Repro Flashcards
The uterus
neonate
Uterus is larger than you would think for a baby (maternal / placental hormones
are still working). If you look close, the shape is a little weird with the cervix often larger than the fundus.
The uterus
prepuberty
The shape of the uterus changes - becoming more tube-like, with the cervix and uterus the same size.
The uterus
puberty
The shape o f the uterus changes again, now looking more like an adult (pear-like)
- with the fundus larger than the cervix. In puberty, the uterus starts to have a visible endometrium - with phases that vary during the cycle.
The Ovaries - Changes During Life
Just like with the uterus, infants tend to have larger ovaries (volume around 1 cc), which then
decrease and remain around or less than 1 cc until about age 6. The ovaries then gradually
increase to normal adult size as puberty approaches and occurs.
Turner Syndrome
The XO kids. Besides often having aortic coarctations, and
horseshoe kidneys they will have a pre-puberty uterus and streaky ovaries.
Embryology
The quick and dirty of it is that the mullerian ducts make the uterus and upper 2/3 of the vagina.
The urogenital sinus grows up to meet the mullerian ducts and makes the bottom 1/3 o f the vagina.
Wolffian ducts are the boy parts, and
should regress completely in girls.
Mullerian Ducts
Uterus
Fallopian Tubes
Upper 2/3 o f the Vagina
Wolffian ducts
Vas Deferens
Seminal Vesicles
Epididymis
Urogenital Sinus
Prostate
Lower 1/3 o f the Vagina
Embryology
step 1
Imagine that the stuff that makes the kidneys and the uterus is all the sam soup
you have two bowls of this stuff - half on the left, and half on the right
Embryology
step 2
as development occurs, this soup gets poured down the back of the belly
the upper part making the kiendy and the bottom part making hte uterus
Embryology
step 3
now the bottom two puddles of spilled/poured soup begin to fuse forming one puddle (uterus)
Embryology
step 4
but because they are just mashed together they dont have a central cavity necessary to carry a baby
so there is a clean - up operation (cleavage), and this occurs from bottom to top - like zipping up a jacket.
Embryology ways to screw up
1
You can only have soup on one side. This is a “failure to form” As you can imagine, if you don’t have the soup on one side you don’t have a kidney on that side. You also don’t have half o f your uterus. This is why a unilateral absent kidney is associated with Unicomuate Uterus (+/- rudimentary horn).
Embryology ways to screw up
2
As the soup gets poured down it can fail to fuse completely. This can be on the
spectrum o f mostly not fused - basically separate (Uterus Didelphys) or mostly fused
except the top part - so it looks like a heart (Bicomuate). Because the Bicomuate and
Didelphys are related pathologies - they both get vaginal septa (Didelphys more often
than Bicomuate - easily remembered because it’s a more severe fusion anomaly).
Embryology ways to screw up
3
The clean up operation can be done sloppy (“failure to cleave”). The classic example
of this is a “Septate uterus,” where a septum remains between the two uterine cavities.
Mullerian Agenesis
(Mayer-Rokitansky-Kuster-Hauser
syndrome): Has three features: (1) vaginal atresia, (2) absent or
rudimentary uterus (unicomuate or bicomuate) and (3) normal
ovaries. The key piece of trivia is that the kidneys have issues
(agenesis, ectopia) in about half the cases.
Unicornuate Uterus
4 variants
unicornuate +Communicating Cavitary Rudimentary Horn
U nicornuate + Non Communicating
Cavitary Horn
Unicornuate + Noncavitary Rudimentary Horn
Isolated unicornuate. Most Common Subtype (35%)
Unicornuate Uterus
overview
If you see a unicomuate uterus the classic teaching is to look for a rudimentary horn. The reason is the
rudimentary horns can have endometrium - and if present can cause lots of phantom female belly pain
problems (dysmenorrhea, hematometra, hematosalpinx, etc…, etc…, so on a so forth). Endometrial tissue
in a rudimentary hom (communicating or not) - increases the risk of miscarriage. An additional problem
could be a pregnancy in the rudimentary hom - in both the communicating and noncommunicating typesalthough
especially bad in the non-communicating sub-type because it nearly always results in
rudimentary hom rupture (life-threatening bleeding).
Renal agenesis contralateral to the main uterine hom (ipsilateral to the rudimentary horn) is the most
common abnonnality.
Uterus Didelphys
This is a complete uterine duplication (two cervices, two uteri, and two upper 1/3 vagina).
A vaginal septum is present 75% of the time. If the patient does not have vaginal obstruction this is usually asymptomatic.
Bicornuate uterus
This comes in two flavors (one cervix “unicollis”, or two cervix “bicollis”). There will be separation of the uterus by a deep myometrial cleft - makes it look “heart shaped”. Vaginal septum is seen around 25% of the time (less than didelphys). Although they can have an increased risk of fetal loss, it’s much less of an issue compared to Septate.
Fertility isn’t as much of a “size thing” as it is a blood supply thing. Remember you can have 8 babies in your belly at once and have them live… live long enough to take part in your reality show.
T-shaped uterus
This is the DES related anomaly. It is historical trivia, and therefore extremely high yield for the “exam of the future.” DES was a synthetic estrogen given to prevent miscarriage in the 1940s. The daughters of patients who took this
dmg ended up with vaginal clear cell carcinoma, and uterine anomalies
classically “T-Shaped.”
Septate uterus
This one has two endometrial canals separated
by a fibrous (or muscular) septum. Fibrous vs Muscular can
be determined with MRI and this distinction changes surgical
management (different approaches). There is an increased risk
o f infertility and recurrent spontaneous abortion. The septum
has a shitty blood supply, and if there is implantation on it - it
will fail early. They can resect the septum - which improves
outcomes.
