Uterus and ovary Ultrasound

Rad Abubakar Aminu Abubakar

BUK
Bony Pelvis and Location of the Female
Genitalia
• The bony pelvis consists of the sacrum, coccyx, and innominate bones.

• These bones mark the boundaries of the pelvic cavity. The posterior border of the pelvic cavity is marked by the
sacrum and coccyx.
•
• The innominate bones consist of the ilium, ischium, and pubic symphysis.

• The boundaries of the female pelvis are considered to be from the iliac crest to a group of muscles known as
the pelvic diaphragm, located at the base of the pelvis

• The pelvis can further be divided into a true pelvis (lesser pelvis) and false pelvis (major pelvis) by an imaginary
line known as the linea terminalis

• The false pelvis is located more superiorly than the true pelvis, the latter of which contains the urinary bladder,
small bowel, sigmoid colon, rectum, ovaries, fallopian tubes, and uterus.
• Within the pelvis, the nongravid uterus lies within the midline of the
pelvis between the urinary bladder and the rectum.

• The vagina extends inferiorly from the external os of the cervix to the
external genitalia, where it is positioned posterior to the urethra.

• The fallopian tubes and ovaries are considered bilateral adnexal

structures.

• However, the course of the fallopian tubes and location of the ovaries
are relatively unpredictable.
 Pelvic Muscles
• Several pelvic muscles may be identified sonographically within the female pelvis . Muscles visualized on a sonogram
include;

• the rectus abdominis muscles,

• the iliopsoas muscles,

• obturator internus,

• piriformis muscles, and a group of muscles known as the

• pelvic diaphragm (levator ani and coccygeus muscles)

• pelvic diaphragm muscles provide support to the pelvic organs. A weakening in the levator ani muscles could result in
prolapse of the pelvic organs
• Since pelvic muscles can be seen sonographically, sonographers must
have an understanding of their locations and sonographic appearance in
order to differentiate them from pelvic masses.

• For instance, the piriformis muscles or iliopsoas may be confused for the
ovaries or adnexal masses because of their location within the pelvis.

• Pelvic muscles will appear as hypoechoic structures with varying

degrees of hyperechoic, striated muscle fibers noted in the transverse
and longitudinal scanning planes
Pelvic Ligaments
• The ligaments of the pelvis provide support to the ovaries, uterus, and fallopian tube

• The broad ligaments and suspensory ligament of the ovary are actually double folds of peritoneum.

• In addition to providing support, the suspensory ligament of the ovary contains the ovarian artery,
ovarian vein, lymphatics, and ovarian nerves.

• Conversely, the cardinal ligaments house the vasculature of the uterus.

• The majority of pelvic ligaments are not identified during a routine sonographic examination of the
pelvis.

• However, when surrounded by free fluid, the dense broad ligaments may be identified as echogenic
structures extending from the lateral borders of the uterus bilaterally
Ligamentous support of the uterus
• Pubocervical ligaments or fascia which run anteriorly from the cervix, around
the base of the bladder to the pubic bone;

• Transverse cervical (cardinal) ligaments which run laterally from cervix and
lateral aspect of vaginal fornix to pelvic side wall;

• Uterosacral ligaments which run posterosuperiorly to the midsacrum on the

upper surface of the levator ani muscle

• The round ligament is a fibromuscular band that passes from the upper lateral
part of the uterus to the inguinal canal, ending in the labium majoris.
The broad ligament
• This double layer of peritoneum is a mesentery that encloses the fallopian tubes in its upper part
and extends from the sides of the uterus to the pelvic side walls and floor.

• The two layers are continuous with each other laterally at a free edge that surrounds the uterine
tube where this opens into the abdominal cavity.

• The uterine artery runs medially in its base.

• The ureter loops under the uterine artery within the ligament, passing just lateral to the cervix
above the lateral vaginal fornix to enter the bladder.

• The uterine plexus of veins in the base of the broad ligament communicates with the veins of the
vagina and bladder via the pelvic plexus of veins.

• The ligament of the ovary (from ovary to uterus) lies posterosuperiorly within the broad ligament
and the round ligament lies anteroinferiorly within the layers.

• Both of these structures attach to the uterus close to the attachment of the uterine tubes.
Other uterine supports
• The bladder supports the uterus on its upper surface in the normal anatomic
arrangement.

• This arrangement and the transverse cervical ligaments are the main passive
support of the uterus.

• It is also supported below by the muscles of the pelvic floor, which provide active
support by contracting when intra-abdominal pressure is raised.

• levator ani muscles, the puborectalis and iliococcygeus are the most important
uterine supports.

• At rest, the levator ani muscles are in contraction, keeping rectum, vagina and
urethra elevated and closed
Pelvic Spaces
• Fluid may accumulate within potential spaces or recesses within the female pelvis.

• When filled with fluid, these regions can be easily identified sonographically.

• The vesicouterine pouch, or anterior cul-de-sac, is located anterior to the uterus and
posterior to the urinary bladder.

• The rectouterine pouch, located between the rectum and uterus, may also be referred to as
the posterior cul-de-sac or pouch of Douglas.

• Between the anterior wall of the urinary bladder and symphysis pubis lies the space of
Retzius, or retropubic space, an area that contains extraperitoneal fat.

• Free fluid, when excessive, may also be noted within the adnexa, lower quadrants of the
abdomen, and may delineate the borders of pelvic organs
ANATOMY AND PHYSIOLOGY OF THE
UTERUS AND VAGINA
• The uterus is a pear-shaped, retroperitoneal organ that lies anterior to the rectum,
posterior to the urinary bladder, and is bounded laterally by the broad ligaments.

• Its primary function is to provide a place for the products of conception to implant
and develop.

• The uterus can be divided into four major divisions:

• Fundus,
• Corpus (body)
• Isthmus,
• Cervix
 ORGANS IN FEMALE PELVIS
• Uterus
• Adnexa
• Fallopian tubes
• Ovaries
• Bladder

2004 18
EMBRYOLOGIC DEVELOPMENT OF
THE FEMALE UROGENITAL TRACT
• During the embryonic period, the uterus and kidneys develop at essentially the same time.

• Therefore, it is safe to assume that when there are congenital anomalies recognized on a routine
sonogram within the uterus, co-existing anomalies may be present in the kidneys.

• For this reason, patients who present with uterine anomalies may also require a urinary tract
sonogram.

