Gynecological Ultrasound and Imaging
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Ultrasound of Submucous Myoma
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3.5 – 5 MHz sector
TRANSABDOMINAL APPROACH
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4 – 7 MHz
TRANSVAGINAL APPROACH
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Can be used when there are cysts or masses in the vaginal
wall or along the labia
wall or along the labia
TRANSLABIAL APPROACH
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Done in virgins if the uterus and adnexa are not visualized
through the abdominal approach; Useful in patients with polycystic ovarian morphology,
through the abdominal approach; Useful in patients with polycystic ovarian morphology,
TRANSRECTAL APPROACH
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visualize the endometrial cavity and assess fallopian tube patency
SONOHYSTEROGRAM
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X-ray Examination of the uterus and fallopian tubes
HYSTEROSALPINGOGRAM
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timing for sonohysterogram
4-7 days to 10 days from LMP
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Cannula is inserted through the cervical canal
Leech Wilkenson Cannula
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Contraindication for donohysterogram
Pelvic Inammatory diseases
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detect an endometrial polyp
Sonohysterogram
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To check fallopian tube patency
Hysterosalpingogram
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No spillage
tubal obstruction
14
WHAT TO ASSESS?
size, shape, contour, orientation, and sppearance of Myometrium, Endometrium, and Cervix
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Relationship of the uterus to the vagina in a sagital plane
VERSION
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Relationship of the uterus to the cervix
FLEXION
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Most common position of the uterus
o Anteverted: Cervix angles forward
o Anteexed: Body is exed forward
o Anteexed: Body is exed forward
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hugging the urinary bladder
anteverted
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uterus is pointing backwards towards the rectum
Retroverted Uterus
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arcuate arteries are calcied
Monckeberg’s Sclerosis
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medium-level echoes.
➢Granular in texture
➢Granular in texture
MYOMETRIUM
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Varies in thickness and appearance because of the effects of estrogen and progesterone
ENDOMETRIUM
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Thin, broken echogenic line (1 – 2 mm
Menstrual phase
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Hypoechoic thickening (4 – 8 mm)
Proliferative phase
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Triple layer (6 – 10 mm)
Periovulatory phase
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Hyperechoic thickening (7 – 14 mm)
Secretory phase
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Menstruating Patient: endometrial thickness >14 mm
Endometrial Hyperplasia
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Postmenopausal: Endometrial thickness >14 mm
endometrial cancer
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7 – 12 mm in length; Extends laterally from the uterus
FALLOPIAN TUBE
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Parts of the fallopian tube
○ Intramural
○ Isthmus
○ Ampulla
○ Infundibulum / fimbriae
○ Isthmus
○ Ampulla
○ Infundibulum / fimbriae
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CAUSES OF ENDOMETRIAL THICKENING
➢ Early intrauterine pregnancy
➢ Incomplete abortion
➢ Ectopic pregnancy (Arias-Stella reaction)
➢ Incomplete abortion
➢ Ectopic pregnancy (Arias-Stella reaction)
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Hormone-related atypical endometrial change characterized by hypertrophy and vacuolization of glandular epithelial cells, associated with marked nuclear pleomorphism, enlargement, and hyperchromasia.
Arias Stella reaction
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unopposed stimulation of the endometrium by estrogen
ENDOMETRIAL HYPERPLASIA
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treatment for endometrial hyperplasia if medications do not work
Curetage
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not appreciated during the secretory phase 
ENDOMETRIAL POLYP
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If a polyp becomes large
may cause infertility or ectopic pregnancy by tubal blockade
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Treatment for endometrial polyp
Dilatation and curetage
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Polypectomy via curetage
if polyp is inside the endometrium
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Best time to look for polyp
menstrual phase or the early proliferative phase
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To check for endometrial polyps
sonohysterogram
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MC gynecologic malignancy; thickened, heterogeneous endometrium
ENDOMETRIAL CARCINOMA
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endometrium becomes thickened and may present with cystic changes
TAMOXIFEN-RELATED ENDOMETRIAL CHANGES
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Circular and hypoechoic
SUBMUCOSAL LEIOMYOMA
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IUD in the uterine cavity
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Fluid in the uterine cavity
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Gas within the endometrial cavity; Most commonly occurs after a septic abortion; Common in induced abortions involving catheters
ENDOMETRITIS
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air echoes within endometrial cavity (echogenic foci with artifact – white)
ENDOMETRITIS
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Endometritis with air echoes
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Due to an Imperforate hymen
HEMATOCOLPOS / HYDROMETROCOLPOS
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Accumulation of menstrual blood,within the vagina due to an obstruction of the vaginal outow tract.
Hematocolpos
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Accumulation of uid in both the uterus (hydrometra) and the vagina (hydrocolpos) due to obstruction of the genital outow tract.
