Benign Diseases

Adhesiolysis

Surgical removal of adhesions

Anovulation

Failure to ovulate

Hirsutism

Excessive hair on a woman

Hydatidiform mole

Genetically abnormal pregnancy that develops into a grape-like mass within the uterus

Hysteroplasty

Reconstructive surgery of the uterus

Involute

Collapsing and rolling inward

Menorrhagia

Abnormally heavy or prolonged menses

Lysis

Breaking up of tissue

Oligoanovulation

Infrequent ovulation

Oligomenorrhea

Infrequent menses

Placenta accreta

Growth of the placenta into the myometrium

Placenta previa

Implantation of the placenta in the lower uterine segment of the cervix

Red degeneration

Hemorrhage into a leiomyoma that has outgrown its blood supply

Tamoxifen

Antiestrogenic drug used to decrease the occurrence of certain estrogen-sensitive breast cancers

Uterine dehiscence

Partial separation of the myometrium at the location of the uterine scar

Gartner’s Duct Cyst

• Remnant of the mesonephric duct

• single or multiple

• usually asymptomatic

• If large, they can cause symptoms such as dyspareunia

Benign cervix conditions are causes by:

• abnormal uterine fusion

• abnormal cervical fusion

• DES exposure

Enlarged cervix caused by:

• Nabothian cysts

• Cervical polyps

• Cervical fibroids

• Cervical stenosis

Nabothian Cysts

• Considered normal in adults

• may be multiple or single

• Size ranges from 3mm - 3cm

• require no treatment

• often occur after pregnancy or chronic cervicitis

Cervical Polyp

• Most common benign cervical lesion

• Most often occur in multigravitas, peri or post-menopausal patients

• usually asymptomatic

Cervical polyps U/S appearance:

• Attached by a stalk to cervical wall

• May be difficult to see on US due to size

• “teardrop” appearance

Cervical Fibroids

• 8% of fibroids (myomas, leiomyomas, fibromyoma)

• Most are small and asymptomatic

• Observe for growth

• Common during reproductive years

Cervical fibroid symptoms include:

• Dyspareunia

• Dysuria

• Urgency

• Genitourinary obstruction

• cervical obstruction

• prolapse

• bleeding

• obstructed labor

Cervical Stenosis

• Stenosis of the uterine cervix is the pathologic narrowing of the uterine cervix

• Defined as cervical narrowing that prevents the insertion of a 2.5 mm wide dilator

• 1/5 of patients have history of diethylstilbesterol (DES) exposure while in-utero

• also associated with endometriosis

If the cervical stenosis is severe enough it may result in proximal obstruction resulting in:

• hematometra → women of childbearing age with cervical stenosis are less likely to show evidence of hematometra than postmenopausal patients

• hydrometra

• pyometra

Other potential consequences of cervical stenosis include:

• infertility

• difficulty with fertility treatments such as:

  • embryo transfer

  • intra-uterine insemination

Causes of cervical stenosis:

• congenital

• chronic infection - cervicitis

• trauma

• from previous instrumentation

  • cone biopsy/loop electrosurgical excision procedures (LEEP)

  • cryotherapy

  • laser treatment

• stenosis secondary to a tumor/mass:

  • cervical polyp

  • cervical cancer

• post-radiation therapy

• Cervical endometriosis

Cervical Stenosis Diagnosis:

• Hysterosalpingogram

  • Narrowing of the endocervical canal or complete obliteration of the cervical os

    • prevents catheter insertion

• Ultrasound

  • thickened or normal endocervix appearance

• CT

  • may have hydrometra and/or hematometra

  • cervix may be normal in appearance

  • uterine cavity may be fluid distended

  • further complications such as hematosalpinges may be visualized

Endometrial polyps

• Common lesion

• Usually occur in 40’s

• Malignant potential

• Most appear hyperechoic

• Large polyps associated with bleeding

• Best diagnosed by sonohysterography

Sonohysterography

• Ultrasound-guided procedure used to evaluate endometrial cavity and lining

• Physician inserts speculum and catheter with balloons

• Removes speculum

• Sonographer inserts TV probe

• Physician injects saline through catheter

• Image lining of uterus

Fibroid AKA:

• Leiomyoma

• Myoma

• Fibromyoma

Fibroid

• Tumor of smooth muscle origin

• Most common tumor of the female pelvis

• Occurs in 20-30% of women of reproductive age

• African American females > caucasian females

• can be single or multiple

• leading cause of hysterectomy

Fibroid causes:

