Ob/Gyn Experts Recommend “Ultrasound First” for Imaging the Female Pelvis

Ultrasound more cost-effective and safer than other imaging modalities, reports the American Journal of Obstetrics & Gynecology

Philadelphia, PA, , March 31, 2015

Ultrasound technology has evolved dramatically in recent years. A group of noted obstetricians and gynecologists maintain that ultrasound is more cost-effective and safer than other imaging modalities for imaging the female pelvis and should be the first imaging modality used for patients with pelvic symptoms. Writing in the American Journal of Obstetrics & Gynecology and supporting an American Institute of Ultrasound in Medicine (AIUM at www.AIUM.org) initiative, they urge practitioners to “put ultrasound first.”

In 2012, the AIUM launched “Ultrasound First, which advocates the use of ultrasound examinations before other imaging modalities, when evidence shows that ultrasound is at least equally, if not more effective, for the target anatomic area.

“This recommendation applies particularly to obstetric and gynecologic patients. A skillfully performed and well-interpreted ultrasound usually eliminates the need to perform additional more costly and complex cross-sectional imaging techniques,” explained lead author and AIUM president Beryl R. Benacerraf, MD, Clinical Professor in Obstetrics, Gynecology, and Reproductive Biology and Radiology at Harvard Medical School, and Brigham and Women’s Hospital. She pointed out that, still today, many women presenting with pelvic pain, masses, or flank pain first undergo CT (computerized tomography) scans and those with Müllerian duct anomalies typically have MRIs (magnetic resonance imaging). CT or MRI of the pelvis often yields indeterminate and confusing findings that require further clarification using ultrasound.

Immediate Past-President of AIUM and co-author Steven R. Goldstein, MD, Professor of Obstetrics and Gynecology at the NYU School of Medicine and Director of Gynecologic Ultrasound and Co-Director of Bone Densitometry, highlighted the safety concerns when using other modalities: “The use of CT scans has tripled since 1993. An estimated 29,000 future cancers could be related to CT done in the U.S. in 2007. The largest contribution to this projected risk of cancer (14,000 cancers) was attributed to CT of the pelvis and abdomen.

“For example, patients with suspected kidney stones frequently have a CT scan first, despite the associated radiation burden. In a recent study, most of the patients evaluated first by ultrasound did not ultimately need a CT scan, sparing radiation exposure.”

Ultrasound has evolved very rapidly from the early days of black dots on a white screen, said the experts. Several key technical advances such as 3D volume imaging (similar to CT and MR), real time evaluation of pelvic organs along the physical examination, and Doppler blood flow mapping (without contrast) have rendered ultrasound an effective first line (and often only) imaging modality for most gynecologic patients.

Ultrasound exams used to require filling a woman’s bladder and obtaining a series of 2D images one at a time, which was operator-dependent and limited to certain views that did not require reconstruction.  Today, 3D volume ultrasound allows the automated acquisition of an entire volume that in turn can generate hundreds of images and be used to reconstruct any view in any orientation. It is less expensive and less time-consuming than MRI. Images are of comparable quality and orientation to those of MRI and CT but without radiation, and at relatively lower cost. “Doing a CT scan first for female patients with lower abdominal pain is dangerous, wasteful, and expensive,” noted Dr. Benacerraf. “We must educate the medical community to consider adopting 3D ultrasound as the first assessment tool for specific gynecologic indications, such as evaluating the uterus for Müllerian anomalies or localization of IUDs or other intracavitary lesions.”

The transvaginal ultrasound transducer is one of the most important innovations in pelvic imaging in recent decades as it allows the operator to place a probe in close proximity to target pelvic organs and to examine and image the patient at the same time. Ultrasound has proved accurate for evaluating deep infiltrating endometriosis and for patients with pain due to extensive pelvic adhesions.

The third development described is Doppler Interrogation, which provides information about the location and degree of blood flow in and around pelvic lesions without the need to inject contrast. Cancers characteristically have abundant and disorganized blood flow patterns, whereas benign lesions have limited flow, and cysts lack flow altogether. Color Doppler mapping often furnishes the key to the evaluation of an adnexal mass and differentiating an endometrioma from an ovarian tumor or an ovarian fibroma.