This is the most common Mullerian duct anomaly associated
with miscarriage. This is improved with resection o f the
septum.
A rc u a te U te ru s
Mild smooth concavity o f the uterine
fundus (instead o f normal straight or convex) This is not really
a malformation, but more o f a normal variant. It is NOT
associated with infertility or obstetric complications.
Bicornuate quick
• “H e a rt S h a p e d ’’ - Fundal co n to u r is less than 5 mm above the tuba l ostia
• No s ig n ifica n t infertility issues
• Resection of the “s e p tum ” results in
poo r o u tcom e s
Septate quick
- Fundal co n to u r is Normal; more than 5 mm abo ve the tubal ostia
- L e g it infertility issues - impla ntation fails on the se ptum (it’s a b lo od s u p p ly th in g )
- Resection of the septum can help
Hysterosalpingogram (HSG)
overview
If you haven’t seen (or done one) before - this is a procedure that involves cannulation
of the cervix and injecting contrast under fluoro to evaluate the cavity of the uterus.
Hysterosalpingogram (HSG)
trivia
’ HSGs are performed on days 7-10 of menstrual cycle, (after menstrual bleeding complete - i.e. “off the rag”)
“ Contraindications: infection (PID), active bleeding (“rag week’’), pregnancy, and contrast allergy.
■ Bicornuate vs Septate is tough on HSG - you need MRI or 3D Ultrasound to evaluate the outer fundal contour.
Cycle days
0-7 “Rag Week,” 7-14 Proliferative, 14-28 Secretory
*Day 14 Ovulation
Salpingitis Isthmica Nodosa (SIN)
This is a nodular scarring o f the fallopian tubes that
produces an Aunt Minnie Appearance. As trivia, it
usually involves the proximal 2/3 o f the tube. This is
of unknown etiology, but likely post inflammatory /
infectious (i.e. being a woman of questionable moral
standard / “free spirit”). It’s strongly associated with
infertility and ectopic pregnancy and that is likely
the question.
Salpingitis Isthmica Nodosa (SIN)
aunt minnie
Nodular diverticula of the
fallopian tubes
No dominant channel
Uterine AVM
These can be congenital or acquired, with acquired types being way more
common. They can be serious business and you can totally bleed to death from them. The typical ways to acquire them include: previous dilation and curettage, therapeutic abortion, caesarean section, or just multiple pregnancies. Doppler ultrasound is going to show: serpiginous and/or tubular anechoic structures within the myometrium with high velocity color Doppler flow.
Intrauterine Adhesions (Ashermans) -
This is scarring in the uterus, that occurs secondary to injury: prior dilation and curettage, surgery, pregnancy, or infection (classic GU TB). This is typically shown on HSG, with either (a) non filling o f the uterus, or (b) multiple irregular linear filling defects (lacunar pattern), with inability to appropriately distend the endometrial canal. MRI would show a bunch of T2 dark bands. Clinically, this results in infertility.
Endometritis
This is in the spectrum o f P1D. You often see it 2-5 days after delivery,
especially in women with prolonged labor or premature rupture. You are going to have fluid and a thickened endometrial cavity. You can have gas in the cavity (not specific in a postpartum women). It can progress to pyometrium, which is when you have expansion with pus.
Pelvic Floor
overview
Getting old and having a bunch o f kids can sometimes make stuff hang out o f your vagina and cause you to
pee your pants (when you don’t actually want to pee your pants). It is important to make that distinction
between “prolapse” (stuff hanging out o f your vagina), and “relaxation” (peeing and/or pooping your pants
when you sneeze). Both are b a d … although one is worse — I ’ll let you decide which one that is.
Pelvic Floor
anatomy
This anatomy is complicated - buncha facial bands “ligaments” muscles etc… created a
“sling” which keeps all this stuff from falling out the bottom. The best way to think about the pelvic sling o f a
female is to group it into 3 functional compartments: Anterior compartment (bladder and urethra), Middle
compartment (vagina, cervix, uterus, and adnexa), and Posterior compartment (anus and rectum). This anatomy
is incredibly complex - but a few o f these vocab terms could make easy questions:
Pelvic Floor
endopelvic fascia
Buncha ligaments / fascia (pubocervical fascia, rectovaginal fascia, cardinal ligaments,
etc..) most o f which have vaginal or cervix in the name. Main support for the anterior & middle compartments.
Pelvic Floor
levator ani
This is the main muscular component o f the pelvic floor composed o f the puborectalis,
pubococcygeus, and iliococcygeus. This muscle groups constant contraction maintains the pelvic floor height.
Pelvic Floor Relaxation
Pelvic floor relaxation has two components (pelvic floor descent and widening) that can be graded during maximal strain on sag MR1: • Hiatal enlargement (H line) — less than 6cm - measurement o f widening • Pelvic floor descent (M line) - less than 2cm - measurement o f descent Wider H or longer M = Worse. Organs hanging out = worse.
Pelvic Floor
MRI protocol
Steady State - T2 - 3 planes Dynamic State - Rapid T2 with Fat Sat, Sag Plane Only —performed during Valsalva, Kegel, and/or taking a shit (seriously)
Pelvic Floor
PCL
(pubococcygeal line) = drawn from
inferior margin o f the symphysis pubis to
the junction between the first and second
coccygeal elements.
Pelvic Floor
H line
drawn from the inferior margin
o f the symphysis pubis to the posterior
aspect o f the puborectalis muscle sling.
