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The NCI notes that a serious potential harm is the false-positive test result, which may lead to anxiety and invasive diagnostic procedures.

The NCI states that there is good evidence that screening for ovarian cancer with TV-US would result in more diagnostic laparoscopies and laparotomies than new ovarian cancers found. Unnecessary oophorectomies may also result. Use of the Doppler mode, however, is not medically necessary for this indication.

Specifically, it is unknown whether the diagnostic abilities of TV-DUS are sufficient to confidently identify those patients who can forego surgery and be followed conservatively. Furthermore, the diagnostic abilities of TV-DUS are probably different among pre- and post-menopausal patients due to the differing prevalence of malignancy between these 2 groups.

Fields and Chevlen stated that currently available tests CA, TV-US, or a combination of both lack the sensitivity and specificity to be useful for screening ovarian cancer in the general population. Lacey and colleagues examined the positive predictive values of CA or TV-US screening for ovarian cancer according to family history of breast or ovarian cancer. In the screening arm of a randomized controlled trial of screening compared with usual care, a total of 28, women with family history data received baseline and annual CA and TV-US examinations.

Cancers were identified by active follow-up of women with abnormal screening results and annual questionnaires. These researchers calculated positive predictive values for screening combinations. Similar proportions 4. Higher-risk women were more likely than lower-risk women to undergo biopsy after a positive screen. Screening identified 43 invasive ovarian cancers. The positive predictive values for abnormal screening results were 0.

The positive predictive values for post-baseline abnormal screening results were also higher in the higher-risk groups. The positive-predictive values did not significantly differ across risk groups. The authors concluded that the probabilities of abnormal annual CA and TV-US screens were similar across groups based on family history of breast or ovarian cancer.

However, ovarian cancer was more likely to be diagnosed after an abnormal screening result among women at higher family history-based risk than among women at lower risk. Until the results of these studies are available, the findings of this analysis demonstrated that stratifying women into risk groups based on family history slightly enhanced the positive predictive values of a combined CA and TV-US-based screening approach.

These researchers stated that whether these differences prove to be efficacious, cost-effective, or clinically useful in screened populations awaits the results of the PLCO and other cancer screening studies. The Gynecologic Cancer Foundation, the Society of Gynecologic Oncologists, and the American Cancer Society have issued a consensus statement to promote early detection of ovarian cancer, which recommends that women who have symptoms specifically bloating, pelvic or abdominal pain, difficulty eating or feeling full quickly, and urinary frequency and urgency are urged to see a gynecologist if symptoms are new and persist for more than 3 weeks ACS, ; SGO, The consensus statement recommendations are based on studies that show the above symptoms appeared in women with ovarian cancer more than in other women Goff et al, ; Daly and Ozols, The recommendations acknowledge that there is not consensus on what physicians should do when patients present with these symptoms.

According to a consensus statement issued by the Gynecologic Cancer Foundation, patients should be evaluated with pelvic and rectal examinations. If there is a suspicion of cancer, the clinician may chose to perform a TV-US to check the ovaries for signs of cancer. Testing for CA levels should also be considered. Jokubkiene et al examined if tumor vascularity as assessed by 3-dimensional 3D power Doppler ultrasound can be used to discriminate between benign and malignant ovarian tumors, if adding 3D power Doppler ultrasound to gray-scale imaging improves differentiation between benignity and malignancy, and if 3D power Doppler ultrasound adds more to gray-scale ultrasound than does 2-dimensional 2D power Doppler ultrasound.

A total of women scheduled for surgery because of an ovarian mass were examined with transvaginal gray-scale ultrasound as well as 2D and 3D power Doppler ultrasound.

The color content of the tumor scan was rated subjectively by the ultrasound examiner on a visual analog scale. Vascularization index VI , flow index FI and vascularization flow index VFI were calculated in the whole tumor and in a 5-cm 3 sample taken from the most vascularized area of the tumor. Logistic regression analysis was used to build models to predict malignancy.

