Empowering OB/GYN Trainees Through Point-of-Care Ultrasound: Bridging Imaging and Clinical Care

Posted on December 9, 2025 by aium1952

Point-of-care ultrasound (POCUS) has rapidly become an essential advancement in modern clinical practice. By bringing real-time imaging directly to the bedside, POCUS allows the same clinician who examines the patient to also visualize anatomy, assess pathology, and immediately act on findings. This integration of imaging and decision-making has made POCUS indispensable across multiple specialties, and obstetrics and gynecology are no exception.

The American Institute of Ultrasound in Medicine (AIUM) has long recognized the importance of standardization and quality in ultrasound practice. Its Practice Parameter for the Performance of Point-of-Care Ultrasound¹ provides clear specifications for evaluating the abdomen, retroperitoneum, thorax, heart, and extremities for deep venous thrombosis. These guidelines form the foundation for ensuring that the benefits of POCUS—speed, accuracy, and accessibility—are balanced with safety and quality.

POCUS in Everyday OB/GYN Practice

Within obstetrics and gynecology, POCUS is a natural extension of bedside care. On labor and delivery units, it enables rapid assessment of fetal presentation, amniotic fluid, and placenta and fetal well-being through biophysical profiles. In emergency and postoperative settings, clinicians can use POCUS to quickly evaluate for intraperitoneal free fluid, aiding in the diagnosis of ruptured ectopic pregnancy or postoperative bleeding.

Evidence continues to support the diagnostic reliability of POCUS in OB/GYN. For instance, Boivin et al² evaluated its accuracy in diagnosing retained products of conception in 265 patients. They found that point-of-care ultrasound demonstrated a sensitivity of 79% and specificity of 93.8%, validating its value in streamlining diagnosis and guiding timely management.

Training Gaps and the Case for Structured Education

Despite its broad applicability, ultrasound training in OB/GYN residency and MFM fellowship remains highly variable. Currently, emergency medicine is the only specialty with formal requirements for ultrasound training and credentialing. This gap has led to inconsistent proficiency among new OB/GYN graduates, even though ultrasound is fundamental to the specialty.

A structured curriculum in POCUS can address this gap. Training should combine didactic instruction, hands-on scanning, and supervised image review, building both technical skills and diagnostic reasoning. Defining competency benchmarks and maintaining image portfolios reviewed by credentialed sonographers or MFM faculty can help standardize skill acquisition and ensure quality.

Expanding POCUS Applications in Obstetric Critical Care

POCUS offers unique advantages beyond fetal and gynecologic imaging, particularly in the management of acutely ill obstetric patients. In the setting of hypertensive disorders, sepsis, or peripartum cardiomyopathy, bedside ultrasound can provide immediate insights into maternal cardiopulmonary status.

Lung ultrasound helps identify pulmonary edema, distinguishing cardiac from non-cardiac causes of dyspnea.
Cardiac views allow assessment of contractility and pericardial effusion.
Inferior vena cava (IVC) measurements help estimate fluid status and guide resuscitation in acutely ill patients.

Learning Early, Learning Effectively

Training in ultrasound doesn’t have to wait until residency. Vyas et al³ demonstrated that even first-year medical students could perform a basic obstetric triage scan after only twelve hours of training. Students correctly identified fetal lie, placental location, amniotic fluid index, biparietal diameter, and head circumference in more than 90% of cases, showing that structured, feedback-driven instruction can produce reliable results even among novice learners.

Sustaining Competence Through Practice

Ultrasound is a skill that requires repetition, reflection, and review. A comprehensive program should integrate longitudinal opportunities for scanning, image storage, and expert feedback. Access to curated image archives can help trainees build pattern recognition and diagnostic confidence. Incorporating POCUS assessments into rotations, such as emergency triage, obstetric critical care, or ultrasound electives, reinforces learning through real-world application.

Conclusion

Point-of-care ultrasound represents both an art and a science, merging clinical intuition with immediate visual data. For OB/GYN residents and MFM fellows, POCUS is not simply a diagnostic adjunct but a core competency that enhances patient safety, efficiency, and confidence at the bedside.

By embedding structured POCUS training and competency assessment into OB/GYN education, we can ensure the safe and effective use of ultrasound in medicine. Doing so ensures that the next generation of clinicians will not only interpret images but truly see their patients more completely, more immediately, and more compassionately.

References

1. American Institute of Ultrasound in Medicine. AIUM Practice Parameter for the Performance of Point-of-Care Ultrasound Examinations. J Ultrasound Med 2021; 40(8):E34–E52. https://doi.org/10.1002/jum.14972

2. Boivin J, et al. Utility of Point-of-Care Ultrasound in the Diagnosis of Retained Products of Conception. J Obstet Gynaecol Can 2020; 42(4):440–446. https://doi.org/10.1016/j.jogc.2019.08.026

3. Vyas KS, et al. Point-of-Care Obstetric Ultrasound Training for First-Year Medical Students in Rural Settings. J Ultrasound Med 2018; 37(3):715–722. https://doi.org/10.1002/jum.14404

Ruchira Sharma, MBBS, MD, FACOG, is a Maternal-Fetal Medicine Specialist, Director of MFM Fellowship, and Director of the Obstetric Ultrasound and Antenatal Testing Unit at Rutgers Robert Wood Johnson Medical School.

Sara Buhmaid, MD, is a Maternal-Fetal Medicine Fellow at Rutgers Robert Wood Johnson Medical School.

Ruchira Sharma, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ. 10/25/2021 Photo by Steve Hockstein/HarvardStudio.com

Ovarian Cancer Awareness: Risk Factors and Screening Techniques

Posted on September 2, 2025 by aium1952

There’s nothing lighthearted about ovarian cancer.

Ovarian cancer is often referred to as a ‘silent killer’ because it is usually diagnosed at an advanced stage, when treatment is less likely to result in a complete cure and full recovery.

Why is a reproductive endocrinology and infertility (REI) specialist discussing ovarian cancer? While this disease most commonly affects postmenopausal women over the age of 60 who have completed childbearing, about 10% of cases occur in women under 45, during their reproductive years. This makes ovarian cancer a highly relevant concern within my field.

