Gynecologic Ultrasound
Sujata Ghate, MD
Duke University Medical Center
Objectives
• Understand work-up of endometrial
abnormalities
• Show examples of uterine and
endometrial abnormalities
• Recognize features of benign and
malignant adnexal lesions and
understand work-up of ovarian masses
Uterus and
Endometrium
Uterus--layers
• Endometrium—
inner, mucosal
layer
• Myometrium—
thick muscular
layer
• Serosa--outer
Uterine (myometrial)
Masses
• Leiomyoma (fibroid)
• Lipoleiomyoma—very rare
• Leiomyosarcoma—rare (1.3%) similar in
app. to rapidly growing or degenerating
fibroid
• Adenomyosis
Uterine (myometrial)
masses
• Leiomyoma (fibroid)
Uterine (myometrial)
masses
• Lipoleiomyoma
Uterine (myometrial)
masses
• Adenomyosis
Endometrium
• Normal cycle
Early proliferative
Midcycle secretory
Late secretory
Endometrium
What is abnormal?
• Focal abnormality seen on US
• >5 mm in postmenopausal women with
bleeding or >8mm if on unopposed HRT
• No upper threshold in premenopausal pts
• No known threshold for asymptomatic
postmenopausal women (some use
>5mm, others use > 8mm)
Endometrium
Note: Focal thickening is always
abnormal
DDX Focal thickening
• Polyps
• Fibroids
• Blood clot
Endometrium
Note: Clinical history is extremely important
for accurate DDX
DDX Diffuse thickening
• Hematometrocolpos
• Endometritis
• Tamoxifen therapy
• Endometrial hyperplasia
• Endometrial carcinoma
Endometrium
Diffuse Abnormality
• Hematometrocolpos
• Accumulation of blood/secretions in
endometrial canal
Endometrium
Diffuse Abnormality
• Hematometrocolpos
• Congenital causes (vaginal web, imperforate
hymen, etc)
• Acquired causes (usually iatrogenic)
Endometrium
Diffuse Abnormality
• Tamoxifen therapy
• Irregular with cystic changes
Endometrium
Diffuse Abnormality
• Tamoxifen therapy
• Symptoms of vaginal bleeding—needs
endometrial biopsy
• Incidental finding—no intervention needed
Endometrium-SIS
Indications:
1. Define focal abnormality
2. Abnormal, persistent uterine
bleeding
3. Evaluate thickened
endometrium (focal vs diffuse
thickening)
Endometrium-SIS
Technique:
Endometrium-SIS
Polyps
• Most are homogeneous, echogenic,
narrow stalk
Endometrium-SIS
Submucosal fibroids
• Characteristic shadowing pattern, broad based
Work-up of Endometrial
Thickening and abnormal bleeding
Pre or postmenopausal patients
Routine
TVS
US
Diffuse, focal
or normal
SIS
Work-up of Asymptomatic
Diffuse Endometrial Thickening
Pre or postmenopausal patients
Premenopausal
Routine
TVS
US
<5mm
Likely
Physiologic
Do
Nothing
Do
Nothing
Postmenopausal
>5-8 mm *
* Gyn
Consult
*threshold and
management is
controversial
Adenexa
Adenexal Lesions
• Determine if ovarian or extraovarian
• Recognize classically benign
lesions
• Understand work-up of ovarian
lesions
Extra-ovarian Lesions
DDX:
• Myoma (pedunculated or broad
ligament)
• Hydrosalpinx
• Peritoneal inclusion cyst
• Para-ovarian cyst
• Non-gyn lesion
Extra-ovarian Lesions
• Hydrosalpinx
• Anechoic, tubal shape, infolding
Extra-ovarian Lesions
Peritoneal inclusion cyst
• Fluid collection with geometric margins, ovary
on the edge of the collection
• Contained ovulated fluid
Extra-ovarian Lesions
Para-ovarian cyst—Wolffian duct
remnant
• Simple cyst, round
• Follow-up not necessary
if <3 cm in size
Levine, et al. Radiology, 9/2010
Normal Ovarian Cycle
Follicular phase
Dominant follicle
By Day 10
Luteal phase
Ovarian Lesions
Classically benign
• Functional cyst
• Hemorrhagic cyst
• Endometrioma
• Dermoid
Benign Ovarian Masses
• Follicular Cyst
Unilocular, anechoic, smooth borders, ?thin
septations, generally resolve in 1-2 cycles
Benign Ovarian Masses
• Corpus luteal cysts
Thicker walled, rim of blood flow, generally
regress by day 14
Benign Ovarian Masses
• Hemorrhagic cysts
• Mostly corpus luteal
• Mobile echoes, trabeculated/reticular
pattern, geometric, mobile solid component
Benign Ovarian Masses
• Hemorrhagic cysts
• Mostly corpus luteal
• Mobile echoes, trabeculated/reticular
pattern, geometric, mobile solid component
