Professional Documents
Culture Documents
INDICATIONS:
P/V bleeding/discharge, Menorrhagia, Metrorrhagia (irregular uterine
bleeding), Polymenorrhea, Menometrorrhagia (excessive irregular bleeding)
Amenorrhea, Oligoamenorrhea, Pelvic pain, Dysmenorrhea (Painful Menses)
F/H uterine or ovarian Cancer, Palpable lump, Infertility- primary or secondary
(evaluation, monitoring and/or treatment), Anomalies/evaluation, Follow-up
of previous abnormality, Precocious Puberty, delayed menses or vaginal
bleeding in a prepubertal child. postmenopausal bleeding, Signs/symptoms of
pelvic infection, IUCD Localization (intrauterine contraceptive Device)
Guidance for interventional or surgical procedures.
urinary incontinence or pelvic organ prolapse.
COMMON PATHOLOGIES
VAGINAL
Gartners duct cyst, Epidermal inclusion cysts, Bartholin Gland Cysts, Vaginal
carcinoma, Hydro/hematocolpos (secondary to imperforate hymen or vaginal
stenosis), Foreign body, leiomyoma and endometriosis.
CERVICAL
Nabothian (retention) cysts, Polyps, Cervical fibroids, Cervical carcinoma, Cervical stenosis
UTERINE
Fibroids (leiomyoma), submucosal, intramural, subserosal, pedunculated
Leiomyosarcoma
Adenomyosis
Lipoleiomyoma
ENDOMETRIAL
Endometrial Polyps, Endometrial Carcinoma, Endometrial hyperplasia
Endometritis, endometriosis.
Cystic hyperplasia secondary to Tamoxifen
Adhesions- Ashermans Syndrome
Submucosal fibroids
Arterio-venous malformation (AVM)
Hydro/hematometra
Blood/fluid/infection or retained products of conception (RPOC)
Common cystic lesions of the vagina and their origins.
Gartner duct cysts are embryologic secretory
retention cysts that arise from the residual wolffian
(mesonephric) duct remnant usually solitary and less
than 2 cm, most commonly develop in the
anterolateral wall of the proximal one-third of the
vagina; may contain septa; when located at the level
of the urethra, they can cause mass effect on the
urethra, giving rise to urinary tract symptoms; often
associated with other wolffian abnormalities
(unilateral renal agenesis, renal hypoplasia, and
ectopic ureteral insertion); although usually
asymptomatic, cyst aspiration, tetracycline
sclerotherapy, or surgical excision may be used to
treat larger lesions.
Gartner’s cyst (*) in a young woman with dysuria imaged with (a) suprapubic, (b) trans-
labial approach and (c) reconstructed images from translabial volume acquisition.
Posterior urethral diverticula (*) creating mass effect on the anterior wall
of the vagina in a woman with dysuria, and severe dyspareunia imaged
during voiding. The inhomogeneous appearance is due to turbulent flow.
u, urethra; b, bladder; ant and post, anterior and posterior vaginal walls.
Imperforate hymen is the most common congenital obstructive abnormality of
the female genital tract, with a frequency that can vary from 1 case per 1000
population to 1 case per 10,000 population; most commonly occurs in
isolation; occurs due to a failure of recanalization of this membranous vestige;
Sagittal US scan with a linear probe of a slow-growth inhomogeneous solid mass of the right
major labrum. Dynamic CEUS (D, E and F) shows a ready enhancement of the lesion. The lesion
appeared hyperintense in T2-fatsat MR sequences (G) and iso-hypointense on T1 (H). At
microscopical examination the lesion was demonstrated to be an angiomixoma of the vulva.
Cancer vagina with translabial sagittal US (a) of the vagina in a patient with
vaginal bleeding and dyspareunia. A large, solid, inhomogeneous vaginal
mass (arrowheads) is demonstrated with compression of the urethra (u).
Sagittal (b) and coronal (c) T2-weighted MR images show inhomogeneous
signal intensity of the mass and micro-infiltrative behavior.
Bartholin Gland Cysts
Bartholin’s glands secretions provide to lubricate vulvar vestibule with
ducts that drain at the 4 and 8 o’ clock positions of the vaginal vestibule.
Bartholin gland cysts are the most common vulvar cysts, developing in 2%
of women during their lifetime; located at the posterolateral vaginal
introits, medial to the labia minora; their location at or below the level of
the pubic symphysis helps differentiate them from Gartner duct cysts;
range in size from 1 to 4 cm (but can increase with repeated sexual
stimulation develop as a result of an obstruction of the gland’s duct by a
stone or a stenosis related to prior infection or trauma); patients are often
asymptomatic but can present with mild dyspareunia, typically in the 2nd
to 3rd decade of life; superimposed infection or abscess formation may
require drainage; a rare complication is development of squamous car-
cinoma or adenocarcinoma in a Bartholin's gland duct or cyst,
respectively; at US, simple cysts are anechoic, thin-walled and unilocular,
but septations can be seen. the cyst wall may be thickened and, if infected,
enhancement can be observed at CEUS examination; visualization of any
solid component within the cyst should raise concern for malignancy.
