Chapter 5 — Uterine Pathology

Question 1

What is developed from the Müllerian ducts (paramesonephric ducts)

Answer 1

Uterus
Fallopian tubes
Upper vagina

Question 2

Most uterine and cervical anatomical variants are caused by failure development of what

Answer 2

Müllerian ducts

Question 3

Urinary and genital development is close in relation so there’s common association of anomalies

Question 4

Since _______ aren’t developed from Müllerian ducts then in presence of Müllerian anomalies this is normal

Answer 4

Ovaries

Question 5

What are the 4 categories of anomalous internal genital development

Answer 5

Failure of formation
Failure of fusion
Failure of dissolution
Failure of structure to disappear

Question 6

This occurs secondary to bilateral arrest of Müllerian duct development
Complete absence of vagina cervix uterus and fallopian tubes
This congenital uterine anomaly is associated with Mayer-Rokitansky-Kuster-Hauser (MRKH) Syndrome

Answer 6

Complete agenesis

Question 7

A unicorn ate uterus results from unilateral arrest of Müllerian duct development
Range of anomalies — absence of upper vagina and cervix with persistence of uterus and fallopian tubes
More common unicornate uterus and single fallopian tube
Which congenital uterine anomaly is this

Answer 7

Partial agenesis

Question 8

Complete duplication of the uterus cervix and vagina
Which failure of fusion is this

Answer 8

Uterus didelphys

Question 9

This is the most common Müllerian anomaly in which there is a single vagina 1 or 2 cervices and variable lack of fusion of the upper uterine cavity
Which failure of fusion is this

Answer 9

Bicornuate uterus

Question 10

When the median septum fails to dissolve after fusion of the 2 separate Müllerian ducts and result in a single vagina cervix and uterus with intrauterine septum
This is known as

Answer 10

Septate uterus

Question 11

The least severe Müllerian anomaly is a septum slightly protruding into the uterine cavity creating ___________

Answer 11

Arcuate uterus

Question 12

Failure of disappearance
Abnormalities can result from failure of disappearance of structures that do not normally persist

The persistent structures are sometimes referred to as ___________

Answer 12

Vestigial remnants

Question 13

This cyst occurs on the anterolateral wall of the vagina and arises from the caudal remnants of the mesonephric (wolffian) duct and is the most common vestigial remnant

Answer 13

Garters duct cyst

Question 14

Daughters of women who received __________ from late 1940s to early 1970s for TAN have increased risk of certain genital abnormalities

Answer 14

DES (diethylstilbestrol) syndrome

Question 15

In utero exposure to _________ has been associated with vaginal epithelial changes, poor pregnancy outcome, increased risk of cervical carcinoma, breast carcinoma and T-shaped uterus with constricting bands in the uterus and intrauterine wall defects

Answer 15

DES (diethylstilbestrol) syndrome

Question 16

Vaginal anomalies can be a result of either Müllerian duct and/or urogenital sinus malformations in the developing embryo

Question 17

Which vaginal anomaly is the congenital absence of the vagina

Answer 17

Vaginal atresia

Question 18

Which vaginal anomaly is the presence of traverse separations within the vagina

Answer 18

Vaginal septa

Question 19

Which vaginal anomaly is the presence of 2 complete vaginas

Answer 19

Vaginal duplication

Question 20

Always evaluate the urinary tract (include the kidneys) in patients with uterine congenital malformations due to increased incidence or renal abnormalities

Question 21

These are the most common tumors of the female pelvic uterus
Greater incidence in black nulliparous women
Usually located in the uterine corpus and also found in the cervix and broad ligament

Answer 21

Leiomyomas (fibroids/ myomas)

Question 22

What location is this leiomyoma
Beneath the endometrial cavity and often project into the uterine cavity; most commonly produce symptoms (bleeding)

Answer 22

Submucous/ submucosal (distorted endo)

Question 23

What location is this leiomyoma
Within the myometrium; most common type

Answer 23

Intramural/ interstitial

Question 24

What location is this leiomyoma
Beneath the perimetrium

Answer 24

Subserous/subserosal

Question 25

What location is this leiomyoma
Between the layers of the broad ligament

Answer 25

Intraligamentous

Question 26

What location is this leiomyoma
Location in cervix; uncommon

Answer 26

Cervical

Question 27

What location is this leiomyoma
On a pedical or stalk; only occurs with submucous and subserous; torsion may occur with pedunculated fibroids

Answer 27

Pedunculated

Question 28

Clinical signs - myomas are often asymptomatic when symptoms are present, they may include:
Heavy periods (menometrorrhagia) especially with submucisal myomas
Frequent urination
Enlarged uterus on pelvic exam
Increasing pain with degenerative changes
Infertility or spontaneous anortions
Alteration in normal menstrual flow

Question 29

Sonographic findings
Appearance depends on amount of degeneration as well as the size and location of the fibroid. Most common sonographic findings include
Well circumscribed hypoechoic mass
Lobulated uterine contour
Shadowing (with increased attenuation and with calcification degeneration)
Whorled internal architecture
Displacement of endometrial echoes
Extrinsic compression of posterior bladder wall
Pedunculated fibroid may appear as a hypoechoic adnexal mass

Question 30

What is an extremely rare malignancy arising from the myometrium, single large hypoechoic solid uterine mass, only clue its malignant is usually the only clue is relatively rapid growth of the mass in postmenopausal women

