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Questions and Answers
What is the most common type of cervical carcinoma?
Which of the following is NOT a risk factor for cervical carcinoma?
What characterizes a suspected leiomyosarcoma in comparison to a leiomyoma?
What staging of cervical carcinoma indicates that the cancer has spread beyond the true pelvis?
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Which diagnostic method is considered the best for visualizing cervix-related issues?
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What is the role of the serosa layer of the uterus?
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In which position is the uterus when it is described as retroverted?
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What is the significance of the ampulla of the fallopian tube?
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How does the myometrium of the uterus typically appear on ultrasound?
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Which ligament is responsible for anchoring the ovary to the pelvic brim?
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What characteristic defines the endometrial cavity during menstruation?
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Which muscle forms the anterior part of the abdominal pelvic wall?
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How does the size of a mature uterus change after menopause?
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What is the anatomical term for the reflection of peritoneum over the anterior surface of the uterus and bladder?
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Which of the following are features of fibroids on ultrasound?
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What size range is characteristic for a Graafian Follicle prior to ovulation?
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What is a common risk factor for developing endometrial carcinoma?
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In the presence of an enlarged uterus, which technique may enhance the visualization of the fundus during an ultrasound?
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Which condition is NOT a differential diagnosis for a pedunculated fibroid?
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What diagnostic procedure is important for early detection of cervical carcinoma?
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What is a symptom of endometrial carcinoma that may occur after menopause?
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What is the relationship between estrogen and endometrial health?
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Which of the following treatments is commonly used for endometrial carcinoma?
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At what point in the menstrual cycle does ovulation typically occur?
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What is the primary disadvantage of a transvaginal pelvic exam compared to a transabdominal exam?
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Which hormone surge triggers ovulation according to the menstrual cycle's hormonal regulation?
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What are the symptoms associated with vaginal anomalies starting from puberty?
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What is the thickness of the endometrium during the secretory phase of the menstrual cycle?
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Which congenital anomaly is characterized by the retention of blood in the vagina?
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What is a primary cause of congenital anomalies in the reproductive system?
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What is the role of estrogen during the proliferative phase of the menstrual cycle?
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What is the term for the absence of menstrual flow?
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Which technique is used for evaluating endometrial polyps and fibroids by injecting saline into the uterine cavity?
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During which phase of the menstrual cycle do glandular and vascular changes primarily occur due to progesterone?
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What happens to non-dominant follicles during the menstrual cycle?
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What are the key sonographer responsibilities during pelvic exams?
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What does the term oligomenorrhea refer to?
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What is the typical size range for a Nabothian cyst?
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Which benign cervical condition is more common in women aged 40 to 50?
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What impact does Tamoxifen have on the endometrium?
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Which classification of myoma is located in the outer region of the uterus?
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What is the most common tumor of the female pelvis?
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What may cause fibroids to grow during pregnancy?
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At what age is adenomyosis most commonly diagnosed?
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Which symptom is commonly associated with cervical myomas?
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What is a defining characteristic of adenomyosis on ultrasound?
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What percentage of the time do cervical myomas occur within the cervix?
