Benign and Malignant Diseases of the Uterus

What are some indications for pelvic examination

Uterine enlargement, pelvic pain, irregular or post menopausal bleeding , palpable pelvic mass infertility

Vaginal cuff

Seen in patients after hysterectomy. Small symmetric and homogeneously hypoechoic, with h thin central echogenic line representing vaginal mucosa

Normal measurement of vaginal cuff

2 cm

Rectouterime recess (posterior cul-de-sac)

Small amount of fluid 5ml through entire menses - assosclated with ascites ruptured ectopic pregnancy, or hemorrhagic ovarian cyst

Nabothian cyst

Aka epithelial inclusion cyst. Measures <2cm. Anecholc with entranced transmission n cervix

Cervical stenosis

Obstruction of cervical canal at internal or external Os causing dilation of endometrial canal

Causes of cervical stenosis

Radiation therapy, previous come biopsy, post menopausal cervical atrophy chronic infection laser or cryosurgery, cervical masses

Cervical polyps

Benign, most common benign cervical neoplasm, more common in mult-gravidas, common in women in late middle age. Clinically present with irregular bleeding. Arises from hyperplastic protrusion of epithelium of endocervix or ectocervix

Cervical Myoma

Benign masses of cervical muscles (fibroid in cervix). Usually asymptomatic, can cause dysuria, dyspareunia, or obstruction if large

What is the most common type of cervical carcinoma?

Squamous cell carcinoma

Cervical carcinoma

Hypoecholc, retro vesicle mass (compresses the bladder). Increased invascularity. Vaginal bleeding or discharge common

Uterine leiomyosarcoma

Rare solid tumor arising from myometrium, common in fundus of uterus rapid growth with Mets common. Solid or mixed-solid and cystic texture

Clinical findings of leiomyosarcoma (risk factors)

Nulliparity, >40 years, obesity pelvic radiation, tamoxifen exposure. Vaginal bleeding, pelvis or abdominal pain, rapid increase in size, enlarged bulky uterus, dsyuria , constipation

Sonographic findings of leiomyosarcoma

Rapid growing mass in uterus, hypoechoic, posterior shadowing. Posterior shadowing. Diffusely heterogenous if multiple

Fibroids

Aka leomyoma, myoma fibromyoma. Benign tumor of myometrium. Common in women over 30, common in African American women, estrogen dependent

Clinical findings of fibroids

Asymptomatic, pelvic pain menorrhagia •menometrorrhagia, bladder or rectum pressure, infertility, spontaneous abortion

Submucosal

Causes displacement or distorting of endometrial cavity with irregular or heavy menstrual bleeding

Intramural fibroid

Confined to myometrium (most common types)

Sub Serosal fibroid

Projecting from peritoneal surface of uterus

Pedunculated

appear as extrauterine masses can twist causing interruption of blood supply

What is the most common type of degenerative change of fibroids?

Cystic

Types of fibroid degeneration

Cystic, calcification, red degenerative changes (necrotic)

What fibroid degenerative change is most common in pedunculated fibroid?

Red degenerative changes (necrotic)

Treatment of myomas

Hormonal suppression, endometrial ablation, uterine artery embolization, high intensity focused ultrasound

Adenomyosis

Invasion of endometrial tissue into myometrium

Clinical findings of adenomyosis

Uterine enlargement, boggy tender uterus, dysmenorrhea, menometrorrhagia, pelvic pain, dyschezia, dyspareunia, multiparous

Sonographic appearance of adenomyosis

Diffusely enlarged uterus, hypoechoic or echogenic areas adjacent to endometrium. Striations seen in myometrium (heterogenous myometrium) myometrial cyst, ill defined interface between myometrium and endometrium. Thickening of the fundus of posterior myometrium.

Endometrial polyps

Overgrowths of endometrial tissue covered by epithelium. Can be pedunculated or broad, single or multiple.

Sonographic appearance of endometrial polyps

Appear towards end of luteal phase as round echogenic mass within endometrial cavity. Internal vascularity, identified with sono-histerography

When is a sonohysterography performed in premenopausal women?

Mid cycle 6-10 days

Endometrial Hyperplasia

Precursor of endometrial cancer. Follows prolonged endogenous or exogenous estrogen stimulation (HRT).

Clinical findings of endometrial hyperplasia?

Abnormal uterine bleeding, PCOS, obesity, tamoxifen therapy

Sonographic findings of endometrial hyperplasia

Thickened echogenic endometrium, small cystic spaces within endometrium l

Clinical findings of endometrial carcinoma

Postmenopausal bleeding, intermenstrual bleeding, enlarged uterus, CA 125 elevation, uterine distention,

Endometrial carcinoma risk factors

Obesity, null parity, early menarche, last menopause, diabetes, tamoxifen use for breast cancer, white, anovularion, unopposed estrogen therapy

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Sonographic appearance of endometrial cancer

Thickened endometrium, heterogenous uterus, enlarged uterus with lobular contour, endometrial fluid, polyploid mass within endometrium

Endometritis

Infection within endometrium of uterus. Most often in association with PID o patient presents with pelvic pain, menorrhagia, and dysmenorrhea

Sonographic findings of endometritis

Endometrium is prominent, irregular or both, with small amount of endometrial fluid. Hyper-vascular, possible echogenic particles from pus

Uterine synechiae

Aka Shermans syndrome. Amniotic sheets are linear bands of scar tissue in the uterus resulting from intrauterine adhesions

Sonographic appearance of uterine synechiae

Linear echogenic bands in uterine cavity, best seen in secretory phase • easily seen in gravid uterus . Blood flow common