Although the exact causes of ovarian cancer remain unclear, in women of reproductive age, it is often linked to genetic mutations such as BRCA1, BRCA2, or Lynch syndrome. Other contributing factors may include conditions like endometriosis (particularly endometriomas, where endometrial tissue grows within the ovary), or a family history of ovarian, breast, or colorectal cancer, even in the absence of a confirmed genetic mutation.

There is a common misconception that fertility treatments cause ovarian cancer; however, this is not supported by evidence. It’s important to clarify that women undergoing fertility treatments often have underlying conditions such as endometriosis, which are independently associated with an increased risk of ovarian cancer. The link is one of association, not causation. In fact, ovarian cancer is occasionally first detected by reproductive endocrinology and infertility (REI) specialists during the course of evaluating or treating infertility.

If you have a strong family history of cancer, talk to your doctor about genetic counseling and start early surveillance.

So, how should we approach surveillance for ovarian cancer? Pelvic exams alone are limited in sensitivity and often cannot detect ovarian masses smaller than 5 cm, even in experienced hands. While serum markers such as CA-125, CA 19-9, CA 72-4, CA 15-3, HE4 (human epididymis protein 4), and CEA (carcinoembryonic antigen) are more specific to malignancy, they are not all specific to ovarian cancer and are typically only ordered after a mass has already been identified. These markers are not routinely used in serial testing for early detection.

In contrast, imaging, particularly transvaginal ultrasound with Doppler flow analysis, can detect even small ovarian abnormalities and raise early suspicion for malignancy. When performed regularly in reproductive-age women at risk, ultrasound may aid in detecting ovarian cancer in its earliest stages, when it remains confined to the ovary and before local or distant spread occurs.

Why, then, are physicians hesitant to adopt ultrasound for early ovarian cancer detection? First, from a financial standpoint, performing annual ultrasounds on all women of reproductive age is not cost-effective. Second, because ovarian cancer is relatively rare in this population, the low incidence reduces the test’s sensitivity and positive predictive value, ultimately limiting its effectiveness as a widespread screening tool.

Still, it is essential for physicians to recognize when an ovarian lesion displays features suggestive of malignancy. Two diagnostic tools have significantly advanced the role of ultrasound in evaluating ovarian conditions: the International Ovarian Tumor Analysis (IOTA) group, established in 1999, and the Ovarian-Adnexal Reporting and Data System (O-RADS), introduced in 2021. Both systems provide structured frameworks for assessing and scoring ultrasound characteristics of ovarian lesions, offering a more objective and standardized interpretation.

When an ultrasound-detected lesion raises suspicion for malignancy, further imaging, such as CT or MRI, can offer additional detail, help identify local or distant spread, and support initial staging to guide surgical planning.

As a reproductive endocrinologist, I feel a strong responsibility to support early detection during initial ultrasounds. Ongoing ultrasound surveillance empowers women to take an active role in advocating for their health.

September is Ovarian Cancer Awareness Month, but awareness should be year-round. Speak up about symptoms, intensify surveillance, support research, donate, or simply share this post, as every action counts.

Ovarian cancer may be elusive, but knowledge empowers, and imaging provides proof. Advocate for your health. Support the women in your life. Early detection saves lives, and awareness is the first step.

Laura Detti, MD, is a Professor of Obstetrics and Gynecology, the Division and Fellowship Director of Reproductive Endocrinology and Infertility at Baylor College of Medicine, and Chief of Reproductive Endocrinology Services at the Pavilion for Women at Texas Children’s Hospital. She is also a leader of the AIUM’s Gynecologic Ultrasound Community.

Portrait of Laura Detti, MD, a reproductive endocrinologist, wearing a white lab coat with badges from Baylor College of Medicine and Texas Children's Hospital.

Diagnosing and Mapping Endometriosis With Ultrasound

Posted on March 18, 2025 by aium1952

About four years ago, I felt like I had made a massive discovery akin to cracking cold fusion or inventing time travel. Although my revelation didn’t win me a Nobel Peace Prize, it forever changed the course of my medical training and gynecology practice. This discovery came through a podcast on Advanced Imaging for Endometriosis. Thus, my journey into the world of advanced gynecologic ultrasound (AGU) and endometriosis began.

My years of medical school and residency training had never included this kind of diagnostic capability for endometriosis. The axiom that surgery was how endometriosis was diagnosed was firmly established in my mind. Furthermore, I was astonished that ultrasound, something so ubiquitous in obstetrics and gynecology, was the way to achieve this paradigm shift. I remember sitting in my car listening to Dr. Mathew Leonardi talk about the possibility of not just diagnosing endometriosis before surgery but specifically mapping out where the disease was present. My mind was blown. In my new-found passion for endometriosis diagnosis, I took to the internet.

After a brief exchange on Twitter, Dr. Leonardi graciously agreed to let me shadow his practice for a week. Fortunately for me, Hamilton, Ontario, where Dr. Leonardi worked, was just a short drive and a (sometimes) quick border crossing from where I was completing a residency in Buffalo, New York, so I could witness these transformative ultrasound techniques firsthand. What I experienced that week was a game-changing way to care for patients. Patients with pelvic pain and suspected endometriosis could visit the clinic, undergo a comprehensive pelvic ultrasound, and receive an informed management plan. It wasn’t a model of “let’s see what we find” or broad counseling about options. Patients received immediate information about the scan findings and knew what to expect in the management plan. Furthermore, the therapeutic benefit here cannot be understated. Many patients would tear up feeling validated as their experiences were finally reflected in tangible scan results.

Of course, I was impressed by the patient experience side of AGU. What hooked me even further was the amazing amount of information that one could garner from these ultrasound techniques. Cul-de-sac obliteration, deep endometriosis of the bowel, ureteral strictures, uterosacral ligament lesions, ovarian mobility, and the list goes on. With the wealth of information accessible through ultrasound and my sights set on a surgical practice, I had to learn this transformative skill. A few years later, while in my minimally invasive gynecologic surgery fellowship, I was fortunate to be able to travel to McMaster University and complete a month-long elective with Dr. Leonardi to develop my AGU skills. While this experience greatly advanced my ultrasound capabilities, I believe that anyone interested in AGU does not necessarily need a dedicated month of intensive scanning to bring this skill into practice. The journey starts with a single scan.