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Study Notes
Pelvic Anatomy
-
Uterus
- Three tissue layers:
- Serosa (Perimetrium): outermost
- Myometrium: middle layer (muscle)
- Endometrium: innermost functional layer
- Internal & External Os of Cervix:
- Internal Os: leads to the uterine cavity
- External Os: opening between cervix & vagina
-
Shape, Size & Position
- Premenarche (never had a menstrual cycle): cylindrical & narrow
- Prepuberal: cervix longer than the body/fundus
- Mature uterus: corpus & fundus enlarge
- Postmenopausal: regresses in size
-
Nulliparous (never given birth vaginally):
- SAG: less than or equal to 8 cm
- TRV: up to 5 cm
- AP: 3 cm
-
Common Variants in Uterine Position
-
Anteflexed & Anterverted: most common
- Anteverted: normal; uterine body tilts forward, forms 90 degrees angle or less within cervix
- Anteflexed: uterine corpus tilts forward & comes in contact with cervix forming acute angle between body & cervix
- Retroverted: corpus, fundus & cervix displaced posteriorly; most common type of displacement
- Retroflexed: only fundus is displaced posteriorly
- Dextroposed: uterine body angled to the right of the cervix
-
Anteflexed & Anterverted: most common
-
Ultrasound Appearance
- Uterus Myometrium: mid gray or medium level echoes, homogeneous, smooth contour
- Cervix of Uterus: donut shape in TRV
- Endometrial Cavity: thin echogenic line, varies in thickness in relation to menstrual phase
- Vagina: mid gray to medium level echoes, vaginal canal is hyperechoic line
- Three tissue layers:
-
Fallopian Tube (four parts):
- Interstitial: narrowest part, nearest cornu
- Isthmus: slightly wavy & longer
- Ampulla: tortuous & longest part (most common place for an ectopic pregnancy to occur)
- Infundibulum: lateral, trumpet shaped fimbriae; widest
-
Adjacent Spaces
- Anterior Cul de Sac (vesicouterine pouch): reflection of peritoneum over anterior surface of uterus & bladder
- Posterior Cul de Sac (rectouterine pouch, pouch of douglas): reflection of peritoneum over posterior surface of uterus & rectum
- Space of Retzius (prevesical or retropubic): area lying between bladder & symphysis pubis
-
Ligaments
- Cardinal Ligament: anchor uterine corpus (body) & cervix to lateral pelvic wall (contains uterine artery & vein)
- Uterosacral Ligament: anchor uterine cervix to sacrum
- Round Ligament: anchor uterine fundus anteriorly
- Broad Ligament: part of peritoneum that divides true pelvis into anterior & posterior portions (seen well on US when fluid is present; bat wing)
-
Pelvic Girdle
- Four Bones: Sacrum, Coccyx, 2 Innominate Bones (Ilium, Ischium & Pubis)
-
Division of True & False Pelvis
-
Linea Termnialis (conjugate vera)
- True Pelvis: all reproductive organs are here
- False Pelvis (greater pelvis): bladder
-
Linea Termnialis (conjugate vera)
-
Muscles of the Pelvis
- Rectus abdominis: most anterior muscle; form anterior abdomino-pelvic wall; behind this is TRV abdominis
- Psoas & Iliacus: large muscles laterally, located in false pelvis
- Iliopsoas muscle: seen laterally in TRV
- Obturator Internus: laterally in true pelvis
- Piriformis: posterior in true pelvis
- Muscles of Pelvic Floor: levator ani & coccygeus
-
Ovaries
-
Location
- most common: lateral to uterus in the adnexa
- in posterior fold of broad ligament
- may be superior or posterior to uterine fundus
- may be posterior cul de sac
-
Size
- SAG: 2.5 - 5 cm
- TRV: 1.5 - 3 cm
- AP: .60 - 2.2 cm
-
Ligaments
- Mesovarian: anchors ovary to posterior surface of broad ligament
- Ovarian ligament: anchors ovary to uterine
- Infundibulopelvic ligament: anchors ovary to pelvic brim
-
Facts
- Only abdominal organs not covered by peritoneum (nude ovary)
- Produces hormones (estrogen) & gametes (sex cell)
- Composed of 2 parts: cortex (outer) - contains primordial follicles & medulla (inner) - contains CT, nerves, blood supply, lymphatics & smooth muscle tissue
-
Location
-
Ovarian Follicles
- Born w/ million of primordial follicles
- Graafian Follicle: most dominant/largest follicle that matures each month
- Graafian Follicle ruptures w/ ovulation: appx 1.8 to 2.5 cm (25 mm)
-
Scanning Tips
- You can push harder than you think
- Perform the exam as quickly as possible w/o missing anything
- The Uterus ML is not always ML of the Pelvis
- Ovaries can be recognized by follicles, posterior enhancement, & internal iliac vessels
-
Transvaginal (TV) / Endovaginal (EV) Pelvic Exam (internal)
- Empty Urinary Bladder
- Disrobe from waist down
- Elevated hips, if gynecology table not available
- Position: Lithotomy
