Is UltrasonographyIs Ultrasonography helpfulhelpful inin

Gynecologic DiagnosisGynecologic Diagnosis ? ?

Azza Al-YamaniAzza Al-Yamani Prof. of Obstetrics andProf. of Obstetrics and

GynecologyGynecology

The objectives of this slide show areThe objectives of this slide show are : :

** Know the principles of Ulrtasuond imagingKnow the principles of Ulrtasuond imaging . .

** Be familial with the US Be familial with the US normalnormal appearance of appearance of

different pelvic structuresdifferent pelvic structures . .

** Be able to interpret US images in commonBe able to interpret US images in common

gynecologic pathologygynecologic pathology . .

** Be able to differentiate between USBe able to differentiate between US

appearance of appearance of benignbenign and and malignantmalignant pelvic pelvic

massesmasses . .

** Know the advantages of Know the advantages of TV/ USTV/ US over over

abdominal transducers in Gynabdominal transducers in Gyn . .

US imaging is a simple and noninvasiveUS imaging is a simple and noninvasive

procedure that has the advantage of avoidingprocedure that has the advantage of avoiding

radiation hazardsradiation hazards . .

It is especially helpful in patients in whomIt is especially helpful in patients in whom

pelvic exam. is difficult as pelvic exam. is difficult as childrenchildren , ,virginsvirgins & &

incooperativeincooperative . .

Doppler sonographyDoppler sonography

Can measure the velocity profile of blood flowing Can measure the velocity profile of blood flowing through pelvic bl. vessels to differentiate benign through pelvic bl. vessels to differentiate benign

from malignant adnexal massesfrom malignant adnexal masses . .

FinallyFinally

TV/US can be used to assistTV/US can be used to assist in performingin performing invasive gynecological procedures asinvasive gynecological procedures as

vaginal oocyte collectionvaginal oocyte collection . .

Transvaginal ultrasound (TV/US) has the advantageTransvaginal ultrasound (TV/US) has the advantage

over the abdominal US in gynecology , becauseover the abdominal US in gynecology , because

the close proximity of the intravaginal trancducerthe close proximity of the intravaginal trancducer

allows for high – frequency scanning and betterallows for high – frequency scanning and better

resolution of the pelvic organsresolution of the pelvic organs. .

However , every TV/US examination should beHowever , every TV/US examination should be

preceded by transabdominal imagingpreceded by transabdominal imaging. .

TechnologyTechnology

Intermittent high – frequency sound waves areIntermittent high – frequency sound waves are

generated by applying an alternating electricgenerated by applying an alternating electric

current to a transducer made of a current to a transducer made of a piezoelectricpiezoelectric

materialmaterial . .

The transducer is connected to the abdominalThe transducer is connected to the abdominal

wall by placing a water –soluble gel on the skinwall by placing a water –soluble gel on the skin

to diminish the loss of US waves at the interfaceto diminish the loss of US waves at the interface

between the transducer and the skinbetween the transducer and the skin . .

The transducer emits a pulse of The transducer emits a pulse of sound wavessound waves

that passes through structures of different tissuethat passes through structures of different tissue

densities , some of the energy proportional todensities , some of the energy proportional to

the the difference difference in in densitiesdensities is reflected or echoed is reflected or echoed

back to the transducerback to the transducer . .

This in turn ,stimulates the transducer to generateThis in turn ,stimulates the transducer to generate

a small electrical voltage that is then amplifieda small electrical voltage that is then amplified

and displayed on a screenand displayed on a screen . .

Clinical ApplicationsClinical Applications in gynecologyin gynecology

The use of ultrasonography in the diagnosisThe use of ultrasonography in the diagnosis of gynecological lesions can be summarizedof gynecological lesions can be summarized

in 3 indicationsin 3 indications : : ))11 ( (Pelvic mass differentiationPelvic mass differentiation

* *UterineUterine masses masses . . * *OvarianOvarian masses masses . .

cystic or solidcystic or solid * *AdnexalAdnexal masses masses . .

cystic or solidcystic or solid . .

))22 ( (evaluation of the uterine cavityevaluation of the uterine cavity

including IUCD localizationincluding IUCD localization . .

