Clinical Opinion ajog.

org

GYNECOLOGY
Consider ultrasound first for imaging the female pelvis
Beryl R. Benacerraf, MD; Alfred Z. Abuhamad, MD; Bryann Bromley, MD; Steven R. Goldstein, MD;
Yvette Groszmann, MD, MPH; Thomas D. Shipp, MD; Ilan E. Timor-Tritsch, MD

yield indeterminate and confusing

Ultrasound technology has evolved dramatically in recent years and now includes ap- ndings that then require clarication
plications such as 3-dimensional volume imaging, real-time evaluation of pelvic organs by ultrasound imaging. The use of CT
(simultaneous with the physical examination), and Doppler blood flow mapping without scans has tripled since 1993, and CT
the need for contrast, which makes ultrasound imaging unique for imaging the female scans done in 2007 could result in as
pelvis. Among the many cross-sectional imaging techniques, we should use the most many as 29,000 future cancers in the
informative, less invasive, and less expensive modality to avoid radiation when possible. United States, with the largest contri-
Hence, ultrasound imaging should be the first imaging modality used in women with bution to this risk arising from the CT
pelvic symptoms. of the pelvis and abdomen.6,7 For
example, patients with suspected kidney
Key words: female pelvis, tenderness guided imaging, 3D ultrasound imaging stones frequently have a CT scan rst,
despite the associated radiation burden.
A recent study compared initial evalua-
tion of patients with nephrolithiasis
by ultrasound imaging or by CT.4
E ver-present concerns regarding
escalating health care costs and the
appropriate use of medical technology
evidence shows that ultrasound imaging
is at least equally, if not more, effective
for the target anatomic area.1 This tenet
This analysis showed no signicant
differences in subsequent complications,
demand careful choices regarding rst- applies particularly to obstetric and gy- pain scores, return emergency visits, or
line medical diagnostic tests to serve necologic patients for whom a skillfully hospitalizations. In addition, most of
our patients and society best. We should performed and well-interpreted ultra- the patients who were evaluated rst
favor the most informative, least inva- sound image usually obviates the need by ultrasound imaging ultimately did
sive, and less expensive technology to proceed to additional more costly not need a CT scan, sparing radiation
among the multitude of available cross- and complex cross-sectional imaging exposure.
sectional imaging modalities and mini- techniques.1-3 This clinical opinion presents the
mize radiation when possible. Yet still today, many women with current capabilities of ultrasound
In this regard, the American Institute pelvic pain, masses, or ank pain rst imaging as the rst-line imaging
of Ultrasound in Medicine (AIUM.org) undergo computed tomography (CT) technique for the nonpregnant female
launched an initiative in 2012 Ultra- scans and those with Mllerian duct pelvis for most clinical scenarios.
sound First, which advocates the use anomalies typically have magnetic reso- Ultrasound imaging has evolved very
of ultrasound examinations before nance images (MRIs).1-5 Not uncom- rapidly from the early days of black
other imaging modalities when the monly, CT or MRI of the pelvis often 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 ow
From Harvard Medical School (Drs Benacerraf, Bromley, Groszmann, and Shipp); the Department
of Obstetrics and Gynecology (Drs Benacerraf, Bromley, Groszmann, and Shipp), the Department of mapping. The advent of the high-
Radiology (Drs Benacerraf, Bromley, and Shipp), Brigham and Womens Hospital; the Department resolution endocavitary probes and
of Obstetrics and Gynecology, Massachusetts General Hospital (Drs Benacerraf and Bromley), the use of color Doppler imaging for
Boston, MA; the Diagnostic Ultrasound Associates, Brookline, MA (Drs Benacerraf, Bromley, blood ow mapping have further
Groszmann, and Shipp); Eastern Virginia Medical School, Norfolk, VA (Dr Abuhamad); the
enhanced the diagnostic capabilities
Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine (Drs Goldstein and
Timor-Tritsch) and Department of Obstetrics and Gynecology, New York University School of
of this imaging modality. Several
Medicine, New York, NY. key technical advances have rend-
Received Dec. 2, 2014; accepted Feb. 18, 2015. ered ultrasound imaging an effective
Dr Goldstein has a Philips ultrasound machine on loan. The other authors report no conicts.
rst-line (and often only) imaging
modality for most gynecologic pati-
Corresponding author: Beryl Benacerraf, MD. dua.ultrasound@gmail.com
ents: (1) volume (3D/4-dimensional)
0002-9378/$36.00  2015 Elsevier Inc. All rights reserved.  http://dx.doi.org/10.1016/j.ajog.2015.02.015
imaging, (2) real-time transvaginal
Click Supplemental Materials under the article title in the online Table of Contents ultrasound imaging with sonographi-
cally enhanced physical examination,

