Monday, September 8, 2014

3D Trumps 2D For Localizing IUD's

In the August issue of OBG Management, NYU's Dr.Steven R. Goldstein penned an article suggesting that we stop relying on the standard 2D ultrasound for localizing an IUD. The reason: that 3D or volume ultrasound allows visualization of planes, specifically a coronal plane, not often seen on the standard sonogram. Why is this important? Read on.

Dr. Goldstein's article demonstrates several images from studies in which the IUD's location doesn't look unusual on the 2D image. However, in the coronal plane of 3D imaging, a problem is demonstrated. Benacerraf et al found that 75% of patients with abnormally situated IUD's presented with either pain or bleeding - more than twice the rate of women whose IUD's were found normally situated. We recently saw a young woman who had been in the Emergency Department complaining of pelvic pain for whom the diagnosis of her problem was far from clear. Visualization of the IUD in the coronal plane of her 3D sonogram clearly showed that not only was the device malpositioned in the lower uterus but one of the lateral arms penetrated the wall as well.

So now that you know a 3D study is superior, where should it be done? My answer would be more shameless self-promotion. For more information or to schedule a 3D ultrasound, please call (718) 925-6277.

Monday, August 25, 2014

Shameless Self-Promotion

Many patients, colleagues, friends and family have all asked me: "Who's the most qualified to perform Ob-Gyn ultrasounds?" So here is my unvarnished and completely biased opinion.

An ultrasound study can be performed by either a sonographer or a sonologist (a doctor who performs or supervises ultrasounds.) However, a doctor will have a more extensive background in both health and disease processes than someone who is not a physician as a general rule. A physician will have spent far more time on the clinical side of the equation so will be more able to formulate a better differential diagnosis.

Now while a radiologist and gynecologist can both perform a decent pelvic ultrasound study, a gynecologist is generally far more familiar with female pelvic physiology and pathophysiology than a general radiologist. When it comes to a vaginal ultrasound, this shouldn't even be a question. An old friend once remarked that if radiologists performed vaginal sonography, the transducer handle would be long enough to reach into the reading room. Instead, most if not all radiologists read the studies performed by sonographers. A gynecologist performs a vaginal sonogram in much the same way an old-fashioned pelvic exam is performed, even down to occasionally using the abdominal hand.

Also, when a sonographer performs a sonogram in the standard radiology practice, the patient usually has to leave without knowing the result. When a gynecologist performs the exam, the result, at least preliminarily, is available right away. This eliminates a great deal of anziety.

OK, so now we've agreed your pelvic sonogram is best performed by an Ob-Gyn, why should it be performed by THIS "Recovering Obstetrician?" The short answer is Experience. I have been performing Ob-Gyn sonography since the late 1970's and exclusively since 1986. Since that time, when I decided to limit my practice to consultative ultrasound, I have had a chance to learn what works, what doesn't work, and have climbed to the summit of a rather steep learning curve. I've also learned a great deal about how to deal with both anxious patients and concerned referring clinicians. Do keep all this in mind if and when you need an ultrasound.

Thanks for reading. This concludes my infomercial.

For more information or to schedule an ultrasound, please call 718-925-6277.

Friday, August 22, 2014

Vitamin D: Shedding Some Light on Infertility

I've posted on the present epidemic of low vitamin D previously. Now we find yet another association of low levels of Vitamin D - Infetility.

Publishing in the European Journal of Endocrinology, researchers Elizabeth Lerchbaum and Barbara Obermayer-Pietsch performed a systematic review of studies published until October of 2011. A short summary of their results from PubMed:

The vitamin D receptor (VDR) and vitamin D metabolizing enzymes are found in reproductive tissues of women and men. Vdr knockout mice have significant gonadal insufficiency, decreased sperm count and motility, and histological abnormalities of testis, ovary and uterus. Moreover, we present evidence that vitamin D is involved in female reproduction including IVF outcome (clinical pregnancy rates) and polycystic ovary syndrome (PCOS). In PCOS women, low 25-hydroxyvitamin D (25(OH)D) levels are associated with obesity, metabolic, and endocrine disturbances and vitamin D supplementation might improve menstrual frequency and metabolic disturbances in those women. Moreover, vitamin D might influence steroidogenesis of sex hormones (estradiol and progesterone) in healthy women and high 25(OH)D levels might be associated with endometriosis. In men, vitamin D is positively associated with semen quality and androgen status. Moreover, vitamin D treatment might increase testosterone levels. Testiculopathic men show low CYP21R expression, low 25(OH)D levels, and osteoporosis despite normal testosterone levels.

While more work needs to be done, the impact of Vitamin D on both the male and female reproductive systems is far-reaching and still poorly understood. Stay tuned.

For more information or to schedule a sonogram, please call 718-925-6722.

Thursday, August 7, 2014

Screening Guidelines And Ageism

Most of the controversy surrounding mammography involves when to start screening - 35? 40? 50? However, the US Preventative Services Task Force has also suggested that the evidence for continued screening after age 75 is lacking. Now there may be some evidence for older women.

Malmgren et al from the Swedish Cancer Institute in Seattle reported on findings to suggest the benefit of continued breast cancer screening in older women.

The researchers recently looked at the impact of mammography detection on older women by studying data from an institutional registry that includes more than 14,000 breast cancer cases with 1,600 patients aged older than 75 years.

The majority of mammography-detected cases were early stage, while physician- and patient-detected cancers were more likely to be advanced stage disease. Patients with mammography-detected invasive breast cancer were more often treated with lumpectomy and radiation and had fewer mastectomies and less chemotherapy than patient- or physician-detected cases.

Mammography detection was associated with a 97% five-year disease-specific invasive cancer survival rate, compared with 87% for patient- or physician-detected invasive cancers.