))33 ( (Early pregnancy complicationsEarly pregnancy complications

including ectopic pregnancyincluding ectopic pregnancy . .

))11 ( (Pelvic MassesPelvic Masses

Uterine massesUterine masses

11 . .Leiomyoma Leiomyoma ( ( fibroidfibroid ) ) • •more in the midline positionmore in the midline position . .

• •contiguous with the uteruscontiguous with the uterus . .

• •well definedwell defined . .

• •homogeneous ,hypoechoic masshomogeneous ,hypoechoic mass . .

• •may have small cysts ( degeneration)may have small cysts ( degeneration) , ,

or calcified areas (calcification)or calcified areas (calcification) . .

N. Secretory N. proliferativeN. Secretory N. proliferative

endometrium endometriumendometrium endometrium

Submucous fibroidSubmucous fibroid

anterior wall fibroidanterior wall fibroid

pedunculated subserous fibroidpedunculated subserous fibroid

Broad ligament fibroidBroad ligament fibroid

Interamural fibroidInteramural fibroid

Calcified fibroidCalcified fibroid

22 . .endometrial polypendometrial polyp

• •discrete mass (es) within the uterine cavitydiscrete mass (es) within the uterine cavity..

••enlargement of the uterusenlargement of the uterus . .

• •prominent endometrial echo complex withprominent endometrial echo complex with

saline contrastsaline contrast . .

endometrial polypendometrial polyp

33 . .AdenomyosisAdenomyosis

• •uterine enlargementuterine enlargement . .

• •normal central endometrial echonormal central endometrial echo . .

• •honey comb appearancehoney comb appearance . .

44 . .endometrial carcinomaendometrial carcinoma

• •very important that it may not alter thevery important that it may not alter the

uterine echo patternuterine echo pattern . .

• •prominent endometrial echo complexprominent endometrial echo complex

> >4mm in postmenopausal woman4mm in postmenopausal woman . .

• •loss of the normal endometrial / myometrialloss of the normal endometrial / myometrial

junctionjunction . .

• •pyometria , or hematometriapyometria , or hematometria . .

Pyometria endometrial carcinomaPyometria endometrial carcinoma

Ovarian massesOvarian masses

11..CysticCystic cystic mass free in the adenexal areacystic mass free in the adenexal area

not related to the uterusnot related to the uterus . .

a) a) BenignBenign < • < •5cm ( cystic ovary ) physiological5cm ( cystic ovary ) physiological . .

• •walls of the cyst are well delineatedwalls of the cyst are well delineated . . • •echolucentecholucent . . • •sharply defined posterior bordersharply defined posterior border . . • •uniocular ,if multiocular the septa areuniocular ,if multiocular the septa are thin wallsthin walls . .

• •no significant internal echono significant internal echo . .

Normal ovaryNormal ovary

N. Gaafian follicle corpus luteum cystN. Gaafian follicle corpus luteum cyst

OHSS PCOOHSS PCO

Multilocular simple ov. cyst Unilocular simple ov. CystMultilocular simple ov. cyst Unilocular simple ov. Cyst

Dermoid cystDermoid cyst

) )mature cystic teratomamature cystic teratoma ( (

b) b) malignantmalignant

> • > •55 cmcm. . • •bilateral in the majoritybilateral in the majority . . • •multilocularmultilocular . . • •echoicechoic . . • •thick wallsthick walls . . • •thick incomplete septathick incomplete septa . . • •may, intracystic papillary projectionsmay, intracystic papillary projections . . • •may ,fluid in cul de sacmay ,fluid in cul de sac . .

ExamplesExamples : : * *Serous cystadenocarcinomaSerous cystadenocarcinoma . . * *Mucinous cystadenocarcinomaMucinous cystadenocarcinoma . . * *Endometriod carcinomaEndometriod carcinoma . .

malignant ovarian cystmalignant ovarian cyst

with intracystic papillary projectionswith intracystic papillary projections

22 . .SolidSolid

Predominent solid ovarian mass in thePredominent solid ovarian mass in the

adnexal areaadnexal area . .

a) a) benignbenign

• •usually , bilateralusually , bilateral . .

