WOMEN’S IMAGING

Genital Tract Diseases

Maria Theresa M. Navarro, MD

Fourth Year Radiology Resident
Department of Medical Imaging
Quirino Memorial Medical Center

SOURCE: Ultrasonography in Obstetrics and

Gynecology, 4th ed by Peter W. Callen, MD
ULTRASOUND OF
THE UTERUS
ANATOMY OF THE
UTERUS
 UTERUS
 uterus is located in the true pelvis between
the urinary bladder anteriorly and
rectosigmoid posteriorly
 anterior surface is covered with peritoneum
to the level of the junction between the
uterine corpus and cervix
 vesicouterine pouch or anterior cul-de-sac –
peritoneal space anterior to the uterus
 posterior cul-de-sac – peritoneal reflection
extends to the posterior fornix of the vagina
 UTERUS
 lateral peritoneal reflection forms the broad
ligament
 uterus has two major body parts :
 body or fundus

 cervix – lower cylindrical portion that projects

into the vagina
 isthmus – narrow portion of the uterus that
corresponds to the approximate position of
the internal os and is the separation between
the corpus and cervix.
 Size Of The Uterus
AP
Length (cm) Width (cm) Diameter
(cm)

Nulliparous 6.0 – 8.5 3- 5 2- 4

Multiparou
8 – 10.5 4-5 3- 5
s

Menopause 3.5 – 7.0 2-4 1.7 – 3.3

 UTERUS
 Uterine Position
 anteversion – cervix and vagina form a 90 deg
angle
 retroversion, retroflexion, and tilting of the
uterus to the right or the left  normal variants
 Zonal Anatomy of the Body of the Uterus (MRI)
 centrally  endometrium demonstrates high
signal intensity
 junctional zone  inner myometrial layer
shows low signal intensity
 outer myometrium  intermediate signal
intensity
Zonal Anatomy
 Endometrium (UTZ)
 thin echogenic stripe
 thickness and sonographic appearance of the endometrium
change cyclically with the menstrual cycle
 Ultrasound of the Uterus

 Transabdominal and transvaginal ultrasound

 Hysterosonography – endometrial imaging
 may confidently diagnose submucosal
fibroids and may distinguish between a
hyperplastic endometrium and a polyp.
Uterus
 Hysterosonography

A. Hysterosalpingogaphy catheter is inserted into the lower uterine segment

with a distended occluding balloon.
B. Coronal hysterosongoram obtained after instillation of saline shows air
within the occluding balloon of the catheter, with a resultant artifact along
the left uterine wall
 Sonohysterography

Sagittal transvaginal US (A) demonstrates the inflated balloon of the

sonohysterographic catheter (*) within the endometrial canal.
Following the instillation of 40 cc of sterile saline (B), fluid distends
the endometrial canal.
Hysterosalpingogram
 Congenital Malformations
 diagnosed during work-up for infertility, frequent
miscarriages, or menstrual disorders
 Three different causes:
1. arrested development of mullerian ducts

2. failure of fusion of the mullerian ducts

3. failure of resorption of the median septum

CONGENITAL MALFORMATIONS

Unicornuate Uterus
 agenesis of a unilateral
mullerian duct
 poorest fetal survival
 most difficult to
diagnose (confused as small
uterus )
CONGENITAL MALFORMATIONS
Didelphic Uterus
 complete failure of fusion of the mullerian
duct
 has two complete uteri, including
endometria, myometria and serosal
surfaces on each side
 may extend down to the cervix and
may also involve a septated vagina
CONGENITAL MALFORMATIONS
Bicornuate Uterus
 partial fusion of the mullerian ducts

 has some fusion of the lower uterine

segment, but there are two uteri in the
superior segment complete with
endometrial cavities, myometria, and
covering serosa
 Bicornuate Uterus

Bicornuate Uterus Bicornuate uterus with pregnancy in

one horn
 CONGENITAL MALFORMATIONS
Septate Uterus
 failure of resorption of the septum after
complete fusion of the mullerian ducts
 may have thick or thin fibrous septation,
including a significant myometrial component
Arcuate Uterus
 characterized by a small dimple or concave
superior surface of the fundus.
 variant than a deviant of normal
 BENIGN UTERINE CONDITIONS
 ADENOMYOSIS

 migration of endometrial glands from the

stratum basale into the myometrium
 ectopic glands tend to be 2 – 3 mm below
the endometrial-myometrial junction
 Sonography and MRI

 round appearance of the uterus without a

discrete mass or contour deformity
 BENIGN UTERINE CONDITIONS
 ADENOMYOSIS

 TVS : abnormal heterogenous

myometrium with areas of increased or
decreased echogenicity
 Color Doppler Imaging : hypervascularity
throughout the lesion (vs. fibroids –
peripheral flow)
Adenomyosis
Sagittal (A) and axial (B) T2-
weighted MR images through
the pelvis demonstrate focal
junctional zone widening and
multiple punctate high signal
intensity foci with the areas of
thickening (*, A, B)
characteristic of focal
adenomyosis.

