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Consider ultrasound first for imaging the female pelvis

  • Beryl R. Benacerraf
    Correspondence
    Corresponding author: Beryl Benacerraf, MD.
    Affiliations
    Harvard Medical School, Brigham and Women's Hospital, Boston, MA

    Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA

    Department of Radiology, Brigham and Women's Hospital, Boston, MA

    Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA

    Diagnostic Ultrasound Associates, Brookline, MA
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  • Alfred Z. Abuhamad
    Affiliations
    Eastern Virginia Medical School, Norfolk, VA
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  • Bryann Bromley
    Affiliations
    Harvard Medical School, Brigham and Women's Hospital, Boston, MA

    Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA

    Department of Radiology, Brigham and Women's Hospital, Boston, MA

    Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA

    Diagnostic Ultrasound Associates, Brookline, MA
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  • Steven R. Goldstein
    Affiliations
    Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine and Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY
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  • Yvette Groszmann
    Affiliations
    Harvard Medical School, Brigham and Women's Hospital, Boston, MA

    Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA

    Diagnostic Ultrasound Associates, Brookline, MA
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  • Thomas D. Shipp
    Affiliations
    Harvard Medical School, Brigham and Women's Hospital, Boston, MA

    Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA

    Department of Radiology, Brigham and Women's Hospital, Boston, MA

    Diagnostic Ultrasound Associates, Brookline, MA
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  • Ilan E. Timor-Tritsch
    Affiliations
    Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine and Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY
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      Ultrasound technology has evolved dramatically in recent years and now includes applications such as 3-dimensional volume imaging, real-time evaluation of pelvic organs (simultaneous with the physical examination), and Doppler blood flow mapping without the need for contrast, which makes ultrasound imaging unique for imaging the female pelvis. Among the many cross-sectional imaging techniques, we should use the most informative, less invasive, and less expensive modality to avoid radiation when possible. Hence, ultrasound imaging should be the first imaging modality used in women with pelvic symptoms.

      Key words

      Click Supplemental Materials under the article title in the online Table of Contents
      Ever-present concerns regarding escalating health care costs and the appropriate use of medical technology demand careful choices regarding first-line medical diagnostic tests to serve our patients and society best. We should favor the most informative, least invasive, and less expensive technology among the multitude of available cross-sectional imaging modalities and minimize radiation when possible.
      In this regard, the American Institute of Ultrasound in Medicine (AIUM.org) launched an initiative in 2012 “Ultrasound First,” which advocates the use of ultrasound examinations before other imaging modalities when the evidence shows that ultrasound imaging is at least equally, if not more, effective for the target anatomic area.
      • Minton K.K.
      • Abuhamad A.Z.
      2012 Ultrasound First Forum Proceedings.
      This tenet applies particularly to obstetric and gynecologic patients for whom a skillfully performed and well-interpreted ultrasound image usually obviates the need to proceed to additional more costly and complex cross-sectional imaging techniques.
      • Minton K.K.
      • Abuhamad A.Z.
      2012 Ultrasound First Forum Proceedings.
      • Coccia M.E.
      • Rizzello F.
      • Romanelli C.
      • Capezzuoli T.
      Adnexal masses: what is the role of ultrasonographic imaging?.
      • Ghi T.
      • Casadio P.
      • Kuleva M.
      • et al.
      Accuracy of three-dimensional ultrasound in diagnosis and classification of congenital uterine anomalies.
      Yet still today, many women with pelvic pain, masses, or flank pain first undergo computed tomography (CT) scans and those with Müllerian duct anomalies typically have magnetic resonance images (MRIs).
      • Minton K.K.
      • Abuhamad A.Z.
      2012 Ultrasound First Forum Proceedings.
      • Coccia M.E.
      • Rizzello F.
      • Romanelli C.
      • Capezzuoli T.
      Adnexal masses: what is the role of ultrasonographic imaging?.
      • Ghi T.
      • Casadio P.
      • Kuleva M.
      • et al.
      Accuracy of three-dimensional ultrasound in diagnosis and classification of congenital uterine anomalies.
      • Smith-Bindman R.
      • Aubin C.
      • Bailitz J.
      • et al.
      Ultrasonography versus computed tomography for suspected nephrolithiasis.
      • Smith B.C.
      • Brown D.L.
      • Carter R.E.
      • Famuyide A.O.
      Double cervix: clarifying a diagnostic dilemma.
      Not uncommonly, CT or MRI of the pelvis often yield indeterminate and confusing findings that then require clarification by ultrasound imaging. The use of CT scans has tripled since 1993, and CT scans done in 2007 could result in as many as 29,000 future cancers in the United States, with the largest contribution to this risk arising from the CT of the pelvis and abdomen.
      • Fazel R.
      • Krumholz H.M.
      • Wang Y.
      • et al.
      Exposure to low-dose ionizing radiation from medical imaging procedures.
      • Berrington de Gonzalez A.
      • Mahesh M.
      • Kim K.P.
      • et al.
      Projected cancer risks from computed tomographic scans performed in the United States in 2007.
      For example, patients with suspected kidney stones frequently have a CT scan first, despite the associated radiation burden. A recent study compared initial evaluation of patients with nephrolithiasis by ultrasound imaging or by CT.
      • Smith-Bindman R.
      • Aubin C.
      • Bailitz J.
      • et al.
      Ultrasonography versus computed tomography for suspected nephrolithiasis.
      This analysis showed no significant differences in subsequent complications, pain scores, return emergency visits, or hospitalizations. In addition, most of the patients who were evaluated first by ultrasound imaging ultimately did not need a CT scan, sparing radiation exposure.
      This clinical opinion presents the current capabilities of ultrasound imaging as the first-line imaging technique for the nonpregnant female pelvis for most clinical scenarios. Ultrasound imaging has evolved very rapidly from the early days of “black dots on a white screen” to the current very sophisticated and high-resolution displays that use both 2-dimensional (2D) and 3-dimensional (3D) technology and blood flow mapping. The advent of the high-resolution endocavitary probes and the use of color Doppler imaging for blood flow mapping have further enhanced the diagnostic capabilities of this imaging modality. Several key technical advances have rendered ultrasound imaging an effective first-line (and often only) imaging modality for most gynecologic patients: (1) volume (3D/4-dimensional) imaging, (2) real-time transvaginal ultrasound imaging with sonographically enhanced physical examination, and (3) Doppler techniques for blood flow evaluation.

