Gynecologic Ultrasound has refined Diagnosis of masses

05/01/2013

An article appeared in yesterday’s NY Times Science section about the lack of benefit and even potential harm of the routine bimanual pelvic examination in gynecology. It is so inaccurate and one sided that I have sent a letter to the Times which I have reproduced for you. (I am not optimistic that they will choose to run it.) This is such important information you may want to share it with friends, colleagues and family…

All reporters and most readers appreciate there are two sides to every story. So usually if I disagree with some of a given story I accept a divergence of opinion. But some of the misstatements and glaring inaccuracies of “An Exam with Poor Results” by Jane Brody (4/30/13) mandate a response.

I can agree that a blindly performed bimanual pelvic examination is extremely crude and may yield limited information. However, the statement by Dr. George Sawaya of UCSF that after finding an enlargement during a bimanual pelvic examination he gets “follow-up with a sonogram which shows a mass but I can’t tell what the mass is without surgical exploration. Yet nearly always it is benign.” must be commented on.

The field of gynecologic ultrasound with the introduction of vaginal probe sonograms in the last 30 years has refined gynecologic diagnosis to the point where the overwhelming majority of masses detected are clearly benign and can be left alone without surgery. It seems that Dr. Sawaya, and unfortunately many other physicians and patients, do not understand that benign ovarian growths do not become malignant.

Perhaps this misconception is a result of the fact that virtually all other gynecologic cancers (cervix, uterus, and breast) have well defined premalignant stages that we attempt to identify before they become frank malignances. I also believe that another major reason that the rate of surgery for ovarian cysts and hysterectomy in the United States is twice as high as European countries is because their ability to better understand that gynecologic ultrasound can reliably suggest “benign” is far ahead of most doctors in the United States.

Further proof of this is underscored by the United States Preventive Services Task Force’s (USPSTF) refusal to recommend routine ultrasound screening for early detection of ovarian cancer partly because there were 30 surgeries for every malignancy detected in the PLCO  (prostate, lung, colon, ovary) study. This stems from that study having used a definition of a “positive” screen for entities that many of us, even in 1993 when it was designed, and surely today, would clearly recognize as benign and avoid surgery.

You can click here for the original NYT article. http://well.blogs.nytimes.com/2013/04/29/an-exam-with-poor-results/?smid=pl-share

Dr Steven R. Goldstein is a Transvaginal Ultrasound Specialist in NYC