- Prepare the probe, insert probe or ask patient to insert probe like a tampon
- Male sonographers must have a female chaperone present during the exam
- Advantage: better resolution, can measure & analyze smaller structures, no need for bladder filling, preferred method for visualizing the ovaries
- Disadvantage: smaller more limited field of view due to frequency & limitation in prove movements
-
Transvaginal Orientation
- Anterior - screen left
- Posterior - screen right
- Inferior - top of screen
- Superior - bottom of screen
- 90 degree counterclockwise rotation from transabdominal orientation***
-
Transperineal Exam
- Scanning between labia & perineum
- Patient Position: Lithotomy
- Useful when transvaginal US is contraindicated
-
Newer Developments
-
Sonohysterography
- 25 - 30 ML of sterile saline in endometrial (uterine) cavity
- Delineates endometrial cavity
- Used in evaluation of endometrial polyps, fibroids, endometrial hyperplasia, & patency of fallopian tubes
-
Contrast Agents
- Enhance color & pulse wave characteristics in small vessels
-
Three Dimensional Imaging
- Current development & investigation on-going
- Provides topographical imaging info
- Useful in evaluation of face, digits, limbs & neural tube defects (spinal cord)
-
Sonohysterography
-
Sonographer’s Responsibilities
- Proper Equipment
- Reduce patient discomfort
- Minimize exposure to US
- Provide through & systematic examination
- Adhere to code of conduct
- Achieve registration through ARDMS
- Stay current on emerging trends w/ continuing medical education
Menstrual Cycle
-
Menstruation
- A cyclic process whereby the endometrial lining is shed if implantation of a conceptus has not occurred
- Starts @ Menarche (first period) 10 - 14 years old
- Ends @ Menopause 45 - 55 years old
-
Three Phases of Menstrual Cycle
- Menstrual Phase - bleeding - days 1 - 5
- Proliferative Phase - endometrium gets thicker - pro-life - preparing for life - days 6 -14
- Secretory Phase (luteal phase) - endometrium is the thickest in this phase, eggs is secreted from the graafian follicle - once ovulation occurs - days 15 - 28
-
Menstrual Phase
- Endometrium degenerates - shedding of the lining
- Sloughs off the myometrium
- Expelled as menses (blood)
- Typically 12 - 24 hours of heavy flow, with less flow for the next 4 - 7 days
-
Proliferative Phase
- Regrowth of endometrium
- Mainly under influence of estrogen
- Estrogen released by ovarian follicles****
- Ends @ ovulation - ovulation is appx day 14 of 28 day cycle
-
Secretory (Luteal) Phase
- Begins @ ovulation
- The rise in LH will cause the graafian follicle to release a secondary oocyte which leads to ovulate
- Ends when menstruation starts
- Glandular & Vascular changes in endometrium
- Primarily under influence of progesterone
- Absence of fertilization results in fall in estrogen & progesterone; start of menstruation
- Endometrium is the thickest during this phase
-
Endometrial Thickness
- In premenopausal patients, there’s significant variation at different stages of the menstrual cycle
- Menstruation: 2 - 4 mm
- Early Proliferative Phase (day 6-14): 5 - 7 mm
- Late Proliferative / Preovulatory Phase: up to 11 mm
- Secretory Phase: 7 - 16 mm
- S/P D&C or Spontaneous Abortion: < 5 mm (if thicker) consider RPOC (retained products of conception)
- Postmenopausal endometrial thickness: typically < 5 mm
- In premenopausal patients, there’s significant variation at different stages of the menstrual cycle
-
Hormonal Regulation
- Endometrium responds to estrogen & progesterone levels in the blood
- Levels controlled by feedback system between: ovaries, hypothalamus, anterior hypophysis of pituitary
-
Chain of Events
-
Hypothalamus
- Secretes Gonad Releasing Hormone (GnH)
- Rise in GnH causes Pituitary Gland to released Follicle Stimulating Hormone (FSH) - allows follicles to grow eggs
-
Pituitary Gland
- Releases FSH
- FSH causes numerous follicles in ovary to grow
- Rising estrogen levels trigger Pituitary to release Luteinizing Hormone (LH)
- Rise in LH causes ovulation to occur
-
Things to Remember
- Proliferative Phase - Estrogen
- Secretory phase - Progesterone
- LH causes ovulation to occur
- Hypothalamus - GnH
- Pituitary - FSH, LH
- Ovaries - Estrogen, Progesterone
-
Hypothalamus
-
Follicular Development
- 5 - 7 follicles stimulated each month by FSH
- Ovarian follicles grow @ a rate or 2 - 3 mm per day, prior to ovulation
- Non-dominant follicles normally do not exceed 11 mm
- Dominant follicle is Graafian follicle
- Ruptures through tunica albuginea @ ovulation