      3D ultrasound imaging

      Currently available 3D/4-dimensional volume ultrasound imaging can produce images of the female pelvis of comparable quality and orientation to those of MRI and CT but without radiation and at relatively lower cost.
      • Bermejo C.
      • Martínez Ten P.
      • Cantarero R.
      • et al.
      Three-dimensional ultrasound in the diagnosis of Müllerian duct anomalies and concordance with magnetic resonance imaging.
      • Faivre E.
      • Fernandez H.
      • Deffieux X.
      • Gervaise A.
      • Frydman R.
      • Levaillant J.M.
      Accuracy of three-dimensional ultrasonography in differential diagnosis of septate and bicornuate uterus compared with office hysteroscopy and pelvic magnetic resonance imaging.
      • Deutch T.D.
      • Abuhamad A.Z.
      The role of 3-dimensional ultrasonography and magnetic resonance imaging in the diagnosis of Müllerian duct anomalies: a review of the literature.
      • Sakhel K.
      • Benson C.B.
      • Platt L.D.
      • Goldstein S.R.
      • Benacerraf B.R.
      Begin with the basics: role of 3-dimensional sonography as a first-line imaging technique in the cost-effective evaluation of gynecologic pelvic disease.
      Years ago, ultrasound examinations required filling a woman’s bladder and obtaining a series of 2D images one at a time, which rendered this approach very operator-dependent and limited to certain views that did not require reconstruction. Today, 3D volume ultrasound imaging 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. Furthermore, 3D ultrasound imaging is less expensive and less time-consuming than MRI. Bowel peristalsis does not affect ultrasound imaging as it does MRI, and many patients find this modality more comfortable than MRI. In contrast to MRI, patients with metal prostheses and pacemakers can undergo 3D ultrasound imaging that will yield similar images. Since the advent of volume imaging in ultrasound imaging, reconstructed views of the pelvis (such as the coronal view of the uterus) have greatly improved our ability to use ultrasound imaging to answer the vast majority of clinical questions in gynecology.
      • Minton K.K.
      • Abuhamad A.Z.
      2012 Ultrasound First Forum Proceedings.
      • Deutch T.D.
      • Abuhamad A.Z.
      The role of 3-dimensional ultrasonography and magnetic resonance imaging in the diagnosis of Müllerian duct anomalies: a review of the literature.
      • Sakhel K.
      • Benson C.B.
      • Platt L.D.
      • Goldstein S.R.
      • Benacerraf B.R.
      Begin with the basics: role of 3-dimensional sonography as a first-line imaging technique in the cost-effective evaluation of gynecologic pelvic disease.
      Three-dimensional volume sonography has now become an essential new tool in the ultrasound armamentarium that has proved just as effective as MRI for the demonstration of Müllerian duct anomalies, which include cervical duplications (Figure 1).
      • Bermejo C.
      • Martínez Ten P.
      • Cantarero R.
      • et al.
      Three-dimensional ultrasound in the diagnosis of Müllerian duct anomalies and concordance with magnetic resonance imaging.
      • Faivre E.
      • Fernandez H.
      • Deffieux X.
      • Gervaise A.
      • Frydman R.
      • Levaillant J.M.
      Accuracy of three-dimensional ultrasonography in differential diagnosis of septate and bicornuate uterus compared with office hysteroscopy and pelvic magnetic resonance imaging.
      • Deutch T.D.
      • Abuhamad A.Z.
      The role of 3-dimensional ultrasonography and magnetic resonance imaging in the diagnosis of Müllerian duct anomalies: a review of the literature.
      • Sakhel K.
      • Benson C.B.
      • Platt L.D.
      • Goldstein S.R.
      • Benacerraf B.R.
