Mala Sibal

Ultrasound in
Gynecology
An Atlas and Guide

123
Ultrasound in Gynecology
Mala Sibal

Ultrasound in Gynecology
An Atlas and Guide
Mala Sibal
Department of Fetal Medicine and Obstetric & Gynecological Ultrasound
Manipal Hospital
Bangalore
Karnataka
India

ISBN 978-981-10-2713-0 ISBN 978-981-10-2714-7 (eBook)

DOI 10.1007/978-981-10-2714-7

Library of Congress Control Number: 2017930417

© Springer Nature Singapore Pte Ltd. 2017

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This book is dedicated to my patients, in whose service I learnt medicine,
and to my husband, Abbas Shad, for his unstinting love and support.
Foreword by Suresh Seshadri

It is indeed a pleasure to pen a few words about this book, which is a felt need in the field of
gynecological ultrasound. This book is the culmination of decades of the author’s experience
and a strong commitment to share the knowledge to the fraternity. The chapters have been
well thought out and give several practice points which can be easily adapted to improve qual-
ity of imaging and reporting. The initial chapters of the book describe not only the basic
techniques in imaging but also advanced techniques like 3D and other innovative methods
like gel sonovaginography. Each chapter has been structured in a simple, comprehendible
fashion. The flow of information has been well thought out which not only makes for easy
reading but also for easy recall. The illustrations are of high quality from the author’s own
body of work. The summary boxes at the end of each chapter give the key points in a nutshell,
which are a ‘must know’.
When any book is written, the one important question that comes to the mind is ‘who is this
book meant for?’ I remember asking the author the same question when she embarked on this
journey. Her answer was ‘to everyone who wants to know about gynecological ultrasound!’
I’m very happy to note that this book has fulfilled her desire as it is written in a way that will
be useful for students, clinicians and imaging specialists alike. This indeed is one of the best
books written on the subject with an international appeal and a ‘must possess’ for any
practitioner.

Mediscan Systems Suresh Seshadri

Chennai, India 07.07.2016

vii
Foreword by Lil Valentin

It is a great privilege for me to have been given the possibility to read this book on gynecologi-
cal ultrasound written by Mala Sibal. It is a book that fulfils the needs of those practicing
gynecological ultrasound and wanting to improve their skills, as well as the needs of those
planning to practice gynecological ultrasound and wishing to learn how to do it and how to
interpret the images.
This book is full of tips and tricks that help improve visualisation of both simple and com-
plex structures. It presents clinically important facts about each type of pathology, and facts are
presented in a concise and structured manner – the structure being the same in all chapters. No
information is redundant. The structured and concise format makes this book very easy to read
and to digest. Last, but not least, there are hundreds of beautiful and instructive ultrasound
images illustrating the typical ultrasound features of each type of pathology. Images are essen-
tial, because one image tells us more than 1000 words.

Lund University Lil Valentin

Lund, Sweden 02.10.2016

ix
Preface

In recent years, gynecological ultrasound has seen rapid advances in new investigative tech-
niques, primarily owing to improved ultrasound technology, imaging equipment and expand-
ing research in the field. There is a need to provide a practical guide and comprehensive atlas
that covers new-found knowledge and novel diagnostic techniques to update and supplement
the limited literature that is currently available. The literature in this field is limited partly
because gynecological ultrasound has historically been in the shadow of obstetric and fetal
ultrasound. There is often a lack of focused effort to follow-up on gynecological cases to vali-
date diagnoses through either surgery or histopathology, due to which definitive developments
have not been rapid enough and quality literature relatively sparse. Further, since a typical
medical residency provides precious little exposure in the use of ultrasound to diagnose gyne-
cological pathologies, it is not uncommon for clinicians and radiologists to lack an in-depth
knowledge of gynecological ultrasound.
This book is intended to fill these gaps. It is a comprehensive atlas and guidebook which is
accompanied by abundant illustrations of classical and new ultrasound features and gyneco-
logical pathologies. The text and images contained in this book are primarily based on my
work as an instructor, researcher and practitioner, having personally performed detailed scans
and thorough investigations in numerous complex gynecological cases over my career, some
of which have resulted in novel biomarkers for early detection of pathologies which I have
reported in research journals and have included in this book.
This atlas and guide has been written to cater to practicing sonologists, gynaecologists and
radiologists and those who are training to become practitioners in these fields, as well as post-
graduate medical students in these fields. It will be useful not only for the routine diagnosis of
gynecological pathologies but also in cases of emergencies like ovarian torsion, where a delay
in diagnosis can cause infarction and loss of the ovaries, or where a wrong diagnosis can lead
to unnecessary surgery with added risks and cost. It will also help practitioners differentiate
between multiple conditions that are often lumped together as a single diagnosis, like the com-
monly used ambiguous term ‘complex adnexal cyst’, which provides no information on
whether the cyst may be physiological, malignant or benign. Specificity is the key to an effec-
tive diagnosis, determination of specialists who need to be consulted, surgeries that may need
to be performed and, more generally, proper disease management. This is particularly relevant
in today’s world where medical litigations are on the rise.
A frustrating challenge in gynecological ultrasound has been the lack of a global consen-
sus in the use and meaning of terminologies employed in the field. Of late, the International

xi
xii Preface

Endometrial Tumor Analysis (IETA), Morphological Uterus Sonographic Assessment

(MUSA) and International Ovarian Tumour Analysis (IOTA) groups have arrived at a consen-
sus to describe various sonographic features and gynecological pathologies. I am a primary
researcher of the ongoing IOTA study, and this book uses and provides an explanation of
these terminologies, thereby encouraging the reader to use standard terms for evaluation and
reporting.
This book has been organised into chapters, based on the origin of pathologies in various
gynecological organs and structures of the female pelvis, with a summary of key points in each
chapter for quick reference. The chapters include drawings and a rich set of comprehensive
single and composite images to illustrate key concepts and pinpoint various features and pathol-
ogies. In addition to basic greyscale images of two-dimensional scans, there are also relevant
images of Doppler and three-dimensional ultrasound scans.
I sincerely hope the reader uses this book as an essential guide, lucid atlas and a reliable
reference for accurate diagnosis and research of gynecological pathologies, and in turn helps
further this important and fascinating field.

Bangalore, India Mala Sibal

Acknowledgements

The compiling of knowledge, examination of cases and follow-up over the years that led to this
book have been due to the support and help of many colleagues, friends and family members.
The first among them is Dr. Priti Venkatesh who is my senior, friend, mentor and the head of
our department at Manipal Hospital. It was by observing her scans that I developed an enduring
fascination for the field of gynecological ultrasound. I shall remain indebted to her for the sup-
port she provided me, especially during my initial years, when literature in this field was sparse.
I am also grateful to Dr. Jaya Bhat, the head of the Obstetrics and Gynecology Department when
I first began, who encouraged me to focus on ultrasound and supported my work. In addition I
would like to acknowledge the support I have received from my colleague Dr. Thankam
Rathinaswami for her critical review of my research and academic work over the years.
I would also like to thank Manipal Hospital, a large multi-speciality hospital in Bangalore,
where I have the opportunity to investigate a variety of cases and also gain access to informa-
tion from follow-up visits of patients, which has helped my learning process tremendously.
I would like to thank my referring clinicians who keep me posted and provide an excellent
feedback and follow-up of cases evaluated using ultrasound. I would like to especially thank
Dr. Gayathri Karthik who has supported my professional endeavours with great interest.
I also thank the pathologists of our hospital with whom I interact on the pathology of com-
plex cases. A special thanks to Dr. Mahesha Vankalakunti who helped with the pathological
correlation of the ‘follicular ring sign’, a new ultrasound feature for early diagnosis of ovarian
torsion, which is included in this book.
I would like to thank the staff and nurses of our department as well, who support not only
my clinical work but also help with the follow-up of cases.
I also thank the postgraduates of the Obstetrics and Gynecology Department at Manipal
Hospital who assisted me through the process of writing this book. These include Dr. Supriya
Preman, Dr. Bharti Singh, Dr. Vasumathi Pasupaleti and Dr. Spurthi Janney.
A special word of thanks goes out to Padmini Baruah, a bright young law school graduate,
who played a significant role in helping me write and proofread various parts of this book. I am
also thankful to Shibani Timothy and Nomita Singh for helping me with the final proof-reading
of this book.
I would also like to specially thank Dr. Rajesh Uppal, a distinguished radiologist, who criti-
cally evaluated and proofread the chapters.
I also thank Dr. Suresh Seshadri for encouraging me to write this book and for authoring the fore-
word. I would also like to thank Springer for their effort and support in the publication of this book.
Finally, I would like to thank my family. A special thanks to my parents Pushpa Sibal and
Anil Sibal, for their support and for the interest in science that they inculcated in their children.
I also wish to thank my aunt Shashi Sibal, an amazing teacher, who taught me biology and got
me interested in pursuing medicine. A big thanks to my brother, Dr. Sandeep Sibal, for step-
ping in at various points to help solve challenges I faced during the writing of this book. Lastly,
I would like to thank my children Sohail Shad and Sonia Shad for completing my life, helping
me structure chapters and encouraging me to write this book.

xiii
Contents

1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 General Techniques in Gynecological Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . 3
2.1 Transabdominal Scan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.2 Transvaginal Scan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.3 Three-Dimensional Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2.4 Doppler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2.5 Tips and Tricks of Pelvic Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
2.6 Sonohysterography (SHG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
2.7 Gel Sonovaginography (GSV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
3 Ultrasound Evaluation of Myometrium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
3.1 Evaluation of Myometrium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
3.2 Normal Myometrium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
3.3 Fibroids (Leiomyoma or Myoma) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
3.3.1 Fibroid Mapping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
3.3.2 Red Degeneration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
3.3.3 Fibroid Embolization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
3.3.4 Diffuse Uterine Leiomyomatosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
3.3.5 Disseminated Peritoneal Leiomyomatosis (DPL) . . . . . . . . . . . . . . . . . 79
3.4 Adenomyosis and Adenomyomas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
3.4.1 Adenomyoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
3.5 Sarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
4 Ultrasound Evaluation of Endometrium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
4.1 Evaluation of Endometrium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
4.2 Normal Endometrium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
4.2.1 Endometrium in Paediatric Age Group . . . . . . . . . . . . . . . . . . . . . . . . . 105
4.2.2 Endometrium in Reproductive Age Group . . . . . . . . . . . . . . . . . . . . . . 105
4.2.3 Endometrium in Postmenopausal Women . . . . . . . . . . . . . . . . . . . . . . . 105
4.3 Endometrial Polyps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
4.4 Endometrial Hyperplasia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
4.4.1 Tamoxifen-Associated Endometrial Changes . . . . . . . . . . . . . . . . . . . . 121
4.5 Endometrial Malignancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
4.6 Differential Diagnosis of Thickened Endometrium . . . . . . . . . . . . . . . . . . . . . . 143
4.7 Asherman’s Syndrome or Intrauterine Adhesions . . . . . . . . . . . . . . . . . . . . . . . 145
4.8 Subendometrial Fibrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
4.9 Endometritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
4.10 Intracavitary Fluid in the Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

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5 Ultrasound Evaluation of the Cervix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

5.1 Evaluation of the Cervix and Its Normal Appearance . . . . . . . . . . . . . . . . . . . . 163
5.2 Nabothian Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
5.3 Cervical Polyps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
5.4 Cervical Fibroids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
5.5 Cervical Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
6 Ultrasound Evaluation of the Vagina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
6.1 Normal Vagina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
6.2 Congenital Vaginal Anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
6.3 Vaginal Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
6.3.1 Gartner Duct Cysts and Mullerian Cysts . . . . . . . . . . . . . . . . . . . . . . . . 189
6.3.2 Bartholin Gland Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
6.3.3 Skene Gland Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
6.4 Vaginal Masses and Vaginal Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
6.5 Other Vaginal Pathologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
6.5.1 Vaginal DIE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
6.5.2 Foreign Body in the Vagina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
6.6 Vulval Carcinoma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
7 Ultrasound Evaluation of Ovaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
7.1 Evaluation of Ovaries and Persistent Adnexal Masses . . . . . . . . . . . . . . . . . . . 203
7.1.1 Morphology, Measurement and Doppler Evaluation of the Ovary
and Ovarian Masses (Including Persistent Adnexal Masses). . . . . . . . 203
7.1.2 Morphological Classification of Ovarian/Adnexal Masses . . . . . . . . . 215
7.2 Normal Ovaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
7.3 Polycystic Ovaries (PCO) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
7.3.1 PCO in the Absence of PCOS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
7.4 Ovarian Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
7.4.1 Functional or Physiological Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
7.4.2 Endometriotic Cysts (Endometriomas) . . . . . . . . . . . . . . . . . . . . . . . . 228
7.4.3 Ovarian Neoplasms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 294
8 Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
8.1 Deep Infiltrating Endometriosis (DIE). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295
8.1.1 DIE of Large Bowel (Rectosigmoid) . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
8.1.2 DIE of the Vaginal Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
8.1.3 Cervical DIE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
8.1.4 Uterosacral DIE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305
8.1.5 Bladder DIE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
8.1.6 DIE Involving the Ureters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309
8.1.7 Uterus in Cases with DIE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
8.2 Extra-Pelvic Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
8.2.1 Abdominal Wall Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
8.2.2 Abdominal and Thoracic Endometriosis . . . . . . . . . . . . . . . . . . . . . . . . 315
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
9 Ultrasound Evaluation of Adnexal Pathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
9.1 Fallopian Tube . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
9.2 Pelvic Inflammatory Disease (PID) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319
9.3 Chronic PID . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
9.4 Hydrosalpinx . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 340
Contents xvii

9.5 Tubal Malignancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 346

9.6 Paraovarian and Paratubal Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 349
9.7 Peritoneal Inclusion Cysts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361
10 Ultrasound Evaluation of Pregnancy-Related Conditions . . . . . . . . . . . . . . . . . . 363
10.1 Ectopic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 363
10.1.1 Tubal Ectopic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
10.1.2 Interstitial Ectopic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
10.1.3 Cornual Ectopic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
10.1.4 Ovarian Ectopic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
10.1.5 Cervical Ectopic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381
10.1.6 Scar Ectopic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
10.1.7 Intra-abdominal Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 387
10.1.8 Heterotopic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 388
10.1.9 Intra-myometrial Ectopic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . 390
10.2 Retained Products of Conception (RPOC) . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
10.3 Gestational Trophoblastic Disease (GTD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
10.3.1 Molar Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 401
10.3.2 Gestational Trophoblastic Neoplasia (GTN) . . . . . . . . . . . . . . . . . . . . 406
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411
11 Torsion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
11.1 Ovarian Torsion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
11.2 Non-ovarian Torsion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 429
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
12 Ultrasound Evaluation of Congenital Uterine Anomalies . . . . . . . . . . . . . . . . . . . 435
12.1 Embryopathogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 435
12.2 AFS Classification of Uterine Anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 438
12.3 Approach to Diagnosing a Uterine Anomaly . . . . . . . . . . . . . . . . . . . . . . . . . . 439
12.4 Types of Uterine Anomalies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444
12.4.1 Arcuate Uterus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 444
12.4.2 Subseptate Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 446
12.4.3 Septate Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447
12.4.4 Bicornuate Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448
12.4.5 Uterus Didelphys . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 450
12.4.6 Unicornuate Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 451
12.4.7 Absent/Hypoplastic Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453
12.4.8 ‘T-Shaped’ Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 454
12.5 Cervical and Vaginal Anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 455
12.6 ESHRE/ESGE Classification of Congenital Uterine Anomalies . . . . . . . . . . . 464
12.7 Reporting Uterine Anomalies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 466
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 467
13 Ultrasound in Other Miscellaneous Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . 469
13.1 Uterine Vascular Abnormalities (Arteriovenous Malformations) . . . . . . . . . . 469
13.2 Perforation of the Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475
13.3 Vesicouterine Fistula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 478
13.4 Retroflexed Uterus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 480
13.5 Caesarean Scar Defect (LSCS Scar Defect) . . . . . . . . . . . . . . . . . . . . . . . . . . 482
13.6 Intrauterine Contraceptive Device (IUCD) . . . . . . . . . . . . . . . . . . . . . . . . . . . 489
13.7 Follicular Monitoring and Ultrasonography in Patients with Infertility . . . . . 498
13.7.1 Cyclical Changes During Menstrual Cycle
(Both Natural and Induced) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498
xviii Contents

13.7.2
Types of Scans Done in Patients Presenting or
on Treatment for Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 498
13.7.3 Luteinised Unruptured Follicle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
13.8 Ovarian Hyperstimulation Syndrome (OHSS) . . . . . . . . . . . . . . . . . . . . . . . . 503
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
14 Exploring Pathologies Based on Clinical Presentation . . . . . . . . . . . . . . . . . . . . . 509
14.1 Abnormal Uterine Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
14.1.1 Common Forms of Abnormal Uterine Bleeding . . . . . . . . . . . . . . . . 509
14.1.2 Abnormal Uterine Bleeding in the Reproductive Age Group . . . . . . 509
14.2 Pelvic and Adnexal Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 512
14.2.1 Ovarian Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514
14.2.2 Uterine Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515
14.2.3 Tubal Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515
14.2.4 Tubo-ovarian Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515
14.2.5 Paraovarian Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515
14.2.6 Pseudoperitoneal or Peritoneal Inclusion Cysts . . . . . . . . . . . . . . . . 515
14.2.7 Pelvic Hematomas and Pelvic Abscess . . . . . . . . . . . . . . . . . . . . . . . 515
14.2.8 Non-gynecological Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515
14.2.9 IOTA Recommendation for Evaluation of Persistent
Adnexal Masses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
14.3 Acute Pelvic Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 526
14.4 Locating the Pregnancy and Pregnancy of Unknown Location (PUL) . . . . . . 532
Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 537
List of Abbreviations

2D Two-dimensional
3D Three-dimensional
AF Anteflexed
AFC Antral follicle count
AV Anteverted
AVC Automated volume calculation
AVM Arteriovenous Malformation
B hCG Beta human chorionic gonadotropin
BMI Body mass index
CL Corpus luteum
CS Caesarean section
CSD Caesarean scar defect
CT Chemotherapy
D&C Dilation and curettage
DIE Deep infiltrating endometriosis
EMJ Endomyometrial junction
EP Early pregnancy
ESHRE European Society of Human Reproduction and Embryology
ET Endometrial thickness
ETT Epithelioid Trophoblastic Tumour
F French
FHR Fetal heart rate
FI Flow index
FIGO International Federation of Gynecology and Obstetrics
FP Fetal pole
FSH Follicle-stimulating hormone
GS Gestational sac
GSV Gel sonovaginography
GTD Gestational trophoblastic disease
GTN Gestational trophoblastic neoplasia
hCG Human chorionic gonadotropin
HD flow High-definition flow
HDI High-definition imaging
HPE Histopathological examination
IDEA International Deep Endometriosis Analysis
IETA International Endometrial Tumor Analysis
IMB Intermenstrual bleeding
IOTA International Ovarian Tumour Analysis
IU International units
IUCD Intrauterine contraceptive device

xix
xx List of Abbreviations

IVF In vitro fertilisation

JZ Junctional zone
LH Luteinising hormone
LIF Left iliac fossa
LS Longitudinal section
LSCS Lower segment caesarean section
LUF Luteinised unruptured follicle
ML Midline
MP Mid-positioned
MRI Magnetic resonance imaging
MRP Manual removal of placenta
MTP Medical termination of pregnancy
MUSA Morphological Uterus Sonographic Assessment
NSAID Non-steroidal anti-inflammatory drug
OHSS Ovarian hyperstimulation syndrome
PCB Post-coital bleeding
PCO Polycystic ovaries
PCOD Polycystic ovarian disease
PI Pulsatility index
PID Pelvic inflammatory disease
PO Paraovarian
POD Pouch of Douglas
PPH Post-partum haemorrhage
PRF Pulse repetition frequency
PS Per speculum
PSTT Placental site trophoblastic tumour
PSV Peak systolic velocity
PUL Pregnancy of unknown location
PV Per vagina
RF Retroflexed
RI Resistance index
RIF Right iliac fossa
ROI Region of interest
RPOC Retained products of conception
RT Radiotherapy
RV Retroverted
SHG Sonohysterogram
SIS Saline infusion sonohysterogram
SLT Single-layer thickness
TAH Total abdominal hysterectomy
TAS Transabdominal scan
TO Tubo-ovarian
TOP Termination of pregnancy
TS Transverse section
TSH Thyroid-stimulating hormone
TUI Tomographic ultrasound imaging
TVS Transvaginal scan
UPT Urinary pregnancy test
UPT Urine pregnancy test
USG Ultrasonography
UV Uterovesical
VFI Vascularisation flow index
VI Vascularisation index
VOCAL Virtual organ computer-aided analysis
YS Yolk sac
About the Author

Dr. Mala Sibal is a consultant physician in the Department of Fetal Medicine and Obstetric and
Gynecological Ultrasound at Manipal Hospital, Bangalore. She has fourteen years of experi-
ence in the field of gynecological ultrasound prior to which she practiced clinical obstetrics
and gynecology for 7 years.
Dr. Sibal has been an invited speaker at numerous national and international conferences
on this subject and has authored peer-reviewed journal articles on novel diagnostic ultrasound
techniques in the American Journal of Ultrasound in Medicine. She has also trained and
taught several practitioners and medical students in the field of gynecological ultrasound. Dr.
Sibal is also a principal investigator in the ongoing International Ovarian Tumour Analysis
(IOTA-5) International Research Programme. She has also begun an online portal,
‘Gynecology Academy’ (www.gynac.org), for training and skill enhancement in gynecologi-
cal ultrasound.
She has a DNB postgraduate degree in obstetrics and gynecology and an MBBS graduate
degree from Jawaharlal Nehru Medical College, Belgaum, where she stood first in
gynecology.

xxi
 Introduction
1

Before the advent of ultrasound, diagnosis in gynecology in the chapters ahead, and accordingly, images generated
was difficult and inaccurate, since it had to be made with the using these techniques can be found across various chapters
use of bimanual vaginal examination, wherein one would of this book.
physically feel various pelvic structures and make an attempt There are13 chapters that follow. Chapter 2 is based on
to diagnose the pathology. Ultrasound, specifically transab- basic methods of 2D, 3D and Doppler ultrasound along with
dominal ultrasound (TAS), revolutionised gynecology and newer available techniques in ultrasound examination, appli-
for the first time allowed the clinical practitioner to visualise cable to all pathologies. It also includes a few ‘tips and tricks’
the structures in the pelvis in addition to feeling them biman- that can make a significant difference in gynecological ultra-
ually. Today, with the advent of transvaginal ultrasound sound diagnosis. The bulk of the remaining chapters (Chaps.
(TVS), we can not only see the pathology at close range with 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12) describe features and pathol-
better resolution, but also simultaneously touch the various ogies that are categorised by the various gynecological
structures with the probe and identify whether they are ten- organs and structures in the female pelvis where these
der, fixed, etc. This interactive component of TVS has fur- pathologies originate. Some topics that are better dealt with
ther increased the accuracy of diagnosis, giving it in many individually or require special focus have been discussed
cases an edge over CT or MRI. Ultrasound for evaluation is separately as well. Chapter 13 has a mix of miscellaneous
also easily available and more affordable. Since TVS topics of interest that don’t fit in too well into the themes of
accesses many of the pelvic structures at closer range, it also other chapters but are nonetheless important in practice.
enhances tissue resolution and Doppler evaluation. The addi- Chapter 14 explores pathologies based on four common clin-
tion of Doppler to ultrasound examination, and in particular ical situations: abnormal uterine bleeding, pelvic/adnexal
‘Power Doppler’ that studies low-velocity flows, helps visu- masses, acute pelvic pain and scans to locate the pregnancy –
alise the presence of flow within tissues and vascular patterns including pregnancies of unknown location (PUL).
that further enhances the accuracy of diagnosis and also In most of the chapters, the first subsection typically dis-
helps in differentiating between pathologies. Images gener- cusses how to evaluate and report on the region of interest
ated by using all these three techniques have been exten- using ultrasound. These are based primarily on the consen-
sively used in the chapters that follow. sus statement of the International Ovarian Tumour Analysis
In addition to 2D ultrasound (TAS and TVS) and Doppler, (IOTA), International Endometrial Tumor Analysis (IETA)
3D ultrasound is also a useful adjunct and is indispensable in and Morphological Uterus Sonographic Assessment
the diagnosis of certain conditions like uterine anomalies or (MUSA) groups. This subsection is usually followed by
the location of intrauterine contraceptive devices (IUCDs). normal findings in that region, including variations with
3D ultrasound has also contributed to accurate volume esti- age and variations across phases of the menstrual cycle.
mations, as well as reproducibility and storage of data, which This is followed by subsections of the chapter that are
is important in the research and study of pathologies. There devoted to various pathologies. Each of the pathologies has
has also been further progress in ultrasound diagnosis with some basic information on the pathology, along with the
sonohysterogram (SHG) and gel sonovaginography (GSV), classification and clinical presentations mentioned briefly
which is resorted to in special cases. All of the above tech- upfront. This is followed by ultrasound features that are
niques of gynecological ultrasound have been described and captured in succinct itemised points. This, in turn, is fol-
employed to identify features and gynecological pathologies lowed by a large number of images – many of which are

© Springer Nature Singapore Pte Ltd. 2017 1

M. Sibal, Ultrasound in Gynecology, DOI 10.1007/978-981-10-2714-7_1
2 1 Introduction

composite images of a single case showing various aspects techniques that were curated over a period of 14 years.
of ultrasound imaging that aid in the diagnosis. These fig- Further, most of the patients have been followed up clini-
ures have legends below that highlight the ultrasound find- cally, with operation notes, discharge summaries and histo-
ings and, in some cases, additional clinical information of pathology reports. This is particularly important so that the
the patient that is relevant. reader sees ultrasound images of cases with confirmed
All the images shown in the chapters are of patients that pathologies, as opposed to images where the diagnosis of the
the author has personally scanned using multiple ultrasound pathology has been presumed but not confirmed.
 General Techniques in Gynecological
Ultrasound 2

Today, with ultrasound, we can actually see pathology, and of a specimen (both the external surface and cut sections). Not
with a transvaginal ultrasound (TVS), one can not only see the only that, one can in addition see flow patterns within the mass
pathology at close range, but also simultaneously touch the which cannot be ascertained by gross examination of the
various structures that are seen, making it a dynamic and inter- specimen.
active examination (Fig. 2.1). This is a distinct advantage of Ideally a transabdominal scan (TAS) is done first with a
TVS over CT and MRI. Presently, ultrasound technology has full bladder, followed by a transvaginal scan (TVS) after
advanced to such an extent that one can see on ultrasound having emptied the bladder. It is important that the technique
almost as much as a pathologist can see on gross examination is standardised, fixed and predetermined.

a b

Fig. 2.1 (a) Bimanual per vaginal examination which uses touch sensation to assess pathology of pelvic structures; (b) with TVS, which allows
one to see pathology while touching the various structures simultaneously

© Springer Nature Singapore Pte Ltd. 2017 3

M. Sibal, Ultrasound in Gynecology, DOI 10.1007/978-981-10-2714-7_2
4 2 General Techniques in Gynecological Ultrasound

2.1 Transabdominal Scan seen on the right side of the screen, and those on the left side
of the patient are seen on the left side of the screen.
Filling the Bladder
For a good transabdominal scan, the bladder should be suf- Ovaries and Adnexa
ficiently filled, so as to push the bowels that lie in front of To visualise the ovaries and adnexa, one can move and/or
the pelvic organs towards the upper abdomen. Another angulate the probe to one side. Regardless of whether one is
advantage of a full bladder is that urine, being fluid, enhances examining structures on the left or the right, the rotation
the sound waves of the ultrasound beam, resulting in better from LS to TS is always anticlockwise.
visualisation. The bladder should not be over-distended
because that would cause discomfort to the patient. In addi- Advantages of a Transabdominal Scan
tion, a very full bladder increases the distance of the uterus • TAS provides a panoramic view and thus furnishes a
and ovaries from the probe, decreasing resolution and result- global survey of pelvic anatomy. One is, therefore, less
ing in suboptimal visualisation. A few points to be kept in likely to miss any small pathology (like an ectopic preg-
mind here are: nancy mass or a pedicle of a torsed ovary), and while
doing TVS, one would know exactly where to look in
1. Very often one may be able to see sufficiently well on order to study the pathology.
TAS even with a suboptimally filled bladder. Especially • Large masses extending into the upper abdomen are bet-
in cases that are to be followed by TVS, there is no need ter assessed on TAS and may be missed with TVS alone,
to insist that the bladder should be further filled. as those structures lie too far away from the transvaginal
2. In emergency cases (like a case of a ruptured ectopic probe (e.g. a subserous or pedunculated fundal fibroid).
pregnancy), waiting for the bladder to fill may not be • The endometrium of mid-positioned uterus is better seen
justified. on TAS than TVS. Endometrial polyps can thus be missed
3. In cases with a previous caesarean, the bladder may be on a TVS in a patient with a mid-positioned uterus.
adherent to the uterus at the site of the LSCS scar, and • Masses like fibroids in the lower corpus or cervix can cause
filling the bladder so as to visualise the upper uterus may shadowing resulting in suboptimal visualisation of struc-
not be possible. Instead, the more the patient fills her tures above it, like other fibroids, ovaries, etc. on TVS. In
bladder, the more the lower uterine body and cervix get such cases, the structures lying above are best seen on TAS.
stretched, causing discomfort. • In dermoids (particularly large ones) one may not be able
4. With a very large and bulky uterus, a full bladder may not to see its superior parts and margins due to shadowing on
be able to overlie the entire uterus. Very often in these TVS. Measuring such dermoids is easier on TAS
cases, the bulky uterus itself pushes the intestines out of (Fig. 2.4).
the pelvis into the upper abdomen. • TAS in most cases is not time consuming.
• Sometimes TAS is the only method to scan a patient who
Scanning Technique for TAS (Figs. 2.2 and 2.3) declines a TVS (as is sometimes the case with virgins/
For a transabdominal scan, typically a 3.5–5 MHz transducer unmarried patients). Transrectal scan is another option,
is used. The transducer is placed longitudinally on the provided the patient consents and facilities are available
patient’s abdomen in the midline. It has a groove on one side for the same.
and it is placed such that this groove lies facing the superior
end of the patient. This produces a sagittal section of the Most sonologists measure the uterus and take a cursory look
uterus, and the area corresponding to the groove is high- at the rest of the pelvis prior to a TVS. The author, however,
lighted on the screen by a ‘GE’ mark which is green on the prefers to measure the uterus and endometrium and also to study
active screen and white on the adjacent frozen image. This the endometrium qualitatively as in many cases the endome-
corresponds to the upper end of the uterine body. That is, trium of a mid-positioned uterus is not clearly seen on TVS. In
basically, structures that are in the superior part of the addition, large masses extending beyond the pelvis and fibroids
patient’s body are seen on the right of the screen, and struc- high up in the uterine body can be studied in greater detail on
tures in the inferior part are seen on the left of the screen. TAS. Furthermore, in cases with uterine anomalies, it is prefer-
After studying the LS, the probe is rotated in an anticlock- able to execute the 3D rendering of the uterus on TAS as well,
wise direction, such that the groove now lies on the right of prior to carrying out a TVS. This is recommended because with
the patient. The area corresponding to the groove is high- a full bladder, the uterus is most often stretched, more linear and
lighted by the ‘GE’ mark and is seen on the right side of the perpendicular to the probe, which makes 3D rendering of the
screen. Thus, structures on the right side of the patient are uterus simpler to obtain and assess.
2.1 Transabdominal Scan 5

a b

c d

RT LT

Fig. 2.2 TAS for uterus. (a) Placement of probe for LS scan. Arrow indicative of marker on the probe. (b) Placement of probe for TS scan (after
90° anticlockwise rotation). Arrow indicative of the marker on the probe, now to the right of the patient. (c) Midsagittal section of uterus. Arrow,
showing upper end of the uterus, corresponds to the marker on the probe in the image (a). (d) TS of uterus – arrow, showing right side of the uterus,
corresponds to the marker on the probe in the image (b). Structures on the right side of the patient are seen on the right side of the screen and, simi-
larly, those on the left side of the patient are observed on the left of the screen
6 2 General Techniques in Gynecological Ultrasound

b c
TS LS

Fig. 2.3 TAS for examining the adnexa. (a) The probe can be placed on either side of the midline and the rotation should be anticlockwise from
LS to TS. (b, c) Right ovary seen in TS and LS
2.1 Transabdominal Scan 7

a b

Fig. 2.4 Case with a large dermoid. (a) TAS – the entire dermoid seen. (b) TVS – Dermoid was not seen. Due to significant acoustic shadowing
by the dermoid, only its lower end which resembles the bowel is seen, making it difficult to visualise the dermoid
8 2 General Techniques in Gynecological Ultrasound