- Other follicles undergo atresia & form scar tissue (corpus albicans)
-
Follicular Development
- Blood and/or fluid drain to posterior cul de sac @ ovulation
- Follicles are measure if large or in patient undergoing ovulation induction
- Follicle ruptures between 1.8 - 2.5 cm (2.0 average)
- Mittelschmerz is mid cycle pain associated w/ ovulation
- Depo provera birth control prevents dominant follicle formation and ovulation
-
Abnormal Menstrual Patterns
- Dysfunctional Uterine Bleeding (DUB) = vaginal bleeding not related to menstrual cycle - random spotting
- Hypermenorrhea = excessive volume during cyclic menstrual bleeding
- Hypomenorrhea = abnormally small amount of menstrual bleeding
- Polymenorrhea = frequent menstrual bleeding less than 21 days apart
- Oligomenorrhea = menstrual bleeding greater than 35 days apart
- Menorrhagia = excessive bleeding in time and/or volume
- Dysmenorrhea = painful uterine bleeding
- Dyspareunia = painful intercourse
- Amenorrhea = absence of menstrual flow // primary - patient never menstruated // secondary - patient had menstrual periods but stopped
-
Oral Contraceptives
- Combined estrogen-progestin BC & progestin-only pills or implants prevent the pituitary gland’s release of hormones that stimulate ovulation
-
Hormone Replacement Therapy (HRT)
- Used to treat the symptoms of menopause: hot flashes, mood swings, sleep disorders, vaginal dryness
- Pros: decreases menopausal symptoms
- Cons: increased risk of breast cancer, uterine cancer, ovarian cancer
Congenital Anomalies
- Rare; Incidence.10 -.50%
- Usually w/o symptoms
- Can mimic other pathologies
- 50% of time occur w/ malformations of Urinary System
-
Causes
- Most anomalies are the result of:
- Total or partial atresia of the Mullerian Ducts
- Failure of Mullerian Ducts to fuse
- Failure of uterovaginal septum to disappear
- Most anomalies are the result of:
-
Anomalies of the Vagina
- Symptoms begin @ puberty
- Signs & Symptoms: pelvic pain, dysmenorrhea, dyspareunia, delayed onset of menses
- Cause: obstruction at some level of uterus, cervix or vagina
- COLPOS = VAGINA // METRA = UTERUS
- Blood in Uterus will hypoechoic
- Look for body of endometrium to find retention of menstrual blood in uterus
-
Conditions Associated w/ Vaginal Anomalies
- Hematocolpos - retention of blood in vagina
- Hematometra - retention of menstrual blood in uterus
- Hematometrocolpos - retention of menstrual blood in uterus & vagina
- Vaginal Agenesis - absent vagina
- Vaginal Atresia - lack of vaginal development
-
Uterine Anomalies
- Most common are septate uterus, bicornuate uterus & didelphic uterus
- May be found w/ vaginal anomalies
- Cause: failure of septum to disappear, failure of ducts to fuse, partial fusion of ducts
- Arcuate Uterus - slight indentation of fundus
- Uterus Subseptus - failure of septum to reabsorb completely; separation of uterine corpus
- Uterus bicornis - uterus has two horns (bicervical or unicervical)
- Uterus didelphys - two uteri, two cervices & vaginas
- More than 1 Uterus = Uteri // More than 1 Cervix = Cervices
- Coronal (side) will be the best cut to see urine anomalies
-
Diethylstilbestrol (DES) Syndrome
- Drug given pregnant mothers to prevent miscarriage
- Causes reproductive tract anomalies in the fetus
- Most common anomalies are bands in uterus, uterine wall defects & T-shaped uterus
-
Fallopian Tube Anomalies
- Rare
- Absent
- Doubling on one side
- Atresia of a portion (infertility or ectopic pregnancy)
-
Ovarian Anomalies
- Absence of ovaries rare
- Fallopian tubes also absent
- Supernumerary ovaries
- Accessory Ovarian Tissue
-
Paraovarian Cyst
- Found in broad ligament or in the fallopian tubes near the ovaries
- Arise from rosenmuller’s organ
- AKA: paratubal cyst or hydatid cyst of morgagni - type of paraovarian cyst (pedunculated)
- These don’t usually cause symptoms & are incidental findings
-
Gartner’s Duct Cyst
- Cyst in anterolateral portion of vagina
- Remnant of Mullerian Duct System
- Appears as anechoic mass in Vagina
- Prone to infection
-
Congenital Anomalies in Pregnancy
- Anomalies tend to be obliterated on US after 22 weeks gestation
- Pregnancy may occur in one or both uteri
- Associated w/ higher rate of premature labor & labor complications
-
US Appearance
- Wide variety of appearances
- Coronal (EV) / Transverse (TA) images more diagnostic
- Sagittal images may no show duplication
- Fundus wider than 5 cm
- Two separate endometrial echoes
- Incompetent Cervix: a cervix that is opened. A competent cervix needs to be 2.5cm in length or greater.
