Gynae Flashcards
Turner syndrome
XO
Aortic coactation
horseshoe kidney
Pre puberty uterus and streaky ovaries
Re SIN- Salpingitis Isthmica Nodosa
What is it?
Aetiology?
Symptoms?
This is a nodular scarring of the fallopian tubes involving the proximal 2/3 of the tube.
Unknown aetiology, post infectious/inflam
Associated with infertility and ectopic pregnancy
Re uterine AVM:
Causes
Doppler?
Acquired after D&C, Abortion, C section, multiple pregnancies
Doppler: Serpingous , tubular anechoic structures within the myometrium with high velocity colour doppler flow.
Intrauterine adhesions/ Ashermans
- What is it?
- HSG?
This is scarring in the uterus secondary to injury : prior D&C, surgery, pregnancy, and infection (GU TB).
- Non filing of the uterus,
- Multiple irregular linear filling defect with inability to distend the endometrium.
Can result in infertility
MRI appearances of Ashermans
Bands of T2 dark .
Fibroid/ uterine leiomyoma
Location?
Locations: Intramural, subserosal, submucosal
Fibroid appearance:
Can look like anything…
USS: Hypoechoic, with peripheral blood flow in a Venetian band pattern
CT: Peripheral calcification- popcorn on X ray
MRI: T1 and T2 dark with variable enhancement.
What are the 4 types of degeneration?
- Hyaline: most common- T2 dark, no enhancement post Gd
- Red (carneus): During pregnancy. Cause of venous thrombosis. Peripheral rim of T1 high signal- T2 variable
- Myxoid: Uncommon, T1 dark, T2 bright, minimal enhancement
- Cystic: Uncommon
This type of fibroid degeneration happens during pregnancy and is a common cause of venous thrombosis:
Red degeneration
Typical appearance of fibroid red degeneration :
Peripheral rim of T1 high signal- T2 variable
Name the degeneration:
1) T2 dark:
2) T1 bright rim
3) T2 bright
1) T2 dark: Hyaline
2) T1 bright rim: Red
3) T2 bright: Myxoid
Re adenomyosis:
- Define it
- RF?
This is endometrial tissue that has migrated into myometrium.
Mostly seen in multiparous women of reproductive age
RF: History of uterine procedures: C section, D&C
Most common location for adenomyosis:
Usually at the posterior wall but sparring the cervix.
Causes marked enlargement of the uterus with preservation of the overall contour.
Appearances of the adenomyosis:
Thickening of the junctional zone of uterus >12mm (normal <5mm). The thickening can be focal or diffuse
- Small high T2 signal regions –> cystic changes is a classic findings.
HSG: small diverticula extending from endometrial cavity into myometrium.
When would you sample endometrium in post menopausal women?
> 5MM
Which group of patients with colorectal cancer would have an increased risk of endometrial cancer?
Hereditary Non Polyposis of Colon Cancer HNPCC
Which group of tumours will thicken the endometrium?
Oestrogen secreting tumours- Granulosa Cell tumours of the ovary.
What is the effect of tamoxifen on endometrium?
This is a SERM- acts like oestrogen in the pelvis- it blocks the effect of oestrogen on the breast. But increases the risk of endometrial cancer.
Endometrial cysts and polyps.
What is the upper limit of normal for endometrial thickness for women on tamoxifen
8mm
What are the two causes of endometrial fluid in post menopausal women?
- Cervical stenosis
2. Obstructing mass
What type of cancer is cervical cancer?
Squamous cell related to HPV.
Staging of cervical cancer: FIGO
I: confined to uterus/ cervix
IIa: Spread beyond the cervix ( to upper 2/3 of vagina), but NO parametrial invasion- surgery
IIb: Parametrial involvement but DOES NOT extend to pelvic side wall- Chemo/ radiation
IIIa: invasion into lower 1/3 of vagina
IIIb: Pelvic side wall invasion +/- hydronephrosis.
IV: distant metastases.
Management of cervical cancer:
IIa or below: surgery
IIb: Parametrial invasion or involvement of the lower 1/3 of vagina : chemo/ radiation
What is parametrium?
This is a fibrous band that separates the supravaginal cervix from the bladder. It extends between the layers of broad ligament.
The uterine artery runs inside the parametrium- hence the need for chemo-once invaded.
Most common location for vaginal leiomyoma:
Rare in vagina: most commonly in the anterior vaginal wall/
What are the tumours of the vagina:
- Squamous cell carcinoma - most common type, associated with HPV.