Sagittal (C) and axial (D) T2-

weighted MR images in a
different patient demonstrate
widening of the entire
junctional zone (*, C, D)
which contains multiple foci
of high signal intensity that
represent endometrial rests.
Appearances are typical of
diffuse adenomyosis.
 BENIGN TUMORS
 LEIOMYOMAS
 most common neoplasm of the uterus
(20% to 30% of women older than 30 yo)
 misnamed fibromyomas or fibroids
 interleaved bundles of smooth muscle
with varying amounts of fibrous
connective tissue
 BENIGN TUMORS
 LEIOMYOMAS
 Submucosal (5%- 10%)
most symptomatic
may cause menorrhagia, metrorrhagia, or
postmenopausal bleeding
 Intramural (most common) and Subserous (10%
- 20%)
if large may cause pressure effects on the
adjacent pelvic organs or ligaments
 Leiomyoma

Leiomyoma, MRI. T2-weighted sagittal MRI. A subserosal leiomyoma (arrows)

distends the posterior aspect of the uterus, displacing the endometrium
BENIGN TUMORS
 LEIOMYOMAS

 acute symptoms are seen if the

leiomyomas undergo torsion or necrosis
 Broad-ligament myomas can simulate
adnexal masses
 estrogen dependent
 BENIGN TUMORS
 LEIOMYOMAS
 Ultrasound appearance depends on size, site, and age of
tumor
 sole manifestation of fibroids may simply be uterine
enlargement or nodularity of the contour.
 may also displace or distort the endometrial echo or alter the
homogeneous midecho of the myometrium
 great “mimickers” and may masquerade as endometrial
polyp, ovarian masses or even stool-filled large bowel
 BENIGN TUMORS
 Leiomyomas
 Frequently, fibroids can be diagnosed
sonographically by their decreased
echogenicity and decreased sound
through-transmission (shadowing),
even though the relationship to the
uterus is obscured.
 Leiomyomas

Transvaginal US demonstrating hypo- to isoechoic well-

defined intramural heterogeneous masses (T), the typical
ultrasound appearance of leiomyomas
Leiomyoma
 BENIGN TUMORS

 Leiomyomas
 Definitive diagnosis can be made by
showing the “claw sign”, analogous to
renal masses, of stretching of
myometrium around the base of the
lesion
BENIGN TUMORS
 ENDOMETRIAL HYPERPLASIA

 MOST COMMON cause of vaginal bleeding

in both pre- and postmenopausal women
 results from unopposed estrogen stimulation

 On ultrasound
 pronounced endometrial stripe
 may be indistinguishable from an endometrial
polyp or carcinoma, even on TVS
BENIGN TUMORS
 ENDOMETRIAL HYPERPLASIA

 HSG can be definitive, but the diagnosis

is usually confirmed by endometrial
biopsy
 Pipelle biopsy is often used as an office
procedure at first referral for vaginal
bleeding;
 D & C and hysteroscopy are reserved
more for therapeutic procedures
 BENIGN TUMORS
 POLYPS
 represent areas of overgrowth of endometrial
glands and stroma covered by endometrial
epithelium
 lesions may be pedunculated or sessile

 fundus and multiple in 20%

 at autopsy, seen up to 10% of women

 vaginal bleeding or mucous discharge

BENIGN TUMORS
 POLYPS

 appear as focal areas of increased

endometrial thickening
 confident ultrasound diagnosis may
sometimes require HSG
 TAS may be normal, whereas TVS images
show focal irregularity of the endometrial
stripe
BENIGN TUMORS
 POLYPS

 HSG permits more accurate TVS

identification of the lesion and more
accurate distinction among hyperplasia,
polyp, fibroid, or carcinoma
 MRI can be used to confirm a lesion
suspected to be a polyp, which has a
moderately high signal on T2, versus
fibroids, which, is especially when small,
have a low signal.
 BENIGN TUMORS
 ARTERIOVENOUS MALFORMATION

 multiple communications between the

arterial and venous system without an
intervening capillary network.
 congenital or more often iatrogenic due to
intrauterine instrumentation.
 BENIGN TUMORS
 ARTERIOVENOUS MALFORMATION

 Color and duplex Doppler sonography

shows serpiginous cystic areas and a
vascular tangle of blood vessels
 demonstrate high velocity, low-resistance
flow on duplex Doppler.
 BENIGN TUMORS
 Arteriovenous Malformation