There were 79 benign tumors, 6 borderline tumors and 21 invasive malignancies. A logistic regression model including only gray-scale ultrasound variables the size of the largest solid component, wall irregularity, and lesion size was built to predict malignancy.

It had an area under the receiver-operating characteristics ROC curve of 0. The diagnostic performance of the 3D flow index with the best diagnostic performance, i. Adding the color content of the tumor scan or FI in a 5-cm 3 sample to the logistic regression model including the 3 gray-scale variables described above improved diagnostic performance only marginally, an additional 2 tumors being correctly classified.

The authors concluded that even though 2D and 3D power Doppler ultrasound can be used to discriminate between benign and malignant ovarian tumors, their use adds little to a correct diagnosis of malignancy in an ordinary population of ovarian tumors.

Objective quantitation of the color content of the tumor scan using 3D power Doppler ultrasound does not seem to add more to gray-scale imaging than does subjective quantitation by the ultrasound examiner using 2D power Doppler ultrasound. Data from the first 4 annual screens, denoted T0-T3, were reported. Diagnostic follow-up of positive screens was performed at the discretion of participants' physicians.

Diagnostic procedures and cancers were tracked and verified through medical records. Among 34, screening arm women without prior oophorectomy, compliance with screening ranged from Screen positivity rates declined slightly with TV-US, from 4. A total of 89 invasive ovarian or peritoneal cancers were diagnosed; 60 were screen-detected. The positive-predictive value PPV and cancer yield per 10, women screened on the combination of tests were similar across screening rounds range of 1.

The overall ratio of surgeries to screen-detected cancers was The authors concluded that through 4 screening rounds, the ratio of surgeries to screen-detected cancers was high, and most cases were late stage. However, the effect of screening on mortality is as yet unknown. All women provided a blood sample at recruitment. Women with abnormal screens had repeat tests. Women with persistent abnormality on repeat screens underwent clinical evaluation and, where appropriate, surgery.

In the prevalence screen, 50, Overall, 4, of 50, 8. A total of 97 of 50, 0. The sensitivity, specificity, and PPV for all primary ovarian and tubal cancers were For primary invasive epithelial ovarian and tubal cancers, the sensitivity, specificity, and PPV were This in part reflects the high prevalence of benign adnexal abnormalities and the more frequent detection of borderline tumors in the USS group. The prevalence screen has established that the screening strategies are feasible.

The results of ongoing screening are awaited so that the effect of screening on mortality can be determined. The specificity of transvaginal ultrasound is low. The low prevalence of ovarian cancer means that even screening tests that have very high sensitivity and specificity have a low positive predictive value for disease detection".

Buhling and colleagues systematically analyzed the effect of TV-US in an asymptomatic female population as an annual screening procedure with regard to mortality data. Studies were evaluated descriptively on their strengths and weaknesses considering the methods and results.

Currently, no clear recommendation for the screening for ovarian cancer in an asymptomatic population can be given based on these 3 studies. The authors could not show a change in mortality using TV-US for annual screening. The authors concluded that an annual palpation does not offer a beneficial effect.

The development of new ultrasound machines with higher image resolution in combination with a well-standardized algorithm for ovarian cancer in upcoming years might provide an improvement regarding mortality. The current studies do not show a benefit in screening an asymptomatic population annually with TV-US, but the most recent publication showed a trend toward lower mortality in patients who underwent screening after 7 to 14 years of follow-up.

Nevertheless, all 3 heterogeneous RCTs had weaknesses in their methods and therefore they neither contradict the general recommendation for screening in an asymptomatic population nor do they support it. Montgomery et al noted that endometrial hyperplasia is a precursor to the most common gynecological cancer diagnosed in women: endometrial cancer of endometrioid histology.

It is most often diagnosed in post-menopausal women, but women at any age with unopposed estrogen from any source are at an increased risk for developing endometrial hyperplasia. Hyperplasia with cytological atypia represents the greatest risk for progression to endometrial carcinoma and the presence of concomitant carcinoma in women with endometrial hyperplasia. Abnormal uterine bleeding is the most common presenting symptom of endometrial hyperplasia.

