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STUDY OBJECTIVE Learning to evaluate and treat chronic pelvic pain (CPP) is an established curriculum objective within the Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS). Our aim was to investigate current educational experiences related to the evaluation and management of CPP and the impacts of those experiences on FMIGS fellows and recent fellowship graduates, including satisfaction, confidence in management, and clinical interest in CPP. DESIGN The AAGL-Elevating Gynecologic Surgery Special Interest Group for pelvic pain developed a 33-item survey tool to investigate the following topics: (1) current educational experiences with the assessment and management of patients with CPP, (2) satisfaction with fellowship training in CPP, (3) perceived preparedness to treat patients with CPP, (4) plans to incorporate management of CPP into clinical practice, and (5) perceived desires to expand CPP exposure. Composite scores were created to examine experiences related to diseases associated with CPP and pharmaceutical and procedural treatment options. SETTING Electronic survey. PATIENTS Not applicable. INTERVENTIONS The survey was distributed via AAGL email lists and offered on FMIGS social media sites from August 2017 to November 2017 to all active FMIGS fellows and individuals who graduated the fellowship during the preceding 5 years. MEASUREMENTS AND MAIN RESULTS Fifty-three of 82 (65%) current FMIGS fellows and 104 of 169 (62%) recent fellowship graduates completed the survey. Only 66% of current fellows endorsed working with a fellowship faculty member whose clinical work focused on CPP. Most current fellows reported having a "good amount" of experience or "extensive" experience with superficial endometriosis (39/53, 74%) and deeply infiltrative endometriosis (34/53, 64%), whereas the majority reported having "no" or "little" experience with frequently comorbid conditions like irritable bowel syndrome (68%), pelvic floor tension myalgia (55%), and interstitial cystitis/painful bladder syndrome (51%). For both current fellows and recent graduates, increased CPP Disease Experience composite scores were associated with satisfaction with CPP training (current fellows odds ratio [OR] 1.9, p =.002; recent graduates OR 1.5, p < .001), perceived preparedness to treat patients with CPP (current fellows OR 2.0, p = .0021; recent graduates OR 1.5, p

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.

Study Objective To present updated information regarding compensation patterns for Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS)–graduated physicians in the United States beginning practice during the last 10 years, focusing on the variables that have an impact on differences in salary, including gender, fellowship duration, geographic region, practice setting, and practice mix. Design An online survey was sent to FMIGS graduates between March 15, 2019 and April 12, 2019. Information on physicians’ demographics, compensation (on the basis of location, practice model, productivity benchmarks, academic rank, and years in practice), and attitudes toward fairness in compensation was collected. Setting Online survey. Participants FMIGS graduates practicing in the United States. Intervention E-mail survey. Measurements and Main Results We surveyed 298 US FMIGS surgeons who had graduated during the last 10 years (2009–2018). The response rate was 48.7%. Most of the respondents were women (69%). Most of the graduates (84.8%) completed 2- or 3-year fellowship programs. After adjustment for inflation, the median starting salary for the first postfellowship job was $252 074 ($223 986–$279 983) (Table 1). The median time spent in the first job was 2.6 years, and the median total salary at the current year rose to $278 379.4 ($241 437–$350 976). The median salary for respondents entering a second postfellowship job started at $280 945 ($261 409–$329 603). Significantly lower compensation was reported for female FMIGS graduates in their initial postfellowship jobs and was consistently lower than for that of men over time. Most FMIGS graduates (59.7%) reported feeling inadequately compensated for their level of specialization. Conclusion A trend toward higher self-reported salaries is noted for FMIGS graduates in recent years, with significant differences in compensation between men and women. Among obstetrics and gynecology subspecialists, FMIGS graduates earn significantly less than other fellowship-trained physicians, with median salaries that are lower than those of generalist obstetrics and gynecology physicians.

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.

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.

Pelvic pain is common in both reproductive age and postmenopausal women, and the major etiologies change throughout the life cycle. Chronic pain is defined as lasting for at least 6 months. There are many gastrointestinal and urinary disorders associated with chronic pain in this age group, which are not discussed in this guideline. Pain may be localized to the deep pelvis, with potential causes including pelvic congestion syndrome, intraperitoneal adhesions, hydrosalpinx, chronic inflammatory disease, or cervical stenosis. Ultrasound is the initial imaging modality of choice, while CT and MRI may be appropriate for further characterization of sonographic findings. Alternatively, pain may be localized to the vagina, vulva, or perineum, with potential causes including vaginal atrophy, vaginismus, vaginal or vulvar cysts, vulvodynia, or pelvic myofascial pain. Imaging is primarily indicated in context of an abnormal physical exam and ultrasound is the initial modality of choice, while MRI may be appropriate for further characterization in select cases. 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.

