Gynecology Flashcards
Gravida ?
Number of pregnancies
Para / Parity?
Number of pregnancies carried to term
List of laboratory values that may warrant a pelvic sonogram?
HCG
Hematocrit
White blood cell count
HCG laboratory value indicative of ?
Elevated in some malignant ovarian tumors
But it mostly indicates developing of gestation / pregnancy
Elevated HCG most often indicative of ?
Pregnancy
An abnormally low hematocrit is indicative of ?
“Bleeding”
Ectopic pregnancy
Pelvic trauma
Elevated white blood cell count is indicative of ?
Leukocytosis
Inflammation or infection
Pelvic inflammatory disease
Abscess present
Some form of “ITIS”
Amenorrhea is associated with ?
PCOS
Ashermann syndrome
Associated with Dysmenorrhea?
Adenomyosis
Endometriosis
Dysmenorrhea ?
Painful menses
Painful sexual intercourse?
Dyspareunia
Amenorrhea ?
Absence of menses
Polymenorrhea ?
Frequent regular cycles but less than 21 days apart
Dyspareunia associated with ?
PID
Adenomyosis
Endometriosis
Dysuria ?
Painful urinating
Dysuria is associated with ?
Leiomyoma / fibroid uterus
Leiomyosarcoma
Elevated serum AFP associated with?
Ovarian yolk sac tumor
Elevate serum LDH is associated with ?
Ovarian Dysgerminoma
Associated with post D & C procedure ?
Endometritis
Asherman syndrome
Retained products of conception
Causes precocious puberty ?
Ovarian dysgerminoma
Ovarian granulosa cell tumor
Associated with right upper quadrant pain ?
Fitz Hugh Curtis syndrome
Associated with taxoxifen therapy ?
Endometrial hyperplasia
Urinary frequency associated with ?
Leiomyoma / fibroid uterus
Leiomyosarcoma
Associated with vaginal discharge ?
Pelvic Inflammatory disease
Virilization is associated with?
Sertoli Leydig cell tumor / androblastoma
Ovarian carcinoma
Intravenous therapy patient care rule ?
Bag needs to be kept above the heart
Urinary catheter patient care rule ?
Keep the bag of fluids below the bladder to prevent retrograde urine flowing back through the urethra (can cause a UTI)
3D imaging can be used for the following ?
Provides an enhanced resolution of the female pelvis
Uterine malformations
Proper location of the IUD/ position assessment
For investigating the uterine cavity during sonohysterography
To assess complex ovarian masses
Also employed in fertility assessment during the ovarian follicular phase
Adolescent females may suffer from ?
Ovarian torsion
PID
PCOS
Ectopic pregnancy
And although rare an ovarian malignant neoplasm
Ovarian torsion is associated with ?
Has been associated with a large ovarian cyst
Excessively mobile adnexal structures
Dirty shadowing can be seen posteriorly emanating from ?
Gas within a abscess
Bowel
Shadowing is seen posterior to ?
Pelvic bones
Tooth within a cystic teratoma
Ring down artifact associated with ?
Gas or air within the endometrium, secondary to Endometritis
Enhancement is seen posterior to ?
Urinary bladder and simple ovarian cysts
Ambiguous Genitalia ?
Newborns external genitalia are neither recognizable male nor female
Patients should be assessed for female or male reproductive organs (uterus/ testes), and possibly even assessing the adrenal glands for masses or swelling
Most common disorder of sex development ?
Turner’s syndrome / Monosomy X
Turners Syndrome ?
Monosomy X
Most common disorder of sex development
Patients suffer from gonadal dysfunction, short stature, and webbing of the skin on the neck
Common female pelvis sonographic finding?
Small amount of anechoic fluid within the pouch of Douglas/ Rectouterine
Normal association with the ovarian cycle
Massive amounts of pelvic ascites is associated with ?
Some ovarian tumors
Ectopic pregnancy
Cirrhosis
Portal hypertension
Meigs syndrome
Meigs syndrome ?
Pelvic ascites
Pleural effusion
Benign ovarian mass
Pseudomyxoma peritonei?
Malignant ovarian tumor may leak mucinous material
In cases of ruptured ovarian mucinous cystadenocarcinoma
A 32-year-old multiparous patient presents to the sonography department with a history of abnormal uterine bleeding and dyspareunia. Sonographic findings include a diffusely enlarged uterus with notable thickening of the posterior myometrium. What is the most likely diagnosis?
Adenomyosis
POD?
Rectouterine pouch / retropubic
Between the uterus and rectum
Paracolic gutters?
Extend alongside the ascending and descending colon
Anterior cul de sac ?
Between the bladder and uterus
Vesicouterine pouch
Defined as excessive hair growth in women in areas where hair growth is normally negligible?
Hirsutism
AKA intermenstrual bleeding ?
Metrorrhagia
Irregular menstrual bleeding between periods
Adnexa ?
The area located posterior to the broad ligaments and adjacent to the
uterus
What Doppler artifact occurs when the Doppler sampling rate is not high enough to display the Doppler shift frequency?
Aliasing
Bony pelvis consists of ?
Sacrum
Coccyx
Innominate bones
Posterior border of the pelvic cavity ?
Sacrum and coccyx
Innominate bones consist of ?
Ilium
Ischium
Symphysis pubis
True and false pelvis are divided by ?
Linea Terminalis
True pelvis ?
Lesser pelvis
False pelvis ?
Major Pelvis
Located more superior to the true / lesser pelvis
Contains the urinary bladder, small bowel, sigmoid colon, rectum, ovaries, fallopian tubes, and uterus (which pelvis)
True pelvis / lesser pelvis
Vagina position ?
Posterior to the urethra
Fallopian tube course and ovaries location ?
Unpredictable and vary with each patient
Pelvic muscles ?
rectus abdominis
iliopsoas
obturator internus
piriformis
Pelvic diaphragm is composed of ?
Coccygeus and Levator ani muscles
Weakening of the Levator ani muscles can result in ?
Pelvic organs prolapsing
Which pelvic muscles may be confused for the ovaries or adnexal masses because of their location ?
Piriformis and iliopsoas muscles
Actually double folds of peritoneum ?
Suspensory ligaments
Broad ligaments
Ligament that contains the ovarian arteries / veins, nerves and lymphatics ?
Suspensory ligaments
Cardinal ligaments ?
House the uterus vasculature
Extends from the lateral surface of the cervix to the lateral fornix of vagina
When surrounded by free fluid, which ligament can be seen extending bilaterally from the uterus’ lateral sides
Broad ligaments
Round ligaments ?
Extends from uterine cornua to labia majora between the folds of the broad ligaments
Supports the uterus (fundus)
Most dependent peritoneal cavity of the female pelvis?
POD/ Rectouterine recess
Right and left uterine arteries branch from the ?
Internal iliac arteries
Which arteries supplies blood to the uterus, fallopian tubes, ovaries.
They course along the lateral borders of the uterus within the broad ligaments ?
Uterine arteries
Lateral pelvic muscles ?
Iliopsoas
Obturator internus
Muscles located laterally to the ovaries ?