 On MRI, AVMs appear as a focal

uterine mass or a disruption of the
junctional zones, with serpiginous
flow-related signal voids and
prominent parametrial vessels.
 MISCELLANEOUS BENIGN PROCESS
 PELVIC INFLAMMATORY DISEASE
 rarely confined to the uterus
 endometrium shows histologic changes of
inflammation in more than 70% of women with
acute PID
 40% with mucopurulent cervicitis
 nonspecific on ultrasound, correlated with
clinical picture
 thickening and irregularity of the endometrium
and fluid, debris, or even gas within the
endometrial cavity
 MISCELLANEOUS BENIGN PROCESS
 Pyometra (pus in the uterine cavity)
 may complicate cervical stenosis
 acquired causes : infection, neoplasia, and iatrogenic
factors
 clinical findings : more pronounced in premenopausal than
postmenopausal women
 ultrasound appearance :
 dilated, fluid-filled endometrial cavity

 echogenicity of the cavity varies with the degree of

debris or clot
 distinction from endometrial polyp or even carcinoma is
occasionally impossible when the fluid becomes
uniformly echogenic.
Pyometra
 MISCELLANEOUS BENIGN PROCESS
 Hydrometocolpos
 when the hymen is imperforate, allowing the
accumulation of secretions within the uterus and
vagina
 Asherman Syndrome
 intrauterine fibrous adhesions cross the endometrial
cavity.
 the synechiae form a mesh or spider’s web within
the uterine lumen
 may cause infertility or hypo- or amenorrhea
 the fibrous strands can calcify, with a characteristic
sonographic appearance.
 MISCELLANEOUS BENIGN PROCESS
 Nabothian Cysts

 obstructed and hence dilated inclusion

cysts, of no clinical relevance, located
within the cervix
 routinely seen on TAS and especially TVS

 Monckeberg’s Medial Sclerosis

 manifesting as peripheral punctate echoes,

is due to calcification in the smaller uterine
artery branches
 MALIGNANT DISEASE OF THE UTERUS
 Cervix
 Ultrasound : not especially useful in the
diagnosis of cervical disease, including
neoplastic conditions
 Papanicolaou-stained cervical smears -
incidence of cervical dysplasia and carcinoma
in situ has risen sharply
 whereas, that of invasive carcinoma has
plummeted reciprocally.
 women at risk : multiple sexual partners and
precocious onset of coitus
 MALIGNANT DISEASE OF THE UTERUS
 Cervix
 90% of invasive cervical carcinomas – originate from
squamous cells in the ectocervix.
 10% - arise as adenocarcinoma, usually from the
more deeply situated columnar epithelium
 Imaging : chief role is staging of cervical carcinomas
 MRI – most impact on preoperative staging
 squamous cell carcinoma usually spread by local and
lymphatic invasion
 Gadoliniuim contrast enhancement at MRI is important
in assessing patients with suspected recurrence after
radiotherapy or surgery for the initial disease.
 MALIGNANT DISEASE OF THE UTERUS
 Cervix
 Sonography :

to document the complications of

advanced cervical disease and its
treatment
example : cervical stenosis,
intrauterine fluid collection, or
hydronephrosis
 MALIGNANT DISEASE OF THE UTERUS
 ENDOMETRIAL CARCINOMA
 MOST COMMON form of gynecologic
malignancy
 Incidence : 33,000 new case per year in the US
 mostly confined to postmenopausal women
 present early with postmenopausal bleeding
 Ultrasound : either diffusely or partially
echogenic
 although 10% - 15% maybe isoechoic
 when these features are seen, warrants HSG
and biopsy
Staging of Endometrial Carcinoma
 Prognostic Factors:

 histologic grading of the tumor

 extent of myometrial invasion

 documentation of lymph node

metastases
 Endometrial Carcinoma (TVS)

The endometrium is thickened and irregular in this postmenopausal patient.

Near the fundus, the endometrial–myometrial junction is indistinct, indicating
myometrial invasion (arrow).
 Endometrial Carcinoma (MRI)

Sagittal gadolinium-enhanced T1-weighted fat-suppressed MR image shows an endometrial

cancer (T) with deep myometrial invasion. Note the thin rim of normal myometrium (black
arrows). The disease extends to the upper third of the vagina (white arrow).
Staging of Endometrial Carcinoma
 Stage IA - depth of myometrial invasion is none

 Stage IB – depth is superficial

 less than half of the myometrium

 Stage IC – deep

 more than half of the myometrium

 Stage II - invasion of the cervix

 worse prognosis

 TVS is not as accurate as MRI in monitoring

cervical involvement
 Endometrial Carcinoma
 Incidence of regional and distant lymph node
involvement is linked to the degree of
myometrial invasion.
 Role of imaging is negligible once a
suspicious lesion has been identified
 After biopsy diagnosis  hysterectomy

 Ultrasonography: more accurate than serum

CA125 levels in predicting myometrial
invasion of endometrial carcinoma.
 distant spread, beyond the serosa, is not
reliably documented by ultrasound
 DIFFERENTIATION OF BENIGN FROM MALIGNANT CONDITIONS OF THE
ENDOMETRIUM

 Benign Conditions
 cystic atrophy, cystic and adenomatous
hyperplasia, endometrial polyps
 76% of benign conditions show cystic changes

 Malignant uterine tumors

 thickened echogenic endometrium
 enlarged
 retroverted
 lack subendometial halo
 24% of endometrial malignancies show cystic
changes
 DIFFERENTIATION OF BENIGN FROM
MALIGNANT CONDITIONS OF THE
ENDOMETRIUM