      Begin with the basics: role of 3-dimensional sonography as a first-line imaging technique in the cost-effective evaluation of gynecologic pelvic disease.
      Three-dimensional ultrasound imaging, like MRI, can produce an image of the uterine contour and the entire endometrial cavity simultaneously. Furthermore, 3D ultrasound imaging provides the ability to manipulate the volumes in any orientation for complete evaluation of the uterus, regardless of its orientation or rotation. Multiple studies have compared 3D ultrasound imaging with other imaging modalities and with operative findings, hence establishing the equivalency of 3D ultrasound imaging to MRI in diagnostic accuracy of Müllerian anomalies.
      • Ghi T.
      • Casadio P.
      • Kuleva M.
      • et al.
      Accuracy of three-dimensional ultrasound in diagnosis and classification of congenital uterine anomalies.
      • Bermejo C.
      • Martínez Ten P.
      • Cantarero R.
      • et al.
      Three-dimensional ultrasound in the diagnosis of Müllerian duct anomalies and concordance with magnetic resonance imaging.
      • Faivre E.
      • Fernandez H.
      • Deffieux X.
      • Gervaise A.
      • Frydman R.
      • Levaillant J.M.
      Accuracy of three-dimensional ultrasonography in differential diagnosis of septate and bicornuate uterus compared with office hysteroscopy and pelvic magnetic resonance imaging.
      • Deutch T.D.
      • Abuhamad A.Z.
      The role of 3-dimensional ultrasonography and magnetic resonance imaging in the diagnosis of Müllerian duct anomalies: a review of the literature.
      Indeed, the accuracy of both 3D ultrasound imaging and MRI for the diagnosis of the specific type and extent of uterine malformations typically exceeds 90-95%.
      • Minton K.K.
      • Abuhamad A.Z.
      2012 Ultrasound First Forum Proceedings.
      • Deutch T.D.
      • Abuhamad A.Z.
      The role of 3-dimensional ultrasonography and magnetic resonance imaging in the diagnosis of Müllerian duct anomalies: a review of the literature.
      Three-dimensional ultrasound imaging has emerged as the ideal imaging modality not only when examining patients with infertility but also for examining patients with pelvic pain associated with embedded intrauterine devices, fibroid tumors, adenomyosis, adnexal masses, torsion, endometriosis (Figure 2, Figure 3, Figure 4, Figure 5).
      • Sakhel K.
      • Benson C.B.
      • Platt L.D.
      • Goldstein S.R.
      • Benacerraf B.R.
      Begin with the basics: role of 3-dimensional sonography as a first-line imaging technique in the cost-effective evaluation of gynecologic pelvic disease.
      • Benacerraf B.R.
      • Shipp T.D.
      • Bromley B.
      Three-dimensional ultrasound detection of abnormally located intrauterine contraceptive devices which are a source of pelvic pain and abnormal bleeding.
      • Benacerraf B.R.
      • Groszmann Y.
      Sonography should be the first imaging examination done to evaluate patients with suspected endometriosis.
      • Armstrong L.
      • Fleischer A.
      • Andreotti R.
      Three-dimensional volumetric sonography in gynecology: an overview of clinical applications.
      • Timor-Tritsch I.E.
      • Monteagudo A.
      • Tsymbal T.
      Three-dimensional ultrasound inversion rendering technique facilitates the diagnosis of hydrosalpinx.
      Ultrasound volume imaging makes it possible to localize fibroid tumors, polyps, and hydrosalpinges with high precision, as well as other uterine abnormalities (Figure 3, Figure 4, Figure 5, Figure 6). We must educate the medical community to consider adopting 3D ultrasound imaging as the first assessment tool for specific gynecologic indications, such as the evaluation of the uterus for Müllerian anomalies or localization of intrauterine devices or other intracavitary lesions. In this setting, it is likely that fewer women would require a costly workup that involves multiple advanced imaging studies if 3D ultrasound images were performed first.
