imaging in women's health (DM)_

Uses for Hysterosalpingogram (HSG)

Used to image uterus and fallopian tubes

Used after some sterilization procedures to verify that the tubes are blocked

Indication for HSG imaging

Submucous fibroids

Endometrial polyps

Localization of tubal occlusion

Uterine anomalies

Infertility evaluation

What are pre-op recommendations of HSG

Have procedure done during the first half of the cycle (Follicular / Ovulation) to reduce pregnancy chance

Recommend NSAIDs 1 hour prior to reduce cramping with dye

Hysterosalpingogram (HSG)

Water soluble contrast medium is injected into uterine cavity by cannula/tube

Speculum removed and films are taken

Cannula/tube removed after films are taken

What is a common symptoms to HSG

Vaginal discharge (contrast medium)

Slight vaginal bleeding

Uterine cramps

Dizziness and nausea may occur

Complications of doing HSG

Vomiting

Fainting

Heavy vaginal bleeding

Severe abdominal pain

Fever/chills

Normal HSG

Septate Uterus

Asherman’s Syndrome

Biconate Uterus

When are abdominal XR done for Women’s Health

Calcified fibroids

IUD localization

Ovarian dermoid with calcification

IUD

test of choice for imaging of the female pelvic organs

Pelvic ultrasound

How can US be done for women’s health

transabdominal or transvaginal

What is required to do a transabdominal ultrasound for female orgasn

Full baldder

Steps to Transabdominal US

Patient is supine, water-based gel is applied

Transducer is moved over the area of interest in order to capture desired images

What is the function of gel during a US

helps the transducer contact body and eliminate air pockets between transducer and skin

What is required to do a transvaginal ultrasound for female organs

empty bladder

Steps to Transvaginal US

Patient is supine, +/- stirrups

Transducer is placed in the vagina, with a protective cover similar to a condom, water-based lubricant is used

Transducer inserted 2-3 inches in the vagina

Images are obtained from different orientations of the transducer

Benefit of Doing a Transvaginal US over Transabdominal US

Better for an obese patient

Better for early pregnancy confirmation and evaluation

Usually more comfortable than a standard pelvic examination

What is normal endometrial thickness for follicular phase

4-8mm

What is normal endometrial thickness for luteal phase

7-14mm

What is normal endometrial thickness for menopause

< 4mm

When is the best time to perform a pelvic US of the endometrium

Follilcular as endometrium will have the most uniform linear appearance

Uterine Fibroid (US)

What uterine dx may be seen on US but cannot confirm

Adenomyosis

What is the test of choice for imaging ovaries

Transvaginal ultrasound is test of choice,

then CT,

then MRI if further evaluation needed

Indications to US the Ovaries

Ovarian torsion (Doppler)

Ovarian cysts (Simple vs Complex)

Ovarican Cancer (Benign vs Malignant)

On pelvic US, you notice a Homogeneous-appearing mass with low to medium echoes. Most likely

Endometrioma

What are benign findings for pelvic US

Anechoic fluid-filled cyst

Thin walled

Homogeneous-appearing mass with low to medium echoes

Fishnet or reticular pattern of internal echoes

Markedly hyperechoic nodule with shadowing, +/- calcifications

What is considered “thin walled” for a pelvic US mass

< 30 mm in premenopausal

< 10 mm in postmenopausal

Teratoma

hemorrhagic cyst

Fishnet or reticular pattern of internal echoes in pelvic US is most likely

hemorrhagic cyst

Markedly hyperechoic nodule with shadowing on pelvic USis most likely

teratoma

What are malignant pelvic US findings

Solid component, not hyperechoic

Thick septations

Doppler demonstration of flow in solid component

Ascites

Peritoneal masses, enlarged nodes, matted bowel

Sonohysterosalpingogram with saline infusion (SIS)

Saline infusion is performed to distend the uterine cavity
Then the area is imaged by transvaginal ultrasound

Use of SIS

Can be used to measure the endometrium

evaluate endometrial pathology such as polyps and fibroids

Benefits to SIS

Allows for more accurate view

Will show abnormalities of the uterine lining, or uterine cavity

Provides three-dimensional view

Has the potential to replace more invasive diagnostic methods such as hysteroscopy and endometrial biopsy

Can be done in an office setting without use of anesthesia

Downside to SIS

Is painful

Indications for SIS

Evaluation of postmenopausal bleeding

Evaluation of abnormal uterine bleeding

Monitor endometrial thickness

Investigate recurrent pregnancy loss (looking for uterine anomalies)