Obterator internus muscles
Which muscle is located lateral and anterior to the iliac crest ?
Iliopsoas muscles
Posterior pelvic muscles ?
Piriformis muscles
Uterine artery branches into ?
Arcuate arteries (seen along the lateral aspect of the myometrium)
Arcuate artery branches into ?
Radial arteries
Supply blood to the deeper layers of the myometrium
They divided into straight and spiral arteries
What are the tiny, coiled arteries that supply blood to the functional layer of the endometrium? (Superficial )
Spiral arteries (branch off radial arteries)
Uterine artery branch pathway
Internal iliac
Uterine
Arcuate
Radial
Straight / spiral
Where does the ovaries receive its dual blood supply from ?
Branch of the uterine artery and ovarian artery
Ovarian artery branches arises from the ?
Abdominal aorta (lateral aspect)
Right ovarian vein drains into ?
IVC
Left ovarian vein drains into?
Left renal vein
Straight arteries ?
uterine radial artery branch that supplies blood to the basal layer of the endometrium
The pelvic ligament that provides support to the ovary and extends from the ovary to the lateral surface of the uterus is the?
Ovarian ligament
Pelvic bones appear ?
Hyperechoic
What two structure during fetal gestation essentially develop at the same time ?
Uterus and Kidneys
It’s safe to assume then that if an anomaly is present in the uterus,
There is most likely an anomaly in the kidney as well
Uterus, fallopian tubes, and vagina develop from ?
Müllerian ducts / paramesonephric
Uterus?
Retroperitoneal
Anterior to the rectum, posterior to the bladder, laterally bounded by the broad ligaments
Fundus/ corpus/ isthmus / cervix
Most superior and widest portion of the uterus ?
Fundus
Largest part of the uterus ?
Body / corpus and located inferior to the fundus
Known as the lower uterine segment during pregnancy ?
Isthmus
(Located between the corpus and isthmus)
Located inferior to the isthmus of the uterus ?
Cervix (internal os / external os)
Vagina ?
Tubular structures that extends from the external os/ cervix / fornices to the external genitalia
Vaginal wall layers?
Mucosal (inner)
Muscular
Adventitia (outer)
Uterine wall layers ?
Endometrium / inner mucosal layer (inner)
Myometrium/ muscular layer
Perimetrium / serosal layer (outer)
Parts of the endometrium ?
Basal layer
Superficial / functional layer
Located between the two functional layers of the endometrium ?
Endometrial / uterine cavity
Endometrium layer ; BASAL?
Thickness remains consistent with varying hormone levels and the menstrual cycle
Endometrium layer ; functional / superficial ?
Thickness varies with menstruation and hormone stimulation
Prepubertal cerivix to uterus ratio ?
2:1
Menopausal uterus ?
Atrophies and normally less than 5cm >
Normal menarcheal uterus ?
Fundus begins to enlarge after puberty,
Uterine fundus becomes much larger than the cervix
Normal uterine position ?
Anteverted / Anteflexed
Uterine body tilts forward making a 90 degree angle with the vagina ?
AnteVERTED
Uterine body folds forward, potentially coming in contact with the cervix ?
AnteFLEXED
Flexion?
Cervix coming in contact (retro/ ante)
RetroVERTED?
Uterine body tilts backward, without a bend where the cervix and uterine body meet
RetroFLEXED ?
Uterine body tilting backward, potentially coming in contact with the cervix
Dextroverted uterus ?
More located to the RIGHT of the midline
Levoverted uterus ?
Located more to the left of the midline
Uterine malformations are a result of ?
Fusion anomaly of the Müllerian ducts
Common uterine anomaly resulting the endometrium divides into two endometrial cavities with one cervix
With a prominent concavity in the uterine fundus ?
Bicornuate uterus
Uterus has only one horn ?
Unicornuate uterus
Septate uterus ?
Uterus that has two complete separate uterine cavities, and separated by a anteroposterior septum
Subseptate uterus ?
Incomplete septum
Has a normal uterine contour with an endometrium that branches into two horns
Arcuate uterus ?
Subtle variant where the endometrium has a concave contour at the uterine fundus
Uterus didelphys ?
Complete duplication of the vagina, cervix and uterus
One of the most common Müllerian duct anomalies ?
Septate uterus
Bicornuate uterus
Diethylstilbestrol / DES which was administered to pregnant women from 1940 - 1970s to treat threatened abortions and premature labor is associated and linked with the following ?
Has resulted in the formation of congenital malformation of the uterus
Congenital malformation has been linked to ?
Menstrual disorders
Infertility
Obstetric complications
Can lead to accumulation within the female genital tract secondary to obstruction which can lead to distension of the vagina, cervix, uterus, and fallopian tubes with blood/ fluid
Has an explicit connection with spontaneous abortion ?
Septate uterus anomaly
Colpos?
Accumulation within the VAGINA
Metra ?
UTERUS accumulation
Metracolpos?
Accumulation within the uterus and vagina
Patients suffers from pelvic / abdominal palpable mass as a result of excessive accumulation ?
Symptoms of vaginal obstructions
Hematometra / Hematocolpos ?
Accumulation of blood /retained menses in vagina and uterus
Hematometracolpos is often associated with ?
Imperforate hymen / young girls
Imperforate hymen, resulting in Hemetrocolpos symptoms ?
Present with amenorrhea, cyclic abdominal pain, an abdominal mass, enlarged uterus, and possibly urinary retention.
Adenomyosis ?
Invasion of endometrial / basal layer tissue into the myometrium
(Depth atleast < 2.5 cm)
Focal /diffuse
Focal ; adenomyoma
Found more often within the uterine fundus and posterior portion of the uterus with posterior thickening of the myometrium commonly seen
Often present in already affect fibroid uterus
Adenomyosis symptoms ?
Enlarged boggy and tender uterus
Dyschezia, dysmenorrhea, menometrorrhagia, pelvic pain and Dyspareunia
Women are often older and multiparous
Adenomyosis appearance ?
Focal ; adenomyoma or diffuse involvement
Typically seen in the fundus or posterior portion of the uterus
Uterus will be diffusely enlarged and heterogeneous
May be indistinct hypoechoic or echogenic areas scattered throughout the myometrium, with small myometrial cysts present
Hypochoic areas adjacent to the endometrium
Thickening of the posterior myometrium
Uterine Leiomyoma ?
Benign smooth muscle tumor / FIBROID / uterine myoma
Most common benign gynecologic tumor
Leading cause of hysterectomy and gynecologic surgery
Tumors may vary in size, and may alter the shape of the uterus and have varying sonographic appearances
Uterine leiomyoma ?
Benign smooth muscle tumor of the uterus
Fibrous/ uterine myoma
Most common benign gynecologic tumor
Leading cause of gynecologic surgery and hysterectomy
Vary is size and may alter the shape of the uterus and have varying sonographic appearances
Growth has been associated with estrogen stimulation
(Pregnancy = enlarges )
(Post menopausal = shrinks)
Greater risk facts for developing fibroids ?