Mathew Leonardi and Daniel Nassar smiling and standing in front of the sign for the Department of Obstetrics and Gynecology at McMaster University — Mathew Leonardi, MD, and Daniel T. Nassar, DO, MPH

If you’re interested in starting this journey, enhancing your scanning techniques, or polishing your skills at The Ultrasound Event 2025 conference, I encourage you to sign up for the hands-on training session co-chaired by Dr. Leonardi and me: The UltraSolution Experience: Mastering Next-Gen Endometriosis Ultrasound. In this session, we, along with other experts in AGU, will guide you through simulated endometriosis ultrasounds using the Intelligent Ultrasound ScanTrainer® platform to focus on assessments of findings including bowel and bladder endometriosis. I hope you are as excited to join as we are to share the transformative capabilities of advanced gynecologic ultrasound with you all!

Please feel free to ask any questions about the course or share your journey with gynecologic ultrasound.

I hope to see you at the conference,

Daniel Nassar, DO, MPH
Minimally Invasive Gynecologic Surgery
Dept. of Obstetrics & Gynecology

You Won’t Be Left in the Dark at UltraCon (except during the total eclipse!)

Posted on March 5, 2024 by aium1952

Have you considered how you will spend April 8 (well, April 6–10, 2024, actually)? The place to be on the 8^th is somewhere you can be in the path of totality during the total solar eclipse, and what better place to be than Austin, TX, where you can see the eclipse and get your fill of everything ultrasound?

(and probably the cheapest way to get a hotel room is to register for UltraCon 2024 and grab a room while we still have affordable rooms in our block).

The AIUM brings our annual meeting to Austin, TX, for the first time, and there will be lots to take in. We are bringing back Educational Tracks. No matter where your interests lie, MSK or Fetal Echo or General US or OB or GYN, there is a track for you! There is something for you, whether you are early in your career or an experienced sonographer/sonologist. You will hear presentations from experts that will keep you up to date on changes in the field and tell you what is coming down the pike. For our members who are deep into the basic sciences, some presentations will stimulate new thinking and show you what other colleagues are up to. One of the best parts of the program is that you aren’t stuck in one track—you can mix and match to customize your experience. Check out the tracks here.

UltraCon brings you more than just the educational tracks. Is there a product that you have always wanted to develop and commercialize? Perhaps an invention, a training program, or another idea you are sure could be monetized? If so, the AIUM’s Shark Tank is for you! Put together your best proposal and present it to our panel of experts from industry, venture capital, and academia. $1,000 is up for grabs, but win or lose, you will gain valuable insights and critical appraisal of your concept, along with suggestions for what you need to do to take your proposal to the next step.

Scientific sessions run throughout the meeting, allowing you to hear cutting-edge research that will help answer some of the questions you might be having or possibly give you ideas to pursue on your own. You will hear from young researchers just starting out their careers as well as experienced scientists who have gotten us where we are today but aren’t done leading us yet.

One of the best aspects of the annual meeting is the chance to hear from luminaries and others with cutting-edge ideas, whether in ultrasound directly or in fields that will impact ultrasound, such as artificial intelligence and other new technologies. This year’s plenary sessions will be captivating as we hear from Dr Omar Ishrak on the future of ultrasound technology and from Dr Gil Weinberg on an amazing application of ultrasound to offer amputees the opportunity to play musical instruments.

Other talks will cover how CPT codes are developed, how to efficiently complete your application for accreditation, and so much more that will round out your experience in Austin.

UltraCon 2024 promises to be a Top Shelf event that you really don’t want to miss—and yes, we have scheduled a break to go outside to see the eclipse, so you won’t be asked to decide between these 2 once-in-a-lifetime events! Note that our hotel block is probably the least expensive deal in town, as our rates were negotiated years ago before many were paying attention to this eclipse. It is entirely possible we will sell out our block of rooms, so make your plans and register as soon as possible!

David C. Jones, MD, FACOG, FAIUM, the AIUM’s President Elect, is a Professor at the University of Vermont and the Director of the Fetal Diagnostic Center at the University of Vermont Medical Center.

Ultrasound to Differentiate Benign From Malignant Ovarian Tumors—Are We There Yet?

Posted on August 8, 2023 by aium1952

Adnexal (ovarian) tumors present a complex problem. Ovarian cancer (Ovca) is the second most common gynecologic cancer in the United States with the highest mortality rate of all gynecologic cancer, 7^th among all cancers, and with a general survival rate of 50%.¹ Thus, missing Ovca when performing any kind of test (false negative) will have grave consequences but suspecting it when not present (false positive) can have almost as critical results with morbidity and mortality secondary to (unnecessary) intervention.

The purpose of this post is not to review the differential diagnosis of ovarian tumors nor to discuss chemical markers such as CA125 or cancer-specific signal found on cell-free DNA (cfDNA) but to concentrate on ultrasound. Some tumors are relatively easy to recognize because of defined ultrasound characteristics: corpus luteum with the classic “ring of fire” or endometrioma with the ground-glass appearance content, for instance (image 1a and b). Conversely, a large, multilocular lesion with solid components and profuse internal Doppler blood flow leaves little doubt about its malignant nature (image 2).

Image 1a: Corpus luteum with the classic
“ring of fire”.

Image 2: A large, multilocular lesion with solid components.

What are the ultrasound characteristics we look at?

Size: Unilocular cystic ovarian tumor < 10 cm in diameter or simple septated cystic ovarian tumor < 10 cm in diameter rarely, if ever, are neoplastic.²
Volume: Normal volume for premenopausal and postmenopausal ovaries are < 20 cm³ and 10 cm³, respectively.
Appearance: Risk of malignancy in simple, unilocular anechoic cyst, less than 5 cm is < 1% in premenopause and about 2.8% in postmenopause.³
Blood flow criteria: The rationale is that arteries formed by neovascularization in malignant tumors lack tunica media, resulting in lowered impedance (= less resistance to blood flow). Thus, resistance indices will be lower in cancer than in benign tumors. Malignancy was suspected with Doppler indices: pulsatility index (PI)<1 and/or resistive index (RI)<0.4.⁴ However, too much overlap makes reliance on only Doppler unjustified.