 No difference in Doppler parameters has been

found between malignant and benign uterine
diseases
 calculated sensitivity of increased color flow
in predicting malignancy is low, approx. 40%
 Neither TVS nor color Doppler imaging can
distinguish benign lesions from their
malignant counterparts
 Differentiation is made by D & C, by
hysteroscopy, and biopsy, or by ultrasound-
guided suction biopsy.
 CLINICAL PERSPECTIVE
 ABNORMAL UTERINE BLEEDING
 MOST COMMON indication for gynecologic intervention
 Endometrial carcinoma is only seen in less than 1% of
postmenopausal patients with abnormal vaginal bleeding
 D & C is insensitive for small polyps or foci of endometrial
carcinoma
 Suction endometrial biopsies obtained with a Pipelle de
Cornier device are renowned for sampling inaccuracies.
 Hysteroscopy is the most accurate method for excluding, or
confirming, uterine disease as a cause for abnormal uterine
bleeding
 most invasive procedure and the most costly
 TVS and HSG – preliminary screening
 Normal endometrial appearances on HSG correlate strongly
with negative histology
 CLINICAL PERSPECTIVE
 Abnormal Uterine Bleeding
 TVS and HSG – preliminary screening
 Normal endometrial appearances on HSG correlate
strongly with negative histology
 In several large studies in perimenopausal women
with uterine bleeding, HSG recorded 90% - 99%
sensitivity, and 75% - 83% specificity in
differentiating women with intrauterine lesions and
those with normal or atrophic endometrium
 CLINICAL PERSPECTIVE
 INFERTILITY
 Causes of acquired infertility:
 endometrial adhesions (Asherman syndrome)
 endometritis

 PID

 endometriosis

 Septate uterus
 Radiographic hysterosalpingography –
superior technique
 CLINICAL PERSPECTIVE
 Menopause and Hormone Replacement
Therapy
 endometrial regression  halted or reversed by
administration of exogenous estrogen
 unopposed estrogen can induce endometrial
carcinoma
 HRT regimens include progesterone supplements to
counteract the effect of estrogen alone on endometrial
proliferation
 Continuous HRT significantly influences the
thickness of the postmenopausal endometrium but not
of the myometrium
 endometrial thickness of 8 mm - cutoff normal range
 CLINICAL PERSPECTIVE
 Tamoxifen
 menopausal patients with breast cancer receive
tamoxifen therapy (partial estrogen receptor
agonist)
 Effects on uterus :
 epithelial metaplasia
 hyperplasia

 carcinoma

 TVS
 may show thickened, irregular cystic endometrium
 cystic changes in the subendometrial zone without
epithelial disease have also been documented.
 CLINICAL PERSPECTIVE
 Peurperium
 postpartum uterus should return to near normal
size within 6 to 8 weeks after delivery.
 increasing maternal parity is associated with
slightly but significantly larger uterine dimensions
up to 4 weeks postpartum.
Pathologies in the
Cervix
 Morphology of Uterine Cervix
 cylindrical portion of the uterus
 enters the vagina and lies at right angles to it
 2-4 cm long
 isthmus –point of juncture with the uterus, marked by
constriction of the lumen
 separated anteriorly from the bladder by a layer of
fatty tissue
 posteriorly, covered by peritoneum
 Morphology of Uterine Cervix
 laterally, cervix is connected to the parametria and broad
ligament
 ureters descend about 2cm lateral to the cervix and curve
under the uterine arteries
 cervical canal – extends from the internal os, where it joins
the uterine cavity, to the external os, which projects into the
vaginal vault.
 internal os – where histologic transition from endometrial to
endocervical glands is seen.
 upper third of the cervical canal or isthmus – undergo
menstrual changes although less pronounced than the
endometrial lining
 CERVICAL ANATOMY
 DIVIDED INTO THREE ZONES (MRI):
1. endocervical mucosa – increased signal
intensity due to mucus glands
2. cervical stroma – low signal intensity owing
to the presence of fibrous connective tissue
3. peripherally located smooth muscle, which
demonstrates intermediate signal intensity
Benign Gynecologic Conditions
 CERVICITIS
 chronic inflammation of the cervix

stimulates reparative upward growth of

the squamous epithelium, causing
obstruction of some of the ducts of the
endocervical glands
NABOTHIAN CYSTS
 results from retention of mucus within
the glands
 Nabothian Cysts

(a) Sagittal T2-weighted MR image shows multiple small cysts in the deep
stroma of the anterior cervix (arrows). (b) Sagittal T1-weighted MR image
shows that the lesions have slightly high signal intensity (arrows).  
 Benign Gynecologic Conditions
 CERVICAL POLYP
 pedunculated, soft, smooth , red or purple and
vary in size from a few millimeters to 3 cm.
 microscopically, hyperplastic condition of the
endocervical epithelium and contains a large
number of blood vessels at the surface
 edematous and inflamed
 can cause leukorrhea and intermentrual spotting
 Cervical Polyp