Black
Nonsmokers
Perimenopausal
Fibroids symptoms ?
Pelvic pressure, Menorrhagia, palpable abdominal mass, enlarged uterus, urinary frequency, dysuria, constipation and possibly infertility
Degenerating fibroids appearance ?
Have calcifications and cystic components
Fibroid uterus ?
Uterus that is distorted by multiple fibroids
Fibroids types that have a higher incidence linked with spontaneous abortion / impacted fertility ?
Intracavitary
Submucosal
Types of fibroids ?
Intramural
Submucosal
Intracavitary
Pedunculated
Subserosal
Cervical
Most common type of fibroid ?
Intramural
Pregnancy complications associated with fibroids ?
Cervical types can osbtruct natural delivery
Not allowing the cervix to dilate at time of labor (caesarian section delivery required)
Sonographic appearance of fibroids ?
Hypoechoic solid masses that produce shadowing
(Degenerating masses will have calcifications and cystic components)
Submucosal fibroids ?
Located adjacent to the endometrial cavity and often distort the shape of the endometrium
Usually lead to abnormal uterine bleeding
What type of fibroid most often leads to abnormal uterine bleeding ?
Submucosal fibroid
Because of their location in relationship to the endometrium
Pedunculated fibroid ?
Pedunculated / on a stalk
Associated with the broad ligament, and can resemble a adnexal mass
Because these masses are prone to torsion when large enough the twisting of blood supply can cause necrosis and the patient will suffer from acute localized pelvic pain
Subserosal fibroid ?
Grows outward and distorts the contour of the uterus
Have a potential of being pedunculated which has a propensity of torsion / necrosis
Intramural fibroid ?
Most common type of fibroid
(Within the myometrium)
Fibroid treatment options ?
Hormone therapy
Hysterectomy/ Myomectomy
Uterine Artery Embolization
Common fibroid sonographic findings ?
Solid hypoechoic masses that shadow
Multiple fibroids may cause uterine diffuse enlargement with an irregular shape that is heterogeneous
Leiomyosarcoma ?
Leiomyosarcoma ?
Malignant counterpart of the fibroid
Defined by rapid growth rate over a short period of time
Seen commonly in perimenopausal or postmenopausal women
Sonographic appearance is variable but can appear similar to a fibroid mass
May be asymptomatic or present the same clinically as benign leiomyoma
Leiomyosarcoma symptoms ?
Pelvis pressure, Menorrhagia, palpable abdominal mass, enlarged and bulky uterus, urinary frequency, dysuria, constipation, and infertility
Appearance of leiomyosarcoma ?
Rapidly growing hypoechoic uterine mass
Shadowing
Degeneration ; calcifications or cystic components
Fibroid uterus ; multiple fibroids cause the uterus to become enlarged, irregular shaped, and diffusely heterogeneous
Nabothian cyst ?
Benign retention cysts located within the cervix
May cause cervix enlargement
Classically simple cyst appearance, but may contain some septations or internal debris (hemorrhage/ infection)
Typically asymptomatic and may be multiple present
Cervical carcinoma ?
Most common female malignancy younger than < 50 years old
May present as a inhomogeneous, bulky enlarged cervix or as a focal mass within the cervix
Loss of the cervical canal may occur
If the cyst becomes large enough it can cause obstruction of the cervix Hema/ hydro metra
most common female malignancy in women under 50 years old ?
Cervical carcinoma
Cervical canal should not exceed?
< 4 cm
after a hysterectomy, the cervical remnant measurement should not exceed ?
<4.4 cm (AP)
Length ; 4.3 cm
After a hysterectomy, the vaginal cuff should not exceed ?
<2 cm
Cervical Stenosis ?
Narrowing of the endocervical canal
May result from an obstructing tumor, fibroid, or polyp in the cervix, cervical infection, cervical atrophy, or scarring of the cervix following radiation treatment for cancer
Patients may be asymptomatic,
But patients still menstruating may have absence of menses / amenorrhea
May have a enlarged uterus
Gartner Duct Cyst ?
Vaginal wall cyst
Usually small and asymptomatic
Incidentally found
Patients presenting with precocious puberty should be assessed where and for what?
Ovarian adrenal and liver tumors
True precocious puberty has been associated with ?
Intracranial tumors or simply idiopathic
Pseudoprecocious puberty associated with ?
Ovarian, adrenal and liver tumors
Or may be idiopathic.
Peripheral pseudosexual precocity or gonadotropin-independent precocious puberty
Precocious puberty is defined as?
pubertal development before the age of 8
Delayed puberty?
Absent or incomplete breast development after the age of 12
Endometriosis ?
Young and fertility troubles
Adenomyosis ?
OLDER and multiparous
Outer layer of the endometrium ?
Basal layer
Inner layer of the endometrium ?
Functional layer
Abnormally heavy and prolonged menstrual flow between periods is termed:
Menometrorrhagia
Menorrhagia ?
Abnormal heavy and prolonged menstruation
Upon sonographic evaluation of a patient complaining of abnormal distention, you visualize a large, hypochoic mass distorting the anterior border of the uterus. What is the most likely location of this mass?
Subserosal fibroid
Ovaries ?
Intraperitoneal
located in the true pelvis (variable)
Blood supply from the ovarian artery branch of the uterine artery and ovarian artery
Endocrine gland responsible for releasing estrogen and progesterone in varying amounts throughout the menstrual cycle
Consist of medulla / cortex layers
Ovarian fossa location ?
Posterior to the ureter and internal iliac arteries
Superior to the external iliac arteries
Ovary medulla layer ?
Consists of ovarian vasculature and lymphatics
Ovary cortex layer ?
Encases the ovary and the site of oogenesis
Ovaries are stimulated by ?
Follicle stimulating hormone which is released by the anterior pituitary gland to develop multiple follicles during the first half of the menstrual cycle / follicular phase
The cells surrounding the tiny follicles produce estrogen that stimulates the endometrium to thicken
Only one of these follicles will become the dominant follicle, or Graafian follicle, prior to ovulation, while all other follicles will undergo atrophy
After the Graafian follicle has ruptured, its structure is converted into the corpus luteum
Ovulation ?
Day 14
occurs when the dominant follicle ruptures, releasing the mature ovum and a small amount of follicular fluid into the peritoneal cavity (Rectouterine/ POD)
Mittelschmerz, which means middle pain, describes pain at the time of ovulation, typically on the side of the dominant follicle
Second half of menstrual cycle ?
Luteal phase
corpus luteum produces progesterone and, in small amounts, estrogen.
If fertilization occurs, the corpus luteum is maintained and becomes the corpus luteum of pregnancy.
If fertilization does NOT occur, the corpus luteum regresses and becomes the corpus albicans.
Ovarian cycle phases ?
Follicular and Luteal
Ovarian blood flow (low / high) ?
Varies with the menstrual cycle ;
During early follicular and late Luteal phase ; high resistance
During late follicular and early luteal phase ; low resistance
Blood flow resistance of the ovarian artery during early follicular and late luteal phase ?
HIGH resistance
with increased impedance, and absent or low end-diastolic velocity.