Specific Pap smear findings and endometrial thickness per ultrasound could also suggest the diagnosis. Epstein and Valentin stated that a measurement of endometrial thickness is a simple and accurate method for estimating the risk of endometrial cancer.

In addressing whether TV-US should be performed at annual examination in asymptomatic women, Cohen stated that there is little evidence that death rates from either endometrial or ovarian cancer would improve with this approach.

If TV-US is to be used in screening asymptomatic women, it should be as part of a controlled study and at no cost to the patient. This is in agreement with Robertson who stated that routine screening for endometrial carcinoma is currently not justified. Post-menopausal women need to be educated about the importance of seeking attention if any vaginal bleeding occurs.

All post-menopausal bleeding requires review and appropriate investigation. Women taking tamoxifen have a higher risk of endometrial cancer and should report any bleeding or spotting; however, ultrasound screening is not recommended for asymptomatic women taking tamoxifen. Families with hereditary non-polyposis colon cancer have a higher risk of endometrial cancer and require counseling about this risk. A Pap test is not a screening test for endometrial cancer, but the incidental finding of endometrial cells on a Pap smear in a post-menopausal woman requires investigation.

The National Cancer Institute NCI, has stated that there is insufficient evidence to establish whether a decrease in mortality from endometrial cancer occurs with screening by TV-US. The NCI notes that risks associated with false-positive test results include anxiety and additional diagnostic testing and surgery.

In addition, endometrial cancers may be missed by ultrasound. Lynch syndrome also known as hereditary non-polyposis colorectal cancer syndrome , an autosomal-dominant inherited cancer susceptibility syndrome caused by a germline mutation in one of the DNA mismatch repair genes, accounts for the majority of inherited cases.

Lynch syndrome is associated with early onset of cancer and the development of multiple cancer types, especially colon and endometrial cancer.

These researchers reviewed the current status of knowledge regarding Lynch syndrome-associated endometrial cancer and methods for diagnosis, screening, and prevention of cancers. No current evidence suggests either a survival advantage or disadvantage to endometrial cancer that is associated with Lynch syndrome when these cases are compared with sporadic cases.

A combination of family and personal medical history and tumor testing provides an efficient basis for diagnosing Lynch syndrome in women with endometrial cancer. Current gynecologic cancer screening guidelines for women with Lynch syndrome include annual endometrial sampling and TV-US beginning at age 30 to 35 years.

The authors concluded that diagnosing endometrial cancer patients with Lynch syndrome has important clinical implications for the individual and family members.

Screening and prevention practices can decrease the likelihood of developing additional cancers. Sharma and Menon noted that the role of screening in gynecological cancers is being studied. With mass screening proven effective in significantly lowering cervical cancer mortality, there is an intense interest in developing other screening methods to detect gynecological cancers early.

These researchers reviewed advances in cervical cancer screening, strategies being investigated in ovarian cancer screening and the lack of justification in screening for endometrial, vaginal and vulvar cancers.

A Medline-based literature search was performed for studies relating to screening for different gynecological malignancies. Additional papers cited in those identified by the initial search were also reviewed. Advances in cervical cancer screening include liquid-based cytology and human papillomavirus testing. Results of ongoing trials are awaited before these can be fully implemented. The results of the 2 large, multi-center, randomized controlled trials being conducted in the United Kingdom and United States UKCTOCS and PLCO study, respectively to evaluate the impact of screening on ovarian cancer mortality will shed some light on the need to implement screening for ovarian cancer in the general population.

Novel markers, serum proteomic profiles and Doppler ultrasonography are some of the other technologies being examined. Presently, screening for endometrial cancer is not advocated since most women present with symptoms in early disease exhibit good survival outcomes. Vaginal and vulval cancers are too rare to justify mass screening. The authors concluded that methods to screen for various gynecological malignancies need further evaluation before implementation in the general population; results of large multi-center trials are awaited.

They stated that currently, screening for endometrial, vaginal and vulval cancers is not justified. The ACOG's Committee Opinion on the role of TV-US in the evaluation of women with post-menopausal bleeding stated that the clinical approach to post-menopausal bleeding requires prompt and efficient evaluation to exclude or diagnose carcinoma.

