Gynecological Ultrasound
Transabdominal Pelvic Ultrasound: Sagittal Orientation Anterior Head Foot Transvaginal Posterior
TA TV
Uterus; Sagittal View Abdominal and Transvaginal Pre-menarchal Adult Post-menopausal
Endometrium Proliferative Secretory Menstrual Postpartum Post-menopausal Post-menopausal + HRT Normal Sonohysterogram (Hysterosonogram)
Ovaries Pre-menarchal Adult Post-menopausal
Follicular Development and Ovarian Flow Day 10 Day 12 Early luteal Late luteal
Colour doppler Vascular anatomy Confirmation of normal architecture Exploration of unusual or abnormal architecture Patterns of shape and distribution Guide for pulsed doppler Location and identity of vessels Direction of interrogation Non-vascular Fluids in motion Surfaces in motion
Doppler Wave Forms and Arterial Structure
Sites for Colour and Pulsed Doppler Detection in Normal and Abnormal Ovaries
Neovascularization New blood vessel formation Benign conditions Ovulation (follicular development) Corpus luteum Placentation Ectopic pregnancy Wound healing Arthritis Chronic inflammation Benign tumors Endometriomas Occasional fibroids Malignancies
Pelvic Tumor Neovascularity
Optimizing Low Velocities and Small Vessels Colour doppler Wall filters 0 Persistance 0 Gain, short of widespread artifact Other settings specific to machine e.g. Siemens Versa has a low velocities setting A steady hand (minimize transducer motion) Pulsed doppler All of the above plus; Angle of insonation (parallel vs. perpendicular) Angle adjustment Open gate Multiple small vessels Tortuous vessels Systematic search of multiple vessels Central, perpheral,septal, papillary projections, areas of cyst wall thickening
Neoplastic Risk in Adnexal Masses Risk is age and state dependent High Intermediate Low 0 0.2 0.4 0.6 0.8 1.0 Resistance Index
Borderline Serous Cystadenoma
Endometriosis, Adenomyosis, Endometriomas Endometriosis no signs Adenomyosis thickened uterine wall Endometrioma ovarian mass
An Endometrioma
Cervical Cancer Ultrasound useless for either screening or diagnosis
Congenital Malformations of Uterus the Reproductive Tract Bicornuate Septate Didelphus Rudementary horn Gartner s duct cysts
Abnormal Endometrium Polyps Submucosal fibroids Synechiae Retained products of conception Tamoxifen Endometrial hyperplasia/cancer Hematocolpos Cervical stenosis IUCDs
Small Endometrial Polyp
Endometrial Polyp
Another Small Endometrial Polyp
Endometrial Polyp
Endometrial Carcinoma Detectable flow is unusual in Normal endometrium Atrophic endometrium Most endometrial hyperplasias Flow is usually detectable (91%) of endometrial Ca Flow pattern shows low resistance (average RI ~ 0.42)
IUCD
Abnormal Myometrium Fibroids Leiomyosarcoma
Myometrial Tumors Fibroids (Myomas, leiomyomas) peripheral vascularization Leiomyosarcoma thin irregularly spaced vessels some end-diastolic flow (e.g. RI = 0.6) Low velocities (<= 17 cm/sec) necrotic and inflammatory change increases end-diastolic flow - may overlap malignant range high end-diastolic flow(ri < 0.4)
Abnormal Cervix Nabothian cysts Incompetent cervix Cervical fibroids Cervical carcinoma Double cervix
Nabothian Cysts
Fallopian Tubes Hydrosalpynx Pyosalpynx Tubovarian abcess Ectopic pregnancy Fallopian tube carcinoma
Hydrosalpynx
Ectopic pregnancy Tubal ring (fluid in tube) Gestational sac +/-embryo or yolk sac FHR in real time, M-mode, colour, or pulsed doppler Movement relative to ovary on the same side Free fluid in cul-de-sac +/- behind adnexae Ovary (usually on the same side) with a corpus luteum Increased end-diastolic blood flow in vessels in the mass RI < 6
Acute PID Early on, there may be no U/S signs Free fluid in cul-de-sac +/- behind adnexae Fluid in endometrial cavity Fluid in lumen of fallopian tubes No typical changes in doppler patterns or indices Follicles (infected), with fuzzy margins
Tubovarian Abcess Complex, hypoechogenic, septated mass Acoustic enhancement Absent colour doppler blood flow in mass Ill-defined margins Fluid in cul-de-sac Loss of anatomical landmarks as disease becomes chronic
Chronic PID Hydrosalpynx Tubular anechoic structure Absent colour doppler blood flow i.e. not a vessel Mucosal folds and nodular projections Pyosalpynx Internal echoes Absent colour doppler blood flow Adjacent ovary may indent tube wall
Fallopian Tube Carcinoma Rare, <1% of gynecological cancers Average age 52 years (peri- or postmenopausal) Adnexal mass with mixed echogenicity Ovary on same side normal and adjacent May be sausage-shaped As it grows along and within the tube Low RI in supply vessels (one case 0.35)
Fallopian Tube Carcinoma
Ovaries Cysts Simple Complex PCO Ovarian hyperstimulation Solid and cystic Dermoids Solid Para-ovarian
Ovarian Hyperstimulation
Ovarian Hyperstimulation
Resistance Patterns in Ovarian Masses High resistance (RI 1<>0.6) Cystadenomas, hemorrhagic cysts, dermoid tumors, endometriomas Intermediate resistance (RI 0.6<>0.4) Dermoid tumors, endometriomas Low resistance (RI 0.4<>0) Ovarian cancer, inflammatory masses, endometriomas, dermoids, corpus luteum
Simple Thin-walled Anechoic Cyst
Septated Ovarian Cyst
Suspicious Ovarian Cyst Borderline Serous Cystadenoma
Borderline Cystadenoma
Ovarian Cancer Issues Normal time of clinical diagnosis is very late Large abdominal mass, ascites, multiple metastases Low cure rate ~30% High mortality 75% High morbidity Early detection (Stage 1) 75-96% survival Current screening tools insensitive and not specific enough Symptoms Bimanual exam Ca-125 Transvaginal ultrasound