Ovarian artery flow resistance during the late follicular and early luteal phase ?
LOW resistance
with low impedance and higher levels of diastolic flow
Follicular cyst ?
When the Graafian follicle does rupture it continues to enlarge and become a cystic structure
Appears as anechoic, unilocular simple cyst (thin walled)
Mostly asymptomatic but may lead to pain
Can grow quite large ; 3- 8 cm and prone to cause ovarian torsion
Torsion of the ovary is more prone when associated with
Larger ovarian masses
Results in the development of multiple enlarged follicular cysts ?
OHS / ovarian hyperstimulation syndrome associated with fertility treatment
Hemorrhagic cyst?
Follicular cyst that contains blood
Weblike / Lacey appearance
Appears as a complex or completely echogenic depending on stage of lysis
Corpus Luteum cyst ?
Functional physiologic cyst that develops after ovulation
May reach sizes up to < 8 cm, with regression occurring within 1 - 2 months
Asymptomatic but might suffer from pain because of enlargement of the cyst, rupture and hemorrhage
(Increased risk of torsion with cyst enlarging)
Most often resolves within 16 weeks of gestation at a size less than < 3 cm
Corpus Luteum ?
Result from a mature Graafian follicle rupturing .
produces progesterone
(maintaining the endometrial thickness during early pregnancy for implantation)
Usually regresses after fertilization has not occurred
Corpus luteum regression byproduct ?
Corpus albicans
Appears as a small echogenic structure with the ovary
Most common female pelvic mass seen during a first trimester sonographic examination ?
Corpus luteum cyst
Corpus Luteum Cyst appearance ?
Simple cyst appearing
May have thick walls, and difficult to differentiate from ectopic pregnancy and from cystic to solid adnexal masses
LARGEST and least common functional ovarian cyst ?
Theca Lutein cyst
Theca Lutein Cyst ?
Associated with HIGH levels of HCG (> 100 000 mIU per ml)
Multiple gestations, gestational trophoblastic disease/ molar pregnancy and ovarian hyperstimulation syndrome / OHS
Such high levels of HCG causes the patient to suffer hyperemesis and complain of pelvic fullness
Most Largest and least common functional ovarian cyst
They tend to regress however when the high amounts of HCG diminish from circulation
Theca Lutein Cyst appearance?
Bilateral
Sizes range up to < 15 cm
Multiloculated
(May contain hemorrhagic components)
Paraovarian cyst ?
Small cyst adjacent to the ovary
Most commonly arise from the fallopian tubes or broad ligaments,
May contain small areas of septations and hemorrhage
Clinical presentation varies, pain being felt when the cyst is larger in size and increased lower abdominal girth size
Size can range from 1.5 - 19 cm
Cystic Teratoma / Dermoid cyst ?
Result from retention of an unfertilized ovum that differentiates into the 3 germ cell layers
May contain any number of tissues
(Teeth, bone, glandular thyroid tissue, muscle, fat, hair, cartilage, digestive elements, and sebum)
Most commonly seen in reproductive aged and postmenopausal
Patients can present asymptomatic or suffer from from pain secondary to hemorrhage or torsion secondary to large size of cyst/ mass
Hemorrhage can also lead to peritonitis and have a rare potential of malignant degeneration
Most common benign ovarian tumor ?
Cystic teratoma / dermoid cyst
Germ cell layers ?
Endoderm
Ectoderm
Mesoderm
Cystic teratoma /dermoid cyst appearance ?
Tip of iceberg sign - only seen is the anterior hyperchoic/ echogenic anterior interface and posteriorly totally obscured by shadowing (occurs as a result of total attenuation)
Appear complex or a partially cystic mass within the ovary that includes one or more echogenic structures, which may produce shadowing posterior
Fluid - fluid level may be seen within the mass ; clear demarcation between sebum and serous fluid
Dermoid plug / dermoid mesh (hair)
Thecoma?
Benign ovarian sex cord stromal tumor consisting of theca cells
Most often seen in postmenopausal women
Associated with Meigs Syndrome
Patients often complain of vaginal bleeding associated with unconstrained estrogen stimulation upon the endometrium
Meigs Syndrome ?
Benign ovarian tumor with ascites and pleural effusion
Thecoma appearance?
Appear as hypoechoic solid mass with posterior attenuation
No enhancement
If large may mimic a pedunculated leiomyoma
Granulosa Cell Tumours ?
Sex cord stromal tumor
Typcially appear unilaterally and seen in postmenopausal women and young girls as well
postmenopausal patient may present with vaginal bleeding,
whereas adolescent patients may present with pseudoprecocious puberty
Present clinically like thecoma
Potential of malignant degeneration
Most common estrogenic tumor ?
Granulosa theca cell tumour
Granulosa cell tumor appearance ?
Ranging from ;
Solid hypoechoic mass to one that has some cystic components
Can reach sizes up to 40 cm >
Fibroma ?
Sex cord stromal tumor
Does NOT produce estrogen like the granulosa cell and Thecoma
Most often found in middle aged women
May be complicated by Meigs syndrome
Appears as a hypoechoic solid mass with posterior attenuation
When the tumor is resected the pleural effusion and ascites associated with Meigs syndrome resolves
Brenner tumor ?
Transitional cell tumor
Most often solid, small, hypoechoic unilateral mass that may contain calcifications
May appear similar to uterine Leiomyoma, fibroma, and thecoma
Almost always benign but has the potential of undergoing malignant degeneration
Patients may suffer from being symptomless, or
Present with a palpable mass or pain, also patients can present with Meigs syndrome (ascites and pleural effusion)
Endometrioma ?
benign, blood-containing tumor that is associated with endometriosis and forms from the implantation of ectopic endometrial tissue that is functional and reactive to hormone fluctuation
Chocolate cysts
More commonly seen on the ovary but can be seen anywhere in the pelvis, abdomen and prior caesarian section scar => scar endometriosis
Most often multiple present and seen in reproductive ages
Patients suffer from ; Dyspareunia, Dyschezia, menorrhagia, pelvic pain and possibly infertility present
Cause is unknown
Endometrioma appearance ?
predominately cystic mass with low-level echoes that resembles the sonographic appearance of a hemorrhagic cyst
May also demonstrate a fluid-fluid level.
Serous Cystadenomas ?
BENIGN
Commonly seen in women 40 to 50’s and in pregnancy
Often asymptomatic but
Often large and BILATERAL
Appears as predominately anechoic lesion that contains septations and/or papillary projections
Comprise most neoplasms of the ovaries ?
Serous Cystadenoma
Cystic Teratoma / Dermoid Cyst
Mucinous Cystadenoma?
BENIGN
LARGER than serous cystadenoma lesions
Sizes rang up to < 50 cm
Tend to have septations and papillary projections and UNILATERAL
Distinguishable sonographic finding between MUCINOUS and serous cystadenomas ?
The presence of internal debris within the mucinous type of cystadenoma,
Secondary to the solid components of the material contained within it
Patients often complaining of pelvic pressure and swelling, secondary to the large size of the mass.
