Is Ultrasonography helpful Gynecologic Diagnosis ? Azza Al-Yamani 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.

vaginal oocyte collection. 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 N. proliferative endometrium 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.

Adenomyosis

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

Key message Fibroid Endometrial polyp Uterine mass Adenomiosis 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 Examples: * Serous cystadenocarcinoma. • > 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

* Krukenberg ′s tumours. * Fibrosarcoma. 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.

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