Chronic pelvic pain, which persists longer than 6 months by definition, is a common condition which affects women of all ages with causes differing by age group. This document will focus on gynecologic origins of chronic pelvic pain, etiologies including chronic pelvic inflammatory disease, postsurgical changes, vaginal or vulvar cysts, and pelvic venous congestion disorder. Ultrasound is the initial imaging modality of choice with MRI or CT of the pelvis may be used in select cases when initial ultrasound is inconclusive. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Academic specialists in general obstetrics and gynecology are clinicians practicing the full breadth of the specialty while also contributing to medical education and scientific discovery. Residency programs in obstetrics and gynecology provide exposure to research training that is variable but frequently limited. This creates challenges for junior faculty and in many cases limits their research productivity, typically measured by published original research articles and grant funding. This frequently disadvantages academic specialists in promotion compared with their subspecialty fellowship–trained colleagues. A few research fellowship programs were recently launched to address this issue. However, these programs are not uniform and encounter challenges such as sustainable funding. In this article, building on knowledge from current academic specialist fellowship programs, we discuss the needs, challenges, and proposed solutions. We also propose some details needing further discussion among the academic obstetrics and gynecology community. We discuss how such fellowships can integrate with current development and training opportunities such as the Women's Reproductive Health Research award, Building Interdisciplinary Research Careers in Women's Health award, other K and K-type career development programs, NIH T32 grants, and clinical research courses for obstetricians and gynecologists. Academic specialist fellowship programs can have synergy with other women's health fellowship programs offered by other specialties. They can additionally leverage institutional resources. We conclude by summarizing a proposed model for academic specialist research fellowship programs.

This review focuses on the initial imaging in the reproductive age adult population with acute pelvic pain, including patients with positive and negative beta-human chorionic gonadotropin (β-hCG) levels with suspected gynecological and nongynecological etiology. For all patients, a combination of transabdominal and transvaginal pelvic ultrasound with Doppler is usually appropriate as an initial imaging study. If nongynecological etiology in patients with negative β-hCG is suspected, then CT of the abdomen and pelvis with or without contrast is also usually appropriate. In patients with positive β-hCG and suspected nongynecological etiology, CT of the abdomen and pelvis with contrast and MRI of the abdomen and pelvis without contrast may be appropriate. In patients with negative β-hCG and suspected gynecological etiology, CT of the abdomen and pelvis with contrast, MRI of pelvis without contrast, or MRI of pelvis with and without contrast may be appropriate.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Folate is an antioxidant micronutrient present in many vegetables, fruits, whole grains, beans, and the liver. Its synthetic counterpart, folic acid, is used as a dietary supplement for fortification of wheat and other foods. An average daily intake of 250 mu g dietary folate equivalents is recommended by the European Food Safety Authority for adult women. In a 2015 cohort study of American women undergoing assisted reproductive technology, a positive association was found between total folate intake (from natural sources, fortified foods, and supplements) and implantation, clinical pregnancy, and live birth rates. This association, however, was attenuated when the exposure to folate was exclusively dietary, even though folic acid from fortified foods was included. Intake of supplemental folic acid has been associated with improved fertility, but there are few data about the relation between dietary folate and fecundability. Recommendations for dosage of preconception dietary folate and folic acid supplementation are important not only to prevent neural tube defects but also to enhance fecundability. No prior study has examined the role of dietary folate and total folate (dietary and supplemental intakes) on fecundability, the per-cycle probability of conception among couples trying to conceive naturally. The aim of this study was to determine the association of dietary folate intake and total folate intake (dietary and supplemental intakes) on fecundability in 2 similar cohorts of women trying to conceive naturally. Data were obtained from 2 internet-based prospective cohort studies of pregnancy planners: SnartForaeldre.dk (SF; n = 3755), a study from Denmark, where folic acid fortification is not performed and Pregnancy Study Online (PRESTO; n = 5804), a study from North America, where the food supply is fortified with folic acid. Menstrual cycles at risk were contributed by women until pregnancy or a censoring event, whichever came first. The association between dietary folate and total folate intake and fecundability was examined by computing fecundability ratios (FRs) and 95% confidence interval (CI) using a proportional probabilities regression model. Compared with dietary folate intake =400 mu g/d, the adjusted FRs (aFRs) for women in SF were 0.92 (95% CI, 0.85-0.99) for intake 250 to 399 mu g/d and 0.80 (95% CI, 0.68-0.94) for intake less than 250 mu g/d. The corresponding aFRs in PRESTO were similar: 0.95 (95% CI, 0.89-1.01) for intake 250 to 399 mu g/d and 0.81 (95% CI, 0.65-1.00) for intake less than 250 mu g/d. Compared with the highest level of total folate intake (diet folate =400 mu g/d plus folic acid supplementation), fecundability was lowest in both cohorts among women with the lowest dietary folate intake (<250 mu g/d dietary folate intake and no supplementation) (aFR, 0.76; 95% CI, 0.59-0.98 [SF] and 0.49; 95% CI, 0.31-0.77 [PRESTO]). In addition, the aFR among SF participants for dietary intake less than 250 mu g/d plus folic supplementation was 0.79 (95% CI, 0.65-0.98), and the corresponding aFR in PRESTO was 0.92 (95% CI, 0.72-1.16). Overall, there was a monotonic positive association between folate intake and fecundability. The data suggest that supplementation of 400 mu g/d folic acid may not be sufficient to compensate for low dietary folate intake (<250 mu g/d) with respect to fecundability, regardless of whether fortification is provided. Compared with no supplementation, fecundability in both cohorts was higher among women with low dietary folate intake (<250 mu g/d) who supplemented with 400 mu g/d folic acid. However, supplementation does not appear to compensate completely for the low dietary intake. The data suggest that supplementation of 400 mu g/d folic acid may not be sufficient to compensate for low dietary folate intake (<250 mu g/d) in relation to fecundability, regardless of whether fortification is provided.