Pelvic Floor
m line
shortest distance between the
posterior aspect o f the puborectalis
muscle sling and the PCL
Pelvic Floor
Axial image through the Ischioanal space
(Triangular o f fat lateral and caudally to the
levator ani - could show a loss o f the normal “H shaped” vagina or direct defects /
asymmetric thinning in the muscular sling. Having said that - for the purpose o f multiple
choice - this anatomy is usually demonstrating an anal fistula in the setting o f Crohns
Pelvic floor
urogenital diaphragm
This is the most caudal or superficial musculofascial structure. It does not have a marketable sex toy name (unlike Levator Ani). This thing usually finds it way into multiple choice exams as
the anatomic landmark used in the classification o f urethral injury - as discussed in the GU chapter.
Cystocele
overview
Bladder Descent > 1 cm
below the pubococcygeal line.
Cystocele
urethral hypermobility
what you say if the urethra is rotated horizontally. This changes the treatment f rom , retropubic urethropexy (for normal stress incontinence) to a pubovaginal sling.
Cystocele
risk factors
Squeezing a bunch of
kids out o f your vagina - can rupture
o f the pubocervical fascia
Cystocele
risk factors
Squeezing a bunch of
kids out o f your vagina - can rupture
o f the pubocervical fascia
Uterine prolapse
overview
Decent o f the cervix or posterior vaginal fornix < 1 cm above the pubococcygeal line.
A big turd can prop up the uterus - so
it is best to measure them with an
empty rectum (post defecation phase).
Uterine prolapse
risk factor
hysterectomy
Uterine prolapse
axial imag
Axial images could show the vagina
lose its normal “H” shape - hanging
low like the sleeve o f a w izard (or the
tongue o f a tired dog).
Rectocele
overview
Abnormal rectal
bulging (typically anteriorly).
Due to weakening
o f the rectovaginal fascia.
The describe them by how far
they bulge relative to the anal
canal.
Rectocele
risk factors
Vaginal surgery.
Hysterectomy, Chronic
Constipation, Being Old as
Dirt.
Fibroids (Uterine Leiomyoma)
hyaline (classic)
Most common type
T1 dark
T2 dark
Tl+C homogenous
Fibroids (Uterine Leiomyoma)
hypercellular
Densely packed smooth muscle (without much connective tissue). Respond well to embolization
T1 dark
T2 bright
Tl+C homogenous
Fibroids (Uterine Leiomyoma)
lipoleiomyoma
Rare fat containing subtype (maybe the result of degeneration!. This thing will be hvperechoic on ultrasound. Will look like a fattv uterine mass on CT. Will drop signal on fat saturation sequences.
T1 Bright (dark if fat sat)
T2 bright
Tl+C maybe rim enhancement
Fibroids (Uterine Leiomyoma)
degeneration
4 types of degeneration are generally described. What they have in common is a lack
of / paucity of enhancement (fibroids normally enhance avidly). The process of degeneration (basically
a fibroid stroke) can cause severe pain as well as fever and/or leukocytosis.
Fibroid Degeneration
Hyaline
Classic
Degeneration
Most common type. The fibroid outgrows its blood supply, and you end up getting the accumulation o f proteinaceous tissue.
T1 variable (usually dark)
T2 heterogenous ( usually dark)
Tl+C none
Fibroid Degeneration
Red
Carneous
This one occurs during pregnancy - caused by venous thrombosis. The classic imaging finding is a peripheral rim o fT l high signal.
T1 peripheral rim ov bright T1
T2 variable
Tl+C none
Fibroid Degeneration
Myxoid
Degeneration
uncommon
T1 dark
T2 bright
Tl+C minimal
Fibroid Degeneration
Cystic
Degeneration
uncommon
T1 dark
T2 bright
Tl+C none
Uterine Leiomyosarcoma
The risk o f malignant transformation to a leiomyosarcoma is super low (0.1%). These look like a fibroid, but rapidly enlarge. Areas of
necrosis are often seen.
Adenomyosis
overview
This is endometrial tissue that has migrated into the myometrium. You
see it most commonly in multiparous women of reproductive age, especially if they’ve
had a history of uterine procedures (Caesarian section, dilatation and curettage).
Adenomyosis
types
Although there are several types, adenomyosis is usually generalized, favoring large portions
of the uterus (especially the posterior wall), but sparing the cervix. It classically causes
marked enlargement o f the uterus, with preservation o f the overall contour.
Adenomyosis
imaging
They can show it with Ultrasound or MRI.
Ultrasound is less specific with findings
including a heterogeneous uterus
(hyperechoic adenomyosis, with
hypoechoic muscular hypertrophy), or just enlargement of the posterior wall. MRI is the way better test with the most classic feature being thickening of the junctional zone of the uterus to more than 12 mm (normal is < 5 mm). The thickening can be
either focal or diffuse. Additionally, the
findings o f small high T2 signal regions
corresponding to regions o f cystic change is
a classic finding.
Adenomyosis of the Uterus
T2 Bright Cystic Foci and thick junctional zone
Adenomyosis of the Uterus
T2 Bright Cystic Foci and thick junctional zone
Thick Endometrium
overview
Remember the stripe is measured without including any fluid in the canal. Focal or
generalized thickening in post menopausal women greater than 5mm should get sampled.
Premenopausal endometriums can get very thick - up to 20mm can be normal.
Thick Endometrium
trivia
• Estrogen secreting tumors - Granulosa Cell
tumors o f the ovary will thicken the
endometrium.
• Hereditary Non-Polyposis Colon Cancer
(HNPCC) - have a 30-50x increased risk of
endometrial cancer
Postmenopausal Bleeding:
Is it from atrophy or cancer?