Benign Ovarian Masses
• Benign mature teratoma (dermoid)
• Mixed solid/cystic, “tip of iceberg”
sign, fat/fluid level
Benign Ovarian Masses
• Dermoid management
– Malignant transformation rare (0.2-2%) and
usually squamous cell type
– Age > 50, size >10 cm risk factors
– Sonographic suspicious features: central flow,
isoechoic branching structures, solid areas with
flow
• If typical appearance, follow initially at 6 mths,
then yearly if not removed; look for growth, other
Levine, et al. Radiology, 9/2010
change
Benign Ovarian Masses
• Endometrioma
• Homogeneous low level echoes,
septations possible (no flow)
Benign Ovarian Masses
Endometrioma management
• 1% risk of malignant transformation
– Endometroid or clear cell carcinoma
– Age >45, size >9 cm (rare in lesions <6 cm)
– Mean latency period=4.5 yrs
• If typical appearance, yearly follow-up (look for
growth, change in architecture)
Levine, et al. Radiology, 9/2010
US Predictors of Malignancy
• Solid component (nodular or
papillary)
• Thick septation (2-3 mm)
• Flow within solid areas or septations
• Free fluid
Brown DL, Radiology 1998; 208:103
Role of Doppler
• Limited in its use for predicting malignancy
• Suspicious if color flow seen in solid
nodules/septations
• PI<1 and RI<0.4 suspicious for malignancy (very
little data, still controversial)
Kurjak A, JUM 1991;10:295.
Note: Pulsed doppler findings only useful in
postmenopausal women!
Indeterminate Ovarian
Neoplasms
• Epithelial tumors (65-75%)
– Majority of ovarian cancer
• Germ cell tumors (15%)
• Sex-cord stromal tumors (5-10%)
• Metastasis (5-10%)
(Brown DL, SRU ’04)
Indeterminate Ovarian
Neoplasms
• Epithelial tumors (65-75%)
– Majority of ovarian cancer
– More cystic than solid
– Benign types: serous or mucinous cystadenoma
– Borderline types
– Malignant: serous or mucinous
cystadenocarcinomas, endometroid carcinoma,
clear cell carcinoma
(Brown DL, SRU ’04)
Indeterminate Ovarian
Neoplasms
• Sex Cord Tumors (5-10%)
Solid
– Benign: fibromas, thecomas
Mostly solid
– Granulosa cell tumor (secrete estrogen)
– Sertoli-Leydig cell tumors (secrete androgens)
(Brown DL, SRU ’04)
Indeterminate Ovarian
Neoplasms
• Metastases (5-10%)
– Breast
– Colon
– Stomach
– Lymphoma
(Brown DL, SRU ’04)
Ovarian Malignancy
Management of Ovarian Cysts
SRU expert panel 10/09:
• Panel members: radiologists, gynecologists
including gyn oncologists, pathologists, etc
• Drafted a consensus statement on
management of ovarian lesions
• Publication:
Levine D, Management of asymptomatic ovarian and other adnexal
cysts imaged at US: Society of Radiologists in Ultrasound
Consensus, Radiology 256:3, Sept 2010, p. 943-954.
Work-up of Ovarian Masses
Premenopausal patients
Routine
TVS
US
>5 and
<7 cm
Simple cyst
<3 cm
Benign
Do nothing
Describe in report
As prob benign;
Rec yearly f/up US
>7 cm
>3 and
<5 cm
Describe in report
As benign
MRI or surg.
consult
Levine, et al. Radiology, 9/2010
Work-up of Ovarian Masses
Premenopausal patients
Routine
TVS
US
>5 cm
Typical
hemorrhagic
cyst
<3 cm
Benign
Do nothing
>3 and
<5 cm
Describe in report
As benign
Describe in report
As prob benign;
6-12 wk US f/up
until resolution
On f/up, preferably
image in follicular
phase (days 3-10)
Levine, et al. Radiology, 9/2010
Work-up of Ovarian Masses
Premenopausal patients
Routine
TVS
US
Could it be
a hemorrhagic
cyst?
Yes
Follow-up
US in
6 weeks
Complex or solid
Mass
No flow in solid
areas
or septations
(less risk of
malignancy)
+ flow in solid
areas
or septations
(higher risk of
malignancy)
No
MRI or Surg
Consult
Work-up of Ovarian Masses
Postmenopausal patients
Routine
TVS
US
>1.0 cm
and <7 cm
Describe in report;
Yearly f/up
Simple cyst
> 7 cm
< 1.0 cm
+ Describe in
report: no f/up
MRI or Surg
Consult
Work-up of Ovarian Masses
Postmenopausal patients
Routine
TVS
US
Complex or solid
Mass
No flow in solid
areas or septations
(less risk for
malignancy)
Gyn
consult
+ flow in solid
areas or septations
RI < 4.0
(higher risk of
malignancy)
Thank you!