terminology & tests
Menstrual Terminology
Monarchy (historical term for menarche) and its etymology
meno = month; arche = beginning; therefore first menstruation or first monthly flow
Menstruation (Latin menstrualis) = monthly period
Puberty
Involves monarchy (menarche) plus appearance of secondary sexual characteristics (body hair, hip broadening, breast development)
Reproduction becomes possible with puberty; monthly ovulation is expected with monarchy in theory
Precocious puberty
Puberty and menarche occurring before age
9 years is the typical lower bound; puberty before 9 is termed precocious puberty
Premature vs precocious terminology
Precocious: puberty before the usual age (e.g., before 9)
Premature: occurring before the usual time (synonymous in some contexts here, but keep context-specific definitions in notes)
Menopause
End of reproductive years; defined as 12 consecutive months without menses after which menopause is confirmed
Mentions that menopause is a “rest” from menstruation; should not resume thereafter
Perimenopause
The transition period around menopause; bleeding patterns can be unpredictable (stopping and starting; heavy or light bleeding fluctuations)
Amenorrhea (absence of menses)
Prefix a- = without/not; “meadow” relates to menstruation; therefore amenorrhea = without monthly flow
Primary amenorrhea: no menarche by expected age; e.g., delayed onset; gymnasts with low body fat may have delayed monarchy due to lower estrogen
Secondary amenorrhea: prior menstruation but cessation for ≥
Physiologic amenorrhea: normal bodily states causing absence of menses (pregnancy, lactation, postmenopausal state)
Normal menstrual cycle definition (in this course)
Normal cycle length: 28 days
Bleeding window: roughly 5 days within the cycle
Annual cycles: about 13 cycles per year (based on 365 days)
Abnormal menstrual cycle terms by frequency and duration
Polymenorrhea (poly- = many): cycle length < 21 days; many cycles per year (≥ ~17 per year)
Oligomenorrhea (oligo- = few): cycle length > 35 days; ≤ ~10 cycles per year
Abnormal flow and duration terms
Hypomenorrhea: ↓ menstrual blood flow or shorter periods; bleeding volume is below normal
Hypermenorrhea/menorrhagia: ↑ menstrual blood flow; more blood during the cycle
Metrorrhagia (metrorrhagia/menometrorrhagia) = irregular/spotty bleeding between periods or longer/irregular bleeding
Menometrorrhagia: combination of heavy flow and bleeding between cycles (longer and heavier cycles)
Painful periods
Dysmenorrhea: painful menstruation (cramps)
Primary dysmenorrhea: painful periods with no identifiable cause
Secondary dysmenorrhea: painful periods with identifiable pathology (e.g., endometriosis)
Endometriosis and example discussion
Ectopic endometrium tissue responds to ovarian hormones; can cause severe dysmenorrhea; example anecdote about patient describing painful periods
Quick review prompts (sample questions appearing in slides)
One year after last menstrual period term: menopause
Shorter or lighter periods: hypomenorrhea
Excessive flow and bleeding between periods: combine terms such as meno- and metro- terms to describe the situation
Painful periods: dysmenorrhea
Excessive flow with normal duration: hypermenorrhea or menorrhagia depending on context
Longer period with heavy bleeding: metroraja (metrorrhagia with heavier blood volume)
Summary of cycle terminology
28-day cycle; typical bleeding window ~5 days; 13 cycles/year
Polymeria: more frequent cycles per year; cycles < 21 days
Oligomenorrhea: fewer cycles; cycles > 35 days; ≤10 cycles/year
Hypermenorrhea/menorrhagia: extra blood per day or overall more blood; metroraja: longer or bleeding between periods
Dysmenorrhea: painful periods; primary vs secondary; endometriosis is a common secondary cause
Gynecological History
Purpose of gynecological history
Identify why ultrasound is ordered (clinical question) and any previous results
Gather context for the test beyond what the requisition states
Sources of information
Requisition: lists the test and indications (e.g., hypermenorrhea); not always perfectly accurate
Medical chart: hospital records; prior tests and interventions