US coronal scan of a Bartholin’s cyst in a patient with discomfort and dyspareunia. A cystic
mass (*) in (a) is demonstrated in the right major labrum. Color-Doppler evaluation (b) shows
an implementation of vascular signs related to hyperemia and inflammation. V, vagina.
Vaginal endometriosis consists in the presence of ectopic endometrial glandular
and stromal tissue within the vaginal walls. May occur during surgical procedures
or from the spread of a recto-vaginal pouch endometriosis; often associated with
dysmenorrheal, postcoital spotting, dyspareunia and infertility; the condition is
almost always associated with endometriosis in other pelvic locations.
Transvaginal US and
color-Doppler scan of a
recurrent gynecologic
malignancy (arrows)
on the vaginal cuff
after hysterectomy.
Vagina is an unlikely location to develop varices, because of the presence of a
bilateral draining system (similar to uterus), which largely communicates with
the uterine, vesical and hemorroidal plexuses; vaginal varices are usually
found in cirrhotic patients or after hysterectomy; color-Doppler US reveals
venous flow inside these hypoechoic, serpiginous lesions.
Cervical fibroid.
Sagittal transabdominal US (a) and color-Doppler (b) demonstrating a large
intracavitary pedunculated myoma (*) protruding in vagina from cervical os.
The vascular pedicle is depicted at color-Doppler US. b, bladder; c, cervix.
Carcinoma of the cervix is a malignancy arising from the cervix and is
considered the third most common gynecologic malignancy.
Ultrasound
hypoechoic, heterogeneous mass involving the cervix
may show increased vascularity on colour Doppler
although cervical cancer is staged clinically, ultrasound can be a useful
adjunct by showing
size (<4 cm or >4 cm)
parametrial invasion
tumour invasion into the vagina
tumor invasion into adjacent organs
hydronephrosis: implies stage IIIB tumour.
Subserosal leiomyoma.
Subserosal Leiomyoma.
Intra-mural uterine leiomyoma.
TA USG image (A) shows a 7-cm intramural fibroid containing cystic areas
(arrows). Axial T2W MRI image (B) shows an 11 × 8 cm fibroid (arrows)
containing central high signal, consistent with cystic degeneration (arrowhead)
Transabdominal (TA) USG image (A) shows a bulky uterus showing a 10-cm
submucosal fibroid (between cursors). Sagittal T2W MRI image (B) in the same
patient shows that the submucosal fibroid (arrowhead) is heterogeneous
indicating degeneration. There is also a 2.5-cm cervical fibroid (arrow)
Ultrasound image shows sub mucosal fibroid Picture
B. MRI image shows multiple intramural fibroids.
Multiple uterine fibroid.
Endometrial polyps are benign nodular protrusions of the endometrial surface, and one
of the entities included in a differential of endometrial thickening. Endometrial polyps
can either be sessile or pedunculated. They can often be suggested on ultrasound or MRI
studies, but may require sonohysterography or direct visualization for confirmation.
Ultrasound.
Although endometrial polyps may be visualized at transvaginal ultrasound as nonspecific
endometrial thickening, they may also be identified as focal masses within the
endometrial canal. a stalk to the polyp may either be thin or broad based a feeding
vessel may be seen extending to the polyp on colour Doppler imaging cystic spaces
corresponding to dilated glands filled with proteinaceous fluid may be seen within the
polyp and is considered a relatively characteristic feature may appear as just diffusely
thickened endometrium, without visualization of a discrete mass (mimicking endometrial
hyperplasia)
3D ultrasound may be useful to help delineate the borders of a polyp.
Sonohysterography .
Polyps are best characterized on sonohysterography and appear as echogenic, smooth,
intra-cavitary masses outlined by fluid. The typical appearance of an endometrial polyp
at sonohysterography is as a well-defined, homogeneous, polypoid lesion that is
isoechoic to the endometrium with preservation of the endometrial-myometrial interface
There is usually a well-defined vascular pedicle within the stalk.
Colour Doppler interrogation may show flow within the stalk.
Endometrial polyp.
TVS of an endometrial polyp hidden After transcervical instillation of saline
(SISH), applying power Doppler, a polyp with
within a secretorial endometrium
single vessel arrangement can be seen.
Images show endometrial polyp within the uterine cavity
with its vascular pedicle visible on color Doppler scans.
Multiple endometrial polyp.
Endometrial hyperplasia (EH) refers to an abnormal proliferation
of endometrial stromal and glandular components. It represents a
spectrum of endometrial changes ranging from cystically dilated
glands to cellular atypia.
Ultrasound
premenopausal
normal endometrial thickness depends on the stage of the
menstrual cycle, but a thickness of >10 mm is top normal or
abnormal
hyperplasia can be reliably excluded in patients only when the
endometrium measures less than 6 mm
postmenopausal
a thickness of >5 mm is considered abnormal
The appearance can be non-specific and cannot reliably allow
differentiation between hyperplasia and carcinoma. Usually there is
a homogeneous increase in endometrial thickness, but endometrial
hyperplasia may also cause asymmetric/focal thickening with surface
irregularity, an appearance that is suspicious for carcinoma.
