1. Uterine Abnormalities
Continued

2. Uterine Abnormalities
Leiomyoma (Fibroids)
Lipomatous Uterine tumors
Leiomyosarcoma
Adenomyosis
Arteriovenous Malformations

3. Leiomyoma or Fibroids Most common neoplasm of uterus
Estrogen dependant
Composed of smooth muscle and fibrous connective tissue

4. Fibroids- symptoms Frequently asymptomatic Symptoms Pain
Uterine bleeding

5. Fibroid Classification
Intramural
most common
Confined to the myometrium
Submucosal
Projecting into uterine cavity (distorting or displacing endo)
Produce symptoms frequently (less common)
Associated with infertility
Subserosal
Projecting from peritoneal surface

6. Fibroids Sonographic Features Figure 15-10
Variable appearance
Hypoechoic or heterogeneous mass
Distortion of external uterine contour
Attenuation of sound beam or shadowing w/o discrete mass
Calcification
Degeneration or necrosis

7. Fibroids

8. Lipomatous Uterine Tumors or Lipoleimyomas
Uncommon
Benign
Consist of
Mature lipocytes
Smooth muscle
Or fibrous tissue

9. Sonographically
Highly echogenic, attenuating mass within the myometrium
Absence of Color Flow within
Usually asymptomatic
Make sure within uterus (confuse with ovarian dermoid)

10. Leiomyosarcoma Rare Malignant (1.3% of uterine cancers)
may arise from a leiomyoma
Asymptomatic or uterine bleeding
Same symptoms and appearance “Fibroid”

11. Sonographically Fig 15-12 Rumack
Similar to a rapidly growing or degenerating Fibroid
Rarely diagnosed preoperatively
Exception
May see local invasion (bladder or rectum)
Distant metastases
Clue: Rapid growth & post menopausal growth

12. Adenomyosis Common condition
Endometrial glands and stroma within myometrium
Associated with adjacent smooth muscle hyperplasia
Two Forms
Diffuse
Nodular
Can have fibroids present as well
Makes severity of adenomyosis difficult to diagnose

13. Adenomyosis More common
Diffuse
Nodular
More common
Widely scattered adenomyosis foci within the myometrium
Composed of adenomyomas (circumscribed nodules)

14. Clinical presentation
Nonspecific
Uterine enlargement
Pelvic pain
Dysmenorrhea
Menorrhagia
Seen more in women who have had children

15. Adenomyosis Not well seen using transabdominal ultrasound
Transvaginal much better

16. Sonographic Features of adenomyosis fig.15-13 Rumack
Diffuse ut enlargement
Diffusely heterogeneous myometrium
Asymmetrical thickening of myometrium
Inhomogeneous hypoechoic areas
Myometrial cysts
Poor delineation of endo-myometrial border
Focal tenderness with transvaginal transducer
Subendometrial echogenic linear striations
Subendometrial echogenic nodules

24. LOCALIZED aDENOmyosis
Can be confused with fibroid
Inhomogeneous, circumscribed areas within myometrium

25. Localized Adenomyomas
Lieomyomas
Localized Adenomyomas
Usually well defined borders
Peripheral vascularity
Ill defined borders
Internal vascularity

26. MRI and ultrasound both good at diagnosing adenomyosis

27. Arteriovenous malformations
AVM’S
Vascular plexus of arteries and veins with no capillary network
Rare lesions
Most cases acquired
Pelvic trauma
Surgery
Gestational trophoblastic neoplasia

28. AVM’s usually diagnosed
Postabortion and postpartum periods
Symptoms
Severe vaginal bleeding
D&C
Could worsen bleeding leading to hemorrhage

29. Sonographic appearance of avm’s (Fig 15-14)
Nonspecific 2D ultrasound
Multiple tortuous anechoic structures
Subtle myometrial heterogeneity
Myometrial or endometrial mass
Color Doppler
Better
+++color flow shown, colored mosaic pattern
Spectral Doppler
High velocity, low resistance arterial flow, high velocity venous flow (more like an artery)

30. Differential Diagnosis of avm’s
RPOC
GTN (gestational trophoblastic neoplasia)
Subinvolution of placental bed
***negative hCG help to distinguishing

31. Treatment of avm’s Wait to see if resolve (maybe not AVM)
If severe bleeding immediate treatment
emboization

32. Abnormalities of Cervix
Nabothian cysts
Cervical polyps
Leiomyomas
Cervical carcinoma

33. Nabothian cysts Vary in size mm’s – 4cm Single or multiple Benign
Simple or have internal echoes ?infection or hemorrhage
Multiple cysts can result enlargement of cervix

34. Cervical polyps Leiomyoma's 8% cx Cause vaginal bleeding
Can be seen U/S usually diagnosed clinically
Leiomyoma's 8% cx
Pedunculated
May prolapse into vagina

35. Cervical carcinoma Adenoma Malignum Usually Diagnosed clinically
U/S may show solid retrovesical mass (look like fibroid)
MRI best for staging
Adenoma Malignum
Rare
Associated Peutz-Jeghers syndrome (inherited)
U/S appears as multiple cystic areas seen within a solid cx mass (nabothian cysts not associated with a mass)

36. Pitfall after hysterectomy
Cervical remnant mistaken for Mass
Can measure 4.4mm AP AND 4.3 mm Length

37. terminology Salpinges- fallopian tubes
Cornua- “Horns” or lateral angle
Collis- “neck” Cervix
Colpos- Vagina
Metra- Endometrial Cavity
Hemata- Blood
Hydro- Water
Pyo- pus

38. Short answers Obstruction of the genital tract
1. Congenital causes?
2. Acquired causes?
3. Define
Hydrometrocolpos, pyometracolpos,hematometracolpos
Hydrocolpos, pyocolpos, hematocolpos
Hematometra, pypmetra, hydrometra
4. What are the sonographic appearances of genital tract obstruction? Are there differences before the age of menstruation and after?

39. Abnormalities of vagina
Imperforate hymen
Most common congenital abn. Female genital tract
Gartner’s duct cysts
Remnants of caudal end of mesonephric duct
Anterolateral or anterior wall of vagina
Asymptomatic
Usually small
Associated with renal and ureteral abnormalities

40. Solid masses very rare Pitfalls Neurofibroma
u/s not used for diagnosis (may be used for staging)
Pitfalls
Vaginal cuff and cervical cuff after hysterectomy
Mistaken for mass
Vaginal cuff upper limit
Transvag- 2.2mm (AP)
Transabd- 2.4mm (AP)

41. Rectouterine recess or pcds
Fluid within is a normal finding in asymptomatic women
Found throughout phases of cycle
Possible Sources of fluid
Blood or fluid from (follicular rupture, retrograde menses)

42. Pcds fluid collections
Pathological
Seen with general ascites, blood (ruptured ectopic or hemorrhagic cyst), pus (infection)
U/S
Used to differentiate type of fluid
Anechoic
Serous fluid
Fluid containing echoes
Blood, pus, mucin (clotted blood can look very echogenic)

43. PcDS
Pelvic abscesses
hematomas