2.2 Transvaginal Scan now lies on the patient’s left. This produces a transverse sec-
tion (TS) of the uterus, and the area corresponding to the
The patient’s bladder should be empty for a TVS. groove is highlighted by a ‘GE’ mark on the screen. This
corresponds to the left side of the uterine body. Structures on
Scanning Technique for TVS (Figs. 2.5, 2.6 and 2.7) the left of the patient are seen on the left of the screen and,
For a transvaginal scan, typically a 5–9 MHz transducer similarly, those on the right are seen on the right of the
is used. screen.
The ideal position in such cases is the lithotomy position.
This facilitates downward movement of the hand with the Ovaries and Adnexa
probe, so that structures placed anteriorly in the pelvis are To assess the ovaries and adnexa on either side of the uterus,
clearly seen. one can either angulate the probe from the LS section of the
The probe is always covered with a probe cover, with jelly uterus to obtain the LS of any adnexa/ovary, or, as is more
between the two. Air bubbles should be avoided. Jelly is frequently done, the probe can be angulated from the TS of
applied to the tip of the probe and then the probe is gently the uterus to obtain the TS of any adnexa/ovary. On TS, the
introduced into the vagina. ovaries are typically seen lying just medial to the external
The transducer has a groove which should face upwards iliac vessels.
(anterior part of patient’s abdomen) at insertion. This pro- Rotation from LS to TS is to be done in a clockwise direc-
duces a sagittal section of the uterus, and the area corre- tion. It is imperative to keep in mind that rotation from LS to
sponding to the groove is highlighted by a ‘GE’ mark on the TS must always be standardised, regardless of which struc-
screen. This corresponds to the anterior part of the uterine ture or which side is being studied.
body at the UV fold. A transvaginal probe offers a combination of touch along
The probe is angulated and rotated a little so as to obtain with simultaneous visualisation of pelvic structures, making
the midsagittal (LS) section of the uterus. TVS dynamic and interactive. TVS should include the
There are two commonly used methods of observing the following:
image on the screen (Fig. 2.5b, c). The first with the TVS
probe footprint below is generally considered ideal because • Measurement and morphological evaluation of the myo-
of two reasons: metrium, endometrium and ovary (including adnexa) for
normal and pathological conditions. The evaluation of the
• The image orientation is more natural, with superior uterus (myometrium and endometrium) is discussed in
structures seen in the upper part of the screen and inferior Chaps. 3 and 4. The ovary and adnexal masses are evalu-
structures in the lower part. In the alternative method, ated as given in Chap. 7.
structures higher up are seen lower down on the screen • Assessment of the cervix and vagina has been discussed
and vice versa. in Chaps. 5 and 6. These structures are often not given
• There is a clear-cut difference in images that are TAS ver- attention during an ultrasound examination because
sus TVS because in the former, the footprint lies above pathologies of these structures are infrequent and visual-
and in the latter the footprint of the probe lies below. ising them is often challenging. Currently, ultrasound
machines provide better resolution, and there is increas-
In this book, the images will be seen in the orientation ing literature available on cervical and vaginal patholo-
that is considered ideal (that is with the footprint below), as gies. This has facilitated diagnosis of vaginal and cervical
the author has been following that orientation over the pathology on ultrasound, and their examination is now
years. It is now suggested that students and those learning considered an integral part of routine pelvic
gynecological ultrasound for the first time should follow examination.
the ideal orientation with the footprint at the lower end of • Assessment of uterine version and flexion – which may
the screen. Standardisation of orientation on screen is serve as a marker to pathology and a guide for possible
important. It does not really matter how one is used to intrauterine procedures (details provided later in this
observing the image on the screen, provided it is consis- chapter).
tently done in the same manner. • Looking for fixity of ovaries by applying pressure with
The following methodology is one with the footprint the probe. By doing this, one can assess whether the ova-
of the probe lying in the lower part of the screen, which ries are adherent to the uterus and/or the pelvic walls.
is considered ideal. • Assessing the fixity of the uterus. In cases where the
uterus is adherent posteriorly, a typical ‘ear’- or ‘question
Uterus mark’-shaped uterus is often noted (details in Chap. 8).
To obtain TS of the uterus after LS, on TVS, rotation is done • Looking for any tenderness, and if present, that should
in a clockwise direction. The groove which lay anteriorly serve as a guide for a detailed search in that area for any
2.2 Transvaginal Scan 9

pathology. This ‘pain-guided approach’ is useful in diag- a partially filled bladder, it is best done towards the end of
nosing conditions like DIE and ectopic pregnancy. In the TVS evaluation.
patients presenting with pain, TVS is useful in assessing
whether the pathology being observed is the cause for Advantages of Transvaginal Scan
pain. The tender organ will elicit the same pain that the • Because of the close proximity of the various structures to
patient complains of. the probe, a higher frequency probe is used for TVS, which
• Assessing whether the bowels are adherent to the poste- provides a close-up view of pelvic structures with high
rior wall of the uterus. Normally the large bowel (recto- resolution. Thus:
sigmoid), on applying pressure on the cervix and uterus 1. Small lesions not seen on TAS may be observed on
with the probe, is seen to slide smoothly over the posterior TVS (e.g. small endometriotic cysts).
cervix and vagina (‘low sliding sign’) and the uterine 2. There is better characterisation of pathology (e.g.
body and fundus (‘high sliding sign’). The absence of fibroid or adenomyoma).
sliding sign indicates that the bowels are adherent to the 3. Doppler studies are also better because of proximity of
posterior wall of the uterus and raises a high suspicion of structures to probe.
bowel DIE. • The transvaginal probe offers a superb combination of
• Ideally, specific search for DIE nodules (described in visualisation of pelvic structures with a simultaneous pos-
Chap. 8) should also be done. This is particularly so in sibility of touching them. This is analogous to performing
women with pain, endometriomas or any tenderness. The an internal physical pelvic examination and simultane-
bladder wall and mucosa should also be examined for ously seeing the structures. This helps us identify which
possible DIE. Since visualisation of bladder DIE requires structures are tender or adherent.
10 2 General Techniques in Gynecological Ultrasound

b c
FP

POST ANT

FP

Fig. 2.5 Orientation for TVS. (a) Placement of probe for LS view of uterus. Arrow indicative of marker on the probe seen anteriorly. (b)
Midsagittal section of the uterus with footprint (FP) of the probe lying in the lower part of the image. Arrow, showing anterior margin of the
uterus (in the UV fold), corresponds to the marker on the probe. (c) Footprint (FP) of the probe lying in the upper part of the image, which is
an alternate acceptable method of observing the image on the screen
2.2 Transvaginal Scan 11

a b

c d

ANT RT LT
POST

Fig. 2.6 TVS for uterus. (a) Placement of probe for LS scan. Arrow indicative of marker on the probe. (b) Placement of probe for TS scan (after
90° clockwise rotation). Arrow indicative of the marker on the probe, now to the left of the patient. (c) Midsagittal section of the uterus. Arrow,
showing anterior margin of the uterus and UV fold which corresponds to the marker on the probe in (a). (d) TS of uterus. Arrow, showing left side
of the uterus which corresponds to the marker on the probe in (b). Structures on the left of the patient are seen on the left of the screen and similarly,
those on the right of the patient are observed on the right of the screen

Fig. 2.7 Right ovary TS and LS

view. Rotation from LS to TS is done
TS LS
in a clockwise direction and vice
versa
12 2 General Techniques in Gynecological Ultrasound

Version–Flexion (Figs. 2.8 and 2.9) termed an ‘anteverted uterus’, and if it is directed away from
Version is the angle between the vagina and the cervix, and the bladder, it is termed a ‘retroverted uterus’. Similarly, in
flexion is the angle between the cervix and the uterine body. comparison with the cervix, if the uterus is directed towards
The prefix ‘ante’ is used to denote forward or anterior (i.e. the bladder, it is termed an ‘anteflexed uterus’, and if it is
towards the bladder) and the prefix ‘retro’ to denote back- directed away from the bladder, it is termed a ‘retroflexed
ward or posterior (i.e. away from the bladder). uterus’. Thus, based on the angle of version and flexion, vari-
In comparison to the vaginal axis (i.e., the direction of the ous uterine positions are possible.
TVS probe), if the cervix is directed towards the bladder, it is

a b

Bladder

Bladder

Fig. 2.8 Uterine version and flexion. Yellow/lowest arrows indicate angle of the vaginal axis, red/middle arrows indicate the cervical axis and
blue/highest, the axis of the uterine cavity. (a) AVAF uterus. Cervix directed towards the bladder (anteriorly) as compared to the vagina (antever-
sion). Endometrial axis directed towards the bladder (anteriorly) as compared to the cervix (anteflexed). (b) RVRF uterus. Cervix directed away
from the bladder (posteriorly) as compared to the vagina (retroversion). Endometrial axis directed away from the bladder (posteriorly) as compared
to the cervix (retroflexed)
2.3 Three-Dimensional Ultrasound 13

2.3 Three-Dimensional Ultrasound

a (Figs. 2.10, 2.11, 2.12, 2.13, 2.14, 2.15, 2.16, 2.17,
2.18, 2.19, 2.20, 2.21, 2.22, 2.23 and 2.24)

The addition of three-dimensional (3D) ultrasound to trans-

vaginal scan has improved the diagnostic utility of ultra-
sound in gynecological imaging to a great extent. In 3D
ultrasound, the entire volume of a tissue block is acquired,
from which sections along multiple planes can be displayed
and analysed for better assessment. The addition of Doppler
to 3D has further enhanced its utility. This means that, in 3D
ultrasound, three-dimensional information of the entire vol-
ume of the region of interest can be obtained for analysis.
This data can even be stored for manipulation at a later time.
Four-dimensional ultrasound is useful to assess moving
structures (where the fourth dimension is time) like the fetal
face and cardia in obstetric ultrasound, but in gynecological
ultrasound, since these structures are stationary, 3D is
preferred.
In some gynecological conditions 3D ultrasound is essen-
tial for proper diagnosis. These include uterine anomalies
and pelvic floor studies. In many other conditions, however,
it is a value-added modality that increases the clarity and
b
accuracy of the 2D ultrasound findings. The advantages of
3D in gynecological ultrasound are mentioned in the follow-
ing paragraphs. However, their utility in various gynecologi-
Bladder cal pathologies will be discussed in the relevant chapters.

Rendering (Fig. 2.10) This is viewing the block along a

cut section. Here, masses with different echo densities are
well outlined. One of the greatest advantages of 3D ultra-
sound is the capacity to render an image in various planes,
particularly the coronal plane. On 2D, the uterus is gener-
ally clearly seen on sagittal and transverse planes both on
TAS and TVS. However, 3D is able to provide a coronal
section of the uterus, which cannot be visualised on 2D.
This is very useful in assessing the shape of the uterine cav-
ity, which is clearly visualised on 3D because of the differ-
ence in echo densities between the endometrium and
myometrium. 3D can also be used in cases where delinea-
Fig. 2.9 Version and flexion. Yellow/lowest arrows indicate angle of
tion of masses is difficult on 2D.
the vaginal axis, red/middle arrows indicate the cervical axis and blue/
highest, the axis of the uterine cavity. (a) Diagrammatic representation Volume Contrast Imaging (VCI) (Fig. 2.11) This feature
of an AVAF uterus. (b) TAS of an AVRF uterus allows the addition of slices of different thickness onto the
rendered section, for better contrast differentiation. This pro-
vides a better outline of structures and is useful in gynecol-
ogy to outline a poorly circumscribed fibroid or to assess the
endomyometrial junction in cases with adenomyosis or
endometrial malignancy (to look for myometrial invasion).
14 2 General Techniques in Gynecological Ultrasound

Multiplanar Imaging (Fig. 2.12) Here, a structure/tissue 1. Data acquisition:

block can be visualised in all three dimensions simultane- (a) Orientation of 2D image – The 2D image of the
ously. There is a dot provided at the intersection of three region of interest should be well visualised for a
planes so that one can see the same anatomical landmark in proper 3D assessment. The best 2D plane for acquisi-
all three planes at the same time. While walking through one tion of the volume may depend on the structure being
plane with the dot, the dot moves to the corresponding spot assessed, for example, in order to acquire a volume in
in the other two planes. This is very helpful when the anat- cases of uterine anomalies, the most commonly used
omy is confusing. plane is the mid sagittal plane of the uterus.
(b) Defining the region of interest (ROI) – The region of
Depth Perception (Fig. 2.13) 3D rendered images, particu- interest should be completely included within the
larly of cystic areas, are able to provide a sense of depth 3D box, and the angle of acquisition should be such
which is useful for a subjective assessment of depth. This that the entire volume of ROI is included in the 3D
helps not only the sonologist but also the patient and refer- sweep.
ring clinician to understand the pathology better. The addi- (c) Volume acquisition – Once the ROI and angle of
tion of cine loop, by which the 3D rendered image can be acquisition have been decided, a volume sweep is
rotated, and editing the direction of the light source in ren- taken so that the entire volume of ROI is now avail-
dered images further add to this perception. able for analysis.
2. 3D/4D Visualisation (Display Mode) (Figs. 2.19, 2.20,
Volume Calculation (Figs. 2.14, 2.15 and 2.16) Volume 2.21, and 2.22) – Once the volume has been acquired, it is
calculation is more accurate with 3D ultrasound using vir- possible to display and study it in various ways:
tual organ computer-aided analysis (VOCAL) software, (a) Multiplanar display – This basically displays the
particularly for masses with irregular outline. This can be region of interest in three different orthogonal planes
done for both solid structures like the endometrium and for simultaneously. The utility of this has been explained
cystic spaces. In addition, when there are both solid and earlier in this section.
cystic components in a mass, the percentage of cystic ver- (b) Surface-rendered image (including high-density
sus solid can also be calculated. This software can also be imaging or HDI) – In this, the ROI can be visualised
used for quick and more accurate assessment of antral fol- in any cut section desired, the utility of which has
licle count. been discussed earlier in this section. The addition of
cine loop, where the image can be rotated, and the
Assessing Flows (Figs. 2.17 and 2.18) The vascular pattern capacity to edit the direction of the source of light on
of flow indices of the region of interest (ROI) can also be the rendered image further enhance the image quality
done by a combination of Doppler with 3D (discussed in and assessment.
greater detail later in this chapter, in the section on Dopplers). (c) Tomographic display (TUI) – In this, the volume can
Flow indices of the ROI can also be obtained. be imaged in multiple parallel sections similar what
is done in a CT scan.
Working Offline The advantage of storing 3D volumes is (d) Glass body display – This is a combination of surface
that they can be used to assess the pathology at a later time. or transparent rendering with colour/power Doppler.
This is particularly useful in a busy ultrasound clinic and also The pattern of vascular flow to the ROI can be well
when a patient is in pain and one cannot toggle with the assessed. This is even better appreciated with the help
probe and knobs for a long time. It has also been used for of a cine loop by which the image can be rotated.
assessing subjective reproducibility of ultrasound findings in (e) OmniView (GE Healthcare, Zipf, Austria) – In
various studies. In difficult cases, these stored volumes may OmniView the software helps to obtain sections in
facilitate access to a second opinion from an expert various non-linear planes. Planes of interest are often
examiner. not geometrically uniform, and the polyline option is
particularly useful in assessing uterine anomalies
Steps in 3D Ultrasound where the cervix and uterine body are not in the same
It is out of the scope of this book to explain in detail the steps plane.
involved in 3D ultrasound. This has been briefly discussed as (f) Inversion mode – This is used to obtain a solid outline
follows: of a cystic structure, for example, a hydrosalpinx. Its
2.3 Three-Dimensional Ultrasound 15

diagnostic utility in gynecological ultrasound is (b) Contrast and brightness control – This can be used to
limited. enhance the image.
(g) Volume analysis (VOCAL and SonoAVC) – Volume (c) Colour selection – The images displayed can be
calculations are very accurate with 3D ultrasound, shown in various colours like grey, sepia, ice blue,
using VOCAL software. After the volume has been etc., depending on the choice of the sonologist. It is
acquired, one section is selected and is rotated believed that colour enhances visual perception by
through 180 degrees, step by step. The angle selected the human eye.
for each step can be 6°, 12°, 15° or 30°. At each step (d) Edit light – This facility is useful particularly when there
the margin of the structure whose volume is to be cal- are structures projecting into a cavity, like papillae in a
culated is outlined. After 180° of rotation is com- cyst. Many machines now have multiple options of
pleted, the calculated volume is displayed on the directions of light source for the given image displayed
screen. on the panel. This helps to quickly choose the best
The SonoAVC software calculates the volume of all fluid- image.
filled structures and colour codes them, which is of great 4. Storage of volumes – This feature is of great advantage
help in calculating the number and size of antral follicles as it allows the sonologist to assess structures at a later,
when an antral follicle count is required. convenient time. The acquired volume can be stored
3. Volume/image processing (Figs. 2.23 and 2.24) – These are immediately. However, it is most often done after work-
various tools used to enhance the displayed image: ing on the volume to some extent, so as to ensure that
(a) Electronic scalpel – This helps to cut out and visual- the volume acquired is appropriate in quantity and
ise just the region of interest; the structures outside quality.
the ROI can be cut away.
16 2 General Techniques in Gynecological Ultrasound

b c

Fig. 2.10 Sections of the uterus. (a) Coronal section of the uterus on a 3D rendered image. (b) Sagittal section of the uterus on regular TVS. (c)
Transverse section of the uterus on regular TVS
2.3 Three-Dimensional Ultrasound 17

a b

c d

Fig. 2.11 Sagittal section of the uterus showing EMJ. (a, b) Postmenopausal lady with an endometrial polyp, (a) on 2D greyscale, EMJ is seen
but not well defined (arrow). (b) 3D image of the same section of the uterus as in (a) with VCI showing a very well-defined EMJ (arrow), as com-
pared to (a). (c, d) Postmenopausal lady with endometrial cancer (c) on 2D greyscale. EMJ not well defined. (d) 3D image of the same section of
the uterus as in (a) with VCI showing an irregular EMJ with myometrial invasion (small arrows)
18 2 General Techniques in Gynecological Ultrasound

Fig. 2.12 Multiplanar imaging. a

(a) Fibroid seen in all three
perpendicular planes of the
uterus (LS/TS/coronal). (b)
Multiplanar view with all
three-dimensional planes
visualised simultaneously. Dot
(here enlarged and in red) of
intersection of the three planes is
visualised, which helps in
observing the corresponding
point in the two other planes

a b

Fig. 2.13 3D rendered image.

(a) HDI view of a papillary cyst
(arrow showing papilla). (b) 3D
rendered image of a hydrosal-
pinx showing incomplete septae
(short arrows) and compressed
mucosal folds (long arrow)
2.3 Three-Dimensional Ultrasound 19

Fig. 2.14 3D volume of an a

adnexal mass with solid and
cystic components. (a) VOCAL
software used to calculate
Volume of the mass. (b) Volume
of cystic (‘below threshold’) and
the solid components (‘above
threshold’) can be assessed
separately

b
20 2 General Techniques in Gynecological Ultrasound

Fig. 2.15 Volume assessment of endometrium. VOCAL is especially useful in volume calculation of masses which are not regular in shape, like
the endometrium

Fig. 2.16 Antral follicle count with SonoAVC

2.3 Three-Dimensional Ultrasound 21

Fig. 2.17 Fibroid polyp with its vascular morphology using

3D Doppler with glass body display

Fig. 2.18 3D flow assessment in a

a case of carcinoma endome-
trium. (a) Volume of endome-
trium is calculated. (b) VI, FI
and VFI of the region of interest
(endometrium) are calculated
22 2 General Techniques in Gynecological Ultrasound

Fig. 2.18 (continued)

Fig. 2.19 Coronal section of uterus – rendering with high-definition

imaging (HDI)
2.3 Three-Dimensional Ultrasound 23

Fig. 2.20 Tomographic display of a submucous fibroid

Fig. 2.21 Glass body display showing vessels in the septum of a cyst
24 2 General Techniques in Gynecological Ultrasound

Fig. 2.22 OmniView (polyline) showing a coronal section of the uterus along with the cervix in a patient with septate uterus

Fig. 2.23 (a) 3D rendered HDI a

image of a papillary cyst.
(b) ‘Magic cut’ with electronic
scalpel showing only the ROI
(cyst) with its papillae.
Surrounding structures have been
cut out. (c) ‘Edit light’ facility
provides various options of
directions of the light source
from which the best rendered
image can be selected

b c
2.4 Doppler 25

2.4 Doppler (Figs. 2.25, 2.26, 2.27, 2.28, 2.29, 2.30,

2.31 and 2.32)

Doppler helps pick up blood flow in various tissues and is

therefore a very useful adjunct to greyscale imaging for
ultrasound diagnosis in gynecology. When sound is reflected
from a moving object, the returning wave has a different fre-
quency, and this change in frequency is called ‘Doppler
shift’. There are various types of Doppler studies that are
used for ultrasound diagnosis (Fig. 2.25):

• Colour Doppler: This provides a directional semi-

quantitative flow assessment. Flow towards the probe is
seen in red and flow away from the probe is seen in blue.
The intensity of the flow affects the brightness of colour
and turbulent flows show mosaic patterns.
• Power Doppler: This is a non-directional Doppler that
can pick up low-velocity blood flows. It is useful in gyne-
cology, where often the quantity of flow is important
Fig. 2.24 ‘Magic cut’ with electronic scalpel showing only the ROI rather than the direction.
(uterus and uterine cavity). Other surrounding structures that are not • High-Definition Doppler: This is a combination of the
relevant can be cut away. It is important to cut just beyond the ROI above two, where low-velocity flows are picked up and
(here, the serosal surface of the uterus which is seen as white margins in
the direction can also be assessed with red flows towards
the image above), so that the shape or outline of the structure does not
get altered by the ‘magic cut’ the probe and blue flows away from the probe.
• Pulsed Wave Doppler or Spectral Doppler: This provides
a quantitative assessment of flow, by obtaining a continu-
ous tracing of flow from a vessel. Flow towards the probe
is seen above the baseline and flow away from the probe
is seen below the baseline.
The pulse wave gate should generally be equal to the
diameter of the vessel being sampled. The sample angle is
best when it is parallel to the flow. However, this may not
always be possible, and therefore, there is a provision to cor-
rect the sample angle, which should be less than 60°. Various
flow indices like RI, PI and PSV can be calculated using the
traced spectral waveforms. The resistance index (RI) and the
pulsatility index (PI) depict resistance to flow. The peak sys-
tolic velocity (PSV) shows the velocity (PSV) of flow in the
vessel. Angle correction may result in incorrect PSV values.
• 3D Colour Doppler or Power Doppler: Here, 3D acquisition
is done with power Doppler in glass body or angio mode. This
helps in assessing soft tissue details with its vascular anatomy
(in the glass body mode) or only blood vessel morphology (in
the angio mode). In glass body mode, the greyscale morphol-
ogy is seen simultaneously (though it is not very distinct) in
the background, providing additional information of the rela-
tionship of vessels to the anatomy seen on greyscale.
With volume histogram, quantitative assessment of vas-
cular flow is possible in the region of interest within the
acquired volume.

Doppler is a useful add-on to greyscale imaging as it

increases the accuracy of diagnosis either by providing
additional information or confirming greyscale diagnosis.
26 2 General Techniques in Gynecological Ultrasound

The advantages of using Doppler in gynecology include the – Randomly dispersed vessels (no uniformity in
assessment of: distribution).
– Tortuous and coiled vessels – in contrast to the straight
• Presence or absence of flow (Fig. 2.26): Live tissue shows or gently curved paths of vessels in benign masses.
flow, whereas avascular tissues (like clots) do not show – Vessels of varying calibre are seen.
flow. To assess this, it is important that Doppler settings – In a single vessel itself the calibre varies. Segments
are optimised. with microaneurysms and stenotic areas may be seen.
• Abundance of flow (Fig. 2.27): The quantity of flow can – Looping and bridging of vessels.
be assessed subjectively (by use of colour score which is • Direction of flow (Fig. 2.30): For this, other than appro-
explained in the following table) or with the help of 3D priate settings, it is important to know that any flow per-
power Doppler with volume histogram, which is objec- pendicular to the ultrasound beam will not be picked up
tive and quantitative. on Doppler. It may, therefore, be required to angulate the
probe or move structures around to pick up flows or trace
vessels. By tracing vessels, the site of origin of the pathol-
Colour score Vascularity
ogy can often be deciphered.
1 No flow • Location of flow (Fig. 2.31): Doppler helps to assess
whether flow is in the periphery or the centre of a
2 Minimal flow (few colour spots) lesion.
3 Moderate flow
• Flow impedance and velocities (Fig. 2.32): These can be
assessed with flow indices like RI, PI and PSV. They are
4 Abundant flow helpful as high-velocity and low-resistance flows are
more indicative of malignancy, inflammation and tropho-
blastic tissue. Flow indices typically show low resistance
The absence of flow or a colour score of 1 increases the (RI less than 0.45) in these cases, but often it is not so. In
likelihood of the mass being benign. A colour score of addition, variable values may be obtained in a given case.
3–4 increases the likelihood of malignancy, but may also It is, therefore, recommended that in assessing flow in
be seen in benign masses, infections, corpora lutea and tissues, particularly tumours, multiple values should be
trophoblastic tissue. obtained from various sites. If variable values are
• Vascular morphology (Figs. 2.28 and 2.29): This can obtained, one can either provide the range of values, or it
help in assessing the nature of a mass (benign or malig- is recommended that one selects the tracing with the
nant). With 2D Doppler, vessels can be seen only in a highest peak systolic value and the corresponding RI of
given plane, therefore, one may see the path of linear that tracing is reported. Pressure from probe should also
vessels. But to visualise the entire vascular tree/pattern, be avoided as it can alter Doppler flow indices.
3D Doppler is essential (especially when vessels are For proper evaluation of flows, Doppler settings must
non-linear and follow tortuous paths). Subjective evalu- be optimised. A few tips have been briefly mentioned.
ation of the morphology of the vessel is best seen on 3D (Details of this are beyond the scope of this book.)
power Doppler with glass body display. This can be fur- Generally the application specialist provides presets for
ther enhanced by cine rotation for views from different gynecology and also explains how these can be altered in
angles. This vascular morphology is best studied in various cases. Points that need attention during Doppler
bulky solid tissue. If the tissue is scant or has multiple studies include:
cystic areas, the vascular tree cannot be evaluated either – Colour box size – Like in greyscale the size of the
because the tissue is minimal in amount or because of colour box should be kept minimal.
distortion of the tissue and its vessels, secondary to – Pulse repetition frequency (PRF) – PRF should be set
pressure and displacement by the cysts. at high for high-velocity flows; however, for low-
After completion of the greyscale ultrasound examina- velocity flows, as is commonly required in assessing
tion, the power Doppler mode and then the 3D mode are masses in gynecology, low PRF values of 0.3 to 0.9 are
turned on. One must try to include the whole ROI in the ideal.
3D volume. The patient is asked to remain still during vol- – Wall filter – This should be set at low for low-velocity
ume acquisition. Then the glass body display is selected. flows and smaller vessels (for most masses in gynecol-
Abnormal features in vascular morphology that sug- ogy it should be set at L1).
gest malignancy include: – Gain – Doppler gain should be stepped up till artefacts
– High density of vessels. appear and then gradually brought down till the arte-
– Multiple and frequent branching. facts just disappear.
2.4 Doppler 27

a b

c d

e f

Fig. 2.25 Various types of Dopplers: (a) Colour Doppler; (b) Power Doppler; (c) High-definition Doppler; (d) Pulse wave or spectral Doppler;
(e) 3D colour Doppler with glass body display mode (showing greyscale image of the tissue studied in background); (f) 3D power Doppler with
angio display mode (the vascular tree morphology is seen, but greyscale tissue display to correlate is absent); (g) Volume histogram for flow indices
(VI, FI, VFI)
28 2 General Techniques in Gynecological Ultrasound

Fig. 2.25 (continued)

Fig. 2.26 No flow seen within the clot of a hemorrhagic cyst

2.4 Doppler 29

a b

c d

Fig. 2.27 Colour score: (a) 1 – no flow; (b) 2 – minimal flow; (c) 3 – moderate flow; (d) 4 – abundant flow
30 2 General Techniques in Gynecological Ultrasound

b c

Fig. 2.28 Abnormal vascular morphology well seen with glass body mode (TVS) in a patient with (a) ovarian cancer. In the image, three multipla-
nar sections are seen which show colour signals and splashes, but for most part the vessel pathway cannot be seen. In contrast the entire vascular
network of vessels is seen in the 3D rendered image (arrow). (b) Cervical cancer showing increased vascularity in the thickened posterior wall of
the cervix. Arrow shows a tortuous, looped vessel. Short arrows highlighting cervical canal and lower endometrial cavity. (c) Endometrial cancer
(LS of uterus with endometrial cavity outlined). Vessels are randomly dispersed and vary from each other in calibre. Vessels show dilated segments
(short arrows) and stenotic segments (long arrows). Looping (stars) and branching (arrowheads) can also be seen
2.4 Doppler 31

a b

c d

Fig. 2.29 Benefit of 3D power Doppler with glass body display is primarily to detect vascular morphology of tortuous vessels that don’t flow
along a single plane. Linear vessel flowing along a single plane and can be seen pretty well even on 2D Doppler. (a, b) Flow in normal secretory
endometrium (a) regular 2D Doppler showing linear vessels crossing the EMJ (arrows), (b) 3D – glass body display shows the same linear vessels
crossing the EMJ (arrows). (c, d) Case of endometrial malignancy (c) regular 2D Doppler showing colour signal dispersed in the endometrium
(most of the vessels could not be traced along their length). Only a few linear vessels crossing the anterior EMJ can be traced. (d) 3D – glass body
display shows the tortuous path of the endometrial vessels and the abnormal vascular tree. The few linear vessels crossing the EMJ seen in (c) are
also seen
32 2 General Techniques in Gynecological Ultrasound

a b

Fig. 2.30 Direction and origin of flow in a case with a polyp in the cervix. (a) The flow to the polyp was seen approaching it from higher up in
the endometrial cavity. (b) The origin of the feeder vessel (arrow) is seen at the upper end of the endometrial cavity after angulation of the probe
so as to pick up Doppler signals

a b

Fig. 2.31 Location of flow. (a) Fibroid showing peripheral flow. (b) Adenomyoma showing central flow
2.4 Doppler 33

a b

Fig. 2.32 Flow indices: Low-resistance, high-velocity flows seen in (a) RPOC and (b) ovarian carcinoma
34 2 General Techniques in Gynecological Ultrasound

2.5 Tips and Tricks of Pelvic Ultrasound mass in three orthogonal (perpendicular) planes are
required. One half of the screen should preferably have an
This section provides a few practical tips on how ultrasound image of the transverse section of the structure while the
evaluation in gynecology is done and also how it can be opti- other should have an image of the longitudinal section of
mised to the investigator’s advantage. the strutures (at right angles to the first). One must try and
ensure that the maximum dimension of the mass has been
• Adjustment of scan parameters: The details of the physics included in one of the two images, for which the probe may
of ultrasound are beyond the scope of this book. A few have to be angulated a little from a pure transverse or a pure
important adjustments for enhanced resolution are: longitudinal section. One must, however, ensure that even
– Depth: Scan depth should be adjusted so as to only if the probe has been angulated for the above reason, the
include the region of interest. two images on both sides of the screen are taken in planes
– Focus: Focal zone is the level at which the image is the perpendicular to each other, by rotating the probe through
sharpest, and therefore, it should be adjusted to the 90°. One measurement is taken transversely across the
level of the area of interest. structure in one image, the second transversely across the
– Scan angle: Large scan angle is useful to obtain a pan- second image and the third perpendicular to either the first
oramic view, but for a higher resolution, the angle or the second measurement. The volume can be calculated
should be reduced to cover only the region of interest. with the formula – x × y × z × 0.523, where x, y and z are
– Zoom: The image should be zoomed such that the ROI the three dimensions of the mass measured as mentioned
occupies about three fourths of the screen. earlier. Most ultrasound machines calculate the volume
• Fixing TS and LS on a split image screen (Fig. 2.33): It is automatically from the three measurements of the struc-
a good idea to follow a consistent protocol of fixing the ture. This automated calculation is what is most often
transverse sections (TS) and long sections (LS) of struc- resorted to, instead of manual calculation of volume with
tures on the screen, so that we do not have to label each the formula given above. Volume analysis is very important
image. This helps save time. For example, the left half of not only for assessing the present size that may help in
the screen can be fixed for transverse sections and the diagnosis, but also for assessing regression or growth of
right half for longitudinal sections. cysts and masses during follow-up. Two-dimensional mea-
• Use of sepia or other colour tints (Fig. 2.34): This is surements in a single plane are not acceptable for evalua-
believed to enhance visual perception by the human eye, tion of the size of any mass. With 3D ultrasound, assessment
which has a greater accuracy for colour vision than for of volume is even more accurate, particularly for structures
black and white. that are not uniform in shape, as mentioned in the section
• Enhancing the image resolution, by altering the angle of on 3D ultrasound earlier in this chapter.
the ultrasound beam, to the structure being assessed • Assessing the echogenicity of a structure/mass (Fig. 2.38):
(Figs. 2.35 and 2.36) On ultrasound, echogenicity is compared typically
On TAS, sometimes the bladder is not optimally filled using the liver as a yardstick. In gynecological ultrasound,
or the uterus is large and bulky. In such cases, the TAS the echogenicity of the normal myometrium is used as the
probe is moved a little lower down and tilted (or angu- standard for assessment of the echogenicity of other struc-
lated) superiorly so that the entire length of the uterus can tures. Myometrium and structures with echogenicity simi-
be seen through the partially filled bladder. lar to that of the myometrium are considered isoechoic.
Structures that lie perpendicular to the ultrasound beam The structures that are less echoic (darker grey) than the
are well seen. Therefore, on TVS, in a mid-positioned normal myometrium are considered hypoechoic, e.g. a
uterus, (which lies parallel to the ultrasound beam on TVS), cyst with turbid contents. Structures that are more echoic
the assessment of structures, particularly the endometrium, (whiter) than the myometrium are considered hyperechoic,
becomes difficult. To overcome this difficulty, one can place e.g. endometrium. Structures which show no echoes
the probe in the anterior or posterior fornix and push on the (black) are considered anechoic, e.g. a follicle with clear
cervix to retrovert or antevert the uterus further, to try and fluid. The echogenicity of a structure on ultrasound can be
make the endometrium as perpendicular to the beam as pos- altered by altering the gain settings. The gain setting
sible. Alternatively one can push the uterine fundus manu- should be such that the myometrium appears grey in
ally from the abdomen towards the probe. In cases with a colour and normal urine in the bladder, black. This is help-
midpositioned uterus, a TAS may be more informative. If it ful in adjusting the gain settings, especially for beginners.
is still not possible to assess or measure the endometrium Often cystic masses that appear anechoic on TAS (because
accurately, it should be mentioned so in the report. of the increased distance of the cystic mass from the probe)
• Calculating the volume of any mass (cystic or solid) may, on TVS, be found to show internal echoes suggestive
(Fig. 2.37): For volume calculation of any structure (cystic of turbid fluid (because of close proximity of the mass to
or solid) on 2D greyscale imaging, the dimensions of the the probe, resulting in improved resolution).
2.5 Tips and Tricks of Pelvic Ultrasound 35