Women with post-menopausal bleeding may be evaluated initially with either endometrial biopsy or TV-US; this initial evaluation does not require performance of both tests. Transvaginal ultrasonography can be useful in the triage of patients in whom endometrial sampling was performed but tissue was insufficient for diagnosis.

When TV-US is performed for patients with post-menopausal bleeding and an endometrial thickness of less than or equal to 4 mm is found, endometrial sampling is not required. Meaningful assessment of the endometrium by ultrasonography is not possible in all patients. In such cases, alternative assessment should be completed. When bleeding persists despite negative initial evaluations, additional assessment usually is indicated.

In a prospective comparative study, de Kroon and colleagues evaluated the accuracy of clinical evaluation of intra-uterine device IUD position. The clinical evaluation was compared with the TV-US measurement of IUD position both immediately after insertion and 6 weeks after insertion. A total of women were included consecutively, women The prevalence of an abnormally positioned IUD was 7. The prevalence of abnormal position was 4. The authors concluded that clinical evaluation is an excellent test for the evaluation of the position of an IUD and routine TV-US is not indicated for this purpose.

Bazot et al compared the accuracy of TV-US and rectal endoscopic sonography RES for the diagnosis of deep infiltrating endometriosis DIE , with respect to surgical and histological findings. The diagnostic criteria were identical for TV-US and RES, and were based on visualization of hypoechoic areas in specific locations utero-sacral ligaments, vagina, recto-vaginal septum and intestine.

Endometriomas and DIE were present in For the diagnosis of utero-sacral endometriosis, they had a sensitivity of For the diagnosis of intestinal endometriosis, they had a sensitivity of Several lines of recent evidence strongly suggests that the use of TV-US also has an important role in detecting DIE of the pelvis not only involving the ovaries but also structures such as the vagina, the recto-vaginal space, the utero-sacral ligaments, the bladder or the rectal wall.

Hudelist et al analyzed the diagnostic value of TV-US for non-invasive, pre-surgical detection of bowel endometriosis. Likelihood ratios LRs were re-calculated in addition to traditional measures of effectiveness. Out of papers, a total of 10 studies fulfilled pre-defined inclusion criteria involving 1, patients with suspected endometriosis. The prevalence of bowel endometriosis varied from 24 to Three of the studies used bowel preparations to enhance the visibility of the rectal wall; 1 study directly compared the use of water contrast versus no prior bowel enema, for which the LR- was 0.

The authors concluded that TV-US with or without the use of prior bowel preparation is an accurate test for non-invasive, pre-surgical detection of DIE of the rectosigmoid. Egekvist and colleagues evaluated the inter-observer variation of transvaginal ultrasonographic measurements of the size of DIE lesions in the recto-sigmoid wall performed by an experienced and a less experienced sonographer. Fifteen outpatient women were seen for a gynecologic examination and 24 women were seen with recto-sigmoid endometriosis.

Transvaginal ultrasonography was performed independently by 2 observers with a focus on the presence and size of recto-sigmoid endometriosis. The senior observer had several years of experience, whereas the junior observer was a medical student with no prior experience in TV-US. The findings of the 2 observers were identical concerning the identification of recto-sigmoid endometriosis.

The authors concluded that these findings suggested that fair skills in this technique can be acquired by inexperienced examiners within a short period of time. This diagnostic accuracy study was conducted during a 2-year period including a total number of patients with signs and symptoms of endometriosis.

The criterion standard was considered to be the laparoscopy and histopathologic examination. Of patients being included in the present study, tested positive for DIE. These variables were MRI had the highest accuracy On the contrary, specificity had a reverse trend, favoring MRI Participants included women undergoing laparoscopic surgery and scheduled for segmental resection for clinically suspected bowel endometriosis.