(a) Sagittal T2-weighted MR image shows a large multicystic mass

filling the endocervical canal (arrows). (b) Sagittal T1-weighted MR
image shows hypointense fluid filling the cysts (arrows). At histologic
analysis, the lesion was proved to represent cystically dilated
endometrial glands and was diagnosed as a cystic polyp.
 Benign Gynecologic Conditions
 CERVICAL STENOSIS
 usually asymptomatic, but may cause
abnormal vaginal bleeding, dysmenorrhea,
and infertility
 if stenosis is severe, accumulation of
uterine secretions (hydrometra or
pyometra) or blood (hematometra) results
 intracavitary fluid – indirect indicator of

cervical stenosis
 Malignant Gynecologic Conditions
 SQUAMOUS CELL CARCINOMA
 MOST COMMON TYPE OF CERVICAL
CANCER
 precursors are the cervical dysplasias

classified as mild (CIN-1), moderate (CIN-

2), or severe (CIN-3).
 screening with Papanicolaou smears

 average transit time to carcinoma in situ for

 Malignant Gynecologic Conditions
 ADENOCARCINOMA OF THE CERVIX
 10% -15% of cervical cancer

 arises from the columnar epithelium of the

endocervical canal and glands
 behavior, staging, and treatment of
squamous cell and adenocarcinoma of
cervix are similar.
 Staging
 Stage I
 carcinoma confined to the cervix

 minimally invasive disease

 disease with invasion of > 5 mm depth from

the base of the surface or gland\
 > 7 mm horizontal spread Stage IIA

 extension to the upper vagina

 Stage IIB
 to the cardinal ligaments but not the lateral walls
 Stage I B Cervcal Carcinoma

Sagittal (a) and axial (b) T2-weighted MR images show a slightly

hyperintense mass in the uterine cervix. The mass protrudes into the
posterior vaginal fornix; however, the vaginal mucosa attached to the
tumor is intact (arrows in a). The tumor is completely surrounded by
hypointense cervical stroma on the axial image (arrowheads in b).
 Stage IIB Cervical Carcinoma

Sagittal (a) and axial (b) T2-weighted MR images show that the
cervix is almost entirely replaced by a slightly hyperintense mass.
The tumor protrudes into the parametrium bilaterally (arrowheads in
b); however, it does not reach the pelvic wall. Hydrometra, which is
caused by the obstructed internal cervical os, is also noted (arrow in
a).
CERVICAL CARCINOMA
Cervical carcinoma with
endophytic growth in a 59-year-
old woman.
The preoperative imaging
diagnosis was stage IIb carcinoma.
Sagittal T2-weighted MR image
shows a slightly hyperintense mass
that replaces the cervix (white
arrows).
The lesion is located almost within
the cervical canal. The patient also
has a mature cystic teratoma of the
right ovary, which is seen as a
cystic mass (black arrow) behind
 Staging
 Stage IIIA
 extension to the lower third of the vagina,
without extending to the pelvic wall
 Stage IIIB
 to the pelvic side wall, including cases of
hydronephrosis
 Stage IV
 carcinoma extending beyond the true pelvis
and involving the mucosa of the bladder and
rectum
 Stage IIIA Cervical Carcinoma

a) Sagittal T2-weighted MR image shows a slightly hyperintense, exophytic, solid

mass that extends along the anterior vaginal wall and reaches the lower one-third of
the vagina (arrow). (b) Axial T2-weighted MR image shows that the low signal
intensity of the anterior vaginal wall is partly disrupted (arrowheads) and the fatty
tissue between the mass and the posterior bladder wall has disappeared. However,
the mass does not infiltrate the vesical mucosa.
 Stage IIIB Cervical Carcinoma

(a) Sagittal T2-weighted MR image shows a slightly hyperintense,

large, solid mass that extends from the uterine cervix to the lower
part of the uterine body. It also extends to the lower one-third of the
anterior vaginal wall (arrow). (b) Axial T2-weighted MR image
shows that the tumor also reaches the left posterior wall of the
bladder, although the thinned vesical muscular layer remains
(arrowheads). (c) MR urogram clearly shows left hydronephrosis
 Stage IV Cervical Carcinoma

Stage IVA. Sagittal T2-weighted MR image shows a

hypointense mass that occupies the uterine cervix and invades
the vaginal wall anteriorly. At the level of the vaginal
extension, the tumor reaches the mucosa of the posterior vesical
wall (arrows).
 Stage IV Cervical Carcinoma

Stage IVb cervical carcinoma. (a) Sagittal T2-weighted MR

image shows a large mass in the uterine cervix. (b, c) CT scans
show metastases of paraaortic lymph nodes (arrows in b) and
hematogenous hepatic metastases
 Cervical carcinoma
 CERVICAL CARCINOMA with exophytic
growth in a 44-year-
old woman. The
pathologic stage was
Ib-1. Sagittal T2-
weighted MR image
shows a slightly
hyperintense,
cauliflower-like
tumor in the posterior
lip of the portio
(arrows). The tumor
markedly expands
the posterior vaginal
 Staging
 Lymphatic spread occurs by direct
extension or tumor emboli
 Lymphatic node metastases occurs in:
 15% of Stage I
 30% of Stage II