• The uterus, vagina, and fallopian tubes develop from the paired müllerian ducts (paramesonephric
ducts).
•
• Thus, incomplete fusion, partial fusion, or agenesis of the müllerian ducts will result in an anatomic
variant of the uterus, cervix, and/or vagina that may be recognized sonographically.
• The fundus is the most superior and widest portion of the uterus.

• Each fallopian tube attaches to the uterus at the level of the uterine horns called the cornua.

• The largest part of the uterus is the corpus, or body. The corpus is located inferior to the
fundus.

• The isthmus is the area located between the corpus and the cervix.

• During pregnancy the isthmus may be referred to as the lower uterine segment.

• The cervix is the rigid component of the uterus that is located inferior to the isthmus and it is
the portion of the uterus that projects into the vagina.

• The cervix is marked superiorly by the internal os, which is in contact with the isthmus, and
inferiorly by the external os, which is in close contact with the vagina
• The vagina is a tubular organ, which extends from the external os of the
cervix to the external genitalia.

• The vaginal fornices envelop the inferior aspect of the cervix.

• The vagina is composed of three layers:
• inner mucosal layer
• middle muscular layer
• an outer layer that may be referred to as the adventitia.

• Sonographically, the divisions of the uterus can be demonstrate

• The uterine wall consists of three layers.

• The outermost layer is referred to as the serosal layer or perimetrium, which is continuous with the
fascia of the pelvis.

• The middle layer is the myometrium or muscular layer, which constitutes the bulk of the uterine tissue,
providing the area where contractile motion occurs.

• The inner mucosal layer of the uterus is referred to as the endometrium.

• The endometrium can be further divided into a deep or basal layer and a superficial or functional layer.

• The functional layer of the endometrium is the component that is shed during menstruation; thus, the
thickness of the functional layer of endometrium will vary during the menstrual cycle as a result of
hormonal stimulation.

• Between the two layers of the endometrium lies the endometrial (uterine) cavity, which is contiguous
with the lumen of the fallopian tubes laterally, and the cervix inferiorly
Uterine Size and Shape
• The size and shape of the uterus depends on the age of the patient, parity, and the presence of pathology or
congenital anomalies that may alter its contour.

• The normal neonatal uterus is tubular in appearance and may exhibit distinct endometrial echoes in the first
week of life as a result of maternal hormone stimulation.

• Following the neonatal period, the cervical anteroposterior diameter is equal to or slightly greater than that of
the uterine fundus.

• The normal prepubertal uterus has a cervix to uterus ratio of 2:1.

• The uterus grows minimally during prepubertal years, whereas after puberty the uterine fundus becomes much
larger than the cervix, thus providing the pear-shaped appearance of the normal adult uterus.

• Following menopause, the uterus typically becomes much smaller than the premenopausal uterus
???
• normal standards of uterine dimensions are7.6x4.5x3.
• normal adult uterus measures approximately ;
• 7.2-9.0cm long,
• 4.5-6.0cm wide
• 2.05-3.5 deep
Uterine Positions
• The uterine position within the pelvis is variable.

• The normal position of the uterus is considered to be anteversion or anteflexion.

•
• Anteversion describes the uterine position in which the body tilts forward, forming a 90-degree
angle with the cervix.

• Anteflexion of the uterus denotes the position in which the uterine body folds forward and
comes in contact with the cervix, forming an acute angle between the body and the cervix.

• Retroflexion is the uterine position that results in the uterine body tilting backward and actually
coming in contact with the cervix, thus forming an acute angle between body and cervix.

• Retroversion of the uterus is the position in which the uterine body tilts backward, without a
bend where the cervix and body meet. It may also be oriented more to the left or right of the
midline, resulting in a variation between anatomic midline and functional midline.
 The uterine tubes
• The uterine (fallopian) tubes lie in the 'free edge' of the broad ligament and convey ova from the ovaries to the uterus.
They open into the uterine cornua.

• They are described as having four parts as follows:

• The uterine part - this is the part within the wall of the uterus and opens into it;

• The isthmus - this is long and narrow and leads to the ampulla

• The ampulla - this is a wide, dilated tortuous part at the outer end where fertilization of the ovum usually occurs
• The infundibulum - this is the outer extremity of the tube.

• It is funnel shaped and its rim is fimbriated.

• It extends out beyond the broad ligament through the abdominal ostium and opens into the peritoneal cavity.

• The fimbriae spread over the upper surface of the ovary. One of the fimbriae is longer than the rest. This is called the
ovarian fimbria as it is attached to the ovary.
Blood supply of the uterus and uterine tubes
• The uterine artery, a branch of the internal iliac, runs medially in the
base of the broad ligament to reach the lower lateral wall of the
uterus.

• It ascends tortuously within the broad ligament to supply the uterus

and tubes and anastomoses with the ovarian artery.

• Venous drainage is via a venous plexus in the base of the broad

ligament to the internal iliac vein.
Lymph drainage
• The fundus drains along ovarian vessels to para-aortic nodes.

• The body drains via the broad ligament to nodes around the external
iliac vessels and occasionally via the round ligament to inguinal nodes.

• The cervix drains to external and internal iliac nodes and posteriorly
to sacral nodes.
The ovaries
• These are paired oval organs measuring approximately 3 cm x 2 cm x 2 cm.

• They are usually orientated somewhat vertically and thus can be described as
having upper and lower poles.
•
• They lie on the posterior surface of the broad ligament in close contact with
the infundibulum of the fallopian tube and attached to its ovarian fimbria.

• The fimbriae of the uterine tubes lie superior and lateral.

• The surface of the ovary is not covered by peritoneum, but by a layer of

germinal epithelium that becomes continuous with the peritoneum at the
hilum of the ovary.
ANATOMY AND PHYSIOLOGY OF THE
OVARY
• The ovaries form in the upper abdomen and descend into the pelvis in utero.

• They are paired, oval-shaped, intraperitoneal organs that have a dual blood supply from
both the ovarian artery and ovarian branches of the uterine arteries.

• As endocrine glands, the ovaries are responsible for releasing estrogen and progesterone
in varying amounts throughout the menstrual cycle.

• They may be located anywhere within the true pelvis, excluding the anterior cul-de-sac.

• The ovarian fossa is located posterior to the ureter and internal iliac artery and superior to
the external iliac artery
• The ovary consists of an outer cortex and an inner medulla.

• The medulla contains the ovarian vasculature and lymphatics, while the cortex involves the
mass of the ovary and is the site of oogenesis.