In all women clinically suspected for bowel endometriosis, an US scan was performed before surgery to detect and measure the 3 diameters of bowel endometriotic lesions. These diameters were compared with those obtained by direct measurement on the fresh specimen. Mean diameters of endometriotic nodules calculated by US evaluation and by direct measurement on fresh specimen were The authors concluded that US can be considered an accurate diagnostic technique for the evaluation of deep infiltrating bowel endometriosis when performed by a dedicated experienced sonographer in the setting of a specialized center.

Guerriero and colleagues carried out a systematic review of studies comparing the accuracy of TV-US and MRI in diagnosing deep infiltrating endometriosis DIE including only studies in which patients underwent both techniques.

Studies were considered eligible for inclusion if they reported on the use of TV-US and MRI in the same set of patients for the pre-operative detection of endometriosis in pelvic locations in women with clinical suspicion of DIE and using surgical data as a reference standard.

Confidence intervals of pooled sensitivities, specificities and DOR were wide for both techniques in all the locations considered. Deslandes and colleagues stated that endometriosis is a common gynecologic condition affecting as many as 1 per 10 women; TVUS has become a frontline tool in the diagnosis of DIE before surgery. They also determined the accuracy specifically when a sonographer performed the TVUS examination.

A systematic review was performed, searching literature by following a population, intervention, comparator, and outcome outline. Including "sonographer" in the search terms yielded no results, so the terms were expanded. A total of articles were returned from the searches, 35 were ultimately included in the final review. Sensitivities ranged from Most authors reported site-specific sensitivities and specificities, which varied greatly between locations. The authors concluded that TVUS is an accurate tool in the diagnosis of DIE; however, limited data exist as to whether this technique is accurate when performed by sonographers.

The Society of Obstetricians and Gynaecologists of Canada stated that routine transvaginal cervical length assessment was not indicated in women at low-risk Lim et al, However, this recommendation is based on low- quality evidence. In a Cochrane review, Berghella et al evaluated the effectiveness of antenatal management based on transvaginal ultrasound of cervical length TVU CL screening for preventing preterm birth PTB.

These investigators searched the Cochrane Pregnancy and Childbirth Group's Trials Register August 31, , reviewed the reference lists of all articles and contacted experts in the field for additional and ongoing trials.

All potential studies identified from the search were independently assessed for inclusion by 3 review authors. They also analyzed studies for quality measures and extracted data.

Delivery occurred at a later gestational age in the knowledge versus no knowledge groups mean difference MD 0. For all other outcomes for which there were available data PTB at less than 34 or 28 weeks; birth-weight less than 2, grams; perinatal death; maternal hospitalization; tocolysis; and steroids for fetal lung maturity , there was no evidence of a difference between groups.

The authors concluded that currently, there is insufficient evidence to recommend routine screening of asymptomatic or symptomatic pregnant women with TVU CL. Since there is a non-significant association between knowledge of TVU CL results and a lower incidence of PTB at less than 37 weeks in symptomatic women, the authors encouraged further research. Future studies should look at specific populations separately e. Most importantly, they stated that future studies should include a clear protocol for management of women based on TVU CL results, so that it can be easily evaluated and replicated.

In an observational, prospective study, Kuusela and colleagues evaluated cervical length in asymptomatic women with singleton pregnancies in the second trimester by means of TV-US, and examined the relation between cervical length and spontaneous preterm delivery. A total of 2, asymptomatic women with live singleton pregnancies without fetal anomalies were included in this study. Cervical length was measured at between 16 and 23 weeks of gestation by means of TV-US; data were analyzed using logistic regression analysis.

Main outcome measure were cervical length in relation to spontaneous preterm delivery less than 34 weeks primary outcome and less than 37 weeks of gestation secondary outcome. Eleven women had a cervical length of less than or equal to 25 mm 0. There was a significant association between cervical length and spontaneous preterm delivery at less than 34 weeks odds ratio [OR] 1. The authors concluded that the rate of short cervical length of less than or equal to 25 mm was lower than expected.

The study confirmed the increased risk of spontaneous preterm delivery in women with a short cervix, although the analysis was based on only a few cases. They stated that in Sweden, a larger study is needed to evaluate the prevalence of short cervical length and the possible association with preterm delivery before universal screening can be recommended. In a systematic review and meta-analysis, Conde-Agudelo and Romero examined the accuracy of changes in transvaginal sonographic cervical length over time in predicting preterm birth in women with singleton and twin gestations.