      Figure thumbnail gr1
      Figure 1Complete septate uterus using 3D volume imaging
      A, Three-dimensional ultrasound image shows the reconstructed coronal view of a septate uterus. Note the complete separation of the endometrial echo but with an intact flat serosal surface. B, Three-dimensional reconstructed view of the double cervix in the same patient. C, Three-dimensional ultrasound image shows the 3 orthogonal planes and the reconstructed view of the cervix. These images show how the different planes are accessed within the volume.
      Benacerraf. Consider ultrasound first for imaging the female pelvis. Am J Obstet Gynecol 2015.
      Figure thumbnail gr2
      Figure 2Malpositioned IUDs seen using the coronal view reconstructed from a 3D volume
      A, Three-dimensional reconstructed coronal view of uterus that contains a Paragard (Teva Women's Health, Inc, North Wales, PA) intrauterine device (IUD). The IUD is in the lower uterine segment with the right arm partly embedded in the myometrium. B, Three-dimensional reconstructed coronal view of another uterus that contains a Mirena (Bayer HealthCare, Whippany, NJ) IUD. Note that the uterine cavity is too small to accommodate the open IUD so that the left arm is embedded partly in the myometrium.
      Benacerraf. Consider ultrasound first for imaging the female pelvis. Am J Obstet Gynecol 2015.
      Figure thumbnail gr3
      Figure 3Submucosal fibroid seen using 2D and 3D ultrasound
      A, Two-dimensional longitudinal view of the uterus that contains a central fibroid tumor (calipers). B, The 3-dimensional coronal view shows that the fibroid tumor is partly submucosal in the left cornual region, hence mapping the location of the fibroid tumor precisely.
      Benacerraf. Consider ultrasound first for imaging the female pelvis. Am J Obstet Gynecol 2015.
      Figure thumbnail gr4
      Figure 4Adenomyosis demonstrated by 2D and 3D ultrasound imaging
      A, Two-dimensional longitudinal view of the uterus with extensive adenomyosis. Note the heterogeneity of the anterior myometrium and the irregular cystic areas that are consistent with dilated glands. A distinct endometrial echo is not seen. B, The 3-dimensional coronal view shows more clearly the very irregular and cystic junctional zone between the endometrium and myometrium, which is typical of severe adenomyosis.
      Benacerraf. Consider ultrasound first for imaging the female pelvis. Am J Obstet Gynecol 2015.
      Figure thumbnail gr5
      Figure 5Coronal view of the uterus containing a fibroid and polyp
      Three-dimensional reconstructed coronal view of uterus shows a small polyp within the uterine cavity and a partially submucosal fibroid tumor at the fundus of the uterus (both shown by calipers). 1, 2, 3, and 4 are the normal caliper measurement numbers inserted by machine.
      Benacerraf. Consider ultrasound first for imaging the female pelvis. Am J Obstet Gynecol 2015.
      Figure thumbnail gr6
      Figure 62D and 3D inverse view of a hydrosalpinx
      A, Two-dimensional oblique view of a multiseptate adnexal fluid collection, suspected of being a hydrosalpinx. Numbers 1 and 2 are normal caliper measurement numbers inserted by machine. B, Three-dimensional inverse mode view of the same adnexal fluid collection definitively demonstrates a hydrosalpinx. With the use of the inverse mode, the cystic areas all become solid, and the solid areas disappear from the image; hence, a cast of the hydrosalpinx can be viewed even as it traverses multiple planes.
      Benacerraf. Consider ultrasound first for imaging the female pelvis. Am J Obstet Gynecol 2015.