•Endometrium less than 5 mm =
Probably Atrophy
•Endometrium > 4-5 mm = Maybe
cancer and gets a biopsy
Tamoxifen Changes
This is a SERM (acts like estrogen in the pelvis, blocks the estrogen effects on the breast). It’s used for breast cancer, but increases the risk of endometrial cancer. It will cause subendometrial cysts, and the development of endometrial polyps (30%). Normally, post menopausal endometrial tissue shouldn’t be
thicker than 4mm, but on Tamoxifen the endometrium is often thick (some papers say the mean is 12 mm at 5 years). When do you biopsy? Clear guidelines on this are illusive (if forced to guess I’d pick 8 or 10 mm). The only thing that seems consistent is that routine
screening is NOT advised. If you are wondering if a polyp is hiding you can get a sonohysterogram (ultrasound after instillation o f saline).
Endometrial Fluid
In premenopausal women this is a common finding. In postmenopausal women it means either cervical stenosis or an obstructing mass (usually
cervical stenosis).
Endometrial Fluid
In premenopausal women this is a common finding. In postmenopausal women it means either cervical stenosis or an obstructing mass (usually
cervical stenosis).
Endometrial Cancer
overview
Basically all uterine cancers are adenocarcinoma (90%+). The only possible exception for the purpose o f multiple choice would be the rare “leiomyosarcoma” - which looks like a giant fucking fibroid.
Endometrial Cancer
typical scenario
A postmenopausal patient (60s) with bleeding.
Endometrial Cancer
work up
First step is going to be an ultrasound. If the endometrium is too thick (most
people say 4- 5mm) then it gets a biopsy. Almost always this will be stage 1 disease, and no further imaging will be done. If there is concern that it’s more than stage 1 - that is
when you would get MRI (CT is shit for the uterus and would never be the right answer).
• First Step Postmenopausal Bleeder = Ultrasound
• Too Thick ? = Biopsy
• Extent of Disease = MRI
Endometrial Cancer
appearance on MRI
- T1 Iso
- T2 Mildly Hyper
- Tl+C Homogenous, but less enhancement compared to adjacent myometrium ( it’s dark).
- DWI Will show restricted dijfusion. This sequence is good fo r “Drop mets ” into the vagina, and fo r lymph node detection.
Endometrial Cancer
critical stage
• Stage 2 disease is defined as cervical stroma invasion. This is supposedly high risk for
lymph node mets.
• The diagnostic key is the post contrast imaging (obtained 2-3 mins after injection). If
the cervical mucosa enhances normally, you have excluded stromal invasion.
• Stage 2 is probably going to change management by adding pre-op radiation to the
cervix, plus a change from TAH to radical hysterectomy (obviously this varies from
center to center).
Endometrial Cancer
stage 1 imaging
T1+C: Normal Dark Cervical Stroma (star).
Enhancement of the Cervical Mucosa
(arrows) Excludes Invasion.
Endometrial Cancer
stage 2 imaging
T1+C: Tumor Invasion o f the Cervix
Endometrial Cancer
other possible trivia
• Moving from stage 1A (<50% myometrium) to stage 1B (>50% o f the myometrium)
also increases the risk o f lymph node disease.
• Some sites will do lymph node sample at stage 1 A, and radical lymph node dissection at stage IB.
Cervical Cancer
overview
It’s usually squamous cell, related to HPV (like 90%). The big thing to know is parametrial invasion (stage lib). Stage Ila or below is treated with surgery. Once you have parametrial invasion (stage lib), or involvement o f the lower 1/3 o f the vagina it’s gonna get chemo/ radiation. In other words, management changes so that is the most likely test question.
Cervical Cancer
stage IIA
Spread beyond the cervix, but NO parametrial invasion
Surgery
Cervical Cancer
Stage IIB
Parametrial involvement but NOT extension to pelvic side wall.
Chemo/ Radiation
Cervical Cancer
what is the parametrium
The p aram etrium is a fib ro u s b an d that separates the supravaginal cervix from the bladder. It e x te n d s between the layers of the bro ad ligament.
Cervical Cancer
why is the parametrium important
The uterine artery runs inside the parametrium, hence the need for chemo - o n ce in va de d .
Cervical Cancer
how do you tell if the parametrium is invaded
Normally the ce rv ix has a T2 d a rk ring. That thing should be intact. If the tum o r goes throug h th a t thing, you g otta call it invaded.
Solid Vaginal Masses
An uninvited solid vaginal mass is usually a bad thing. It can be secondary (cervical or uterine carcinoma protruding into the vagina), or primary such as a clear cell adenocarcinoma or rhabdomyosarcoma.
leiomyoma
squamos cell carcinoma
clear cell adenocarcinoma
vaginal rhabdomyosarcoma
Solid Vaginal Masses
Leiomyoma
Rare in the vagina, but can occur (most commonly in the anterior wall).
Solid Vaginal Masses
Squamous Cell Carcinoma
The most common cancer of the vagina (85%). This is associated with HPV. This is just like the cervix.
Solid Vaginal Masses
Clear Cell Adenocarcinoma
This is the zebra cancer seen in women whose mothers took DES (a synthetic estrogen thought to prevent miscarriage). That plus “T-Shaped Uterus” is probably all you need to know.
Solid Vaginal Masses
Vaginal Rhabdomyosarcoma
This is the most common tumor o f the vagina in children. There is a bimodal age distribution in ages (2-6, and 14-18). They usually come off the anterior wall near the cervix. It can occur in the uterus, but typically invades it secondarily. Think about this when you see a solid T2 bright enhancing mass in the vagina / lower uterus in a child.
Solid Vaginal Masses
mets trivia
- A met to the vagina in the anterior wall upper 1/3 is “always ” (90%) upper genital tract.