A very important point is that the expert performs very well when analyzing the ultrasound images of an ovarian mass, with a sensitivity of 92–98% and a specificity of 89%. The issue is how to help the non-expert decide whether he/she can continue the care of the patient or needs to refer her to a specialist. Based on several ultrasound criteria, scoring systems were implemented. The first one, in 1990, included appearance (unilocular, unilocular solid, multilocular, multilocular solid, or solid cyst) and presence of papillae (graded according to their number: 0 [none], 1 [one to five], or 2 [more than five]). This method had a sensitivity (true positive rate, or chance that person testing positive actually has Ovca) for malignancy of 82% with a specificity (true negative rate or chance that person with a negative test does not have Ovca) of 92%.5 Two important additional scoring systems were described later: the Morphology Index (MI) combining tumor volume, wall structure, and septal structure and the Risk of Malignancy Index (RMI), the product of ultrasound morphology score, CA 125 level, and menopausal status.⁶ Additional systems included the Logistic Regression 1 (LR1) and 2 (LR2). None of the published scoring systems were superior to image assessment by an expert, including in a meta-analysis of 47 articles, including over 19000 adnexal masses⁷ and, in reality, were not used widely in clinical practice.

The International Ovarian Tumor Analysis (IOTA) models

In 2000, a large group of European experts (gynecologists, radiologists, statisticians, biology, and computer experts) published a standardized terminology for the characterization of adnexal masses.⁸

The two important systems are the Simple Rules (SR) and the Assessment of Different NEoplasias in the adneXa (ADNEX) model. These were externally validated in numerous centers across the world but not in the USA.⁹ Recently, however, validation on the largest hitherto US population was published.¹⁰ This study showed for the first time that the models were effective in this population, regardless of menopausal status or race. These models are easy to learn and are geared towards non-experts.¹¹ It is important to note that the IOTA group was one of the first to incorporate acoustic shadow as a key feature, and the acoustic shadow has been shown to be an important sonographic feature to consider.¹²

Simple Rules: The IOTA Simple-Rules consist of 2 sets of 5 elements each: benign and malignant.¹³ Three simple rules are applied: if only benign characteristics are present, the mass is classified as benign. If only malignant features are present, the mass is considered malignant. If no features or both are, the findings are inconclusive. This model works well in about 80% of cases. The other 20% should be referred to an expert.
ADNEX model¹⁴: This is a multiclass prediction model to differentiate between benign and malignant tumors and allows automatic calculation of sub-classification of malignant tumors into borderline tumors, Stage I, and Stage II–IV primary cancers, and secondary metastatic tumors. “The advantage of this model is that it gives a personalized risk score for each patient, based on age, whether the patient is seen at an oncology center or not, maximal diameters of the lesion and the solid parts, number of cysts and papillary projections, whether acoustic shadows are present, whether ascites is present and CA125 value (if available, not mandatory for calculation). With a cut-off value for malignancy risk set at 10%, the ADNEX model (with CA125) had a sensitivity of 94.3%, with a specificity of 74%, positive predictive value of 76%, and negative predictive value of 93.6%.”¹⁴

The O-RADS model

In 2020, the American College of Radiology convened an international multidisciplinary committee that developed an ultrasound model based on an MRI model used in mammography (the BI-RADS atlas), the O-RADS model (the Ovarian-Adnexal Reporting and Data System) to facilitate differentiation between benign and malignant ovarian tumors.¹⁵ It relies on the sonographic nomenclature developed by the IOTA group, but it classifies tumors into 1 of 6 categories (O-RADS 0–5), from normal to high risk of malignancy. O-RADS also includes guidelines for the management of the findings. It should be noted that the O-RADS first model did not take into account the presence or absence of an acoustic shadow, although this has now been amended.

A description of the most recent common ultrasound scoring systems (SR, ADNEX, and O-RADS) is available in the Journal of Ultrasound in Medicine (JUM): Yoeli-Bik R, Lengyel E, Mills KA, Abramowicz JS. Ovarian masses: The value of acoustic shadowing on ultrasound examination. J Ultrasound Med 2023; 42:935–945.

References

https://www.cancer.org/cancer/types/ovarian-cancer/about/key-statistics.html
Saunders et al. Risk of malignancy in sonographically confirmed septated cystic ovarian tumors. Gynecol Oncol 2010; 118:278–282.
Valentin et al. Risk of malignancy in unilocular cysts: a study of 1148 adnexal masses classified as unilocular cysts at transvaginal ultrasound and review of the literature. Ultrasound Obstet Gynecol 2013; 41:80–89.
Bourne et al. Transvaginal colour flow imaging: a possible new screening technique for ovarian cancer. BMJ 1989; 299:1367–370.
Granberg S et al. Tumors in the lower pelvis as imaged by vaginal sonography. Gynecol Oncol 1990; 37: 224–229.
Yamamoto Y, Yamada R, Oguri H, Maeda N, Fukaya T. Comparison of four malignancy risk indices in the preoperative evaluation of patients with pelvic masses. Eur J Obstet Gynecol Reprod Biol 2009; 144:163–167.
Meys EM et al. Subjective assessment versus ultrasound models to diagnose ovarian cancer: A systematic review and meta-analysis. Eur J Cancer 2016; 58:17–29.
Timmerman D, Van Calster B, Testa A, et al. Predicting the risk of malignancy in adnexal masses based on the simple rules from the international ovarian tumor analysis group. Am J Obstet Gynecol 2016; 214:424–437.
Abramowicz JS, Timmerman D. Ovarian mass-differentiating benign from malignant: the value of the International Ovarian Tumor Analysis ultrasound rules. Am J Obstet Gynecol 2017; 217:652–660.
Yoeli-Bik R, Longman RE, Wroblewski K, Weigert M, Abramowicz JS, Lengyel E. Diagnostic performance of ultrasonography-based risk models in differentiating between benign and malignant ovarian tumors in a US cohort. JAMA Netw Open 2023; 6:e2323289.
Valentin L, Ameye L, Jurkovic D, et al. Which extrauterine pelvic masses are difficult to correctly classify as benign or malignant on the basis of ultrasound findings and is there a way of making a correct diagnosis? Ultrasound Obstet Gynecol 2006; 27:438–444.
Yoeli-Bik R, Lengyel E, Mills KA, Abramowicz JS. Ovarian masses: The value of acoustic shadowing on ultrasound examination. J Ultrasound Med 2023; 42:935–945.
Timmerman D, Testa AC, Bourne T, et al. Simple ultrasound-based rules for the diagnosis of ovarian cancer. Ultrasound Obstet Gynecol 2008; 31:681–90.
Van Calster B, et al. Evaluating the risk of ovarian cancer before surgery using the ADNEX model to differentiate between benign, borderline, early and advanced stage invasive, and secondary metastatic tumours: prospective multicentre diagnostic study. BMJ 2014; 349:g5920.
Andreotti RF, Timmerman D, Strachowski LM, et al. O-RADS US risk stratification and management system: a consensus guide-line from the ACR ovarian-adnexal reporting and data system committee. Radiology 2020; 294:168–185.