- Clear cell adenocarcinoma: whose mom took DES to prevent miscarriage- also causes T shaped uterus.
- Rhabdomyosarcoma: most common type in children.
Bi modal age distribution: (2-6, 14-18). Anterior wall near the cervix.
What makes you suspicious for rhabdomyosarcoma of vagina
Solid T2 bright enhancing mass in the vagina / lower uterus in a child.
Origin of vagina metastases:
Anterior wall and upper 1/3?
Posterior wall and lower 2/3?
Met to the vagina in the anterior wall upper 1/3 is always upper genital tract.
Met to the vagina in the posterior wall lower 2/3 is always GI tract.
Nabothian cysts:
Usually on the cervix. They are the result of inflammation causing epithelium plugging of mucus glands.
Gartner duct cyst
As a result of incomplete regression of Wolffian ducts.
Classically located in the anterior lateral wall of the upper vagina. If at level of urethra: Cause mass effect on the urethra.
Bartholian cyst
Obstruction of bartholian glands.
Bartholian cysts Below the pubic symphysis.
Skene gland cyst
These are periurethral glands can causing recurrent UTI and urethral obstruction.
Functional ovarian cyst:
Benign, < 25mm. They will usually change / disappear in 6 weeks. If no change- non functioning ovarian cyst.
> 7cm = Further evaluation with MRI or surgical evaluation
Corpora lutea
Appearance
Variable appearance: solid and hypoechoic with a RING OF FIRE (intense peripheral blood flow).
Can be large 5-6cm.
Haemorrhagic cysts
Signs?
Doppler?
Homogenous mass with “enhanced through transmission.”
Fishnet appearance.
No Doppler flow.
They should disappear in 6-12 weeks. Rescan
Differences bwn ectopic pregnancy and corpus luteum:
Ectopic:
- RI < 0.4 or > 0.7
- Moves separate from the ovary
- Ring of fire
- Thick echogenic rim
CL:
- RI 0.4- 0.7
- Moves with the ovary
- Ring of fire
- Thin echogenic rim
Haemorrhagic cyst on MRI
T1 bright
FAT SAT will not suppress the signal- therefore not a teratoma.
The lesion should not enhance.
Polycystic ovaries
Imaging criteria:
- > 10 peripheral simple cyst, typically small < 5mm
- String of pearl appearance
- Ovaries are typically enlarged > 10cc, although 30% could have normal volume ovaries.
What is the typical history for endometriosis?
Infertility, dyspareunia, and dysmenorrhoea.
What is the typical buzzword classic appearance of endometrioma?
Ddx?
This is a rounded mass with homogenous low-level internal echoes and increased through transmission.
Fluid level and internal septation can be seen.
Ddx: haemorrhagic cysts
Where is the most common location for solid endometriosis?
Uterosacral ligaments
What is the most sensitive imaging feature on MRI for the diagnosis of malignancy in an endometrioma?
Enhancing mural nodule
What are the risk factors for endometrioma to become malignant?
- Women older than 45 years old
- Mass lesion bigger than 6-9 cm
What is a decimalised endometrioma?
This is used to describe the solid nodule with bloodflow in the endometrioma of pregnant lady. Follow-up is required. It is a mimic of malignancy.
What is the appearance of endometrioma on MRI?
- T1 bright ( From the blood).
- FATSAT Will not suppress the signal (it’s not a teratoma)
- T2 will be dark ( from iron in the endometrioma)
SHADING SIGN (T2 dark when T1 is bright)
What is the buzzword sign for dermoid?
Tip of the iceberg sign. This refers to absorption of most of the ultrasound beam at the top of the mass. Septation is seen in 10%
What is the appearance of dermoid on MRI?
- T1 bright
* fat suppression
Name the cancer transformation subtypes:
- Endometrioma?
- Dermoid?
- Endometrioma- Clear cell
- Dermoid- Squamous
Ddx for BFM ( Big Fucking Masses): (3)
- Ovarian masses (mucinous and serous)
- Desmoid (Gardner syndrome)
- Sarcomas
This vs that: Serous vs mucinous
Serous:
Unilocular- fewer septation
Papillary projection common
Mucinous:
Multilocular- more septation
Papillary projections- less common
Re serous ovarian/ cystadenocarcinoma/ cystadenoma:
- Age group:
- Appearance?
- What does ascites mean?
60% are benign, 15% are borderline, rest malignant.
Child bearing age- with malignant ones in older women.
Usually unilocular with few septation.
Frequently bilateral- esp when malignant.
