Adnexal Path

Question 1

Describe the ultrasound assessment of the ovaries and adnexae

Answer 1

Assessment of the ovaries:
○ Size 
○ Classification in context of menstrual cycle
○ Number and size of follicles
○ Mobility
○ Relationship to pain
○ Evidence of pathology
Women with PID or endometriosis may have the ovaries in an abnormal position

Question 2

What is PCOS?

Answer 2

Polycystic ovarian syndrome
LH levels are elevated
FSH is depressed
Results in abnormal oestrogen and androgen production
Results in chronic anovulation

Question 3

What are the symptoms of excessive androgen production?

Answer 3

• Greasy skin
• Acne
• Hirsutism
• Androgenic alopecia

Question 4

What is PCOS associated with?

Answer 4

• Obesity, abnormal carbohydrate metabolism and disturbance of lipid profile
• Increased risk of endometrial and ovarian carcinoma, diabetes and cardiovascular disease

Question 5

What is the difference between PCO and PCOS?

Answer 5

PCO is an ultrasound diagnosis.

Clinical manifestations and/or bloods = PCOS

Question 6

Describe the criteria for PCOS diagnosis

Answer 6

Ultrasound should not be used for the diagnosis of PCOS in those with a gynaecological
age of < 8 years (< 8 years after menarche), due to the high incidence of multi-follicular
ovaries in this life stage.

Using endovaginal ultrasound transducers with a frequency bandwidth that includes 8MHz,
the threshold for PCOM should be on either ovary, a follicle number per ovary of > 20 and/or
an ovarian volume ≥ 10ml, ensuring no corpora lutea, cysts or dominant follicles are present

In patients with irregular menstrual cycles and hyperandrogenism, an ovarian ultrasound
is not necessary for PCOS diagnosis; however, ultrasound will identify the complete
PCOS phenotype.

Question 7

What are the functional cysts of the ovaries?

Answer 7

Follicular cyst
corpus luteum
Theca lutein cyst
haemorrhagic cyst

Question 8

What is a follicular cyst?

Answer 8

Follicular cyst develops when a mature follicle fails to ovulate or to involute. Follicular cyst cannot be diagnosed unless it’s larger than 2.5cm.

Question 9

What is a corpus luteum?

Answer 9

Corpus luteum contains low level internal echoes, frequently with a thicker wall than a follicle and a crenulated appearance. Peripheral rim of colour. Usually involutes before menstruation but may persist because of failure of absorption or internal bleeding. Usually unilateral, prone to hemorrhage and sometimes rupture.

Question 10

What is a theca lutein cyst?

Answer 10

Theca lutein cysts are associated with high B-HCG. Largest of the ovarian cysts increasing the risk of ovarian torsion. Occur in patients with gestational trophoblastic disease but can also be seen as a complication of drug therapy for infertility causing ovarian hyperstimulation syndrome. Usually bilateral, multilocular and very large, may undergo hemorrhage or rupture.

Question 11

What is a haemorrhagic cyst?

Answer 11

An acute hemorrhagic cyst is usually hyperechoic and may mimic a solid mass. Smooth posterior wall, and acoustic posterior enhancement. There may be acute onset of pelvic pain.

Question 12

What is ovarian remnant syndrome?

Answer 12

A cystic mass may be encountered in a patient who has undergone bilateral oophorectomy due to a small amount of residual ovarian tissue that has been left behind
Residual ovarian tissue can develop functional cysts and produce pelvic pain
Cysts vary in size and can be both simple and hemorrhagic
Thin rim of ovarian tissue is usually present in the wall of the cyst

Question 13

What are hyperstimulated ovaries?

Answer 13

normal response to elevated circulating levels of hCG. Most common in women undergoing ovulation induction. The ovaries are enlarged with multiple cysts. Enlarged ovaries may undergo torsion. They usually regress spontaneously during pregnancy.

Question 14

What is ovarian hyperstimulation syndrome?

Answer 14

OHS is used when the hyperstimulation is accompanied by fluid shifts.
It can be mild, moderate and severe
Mild is associated with lower abdominal discomfort, no significant weight gain. Ovaries enlarged but less than 5cm in average diameter.
Moderate OHS presents with weight gain of 5-10 pounds and ovarian enlargement 5-12cm. May have nausea and vomiting.
Sever OHS there is weight gain of more than 10 pounds and the patient has severe abdominal pain and distention. Ovaries are > 12cm. Contain numerous large, thin walled cysts which may replace most of the ovary.