Pelvic floor disorders including pelvic organ prolapse (POP), urinary dysfunction, defecatory dysfunction, and complications after pelvic floor surgery are relatively common in the female population. Imaging tests are obtained when the initial clinical evaluation is thought to be incomplete or inconclusive or demonstrates findings that are discordant with patients' symptoms. An integrated imaging approach is optimal to evaluate the complex anatomy and dynamic functionality of the pelvic floor. Fluoroscopic cystocolpoproctography (CCP) and MR defecography are considered the initial imaging tests of choice for evaluation of POP. Fluoroscopic voiding cystourethrography is considered the initial imaging test for patients with urinary dysfunction. Fluoroscopic CCP and MR defecography are considered the initial imaging test for patients with defecatory dysfunction, whereas ultrasound pelvis transrectal is a complementary test in patients requiring evaluation for anal sphincter defects. MRI pelvis without and with intravenous contrast, MRI pelvis with dynamic maneuvers, and MR defecography are considered the initial imaging tests in patients with suspected complications of prior pelvic floor surgical repair. Transperineal ultrasound is emerging as an important imaging tool, in particular for screening of pelvic floor dysfunction and for evaluation of midurethral slings, vaginal mesh, and complications related to prior pelvic floor surgical repair. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

OBJECTIVE:To implement a quality-improvement intervention aimed at reducing unnecessary opioid prescriptions for patients who are undergoing gynecologic surgery.METHODS:This was a retrospective cohort study that included data from the pre- and post-quality-improvement initiative cohorts. Patients at an urban, tertiary academic medical center who were undergoing scheduled minimally invasive surgery and open abdominal surgery by a gynecologic oncologist were included. Patients underwent preoperative counseling, standardization of perioperative analgesia, and a postoperative opioid prescribing algorithm. Descriptive statistics were calculated for demographic and perioperative characteristics, process measures, and outcome measures.RESULTS:A total of 532 abdominal surgeries were analyzed. The total percentage of patients discharged with an opioid prescription decreased from 82.7% (n=229/276) to 23.1% (n=59/256) (P<.001) and was significantly reduced for all routes of surgery. The mean number of opioid tablets prescribed for all patients was significantly reduced from 7.2 tablets (SD=5.7) to 1.8 tablets (SD=4.3) (P<.001). Eighty-three percent of patients (n=97/117) who underwent minimally invasive hysterectomy and were discharged on postoperative day 0 or day 1 were not provided an opioid prescription. Fifty-one percent of patients who underwent laparotomy were discharged without an opioid prescription. The percentage of patients who required an opioid refill or new prescription in the preintervention and postintervention cohorts remained constant (6.5%, n=18/276 vs 5.9%, n=15/256, P=.75), as did postoperative calls for pain (8.3%, n=23/276 vs 10.9%, n=33/256).CONCLUSION:Patients who are undergoing scheduled abdominal gynecologic surgery can be safely discharged without opioid prescriptions with appropriate education and perioperative analgesia prescribing practices. These protocols and prescribing practices profoundly limit opioid prescriptions, which is an important factor in combating the ongoing opioid crisis.