• The ovaries are stimulated by follicle-stimulating hormone, released by the anterior pituitary
gland, to develop multiple follicles during the first half of the menstrual cycle (follicular phase).

• The cells surrounding the tiny follicles produce estrogen, which stimulates the endometrium to
thicken.

• Only one of these follicles will become the dominant follicle, or graafian follicle, prior to
ovulation, while all other follicles will atrophy
• The ovary has a tough outer layer of tunica albuginea beneath the germinal layer.

• The anterior surface of the ovary is attached to the posterior surface of the broad ligament by a short
meso-ovarium that fuses with the surface of the ovary.

• The lower pole of the ovary is attached to the uterus by the ovarian ligament.

• A superolateral extension of the broad ligament, the suspensory ligament of the ovary, runs from the
upper pole of the ovary to the pelvic side wall.

• The ovarian vessels and nerves run in this, crossing over the external iliac vessels. Despite all its
attachments the ovary is very mobile, especially in women who have had children.

• It is frequently found behind the uterus in the pouch of Douglas

• The ovum is contained within the cumulus oophorus of the dominant follicle.

• The cumulus oophorus may be seen within the ovary during a sonographic
examination, with the sonographic appearance resembling that of a daughter cyst.

• At approximately day 14 of the menstrual cycle, ovulation occurs, as the dominant

follicle ruptures, releasing the mature ovum and a small amount of follicular fluid
into the peritoneal cavity.

• middle pain, describes pain at the time of ovulation, typically on the side of the
dominant follicle
• The fluid from the ruptured follicle most often will settle in the rectouterine pouch (pouch
of Douglas), the most dependent portion of the peritoneal cavity.

• After the graafian follicle has ruptured, its structure is converted into the corpus luteum.

• During the second half of the menstrual cycle (luteal phase), the corpus luteum produces
progesterone and, in small amounts, estrogen.

• If fertilization occurs, the corpus luteum is maintained and becomes the corpus luteum of
pregnancy.

• If fertilization does not occur, the corpus luteum regresses and becomes the corpus albicans
Corpus Luteum Cysts (Corpus Luteal Cysts)
• The corpus luteum cyst is a physiologic cyst that develops after ovulation has
occurred.

• The corpus luteum is formed as a result of the rupture of the graafian follicle and is
responsible for producing progesterone, thereby maintaining the endometrium during
an early pregnancy in preparation for implantation.

• The corpus luteum will normally regress if fertilization does not occur but may rarely
be maintained and continue to enlarge.

• When regression takes place, a small, echogenic structure may be noted within the
ovary, representing the corpus albicans
• Corpus luteum cysts may reach sizes up to 8 cm.

• Pain is associated with enlargement of the cyst, hemorrhage, and

rupture.

• If the cyst is large, it can lead to ovarian torsion

• In the presence of a pregnancy and human chorionic gonadotropin (hCG),
the corpus luteum is also preserved.

• In this case, the cyst may be referred to as the corpus luteum of pregnancy.

• These cysts are considered the most common pelvic masses seen during a
first-trimester sonographic examination.

• They may even reach sizes of up to 10 cm, although most often they
resolve by 16 weeks gestation and do not exceed 3 cm.

• They tend to appear as simple cysts, although they may also have thick
walls and may be difficult to differentiate from other solid and cystic
adnexal masses
• Patients with large corpus luteum cysts may present with pelvic pain if
the cyst has ruptured or if hemorrhage within the cyst has occurred.

• Often, complex or thick-walled corpus luteum cysts resemble an

ectopic pregnancy, so precautions to establish the presence of an
intrauterine pregnancy should be taken in this regard.
 SONOGRAPHIC APPEARANCE OF THE
OVARY
• Sonographically, the normal ovary is homogenous with a medium-level to low-level echogenicity.
•
• Multiple follicles may be noted with sonography during the neonatal and prepubertal ages.

• Also, follicles on the ovaries, of varying sizes, may be seen throughout the normal menstrual cycle
during reproductive years

• Typical ovarian flow is said to be high-resistant during the menstrual and proliferative phases and
lowresistant at midcycle.

• The size of the ovary depends on the age of the patient.

• Ovarian volume can be determined sonographically by utilizing the following formula: volume !
length " width " height " 0.5233.

• It is important to note that the postmenopausal ovaries atrophy and are often difficult to locate
sonographically.
• Hyperstimulation of the ovaries, or ovarian hyperstimulation
syndrome, from fertility treatment will also result in the development
of multiple, enlarged follicular cysts.

• A follicular cyst that contains blood is referred to as a hemorrhagic

cyst, and it most often appears complex or completely echogenic
depending on the hemorrhagic component present and the stage of
lysis
AIUM Practice Parameter for the Performance of an
Ultrasound Examination of the Female Pelvis
• The American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary
association dedicated to advancing the safe and effective use of ultrasound in medicine
through professional and public education, research, development of clinical practice
parameters, and accreditation of practices performing ultrasound examinations.

• The AIUM Practice Parameter for the Performance of an Ultrasound Examination of the
Female Pelvis was developed (or revised) by the AIUM in collaboration with other
organizations whose members use ultrasound for performing this examination(s).

• Recommendations for personnel requirements, the request for the examination,

documentation, quality assurance, and safety may vary among the organizations and
may be addressed by each separately
• This Practice Parameter is intended to provide the medical ultrasound
community with recommendations for the performance and
recording of high-quality ultrasound examinations.

• The parameter reflects what the AIUM considers the appropriate

criteria for this type of ultrasound examination.

• Examinations performed in this specialty area are expected to follow

the parameter with recognition that deviations may occur depending
on the clinical situation.
Indication
• Pelvic pain
• Dysmenorrhea
• Menorrhagia
• Metrorrhagia
• Menometrorrhagia
• Follow-up of previously detected abnormality (e.g., hemorrhagic cyst)
• Evaluation and/or monitoring of infertile patients
• Delayed menses or precocious puberty
• Postmenopausal bleeding
• Localization of an intrauterine contraceptive device
• Screening for malignancy in patients with an increased risk
Request for the Examination
• The written or electronic request for an ultrasound examination must
originate from a physician or other appropriately licensed health care
provider or under the provider’s direction.

• The clinical information provided should allow for the performance

and interpretation of the appropriate ultrasound examination and
should be consistent with relevant legal and local health care facility
requirements
Specifications of the Examination
• The following section details the examination to be performed for each organ
and anatomic region in the female pelvis.