• Cystic or solid (Fig. 2.39): We know that on ultrasound, tions, RPOC or polyps, it is prudent to wait for a few
the denser the structure, the whiter it appears. Clear fluid seconds, if flow is not initially seen.
is therefore anechoic. Many cysts, however, have dense or • Complex masses with blood and clots (Fig. 2.41): At
thick contents which may give them a solid appearance. times, there may be a complex mass seen in the adnexa or
Factors that assist in differentiating a solid mass from a POD with no well-defined structure made out within.
cyst with turbid contents are outlined as follows. This is usually because of blood and clots surrounding
– A cystic structure generally shows acoustic enhance- the structure. In such cases, Doppler helps to detect live
ment distal to the cyst. tissues like the margins of the fallopian tube, cyst wall or
– A cystic structure does not show any flow in the fluid ectopic tissue, which are not clear on greyscale, because
contents within it on Doppler. However, most solid Doppler is able to pick up colour flow in these live
structures with live tissue will show some flow within. tissues.
For Doppler evaluation, it is very important that • Sliding sign and splitting sign: The sliding sign is noth-
Doppler settings be optimised, as mentioned in the ing but the movement of one structure/mass along
section on Doppler earlier in this chapter. another when the TVS probe is used to push any one of
– Cystic structures, particularly with thick contents, these structures. The splitting sign is the moving away
show movement of fluid particles on release of pres- of two structures from one another when the TVS
sure by the TVS probe. Streaming is another phenom- probe is pushed between the two. These signs basically
enon seen in cystic structures with hyperechoic internal tell us that these two structures are not adherent to one
echoes on ultrasound. Streaming is nothing but move- another and also that they are not of common origin
ment of particles (echoes) within the cyst during ultra- (unless there is a pedicle connecting the two, e.g. a
sound examination when the probe is held still. subserous pedunculated fibroid sliding along the uter-
• Evaluation of hyperechoic areas within a cyst (Fig. 2.40): ine wall). This sliding sign is often used to assess
Hyperechoic areas within a cyst could either be clots whether structures like the ovary and bowel are adher-
or solid tissue. Factors that help differentiate between the ent to the uterus.
two are outlined as follows. • Detecting the presence of adhesions (Fig. 2.42): Structures
– Clots often show jelly-like movement on release of are assessed as adherent
pressure. – If there is no sliding or splitting sign between two dif-
– Typically, clots have concave margins facing the ferent structures, they are either adherent or of com-
lumen. mon origin.
– Clots are usually not attached to the cyst wall along their – When an attempt is made to move fixed structures, the
entire length, and part of the outer margins of the clot patient will complain of pain or one may see the two
are usually some distance away from the cyst wall. structures move en masse.
– Clots are avascular, and this feature is very important – Adhesions and loculated fluid between structures sug-
in distinguishing these areas of haemorrhage from gest they are adherent to each other, for example,
solid tissue within a cyst that could have a similar between the ovary and the uterine wall.
appearance. For this, however, the Doppler settings – Sudden angulation in one part of the circumscribed
must be optimised. margin of a cyst is indicative of the cyst being adherent
Debris within a cyst may be seen as a relatively hyperechoic in that area.
avascular area in the dependent portion of the cyst usually • Structure of origin (Figs. 2.43, 2.44, 2.45, 2.46, and
along the posterior/inferior margins. Denser fluid (more 2.47):
hyperechoic) with debris may collect in the dependent por- – A common problem faced, particularly when one sees
tion of the cyst as a result of which a fluid–fluid level may be an adnexal mass, is to know whether it is of ovarian
seen within the cyst. In cysts with thicker contents, however, origin or not. Points that assist in this identification are
this fluid–fluid level may be less regular and well defined. In detailed as follows:
cysts with debris, changing the position of the patient will 1. Visualisation of the ovaries away and separate
show the debris gradually moving into a different location from the mass clearly tells us that the mass is not
(the new dependent part of the cyst). of ovarian origin.
• Evaluating Doppler flows (for the presence of flow and 2. The splitting and sliding sign can also be used to
for flow indices): push the mass away from the ovaries, if the mass is
– Avoid applying pressure with the probe, as this can alter not of ovarian origin.
(decrease) flow in vessels. 3. If ovarian tissue is seen stretched along the walls
– Uterine contractions can transiently diminish flows in of a mass or a cyst as if it were hugging the cyst,
the endometrium and myometrium – and so while the so-called crescent sign, the mass is likely to be
assessing vascularity in conditions like AV malforma- of ovarian origin.
36 2 General Techniques in Gynecological Ultrasound

4. If the contour/outline of the ovarian tissue is con- tracing it upwards. This is important because the location
tinuous with that of the mass, the mass is likely to of a fibroid is typically defined by four parameters:
be of ovarian origin. However, if there is any other 1. Whether it is in the anterior or posterior wall
tissue invaginating between the ovarian tissue and 2. Whether it is in the midline or to the left or right
the mass, it could be an extra ovarian mass. 3. Whether it lies in the uterine fundus, upper corpus,
– The presence of a pedicle and the source of blood sup- mid corpus, lower corpus or cervix
ply to a structure helps not only in identifying the 4. Its relationship to the serosa and endometrial mucosa,
structure of origin, but also in locating the site of ori- that is, whether it is submucous, intramural or subserous
gin. For example, a solid mass with coarse striated Diagrams of fibroid mapping showing the uterus with
echoes could be either a subserous pedunculated fibroids, in one or more planes, are very useful to the cli-
fibroid or an ovarian fibroma. In case ovarian tissue is nician to assess how best to manage the fibroids.
not seen separately or along the mass, it may be diffi- • Delineating the margins of a dermoid: The margins of a
cult to ascertain the diagnosis. The presence of a pedi- dermoid are not well defined because of acoustic shadow-
cle connecting the mass to the uterus will tell us not ing and its resemblance to the bowel. The method used to
only that it is a subserous pedunculated fibroid, but delineate the entire margin of a dermoid (particularly a
also the exact location from where the fibroid is arising large dermoid) is to move the dermoid by applying pres-
from the uterus. The pedicle can be seen both on sure with the TVS probe. The entire part that moves en
greyscale and colour Doppler and is particularly well masse is the dermoid.
visualised if there is fluid surrounding it. Another • The ‘hyperechoic line’ (Fig. 2.49): On ultrasound the
example is a polyp at the cervix, the site of origin of interface between two smooth surfaces appears as a
which is assessed on Doppler, when it is often found to hyperechoic line. Examples of this include the midline of
be arising from high up in the endometrial cavity. the endometrium, margins of a polyp and the lumen of the
– When two structures move en masse on pressure from opposite half of a septate vagina with the TVS probe in
the probe or manually, it indicates that the two are of one hemivagina.
common origin or adherent to each other. • Special manoeuvres with the probe:
– The shape and appearance of a structure often helps in In torsion, gradual movement of the probe along the
deciding the structure of origin. For example, ovarian tis- long axis of the pedicle showing the transverse section of
sue is identified by the presence of antral follicles in a the twisted pedicle produces a whirlpool pattern both on
premenopausal woman; a cystic structure with an incom- greyscale and Doppler, namely, the whirlpool sign. This is
plete septum is of tubal origin, and an elongated tortuous a very specific sign for the diagnosis of torsion of any
mass in the adnexa is likely to be the fallopian tube. structure (ovary, paraovarian cyst or hydrosalpinx).
– Very often, antral follicles of the ovary are seen along In a hydrosalpinx, on moving the probe, one can see
its periphery. This helps in delineating the margins of the cystic spaces communicating with each other, which
the ovary, which is helpful when the ovary forms a part may not be obvious without the movement of the probe.
of a complex mass, like a TO mass. • Tenderness:
– Carefully visualising the outer contour and surroundings Since TVS provides us with the ability to simultane-
also helps in assessing the origin and the nature of the ously see and touch structures with the probe, it is possi-
mass. The presence of fluid at the lower end of a large ble to identify which structure is tender and the cause of
endometrial polyp, for example, indicates that thickened pain. Also, at times the lesion causing pain may be small
endometrium is really a bulky polyp within the endome- and difficult to visualise, but a pain-guided approach may
trial cavity. help locate the lesion, e.g. an ectopic mass or a focus of
– Loculated fluid within adhesions is generally not of deep infiltrating endometriosis. The patient usually
smooth contour, and the presence of narrow beak-like acknowledges that the pain she is experiencing during
extensions between tissue planes indicates that this is TVS is the same pain that she has been suffering from.
cystic fluid encompassed between tissue planes, and • Reproducibility in multiple planes and with multiple
not an ovarian or a paraovarian cyst. modalities (Figs. 2.50 and 2.51):
• Fibroid mapping (Fig. 2.48): In order to study the location When a structure is visualised in one plane, assessment
of any mass like a fibroid in the uterus, one must be able may sometimes be challenging, and rotating the probe by
to assess the uterine midline (which is the endometrial 90° and revaluating the same area provides a better impres-
cavity). Every now and then, when the architecture of the sion of the structure/pathology. There are lesser chances of
uterus is distorted by multiple fibroids, locating the endo- error or artefact if the structure one is suspecting is seen even
metrium may become challenging. One must, however, after a 90° rotation, i.e. if it is reproducible in multiple planes.
move the probe in various directions to try one’s best to Similarly, reproducing the pathology/lesion with mul-
trace the endometrium. Sometimes, tracing the endome- tiple modalities also enhances diagnostic accuracy. For
trium is facilitated by visualising the cervical canal and example, a polyp may be seen on 2D greyscale imaging and
2.5 Tips and Tricks of Pelvic Ultrasound 37

with 3D rendering. In addition, a Doppler evaluation will that nothing is missed. Reporting should therefore
show us its feeder vessel, which further helps to confirm the include:
diagnosis. – Relevant history and indication of ultrasound. This
• Importance of previous scan reports and images should be mentioned in the report.
Availability of previous scan reports and images is use- – Uterus – The size and position should be mentioned.
ful in making a diagnosis and assessing the effectiveness – Endometrium – The appearance and thickness should
of management. For example, a physiological ovarian cyst be mentioned. Any pathology seen within should be
does not persist at follow-up scans, while an endometriotic described (in terms of size, location, greyscale mor-
or neoplastic cyst continues to increase in size. Similarly, phology and Doppler flows).
if one is aware that a patient has an endometriotic cyst – Myometrium – If the myometrium is homogeneous
documented at a previous scan, the presence of solid vas- and shows no pathology, it should be reported as nor-
cular areas along its cyst walls during pregnancy, due to mal. If any pathology is present, it should be described
decidualisation of the endometriotic cyst, will not be mis- (in terms of size, location, greyscale morphology and
interpreted as a neoplastic malignant mass. Along the Doppler flows).
same lines, in patients on medical treatment for chronic – Ovaries – Their size and mobility should be men-
infection like pelvic tuberculosis or endometriosis, the tioned. The presence of developing follicles or corpus
efficacy of management can be assessed only if previous luteum should also be reported. Any pathology in the
reports are available. ovary should be described (in terms of size, location,
• Timing of ultrasound greyscale morphology and Doppler flows).
Baseline assessment of the ovary for antral follicle – Adnexa – The presence or absence of any pathology
count and ovarian reserve in patients with infertility is should be mentioned. If present, it should be described
done on Day 2 or 3* of the menstrual cycle. (in terms of size, location, greyscale morphology and
For Doppler evaluation of the ovaries, particularly in Doppler flows).
the presence of small masses, Day 2 to Day 6* of men- – Cervix and vagina – The presence or absence of any
strual cycle is ideal. pathology should be mentioned, if present.
For assessment of endometrial pathology like polyps, – Pouch of Douglas – the presence of any fluid, adhe-
the preovulatory phase (Day 10 to Day 12*) is ideal. sions or any other pathology, if present, should be
For 3D evaluation of the endometrial cavity, the secre- mentioned.
tory phase (Day 18 to Day 23*) is ideal as the endome- – High and low sliding sign – This (i.e. the sliding of the
trium is fluffy and edematous at that time and therefore is bowels along the upper and lower posterior wall of the
visualised well on a 3D rendered image. uterus) should be mentioned in the report.
For evaluation of cervix (as in uterine anomalies or cer- – Tenderness – If tenderness is present during TVS, it
vical polyps), mid-cycle (Day 12 to Day 14*) is ideal as should be mentioned. DIE nodules if present should be
the cervical mucous present helps to delineate better the described (size and location).
cervical canal or any pathology within. – Kidneys – Many sonologists include evaluation of the
* (This is applicable in women with regular menstrual kidneys as a part of routine examination. This is
cycles of 28–30 days.) because hydronephrosis may be seen secondary to
• Reporting of ultrasound in gynecology some gynecological pathologies, and in patients with
After a good ultrasound evaluation of the pelvis, it is uterine anomalies there may be associated renal
important that reporting is done systematically to ensure anomalies.
38 2 General Techniques in Gynecological Ultrasound

Fig. 2.33 Ovaries seen in TS

and LS views

a b

c d

Fig. 2.34 Sepia and greyscale

images in two different patients
– for comparison. (a, b)
Retained placenta. (c, d) Normal
cervix
2.5 Tips and Tricks of Pelvic Ultrasound 39

Fig. 2.35 Imaging the uterus with a partially filled bladder.

Changing the angle of the ultrasound beam from above the uterus
(short arrow), by moving the probe downwards on the patient’s
abdomen and tilting it upwards, provides better visualisation of the
uterus as the angle of the beam passes through the fluid-filled
bladder (long arrows)

a b

Fig. 2.36 Visualisation of endometrium. (a) In an RF uterus with the endometrium perpendicular to the ultrasound beam (arrows). The endome-
trium is clearly visualised. (b) In a mid-positioned (axial) uterus, with endometrium parallel to the ultrasound beam (arrows). The endometrium is
not well seen
40 2 General Techniques in Gynecological Ultrasound

Fig. 2.37 Calculating the

volume of a right ovarian
neoplastic mass by TS LS
measuring its three
dimensions in two
perpendicular planes (TS
and LS)

a b

Fig. 2.38 Cyst echogenicity can

be altered by changing the 2D
gain settings. (a) Appears
anechoic with low gain settings.
(b) Shows low-grade internal
echoes with high gain settings
2.5 Tips and Tricks of Pelvic Ultrasound 41

a b

Fig. 2.39 Differentiation between cystic and solid masses. (a) Cystic mass with turbid contents showing acoustic enhancement (arrows) and no
flow on Doppler within. (b) Solid mass showing flow within on Doppler and no acoustic enhancement

b c

PRF 1.3 PRF 0.6

Fig. 2.40 Hyperechoic areas within a cyst. (a) Clot in an endometriotic cyst showing no flow on Doppler. (b) Cyst with a hyperechoic solid area
(arrow) showing no flow on Doppler because of a high PRF setting of 1.3. (c) The same cyst seen a few months later, with the solid area (arrow)
showing flow within on Doppler, because of an optimally low PRF of 0.6
42 2 General Techniques in Gynecological Ultrasound

a
b

Fig. 2.41 Doppler in complex adnexal masses containing clots in two different patients with ectopic pregnancy. (a) Flow is seen in the tubal walls
of the hematosalpinx. (b) Spectral tracing of flow around ectopic tissue in a hematosalpinx

a
b

Fig. 2.42 Adherent ovaries in two different patients with endometriosis. (a) Ovary is adherent to the posterior wall of the uterus showing a sudden
angulation (arrow) of its otherwise regular circumscribed margin. (b) Both ovaries adherent to each other with a sudden angulation seen in their
contour (arrow)
2.5 Tips and Tricks of Pelvic Ultrasound 43

a b

Fig. 2.43 To assess ovarian origin of a mass. (a) Cyst of ovarian origin showing ‘crescent sign’ (ovarian tissue stretched out and hugging the cyst,
denoted by the arrow). (b) Paraovarian cyst with a wedge of tissue (arrows) intervening between the ovary and paraovarian cyst. (c) Atrophic
ovaries (small arrows) seen separate from the cyst
44 2 General Techniques in Gynecological Ultrasound

Fig. 2.44 Subserous

pedunculated fibroid seen
attached to the uterus by a
pedicle (arrow)

a b

Fig. 2.45 Visualising the margins of the ovary by the presence of antral follicles (arrows) along its margins in two different patients. (a) Ovary
adherent to a malignant tubal mass. (b) Ovary lying along one side of a pseudoperitoneal cyst

a b

Fig. 2.46 Endometrial polyp presenting as a case with thickened endometrium. (a) Thick endometrium with tiny cystic spaces. (b) Lower end of
the endometrial cavity showing minimal fluid and the lower margins of an endometrial polyp, which helped in diagnosing the condition
2.5 Tips and Tricks of Pelvic Ultrasound 45

a b

Fig. 2.47 Assessing origin of adnexal cystic areas in three different cases. (a) Loculated fluid (arrow) showing irregular margins. (b) Loculated
periovarian fluid (short arrow) showing narrow extension (long arrow) of fluid between tissue planes. (c) Paraovarian cyst (arrow) showing circum-
scribed regular margins

Fig. 2.48 TAS of uterus showing multiple fibroids. Arrows showing Fig. 2.49 Hyperechoic line (arrow) along the interface between the
endometrium. Locating the endometrium is essential for fibroid mapping smooth walls of the polyp and the endometrium
46 2 General Techniques in Gynecological Ultrasound

Fig. 2.50 Reproducibility of

pathology in different planes. TS LS
TS and LS of uterus showing
RPOC. Endometrial outlines
on LS are not well visualised
because of the submucosal
adenomyoma (arrow). TS
views of the endometrial
cavity help in confirming the
presence of RPOC

a b

Fig. 2.51 Confirming the presence of lesion with multiple modalities. Polyps seen on greyscale confirmed by (a) Doppler by the presence of a
feeder vessel (the feeder vessel of one of the two polyps is seen in this image) and (b) by 3D rendering
2.6 Sonohysterography (SHG) 47

2.6 Sonohysterography (SHG) Prophylactic antibiotic may be administered. In some

centres the use of prophylactic antibiotic is a routine, while
Sonohysterography (Figs. 2.52, 2.53, and 2.54) is an in other centres it is used only in those patients with known
enhanced technique of doing a transvaginal scan. This can be tubal occlusion or peritubal adhesions. Pain may be pre-
done with either gel or saline infusion into the endometrial vented or minimised by administering a non-steroidal anti-
cavity. Saline infusion sonohysterogram (SIS) is more popu- inflammatory drug (NSAID), half an hour to one hour prior
lar and involves instillation of saline into the endometrial to the procedure.
cavity with a simultaneous transvaginal scan. The advantage A routine transvaginal scan should be done prior to
of instilling saline is that it distends the endometrial cavity, SIS. After taking the patient’s written consent, the parts are
outlining any intracavitary lesions distinctly. SIS is more cleaned with Betadine. With the help of a speculum, the cer-
accurate than TVS for endometrial pathology and less inva- vix is visualised and may be held with the help of a tenacu-
sive than hysteroscopy. lum or a vulsellum, if required. A size 7 F catheter
(sonohysterography catheter), flushed with saline (to ensure
Indications there are no air bubbles), is inserted into the cervical canal.
• Abnormal uterine bleeding. In cases with cervical stenosis, a cervical dilator may be
• Thickened endometrium particularly in postmenopausal carefully used. Once the catheter is inside, the catheter bal-
women. loon is inflated, and then saline, preferably warm, is instilled
• Submucous fibroids to assess its grade and the possibility with the help of a syringe into the endometrial cavity. Initially
of a hysteroscopic resection. about 10 ml is instilled, but if required, further instillation
• The presence of intracavitary lesions which are difficult may be done (up to 40 ml). If the balloon of the catheter is
to delineate. obscuring visualisation, it may be deflated. It has been
• Other indications include infertility and recurrent noticed that Doppler flows in tissues may be minimised dur-
miscarriage. ing SIS due to the pressure effect of the instilled fluid.
• It can also be used to assess tubal patency. The presence of air bubbles and suboptimal distension of the
endometrial cavity may result in poor evaluation of endometrial
It is contraindicated in the presence of or the suspicion of pathology. SIS may be technically unsuccessful if the cervix is
pregnancy or PID. stenosed and the catheter cannot be passed through the cervical
canal or if the endometrial cavity cannot be distended.
Technique This procedure can also be done using a size 7 infant
It should be done between Day 6 and Day 10 of the men- feeding tube which is stiffer and easier to insert into the
strual cycle when the endometrium is the thinnest and the endometrial cavity. The disadvantage, however, is that very
patient is not likely to be pregnant. In postmenopausal often the instilled saline may drain out quickly, resulting in
women it can be done at any time. suboptimal distension of the endometrial cavity.
48 2 General Techniques in Gynecological Ultrasound

a b

c d

Fig. 2.52 A case of cystic hyperplasia with polypoid endometrium. (a) Regular TVS – greyscale image of uterus showing thickened complex
endometrium. (b) Doppler showing multiple vessels crossing the EMJ on regular TVS. (c) SHG showing fluid in the endometrial cavity and a
posterior polypoidal endometrium with vascular flow. (d) SHG with 3D rendered image of the uterus showing the polypoidal endometrium along
its lateral walls
2.6 Sonohysterography (SHG) 49

a b

c d

Fig. 2.53 Endometrial polyp in a postmenopausal patient. (a) Regular TVS showing a thick hyperechoic endometrium of 19 mm. (b) Regular
TVS showing vessels in the endometrium on Doppler. No single prominent feeder vessel was, however, noted. (c) SHG showing an unanticipated
teardrop-shaped large endometrial polyp conforming to the shape of the endometrial cavity. (d) 3D rendered image showing the endometrial polyp
attached to the posterolateral wall of the uterus
50 2 General Techniques in Gynecological Ultrasound

a b

c d

Fig. 2.54 Submucous fibroid. (a) Regular TVS showing a poorly defined fibroid in the endometrial cavity with the anterior endometrium mea-
sured. (b) Regular TVS with 3D rendering. The fibroid seen in multiplanar view. (c) SHG on greyscale showing a completely intracavitary submu-
cous fibroid arising from the posterior wall. Catheter seen in situ (arrow). (d) SHG with 3D rendering showing completely intracavitary submucous
fibroid
2.7 Gel Sonovaginography (GSV) 51

2.7 Gel Sonovaginography (GSV) • Deep infiltrating endometriosis: to assess the involvement
and extent of lesions in the cervix, vagina and anterior
Gel sonovaginography is an enhanced technique of doing a rectal wall.
transvaginal scan, wherein about 20 ml of ultrasound gel is
instilled into the vagina, followed by ultrasound evaluation Technique (Fig. 2.55)
by a transvaginal probe. Following a regular TVS, consent should be taken after
Visualisation of the cervix and vagina is known to be sub- informing the patient of the procedure. A 20 ml syringe is
optimal on regular transvaginal scan. This is primarily filled with ultrasound gel in such a manner that there are
because of close proximity of these structures to the trans- minimal air bubbles within. To fill in such a manner, a fresh
vaginal probe and the collapsed vaginal lumen. The advan- new bottle of gel (company packed) is held with its mouth
tages of instilling intravaginal gel are: facing downwards, preferably by an assistant. The syringe is
introduced into the lower part of the inverted bottle. Then,
• It creates a stand-off between the probe and the structures instead of pulling the plunger out to fill the syringe, as is the
that have been evaluated resulting in better resolution. usual practice, the plunger is held steady in position, and the
• The intravaginal gel partially distends the vagina, so spa- barrel (outer sleeve) is slowly pushed further up into the
tial orientation, relationship between various structures inverted bottle of gel so as to fill the 20 ml syringe with mini-
and inner vaginal contours are better assessed. mal air bubbles within. Next, the syringe is gently introduced
• It surrounds the various structures (cervix, vagina and any into the vagina directed by the fingers of the right hand in the
lesion) and fills narrow gaps between tissue planes, vagina. The fingers of the right hand are then removed and
thereby enhancing delineation. the syringe gently pushed further inside the vagina to intro-
duce the gel into the upper vagina (mainly in the posterior
GSV is therefore useful in assessing a variety of known or fornix).
suspected local pathologies of the cervix and vagina (and It is important to assess the lower vagina initially before
surrounding structures), where regular TVS is known to have assessing the upper vagina and the cervix. The initial few
its limitations. Its utility also lies in its capability to rule out minutes are the best time to make the assessment, as with the
pathology in suspected cases. passage of time, air bubbles begin to collect along the sur-
face of the cervix and upper vagina.
Indications After completing the examination, the patient is asked to
Cases are selected predominantly during the process of empty her bladder once more and strain after doing so, so
regular TVS, when a lesion is either seen or suspected that most of the gel passes out.
(which include a mass, an area of increased vascularity, a If too many air bubbles are introduced accidentally, pre-
feeder vessel in the cervical canal, thickened vaginal walls venting proper evaluation, repeating the procedure in the
and uterine anomalies). Other cases are those, where the same sitting is not helpful in dismissing the air bubbles. In
referring clinician has seen or has a strong suspicion of such cases, gel sonovaginography can be redone the follow-
some local pathology on bimanual or per speculum. GSV ing day with good results.
is not done on pregnant women and on women with active GSV is an effective technique for assessment of a variety
bleeding. of known or suspected local cervical and vaginal patholo-
GSV can be used in cases with: gies, where regular TVS is known to have its limitations. It is
• Uterine anomalies: to assess the cervix and vagina for any well tolerated in an outpatient setting, requires a single oper-
septum. ator and can be performed at a single visit as an extension of
• Cervical polyps (Fig. 2.56): to assess the number, size, regular TVS.
location, origin and vascularity of the polyps. Cases where GSV has been resorted to have been refer-
• Cervical and vaginal cancers (Fig. 2.57): to assess the enced throughout the book in various chapters depending
presence of the lesion, its vascularity, location and extent. upon the pathology studied.
52 2 General Techniques in Gynecological Ultrasound

a b

Fig. 2.55 Technique of GSV. (a) Technique of filling the 20 ml syringe. A bottle container of ultrasound gel is held with its mouth facing down-
wards, and the syringe is introduced into the lower part of the inverted bottle. The plunger is held steady in position and the outer barrel is slowly
pushed further up into the inverted bottle of gel so as to fill the syringe. (b) Technique of instilling gel into the vagina. The syringe is held in such
a manner that its tip (hub end) lies in the groove between the index and the middle finger. It is then gently introduced into the vagina, directed by
the fingers of the right hand in the vagina. The fingers of the right hand are then removed and the syringe gently advanced into the vagina. The
plunger of the syringe is pushed, thus introducing the gel into the vagina

a b

CX

CX
Vag. gel Bladder P

Vag. gel

Fig. 2.56 GSV. (a) LS of the normal cervix and vagina. (b) LS of the cervix and vagina showing a cervical polyp (P) with a feeder vessel (arrow)
2.7 Gel Sonovaginography (GSV) 53

Fig. 2.57 Vaginal cancer in

a post-hysterectomy patient. a
(a) Mass seen at vaginal vault
on regular TVS is measured –
vaginal walls not delineated.
(b) GSV – vaginal walls
(long arrow) and tumour
mass (short arrow) well
visualised. Image (b) with gel
corresponds to image (a)
without gel

b
54 2 General Techniques in Gynecological Ultrasound

Suggested Reading pathology. Ultrasound Obstet Gynecol 11:337–342. doi:10.104

6/j.1469-0705.1998.11050337
Sibal M (2016) Gel Sonovaginography: A New Way of Evaluating a
Allison SJ et al (2011) Saline-infused Sonohysterography: Tips for
Variety of Local Vaginal and Cervical Disorders. J Ultrasound Med
Achieving Greater Success. Radiographics 31(7):1991–2004
35(12):2699–2715
Ando H et al (2004) Which infertile women should be indicated for
Sladkevicius P et al (2007) Contribution of morphological assessment
sonohysterography? Ultrasound Obstet Gynecol 24:566–571.
of the vessel tree by three-dimensional ultrasound to a correct diag-
doi:10.1002/uog.172
nosis of malignancy in ovarian masses. Ultrasound Obstet Gynecol
Jurkovic D (2002) Three-dimensional ultrasound in gynecology: a criti-
30:874–882. doi:10.1002/uog.5150
cal evaluation. Ultrasound Obstet Gynecol 19:109–117. doi:10.104
Testa AC et al (2009) Dynamic and interactive gynecological ultrasound
6/j.0960-7692.2001.00654
examination. Ultrasound Obstet Gynecol 34:225–229. doi:10.1002/
Schwärzler P et al (1998) An evaluation of sonohysterography
uog.7309
and diagnostic hysteroscopy for the assessment of intrauterine
 Ultrasound Evaluation of Myometrium
3

The myometrium is the muscular tissue of the uterus and the Measurements (Figs. 3.1, 3.2 and 3.3)
cervix, which encloses the uterine cavity and its lining, the • Uterine size: With myometrial pathologies, the uterus is
endometrium. The myometrium is generally isoechoic (simi- often enlarged. It could be asymmetrically enlarged or glob-
lar to the liver) and homogeneous. The myometrial echo- ally enlarged. The uterus is measured in three dimensions:
genicity, thickness, contour and presence of any mass or – The total length of the uterus is the length from the
cysts are noted during ultrasound examination. The two upper margin of the uterine fundus to the external os in
commonly encountered pathologies of the myometrium are the sagittal section of the uterus.
fibroids and adenomyosis. – The anteroposterior diameter of the uterus is the maxi-
mum AP measurement in the sagittal section of the
uterus.
– The transverse diameter of the uterus is the maximum
3.1 Evaluation of Myometrium transverse measurement taken in the transverse section
of the uterus.
The myometrium can be evaluated both on transabdominal • The thickness of the anterior and posterior myometrial
and transvaginal scan. Ideally, like in all other conditions, walls is measured from the external uterine serosa to the
both TAS and TVS should be done, as they complement each endometrial margins and should include the JZ. The
other. In myometrial pathologies like fibroids and adenomy- measurement is done in the sagittal plane, perpendicular
osis, the uterus is sometimes of large size extending beyond to the endometrium, in a single image where the endo-
the pelvis, and a TAS becomes essential to evaluate the metrium is thickest. The myometrial walls are not mea-
uterus. In addition, TVS may be suboptimal if there is a large sured routinely, unless there is some pathology or
mass (like a fibroid) in the cervix or lower corpus that causes asymmetry noted.
shadowing and prevents assessment of the structures above • Any mass, like a fibroid, seen within the myometrium is
it. When the uterus is of a large size, one may not require a measured in three orthogonal dimensions (three measure-
very full bladder because the large uterus itself often pushes ments perpendicular to each other), in two images whose
the bowels away into the upper abdomen. plane is perpendicular to each other (as explained in
The evaluation of the uterus should be systematic, and Chap. 2).
reporting should be standardised. The MUSA (Morphological
Uterus Sonographic Assessment) statement is a consensus
statement by a panel of experts (MUSA consensus group) for Qualitative Assessment of the Myometrium (Fig. 3.4)
terms, definitions and measurements for describing and • The outer serosal contour of the uterus is noted to see if it
reporting the myometrium and its pathologies. The terms is regular or not.
and definitions laid down by the MUSA will be relied on for • The uterine myometrial echogenicity is assessed as uni-
the most part in this chapter. form (homogeneous) or non-uniform (heterogeneous).
The uterus is first evaluated in the sagittal and transverse sec- • The normal myometrium is used as a standard to evaluate
tions on 2D. 3D is used to get a coronal section of the uterus, echogenicity of other structures in the myometrium, i.e.,
which provides good information of the external uterine contour, structures that are as echogenic as the normal myome-
cavity shape, endomyometrial junction and relation of myome- trium are considered to be isoechoic. Lesions that are less
trial pathology to the endometrial mucosa and serosa. Dopplers echogenic are termed hypoechoic, whereas those which
are used as and when relevant, typically when pathology is noted. are more echogenic are termed hyperechoic.