Question 15

What is hyperreactio luteinalis?

Answer 15

Hyperractio luteinalis: caused by an abnormal response to circulating hCG in the absence of ovulation induction therapy.
Approx 60% of these cases occur in singleton pregnancies with normal circulating levels of hCG
Usually occurs in the third trimester
Risk increases in women with PCO
There are bilaterally enlarged ovaries with multiple cysts similar to OHS, although the ovaries tend not to be as large and the condition occurs later in pregnancy
Resolves spontaneously

Question 16

What is a luteoma of pregnancy?

Answer 16

Luteoma of pregnancy: only solid mass in this group of pregnancy- related processes.
Rare benign process due to stromal cells that may have hormonally active producing androgens and replacing the normal ovarian parenchyma
Most patients with asymptomatic, maternal virilization may occur in 30% of patients
Patients have a 50% risk of virilization of the female fetus
Non specific, heterogeneous, predominantly hypoechoic mass that may be highly vascular

Question 17

What is a surface epithelial inclusion cyst?

Answer 17

Surface epithelial inclusion cysts: non functional cysts usually seen in postmenopausal women and are usually located peripherally in the cortex.
Arise from the cortical invaginations of the ovarian surface epithelium
Appear as punctate echogenicities in the surface of the ovary
Tiny, unilocular, thin walled, these cysts can measure up to several cm in diameter

Question 18

What are paraovarian cysts?

Answer 18

Paraovarian and paratubal cysts are wolffian or mullerian duct remnants in the mesosalpinx often located superior to the uterine fundus
Epithelium lined simple cysts rarely multiloculated or containing small wall nodularities
Small but may range in size up to 8cm
3rd and 4th decades
Most are asymptomatic but patients with large cysts may have pelvic pain or cysts may act as a fulcrum for torsion

Question 19

What is a peritoneal inclusion cyst?

Answer 19

Peritoneal Inclusion cysts seen in patients with peritoneal adhesions occurring mostly in postmenopausal women. Multiloculated cystic adnexal masses often with a bizarre shape frequently describe as a spider web pattern

Question 20

What is PCOS?

Answer 20

Polycystic Ovarian syndrome: known to be an multifaceted endocrinologic disorder of ovarian dysfunction that includes abnormal estrogen and or androgen production resulting in chronic anovulation and hyperandrogenism.

Question 21

What is the U/S appearance of PCOS?

Answer 21

Bilaterally enlarged ovaries containing multiple small 2-9mm follicles and increased stromal echogenicity
Rounded shape, follicles usually located peripherally
Increased ovarian greater than 10cc, 20 or more follicles

Question 22

What is endometriosis?

Answer 22

Endometriosis: presence of functioning endometrial tissue outside the uterus.
Most common benign gynecologic disorder
Causes pelvic pain, dysmenorrhea, dyspareunia, dyschezia, urinary symptoms and infertility
May present in different forms including; adnexal cysts, peritoneal plaques and adhesions, deep infiltrating endometriosis or nodules that contain glands and stroma
Most commonly involved areas in the pelvis are the fallopian tube, broad ligament and posterior cul de sac
Most common manifestation of endometriosis tissue is the endometrioma

Question 23

Describe the sonographic appearance of an endometrioma

Answer 23

Sonographically appears as a diffuse homogenous low level internal echoes
Endometriomas (chocolate cysts) are multiple with a variety of appearances from an anechoic cyst to a solid appearing mass caused by the degradation of blood products over time
Well defined unilocular, multilocular, predominantly cystic mass containing diffuse homogeneous low level internal echoes
May present in postmenopausal women but their appearance differs. Will appear as a multilocular mass.
Appearance of an endometrioma may be similar to a hemorrhagic ovarian cyst.

Question 24

What is adnexal torsion?

Answer 24

Affects women of a reproductive age or younger
There is the twisting of the ovary, the fallopian tube or both structures causing venous and lymphatic compromise with resulting ovarian edema and adnexal enlargement
Torsion may be partial or complete and acute or chronic
Most consistent presenting symptom is abdominal and pelvic pain, with fever, nausea and vomiting
Most cases of ovarian torsion are associated with adnexal pathologic conditions such as ovarian tumours or cysts
Usually involves ipsilateral ovarian mass 5-10cm in diameter that acts as a fulcrum to potentiate torsion due to increased ovarian volume
Enlarged edematous ovary or ovarian complex of ovary and adnexal mass
Endometriomas, PCO, hemorrhagic cysts, tubo- ovarian complexes and hyperstimulated ovaries might be seen
Absence of blood flow might suggest a nonviable ovary

Question 25

What is ovarian carcinoma?