- A met to the vagina in the posterior wall tower 1/3 is “always ” (90%) from the Gl tract.
Cystic Vaginal I Cervical Masses
Nabothian Cysts
These are usually on the cervix and you see them all the time. They are
the result o f inflammation causing epithelium plugging o f mucous glands.
Cystic Vaginal I Cervical Masses
Gartner Ducts Cysts
These are the result o f incomplete regression of the Wolffian ducts.
They are classically located along the anterior lateral wall of the upper vagina. If they are located at the level o f the urethra, that can cause mass effect on the urethra (and symptoms).
Cystic Vaginal I Cervical Masses
Bartholin Cysts
These are the result o f obstruction o f the Bartholin glands (mucinsecreting
glands from the urogenital sinus). They are found below the pubic symphysis
(helps distinguish them from Gartner duct).
Cystic Vaginal I Cervical Masses
Skene Gland Cysts
Cysts in these periurethral glands, can cause recurrent UTIs and urethral obstruction.
Gartner duct cyst quick
anterior lateral upper vagina
Bartholin gland cyst quick
— “Ba rth o lin is B e low ” the p u b ic s ymphysis
— “B a rth o lin is n e a r the Butthole.
O V A R Y / A D N E X A
ovulation
Follicles seen during the early menstrual cycle are typically small (< 5 mm in diameter). By day 10 of the cycle, there is usually one follicle that has emerged as the dominant follicle. By mid cycle, this dominant follicle has gotten pretty big (around 20 mm). The size isn’t surprising because it contains a mature ovum. The LH surge causes the dominant follicle to
rupture, releasing the egg. The follicle then regresses in size, forming a Corpus Luteum. A small amount of fluid can be seen in the cul-de-sac. Occasionally, a
follicle bleeds and re-expands (hemorrhagic cyst) - more on this later.
O V A R Y / A D N E X A
ovulation quick
LH durring faollicular phase with dominant follicle right before ovulation then LH surge with ovulation then luteal phase with corpus luteum
O V A R Y / A D N E X A
meaningless vocab premenopausal ovarian cyst
< 1 cm = Follicle
1-2 cm = Dominant Follicle
> 3 cm = Cyst
Cumulus Oophorus
This is a piece of anatomy trivia. It is a collection of
cells in a mature dominant follicle that protrudes into the
follicular cavity, and signals imminent ovulation (its
absence means nothing).
Fertility Meds
Medications such as a Clomiphene Citrate (Clomid), force the maturation of multiple
bilateral ovarian cysts. It is not uncommon for the ovaries of women taking this drug
to have multiple follicles measuring more than 20 mm in diameter by mid cycle.
Theca Lutein Cysts
this is a type of functional
cyst (more on that below), related to overstimulation
from b-HCG. What you see are large cysts (~ 2-3 cm)
and the ovary has a typical multilocular cystic “spokewheel”
appearance.
Theca Lutein Cysts
think about 3 things
- Multifetal pregnancy,
- Gestational trophoblastic disease (moles),
- Ovarian Hyperstimulation syndrome.
Ovarian Hyperstimulation Syndrome
This is a complication associated with fertility therapy (occurs in like 5%). They will show you the ovaries with theca lutein cysts, then ascites,
and pleural effusions. They may also have pericardial effusions. Complications include increased
risk for ovarian torsion (big ovaries) and hypovolemic shock.
Paraovarian (Paratubal) Cyst
Cyst that is in the adnexa but not within the ovary. Instead
these things are located adjacent to the ovary or tube. If the cyst is simple (not septated or nodular) and
clearly not ovarian they will not need followup — is doesn’t matter how big it is, as they have incredibly
low rate of malignancy.
TLDR
Simple paraovarian cysts do not require follow up.
TLDR
Simple paraovarian cysts do not require follow up.
Premenstrual ovaries
- The ovaries o f a pediatric patient stay small until around age 8-9.
- Ovaries may contain small follicles.
premenopausal ovaries
- A piece o f trivia; premenopausal ovaries may be HOT on PET (depending on the menstrual cycle).
- This is why you do a PET in the first week o f the menstrual cycle.
postmenopausal ovaries ( > one year after menses stops):
- Considered abnormal if it exceeds the upper limit of normal, or is twice the size of the other ovary (even if no mass is present).
- Small cysts (< 3 cm) are seen in around 20% o f post menopausal women.
- In general, postmenopausal ovaries are atrophic, lack follicles, and can be difficult to find with ultrasound.
- The ovarian volume will decrease from around 8cc at age 40, to around 1 cc at age 70.
- The maximum ovarian volume in a post menopausal woman is 6 ml.
- Unlike premenopausal ovaries, post menopausal ovaries should NOT be hot on PET.
Ovarian cyst
If the cyst is simple, regardless o f age it’s almost
certainly benign.
What if they don’t tell you if the patient is pre or post menopausal ? You can use 50 years old as a cut off. Under 50 Pre, 50 & up Post.
Incidental Simple Appearing Ovarian Cyst -Shown on CT
PreMenopausal:< 3 cm = Call it Normal Follicle
PreMenopausal: > 3 cm = Get an US
PostMenopausal: < 1cm = Call it Normal Cyst
PostMenopausal: > 1cm = Get an US
Incidental Simple Appearing Ovarian Cyst
-Shown on US
PrcMenopausal:< 7 cm = No Follow Up
PreMenopausal: > 7 cm = Follow Up (3 months)
PostMenopausal: < 5 cm = No Follow Up
PostMenopausal: > 5 cm = Follow Up (3 months)
Ovarian cyst that is not simple
Cyst is not simple (irregular septations, papillary proiections. or solid elements) = GYN consult.