© Springer Nature Singapore Pte Ltd. 2017 55

M. Sibal, Ultrasound in Gynecology, DOI 10.1007/978-981-10-2714-7_3
56 3 Ultrasound Evaluation of Myometrium

• The symmetry of the myometrial walls is then assessed. • It may not be possible to assess the junctional zone in a
Asymmetrical thickening of the myometrium is often due mid-positioned uterus or shadowing by fibroids.
to pathology. If the walls are of symmetric thickness, then • In adenomyosis (discussed later in a separate section), the
one does not need to measure them. JZ shows tiny cystic spaces, hyperechogenic dots, hyper-
• The myometrium is also assessed for the presence of any echoic buds or echogenic lines. It may also be thickened
mass or cyst. These are further assessed for their echo- in cases of adenomyosis.
genicity, blood flows, acoustic shadowing and relation to
the endometrial mucosa and outer serosa. Doppler Assessment (Figs. 3.6 and 3.7)
• In order to assess the location of the pathology in the myo- The arcuate vessels can be seen in the outer part of the myo-
metrium, it is important to delineate the endometrial cavity metrium running parallel to the serosa. Perpendicular to the
which could be a challenge when there are existing myome- arcuate vessels are the radial arteries and veins. Flow can be
trial pathologies like fibroids. One useful tip that may help seen in these arcuate and radial vessels of the myometrium.
to trace the endometrium is to find the cervical canal and Power Doppler is preferred to colour Doppler in assessing
trace it upwards. flows in the myometrium because power Doppler is more
sensitive to detect flows in small vessels and low-velocity
Assessing the ‘Junctional Zone’ (JZ) (Fig. 3.5) flows.
The junctional zone is basically the inner myometrium com- Whenever a lesion is visualised, its vascularity should be
posed of longitudinal and circular closely packed smooth reported using subjective colour scoring from 1 to 4
muscle fibres. The JZ is visualised as a hypoechoic (dark), (discussed in detail in Chap. 2 under the section on Doppler).
halo (layer) just beside the endometrium. It is clearly visual- One can also do a spectral flow analysis to assess resistance
ised on 3D rendered images and VCI (discussed in Chap. 2). to flow (RI or PI) and flow velocity (PSV) in a vessel.
Lesions of the myometrium may show circumferential flow
• The JZ may be well defined or poorly defined. running along the periphery of the lesion or intralesional
• It may be regular, irregular or interrupted. flow running through the mass.
3.1 Evaluation of Myometrium 57

a LS TS b

UTERUS

Fig. 3.1 Uterus measured on TAS. (a) LS and (b) TS views

LS

Fig. 3.2 Thickness of asymmetrical myometrial walls measured in a

midsagittal section, perpendicular to the endometrium. The anterior
wall is much thicker than the posterior wall
58 3 Ultrasound Evaluation of Myometrium

Fig. 3.3 Myometrial fibroid

measured in three dimensions in
TS LS
two perpendicular planes

a b
LS LS
F

Fig. 3.4 Contour of uterus in two different cases. (a) Regular, in a normal uterus. (b) Irregular in a uterus with multiple fibroids (F), which are
seen as circumscribed hypoechoic masses with shadowing
3.1 Evaluation of Myometrium 59

a Outer
myometrium Inner
myometrium (JZ)

EMJ

Basal
Functional endometrium
endometrium

b c

d e

Fig. 3.5 Endomyometrial junction (EMJ). (a) Diagrammatic representation. (b, c) Regular EMJ on 2D and 3D. (d, e) Irregular EMJ on 2D and
3D in a patient with adenomyosis
60 3 Ultrasound Evaluation of Myometrium

a LS b LS

Fig. 3.6 Normal vasculature of myometrium on (a) colour Doppler and (b) on 3D glass body display. Short thick arrows showing arcuate vessels,
medium-sized arrows showing radial vessels and long arrows showing spiral vessels

Fig. 3.7 Peripheral flow seen on

Doppler around a fibroid
3.2 Normal Myometrium 61

3.2 Normal Myometrium (Figs. 3.8, 3.9 Uterus in the reproductive age group (Fig. 3.9): The size
and 3.10) of the normal uterus varies with parity. Dimensions of a nor-
mal uterus are about 8 cm in length, 4 cm in AP diameter and
5 cm in width, with the multiparous uterus being about a
Uterine size, myometrial thickness and the proportion of the
centimetre larger in each dimension. The uterine body is
uterine body to the cervix change with the age of an indi-
approximately twice the size of the cervix. After delivery, the
vidual and occurrence of pregnancy.
uterus undergoes physiological evolution during the
6–8 weeks of puerperium to return to its normal size.
Immediately after delivery, the uterus is about 20 cm in
Neonatal uterus: The uterus is relatively prominent
length, and after 3 weeks, it is about 11 cm in length.
because of exposure to maternal hormones with an average
uterine length of 3.5 cm and thickness of 1.4 cm.
Postmenopausal uterus (Fig. 3.10): The uterus is smaller in
size, usually less than 7.5 cm. This of course depends on the
Paediatric uterus (Fig. 3.8): The uterus in the paediatric time since menopause, parity of the patient and the presence of
age group is usually less than 3 cm and becomes 3–4.5 cm in pre-existing myometrial pathology. The uterine body to cervix
the prepubertal age group. At puberty the uterus is usually ratio approaches 1:1. In elderly postmenopausal women
5–8 cm long. The cervix in the paediatric age group is promi- (particularly those with vascular disease, diabetes or
nent and equal in proportion to the uterine body. At puberty, hypertension), calcified arcuate vessels are noted. These are
the uterine body becomes thicker and pear shaped with a seen in the outer myometrium as peripheral bright scattered
uterine body to cervix ratio of about 1.5: 1. foci with some shadowing which are arranged circumferen-
tially around the uterus.
62 3 Ultrasound Evaluation of Myometrium

a
LS TS

b LS

Uterine Body
Cervix

Fig. 3.8 Prepubertal uterus (a) measuring 3.5 × 0.9 × 1.2 cm. (b) Cervix appears relatively bulkier than the uterus
3.2 Normal Myometrium 63

Fig. 3.9 Uterus in a patient of the

reproductive age group showing normal LS
homogeneous myometrium

a b
LS TS

Fig. 3.10 Postmenopausal uterus with calcified arcuate vessels seen as hyperechoic scattered foci close to the uterine periphery (arrows), on (a)
LS and (b) TS of the uterus
64 3 Ultrasound Evaluation of Myometrium

3.3 Fibroids (Leiomyoma or Myoma) • Fibroids show variable echogenicity depending upon the
proportion of muscle cells and fibrous stroma and the
Fibroids, also known as leiomyomas, are benign tumours of presence of any degenerative changes. They can appear
the myometrium. They are composed of smooth muscle cells from hypoechoic to hyperechoic.
and connective tissue in densely packed whorls. They are • Fibroids generally show linear stripy fan-shaped internal
common, and about 40 % of women by the age of 40 years acoustic shadowing and also shadowing from its edges
have fibroids. Very often they are multiple. (reported as ‘edge shadows’).
Many of the women with fibroids are asymptomatic, • They may show calcification and cavitation.
while others may have symptoms like menorrhagia, poly- • On Doppler, fibroids typically show pericapsular flow
menorrhagia, intermenstrual bleeding, dysmenorrhoea and (i.e. circumferential flow around its margins). Some
subfertility. With submucous fibroids and fibroid polyps, amount of intralesional flow is also commonly seen
intermenstrual bleeding (metrorrhagia) could be a presenting within the fibroid. Some fibroids may, however, show
complaint. high vascularity (increased vascularity seems to be related
to increased cellularity in fibroids).
Ultrasound Features of Fibroids (Figs. 3.11, 3.12, 3.13,
3.14, 3.15, 3.16 and 3.17) Despite the variable appearance of fibroids, diagnosing
• Fibroids typically appear as round, well-defined, oval them on ultrasound is not challenging because any mass in
or lobulated solid masses seen in the uterus or arising the uterus (once an adenomyoma is excluded) or arising
from it. from it is almost always a fibroid.

a b

Fig. 3.11 Typical fibroids (a, b) are seen on ultrasound as well-demarcated, solid masses with stripy, linear, fan-shaped, internal shadowing and
shadowing from their edges (arrows)

a LS b LS c LS

Fig. 3.12 Fibroids showing varying echogenicity. (a) Hypoechoic, (b) isoechoic (arrow) and (c) hyperechoic
3.3 Fibroids (Leiomyoma or Myoma) 65

Fig. 3.13 Fibroids (a, b) show- a b

ing complex internal echoes

Fig. 3.14 Fibroids (a, b) a b

showing cavitation (seen as
irregular, anechoic or
hypoechoic, cystic areas
within the fibroid)

Fig. 3.15 Fibroids showing a b

calcification. (a) Peripheral
calcification, appearing like a
shell around the fibroid. (b)
Internal calcification causing
acoustic shadowing
66 3 Ultrasound Evaluation of Myometrium

a b
TS LS

c LS d LS

CX

Fig. 3.16 Vascularity of fibroids. (a, b) Fibroids showing typical peripheral vascularity. (c) Atypical fibroid with significant internal vascularity.
(d) 3D power Doppler with glass body display showing the vascular morphology in fibroids with high vascularity
3.3 Fibroids (Leiomyoma or Myoma) 67

Fig. 3.17 Fibroid. (a)

a
Isoechoic fibroid seen in the LS TS
anterior wall of uterus with its
margins not clearly defined. (b)
Peripheral vascularity helped
define the margins of the fibroid
and confirm the diagnosis

b LS
68 3 Ultrasound Evaluation of Myometrium

3.3.1 Fibroid Mapping Locating the fibroid or ‘fibroid mapping’ is very impor-
tant because:
3.3.1.1 Basics of Fibroid Mapping (Figs. 3.18, 3.19
and 3.20) • It gives us information about whether the fibroid is the
To map or describe the location of any mass like a fibroid, in cause for the patient’s symptoms. For example, fibroids
the uterus, one must know four parameters: that are submucous are more likely to cause menorrhagia;
fibroid polyps are more likely to cause metrorrhagia and
1. How superior or inferior the mass is. For this, the uterus dysmenorrhoea.
can be divided into fundus, upper corpus, midcorpus, • It also helps to decide if surgery is required and, if so, the
lower corpus and cervix. type of surgery that is appropriate – a hysterectomy, myo-
2. How anterior or posterior the mass is. The mass could be mectomy or a hysteroscopic resection.
in the anterior wall or the posterior wall. • A good mapping also helps the surgeon during surgery to
3. How much to the left or right the mass is. The mass could know the exact site of the various fibroids for a proper
be right sided, left sided or in the midline. surgical approach and to ensure that all the fibroids are
4. How close is the mass to the inner endometrial mucosa or managed optimally.
the outer serosa? The mass could be subserous, intramu-
ral or submucous. A fibroid or mass reaching both the Submucous fibroids have again been graded into:
serosa and the mucosa is termed transmural. In some
cases, noting the exact distance of a fibroid from the G0 – completely intracavitary
mucosa or serosa provides useful information to the sur- G1 – more than 50 % intracavitary
geon in planning surgical management. This is particu- G2 – less than 50 % intracavitary
larly so in cases of submucous fibroids which are being
considered for hysteroscopic resection, where the thick- Presently it is suggested in the MUSA consensus statement
ness of the remaining overlying myometrium becomes that the site of any well-defined myometrial lesion like a fibroid
important. should be reported based on FIGO classification of fibroids:

At times, the uterine architecture is significantly distorted • 0 = pedunculated, intracavitary (completely within the
by multiple fibroids making their location within the uterine endometrial cavity)
body difficult to ascertain. To locate them, finding the endo- • 1 = submucosal, less than 50 % intramural
metrial stripe is important. If this becomes difficult due to • 2 = submucosal, more than or equal to 50 % intramural
shadowing by multiple fibroids, tracing it up from the cervi- • 3 = 100 % intramural but in contact with endometrium
cal canal is usually helpful. • 4 = intramural
Fibroids can be located and mapped with the help of a 2D • 5 = subserosal, more than or equal to 50 % intramural
live scan, by gently moving the probe from the left to the • 6 = subserosal, less than 50 % intramural
right in a longitudinal section and from up to down in a trans- • 7 = subserosal pedunculated
verse section. Visualisation of the fibroid in a coronal section • 8 = other (cervical, parasitic)
is better on 3D, particularly in assessing the relation of the The locations of transmural fibroids in this FIGO classifi-
fibroid to the endometrial cavity. cation are described as ‘2–5’.
3.3 Fibroids (Leiomyoma or Myoma) 69

Fig. 3.18 Diagrammatic representation of submucous fibroids. G0 is

completely intracavitary, G1 is less than 50 % intracavitary and G2 is Fig. 3.19 FIGO classification of fibroids
more than 50 % intracavitary

Fig. 3.20 Endometrium identified in

this case with multiple fibroids. This is
crucial for fibroid mapping
70 3 Ultrasound Evaluation of Myometrium

3.3.1.2 Site of Origin of a Fibroid (Figs. 3.21, 3.22 A fibroid may appear as an adnexal solid mass, but a
and 3.23) careful search of its vascular pedicle, connecting it to the
The site of origin of a fibroid can be deciphered by noting uterine body, will help in clinching the diagnosis of a sub-
Doppler flows to the fibroid. A fibroid that is attached to the serous pedunculated fibroid (except perhaps in the case of
uterine body through a vascular pedicle is called a subserous a true broad ligament fibroid). Also, identifying the ova-
pedunculated fibroid (if attached to the outside of the uterine ries separate from such an adnexal mass will help in
surface) and a submucosal fibroid polyp (if attached to the differentiating it from a solid or solid-cystic ovarian
inside of the uterine cavity). mass.

a b
TS LS

UTERUS

UTERUS

c LS d LS

UTERUS

Fig. 3.21 Subserous pedunculated fibroids. (a) A large fibroid seen attached to the uterus through an isoechoic, 7.7 mm broad pedicle (arrow).
(b) A subserous fibroid with flow approaching it from its origin in the posterior wall of the uterus. (c, d) A large, subserous fibroid arising from the
anterior fundal wall of the uterine fundus. A broad pedicle is seen on greyscale and with Doppler
3.3 Fibroids (Leiomyoma or Myoma) 71

a TS b LS

c LS d LS

Fig. 3.22 Large fibroid of volume 9.27 L presenting as a huge, firm abdominal mass extending from the pelvis to the xiphisternum. (a) Transverse
dimension of fibroid measured by the help of dual images with measurements from each end to a common reference point. (b) AP diameter of the
fibroid is seen as a single vertical line in the first half of the image. Length of the fibroid measured in a similar manner with dual images, as the
transverse dimension. (c) LS of the uterus on TAS with a broad attachment of this large fibroid to the anterior wall of the uterus at the upper corpus
(arrow). (d) Vascular flow from the uterus onto the fibroid at its attachment. (e) Specimen of fibroid at surgery. The fibroid is being pulled out of
the abdomen with the help of two myomectomy screws
72 3 Ultrasound Evaluation of Myometrium

a LS b LS

CX

FIBROID CX

Fig. 3.23 Fibroid polyp. (a) Fibroid protruding out through the cervical os. (b) Its site of origin from the anterior wall of the lower corpus of the
uterus is seen on 3D Doppler with glass body display
3.3 Fibroids (Leiomyoma or Myoma) 73

3.3.1.3 Role of 3D in Fibroid Mapping (Figs. 3.24, assessment for preoperative grading of submucous fibroids has
3.25 and 3.26) been described to be more accurate with a sonohysterogram
Fibroids can be located and mapped with 2D imaging on longi- (Leone UOG 2007). MRI may be considered for fibroid map-
tudinal and transverse sections of the uterus. But visualisation ping when there are more than five fibroids or if the uterus is
of the coronal section requires 3D. 3D is particularly helpful in very large (more than 375 cc).
assesing the relation of a fibroid to the endometrial cavity. 3D

a b c

d e f

g h

Fig. 3.24 3D rendered coronal images of a uterus showing fibroids’ relationship to the endometrial cavity. All the fibroids (a–g) except for the
fibroid in (h) are submucous and are seen distorting the shape of the endometrial cavity
74 3 Ultrasound Evaluation of Myometrium

a LS b

c d
LS

Fig. 3.25 Submucous fibroid seen on (a) regular TVS, (b) TUI, (c) SHG – showing fluid surrounding a completely intracavitary fibroid (F). Its
attachment to the posterior wall of the uterus is measured in the image. (d) 3D rendered image of the same

a b

Fig. 3.26 Submucous fibroid. (a) 3D

rendered image where the inferior
margins are well made out due to the
presence of minimal intracavitary fluid.
(b) Post-operative specimen of the same,
correlating well with the 3D rendered
image in (a)
3.3 Fibroids (Leiomyoma or Myoma) 75

3.3.1.4 Reporting of Fibroids/Fibroid Mapping Fibroid mapping is essential particularly in symptomatic

(Figs. 3.27 and 3.28) women, for management. It may not be essential in asymp-
The ultrasound report of fibroid mapping should include the tomatic women who are either postmenopausal or have no
location of the fibroid using the four parameters described in further desire for fertility. In such cases, their location in four
Sect. 3.3.1.1 above. If considered relevant, the measurement of parameters (mentioned above) may be reported, but fine
their distance from the mucosa and serosa should be reported. details and diagrams are not essential. If a uterus is riddled
Relevant 2D and 3D images should also be attached to the with fibroids, it is appropriate to mention, measure and map
report. A diagrammatic representation of the fibroid sketched in a few relevant ones (especially the submucous and the large
one or more planes is very useful to the referring clinicians for ones). Also, one should mention that there are many smaller
a better understanding of the location of the fibroids. ones that have not been measured or mapped.

Fig. 3.27 Reporting of fibroid

mapping with diagrams. (a) LS
a b
and TS views of uterus showing
five fibroids. (b) LS, TS and
coronal images showing a single
fibroid

a LS b

Fig. 3.28 (a) Intracavitary fibroid arising from the posterior wall with a very thin overlying myometrium of 4 mm. (b) Diagrammatic representa-
tion of the same
76 3 Ultrasound Evaluation of Myometrium

3.3.2 Red Degeneration (Fig. 3.29) examination there is a tender palpable mass. Ultrasound can
detect the fibroid, but it is not sensitive in diagnosing red
Most pregnant women with fibroids are asymptomatic. Some, degeneration. Ultrasound examination shows a tender fibroid
however, may experience complications like pain, bleeding with absence of vascularity or poor vascularity. The fibroid
or miscarriage. When a fibroid causes pain in pregnancy, the usually shows a rapid increase in size, which can be assessed
most common cause is red degeneration, which is believed to if previous reports are available. If infarction and necrosis
occur when a fibroid outstrips its blood supply. This is a rare have set in, it may show a mixed echogenic appearance. This
condition and even more rare in non-pregnant women. may not be noted in early cases. On MRI, these fibroids typi-
Patients complain of acute abdominal pain which may be cally show an increased T1 signal intensity. Most often, red
associated with nausea, vomiting and low-grade fever. On degeneration is self-limiting and managed conservatively.

b c LS

CX

Fig. 3.29 Suspected case of red degeneration of a fibroid. A 23-week-pregnant lady, known to have a fibroid, presented with acute abdominal
pain. On ultrasound examination, the fibroid was very tender. (a) Fibroid on measurement was found to have increased in size suddenly. (b) No
flow was seen on power Doppler in the fibroid. (c) Cervix was found to be of normal length, and there was no evidence of placental abruption
3.3 Fibroids (Leiomyoma or Myoma) 77

3.3.3 Fibroid Embolization vomiting and low-grade fever that peak at 24 hours and usu-
(Figs. 3.30 and 3.31) ally subside in a week. Air may be seen in the fibroid after
embolisation – a feature thought to be the result of gas filling
Uterine fibroid embolisation is an alternative to hysterec- potential spaces.
tomy. Post-embolisation complications are pain, nausea,

a b
LS

Fig. 3.30 Fibroid seen on the third day after embolisation. The patient presented with acute abdominal pain. On ultrasound, the fibroid was found
to be tender. (a) LS of a uterus showing a posterior wall, lower corpus and upper cervical fibroid. (b) Fibroid is measured. It showed a 10 % increase
in size from the previous scan done a month earlier. Scattered bright linear echoes suggestive of air are seen within the fibroid which were not seen
in the earlier scan done a month ago. This is a known feature following embolisation. (c) No flow was seen on Doppler in the fibroid, which is
expected following embolisation

a b Uterus Coronal

Fig. 3.31 Fibroid embolised 8 years earlier, showing dense peripheral calcification. This is a known finding post embolisation that is seen on (a)
2D greyscale and (b) 3D rendering
78 3 Ultrasound Evaluation of Myometrium

3.3.4 Diffuse Uterine Leiomyomatosis plete replacement of the myometrium by innumerable poorly
(Figs. 3.32 and 3.33) defined confluent leiomyomatous nodules.

This is a benign and extremely rare condition, where the

uterus is symmetrically enlarged as a result of almost com-

a LS b LS

Fig. 3.32 Diffuse uterine leiomyomatosis. LS of uterus on (a) greyscale and (b) Doppler, showing multiple hypoechoic, poorly defined, irregular
areas, giving the uterus a heterogeneous appearance. The margins of most of the fibroids are difficult to delineate

a b LS

Fig. 3.33 Diffuse uterine leiomyomatosis in a patient who had undergone myomectomy. (a) Loculated fluid is seen adjoining the uterus, probably
secondary to surgery. Uterus shows multiple hypoechoic areas, many of which have poorly defined margins, giving the uterus a heterogeneous
appearance. One of the larger fibroids is measured in the image. (b) LS of uterus showing a well-defined fibroid along with multiple poorly defined
hypoechoic areas
3.3 Fibroids (Leiomyoma or Myoma) 79

3.3.5 Disseminated Peritoneal The aetiology of DPL remains controversial, but it is sus-
Leiomyomatosis (DPL) (Fig. 3.34) pected that the disease originates from metaplasia of sub-
peritoneal mesenchymal cells. It is common in women of the
This is an exceedingly rare condition characterised by dis- reproductive age group. It is usually associated with elevated
creet smooth muscle nodules, scattered throughout the levels of exogenous or endogenous oestrogen. This is an
peritoneum of the abdomen and pelvis. This condition can established, yet rare complication associated with laparo-
occur spontaneously or iatrogenically after surgical seeding. scopic morcellation of fibroids.

a LS TS

b c

Fig. 3.34 Case of disseminated peritoneal leiomyomatosis with multiple fibroids in the peritoneal cavity. Turbid fluid and adhesions were noted
in the pelvis. The patient had undergone a laparoscopic myomectomy (with morcellation) for a large fibroid, 6 years prior to this scan. She now
presented with abdominal pain. (a) Uterus measured on LS and TS, which appears essentially normal. (b) Large fibroid (8 × 6 x 11 cm) seen in the
RIF. (c) This fibroid, seen in image (b), was seen distinctly separate and 2.2 cm away from the uterus. It was attached to the peritoneal wall. (d)
Fibroid (5 × 3 × 5 cm) seen attached to the peritoneum in the LIF. It was also a significant distance away from the uterus. Minimal flow seen along
the periphery of this fibroid. (e) Another fibroid (5 × 2 × 4 cm) seen in the right lower abdomen. (f) TVS showing a small fibroid (1.4 × 1.2 ×
1.3 cm) close to the posterior wall of the uterus but attached to the peritoneal surface and not the uterus. (g) Another fibroid seen attached to the
pelvic wall lateral to the right ovary
80 3 Ultrasound Evaluation of Myometrium

d e

f g

Fig. 3.34 (continued)

Summary: Fibroid

• Fibroids are a commonly seen pathology, with

women being either asymptomatic or complaining
of excessive bleeding, dysmenorrhoea, etc.
• On ultrasound, they appear as solid masses in the
uterus or arising from it. They have variable echo-
genicity and well-defined margins. They show both
linear coarse stripy shadowing and shadowing from
their edges. Typically, pericapsular flow is seen.
Some may show calcification or cavitation.
• Atypical, large and vascular fibroids are to be evalu-
ated carefully and rescanned in a short period, as
there is very small chance of these being malignant
sarcomas.
• Fibroid mapping and relationship of the fibroids to
the endometrial mucosa are particularly important
for appropriate management. If possible, a sketched
diagram should be provided with the report.
3.4 Adenomyosis and Adenomyomas 81

3.4 Adenomyosis and Adenomyomas hypoechoic with turbid contents within. The cystic spaces
may be surrounded by a hyperechoic rim.
Adenomyosis is another common gynecological disorder • Hyperechoic islands of endometrial tissue may be seen
where there is proliferation of endometrial glands and stroma within the myometrium. They may be regular, irregular or
within the myometrium along with hypertrophy and hyperpla- ill-defined and are typically seen in the submucosal area.
sia of surrounding adjacent myometrium. Adenomyosis is seen • The junctional zone is a very important site for diagnosis
in about 20 % of women. In most women, there are no known of adenomyosis. It can be assessed better on 3D imaging
causes for the adenomyosis. However, in some women it is (multiplanar, rendered or VCI):
seen associated with deep infiltrating endometriosis or obstruc- – The JZ may be ill-defined as a result of which endome-
tion to antegrade menstrual flow (as is seen in the uterine wall trial margins may be difficult to delineate.
of a non-communicating uterine horn). Women with adeno- – The JZ may be thickened and this is better visualized
myosis may be asymptomatic but could suffer from menorrha- with 3D imaging. There are studies focusing on the
gia, polymenorrhagia, dysmenorrhoea and infertility. thickness of the JZ in the diagnosis of adenomyosis
(Exacoustos UOG 2011).
Ultrasound Features of Adenomyosis and Adenomyoma – Hyperechogenic subendometrial buds and lines
(Figs. 3.35, 3.36, 3.37, 3.38, 3.39, 3.40, 3.41, 3.42, 3.43, (almost perpendicular to the endometrial cavity and
3.44, 3.45 and 3.46) arising from it) can also be seen in the JZ.
• The uterus is generally enlarged and globular (with the – The JZ may show hyperechogenic spots.
uterine contour being maintained). It is symmetrically – Tiny cystic spaces may be seen in the junctional zone,
enlarged when adenomyosis involves the entire uterine along the endomyometrial junction, and their presence
body or asymmetrical if it is limited to only some areas of in an otherwise grossly appearing normal uterus is
the uterus. The myometrial walls may be asymmetrically considered to be a feature of early adenomyosis.
thickened. An adenomyoma is a focal area of adenomyo- – The JZ as a result of these hyperechogenic buds, lines
sis with poorly circumscribed margins. and cystic spaces appears irregular.
• The shape of the endometrial cavity is maintained because • On Doppler, the affected myometrium may show
of the diffuse myometrial involvement (unlike what might increased vascularity (which is intralesional and not cir-
be seen with fibroids). This helps in distinguishing it from cumferential like in fibroids).
a large fibroid where the endometrial lining may be • The uterus may be tender during TVS examination.
pushed by the fibroid to one side. In adenomyosis, the • In classic adenomyosis, the myometrial invasion by the
endometrium is seen passing through the globular mass endometrium is directly from the endometrium lining
(enlarged adenomyotic uterus). the cavity, and, therefore, features are well noticed in the
• Myometrium shows coarse echotexture with linear acous- JZ. However, in women with endometriosis, the invasion
tic shadowing (described as ‘fan-shaped’ shadowing or is from the endometrial implants on the serosal surface of
‘rain in the forest’ appearance). Edge shadows are not seen the uterus (from endometriomas or DIE nodules) (Kishi
because the lesion does not have well-defined margins. Y., AMJ Ob Gyn 2012). In women with adenomyosis
• Small myometrial cysts are seen. Some may be large and associated with deep infiltrating endometriosis of the pos-
measurable, but generally they are not measurable indi- terior compartment, the uterus is retroflexed at the mid-
vidually and are seen as tiny hypoechoic or anechoic corpus due to the fixity of its posterior wall and fundus
microcysts dispersed within the myometrium. The cystic posteriorly. This gives the uterus an ‘ear shape’ or a ‘ques-
contents may be anechoic, but generally the cysts are tion mark shape’ (called the ‘question mark sign’).
82 3 Ultrasound Evaluation of Myometrium

a LS b TS

c LS TS d LS

Fig. 3.35 Enlarged globular uterus secondary to diffuse adenomyosis. Myometrium in these cases shows coarse echotexture with linear shadow-
ing. No edge shadows are noted. (a, b) Case 1, LS and TS of the uterus. (c) Case 2, LS and TS of the uterus. (d) Case 3, LS showing the endome-
trium (arrows) passing through the middle of the globular mass formed by the adenomyotic uterine body
3.4 Adenomyosis and Adenomyomas 83

a LS b LS

c LS

Fig. 3.36 Cases with asymmetrical adenomyosis involving (a) mainly the posterior wall, (b) mainly the anterior wall, (c) anterior wall (on TAS).
In (a) and (c), typical fan-shaped linear shadowing is noted

a LS b TS

Fig. 3.37 Adenomyosis (a) LS and (b) TS of the uterus. Tiny myometrial cysts are seen dispersed within the myometrium, giving it a coarse
echotexture with linear shadowing
84 3 Ultrasound Evaluation of Myometrium

a b

c Uterus coronal d LS VCI

Fig. 3.38 Myometrial cysts in adenomyosis. (a) Tiny myometrial cysts seen showing turbid contents. (b) Myometrial cysts show hyperechoic mar-
gins. (c) 3D rendered image showing myometrial cysts with hyperechoic margins. (d) Large myometrial cysts (arrows) seen showing turbid contents
in the posterior wall of the uterine fundus in a patient who had undergone a cystectomy for an endometrioma but found no relief from pain. The mar-
gins of the cysts were not distinct, and therefore VCI was utilised (in the image on the right half) for better delineation of the myometrial cysts

a b
LS

Fig. 3.39 Hyperechoic islands of endometrial tissue are seen within the myometrium of the posterior wall mainly in the submucous area, on (a)
2D greyscale and (b) 3D rendering
3.4 Adenomyosis and Adenomyomas 85

a b
LS Uterus coronal

Fig. 3.40 Case of diffuse adenomyosis. (a) Ill-defined EMJ on 2D greyscale. (b) 3D rendered image showing irregular/poorly defined EMJ (par-
ticularly superiorly). Small hyperechoic lines (arrow) are seen arising from the EMJ – a known feature of adenomyosis

a LS TS b LS

Fig. 3.41 JZ in a case of adenomyosis. (a) Irregular EMJ showing tiny cystic spaces (short arrows) and hyperechogenic foci (long arrow) in the
JZ. (b) Irregular EMJ showing hyperechogenic, subendometrial buds/lines in the JZ (arrow)
86 3 Ultrasound Evaluation of Myometrium

a LS b

Fig. 3.42 Cases of adenomyosis showing thickened JZ (long arrows). (a) Case 1, showing, in addition, a few cystic spaces (short arrows). (b)
Case 2, seen on greyscale. (c) Case 3, a 3D rendered coronal image with the JZ showing, in addition, hyperechoic endometrial buds (short arrows),
cystic space (pointer) and an irregular endomyometrial junction
3.4 Adenomyosis and Adenomyomas 87

a LS b

c d
LS LS

Fig. 3.43 JZ in a case of adenomyosis (a) on 2D greyscale showing cystic space (short arrow), hyperechogenic foci (long arrow) and hyperechoic
endometrial buds (medium length arrow). (b–d) On 3D multiplanar imaging with VCI, the JZ is more distinct. (c) Cystic space (short arrow),
hyperechogenic foci (long arrow) and (d) hyperechoic endometrial bud (arrow)

a b LS

Fig. 3.44 Vascularity may be increased in adenomyosis. (a) Increased in the anterior myometrium (on TAS) in a case of anterior wall adenomyo-
sis. (b) The globular adenomyotic myometrium shows flow within, i.e. intralesional flow (unlike a fibroid which typically shows peripheral flow)
88 3 Ultrasound Evaluation of Myometrium

Fig. 3.45 3D rendered coronal

a
views in a case of adenomyosis
of the JZ with the plane of
rendering, (a) through the
endometrium primarily showing
irregularity along its lateral
margins, (b) closer to EMJ,
showing significant irregularity
in the anterior wall and the
lateral margins, (c) in the JZ,
just anterior to the
endometrium, showing multiple
endometrial buds (arrows)
giving it an irregular appearance

c
3.4 Adenomyosis and Adenomyomas 89

a b
LS LS

c LS d LS

Fig. 3.46 (a–d) Four cases of posterior compartment DIE showing thick and coarse posterior walls (arrows) suggestive of adenomyosis
90 3 Ultrasound Evaluation of Myometrium

3.4.1 Adenomyoma (Figs. 3.47 and 3.48) tissue, etc. They are typically seen in the submucosal area
because of direct myometrial invasion from the endome-
An adenomyoma is a focal area of adenomyosis and, there- trium. At times, adenomyomas may protrude into the
fore, shows the same features described on ultrasound as endometrial cavity. On Doppler, flow in the adenomyoma
adenomyosis. The lesion, though focal, is not well defined. is intralesional, i.e. central (which is important sometimes
It shows ‘fan-shaped’ shadowing, heterogeneous echoes in confirming diagnosis and differentiating it from a
with cystic spaces, hyperechogenic islands of endometrial fibroid).