Patient interview: essential for context; helps tailor the exam and internal examination decisions
Role-play example: messy history writing by support staff may misrepresent clinical findings; always verify with patient
Requisition example and cautions
Requisition may state a diagnosis such as hypermenorrhea or other terms; do not assume the term is accurate—verify with patient and chart
Importance of patient conversation and listening
Speaking with the patient can uncover important details missed on forms
The goal is to obtain a complete clinical picture while respecting patient comfort
Information access in hospital systems
PACS: Picture Archiving and Communication System; stores imaging (MRI, CT, X-ray, ultrasound) and allows cross-site viewing of prior studies
Access levels may vary; in many places, clinicians can access prior ultrasound, MRI, etc., to guide current ultrasound interpretation
Requisites and exam workflow notes
Examples of information you might collect include age, reproductive history, prior pregnancies, prior surgeries, medications, and family history where relevant
Always prioritize patient safety, consent, and privacy; do not assume information is accurate from forms alone
Reproductive History: Gravity, Parity, and GTPAL
Key definitions
Gravity (G): number of pregnancies, including the current one if applicable
Parity (P): number of pregnancies that reached viability (roughly 20–24 weeks) and resulted in a birth, regardless of live birth status
Viability threshold used in notes: generally around 20–24 weeks for counting parity
Simple method: G and P
Example: G2P2 means two pregnancies with two pregnancies reaching viability (live or stillborn), previous pregnancies counted, current pregnancy not yet included in parity
Important caveat: parity does not count non-viable pregnancies; twins count as a single parity event
GTPAL method (more detailed)
G = Gravidity (all pregnancies, including current)
T = Term deliveries (> 37 weeks)
P = Pre-term deliveries (between 20 and 37 weeks)
A = Abortions (pregnancies ending before viability, historically < 20 weeks; some contexts use <= 20 weeks)
L = Live births (number of living children at birth; not the number of pregnancies)
Practical notes and examples
Current pregnancy: counted in G but not in P/T/A/L until viability is confirmed
Ectopic pregnancy: pregnancy status is counted in G but viability for parity is not assumed; ectopics are rarely viable
Stillbirth: counted as a pregnancy for G but not as a live birth (L)
Miscarriage: counted as an abortion (A) if occurring before viability; not a live birth
Twin pregnancies: one pregnancy event but parity may reflect number of live births; per hospital policy, parity can be counted as one or more depending on system conventions (often one for parity despite twins)
Example walkthroughs
Simple method example: a patient not currently pregnant with two prior singleton pregnancies and two live births would be G2P2
Current pregnancy example: if a patient is pregnant and had two prior pregnancies with two live births, the GTPAL string might reflect G3T2P0A0L2 depending on outcomes; the precise formatting varies by institution
Ectopic pregnancy example: a patient with a prior ectopic pregnancy (not viable) would still have GxP0A1 in certain contexts; GTPAL would reflect A for abortion/miscarriage; L remains the count of live births
Important clinical note
Different institutions may record parity differently (e.g., some count twins as one pregnancy for parity; others count based on outcomes). Manitoba practices (as described) count parity as the number of pregnancies that reached viability, not the number of live births
Always confirm reproductive history coding with the clinical site and the patient to ensure consistent interpretation
Menstrual History
Core questions in menstrual history
When did the last normal menstrual period begin? Start date anchors the counting clock
Do you have a regular cycle? Regularity; timing consistency
How long do you bleed? How heavy is the flow? Is there spotting?
Any associated symptoms (pain, mid-cycle ovulation symptoms, etc.)