• All relevant structures should be identified by the transabdominal and/or

transvaginal approach.

• A transrectal or transperineal approach may be useful in patients who are not

candidates for introduction of a vaginal transducer and in assessing the patient
with pelvic organ prolapse.

• More than 1 approach may be necessary

General Pelvic Preparation
• Transabdominal pelvic sonogram:
• The patient’s bladder can be distended if necessary;
• to displace the bowel from the field of view
• to provide an optimal acoustic window to better visualize the pelvic structures,
particularly if a transvaginal examination cannot be performed.

• Occasionally, overdistention of the bladder may compromise the evaluation.

• When this occurs, imaging may be repeated after partial bladder emptying.
If an abnormality of the urinary bladder is detected, it should be
documented and reported.
Transvaginal sonogram
• The urinary bladder is preferably empty.

• The patient, the sonographer, or the physician may introduce the

vaginal transducer, preferably under real-time monitoring.

• Consideration of having a chaperone present should be in accordance

with local policy.
Uterus
• In examining the uterus, the following should be evaluated:
• (a) the uterine size, shape, and orientation
• (b) the endometrium
• (c) the myometrium
• (d) the cervix.

• The vagina may be imaged while introducing the transducer and can be a landmark for
the cervix.

• If evaluations of the vaginal mucosa and rectovaginal septum are desired, instillation of
20 mL of sterile gel into the vagina with distension of the vaginal fornices may be helpful.
• The overall uterine length is evaluated in the sagittal view from the fundus to
the cervix (to the external os, if it can be identified).

• The length can be measured as a straight line from the fundus to the external
os by using the outer-to-outer technique or by measuring from the fundal
region along the endometrial lining and endocervical canal using the outer to-
outer technique.

• The depth of the uterus (anteroposterior dimension) is measured in the same

sagittal view from its anterior to posterior walls, perpendicular to the length.

• The maximum width is measured in the transverse or coronal view.

• If volume measurements of the uterine corpus are performed, the cervical

component should be excluded from the uterine length measurement
 Abnormalities of the uterus should be
documented
• The myometrium and cervix should be evaluated for;
• contour changes
• echogenicity,
• masses
• cysts
• symmetry between the anterior and posterior segments of the
myometrium.
• The size and location of clinically relevant lesions should be documented.
• Masses that may require follow-up or intervention should be measured in
at least 2 dimensions, acknowledging that it is not usually necessary to
measure all uterine fibroids
• The endometrium should be analyzed for its

• Thickness

• Focal abnormalities

• Echogenicity

• Presence and characteristics of fluid or masses in the cavity.

• The thickest part of the endometrium should be measured perpendicular to its

longitudinal plane in the anteroposterior diameter from echogenic to echogenic
borders, using the outer-to-outer technique
• The adjacent hypoechoic myometrium and fluid in the cavity should be excluded.

• In reproductive-aged postmenarchal patients, assessment of the endometrium

should allow for variations expected with phases of the menstrual cycle and with
hormonal supplementation.

• It should be reported if the endometrium is not adequately seen in its entirety or is

poorly defined; in this circumstance, the measurement should not be included in
the report.

• Sonohysterography may be a useful adjunct to evaluate the patient with abnormal

uterine bleeding or to further clarify an abnormally thickened endometrium and to
further evaluate an incompletely visualized endometrium.

• If the patient has an IUD, its location should be documented

Adnexa Including Ovaries and Fallopian
Tubes
• When evaluating the adnexa, an attempt should be made to identify
the ovaries first because they can serve as a major point of reference
for assessing the presence of adnexal pathology.

• Ovarian size may be determined by measuring the ovary in 3

dimensions (longitudinal, transverse, and anteroposterior diameters)
on views obtained in 2 orthogonal planes with calculation of the
ovarian volume as necessary.

• Any ovarian abnormalities should be documented

• The ovaries may not be identifiable in some patients.

• This occurs most frequently before puberty and after menopause

when the ovaries are smaller and/or follicles are not consistently
present to serve as a landmark.

• The adnexal region should be surveyed for abnormalities, particularly

masses and dilated tubular structures.
• If an adnexal abnormality is noted, its relationship with the ovaries
and uterus should be assessed.

• The size and sonographic characteristics of adnexal masses should be

documented.

• The addition of 3-dimensional to 2-dimensional ultrasound can be

helpful to differentiate ovarian multiseptated cysts from
hydrosalpinges.

• Additionally, the use of the “slide-by” technique can demonstrate the

presence or absence of mobility of the adnexal structures.
• An abnormal ovarian location, should be documented.

• Documentation should include whether the mass is cystic or solid

and, if cystic, simple or complex
• A detailed description of complex cysts should be provided, including the
presence or absence of septations (thick or thin), solid components, mural
nodules, excrescences or papillations, and vascular characteristics if
appropriate.

• If the sonographic characteristics are suggestive of a specific diagnosis, such

as a hemorrhagic cyst, an endometrioma, a mature teratoma, hydrosalpinx,
or a pedunculated fibroid, this information should also be provided.

• Spectral, color, and/or power Doppler ultrasound may be useful to evaluate

the vascular characteristics of pelvic lesions.
Cul-de-Sac
• The cul-de-sac and bowel posterior to the uterus may be evaluated for the presence of free fluid, loculated
fluid, or a mass.

• If a mass is detected, its size, position, shape, sonographic characteristics, and relationship with the ovaries and
uterus should be documented.

• Differentiation of normal loops of bowel from a mass may be difficult if only a transabdominal examination is
performed.

• The rectosigmoid colon wall may be imaged from the posterior vaginal fornix.

• Special attention to the posterior cul-de-sac should be made in women with pelvic pain, fixed retroflexion of
the uterus, or sonographic evidence of posterior adenomyosis and in those with known or clinically suspected
endometriosis.

• Hypoechoic masses with tapering ends in the rectosigmoid wall may be seen in deeply infiltrating
endometriosis.

• The presence of adhesions in the cul-de-sac may be inferred in the absence of a normal uterine sliding
Equipment Specifications
• The ultrasound examination of the female pelvis should be conducted
with a real-time scanner, preferably using sector, curved linear, and/or
endocavitary transducers.

