30

OVARIAN MASSES
SIMPLE OVARIAN CYST
Ultrasound features:
Has sharp margins.
Anechoic.
Prominent through transmission.

Normal follicular cysts are frequently seen and should not be mistaken for pathology.
Incidental cysts less than 2 cm in diameter in a premenopausal patient may safely be watched.
A subsequent scan after the next menstrual period usually shows disappearance of the lesion.
At times, after ovulation, the corpus luteum of the ovary undergoes hemorrhagic change
which causes it to enlarge (3-4 cm). These bodies are properly termed corpus luteum cvsts.
They are particularly common during the first trimester of pregnancy and require no special
therapy.

HEMORRHAGIC CYSTS

May be formed due to bleed into a normal follicle or into corpus luteum.
Varying appearances on ultrasound----
• Homogenous internal echoes.
• Thin septations. (fishnet appearance)
• Anechoic fluid with retracted clot
• Fluid fluid level
Usually resolve in 6 weeks -12 weeks .

Endometriotic and physiological hemorrhagic cysts often have similar appearance.

Differential diagnosis can be made by correlating with clinical history and follow up scan.
History of dysmenorrhoea and no change in picture on follow-up scan favours endometriosis.

TVS-HHemorrhagic cyst with homogenous TVS-Hemorrhagic cyst with septations

internal echoes

Institute Of Ultrasound Training,New Delhi,India

 31

TVS-Hemorrhagic cyst with retracted TVS-Hemorrhagic cyst with heterogenous

clot(C) texture

ENDOMETRIOSIS
. On U/S endometriotic collections may present as mass lesions. These mass lesions are more
commonly multiple and majority have internal echoes due to blood collections .A fishnet
appearance is seen on many occasions due to blood /fibrotic strands.

TVS- Endometriotic cysts(e) TVS- Endometriotic cyst with carpet like echoes
Homogenous low level internal echoes giving a ground glass appearance(carpet like echoes)
are fairly specific for endometriosis. The internal echoes within the cystic collections are
usually more apparent with transvaginal U/S. Echogenic wall foci are often seen and when
seen are more specific features of endometriosis..

Endometriotic cyst with hetrogenous TVS-Endometriosis as tubo-ovarian mass

Texture T-Hematosalpinx ; C-Endometriotic
cysts in ovary

Institute Of Ultrasound Training,New Delhi,India

 32

Cyst walls are generally thick and fibrotic,however it can be smooth

Fluid may be seen in Pouch of Douglas that may have homogenous internal echoes when
fresh blood is there & later it may have an anechoic appearance intermixed with fibrotic
bands. Clinically patient presents with pain which may be quite severe .The pain is always
related to the periods whether it is at the beginning, in the midpart or towards the end.
D/D:
1.Hemorrhagic Corpus luteum cyst—It is usually single while cysts of endometriosis may
be multiple. Clinical history is also entirely different. Patient usually presents with sudden
onset of pain, which may be mild or severe & gets relieved with the passage of time.
2.Pelvic Inflammatory Disease: U/S picture may be similar & usually clinical history is
important in differentiating.A patient of PID may have fever, pain & vaginal discharge.Also
pain has no relationship with menstrual periods.
3-Dermoid –can have low level echoes or can have septations with cystic components but
echogenic areas of calcification ,hair or fat if seen may help in differentiation. On color
Doppler most of the dermoids are avascular while most of the endometriomas are vascular.

POLYCYSTIC OVARIES

Ultrasound Features
• 1-Multiple cysts ,greater than 5 per ovary.
•2-Cysts at the periphery with necklace appeareance or generalized (both centrally and peripheraly )
•3-Generalized cystic variety is more common in early stage of disease(teenage group) and may later
change to the peripheral follicular variety.
•4- size of the ovary --usually increased (volume more than 8 cc) but it may be normal.Ovarian volume is
more on rt . side compared to Lt. in PCOD pt.
•5-Ovarian stroma is thick and echogenic

In early PCOD the ovarian enlargement is mild & it may be possible that only one ovary is
enlarged. Also nearly 30% of the patients may have both ovaries of normal size & in a minority
percentage the ovaries may be enlarged and have a predominantly solid texture & less appreciable cysts.

TAS-Polycystic ovaries-Bilateral enlarged TVS-polycystic ovaries-Necklace

Ovaries with multiple small follicles appearance with prominent stroma

Institute Of Ultrasound Training,New Delhi,India

 33

THECA LUTEIN CYSTS

Asso. with increased HCG level.
1.Molar preg.
2.Medication for infertility.
3.Normal singleton preg.
Presents as b/l ,multiloculated cystic masses.

THECA LUTEIN CYSTS

CYSTADENOMA& CYSTADENOCARCINOMA

Cystadenoma: Multiloculated , multiseptate cystic structure.Can be unilocular

Cystadenocarcinoma:Difficult to differentiate from cystadenoma on u/s.Usually more solid
appearing.

Cystadenoma Cystadenocarcinoma

DERMOID

Dermoid-mass(M) with calcification Dermoid with fat seen as hyperechoic mass

Casting shadow(Sh)

Institute Of Ultrasound Training,New Delhi,India

 34

PELVIC INFLAMMATORY DISEASE

Pelvic inflammatory disease is usually bilateral when it is caused by hematogenous spread

e.g.: Tuberculosis or STD’S eg: gonorrhoea. It is usually unilateral with the nonvenereal
pathology e.g.: IUCD, post abortion & post delivery complications. Clinically patient presents
with pain, fever & vaginal discharge .On U/S features of endometritis may be seen. Also fluid
may be seen in POD with internal echoes suggesting pus collections. Pyosalpinx may develop
as a result of occlusion of the tube. Dilated tubes may appear as complex adenexal masses.
Later ovaries (which are initially resistant to infection) may also be involved (forming tubo-
ovarian abscesses .In chronic PID a common presentation is diffuse obliteration of the tissue
planes within the pelvis. Adhesions & fibrosis may result in ill-defined or well-defined mass.
At times the mass may be nearly solid in appearance.

TVS-Tubo Ovarian mass in PID TVS-Pelvic abscess(AB) with air(arrow)

UT-Uterus BL-Bladder

TVS-Tubular mass with internal echoes in TVS-Hydrosalpinx seen as tubular mass with
PID-Pyosalpinx(Py) M ma incomplete septa representing folds of the tube

Institute Of Ultrasound Training,New Delhi,India