Answer 30

Leiomyosarcoma

Question 31

This is a benign invasion of the endometrial glands and stroma into the myometrium
Can be diffuse or focal
Most often affects the posterior myometrium
Suspected in parous women ages 40-50 years old with dysmenorrhea and irregular bleeding

Answer 31

Adenomyosis

Question 32

Adenomyosis sono findings
- enlarged uterus with normal contours
- asymmetric thickening of the anterior or posterior uterine wall
- myometrial cysts (2-6m in diameter)
- mottled inhomogeneous myometrium
- “Venetian blind” type shadowing

Question 33

This is the second most common Gyn malignancy
Typically seen in women 20-30
Most common symptom is post-coital vaginal bleeding
Dx with Pap smear, colposcopy and con biopsy
Treated surgically

Answer 33

Cervical cancer

Question 34

Cervical cancer risk factors
- HPV infection
- early sexual activity
- multiple sex partners
- smoking
- OCP use

Question 35

Cervical cancer sono findings
- normal appearance early in disease
- enlarged or bulky cervix
- may appear similar to cervical myoma
- hydronephrosis
- involvement of other pelvic organs

Question 36

This is a mucus retention cyst due to obstructed and dialated endo cervical glands
They are common benign and of no clinical significance

Answer 36

Nabothian cyst

Question 37

Sono findings of nabothian cyst
- small well circumscribed anechoic strcture located within cervical wall
- posterior acoustic enhancement

Question 38

This is a collection of Seoul’s fluid within the endometrial cavity
May be secondary to
- cervical stenosis (pops menopause patients)
- endometrial ablation (burn or scrape endo - to for heavy bleeding)
- pelvic radiation therapy

Answer 38

Hydrometra

Question 39

This may be congenital but more commonly acquired after surgical procedure or uterine trauma
Associated with heavy vaginal bleeding
Treated with embolization of feeding vessels

Answer 39

Uterine arteriovenous malformation (AVM)

Question 40

Uterine arteriovenous malformation (AVM) sono findings
- hypoechoic myometrial abnormality
- abundant flow on color Doppler
Low resistance high cvelocity flow on spectral Doppler

Question 41

This is most commonly encountered gynecological malignancy
75-80% of this carcinoma occurs in postmenopausal women who usually present early with postmenopausal bleeding
Increased estrogen and development of endometrial cancer

Answer 41

Endometrial carcinoma

Question 42

Associated risk factors for endometrial carcinoma include
- obesity and anovulatory cycles in premenopausal women
- postmenopausal with an increased risk if on estrogen replacement therapy
- history of atypical hyperplasia of endometrium (endometrial intraepithelial neoplasia)
- strong family history of uterine cancer

Question 43

Endometrial carcinoma clinical signs
- postmenopausal vaginal bleeding
- hypermenorrhea, intermenstural flow in patients still having periods
- pain (result of uterine distension)

Question 44

Endometrial carcinoma sono findings
- alteration in size, shape and sono texture of uterine parenchyma
- increased uterine size
- inhomogeneity and thickening of endometrial echoes (> 4-5mm) especially in postmenopausal women (varies with patients hormone status)
- fluid in endometrial cavity

Question 45

This is proliferation of the endometrial glandular tissue
May be focal or diffuse
25% of patients with atypical hyperplasia (endometrial intraepithelial neoplasia) will undergo malignant change and progress to endometrial carcinoma
It’s a common cause of abnormal uterine bleeding in peri-menopausal patients
Both peri- and postmenopausal women it may be caused by unopposed estrogen hormone replacement therapy (HRT)
Other causes
- persistent anovulatory cycles
- PCOS
- obesity
- estrogen producing tumors of the ovary

Answer 45

Endometrial hyperplasia

Question 46

Endometrial hyperplasia sono findings
- smooth borders
- more homogeneous texture but possibly cystic changes
- premenopausal women EC > 14mm
- postmenopausal women on estrogen EC > 5mm
- postmenopausal women in estrogen phase EC can be up to 8mm then in progesterone phase EC decreases

Question 47

These are localized overgrowths of endometrial tissue
May be pedunculated broad-based or have a thin stalk
Occasionally this will have a long stalk and prolapse into the cervix or even vagina
Color Doppler may reveal a feeding artery in the stalk or pedicle

Answer 47

Endometrial polyps

Question 48

Endometrial polyps clinical signs
- usually asymptomatic
-infertility
- abnormal uterine bleeding
- usually discovered incidentally in D&C
- occasionally causes postmenopausal bleeding

Question 49

Endometrial polyps sono findings
- non-specific thickened endometrium usually focal but occasionally diffuse
- discrete mass in the endometrium focal round and echogenic
-possibly vascular stalk demonstrated with color Doppler
- may be indistinguishable from endometrial hyperplasia
- sonohysterography is ideal for demonstratingpolyp size and location

Question 50

This is a technique of introducing saline into the endometrial cavity to evaluate endometrium sonographically

Answer 50

Sonohysterography (SIS)
Also called hysterosonography

Question 51

Indications for SIS include
- infertility and habitual abortion
- congenital anomalies and/or anatomical variants or the uterine cavity
-pre- and post-operative evaluation of uterine cavity (especially with regard to myomas polyps and cysts)
- suspected uterine cavity synechiae (scarring associated with Ashermans syndrome)
- further evaluation of abnormalities detected sonographically

Question 52

Preliminary transvaginal imaging is performed prior to SIS to evaluate the uterus endometrium ovaries and adnexae
External os is cleansed and the catheter placed into the cervix
Sterile saline is infused during transvaginal sono
Fluid in posterior cue-de-sac endures at least one patent fallopian tube