      The real-time transvaginal ultrasound imaging

      The advent of the transvaginal transducer is one of the most important innovations in pelvic imaging in recent decades. This advance allows the operator to place a high-frequency endocavitary ultrasound transducer in close proximity to target pelvic organs, thus improving image resolution and obviating the need for patients to have a full bladder before ultrasound examinations.
      • Benacerraf B.R.
      • Shipp T.D.
      • Bromley B.
      Is a full bladder still necessary for pelvic sonography?.
      Ultrasound imaging has the added advantage of real-time imaging, which allows for the probing of pelvic organs to elicit patient’s symptoms and thus correlate symptoms with specific pelvic anatomic locations. The practitioner therefore can gain crucial information about the degree and area of pain and mobility of organs in the pelvis and correlate the ultrasound findings with the physical examination.
      • Saba L.
      • Guerriero S.
      • Sulcis R.
      • et al.
      MRI and “tenderness guided” transvaginal ultrasonography in the diagnosis of recto-sigmoid endometriosis.
      • Guerriero S.
      • Ajossa S.
      • Gerada M.
      • D’Aquila M.
      • Piras B.
      • Melis G.B.
      “Tenderness-guided” transvaginal ultrasonography: a new method for the detection of deep endometriosis in patients with chronic pelvic pain.
      • Exacoustos C.
      • Manganaro L.
      • Zupi E.
      Imaging for the evaluation of endometriosis and adenomyosis.
      The ability to examine and image the patient at the same time offers considerable and too often neglected value, which is unique to ultrasound imaging as a cross-sectional imaging technique. Tenderness-guided ultrasound imaging has become the most effective way of the detection of implants of painful deep-penetrating endometriosis throughout the pelvis.
      • Saba L.
      • Guerriero S.
      • Sulcis R.
      • et al.
      MRI and “tenderness guided” transvaginal ultrasonography in the diagnosis of recto-sigmoid endometriosis.
      • Guerriero S.
      • Ajossa S.
      • Gerada M.
      • D’Aquila M.
      • Piras B.
      • Melis G.B.
      “Tenderness-guided” transvaginal ultrasonography: a new method for the detection of deep endometriosis in patients with chronic pelvic pain.
      • Exacoustos C.
      • Manganaro L.
      • Zupi E.
      Imaging for the evaluation of endometriosis and adenomyosis.
      Ultrasound imaging has proved to be accurate for the evaluation of deep infiltrating endometriosis and for patients with pain because of extensive pelvic adhesions (Figure 7).
      • Hudelist G.
      • English J.
      • Thomas A.E.
      • Tinelli A.
      • Singer C.F.
      • Keckstein J.
      Diagnostic accuracy of transvaginal ultrasound for non-invasive diagnosis of bowel endometriosis: systematic review and meta-analysis.
      • Abrao M.S.
      • Gonçalves M.O.
      • Dias Jr., J.A.
      • Podgaec S.
      • Chamie L.P.
      • Blasbalg R.
      Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis.
      Not only can we identify abnormalities on the images, but also simultaneous gentle pushing can show whether organs slide past each other, thus providing crucial information about the origin of a mass (adnexal mass vs broad ligament fibroid tumor) and the connections and adhesions between the organs. Real-time ultrasound imaging also permits the performance of sonohysterography, a procedure that involves placement of a small catheter through the cervix into the uterus and the injection of a small amount of saline solution.
      • Miller J.C.
      • Schiff I.
      • Thrall J.H.
      • Lee S.I.
      Ultrasound and sonohysterography in the evaluation of abnormal vaginal bleeding.
      By distending the endometrial cavity, the clinician can evaluate the endometrium for polyps, submucosal fibroid tumors, synechiae, and uterine shape when necessary.
      • Miller J.C.
      • Schiff I.
      • Thrall J.H.
      • Lee S.I.
      Ultrasound and sonohysterography in the evaluation of abnormal vaginal bleeding.
      Adjunctive to sonohysterography, the installation of microbubbles is useful for the determination of tubal patency and is critical to those patients with contrast allergies.
      • Luciano D.E.
      • Exacoustos C.
      • Luciano A.A.
      Contrast ultrasonography for tubal patency.
      Figure thumbnail gr7
      Figure 7Deep infiltrating endometriosis of the bowel and cul de sac
      A, Two-dimensional longitudinal view of the cul de sac in a patient who has extensive endometriosis. The calipers outline a deep endometriotic implant in the anterior wall of the rectosigmoid, behind the posterior fornix of the vagina and just caudad to the cervix. B, Three-dimensional image of the same area, with the use of the tomographic technique that generates multiple slices parallel to each other, similar to the computed tomography and magnetic resonance imaging displays.
      Benacerraf. Consider ultrasound first for imaging the female pelvis. Am J Obstet Gynecol 2015.