Hydrometrocolpos
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Vagina lled with fluid collection
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Collection of blood inside the uterus
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The most common neoplasia in the myometrium; oes not cause dysmenorrhea
LEIOMYOMA
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Intramural leiomyoma with gestational sac (red arrow)
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Subserosal fibroid
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SUBMUCOSAL Projects to the uterine cavity
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Presence of endometrial tissue in the myometrium; Severe form of dysmenorrhea; Heterogeneous* patern of the myometrium
ADENOMYOSIS
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Enlarged uterus with normal appearing endometrium
Diffuse adenomyosis
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Enlarged uterus with heterogeneous* myometrium
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Most common (benign)
Nabothian Cyst
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Absent uterus; failed to form
Uterine Aplasia
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Result of unilateral developmental arrest
Uterus Unicornis, Unicollis
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Most common uterine anomaly with renal agenesis; 2 uterus, 2 cervix, 1 vagina.
UTERUS BICORNIS, BICOLLIS
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2 uterus, 1 cervix, 1 vagina
UTERUS BICORNIS, UNICOLLIS
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Indentation of the uterine fundus
UTERUS ARCUATUS
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FAILURE OF RESORPTION OF THE MEDIAN SEPTUM
Septate or subseptate uterus
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polycystic ovary
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More than 25 mm; mature follicle fails to involute
Follicular cyst
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Seen in pregnancy; Regress after 3 menstrual cycle
Corpus Luteal Cyst
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Network of fine interdigitation avascular strands; Fish-net appearance
HEMORRHAGIC CYST
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Occurs in pregnancy (looks like Poly Cystic Ovaries)
Theca Lutein Cyst
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Endometrial tissue outside of the uterus; Possibility of infertility; Symptom: Severe dysmenorrhea
ENDOMETRIOMA / ”CHOCOLATE CYST”
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Contains fats, bones, parts of the skin, and hair
Dermoid cysts
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Due to chronic anovulation
POLYCYSTIC OVARIAN SYNDROME
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Polycystic Ovarian Morphology (PCOM) Diagnosis
Follicle Number Per Ovary (FNPO) ≥20 follicles (2 – 9
mm) in at least one ovary; Ovarian volume (OV) ≥10 mL in at least one ovary; Follicle Number Per Section (FNPS) ≥10 follicles in one ovary (one plane or slice)
mm) in at least one ovary; Ovarian volume (OV) ≥10 mL in at least one ovary; Follicle Number Per Section (FNPS) ≥10 follicles in one ovary (one plane or slice)
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menstruation has been irregular for more than 8 years
diagnose PCOM
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➢ Irregular thick walls
➢ Solid mural nodules
➢ Increase CA-125
➢ Lesions are greater than 4 cm
➢ Solid mural nodules
➢ Increase CA-125
➢ Lesions are greater than 4 cm
NEOPLASTIC/OVARIAN CANCER
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Ovarian Carcinoma
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Ovarian cancer
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The most common type of ovarian tumor; Unilocular, thin septations; Can be bilateral; Suggestive of malignant
Serous Cystadenoma and Cystadenocarcinoma
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Serous Cystadenoma and Cystadenocarcinoma associated with:
Papillary projections
Echogenic materials
Ascites
Echogenic materials
Ascites
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Serous cystadenoma
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Bilateral papillary serous cystadenocarcinoma
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2nd most common epithelial tumor; he patient may appear pregnant due to the huge size (15 – 30 cm)
Mucinous Cystadenoma and Cystadenocarcinoma
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Thin septations
cystadenoma
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Thickened septations or solid components
cystadenocarcinoma
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Ruptured Mucinous Cystadenoma/cystadenocarcinoma
pseudomyxoma peritonei
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Mucinous Cystadenocarcinoma
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Nearly all are malignant; Present as a cystic mass with papillary projections; 2nd most common epithelial malignancy
Endometroid Tumor
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Mullerian duct in origin; Non-specic in appearance; Complex mass that can be cystic or solid
Clear Cell Carcinoma
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Denitely malignant
➢ Hypoechoic solid masses
➢ May contain calcications
➢ Differentiation: Pathologic
➢ Hypoechoic solid masses
➢ May contain calcications
➢ Differentiation: Pathologic
Brenner Tumor
93
Most radiosensitive type of tumor; Morphologically identical to male testicular seminoma; Occurs in women less than 30 years of age
Dysgerminoma
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Causes/correlated with increased AFP
Similar appearance to dysgerminoma
Similar appearance to dysgerminoma
Endometrial Sinus Tumor (Yolk Sac)
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Occur in post-menopausal women
95% unilateral
Most estrogenically active ovarian tumor
95% unilateral
Most estrogenically active ovarian tumor
Granulosa Cell Tumor
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Occurs in women under 30 years old; 70% occurs in post-menopausal women
Thecoma and Fibroma
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Triad of benign tumor (broma), ascites, and pleural effusion
Meigs Syndrome
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Most common origins are the breast and the GIT
METASTATIC TUMORSBaby is radiosensitive
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Reserved for tumors containing signet ring cells, usually gastric in origin
Krukenberg Tumor
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From conception to 13th week AOG; Greatest risk for maldevelopment, injury, and death; Baby is radiosensitive
FIRST TRIMESTER
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Beter for direct visualization of the embryo at 0 – 8 weeks AOG
Transvaginal UTS
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no embryo is found
anembryonic pregnancy or blighted ovum
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used to measure cardiac activity (6 wks)
M-mode
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Used only in >13 wks AOG
Doppler
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Presence of intradecidual sign
Very Early Pregnancy or ENDOMETRIAL CYST
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First structure to be visible within the gestational sac
➢ Visible by TVS at the 6th week AOG
➢ Visible by TVS at the 6th week AOG
Secondary Yolk Sac
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yolk sac exceeding 6 mm
NON- VIABLE PREGNANCY
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baby gets the nutrients from the yolk sac from
0 to the 8th week AOG
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takes over after the 8th week.