• The transducer should be adjusted to operate at the highest

frequency appropriate for the clinical circumstance, realizing that
there is a trade-off between resolution and beam penetration
Transabdominal Scanning
• The sonographic examination should begin in a longitudinal fashion by attempting to
align the uterus with the vagina.
• The uterus can be recognized by the central line the endometrial cavity and by its
alignment with the vagina.
• The vagina is visualized as an echogenic line with relatively sonolucent walls.
• The uterus is normally located in the midline, but it may be deviated to either side in
an oblique axis.
• Scanning at right angles to the axis o the uterus should demonstrate the ovaries.
• The ovaries are usually close to the triangular cornual regions near the uterine undus.
• Caudal angulation is helpul or visualizing the pelvic musculature and retroverted uteri.
• Cranial or caudal angulation may be necessary to see the ovaries.
UTERINE PATHOLOGY (Adenomyosis)
• Is the invasion of endometrial tissue into the myometrium.

• The basal layer of the endometrium can often extend into the myometrium at depths of at least
2.5 mm.

• The involvement of adenomyosis may be either focal or diffuse and is typically found more often
within the posterior portion of the uterus

• Focal adenomyosis in the form of a mass is termed an adenomyoma.

• Sonographically;
• the uterus will appear diffusely enlarged and heterogeneous.
• There may be indistinct hypoechoic or echogenic areas scattered throughout the myometrium, with small
myometrial cysts noted as well.
• Thickening of the posterior myometrium can also be recognized.
• Adenomyosis is often present in the uterus afflicted with fibroid tumors.
• The clinical presentation of adenomyosis is varied and nonspecific,
with most women experiencing
• Dysmenorrhea
• Menometrorrhagia
• pelvic pain
• dyspareunia.
• Patients often have a tender uterus upon physical examination.
• Although sonography is steadily becoming a valuable diagnostic instrument in the
diagnosis of adenomyosis, MRI appears to provide important diagnostic information.

• Treatment for adenomyosis is hysterectomy or hormone therapy, with the latter

often producing limited, if any, relief from symptoms.

• An important differentiation should be made between endometriosis and

adenomyosis.

• Patients with endometriosis tend to be younger and have fertility troubles, while
those with adenomyosis are often older and multiparous
 Uterine Leiomyoma
• A leiomyoma is a benign, smooth muscle tumor of the uterus that may also be referred to as a fibroid
or uterine myoma.

• Leiomyomas are the most common benign gynecologic tumors and the leading cause of hysterectomy
and gynecologic surgery.

• These tumors can vary in size and may alter the shape of the uterus and have varying sonographic
appearances.

• Those who are at greater risk for the development of fibroids

• Women who are obese
• Black,
• Nonsmokers
• Perimenopausal.

• Clinical findings include pelvic pressure, menorrhagia, palpable abdominal mass, enlarged uterus,
urinary frequency, dysuria, constipation, and possibly infertility
Sonographic ally
• Fibroids often appear as
• Solid
• Hypoechoic masses that produce posterior shadowing.
• Degenerating fibroids may have calcifications or cystic components
• while multiple fibroids may cause diffuse uterine enlargement and heterogeneity.
• Fibroids are also described sonographically by their location.
• The most common location for fibroids is intramural, or within the myometrium.
• A subserosal fibroid grows outward and distorts the contour of the uterus. Subserosal
fibroids that are pedunculated (on a stalk), or those associated with the broad
ligament, could resemble adnexal masses.
• Pedunculated fibroids may torse, thus cutting off the blood supply to the mass
• This lack of blood supply results in necrosis and clinically the patient will
present with acute, localized pelvic pain.

• Submucosal fibroids are located adjacent to the endometrial cavity and often
distort the shape of the endometrium.

• Intracavitary fibroids, the fibroids located within the uterine cavity, and
submucosal fibroids usually lead to abnormal uterine bleeding because of
their location in relationship to the endometrium.

• Intracavitary fibroids may also extend into the cervix when pedunculated
• Fibroid growth has been associated with estrogen stimulation and consequently their size may
increase during pregnancy and reduce after menopause.

• Fibroids may also impact fertility if they are intracavitary or submucosal fibroids, as the location of
these fibroids may result in a higher incidence of spontaneous abortion.

• Fibroids may also affect the contractile motion of the uterus, thus leading to interference with sperm
migration.

• A concurrent intrauterine pregnancy and fibroid can be sonographically identified and often do not
result in preterm labor or early pregnancy loss.

• Alternatively, fibroids may prevent cervical dilatation during pregnancy, thus often requiring a cesarean
section to be performed at the time of delivery
• The medical treatment for fibroids is hormone therapy, which typically results in a reduction in
tumor size.

• Surgical treatment may either be hysterectomy or myomectomy.

• Myomectomy is the surgical removal of a fibroid and may be performed abdominally or

laparoscopically.

• Another alternative treatment for fibroids involves uterine artery embolization, which is used to
inhibit blood supply to the mass.

• Uterine artery embolization results in a reduction in the size of the mass and also in a decline in
the associated clinical symptoms
Endometrial Polyp
• Polyps within the endometrial cavity are common.
• Typically, they are round and echogenic.

• If the examination is perormed in the secretory phase on the menstrual

cycle, polyps may be concealed within the normal echogenic thickening
that occurs at this phase o the cycle.

• Many are asymptomatic, but some present with heavy periods or

intermenstrual bleeding. If there is uncertainty whether a polyp is
present, a hysterosonogram is helpful
• When outlined by fuid with a hysterosonogram, polyps are markedly
echogenic, have an irregular border, and can be seen to move if they
are on a stalk, as they often are.

• Color f ow shows a single supplying vessel to the polyp about half the
time.
• This finding favors a benign origin to the polyp.
• Almost no polyps are malignant.
• Polyps may be multiple and may be located anywhere in the
endometrium or cervical canal
Unicornuate Uterus
• The unicornuate uterus arises due to agenesis or hypoplasia of one of the two Müllerian ducts.

• The unicornuate uterus is a functional uterus with a normal-appearing cervix and a single fallopian tube,
and the contralateral side may have a variety of configurations: agenesis or a rudimentary horn in 74 % .

• The rudimentary horn can be noncommunicating (70 to 90 %) or communicating with the unicornuate
uterus and may contain functional endometrium.