Additionally patients may suffer abnormal uterine bleeding, gastrointestinal symptoms, and acute abdominal pain secondary to rupture or ovarian torsion
Most common malignancy of the ovary ?
Serous cystadenocarcinoma
Serous cystadenocarcinoma?
Malignant counterpart of serous cystadenoma and presents /appears the same as its benign counterpart
Frequently BILATERAL but has more prominent papillary projections and thicker separations present
Patients suffer from abnormal vaginal bleeding, swelling, gastrointestinal symptoms, weight loss, and pelvic pressure
May also have a elevated cancer antigen 125 / ca 125
CA 125 ?
Protein that may be increased in the blood of women with ovarian cancer and other abnormalities
Mucinous cystadenocarcinoma?
Malignant counterpart of mucinous cystadenoma
More often UNILATERAL
Associated with pseudomyxoma peritonei, often the fluid seen escaping from the mass resembles ascites
Krukenberg tumor?
Malignant ovarian tumor
Associated with primary metastatsis from the GASTROINTESTINAL tract malignancy/ stomach/ colon (breast, lung, contralateral ovary, pancreas or biliary tract cancers)
Patients may present asymptomatically or complain of pelvic pain and weight loss
Also present with a history of gastric or colon cancer
krukenberg tumor appearance ?
Smooth walled hypoechoic or hyperechoic tumor that often present BILATERAL
May be accompanied by ascites
“Moth - eaten” appearance
Solid mass containing scattered cystic spaces
Sertoli Leydig cell tumor
Androblastoma / sex cord stromal ovarian neoplasm associated with virilization
Associated with abnormal menstruation and hirsutism because of androgen production
Often seen in women younger than < 30 years old, and if seen in older women may be malignant
Appears as a solid hypoechoic ovarian mass or a complex partially cystic mass
Dysgerminoma?
Most common germ cell tumor of the ovary
Often seen in patients younger than < 30 years old and may be found in pregnancy
Associated with elevated LDH / lactate dehydrogenase
Testicular equivalent ; seminoma
Most common malignant germ cell tumor of the ovary?
Dysgerminoma
Most frequent ovarian malignancy found in childhood?
Dysgerminoma
Yolk Sac Tumor ?
Endodermal sinus tumor
Second most common malignant germ cell tumor
Defined by rapid growth
Found in women younger than < 20 years
HIGHLY MALIGNANT
Elevation in AFP
Sonographic appearance varies
Endometroid Tumor / carcinoma ?
Ovarian tumor that has a high incidence of being malignant
Often seen in women 5th/6th decades of life
Often associated with a history of endometrial carcinoma, endometriosis, or endometrial hyperplasia
Appears as a complex mass with solid components or a cystic mass with papillary projections
Malignancy ovarian malignancies often reveal on doppler ?
Higher diastolic flow velocities because of the abnormal vessels that are created with malignancy
Producing a low resistive waveform pattern
Resistive index under < 0.4
Pulsatility index under < 1.0
Colour flow and spectral doppler characteristic within a mass is not a specific finding and not typically used to determine the presence of malignancy
Ovarian Torsion ?
Results from the adnexal structures twisting on their mesenteric connection, cutting off its blood supply
Most commonly seen on the RIGHT side and caused by OHS and an ovarian mass / cyst (benign cystic teratoma and paraovarian cyst)
URGENT condition
May also be detected in the fetus and normal ovaries
Slight leukocytosis, nausea/ vomiting, and acute unilateral pelvic or abdominal pain
Presenting with abnormal amount of free fluid in the pelvis
Causes of ovarian torsion ?
ovarian hyperstimulation syndrome
Paraovarian cyst
Benign cystic teratoma
(Large ovarian masses are more prone to torsion)
Torsed ovary appearance ?
Enlarged ovary > 5 cm - mean 9.5 cm
with / without multifollicular development
May also be peripherally displaced small follicles secondary to edema
WHIRLPOOL sign
(Round mass with concentric hypoechoic and hyperechoic rings that demonstrates a swirling color doppler signature)
Abnormal amount of free fluid in the pelvis
Worrisome sonographic findings for ovarian carcinoma ?
Complex ovarian mass
Solid wall nodules within a cystic mass
(Larger the solid component amount - more likely malignant)
Thick septations > 3 mm
Wall thickening
Irregular wall or poorly defined walls
Blood flow within the septations, wall, or nodules
Ascites present
Fallopian tubes ?
Length ; 7 to 12 cm
Layers of the tube consists of ;
Outer / serosa ,Middle / muscular and Inner/ mucosal
Extend from the cornua of the uterus travelling through the broad ligaments
Segments; Interstitial/ ampulla / isthmus/ infundibulum
Interstitial segment of the fallopian tube ?
Lies within the Cornu of the uterus and most proximal segment of the fallopian tubes
Isthmus of fallopian tubes ?
Short and narrow segment connecting the interstitial segment to the ampulla segment of the fallopian tube
Ampulla of fallopian tube ?
Longest and most tortuous segment of the fallopian tube
Location of fertilization
Most common place for ectopic pregnancy to embed and fertilize
Infundibulum of the fallopian tube ?
Most distal segment of the fallopian tube
Provides an opening to the peritoneal cavity within the pelvis
Fingerlike projections are seen distally from the infundibulum aka Fimbria
Fallopian tubes can be seen sonographically when associated with ?
Inflammatory process
Infection
Obstruction leading to distended tubes
What can be used to assess the fallopian tubes for patency ?
Sonohysterography or hysterosalpinography
Carcinoma of the fallopian tube ?
Rare
Form of adenocarcinoma
Solid mass within the adnexa
Distention of the fallopian tubes can be secondary to obstruction
Pyosalpinx/ hematosaplinx/ hydrosalpinx
Hematosalpinx appearance?
Internal components seen within the anechoic fluid distending the fallopian tubes
And may appear echogenic or have a fluid - fluid level
Salpingitis ?
Inflammation of the Fallopian tubes due to infection, such as
Pelvic Inflammatory Disease / PID
With what ovarian tumor is Meigs syndrome most likely associated?
Fibroma
Sonographically, which of the following would most likely be confused for a pedunculated fibroid tumor because of its solid appearing structure?
Fibroma
Normal ovarian flow ?
High resistant during menstruation and low resistant at the time of ovulation
A 24-year-old female patient presents to the emergency department with severe right lower quadrant pain, nausea, and vomiting. The sonographic examination reveals an enlarged ovary with no detectable Doppler signal.
What is the most likely diagnosis?
Ovarian torsion
What ovarian tumor will most likely have a moth-eaten appearance on sonography?
Krukenberg tumor
55-year-old patient presents to the sonography department with a history of pelvic pressure, abdominal swelling, and abnormal uterine bleeding. A pelvic sonogram reveals a large, multiloculated cystic mass with papillary projections. What is the most likely diagnosis?
Serous Cystadenoma
Menstrual cycle average length ?
28 days
(LMP ; onset of menses)
Day 1 to 5 correlates ?
Menstruation and endometrial being shed
Menarche ?
First menstrual cycle
Primary amenorrhea ?
