Ultrasound of ovaries
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Transcript of Ultrasound of ovaries
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The OvariesThe OvariesDurr-e-SabihDurr-e-Sabih
MBBS. MS. FRCP. FANMBMBBS. MS. FRCP. FANMBDirector MINARDirector MINAR
MultanMultanPAKISTANPAKISTAN
[email protected]@yahoo.com
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Early on Early on
• A baby girl is born with a huge number of potential eggs ( 700,000 to 2 million)
• By puberty only 400,000 are left• Around 500 are used during lifetime of
ovulation
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The Normal Adult OvaryThe Normal Adult Ovary
• Resting ovary is moderately echogenic, ovoid, well marginated, seen along the side of uterus usually but can be seen behind the uterus or even in the lower abdomen.
• Cysts in the ovary in premenopausal age are the distinguishing feature
• Menopausal ovaries can be smooth and be difficult to identify
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ReviewReview
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The Normal Adult OvaryThe Normal Adult Ovary
• Primordial follicles are too small to be seen by ultrasound
• Solid background, scattered antral follicles (3-6mm)
• Volume 8- 20 ml
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The Normal Adult Ovary (Cont’d)The Normal Adult Ovary (Cont’d)
• 4-8 antral follicles (day 6-7) in each ovary measuring 3-6 mm
• By day 7 one follicle is selected and increases in size more than others
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The Normal Adult Ovary (Cont’d)The Normal Adult Ovary (Cont’d)
• 10 mm by day 8-9 (dominate follicles >11mm)• 18- 24mm by day 14 • Subordinate follicles also continue to grow to
about 10 mm, then become smaller• > 50% reduction in volume on ovulation• Corpus luteum is irregular and complex cystic
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ReviewReview
What When How
Primordial follicles …. Too small, not visible
Antral follicles(4-8)
D 6-7 3-6mm
Dominate follicle D 8-9 10 – 11 mm
Dominate follicle D 14 18-24mmSubordinate follicles
D 14 Up to 10mm then regress
Corpus luteum D >14 50% volume, irregular contour
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OvariesOvaries(Volume)(Volume)
• Birth – 3 Mo 0.3 – 3.6 ml• 2-8 yrs 1.0 - 1.5 ml• 10 yrs2.2 – 3.6 ml• 13 yrs4.2 – 9.0 ml• 15-19 yrs 8.0 – 18 ml• 20-49 yrs 10-23 ml• 50-65 yrs 6 – 14 ml • 70 yrs1 – 6 ml
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OvaryOvary
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Day 3 OvaryDay 3 Ovary
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Normal/Normal/multimulticystic Ovariescystic Ovaries
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Dominant FollicleDominant Follicle
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The Corpus LuteumThe Corpus Luteum
• One-third will be typical irregular cysts• One-third will look echogenic and solid• One third will not be visible at all
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Corpus LuteumCorpus Luteum
© Allen Worrall, Alaska
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Corpus Luteum Ring of FireCorpus Luteum Ring of Fire
© Allen Worrall, Alaska
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Calcified Area in OvaryCalcified Area in Ovary
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Ultrasound Monitoring of Follicles:Ultrasound Monitoring of Follicles:
• Finding• Counting• Measuring• Documenting
Follicles on serial studies
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HowHow
• Baseline study….day 4-5 to look for any cyst left over from previous cycles, rule out other lesions
• Start on day 8-10, identify developing follicles of 8-10 mm
• Monitor daily or on alternate days until size of 16-18mm seen (mature follicle)….give HCG pulse
• Ovulation >50% reduction in size
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• Very dynamic organs• Changing appearance with the time of the
menstrual cycle, age and pregnancy• Must correlate findings with the expected
physiological findings
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Dominant FollicleDominant Follicle
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OvulationOvulation
Dominate follicle on day 14Corpus luteum on day 16
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Pathological StatesPathological StatesAbsent/Abnormal OvulationAbsent/Abnormal Ovulation
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Abnormal Ovarian CyclesAbnormal Ovarian Cycles
• Sporadic ovulation failure in about 7% of cycles
• Sporadic anovulatory syndromes• Chronic anovulatory syndromes
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Abnormal Ovarian CyclesAbnormal Ovarian Cycles
• Sporadic ovulation failure in about 7% of cycles
• Sporadic anovulatory syndromeso Follicular Atresiao Empty Follicle Syndromeo Luteinized Unruptured Follicle Syndrome
• Chronic anovulatory syndromes
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Abnormal Ovarian CyclesAbnormal Ovarian Cycles
• Sporadic ovulation failure in about 7% of cycles
• Sporadic anovulatory syndromes• Chronic anovulatory syndromes
o Hypergonadismo Hypogonadismo Polycystic Ovarian Syndrome (PCOD)
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Sporadic Anovulatory SyndromesSporadic Anovulatory Syndromes
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Follicular AtresiaFollicular Atresia
• Dominate follicle starts developing but o Does not reach full sizeo Rapidly becomes smallero Common in oral contraceptive users
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Empty Follicle SyndromeEmpty Follicle Syndrome
• Follicle development looks normal• Oocyte is not formed• Cannot differentiate from normal cycles on
ultrasound
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Luteinized Unruptured Follicle Luteinized Unruptured Follicle Syndrome (LUFS)Syndrome (LUFS)
• Apparently normal follicle develops but fails to rupture
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Chronic Anovulatory SyndromesChronic Anovulatory Syndromes
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Primary Ovarian FailurePrimary Ovarian Failure
• Ovaries are small and smooth with no follicular activity
• Estrogen levels are low• Gonadotropin levels are very high