Answer 25

Peak incidence in the 6th decade of life
Highest mortality rate of all gynecologic malignancies
Few clinical symptoms, late diagnosis
Most patients usually diagnosed at stages 3 or 4
5 year survival rate is 20-30%, but if detected in stage 1 rate is 80-90%
Risk factors: increasing age, nulliparity, family history of ovarian cancer, patient history of breast, endometrial or colon cancer
BRCA1, BRCA2 and hereditary nonpolyposis colorectal cancer syndrome (Lynch 2)

Question 26

Describe the sonographic appearance of an ovarian neoplasm.

Answer 26

Presents as an adnexal mass
Well defined anechoic cysts are more likely to be benign
Lesions with irregular walls, thick irregular septations, mural nodules and solid elements with flow are more likely to be malignant. Malignant lesions tend to have a more central flow.

Question 27

What is surface epithelial stromal tumours?

Answer 27

Epithelial ovarian cancers that arise from varying cells of origins. Mode of spread is primarily intraperitoneal.

Question 28

Describe a type 1 SEST

Answer 28

Type 1 tumours often present at a low stage and include low grade serous, endometrioid, clear cell and mucinous carcinomas. These clinically do not cause pain.

Question 29

Describe type 2 SEST

Answer 29

Type 2 tumours include high grade serous, endometrioid and undifferentiated carcinomas, and carcinosarcomas. These are highly aggressive.

Question 30

What is a serous tumour?

Answer 30

Serous tumours are the most common SEST. Peak incidence is in the 4th and 5th decades.

Question 31

Describe a serous cystadenoma

Answer 31

Serous cystadenomas are thin-walled cysts. Usually unilocular but may contain thin septations.

Question 32

Describe serous cystadenocarcinomas

Answer 32

May be quite large and usually present as a multilocular cystic mass containing multiple papillary projections arising from the cyst walls and septa. The septa and walls may be thick. There may be echogenic solid material seen within the loculations. Ascites is frequently seen.

Question 33

What is a mucinous tumour?

Answer 33

Second most common SEST

Question 34

Describe a mucinous cystadenoma

Answer 34

Most frequently seen in 3rd and 6th decade of life. Can be huge, measuring up to 30cm filling the entire pelvis and abdomen. Multiple thin septa are present and low level echoes caused by mucoid material may be seen in loculations. Papillary projections are less frequently seen.

Question 35

Describe a mucinous cystadenocarcinoma

Answer 35

Often seen in 4th and 7th decades. Large, multiloculated cystic mass containing papillary projections and echogenic material. The sonographic appearance is similar to that of a serous cystadenocarcinoma.

Question 36

What is pseudomyxoma peritonei?

Answer 36

Pseudomyxoma peritonei is when there is penetration of the tumour capsule or rupture which may lead to intraperitoneal spread of mucin-secreting cells into the peritoneal cavity. This may appear as ascites or multiple septations or floating debris in fluid filling the pelvis and abdomen.

Question 37

What is an endometrioid tumour?

Answer 37

Almost all endometrioid tumours are malignant
Second most common epithelial malignancy
Occur most frequently in 5th and 6th decades
Presents as a cystic mass containing papillary projections although some endometrioid tumours are predominantly a solid mass that may contain areas of hemorrhage or necrosis

Question 38

What is a clear cell tumour?

Answer 38

Considered to be of mullerian duct origin and a variant of endometrioid carcinoma
Almost always malignant
Occurs frequently in the 5th to 7th decades and is bilateral in about 20% of patients
Presents as a non- specific complex predominantly cystic mass

Question 39

What is a transitional cell (Brenner) tumour?

Answer 39

Also known as the brenner tumour
Derived from the surface epithelium that undergoes metaplasia to form typical uroepithelial- like components
Uncommon and is almost always benign
Most patients are asymptomatic and the tumour is discovered incidentally on sonographic examination or at surgery
Hypoechoic solid masses
They are solid tumours composed of dense fibrous stroma, appear similar to ovarian fibromas and thecomas and to uterine fibroids

Question 40

What are germ cell tumours?