Acute pelvic pain is a common presenting complaint in both the emergency room and outpatient settings. Pelvic pain of gynecologic origin in postmenopausal women occurs less frequently than in premenopausal women; however, it has important differences in etiology. The most common causes of postmenopausal pelvic pain from gynecologic origin are ovarian cysts, uterine fibroids, pelvic inflammatory disease, and ovarian neoplasm. Other etiologies of pelvic pain are attributable to urinary, gastrointestinal, and vascular systems. As the optimal imaging modality varies for these etiologies, it is important to narrow the differential diagnosis before choosing the initial diagnostic imaging examination. Transabdominal and transvaginal ultrasound are the best initial imaging techniques when the differential is primarily of gynecologic origin. CT with intravenous (IV) contrast is more useful if the differential diagnosis remains broad. MRI without IV contrast or MRI without and with IV contrast, as well as CT without IV contrast may also be used for certain differential considerations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

OBJECTIVE: To characterize the indications for and complication rates of excision of the retained cervix after supracervical hysterectomy. METHODS: We performed a retrospective cohort study of women undergoing excision of the retained cervix after supracervical hysterectomy in the 2010-2014 National Inpatient Sample. International Classification of Diseases, Ninth Revision codes were used to identify indication for the procedure and surgical complications. We weighted the hospital-level data to obtain nationwide estimates of patient characteristics, surgical complications, and length of stay. RESULTS: Nationwide, 1,140 women underwent excision of the retained cervix after hysterectomy. Their mean age was 49 years, and the majority were White and privately insured. Leiomyomas were the most commonly coded indication (35%, 95% CI 29-42), followed by prolapse (14%, 95% CI 9-18). Eighteen percent (95% CI 13.0-23.1) were performed for malignancy, including 5.3% (95% CI 2.3-8.2) for cervical cancer. Only 11.5% (95% CI 7.3-15.6) of cases were performed laparoscopically. The overall complication rate was high (38%, 95% CI 32-45), particularly for bleeding complications (26%, 95% CI 20-31) and transfusion (15%, 95% CI 11-20). Gastrointestinal complication rates were second highest (8%, 95% CI 5-12); ileus was the most common gastrointestinal complication (7.0%, 95% CI 3.7-10.4). The median length of stay was 2 days (range 0-34). CONCLUSION: Women who undergo excision of the retained cervix after supracervical hysterectomy experience high rates of complications, the most common of which was bleeding. Patient counseling regarding removal of the cervix at the time of hysterectomy should include this information.

(Abstracted from Obstet Gynecol 2021;137:156–163) It is estimated that 1 in 4 women will experience a pregnancy loss in her lifetime. The emotional impact of a pregnancy loss in many women is devastating.

As the importance ofpelvic venousdisorders (PeVD) hasbeenincreasingly recognized, progress in the field has been limited by the lack of a valid and reliable classification instrument. Misleading historical nomenclature, such as the May-Thurner, pelvic congestion, and nutcracker syndromes, often fails to recognize the interrelationship of many pelvic symptoms and their underlying pathophysiology. Based on a perceived need, the American Vein and Lymphatic Society convened an international, multidisciplinary panel charged with the development of a discriminative classification instrument for PeVD. This instrument, theSymptoms-Varices-Pathophysiology ("SVP") classification for PeVD, includes three domains-Symptoms(S), Varices (V), and Pathophysiology (P), with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H), and Etiologic (E) features of the patient's disease. An individual patient's classification is designated as SVPA, H,E. For patients with pelvic origin lower extremity signs or symptoms, the SVP instrument is complementary to and should be used in conjunction with the Clinical-Etiologic-Anatomic-Physiologic (CEAP) classification. The SVP instrument accurately defines the diverse patient populations with PeVD, an important step in improving clinical decision making, developing disease-specific outcome measures and identifying homogenous patient populations for clinical trials.

Postpartum hemorrhage (PPH) can be categorized as primary or early if occurring in the first 24 hours after delivery, whereas late or delayed PPH occurs between 24 hours and 6 weeks. Most of the causes of PPH can be diagnosed clinically, but imaging plays an important role in the diagnosis of many causes of PPH. Pelvic ultrasound (transabdominal and transvaginal with Doppler) is the imaging modality of choice for the initial evaluation of PPH. Contrast-enhanced CT of the abdomen and pelvis and CT angiogram of the abdomen and pelvis may be appropriate to determine if active ongoing hemorrhage is present, to localize the bleeding, and to identify the source of bleeding. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

(Abstracted from Acta Obstet Gynecol Scand 2019;98:1341–1350) Animal models suggest that increased uterine prolactin concentration is a risk factor for adenomyosis. Prolactin is produced in the human endometrium, myometrium, and the pituitary gland and acts as a smooth muscle cell mitogen in vitro.