Placenta
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Early pregnancy ultrasound
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Intradecidual sign of early intrauterine pregnancy
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Echogenic disc-like structure approximately 2 mm long; Seen at the end of the 5th week AOG
EMBRYO
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Gestational sac, yolk sac, and the embryo
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a common early pregnancy complication, may indicate a threatened abortion or a subtle sign of placenta abruptio
subchorionic
hemorrhage
hemorrhage
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marks early abdominal wall formation
8 weeks AOG.
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Mean sac diameter >8 mm
“blighted
ovum”
ovum”
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distorted gestational sac
Abortion in Progress
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Typically occurs 6 weeks AOG and above
ECTOPIC PREGNANCY
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Simultaneous intrauterine and extrauterine pregnancy
Heterotopic pregnancy
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Heterotopic pregnancy
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Free uid (FF) in the pelvic cavity
ruptured ectopic pregnancy or hemorrhage
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fertilization of a 23X sperm
COMPLETE MOLE
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Snowstorm appearance; Increased β-hcg by 3x
COMPLETE MOLE
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fertilization of an ovum by 2 sperms
Triploid (69XXX, 69XXY, 69XYY)
Triploid (69XXX, 69XXY, 69XYY)
PARTIAL MOLE
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SECOND TRIMESTER AND THIRD TRIMESTER Document the following:
1. Fetal life- Heartbeat
2. Number- Single or twins
3. Presentation- Cephalic or Breech
2. Number- Single or twins
3. Presentation- Cephalic or Breech
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Assessment of the gestational age
Biparietal Diameter (BPD), Femur Length and Abdominal Circumference (AC)
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MSD
<6 weeks gestational sac
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CRL of embryo
6-13 weeks
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BPD, FL, and AC
13 weeks and above
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Taken at the level of the thalamus
BPD
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Measured at the axial plane at the,junction of the umbilical vein and the left portal vein
Abdominal circumference (AC)
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Estimated
Fetal Weight
(EFW)
Fetal Weight
(EFW)
➢ BPD + AC = EFW
➢ AC + FL = EFW
➢ AC + FL = EFW
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1.st seen at 8 weeks AOG as focal thickening at the periphery of the gestational sac
PLACENTA
134
Causes of thick placenta: >4cm
Diabetes, Fetal hydrops, Anemia, Triploidy
135
Measure the vertical height of the deepest uid pocket in each quadrant of the uterus and sum up the 4 measurements (4 pockets)
AMNIOTIC FLUID INDEX (AFI)
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AFI <5 cm
Oligohydramnios
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Single pocket
>8 cm
>8 cm
Polyhydramnios
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Dichorionic, diamniotic
3 – 4 days
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Monoamniotic, dichorionic
4 – 7 days
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Monochorionic,monoamniotic
After 8 days
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conjoined twins
>13 days
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Abnormal accumulation of uid in at least 2 body cavities
HYDROPS FETALIS
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Fluid collection in the fetal nape
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Most common cause of neural tube defects; Absence of the cranium and cerebral hemispheres;
ANENCEPHALY
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Abnormal uid accumulation in the ventricles; Due to total cerebral infarction in utero caused by bilateral thrombosis of the internal carotid arteries; no cerebral hemispheres.