“Mammography enables detection when breast cancer is at an early stage and is easier to treat with more tolerable options,” said Dr. Malmgren. “In this study, older women with mammography-detected invasive cancer had a 10% reduction in breast cancer disease-specific mortality after 5 years.”


This all has little to do with ultrasound but everything to do with the doctor patient relationship. Ultimately, the decision to screen or not to screen should properly rest with the patient and her doctor, based on medical evidence, not cost. Older folks are people too.

If you've any questions or need to schedule an ultrasound, please call (718) 925-6277.

Monday, July 28, 2014

Vitamin D Is More Than Just Bones

Since someone close to me was recently diagnosed with Systemic Lupus Erythematosus aka Lupus aka SLE, I started thinking about the effect that being told to avoid the sun might have on both vitamin D levels and the impact on lupus.

Since the root cause of many diseases such as SLE remains elusive, I was intrigued to find that specialists in the field were asking similar questions. Abou-Raya and colleagues conducted a placebo-controlled trial of vitamin D supplementation in patients with lupus.

Their findings were interesting. First, the lupus patients tended to have lower baseline vitamin D levels when compared with the control group. Second, and more importantly, vitamin D supplementation for 12 months led to significant improvements in both markers of disease activity and in clinical disease activity as well.

From the discussion: ... The overall effect of vitamin D is enhancement of protective innate immune response, while maintaining self-tolerance by dampening overactive adaptive immune responses30. Amelioration of proinflammatory cytokines by vitamin D supplementation may be attributed to the antiinflammatory and immunomodulation effect of vitamin D.

Finally, they conclude: Vitamin D, a safe, inexpensive, and widely available agent, may be effective as a disease-suppressing intervention for patients with SLE. In addition to the potential benefit of vitamin D replacement on improvement of SLE activity, vitamin D seems to have an immune-inflammatory-modulatory role that may benefit musculoskeletal and cardiovascular manifestations of SLE. This role could also help maintain immune health, thus avoiding the excess morbidity and mortality associated with vitamin D deficiency. We recommend routine assessment of vitamin D levels and adequate supplementation of the vitamin in patients with SLE.

When it comes to knowledge about vitamin D, let the sunshine in.

I know this has little to do with ultrasound but a lot to do with our health and that of our loved ones. If you do need an appointment for an ultrasound, feel free to call (718) 925-6277.

Monday, July 14, 2014

Pelvic Exam for the 21st Century

The American College of Physicians (ACP) certainly stirred up a hornets' nest with their pronouncement on the value of pelvic exams.

...“Routine pelvic examination has not been shown to benefit asymptomatic, average risk, non-pregnant women. It rarely detects important disease and does not reduce mortality and is associated with discomfort for many women, false positive and negative examinations, and extra cost,” said Dr. Linda Humphrey, a co-author of the guideline and a member of ACP’s Clinical Practice Guidelines Committee.

As I have posted previously, perhaps it's time to think about replacing the pelvic exam with ultrasound.

...So how would ultrasound stack up? Tayal et al conducted a study of emergency patients who were being evaluated for pain. Patients underwent both a transvaginal sonogram and the clinical pelvic examination. The order of examinations was randomized. The group found the sonographic pelvic exam superior to the digital pelvic exam across all BMI classes. And remember, these were patients already in pain.

When it comes to the issue of screening for ovarian cancer, the pelvic exam has failed miserably. Dr. Nick Summerton writes in the Spectator :

In seeking to pick up ovarian cancer at an early stage — with an improved chance of cure — much better alternatives to the vaginal examination are trans-vaginal ultrasound and CA125 testing. CA125 is a chemical given off by cancer cells that circulates in the bloodstream and women with ovarian cancer tend to have higher levels.

In 2015, the UKCTOCS screening trial for ovarian cancer will publish its results. Preliminary findings look very promising but, of course, "it ain't over 'til it's over."

Stay tuned.

For more information or to schedule an ultrasound, please call (718) 925-6277.

Tuesday, July 8, 2014

Where's Waldo?

We've all seen Waldo, the guy with the striped shirt and matching cap.



Seems pretty easy to spot, right?

But what if Waldo is in a large, busy crowd - is he still easy to spot?



Sometimes, an early pregnancy is harder to spot than Waldo. Because pregnancy tests are so sensitive, women are getting that first ultrasound quite early on in gestation. There is a window of about 2 - 3 weeks after conception when an early intrauterine pregnancy might not be visualized. This creates a quandary - is she really pregnant, is there a problem with the pregnancy or a problem with the dates, and, worst case scenario, is the pregnancy ectopic. Doctors refer to this clinical situation as "Pregnancy of Uncertain Location" or PUL. The usual management consists of serial measurements of the blood pregnancy hormone or Beta HCG and repeating the ultrasound until the situation is resolved. The protocol had been that failure to see a normally-situated pregnancy on ultrasound at a critical level of Beta HCG was highly suspicious for an ectopic pregnancy or a failed intrauterine pregnancy. Unfortunately, as we all are aware, life is not always so neat.

Doubilet et al, writing in the New England Journal of Medicine reviewed the diagnostic criteria of pregnancy of uncertain location and failed pregnancy and found that previously utilized criteria were a set up for diagnostic error, resulting in administration of a powerful teratogenic drug, Methotrexate, in cases subsequently found to be normal pregnancy. Nurmohamed et al found 8 cases of intrauterine pregnancy in which methotrexate was administered for suspected ectopic. None of these cases had a happy outcome.

Doubilet's review offered new consensus guidelines for the diagnosis of both early pregnancy failure and pregnancy of uncertain location, nicely summarized Here.

So if you find yourself in this situation, please review this post again and perhaps ask your doctor to review it as well.

For more information or to schedule an ultrasound, please call (718) 925-6277.