From the Guidelines
I strongly recommend ordering a transvaginal ultrasound (TV U/S) for this 45-year-old patient with hypertension and a history of HPV who is reporting ongoing pelvic pain, as it is the most useful imaging modality for initial assessment when an obstetrical or gynecological etiology is suspected 1. The patient's gynecologist has already recommended this imaging study, and it would be appropriate to order it during today's visit for medication refills. The TV U/S will help evaluate potential causes of her pelvic pain, which could include conditions such as ovarian cysts, fibroids, endometriosis, or pelvic inflammatory disease. Some key points to consider when interpreting the results of the TV U/S include:
- The sensitivity of TVUS for various pathological entities, such as ovarian torsion (83.3%), endometriotic cyst (84%), hemorrhagic cysts (88.2%), and dermoid cysts (62.5%) 1
- The signs of ovarian torsion on US, including ovarian tissue edema, absence of intraovarian vascularity, and absence of arterial flow, which have varying accuracy 1
- The detection rate of moderate-to-severe salpingitis with US, which is 100% compared to 25% for mild salpingitis 1 While processing her medication refills for hypertension, I would verify her current medications, dosages, and ensure she has adequate supply until her next follow-up. I would also document her reported good adherence and absence of side effects from her current regimen. The transvaginal ultrasound is medically necessary given her persistent symptoms, and coordinating this test through primary care may help address her concerns about cost. After obtaining the results, appropriate follow-up should be arranged, potentially including referral back to gynecology with the new imaging information if abnormalities are detected.
From the Research
Patient's Condition and Request
- The patient is a 45-year-old woman with a history of hypertension (HTN) and human papillomavirus (HPV) infection.
- She reports ongoing pelvic pain and was recommended to undergo a transvaginal ultrasound (TVUS) by her gynecologist, but she finds it too expensive.
- She is currently in the clinic for medication refills and denies any side effects from her medication, reporting good adherence.
Human Papillomavirus (HPV) Infection
- HPV is the most common sexually transmitted disease in the world, with almost 80% of the world's population exposed by the age of 50 2.
- HPV can cause oropharyngeal, genital, and anal cancers, as well as genital warts 2, 3.
- There is no cure for HPV, but vaccines are available to prevent infection by the most common HPV viruses 2, 4.
Transvaginal Ultrasound (TVUS)
- There are no universal guidelines for TVUS at the time of the anatomy scan 5.
- TVUS can provide information on placental location and cervical length, but may lead to more interventions 5.
- A study found that routine TVUS at the time of the anatomy scan did not decrease adverse pregnancy outcomes, such as preterm birth, postpartum hemorrhage, or neonatal intensive care unit admission 5.
Cervical Cancer Prevention and Screening
- Cervical cancer is one of the most common cancers in women, with an estimated 528,000 new cases reported in 2012 3.
- HPV testing is clinically valuable in triaging low-grade cytological abnormalities and is more sensitive than cytology as a primary screening 3.
- Healthcare providers can help prevent cervical cancer by recommending HPV vaccination, regularly screening women for cervical cancer, and following up on abnormal test results 6.