 50%of Stage III

 >60% of Stage IV
 Imaging
 Transvaginal Ultrasound
 Transrectal Sonography

 tumor is seen as a hypo- or isoechoic area poorly

distinct from normal cervical stroma
 when endocervical canal is involved, its linear
echoes are disrupted or appear as hyperreflecting
areas (gaseous necrosis)
 Imaging
 sonography can evaluate gross invasion of
the parametrium, pelvic side walls, and
bladder.
 parametrial invasion – irregular lateral
tumor margins or vascular encasement
 invasion of lateral side walls – parametrial
thickening or a soft tissue mass extending
to the side walls.
 bladder invasion – include direct tumor
invasion or immobility
 Imaging

 Sonography is limited in its ability to

evaluate lymph nodes and to
differentiate benign pelvic disease such
as endometriosis from tumor invasion.
 Thus, sonography is not recommended
as the sole imaging technique for
evaluation of invasive disease.
 Imaging
 CT scanning cannot reliably evaluate tumor
size and parametrial invasion

 CT scan is useful in :
 detecting invasion of the pelvic side wall

 evaluation of obstruction of the urinary

tract
 detection of nodal disease
 Imaging
 Soft Tissue Contrast Resolution of MRI

 allows accurate determination of tumor size

 positive predictive value for detecting

parametrial disease is 67%
 high negative predictive value of 95%,
making it useful for selecting candidates for
surgery
 detect lymph node metastases
(similar to CT)
 Imaging
 SoftTissue Contrast Resolution of MRI
 For extended clinical staging, MRI surpasses
other modalities and is indicated for :
 clinical stage I disease,

 when the tumor is greater than 2 cm,

 when tumor size is difficult to determine

clinically,
 and when the lesion is endocervical
 DIAGNOSIS AND
FOLLOW-UP OF
GESTATIONAL
TROPHOBLASTIC
DISORDERS
 Introduction
 GESTATIONAL TROPHOBLASTIC DISORDER (GTD)
 term commonly applied to a spectrum of interrelated diseases,
originating from the placental trophoblast that includes:
 complete

 partial

 invasive moles

 placental site trophoblastic tumors

 choriocarcinoma

 Incidence of Molar Pregnancies : 1:41 miscarriages

COMPLETE HYDATIDIFORM MOLE

 generalized swellling of the villous tissue

 diffuse trophoblastic hyperplasia

 no embryonic or fetal tissue

 diploid, with chromosomes totally derived

from the paternal genome probably resulting
from the fertilization of an “empty oocyte”,
devoid of maternal 23,X by a single
spermatozoon
 PARTIAL HYDATIDIFORM
MOLE (PHM)
 refers to the combination of a fetus with
localized placental molar degenerations
 Histologically:
 focal swelling of the villous tissue

 focal trophoblastic hyperplasia

 embryonic or fetal tissue

 abnormal villi are scattered within

macroscopically normal placental tissue,
which tends to retain its shape.
 PARTIAL HYDATIDIFORM
MOLE (PHM)
 90% triploid, having inherited two sets of
chromosomes from the father and one from
the mother
 Ultrasound :

 enlarged placenta (thickness > 4 cm at 18

to 22 weeks)
 containing multicystic, avascular,
sonolucent spaces
 Gold standard for the definitive
diagnosis, and subtyping of
Hydatidiform Moles is
histopathologic examination
 Diagnostic pathologic features of
molar pregnancies are essentially
characterized by abnormal
proliferation of villus trophoblast
 INVASIVE HYDATIDIFORM MOLE
 defined as the penetration of molar villi from a CHM
or PHM into the myometrium or the uterine
vasculature
 contains villous structures with a variable degree of
trophoblastic proliferation
 produces lower levels of hCG.
 SSx: heavy vaginal bleeding
 Ultrasonography : focal areas of increased
echogenicity within the myometrium.
 nodules appear several weeks after evacuation
 similar to lesions of placental site trophoblastic tumors
PLACENTAL SITE TROPHOBLASTIC TUMOR
 RAREST FORM of GTD
 composed of intermediate trophoblastic cells from the
extravillous trophoblast of the placental bed invade the
myometrium by separating muscle bundle and fibers
 15% - 20% behave in a malignant fashion, with
metastasis to the lungs, liver, abdominal cavity, and
brain.
 90% of cases develops after a normal pregnancy
 SSx:amenorrhea of up to 1 year and irregular vagina
bleeding of varying duration
 CHORIOCARCINOMA
 highly malignant tumor
 arises from the trophoblastic epithelium
 metastasize readily to the lungs, liver, and brain
 SSx: dyspnea, neurologic symptoms, abdominal
pain a few weeks or months and sometimes up
to 10-15 years after their last pregnancy
 Necrosis and hemorrhage are often present inside
chorocarcinomas, and corresponding metastasis
produces a sonographic picture of a semisolid
echogenic mass.
 Better evaluated by computed tomography or MRI
 CHORIOCARCINOMA
 serum hCG level must be measured a
 appropriate histologic examination performed in
any woman of reproductive age presenting with
widespread lesions, metastasis of unknown origin,
cerebral, or intra-abdominal bleeding
 50% follow molar pregnancy