Evaluate tubal fertility

Preoperative view of uterine fibroids

Uterine Polyps

Indications for MRI of the pelvis

Fibroids, especially malignant degeneration

Adenomyosis

Congenital abnormalities of the uterus

Endometriosis

Adenomyosis

Indications for CT of the pelvis

PID

Adnexal torsion

Hemorrhagic ovarian cysts

Malignancy

When do we typically order MRI of head with coned down view of Sella

Prolactin > 100

Indications of Breast US

Patients under the age of 35

Fibroadenoma

Fibrocystic breasts

Nipple discharge

a well-defined solid mass that has benign appearance on breast US is most liekly

Fibrocystic breast changes

Fibroadenoma

Imaging of choice for screening for breast cancer

Mammography

When can mammography see changes suspicious for malignancy

2 years before lesion is palpable

normal mammography in a patient with a palpable breast mass needs a

Biopsy

Why is compression needed in mammography

Compression of the breasts during the procedure spreads out normal tissue of the breast

This allows the radiologist to see through the breast tissue and locate abnormalities easier

Compression also helps reduce motion artifacts (movement or breathing motions)

What views are done in screening mammography

Craniocaudad

mediolateral

When is screening mammography used

Screening in asympatomatic patients

When is diagnostic mammography used

Breast complaint

Hx of Breast Cancer

Mammography is always done

Bilaterlay

What views are done in diagnostic mammorgraphy

Craniocaudad and mediolateral done with spot compression views

Computer aided detection (CAD)

technology using a computer that will pick up mammographic patterns

Used to help radiologist identify suspicious areas

BI-RADS

A classification system for breast assessment on mammography

• 0 → Incomplete

• 1 → Normal

• 2 → Benign

• 3 → Likely benign

• 4 → Suspicious

• 5 → Highly suggestive

• 6 → Biopsy proven carcinoma

IBIS (International Breast Cancer Intervention Study) / Gail model and Tyrer-Cusick prevention model

risk determination tool for breast cancer

All recommendations start what age group should be screened for breast canceer

50-69

Indications for MRI of breast

Known BRCA1 or BRCA2 gene mutation

first-degree relative BRCA1 or BRCA2 gene mutation and have not had genetic testing

lifetime risk of breast cancer of 20-25% or greater

Radiation therapy to the chest between the ages of 10 and 30 years

Li-Fraumeni syndrome,

Cowden syndrome,

Bannayan-Riley-Ruvalcaba syndrome,

syndromes in first-degree relatives

Most common noninvasive diagnostic test used in pregnancy

Prenatal ultrasound

What information can be obtained from prenatal US

Confirm intrauterine pregnancy

Confirm presence of fetal heartbeat

Diagnose multiple gestation

Estimate gestational age

Screen for fetal structural anomalies

To measure fetal growth

If fetal heart tones are not auscultated by 11-12 weeks, what should be done

Prenatal US to confirm viable pregnancy

When is the best time to assess gestational age and growth by US

1st Trimester

What is the use for Doppler in prenatal US

at velocity of blood in fetal and placental vessels

Fetal anatomy best evaluated on US during

2nd trimester

Most routine US for prenatal are done during

2nd trimester

Uses of 3rd trimester US

Fetal anatomy best evaluated during

Monozygotic twins

Started from one single zygote

Identical

Dizygotic twins

Start from two zygotes

Fraternal

Monochorionic/monoamniontic twins

Share a single amnion and single chorion

Monochorionic/diamniotic twins

Have separate amnions and share a single chorion

Dichorionic/diamniotic

Have separate amnions and separate chorions

All dizygotic / franteral twins are what type of twin

Dichorionic/diamniotic

Intrauterine pregnancy can be seen with vaginal ultrasound when βhCG is

>1,500

Intrauterine pregnancy can be seen with abdominal ultrasound when βhCG is

>6,000

Concerning findings for ectopic pregnancy on US

Empty uterus with thick-walled adnexal mass separate from the ovary (95%)

Empty uterus with complex adnexal mass with solid and cystic components (70%)

Empty uterus with moderate-large amount of fluid in cul de sac (50%)

A thin-walled cyst arising from the ovary is usually a simple corpus luteum cyst

Signs of true intrauterine pregnancy

(Double Ring Sign)

Presence of an embryo in the gestational sac in the uterine cavity

Presence of a yolk sac in the intrauterine sac

Intradecidual sign

Seen before 5 weeks of gestational age,

It is a small anaechoic sac on either side of the central endometrial echo within the thickened decidua

Sign of intrauterine pregnancy

Double decidual sign

Occurs after 5 weeks

This is a hyperechoic ring (the decidual capsularis) surrounded by another hyperechoic ring (the decidual paretalis)

Sign of intrauterine pregnancy

a heterotopic pregnancy

Pregnancy in the uterus and ectopic at the same time

Risk factor for heterotopic pregnancy

IVF

Amniotic fluid index (AFI)

total linear measurement (in cm) of the largest amniotic fluid pockets in each of the four quadrants

Oligohydramnios

•reduced amniotic fluid volume (AFI<5cm)

Polyhydramnios

excessive amniotic fluid volume (AFI >20cm)