervical Ca are between 35-55 years
 >20 years of age account for 63% of genital warts
 Type 16 &18  70% associated with cervical Ca
 Type 6 & 11  90% associated with genital warts
 Women between 25-54  20% will have at least 1
abnormal pap smear test.
ENDOMETRIAL CYTOLOGY

Procedure


Aspiration and brush lavage of
endometrial cavity
Advantage

Simple and less expensive way to diagnose
endometrial pathology
ENDOMETRIAL CYTOLOGY

Disadvantages

There is difficulty in identifying pre-malignant
changes of the endometrial cells on
cytopathological material

It is difficult to differentiate secretory
endometrium, hyperplastic and endometrial
hyperplasia

Sensitivity and specificity of endometrial
cytology is less than desirable
ENDOMETRIAL CYTOLOGY

Conclusion

Disadvantages outweigh the advantages,
thus it cannot be recommended as a routine
screening.
WET SMEAR & GRAM STAINING

Cervicitis and vaginitis are the most frequent
complaints evaluated by the gynecologist

Organisms most often associated with cervicitis:

Chlamydia trachomatis (most common)

Neisseria gonorrhea

Herpes simplex II
WET SMEAR & GRAM STAINING

In vaginitis, the most common offending organisms can
be easily diagnosed by simple wet smear with the use of
NSS

Candidiasis – Candida albicans

Trichimoniasis – Trichomonas vaginalis

Bacterial Vaginosis – Gardnerella vaginalis and anaerobic
bacteria
WET SMEAR & GRAM STAINING

TRICHOMONAS VAGINALIS

The organism seen are actively motile,
normally moving with the direction of flagella.
WET SMEAR & GRAM STAINING

GARDNERELLA VAGINALIS

Will show the typical clue cells which consists of
epithelial cells that appear stippled or granulated.

Mobilinus species will appear as highly motile
curved bacterial rods with cork-screw spinning
action which is seen in approximately 50% of
cases.
WET SMEAR & GRAM STAINING

CANDIDA ALBICANS

Typical hyphae and spore formation is also seen in
wet smears. It is however, better visualized with
KOH smears.

Bacterial vaginosis can also be diagnosed by
adding KOH in the discharge. This produces a fishy
amine odor which is the basis for the Whiff test.
WET SMEAR & GRAM STAINING

In Gram staining of discharge from patients with
bacterial vaginosis. It will show presence of clue cells
with few polymorphonuclear cells (PMN).

There will be few lactobacilli and small pleomorphic
gram (-) rods.

In Gardnerella vaginitis, minute rod-shaped gram (-)
bacilli will be seen.

Gonococcal infection will manifest gram (-) diplococci
in the cytoplasm of PMNs.
CULTURE & SENSITIVITY STUDIES

Routine bacterial culture of the vaginal
discharge may be misleading and of no
diagnostic value

In herpes and Chlamydia infection, proper
media and transport vials are necessary.

It is however indicated in the following:

1. Recurrent infection

2. Abscess of vulva, groin, and pelvis
CULTURE & SENSITIVITY STUDIES

The following culture media are suggested:

1. Gonococcal infection – Thayer Martin

2. Trichomonal infection – Freiberg, Whiethylin, or
diamond’s media culture however are seldom necessary.

3. Candida albicans – Wickerson’s and Saboraud’s media

4. Gardnerella vaginitis – Casman’s blood agar

Colonies are identified by different beta hemolysis
produced.
CERVICAL MUCUS ARBORIZATION
TEST

Formation of fern patterns

Directly dependent on the ovarian hormonal
status of the patient at the particular time

Seen in its typical form with the presence of
adequate estrogens.

Progesterone inhibits or completely abolishes
ferning formation even with the presence of
sufficient estrogen
CERVICAL MUCUS ARBORIZATION
TEST

Procedure:

A sample of endocervical mucus is
spread on a clean dry slide.