Papillary projection
If ascites: mets- 70% have peritoneal involvement at time of diagnosis.
Re Mucinous ovarian cyst adenocarcinoma:
Large mass.
Multiloculated with thin septa
Papillary projections are less common
Pseudomyxoma peritonei with scalloping
Re endometroid cancer:
- 2nd most common cancer (serous 1, mucinous 3)
- Bilateral 15%
- 25% will have concomittant endometrial cancer. The endometrial cancer is primary and ovary is met
- Endometriomas can turn into endometroid cancer
Endometrial and ovarian pathology relationship:
granulosa cell and endometrial cancer
Endometrial cancer causing mets to ovary and endometrioma.
Granulosa cell tumour of the ovary in which the oestrogen causes hyperplasia of the endometrium
Fibroma/ fibrothecoma:
Appearance:
USS
MRI
Benign tumour. Fibrothecoma / thecoma spectrum has similar histology. It is very similar to fibroid
USS: hypoechoic and solid. 18-25% marked acoustic shadowing not secondary to calcification.
MRI: T1 and T2 dark with the band of T2 dark signal around the tumour on all planes.
Calcifications are rare.
Meig’s syndrome:
- Ascites
- Pleural effusion
- Benign ovarian tumour (Most commonly fibroma)
Fibromatosis:
- Define it:
- Association
- MRI?
- BUZZWORD
- Ovarian enlargement due to ovarian fibrosis.
- Age 25
- Associated with omental fibrosis and sclerosing peritonitis.
- Dark T1 and T2 signal
- BUZZWORD: Black garland sign
Brenner Tumour/ Ovarian transitional cell carcinoma
- Define it
- Appearance
This is epithelial tumour of the ovary seen in women in their 50-70’s
- It is fibrous and T2 dark. Unlike fibromas, calcifications are common 80%
What is a struma ovarii?
This is a subtype of ovarian teratoma.
Multilocular, predominantly cystic mass with intensely enhancing solid component.
What is the MRI appearance of struma ovarii?
T2 low signal in the cystic areas which is thick colloid.
These tumours contain thyroid tissue, be aware if the question mentions that patient is hyperthyroid or in a thyroid storm.
Metastatic deposits to ovaries from: (5)
Colon Gastric- Krukenburg tumour Breast Lung Contralateral ovary
Most constant finding in ovarian torsion is …
What are the features?
Large ovary
- Unilateral enlarged ovary > 4cm
- Mass on the ovary
- Peripheral cysts
- Free fluid
- Lack of arterial or venous flow.
Name the signs associated with hydrosalpinx:
Cogwheel appearance: normal longitudinal folds of Fallopian tube becoming thickened.
String sign: Incomplete septae
Waist sign: Tubular mass with indentation of its opposing wall. This is supposed to DDx it from ovarian mass
What are the causes of hydrosalpinx?
- PID
- Endometriosis
- Tubal cancer
- Post hysterectomy without oopherectomy
- Tubal ligation
BUZZWORD for PID
Indefinite/ ill defined uterus on USS
What is the key finding for paraovarian cyst?
These are simple round or oval masses that DO NOT distort the adjacent ovary.
Ovarian vein thrombophlebitis:
Most commonly seen in post partum patients presenting with acute pelvic pain and FEVER.
80% of the time, it is on the right.
Dreaded sequalae: PE
Peritoneal inclusion cyst:
Define:
Classic history:
This is an inflammatory cyst of peritoneal cavity that occurs when adhesions envelop an ovary.
Classic history: Previous pelvic surgery/ PID? endometriosis, now with pain
What are the two key features of Peritoneal inclusion cyst?
- Lack of walls- they have passive shape- conforms to and is defined by surrounding structures.
- Entrapment of an ovary- either in the collection or at the periphery.
What is Gartner duct cyst is associated with?
Herlyn Werner Wunderlich syndrome- ipsilateral renal agenesis amd ipsilateral blind vagina. and ectopic ureter inserting into the cyst.
Endometrial polyp on USS and MRI:
USS: Hyperechoic endometrial mass+/- cystic spaces. A feeding vessel is seen at the base on power doppler.
MRI: mass with central fibrous core that enhances post contrast and also contains well demarcated T2 hyperintense cyst
Krukenburg tumour appearance
Usually bilateral sharply marginated oval tumours which preserve the contour of oavry.
Hypointense solid components on T2 weighted imaging corresponding to areas of dense collagenous stroma is also considered characteristis.
