An overview of GYN Ultrasound

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1 An overview of GYN Ultrasound Johanna R. Jorizzo, M.D. Associate Professor Of Radiology Associate Professor of OB/GYN Wake Forest School of Medicine Wake Forest School of Medicine Winston-Salem, North Carolina 1

2 Septate Uterus Most common mullerian duct anomaly (55%) Complete when septum extends to the external cervical os External uterine contour convex, flat or mildly (< 1 cm.) concave) Often treated with hysteroscopic resection of septum Bicornuate Uterus 10% of mullerian duct anomalies Cleft of at least 1 cm. of the external fundal contour 40 yo with dysfunctional uterine bleeding Uterus Didelphys: 5% Each mullerian duct develops its own hemiuterus and cervix 2

3 64 yo with postmenopausal bleeding 45 yo with prolonged periods 3

4 47 yo with dysfunctional uterine bleeding; Hemoglobin yo G3 with painful, heavy periods 4

5 42 yo with dysfunctional bleedingheavy, painful, clots 5

6 Premenopausal heavy menses; pelvic pain 6

7 Uterine myometrium Uterine fibroids Focal (discrete mass) Non tender uterus (usually) Hypoechoic with streaky shadowing Often nulliparous Prolonged menses Adenomyosis Diffuse (occ. focal adenomyoma) Tender, enlarged uterus Ht Heterogeneous myometrial ti echotexture with indistinct endometrial myometrial interface; asymm wall thick Subendometrial cysts Multiparous (usually) Painful, heavy menses Premenopausal with dysfunctional uterine bleeding 7

8 36 yo cramps; heavy menses 45 yo with irregular bleeding 8

9 Endometrium How thick is too thick? 9

10 Abnormal Endometrial Thickness Endometrial Hyperplasia Endometrial Carcinoma Endometrial lpolyp (Prolapsed) submucosal fibroid 56 yo with an episode of vaginal bleeding DDX: Secretory phase endometrium 54 yo PMB 10

11 PMB h/o Tamoxifen 11

12 12

13 Tamoxifen Estrogen antagonist in the breast/ Partial estrogen agonist in the uterus: Increased incidence of: 1.Endometrial hyperplasia 2. Endometrial carcinoma 3. Endometrial polyps 4. Subendometrial cysts Postmenopausal bleeding 13

14 70 yo bleeding x 4 mos 14

15 PMB 290 lbs 15

16 64 yo bleeding x 6 mos 16

17 Recent IUD placement ; pain and spotting Difficult IUD placement today 17

18 24 yo with RLQ pain 18

19 18 yo with LLQ pain 19

20 21 yo with tender right adnexal mass on exam 20

21 SRU Consensus Recommendations 2010 Premenopausal Cysts: 1. Up to 3 cm: Normal; No F/U cm.: Describe as benign; no F/U 3. >5 7 cm.: Describe as likely benign; yearly F/U 4. >7 cm.: Surgery (MR) (risk of incomplete evaluation, torsion) SRU Consensus Recommendations 2010 Postmenopausal Cysts: 1. Up to 1 cm.: Insignificant; no F/U cm.: Likely benign; yearly F/U 3. >7 cm.: Surgery (MR) (risk of torsion, incomplete assessment with US) SRU Consensus Recommendations 2010 Hemorrhagic Cysts: (Women of reproductive age) 1Upto 1.Up 3 cm.: May describe: no F/U cm.: Describe; no F/U 3. > 5 cm.: Describe; F/U 6 12 wks. to ensure resolution SRU Consensus Recommendations Up to 5 yrs. Postmenopause: F/U hemorrhagic cyst 6 12 wks. (occ. Ovulation) 2. Late Postmenopause: Should never have a hemorrhagic cyst surgery 21

22 44 yo with chronic pelvic pain cyclical Severe pelvic pain, worse during menses, infertility 22

23 Endometriosis Functional end l tissue outside uterus Microscopic implants to large endometriomas, adhesions Asymptomatic to severe pain, infertility ili 5 10% women, mean age dx sites: uterus, ovaries, pouch of Douglas, rectosigmoid, fallopian tubes, occ. urinary tract, C section scars and skin Endometriosis Ultrasound findings Endometriomas often occur within the ovaries=repeated hemorrhage May completely replace normal ovarian tissue Thick wall, low level, l l regular echoes with through transmission (95%)* A specific feature =echogenic wall foci (35% vs 6% of non endometriomas) * cholesterol deposits *( Patel et al in Radiology1999) 30 yo acute onset pelvic pain 23