Air dry for 20-30 minutes

Read under the microscope
CERVICAL MUCUS ARBORIZATION
TEST

Result

(+) - presence of arborization with crystallization
indicative of predominance of estrogen effect

(-) - cellular pattern without crystallization and
arborization; indicative of little or no estrogen or
suppression of estrogen by progesterone

False (-) results – presence of blood, or if the sample
was spread too thinly.
CERVICAL MUCUS ARBORIZATION
TEST

Diagnostic Uses

Indirect quantification of estrogen effect


Ferning can be graded according to the branching of the
ferning pattern upon crystallization
GRADE I
primary branching
GRADE II
secondary branching
GRADE III
tertiary branching
GRADE IV
quarternary branching
Index of ovulation and normal corpus luteum function
(shifting from (+) to (-) ferning test)
CERVICAL MUCUS ARBORIZATION
TEST

Diagnostic Uses

Timing of post coital test

Diagnosis of pregnancy vs anovulatory cycles

Disorders of early pregnancy

Patients with (+) ferning during early pregnancy
were found to have higher incidence of abortion
TOLUIDINE BLUE STAIN TEST

Procedure

Toluidine blue 1% is applied liberally to the vulva
and perineal area.

Dry for 2-3 minutes

Decolorize with acetic acid

Acetic acid enhances the diagnostic capabilities
and augmentation or recognition of white or
hyperpigmented lesions
SCHILLER’S TEST


Basis

Glycosylated squamous epithelium takes up
iodine based atain.

For cervical dysplasia in which the nuclearcytoplasm ratio is increased and therefore the
glycogen is diminished, the epithelium will not
take up stain and may appear as light yellow
Indication

Guide for surgical biopsy
SCHILLER’S TEST

Procedure
Schiller’s solution (1 part iodine + 2 parts KI + 300
parts water) is applied in the vagina and upper cervix
with cotton pledget
SCHILLER’S TEST

Result

(-) mahogany brown (normal epithelium)

(+) light yellow , as in

Dysplasia

Traumatized tissue

Cervicitis

Columnar epithelium
NUCLEAR SEX CHROMATIN

Basis

Nuclear sex chromatin recognition of a chromatin mass
(sex chromati body) in individual with 2x chromosomes
as in normal females.

It is present in 65-75% female tissue and absent in
around less than 4% in males
NUCLEAR SEX CHROMATIN

Procedure

Specimen taken from oral buccal smear is
commonly employed

Chromatin mess or sex chromosome body is
recognized in the cell nucleus adjacent to the
nuclear membrane in the female
NUCLEAR SEX CHROMATIN

Indication

Primary amenorrhea in apparent female

Ambiguous external genitalia at any age

Prepubertal girls with pronounce shortness of stature

Male infertility

Mental retardation and or psychotic or antisocial
behavior in either male and female

Aggressive, antisocial behavior in males with excessive
height
CULDOCENTESIS

Aspiration of fluid from posterior cul-de-sac
(pouch of Douglas) by needle placed through
posterior fornix of the vagina

Usually done in office with local or no anesthesia
CULDOCENTESIS

Indications

Most commonly performed for confirmation of suspected
hemoperitoneum (finding of non clotting blood)

Can help diagnose ectopic pregnancy, hemorrhagic ovarian
cyst or upper abdominal pathology

If WBC count > 30,000/ml of peritoneal fluid, suspect pelvic
inflammatory disease (normal WBC count <1000/ml)

Identification of possible ovarian carcinoma
CULDOCENTESIS

Benefits

Allows rapid diagnosis of a life-threatening
condition

Office procedure

Allows culture of organisms for treatment of PID
CULDOCENTESIS

Risks

Does not distinguish between sources of intraabdominal bleeding

Painful for patient

Bleeding, infection risks minimal
COLPOSCOPY
COLPOSCOPE
 Use of a magnifying instrument to
identify abnormal (precancerous,
cancerous) areas of cervical
mucosa
 Usually performed at 10-20x
magnification
COLPOSCOPY

Must be observed
 Squamo-columnar
junction is noted for
color, topography of epithelial surface and
vascular architecture
 Vascular pattern may be described
as
punctuation or mosaicism
 White discoloration or “oyster shell”
appearance
COLPOSCOPY

3 to 5% acetic acid applied to cervix

Normal mucosa appears smooth, opaque pink

Abnormal mucosa appear white due to increased nuclear-cytoplasmic ratio

Abnormal vascular patterns



Mosaicism

Punctation

Atypical (compatible with cancer)
Result from neovascularization of neoplasia
“Satisfactory exam” – must be able to see:

Transition zone in its entirety (360°)

All margins of the lesions, i.e. doesn’t extend into canal beyond view

If “unsatisfactory,” invasive cancer not ruled out
COLPOSCOPY

CIN
 Appears as white lesion and a minor alteration
of surface contour
 Vascular pattern may be prominent with
mosaicism and punctuation