• Women with a rudimentary uterine horn containing functional endometrium may present with cyclic or
chronic pain, endometriosis, or a horn gestation

• Nonfunctional rudimentary horns are usually asymptomatic. Lastly, the unicornuate uterus is associated
with a 40 % incidence of renal anomalies, usually ipsilateral to the anomalous side.
Bicornuate Uterus
• incomplete lateral fusion of the Müllerian ducts at the fundus results in
a bicornuate uterus.
• Commonly, a single cervix and two endometrial cavities are present

• Variability exists in the extent of separation between the two cavities,

with maximal separation extending down to the internal cervical os
(complete bicornuate).

• A fundal indentation of at least 1 cm has been found to be reliable for

differentiating a bicornuate from a septate uterus.
Septate Uterus
• the septate uterus occurs due to a defect in resorption of the midline division between the two
fused Müllerian ducts, and a fibromuscular septum remains.

• The degree of septation can vary from complete, extending from the uterine fundus through the
cervix, to partial, in which a portion of the caudal aspect of the septum is resorbed.

• Since the Müllerian ducts are completely fused, a normal external fundal contour is present
despite a complete or partial division of the endometrial cavity.
• A longitudinal vaginal septum is a common finding with a complete septate uterus and can also
occur with a partial septate uterus

• Endometriosis is also associated with septate uteri and has been documented in 30 % of fertile
and infertile women with septate uteri
Uterus Didelphys

• The uterus didelphys results from complete failure of lateral fusion of the two
Müllerian ducts; duplication of the Müllerian structures is the result.

• Anatomically, these women have two unicornuate uteri, two separate

endometrial cavities, and two cervices.

• In the majority of women with a uterus didelphys, vaginal duplication also

occurs and a longitudinal vaginal septum is present.

• Additionally, this anomaly can present with an obstructed hemivagina and

associated ipsilateral renal anomaly
Arcuate Uterus
• The arcuate uterus demonstrates a slight, rounded midline septum
with a broad fundus and sometimes has a small indentation at the
fundus.

• It has been characterized as a variant of normal uterine anatomy or a

uterus with a small partial septum or a bicornuate uterus.
•
• Appropriate imaging to define uterine anatomy is essential so as not
to misclassify a uterus as arcuate instead of partial septate or
bicornuate, which have different reproductive implications.
• Some studies claim that intrauterine exposure to diethylstilbestrol (DES) has
resulted in the formation of congenital malformation of the uterus.

• DES was a drug administered to pregnant woman from the 1940s to the 1970s
to treat threatened abortions and premature labor.

• The female fetus exposed to DES in utero had an increased likelihood of

developing a congenital uterine malformation.

• Congenital malformations have been linked to menstrual disorders, infertility,

and obstetric complications
Müllerian Agenesis
• The most extreme of the Müllerian anomalies is Müllerian agenesis, otherwise known as
Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, which occurs due to agenesis or
hypoplasia of the Müllerian ducts and affects approximately .

• Müllerian agenesis involves congenital absence of the vagina and variable uterine
development that ranges from agenesis to hypoplastic and rudimentary structures.

• One study demonstrated that in females with MRKH, 87 % had Müllerian remnants, 26 % of
the remnants were cavitated and contained endometrial mucosa, 7 % had a Müllerian
remnant measuring >4 cm, and 30 % had anomalies of the urinary tract.

• Along with urologic anomalies, Müllerian agenesis is associated with other extragenital
anomalies involving skeletal, cardiac, and auditory systems and digits and palates.
Congenital Malformation of the Vagina
• Congenital malformations of the vagina can lead to the accumulation of fluid within the female genital tract
secondary to an obstruction.

• The obstruction can be the result of vaginal atresia, a vaginal septum, or an imperforate hymen.

• The consequence of this obstruction could lead to the distension of the vagina, cervix, uterus, and fallopian
tubes with fluid or blood.

• Hydrocolpos describes the condition in which the vagina is distended with simple, anechoic fluid, and is seen
more often in the neonatal period.

• As the vagina distends with fluid, excessive amounts may lead to further accumulation of the fluid into the
uterus, a condition known as hydrometrocolpos.
• Clinically, neonatal patients with vaginal obstruction present with a palpable pelvic or abdominal mass as a
result of an excessive buildup of vaginal secretions in utero.
• Adolescent girls may have blood components from menstruation retained in the
uterine cavity or vagina, termed hematometra and hematocolpos, respectively.

• They may also have hematometrocolpos, a condition when both the uterine
cavity and vagina are filled with blood.

• This obstruction is frequently associated with the presence of an imperforate

hymen.

• Clinically, these young girls present with amenorrhea, cyclic abdominal pain, an
abdominal mass, enlarged uterus, and possibly urinary retention
Nabothian Cyst
• Nabothian cysts are common findings on routine ultrasound
examinations.

• These benign retention cysts are located within the cervix and may cause
cervical enlargement on physical examination.

• Nabothian cysts are classically simple but may have some internal debris
or septations, which may represent hemorrhage or infection.

• Nabothian cysts are typically asymptomatic and may be multiple

Cervical Carcinoma
• Cervical carcinoma is the most common female malignancy in women
younger than age 50.

• Although cervical carcinomas are not routinely diagnosed with

sonography, they may be present as an inhomogeneous, enlarged
cervix or as a focal mass within the cervix.

• Transvaginal and transrectal imaging are methods in which

sonography can be used to better visualize the cervix.
Endometriosi
• During the reproductive years, endometrial tissue may become
implanted outside the uterine cavity, adhering to any structure but
particularly to the ovaries, allopian tubes, and broad ligaments

• The ectopic tissue undergoes cyclic changes with the menstrual cycle,
and bleeding can occur, producing endometriomas, masses known as
chocolate cysts, and adhesions.