• etiology unknown

• Typically arise after menarch and regress after menopause

• estrogen-influenced

• can increase in size during pregnancy

Fibroid signs / symptoms:

• may be asymptomatic

• can cause heavy bleeding

  • menorrhagia

  • can cause spotting/bleeding between periods

• enlarged uterus on pelvic exam

• urinary frequency if pressing on bladder

Fibroid Locations

• Intramural

• Submucosal

• Subserosal

Intramural Fibroid

• Located within the myometrium

• 95% of fibroids located here

• may enlarge to cause pressure on adjacent organs

• may lead to infertility

Submucosal Fibroid

• Beneath endometrium and protrudes into endometrial cavity

• Least common

• Causes most symptoms

• Can cause infertility

Subserosal Fibroid

• Serosal surface → outside the uterus

• Pendunculated - on a “stalk” or peduncle

• May twist and cause severe pain

Fibroid Degeneration

• Fibroids demand blood supply, when they outgrow their blood supply, degeneration may occur

• Cystic degeneration - liquefaction necrosis

• Calcific degeneration - after menopause

• Degeneration process can cause significant pain

• Myomectomy or hysterectomy may be performed to reduce pain

Fibroids U/S appearance:

• Depends on number and size

• Uterine enlargement

• Hypo- to hyper- echoic

• Heterogenous texture

• Distorted uterine contour

• May displace endometrium

• Calcification causes shadowing

• Trandsabdominally → able to appreciate large fibroids

• Transvaginally → small fibroids

Ovarian Cysts

• Most fluid-filled pelvic masses are ovarian in origin

• Ovarian cyst prognosis

  • Less than 3cm usually regress spontaneously

  • 3-5cm follow up ultrasound 6-8 weeks

    • may regress w/ BCP’s

  • >10cm usually do not regress

    • surgical removal

    • greater potential for malignancy

Ovarian Cyst U/S appearance:

• Assess: Size, Location, Composition, and Age of Patient

• Smooth, well-defined borders

• Absence of internal echoes

• Increased posterior enhancement

Functional Cysts

• Ovarian Follicles

• Follicular cysts

• Corpus Luteum “Cyst”

• Theca Lutein Cyst

Ovarian Follicle

• Anechoic structures within ovary

• Approx. 10 days prior to ovulation, ovaries may contain multiple small follicles

• Single follicle becomes dominant

  • 2-2.5 cm

• 1-3 days prior to ovulation, dominant follicle is seen as a “cloudy cone”

Follicular Cyst

• Results from either non-rupture of dominant mature follicle or failure of immature follicle to undergo normal process of atresia

• May be multiple

• Usually unilateral

• Range 1-10 cm (usually 2 cm)

• usually asymptomatic → regress spontaneously

• Any simple cyst measuring less than 5 cm in an ovulating woman should be re-evaluated in 6-8 weeks

• Ruptured cysts will have free fluid in the cul-de-sac (likely posterior cds)

Corpus Luteum “Cyst” AKA:

“Great Pretender” cyst → variable appearance

Corpus Luteum “Cyst”

• as dominant follicle ruptures, corpus luteum develops (1.5-2.5 cm)

• not considered a true cyst until >3cm, may measure up to 6-8 cm in diameter

• Unilateral and unilocular

Corpus Luteum “Cyst” U/S appearance:

• hypoechoic w/ irregular or thick borders around a central anechoic area

• may contain hemorrhage

• demonstrates peripheral blood flow → “Ring of Fire” sign

Corpus Luteum “Cyst” signs / symptoms:

• pain

• nausea

• vomiting

• enlarged, tender ovary

Theca Lutein Cyst AKA:

Hyperreactio luteinalis

Theca Lutein Cyst

• largest of functional cysts

• may range in size from 3-20 cm

• multiloculated, bilateral fluid filled

• patients will have high hCG levels

• often associated with Gestational Trophoblastic Disease (Molar Pregnancy)

Theca Lutein Cyst

• May be seen with ovarian hyperstimulation syndrome

  • complication of infertility drug therapy

• will persist for several months after trophoblastic evacuation

• like other cysts, may undergo hemorrhage, torsion, or rupture

Theca Lutein Cysts tend to appear:

• Multi-loculated

• thin-walled

• large

• bilateral

Hemorrhagic Cyst

• Any type of cyst may become hemorrhagic

• Bleeding within the cyst

• Typical with follicular or corpus luteal cysts

• Will vary in US appearance

  • stage of bleed

  • internal debris

  • septations

  • free fluid

Polycystic Ovarian Disease (PCOS)(PCOD)