Does not experience menarche before age 16
Primary amenorrhea causes ?
Congenital abnormalities
Congenital obstructions - imperforate hymen
Secondary amenorrhea may be associated with ?
Endocrinologist abnormalities or pregnancy
Master gland ?
Pituitary gland
(Located within the brain, consists of anterior/ posterior lobes)
Main hormones that influence the menstrual cycle ?
FSH/ follicular Stimulating Hormone
LH/ Luteinizing Hormone
Resulting in ovulation ?
Whereas LH surges around the day 14 of the menstrual cycle
Ovary produces what hormones during the menstrual cycle ?
Estrogen
Progesterone
During the first half of the menstrual a cycle ?
Estrogen initiates the proliferation and thickening of the endometrium by encouraging the growth and expansion of the spiral arteries and glands within the functional layer of the endometrium
Which also stimulates contractile motions within the uterine myometrium and the Fallopian tubes
During the second half of the menstrual cycle ?
Following ovulation
Progesterone is produced by the corpus luteum of the ovary
Maintains the thickness of the endometrium ?
Progesterone
Common occurrence in postmenopausal women ?
Vaginal bleeding
Menometrorrhagia?
Excessive or prolonged bleeding at irregular intervals
Oligomenorrhea ?
Irregular menses cycle greater than 35 days apart
Causes of AUB / abnormal uterine bleeding ?
Uterine fibroids
Adenomyosis
Cervical polyps
Endometrial polyps
Endometrial hyperplasia
Endometrial cancer
Hypothyroidism
Anovulation
Which hormone maintains the corpus luteum during pregnancy?
Human chorionic gonadotropin / HCG
The hormone produced by the hypothalamus that controls the release of the hormones for menstruation by the anterior pituitary gland is:
Gonadotropin-releasing hormone / GnRH
The hormone produced by the trophoblastic cells of the early placenta is:
HCG
During which phase of the endometrial cycle would the endometrium yield the three-line sign?
Late proliferative phase
Which of the following hormones is released by the ovary during the second half of the menstrual cycle?
Progesterone
The measurement of the endometrium during the early proliferative phase ranges from:
4 to 8 mm
Menopause ?
Ages 42 to 58 (mean age 51)
Follicles cease to mature due to lack of estrogen and progesterone so menses ceases subsequently
Ovaries tend to atrophy and shrink, becoming more echogenic
Decrease in uterine size and endometrial thickness occurs as well
The breasts tend to accumulate more adipose / fat tissue within
Menopause symptoms ?
Suffer from night sweats/ hot flashes, mood changes, depression, dyspareunia, dysuria and a decrease in sexual libido
Menopause has a link / association increased risk of the following ?
Osteopenia
Osteoporosis
Coronary heart disease
Hormone Replacement Therapy / HRT ?
Often used to combat menopausal symptoms (hot flashes and vaginal atrophy) caused by reduced estrogen circulating
HRT administered to menopausal women reduces the risk of ?
Osteoporosis
Coronary heart disease
(Which is an increased risk factor after menopause occurs )
HRT administered to menopausal women has an associated increased risk of?
Endometrial Hyperplasia
Endometrial Carcinoma
Breast Cancer
Thromboembolism
Hypertension
Possibly diabetes
Causes post menopausal bleeding / PMB?
Endometrial atrophy
Uncontrolled HRT
Endometrial hyperplasia
Endometrial polyps
Submucosal or Intracavitary leiomyoma / fibroid
Endometrial carcinoma
Some ovarian tumours
Endometrial carcinoma criteria when menopausal patients presents with PMB ?
Endometrium measure less than < 5 mm
Bleeding is typically caused by endometrial ATROPHY
Endometrial carcinoma sonographic findings ?
with PMB < 5 mm endometrium thickness
Without PMB < 8 mm endometrium thickness
Focal irregularity and myometrial distortion may be more specific findings than just endometrial carcinoma
Most common cause of post menopausal bleeding / PMB ?
Endometrial ATROPHY
Endometrial ATROPHY?
Most common cause of PMB
Endometrium will appear thin and should not exceed < 5 mm
May also contain some Intracavitary fluid
Endometrial Hyperplasia ?
Common cause of AUB
Not only seen in postmenopausal women but also in reproductive years
Results from unopposed estrogen stimulation
Higher risk of endometrial carcinoma developing in postmenopausal women with hyperplasia present
Endometrium may contain small cystic spaces or appear diffusely thickened and echogenic
Endometrial hyperplasia is associated with ?
PCOS
Obesity
Tamoxifen therapy for breast cancer
Estrogen producing ovarian tumor
(Thecoma and Granulosa cell tumor)
Most common female genital tract malignancy ?
Endometrial Carcinoma
Endometrial Carcinoma ?
Form of adenocarcinoma
Seen in women aged 50 to 65 years old
Linked with unopposed estrogen therapy, multiparity, obesity, chronic anovulation, PCOS, estrogen producing ovarian tumors, and the use of tamoxifen
Tumors with penetration into the surrounding myometrium — poor prognosis
Treatment involves polypectomy
Most common clinical presentation of endometrial carcinoma ?
Post menopausal bleeding
Stein Leventhal Syndrome ?
polycystic ovarian syndrome / PCOS
Endometrial Carcinoma sonographic findings?
Thickened endometrium with variable echogenicity
Fluid with a polypoid mass may also be noted
Color doppler signal will be present within the thickened endometrium -
low resistance flow
Typically leads to endometrial biopsy, endometrial curettage, cancer antigen 125 testing
Process of staging endometrial carcinoma ?
Staging of the disease is performed surgically to determine the involvement of lymph nodes and the present of extrauterine metastases
Endometrial carcinoma symptoms ?
Postmenopausal bleeding / PMB
Intermenstrual bleeding
Enlarged uterus
Elevated CA 125
Also obstruction of the cervix can occur leading to accumulation of blood or pus within the uterus (hematometra/ pyometra)
Endometrial Polyps?
Small nodules of hyperplastic tissue that may cause abnormal vaginal bleeding in both postmenopausal and perimenopausal women
Linked with infertility regarding women in there reproductive years
Suffers from intermenstrual bleeding / menometrorrhagia or asymptomatic
Appearance varies
Better assessed with SIS (sonohysterography)
Endometrial Polyps appearance ?
Can appear as focal/ solitary echogenic area of thickening within the endometrium
Diffuse thickening of the endometrium in the presence of multiple or large polyps
Most often contains a small vessel and have cystic areas within it
CA 125?
Linked with cancers of the ovary, endometrium, breast, gastrointestinal tract, and lungs
Also can be elevated with benign conditions such as ;
Endometriosis, PID, fibroids, and pregnancy
Tamoxifen ?
Breast cancer drug that inhibits the effects of estrogen on the breast, thus slowing the growth of malignant breast cells
Can also be used to treat infertility
But has been linked with endometrial polyps, endometrial hyperplasia, and endometrial carcinoma
Sonographic findings of the endometrium when a patient is administered tamoxifen?
Cystic changes to occur within endometrium, and it produces a more heterogenous and thickened endometrial appearance
Sonohysterography (SIS)?