Invasive Cell Ca
 Abnormal surface contour with heavy vessels
COLPOSCOPY

Indications

In abnormal pap smear, it determines the site of abnormal cells
and thus eliminate hazards of diagnostic conization

Atypical squamous cells of undetermined significance (ASCUS - H
or + high risk HPV)

Low grade squamous intraepithelial lesion (LGSIL)

High grade squamous intraepithelial lesion (HGSIL)

Carcinoma in-situ or invasive carcinoma

Repeated (>2) atypical pap smears

Atypical glandular cells
COLPOSCOPY

Indications

(+) ECC

Radiation changes

Following radiation , pap smear is occasionally abnormal.
Colposcompy can locate white epithelium due to radiation
changes

HPV and Herpes infection

DES exposed offspring

Pregnant patients can undergo colposcopy, as well
COLPOSCOPY

Risks


minimal risk, since colposcopy is not invasive
Benefits

Allows better visualization of cervical tissue than the naked
eye

Without biopsies, no more uncomfortable for patient than a
Pap

Identifies areas of concern for dysplasia

Defines histologic diagnosis, severity of disease,
extent/location of disease

Information obtained guides management/treatment
choices
CERVICAL BIOPSIES

Removing a small (2-3mm) sample of cervical
tissue

Usually done under colposcopic guidance

Usually fixed in formalin, in separate containers

Instruments (Tischler or Kevorkian biopsy
forceps)
CERVICAL BIOPSIES

Indications

Evaluation of a cervical lesion visible

To the naked eye

With colposcopy
CERVICAL BIOPSIES

Risks
◦
Bleeding from biopsy site

Usually minimal, hemostatics applied p.r.n.

May be more significant with increased vascularization
◦
◦

Pregnancy

Neovascularization of severe dysplasia and cancer
Infection rare, as tissue is well vascularized and heals easily
Misdiagnosis


False positive results may be due to:

Improperly oriented specimen

Inflammatory changes in the tissue
False negative results may be due to:

Sampling error – Inadequate colposcopic skills
CERVICAL BIOPSIES

Benefits

Allows specific dysplasia diagnosis and treatment
plan to be made based on tissue sample
(histology), not screening test (Pap, cytology)

Can also diagnose infections such as herpes,
syphilis and chronic cervicitis

No anesthesia required
D IAGNOSIS
CONE BIOPSY

Excision of transformation zone in a cone shape
(T-zone area at greatest risk for cervical neoplasia)

Anesthesia required – local, regional or general

Can be performed in OR using a scalpel, cold knife
cone or CO2 laser

Can be performed in the office setting
◦
◦
◦
◦
Loop electrosurgical excision
Not recommended for cervical lesions high in the canal
Not recommended for large or wide lesions
Local anesthesia is usually sufficient
CONE BIOPSY

Technique of cold knife cone biopsies

Adequate anesthesia

Sutures at 3 and 9 o’clock of lateral cervix for better hemostasis

Can use intracervical injections of vasopressin for hemostasis

Locate endocervical canal and transformation zone

Circumferential excision of transformation zone in cone shape

Ablation of base with cauterization

Perform endocervical curettage

Ensure hemostasis with sutures if necessary
CONE BIOPSY

Indications

Treatment of any high grade dysplastic lesion (CIN II or III) or
abnormal endocervical curettage

Evaluation of high grade lesion seen on an unsatisfactory
colposcopic exam (e.g. lesion extends into the cervical
canal)

Rule out invasive cancer (suspected by Pap or colposcopy,
but unable to confirm by office biopsy)

Resolve discrepancy between Pap finding and cervical
biopsy findings

Suspicion of glandular neoplasia (by Pap or colpo)

Microinvasive cancer on biopsy – rule out frank invasion, as
therapy differs
CONE BIOPSY

Benefits

Often done as day surgery

Provides tissue for further analysis by pathology

Not as destructive to specimen as electrocautery or
laser procedures

Ablation of base may destroy residual, neoplastic
disease
CONE BIOPSY

Risks

Bleeding

Infection

Future pregnancy loss due to loss of cervical
“competence”

Inability to remove all disease

Recurrence of disease
CRYOTHERAPY

Rapid expansion of carbon dioxide or nitrous
oxide in a probe placed against cervix causing
freezing of cervical tissue

Freezing process usually performed twice during
procedure to ensure destruction of tissue
CRYOTHERAPY