24 24

25 Ovarian Torsion Rare cause of acute abdominal pain (2.5% of all GYN emergencies) Underlying ovarian tumor in 50 80% (dermoids/paraovarian cysts) Often present with a midline mass above the uterine fundus Symptoms similar to acute appendicitis Ovarian Torsion US Nonspecific DDx hemorrhagic cyst/endometriosis/pid/ectopic pregnancy Findings related to degree, complete or incomplete, and duration of torsion; presence or absence of associated mass or hemorrhage Multiple peripherally oriented follicles in a unilaterally enlarged ovary =detection rate of 64% May see pelvic free fluid Ovarian Torsion Ultrasound 87% with twisted vascular pedicle=broad ligament, fallopian tube, adnexal and ovarian branches of the uterine artery and vein Whirlpool sign =color Doppler demonstration of flow within twisted vascular pedicle Lack of flow seems to correlate with hemorrhagic necrosis of ovaries in most studies Presence of venous flow in the ovaries tends to correlate with viability Ovarian Torsion Ovary ALWAYS enlarged Usually SEVERE pain often with vomiting Often unusual position of the ovaryanterior to the uterus/posterior(deep) in the cul desac 22 yo with amenorrhea 25

26 Polycystic Ovaries 1. >12 peripherally located ovarian follicles 2. Follicles <10 mm. in diameter 3. Ovarian volume >10 ccs. 4. Stroma usually very vascular (vs. decreased vascularity seen with small follicles in patients on OCPs) 56 yo with abnormal appearance of the adnexa on CT scan 26

27 Ovarian Neoplasms Cystic Epithelial Neoplasm Serous/Mucinous 60% of ovarian neoplasms 80 90% of ovarian carcinomas Benign Low Malignant Potential Malignant Malignant Features: Solid components, mural nodules, especially with internal blood flow; Thick septations, irregular septations; Doppler flow central, within septae; Free fluid; Metastases peritoneal implants, omentum, liver surface Ovarian Neoplasms % Germ Cell Tumors: Teratoma: Mature/Immature/Monodermal/Mixed Dysgerminoma Yolk sac tumor Embryonal carcinoma Choriocarcinoma Ovarian Neoplasms 5% Sex Cord Stromal Tumors Granulosa Cell (Estrogen) Sertoli Leydig (Androgen) Both low malignant potential Fibroma Thecoma Benign Ovarian Neoplasms <10% Metastasis: GI >50% stomach, breast, lymphoma, uterus (solid) colon, appendix, biliary (multilocular or solid) >50% bilateral Breast 27

28 47 yo with a palpable mass right adnexa on routine exam 28

29 45 yo w/pelvic pressure 29

30 42 yo incidental finding 46 yo with pelvic complex mass on outside CT scan 30

31 42 yo with dysfunctional uterine bleeding 31

32 Mature Cystic Teratoma(Dermoid Cyst) 8 15% bilateral Classic ultrasound features: tip of the iceberg (shadowing fat/hair) Dermoid plug/mural (Rokitansky) nodules Dermoid mesh/ spaghetti (hair) Fat/fluid level (sebum layered on serous fluid) Floating fat ball (hair) rare SRU rec.< 7cm. f/u 6 12 mos. then yearly 2 3% malignant degeneration (squamous cell). Positive pregnancy test 32

33 24 yo with palpable adnexal mass 33

34 Incidental finding on transabdominal scan PMB; cyclical; breast tenderness 34

35 Granulosa Cell Tumors 1 2% of ovarian tumors most often postmenopausal (peak yo) Most common clinically estrogenic tumors 5% with ihassociated endometrial carcinoma Low grade malignancy/malignant potential Small ones usually solid; larger multiloculated/cystic like cystadenomas 92 yo with postmenopausal bleeding 35

36 52 yowith PMB 68 yo asymptomatic 36

37 24 yo with 7wk IUP 37

38 Dysgerminoma Malignant Germ Cell Tumor Represents 3 5 %of ovarian malignancies 10 17% bilateral Solid, multilobulated with a fibrovascular septa One of the two (along with serous cystadenoma) most common ovarian neoplasms seen in pregnancy H/O hysterectomy; pelvic pain Grows rapidly but metastasizes late favorable prognosis 38

39 23 yo w/ IUD; pelvic pain, discharge, cervical motion tenderness 39

40 FINALMENTE! 40

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