Fig. 3.47 Adenomyoma. (a) LS

a LS
and TS of a large anterior wall TS
adenomyoma showing coarse
echoes, linear acoustic
shadowing and tiny cystic spaces,
some of which show hyperechoic
margins. It is seen bulging into
the anterior endometrium and is
extending from the mucosa,
almost up to the serosa. (b)
Increased vascularity of the
adenomyoma on Doppler

b LS

Fig. 3.48 Poorly circumscribed

area showing coarse echoes,
cystic spaces and central
vascularity, suggestive of an
adenomyoma seen on (a)
Doppler and (b) greyscale
3.4 Adenomyosis and Adenomyomas 91

Differentiation between a fibroid and an adenomyoma or

Summary: Adenomyosis/Adenomyoma adenomyosis
• Adenomyosis is a common gynecological disorder This can sometimes be challenging. The differentiation is,
in women of reproductive age with typical com- however, important in the management of these patients. The
plaints being menorrhagia and dysmenorrhoea. most significant point in management being that fibroids can
• Typical ultrasound features include a globular be enucleated surgically unlike adenomyoma.
enlargement of uterus, often with asymmetrically Features that help differentiate the two are tabulated
thickened walls. Myometrium shows coarse below (Fig. 3.49).
echotexture with tiny myometrial cysts and linear
shadowing. Endometrial margins are poorly defined Adenomyoma/
and JZ may show tiny cystic spaces, hyperecho- Feature Typical fibroid adenomyosis
genic dots, buds and echogenic lines. Uterine Regular or lobulated Regular
contour
• A focal area of adenomyosis is termed an
Margins Well defined and smooth Poorly defined and
adenomyoma.
irregular
• In women with endometriosis, particularly deep Shape Round/oval/lobulated Ill-defined
infiltrating endometriosis of the posterior compart- Shadowing Internal linear shadowing Internal linear with no
ment, the posterior wall of the uterus may show fea- and edge shadows edge shadows
tures of adenomyosis. Vascularity Mainly circumferential Intralesional (central)
• It is important to differentiate adenomyosis and Junctional Typical adenomyotic JZ JZ shows the typical
adenomyoma from fibroids as their management zone abnormalities not seen. adenomyotic features
differs considerably. The JZ is usually well (ill-defined, irregular,
defined but may be thickened, tiny cystic
stretched around the spaces and echogenic
fibroid buds/lines)
92 3 Ultrasound Evaluation of Myometrium

Fig. 3.49 Differentiating

a b Uterine coronal
between a fibroid and
adenomyoma/
adenomyosis. (a, b)
Fundal fibroid showing
well-defined margins
on 2D and 3D (arrow).
Edge shadows are seen
(short arrow). The
endometrial deformity
is not uniform. (c, d)
Adenomyosis,
particularly of the
uterine fundus. (c) On
greyscale, showing
poorly defined margins
and no edge shadow-
ing. (d) 3D showing
regular, uniform,
concave deformity of
the upper margin of the
endometrium. (e) c
Fibroid showing LS d Uterine coronal
peripheral vascularity.
(f) Adenomyoma
showing central
vascularity

e f
3.5 Sarcoma 93

3.5 Sarcoma • Their margins may be regular or irregular (due to invasion

into the surrounding myometrium).
Uterine sarcomas are malignant myometrial lesions. They • On Doppler, they tend to be more vascularised than
are very rare, and their ultrasound features may be indistinct fibroids. Flow may be central and chaotic with irregular
from that of ordinary fibroids. In addition, their symptoms and randomly dispersed vessels (as is seen with malignant
are similar to that of fibroids which include dysmenorrhoea, masses). Typically the flow is of low resistance (RI less
menorrhagia and pelvic pain. They are, therefore, most often than 0.42) and high velocity (more than 42 cm/sec). It is
diagnosed only at surgery. suggested that Doppler flows should be assessed in all
They tend to be seen in slightly older women (perimeno- large and atypical fibroids from multiple sites.
pausal women). • Rapid growth of the mass and the uterus is often seen in
sarcomas.
Ultrasound Features of Sarcoma (Fig. 3.50)
• They are typically single and large tumours appearing sim- The prediction of uterine sarcoma by ultrasound is based
ilar to fibroids, particularly the ones that appear atypical. primarily on small retrospective case series, and, therefore,
• They are either hypoechoic or isoechoic. there are no established guidelines. It is, however, suggested
• They usually do not show the typical stripy shadows of a that all large fibroids, particularly atypical or heterogeneous
fibroid. ones, should be assessed with Doppler and be followed up
• They may appear heterogeneous and may show irregular closely. A rescan of these masses in a case of sarcoma would
anechoic/hypoechoic cystic areas due to necrosis. typically show a rapid increase in size, unlike a benign fibroid.
94 3 Ultrasound Evaluation of Myometrium

a b
LS LS

c d

a
e f

Fig. 3.50 Case of leiomyosarcoma. (a) Enlarged uterus showing a mass with slightly irregular outline (arrow) – in retrospect, suggestive of myo-
metrial invasion. (b) TVS-LS of uterus with a small posterior wall fibroid and a large heterogeneous mass in its anterior wall appearing like an
atypical fibroid. (c) Large, circumscribed, heterogeneous mass which was thought to be an atypical fibroid (measuring 8.2 × 7.5 × 8.6 cm). It did
not show typical stripy shadows of a fibroid. (d) The mass was lobulated and showed flow within its septae, another atypical finding for a fibroid.
(e, f) Flow in the mass showed variable flow indices, when assessed from different sites. A high PSV of 54.0 cm/sec in (e)
Suggested Reading 95

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netic resonance imaging and their specification. Am J Obstet
Gynecol 207(2):114–117
Bosch VD et al (2015) Terms, definitions and measurements to describe
Kurjak A, alud I (1991) The characterization of uterine tumors by
sonographic features of myometrium and uterine masses: a consen-
transvaginal color Doppler. Ultrasound Obstet Gynecol 1:50–52.
sus opinion from the Morphological Uterus Sonographic Assessment
doi:10.1046/j.1469-0705.1991.01010050
(MUSA) group. Ultrasound Obstet Gynecol 46(3):284–298
Leone FPG et al (2007) Sonohysterography in the preoperative grading
Covarrubias DA et al (2009) Multimodality imaging findings of leio-
of submucous myomas: considerations on three-dimensional meth-
myomatosis peritonealis disseminata. Ultrasound Obstet Gynecol
odology. Ultrasound Obstet Gynecol 29:717–718. doi:10.1002/
33:247–249. doi:10.1002/uog.6293
uog.4043
Exacoustos C et al (2011) Adenomyosis: three-dimensional sono-
Murase E et al (1999) Uterine leiomyomas: histopathologic features,
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Giunchi S (2010) OC27.05: uterine sarcomas: clinical and sonographic
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adenomyosis: which findings are most accurate? Ultrasound Obstet
Gynecol 30:341–345. doi:10.1002/uog.3985
 Ultrasound Evaluation of Endometrium
4

Endometrium is the mucous membrane that lines the inside of mid-positioned uterus, because structures that lie perpen-
the uterus. It has a cell-rich connective tissue that surrounds dicular to the ultrasound beam are clearly visible but struc-
the endometrial glands. It is composed of two layers: the tures lying parallel to it are not. In such cases, one can
superficial functional layer and the deeper basal layer. In each place the probe in the anterior or posterior fornix and push
menstrual cycle, the superficial functional layer of the endo- on the cervix to retrovert or antevert the uterus further, to
metrium is shed and reconstituted from the underlying basal try and make the endometrium more perpendicular to the
layer. Its thickness, morphology and vascularity change beam. TAS in such cases may provide better resolution. If
throughout the menstrual cycle in women of reproductive age. visualisation is suboptimal, then that must be mentioned in
the report. Saline or gel instillation (sonohysterogram) may
help in better evaluation of the endometrium in cases where
assessment is difficult or in those with an intracavitary
4.1 Evaluation of Endometrium pathology.

The evaluation of the endometrium should be systematic, Measurements (Figs. 4.1, 4.2, 4.3, 4.4 and 4.5)
and reporting should be standardised. The IETA (International • The endometrium is measured in a sagittal plane. The
Endometrial Tumor Analysis group) statement is a consen- measurement is taken perpendicular to the endometrial
sus statement that has been published by a panel of experts midline, where the endometrium is thickest, excluding the
(IETA consensus group) for terms, definitions and measure- hypoechoic adjoining myometrium. Two-layer thickness
ments for describing and reporting the endometrium and its is measured and reported in millimetres (rounded off to 1
pathologies. decimal point). If there is intracavitary fluid, then a single-
The evaluation of the endometrium and uterine cavity can layer thickness is measured where it is thickest, and it
be done both by TAS and TVS. The TVS route is considered should be mentioned in the report that it is a single-layer
ideal for evaluating the endometrium. However, TAS may thickness, or one can add the thickness of the endome-
help, particularly in the presence of fibroids, an enlarged uterus trium of the opposite wall and report a two-layer thick-
or a mid-positioned (axially placed) uterus. Transrectal ultra- ness. When the endometrium cannot be visualised clearly,
sound scan should be considered if TVS is not possible due to as is sometimes the case with a mid-positioned uterus, it
any condition like vaginismus. It is best to do both a TAS and should be reported as nonmeasurable.
a TVS scan, because very often they complement each other. • When an intracavitary pathology is present, the total
The uterus is scanned (on 2D) in the sagittal plane from endometrial thickness including the lesion should be
one cornu to the other and in the transverse plane from the recorded. If an intracavitary myoma is clearly identified,
cervix to the fundus. This gives us a good overall view of the then it should not be included in the measurement of
uterus in the sagittal and transverse sections. 3D is useful for endometrial thickness. Intracavitary lesions should be
visualisation of the coronal section of the uterus which pro- measured in millimetres in three perpendicular dimen-
vides better information of the uterine cavity and EMJ (endo- sions (as explained in Chap. 2). This helps calculate the
myometrial junction). Once the overview is done on volume of the lesion.
ultrasound, the magnification should be increased focusing • The amount of intracavitary fluid can be measured in
on the area of interest, i.e. the endometrium. three perpendicular dimensions to assess the volume. The
Generally the endometrium is easy to visualise. IETA recommendation is that intracavitary fluid should
However, it may be difficult to study the endometrium in a be defined by its largest measurement in the sagittal plane.

© Springer Nature Singapore Pte Ltd. 2017 97

M. Sibal, Ultrasound in Gynecology, DOI 10.1007/978-981-10-2714-7_4
98 4 Ultrasound Evaluation of Endometrium

Qualitative Assessment of the Endometrium (Figs. 4.6, maximum transverse diameter is more than the diameter
4.7 and 4.8) of its base.
This includes the assessment of the endometrial echo- • In the presence of fluid in the endometrial cavity (includ-
genicity, the endometrial midline and the endomyometrial ing sonohysterogram), the endometrial outline (i.e. the
junction (EMJ). endometrial surface facing the uterine cavity) is defined
• The echogenicity of the endometrium is compared with as ‘smooth’ if it appears regular; as having endometrial
that of the myometrium. It could be hyperechoic, folds if there are multiple thickened ‘undulating’ areas
isoechoic or hypoechoic. with a regular profile; as ‘polypoid’ if there are deep
• The endometrial echogenicity is considered uniform, if indentations; or as ‘irregular’ if the surface is cauliflower-
the endometrium is homogeneous with symmetrical ante- like or sharply toothed (‘spiky’).
rior and posterior walls. The echogenicity is termed non-
uniform, if the endometrium appears heterogeneous,
asymmetrical or cystic. Doppler (Fig. 4.9)
• The endometrial midline is the interface between the For Doppler evaluation of the endometrium, the colour/
opposing surfaces of the two endometrial walls. It is power Doppler box should include the endometrium with the
defined as ‘linear’ if it is straight and hyperechogenic; surrounding myometrium. Magnification is important and
‘non-linear’ if it is waved and hyperechogenic; and ‘irreg- the Doppler setting should be optimised to ensure maximal
ular’ or ‘not defined’ in the absence of any distinct mid- sensitivity for blood flow (details in the section on Doppler
line echoes. in Chap. 2).
• The EMJ is basically the outer margin of the endome-
trium. It could be described as regular, irregular, inter- • Vascularity is assessed subjectively by the use of colour
rupted or not defined. score from 1 to 4, 1 being no colour and 4 being maximal
• When an intracavitary lesion is present, a bright line is gen- colour (details in the section on Doppler in Chap. 2).
erally seen at the interface between the lesion and the endo- Spectral wave forms can also be used to measure RI and
metrial walls, particularly if the lesion is smooth walled. If PI of lesions in some cases.
any lesion is seen within the cavity, its morphology should • The vascular pattern in the endometrium is reported with
be described, i.e. its margins, echogenicity and vascularity. respect to the presence or absence of ‘dominant’ vessels.
• Intracavitary lesions are better visualised in the presence A ‘dominant’ vessel is defined as a distinct vessel cross-
of fluid in the endometrial cavity (including sonohystero- ing the EMJ. This may show branching within the endo-
gram). The lesion is defined as ‘extended’ if the endome- metrium. ‘Dominant’ vessels could be a single vessel
trial abnormality involves 25 % or more of the endometrial (feeder vessel or pedicle artery sign) or could be multiple
surface, and as localised if less than 25 % of the endome- having either a ‘focal origin’ at the EMJ or a ‘multifocal
trial surface is involved. Localised lesions are defined as origin’. Other vascular patterns include scattered vessels
‘pedunculated’, if their maximum transverse diameter is in the endometrium, without origin at EMJ and circular
less than the diameter of its base, and ‘sessile’ if their flow (e.g., submucous fibroid).
4.1 Evaluation of Endometrium 99

a LS b LS

Fig. 4.1 (a, b) Endometrium is measured in the midsagittal section of the uterus perpendicular to the endometrial midline, excluding the
hypoechoic adjoining myometrium. The measurement is most accurate when the ultrasound beam is perpendicular to the endometrial stripe

a LS b LS

Fig. 4.2 Measuring the endometrium in the presence of intracavitary fluid. (a) A single-layer thickness is measured and reported as such, or (b)
one may measure the endometrial thickness of the opposite walls and add the two for reporting

a LS b LS

Fig. 4.3 (a, b) In a mid-positioned uterus, the endometrium is difficult to measure and assess, as the ultrasound beam lies parallel to the endome-
trial stripe
100 4 Ultrasound Evaluation of Endometrium

Fig. 4.4 Intracavitary patholo-

gies like polyps should be TS LS
measured in three perpendicular
dimensions so that their volume
can be calculated. Arrow shows a
hyperechoic line between the
polyp and the endometrium

a b
LS TS LS

Fig. 4.5 Intracavitary fluid measured (a) in three perpendicular dimensions to obtain volume or (b) as the largest measurement in the sagittal
plane (IETA recommendation)
4.1 Evaluation of Endometrium 101

a LS b LS

c LS

Fig. 4.6 The endometrial midline: (a) linear, (b) non-linear, (c) not defined. The endometrium in (c) is hyperechoic and thick
102 4 Ultrasound Evaluation of Endometrium

a LS b Coronal

c LS d Coronal

e Coronal
f
c

Fig. 4.7 Endomyometrial junction 2D and 3D coronal view: (a) and (b) regular, (c) and (d) irregular, (e) and (f) not defined
4.1 Evaluation of Endometrium 103

a LS b LS

Fig. 4.8 Endometrial outline: (a) regular, (b) polypoidal, (c) irregular
104 4 Ultrasound Evaluation of Endometrium

a LS b

c LS d LS

e LS f LS

Arcuate

Fig. 4.9 Vascular pattern in endometrium. (a) Dominant single vessel with origin at EMJ – endometrial polyp. (b) Multiple vessels with focal
origin at EMJ – focal endometrial carcinoma. (c) Multifocal origin at EMJ – endometrial hyperplasia. (d) Scattered vessels without origin at
EMJ – invasive endometrial carcinoma. (e) Multifocal origin at EMJ – normal secretory endometrium (note the similarity in pattern with endo-
metrial hyperplasia in (c)). (f) Same case as (e) flow with 3D glass body display, showing arcuate vessels, radial vessels (short arrow) and spiral
arteries (long arrow) in a normal secretory endometrium
4.2 Normal Endometrium 105

4.2 Normal Endometrium imaging for infertility, the endometrial thickness should
be at least 6 mm, and the results are best when the thick-
Endometrial thickness, morphology and vascularity change ness is 8 mm. The proliferative phase endometrium is
throughout the menstrual cycle in women in the reproductive typically seen as a three-layer endometrium with an
age group. In addition, the endometrium appears different in echogenic basal layer, a hypoechoic inner functional
women prior to menarche and after menopause. layer and an echogenic midline at the interphase of the
Most often the endometrial types seen and reported on two layers. Minimal intracavitary fluid may be seen in
ultrasound are menstruating, proliferative, early secretory, the preovulatory phase. The vascularity of the endome-
secretory and hyperechoic. trium gradually increases to a maximum, just prior to
ovulation.
• Secretory phase or luteal phase (Day 14–28 of menstrual
4.2.1 Endometrium in Paediatric Age Group cycle*):
(Fig. 4.10) The endometrial thickness may decrease minimally at
ovulation, but after that it increases gradually in thickness
The endometrium appears as a thin echogenic line, and a (7–15 mm). The endometrium also becomes hyperechoic
small percentage of neonates have minimal fluid collection starting from the periphery towards the centre. This
within the endometrial cavity. At the onset of puberty, the increased echogenicity is believed to be due to stromal
endometrium gradually increases in thickness and becomes oedema and the presence of mucus and glycogen in the
like that of an adult. glands. This stromal oedema is also responsible for the
increased echogenicity of the myometrium beyond it due
to acoustic enhancement.
4.2.2 Endometrium in Reproductive Age
Group (Figs. 4.11 and 4.12) Endometrium in the Post-partum Period
The endometrium following delivery is less than 2 cm. Some
Endometrial changes during the menstrual cycle, parallel amount of fluid, blood products and echogenic debris,
cyclical ovarian changes. including a small amount of gas, are normal in the first week
after delivery and may be seen up to 3 weeks post-partum.
• Menstrual phase (Day 1–6 of menstrual cycle*):
During menstruation, the endometrium appears hyper-
echoic and complex. By the end of menstruation, the 4.2.3 Endometrium in Postmenopausal
endometrium is thin, about 1–4 mm in thickness. Baseline Women (Fig. 4.13)
scans in women on the treatment for infertility are done
on Day 2 or 3 of the menstrual cycle. No subendometrial The normal postmenopausal endometrium is thin, homoge-
flow is seen at this time. neous and echogenic. In postmenopausal women, simple
• Proliferative phase or follicular phase (Day 6–14 of men- measurement of the endometrial thickness is useful in
strual cycle*): assessing the risk for endometrial cancer (unlike in premeno-
The endometrium gradually increases in thickness pausal women). An endometrial thickness of 4 mm or less
from 5 mm to about 10–12 mm. At the time of adminis- decreases the likelihood for endometrial cancer by a factor of
trating the hCG injection in women undergoing follicular 10, in a postmenopausal woman.
106 4 Ultrasound Evaluation of Endometrium

LS

Fig. 4.10 Thin echogenic endometrium measuring 1 mm, in a preme-

narchal girl

a LS b LS

c LS d LS

Fig. 4.11 Endometrium in different phases of menstrual cycle. (a) Menstruating endometrium, (b) proliferative endometrium, (c) early secretory
endometrium, (d) secretory endometrium
4.2 Normal Endometrium 107

a LS

b LS c LS

Fig. 4.12 Normal post-partum endometrium. (a) Post-partum second week – fluid, debris and minimal gas shadows seen in the endometrial cav-
ity. Single-layer thickness of the endometrium was 4.4 mm. (b, c) Uterus – on post-partum Day 18 with (b) single-layer endometrial thickness of
3.5 mm. This can be wrongly interpreted as being much thicker (marked in the image) because of isoechoic endometrium and prominent arcuate
vessels wrongly interpreted as the EMJ. (c) Arcuate vessels seen on Doppler

LS

Fig. 4.13 Thin echogenic endometrium measuring 2 mm, in a post-

menopausal lady
108 4 Ultrasound Evaluation of Endometrium

4.3 Endometrial Polyps TVS because the direction of flow on TVS may be per-
pendicular, but on TAS it may be parallel, enabling visu-
Endometrial polyps are frequently diagnosed in both symp- alisation of the vessel.
tomatic and asymptomatic women. They are growths arising • These polyps are often visualised well on 3D rendered
from the endometrial lining of the uterus and may be associ- coronal images of the uterine cavity.
ated with hyperplasia. Though most are benign, some may • Polyps could be multiple, each with its individual feeder
show malignancy within. vessel.
Polyps could cause intermenstrual spotting and infertility/ • Some of these polyps may have a long pedicle, and though
subfertility. Polyps that cause abnormal uterine bleeding are they may originate higher up, they may be seen much
more likely to be polyps with atypical hyperplasia. lower down, often in the cervical canal.
• When there is fluid in the endometrial cavity, either blood
Ultrasound Features of Endometrial Polyps (Figs. 4.14, or at sonohysterogram, polyps are well visualised. They
4.15, 4.16, 4.17, 4.18, 4.19, 4.20, 4.21, 4.22, 4.23, 4.24, are seen as echogenic, smooth-surfaced, intracavitary
4.25, 4.26, 4.27, 4.28, 4.29, 4.30 and 4.31) masses. Their site of origin is also well seen. The polyp
• A polyp typically appears as a circumscribed hyperechoic may be broad based or sessile.
area within the endometrial cavity and, therefore, is better • Sometimes, one is able to see the rounded, blunt lower
seen in a proliferative endometrium. The polyp is mea- margins of a polyp in the endometrial cavity, especially if
sured in three perpendicular dimensions. there is some minimal fluid below it, which helps in dif-
• Very often, a fine hyperechoic line is seen around the ferentiating it from a thickened endometrium.
polyp along the interphase between the polyp and the sur- • Some polyps show hyperplastic endometrium, and in rare
rounding endometrium (similar to the central line in a cases they could be malignant. One must consider the
proliferative endometrium). This hyperechoic line is seen possibility of malignancy in a polyp especially if they are
to be discontinuous at the site of entry of the feeder vessel fleshy and heterogeneous, and a Doppler study of the
into the polyp. The presence of this hyperechoic line often feeder vessel shows a low RI of 0.42 or below.
helps in delineating a polyp on 2D, in a hyperechoic or • Sometimes clots within the endometrial cavity can mimic
secretory endometrium. a polyp. However, neither feeder vessel nor flow will be
• Sometimes these polyps show tiny cystic spaces within. seen in these clots. One must be aware of the artefact
The cystic spaces relate to dilated endometrial glands caused by menstrual flow of blood in the endometrial
within the polyp. In postmenopausal women with a thick cavity. This could even produce a tracing like that of a
endometrium, a focal area with small cystic areas within venous flow on pulse wave Doppler. However, no arterial
should raise the possibility of an endometrial polyp. flow will ever be seen in the case of a clot. In addition,
Polyps in patients on tamoxifen also show cystic spaces. menstrual flow is seen along the periphery of clots, unlike
• At times they are fleshy and large, and these could be polyps where vascular flow is seen within the tissue of
adenomyomatous polyps. the polyp. Also, if one applies pressure with the probe, in
• On Doppler, a dominant vessel (‘feeder vessel’/‘pedicle cases with menstrual flow artefacts, a reversal of flow
artery sign’) is seen approaching the polyp from the adjoin- direction may be noticed (blue to red or vice versa).
ing myometrium across the EMJ. This vessel may show In cases with clots appearing like polyps, the clots may be
branching within the polyp. This feeder vessel is very help- dislodged or missing either when a repeat scan is done after
ful in making a diagnosis of polyps and also in identifying the patient has been asked to strain or if the scan is repeated
the site of origin of the polyp within the endometrial cavity. after a day or two.
The average RI for feeder vessels of polyps is about 0.6. As mentioned earlier, the best time to evaluate the endo-
• One may not see the feeder vessel of a polyp. This could metrium for polyps is the proliferative phase (Day 9–12 of
happen if the Doppler settings are not proper or the direc- menstrual cycle). The polyp stands out clearly in the triple
tion of flow in the vessel is perpendicular to the ultra- line pattern of the proliferative endometrium. In all other
sound beam. In the latter case, angulating the probe could types of endometrium, a polyp may not be clearly seen since
help. Sometimes the vessel is better seen on TAS than it is isoechoic with the rest of the endometrium. In such
4.3 Endometrial Polyps 109

cases, the hyperechoic line around the polyp and the feeder Polyps, particularly small ones, can be left unattended unless
vessel may help in diagnosis. they are symptomatic. Hysteroscopy is the method of choice
A thick endometrium diagnosed on greyscale ultrasound for management. It is important to note that often a polyp pre-
sometimes turns out to be a polyp on Doppler (on visualisa- senting as a thickened endometrium is missed on regular D&C,
tion of the feeder vessel) or at surgery and there is scanty endometrium on curettage. This is because
A mid-positioned uterus often results in suboptimal eval- the curette has missed the polyp and gone around it curetting
uation of the endometrium on TVS, and therefore a polyp the surrounding thin endometrium. The referring gynecologist
can be missed. In some of these cases, it may be better visu- is surprised that the ultrasound report mentioned a thick endo-
alised on TAS instead. metrium and there were hardly any curettings!

Fig. 4.14 Hyperechoic small

polyp in a proliferative TS LS
endometrium
110 4 Ultrasound Evaluation of Endometrium

a LS b LS

Fig. 4.15 Hyperechoic polyp clearly visualised in a proliferative endometrium. The hyperechoic line surrounding the polyp is discontinuous at
the site of entry of the feeder vessel (arrow) which is seen on (a) greyscale and (b) Doppler

a LS b Coronal

Fig. 4.16 Polyp in a secretory endometrium. Hyperechoic line (arrows) between polyp and endometrium helps delineate and diagnose the polyp
(a) on 2D greyscale and (b) on 3D
4.3 Endometrial Polyps 111

a b TS
LS

c LS d LS

Fig. 4.17 (a, b) 67-year-old postmenopausal lady with an endometrial thickness of 17.8 mm. (a) Polyp with tiny cystic spaces. (b) Feeder vessels
supplying the polyp, (c, d) 70-year-old postmenopausal lady with ET of 26 mm. (c) TAS – a, single prominent feeder vessel crossing the EMJ and
branching within the thickened endometrium raises a high possibility of an endometrial polyp; (d) TVS – flow seen in the endometrium in more
than one vessel (PRF 0.3), but despite repeated attempts, the origin of flow across the EMJ is not seen. With TVS alone, it was not possible to see
the feeder vessel from the EMJ probably because it is perpendicular to the ultrasound beam at its origin. To improve accuracy of diagnosis, doing
both TAS and TVS routinely is therefore ideal

a LS b
TS

Fig. 4.18 Patient on tamoxifen for carcinoma breast. (a) Shows a polyp and cystic spaces (small white arrows) in the endometrium. (b) Shows
the feeder vessel of the polyp
112 4 Ultrasound Evaluation of Endometrium

a b

Fig. 4.19 Adenomyomatous polyp. (a) Seen on greyscale. (b) Showing Doppler flow. (c) Seen at hysteroscopy

Fig. 4.20 Pedicle artery sign: A dominant feeder vessel is

seen approaching the polyp across the EMJ LS
4.3 Endometrial Polyps 113

a LS b LS

c d
Coronal

RI 0.63

Fig. 4.21 (a) Thickened isoechoic endometrium with a hyperechoic line (arrow) raising a suspicion of a polyp. (b) A single feeder vessel with
branching, suggestive of an endometrial polyp. (c) Glass body rendering of the polyp with feeder vessel. Branching of the feeder vessel within the
polyp is well seen. (d) Spectral Doppler flow of feeder vessel. HPE: polyp with complex hyperplasia without atypia

Fig. 4.22 Endometrial polyp well seen on 3D rendered coronal

image view of the endometrial cavity. In this case, there was Coronal
minimal fluid in the endometrial cavity, and therefore the polyp is
well delineated
114 4 Ultrasound Evaluation of Endometrium

a LS b LS

c
Coronal

Fig. 4.23 Two endometrial polyps showing cystic spaces seen distinctly. (a) A narrow anechoic wedge seen between the two (arrow) on greyscale.
(b) Each polyp has its own feeder vessel arising from the anterior uterine wall. (c) 3D rendered image showing the two polyps
4.3 Endometrial Polyps 115

a b LS
LS

c LS d

RI 0.36

Vaginal gel

Fig. 4.24 Endometrial polyp seen arising from the upper corpus of the uterus and presenting as a fleshy, large (42.7 cm3) polyp with multiple
cystic spaces protruding out of the cervix . The external os diameter was 1.8 cm. Polyp seen (a) on greyscale and (b) on Doppler. (c) Lower margins
of the polyp are well seen on GSV. (d) The polyp shows high vascularity with low resistance flows. One of the causes for such flows (high colour
score and low RI) can be superadded infection. HPE: endometrial polyp with cystic hyperplasia
116 4 Ultrasound Evaluation of Endometrium

a LS b Coronal

Fig. 4.25 Blood in the endometrial cavity enhancing delineation of two endometrial polyps (a) on 2D with Doppler and (b) on 3D
4.3 Endometrial Polyps 117

a LS TS

b LS c
LS

Fig. 4.26 (a) Hyperechoic, 4.4 cm long polyp seen filling the endometrial cavity. (b) Lower rounded end of polyp (arrow) is visualised which
helps in differentiating it from other causes of thickened endometrium. (c) The feeder vessel of the polyp is seen approaching it from the anterior
wall of the uterus. HPE: simple hyperplasia
118 4 Ultrasound Evaluation of Endometrium

Fig. 4.27 Large, fleshy polyp with a thick feeder vessel showing
low RI. HPE: endometrioid adenocarcinoma arising in an LS
adenomyomatous polyp

RI 0.39

a LS TS

b c
LS LS

Fig. 4.28 (a) Hyperechoic clot filling the endometrial cavity in a menstruating patient complaining of menorrhagia, which can raise a suspicion
of a fleshy endometrial polyp. (b) Flow seen on colour Doppler is the menstrual flow. This raises a false suspicion of flow within an endometrial
polyp. (c) Empty uterine cavity noted the next day, confirming the diagnosis of a clot in the endometrial cavity the previous day
4.3 Endometrial Polyps 119

a LS b LS

Fig. 4.29 Thickened endometrium with hyperechoic scattered foci within. (a) TAS – shows feeder vessel. (b) TVS – shows the rounded lower
end of polyp. HPE: adenomyomatous polyp

a b

Fig. 4.30 Hypoechoic polyp with a feeder vessel approaching it from the uterine fundus on (a) Doppler and (b) 3D with glass body rendering
120 4 Ultrasound Evaluation of Endometrium

b c

Fig. 4.31 (a) Polyp with cystic hyperplasia. (b, c) Feeder vessel is difficult to trace. This happens in polyps that are primarily cystic with minimal stroma

Summary: Endometrial Polyps

• Endometrial polyps are commonly seen in both
symptomatic and asymptomatic women. They may
present with intermenstrual spotting or subfertility.
• On ultrasound, they appear as hyperechoic circum-
scribed areas and are best seen in the proliferative
phase. The presence of hyperechoic bright margins
between the polyp and endometrium and a single
feeder vessel are useful in clinching diagnosis.
Polyps may show cystic spaces and may be single
or multiple.
• Some polyps may be large and fleshy (e.g. adeno-
myomatous polyps). On rare occasions, polyps may
show malignant tissue within.
4.4 Endometrial Hyperplasia 121

