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Basic Gynae Ultrasound

Roziana Ramli, OBGYN, HSNZ

Introduction
USG: not a substitute for
history, examination etc.
LMP?
Longer learning curve
Normal versus abnormal
TAS versus TVS, full
bladder?
Pelvic Organs

NORMAL UTERUS;
SHAPE AND SIZE
Length - Fundus to Cervix(7.5-8.0cm)
Depth - Antero-posterior(4.5-5.0cm)
Width - Coronal view (2.5-3.0cm)

Menstrual
Cycle
Endometrial
Development
Cyclic changes during
the menstrual cycle
Endometrial
thickness(ET): double
wall thickness including
both the anterior and
posterior walls.

Menstrual Appearan
Cycle
ce

Thickn
ess
(mm)

Right after
menses

Homogenous

1-4

Proliferativ
e phase

Triple layer
/Trilaminar

7-10

Luteal
phase

Hyperechoge
nic

8-16

NORMAL OVARY; SHAPE AND SIZE


The average size of the ovary in a
premenopausal woman is 3.5 cm long
by 2.0 cm wide by 1.0 cm thick

Ovary
Moderately echogenic
Found in POD to the lower
abdomen
Anterior and lateral to the iliac
vessels
Typically found lateral to uterine
fundus
TAS: patient with thin adipose,
TVS in others

FOLLICLE AND CORPUS LUTEUM


Developing follicles are first seen by ultrasound as group
of 4-8 antral follicles 3-5mm on a TVS
Around cycle days 9 to 10 the leading follicle can be
identified; it has a diameter of about 10 mm. Thereafter it
grows rapidly, and by ovulation it is 20 to 24 mm in
diameter.
The subordinate(non dominant) follicle reach 10mm then
become atretic
After ovulation the follicle collapses, and as the corpus
luteum develops, the content of the cyst may have a
slightly heterogeneous consistency. The wall thickens as
cells are luteinized (lining cells enlarge and fill with lipid)
and in most cases the antrum fills with blood
Occasionally, corpus luteum forms a homogeneous
hypoechogenic thin-walled structure. The diameter of a
normal follicle or corpus luteum does not usually exceed
30 mm.

Uterus
Fibroid
Adenomyosis
Patients with
abnormal bleeding

Ovary

Ovarian Cyst
Endometriosis
Teratomas
Ovarian Cancer

Others

Uterine fibroid

Ultrasound: fibroid

Solid mass inside the body of the uterus


Well defined, encapsulated
Hyperechoeic OR hypoechoeic OR both

Fibroid: degenerative
changes
Fibroids can undergo various
degenerative changes,
especially when large.
This fibroid shows multiple
hypoechoic and hyperechoic
patchy areas.
Sometimes degenerative
changes can take place in
fibroids with areas of necrosis
and hemorrhage and result in
varying appearances from
cystic to inhomogenous
appearances.

Fibroid: calcification
Calcification of fibroids may occur as
a peripheral ring or as popcorn type.

m
o
n
e
d
A

o
y

s
i
s

Diagnosis with ultrasound is difficult as


there are no characteristic features
Diagnosed based on:
Myometrial echogenicity
Posterior uterine wall thickening
Anterior displacement of the endometrial cavity

Features suggestive of adenomyosis


Uterine enlargement not explained by fibroid
Asymmetrical thickening of anterior or usually posterior uterine
walls
Lack of contour or abnormality effect despite enlarged bulky
uterus
Heterogenous and poorly circumscribed areas in the myometrium
Poorly defined focal area/s of hypo/hyperechoeic texture within
the myometrium
Anechoeic cysts or lacunae within the myometrium (myometrial
cysts)

A large (bulky) uterus with a diffusely infiltrative,


inhomogenous appearance of the myometrium with
dirty, streaky shadowing posteriorly.
The uterus shows a GLOBULAR shape with the
endometrium almost obscured.

Cystic areas within myometrium and endometrium.


The hyperechoic areas: caused by the migration of
endometrial tissue into the myometrium.
The hypoechoic areas: are the result of hyperplasia
of the myometrial smooth muscle around the
ectopic endometrial tissue.

Bleeding Disorders
Fertile Age
The most common causes
Functional bleeding disorder of hormonal
origin
Deviation from the normal structure of the
endometrium in the different phases of the
menstrual cycle described above is not
sufficient for making a diagnosis.
Endometrial thickness of more than 18 mm
suggests endometrial disease.

Bleeding disorders
Fertile Age
The most common causes
Functional bleeding disorder of hormonal origin
Deviation from the normal structure of the endometrium in
the different phases of the menstrual cycle described above
is not sufficient for making a diagnosis.
Endometrial thickness of >18 mm suggests endometrial
disease.

Postmenopausal Bleeding Disorders

Postmenopausal bleeding is a sign of endometrial cancer


until otherwise proven.
An endometrial thickness >10 mm in a postmenopausal
patient strongly suggests endometrial cancer and
extremely rarely when the endometrium is < 5 mm thick.
A histological sample of the endometrium is always
needed these cases.

Endometrial polyp
An echodense, well-defined,
round mass in the uterine cavity,
which is best visualised during
the proliferative phase. It may
have a cystic structure.
The polyp can be imaged even
better should any liquid be
present in the uterine cavity, or if
fluid is introduced with a catheter.

Ovarian Cyst

Physiological versus pathologica


Size < 5cm

Benign versus malignant


95% of cysts are benign

Persistent of cyst >3 menstrual


cycles

10 simple rules identifying benign


& malignant ovarian tumour
Malignant (M) rules

M1 Irregular solid tumor


M2 Presence of ascites
M3 At least 4 papillary structures
M4 Irregular multilocular solid
tumor with largest diameter
100 mm
M5 Very strong blood flow (color
score 4)

Benign (B) rules


B1 Unilocular
B2 Presence of solid components
where the largest solid component
has a largest diameter <7 mm
B3 Presence of acoustic shadows
B4 Smooth multilocular tumor with
largest diameter <100 mm
B5 No blood flow (color score 1)

Pelvic Infection
Tubo-ovarian abscess is seen in US
examination as a multilocular, thick-walled
mass that contains echo-dense fluid
collections.
When the infection subsides, the infectious
complex may disappear or it may turn into
a sactosalpinx, which is an elongated
multilocular mass causing a torsion of the
fallopian tube.

The torsion is easily identifiable from


different projections, and the ovary will be
seen as a separate structure.
Small pseudopapillae (1 to 2 mm) may be
seen in the walls. Incomplete septa do not
reach from wall to wall inside the mass.