Pregnancy status and prior pregnancy history when relevant
Practical approach
Start the 28-day cycle clock at the first day of bleeding to standardize cycle calculations
Consider cycle irregularities when planning imaging and interpretation
Use the information to contextualize ultrasound findings (e.g., ovulatory status, endometrial thickness expectations)
Pregnancy Tests: Urine vs Blood (Qualitative vs Quantitative)
Types of tests
Urine pregnancy test (qualitative): detects presence or absence of hCG; usually reported as positive/negative or +/-
Blood pregnancy test (serum): beta-hCG quantitative; reports concentration in ext{mIU/mL}; uses International Units (IU)
Key concepts
hCG (human chorionic gonadotropin) is produced by trophoblastic cells; rises after fertilization and implantation
Urine tests are qualitative (yes/no for pregnancy hormone)
Serum tests are quantitative (provides a numeric concentration of hCG; helps track pregnancy progression)
Units and standard references
hCG concentrations are reported in ext{mIU/mL} (often written as mIU/mL or mIU/mL)
International Reference Preparation (IRP) vs Second International Standard affect numeric values; a table value may be double depending on the standard used
If a lab reports 2,000 mIU/mL using IRP, the corresponding value with Second International Standard would be ~1,000 mIU/mL; always check the standard used
Discriminatory zone (β-hCG) for intrauterine pregnancy visualization by EVS (endovaginal sonography)
Commonly cited threshold around 1,700 to 2,000 ext{ mIU/mL} (values vary by source)
If β-hCG is ≥ the discriminatory zone and no intrauterine gestational sac is seen on ultrasound, consider ectopic pregnancy or very early intrauterine pregnancy; correlation with clinical signs is essential
Gestational timing and ultrasound correlation
Gestational sac in uterus (intrauterine) generally visible by EVS when β-hCG is above the discriminatory zone
EVS detection of an intrauterine gestational sac is typically around 4.5 ext{ weeks} to 5 ext{ weeks} post-fertilization, though individual variation exists
When results are available and interpretation tips
Qualitative urine tests: positive means pregnancy is present; negative means not pregnant at that time
Quantitative serum β-hCG: track the concentration over time; normally doubles every 2–3 days in early pregnancy; plateauing or slower rise may suggest non-viable pregnancy, ectopic pregnancy, or other complications
Serial measurements help determine pregnancy viability and progression
Practical notes for sonographers
Ask patients about whether pregnancy tests were performed, and whether results are urine-based or blood-based
If blood-based, note the concentration and date; compare with expected doubling timeline
If an early pregnancy is suspected but ultrasound is negative, consider the discriminatory zone and repeat testing as indicated
Home pregnancy tests
Typically qualitative; widely available; accuracy around ~99 ext{ extpercent} when used correctly
Sensitivity varies and user error can reduce accuracy; early testing may give false negatives; follow-up testing recommended if suspicion remains
Blood test specifics and interpretation
Beta-hCG quantitative tests provide a numeric value rather than a binary result
Values reported as ext{mIU/mL}; lab-specific references (IRP vs second standard) affect the numeric value
The beta-hCG trend is more informative than a single value; trend helps identify normal progression, miscarriage, or ectopic pregnancy
Quick practice questions (conceptual)
Qualitative pregnancy tests measure presence/absence of hCG in urine
Quantitative pregnancy tests measure concentration of hCG in the blood
Beta-hCG is reported as the beta subunit in front of hCG, i.e., eta ext{-hCG}
Palpable Masses in the Pelvis
What is a palpable mass?
A mass that can be felt during physical examination (palpation); in ultrasound settings, palpation helps localize and characterize the mass for imaging
Common palpable pelvic masses
Myoma (fibroid): benign uterine mass composed of smooth muscle and collagen; often intra- or extra-uterine; can be pedunculated and palpable; sometimes mistaken for pregnancy
Ovarian masses: e.g., septated cysts (internal septations); could be palpated if large enough
Hydrosalpinx: fluid-filled fallopian tube; may be palpable if enlarged
Pelvic kidney: kidney located in the pelvis rather than in the upper abdomen; palpable as a mass
Sonographic approach to palpable masses
Confirm presence of the mass with the transducer at the palpated location
Determine origin: uterus vs ovary vs other structures
Assess morphology: cystic vs solid; measure size; evaluate for septations or complex features
Use Doppler to evaluate vascularity
Check for associated findings (e.g., hydronephrosis if mass causes ureteral obstruction)
Quick reference prompts