Data sources included PubMed, Embase, Cinahl, Lilacs, and Medion all from inception to June 30, , bibliographies, Google scholar, and conference proceedings. Cohort or cross-sectional studies reporting on the predictive accuracy for preterm birth of changes in cervical length over time were selected for analysis.

Two reviewers independently selected studies, assessed the risk of bias, and extracted the data. Summary receiver-operating characteristic curves, pooled sensitivities and specificities, and summary likelihood ratios were generated.

A total of 14 studies met the inclusion criteria, of which 7 provided data on singleton gestations 3, women and 8 on twin gestations 1, women. In the largest and highest-quality study, a single measurement of cervical length obtained at 24 or 28 weeks of gestation was significantly more predictive of preterm birth than any decrease in cervical length between these gestational ages. The authors concluded that change in transvaginal sonographic cervical length over time is not a clinically useful test to predict preterm birth in women with singleton or twin gestations.

A single cervical length measurement obtained between 18 and 24 weeks of gestation appeared to be a better test to predict preterm birth than changes in cervical length over time. Those who complete the lectures and who pass the examination and image review receive documents verifying that they have completed the CLEAR program.

In a prospective, observational, multi-center study, Kuusela and colleagues examined the diagnostic performance of sonographic cervical length for the prediction of PTB. A total of 11, asymptomatic women with a singleton pregnancy were included in this trial. The authors concluded that 2nd-trimester sonographic cervical length could identify women at high-risk of sPTB. Moreover, these researchers noted that in a population of mainly white women with a low prevalence of sPTB, its diagnostic performance was at best moderate.

The authors stated that this study had several drawbacks. First, the study populations included a slightly higher proportion of women at increased risk of sPTB than the control populations, and that sPTB was slightly more common in this study populations than in the control populations.

On the other hand, it was likely that women who perceived themselves at increased risk were those who were the most likely to accept cervical length screening, should such screening be implemented. Third, these researchers chose PTB at less than 33 weeks of gestation as the primary outcome, as opposed to sPTB at less than 33 weeks of gestation, because classifying a delivery as spontaneous or indicated may be difficult.

The secondary outcomes were more clinically relevant because sPTB is potentially detectable with cervical length screening and is potentially preventable. Teixeira et al summarized the current evidence on the effect of using US guidance during embryo transfer ET.

In this systematic review, these investigators included RCTs examining the effect of the use of US guidance during ET; data from studies using the same catheter type in study arms were not pooled with the results from studies that used different catheter types. A total of 21 studies were included in the quantitative analysis: 18 compared "US guidance" with "clinical touch", of which 1 was subsequently excluded from the quantitative meta-analysis owing to a lack of available data; 3 studies compared TVU guidance with trans-abdominal US guidance; and 1 study compared "hysterosonometry before ET" with US guidance.

Comparison of the use of US guidance with clinical touch, in studies that used the same catheter type in the study arms, indicated a benefit of using US guidance during ET on the rates of live-birth RR, 1. However, when comparing the use of US guidance with clinical touch in studies that used different catheter types, the results suggest that using US guidance during ET has no effect on the rates of reproductive outcome: live-birth RR, 0.

The estimates for the rate of miscarriage and for the other identified comparisons were imprecise. The authors concluded that the available evidence suggested that there is a benefit of using US guidance during ET. However, both US-guided transfer and clinical touch should be considered acceptable, as the benefit of US is not large and should be balanced against the increased cost and need to change the catheter type.

They stated that more studies are needed before conclusions can be drawn regarding the effect of other techniques on reproductive outcome. Ruiter and colleagues stated that vasa previa is an obstetric complication in which the fetal blood vessels lie outside the chorionic plate in close proximity to the internal cervical os. In women with vasa previa, the risk of rupture of these vessels is increased, thus potentially causing fetal death or serious morbidity. These investigators evaluated the accuracy of ultrasound in the prenatal diagnosis of vasa previa.