Appendix

Classification of primary ovarian tumors

Ovulatory: functional or corpus luteum cyst; theca lutein cyst; polycystic ovary
Infectious or inflammatory: tubo-ovarian abscess; hydrosalpinx
Benign: serous or mucinous cystadenoma; endometrioma; mature cystic teratoma (most common primary benign tumor of the ovary); paraovarian/paratubal cysts
Borderline: serous, mucinous
Malignant
Epithelial: high-grade serous carcinoma (HGSC; 70 to 80%); endometrioid carcinoma (10%); clear cell carcinomas (10%); mucinous carcinoma (3%); Low-grade serous carcinoma (LGSC; <5%); Brenner tumor; carcinosarcoma or malignant mixed müllerian tumor (MMMT); undifferentiated,
Germ cell (20%): teratoma: immature, specialized teratomas of the ovary (struma ovarii, carcinoid tumor); dysgerminoma; yolk sac tumor: endodermal sinus tumor; embryonal carcinoma; choriocarcinoma: <1% of ovarian tumors; malignant mixed germ cell tumor
Sex cord / stromal ovarian tumors (8–10%): fibrothecoma (fibroma, thecoma); Sertoli-Leydig cell tumor; granulosa cell tumor (juvenile or adult); small cell carcinoma

Jacques S. Abramowicz, MD, is a professor in the Department of Obstetrics and Gynecology at the University of Chicago.

Interested in learning more about gynecologic ultrasound? Check out the following posts from the Scan:

Mastering Ovarian Tumor Analysis: Join the AIUM-IOTA Partnership Course for Advanced Gynecologic Ultrasound

Posted on May 16, 2023 by aium1952

Ovarian lesions are a common finding among women, with etiologies ranging from ovarian changes related to normal hormonal function to aggressive malignancies. Therefore, the proper diagnosis and management of ovarian lesions are critical to women’s health. Here, I’ll give a brief description of ovarian tumor analysis, including descriptors, pattern recognition, and the application of the International Ovarian Tumor Analysis (IOTA) group’s Simple Rules, the IOTA ADNEX model, and O-RADS ultrasound characterization.

Descriptive Analysis of Ovarian Tumors

The first step in the diagnosis of ovarian tumors is descriptive analysis. This step involves a detailed examination of the tumor’s characteristics, including its size, shape, texture, and location. This information is obtained through various imaging techniques, such as ultrasound, MRI, and CT scans. The following descriptors are used in descriptive analysis:

Size: The size of the tumor is measured in centimeters and is one of the critical factors in determining the type of tumor.
Shape: The shape of the tumor is described as either round or irregular. An irregular shape is often associated with malignant tumors.
Texture: The texture of the tumor is classified as either solid, cystic, or mixed.
Location: The location of the tumor is described as either unilateral or bilateral. Unilateral tumors are located on one ovary, while bilateral tumors are located on both ovaries.

Pattern Recognition of Ovarian Tumors

An essential aspect of ovarian tumor analysis is pattern recognition. It involves identifying specific patterns associated with malignant and benign tumors. The following patterns are commonly observed in ovarian tumors:

Solid: Solid tumors are characterized by the absence of cystic components and are often associated with malignancy.
Cystic: Cystic tumors are characterized by the presence of fluid-filled spaces and are typically benign.
Mixed: Mixed tumors have both solid and cystic components and can be either benign or malignant.

Application of the Simple Rules, the IOTA ADNEX Model, and O-RADS Ultrasound Characterization

The Simple Rules, the IOTA ADNEX Model, and O-RADS ultrasound characterization are 3 widely used methods for differentiating ovarian tumors.

The Simple Rules: The Simple Rules are a set of guidelines that assist in the diagnosis of ovarian tumors. The rules are based on the tumor’s size, shape, texture, and location. According to the Simple Rules, a tumor is considered benign if it meets all 3 of the following criteria: 1) it is purely cystic, 2) it is less than 10 cm in size, and 3) it has a thin, smooth wall.
IOTA ADNEX Model: The IOTA ADNEX Model is a predictive model that uses a combination of clinical and ultrasound findings to diagnose ovarian tumors. The model considers the tumor’s size, shape, texture, location, and other factors, such as the patient’s age and menopausal status. Then, the model provides a probability score for each tumor, indicating the likelihood of malignancy.
O-RADS Ultrasound Characterization: O-RADS is a standardized ultrasound reporting system that categorizes ovarian tumors based on their likelihood of malignancy. The system uses a 5-point scale, ranging from 1 (very low risk) to 5 (very high risk). The O-RADS system considers the tumor’s size, shape, texture, location, and vascularity.

The proper diagnosis and management of ovarian lesions are critical to women’s health. Descriptive analysis, pattern recognition, and the application of the Simple Rules, the IOTA ADNEX Model, and O-RADS ultrasound characterization are essential aspects of ovarian tumor analysis. These methods aid in accurately diagnosing and differentiating ovarian tumors and can guide appropriate treatment decisions.