-
Pitfalls of Imaging
- Sonographer misinterpretation: pedunculate or subserosal fibroid, ovarian mass
Benign Pathology - Cervix & Uterus
- Leiomyomas, Myoma, Fibroid, Fibroma & Fibromyoma are all the same thing
-
Indications for US exam
- Uterine enlargement
- Pelvic Pain
- Irregular or Post Menopausal Bleeding
- Palpable Pelvic mass
- Amenorrhea or Dysmenorrhea
- Infertility
- Recurrent UTI
- Dyspareunia
-
Benign Conditions of the Cervix
-
Nabothian Cyst “Inclusion cyst”
- Forms in the response to inflammation of endocervical gland
- Common
- Incidental Finding - serendipitous
- Size: 3 mm to 3cm
- Anechoic w/ enhance sound transmission in cervix
-
Cervical Polyps
- More common in multigravidas
- More common in patients 40 - 50s
- Asymptomatic
- Most common benign cervical neoplasm
- May appear on US as small echogenic areas in cervix
- Pain during intercourse & menstruation
-
Cervical Myoma (Fibroid)
- Occur in cervix 3 to 8% of time
- May be asymptomatic
- May cause dyspareunia, dysuria, cervical obstruction, prolapse, bleeding, obstructed labor
- Treatment: resection or hysterectomy if warranted
- Cervix may appear bulky or distorted
-
Nabothian Cyst “Inclusion cyst”
-
Endometrial Polyps
- Most common in patients 40 - 49 years of age
- Etiology unknown (Idiopathic)
- Localized growths of endometrial tissue
- Most often found in cornual region of fundus
- May be asymptomatic or cause bleeding
- May appear on US as hyperechoic areas within endometrium
-
Tamoxifen Effects
- Non-steroidal anti-estrogen drug
- Given to patients w/ breast cancer
- Associated w/ endometrial changes
- May lead to development of polyps, endometrial cancer, myoma growth
- If endometrium is greater than 5 mm, sonohysterography indicated
-
Adenomyosis (adeno - gland, myo - mass, osis - abnormal condition)
- Endometrial glands & stroma grow into the myometrium
- More common in women over 50 years
- Can be definitely diagnose surgically or with MRI
- Seen in association w/ leiomyoma in over ½ of cases
- US appearance: enlarged uterus of normal or decreased echogenicity
- Can be mistaken for a fibroid (if it’s a focal region)
- Venetian Lamp shade appearance
-
Leiomyoma (fibroid, myoma, fibromyoma, fibroma)
- Benign muscle tumors
- Most common tumor of female pelvis
- Consist of lobulation of myometrial tissue which can distort the uterine contour & endometrial stripe
- Found in 20% of women greater than 35 years
- Braxton hicks can look like a fibroid, but it’s just a contraction
- Much more common in African American populations
- Size: 1 mm to 20 cm
- Signs & Symptoms: pelvic pain, menorrhagia, asymptomatic, bladder or rectum pressure, infertility, spontaneous abortion
-
Myoma Classifications
- Classified in relation to position to uterine wall:
- Intramural (Interstitial) - in the myometrium
- Subserosal - outer region - found in serosa (peritoneum) - body is looking distorted / lobulated
- Submucosal - inner region - distorting endometrium
- Pedunculated (has a tail, stalk, pedicle)
- Classified in relation to position to uterine wall:
-
Estrogen & Fibroids
- During pregnancy, fibroids may grow due to increase in estrogen
- After menopause with decrease in estrogen, fibroid tend to shrink
- Fibroid & Endometrial stripe should shrink after menopause if not, most likely cancer.
