4.6 Uterus Flashcards
Normal endometrial thickness
<4 mm menstrual, 4-8 mm proliferative (GnRH and FSH; d 4-14), 7-14 mm secretory (progesterone from corpus luteum, d 14-28); measured from hypoechoic to hypoechoic (subendometrial halo)
US findings at time of ovulation (<36 hours away)
Decreased echogenicity surrounding follicle
Irregular follicular wall (crenation)
Small echogenic core of tissue projecting into follicle (cumulusoophorus)
Sudden complete collapse of follicle at ovulation, with fluid in pouch of Douglas
Indications and contraindications for HSG
Performed days 7-12 menstrual cycle, 4-10 mL 28% water soluble contrast
6 Fr Foley catheter
Indications Infertility Recurrent miscarriage Postoperative following tubal ligation Preoperative before myomectomy
C/I if pregnant, active pelvic infection, uterine surgery in last 3 days
Normal tubal length 12-14 cm
Doxycycline occasionally given if dilated tubes / adhesions as risk of tubo-ovarian abscess
Complications: Bleeding, infection, contrast reaction, uterine injury
Uterine and ovarian MRI
T2W Signal (indistinct postmenopause) Endometrium - high Junctional zone - low Peripheral myometrium - intermediate Epithelium, mucus - high Ovary (reproductive) - low stroma, high follicles
Congenital Mullerian Duct Anomalies
Prevalence of 2-3%; 50% have renal anomalies (ipsilateral agenesis is commonest, renal ectopia
Class I - absent Mullerian ducts (very rare): Agenesis vagina, uterus, uterine tubes
Class II - agenesis / absent unilateral MD: Unicornuate uterus
Class III - lack of MD fusion; abnormal external contour: Uterus didelphys
Class IV - partial MD fusion; abnormal external contour: Bicornuate uterus
Class V - septation (commonest overall anomaly); normal external contour; on HSG - intercornuate distance <75º:
Fibrous septum - highest incidence of infertility as cannot implant
Complete septate (extends to cervical canal)
Partial septate (cavity alone)
Class VI: Arcuate uterus (normal variant)
Class VII: Associated with diethylstilboestrol exposure - causes uterine hypoplasia, T shaped uterus, increased risk clear cell cancer of vagina
Mayer-Rokitansky-Hauser Syndrome
MD dysgenesis with vaginal / uterine agenesis
Normal karyotype and normal secondary sex characteristics
Renal anomalies
Normal ovaries, increased risk endometriosis
Causes of female infertility
Ovulatory dysfunction (30-40%) Hyperprolactinaemia (drugs, PRL producing tumours) PCOS Tubular dysfunction (30-40%) Adhesions Tubular damage Endometriosis Adenomysosis Leiomyoma
Gestational trophoblastic disease
Chorionic tissue that undergoes hydropic change but continues to produce chorionic gonadotrophins
Causes enlarged uterus with multiple small (3-10 mm) anechoic areas in uterine cavity
Hydatidiform mole
Complete (majority): Hydropic enlargment of chorionic villi, with multiple vesicles of varying size, rarely associated fetal tissue, causes hyperemesis gravidarum, enlarged uterus, heavy first trimester bleeding ± hydropic placental tissue passed PV, ovarian cysts (theca lutein) common
Partial / incomplete: Dysmorphic fetus (often triploid)
Chorioadenoma destruens (<10%): Locally invasive, nonmetastatic
Differential: Hydropic placental degeneration post incomplete abortion, mxyoid degeneration of fibroid, RPoC, Endometrial proliferative disease
Choriocarcinoma
Often but not necessarily post pregnancy, can arise in ovary or testis, no recognisable villous structures with synctial and cytotrophoblasts interspersed between areas of haemorrhage and necrosis
Myometrial invasion ± Haematogenous dissemination to lungs, liver, kidneys, brain and GIT
US: Similar to hydatidiform mole
Theca lutein cysts persisting at 3-4 months post uterine evacuation suggest residual disease
Pelvic Inflammatory Disease US
US: One third normal, fluid filled uterus, thick echogenic tubes, hydro- / pyosalipnx ± adnexal or Pouch of Douglas collections
Asherman Syndrome
Uterine cavity synechiae due to trauma, infection or D&C; can cause infertility
IUCD Complications
Embedding
Perforation
Increased risk PID (x3 risk)
Actinomycosis
Uterine TB
Usually involves fallopian tubes
HSG: Almost always bilateral and asymmetrical, flask-shaped dilatation / sacculation of fallopian tubes (due to fimbrial obstruction) ± tubal calcification, with tubal shortening and rigidity; ultimately leads to obliteration of uterine cavity in later disease
Endometrial carcinoma
Commonest gynaecological malignancy, 85% adenocarcinoma, postmenopausal with unopposed oestrogen risk factors (i.e. nulliparity, failed ovulation, obesity, late menopause)
Thickened endometrial stripe (>8 mm postmenopausal, >15 mm premenopausal), with thinning of inner myometrium suggestive of myometrial invasion (deep invasion if obliteration of hypoechoic layer)
Stage 1 and 2 - confined to uterus; 3 & 4 extrauterine
Metastasis - aortocaval and pelvic LNs, liver, lungs, brain
Endometriosis sites
Ovaries (75%) > Pouch of Douglas (70%) > broad / uterosacral ligaments (35%) > uterus and fallopian tubes > GIT (12-37%, usually rectosigmoid) > urinary tract > chest / soft tissues
Rare (<1%) malignant transformation, 75% from ovary - usually endometroid carcinoma