• •well defined outlineswell defined outlines . .

• •hypoechoichypoechoic . .

ExamplesExamples : :

* *Brenner ′ s tumorsBrenner ′ s tumors . .

* *teratomasteratomas . .

* *fibromafibroma . .

Solid ovarian tumorSolid ovarian tumor

b) b) malignantmalignant

• •usually , bilateralusually , bilateral . .

• •hypoechoichypoechoic . .

• •with ,ascitiswith ,ascitis . .

ExamplesExamples : :

* *Clear cell carcinomaClear cell carcinoma . .

* *Krukenberg ′s tumoursKrukenberg ′s tumours . .

* *FibrosarcomaFibrosarcoma . .

* *Undifferentiated carcinomaUndifferentiated carcinoma . .

malignant ovarian tumormalignant ovarian tumor

Key messageKey message

Simple ov. Cyst malignant ov. CystSimple ov. Cyst malignant ov. Cyst

Adnexal MassesAdnexal Masses

predominent mass in the adnexal areapredominent mass in the adnexal area . .

ExamplesExamples : :

* *Tubal ectopic pregnancyTubal ectopic pregnancy . .

* *hydrosalpenixhydrosalpenix . .

* *hematosalpenixhematosalpenix . .

* *Pyosalpenix or tuboovarian abscessPyosalpenix or tuboovarian abscess..

Ectopic PregnancyEctopic Pregnancy

hydrosalpnixhydrosalpnix

))22 ( (Evaluation of the Uterine CavityEvaluation of the Uterine Cavity

a) a) Echogenic Foci within the Uterine CavityEchogenic Foci within the Uterine Cavity..

As: IUCDAs: IUCD . .

b) b) Endometrial Fluid CollectionEndometrial Fluid Collection . .

As: bleedingAs: bleeding . .

a) Echogenic Foci within the Uterine Cavitya) Echogenic Foci within the Uterine Cavity

asas : :

* *IUCDIUCD . .

* *retained products of conception (bones)retained products of conception (bones) . .

* *Intrauterine adhesionsIntrauterine adhesions . .

IUCD in situIUCD in situ

Intrauterine adhesionsIntrauterine adhesions

b) Endometrial Fluid Collectionb) Endometrial Fluid Collection

11 . .PhysiologicalPhysiological * *At the time of menstruationAt the time of menstruation . . * *Early gestational sacEarly gestational sac . .

22 . .Complicated pregnancyComplicated pregnancy * *Blighted ovumBlighted ovum . . * *Pseudo gestational sac of ectopic pregPseudo gestational sac of ectopic preg . . * *Missed abortionMissed abortion . . * *Incomplete abortionIncomplete abortion . .

33 . .infectioninfection * *Endometritis , PID ( exudate )Endometritis , PID ( exudate ) . . * *Pyometria ( pus )Pyometria ( pus ) . .

44 . .abn. uterine bleedingabn. uterine bleeding * *DUBDUB . .

normal & abnormal GSnormal & abnormal GS

Abnormal GSAbnormal GS

Blighted ovumBlighted ovum

Pseudo gestational sac empty GSPseudo gestational sac empty GS

Key pointsKey points 11 . .TV sonography with or without salineTV sonography with or without saline

instillation is a primary investigation ininstillation is a primary investigation in diagnosis of uterine pathology in womendiagnosis of uterine pathology in women

with with abnormal uterine bleedingabnormal uterine bleeding . .22..TV/S is useful in evaluation of TV/S is useful in evaluation of ovarianovarian

massesmasses combined with color Doppler combined with color Doppler . .33 . .Vaginal US is a gold standard forVaginal US is a gold standard for

diagnosis of diagnosis of PCOPCO.. 44 . .TV/S has a crucial role in monitoring ofTV/S has a crucial role in monitoring of

ovulation ( ovulation ( folliculometryfolliculometry) in infertility) in infertility . . 55 . .TV sonography is helpful in evaluationTV sonography is helpful in evaluation

of of early pregnancy complicationsearly pregnancy complications . .

Thank youThank you