4.4 Endometrial Hyperplasia the menstrual cycle) is considered normal. So, values
above that or, as some suggest, a measurement of more
Endometrial hyperplasia is a condition where there is a pro- than 15 mm at any time in the menstrual cycle could be
liferation of the endometrial glands that may progress to, or considered a thickened endometrium with likelihood of a
coexist with, endometrial carcinoma. About one-third of pathology. Endometrial hyperplasia is most often diffuse
endometrial carcinomas are believed to be preceded by but could less commonly be focal.
hyperplasia. In hyperplasia, there is an increase in the endo- • The endometrium may appear three layered, echogenic or
metrial gland to stroma ratio. Based on glandular features, heterogeneous. Tiny cystic spaces may be seen in the
endometrial hyperplasia is classified into: endometrium of a patient with cystic hyperplasia, giving
it a ‘Swiss cheese appearance’.
• Simple hyperplasia: The glands are mildly crowded and • The endometrium may be polypoid, which may appear as
frequently cystically dilated (commonly termed ‘cystic a non-linear endometrial midline, or as multiple polypoid
hyperplasia’). protrusions in patients with fluid or blood in the endome-
• Complex hyperplasia: The glands are crowded (with trial cavity (including at sonohysterogram).
more than 50 % gland to stroma ratio) and disorganised. • Vascularity of the endometrium generally increases
with multifocal single-scattered peripheral vessels seen
Nuclear atypia can be seen in both types but is infrequent crossing the EMJ. These vessels typically show a linear
in simple hyperplasia and more common in complex or gently curved path and are more uniformly scattered
hyperplasia. as compared to those in cases with endometrial
Risk factors for endometrial hyperplasia are similar to cancer.
those of endometrial carcinoma. Most of these risk factors • In women who are bleeding during the time of evaluation,
are related to excessive or chronic exposure to unopposed the endometrium could appear heterogeneous, with blood
oestrogen, as is noted in women with anovulatory cycles, and clots within the endometrial cavity.
polycystic ovaries and obesity. Women with endometrial • Since hyperplasia is associated with hyperestrogenia, one
hyperplasia most often belong to the perimenopausal age must search for causes of high oestrogen levels. On ultra-
group and present with menorrhagia (prolonged and heavy sound, therefore, the ovaries must be assessed for a poly-
flow), with or without preceding amenorrhoea. cystic appearance or an oestrogen-producing tumour.
Very often, however, the ovaries are normal.
Ultrasound Features of Endometrial Hyperplasia • The endometrium of patients on progesterone therapy for
(Figs. 4.32, 4.33, 4.34, 4.35, 4.36, 4.37, 4.38, 4.39, 4.40, endometrial hyperplasia with atypia or carcinoma endo-
4.41, 4.42 and 4.43) metrium in situ, appears thick and very vascular and
Endometrial hyperplasia is difficult to diagnose on ultra- shows focal cystic changes. This raises concerns, and in
sound, as ultrasound findings can overlap with both that of a the author’s experience in such cases when the endome-
normal endometrium and an endometrial malignancy. Since trial biopsy was repeated, histopathologically, there was
endometrial hyperplasia is a histologic diagnosis, a definitive significant improvement in these cases, in comparison to
diagnosis would require endometrial biopsy. their pre-progesterone tissue biopsy.
Ultrasound is the primary imaging modality in women
presenting with excessive uterine bleeding, which includes
cases with endometrial hyperplasia. 4.4.1 Tamoxifen-Associated Endometrial
Changes (Fig. 4.44)
• Thickened endometrium – endometrial thickness is usu-
ally increased. Normal acceptable thickness of the Tamoxifen is a drug used in the treatment of breast cancer. It
endometrium, in a postmenopausal woman, is 4 mm or has a pro-estrogenic effect on the endometrium, increasing
less. Therefore, a thickness of 5 mm or more would be the prevalence of endometrial hyperplasia, polyps and
considered a thickened endometrium and raise the possi- carcinoma. In these women, the endometrium may appear
bility of a polyp, endometrial hyperplasia or malignancy. thickened and cystic on ultrasound. The degree of endome-
In premenopausal women, it is difficult to assign a cut- trial thickening is believed to be related to the duration of
off. In them, a thickness of 5 mm or less on D4 to D6 (of tamoxifen therapy.
122 4 Ultrasound Evaluation of Endometrium

Fig. 4.32 An 85-year-old postmenopausal lady with a thick endome-

trium of 8.1 mm. Calcification of arcuate vessels seen (arrow) LS

Fig. 4.33 Endometrial hyperplasia with a three-layer endometrium

LS

a LS b LS

Fig. 4.34 Endometrial hyperplasia. (a) Echogenic endometrium. (b) Vessels seen crossing the EMJ. HPE: complex hyperplasia with atypia
4.4 Endometrial Hyperplasia 123

a LS b LS

Fig. 4.35 Endometrial hyperplasia. (a) Echogenic endometrium of 25 mm with tiny cystic spaces. (b) Multifocal linear single vessels crossing
the EMJ. (c) 3D rendered image of an endometrium showing tiny cysts (arrow). HPE: simple cystic hyperplasia

Fig. 4.36 A 22-year-old, known case of polycystic ovaries with

history of infrequent cycles and menorrhagia. 17 mm thick cystic LS
endometrium with multiple vessels crossing the EMJ, likely to be a
case of simple cystic hyperplasia
124 4 Ultrasound Evaluation of Endometrium

a LS b LS

c d
LS

e LS f Coronal

Fig. 4.37 Endometrial hyperplasia in a 37-year-old lady with intermenstrual spotting. (a, b) Endometrium appears thick and polypoid. White
hyperechoic line (arrow) seen which is typical of polyps. (c) Multiple linear vessels seen crossing the EMJ. (d) Spectral flow showing RI of 0.44.
(e) Polypoid endometrium seen on saline sonohysterography. Infusion catheter seen in the image (arrow). (f) 3D rendered imaging of endometrial
cavity showing polypoid endometrium on SHG. HPE: simple hyperplasia
4.4 Endometrial Hyperplasia 125

Fig. 4.38 Polypoid

endometrium with multiple
vessels crossing the EMJ

Fig. 4.39 H/o menorrhagia

since 4 months – thickened
echogenic endometrium of
20 mm with multifocal
single-scattered peripheral
linear vessels crossing the
EMJ. HPE: simple
hyperplasia
126 4 Ultrasound Evaluation of Endometrium

a LS b LS

c d

Fig. 4.40 Endometrial hyperplasia. (a) Thickened endometrium with tiny cystic spaces. (b) Multiple vessels crossing the EMJ. (c, d) Bilateral
polycystic ovaries. HPE: simple cystic hyperplasia
4.4 Endometrial Hyperplasia 127

a b

c d
LS LS

Fig. 4.41 A 31-year-old, known case of endometrioid carcinoma Grade 1 and PCO, on progesterone therapy. (a) 20 mm thick hyperechoic endo-
metrium. (b) Focal area of cystic changes in the endometrium (arrow). Multifocal linear single vessels seen crossing the EMJ. (c) On colour
Doppler and (d) on 3D Doppler with glass body display
128 4 Ultrasound Evaluation of Endometrium

a LS b TS LS

Fig. 4.42 A 29-year-old patient, diagnosed to have PCO 3 years prior to the scan. Curettage for intermenstrual spotting showed carcinoma
endometrium in situ, for which the patient was on progesterone. (a) Thick endometrium of 20 mm. (b) A small hyperechoic polypoid area
(arrow) is seen in the lower corpus. (c) Multifocal linear single vessels seen crossing the EMJ. The polypoid area (arrow) shows high vascular-
ity in the image on the right. Hysteroscopy and biopsy were repeated in view of high vascularity particularly in the polyp. Repeat HPE showed
a great improvement in tissue cytology with no atypia and progestational effect on the endometrium

a LS b LS

Fig. 4.43 Known case of complex hyperplasia with atypia, on progesterone therapy. (a, b) Thickened endometrium is seen with two focal areas
of cystic changes in the endometrium (arrows). (b) Endometrium shows increased vascularity with multifocal scattered linear vessels
4.4 Endometrial Hyperplasia 129

LS Summary: Endometrial Hyperplasia

• This condition is usually secondary to long-standing
unopposed oestrogen effect on the endometrium.
Most women complain of menorrhagia.
• On ultrasound, endometrium is thick and shows
multifocal single-scattered peripheral linear vessels
crossing the EMJ. The endometrium may appear
three layered, echogenic or heterogeneous. Tiny
cystic spaces may be seen.
• Differentiation from endometrial carcinoma is dif-
ficult in most cases, and a diagnosis is made only on
biopsy.

Fig. 4.44 A 40-year-old patient on treatment for carcinoma breast.

She was on GnRH analogues for ovarian suppression and tamoxifen.
7.4 mm thick endometrium with cystic changes is seen which is typical
of patients on tamoxifen therapy
130 4 Ultrasound Evaluation of Endometrium

4.5 Endometrial Malignancy regular EMJ (i.e. areas showing no invasion) act as a good
control for assessing myometrial invasion.
Endometrial carcinoma is the most common gynecological • On Doppler, there is increased vascularity in the endome-
malignancy. Fortunately, however, about 95 % of these trium. Randomly dispersed vessels may be seen in the
patients are symptomatic, because of which early diagnosis endometrium. The vessels may or may not be seen origi-
and management is usually possible. The commonest type of nating from the EMJ on 2D Doppler. The vascular mor-
endometrial carcinoma is endometrial adenocarcinoma phology is best studied on 3D power Doppler with glass
(about 90 % of cases). Ten percent of the cases comprise of body display (described in detail in the section on Doppler
rare cell types like papillary serous, clear cell or mucinous. in Chap. 2). The vessels are tortuous and show increased
The common symptoms of women with endometrial car- or abnormal branching. The size of the vessels may be
cinoma are postmenopausal bleeding, menorrhagia (heavy irregular, and looping and bridging may be seen. The vas-
flow and flow lasting for a long period), metrorrhagia and cular pattern is difficult to assess unless the endometrium
sometimes excessive vaginal discharge, which may be blood is sufficiently thick. Doppler may, at times, assist in pick-
stained or foul smelling. ing up myometrial invasion across the EMJ by recognis-
ing increased flow in that area. Doppler can help determine
Ultrasound Features of Endometrial Malignancy the site of tumour invasion due to its high vascularity,
(Figs. 4.45, 4.46, 4.47, 4.48, 4.49, 4.50, 4.51, 4.52, 4.53, ensuring that the biopsy is done in that region.
4.54 and 4.55) • It has been suggested that spectral Doppler may show low
• Thickened endometrium – endometrial thickness is usu- resistance flows in endometrial carcinoma. However, a
ally increased. In postmenopasual women, a thickness of significant overlap in Doppler indices decreases its utility
5 mm or more is considered a thickened endometrium and in differentiating benign from malignant lesions.
raises the possibility of pathology including malignancy. • Occasionally, an endometrial polyp may show malignant
In premenopausal women, it is difficult to assign a cut- features. Such polyps are more likely to be large and het-
off. Values above 15 mm at any time in the cycle could be erogeneous with feeder vessels showing a low RI.
considered a thickened endometrium with a likelihood of • If there is sufficient fluid or blood in the endometrial cav-
pathology. ity (including sonohysterogram), findings may be more
• The endometrial volume generally increases. More than discreet. Heterogenicity and irregular surface of the endo-
13 ml increases the possibility of malignancy. metrium are more common in malignant than in benign
• Heterogeneous endometrial tissue. endometrium. An irregular endometrial outline was
• The lesion may be diffuse or focal. At times, the lesion is shown to have a positive LR of 10. Doppler evaluation
seen extending into the cervix. This is important to look with saline infusion showed a decrease in blood flow as
for, as cervical extension of the tumour may alter manage- compared to the prior TVS in 25 % of patients in a study
ment protocols. (Epstein UOG 2006). It is, therefore, recommended that
• Intracavitary fluid may be seen due to necrosis and pres- Doppler examinations should be done before saline
ence of blood in the endometrial cavity. Minimal intra- infusion.
cavitary fluid in the absence of other pathology is,
however, often found to be related to benign conditions Concerns have been raised that saline infusion could lead to
like cervical stenosis, submucous fibroids, etc. intraperitoneal dissemination of malignant cells in women
• The EMJ may be disrupted due to myometrial invasion by with endometrial malignancy. Five-year survival has been
the tumour which may be seen on 2D, on 3D or with the reported to be the same in women with early endometrial can-
help of Doppler. The best evaluation of myometrial inva- cer who have undergone hysteroscopy before laparotomy, as
sion is with 3D VCI. One can walk through the volume compared to those that did not have preoperative hysteroscopy.
showing the VCI image to check the entire EMJ for inva- Saline infusion sonohysterography is therefore considered a
sion. Areas of thick normal-looking myometrium with safe procedure, even in women with endometrial cancer.
4.5 Endometrial Malignancy 131

a b

c d

e f

Fig. 4.45 Endometrial carcinoma in a 70-year-old patient with postmenopausal bleeding. (a) Thickened (32 mm) hyperechoic slightly heteroge-
neous endometrium with increased endometrial volume (34.5 cc). (b) Increased vascularity (colour score 4) noted in the endometrium with non-
linear vessels that show up either as colour signals or short segments of vessels, most often not originating from the EMJ on 2D Doppler. (c) Power
Doppler with 3D glass body image is best in depicting abnormal vascular morphology, as is seen here with irregular size of vessels and abnormal
branching. (d) Flow in endometrial tissue showing RI of 0.63. (e) Endometrial volume (35.9 c) measured using 3D VOCAL software. (f) 3D power
Doppler with volume histogram to assess vascular flow quantitatively. (g) 3D study with VCI showing irregular outline due to myometrial invasion
in the posterosuperior wall of the uterus (arrows). (h) 3D power Doppler with VCI showing an irregular EMJ (arrows) and flow in the endometrial
tissue. (i) Postoperative specimen showing a cut section of the uterus. Bulky endometrial tissue is noted. HPE: endometrioid adenocarcinoma with
more than 50 % myometrial invasion. Cervix was free of tumour
132 4 Ultrasound Evaluation of Endometrium

g h

Fig. 4.45 (continued)

4.5 Endometrial Malignancy 133

a b

c d

Fig. 4.46 Endometrial carcinoma. (a) Thickened (14.2 mm) heterogeneous endometrium. (b) Intracavitary fluid seen delineating the irregular
outline (arrow) of the endometrial malignant tissue. (c) Increased vascularity of the endometrial tissue is seen with randomly dispersed vessels,
which are not seen emerging directly from the EMJ. (d) Flow in the endometrium with RI of 0.54 and PSV of 27.6 cm/sec
134 4 Ultrasound Evaluation of Endometrium

a b

c d

e f

Fig. 4.47 Endometrial carcinoma in a 62-year-old patient. (a) Thickened endometrium of 30.3 mm with the thickened tissue seen extending into
the cervical canal. (b) Increased endometrial volume of 73 cc. (c) Endometrial tissue showing increased vascularity with randomly dispersed ves-
sels. Flow is also seen in the tissue extending into the cervical canal. (d) Transverse section of cervical canal showing flow from the cervical walls
into the tissue. (e) Endometrial flow shows a RI of 0.49. (f) 3D rendered image showing irregular endometrial margins. HPE: endometrioid carci-
noma with less than 50 % myometrial invasion
4.5 Endometrial Malignancy 135

a b

c d

e f

Fig. 4.48 Endometrial carcinoma in a 65-year-old patient with 1-month history of postmenopausal bleeding. (a) Minimal fluid seen in the endo-
metrial cavity with a single-layer endometrial thickness of 2.2 mm. A small focal irregularity (arrow) noted in the posterior endometrial wall of
the lower corpus. (b) The same seen in sepia mode (arrow). (c, d) This focal solid tissue (arrows) showed irregular margins and flow approaching
it from the posterior wall through a few small vessels crossing the EMJ. (e) Focal solid irregular area measured 15 × 8 × 13 mm (Vol: 0.9 ml). (f)
3D rendered image of the same showing spiky irregular margins (arrows). These were well seen because of the surrounding fluid in the endometrial
cavity. HPE: endometrioid adenocarcinoma of less than 1 cm with less than 50 % myometrial invasion
136 4 Ultrasound Evaluation of Endometrium

a b

Fig. 4.49 Endometrial carcinoma in a 78-year-old patient. (a) Hyperechoic thick endometrium. (b) Increased endometrial vascularity. The vessels
are not linear and are not seen originating from the EMJ on 2D Doppler. HPE: endometrioid carcinoma

a b

Fig. 4.50 Endometrial carcinoma in a 57-year-old patient. LS views of the uterus. (a) TAS – thickened endometrium with increased endome-
trial vascularity is seen with a few vessels crossing the EMJ, anteriorly and posteriorly. (b) TVS – thickened heterogeneous endometrium with
increased endometrium volume of 13.5 cc. (c) Increased endometrial vascularity on 2D power Doppler showing short segments of vessels with
only some crossing the EMJ. (d) 3D power Doppler with glass body image showing the entire abnormal vascular morphology. (e) 3D with VCI
showing normal EMJ and a myometrial thickness of 5 mm to the right of the midline. (f) 3D with VCI showing an irregular disrupted EMJ
(arrows) secondary to myometrial invasion to the left of the midline. The overlying myometrium is just 1.3 mm (long arrow), suggesting that
there is more than 50 % myometrial invasion. (g) Regular 2D imaging of the uterus showing the EMJ, looking normal though not well defined
to the right of the midline (long arrow) and poorly defined (short arrows) to the left of the midline. Here myometrial invasion is not well made
out. (This is the area corresponding to the area of myometrial invasion in image (e) using 3D VCI.) HPE: endometrioid carcinoma with more
than 50 % myometrial invasion
4.5 Endometrial Malignancy 137

c d

e f

Fig. 4.50 (continued)

138 4 Ultrasound Evaluation of Endometrium

b c

Fig. 4.51 Carcinoma in an endometrial polyp seen in a 61-year-old patient with a history of blood-stained white discharge of one-and-a-half-
month duration. (a) Thickened hyperechoic endometrium with cystic spaces and a volume of 54 cc. (b) A single large feeder vessel noted arising
from the posterior uterine wall. (c) The feeder vessel shows a low RI of 0.39. HPE: endometrioid adenocarcinoma in an adenomyomatous polyp
4.5 Endometrial Malignancy 139

b c

d e

Fig. 4.52 Endometrial carcinoma in a 68-year-old patient with a 4-month history of postmenopausal bleeding. (a) Thickened heterogeneous
endometrium of 22.7 mm showing minimal intracavitary fluid (arrow). Flow is seen within the endometrial tissue, which is seen as a solid circum-
scribed tissue at the upper corpus. (b) Flow is also seen in the endometrium of the mid corpus and lower corpus with RI 0.53. (c) Ascitic fluid is
seen in the right lower abdomen. (d, e) Right and left adnexal masses seen along the external iliac vessels. The masses are heterogeneous and show
vascularity, suggestive of metastatic lymph nodes. HPE: endometrioid adenocarcinoma. PET scan showed spread to iliac, aortic and supraclavicu-
lar lymph nodes
140 4 Ultrasound Evaluation of Endometrium

b c

Fig. 4.53 Endometrial carcinoma with pyometra in a postmenopausal lady who presented with bleeding. (a) Endometrial cavity showing complex
echoes and a volume of 34.5 cc. Scattered echogenic areas seen along the posterior wall of the anteflexed uterus suggestive of air in the endometrial
cavity (arrows) caused by anaerobic infection. (b) Solid tissue is seen in the upper corpus (arrow). The rest of the endometrial cavity appears filled
with turbid complex fluid (blood and pus). (c) Solid tissue (arrow) showing Doppler flow from the anterior wall. (d) 3D rendered image showing
complex echoes in the endometrial cavity and air echoes (arrows) which appear bright. (e) Postoperative specimen of the endometrial curettings.
HPE: endometrioid carcinoma with high-grade malignancy and extensive necrosis
4.5 Endometrial Malignancy 141

d e

Fig. 4.53 (continued)

a b

Fig. 4.54 Endometrial cancer in a 64-year-old patient who presented with postmenopausal bleeding of 4 years’ duration. (a) Hyperechoic thick-
ened endometrium of 27.3 mm seen. Small cystic spaces are seen in the endometrial tissue. (b) Endometrium showing increased vascularity.
HPE: mucinous carcinoma of the endometrium
142 4 Ultrasound Evaluation of Endometrium

a b

Fig. 4.55 A 73-year-old patient with obesity and the first episode of postmenopausal bleeding. (a, b) Visualisation is suboptimal both on greyscale
and Doppler. Endometrial thickness was 1.5 cm. On ultrasound, the only finding in a postmenopausal patient with endometrial carcinoma may be
a thickened endometrium as in this case. HPE: endometrioid adenocarcinoma

Summary: Endometrial Malignancy

• Endometrial carcinoma is commonly seen in post-
menopausal women, who most often present with
postmenopausal bleeding.
• On ultrasound, the endometrium is usually thick-
ened and differentiation from endometrial hyper-
plasia may be difficult. The endometrial tissue is
typically heterogeneous, and the endometrial mar-
gins lining the cavity are irregular (this can be seen
in the presence of sufficient intracavitary fluid or on
sonohysterogram). On Doppler vascularity is
increased with multifocal vessels or multiple ves-
sels from one focal area. Not all vessels show origin
from the EMJ. The vessel morphology is abnormal
with irregular size and excessive branching.
• The EMJ may be disrupted or poorly defined sug-
gesting myometrial invasion.
• Diagnosis of malignancy can only be made on biopsy
of the endometrial lesion.
4.6 Differential Diagnosis of Thickened Endometrium 143

4.6 Differential Diagnosis of Thickened utility is in helping select those patients that require biopsy,
Endometrium (Fig. 4.56) which provides the final definitive diagnosis.
Factors that help to differentiate between these three con-
The three likely pathologies in women with thickened endo- ditions are (Fig. 4.56):
metrium are endometrial polyp, hyperplastic endometrium
and endometrial carcinoma (after having ruled out an intra- • Polyps are usually hyperechoic and well defined. If they
cavitary fibroid). fill the entire endometrial cavity, then their smooth, well-
In premenopausal and perimenopausal women, about 1 % defined margins can be seen on SHG.
of those that undergo curettage have malignancy, whereas in • Heterogeneous endometrial tissue and presence of intra-
postmenopausal women, the percentage increases to 10 %. cavitary fluid – more likely to be carcinoma.
Prior to differentiation between these three conditions, it is • Endometrial volume: Average is 2.6 ml for polyp, 7.8 ml
important to know what measurement defines a ‘thickened’ for hyperplasia and 37 ml for carcinoma. Cut-off sug-
endometrium. Normal acceptable thickness of the endome- gested for malignancy is 13 ml.
trium, in a postmenopausal woman, is 4 mm or less. Therefore, • EMJ is usually uniform in a polyp and hyperplasia but
a thickness of 5 mm or more would be considered a thickened may be disrupted in cases of a carcinoma with myome-
endometrium and raise the possibility of a polyp, endometrial trial invasion. VCI helps delineate the EMJ better.
hyperplasia or malignancy. In premenopausal women, it is • Vascular pattern on 2D Doppler: (a) A single feeder ves-
difficult to assign a cut-off. In them, a thickness of 5 mm or sel likely to be a polyp; (b) multifocal scattered linear ves-
less on D4 to D6 (of the menstrual cycle) is considered nor- sels crossing the EMJ, likely to be endometrial hyperplasia;
mal. So values above that or, as some suggest, a measurement (c) randomly dispersed vessels that are not seen originat-
of more than 15 mm at any time in the cycle could be consid- ing from EMJ, likely to be endometrial carcinoma.
ered a thickened endometrium with likelihood of pathology. • Vascular morphology on 3D power Doppler: Same as seen
Ultrasound (TVS) is the primary modality of investiga- on 2D Doppler (mentioned above) in a polyp and cases of
tion in women with abnormal uterine bleeding or thickened endometrial hyperplasia. In carcinoma, however, abnor-
endometrium. In some cases, a diagnosis may be made (e.g. mal vascular tree with tortuous vessels, variable calibre,
submucous fibroid or endometrial polyp), while in others, its looping, bridging and excessive branching may be seen.
144 4 Ultrasound Evaluation of Endometrium

a b

c d

e f

Fig. 4.56 Differential diagnosis of a thickened endometrium. (a) Single feeder vessel – polyp. (b) Multifocal scattered linear vessels crossing the
EMJ – endometrial hyperplasia. (c) Randomly dispersed vessels that may not originate from EMJ – endometrial carcinoma. (d) 3D power Doppler
of the case in (c) with a glass body display showing abnormal morphology (explained in the section on Doppler in Chap. 2 and in the legend of
image 2.26 (c)). (e) Thickened endometrium in a postmenopausal patient measuring 19 mm. In view of the vascular pattern, this raised the suspi-
cion of carcinoma endometrium or hyperplasia. (f) However, on SHG in the above patient, to our surprise, it turned out to be a large endometrial
polyp. This case illustrates that diagnosis of a thickened endometrium is challenging. It often requires further study with SHG and is very often
only diagnosed on hysteroscopy or biopsy and histopathology
4.7 Asherman’s Syndrome or Intrauterine Adhesions 145

4.7 Asherman’s Syndrome or Intrauterine Ultrasound Features of Asherman’s Syndrome or

Adhesions Intrauterine Adhesions (Figs. 4.57, 4.58, 4.59, 4.60 and
4.61)
Intrauterine adhesions or endometrial scarring is usually • Endometrial scars are seen as hypoechoic breaks in the
post-traumatic or postsurgical, following curettage or man- endometrial continuity.
ual removal of placenta in a gravid uterus. It can also occur • Endometrial margins may be irregular.
because of trauma to a non-gravid uterus during resection of • There may be endometrial pockets seen with loculated
a submucous fibroid or septum. It may also be seen follow- fluid within.
ing endometrial ablation and uterine artery embolisation. It • 3D evaluation of the endometrial cavity is useful in
can be seen with infections like genital tuberculosis. This is assessing the extent of scarring.
the result of the normal wound-healing process of the endo- • The scarred area may extend onto the adjoining
metrium which gets replaced by fibrous tissue, which in turn myometrium.
causes the opposing endometrial surfaces to bond with each • In cases with coexistent subendometrial fibrosis, the
other. This results in the formation of intrauterine adhesions fibrotic scar tissue may appear echogenic and show acous-
with deficient endometrium in that area. There may however tic shadowing.
be pockets of functional endometrium in the non-scarred • On sonohysterography, the synechiae appear as avascular
area. In the scarred area, the distinction between the func- echogenic bands bridging the uterine cavity. In some
tional and basal layers of the endometrium is lost. Intrauterine cases, there may be difficulty in distending the cavity, if
adhesions can involve both the myometrial and the endome- the scarring is significant.
trial layers.
Depending on the extent of scarring, patients with Ultrasound evaluation of the endometrium for intrauter-
Asherman’s syndrome may be asymptomatic or can have ine synechiae is best done when the endometrium is thick, as
scanty or absent periods. Some patients may complain of is seen in the late proliferative phase or the secretory phase.
cyclical pain due to obstruction to the outflow of menstrual Hysteroscopy is not only useful in diagnosis but can also
blood (from the functional endometrium not affected by scar- help with simultaneous management of these cases by hys-
ring). It can also result in infertility and recurrent miscarriage. teroscopic adhesiolysis.

a b Coronal
LS

Fig. 4.57 Asherman’s syndrome. (a) Greyscale showing a break in the hyperechoic endometrium which is seen as a hypoechoic linear disruption
in the endometrial continuity at the upper corpus (arrow). (b) 3D rendered image of the same case showing multiple areas of scar tissue (pointers)
and irregular endomyometrial junction, particularly along the upper margins
146 4 Ultrasound Evaluation of Endometrium

a b Coronal

c d

Fig. 4.58 Case of Asherman’s syndrome. (a) Endometrial outline cannot be delineated. Endometrial tissue is seen as scattered, irregular, hyper-
echoic and poorly defined areas. Focal area of turbid collection is noted (arrow). (b) 3D rendered image of the same showing a completely distorted
endometrial outline and a small pocket of a localised turbid collection (arrow). (c) Minimal fluid is seen in a short segment of the endometrial
cavity (short arrow) with single-layer thickness of endometrium marked. Just beside this is a focal area of the turbid collection (long arrow). (d)
A small segment of endometrium seen appearing thin and proliferative
4.7 Asherman’s Syndrome or Intrauterine Adhesions 147

a LS

b Coronal

Fig. 4.59 Case of Asherman’s syndrome. (a) Hypoechoic area seen at the midcorpus along the posterior EMJ, extending into the endometrial
cavity. It is seen as a break in the hyperechoic endometrium. (b) 3D image with polyline showing three small areas of scar tissue (marked with
pointers). (c) Diagrammatic representation of the same which is handed over to the patient along with the report
148 4 Ultrasound Evaluation of Endometrium

LS

Fig. 4.60 Case of Asherman’s syndrome. Endometrial scarring is best seen when the endometrium is thick, as is seen in the image above. The
scar tissue on the left side (arrow) of the endometrium can be compared with the normal-appearing endometrium on the right side

a LS

Fig. 4.61 Case of Asherman’s syndrome. (a) Scar tissue on the right side (areas within arrows) seen as a hypoechoic irregular area along the EMJ,
producing an irregular endometrial outline. The scar tissue is seen extending onto the adjoining myometrium, but in the myometrium, the margins
are diffuse. (b) 3D rendered image of the same case showing two areas of scarring
4.7 Asherman’s Syndrome or Intrauterine Adhesions 149

b
Summary: Asherman’s Syndrome
• Asherman’s syndrome is secondary to endometrial
scarring usually following trauma caused by surgi-
cal procedures, like curettage or manual removal of
placenta. It may also be caused by chronic infec-
tions like tuberculosis. Patients typically present
with amenorrhoea or scanty periods and infertility.
• On ultrasound, they are seen as hypoechoic breaks
in the endometrial continuity which can be assessed
well on 3D rendered imaging. Endometrial margins
may be irregular, and there may be pockets of locu-
lated menstrual fluid.
• Hysterosonography and hysteroscopy may demon-
strate synechiae. Occasionally, however, if there are
significant adhesions, there may be difficulty in dis-
tending the uterine cavity.