Procedure Appropriateness Category Relative Radiation Level US duplex Doppler pelvis Usually Appropriate O US pelvis transabdominal Usually Appropriate O US pelvis transvaginal Usually Appropriate O US sonohysterography May Be Appropriate (Disagreement) O MRI pelvis without and with IV contrast Usually Not Appropriate O MRI pelvis without IV contrast Usually Not Appropriate O CT pelvis with IV contrast Usually Not Appropriate ☢☢☢ CT pelvis without IV contrast Usually Not Appropriate ☢☢☢ CT pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢

(Abstracted from Acta Obstet Gynecol Scand 2019;98:1420–1428) The minimal invasive procedure, laparoscopic hysterectomy, is safe, has low risk of complications, and requires only a short hospital stay. Within the first 4 weeks after surgery, readmission rates as low as less than 4% have been reported.

This publication summarizes the relevant literature for the imaging of patients with symptoms of abnormal uterine bleeding, including initial imaging, follow-up imaging when the original ultrasound is inconclusive, and follow-up imaging when surveillance is appropriate. For patients with abnormal uterine bleeding, combined transabdominal and transvaginal ultrasound of the pelvis with Doppler is the most appropriate initial imaging study. If the uterus is incompletely visualized with the initial ultrasou2nd, MRI of the pelvis without and with contrast is the next appropriate imaging study, unless a polyp is suspected on the original ultrasound, then sonohysterography can be performed. If the patient continues to experience abnormal uterine bleeding, assessment with ultrasound of the pelvis, sonohysterography, and MRI of the pelvis without and with contrast would be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

OBJECTIVE: To describe implementation of myTIPreport for milestone feedback and to initiate construct validity testing of myTIPreport for milestones. DESIGN: myTIPreport was used to provide workplace feedback on Accreditation Council for Graduate Medical Education required milestone sets. Performance of senior learners (postgraduate year [PGY]-4s) was compared to that of junior learners (PGY-1s) to begin the process of construct validity testing for myTIPreport. SETTING: A convenience-based site selection of Obstetrics and Gynecology (OBGYN) residency programs. PARTICIPANTS: OBGYN residents and faculty. RESULTS: Amongst the 12 participating OBGYN residency programs, there were 444 unique learners and 343 unique faculty teachers. A total of 5293 milestone feedback encounters were recorded. Mean PGY-4 performance was rated higher than mean PGY-1 performance on all 25 of the compared milestone sets, with statistically significant differences seen for 19 (76%) of these 25 milestone sets and nonsignificant differences in the predicted direction observed for the other 6 milestone sets. CONCLUSIONS: myTIPreport detected differences between senior and junior learners for the majority of compared feedback encounters for OBGYN residents. Findings support the emerging construct validity of myTIPreport for milestone feedback. (C) 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

The most common known causes of female infertility are male factor (26%), ovulatory failure (21%), and tubal damage (14%), while in 28% a couple's infertility remains unexplained. Female-specific causes of infertility include deterioration of oocyte quality with increasing maternal age; ovulatory disorders, most notably polycystic ovarian syndrome; history of salpingitis such as that caused by chlamydia infection; endometriosis; and uterine cavity abnormalities interfering with implantation causing inability to become pregnant or causing recurrent pregnancy loss. These potential causes of female infertility are discussed in this document and the appropriate imaging recommendations for each variant are provided. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

(Abstracted from Obstet Gynecol 2020;135:761–769) Between 2007 and 2010, the rate of total vaginal hysterectomy (TVH) in the United States among commercially insured patients undergoing hysterectomy decreased from 21.7% to 19.8% and by 2013 decreased to 11.5%. Between 2007 and 2010, use of robotic-assisted hysterectomy increased from 0.5% to 9.5%.

(Abstracted from Obstet Gynecol 2020;135:1313–1326) Uterine leiomyomas affect up to 80% of reproductive-age women and are the most common benign neoplasm of the uterus. A variety of symptoms occur in approximately half of these women; the most common is heavy menstrual bleeding (HMB), which can result in anemia.