Unit 2 Part 2

Imperforate hymen

Most common congenital anomaly of the female genital tract

Obstruction

____________ due to an imperforate hymen may result in hydrometrocolpos, hemtometrocolpos, or pyometrocolpos

Gartner’s cyst

Most common cystic lesion of vagina, occasionally causes obstruction

Sonographic appearance of a Gartner’s Cyst

Simple cyst on lateral or anterior wall

Rhabdomyosarcoma

Rare malignant tumor, most common soft tissue tumor in children; most common in head, neck, congenital tract, arms, and legs

Appearance of Rhabdomyosarcoma

Grape like cluster protruding from the vagina

Vaginal adenocarcinoma

Rare malignancy, DES pregnancy exposure

Sonographic appearance of vaginal adenocarcinoma

Solid appearance, occasional areas of necrosis

Staging

Sonography is specifically used in the role of ____________ cancers

Vaginal cuff

Result S/P hysterectomy, hysterectomy usually removes cervix and this is what’s left over

Partial hysterectomy

Removal of the uterus and cervix

Total hysterectomy

Removal of the uterus, cervix, and ovaries

Post radiation fibrosis

Mass resulting from radiation

Pathologic collections in the cul-de-sac

Blood resulting from ectopic pregnancy, hemorrhagic cyst, or pus resulting from infection; ascites, abscess, hematoma

Nabothian cyst

Cyst in the cervix, common, presents in middle age, usually < 2cm

Sonographic appearance of nabothian cysts

Cyst, usually not measured unless getting large or complex in nature

Cervical polyp

Hyperplastic protrusion of endocervix or ectocervix, penduculated or broad based; caused by chronic inflammation

Bleeding

Cervical polyp commonly causes abnormal _________ due irritation

Leiomyoma (cervical)

Benign mass, small % originate at cervix, pedunculated, another word for fibroid

Sonographic appearance of leimyomas (cervical)

Varying in echotexture, within cervical tissue, pendunculated, internal protrusion

Cervix

Leiomyomas may get in the way of the __________, it is monitored in pregnancy to eval if it will get in the way of delivery

Cervical stenosis

Premenopausal acquired condition, obstruction at either internal or external os; caused by prior instrumentation, childbirth, surgery, CA, or irradiation

Sonographic appearance of cervical stenosis

Fluid filled uterus as a result

Cervical stenosis symptoms

Asymptomatic, Oligomenorrhea, polymenorrhea, dysmenorrhea

Squamous cell carcinoma

Most common type of cervical CA, when full thickness of epithelium is composed of undifferentiated neoplastic cells it is considered carcinoma in situ

HPV

_____ infections are precursors to cervical carcinoma

8

Cervical carcinoma is the #__ cause of death for women

Sonographic appearance of cervical carcinoma

Areas of increased echogenicity, hypoechoic areas with an irregular outline, invasion of surrounding structures

CT/MRI

Forms of imaging used to stage cervical carcinoma, lymphnodes

Stage 0 Cervical CA

Early, confirmed to surface of cervix

Stage I Cervical CA

Greater than 90% still confined and not spread

Stage II Cervical CA

Approx 60-80% still confined, remaining has spread

Stage III Cervical CA

Approx 50% is still confined, 50% has spread to other areas

Stage IV Cervical CA

Less than 30% is confined, it has spread massively to the body

Cervical cuff

Remaining after a hysterectomy if the cervix is left, typically not left anymore due to the possibility of developing cervical CA

Uterine enlargement differentials

Pregnancy, PP, leiomyoma, adenomyosis, Bicornuate or didelphic uterus

Thickened endometrium differentials

Early intrauterine pregnancy, endometrial hyperplasia, retained products of conceptions, miscarriage, trophoblastic disease, endometritis, adhesions, polyps, inflammatory disease, endometrial carcinoma, tamoxifen

Endometrial fluid differentials

Endometritis, retained products of conception, PID, and cervical obstruction

Uterine leiomyoma

“Fibroid” or “myoma”, most COMMON gyn tumor, 20-50% women in reproductive age group, more prevalent in younger African American women,

Sonographic appearance of uterine leiomyoma

Typically hypoechoic, can be isoechoic, degeneration may occur making them complex, can have multiple, can have a pseudocapsule

Estrogen

Uterine leiomyoma growth is stimulated by ____________

Estrogen

Uterine leiomyoma growth is stimulated by ____________

Infertility

___________ can occur if fibroids are obstructing tubes, birth canal, or growth in general during pregnancy.

Uterine leiomyoma symptoms

Enlarged uterus, irregular uterus, pelvic pressure, pain (degeneration, torsion, infection), irregular, menorrhagia

Uterine Leiomyoma Classifications

Submucosal, intramural, subserosal

Submucosal

Classification of uterine leiomyoma in the endometrial canal, deforms the endometrial canal, may cause irregular or heavy bleeding

Intramural

Classification of uterine leiomyoma within the myometrium, most common, the endometrium is undisturbed

Subserosal

Classification of uterine leiomyoma that protrudes outward, irregular border appearance, may effect adjacent organs