 30% occur after miscarriage

 20% occur after an apparently normal pregnancy

PERSISTENT TROPHOBLASTIC TUMOR
 after uterine evacuation, persistent trophoblastic
tumor will develop in:
 18% - 29% of patients with CHM
 1 % - 11% of patients with PHM
 serial hCG levels – gold standard
 TVS is more accurate than TAS
 TAS is only capable of detecting massive uterine
involvement
 TVS is more accurate in assessing the depth of
myometrial invasion
 PERSISTENT TROPHOBLASTIC TUMOR
 color Doppler imaging (CDI) – with its added
capability of displaying blood flow data throughout
area of interest, has improved the accuracy of TVS
 Ultrasonography :
 nodules of residualGTD are surrounded by newly
formed vessels with frequent AV anastomoses
 hypoechoic areas (blood lacunae) surrounded by
irregular echogenic areas (trophoblastic nodules) and
numerous intramyometrial signals (vascular shunts)
 Ultrasound in the Detection of
Hydatidiform Mole
 uterine cavity filled with central heterogenous
mass with anechoic spaces of varying size and
shape
 snowstorm like appearance

 Doppler : high velocities and low resistance

flow from trophoblastic tissue
 Ultrasound in the Detection of
Hydatidiform Mole

 In Invasive Mole: in addition to the central

uterine lesion, myometrial invasion is present
 Choriocarcinoma appearing as a mass
enlarging the uterus, with a heterogeneity
corresponding to areas of necrosis and
hemorrhage
 Gestational Trophoblastic Disease

Transverse transvaginal US (A) shows an echogenic mass with multiple cystic spaces
within the endometrial cavity in a woman with a hydatidiform mole. The small cystic
spaces (*, A) are felt to represent hydropic villi. Sagittal transvaginal US with colour
flow (arrows, B) documents flow to the mole. Hydatidiform mole is a subtype of
gestational trophoblastic disease.
 ULTRASOUND
EVALUATION OF THE
ADNEXA
( OVARY AND FALLOPIAN
TUBES)

Callen 5th edition

MATURE CYSTIC TERATOMAS
 DERMOID CYSTS
 Ovarian teratomas are the most common
germ cell tumor and are derived from
several histologic types, all of which
contain mature or immature tissues of
germ cell origin
 MATURE CYSTIC TERATOMAS
 or ovarian cystic teratoma
 most common of the ovarian teratomas
 contain mature tissues of ectodermal
(skin , brain), mesodermal (muscle, fat),
endodermal (mucinous or ciliated
eptihelium)
 younger age group (mean 30 years old)
 most common in children
 MATURE CYSTIC TERATOMAS
 Characteristic Ultrasound Features:
1. white ball (hair and sebum)
2. long, echogenic (white) lines and
prominent dots in cyst fluid (hair
floating freely in nonfatty fluid)
3. shadowing
 ENDOMETRIOMAS
 Endometriosis – presence of endometrial
tissue outside of the endometrium and
myometrium
 locations : ovaries, uterine ligaments,
rectovaginal septum, cul-de-sac, pelvic
peritoneum
 Symptoms: aquired dysmenorrhea, lower
abdominal, pelvic and back pain,
dyspareunia, irregular bleeding and
infertility
 ENDOMETRIOMAS
 Ultrasound findings:
 anechoic cyst to a cyst containing
diffuse low level echoes with or
without solid components to a solid-
appearing mass
 unilateral or bilateral
 confused teratomas, abscesses,
ovarian adenofibromas
 BENIGN CYSTIC LESIONS OF OVARIAN
AND PAROVARIAN STRUCTURES
 FUNCTIONAL CYSTS
 most common during reproductive
years
 result from abnormalities in the release
of anterior pituitary gonadotropins
 maybe multiple, recurrent, and
accompanied by corpora lutea
HEMORRHAGIC CORPUS LUTEUM CYSTS

 Ultrasound Findings:

 typically contains spiderweb-like

material
 bizarre blood clots may also be seen
 PELVIC INFLAMMATORY DISEASE
 result of ascending spread of
microorganisms from the vagina and cervix
through the endometrial cavity, through the
endometrium into the fallopian tubes.
 Clinical Presentation: fever, pelvic pain
and purulent vaginal discharge
 commonest causative agents are:
 Chlamydia trachomatis