Sinister six ovraian masses
In most clinical practices, the overwhelming majority o f ovarian masses are benign (don't worry, I’ll talk about cancer, too). Physiologic and functioning follicles Corpora lutea Hemorrhagic cysts Endometriomas Benign cystic teratomas (dermoids) Polycystic ovaries
Functioning Ovarian Cysts
Functioning cysts (follicles) are affected by the menstrual
cycle (as I detailed eloquently above). These cysts are benign and usually 25 mm or less in
diameter. They will usually change / disappear in 6 weeks. If a cyst persists and either does not
change or increases in size, it is considered a nonfunctioning cyst (not under hormonal control).
Simple cysts that are > 7 cm in size may need further evaluation with MR (or surgical
evaluation). Just because it’s hard to evaluate them completely on US when they are that big,
and you risk torsion with a cyst that size.
Corpus Luteum
The normal corpus luteum arises from a dominant follicle (as I detailed
eloquently above). These things can be large (up to 5-6 cm) with a variable appearance (solid
hypoechoic, anechoic, thin-walled, thick-walled, cyst with debris). The most common
appearance is solid and hypoechoic with a “ring of fire” (intense peripheral blood flow).
THIS v.v THAT: Corpus Luteum VS Ectopic Pregnancy
They both can have that “ring of fire” appearance, but please don’t be an idiot about this. Most ectopic pregnancies occur in the tube (the corpus luteum is an ovarian structure). If you are really lucky, a “hint” is that the corpus luteum should move with the ovary, where an ectopic will move separate from the ovary (you can push the ectopic away from it). Also, the tubal ring of an ectopic pregnancy is usually more echogenic when compared to the ovarian parenchyma. Whereas, the wall of the corpus luteum is usually less echogenic. A specific (but not sensitive) finding in ectopic pregnancy is a RI of <0.4 or >0.7.
Ectopic quick
RI <0.4, or >0.7
Thick echogenic rim
Ring of fire
moves separate from the ovary
Corpus luteum quick
RI 0 .4 -0 .7
thin echogenic rim
ring of fire
moves with the ovary
Endometrioma
epidemiology
This targets young women during their reproductive years and can cause chronic pelvic pain
associated with menstruation. The traditional clinical history of endometriosis is the triad of
infertility, dysmenorrhea, and dyspareunia.
Endometrioma
classic appearance
The classic appearance is rounded mass with homogeneous low level internal echoes and
increased through transmission (seen in 95% of cases). Fluid-fluid levels and internal septations
can also be seen. It can look a lot like a hemorrhagic cyst (sometimes).
Endometrioma
imaging findings
As a general rule, the more unusual or varied the
echogenicity and the more ovoid or irregular the shape, the
more likely the mass is an endometrioma. Additionally,
and of more practical value, they are not going to change
on follow up (hemorrhagic cysts are). In about 30% of
cases you can get small echogenic foci adhering to the
walls (this helps make the endometrioma diagnosis more
likely). Obviously, you want to differentiate this from a
true wall nodule.
Endometriosis
complications
The complications of endometriosis (bowel obstruction, infertility, etc…) are due to a fibrotic
reaction associated with the implant. The most common location for solid endometriosis is the
uterosacral ligaments.
Endometrioma
becoming cancer
About 1% of endometriomas undergo malignant transformation (usually endometrioid or clear cell carcinoma). How do you tell which one is which??? Malignancy is very rare in endometriomas smaller than 6 cm. They usually have to be bigger than 9 cm. Additionally, the majority of women with carcinoma in an endometrioma are older than 45 years. So risk factors for turning into cancer: (a) older than 45, (b) bigger than 6-9 cm.
Endometrioma
pregnancy trivia
There is a thing called a “decidualized
endometrioma. ” This is a vocab word used to describe a
solid nodule with blood flow in an endometrioma of a
pregnant girl. Obviously this is still gonna get followed up
- but is a mimic of malignancy. The thing never to forget
is that if the patient is NOT pregnant and you see a solid
nodule with blood flow - that is malignant degeneration -
period - no hesitation, next question.
Endometrioma
on MRI
Will be T1 bright (from the blood). Fat saturation will not suppress the signal (showing you it’s not a teratoma). Will be T2 dark! (from
iron in the endometrioma). The shading sign is a buzzword
for endometriomas on MR imaging. On T2 you should
look for “shading.” The shading sign describes T2
shortening (getting dark) of a lesion that is T1 bright.
Endometrioma
What is the most sensitive imaging feature on MR1 for the diagnosis of malignancy in an endometrioma ?
an enhancing mural nodule
Endometrioma mri findings quick
T1 bright
T2 shaded
Hemorrhagic Cysts
overview
As mentioned on prior pages, sometimes a ruptured follicle bleeds internally and reexpands.
The result is a homogenous mass with enhanced through transmission (tumor
w o n ’t do that) with a very similar look to an endometrioma. A lacy “fishnet appearance”
is sometimes seen and is considered classic. Doppler flow will be absent. The traditional
way to tell the difference between a hemorrhagic cyst vs endometrioma, is that the
hemorrhagic cyst will go away in 1-2 menstrual cycles (so repeat in 6-12 weeks).
Hemorrhagic Cysts
MRI
Will be T1 bright (from the blood). Fat saturation will not
suppress the signal (showing you it’s not a teratoma). The lesion should NOT enhance.
Hemorrhagic Cysts
old ladies
Postmenopausal women may occasionally ovulate, so
you don’t necessarily need to freak out (follow up in 6-12 weeks). Now, late
postmenopausal women should NEVER have a hemorrhagic cyst and if you are shown something that looks like a hemorrhagic cyst in a 70 year old - it’s cancer till proven otherwise.