Are you a healthcare professional looking to enhance your skills in gynecologic ultrasound and ovarian tumor analysis? Look no further than the Advanced Gynecologic Ultrasound course offered by the American Institute of Ultrasound in Medicine (AIUM) in partnership with the International Ovarian Tumor Analysis (IOTA) group.

This course offers a unique and valuable opportunity for healthcare professionals looking to enhance their skills in gynecologic ultrasound and ovarian tumor analysis. The comprehensive curriculum, hands-on training, and networking opportunities make it a worthwhile investment for healthcare professionals looking to improve patient outcomes and advance their careers. Register now for the course, taking place this June, at the AIUM Headquarters in Laurel, Maryland.

Sources
https://www.cancer.org/cancer/types/ovarian-cancer/about/what-is-ovarian-cancer.html
https://acsjournals.onlinelibrary.wiley.com/doi/pdf/10.1002/cncr.11339
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5620878/
https://pubmed.ncbi.nlm.nih.gov/18504770/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4402441/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9728190/
https://www.mdpi.com/2075-4418/13/5/885

Arian Tyler, BS, is the Digital Media and Communications Coordinator for the American Institute of Ultrasound in Medicine (AIUM).

SLOW DOWN: Take Your Time in Diagnosing PCOS in Adolescents

Posted on June 14, 2022 by aium1952

Polycystic ovarian syndrome (PCOS) is the most common ovulation disorder among adult reproductive-age women. This blog post will discuss the latest recommendations, which state that we should wait about 8 years after menarche to make this diagnosis in adolescents!

PCOS is defined by the Rotterdam Criteria as 2 of the following: irregular menstrual cycles (or absent cycles), hirsutism (clinically as acne or male-patterned hair growth or elevated androgens), and polycystic-appearing ovaries on ultrasound, also known as PCO morphology. In addition, other disorders that may look like PCOS need to be ruled out (thyroid disease, hyperprolactinemia, adrenal disorders). The two main areas where patients or providers have difficulty are how cycle lengths are determined and PCO morphology.

In gynecology and infertility, we see a number of women with irregular menstrual cycles. Irregular menstrual cycles are defined as cycles occurring more frequently than every 21 days or less frequently than every 35 days from the beginning of one cycle to the beginning of the next cycle (cycle day 1 to cycle day 1). Some patients get confused and count from the last day of bleeding to the first day of the next period, which artificially makes the cycle seem short. It is good to keep a menstrual calendar (a regular calendar where each day of bleeding is marked with an “X” and review it over a couple of months). It is easy to count the number of days from the beginning of one menstrual cycle to the beginning of the next when counting from the first “X” of one cycle to the first “X” of the next.

One manner of identifying polycystic ovaries is by the volume: If one or both ovaries has a volume of more than 10 cm³ then that meets the criteria for a polycystic ovary on ultrasound.

The other method of identification is counting and measuring follicles. Counting antral follicles, which are follicles that measure as less than 10 mm in diameter, in a polycystic-appearing ovary can be difficult. First, check to see if there are any cysts in the ovary (any large, space-occupying mass greater than 10 mm). If cysts larger than 10 mm are present, then the antral follicle counts and the ovarian volumes will be distorted. Typically, it is easiest to measure the antral follicles and ovarian volume in the early follicular phase, or cycle days 1–5 (where cycle day 1 is the first day of the menstrual period). In this early part of the menstrual cycle, there should not be a dominant follicle growing yet so the ovary commonly has only small antral follicles at this time in the cycle.

Originally, polycystic-appearing ovaries were described as having antral follicles lined up in the periphery of the ovary or a “pearl necklace” sign. In PCOS, the stroma of the ovary produces the androgens, and patients with PCOS tend to have a greater stromal area. However, the Rotterdam criteria did not use these descriptions in defining a polycystic-appearing ovary. Instead, the Rotterdam criteria state a volume or an antral follicle count when there are no cysts. The antral follicle count was initially described in the Rotterdam criteria as either ovary with more than 12 follicles (2–9 mm).

Unfortunately, with this number, a number of adolescents were being misdiagnosed with PCOS. Why would that be?

There are two reasons: one, when girls have menarche, the hypothalamic pituitary ovary axis is not mature and they will have irregular cycles—sometimes this irregularity lasts a couple of years. So, many adolescents were noted to have met the “irregular cycles” criterion. Second, adolescents have an excellent ovarian reserve. They should have a lot of antral follicles because they have a lot of eggs in the early part of their reproductive years. These ovaries are sometimes referred to as multi-follicular ovaries. This is a normal finding.

Consequently, the international guideline, which has been adopted by the ESHRE (European Society of Human Reproduction and Embryology) and the ASRM (American Society of Reproductive Medicine) has concluded that the number of follicles needed to meet the PCO-appearing criteria should be 20 or more antral follicles (2–9 mm) in either ovary and others recommend 25 or more antral follicles.

They all accept that an ovary larger than 10 mL would meet the criterion. In addition, they have stated that we should NOT make the diagnosis of PCOS in adolescents within 8 years of their menarche because the reproductive axis is not mature early after menarche. Others have recommended NOT using the ultrasound criteria as an independent marker in diagnosing adolescents.

In other words, adolescents will need to have evidence of hirsutism and anovulation to meet the criteria of PCOS. The general consensus is that we do not want to inappropriately place a label of PCOS on these young women. PCOS has a lot of medical sequelae such as infertility, increased risk for insulin resistance, metabolic syndrome, diabetes, hypertension, and many others that could unnecessarily worry the young women.

Take home message: Be SLOW to diagnose PCOS in Adolescents!

References:

Teede HJ, Misso ML, Costello MF, Dokras A, Laven J, Moran L, Piltonen T, Norman RJ and International PCOS Network. Recommendations form the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Hum Reprod 2018; 1–17. Doi:10.1093/humrep/dey256

Al Wattar BH, Fisher M, Bevington L, Talaulikar V, Davies M, Conway G, Yasmin E. Clinical practice guidelines on the diagnosis and management of polycystic ovary syndrome: a systematic review and quality assessment study. J Clin Endocrinol Metab 2021; 106(8):2436–2446.