450 American Journal of Obstetrics & Gynecology APRIL 2015

ajog.org Gynecology Clinical Opinion
and (3) Doppler techniques for blood
ow evaluation. FIGURE 1
Complete septate uterus using 3D volume imaging
3D ultrasound imaging
Currently available 3D/4-dimensional
volume ultrasound imaging can pro-
duce images of the female pelvis of
comparable quality and orientation to
those of MRI and CT but without ra-
diation and at relatively lower cost.8-11
Years ago, ultrasound examinations
required lling a womans 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 ul-
trasound 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 ultra-
sound imaging as it does MRI, and
many patients nd this modality more
comfortable than MRI. In contrast to
MRI, patients with metal prostheses
and pacemakers can undergo 3D ultra-
sound imaging that will yield similar
images. Since the advent of volume im-
aging in ultrasound imaging, recon-
structed views of the pelvis (such as
the coronal view of the uterus) have
greatly improved our ability to use ul-
trasound imaging to answer the vast
majority of clinical questions in
gynecology.1,10,11
Three-dimensional volume sonogra-
phy has now become an essential new
tool in the ultrasound armamentarium
that has proved just as effective as A, Three-dimensional ultrasound image shows the reconstructed coronal view of a septate
MRI for the demonstration of Mllerian uterus. Note the complete separation of the endometrial echo but with an intact flat serosal surface.
duct anomalies, which include cervical B, Three-dimensional reconstructed view of the double cervix in the same patient. C, Three-
duplications (Figure 1).8-11 Three- dimensional ultrasound image shows the 3 orthogonal planes and the reconstructed view of
dimensional ultrasound imaging, like the cervix. These images show how the different planes are accessed within the volume.
MRI, can produce an image of the uter- Benacerraf. Consider ultrasound rst for imaging the female pelvis. Am J Obstet Gynecol 2015.
ine contour and the entire endometrial
cavity simultaneously. Furthermore,
3D ultrasound imaging provides the
ability to manipulate the volumes in
any orientation for complete evaluation with other imaging modalities and with Mllerian anomalies.3,8-10 Indeed, the
of the uterus, regardless of its orien- operative ndings, hence establishing accuracy of both 3D ultrasound im-
tation or rotation. Multiple studies the equivalency of 3D ultrasound imag- aging and MRI for the diagnosis
have compared 3D ultrasound imaging ing to MRI in diagnostic accuracy of of the specic type and extent of

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Clinical Opinion Gynecology ajog.org

hydrosalpinges with high precision, as

FIGURE 2 well as other uterine abnormalities
Malpositioned IUDs seen using the coronal view reconstructed from a (Figures 3-6). We must educate the
3D volume medical community to consider adopt-
ing 3D ultrasound imaging as the rst
assessment tool for specic gynecologic
indications, such as the evaluation of the
uterus for Mllerian anomalies or local-
ization 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 ultra-
sound images were performed rst.

The real-time transvaginal

ultrasound imaging
The advent of the transvaginal trans-
ducer is one of the most important in-
A, Three-dimensional reconstructed coronal view of uterus that contains a Paragard (Teva novations in pelvic imaging in recent
Womens Health, Inc, North Wales, PA) intrauterine device (IUD). The IUD is in the lower uterine decades. This advance allows the oper-
segment with the right arm partly embedded in the myometrium. B, Three-dimensional ator to place a high-frequency endoca-
reconstructed coronal view of another uterus that contains a Mirena (Bayer HealthCare, vitary ultrasound transducer in close
Whippany, NJ) IUD. Note that the uterine cavity is too small to accommodate the open IUD so proximity to target pelvic organs, thus
that the left arm is embedded partly in the myometrium. improving image resolution and obvi-
Benacerraf. Consider ultrasound rst for imaging the female pelvis. Am J Obstet Gynecol 2015. ating the need for patients to have a full
bladder before ultrasound examina-
tions.16 Ultrasound imaging has the
added advantage of real-time imaging,
uterine malformations typically ex- pelvic pain associated with embedded
which allows for the probing of pelvic
ceeds 90-95%.1,10 Three-dimensional intrauterine devices, broid tumors,
organs to elicit patients symptoms and
ultrasound imaging has emerged as the adenomyosis, adnexal masses, torsion,
thus correlate symptoms with specic
ideal imaging modality not only endometriosis (Figures 2-5).11-15 Ultra-
pelvic anatomic locations. The practi-
when examining patients with infertility sound volume imaging makes it possible
tioner therefore can gain crucial infor-
but also for examining patients with to localize broid tumors, polyps, and
mation about the degree and area of
pain and mobility of organs in the
pelvis and correlate the ultrasound
FIGURE 3 ndings with the physical examina-
Submucosal fibroid seen using 2D and 3D ultrasound tion.17-19 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 ultra-
sound imaging has become the most
effective way of the detection of im-
plants of painful deep-penetrating en-
dometriosis throughout the pelvis.17-19
Ultrasound imaging has proved to be
accurate for the evaluation of deep
inltrating endometriosis and for pa-
A, Two-dimensional longitudinal view of the uterus that contains a central fibroid tumor (calipers). tients with pain because of extensive
B, The 3-dimensional coronal view shows that the fibroid tumor is partly submucosal in the left pelvic adhesions (Figure 7).20,21 Not only
cornual region, hence mapping the location of the fibroid tumor precisely. can we identify abnormalities on the
Benacerraf. Consider ultrasound rst for imaging the female pelvis. Am J Obstet Gynecol 2015. images, but also simultaneous gentle
pushing can show whether organs slide

