Women's imaging, concentrating on the health and pathology of 51.9% of the total US population,1 is gaining recognition as a new subspecialty. Less similar to organ-based subspecialties, women's imaging is more like the mature subspecialty of pediatric radiology in addressing health problems that are unique to a large subset of the population. Although many disease processes cross both age and sex boundaries, the too-often repeated observation that children are not just small adults justifies the existence and growth of pediatric radiology as a multimodality, multiorgan system subspecialty. Women, too, have physiologies and pathologic processes different from those of men, and a subspecialty similar to pediatric radiology in its scope and organization is evolving to provide consultative expertise to clinicians-obstetrician-gynecologists, internists, family practitioners, and emergency physicians.

The genesis of women's imaging can be explained partly by the bonding of medical needs and new technologies, but there are broader political considerations to this new subspecialty. Bone densitometry, hysterosonography, pelvic MRI, technetium sestamibi scans, and breast MRI and ultrasound in addition to mammography call on the expertise of subspecialists in women's imaging for advising patients and clinicians about the benefits of hormone replacement therapy or endometrial side effects of tamoxifen treatment for breast cancer.

Greater funding for research and a higher profile in general have accrued to radiology because women's health issues are politically hot. A federal agency, The Office of Women's Health, in the Department of Defense, has earmarked multimillion-dollar grant awards for breast cancer research. Mammographic screening for breast cancer is the most developed expression of women's health issues, and consumer demand for low-cost, convenient, high-quality studies, and pressure for government regulation to achieve minimum standards for these radiologic examinations, are a first. Bathed in a political spotlight, with many attendant crises related to false negatives and overcalling abnormalities, mammographic screening for breast cancer has brought radiology and radiologists into the medical foreground with the passage in 1992 of the Mammography Quality Standards Act (MQSA), administered by the Food and Drug Administration and based on the American College of Radiology's rigorous voluntary quality assurance program. Although there is general agreement that mammographic screening has reduced mortality from breast cancer by about 30%, every so often (1993, 1997, and 2002), there is rumbling about the efficacy of screening for breast cancer. Epidemiologists are at odds with diagnostic radiologists and oncologists. Is the negativity related to economic factors or to academic squabbles? It would be tragic to lose ground we have gained against breast cancer, the most common cancer in women.

A Double-edged Sword

Gender focus, however, works in two directions. It works not only to benefit women in the evolution of a new subspecialty within diagnostic radiology but can come into play as reverse gender bias. Women have favored and have even demanded that their physicians also be women because of the increased sensitivity and empathy for women's problems that is attributed to women physicians. For many reasons, this prejudice against men should be discouraged. Skilled, knowledgeable practitioners, men and women, should have equal opportunity to practice in the areas of interest and expertise. Competence should not be assessed by gender. The marketing of women's imaging seems to require the hiring of women radiologists, discouraging men from entering this field. Another negative result of female predominance that can be expected is an income differential, with less income for women physicians than for their male equivalents.

Turning to the practical aspects of women's imaging, this subspecialty fits in well within the structure of managed care medicine. Women's imaging, because of its clinical strength, can also counter some of the raids on radiologic turf that have resulted in shifting from diagnostic radiology the areas of obstetrical ultrasound, vascular ultrasound, and coronary arteriography. In some established radiologic subspecialties, responsibility for patient care has replaced film reading. Breast imaging (and interventions), housed in breast and women's imaging centers, has evolved as has interventional radiology, with the radiologist playing an active role in the management of nonpalpable breast lesions and provision of a histologic diagnosis through core biopsy.

In response to patient demand for these services and medical efficiency, women's imagers need to work closely as both consultants and orchestrators of patient management. In recognition of the fact that additional training is needed for effective practice of this subspecialty, women's imaging fellowships were developed, the first offered in 1992 by Amy Thurmond, MD, then at the University of Oregon. A second fellowship, at The Western Pennsylvania Hospital in Pittsburgh, was begun shortly thereafter. Each year there are greater numbers of these fellowships offered nationally, with curricula in breast imaging, pelvic ultrasound, MRI and CT, bone densitometry, and percutaneous procedures, image-guided, both for diagnosis and, in some instances, for therapy. Although widespread loss of obstetrical sonography from departments of radiology handicaps the training of radiologists in women's imaging, many of these fellowships make provisions for the needed familiarity with obstetrical sonography. Most of the fellowships are 1 year, and some of them, recognizing the need for clinical experience as well as imaging expertise, include rotations in pathology and breast and gynecologic surgery. For practicing physicians, the arrival of subspecialization in women's imaging has been formalized with the institution of the Society for the Advancement of Women's Imaging (SAWI), now a member of the American College of Radiology's Intersociety Commission. The society first met informally in 1992 as radiologists with common interests shared experiences and discussed the potential for developing a subspecialty within diagnostic radiology. The society has grown and, as part of its mission, has begun to detail training requirements and fellowship listings. A continuing medical education course sponsored by SAWI will again be offered in May 2002, to bring practitioners up-to-date in the subspecialty, assessment of its accomplishments, and its incorporation into the medical care of women.

Ellen B. Mendelson, MD, is medical director, breast imaging, Lynn Sage Comprehensive Breast Center, and professor, radiology department, Northwestern University Medical School, Chicago. Portions of this editorial are adapted from Mendelson EB. Women's imaging. Radiology. 1998

References:

1. Reiter RC. The health of women: a current perspective. In: Moore TR, Reiter RC, Rebar RW, Baker VV, eds. Gynecology & Obstetrics: A Longitudinal Approach. New York: Churchill Livingstone Inc; 1993:1-14.