Two reviewers independently selected studies on the accuracy of ultrasound in the diagnosis of vasa previa. Data on sensitivity and specificity were subsequently extracted. The literature search revealed articles, of which 2 prospective and 6 retrospective cohort studies were eligible for inclusion in the qualitative analysis. All studies documented methods suitable for the prenatal diagnosis of vasa previa; 4 out of the 8 studies used TV-US for primary evaluation, while the remaining four studies used trans-abdominal US and performed a subsequent TV-US when vasa previa was suspected.

The authors concluded that the accuracy of US in the diagnosis of vasa previa is high when performed trans-vaginally in combination with color Doppler. An UpToDate review on "Velamentous umbilical cord insertion and vasa previa" Lockwood and Russo-Stieglitz, states that "Prenatal diagnosis of vasa previa is based on identification of membranous fetal vessels passing across or in close proximity to the internal cervical os by real-time transvaginal ultrasound examination with color Doppler.

Close proximity has been defined as within 2 cm of the internal os; however, only limited data are available to support this specific measurement. In a retrospective analysis, Kubesova and associates examined the effectiveness of TV-US in the detection of ectopic pregnancy EP. These researchers evaluated the history, laboratory and US findings in a group of patients who had undergone a surgical procedure due to a positive diagnose or suspicion of EP.

In all cases the diagnose of EP was histologically confirmed. Histological examination confirmed A negative US finding was observed in In a prospective study, Yadav and co-workers examined if endometrial patterns and thickness could be used for the prediction of EP.

This study was carried out in a center in India between October and December It included women with an early pregnancy confirmed by urine pregnancy testing but for whom an intra-uterine gestational sac was not visualized on TV-US. The women were divided into an EP group and an intra-uterine pregnancy IUP group depending on the final diagnosis. The endometrial pattern and endometrial thickness were determined by TV-US.

Sensitivity and receiver operating characteristic curve analyses were performed to determine the predictive value. An endometrial thickness of less than 9. The authors concluded that evaluation of endometrial thickness and pattern by TV-US helps to identify women with a pregnancy of unknown location for close supervision.

Young and colleagues noted that accurate diagnosis of EP is essential in reducing maternal mortality and morbidity; and TV-US is the accepted imaging modality of choice for the diagnosis of EP. These investigators evaluated the effectiveness of TV-US in the detection of EP in consecutive women presenting for ultrasound to a radiology department with a clinical suspicion of EP.

Retrospective analysis of women presenting for TV-US over a 2. Women were classified as having a confirmed EP on the basis of surgery and histology. Women with a suspected EP who were treated medically or expectantly were also included.

A total of 87 women had a confirmed EP and 29 women had a suspected EP. The sensitivity and specificity of ultrasound for the detection of confirmed EP was The authors concluded that TV-US in the radiology setting of a tertiary hospital has excellent diagnostic performance for the detection of EP.

An UpToDate review on "Ectopic pregnancy: Clinical manifestations and diagnosis" Tulandi, states that "TVUS is the most useful imaging test for determining the location of a pregnancy. TVUS should be performed at time of presentation with a suspected ectopic pregnancy and may need to be repeated, depending upon the hCG level or a suspicion of rupture.

The ultrasound should be performed by a clinician with expertise in gynecologic ultrasound and with the evaluation of ectopic pregnancy, whenever possible The diagnosis of ectopic pregnancy is a clinical diagnosis made based upon serial hCG testing and TVUS".

In a systematic reviews of diagnosis and treatment effectiveness of pelvic vein incompetence PVI and chronic pelvic pain CPP in women, Champaneria and associates stated that "Transvaginal ultrasound with Doppler and magnetic resonance venography are both useful screening methods, although the data on accuracy are limited The data supporting the diagnosis and treatment of PCS are limited and of variable methodological quality.