• Endometriosis is sometimes painful and is a very common cause of

infertility
Typical sonographic findings
• Endometriosis are fluid- filled circular or ovoid masses within the
ovary.
• These masses may
• 1) be almost echo- free
• 2) contain low-level “ground glass” echoes (the most typical
appearance)
• 3) look like a solid mass
• 4) have echogenic areas or a septum within a fluid- filled mass.
PATHOLOGY OF THE OVARY: Benign
Ovarian Disease
• Follicular Cysts
• Should the graafian follicle fail to ovulate, it could continue to enlarge and
result in a follicular cyst.
• Follicular cysts range in size from 3 to 8 cm; however, larger cysts have been
documented.
• Their sonographic appearance is most often described as anechoic, thin
walled, and unilocular. Most follicular cysts regress and are asymptomatic,
but some may lead to pain, constituting frequent sonographic
examinations.
• Also, surgical intervention may be warranted. The removal of an ovarian
cyst is referred to as ovarian cystectomy
Cystic Teratoma (Dermoid)
• The most common benign ovarian tumor is the cystic teratoma, or dermoid cyst.
Dermoids result from the retention of an unfertilized ovum that differentiates into the
three germ cell layers.
• Therefore, these germ cell tumors are composed of ectoderm, mesoderm, and
endoderm.
• As a result of the combination of these germ cells, a cystic teratoma may contain any
number of tissues, including glandular thyroid components, bone, hair, sebum, fat,
cartilage, and digestive elements.
• They frequently will contain fully formed or rudimentary teeth as well. Dermoids are
commonly found in the reproductive age group but may also be found in
postmenopausal patients.
• Patients are most often asymptomatic but may suffer from pain associated with torsion
or rupture of the mass, the latter of which can lead to peritonitis. Dermoids also have
the capability of malignant degeneration, but this is rare
• The sonographic appearance of a cystic teratoma has been well documented, and
it has most often been described as a complex or partially cystic mass in the ovary
that includes one or more echogenic structures.
• These echogenic components may produce posterior shadowing. The “tip of the
iceberg” sign denotes the sonographic appearance of the mass when only the
anterior element of the mass is seen, while the greater part of the mass is
obscured by shadowing.
• This occurs as a result of complete attenuation of the sound beam by the dense
tissue components of the mass.
• Often, dermoid tumors contain a “dermoid plug.”
• The dermoid plug contains various tissues that will be a source of posterior
shadowing.
• The “dermoid mesh” has been used to describe the visualization of hair within
the mass. Hair will appear as numerous linear interfaces within the cystic area of
a dermoid.
• A fluid–fluid level may also be visualized, in which case there is a clear
demarcation between serous fluid and sebum
Thecoma
• A thecoma is a benign ovarian sex cord-stromal tumor.
• Thecomas are most often found in postmenopausal women and may
be associated with Meigs syndrome.
• They are estrogen-producing tumors; therefore, patients often
complain of postmenopausal vaginal bleeding associated with the
unconstrained estrogen stimulation upon the endometrium.
• As the term denotes, these tumors are masses that are composed of
multiple ovarian thecal cells.
• A thecoma will sonographically appear as a hypoechoic, solid mass
with posterior attenuation.
• They are most often unilateral and may appear similar to a
pedunculated uterine leiomyoma
Granulosa Cell Tumors
• Another type of sex cord-stromal tumor is the ovarian granulosa cell tumor.
• It, like the thecoma, is an estrogen producing tumor and is considered to be the most
common estrogenic tumor.
• These tumors typically occur unilaterally and are more commonly seen in the
postmenopausal female, but they can also be found in younger patients.
• Because of its estrogen-producing potential, a granulosa cell tumor will present clinically
much like the thecoma.
• Consequently, because of the estrogen interaction upon the endometrium,
postmenopausal patients may present with vaginal bleeding, while adolescent patients
may present with pseudoprecocious puberty findings.
• As a result of consistent estrogen stimulation, postmenopausal patients with granulosa
cell tumors have approximately a 10% to 15% chance of developing endometrial
carcinoma.
• The sonographic findings of a granulosa cell tumor is unpredictable, with appearances
ranging from that of a solid, hypoechoic mass to one that has some cystic components.
Fibroma
• An ovarian fibroma is also considered a sex cord-stromal tumor. Unlike
thecomas, fibromas are not associated with hormone (estrogen) production.
• Fibromas are most often found in middle-aged women.
• They are benign ovarian masses that may be complicated by a condition known
as Meigs syndrome, which is defined as ascites and pleural effusion in the
presence of a benign ovarian tumor.
• The sonographic appearance of a fibroma is that of a hypoechoic, solid mass
with posterior attenuation.
• Often, fibromas, like thecomas, may mimic pedunculated uterine leiomyoma.
• The ascites and pleural effusions associated with Meigs syndromes usually
resolve after resection of the tumor.
Brenner Tumor (Transitional Cell Tumor)
• Brenner tumors, or transitional cell tumors, are most often small,
solid, hypoechoic unilateral tumors that may contain calcifications.
• Consequently, their sonographic appearance may be similar to that of
a uterine leiomyoma, thecoma, and fibroma.
• They are almost always benign, but they can undergo malignant
degeneration.
• Patients may be asymptomatic or may present with a palpable mass
or pain, and possibly signs of Meigs syndrome
Cystadenoma (Serous and Mucinous)
• Together, serous cystadenomas and cystic teratomas comprise most
neoplasms of the ovary.
• Approximately 50% to 70% of serous cystadenomas are benign,
occurring more often in women in their forties and fifties as well as
during pregnancy.
• Patients are often asymptomatic. These types of ovarian neoplasms
are often large and bilateral.
• The sonographic appearance of serous cystadenomas is that of a
predominately anechoic lesion that contains septations and/or
papillary projections
• Mucinous cystadenomas are often larger than serous cystadenomas
and can even reach sizes up to 50 cm.
• Mucinous cystadenomas also tend to have septations and papillary
projections like serous cystadenomas, but are not as often bilateral.
• A supportive sonographic distinguishing factor is the presence of
internal debris within the mucinous cystadenoma, secondary to the
solid components of the material contained within it.
• The clinical presentation of these masses is unpredictable, with
patients often complaining of pelvic
• pressure and swelling, secondary to the large size of the mass.
Additional clinical symptoms include abnormal uterine bleeding,
gastrointestinal symptoms, and acute abdominal pain secondary to
rupture or torsion
MALIGNANT OVARIAN DISEASE:
Cystadenocarcinoma (Serous and Mucinous)
• Serous cystadenocarcinoma is the most common malignancy of the ovary.
• It is, like its benign counterpart the serous cystadenoma, frequently
bilateral.
• In addition, a serous cystadenocarcinoma sonographically resembles a
serous cystadenoma, with the exception that often with malignancy, there
appears to be more prominent papillary projections and thicker septations
• Patients often complain of weight loss, pelvic pressure and swelling,
abnormal vaginal bleeding, and gastrointestinal problems.
• Although not always specific, they may also have an elevated CA-125, a
protein that is increased in the blood of women with ovarian cancer and
other abnormalities.
• Mucinous cystadenocarcinomas are malignant as well, and are less
often bilateral than serous cystadenocarcinomas.
• The mucinous cystadenocarcinoma is associated with a condition
known as pseudomyxoma peritonei, which describes the
intraperitoneal extension of mucin-secreting cells that result from the
rupture of this mucinous tumor.
• Often the fluid escaping from the mass resembles ascites.
• Mucinous cystadenocarcinomas are malignant as well, and are less
often bilateral than serous cystadenocarcinomas.
• The mucinous cystadenocarcinoma is associated with a condition
known as pseudomyxoma peritonei, which describes the
intraperitoneal extension of mucin-secreting cells that result from the
rupture of this mucinous tumor.
• Often the fluid escaping from the mass resembles ascite
Krukenberg Tumor
• A Krukenberg tumor is a malignant ovarian tumor that metastasized
from the gastrointestinal tract, most frequently the stomach.
• The sonographic appearance is that of a smooth-walled, hypoechoic
tumor that is often bilateral and may be accompanied by ascites.
• Patients may be asymptomatic at the time of detection or may
complain of weight loss and pelvic pain
Sertoli–Leydig Cell Tumors (Androblastoma)
• A Sertoli–Leydig cell tumor, or androblastoma, is a sex cord-stromal
ovarian neoplasm that is associated with virilization; thus, patients
may present with abnormal menstruation and hirsutism.
• Sertoli–Leydig tumors are found more often in women younger than
30 years of age but may be seen in older patients and may be
malignant.