Fig. 4.61 (continued)

150 4 Ultrasound Evaluation of Endometrium

4.8 Subendometrial Fibrosis (Figs. 4.62 occur following invasive intrauterine procedures, particu-
and 4.63) larly manual removal of placenta. On ultrasound, it is seen
as echogenic foci in the basal endometrium close to the
In subendometrial fibrosis, the fibrosis occurs in the deeper EMJ. The condition is not usually associated with menstrual
basal endometrial layer with no loss of the functional endo- or fertility issues, and women are asymptomatic. At times,
metrium. It should not be confused with intrauterine adhe- however, both intrauterine adhesions and subendometrial
sions (Asherman’s syndrome). Subendometrial fibrosis can fibrosis may coexist because they are both caused by trauma.

a TS b LS

c Coronal

Fig. 4.62 Subendometrial fibrosis in a patient with a history of manual removal of placenta during the last child birth (1 ½ years ago). (a, b)
Echogenic scattered foci seen close to the EMJ with superficial endometrium appearing normal on TS and LS. (c) 3D rendered coronal image of
an endometrium showing intact endometrial margins with a faint impression of the underlying fibrosis (arrow)
4.8 Subendometrial Fibrosis 151

a
TS LS

b LS c Coronal

Fig. 4.63 Subendometrial fibrosis, seen in an asymptomatic patient with a history of manual removal of adherent placenta. (a) A hyperechoic
irregular band of tissue is seen in the endometrium with significant acoustic shadowing, suggestive of dense fibrotic and calcified tissue. (b) The
upper end of the endometrium appears normal (arrow). (c) 3D rendered image of the same showing fibrotic tissue which appears as a hyperechoic
irregular area in the endometrium of the mid corpus and lower corpus. The scar tissue is seen as dark in some parts, mainly in the lower endome-
trium and adjoining myometrium. This area appears dark because of acoustic shadowing by the scar tissue. In this image, therefore, the plane of
rendering has passed partly proximal to the scar tissue and partly distal to it (in the area of acoustic shadowing). Normal upper endometrium
(arrow) with two cornua is seen
152 4 Ultrasound Evaluation of Endometrium

4.9 Endometritis Ultrasound Features of Endometritis (Figs. 4.64, 4.65,

4.66, 4.67 and 4.68)
Endometritis refers to the inflammation of the endometrium. • Ultrasound appearance of the uterus and endometrium may
Endometritis can be divided into pregnancy-related endome- be normal, as in cases of chronic infection like tuberculosis.
tritis and pregnancy-unrelated endometritis. When it is unre- • Intracavitary fluid may be seen, which may be minimal. It
lated to pregnancy, endometritis is considered a part of the is usually turbid (blood and/or pus). This fluid may show
spectrum of PID. In PID, the endometrium is less susceptible some hyperechoic debris within.
to infection than the fallopian tube. This is so, particularly in • The endometrium may appear thickened, irregular and
women of the reproductive age group, because the endome- heterogeneous.
trium is shed cyclically during menstruation. Occasionally • Increased vascularity in the endometrium and adjoining
however, the endometrium may be the sole focus of infec- myometrium may be noted.
tion. Endometritis could be acute or chronic. • There may be some retained products of conception, or
Acute endometritis in non-obstetric population is com- occasionally, a piece of gauze, etc. may be accidentally
monly associated with PID and invasive gynecologic left behind (gossypiboma) within the uterine cavity.
procedures. In obstetric cases, post-partum infection is the • The uterus may be sub-involuted in cases with puerperal
most common cause of acute endometritis. Acute endometri- endometritis.
tis seen as a part of PID usually presents with symptoms that • In some cases, a neoplastic growth may be seen in the
are like that of PID – which is fever and lower abdominal endometrial cavity.
pain. Acute endometritis in post-partum women is more • In tuberculosis endometritis, few adhesions may be noted
florid, and the patient may present with fever, pain, bleeding within the endometrial cavity. In long-standing cases, with
(secondary haemorrhage) and foul-smelling lochia. In severe fibrosis setting in, hyperechoic foci may be seen along the
cases of puerperal infection, the patient may present with endomyometrial junction. There may be scarring of the
generalised septicaemia. endometrium (Asherman’s syndrome – discussed in the sec-
Chronic endometritis in obstetrics, is seen in patients with tion above) and an irregular endometrial outline.
RPOC. In a non-obstetric population, it may be associated • In infection with anaerobic organisms, there may be air
with chronic infections like tuberculosis, intrauterine contra- within the endometrial cavity which is seen as bright scat-
ceptive devices and neoplastic masses (like endometrial car- tered echoes with dirty acoustic shadowing. Most often, air
cinoma and a submucous fibroid). It can also be seen in in the uterine cavity is seen in the nondependent parts of
patients who have undergone radiation therapy. In a large the cavity above the turbid fluid. It is important to note that
majority, however, no cause is identifiable. Patients with the presence of air in the uterine cavity (pneumatometra)
chronic endometritis may be symptomatic or asymptomatic. may be a normal finding, particularly in the first 3 weeks of
These women may present with abnormal uterine bleeding, puerperium. However, when seen in a patient with clinical
excessive intermenstrual bleeding or with amenorrhoea. features of PID, it is suggestive of anaerobic endometritis.
Patients may also complain of vague crampy lower abdomi- • The adnexa may show evidence of PID in the form of
nal pain or vaginal discharge that may be foul smelling. In tubo-ovarian masses, pyosalpinx, etc.
chronic infections like tuberculosis, the patient is often • In cases with severe widespread infection, there may be evi-
asymptomatic with no clinical findings. Tuberculosis is often dence of pus elsewhere in the pelvic cavity which may
diagnosed in women with infertility when the endometrial extend into the abdominal cavity.
curetting is subjected to testing. • The uterus may be tender during transvaginal scan (TVS).
4.9 Endometritis 153

a TS LS

b c
LS
TS

CX

d e

Fig. 4.64 A 65-year-old patient who presented with a 10-day history of foul-smelling discharge. (a) Endometrial cavity is seen filled with turbid
contents showing mixed echoes, suggestive of pus (Vol, 55 cc). (b) On Doppler, the subendometrial area shows moderate vascularity (which is not
a normal finding in postmenopausal women). (c) The cervix in this patient was examined to rule out any local cause for the pyometra, like a cervi-
cal malignancy. In this patient, no abnormality was noted. (d, e) Both the adnexa appeared normal with bilateral atrophic ovaries. HPE: scanty
endometrium with no malignancy noted in the endometrial and the endocervical curettings
154 4 Ultrasound Evaluation of Endometrium

a LS TS b

Fig. 4.65 (a) Minimal turbid fluid collection seen in the endometrial cavity of a patient with PID. (b) Right adnexa showing a complex TO mass
with pyosalpinx in the same patient

Fig. 4.66 Patient had a twin a

delivery with atonic PPH 25 days LS TS
earlier. She complained of
bleeding PV since delivery and
spasmodic lower abdominal pain
since 3 days. Scan done
elsewhere reported a suspicion of
an intrauterine foreign body. (a)
Uterine cavity is seen filled with
fluid showing scattered hyper-
echoic areas with dirty acoustic
shadowing suggestive of air
secondary to anaerobic infection
(volume of the contents in the
cavity was 258 cc). No evidence
of retained tissue was noted,
which may be because of the
large uterine size and air
shadows. (b) Transverse section
of uterus showing fluid with
some debris (short arrow) and a b TS c LS
hyperechoic area with acoustic
shadowing, more to the left of the
uterine cavity (long arrow).
Moderate vascularity was noted
in the subendometrial area. (c–e)
Two days post dilatation and
curettage with removal of
retained products. A thick
endometrium with irregular
endometrial margins (arrows)
and intracavitary fluid with debris
is seen. No significant flow is
seen in the endometrium or
adjoining myometrium, probably d LS e LS
because the patient was already
on antibiotics
4.9 Endometritis 155

Fig. 4.67 Patient presented a

23 days after LSCS done for LS TS
abruptio placentae, with
abdominal pain and heavy
bleeding. (a) TAS – uterine
cavity was filled with turbid fluid
showing hyperechoic gas echoes
with shadowing. No obvious
retained tissue was noted. (b)
TVS – turbid contents (206 cc)
with complex echoes and stretchy
hyperechoic linear bands
suggestive of pus are seen filling
the entire uterine cavity almost up
to the external os. Hyperechoic
gas echoes (arrow) with shadow-
ing seen along the anterior uterine
wall. (c) No significant flow seen
b LS c LS
on Doppler in the endometrium,
which is often the case with
endometritis. (d, e) Turbid
collection is seen surrounding the
ovaries, bilaterally (arrows). (f)
Turbid fluid suggestive of pus is
seen in the right lower abdomen
and (g) in the right subdiaphrag-
matic area. At surgery, the
abdominal cavity was found to
have multiple pockets of pus
which were drained, and
peritoneal lavage was given d e

f g
156 4 Ultrasound Evaluation of Endometrium

a TS LS b LS

Fig. 4.68 Pyometra in a patient with endometrial carcinoma. (a) Turbid complex fluid with air echoes is seen in the endometrial cavity, suggestive
of pyometra with anaerobic infection. (b) Solid tissue (arrow) seen in the upper uterine cavity which showed flow on Doppler, suggestive of a
neoplastic growth

Summary: Endometritis
• Signs and symptoms are often non-specific and depend
upon whether it is acute or chronic and whether it is seen
in patients with PID or in women in the puerperal period.
• Diagnosis of endometritis is challenging because sono-
graphic findings may vary from normal to minimal
intracavitary fluid to frank pus in the uterine cavity.
• Tuberculosis endometritis is often diagnosed in
women with infertility, many of them being asymp-
tomatic. Adhesions and fibrosis may, however, be
noted in the endometrium.
• Acute puerperal infection tends to be more florid.
• Depending upon the aetiology, one may see RPOC
or a neoplastic mass within the endometrial cavity.
4.10 Intracavitary Fluid in the Uterus 157

4.10 Intracavitary Fluid in the Uterus cancers and cervical cancers. Another cause for fluid collec-
(Figs. 4.69, 4.70, 4.71, 4.72, 4.73 and 4.74) tion in postmenopausal women could be cervical stenosis.
In premenopausal women, most often, the intrauterine
collection is blood associated with menstruation or preg-
Fluid in the uterine cavity may be clear (anechoic) or turbid. nancy. It could also be retained menstrual blood in a patient
Clear fluid could be serum or mucin. Turbid fluid could with hematometrocolpos, acutely retroflexed uterus and cer-
either be blood (hematometra) or pus (pyometra). Pyometra vical stenosis.
is discussed in the previous section (Figs. 4.64, 4.65, 4.67 In the presence of endometritis, turbid fluid suggestive of
and 4.68). pus may be seen in the endometrial cavity.
A tiny amount of clear fluid seen in the endometrial cavity Minimal fluid may also be seen in the presence of polyps
may be normal in postmenopausal women. However, any sig- and submucosal fibroids. A small amount of clear fluid in the
nificant amount of fluid collection or turbid collection requires endometrial cavity may be a finding in patients with carci-
careful evaluation as they may be associated with endometrial noma of the fallopian tube.

a b
LS
LS

C d
e
LS

CX

Fig. 4.69 (a) Anechoic fluid collection in a postmenopausal lady with a thin endometrium. (b) No abnormal flow seen on Doppler. (c) The cervix
in this case appeared normal with no evidence of local pathology as a cause for the collection. (d, e) Normal atrophic ovaries are seen
158 4 Ultrasound Evaluation of Endometrium

Fig. 4.70 Postmenopausal lady with a thin endometrium and

anechoic fluid collection LC

Fig. 4.71 Minimal clear intracavitary fluid (short arrow) in a lady

with fallopian tube carcinoma. The malignant mass is seen just
behind the uterus (long arrow)
LS

Fig. 4.72 A case of imperforate

hymen with hematometrocolpos
LS
4.10 Intracavitary Fluid in the Uterus 159

a b LS
LS

c LS

e
LS

Fig. 4.73 Hematometra seen in a patient with an acutely retroflexed uterus. This could be caused by acute retroflexion, with probable contribution
by scarring at the site of previous LSCS. Patient had undergone surgical termination of a subsequent pregnancy, 3 months prior. Following the
termination, she gave history of amenorrhoea. (a) TAS – image showing an acutely retroflexed uterus with turbid contents. (b) TVS – showing the
same and the LSCS scar (arrow). (c) Patient returned 12 days later with severe abdominal pain associated with vomiting following the intake of
Cytotec medication (which was prescribed by her clinician to assist in uterine emptying). Turbid collection suggestive of blood is seen in the
endometrial cavity. Volume had increased in 12 days from 6.7 cc. to 44.5 cc. The intrauterine fluid collection shows a fluid–fluid level with denser
contents in the dependent upper cavity of the retroflexed uterus. (d) 3D rendering of the same showing the linear fluid–fluid level. (e) Patient had
bleeding for 5 days commencing on the day of previous scan (corresponding to image (c, d)). Scan done a few days later showed a normal endo-
metrial cavity with no hematometra
160 4 Ultrasound Evaluation of Endometrium

Fig. 4.74 Hematometra in a a

22-year-old patient, who
presented with menorrhagia since
menarche. (a) Intrauterine clot
appears complex resembling an
intrauterine mass or polyp. (b) On TS LS
Doppler, no flow was seen in the
intracavitary clot. Blood and
clots may be seen in the uterine
cavity in a menstruating patient

b
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Mascilini F et al (2013) Evaluating myometrial and cervical invasion in
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Nalaboff KM et al (2001) Imaging the endometrium: disease and nor-
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Ultrasound Obstet Gynecol 40(6):621–629
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Parsons AK, Sanders RC (2007) OP17.07: menometrorrhagia due to
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 Ultrasound Evaluation of the Cervix
5

The cervix is the muscular lower end of the uterus. Its inner • The internal os can be identified by the fact that:
cervical canal is continuous with the endometrial cavity – It is the narrowest part of the uterine cavity where the
above at the internal os, and its muscular myometrium is endometrial cavity is continuous with the cervical
continuous with the myometrium of the uterine body. The canal.
cervix is fusiform in shape and has a central cervical canal – The cervical mucosa can be seen to taper off and end at
which extends from the internal os to the external os with its the internal os.
narrowest portion at the internal os. The portion of the cervix – The uterine arteries enter the uterus at the level of the
above the attachment of the vaginal vault is called the supra- internal os.
vaginal cervix, and the lower cervix below the attachment of This feature is especially helpful when the normal cervi-
the vaginal vault that protrudes into the vagina is called the cal architecture is distorted by pathological lesions.
‘portio vaginalis’. Cervical pathologies include nabothian • The external os is small and round in a nulliparous woman
cysts, polyps, fibroids, uterine anomalies, ectopic pregnancy, but appears as a larger transverse slit in a woman who has
endometriosis and carcinoma. Fibroids, congenital anoma- had a normal vaginal delivery. The os can be seen on the
lies and cervical ectopic are dealt with in their respective transverse section of the cervix but is better seen on a 3D
chapters. Congenital cervical anomalies are discussed in the rendering of the external os, especially with GSV.
chapter on uterine anomalies. Cervical fibroids are briefly • The cervical canal just prior to ovulation shows anechoic
discussed in this chapter. cervical mucus which improves visualisation of the cer-
vical canal on ultrasound. This helps in the diagnosis of
cases with cervical polyps and congenital anomalies of
5.1 Evaluation of the Cervix and Its the cervix.
Normal Appearance
Doppler
Measurements • The uterine arteries can be identified on both sides of the
The length of the cervix, on an average, is 3–4 cm and the cervix at the level of the internal os.
diameter is about 2–3 cm. The cervix is about half the size of • The presence of an abnormal vessel in the cervical canal
the uterine body in the reproductive age group. In prepuber- should raise a high suspicion of a feeder vessel of a polyp
tal girls, the cervix is prominent and almost similar in size to at the cervix, which may be originating either from the
that of the uterus. cervix or the endometrium above.
• Cervical carcinoma is difficult to detect on 2D especially
Appearance (Fig. 5.1) when it is small and isoechoic. On Doppler, these lesions are
• The cervix is homogeneous in echotexture with echo- easier to pick up because most of them are highly vascular.
genicity similar (i.e. isoechoic) to that of the myometrium
of the uterine body. Tips to Improve Ultrasound Diagnosis of Cervical
• The central canal is lined by cervical mucosa that usually Lesions (Fig. 5.2)
appears hypoechoic and contains the endocervical glands. • The assessment of the cervix should be a part of all rou-
This cervical mucus makes it easy to identify the cervix tine gynecological ultrasound examinations. Lesions of
and differentiate it from the uterine body above it. the cervix are often missed on ultrasound because most of

© Springer Nature Singapore Pte Ltd. 2017 163

M. Sibal, Ultrasound in Gynecology, DOI 10.1007/978-981-10-2714-7_5
164 5 Ultrasound Evaluation of the Cervix

the sonologists proceed directly to the uterine body and lar to the ultrasound beam and is seen better. When
adnexa in search of gynecological pathology, leaving out cervical pathology is seen or suspected, gel sonovaginog-
the assessment of the cervix. raphy (GSV) may be resorted to (dealt with in Chap. 2)
• Since visualisation of the cervix on ultrasound is subop- for better visualisation of the pathology.
timal at times, because of its proximity to the TVS • Doppler evaluation of the cervix should be done routinely
probe, withdrawing the probe a little helps to evaluate in all patients to help detect cervical lesions like polyps
the cervix. One may push on the cervix with the probe and carcinomas, which may otherwise be missed on 2D
placed in one of the fornices to further antevert or retro- greyscale (as the assessment of the cervix is relatively
vert the uterus so that the cervix lies more perpendicu- suboptimal on TVS).

a b LS
LS

CX

Fig. 5.1 Uterus with cervix on TAS (a) and TVS (b). Long arrows show the internal os; short arrows show the external os

a b
LS LS

Fig. 5.2 When the USG beam is perpendicular to the cervical canal, the entire cervical mucosa and the posterior wall of the upper vagina (short
arrows) abutting the external os of the cervix (long arrows) is well visualised. (a) The cervix in sepia mode, which is supposed to enhance percep-
tion by the human eye. (b) Greyscale image of the cervix corresponding to (a)
5.2 Nabothian Cysts 165

5.2 Nabothian Cysts Ultrasound Features of Nabothian Cysts (Figs. 5.3, 5.4
and 5.5)
Nabothian cysts, also known as nabothian follicles, are com- • These are seen as discreet round or oval cystic spaces in
mon retention cysts seen in the cervix. They are formed as a the walls of the cervix, most often close to the mucosa.
result of the retention of mucoid secretions in the endocervical • They are usually multiple.
glands. They are a sequel to the healing process of chronic • They are generally anechoic but may show turbid
cervicitis, minor trauma of cervix or vaginal delivery. Being contents.
asymptomatic, they are generally picked up on ultrasound • No increase in vascularity is noted around the cysts, on
done for other pathologies. Their main significance lies in Doppler.
distinguishing them from other cervical lesions like DIE,
which may also show cystic lesions in the cervix.

a b LS
LS

UT

CX

Fig. 5.3 Nabothian follicles seen in the cervix on (a) TAS and (b) TVS. These are seen as anechoic cystic areas in the cervix on either side of the
cervical canal (arrow)

a LS b

UT

CX

Fig. 5.4 Occasionally, nabothian follicles are many in number, giving the cervix a multicystic appearance: (a) on 2D and (b) on 3D
166 5 Ultrasound Evaluation of the Cervix

a b

Fig. 5.5 Cervix with multiple (more than 10) nabothian cysts. (a) Nabothian cysts showing turbid contents. (b) Doppler evaluation done to help
with differential diagnosis. HPE: chronic cervicitis
5.3 Cervical Polyps 167

5.3 Cervical Polyps • They may be multiple.

• They can often be identified as separate pedunculated
Cervical polyps are solid circumscribed lesions seen at the masses by pushing with the TVS probe with consequen-
cervix. They have a vascular connective tissue stroma and tial movement of the polyp within the cervical canal or
are covered with epithelium. Polyps in the cervix may be vagina.
seen in the cervical canal or protruding out of the external os • On Doppler, flow is seen within these polyps. By tracing
into the vagina. They may be sessile but most are peduncu- the feeder vessel upwards (which may require some angu-
lated with a slender pedicle. These polyps may arise from the lation of the probe), the site of origin of the polyp can be
cervix or from the uterine cavity above. Malignancy is rarely ascertained. Sometimes polyps in the cervical canal or
found in polyps arising from the cervix, yet, if excised, they protruding out of the cervical os may be originating from
must be subjected to histological evaluation. high up in the endometrial cavity. Very often, a polyp may
Cervical polyps are common in women in the reproductive be detected because of the suspicion raised by a feeder
age group, usually in their 40s. Most of these patients are vessel in the cervical canal.
asymptomatic. Symptomatic cases may present with intermen- • Larger fleshy polyps may show high vascularity because
strual bleeding, post-coital bleeding and vaginal discharge. of the nature of the tissue or secondary infection. Very
often, these fleshy polyps are adenomyomatous polyps
Ultrasound Features of Cervical Polyps (Figs. 5.6, 5.7, (showing muscle and glandular tissue) arising from the
5.8, 5.9, 5.10, 5.11, 5.12, 5.13 and 5.14) endometrium.
• They are typically solid hyperechoic or isoechoic masses • Visualisation of cervical polyps is difficult due to the
seen either in the cervical canal or protruding out through proximity of the cervix to the probe. At mid-cycle, when
the external os. Rarely, they may show cystic areas within. cervical mucus in the canal is present, these may be better
• They are usually circumscribed, oval- or ‘tear drop’-shaped visualised. In other cases, GSV may be used to evaluate
masses but may be irregular or frond-like in appearance. these polyps. On GSV, these polyps (especially if they are
• Their margins are usually smooth, and very often these soft and supple), due to slight pressure from instilled gel,
can be identified in the cervix because of the bright line are seen to abut the external os, obliterating it.
formed at the interphase of the cervical mucosa with the • 3D rendering of the cervix and external os, particularly
smooth walls of the polyp. with GSV, may also help to delineate the polyp.
168 5 Ultrasound Evaluation of the Cervix

a LS b TS

c LS d LS

P
P

Fig. 5.6 Cervical polyp arising from the anterior wall of the upper corpus of the uterus. (a) A feeder vessel is seen on TAS extending from upper
corpus to the upper end of the polyp (P). (b) Transverse section of feeder vessel at the internal os (determined by the uterine arteries entering the
uterus at this level). (c) Feeder vessel of the polyp on TVS (RI-0.34). (d) Polyp protruding out of external os. Arrows showing the splayed cervical
lips. HPE: adenomyomatous polyp
5.3 Cervical Polyps 169

a LS b

c LS d LS

e LS f

Fig. 5.7 Polyp in the cervical canal which is protruding out from the cervical os. (a–d) Are images on regular TVS. The polyp is seen in the cervical
canal (a) on 2D and (b) 3D. The lower margin of the polyp is seen protruding out of the external os. (c, d) On Doppler, there was a suspicion of two
polyps (labelled as 1 and 2) because of the vascular pattern of flow with two vessels approaching the polyp (one venous and one arterial) from two
different locations above the polyp. (e, f) Images on GSV. Single polyp is better seen and delineated on 2D and 3D with GSV
170 5 Ultrasound Evaluation of the Cervix

b c

vagina
vagina

vagina

Fig. 5.8 (a) Tear-shaped polyp seen in cervical canal on regular TVS – on greyscale and on colour Doppler. The vaginal walls (arrows) are seen
just below the polyp opposing each other in the midline. (b–d) GSV – because of the intravaginal gel, the vaginal walls are seen apart and the
lateral fornices are clearly visible. Gel is also seen surrounding the polyp. (b) Polyp on greyscale. (c) Polyp with feeder vessel approaching it
from the cervical walls above. A smaller polyp (arrow) is seen close to its base. (d) 3D rendered image of the cervical os with the polyp (arrow)
protruding out
5.3 Cervical Polyps 171

a LS b LS
TS

Fig. 5.9 (a) Irregular polyp seen in cervical canal. Arrow showing hyperechoic line between the polyp and wall of the cervical canal. (b) Feeder
vessel of the polyp seen
172 5 Ultrasound Evaluation of the Cervix

Fig. 5.10 (a) Irregular polypoid

a TS
mass seen in the vagina just LS
below the cervix on regular TVS.
(b) 3D rendering of the same,
showing three frond-like
projections with central
hypoechoic linear areas
suggestive of vascular core
(arrows) of the fronds. (c)
Pedicle of the polyp at the
external os. (d) Doppler flow in
pedicle. (e) Fronds of polyp seen
on GSV. (f) 3D rendering of the
longest frond seen on GSV is
traced in the image. (g) Gross
morphology of the excised
specimen correlating with USG
in (b) HPE: benign cervical
polyp
b c LS

d LS e LS

Vagina

f g

Vagina
5.3 Cervical Polyps 173

a b

Vaginal gel

Fig. 5.11 Polyp was seen per speculum clinically. (a) Regular TVS – vessels were seen in the cervical canal but polyp was difficult to delineate.
(b) GSV – two polyps (arrows) seen at the cervical os which were obliterating the external cervical os

a b

Fig. 5.12 (a) Vessel in the cervical canal raises a high suspicion that it could be a feeder vessel of a polyp lying below it. (b) Regular TVS – polyp is
difficult to delineate. (c, d) GSV – polyp is clearly seen because of the gel surrounding the polyp and filling narrow gaps (arrows) between tissue
planes
174 5 Ultrasound Evaluation of the Cervix

a b
TS LS LS

cx

Fig. 5.13 (a) Small cervical polyp which is seen because of mucous in the cervical canal. (b) Feeder vessel is seen approaching it from the anterior
cervical wall

a b
LS
LS

cx
cx

1 p

vagina

Fig. 5.14 (a) Feeder vessel seen in the cervical canal on a regular TVS, but the polyp was difficult to delineate. (b) On GSV, polyp seen clearly
outlined with its feeder vessel and protruding out of the cervical os

Summary: Cervical Polyp

• These are commonly seen in benign lesions. Most
cases are asymptomatic or complain of intermen-
strual or post-coital bleeding.
• On ultrasound, they typically appear as oval- or
‘tear drop’-shaped solid masses either in the cervi-
cal canal or protruding out of the external os. A
feeder vessel is seen which helps locate the site of
origin of polyp and often helps raise suspicion of a
possible cervical polyp.
• GSV is useful in evaluating suspected or known
cervical polyps.
5.4 Cervical Fibroids 175

5.4 Cervical Fibroids (Figs. 5.15, 5.16 and menorrhagia, intermenstrual bleeding and vaginal discharge.
5.17) Surgical management of cervical fibroids is more challeng-
ing than those of the uterine body.
Cervical fibroids are less common, as compared to uterine The ultrasound features of cervical fibroids are similar
fibroids. Clinically, they may cause symptoms due to pres- to fibroids elsewhere in the uterine body and are dealt with
sure on the bladder or bowel. Cervical fibroids can obstruct in Chap. 3, in the section on fibroids. On TVS, these
normal deliveries because they are located along the birth fibroids may hamper the view of structures beyond them
canal. They may arise from the cervical myometrium and due to shadowing. Their mapping and origin (deciphered
grow pushing the surrounding structures, or they are seen from the site of vascular supply) is often better assessed on
replacing the cervical wall, or they may be seen as peduncu- TAS than TVS. The uterine body above the cervical fibroid
lated submucosal masses with significant dysmenorrhoea, also most often requires evaluation on TAS.

a b
LS TS LS

Fig. 5.15 Cervical fibroid causing bladder neck obstruction. Patient presented with difficulty in passing urine since 3 days. (a) Small uterine body
seen above the posterior wall cervical fibroid. (b) Fibroid on transverse and long section. Catheter is seen in situ (arrow)
176 5 Ultrasound Evaluation of the Cervix

a b TS LS
LS

c LS

Fig. 5.16 (a, b) TAS – a large anterior cervical fibroid measuring 10 × 9 × 14 cm (volume – 725 cc). (c) TVS – the anterior lip of the cervix is
replaced by the fibroid (F). Post lip with small nabothian follicle (small arrow) and the cervical canal (long arrow) are also seen

a LS b LS

UT

LS

Fig. 5.17 (a) TAS – fibroid (F) seen in the cervical canal. Vascular flow to fibroid shows its origin from the anterior uterine wall of the lower
corpus. (b) TVS – fibroid seen protruding out of the cervix. Cervical lips (arrows) are about 5.8 cm apart. Dilated or distended external os shown
with a straight line
5.5 Cervical Carcinoma 177

5.5 Cervical Carcinoma which often helps in defining the margins of the lesion
(Testa UOG 2009).
Cervical carcinoma is a common malignancy, particularly in • Doppler also helps in detecting and defining the margins
some countries like India, where it is more common than of the tumour, as most of the tumours show high vascular-
endometrial carcinoma, especially in women from low ity. Subjective evaluation by colour score is found to be
socioeconomic backgrounds. It is seen in relatively younger more useful than 2D or 3D flow indices. Abnormal vascu-
women that belong to the reproductive age group. Human lar pattern with irregular calibre and abnormal branching
papillomavirus (HPV) is believed to be primarily involved in may be noted in bulky masses, on 3D power Doppler with
the aetiology of cervical cancer. glass body display.
The two major types of cervical cancer are squamous cell • The location of the tumour should also be mentioned, i.e.
carcinoma and adenocarcinoma. Squamous cell carcinoma is whether it is exophytic or endophytic. This can be done
more common, but their incidence is decreasing in many by identifying the cervical canal and the relation of the
countries due to cytological screening (Pap smear). tumour to it.
In the early stages, women are asymptomatic. Early cases • The lesion should be measured in three dimensions (as
may be picked up following investigations for an abnormal explained in Chap. 2). The maximum dimension should
Pap smear. Women who are symptomatic may present with be also be measured which may be in any plane, as FIGO
post-coital bleeding, intermenstrual bleeding or vaginal dis- staging includes the size of the tumour and the treatment
charge. In advanced cases that have spread to the parame- varies in various stages.
trium, bowel or bladder, patients may complain of pain and • In small lesions, it is important to measure the distance
bladder or bowel symptoms. between the internal os and the upper margin of the
Ultrasound evaluation of carcinoma of the cervix is gen- tumour, particularly in women who would like a fertility
erally considered suboptimal. FIGO staging of cancer of the sparing local surgical procedure like conisation.
cervix is based on clinical examination of the patient, which • The stromal infiltration should be assessed by checking
today is considered inaccurate. Presently, in most cases, car- on the thickness of the tumour-free cervical stroma around
cinoma of the cervix is evaluated by MRI. Of late there has the margins of the lesion.
been an increasing amount of literature with studies show- • Infiltration into the uterovesical space or bladder wall and
ing high accuracy of ultrasound in the detection and the into the rectovaginal septum or rectum should be assessed
evaluation of cervical cancer. Confirmation of diagnosis is by pushing these structures with the TVS probe and
by tissue biopsy. Ultrasound can help not only in the detec- assessing the sliding of the bladder and rectum along the
tion of small tumours but also in staging if done systemati- vaginal and cervical walls (bladder wall infiltration is bet-
cally. It is also helpful in the evaluation of a residual tumour ter noted when the bladder is partially filled with urine).
following treatment. Both MRI and ultrasound, however, • Parametrial infiltration is seen as irregular margins of the
are not adequate for assessing lymph node metastasis. tumour mass with bud-like hypoechoic extensions (inter-
rupting the hyperechoic external visceral fascia surrounding
Ultrasound Features of Cervical Carcinoma (Figs. 5.18, the cervix and vagina) into the surrounding parametrium.
5.19, 5.20, 5.21, 5.22, 5.23, 5.24, 5.25 and 5.26) This can be assessed well on the transverse and coronal sec-
(Please refer to ‘Tips to Improve Ultrasound Diagnosis of tions of the uterus. The distance of the parametrial infiltra-
Cervical Lesions’ given earlier in the chapter.) tion from the external iliac vessels will give us an idea as to
• These lesions appear as solid masses in the cervix. whether the mass is extending up to the lateral pelvic wall.
Squamous cell carcinomas are more likely to appear • Extension of the tumour onto the vaginal wall should also
hypoechoic, whereas adenocarcinomas are more often be assessed, as it alters the staging of the lesion.
isoechoic. Larger lesions that have undergone some • Some patients may show turbid collection in the endome-
necrosis appear more heterogeneous. trial cavity due to obstruction of the cervical canal by the
• Their margins may be difficult to delineate on greyscale tumour. In postmenopausal women with a turbid collection
(particularly the isoechoic lesions). On pushing the cervix in the endometrial cavity (though often a common finding
with a TVS probe to assess firmness/elasticity, the in women with no pathology), one must carefully evaluate
malignant tissue appears firm and noncompressible, the cervix for any subtle malignancy.
178 5 Ultrasound Evaluation of the Cervix

• Kidneys should be evaluated for any evidence of hydrone- In the author’s view, gel sonovaginography is an ideal
phrosis, which could be a complication of cervical cancer. technique which helps to delineate the exophytic lesion
• Lymph node assessment should be attempted by tracing the very well, and also the vaginal extensions of the tumour,
external iliac vessels from the inguinal area onto the pelvis by partially filling and distending the upper vagina. The
up to the aortic bifurcation on a transabdominal scan. assessment of the entire tumour (in the cervix, vagina,
parametrium) on greyscale and Doppler is also much bet-
Instead of a regular transvaginal scan, a transrectal scan can ter on GSV because the gel creates a stand-off resulting in
also be done which has the advantage of a lower probability of better resolution. GSV is not resorted to if the patient is
bleeding from the lesion on contact with the vaginal probe. bleeding actively.

a b LS

Fig. 5.18 Hypoechoic mass seen in the cervix and upper vagina. (a) Mass measured in all three dimensions. (b) Increased flow noted within the
mass. HPE: squamous cell carcinoma
5.5 Cervical Carcinoma 179

a TS LS b TS LS

c TS LS d TS LS

vagina vagina vagina vagina

e LS

BL BL
vagina vagina

Fig. 5.19 58-year-old lady referred with a neoplastic mass in the vagina. (a) Hypoechoic slightly heterogeneous mass seen in upper vagina. (b)
Increased vascularity noted in the mass. (c–e) On GSV, vaginal walls are seen apart with a clear delineation of the tumour margins, the lower cervix
and the external os. In (d), the vascularity helps assess the extension of tumour into the cervical lips around the external os (arrow). This makes
primarily a cervical cancer (and not vaginal). (e) On careful observation, the irregularity of the white external fascia of the posterior vaginal wall
on greyscale and Doppler suggests early paravaginal extension (arrows). HPE: squamous cell carcinoma
180 5 Ultrasound Evaluation of the Cervix

a Coronal b Coronal

c d
Coronal

e LS f LS

Fig. 5.20 A case of squamous cell carcinoma. (a) Coronal section of the cervix on regular TVS showing hypoechoic mass involving cervix and extend-
ing into the right and left parametrium (RT and LT). Vaginal walls are difficult to identify. (b, c) GSV – coronal section showing extension of tumour
from the cervix onto the vagina and parametrium on greyscale and Doppler. Maximum dimension of tumour measured. (d) Diagrammatic representation
of the tumour in the coronal section. The tumour was almost reaching the iliac vessels along the left pelvic wall. (e) Sagittal section of the vagina and
cervix on regular TVS showing the cervical tumour. (f, g) GSV – sagittal section showing tumour spreading to the adjoining anterior vagina (long
arrows) on greyscale and Doppler. The short arrows show a normal posterior vaginal wall. (h) Diagrammatic representation of the tumour in sagittal
section. (i, j) Sagittal and coronal sections of the tumour showing irregularity of the white external fascia of the cervix due to bud-like extensions
(arrows) of the tumour into the posterior and left parametrium. (k) Normal right kidney. Left kidney shows hydronephrosis suggestive of left ureteric
involvement
5.5 Cervical Carcinoma 181

i j
LS TS

k RK LK

Fig. 5.20 (continued)