• Most common androgen disorder

• Endocrine Disorder

  • Obesity

  • Oligomenorrhea

  • Anovulation

    • Caused by thick capsule covering ovary

  • Hirsutism

  • Infertility

  • Hypertension

  • Insulin Resistance and/or increased risk of Diabetes

Polycystic Ovarian Disease AKA:

Stein-Leventhal Syndrome

PCOS U/S appearance:

• Bilateral enlargement

• Contain multiple (12 or more), tiny peripheral cysts 2-9 mm

• Ovarian volume >10 cm

• 25% of pt’s have normal appearing ovaries

• The US appearance of PCOS may appear in women whose ovaries are treated with FSH

• “String of Pearls” or “Black Pearl Necklace”

Benign Cystic Teratoma AKA:

Dermoid or Dermoid Tumor

Benign Cystic Teratoma

• Most common germ cell tumor of the pelvis

• Most frequently visualized ovarian tumor in women under 20

• Made from same germ cell layers that make up hair, skin, glandular tissues, bone, and fat

• malignancy is rare

Benign Cystic Teratoma characteristics:

• Usually asymptomatic, but may present with pain or palpable mass

• Teratomas may twist, butt rarely rupture

• Bilateral in 10-15% of cases

Benign Cystic Teratoma treatment:

• surgical treatment

• young patients → wait to preserve function of ovary

• can usually remove tumor without removing entire ovary

Benign Cystic Teratoma U/S appearance:

• varies

• cystic mass

• complex mass w/ calcifications

• fat-fluid level within complex mass

• diffusely echogenic mass w/o shadowing

• predominantly solid with echogenic foci that represent calcium or fat with or without shadowing

• “Tip of the Iceberg”

Epithelial Tumors

• Arise from ovarian epithelium

• Includes:

  • Serous Cystadenoma

  • Mucinous Cystadenoma

  • Brenner Tumors

  • Clear Cell

  • Mixed Epithelial

Serous Cystadenoma

• Most common type of ovarian cystic tumor

• Seen mostly in post-menopausal women (both types)

• Contains thin serous fluid

• Usually unilocular

• May have thin septations

• May have papillary projections

• Bilateral - 25% of the time

Mucinous Cystadenoma

• Contains thicker, mucinous fluid

• More frequent chance of malignancy

• Usually multi-locular

• VERY LARGE! ( may reach up to 30 cm)

• multiple septations

• may contain debris

• bilateral in <5% of cases

Brenner Tumor

• Solid ovarian tumors

• 2% of all ovarian neoplasms

• Arise from ovarian epithelial surface

• Seen at any age → but usually around 50

Brenner Tumor signs / symptoms:

• may be asymptomatic

• pelvic mass

• pain

• abnormal uterine bleeding

Brenner Tumor U/S appearance:

• usually unilateral

• solid, hypoechoic

• microscopic to 30 cm in size

• Can be associated w/ Meigs Syndrome

Meigs syndrome

Ascites, pleural effusion, and ovarian neoplasm

Granulosa Stromal Cell Tumors

• Hormone producing

• Least common

• Include:

  • Fibromas

  • Thecomas

  • Granulosa Cell Tumors

Ovarian Fibroma

• 5% of all ovarian tumors

• ages 50-60

• usually unilateral - but may be multiple

• appear hypoechoic with shadowing

• 5-16 cm

• can also be associated w/ Meigs Syndrome

Thecoma AKA:

Fibrothecomas

Thecoma

• Estrogen-producing

• Solid

• 1-2% of ovarian tumors

• Abnormal uterine bleeding due to estrogen

• Usually unilateral

• May measure up to 30 cm

• Most frequently occur in post-menopausal women

• Shadowing is common

Sertoli-Leydig Cell Tumors AKA:

• Sertoli-stromal cell tumors

• Arrehnoblastoma

• Androblastoma

Sertoli-Leydig Cell Tumors

• Masculinization effects from elevated testosterone levels

• Unilateral

• Very rare

• Pain or abdominal swelling

• Young women <30 y/o

• Solid echogenic mass

• Can be malignant

Ovarian Remnant Syndrome

• Had ovary removed, but some ovarian tissue is left

• This tissue may develop cysts or tumors

Paraovarian Cyst / Paratubal Cyst

• Arise in broad ligament

• Asymptomatic unless hemorrhage

• Simple, thin walled unilocular cysts up to 18 cm

• Size does not change based on menstrual cycle