      3D Doppler interrogation

      To characterize pelvic masses, ultrasound imaging offers the advantage of combining morphologic and vascular imaging.
      • Timmerman D.
      • Van Calster B.
      • Testa A.C.
      • et al.
      Ovarian cancer prediction in adnexal masses using ultrasound-based logistic regression models: a temporal and external validation study by the IOTA group.
      • Sokalska A.
      • Timmerman D.
      • Testa A.C.
      • et al.
      Diagnostic accuracy of trans- vaginal ultrasound examination for assigning a specific diagnosis to adnexal masses.
      • Sayasneh A.
      • Kaijser J.
      • Preisler J.
      • et al.
      A multicenter prospective external validation of the diagnostic performance of IOTA simple descriptors and rules to characterize ovarian masses.
      The addition of Doppler gives invaluable information about the location and degree of blood flow in and around pelvic lesions without the need to inject contrast.
      • Alcázar J.L.
      • Guerriero S.
      • Laparte C.
      • Ajossa S.
      • Jurado M.
      Contribution of power Doppler blood flow mapping to gray-scale ultrasound for predicting malignancy of adnexal masses in symptomatic and asymptomatic women.
      • Guerriero S.
      • Alcazar J.L.
      • Ajossa S.
      • et al.
      Transvaginal color Doppler imaging in the detection of ovarian cancer in a large study population.
      Not only is the characteristic grey-scale image of pelvic abnormalities key in making a diagnosis, but also 3D Doppler ultrasound imaging can evaluate the mapping and density of blood flow and even provide a quantitative measure of the amount of blood flow in a lesion. Cancers characteristically have abundant and disorganized blood flow patterns, whereas benign lesions have limited blood flow, and cysts lack blood flow altogether (Figure 8, Figure 9). Color Doppler mapping often furnishes the key to the evaluation of an adnexal mass and differentiates an endometrioma from an ovarian tumor or an ovarian fibroma. For example, the unique Doppler pattern of a hemorrhagic corpus luteum permits this definitive diagnosis as a cause of acute pelvic pain (Figure 9).
      • Parsons A.K.
      Imaging the human corpus luteum.
      Figure thumbnail gr8
      Figure 8Two-dimensional color blood flow Doppler view of a large ovarian cancer
      Note the extensive solid areas and abundant blood flow. Note that the vessels are irregular, beaded, and often confluent in the image, which is typical of neovascularity.
      Benacerraf. Consider ultrasound first for imaging the female pelvis. Am J Obstet Gynecol 2015.
      Figure thumbnail gr9
      Figure 9Two-dimensional color blood flow view of a hemorrhagic corpus luteum in a patient who had pelvic pain
      Although there are solid areas within the cyst, they do not contain blood flow consistent with clot. Note the “ring of fire” type of blood flow pattern that can be seen around the cyst, which is characteristic of a corpus luteum.
      Benacerraf. Consider ultrasound first for imaging the female pelvis. Am J Obstet Gynecol 2015.

      Comment

      Unfortunately, not every ultrasound imaging practitioner has achieved comfort with high-resolution 3D ultrasound imaging, tenderness-guided transvaginal imaging, and pelvic Doppler imaging. It is unfortunate that ultrasound users have such a wide range of experience, such that not everyone uses the modality to its full potential. Inexperience should not justify ordering an MRI or CT scan. Ultrasound technology has advanced very quickly, and many practitioners still provide basic 2D ultrasound imaging without implementing the newer modalities that ultrasound imaging offers, which emphasizes the need for education and dissemination of this information. In this era of cost concerns, it is very important to recognize that ultrasound technology now offers multiple applications such as 3D volume imaging (similar to CT and MRI), real-time evaluation of pelvic organs along the physical examination, and Doppler blood flow mapping (without contrast). Collectively, these applications make ultrasound imaging a unique imaging modality that ideally is suited to evaluate the female pelvis. Consistent use of ultrasound imaging first in women with pelvic symptoms, especially with the adjunct of 3D and Doppler if necessary, would likely render further imaging unnecessary and at the same time be cost-effective and safer.

      Supplementary data

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