Dumesic DA, Oberfield SE, Stener-Victorin E, Marshall JC, Laven JS, Legro RS. Scientific statement on the diagnostic criteria, epidemiology and pathophysiology, and molecular genetic of polycystic ovary syndrome. Endocrine Reviews 2015; 36(5):487–525. https://doi.org/10.1210/er.2015-2018

https://www.endocrine.org/advancing-research/scientific-statements/polycystic-ovary-syndrome

Elizabeth E. Puscheck, MD, MS, MBA, FACOG, FAIUM, is a board-certified Reproductive Endocrinologist practicing with InVia Ferility and a tenured Professor at Wayne State University School of Medicine.

O-RADS: Standardizing the way we assess adnexal lesions (and an app to make it easy!)

Posted on May 3, 2022 by aium1952

“When a word has many meanings, it has no meaning at all”. (Anonymous)

Let’s face it: ovarian lesions seen on ultrasound can be some of the most challenging to assess and describe. When not a simple cyst, generic terms such as “complex” are commonly used providing limited insight to the provider and patient regarding the level of concern for risk of malignancy. For instance, shown here are 3 different lesions that could all be described as “complex” or “heterogeneous”, yet range from nonneoplastic to malignant.

Compound the ambiguity of nonspecific descriptors in the imaging report with the angst of possibly missing an ovarian cancer, a rare but deadly disease, and the result is “over treatment”. Too often, surgery or additional imaging are performed for physiologic and benign findings with the added unintended consequences of associated morbidity and patient anxiety.

Enter O-RADS, an acronym for the Ovarian/Adnexal Reporting and Data System.

Similar to other American College of Radiology (ACR) “RADS” systems (ie, BI-RADS for breast imaging), O-RADS gets everyone speaking the same language AND provides a risk of malignancy using a numeric scale of 0 to 5 (Table 1).

Table 1. Risk of malignancy (ROM) associated with O-RADS Risk Stratification and Scoring System for US and MRI. (NOTE: US systems allow for greater sensitivity at the expense of specificity to avoid not missing a cancer.)

In O-RADS, there are two arms: 1) ultrasound (US), the primary imaging modality for the adnexa used by practitioners from many disciplines; and 2) magnetic resonance imaging (MRI), considered a problem-solving tool for radiologists. With O-RADS ultrasound, management guidance is also provided on triaging lesions to follow-up (clinical or imaging surveillance), additional characterization (by a specialist in US or with an MRI exam), or surgery. For the latter group, this is further divided into those lesions that can be excised by a general gynecologist, and those best managed by a gynecologic-oncologist, an important factor in improving long-term survival in the setting of ovarian malignancy.

Using the available descriptors in the O-RADS lexicon and an algorithmic approach, characterizing adnexal lesions is simplified. First, determine whether a finding in a menstruating patient meets criteria for a physiologic finding (follicle or corpus luteum). If it does not, or the patient is postmenopausal, assess for a “classic benign lesion”, a phrase coined for fairly common lesions that are almost certainly benign when typical features are seen (hemorrhagic cyst, endometrioma, dermoid cyst, paraovarian cyst, hydrosalpinx or peritoneal inclusion cyst). The remainder of lesions are assigned to 1 of 5 categories based on their solid or cystic appearance, and if cystic, the presence of septations and solid components as follows: solid lesion, unilocular cystic ± solid component(s), multilocular cystic ± solid component(s). Subsequently, features such as degree of internal vascularity, lesion size, ascites, and peritoneal nodules may come into play.

To score a lesion, color-coded O-RADS risk stratification tables are readily available and a useful resource. I personally find the O-RADS smartphone app to be an efficient and handy tool to quickly obtain a score and management recommendations. On average, I can reach a score in under 30 seconds and all the information I need for the imaging report is literally at my fingertips.

Since we started using O-RADS, our referring clinicians are asking for an O-RADS score whenever we describe an adnexal lesion as it gives them so much more useful information to counsel their patients. For instance, the patient in figure 1 with a hemorrhagic cyst did not require any imaging follow-up, the patient in figure 2 with a dermoid cyst has safely elected to undergo US surveillance in 1 year, and the patient in figure 3 with endometrioid cancer is doing well under the care of her gynecologic-oncologist.

For me, replacing vague terms (with many meanings) with standardized reporting systems not only makes sense, it’s truly meaningful.

Additional resources:

Strachowski, LM, et al. O-RADS for ultrasound: a user’s guide, from the AJR special series on radiology reporting and data systems. Am J Roentgenology 2021; 216:1150–1165.
Andreotti, RF, Timmerman, D, Strachowski, LM, et al. O-RADS US risk stratification and management system: a consensus guideline from the ACR Ovarian-Adnexal Reporting and Data System Committee. Radiology 2020; 294:168–185.
On-demand webinar available on the AIUM Online Learning Center: New Approaches to Adnexal Mass Evaluation in North America: The Use of IOTA and O-RADS Systems

Dr. Lori Strachowski is a Clinical Professor of Radiology at the University of California, San Francisco, where she holds an adjunct title in the department of Obstetrics, Gynecology and Reproductive Sciences. She is a member of the ACR O-RADS committee serving on the steering committee and chairs the education committee for O-RADS US.

Ultrasound-Guided Obstetric and Gynecologic Procedures in the Pelvis

Posted on March 22, 2022 by aium1952

Ultrasound guidance can be a safe and effective technique in obstetric and gynecologic procedures. Before beginning such a procedure, consider which approach will you take, transabdominal, transgluteal, or transvaginal. The approach that uses the shortest distance to the area of interest without transversing other structures is usually the best tolerated by the patient and will rarely result in complications, which are uncommon and usually minor, such as pain or self-limited bleeding. To select the shortest and safest path for access, review prior cross-sectional imaging and determine it on a case-by-case basis.

In cases of fluid management, such as benign adnexal cyst or peritoneal inclusion cyst fluid collection, note that you may need a larger needle gauge (18+) in those instances in which the fluid is thick. If you intend to test for malignancy, also take into account that fluid is generally less likely than solid tissue to give up the cells needed for a diagnosis.

Fine-needle aspiration in a case with mixed cyst and solid mass.