THIS vs THAT: E n d om e triom a vs H em o r rh a g ic C ys t
us
Endometrioma - Homogeneous with Low Level Echoes
Hemorrhagic Cyst - Lacy fishnet appearance
Dermoid
overview
These things typically occur in young women (20s-30s), and are the most common ovarian
neoplasm in patients younger than 20. The “Tip of the Iceberg Sign” is a classic buzzword and
refers to absorption of most of the US beam at the top of the mass. The typical ultrasound
appearance is that of a cystic mass, with a hyperechoic solid mural nodule, (Rokitansky nodule or
dermoid plug). Septations arc seen in about 10%.
Dermoid
MRI
Will be bright on T1
(from the fat). There will be fat
suppression (not true of hemorrhagic
cysts, and endometriomas).
Dermoid
do they ever become cancer
About l% of dermoids can undergo malignant
transformation (almost always to squamous cell CA). Again, risk factors are size (usually
larger than 10cm), and age (usually older than 50).
Dermoid
gamesmanship 1
Gross Fat containing ovarian mass on CT
Dermoid
gamesmanship 2
The Old Tooth Trick - shown on plain film, CT, or even as susceptibility (dark stuff) on MR. Remember Dermoids are basically teratomas, and teratomas grow all kinds of gross shit including teeth, hair, finger nails etc… The tooth is obviously the classic one.
Dermoid
gamesmanship 3
“Dot -dash” pattern has been described for hair within a cyst.
Rare Cancer Transformation Subtypes
Endometrioma > Clear Cell
Dermoid > Squamous
Endometrioma quick MRI
T2 mild hyperintense
Dermoid quick MRI
T1FS hypointense
Hemorrhagic cyst quick MRI
T1, T1FS, T2 hyperintense
Polycystic Ovarian Syndrome
overview
Typically an overweight girl with infertility, acne, and a pencil mustache (not a full Ron Swanson)
Polycystic Ovarian Syndrome
imaging
Ten or more peripheral simple cysts (typically small < 5 mm)
Usually Characteristic ‘string-of-pearls’ appearance.
Ovaries are typically enlarged (> 10 cc),
although in 30% of patients the ovaries have a normal volume
Ovarian Cancer
overview
Ovarian cancers often present as complex cystic and solid masses. They are typically intraovarian
(most extra-ovarian masses are benign). The role o f imaging is not to come down
hard on histology (although the exam may ask this of you), but instead to distinguish benign
from malignant and let the surgeon handle it from there.
Ovarian Cancer
think cancer if
Unilateral (or bilateral) complex cystic adnexal masses with thick ( > 3 mm)
septations, and papillary projections (nodule with blood flow).
Solid adnexal masses with variable necrosis
Ovarian Cancer
knee jerks
Multiple thin or thick septations = Call the Surgeon
Nodule with Flow = Call the Surgeon
Solid Nodules Without Flow =
o Get an MR to make sure it’s not a dermoid plug,
o If it’s not a dermoid, then call the surgeon
Mucinous O v a rian C y s tad e n o c a rc in om a
Often a large mass. They are typically multi-loculated (although septa are often thin).
Papillary projections are less common than with serous tumors. You can see low level
echos (from mucin). These dudes can get Pseudomyxoma peritonei with scalloping
along solid organs. Smoking is a known risk factor (especially for mucinous types).
THIS vs THAT: Serous vs Mucinous
Serous:
Unilocular (fewer septations)
Papillary Projections Common
Mucinous:
Multi-locular (more septations)
Papillary Projections Less Common
E n dome trio id O v a rian C an c e r:
overview
This is the second most common ovarian cancer (serous
number one, mucinous number three). These things are
bilateral about 15% o f the time.
E n dome trio id O v a rian C an c e r:
thigns to know
• 25% o f women will have concomitant endometrial cancer,
with the endometrial cancer as the primary (ovary is met).
• Endometriomas can turn into endometrioid cancer
• 15% are bilateral
Gamesmanship:
Ovarian Mass +
Endometrial Thickening
This is a way to show both Endometrioid CA (which often has both ovarian and endometrial CA), and Granulosa-Theca Cell Tumor (which produce estrogen - and cause endometrial hyperplasia)
B.F.M’s - for Adults
It’s useful to have a differential for a B.F.M.
(Big Fucking Mass) in an adult and a child. I
discuss the child version o f this on page 58.
For adults think about 3 main things:
(1) Ovarian Masses - Mucinous and Serous
(2) Desmoids - Remember Gardner Syndrome
(3) Sarcomas
Fibroma I Fibrothecoma
The ovarian fibroma is a benign ovarian tumor, most commonly seen in middle aged women.
The fibrothecoma / thecoma spectrum has similar histology. It’s very similar to a fibroid. On
ultrasound it’s going to be hypoechoic and solid. On MRI it’s going to be T1 and T2 dark, with
a band of T2 dark signal around the tumor on all planes. Calcifications are rare.
Meigs syndrome
This is the triad of ascites, pleural effusion, and a benign ovarian tumor
(most commonly fibroma).
Fibromatosis
This is a zebra. You have tumor-like enlargement of the
ovaries due to ovarian fibrosis. It typically hits girls around the age of 25.
It’s associated with omental fibrosis and sclerosing peritonitis. You are
going to get dark T1 and T2 signal. The buzzword for that T2 signal is
“black garland sign. ” The condition is benign, and sometimes managed
with surgical removal of the ovaries.
brenner tumor
Epithelial tumor of the ovary seen in women in their 50s-70s. It’s fibrous
and T2 dark. Unlike Fibromas, calcifications are common (80%). They are also sometimes
referred to as “Ovarian Transitional Cell Carcinoma ” for the purpose of fucking with you.
