Table 1.

Recommended rationalization of ultrasound scans for gynecological indications in context of COVID‐19 pandemic

Priority	Action/allocation	Clinical scenario
NOW	Patient should present without delay to emergency department for immediate investigation	Acute persistent pelvic pain ‐ Ovarian torsion ‐ Ruptured hemorrhagic ovarian cyst ‐ Pelvic inflammatory disease and/or tubo‐ovarian abscess Postoperative/procedure complications Ovarian hyperstimulation syndrome Abdominopelvic ‘mass’ with symptoms (e.g. distension secondary to ascites) Abnormal uterine bleeding ‐ Menorrhagia with severe anemia or hemodynamic instability
SOON	Ultrasound can be delayed for 2–4 weeks	Abnormal uterine bleeding ‐ Postmenopausal bleeding ‐ Postcoital bleeding Abdominopelvic ‘mass’ ‐ High risk of malignancy as per IOTA‐ADNEX model (≥ 10%) Ultrasound staging for biopsy‐proven or incidentally diagnosed (during unrelated imaging) gynecological malignancy, if useful for management Signs of recurrent gynecological malignancy Family history of gynecological malignancy with genetic predisposition (e.g. BRCA positive)
LATER	Ultrasound evaluation should be postponed for duration of pandemic   Patients may still be referred for ultrasound assessment, but appointments will not be given until pandemic is over; appropriate systems should be put in place to ensure appointments take place at a later date	Abnormal uterine bleeding, non‐severe, in non‐postmenopausal patients ‐ Breakthrough bleeding while on hormonal medication ‐ Heavy menstrual bleeding/menorrhagia without associated anemia ‐ Infrequent menstrual bleeding (oligomenorrhea) ‐ Intermenstrual/irregular bleeding ‐ Perimenopausal abnormal uterine bleeding Non‐acute pelvic pain ‐ Chronic pelvic pain ‐ Cyclical dyschezia ‐ Dysmenorrhea ‐ Dyspareunia Family history of gynecological malignancy (no genetic predisposition known/identified) Incontinence Infertility and recurrent pregnancy loss Prolapse Review of previously noted ‘likely benign’ adnexal pathology ‐ Unilocular cyst ‐ Endometrioma ‐ Dermoid/mature cystic teratoma ‐ Hemorrhagic ovarian cyst (including corpus luteal cyst) ‐ Hydrosalpinx ‐ Low risk of malignancy as per IOTA‐ADNEX model (< 10%) Review of previously noted pelvic pathology ‐ Uterine polyp(s) ‐ Leiomyoma(s) ‐ Adenomyosis ‐ Endometriosis Review of intrauterine contraceptive device Postmanagement of gynecological malignancy without signs or symptoms of recurrence

BRCA, breast cancer gene; IOTA‐ADNEX, International Ovarian Tumor Analysis Assessment of Different NEoplasms in the adneXa.