There is some evidence to tentatively support a causative association, but it cannot be categorically stated that PVI is the cause of CPP in women with no other pathology The question of the association of PVI and CPP requires a well-designed and well-powered case-control study, which will also provide data to derive a diagnostic standard". Steenbeek and colleagues noted that in the work-up of patients with suspected pelvic congestion syndrome PCS , venography is currently the gold standard.

Yet if non-invasive diagnostic tools are found to be accurate, invasive venography might no longer be indicated as necessary. In a systematic review, these investigators evaluated non-invasive diagnostic tools for PCS. They performed a literature search in PubMed and Embase from inception until May 6, Studies comparing non-invasive diagnostic tools to a reference standard in the work-up of patients with suspected PCS were included.

A total of 9 studies matched the inclusion criteria; 6 studies compared US to venography and 3 studies described a MRI technique. The authors concluded that the sensitivity of US and MRI appeared to be adequate, which indicated a role for both tests in an early stage of the diagnostic work-up. Moreover, they stated that due to methodological flaws and diversity in outcome parameters, more high standard research is needed to establish a clear advice for clinical practice.

Furthermore, an UpToDate review on "Vulvovaginal varicosities and pelvic congestion syndrome" Johnson, states that "Imaging PCS Ultrasound may not detect venous changes in affected women because imaging is generally performed with the patient in the supine position when the veins are flaccid.

Sensitivity is higher if the study is performed with the patient in the upright position or by asking her to Valsalva. Despite these maneuvers, there is still a poor correlation between ultrasound findings and venography for the presence or absence of pelvic varices The diagnosis of PCS is based on a combination of characteristic symptoms, tenderness on physical examination, and documentation of pelvic vein dilatation or incompetence, after exclusion of other causes for these non-specific findings.

Diagnostic laparoscopy is generally utilized to exclude other causes of chronic pelvic pain". Toshev et al noted that endometriosis is a common gynecological disease that is characterized by the presence of endometrial glands and stroma outside the uterus.

Ectopic endometrial tissue can be localized in all organs of the human body, but it affects most often organs in the pelvis.

The localization in the inguinal canal is extremely rare -- 0. These investigators reported 2 cases of inguinal endometriosis in patients with a history of previous surgery in the pelvis. Both patients exhibited formation in the inguinal region of increasing volume, accompanied by severe pain especially in the pre-menstrual period.

The diagnosis was based on an exact medical history and histological examination. The key method of treatment of inguinal endometriosis is radical surgical excision of the lesion. The authors recommended hormone therapy as an adjunctive treatment. Longras et al reported on the case of a year-old woman who presented with right inguinal swelling with 1 year of evolution; MRI was suggestive of inguinal endometriosis adherent to femoral vessels.

The authors stated that due to the rarity of this pathology prevalence of 0. Andres et al carried out a systematic review of the literature on patients with extra-pelvic deep endometriosis. Studies in the past 20 years that reported on primary extra-pelvic endometriosis were included. The initial search identified 5, articles, and articles, mostly case reports and series, were included. A total of parietal PE , 43 visceral VE , thoracic TE , 6 central nerve system CNS , 12 extra-pelvic muscle or nerve, and 1 nasal endometriosis articles were identified.

Abdominal endometriosis was divided into PE and VE. PE lesions involved primary lesions of the abdominal wall, groin, and perineum. Patients with TE presented with the triad of catamenial pain, pneumothorax, and hemoptysis. Pre-operative MRI was performed in all cases of non-thoracic and non-abdominal endometriosis.

Common symptoms were paresthesia and cyclic pain with radiation. The authors concluded that extra-pelvic endometriosis, traditionally thought to be rare, has been reported in a considerable number of cases.

Heightened awareness and clinical suspicion of the disease and a multi-disciplinary approach are recommended to achieve a prompt diagnosis and optimize patient outcomes.

Currently, there are no comparative studies to provide recommendations regarding optimal diagnostic methods, therapeutic options, and outcomes for endometriosis involving extra-pelvic sites. Li et al described the characteristics, diagnosis and surgical treatment of inguinal endometriosis IEM. Relevant features, symptoms, images, surgical treatment, hormonal therapy and follow-up were collected and discussed.

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