• Sonographically, a Sertoli–Leydig cell tumor may appear as a solid,

hypoechoic ovarian mass or a complex, partially cystic mass
Dysgerminoma
• A dysgerminoma is the most common malignant germ cell tumor of
the ovary.
• Dysgerminomas arise more often in patients younger than 30 years of
age and may be found in pregnancy.
• Children with ovarian dysgerminomas present with precocious
puberty and may have an elevation in serum hCG levels, although the
tumor marker used for dysgerminoma is an elevation in serum lactate
dehydrogenase.
• The testicular equivalent of an ovarian dysgerminoma is the
seminoma.
Yolk Sac Tumor (Endodermal Sinus Tumor)
• A yolk sac tumor is the second-most common malignant germ cell
tumor.
• It is characterized by rapid growth.
• A yolk sac tumor occurs in females younger than 20 years of age, is
highly malignant, and carries a poor prognosis.
• Clinically, patients present with an elevation in serum alpha-
fetoprotein (AFP). Sonographically, they have varying appearances.
Staging of Ovarian Carcinoma
• The International Federation of Gynecology and Obstetrics (FIGO)
recommend the proper staging of ovarian carcinoma.
• S Ovarian Carcinoma Condition
• Stage I Tumor is confined to the ovary.
• Stage II Tumor involves one or both of the ovaries with pelvic extension
• Stage III Tumor involves one or both ovaries with confirmed peritoneal
metastasis outside of the pelvis and/or regional lymph node
involvement
• Stage IV Distant metastasis beyond the peritoneal cavity.
OVARIAN TORSION
• Ovarian torsion results from the ovary twisting on its mesenteric
connection, consequently cutting off its blood supply.
• Ovarian torsion occurs most often on the right side, with the most
common cause being an ovarian cyst or mass, such as the benign cystic
teratoma or paraovarian cyst.
• Because of the cystic enlargement of the ovaries produced by ovarian
hyperstimulation syndrome, this condition has also been recognized as a
predisposing circumstance that can result in ovarian torsion.
• Torsion of the ovary has also been detected in the fetus and may even
occur in normal ovaries.
• Patients most often present with nausea, vomiting, and acute unilateral
pelvic or abdominal pain. The sonographic appearance of the torsed ovary
is that of an enlarged ovary, with or without multifollicular development
ANATOMY AND PHYSIOLOGY OF THE
FALLOPIAN TUBES
• The fallopian tubes may be referred to as oviducts, uterine tubes, or
salpinges.
• The primary purpose of the fallopian tube is to provide an area for
fertilization and to offer a means of transportation for the products of
conception to reach the uterine cavity.
• The fallopian tubes consist of three layers: the outer serosa, middle
muscular layer, and inner mucosal layer.
• As the tube experiences peristalsis, within its lumen, small, hairlike
structures referred to as cilia shift, thereby offering a mechanism for
the transportation of the fertilized ovum.
• The 7- to 12-cm paired fallopian tubes extend from the cornu of the uterus, travel within the broad
ligaments, and are composed of five parts.
• It is important to note that the proximal segment of the fallopian tube is located closest to the uterus,
while the most distal part is within the adnexa or closer toward the ovary.
• Within the cornu of the uterus lies the intramural extension of the fallopian tube known as the interstitial
segment.
• The isthmus, which literally means bridge, is a short and narrow segment of the tube connecting the
interstitial area to the ampulla.
• The ampulla is the longest and most tortuous segment of the tube.
• It is a significant portion of the tube because it is the location of fertilization and the area where ectopic
pregnancies often embed.
• The distal portion of the tube is termed the infundibulum, which provides an opening to the peritoneal
cavity within the pelvis.
• The fingerlike projections that extend from the infundibulum are the fimbria. The primary role of the
fimbria is to draw the unfertilized egg into the tube
SONOGRAPHIC APPEARANCE OF THE
FALLOPIAN TUBES
• The fallopian tubes are not customarily identified on a
transabdominal ultrasound examination; however, some segments
can be seen with today’s high-resolution endovaginal transducers.
• Certainly in cases in which the tube has been involved with an
inflammatory process or is obstructed, the tubes, when distended
with fluid, can be visualized with sonography.
• The inner cavity of the fallopian tubes can be visualized and evaluated
for patency using sonohysterography or hysterosalpingography.
Abnormal Fallopian Tubes
• Cancer of the fallopian tubes is rare and is typically in the form of adenocarcinoma.
• The sonographic appearance of fallopian tube carcinoma is that of a solid mass within
the adnexa.
• The fallopian tubes may become distended secondary to obstruction or infection.
• The fluid contained within the distended tubes could be simple serous fluid, blood, or
pus.
• Simple serous fluid within the tube is termed hydrosalpinx
• Hydrosalpinx appears anechoic, while pus (pyosalpinx) and blood (hematosalpinx)
have internal components and may appear echogenic or have a fluid–fluid level
• The fallopian tubes may also undergo an infection, termed salpingitis, which is often
caused by pelvic inflammatory disease.