AIUM Past-President Alfred Z. Abuhamad, MD, Professor and Chairman of Obstetrics and Gynecology and Vice Dean for Clinical Affairs at Eastern Virginia Medical School, commented, “In this era of cost concerns, it is very important to recognize that ultrasound technology now offers multiple applications. Many practitioners still provide basic 2D ultrasound, emphasizing the need for education and dissemination of this information.”

The richly illustrated Clinical Opinion article is openly available and accompanied by a PowerPoint presentation.

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Notes for editors
“Consider ultrasound first for imaging the female pelvis,” by Beryl R. Benacerraf, MD, Alfred Z. Abuhamad, MD, Bryann Bromley, MD, Steven Goldstein, MD, Yvette Groszmann, MD, MPH, Thomas D. Shipp, MD, and Ilan Timor-Tritsch, MD (DOI: http://dx.doi.org/10.1016/j.ajog.2015.02.015), American Journal of Obstetrics & Gynecology, published online in advance of Volume 212, Issue 4 (April 2015), by Elsevier.

Full text of this Clinical Opinion article is available to credentialed journalists upon request. Contact Eileen Leahy at +1 732 238 3628 or ajogmedia@elsevier.com to obtain a copy. It will become openly available when the embargo lifts at http://dx.doi.org/10.1016/j.ajog.2015.02.015. Journalists wishing to interview the article’s authors should contact Haley Bridger, Senior Science Communication Specialist, Brigham and Women's Hospital, at +1 617 525 6383 (office), +1 978 807 5302 (cell), or hbridger@partners.org. Dr. Alfred Z. Abuhamad may be contacted via Blair Holloway at +1 757 446 6041 or news@evms.edu.

About the authors
Beryl R. Benacerraf, MD, Harvard Medical School, Cambridge, MA, and Brigham and Women’s Hospital, Boston, MA, President of the American Institute for Ultrasound in Medicine

Alfred Z. Abuhamad, MD, Eastern Virginia Medical School, Norfolk, VA, Past President of the American Institute for Ultrasound in Medicine

Bryann S. Bromley, MD, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, and Diagnostic Ultrasound, Departments of Obstetrics and Gynecology and Radiology, Brigham and Women's Hospital, Boston, MA

Steven Goldstein, MD, NYU School of Medicine, New York, NY, Immediate Past-President of the American Institute for Ultrasound in Medicine

Yvette Groszmann, MD, MPH, Diagnostic Ultrasound Association, Brookline Boston, MA, and Departments of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA

Thomas D. Shipp, MD, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, MA, and Harvard Medical School. Cambridge, MA

Ilan Timor-Tritsch, MD, NYU School of Medicine Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine New York, NY

About the American Journal Of Obstetrics & Gynecology
The American Journal of Obstetrics & Gynecology (www.AJOG.org), known as “The Gray Journal,” presents coverage of the entire spectrum of the field, from the newest diagnostic procedures to leading-edge research. The Journal provides comprehensive coverage of the specialty, including maternal-fetal medicine, reproductive endocrinology/infertility, and gynecologic oncology. It also publishes the annual meeting papers of several of its eight sponsoring societies, including the Society for Maternal-Fetal Medicine and the Society of Gynecologic Surgeons.

The American Journal of Obstetrics & Gynecology's 2013 Impact Factor is 3.973. The journal now ranks second in Eigenfactor score, and continues to be first in total citations and the number 5 journal in the Obstetrics & Gynecology category according to the 2013 Journal Citation Reports®, published by Thomson Reuters, 2014. The journal has also been recognized as one of the 100 most influential journals in Biology & Medicine over the last 100 years, as determined by the BioMedical & Life Sciences Division of the Special Libraries Association (2009).

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Media contact
Eileen Leahy
Elsevier
+1 732 238 3628
ajogmedia@elsevier.com