Palpable mass composed of smooth muscle or connective tissue in the uterus = myoma (fibroid)
Palpable mass identified as a fluid-filled tubular structure = hydrosalpinx or hydrocele extension
Palpable mass in the pelvis associated with an empty renal fossa = pelvic kidney
Palpable mass identified as a pregnancy-filled tube = ectopic pregnancy
Pelvic Pain: History and Differential Diagnosis
Broad differential and context
Right lower quadrant pain: appendicitis (as a differential; consider other GI or gynecologic etiologies)
Ovarian torsion: twisting of the ovary on its stalk, leading to acute pain and potential loss of ovarian function if not promptly treated
Pelvic inflammatory disease (PID): infection of uterus, fallopian tubes, ovaries; fever and leukocytosis may be present
Endometriosis: ectopic endometrial tissue; cyclical pain; can cause infertility and pelvic pain
Ectopic pregnancy: pregnancy implanted outside the uterus; can cause pain and bleeding; requires urgent evaluation
Specific conditions and signs
Appendicitis: RLQ pain near the appendix; can mimic ovarian etiologies
Ovarian torsion: sudden, severe unilateral pain; often with adnexal mass and decreased Doppler flow; urgent management is required
PID: fever, leukocytosis; lower abdominal pain, cervical motion tenderness; may lead to adhesions and infertility if untreated
Endometriosis: cyclic pain; dyspareunia; potential infertility; may be challenging to diagnose without laparoscopy
Practical clinical approach
Obtain location, duration, intensity, and quality of pain; determine whether it is constant or intermittent
Identify whether there is a palpable mass, menstrual timing correlation, or relation to intercourse (dyspareunia)
Assess for pregnancy status and signs of pregnancy or abortion risk
Consider associated symptoms (fever, nausea, vomiting, vaginal discharge) and prior similar episodes
Pre-Existing Pathology and Surgery History
Pre-existing conditions relevant to imaging
Ectopic pregnancies (prior): may affect current risk and imaging interpretation
PID history or endometriosis history: informs likelihood of adhesions, endometriotic implants, and pelvic pain patterns
Assisted reproductive technologies (ART): IVF etc.; treatments can impact ovarian appearance (multifollicular ovaries during stimulation)
Diethylstilbestrol (DES) exposure in utero: can cause abnormally shaped uterus and cervical anomalies; relevant in interpretation of uterine anatomy
Asherman syndrome: uterine adhesions that can affect imaging and reproductive outcomes
Common surgical histories with gynecologic relevance
Endometrial ablation: destroys endometrium to reduce heavy bleeding; may impact endometrial thickness on ultrasound and future imaging
Hysterectomy: removal of uterus; imaging focus shifts away from uterine body; possible residual masses or omental adhesions
Oophorectomy: removal of the ovaries; affects ovarian size and hormonal milieu; may eliminate ovulation imaging patterns
Salpingectomy: removal of a fallopian tube; can alter tubal anatomy and drainage patterns
Myomectomy: removal of fibroids while preserving uterus; changes uterine contour and potential adhesions
Metroplasty (uteroplasty/hysteroplasty): reconstructive surgery for uterine septum to improve pregnancy outcomes
Salpingostomy: opening the tube to remove an ectopic pregnancy while preserving the tube; can have future fertility implications
Cesarean section (C-section): uterine scar that can impact future pregnancies and ultrasound assessment
Cerclage (cervical suture): stabilizes the cervix in cases of incompetent cervix; may influence internal examination and ultrasound planning
Practical implications for ultrasound practice
Knowledge of prior surgeries guides expectations for anatomy, potential adhesions, and risk of certain pathologies
Some surgeries (e.g., hysterectomy) may limit evaluation of the uterus; shift focus to adnexa or pelvic region
Understanding prior interventions helps anticipate post-procedure anatomy and residual structures
Medications and Hormonal Treatments (Hx: Medication)
Tamoxifen (used for breast cancer)
Can stimulate endometrium and increase endometrial thickness, potentially causing thick cystic endometrium on ultrasound
Important to document if patient has a history of breast cancer and tamoxifen use; can influence endometrial appearance
Infertility medications
Clomiphene (Clomid) and Pergonal (human menopausal gonadotropin) can cause multiple follicle development and ovarian hyperstimulation syndrome (OHSS)
Ultrasound may show enlarged ovaries with multiple small follicles during stimulation
Oral contraceptives (birth control pills)
May result in a thinner endometrium and suppression of dominant follicle development
Practical considerations
Document current medications and relevant past medications that influence uterine or ovarian appearance or cycle characteristics
