Podcast
Questions and Answers
What is the most common type of cervical carcinoma?
What is the most common type of cervical carcinoma?
Which of the following is NOT a risk factor for 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 characterizes a suspected leiomyosarcoma in comparison to a leiomyoma?
What staging of cervical carcinoma indicates that the cancer has spread beyond the true pelvis?
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?
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?
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?
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?
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?
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?
Which ligament is responsible for anchoring the ovary to the pelvic brim?
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What characteristic defines the endometrial cavity during menstruation?
What characteristic defines the endometrial cavity during menstruation?
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Which muscle forms the anterior part of the abdominal pelvic wall?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
What is the relationship between estrogen and endometrial health?
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Which of the following treatments is commonly used for endometrial carcinoma?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
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?
What happens to non-dominant follicles during the menstrual cycle?
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What are the key sonographer responsibilities during pelvic exams?
What are the key sonographer responsibilities during pelvic exams?
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What does the term oligomenorrhea refer to?
What does the term oligomenorrhea refer to?
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What is the typical size range for a Nabothian cyst?
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?
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?
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?
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?
What is the most common tumor of the female pelvis?
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What may cause fibroids to grow during pregnancy?
What may cause fibroids to grow during pregnancy?
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At what age is adenomyosis most commonly diagnosed?
At what age is adenomyosis most commonly diagnosed?
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Which symptom is commonly associated with cervical myomas?
Which symptom is commonly associated with cervical myomas?
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What is a defining characteristic of adenomyosis on ultrasound?
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?
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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