 Neisseria gonorrhoeae
 PELVIC INFLAMMATORY DISEASE
 Imaging Modality of Choice : Ultrasound
 Characteristic Ultrasound Features:
1. fluid-filled sausage-shaped cystic structure
2. presence of incomplete septa, that is, septa
that are not seen to reach the opposite wall
of the cystic structure
3. on transverse section of a fluid-filled
tube, mucosal folds are seen to protrude
into the lumen, resulting in cogwheel
appearance ( swollen), beads-on-a-string
appearance (if not)
 PARAOVARIAN CYSTS
 may arise from embryonic ducts and are
usually located between the tube and the
ovary.
 mesothelial, mesonephric, paramesonephric
origin
 On ultrasound : cyst clearly separate from
the a normal ovary
 papillary projections and septa may develop
 malignancy may develop
 PERITONEAL PSEUDOCYSTS

 fluid collections among adhesions occuring

after an inflammatory process in the
peritoneal cavity or after an operation
 typical ultrasound morphology : cystic mass
following the contours of the pelvis, with a
deformed ovary suspended amongst
adhesions centrally or peripherally echoic
 the cyst contain both septa and papillary
projections
 BENIGN CYSTIC LESIONS OF OVARIAN
AND PAROVARIAN STRUCTURES
 OVARIAN HYPERSTIMULATION
SYNDROME
 women undergoing ovulation induction

 presentation similar to HL,except in

timing
 ovarian expansion with concomittant fluid
shifts typically more rapid in OHS than
HL
 BENIGN CYSTIC LESIONS OF OVARIAN
AND PAROVARIAN STRUCTURES
 POLYCYSTIC OVARIAN SYNDROME (PCOS)
 complex endocrinologic disorder associated with
chronic anovulation
 hyperandrogenism - most consistent feature

 manifestations of unopposed estrogenic

stimulation, including menometorrhagia,
endometrial hyperplasia, and endometrial
carcinoma
 higher risk of OHS
 POLYCYSTIC OVARIAN SYNDROME (PCOS)
 more common in women with recurrent early
pregnancy loss
 TWO DIAGNOSTIC APPROACHES:

 ultrasound appearance of a PCO

 unexplained symptoms of menstrual

disturbance, hyperandrogenism, or anovulation.
 detection of hyperandrogenic chronic
anovulation regardless of ovarian ultrasound
appearance
 POLYCYSTIC OVARIAN SYNDROME (PCOS)
 ULTRASONOGRAPHIC APPEARANCE
 (Transabdominal Technique by Adams et al)
 presence of 10 or more cysts measuring 2 to 18 mm
in diameter in a single plane arranged peripherally
around an increased amount of central stroma
 or less commonly, multiple small cysts 2 to 4 mm
diameter distributed throughout the abundant
stroma
 Polycystic Ovarian Disease

Sagittal (A) and transverse (B) transvaginal ultrasound of the left ovary
depicting multiple subcentimetre peripherally placed follicles in enlarged
ovaries with echogenic central stroma.
 OVARIAN VASCULAR LESIONS
 OVARIAN TORSION
 5th most common gynecologic emergency
(2.7% of all gynecologic emergencies)
 1st three decades of life

 50% to 81% of patients, unilateral ovarian

tumors as cause of torsion
 ovarian and para-ovarian cysts most common
cause
 OVARIAN TORSION
 Ultrasound Findings:
 twisted adnexal masses are often midline, positioned cranial to
the uterine fundus
 early diagnosis : enlarged ovary with absent markedly decreased
ovarian blood flow
 twisted vascular pedicle ( broad ligament, fallopian tube,
adnexal and ovarian branches of the uterine arteries and veins)
 “Whirpool sign” – Color Doppler demonstrates flow within the
pedicle circular or coiled twisted vessels
 Ovarian Carcinoma

Sagittal transvaginal US image demonstrates a large complex cystic mass

arising from the left adnexa. The presence of flow within the solid nodule
suggests malignant aetiology.
 Practice Points
 Benign Tumors : absence of solid components
and no irregularity
 Malignant Tumors : presence of solid
components and irregularity
 Mature Cystic Teratoma : white ball, long
echogenic lines, prominent echogenic dots in
cyst fluid, shadowing
 Endometrioma : ground glass appearance of
cyst contents, wall nodularities
 Practice Points
 Hemorrhagic Corpus Luteum Cyst :
spiderweb-like contents, bizarre blood clots
 Hydro-pyo-hematosalpinx : fluid-filled
sausage-shaped cystic structure, incomplete
septa, cogwheel appearance, beads-on-a- string
appearance
 Paraovarian cyst: cyst clearly separate from a
normal ovary
 Practice Points
 Peritoneal Pseudocyst : cystic mass following
contours of the pelvis and with an ovary, often
deformed, suspended amongst adhesions
centrally or peripherally in the cyst
 Fibroma, Fibrothecoma : echopattern
indistinguishable from that of a pedunculated
myoma, that is, a solid, round, lobular, or oval
tumor with a smooth outline and a regular
stripy echogenicity.
 Practice Points
 Tubo-ovarian Abscess : unilocular cystic
structure, or complex multicystic structure with
thick walls and thick septae, filled with
homogenous echogenic material (ground-glass
appearance)
 Adnexal Torsion : the walls and any septa of the
twisted lesion may look swollen at ultrasound
examinantion; there maybe fluid in the pouch of
Douglas; presence of color and spectral Doppler
signals in the lesion does not exclude torsion
Thank You !