Is Ultrasonography helpful
in
Gynecologic Diagnosis ?
Azza Al-Yamani
Prof. of Obstetrics and
Gynecology
The objectives of this slide show are :
* Know the principles of Ulrtasuond imaging.
* Be familial with the US normal appearance of
different pelvic structures.
* Be able to interpret US images in common
gynecologic pathology.
* Be able to differentiate between US
appearance of benign and malignant pelvic
masses.
* Know the advantages of TV/ US over
abdominal transducers in Gyn.
US imaging is a simple and noninvasive
procedure that has the advantage of avoiding
radiation hazards.
It is especially helpful in patients in whom
pelvic exam. is difficult as children ,virgins &
incooperative.
Doppler sonography
Can measure the velocity profile of blood flowing
through pelvic bl. vessels to differentiate benign
from malignant adnexal masses.
Finally
TV/US can be used to assist in performing
invasive gynecological procedures as
vaginal oocyte collection.
Transvaginal ultrasound (TV/US) has the advantage
over the abdominal US in gynecology , because
the close proximity of the intravaginal trancducer
allows for high – frequency scanning and better
resolution of the pelvic organs .
However , every TV/US examination should be
preceded by transabdominal imaging .
Technology
Intermittent high – frequency sound waves are
generated by applying an alternating electric
current to a transducer made of a piezoelectric
material.
The transducer is connected to the abdominal
wall by placing a water –soluble gel on the skin
to diminish the loss of US waves at the interface
between the transducer and the skin.
The transducer emits a pulse of sound waves
that passes through structures of different tissue
densities , some of the energy proportional to
the difference in densities is reflected or echoed
back to the transducer.
This in turn ,stimulates the transducer to generate
a small electrical voltage that is then amplified
and displayed on a screen .
Clinical Applications
in gynecology
The use of ultrasonography in the diagnosis
of gynecological lesions can be summarized
in 3 indications :
(1) Pelvic mass differentiation
* Uterine masses.
* Ovarian masses.
cystic or solid
* Adnexal masses.
cystic or solid.
(2) evaluation of the uterine cavity
including IUCD localization.
(3) Early pregnancy complications
including ectopic pregnancy.
(1) Pelvic Masses
Uterine masses
1. Leiomyoma ( fibroid )
• more in the midline position.
• contiguous with the uterus.
• well defined.
• homogeneous ,hypoechoic mass.
• may have small cysts ( degeneration) ,
or calcified areas (calcification).
N. Secretory
endometrium
N. proliferative
endometrium
Submucous fibroid
anterior wall fibroid
pedunculated subserous fibroid
Broad ligament fibroid
Interamural fibroid
Calcified fibroid
2. endometrial polyp
• discrete mass (es) within the uterine cavity.
•enlargement of the uterus .
• prominent endometrial echo complex with
saline contrast.
endometrial polyp
3. Adenomyosis
• uterine enlargement.
• normal central endometrial echo.
• honey comb appearance.
4. endometrial carcinoma
• very important that it may not alter the
uterine echo pattern.
• prominent endometrial echo complex
> 4mm in postmenopausal woman.
• loss of the normal endometrial / myometrial
junction.
• pyometria , or hematometria.
Pyometria
endometrial carcinoma
Ovarian masses
1.Cystic
cystic mass free in the adenexal area
not related to the uterus.
a) Benign
• < 5cm ( cystic ovary ) physiological .
• walls of the cyst are well delineated .
• echolucent .
• sharply defined posterior border .
• uniocular ,if multiocular the septa are
thin walls.
• no significant internal echo .
Normal ovary
N. Gaafian follicle
corpus luteum cyst
OHSS
PCO
Multilocular simple ov. cyst
Unilocular simple ov.
Cyst
Dermoid cyst
( mature cystic teratoma)
b) malignant
• > 5 cm .
• bilateral in the majority.
• multilocular.
• echoic.
• thick walls.
• thick incomplete septa.
• may, intracystic papillary projections.
• may ,fluid in cul de sac.
Examples:
* Serous cystadenocarcinoma.
* Mucinous cystadenocarcinoma.
* Endometriod carcinoma.
malignant ovarian cyst
with intracystic papillary projections
2. Solid
Predominent solid ovarian mass in the
adnexal area.
a) benign
• usually , bilateral.
• well defined outlines.
• hypoechoic.
Examples:
* Brenner ′ s tumors.
* teratomas.
* fibroma.
Solid ovarian tumor
b) malignant
• usually , bilateral.
• hypoechoic.
• with ,ascitis.
Examples:
* Clear cell carcinoma .
* Krukenberg ′s tumours.
* Fibrosarcoma.
* Undifferentiated carcinoma.
malignant ovarian tumor
Key message
Simple ov. Cyst
malignant ov. Cyst
Adnexal Masses
predominent mass in the adnexal area.
Examples:
* Tubal ectopic pregnancy.
* hydrosalpenix.
* hematosalpenix.
* Pyosalpenix or tuboovarian abscess.
Ectopic Pregnancy
hydrosalpnix
(2) Evaluation of the Uterine
Cavity
a) Echogenic Foci within the Uterine Cavity.
As: IUCD.
b) Endometrial Fluid Collection.
As: bleeding.
a) Echogenic Foci within the Uterine Cavity
as:
* IUCD .
* retained products of conception (bones).
* Intrauterine adhesions .
IUCD in situ
Intrauterine adhesions
b) Endometrial Fluid Collection
1. Physiological
* At the time of menstruation.
* Early gestational sac.
2. Complicated pregnancy
* Blighted ovum.
* Pseudo gestational sac of ectopic preg.
* Missed abortion .
* Incomplete abortion.
3. infection
* Endometritis , PID ( exudate ).
* Pyometria ( pus ).
4. abn. uterine bleeding
* DUB.
normal & abnormal GS
Abnormal GS
Blighted ovum
Pseudo gestational sac
empty GS
Key points
1. TV sonography with or without saline
instillation is a primary investigation in
diagnosis of uterine pathology in women
with abnormal uterine bleeding.
2.TV/S is useful in evaluation of ovarian
masses combined with color Doppler.
3. Vaginal US is a gold standard for
diagnosis of PCO.
4. TV/S has a crucial role in monitoring of
ovulation ( folliculometry) in infertility .
5. TV sonography is helpful in evaluation
of early pregnancy complications.
Thank you