Thecoma are …producing tumours , but > 80% occur in post menopausal women
Oestrogen
Immature teratomas are super rare , but do occur in children. Raised …. is found in up to 65%
alpha fetoprotein
What is a haematocolpos?
This is accumulation of blood within the vagina and is typically caused by imperforated hymen.
USS: echogenic cystic mass with or without fluid debris level in the region of vagina.
Cloacal malformation
Single perineal orifice for the bladder, vagina and rectum caused by early embryogenic arrest.
Hydrometra
this is fluid within the uterus and may be due to cervical or vaginal dysgenesis.
Gestational Trophoblatic diease
Marked elevation of B-hCG
Hyperemesis
> 40
Previous history
Types of Hydatidiform mole
a) Complete mole: 70%. Involves the entire placenta.No fetus. Diploid karyotype
b) Partial mole- 30%: Portion of the placenta. Triploid in karyotype: fertlisation of an ovuum by 2 sperms (69XXY)- lethal
Appearance of complete mole during first and second trimester:
First trimester: SNOWSTORM: Uterus to be filled with echogenic, solid, highly vascular mass
Second trimester: BUNCH OF GRAPES: vesicles that make up the mole enlarge into individual cyst (2-30mm)
Appearance of partial mole on uss
The placenta will be enlarged and have areas of multiple , diffuse anechoic lesions. You may see fetal parts.
Theca lutein cysts are seen in molar pregnancy. Most commonly in ……trimester and are bilateral
Second
Re Invasive mole:
Define it:
USS
MRI
This is invasion of molar tissue into myometrium. Typically after treatment of a hydatidiform mole. ~10%
USS: echogenic tissue in myometrium.
MRI is better at showing muscle invasion. It also shows focal myometrial masses, dilated vessels, areas of haemorrhage and necrosis.
Re Choriocarcinoma:
- Define
- Typical history
- USS
- Treatment
Aggressive malignancy that forms only trophoblast- no villous structure.
Local invasion into myometrium and parametrium. Then distant mets via blood. Very vascular
B- hCG rise in 8-10 weeks following evacuation of molar pregnancy
USS: highly echogenic solid mass
Treatment: METHOTREXATE
Which ovarian cysts get followed up?
Unilocular cyst > 3cm in a premenopausal woman and > 5cm in post menopausal woman should be rescanned in 6 weeks.
Dysgerminoma:
These are rare ovarian tumours, Predominately in younger women. Serum bHCG is increased in 5%. Calcification may be present in the speckled pattern.
Multi lobulated solid masses with prominent fibrovascular septa. They are rarely if ever bilateral
Endodermal sinus tumour/Yolk sac tumour
Rare malignant ovarian tumour that usually occurs in the second decade of life.
Large complex pelvic mass extending into the abdomen containing both solid and cystic components.
Rarely bilateral. They grow rapidly and have a poor prognosis.
Raised serum alpha feta protein.
What is adenoma malignum associated with?
It is associated with Peutz Jeghers syndrome- mucocutaneous pigmentation, multiple hamartomatous polyps of GI tract and mucinous tumour of ovary.
Adenoma malignum 3% adenocarcinoma of the cervix: Multicystic lesion(high signal T2 and low T1 signal) in the uterine cervix with a solid components (low signal T1 and T2) in the deep cervical stroma.
What are the causes of lymphangitis carcinomatosis?
Certain Cancers Spread By Plugging The Lymphatics: C: cervix C: colon S: stomach B: breast P: pancreas T: thyroid L: larynx and lung
Salpingitis isthmica nodosa
small out pouching from isthmus portion of the fallopian tube.
Polyps on HSG
filling defects on HSG
3 features of Mayer Rokitansky Kuster Hauser syndrome
- Vaginal atresia
- Absent or rudimentary uterus
- Normal ovaries
Didelphys uterus
Complete uterine duplication
2 x cervix, 2 uterus and 2 x 1/3 upper vagina
75% vaginal septum
Bicornuate
Hearts shaped. 1-2 cm fundal depression
25% vaginal septum
Ddx; Septate uterus- HSG cannot help
This type of mullerian duct anomaly is associated with women who take DES
T shaped- Fundus is thinner than cervix
Septate uterus
minimal indentation
Infertility and early abortion
2 types of septum: muscular and fibrous
Arcuate uterus
indentation of funds- saddle shaped on HSG
Normal variant - no complication
HSG are performed on day…..
7-10 menstrual cyscle
Contraindications for HSG
- infection - PID
- Active bleeding
- pregnancy
- contrast allergy