Saline infused sonography
Helps to determine whether the cause of the vaginal bleeding is intracavitary in origin (ex. Endometrial polyp)
Reasons people undergo SIS include the following;
AUB, infertility, abnormally thick endometrium, or suspected intracavitary mass
Also helps with differing between a fibroid Submucosal fibroid and polyps
Asherman Syndrome ?
presence of intrauterine adhesions or synechiae within the uterine cavity
typically occur as a result of scar formation after uterine surgery, especially after a dilation and curettage (D&C)
The adhesions may cause hypomenorrhea or amenorrhea, pregnancy loss, and/or infertility
Sonographic detection is difficult without the use of sonohysterography / SIS
Sonohysterography findings include bright bands of tissue traversing the uterine cavity.
A 31-year-old patient presents to the sonography department for a saline infusion sonohysterogram complaining of intermenstrual bleeding and infertility. Sonographically, a mass is demonstrated emanating from the myometrium and distorting the endometrial cavity. What is the most likely diagnosis?
Submucosal fibroid
A 34-year-old patient presents to the sonography department for an endovaginal sonogram complaining of intermenstrual bleeding. The sonographic findings include a focal irregularity and enlargement of one area of the endometrium. The most likely diagnosis is:
Endometrial Polyp
A 67-year-old patient on HRT presents to the sonography department with abnormal uterine bleeding. Sonographically, the endometrium is diffusely thickened, contains small cystic areas, and measures 9 mm in thickness. The most likely cause of her bleeding is:
Endometrial Hyperplasia
A 60-year-old patient presents to the emergency department with sudden onset of vaginal bleeding. The sonographic examination reveals an endometrium that measures 4 mm. There are no other significant sonographic findings. What is the most likely diagnosis?
Endometrial Atrophy
A 68-year-old patient presents to the sonography department complaining of vaginal bleeding. The most likely cause of her bleeding is:
Endometrial Atrophy
An 84-year-old patient presents to the sonography department with sudden onset of vaginal bleeding. Her endometrium should not exceed:
< 5 mm
An asymptomatic 65-year-old patient presents to the sonography department with pelvic pain but no vaginal bleeding. Her endometrial thickness should not exceed:
< 8 mm
Which of the following ovarian tumor would be most likely to cause postmenopausal bleeding?
Thecoma
The sonographic appearance of a 59-year-old woman on HRT is:
Variable depending upon the menstrual cycle
Unopposed estrogen therapy has been shown to increase the risk for developing:
Endometrial Carcinoma
The breast cancer treatment drug that may alter the sonographic appearance of the endometrium?
Tamoxifen
What would increase a patient’s likelihood of suffering from thromboembolism?
Estrogen Replacement Therapy / ERT
Pelvic Inflammatory Disease ?
Infection of the upper genital tract (ascending infection)
Common cause is STD (gonorrhea and chlamydia)
Bilateral condition affecting not only the uterus but also both fallopian tubes, and possibly ovaries
Relatively easy to treat, usually with potent antibiotic therapy
Can lead to development of tubo - ovarian abscess and even death
Sonographic finding vary with acute and severe forms of PID
Causes of pelvic inflammatory disease ?
Previous history of PID
Utilizing IUD
Postabortion
Post childbirth
Douching
Multiple sexual partners
Early sexual contact
Pelvic surgery, accompanying tuberculosis, or can occur with an association with ruptured abscess or colon diverticulum
Pelvic Inflammatory Disease symptoms?
Fever, chills, pelvic pain, cervical motion tenderness, purulent vaginal discharge with foul odour, vaginal itchiness, and Dyspareunia
Also present will be leukocytosis
Pelvic Inflammatory Disease symptoms?
Fever, chills, pelvic pain, cervical motion tenderness, purulent vaginal discharge with foul odour, vaginal itchiness, and Dyspareunia
Also present will be leukocytosis
Evolution of PID?
Vaginitis
Cervicitis
Endometritis
Salpingitis
Tubo - ovarian complex
Tubo - ovarian abscess
Sonographic findings of acute PID?
Thickened irregular endometrium (Endometritis)
Ill - defined uterine borders
Pyosalpinx and Hydrosalpinx present
Cul de sac fluid present
Multicystic and solid complex adnexal mass(es) (TUBO-OVARIAN complex/ abscess)
Sonographic findings of Chronic PID ?
Dilated fallopian tubes containing simple-appearing, anechoic fluid hydrosalpinx
- Scars may be noted within the dilated tube and appear as echogenic bands within the tube
- Development of adhesions may obliterate distinct borders of organs because they become fixated to each other
- Multicystic and solid complex adnexal mass(es) (see “Tubo-ovarian Complex /Abscess”)
Most common initial clinical presentation in early stages of PID ?
Vaginitis
Vaginitis ?
Vaginitis?
Inflammation of the vagina
first sign / manifestation of PID
Present with excessive vaginal discharge, purulent and foul smelling
Can lead to Endometritis
Endometritis ?
Endometrial inflammation
Results from postpartum, after a dilation and curettage (D&C), in the presence of PID, after surgery, and may be seen with an intrauterine device (IUD).
Patients suffer from pelvic tenderness and leukocytosis
Pyometra may be present (accumulation of purulent material within endometrium)
Endometrium will appear echogenic and thickened, or irregular appearing
May contain intraluminal fluid within the endometrium
Gas or air formation within the endometrial cavity can cause ring down artifact
Effectively treated by curettage and/or antibiotic therapy
Fallopian tubes sonographic findings regarding PID ?
May be seen in the presence of PID
Spread of infection beyond the endometrium can lead to salpingitis / inflamed tubes
Hyperemic flow can be seen within / around the Fallopian tubes
There may be signs of nodular thickening in the wall of the affected tube
Symptoms resemble cholecystitis — aka
Meigs Syndrome -> leading to a perihepatic infection and the subsequent development of adhesions located between the liver and diaphragm
Liver capsule may become inflamed
Tubal infections can often lead to ;
Pyosalpinx and Hydrosalpinx
PID has been linked to ?
Infertility
Ectopic pregnancy
Cause of PID linked to infertility and ectopic pregnancy ?
Secondary to the formation of scarring within the formerly inflamed opening of the fallopian tube
Which increases the risk of pregnancy implantation occuring in the fallopian tube leading to ectopic pregnancy
SONOGRAPHIC FINDINGS OF TUBO-OVARIAN COMPLEX?
- Thickened, irregular endometrium
- Pyosalpinx or hydrosalpinx
- Cul-de-sac fluid
- Multicystic and solid complex adnexal mass(es)
- Ovaries and tubes recognized as distinct structures, but the ovaries will not be separated from the tube by pushing with the vaginal probe
Sonographic findings of tubo - ovarian abscess ?
- Thickened, irregular endometrium
- Pyosalpinx or hydrosalpinx
- Cul-de-sac fluid
- Multicystic and solid complex adnexal mass(es)
- Complete loss of borders of all adnexal structures, and the development of a conglomerated adnexal (possibly bilateral) mass
Tubo -ovarian complex ?