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HypogonadotropismHypogonadotropism
• Low FSH, LH, Low estrogen• Pituitary lesion (tumour?)• Ovaries smooth but can respond to exogenous
cyclical hormones
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PCOSPCOS
• A very complex endocrine abnormality• A very wide spectrum of findings with the
classic Stein Leventhal syndrome at one end and normal looking females with early fertility at the other
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PCOSPCOS
• Typical habitus?o Obeseo Oligo/amennorrhoeao Hirsuitism
• Endocrine abnormalitieso Raised LHo LH/FSH ratio > 3o Raised Sr. Testosterone and Androstenedioneo Insulin resistance
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PCOS PCOS Ultrasound FeaturesUltrasound Features
• Large ovaries• Round shape• Large number of small cysts arranged
peripherally under the capsule (string of pearls sign) or throughout the volume
• >10 cysts on TAS, >15 on TVS on a single section
• Echogenic stroma (compare with myometrium)
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PCOSPCOSUltrasound FeaturesUltrasound Features
• 1//3rd patients have normal ovarian volumes• Many normal ovaries are multicystic
o Adolescentso Oral contraceptive userso Juvenile hypothyroidismo 17 hydroxylase deficiencyo Post Menopausal ovaries with hyperthecosiso PID
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Consensus on diagnostic criteria for Consensus on diagnostic criteria for PCOS (2003)PCOS (2003)Two should be presentTwo should be present
• Oligo and/or anovulation• Clinical and/or biochemical signs of
hyperandrogenism• Polycystic ovaries
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HyperandrogenismHyperandrogenism
• Clinical or biochemicalo Hirsuitism (subjective?, racial?)o Acneo Circulating androgens (wide variability)o Free testosterone, free testosterone index,
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Polycystic ovaries Polycystic ovaries
• 12 or more follicles in each ovary, measuring 2-9mm across and/or increased ovarian volume (>10ml)
• Exclude follicle distribution, exclude stromal echogenicity and volume
• Does not apply to women on contraceptive pills
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Polycystic ovaries Polycystic ovaries
• If findings are seen only on one side, this is still sufficient for diagnosis.
• If there is evidence of dominate follicle or corpus luteum, repeat next month.
• Asymmetric ovarian size or large cyst needs further work-up/follow-up.
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PCODPCOD
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PCODPCOD
© Allen Worrall, Alaska
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Ovarian Hyperstimulation Ovarian Hyperstimulation SyndromeSyndrome
• Numerous follicles grow in a stimulated cycle• Pain, enlarged ovaries (ovaries can become 6-
7 cm in diameter)• If larger, there can be associated ascites,
pleural effusion• On US, enlarged ovaries with multiple large
cysts seen
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Hyperstimulated OvariesHyperstimulated Ovaries
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Hyperstimulated OvariesHyperstimulated Ovaries
© Shlomo Gobi, Jerusalem
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Hyperstimulated OvariesHyperstimulated Ovaries
© Ravi Kadasne, UAE
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The Simple Ovarian CystThe Simple Ovarian Cyst
• If up to 5-7 cm in diameter, observe over 6-8 weeks
• Try to repeat scan during the first 5 days of the cycle
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The Simple Ovarian CystThe Simple Ovarian Cyst
• > than 7 cm in diameter • Persist beyond the length of a normal
menstrual cycle • solid components • Complex internal structure • Associated with pain
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The Simple Ovarian CystThe Simple Ovarian Cyst
© Prof. Nawaz Anjum, Lahore
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The Simple Ovarian CystThe Simple Ovarian Cyst
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Theca Lutein Theca Lutein
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Mural NodulesMural Nodules
© Gunjan Puri, Surat
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The Haemorrhagic Ovarian CystThe Haemorrhagic Ovarian Cyst
Haemorrhage
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The Haemorrhagic Ovarian CystThe Haemorrhagic Ovarian Cyst
Haemorrhage
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Endometriotic cystEndometriotic cyst
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Endometriotic cystEndometriotic cyst
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Haemorrhagic and endometrial cystHaemorrhagic and endometrial cyst
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The parovarian CystThe parovarian Cyst
o A cyst developing within the mesosalpinx between the tube and ovary, from the vestigial remnants of the Wolffian body. These cysts represent 10% of all adnexal masses. They occur in the third to fourth decade.
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The parovarian CystThe parovarian Cyst
o On ultrasound, a paraovarian cyst may be suspected when a thin-walled, unilocular ovoid structure free of internal echoes is demonstrated lying next to the uterus within the plane of the broad ligament and the ovary is seen separately.
o Their size does not change in relation to the menstrual cycle. But they can torse and undergo haemorrhage
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The parovarian CystThe parovarian Cyst
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The parovarian CystThe parovarian Cyst
Hydatid of Morgagni
Epioophoron
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The parovarian CystThe parovarian Cyst
© Allan Worrall, Alaska
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The parovarian CystThe parovarian Cyst
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HydrosalpinxHydrosalpinx
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The parovarian CystThe parovarian Cyst
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MenopausalMenopausal
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TorsionTorsion
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EndEnd