Gynecological Tests and Procedures (Overview of Tests)
Pregnancy tests
Remove patient ambiguity about pregnancy status; CBS includes urine (qualitative) and blood (quantitative) tests
Culdocentesis (caldocentesis)
Posterior cul-de-sac aspiration for fluid collection; used in specific diagnostic scenarios
Laparoscopy
A camera inserted through a small abdominal incision to visualize the peritoneal cavity; gold standard for diagnosing endometriosis and adhesions
Cervical pap smear (Pap smear/test)
Cells scraped from the cervix; used to detect cervical dysplasia and HPV-related changes; often followed by colposcopy if abnormal
Colposcopy
Visual examination of the cervix using a colposcope; allows targeted biopsy if abnormalities are seen
Hysteroscopy
Visualization of the uterine cavity with a scope introduced via the cervix; can diagnose intrauterine pathology
Dilation and Curettage (D&C)
Cervical dilation followed by scraping of endometrium; used for diagnostic sampling or removal of tissue after events like miscarriage
Endometrial biopsy
Sample of endometrial tissue for histological analysis; used to assess endometrial pathology or hormonal status
Hormonal tests (blood analysis)
Assess estrogen, progesterone, and hCG to inform cycles and pregnancy status
Sono-hysterography (sonohysterography)
Ultrasound performed with intrauterine saline infusion to better delineate the endometrial cavity and detect polyps or submucosal fibroids
Sono-salpingography (sonosalpingography)
Ultrasound assessment of tubal patency using intrauterine or intratubal contrast
Hysterosalpingography (HSG)
X-ray imaging of the uterus and fallopian tubes after intrauterine dye injection; visualizes tubal patency and intrauterine anatomy
Computed Tomography (CT) and Magnetic Resonance Imaging (MRI)
CT: cross-sectional imaging with ionizing radiation; good general imaging; newer CT angiography concepts; e.g., post-fibroid embolization imaging
MRI: no radiation; high-resolution imaging; detailed pelvic anatomy; strong soft tissue contrast; commonly used for complex pelvic pathology
Quick reference for test types (summary)
Quantitative vs qualitative tests; e.g., beta-hCG vs home urine tests
Invasive tests: culdocentesis, laparoscopy, dilation and curettage, hysteroscopy, hyterosalpingography
Imaging-based tests: transabdominal/transvaginal ultrasound; sono-hysterography; sono-salpingography; CT/MRI as needed
Summary: Putting It Together for Practical Ultrasound Practice
Always verify requisitions against patient interview and prior charts
Use the patient interview to shape the exam and to determine whether internal examination is appropriate or necessary
Be aware of common terminologies and their standard definitions in your region (GTPAL vs GTPAL conventions vary by institution)
Recognize that labs and imaging have standardized units and reference ranges; always check units (mIU/mL) and reference preparation (IRP vs Second International Standard)
When evaluating suspected pregnancy, use serial β-hCG measurements to track progression and correlate with ultrasound findings
In cases of pelvic pain or palpable masses, maintain a broad differential; use ultrasound to characterize masses and assess for associated findings (bleeding, adhesions, free fluid, signs of infection or endometriosis)
Understand surgical history’s impact on imaging interpretation and future management options
Develop effective patient communication: ask about sensitive topics (e.g., intercourse pain) in a professional, non-judgmental way to gather necessary data
Be mindful of ethical and practical implications when discussing diagnoses derived from tests (e.g., pregnancy viability, ectopic pregnancy risk, or endometriosis)
Review review questions and practice applying GTPAL and related terminology to clinical scenarios to prepare for exams and real-world interpretation
Appendix: Key Notations and Quick Definitions
28-day cycle; 5 days of bleeding; 13 cycles/year
Polymeria: cycles < 21 days
Oligomenorrhea: cycles > 35 days; ≤ 10 cycles/year
Dysmenorrhea: painful menstruation; primary vs secondary
Metrorrhagia: bleeding between periods; irregular intervals
Menometrorrhagia: heavy bleeding with irregular intervals
Beta-hCG: eta-hCG; measured in ext{mIU/mL}; doubling every 2-3 days early in pregnancy
Discriminatory zone: common threshold around ext{approx. } 1700-2000 ext{ mIU/mL} for visualization of intrauterine sac by EVS
GTPAL: Gravida, Term, Pre-term, Abortions, Live births (detailed parity notation)
GTPAL: Gravida, Term, Pre-term, Abortions, Living children (more granular parity including live births)
Descriptions of tests and terms (abbreviations): HSG, D&C, DES, IVF/ART, DES exposure, Asherman syndrome, endometrium, myoma, fibroid, hydro/ hydrosalpinx, colposcopy, hysteroscopy, sono-hysterography, sono-salpingography