Pedunculated

A _____________ uterine lieomyoma is considered extrauterine

Protocol for Uterine Leiomyomas

Routine uterine imaging, 3 dimension measurements (LxHxW), location to uterus, location to endometrium, endometrial impingement, endometrial thickness, texture/echogenicity, color dopp/power dopp

Treatment options for uterine lieomyomas

• Surgery by myomectomy (if infertility and Submucosal)

• If for menorrhagia- hormone suppression, endometrial ablation, uterine artery embolization (UAE), or high intensity focused ultrasound (HIFU)

• Ablation etc is NOT ideal for individuals who want to carry a pregnancy

Lipoleiomyoma

Fatty fibroid, benign, uncommon, typically asymptomatic

Sonographic appearance of Lipoleiomyoma

Highly echogenic, attenuating mass, hard to visualize posterior to the mass, typically within the myometrium, abscence of color flow

Calcifications

Fibroids are the #1 cause of uterine _____________

Adenomyosis

Endometrial tissue within the myometrium, confined to the uterus (internal endometriosis)

Posterior

Most common site of adenomyosis is in the ____________ uterus

Sonographic appearance of adenomyosis

Can be difficult to distinguish from fibroids, areas of cystic necrosis, heterogenous and enlarged posterior uterus, endometrium may be difficult to differentiate from the myometrium

Diffuse

___________ adenomyosis is more common than focal

Painful

Adenomyosis can be difficult to differentiate from fibroids, but it tends to be more _________ to patients.

AVM (Arteriovenous malformation) of the Uterus

Rare condition, has a network of arteries and veins in the myometrium

Hemorrhaging

AVM diagnosis is critical, as instrumentation can cause catastrophic ________________

Sonographic appearance of AVM of the uterus

Heterogenous myometrium, has color mosaic with color dopp (looks like you need to turn your color gain down)

Uterine Leiomyosarcoma

Rare malignant tumor that arises from the myometrium or endometrium, rapid growth of existing fibroid, less than 5% of all uterine CA, impacts 40-60 yr old women

Sonographic appearance of uterine leiomyosarcoma

Enlarged uterus, fundal area most common, heterogenous hypoechoic mass, hard to differentiate from a degenerating fibroid

Endometrial hyperplasia

Abnormal cell growth of the endometrium causing massive thickening, caused by unopposed estrogen

14 mm or more

Premenopausal endometrial hyperplasia measurement

8 mm

Asymptomatic postmenopausal endometrial hyperplasia measurement

15 mm

Sequential estrogen & progesterone endometrial hyperplasia measurement

Endometrial CA

Endometrial hyperplasia is a possible precursor of ______________ ____

Endometritis

Inflammation/infection of the endometrium, either from PID or PP

Sonographic appearance of endometritis

thickened endometrium, irregular endometrium, endometrial fluid, “Gas”, retained tissue

Synechiae

Asherman syndrome, fibrous adhesions across the endometrial cavity, walls become adhered to each other; usually arises from hx of D&C, abortion, etc

Sonographic appearance of Synechiae

Bright echoes within the endometrial cavity, adhesions (almost look like calcifications), typically found in pregnancy due to fluid

Endometrial adenocarcinoma

Perimenopausal CA of the endometrium, usually not caught until later or once metastasized to other parts of the body

Sonographic appearance of endometrial adenocarcinoma

Thickened endometrium, mixed echoes, uterine enlargement with lobular contour, endometrial fluid collections; < 5mm used to r/o CA, <3 mm is 98% specificity for non-cancerous

Endometrial adenocarcinoma sx

Biggest indicator is bleeding, can present with abd pain in advanced stages

Endometrial CA Stage I

Endometrial adenocarcinoma that is confined to teh endometrium

Endometrial CA Stage II

Endometrial adenocarcinoma that has spread from endometrium into cervix

Endometrial CA Stage III

Endometrial carcinoma that has spread to pelvic area lymph nodes, extended through serosal layer

Endometrial CA Stage IV

Endometrial adenocarcinoma that has spread to other organs, extension into bladder and bowel, distal lymph nodes

> .5

High resistance flow in postmenopausal patients have an RI of __ ___

< .4

Low resistance flow will present in endometrial CA have an RI of __ ____

< 2 mL

__ ___ __ of fluid in the endometrium is considered normal

Large amount of endometrial fluid causes

PID, pyometra, hematometra, CA’s, cervical stenosis, congenital anomalies

IUD

Device that prevents implantation, may act as a spermicidal agent, can be misplaced due to a tilted uterus

Sonographic appearance of an IUD

Echogenic linear appearance within the endometrium, perpendicular placement of sound beam, acoustic shadowing; important to document, take 3D image to eval placement, will need to measure the endometrium lat to it

Risks associated with IUDs

Ectopic pregnancy, PID, tuboovarian abscess, can cause ovarian cysts

Uterine prolapse

Downward displacement of the uterus into the vaginal canal

First degree prolapse

Prolapse where cervix at lower vagina

Second degree prolapse

Prolapse where cervix is at the vaginal opening

Third degree prolapse

Prolapse where uterus protrudes through the introitus

Causes of prolapse

Stretching of muscle/fibrous tissue, increased intra-abd pressure, menopause/aging (decrease in estrogen)

Treatment options for prolapse

Surgical repair of supporting tissue, hysterectomy; prevention of kegels and early detection