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
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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
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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
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Causes of thick placenta: >4cm
Diabetes, Fetal hydrops, Anemia, Triploidy
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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
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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
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Complex mass occupying the presacral region
SACROCOCCYGEAL TERATOMA
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Self-Breast examination
Monthly, 1 week AFTER period
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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
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earliest recorded case of breast cancer
1600 BC Edwin Smith Papyrus
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Indicated to asymptomatic patients that is >40 years old
Screening Mammogram
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Indicated to symptomatic patient
Diagnostic Mammogram
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Indication for patient with injectable implants
BREAST MRI
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15 – 18 per breast; Milk-producing regions of the breast
lobes
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○ Extralobular duct + lobule
○ Where cancer can occur
○ Functional unit of breast
○ Where cancer can occur
○ Functional unit of breast
TDLU
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○ 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
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Used for intraductal lesions, bloody nipples
Galactography
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A persistent, non healing nipple lesion
Paget’s Disease
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Involvement of the main glandular units and posterior atachments
poor prognosis
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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
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Key component of triangulation in breast imaging
Posterior Nipple Line
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Category 0
Needs additional imaging
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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
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irregular lesion
BI-RADS 4 (suspicious) or 5 (highly suggestive of malignancy)
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Circumscribed margins
cyst broadenomas, high grade intraductal carcinomas, medullary carcinomas
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BI RADS score is 5
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obscured margins,
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INDISTINCT
BI RADS 4
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LOBULATED
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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
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indistinct, hazy, or ill-dened in appearance
Resembles powder
Resembles powder
Amorphous calcificaion
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Larger, irregular in shape, typically 0.5–1.0 mm in size, with a tendency to coalesce.
Coarse heterogeneous
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➢ 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
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➢ 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
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Amorphous, coarse heterogeneous, and fine pleomorphic calcications
BI-RADS category 4B
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Fine linear or ne-linear branching calcications
BI-RADS category 4C
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Diffuse location
benign
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Regional, Group, Segmental location
malignant
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An abnormality in which the normal breast architecture is disrupted without a discrete mass.
ARCHITECTURAL DISTORTIONS
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Represents the superimposition of typical structures
ASYMMETRIES
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BREAST BIOPSY
ULTRASOUND-GUIDED CORE NEEDLE BIOPSY, VACUUM ASSISTED DEVICE (VAD), MRI GUIDED AND STEREOTACTIC GUIDED CORE NEEDLE BIOPSY, NEEDLE WIRE LOCALIZATION
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Always use with contrast
BREAST MRI
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DCIS on breast MRI
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Implant in breast MRI
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