Answer 40

Derived from the primitive germ cells of the embryonic gonad
Account for 15-20% of ovarian neoplasms with 95% being benign cystic teratomas (dermoids)
Dysgerminomas, endodermal sinus (yolk sac tumours) occur mainly in children and young adults and are almost always malignant
Germ cell tumours are the most common ovarian malignancies in children and young adults
When a large predominantly solid ovarian mass is present in a young girl or woman malignant germ cell tumour should be considered

Question 41

What is a cystic teratoma?

Answer 41

Make up 15-20% of ovarian neoplasms
They are composed of the ectoderm, mesoderm and endoderm
Ectodermal elements generally predominate, cystic teratomas are usually benign
Usually asymptomatic and are often discovered incidentally
Variable appearance ranging from completely anechoic to completely hyperechoic
Predominantly cystic mass with a highly echogenic mural nodule the dermoid plug
The dermoid plug usually contains hair, teeth or fat and casts an acoustic shadow
The cystic component is pure sebum rather than simple fluid
A benign teratoma will have peripheral flow but if there is central flow or within the solid areas than malignancy should be suspected

Question 42

What are the sonographic features of a cystic teratoma?

Answer 42

Dermoid plus
Tip of the iceberg sign
Dermoid mesh
Mobile spherules (rare)
Fat fluid level

Question 43

What is a disgerminoma?

Answer 43

Malignant germ cell tumours that constitute 1-2% of primary ovarian neoplasms
Composed of undifferentiated germ cells and are morphologically identical to the male testicular seminoma
Occurs predominantly in women younger than 30 years and is bilateral in 15% of cases
They are solid masses that are predominantly echogenic but may contain anechoic areas caused by hemorrhage or necrosis
Prominent arterial flow with the fibrovascular septa of a multilobulated solid echogenic mass

Question 44

What is a yolk sac tumour?

Answer 44

Rare rapidly growing tumour and is the second more common malignant ovarian germ cell neoplasm
Poor prognosis
Thought to arise from the undifferentiated, multipotentiality embryonal carcinoma by selective differentiation toward yolk sac or vitelline structures
Usually occurs in females under 20 years of age and is almost always unilateral
Increased levels of serum alpha fetoprotein may be seen
Looks similar to a dysgerminoma

Question 45

What is a sex cord stromal tumour?

Answer 45

Arise from the sex cords of the embyronic gonad and from the ovarian stroma
Granulosa cell tumour, Sertoli- Leydig cell tumour, thecoma and fibroma
Accounts for 5-10% of all ovarian neoplasms and 2% of all ovarian malignancies

Question 46

What is a granulosa cell tumour?

Answer 46

Representing 1-2% of ovarian neoplasms
95% are the adult type and occur predominantly in postmenopausal women almost all are unilateral
The most common estrogenically active ovarian tumour and clinical signs of estrogen production can occur
The juvenile type makes up 5% of granulosa cell tumours occurring mainly in patients younger than 30 years
Have a variable appearance ranging from small solid masses to tumours with variable degrees of hemorrhage or fibrotic changes to multilocular solid lesions

Question 47

What is a Sertoli-Leydig tumour?

Answer 47

Rare tumour also called androblastoma and arrhenoblastoma
Generally occurs in women younger than 30 years of age, almost all unilateral
Malignancy occurs in 10-20% of these tumours
Signs and symptoms of virilization occur in about 30% of cases
Tumours may be associated with estrogen production
Tumours appear as a solid hypoechoic mass or may be similar in appearance to granulosa cell tumours

Question 48

Describe ovarian metastases

Answer 48

About 5-10% of ovarian neoplasms are metastatic in origin
Most common primary sites of ovarian metastases are tumours of the breast and the GIT
Usually bilateral solid masses but they may become necrotic and may have a complex, predominantly cystic appearance that simulates primary cystadenocarcinoma
Ovarian metastasis from primary tumours of the breast, stomach and uterus were solid
Those from the colon and rectum were more heterogeneous most being multicystic with irregular borders
Lymphoma may involve the ovary usually in a diffuse, disseminated from that is frequently bilateral
Appears to solid hypoechoic mass similar to lymphoma elsewhere in the body

Question 49

What is pelvic inflammatory disease?