Indications

Treatment of cervical intraepithelial neoplasia

In theory, dysplasia cure rate should be ~ 90%
for all grades

Some report high failures with carcinoma in
situ and higher-grade lesions

Wide transformation zones may be difficult to
cover with probe

Cryotherapy is usually recommended for CIN
I-II with no endocervical involvement

Treatment of chronic cervicitis – done
historically, not currently recommended
CRYOTHERAPY

Benefits

No anesthesia needed

In-office procedure

Minimal cramping

No bleeding
CRYOTHERAPY

RISKS

No pathologic specimen obtained for review (all tissue
destroyed) – must rule out cancer via colposcopy

As above, cryotherapy cannot extend to vaginal margins or
into canal; therefore large lesions or endocervical lesions
may not be cured.

Cryotherapy may not extend into glands to destroy intra
glandular dysplasia.

Cervical stenosis postoperatively is a rare possibility

Colposcopic follow-up may be more difficult

Cannot be used on vaginal lesions due to varying
thicknesses of tissue and possible intra-abdominal organ
damage

Contraindicated in pregnancy
ELECTROSURGICAL EXCISION
OF CERVIX

Loop electrosurgical wire (unipolar)
with cutting/coagulation current
used to excise entire cervical
transformation zone

Tissue sent to pathology for
definitive diagnosis, rule out
invasive cancer

Base of cervix can then be ablated
for hemostasis and destruction of
residual disease

Local anesthesia used (cervical
block)
ELECTROSURGICAL EXCISION
OF CERVIX

Indications

Diagnosis and removal of
high-grade cervical dysplasia

Evaluation of lesions seen
on unsatisfactory
colposcopy, where a larger
tissue sample which
includes some endocervical
canal is needed

Rule out invasive cancer
ELECTROSURGICAL EXCISION
OF CERVIX

Benefits

Gives tissue diagnosis, rule out
cancer

Office procedure

Minimal discomfort for patient
ELECTROSURGICAL EXCISION
OF CERVIX

Risks

Bleeding – intraoperative or late

Infection

Not recommended for:

Wide lesions which cover ectocervix

Lesions high in canal

Bleeding disorders, anticoagulants

High risk of invasive cancer – cold knife cone
preferred

Pregnancy
ENDOCERVICAL CURETTAGE

Sampling of endocervical canal by
curette scraping

Usually performed with
colposcopy
ENDOCERVICAL CURETTAGE

Indications

Squamous or glandular dysplasia on Pap

Evaluation of cervical lesion in canal

Should be performed even if
transformation zone entirely visible at
first colposcopic exam; may not be
needed subsequently

Used to stage endometrial cancer by
determining cervical involvement
ENDOCERVICAL CURETTAGE

Benefits

Allows evaluation of areas not visible by
colposcopy

Helps determine treatment for dysplasia
– conization or loop excision indicated if
positive for squamous or glandular
disease

No anesthesia needed
ENDOCERVICAL CURETTAGE
Risks

Minimal spotting

Possible cramping during
procedure

Contraindicated in pregnancy
ENDOMETRIAL BIOPSY

Indications

Diagnosis of ovulation

Follow up of medically managed endometrial
pathology cases

Endometrial dating and diagnosis of luteal phase
defects

Abnormal uterine bleeding
ENDOMETRIAL BIOPSY

Diagnosis of Luteal Phase Defects

Discrepancy of 3 days or more between the histology date of
the endometrium and that of the cycle.

Correlation of histology with luteal length as defined by the
serum LH spikes or ultrasound evidence of ovulation

Low serum progesterone

Short luteal phase Basal Body Temperature
ENDOMETRIAL BIOPSY

Benefits

Low risk of uterine perforation (1/1000)

Gives tissue for diagnosis

Sensitivity for diagnosing neoplasia similar to D&C

Minimal bleeding

Unlike D&C, no anesthesia needed
ENDOMETRIAL BIOPSY


Contraindications

Pregnancy

Acute pelvic inflammatory disease
Precautions

Cardiac patients must receive prophylactic
antibiotics to prevent possible bacteremia
HYSTEROSALPINGOGRAPHY

Radiographic delineation of the uterus and
fallopian tubes using contrast material
introduced at the uterus via the cervical canal.

It is done 2-6 days after cessation of menstrual
flow.