Fibroids: US Appearance
- Fibroids can present as well-defined masses with a whorled appearance.
- They can appear hypoechoic to anechoic, with echogenic areas and distal shadowing.
- Fibroids can cause uterine enlargement and endometrial distortion.
- Pedunculated fibroids may extend anteriorly, posteriorly, or laterally.
- They can be differentiated from other conditions like bicornuate uterus, blind uterine horn, ovarian mass, hydatidiform mole, and ectopic pregnancy.
- To improve fibroid visualization, choose a lower frequency transducer and increase overall gain.
- Consider using transabdominal (TA) scanning instead of transvaginal (TV) if the uterus is enlarged.
- Measure the uterus in sagittal (SAG) view by taking two images.
- It may be challenging to visualize the fundus of the uterus, in such cases, place the transducer just superior to the pubic bone and angle sharply superior.
- If the uterus is enlarged, evaluate the kidneys to rule out hydronephrosis.
Endometrial Carcinoma
- Endometrial carcinoma is more common than cervical carcinoma in the US.
- Risk factors include obesity, diabetes, hypertension, short stature, Jewish ethnicity, postmenopausal age, and estrogen use after menopause.
- Estrogen plays a role in endometrial carcinoma development, leading to dysfunctional uterine bleeding, endometrial hyperplasia, polycystic ovary syndrome, theca granulosa cell tumors, and tamoxifen use.
- The carcinoma originates in the endometrium and spreads towards the myometrium.
- Greater infiltration into the myometrium indicates a poorer prognosis.
- Staging is based on tumor spread, while grading depends on differentiation.
- Symptoms include postmenopausal bleeding or discharge, and pain.
- Treatment involves hysterectomy with bilateral oophorectomy, lymphadenectomy, and pre/post-operative radiation therapy.
- US appearance can be normal, enlarged uterus, thickened endometrium, or fluid-filled endometrial cavity.
- Differentiate from endometrial hyperplasia, endometrial polyps, leiomyomas, and cervical carcinoma.
Leiomyosarcoma
- It is the malignant counterpart of fibroids.
- It is rare, occurring in 3% of uterine tumors.
- Suspected when fibroids exhibit rapid growth.
- Most common in women in their 50s.
- Ultrasound cannot differentiate it from leiomyomas; reliance on factors like postmenopausal status and size increase is needed.
- On US, it may present as an inhomogeneous uterine mass with areas of cystic degeneration.
Cervical Carcinoma
- Risk factors include early sexual encounters, multiple partners, STDs, and Human Papillomavirus (HPV) infection.
- The most common type is squamous cell carcinoma.
- Prognosis depends on the stage at diagnosis.
- Metastasis occurs through the pelvic lymphatic system.
- Staging:
- Stage 1: Confined to the cervix
- Stage 2: Spreads to vagina, upper cervix, and parametrium
- Stage 3: Spreads to the lower vagina, pelvic wall, and beyond the true pelvis
- Stage 4: Involves the bladder and/or rectum, or distant metastasis to lungs, bones, and liver.
- Symptoms include abnormal Pap smear, vaginal discharge, intermittent bleeding (especially after intercourse), bladder irritability, back pain, and ureteral obstruction in advanced stages.
- Treatment varies based on the stage and may involve cone biopsy, radical hysterectomy, radiation therapy, and chemotherapy.
- EV/TV ultrasound is the best imaging method.
- US Appearance: - Stage 1 or 2: May appear normal, bulky, irregular, with changes in echogenicity. - Hematometra or pyometra can occur due to cervical stenosis.
- Differentiate from leiomyoma involving the cervix, endometrial carcinoma involving the cervix, and endometrial polyps prolapsed into the vagina.
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