Study Objective The objective of this video is to review relevant surgical anatomy, resection and ablation methods, and techniques to optimize management of diaphragmatic endometriosis. Design Video footage of surgical anatomy and surgical technique. Institutional review board approval was not required. Setting Thoracic endometriosis lesions can involve the pleura, the lung, and the diaphragm. The prevalence of thoracic endometriosis is unknown, but most cases involve the diaphragm. A large percentage of patients are asymptomatic. Those who are symptomatic can present with cyclic shoulder pain, right upper quadrant pain, or catamenial pneumothorax. Symptomatic cases refractory to medical management or recurrence require surgical management [ 1 , 2 ]. Safe and efficient management of these cases depends on an experienced multidisciplinary team. In this video, the experiences and management tools used by our team are described. Interventions Laparoscopic management of primary and recurrent symptomatic diaphragmatic endometriosis. (1) The surgeon performing these procedures must be familiar with liver, diaphragmatic, and thoracic anatomy. (2) Preoperative magnetic resonance imaging should be used to map suspicious lesions. (3) Bronchoscopy should be available for double-lumen endobronchial tube placement for selective ventilation. (4) The operating room should have video-assisted thoracoscopy capability, and a thoracic surgeon should be available. (5) Intercostal nerve block with liposomal bupivacaine can be useful for postoperative pain control [ 3 , 4 ]. Conclusion A multidisciplinary skilled team approach to the surgical management of diaphragmatic endometriosis to optimize outcomes is preferred.

The objective of this study is to review an evidence-based approach to surgical treatment of key chronic pelvic pain (CPP) contributors emphasizing the importance of preoperative evaluation and counseling.CPP is a poorly understood but highly prevalent condition and there are limited, well constructed studies to guide effective, durable treatment. CPP arises from factors originating in multiple organ systems, including reproductive, urologic, gastrointestinal, and myofascial, all informing the central nervous system. For those with severe disabling conditions, who have a suboptimal response to medical management, surgical interventions can be offered for diagnostic evaluation and/or treatment. Leiomyoma, adenomyosis, adnexal disorder, pelvic adhesions, and pelvic varicosities are common considerations in the differential diagnosis of CPP amenable to surgical approach.Surgical treatments of CPP range from conservative/fertility-sparing approaches to extirpative therapy. Consistently, successful outcomes often are predicated on correctly identifying the abnormal peripheral pain process (which often is only part of the complete picture for these patients). Further research is needed to better guide clinicians as to when to choose surgical therapy vs. targeting secondary contributors to pelvic pain.

This project uses an ex vivo human perfusion model for studying transport in benign, fibrous tumors. The uterine arteries were cannulated to perfuse the organ with a buffer solution containing blood vessel stain and methylene blue to analyze intratumoral transport. Gross examination revealed tissue expansion effects and a visual lack of methylene blue in the fibroids. Some fibroids exhibited regions with partial methylene blue penetration into the tumor environment. Histological analysis comparing representative sections of fibroids and normal myometrium showed a smaller number of vessels with decreased diameters within the fibroid. Imaging of fluorescently stained vessels exposed a stark contrast between fluorescence within the myometrium and relatively little within the fibroid tissues. Imaging at higher magnification revealed that fibroid blood vessels were indeed perfused and stained with the lipophilic membrane dye; however, the vessels were only the size of small capillaries and the blood vessel coverage was only 12% that of the normal myometrium. The majority of sampled fibroids had a strong negative correlation (Pearson's r=-0.68 or beyond) between collagen and methylene blue staining. As methylene blue was able to passively diffuse into fibroid tissue, the true barrier to transport in these fibroids is likely high interstitial fluid pressure, correlating with high collagen content and solid stress observed in the fibroid tissue. Fibroids had an average elevated interstitial fluid pressure of 4mmHg compared to -1mmHg in normal myometrium. Our findings signify relationships between drug distribution in fibroids and between vasculature characteristics, collagen levels, and interstitial fluid pressure. Understanding these barriers to transport can lead to developments in drug delivery for the treatment of uterine fibroids and tumors of similar composition.

Essure hysteroscopic sterilization has been US Food and Drug Administration-approved in the United States since 2002. Complications associated with the Essure device include improper placement (malpositioning), unintended pregnancy, pain, infection, and nickel allergy. The rarity of complications, compounded by underreporting, makes it difficult to determine best practices insofar as management. This systematic review synthesizes the national and global experience with management of Essure-related complications and suggests treatment options when data allow.

Study Objective The Fellowship in Minimally Invasive Gynecologic Surgery (FMIGS) is a postresidency fellowship developed with the mission to train the next generation of minimally invasive gynecologic surgeons. The need for surgeons trained in this field has increased, yet there remains a paucity of information regarding the compensation of these specialized surgeons. Design A survey was sent via e-mail to FMIGS graduates (N = 221) using an online survey tool; it was sent twice more to increase the response rate between July and December 2013. The survey collected information on current and starting salaries and benefits as well as academic rank, location, practice type, and practice breadth. Comparisons were analyzed using multivariable linear regression models (Canadian Task Force Classification II-2). Setting E-mail–based survey. Patients Graduates of the FMIGS. Interventions A single survey sent 3 times. Measurements and Main Results Of 221 graduates surveyed, 164 responded (response rate = 74%). Sixty-one percent of respondents (n = 100) were from academic institutions, and the remainder were from private practice (n = 64). Of all respondents, 27 (16.5%) reported less than 1 year of postfellowship experience and had a median starting salary of $216 399 (range, $106 834–$542 930). Survey respondents were on average 3.3 years (range, 0–14) out of fellowship with a median salary of $238 198 (range, $108 200–$993 765). Academic surgeons (average experience = 3.4 years) earned $208 743 (range, $106 834–$542 930) compared with private practice surgeons (average experience = 3.2 years) who earned $233 020 (range, $115 000–$454 448). Conclusion Salaries and compensation benefits of graduates of the FMIGS are varied. This information is very relevant to those attempting to hire or become employed as gynecologic surgical specialists.