Pap smears are a critical screening tool for cervical cancer, but they don’t tell the whole story. Ultrasound imaging can reveal tumors, fibroids, ovarian cysts, and abnormal tissue growth that may not be detected through cytology alone, particularly when symptoms persist despite normal Pap results.
Because healthcare providers have discretion in deciding when to refer patients for ultrasounds, knowing what it takes to cross that threshold can be unclear to patients and biased across demographics. Unfortunately, Black women’s pain is often dismissed, and studies show that even in Canada, similar complaints occur.
However, sending patients with vague symptoms for imaging sooner rather than waiting for the worst may actually shift responsibility from both the patient and the provider. Relying on state-of-the-art technology to detect and rule out gynecologic cancers and other life-threatening conditions earlier. Given the risks of delayed diagnosis, transvaginal or pelvic imaging is a solid option for providers to err on the side of caution.
Which Specific Pathologies Can Be Identified Only by Ultrasound?
“While a pap smear is an extremely important tool for diagnosing abnormal changes in cervical cells, many other common medical problems can only be identified by thorough examination and oftentimes with the assistance of an ultrasound,” explains Tiffany Tonismae, MD, FACOG, a double board-certified physician in obstetrics and gynecology and maternal-fetal medicine, and the assistant professor at the University of Louisville School of Medicine. “These include structural abnormalities in the uterus (such as fibroids, adenomyosis, endometrial hyperplasia, endometrial polyps) and abnormalities of the fallopian tubes and ovaries (cysts, malignancies, blockage).” She says ultrasounds can be used to identify these abnormalities and to correlate symptoms with pathology.
What’s the Purpose of a Pelvic Exam?
As part of an annual visit, many women visit an obstetrician-gynecologist for a pelvic exam and Pap smear. Both are done because they tell doctors different things about a patient’s health.
According to the Mayo Clinic, “A pelvic exam can be part of a routine physical exam. It can find any signs of ovarian cysts, some sexually transmitted infections, growths of the uterus, or early-stage cancer.” It also helps determine the position of the organs in the pelvis, including the uterus, ovaries, fallopian tubes, vagina, and cervix. Combined with an ultrasound, a physical exam can explain symptoms that are hard to explain or persistent. Traditional pelvic exams are used to feel for abnormalities in the size or fullness of the pelvis, but Dr. Tonismae says they often can’t identify pathology.
What Pathologies Can an Ultrasound Detect That a Pap Smear Can’t?
Although Pap smears are common, they have known limitations. Pap exams may not find every abnormal cell, and people can test negative for HPV and still develop cancer. Also, abnormal pap results may not actually be cancer either.
Dr. Tonismae adds that pap smears do not assess pelvic pain. “For those experiencing pelvic pain, it is important to meet with an OB-GYN to discuss symptoms and determine the best next step, which will often include ultrasound imaging. Unfortunately, not all imaging is the same, and women should specifically look for those centers experienced in managing women with pelvic pain.”
Dr. Tonismae adds that with specific ultrasound techniques, structural abnormalities such as fibroids and cysts within the adnexa can be identified. Also, endometriosis can be detected on an ultrasound performed by experienced sonographers and physicians.
Ultrasounds lead to earlier diagnosis, improved discussion of management options, and clarity regarding the appropriate surgical treatment for the pathology, Dr. Tonismae explains. This valuable information helps both the patient and the healthcare provider to take decisive action.
Why Aren’t Ultrasounds More Quickly Recommended?
In the United States, an ultrasound is usually not done by an OBGYN, nor in the same office as the routine exam. Instead, obtaining an ultrasound—even for people who are fully insured—can be a major inconvenience. A sonographer or technician typically performs the process, and the imaging is then reviewed by a radiologist. In addition to ultrasound, a radiologist may also be skilled in X-rays, magnetic resonance imaging (MRI), mammography, and computed tomography (CT) scans.
Perceived inconvenience may reflect an unconscious bias that delays referral; however, in a hospital practice, ultrasounds are often scheduled promptly, and results are available within days.
Although the cost of an ultrasound may be a concern for some patients, health insurance frequently covers it when a doctor documents the medical necessity. 2D ultrasound examinations are generally covered by health insurance, whereas 3D and 4D are typically not. Additionally, ultrasounds are noninvasive, so patients should not experience pain.
While physicians’ inclination may be to consider blood tests first, an NIH study showed that even the cancer antigen 125 test often fails Black and Native American women.
When in doubt, physicians should promptly recommend ultrasounds as the next logical step when patients, especially Black women, express concern about pelvic pain.