Experienced ultrasonographers using some clinical information and their subjective assessment of ultrasonographic images can differentiate malignant from benign masses in most cases. The accuracy and the level of interobserver agreement are both correlated with experience. About 10% of masses were extremely difficult to classify (only < 50% of assessors were correct).

The availability of advanced hysteroscopic surgical techniques has changed the management of abnormal uterine bleeding. The aim of this study was to evaluate the use of transvaginal sonography (TVS), sonohysterography (SH) and diagnostic hysteroscopy (DH) for the preoperative assessment of the uterine cavity. The plan was to investigate 100 patients with abnormal uterine bleeding despite conventional medical treatment. The endpoints were uterine abnormalities detected by operative hysteroscopy and histology, and subjective estimates of discomfort during TVS and SH. A total of 104 patients (aged 26-79 years) were recruited and 98 (94%) underwent all three diagnostic procedures. Uterine abnormalities were present in 52 patients (53%). There were 25 cases with at least one endometrial polyp, 17 with submucous fibroids, seven with endometrial hyperplasia and three with an adenocarcinoma. The overall sensitivity of TVS improved after SH from 67 to 87% and the specificity from 89 to 91%. The positive predictive value increased from 88 to 92% and the negative predictive value from 71 to 86%. The use of SH also improved the quality of information about the location and size of polyps and submucous fibroids. Increased endometrial thickness associated with adenocarcinoma was detected in all cases (three of three) by TVS and in four of seven cases of hyperplasia (five of seven cases after SH). Most patients reported minor discomfort during TVS or SH and no side-effects were apparent. The sensitivity of DH was 90% (92% for polyps, 88% for fibroids); two cases with a polyp, two with a submucous fibroid and one with endometrial hyperplasia were not detected. The use of saline infusion to enhance visualization of the endometrium increases the diagnostic accuracy of transvaginal sonography to approach that of diagnostic hysteroscopy and also provides some additional information. This development has implications for the management of uterine bleeding disorders.

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Non-invasive methods for monitoring reproductive status based on the measurement of urinary steroid conjugates were examined. Levels of urinary oestrone-3-glucuronide, oestrone-3-sulphate, oestradiol glucuronide, oestradiol sulphate and pregnanediol-3 alpha-glucuronide were determined during the ovarian cycle and pregnancy. Sequential hydrolysis showed oestradiol conjugates to be more abundant than oestrone conjugates. The levels of sulphates and glucuronides were similar in the follicular phase whereas sulphates predominated during the luteal phase and pregnancy. Although levels of oestrone-3-sulphate were two- to fourfold lower than those of oestradiol sulphate, measured after hydrolysis, the profiles throughout the cycle and pregnancy were similar. Levels of oestrone-3-sulphate, measured by direct assay, were below 1 mumol/mmol creatinine during the follicular phase, rising 3-4 days after ovulation to reach maximum values (2-8 mumol/mmol creatinine) in the mid-luteal phase. There was no consistent increase before ovulation. Levels during pregnancy rose gradually until days 70-90, after which there was no further increase (gestation length = 144 days). The pattern of pregnanediol-3 alpha-glucuronide was similar to that of oestrone-3-sulphate during the ovarian cycle but levels did not increase during pregnancy. The patterns of excretion of oestrogen and progesterone metabolites were similar to the pattern of the circulating hormones during the ovarian cycle. Circulating and urinary hormone patterns were similar for oestrogens throughout pregnancy but pregnanediol-3 alpha-glucuronide did not reflect progesterone secretion beyond day 70 of gestation.

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Objectives

Summary. Ovarian volumes have been determined by pelvic ultrasonography in 2246 apparently healthy postmenopausal women of whom 2221 were included in the statistical analysis. Factors associated with gonadal size have been identified, and reference ranges for derived indices have been determined for use (in association with criteria for abnormal morphology) in a screening programme for ovarian carcinoma. The right ovary was present in 98·9% of subjects and the left in 99 · 1 %. The mean (SD; range) of right and left ovarian volumes were 3·58 (1·40; 1·00–14.01) and 3·57 (1·37; 0·88–10·9) ml respectively. Significant predictors of ovarian volume were years since the menopause, weight, parity, age at menopause, a history of hormone replacement therapy, and previously diagnosed breast cancer. Abnormal ovarian volumes were assessed from a score equal to the (observed mean log volume (MLV) minus the predicted MLV)/0·327. A simplified nomogram has been prepared for routine clinical use. The relative abnormality of one ovary was assessed from a ratio score equal to loge (larger ovarian volume/smaller ovarian volume)/0·211 compared with the 99th centile for the Gaussian distribution.

Methods based upon the principles of radioimmunoassay have been developed and evaluated for the measurement of oestrone-3-glucuronide, LH and pregnanediol-3\g=a\-glucuronidein samples of unextracted urine. The procedures have been applied to daily urine (early morning fraction and combined 24 hour collections) from 6 women throughout one complete menstrual cycle and to serial samples from an additional 14 women who only collected early morning specimens. The results showed that there were characteristic, well-defined changes in the concentration of all 3 metabolites in both samples of urine and from all subjects. In addition, there was a reasonable correlation between the concentration of all 3 compounds in samples of early morning urine and the corresponding rates of excretion per 24 hours. These findings suggest that the procedures may be of value for monitoring ovarian function over long periods of time, without the problems of stress and inconvenience to the patient. Furthermore, the ratio of values for oestrone-3-glucuronide to pregnanediol-3\g=a\-glucuronidemay be used to indicate the start and finish of the fertile period.The study of factors which enhance or inhibit fertility often necessitates longterm monitoring of ovarian function. At the present time, the most accepted and useful approach has been to measure the concentrations of oestradiol