A history of PID, septic abortion, IUD use,
ruptured appendix, tubal surgery, or ectopic
pregnancy alerts the physician to the
possibility of tubal damage. However cases
eventually found to have tubal damage, and or
pelvic adhesions have no apparent history of
HYSTEROSALPINGOGRAPHY

Indication:

Infertility work up

Treatment plan for gynecological disorders such as abnormal uterine
bleeding.

Asherman’s syndrome or uterine synechiae

Pre-operative evaluation prior to myomectomy, and tubal
reconstruction surgery.

Post-operative assessment of the uterus and tubal integrity.

Documentation that the tubes were lighted in cases where histologic
documentation was not previously done.

Cervical incompetence diagnosis

Mullerian Duct abnormalities

Women exposed to DES

Endometrial pathology diagnosis
HYSTEROSALPINGOGRAPHY


Contraindication:

Pregnancy

Menstruation

Acute PID

Hypersensitivity to the dye
Precautions:

For suspected cases with Pelvic Infection

Water soluble rather than oil dye should be used for better absorption.

Sedimentation rate is done. If elevated, give antibiotics and request
sedimentation rate after 1 month.
HYSTEROSALPINGOGRAPHY

Therapeutic uses of hysterosalpingogram:

It may effect mechanical lavage of the tube and dislodged mucus
plug

It may strengthen the tube and then break down peritoneal
adhesions.

It may provide stimulatory effect for the cilia of the tubes.

It may improve the cervical mucus

Iodine may exert as a bacteriostatic effect on the mucus
membrane.

Ethiodiol decreases the phagocytic capability of macrophages and
this could decrease the infection of the sperm.
ULTRASOUND

Noninvasive imaging technique utilizing acoustic
waves similar to sonar

Ultrasound is approximately 90% accurate in
recognizing the presence of a pelvic mass, but
does not establish a tissue diagnosis.
ULTRASOUND

Disadvantage:


Poor penetration of bone and air, thus the pubic symphysis and
air-filled intestines and rectum often inhibit visualization.
Advantages:

Real time nature of the image

Absence of radiation

Ability to perform the procedure in the office during or
immediately after a pelvic examination

Ability to describe the findings to the patient while she is
watching

Absence of adverse clinical effects from the energy levels used
in diagnostic studies.
ULTRASOUND

Ultrasound evaluation of endometrial pathology
involves measurement of the endometrial
thickness or stripe.

The normal endometrial thickness is 4mm or less
in a postmenopausal woman not taking
hormones.

The thickness varies in perimenopausal women at
different times of the menstrual cycle.

The endometrial thickness is measured in the
longitudinal plane, from outer margin to outer
margin, at the widest part of the endometrium
ENDOVAGINAL ULTRASOUND

During the examination, the woman is in a dorsal
lithotomy position and has an empty bladder.

Because the transducer is closer to the pelvic
organs than when a transabdominal approach is
employed, endovaginal resolution is usually
superior.

If the pelvic structures to be studied have
expanded and extend into the patient’s
abdomen, the organs are difficult to visualize
with an endovaginal probe.
TRANSABDOMINAL ULTRASOUND

A sector scanner is preferable because it provides
greater resolution of the pelvis and an easier
examination than the linear array.

It is helpful for the patient to have a full bladder, this
serves as an acoustic window for the high-frequency
sound waves.
DOPPLER ULTRASOUND

Assess the frequency of returning echoes to
determine the velocity of moving structures.

Measurement of diastolic and systolic velocities
provides indirect indices of vascular resistance.

Muscular arteries have high resistance

Newly developed vessels, such as those arising in
malignancies, have little vascular wall
musculature and thus have low resistance.
COLOR FLOW DOPPLER

A technique that usually displays shades of red and
blue that delineate blood flow within an ovarian
neoplasm

Benign ovarian lesions have little color flow

When a color flow doppler scan does demonstrate
vascularity, the vascular resistance can be calculated.

Low resistance is associated with malignancy, and high
resistance usually is associated with normal tissue or
benign disease.

Highly sensitive in evaluating ovarian malignancy
SONOHYSTEROGRAPHY

In women with abnormal vaginal bleeding,
transcervical injection of saline outlines the
uterine cavity

A thin catheter, a pipelle or intrauterine
insemination catheter, is inserted through the
cervical os and 3 to 10 cc of saline are slowly
injected into the uterine cavity.

Also helpful in the evaluation of uterine septae

It does not make a tissue diagnosis.
THANK YOU 