Ultrasound guidance can also enable delivery of vascular acting medications directly where it is needed, as well as to guide direct gestation sac injection of potassium chloride (KCl) and/or methotrexate for cervical, interstitial, or C-section ectopic or heterotopic pregnancies in appropriate patients.

In conclusion, transvaginal or percutaneous ultrasound guidance can be used in the search for a diagnosis, in fluid collections, and to treat obstetric and gynecologic pathology, such as delivering medications to treat ectopic pregnancy or vascular conditions in select cases.

To learn more about this topic and see examples of its use, watch the full on-demand webinar, “Ultrasound-Guided Interventions to Treat Obstetric and Gynecologic Disease” presented by Tara A. Morgan, MD. Members of the American Institute of Ultrasound in Medicine can access it for free. Join today!

Read more from Tara A. Morgan, MD, on ultrasound guidance in the Journal of Ultrasound in Medicine:

Clear Reporting About Adnexal Torsion

Posted on October 6, 2020 by aium1952

The Challenge: “Can you please rule out torsion?” is a common request ED teams have of their radiologists and gynecologists. Unfortunately, a straightforward answer to this question is rare. The diagnosis of adnexal torsion is full of uncertainty and to make matters worse, we humans are terrible at communicating uncertainty.

Indeed, there are pathognomonic sonographic findings of torsion– whirlpool sign and/or absent flow in the setting of an enlarged, edematous ovary. But certainty is rare. Thus, many reports hedge that “torsion cannot be ruled out.”

We acknowledge that the radiologist interpreting the images is not at fault for this uncertainty. The issue is that the tool itself is imperfect. Ultrasound, as a test, is great at “ruling things in,” but quite mediocre at “ruling things out.” And torsion, as we know, is a surgical diagnosis. However, going to the OR means subjecting a patient to the potential risks of surgical complications, “tying up” healthcare resources, and is expensive.

The Crux: Most imaging is helpful to “rule in,” NOT “rule out” a diagnosis. The complexity and uncertainty of pelvic ultrasonography in the evaluation of women with acute pelvic pain in and of itself is challenging. On top of that, how do we best communicate the uncertainty of NOT seeing something – like looking for a black cat in a dark room — is it even there?

The language we use in ultrasound reports can further complicate the situation. This is especially true when images are interpreted out of context, and a broad differential diagnosis offered. There are incidental findings in asymptomatic patients that warrant further evaluation in the outpatient setting, and there are others that require emergent evaluation in the correct clinical context. A cyst or mass may be an incidentaloma. Torsion is not.

The verbiage used in reports carries significant weight in clinical decision-making and management. When humans read “cannot rule out xyz,” they usually interpret this (for better or worse) as “xyz should be ruled out.” And so, we would love to start a conversation about the linguistics of report-writing for female pelvic ultrasonography.

Cases: Here are a couple of clinical scenarios that illustrate our concern:

A 14-year-old female patient presents to the ED with right upper abdominal and flank pain. Her ultrasound was performed to evaluate the kidneys (area where pain was originating from), however, it also demonstrated an enlarged right ovary (4.9 cm in largest dimension). The report reads “intermittent torsion cannot be excluded.” We agree; it in fact cannot. However, now intermittent torsion MUST be excluded, and we are consulted.

The patient’s lower abdominal examination is benign. Our suspicion for torsion is exceedingly low. However, ultrasound cannot rule out torsion, only surgery can rule out torsion. Now this teenager has been given an additional, unrelated stressor (“your ovary can die”) that was unlikely to ever have significant medical repercussions. To top it off, the report recommends a follow-up scan at 8–12 weeks for what appears to be a physiologic hemorrhagic corpus luteum — an additional expense and time taken from the patient and her family to follow-up.

Final Diagnosis: Pyelonephritis

A 43-year-old female patient scheduled for hysterectomy later in the month presents to the ED with persistent left lower quadrant pain that has been present for several weeks. She has a long-standing history of fibroids and was diagnosed with a 5-cm anechoic left ovarian cyst 2 months ago. Ultrasonography re-demonstrates a leiomyomatous uterus and the left ovary was not visualized.

The report reads “torsion of the left adnexa could not be excluded.” Agreed, it in fact cannot. However, the reason why it cannot be excluded is not that the ovary was not visualized. Additionally, torsion could not be excluded because ultrasound is NOT a test to exclude torsion.

On examination, there was focal tenderness and point-of-care ultrasonography confirmed its location over a pedunculated fibroid (likely degenerating). An overnight, unscheduled diagnostic laparoscopy, in this case, would’ve resulted in a reassuring adnexal evaluation and possible myomectomy, not the procedure the patient truly needed (a laparoscopic hysterectomy).

Final Diagnosis: Degenerating fibroid (noted on hysterectomy later that week)

Why now?

Prior to COVID-19, healthcare overutilization and defensive medicine were problematic. Now, with limited resources and increased demand, the burden is even higher. ER providers, gynecologists, and radiologists must work in tandem to:

prioritize imaging studies when relevant,
report in clear, objective language in the context of the clinical scenario, and
prioritize emergency and inpatient consultations.

Why does this matter?

Most imaging is helpful to “rule in,” not “rule out” a diagnosis. Language and semantics may significantly affect management, especially in the context of less experienced providers. For patients, it may mean the difference between an unscheduled abdominal surgery or observation. In our prior commentary (1) we referenced the language used by our obstetrics colleagues wherein they acknowledge the limitations of the imaging modality and thus, we suggest the following modification to the current style of reporting:

“Ultrasound is not intended to rule out ovarian torsion.”

We understand that this suggestion, for some, is a change of established practice patterns and we would love to hear your thoughts. Please leave comments below or tweet at @StethoscopeOn and @Dmitry_Fridman to continue the conversation!

Reference

Meljen V, Fridman D. Gynecologist’s Perspective: Semantics of “Ruling Out” Ovarian Torsion. J Ultrasound Med 2020; 39:1013. Available at: https://onlinelibrary.wiley.com/doi/10.1002/jum.15175.

Vivienne Meljen, MD, is a resident, and Dmitry Fridman, MD, PhD, is an Assistant Professor of Obstetrics and Gynecology, in the Department of Obstetrics and Gynecology at Duke University Health System in Durham, North Carolina, USA.