Struma Ovarii:
These things are actually a subtype of ovarian teratoma. On imaging you are looking for a
multilocular, predominantly cystic mass with an INTENSELY enhancing solid component. On
MRI - the give away is very low T2 signal in the “cystic” areas which is actually the thick
colloid. These tumors contain THYROID TISSUE, and even though it’s very rare (like 5%), I
would expect that the question stem will lead you to this diagnosis by telling you the patient is
hyperthyroid or in a thyroid storm.
Metastatic Disease to the Ovary
Around 10% of malignant ovarian tumors are mets. The primary is most commonly from colon, gastric, breast, lung, and contralateral ovary. The most common look is bilateral solidtumors.
Krukenburg Tumor
This is a metastatic tumor to the ovaries from the GI tract (usually stomach).
Ovarian Torsion
overview
Rotation of the ovarian vascular pedicle (partial or complete) can result in obstruction to venous outflow and arterial inflow. Torsion is typically associated with a cyst or tumor (anything that makes it heavy, so it flops over on itself).
Ovarian Torsion
critical point
The most constant finding in ovarian torsion is a large ovary.
Ovarian Torsion
features
Unilateral enlarged ovary (greater than 4 cm) Mass on the ovary Peripheral Cysts Free Fluid Lack of arterial or venous flow
Ovarian Torsion
the ovary is not a testicle
The ovary has a dual blood supply. Just because you have flow, does
NOT mean there isn’t a torsion. You can torse and de-torse. In other words, big ovary + pain = torsion. Clinical correlation recommended.
Hydrosalpinx
overview
There are a variety of causes, the most common is being a skank, infidel, or free spirit (PID).
Additional causes include endometriosis, tubal cancer, post hysterectomy (without salpingectomy /
oophorectomy), and tubal ligation. Rare and late complication is tubal torsion.
Hydrosalpinx
buzz 1
Thin (or thick in chronic states) elongated tubular structure in the pelvis.
Hydrosalpinx
buzz 2
The buzzword is “cogwheel appearance,” referring to the normal longitudinal folds of a
fallopian tube becoming thickened. Another buzzword is “string sign” referring to the
incomplete septae. The “waist sign” describes a tubular mass with indentations of its opposing walls
(this is suppose to help differentiate hydrosalpinx from an ovarian mass).
Pelvic Inflammatory Disease (PID)
overview
Infection or inflammation of the upper female genital tract. It’s usually secondary to the cultural
behaviors of trollops and strumpets (collectors of Gonorrhea / Chlamydia). As a hint, the question
writer could describe the patient as “sexually disreputable. ” The question could also describe the
patient as recently appearing as a guest on the Maury Show (the “Not the Father!” show — google if
unfamiliar, it could be on the exam).
Pelvic Inflammatory Disease (PID)
us findings
On ultrasound you are gonna see a Hydrosalpinx. The margin of the uterus may become ill defined
(“indefinite uterus” - is a buzzword). Later on you can end up with tubo-ovarian abscess or pelvic
abscess. You can even get bowel or urinary tract inflammatory changes.
Paraovarian Cyst
This is a congenital remnant that arises from the Wolffian duct. They are more common than you
think with some texts claiming these account for 10-20% of adnexal masses. They are classically
round or oval, simple in appearance, and do NOT distort the adjacent ovary (key finding). They
can indent the ovary and mimic an exophytic cyst, but a good sonographer can use the transducer to
separate the two structures.
Ovarian Vein Thrombophlebitis
This is seen most commonly in postpartum women, often presenting with acute pelvic pain and
fever. For whatever reason, 80% of the time it’s on the right. It’s most likely to be shown on CT
(could be ultrasound) with a tubular structure with an enhancing wall and low-attenuation thrombus
in the expected location of the ovarian vein. A dreaded sequela is pulmonary embolus.
Peritoneal Inclusion Cyst
This is an inflammatory cyst of the peritoneal cavity that occurs when adhesions envelop an ovary.
Adhesions can be thought of as diseased peritoneum. Whereas the normal peritoneum can absorb
fluid, adhesions cannot. So, you end up with normal secretions from an active ovary confined by
adhesions and resulting in an expanding pelvic mass. The classic history is patient with prior pelvic
surgery (they have to tell you that, to clue you in on the presence of adhesions), now with pain.
They could get tricky and say history of PID or endometriosis (some kind of inflammatory process to
piss off the peritoneum). In that case, it is likely they would show an ultrasound (or MR) with a
complex fluid collection occupying pelvic recesses and containing the ovary. It’s not uncommon to
have septations, loculations, and particulate matter within the contained fluid.
Peritoneal Inclusion Cyst
key features
- Lack of walls. “Passive shape” that conforms to and is defined by surrounding structures.
- Entrapment of an ovary. Ovary will be either in the collection, or at the periphery.
Peritoneal Inclusion Cyst
classic vignette
A woman of reproductive age with a history of endometriosis, pelvic surgery, and pelvic inflammatory disease. Accompanied by images (most likely ultrasound, less likely CT or MR)
or a fluid-filled mass that conforms to the shape of the pelvis and surrounds an ovary.
Gestational Trophoblastic Disease
Think about this with marked elevation of B-hCG. They will actually trend betas for tumor
activity. Apparently, elevated B-hCG makes you vomit - so hyperemesis is often part of the
given history. Other pieces of trivia is that moles are more common in ages over 40, and prior
moles makes you more likely to get another mole.
Hydatidiform Mole
overview
This is the most common form, and the benign form of the disease. There are two subtypes