HYDRANENCEPHALY
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Cleft deformity
147
paramedian abdominal wall defect; Defect in the anterior abdominal wall, usually to the right of the umbilicus
GASTROSCHISIS
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Midline mass protruding through the abdominal wall
➢ Covering membrane present
➢ Has a beter survival rate than gastroschisis
➢ Covering membrane present
➢ Has a beter survival rate than gastroschisis
OMPHALOCOELE
149
Complex mass occupying the presacral region
SACROCOCCYGEAL TERATOMA
150
Self-Breast examination
Monthly, 1 week AFTER period
151
Clinical breast examination
EVERY 3 YEARS for women 20 – 39 years old
YEARLY for women 40 years old and above
YEARLY for women 40 years old and above
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Mammogram; Invented in the year 2015
Start at 35 – 40 years old
153
earliest recorded case of breast cancer
1600 BC Edwin Smith Papyrus
154
Indicated to asymptomatic patients that is >40 years old
Screening Mammogram
155
Indicated to symptomatic patient
Diagnostic Mammogram
156
Indication for patient with injectable implants
BREAST MRI
157
15 – 18 per breast; Milk-producing regions of the breast
lobes
158
○ Extralobular duct + lobule
○ Where cancer can occur
○ Functional unit of breast
○ Where cancer can occur
○ Functional unit of breast
TDLU
159
○ Appear tree-like on the breast imaging
○ Trunk: Mammary (lactiferous) ducts
○ Branches: Secondary ducts leading to the lobules
○ Trunk: Mammary (lactiferous) ducts
○ Branches: Secondary ducts leading to the lobules
Ducts
160
Used for intraductal lesions, bloody nipples
Galactography
161
A persistent, non healing nipple lesion
Paget’s Disease
162
Involvement of the main glandular units and posterior atachments
poor prognosis
163
Lesions conned to the TDLU
DCIS
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localization of lesions in the horizontal plane
Cranio-Caudal (CC) View
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Involvement of axilla where the lymph nodes are seen; localization of
lesions in the vertical plane.
lesions in the vertical plane.
MEDIOLATERAL OBLIQUE VIEW (MLO)
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Describe the position of the lesion in “O’Clock” position +
ABC zone
ABC zone
TRIANGULATION
167
Key component of triangulation in breast imaging
Posterior Nipple Line
168
Category 0
Needs additional imaging
169
Category 1
Negative in mammogram
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Category 2
Benign lesion
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Category 3
Probably Benign
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Category 4
Suspicious lesions
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Category 5
Highly Suggestive of Malignancy
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Category 6
Known Biopsy-Proven Malignancy
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Refers to the amount of broglandular tissue in the breast
relative to the amount of fat.
relative to the amount of fat.
BREAST COMPOSITION
176
177
irregular lesion
BI-RADS 4 (suspicious) or 5 (highly suggestive of malignancy)
178
Circumscribed margins
cyst broadenomas, high grade intraductal carcinomas, medullary carcinomas
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BI RADS score is 5
180
obscured margins,
181
INDISTINCT
BI RADS 4
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LOBULATED
183
SPICULATED
BI-RADS 5
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Refers to X-ray atenuation relative to fibroglandular tissue
BREAST DENSITY
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Low density lesions:
lipoma
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Equal density
benign and malignant
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High-density
cysts
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LAYERING in new BI RAD 2025
Milk of calcium (cyst)
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COARSE in new BI RAD 2025
Dystrophic,Popcorn (Trauma,Old broadenomas)
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Calcications can never be seen on UTS
- true
- false
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calcications are clustered,
malignant
192
indistinct, hazy, or ill-dened in appearance
Resembles powder
Resembles powder
Amorphous calcificaion
193
Larger, irregular in shape, typically 0.5–1.0 mm in size, with a tendency to coalesce.
Coarse heterogeneous
194
➢ Variable in size and shape
➢ Generally < 0.5 mm in diameter
➢ Carry a higher likelihood of malignancy compared to amorphous or coarse heterogeneous calcications
➢ Generally < 0.5 mm in diameter
➢ Carry a higher likelihood of malignancy compared to amorphous or coarse heterogeneous calcications
Fine Pleomorphic
195
➢ Thin, irregular lines, often following ductal distributions and occasionally branching
➢ Have the highest likelihood of malignancy almost always requires biopsy
➢ Have the highest likelihood of malignancy almost always requires biopsy
Fine Linear Branching
196
Amorphous, coarse heterogeneous, and fine pleomorphic calcications
BI-RADS category 4B
197
Fine linear or ne-linear branching calcications
BI-RADS category 4C
198
Diffuse location
benign
199
Regional, Group, Segmental location
malignant
200
An abnormality in which the normal breast architecture is disrupted without a discrete mass.
ARCHITECTURAL DISTORTIONS
201
Represents the superimposition of typical structures
ASYMMETRIES
202
BREAST BIOPSY
ULTRASOUND-GUIDED CORE NEEDLE BIOPSY, VACUUM ASSISTED DEVICE (VAD), MRI GUIDED AND STEREOTACTIC GUIDED CORE NEEDLE BIOPSY, NEEDLE WIRE LOCALIZATION
203
Always use with contrast
BREAST MRI
204
DCIS on breast MRI
205
Implant in breast MRI
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