Answer 49

Consists of inflammation of the endometrium, fallopian tubes, pelvic peritoneum and adjacent structures
Usually caused by gonorrhea and chlamydia
Patient can also be infected by her own vaginal flora
Infection typically spreads by ascent from the cervix and the endometrium
Manifested by tubo- ovarian complexes, peritonitis and abscess formation and is usually bilateral

Question 50

How does PID manifest?

Answer 50

chronic pelvic pain, infertility and increased risk of ectopic pregnancy
Less common causes include direct extension from appendiceal, diverticular or post surgical abscesses that have rupture into the pelvis
Pain, fever, cervical motion tenderness and vaginal discharge

Question 51

What is the sonographic appearance of PID?

Answer 51

Increased echogenicity of peritoneal fat and indistinctness of the uterus may be seen early in the disease process but may be difficult to appreciate
Hypervascularity of the fallopian tube
Progessive inflammation and distal occlusion of the lumen, the tubes fill with purulent echogenic fluid becoming a pyosalpinx
Common findings include wall thickness greater than 5mm, incomplete septa seen as the tube folds back on itself and thickening of endosalpingeal folds

Question 52

What is tubal torsion?

Answer 52

Usually seen in conjunction with ovarian torsion but isolated torsion of the fallopian tube is an infrequent finding
May be seen in cases of paratubal cysts but also can be seen in associate with chronic hydrosalpinx
Patient usually presents with sudden onset of severe pelvic pain

Question 53

What is fallopian tube carcinoma?

Answer 53

Patients might present with watery discharge
Tumour usually involves the distal end but may involve the entire length of the tube
It will appear sausage- shaped, solid or cystic mass with papillary projections
Diagnosis should be considered when a solid vascular mass corresponding to the expected location of the fallopian tube seen in associate with normal ovaries especially if the mass is mobile

Question 54

What is ovarian vein thrombosis/thrombophlebitis?

Answer 54

Uncommon condition that is usually seen 48 - 96 hours postpartum
Fever, lower abdominal pain and palpable mass
Underlying cause is venous stasis and spread of bacterial infection from endometritis
Right ovarian vein is involved in 90% of cases
Retrograde venous flow occurs in the left ovarian vein during the puerperium which protects this side from bacterial spread from the uterus

Question 55

What is the sonographic appearance of ovarian vein thrombosis/thrombophlebitis?

Answer 55

May should an inflammatory mass lateral to the uterus and anterior to the psoas muscle
Ovarian vein may be seen as a tubular structure directed cephalad from the mass and containing echogenic thrombus
Usually affects the most cephalic portion of the right ovarian vein and can be demonstrated at the junction of the right ovarian vein with the IVC
Doppler will demonstrate complete or partial absence of flow in these veins

Question 56

What is pelvic congestion syndrome?

Answer 56

Condition that consists of dilation of pelvic veins and reduced venous return causing dull chronic pain that is exacerbated by prolonged standing and relieved by lying down and elevating the legs

Question 57

What is the sonographic appearance of pelvic congestion syndrome?

Answer 57

An ovarian vein with a diameter greater than 5-10mm with reflux, uterine vein engorgement, congestion of ovarian plexuses, filling of the pelvic veins across the midline, or filling of vulvovaginal and thigh varicosities
Dilated arcuate veins may also be seen crossing the myometrium.

Question 58

List types of post-operative pelvic masses

Answer 58

Abscess, hematomas, lymphoceles, urinomas or seromas

Question 59

Describe the sonographic appearance of a pelvic abscess

Answer 59

Abscesses are ovoid shaped, hypoechoic masses with thick irregular walls and posterior acoustic enhancement. Variable internal echogenicity may be seen and high- intensity echoes with shadowing caused by gas may be demonstrated. Vascularity in the wall of the abscess.

Question 60

Describe the ultrasound appearance of a pelvic haematoma

Answer 60

Hematomas show a spectrum of sonographic findings, varying with time. After hyperacute phase, hematomas will be anechoic. After clot formation they are echogenic.

Question 61

Describe the ultrasound appearance of a pelvic lymphocele

Answer 61

Pelvic lymphoceles occur after surgical disruption of lymphatic channels usually after pelvic lymph node dissection or renal transplantation. Are anechoic, having an appearance similar to urinomas which are localised collections of urine or seromas which are collections of serum.