As PID progresses and reaches beyond the fallopian tubes, ovaries, and peritoneum becomes involved
Adhesions develop within the pelvis that lead to fusion of the ovaries and distended fallopian tubes
Beyond this stage leads to tubo - ovarian abscess
Sonographic differentiation finding between tubo - ovarian complex or abscess?
The ovaries and fallopian tubes are more easily distinguishable, but the ovaries will not be able to be separated from the tube by pushing with the vaginal probe
Tubo ovarian abscess?
There will be complete loss of borders and indistinguishability of all adnexal structures
Infertility definition?
Inability to conceive a child after one year of unprotected intercourse
Causes of female infertility ?
Congenial uterine malformation (septate uterus)
Endometriosis
PCOS
Tubal causes
Asherman syndrome
Uterine fibroids (intracavitary and submucosal types)
Endometriosis ?
Ectopic functional endometrial tissue located outside the uterus,
Most commonly seen in the OVARIES but can be found anywhere within the pelvis
Seen in ages from 25 to 35 years old
Hemorrhage of the tissue often occurs, resulting in focal areas of bloody tumors aka endometrioma / chocolate cysts
Endometriosis symptoms ?
Pelvic pain, Dyspareunia, and infertility
May also suffer from ;
Dysmenorrhea, Menorrhagia, Dyschezia and may even be asymptomatic
Appearance of Endometrioma / chocolate cyst ?
Commonly cystic masses with low level echoes that may or /may not contain fluid - fluid levels
PCOS ?
Stein - Leventhal syndrome
Endocrinologic ovarian disorder linked with infertility
Patients suffer anovulation resulting from hormonal imbalances
Amenorrhea, hirsutism, and obesity
Patients may suffer from as well ; Oligomenorrhea and acne
Linked with unopposed high levels of estrogen stimulation on the endometrium ; which increases the risk of endometrial and breast cancer from developing
Most common cause of androgen excess/hyperandrogenism?
PCOS
PCOS appearance ?
Ovaries are often enlarged and contain multiple follicles along the periphery or throughout the ovary
With prominent echogenic stromal elements
String of pearls sign
Criteria being ;
One or both ovaries collectively should contain 12 or more follicles measuring between 2 to 9 mm
And ovarian volume should exceed > 10 ml
String of pearls sign ?
PCOS ovaries appearance
Stein - Leventhal Syndrome ?
Amenorrhea
Hirsutism
Obesity
A.K.A. PCOS
HYDROsalpinx?
Often the result of obstruction of the fimbriae portion of the fallopian tube by adhesions
Adhesions developing are associated with?
Long standing PID
Endometriosis
Tubal surgery
Endometrial factors contributing to infertility ?
Luteal phase deficiency — reduced progesterone production by the ovary
(Luteal corresponds with secretory phase of the endometrial cycle appearing as; thickened and echogenic)
Asherman syndrome associated with infertility?
Adhesions prevent implantation / or recurrent early pregnancy loss of conceptus because of the past D & C/ uterine surgery to cause synechiae to traverse the uterine cavity resulting from scar formation
Results in Hypomenorrhea/ Amenorrhea
Uterine fibroids and its relation to infertility?
Women can still become pregnant with fibroid present
INTRACAVITARY / SUBMUCOSAL types distort the endometrium, thus preventing implantation of conceptus and impair tubal transport due to obstruction
Also fibroids because of estrogen exposure may increase in size / enlarge
ART?
Assisted reproductive therapy is utilized simultaneously with ovarian stimulation is increased for follicular development and higher chances of success
IVF?
In Vitro Fertilization
Is where the egg and sperm are fertilized outside the body, and after the embryo forms (4 -8) are instilled in the uterus via catheter
Increased risk of multiple gestations occurring
GIFT ?
Gamete intrafallopian tube transfer
Where fertilization takes places within the tube
Oocytes and sperm placed within the tube by laparoscopy
ZIFT?
Zygote Intrafallopian transfer
Treated with fertility treatment / ART have an increased risk /association with the following ?
Multiple gestations
Ectopic pregnancy
Heterotopic pregnancy
OHS
Ovulation induction dramatically increases the patients risk of ?
Multiple gestations
OHS
Ovarian Hyperstimulation Syndrome ?
Associated with patients who have a history of ovulation induction
OHS appearance ?
Enlarged ovaries (5 to 12 cm) with multiple large follicles and theca lutein cyst present — increases the risk of the patients suffering from ovarian torsion
(HCG is used in ovulation induction — > theca lutein cysts occur )
Severe OHS symptoms?
Nausea, vomiting, abdominal distension, ovarian enlargement, electrolyte imbalance, oliguria, and sonographic signs of ascites and pleural effusion
OHS can initiate ?
Renal failure
thromboembolism
Acute respiratory disease syndrome
IUD?
Release small amounts of progestin to impede implantation and produce lighter menstrual bleeding
Appears as a echogenic structure with posterior shadowing seen in the fundal region of the endometrium producing a “entrance and exit echo” sign
IUD perforation into the uterine wall symptoms?
Cramping and heavy or irregular bleeding
IUD use has been linked to ?
PID
Ectopic pregnancy
Spontaneous abortions
Essure device?
Permanent form of brith control that uses small coils placed into the proximal isthmic segment of the fallopian tubes / cornua
Over time causes scar formation and obstruction of the tubes eventually
Best seen as bilateral echogenic linear structures within the Cornu of the uterus in the transverse plane
Patient present to the department with history of tubal ligation and a positive pregnancy test is indicative of ?
Ectopic pregnancy
What radiographic procedure is used to evaluate the patency of the tubes ?
Hysterosalpingography
A patient presents to the sonography department with complaints of infertility and painful menstrual cycles. Sonographically, you discover a cystic mass on the ovary consisting low-level echoes. Based on the clinical and sonographic findings, what is the most likely diagnosis?
Endometrioma
A 26-year-old patient presents to the sonography department with a history of infertility and oligomenorrhea. Sonographically, you discover that the ovaries are enlarged and contain multiple, small follicles along their periphery, with prominent echogenic stromal elements. What is the most likely diagnosis?
PCOS
A patient presents to the sonography department with a history of Chlamydia and suspected PID. Which of the following would be indicative of the typical sonographic findings of PID?
Thickened irregular endometrium, cul-de-sac fluid, and complex adnexal masses
A 25-year-old patient presents to the sonography department complaining of pelvic pain, dyspareunia, and oligomenorrhea. An ovarian mass, thought to be a chocolate cyst, is noted during the examination. Which of the following is consistent with the sonographic appearance of a chocolate cyst?
Cystic mass with low level echoes
OHS can cause multiple large follicles to develop on the ovaries termed:
Theca lutein cysts
adhesions within the endometrial cavity?
Synechiae
A female patient presents to the sonography department with a clinical history of Clomid treatment. She is complaining of nausea, vomiting, and abdominal distension. What circumstance is most likely causing her clinical symptoms?
OHS
Heterotopic pregnancy?
Simultaneous intrauterine and extrauterine pregnancies