Endometrial hyperplasia.
Endometrial hyperplasia.
Endometrial hyperplasia.
Endometrial carcinoma is generally considered the most common
gynecological malignancy. It frequently present with vaginal
bleeding and both ultrasound and pelvic MRI are useful modalities
for evaluation.
Transvaginal ultrasound
Endometrial carcinoma usually appears as thickening of the
endometrium though may appear as a polypoid mass
premenopausal: normal endometrial thickness varies through the
menstrual cycle
diagnosing abnormally thickened endometrium depends on
knowing what the patient's point in the menstrual cycle
postmenopausal: >5 mm is thickened (if not on Tamoxifen)
Sonographic features are non specific and endometrial thickening
can also be due to benign proliferation, endometrial hyperplasia or
polyps.
Disruption of a subendometrial halo on ultrasound may be
suggestive of myometrial involvement.
Endometrial carcinoma.
Endometrial Carcinoma.
Stage IC endometrial carcinoma. Sagittal TVUS Multiple vessels in women
image of the uterus shows marked, inhomogeneous
endometrial thickening(thick arrows ). with endometrial cancer.
Endometritis refers to inflammation of the endometrium, the inner
lining of the uterus. Pathologists have traditionally classified endometritis
as either acute or chronic.
Ultrasound
While the sonographic appearance of the uterus and endometrium may be
normal in early stages, findings may include a thickened, heterogeneous
endometrium, intracavitary fluid +/- intrauterine air.
Sagittal image of the uterus showing complex fluid within the endometrial cavity. Endometritis.
Endometriosis is a hormonal and immune system disease in which
cells similar to that which line the uterus (endometrium) grow
outside the uterine cavity, most commonly on the membrane which
lines the abdominal cavity, the peritoneum.
Ovarian endometrioma.
Endometriosis.
Uterine arteriovenous malformations (UAVM)
result from formation of multiple arteriovenous fistulous
communications within the uterus without an intervening
capillary network.
Ultrasound
Gray-scale sonographic appearances can be non-specific and
can have a range of manifestations including areas of subtle
myometrial inhomogeneity, tubular spaces within the
myometrium, a intramural uterine, endometrial or cervical
mass like region or sometimes as prominent parametrial
vessels. The extent of mass is effect is however minimal.
Colour Doppler
Typically shows serpiginous/tubular anechoic structures within
the myometrium with a low resistance (RI ~0.2-0.5), high
velocity flow pattern on colour Doppler interrogation.
Uterine AVM.
Uterine arterio-venous malformation. In addition
a large disproportionately dilated vascular.
ULTRASOUND OF THE OVARIES – Normal.
Dermoid cyst.
Dermoid ovarian cyst.
Ovarian dermoid cyst with Rokitansky nodule.
Complicated septated ovarian cyst.
Endometrioma right ovary with homogenous distribution of low to medium fine echoes in a
cystic mass with only one septation, no solid components. No blood flow within the mass,
Ovarian serous cyst adenomas (OSC) are a type of benign ovarian
epithelial tumour.
Ultrasound
usually seen as a unilocular cystic adnexal lesion
papillary projections are absent
if there is any wall irregularity, it is thin, with an acute angle with the cyst
wall and have a regular surface
some lesions may contain sonographically detectable septations.
Ovarian cystadenocarcinoma.
Ovarian serous cystadenocarcinoma. A. Coronal TVUS image with
superimposed color Doppler of a left ovarian mass shows a cystic mass
with a large vascular solid component. B. Spectral Doppler image of the
same ovary shows high diastolic flow, indicating neovascularization.
Malignant cystic ovarian neoplasm.
TVS image left ovary. bilateral serous
papillary ovarian carcinoma. She had a
normal gynecological checkup without
ultrasound one year prior to diagnosis. TVS of the other ovary, same
Randomly dispersed vessels in the patient. B-mode features
echogenic area of the adnexal mass typical ovarian malignancy.
Polycystic ovarian syndrome (PCOS) is a chronic anovulation
syndrome. Sonographic findings alone are not specific, and the
diagnosis is made on the combined clinical, biochemical and
sonographic grounds.
Ultrasound
Ovaries
may show sonographic features of polycystic ovaries
bilateral enlarged ovaries with multiple small follicles: 50%
increased ovarian size (>10 cc)
12 or more follicles measuring 2-9 mm
follicles of similar size
peripheral location of follicles: which can give a string of
pearl appearance
hyperechoic central stroma
the ovarian outline may be slightly irregular
hypo-echoic ovary without individual cysts: 25%
normal ovaries: 25%.
Polycystic ovary.
Polycystic ovary.
The ovarian hyper-stimulation syndrome (OHSS) is a complication of
ovarian stimulation treatment (ovarian induction therapy).
Ultrasound
typically shows bilateral symmetric enlargement of ovaries (often >12 cm in size)
multiple cysts of varying sizes, giving the classic spoke-wheel appearance
associated ascites and pleural +/- pericardial effusion (which is due to capillary
leak) may also be present.