452 American Journal of Obstetrics & Gynecology APRIL 2015

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FIGURE 4
Adenomyosis demonstrated by 2D and 3D ultrasound imaging
A, Two-dimensional longitudinal view of the uterus with extensive adenomyosis. Note the hetero-
geneity 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 rst for imaging the female pelvis. Am J Obstet Gynecol 2015.
past each other, thus providing crucial
information about the origin of a mass
(adnexal mass vs broad ligament
FIGURE 5
Coronal 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 rst for imaging the female
pelvis. Am J Obstet Gynecol 2015.
Gynecology Clinical Opinion
the clinician can evaluate the endo-
metrium for polyps, submucosal b-
roid tumors, synechiae, and uterine
shape when necessary.22 Adjunctive
to sonohysterography, the installation
of microbubbles is useful for the de-
termination of tubal patency and is
critical to those patients with contrast
allergies.23
3D Doppler interrogation
To characterize pelvic masses, ultra-
sound imaging offers the advantage of
combining morphologic and vascular
imaging.24-26 The addition of Doppler
gives invaluable information about the
location and degree of blood ow in
and around pelvic lesions without the
need to inject contrast.27,28 Not only is
the characteristic grey-scale image of
pelvic abnormalities key in making a
diagnosis, but also 3D Doppler ultra-
sound imaging can evaluate the mapping
broid tumor) and the connections and density of blood ow and even
and adhesions between the organs. Real- provide a quantitative measure of the
time ultrasound imaging also permits amount of blood ow in a lesion. Can-
the performance of sonohysterography, cers characteristically have abundant
a procedure that involves placement and disorganized blood ow patterns,
of a small catheter through the cervix whereas benign lesions have limited
into the uterus and the injection of a blood ow, and cysts lack blood ow
small amount of saline solution.22 altogether (Figures 8 and 9). Color
By distending the endometrial cavity, Doppler mapping often furnishes the
FIGURE 6
2D 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 demon-
strates 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 rst for imaging the female pelvis. Am J Obstet Gynecol 2015.
APRIL 2015 American Journal of Obstetrics & Gynecology 453
Clinical Opinion Gynecology ajog.org

FIGURE 7 FIGURE 8
Deep infiltrating endometriosis of the bowel and cul de sac Two-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 rst for imaging the female
pelvis. Am J Obstet Gynecol 2015.

blood ow 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 ul-
trasound imaging rst in women with
pelvic symptoms, especially with the
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 FIGURE 9
same area, with the use of the tomographic technique that generates multiple slices parallel to Two-dimensional color blood
each other, similar to the computed tomography and magnetic resonance imaging displays. flow view of a hemorrhagic
Benacerraf. Consider ultrasound rst for imaging the female pelvis. Am J Obstet Gynecol 2015.
corpus luteum in a patient who
had pelvic pain

key to the evaluation of an adnexal
mass and differentiates an endome-
trioma from an ovarian tumor or an
ovarian broma. For example, the
unique Doppler pattern of a hemor-
rhagic corpus luteum permits this
denitive diagnosis as a cause of acute
pelvic pain (Figure 9).29
Comment
Unfortunately, not every ultrasound
imaging practitioner has achieved com-
fort 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 imag-
ing without implementing the newer
modalities that ultrasound imaging
offers, which emphasizes the need for
education and dissemination of this in-
Although there are solid areas within the cyst,
formation. In this era of cost concerns,
they do not contain blood flow consistent with
it is very important to recognize that
clot. Note the ring of fire type of blood flow
ultrasound technology now offers mul-
pattern that can be seen around the cyst, which
tiple applications such as 3D volume
is characteristic of a corpus luteum.
imaging (similar to CT and MRI), real-
Benacerraf. Consider ultrasound rst for imaging the female
time evaluation of pelvic organs along pelvis. Am J Obstet Gynecol 2015.
the physical examination, and Doppler

454 American Journal of Obstetrics & Gynecology APRIL 2015

ajog.org
adjunct of 3D and Doppler if necessary,
would likely render further imaging
unnecessary and at the same time be
cost-effective and safer. - J Ultrasound Med 2008;27:413-23.
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