182 5 Ultrasound Evaluation of the Cervix

a LS b LS

c LS d TS LS
TS

e LS f

Fig. 5.21 42-year-old lady with a history of white discharge since 2 years and post-coital bleeding since 5 months. (a) On greyscale, the posterior
wall of the cervix appeared thick and bulky. (b) Increased flow is seen in this bulky posterior wall on Doppler. (c) Isoechoic mass measured on 2D
greyscale. (d) High vascularity (colour score of 4), seen in the mass, raises a high suspicion of malignancy. (e) 3D glass rendered image with power
Doppler shows the abnormal vascular pattern (irregular calibre, looping and abnormal branching) which is seen in malignant masses. With rotation
and cine loop, this is even better perceived. The cervical canal is seen (small arrows), and the tumour is seen to be endophytic. (f) Flow in the
tumour shows a low RI of 0.29. In some other vessels of the same mass, the RI was higher (up to 0.67). (g, h) Iliac vessels should be traced in all
cases of carcinoma of the cervix to look for metastatic iliac lymph nodes. Here, none were seen. HPE: endocervical adenocarcinoma
5.5 Cervical Carcinoma 183

g TS - RT h LS - RT

Fig. 5.21 (continued)

a LS b LS

c TS
LS

Fig. 5.22 Squamous cell carcinoma extending into the lower uterine corpus. (a) Greyscale image showing a bulky, heterogeneous cervix with the
margins of the tumour difficult to delineate. (b) Suspicious area that was seen on greyscale shows increased flow on Doppler. (c) Heterogeneous
cervix with the tumour margins and cervical canal not well delineated. Doppler helped identify the neoplastic tissue
184 5 Ultrasound Evaluation of the Cervix

LS

Fig. 5.23 Early squamous cell carcinoma of the cervix (oval outline).
Anterior cervical wall is bulky with increased vascularity in a focal area

a b
TS LS TS

c d

Fig. 5.24 Case of squamous cell carcinoma of cervix Stage III. Scan was done to assess tumour size after six doses of RT. (a) Small hypoechoic
lesion is seen in the anterior lip of the cervix. (b) Cervical canal (long arrow) seen. Flow seen in tumour mass (short arrows). (c) Extent of the
mass is seen better with Doppler. (d) Normal kidneys, with no evidence of hydronephrosis
5.5 Cervical Carcinoma 185

LS

Fig. 5.25 3D HD Doppler with glass body display, showing abnormal

morphology of tumour vessels in a case of carcinoma cervix

Summary: Cervical Carcinoma Fig. 5.26 Intrauterine turbid collection seen in a case of carcinoma
• This is a malignancy commonly seen in many cervix
developing countries. Typical symptoms are post-
coital bleeding, intermenstrual bleeding and vaginal
discharge.
• Ultrasound is useful in detecting the presence of
tumour, assessing the spread and evaluating the
residual tumour after treatment. Though FIGO stag-
ing is clinical and MRI is the most common modal-
ity used to assess spread, ultrasound, in many recent
articles, has been found to be as effective as MRI in
staging.
• On ultrasound, these appear as solid isoechoic or
hypoechoic lesions that show high vascularity.
Their size, distance from internal os and spread to
adjoining structures, including the parametrium,
can be assessed on regular TVS or transrectal ultra-
sound. GSV, in the author’s opinion, is also a great
technique to assess the tumour and its spread.
186 5 Ultrasound Evaluation of the Cervix

Suggested Reading Gaurilcikas A et al (2011) Early-stage cervical cancer: agreement

between ultrasound and histopathological findings with regard to
tumor size and extent of local disease. Ultrasound Obstet Gynecol
Belitsos P et al (2012) Three-dimensional power Doppler ultrasound
38:707–715. doi:10.1002/uog.9037
for the study of cervical cancer and precancerous lesions. Ultrasound
Sibal M (2016) Gel Sonovaginography: A New Way of Evaluating a
Obstet Gynecol 40:576–581. doi:10.1002/uog.11134
Variety of Local Vaginal and Cervical Disorders. J Ultrasound Med
Chiappa V et al (2015) Agreement of two-dimensional and three-
35(12):2699–2715
dimensional transvaginal ultrasound with magnetic resonance
Testa AC et al (2009) Dynamic and interactive gynecological ultra-
imaging in assessment of parametrial infiltration in cervical cancer.
sound examination. Ultrasound Obstet Gynecol 34:225–229.
Ultrasound Obstet Gynecol 45:459–469. doi:10.1002/uog.14637
doi:10.1002/uog.7309
Epstein E et al (2010) Sonographic characteristics of squamous cell
Wildenberg JC et al (2016) US of the nongravid cervix with multimo-
cancer and adenocarcinoma of the uterine cervix. Ultrasound Obstet
dality imaging correlation: normal appearance, pathologic condi-
Gynecol 36:512–516. doi:10.1002/uog.7638
tions, and diagnostic pitfalls. RadioGraphics 36(2):596–617
Fischerova D (2011) Ultrasound scanning of the pelvis and abdomen
for staging of gynecological tumors: a review. Ultrasound Obstet
Gynecol 38:246–266. doi:10.1002/uog.10054
 Ultrasound Evaluation of the Vagina
6

The vagina is a structure that is generally overlooked during proximity to the urethra and the base of the bladder. The
the ultrasound imaging of the female pelvis done for the space between the hyperechoic outer margin of the vagina
detection of gynecological disease. and the rectum is called the rectovaginal space, while that
On a transabdominal ultrasound (TS) in the midsagittal between the outer margin of the vagina and the bladder is
plane, the normal vagina is seen below the uterus as a called the vesicovaginal space. Both of these spaces are com-
hypoechoic elongated structure with a central bright linear prised of areolar tissue.
echo (which represents the collapsed vaginal lumen between The common vaginal pathologies encountered are con-
opposing vaginal walls). On TAS, only the upper half of the genital vaginal anomalies, vaginal cysts, vaginal masses and
vagina can be seen, as the lower part is obscured by shadow- deep infiltrating endometriosis.
ing from the pubic symphysis.
On a transvaginal scan, evaluating the vagina is possible,
though often considered suboptimal because of the proxim- 6.1 Normal Vagina (Fig. 6.1)
ity of the vagina to the probe and the collapsed nature of the
vaginal walls. MRI has therefore been commonly used in the The vagina is a collapsed fibromuscular tubular sheath
diagnostic evaluation of the vagina. Transrectal examination extending from the vulva to the uterus with the cervix project-
may help when TVS is not possible or there is local bleeding. ing into its upper end. The average length of the vagina is
Gel sonovaginography (GSV) has been used by the author generally 7–9 cm, with the posterior wall being longer than
for evaluating suspected or known vaginal pathology as it the anterior wall. The vaginal fornices are the upper part of
provides better resolution and spatial orientation. the vagina, and based on their relation to the cervix, they are
For ultrasound (TVS) evaluation, it is important that the arbitrarily divided into the anterior, the posterior and the two
probe, once introduced into the vagina, is gradually moved lateral fornices. The vaginal wall is made up of three layers –
upwards, while simultaneously evaluating the anterior and the inner mucosa (stratified squamous epithelium), the mus-
posterior vaginal walls. The vagina is limited on its outer cularis (connective tissue and smooth muscle fibres) and the
surface by the hyperechoic visceral facia. The posterior vagi- adventitia (endopelvic visceral fascia surrounding the vagina).
nal wall is in close proximity to the anterior muscularis of the A small amount of urine within the vaginal lumen in girls of
anus and rectum, and the anterior vaginal wall is in close the paediatric age group could be a normal finding.

© Springer Nature Singapore Pte Ltd. 2017 187

M. Sibal, Ultrasound in Gynecology, DOI 10.1007/978-981-10-2714-7_6
188 6 Ultrasound Evaluation of the Vagina

a LS

Bladder

b LS
c LS

Bladder
Bladder

Fig. 6.1 Normal vagina (a) TAS – the lumen of the upper vagina is seen as a hyperechoic line (arrow) extending down from the lower end of the
cervix. The lower vagina cannot be seen due to shadowing by the pubic bones. (b) TVS – the vagina is not clearly visualised because of its
collapsed lumen (arrow showing the lumen of the distal vagina). (c) GSV – corresponding to the image in (b). Here the vaginal walls are seen apart
because of the intervening gel (arrow), which facilitates optimal visualisation of the vaginal walls and its lumen
6.3 Vaginal Cysts 189

6.2 Congenital Vaginal Anomalies where along the lateral aspect of the vagina. The location
of the cyst can be found out by observing their relation-
The upper two-third of the vagina develops from paired ship to the TVS probe. As the probe is gradually moved
Mullerian ducts (from which the uterus and cervix also upwards, the cyst slides to one side of the probe which
develop), and the lower one-third develops from paired sino- lets us know on which side of the vaginal wall the cyst is
vaginal bulbs. The paired Mullerian and sinovaginal compo- located.
nents are solid to begin with. Later, they get canalised. They • They are seen as unilocular well-defined cysts, varying in
fuse together with that of the contralateral side to form a com- size from 1 to 7 cm, with an average of about 2 cm.
mon canal. In addition, the Mullerian and sinovaginal compo- • Their contents may be anechoic but may appear
nents also fuse together to form a single common vagina. A hypoechoic when they have turbid contents.
persistent transverse septum can result from incomplete • They are non-tender.
canalisation at various levels of the vagina. If the lateral • If infected, they may show turbid contents with thick and
fusion or resorption of the paired Mullerian ducts is abnor- vascular walls.
mal, a longitudinal septum will result (which is common in
association with anomalies of the uterus and cervix like a sep-
tate uterus or a bicornuate uterus). Longitudinal and trans- 6.3.2 Bartholin Gland Cysts
verse vaginal septa are dealt with in the chapter on ‘Uterine
Anomalies’. Bartholin glands are mucin-secreting glands that could
Imperforate hymen is a common congenital abnormality develop into retention cysts because of the obstruction of
of the female genital tract with a prevalence of about 0.1 %. their duct, by trauma or infection. These are usually asymp-
This has also been dealt with in the chapter on ‘Uterine tomatic but may get infected and undergo abscess formation,
Anomalies’ (Chapter 12). at which time they may be very painful and tender. The
patient may complain of a mass at the introitus. The treat-
ment of Bartholin gland cysts appears simple but recurrence
6.3 Vaginal Cysts (Figs. 6.2, 6.3, 6.4, 6.5, is known. These cysts can rarely be malignant.
6.6, 6.7)
Ultrasound Features of Bartholin Gland Cysts (Figs. 6.4
Vaginal cysts are most often incidental findings seen on ultra- and 6.5)
sound or MRI. Common vaginal cysts are Gartner duct cysts, • These cysts are seen located posterolateral to the vaginal
Mullerian cysts and Bartholin gland cysts. Periurethral cysts introitus (medial to labia minora).
(like Skene gland cysts) may also be seen adjoining the vagi- • They are seen as unilocular well-defined cysts, usually
nal wall. 1–4 cm in size.
Other less common vaginal cysts are endometriotic cysts • Their contents often show internal echoes because of the
(in association with DIE), inclusion cysts (area of previous mucin content or due to infection.
surgery), dermoid cysts, etc. • They are non-tender, unless infected.
• Infected cysts may show thick vascular walls with turbid
contents.
6.3.1 Gartner Duct Cysts and Mullerian Cysts • The presence of solid tissue and septa raises the possibil-
ity of malignancy.
These cysts result from incomplete regression of the Wolffian
(mesonephric) duct or Mullerian (paramesonephric) duct,
respectively. It is not possible to differentiate these on ultra- 6.3.3 Skene Gland Cysts
sound, and clinically their distinction is of little importance.
They are usually asymptomatic unless they are infected, at Skene glands are paired glands that lie close to the external
which time they could cause pain and discomfort. urethral meatus with their ducts draining into the urethra. Cysts
of the Skene gland may develop due to obstruction of their
Ultrasound Features of Gartner Duct Cysts and ducts by infection. They are usually asymptomatic but if they
Mullerian Cysts (Figs. 6.2 and 6.3) get infected, can cause pain, dysuria, dyspareunia or discharge.
• These cysts are typically seen along the anterolateral These paraurethral cysts can be differentiated from urethral
wall of the upper vagina, but they may be present any- diverticulae (that are seen higher up) by their position low
190 6 Ultrasound Evaluation of the Vagina

down, close to the urethral meatus and by the fact that on com- • They are seen as unilocular cysts with smooth margins.
pressing the Skene’s cyst, there is no extravasation of fluid. • Their contents are usually anechoic but may show inter-
nal echoes, if infected.
Ultrasound Features of Skene Gland Cysts (Fig. 6.6) • They are non-tender, unless infected.
• These cysts are seen just anterior to the lower vagina, on • They are thick walled and vascular, if infected.
either side of the external urethral meatus.

Fig. 6.2 Vaginal cyst. (a) A large anechoic cyst is a LS TS

seen in the anterolateral vaginal wall. (b) Normal
cervix and vagina is seen below the cyst. The lower
end of the cyst was some distance away from the
introitus. This could either be a Gartner duct cyst or a
Mullerian cyst

b LS
6.3 Vaginal Cysts 191

Fig. 6.3 Vaginal cyst. Unilocular turbid cyst in the

TS LS
anterolateral wall of the upper vagina. This could
either be a Gartner duct cyst or a Mullerian cyst

Bladder

Fig. 6.4 Bartholin gland cyst. A

well-defined circumscribed mass
TS LS
seen just above and posterolateral
to the vaginal introitus with
turbid contents. It did not show
any significant flow on Doppler
and was not tender
192 6 Ultrasound Evaluation of the Vagina

a b

TS LS

Fig. 6.5 Bartholin gland cyst. (a) Hyperechoic scattered foci within. (b) No significant flow is seen on Doppler in the cyst walls

a
TS LS

b c
TS

Fig. 6.6 Infected Skene gland cyst. Patient presented with burning micturition and was found to have a small anterior vaginal wall cyst. (a) Cyst
shows turbid contents. (b) Minimal vascularity noted in the cyst walls. (c) It was a left-sided paraurethral cyst. In this image, shadowing (arrow)
from a urethral catheter in situ is noted. There was no intervening tissue between the urethra and the cyst. The cyst was not communicating with
the urethra
6.3 Vaginal Cysts 193

a
TS LS

b c

Fig. 6.7 Endometriotic cyst of the vaginal wall. Patient presented with a vaginal mass, intermittent pain and a few episodes of spontaneous dis-
charge from the cyst. During gynecological examination, thick chocolate-coloured fluid was seen draining out the cyst suggestive of endometriotic
fluid. (a) Cyst showing turbid contents and thick walls. (b) Cyst is seen in the anterior wall, just behind the bladder and more to the right. (c) Cyst
walls showing moderate vascularity (RI 0.76)

Summary of Vaginal Cysts

• Vaginal cysts can be of varied aetiology. They are
most often asymptomatic except if secondarily
infected. Very rarely are they malignant.
• Gartner duct cysts (remnants of mesonephric ducts)
and Mullerian cysts (remnants of paramesonephric
ducts) are common cysts seen along the anterolat-
eral part of the upper vagina but may be seen any-
where along the lateral wall of the vagina.
• Bartholin gland cysts are seen in the posterolateral
wall of the vagina, close to the vaginal introitus.
• Skene gland cysts are paraurethral cysts seen along
the anterior wall of the lower vagina.
• On ultrasound, these cysts appear as well-defined
unilocular cysts with anechoic or hypoechoic con-
tents. If infected, they show thick vascular walls
with turbid contents.
194 6 Ultrasound Evaluation of the Vagina

6.4 Vaginal Masses and Vaginal Cancer small and was hidden by the blades of the speculum on a prior
clinical examination.
Vaginal masses are not commonly encountered, especially in
isolation. Fibroids (leiomyomas) of the vagina are rare. It is Ultrasound Features of Vaginal Carcinoma (Figs. 6.10,
more common to find a fibroid in the vaginal lumen which is 6.11, 6.12)
protruding out of the cervical canal (fibroid polyp – Fig. 6.8) Evaluation can be done with regular TVS, transrectal scan
or arising from the cervix and distending the vagina. (especially if there is bleeding or vaginal stenosis) or GSV:
Occasionally, a benign vaginal polypoid mass may be seen
(Fig. 6.9). • They are more common in the upper one-third of the
Malignant masses of the vagina can be both primary and vagina and least in the middle one-third. It is important to
metastatic. Metastatic carcinomas are much more common examine the cervix because the tumour may be an exten-
(constituting about 80 % of vaginal malignancies) than pri- sion from a primary cervical tumour and may not be a
mary. Spread may occur from contiguous cancers like that of primary vaginal carcinoma.
the cervix, vulva or from distant sites through the lymphatic • They are typically hypoechoic, solid tumour masses.
system or the bloodstream or haematogenous spread. Larger ones may appear heterogeneous if there is necrosis
within.
Primary Vaginal Carcinoma • They show increased vascularity (colour score 3 or 4)
Primary vaginal carcinomas are rare (1–2 % of all gyneco- with vessels most often appearing to arise perpendicularly
logical cancers) and are most often squamous cell carcino- from the vaginal walls. In large masses, the vascular mor-
mas. Other carcinomas are clear cell carcinoma (seen in phology is abnormal (as in other malignancies), which is
very young women, often in their teens, associated with best assessed with 3D power Doppler and glass body
intrauterine exposure to DES), melanoma, sarcoma botryoi- display.
des (in children of the paediatric age group) and • Their extension into the paravaginal tissue, bladder or
leiomyosarcoma. rectum can be assessed on ultrasound and should be done
Vaginal carcinoma (squamous cell) is mostly seen in post- in the sagittal and transverse planes. The tumour is seen as
menopausal women, but many have also been reported in a hypoechoic irregular vascular extension penetrating the
very young women. Painless vaginal bleeding, often inter- external vaginal hyperechoic visceral fascia. The sliding
menstrual or post-coital, is the commonest symptom. Vaginal sign of the bladder and rectum along the outer walls of the
discharge and pelvic pain are also common symptoms. If the cervix and vagina, on pressure with the TVS probe, may
tumour has spread to the surrounding bladder or bowel, the be absent if there is involvement of the adjoining bladder
patient may complain of dysuria, haematuria, urgency, pain- or bowel wall.
ful defecation and constipation. • On regular TVS, their outline and area of spread are dif-
Most cases are picked up on clinical per-speculum examina- ficult to assess as the vagina is a collapsed structure. On
tion or colposcopy following a positive PAP smear test. GSV, however, the extent of spread along the walls, the
Diagnosis is made on biopsy of the lesion, and staging is done extravaginal extension and the vascular pattern can be
with CT or MRI, though not a FIGO recommendation. Today better assessed.
one can do a good assessment on ultrasound which, though not • A vaginal cancer lesion that involves the cervix (consid-
an established recommendation, is a simple initial assessment ered so, if the lesion extends up to the external os) or
modality. It may also be accidentally picked up on an ultra- vulva is considered to be a primary cervical or vulval
sound done for abnormal bleeding, especially if the lesion is cancer.
6.4 Vaginal Masses and Vaginal Cancer 195

Fig. 6.8 Fibroid polyp (F) seen

in the upper vagina protruding
out of cervical os (cervical lips LS TS
marked with arrows)

F
F

a b

c d

Fig. 6.9 Benign polypoidal mass in the vagina. Patient had undergone a vaginal hysterectomy for cervical dysplasia some years ago. On a routine
check, the patient was found to have a polyp on the left side of the vaginal vault. (a) Polyp is not visualised on regular TVS. (b) On GSV a small
vaginal polyp is seen, which is measured in the image. The polyp shows acoustic shadowing. (c) A small feeder vessel is seen extending from the
vaginal vault into the polyp. No supravaginal extension of the lesion is noted. (d) 3D rendered image showing a small circumscribed smooth-
walled polyp. Features suggested a benign lesion and the patient was managed conservatively with follow-up
196 6 Ultrasound Evaluation of the Vagina

a
TS LS

b c

Fig. 6.10 Vaginal vault metastasis. Patient had undergone panhysterectomy for an endometrial carcinoma the previous year. Clinical examination
showed a polypoid growth in the vagina. (a) A solid heterogeneous mass was seen at the vaginal vault. (b) Irregular margins of the mass are seen.
(c) The mass showed flow within on Doppler. HPE: metastatic endometrioid adenocarcinoma
6.4 Vaginal Masses and Vaginal Cancer 197

Fig. 6.11 Malignant mass

involving the cervix and upper a LS TS
vagina. (a) A hypoechoic, solid,
heterogeneous mass is seen in the
upper vagina. The mass was
extending into the cervix, up to
the external os (arrow), because
of which this mass is not
considered to be a vaginal cancer
but a case of cancer of the cervix.
(b) Mass showing moderate
vascularity

b TS LS

Bladder
198 6 Ultrasound Evaluation of the Vagina

Fig. 6.12 Primary vaginal carcinoma.

Hysterectomy was done 18 years ago for
a
menorrhagia. Patient presented with bleeding.
(a–c) Regular TVS. (a) Showing hypoechoic
mass in the upper vagina, (b, c) 2D and 3D
images showing a hypoechoic narrow extension
(arrows) onto the right side, raising a suspicion
of right paravaginal infiltration. (d–f) GSV –
mass seen involving the left side of the vagina.
The right extension seen earlier on regular TVS
was found to be the normal collapsed vagina on
the right side, which, on being filled up with
vaginal gel, displayed the normal vaginal walls.
Supravaginal extension of the mass is seen on
greyscale and on Doppler (arrows) in (e) and (f)

b c

e f
6.5 Other Vaginal Pathologies 199

6.5 Other Vaginal Pathologies

Summary: Vaginal Carcinoma
• Vaginal carcinoma is rare. Most vaginal carcinomas
are metastatic spreads from the adjoining cervix or 6.5.1 Vaginal DIE
vulva or from distant sites through the bloodstream
or the lymphatic channels. This is usually seen in association with endometriosis else-
• On ultrasound, they are typically seen as hypoechoic, where in the pelvis. Vaginal DIE is most often continuous
solid, vascular masses which appear heterogeneous with rectal DIE when it is termed rectovaginal DIE. Associated
if there is necrosis within. Extension into neigh- cervical and uterosacral DIE may also be seen. This is dis-
bouring bladder, rectum or paravaginal tissue cussed in detail in the chapter on endometriosis (Chapter 8).
should be assessed.
• A vaginal cancer that involves the cervix (once the
external os is involved) is considered to be a pri- 6.5.2 Foreign Body in the Vagina (Fig. 6.13)
mary cervical cancer, and one which involves the
vulva is considered to be a primary vulval cancer. These could be retained tampons, pessaries, surgical gauze,
• GSV provides better evaluation of the mass. A tran- etc. Most often, foreign bodies in the vagina can be visual-
srectal scan may be preferred to a TVS in masses ised on a per-speculum examination without the need for an
that bleed on touch. ultrasound. However, in cases where a speculum examina-
tion is not feasible, as in young girls or women who have had
recent surgery, ultrasound may be helpful in diagnosis.
Occasionally, it could be an incidental finding (e.g. a forgot-
ten pessary).

a b
LS TS

Fig. 6.13 Vaginal pack that was placed in the vaginal vault for bleeding, two and a half weeks after hysterectomy. Scan was done to rule out any
intra-abdominal bleed. On scan, no evidence of intra-abdominal bleed was noted. The vaginal pack (arrows) is seen on (a) LS and (b) TS as a
hyperechoic linear area with significant acoustic shadowing
200 6 Ultrasound Evaluation of the Vagina

6.6 Vulval Carcinoma (Fig. 6.14) monly forms as a lump or a sore on the vulva that often
causes itching. Though it can occur at any age, vulvar cancer
Vulvar cancer is cancer that occurs on the outer surface area is most commonly seen in older women. Patients may pres-
of the female genitalia. The vulva is the area of the skin that ent with a lump, local itching, discolouration of skin or a
surrounds the urethra and the vagina. Vulvar cancer com- growth at the vulva.

TS LS

b c

Fig. 6.14 Vulval carcinoma. (a) A circumscribed, solid, heterogeneous mass is seen. It shows an irregular, central, cystic area suggestive of necro-
sis. (b) The mass shows high vascularity (colour score of 4). (c) 3D Doppler with glass body display shows abnormal vascular morphology of the
mass
Suggested Reading 201

Suggested Reading Walker DK et al (2011) Overlooked diseases of the vagina: a directed

anatomic-pathologic approach for imaging assessment.
Radiographics 31:1583–1598
Fischerova D (2011) Ultrasound scanning of the pelvis and abdomen
Wang X et al (2014) Transvaginal sonographic features of perineal masses
for staging of gynecological tumors: a review. Ultrasound Obstet
in the female lower urogenital tract: a retrospective study of 71 patients.
Gynecol 38:246–266. doi:10.1002/uog.10054
Ultrasound Obstet Gynecol 43:702–710. doi:10.1002/uog.13251
Sibal M (2016) Gel Sonovaginography: A New Way of Evaluating a
Variety of Local Vaginal and Cervical Disorders. J Ultrasound Med
35(12):2699–2715
 Ultrasound Evaluation of Ovaries
7

Ovaries are bilateral ovoid masses on either side of the uterus assessing developing follicles and corpus luteum are given
that have a dual function of producing hormones and ova. in the section on follicular tracking in Chap. 13. The ova-
Each ovary is anchored in the pelvis by the mesovarium to ries are measured in all cases. Their mobility is also
the posterior surface of the broad ligament, by the utero- assessed by applying pressure with the TVS probe.
ovarian ligament to the uterus and by the suspensory liga- Normally the ovaries are mobile structures and slide along
ment to the lateral pelvic wall. These ligamentous structures or can be made to move away from the uterus and lateral
are lax and not rigid, and consequently the position of the pelvic wall. However, they could be adherent to the uterus
ovaries varies in different patients and in the same patient at or the lateral pelvic wall in the presence of pathological
different times. conditions like endometriosis.
• If there is an ovarian mass, then the ovary is evaluated
further in detail as given below, primarily based on IOTA
7.1 Evaluation of Ovaries and Persistent recommendations.
Adnexal Masses
Morphological Description (Figs. 7.2, 7.3, 7.4, 7.5, 7.6,
7.1.1 Morphology, Measurement 7.7, 7.8 and 7.9)
and Doppler Evaluation of the Ovary
and Ovarian Masses (Including • Crescent sign (Fig. 7.2): An ovarian mass may show ovarian
Persistent Adnexal Masses) tissue adjoining and stretched around it, called the ‘crescent
sign’, which helps in determining its ovarian origin. In large
• The ovaries (Fig. 7.1) are identified in the reproductive age masses, the ovarian tissue may be completely compressed,
group by the presence of follicles. They are typically such that no ovarian tissue is identifiable around it.
located just medial to the external iliac vessels and anterior • Solid component (Fig. 7.3): The presence of a solid tissue
to the internal iliac vessels. Therefore, on a transverse sec- increases the likelihood of malignancy. Doppler flow helps
tion, the external iliac vessels lie lateral to it, and on a lon- to confirm the presence of solid tissue. The solid tissue may
gitudinal section, the internal iliac vessels lie posterior to it. be present along the margins of the mass or may be present
Most often, the ovaries are easy to locate on either side of within the mass. Some ovarian masses may be completely
the uterus, but at times this can be challenging. This is more solid. The presence of a papillary projection (as described
likely in postmenopausal women with atrophic (small in later) is also considered a solid component of a cyst. The
size and without follicles) ovaries. The ovaries can usually absence of solid tissue in a mass (i.e. a completely cystic
be located on ultrasound by angulating the probe from a TS mass) increases the likelihood of it being benign.
view of the uterus along the hypoechoic utero-ovarian liga- • Papilla (Fig. 7.4): Any solid projection into the cavity from
ment from one cornu to the lateral pelvic wall. Another the cyst wall, with a height of at least 3 mm (from the inner
method to locate the ovary is to trace along the external margin of the cyst), is considered a papilla. The presence of
iliac vessels in a transverse section of the pelvis. The nor- a papilla increases the likelihood of malignancy.
mal ovary in a woman of reproductive age group shows a Any solid projection of less than 3 mm is considered an
few antral follicles. Antral follicles are seen as small irregularity in the cyst wall. If the maximum diameter of
anechoic cysts in the ovary, 2–9 mm in diameter. A devel- the largest solid component or papilla is less than 7 mm,
oping follicle or corpus luteum (CL) may also be seen, then there is a high probability that the mass is a benign
depending on the phase of the menstrual cycle. Details of cystadenofibroma.

© Springer Nature Singapore Pte Ltd. 2017 203

M. Sibal, Ultrasound in Gynecology, DOI 10.1007/978-981-10-2714-7_7
204 7 Ultrasound Evaluation of Ovaries

• Septum and a number of locules (Figs. 7.5 and 7.6): A second, from the same reference point in the second
septum is a strand of tissue originating from one wall of image to the other opposite margin of the mass. The final
the cyst to the other. The correct way to measure the sep- length is the sum of these two measurements. A large cyst
tum is when it is perpendicular to the ultrasound beam. can also be measured using the panoramic imaging mode,
Septae of less than 3 mm are more commonly seen in available in some ultrasound machines.
benign cysts, whereas septae which are more than 3 mm – Septum (Fig. 7.5) – The septum is measured where it
and irregular are more commonly associated with malig- appears to be the thickest (not close to its attachment to
nant masses. the internal cyst wall). It is preferable to measure a
In the absence of septum, a cyst is considered unilocular. septum with the ultrasound beam perpendicular to it.
A cyst with one or more septae is considered multilocular. – Papilla – The largest projection is measured in three
The locules may vary from 2 to as many as 100. An dimensions, in two perpendicular planes (height, base
incomplete septum as seen in a hydrosalpinx is not con- and base). The number of separate papillary projec-
sidered a true septum, and the cystic mass is still consid- tions should also be noted. When in doubt about the
ered unilocular. number of papillae, particularly when they appear to
Unilocular cysts are more likely to be benign. merge with one another, it is recommended that the
• Walls of the mass (Fig. 7.7): The more irregular the inner worst-case scenario should be applied. For example, if
walls of a cystic mass or the external walls of a solid there is a doubt of 3–5 papillae, it is better to consider
mass, the more likely it is to be malignant. it as 5 papillae.
• Contents of a cyst (Fig. 7.8): The contents of a cyst are not – The number of locules in the tumour is also assessed (1
useful in assessing the likelihood of malignancy. However, to 10 and more than 10).
it is often useful in the characterisation of the mass into – The largest solid component should be measured in
various histopathologies. The cyst may be anechoic, show three orthogonal diameters in two perpendicular
low-grade internal echoes, be hypoechoic with a ground planes. This applies to papillary projections also, if it is
glass appearance or show mixed echoes with hypoechoic the largest solid component.
and hyperechoic contents. The cystic contents may show – Fluid in POD – It is measured in a sagittal section of
fluid–fluid level. the uterus, and the largest AP measurement is noted in
• Acoustic shadowing (Fig. 7.9): Loss of echoes beyond a millimetres.
sound-absorbing structure is called acoustic shadowing. It
is seen typically in dermoids, fibromas and behind the Doppler Study (Figs. 7.12 and 7.13)
papillae of a cystadenofibroma. The presence of acoustic • Doppler study of the ovarian mass: The entire tumour
shadowing increases the likelihood of the mass being should be examined by Doppler imaging. Flow may be
benign significantly. seen in the walls, septae, solid areas and papillae. Flow
within solid areas and papillae is, however, more often
Measurements (Figs. 7.10 and 7.11) associated with malignancy. For Doppler flow assess-
• Lesions and ovaries – The size of both the ovaries and any ment, settings must be optimised. Generally, the PRF
lesion should be measured in three perpendicular dimen- should be set at 0.3 for colour Doppler and 0.6 for power
sions (x, y and z) in two perpendicular planes and given in Doppler (in some machines, this is equivalent to velocity
millimetres (as explained in Chap. 2). From this, the vol- scale of 3–6 cm/sec). Thereafter, the Doppler gain should
ume of the mass can be calculated by the formula be increased until artefacts appear, following which gain
‘x × y × z × 0.523’. should be gradually reduced to when the artefacts just dis-
At times, the cyst is very large and its entire margins can- appear. Ultrasound frequency should be at least 5.0 MHz
not be visualised in a single screen. One can increase the and wall filter should be between 30–50 Hz. It is useful to
sector angle and depth. However, with very large masses, have preadjusted Doppler settings for gynecological
even this may not suffice. In such cases, in order to scans to save time and for appropriate evaluation.
approximately measure these masses (particularly the – Colour index (Fig. 7.12): The most accepted method of
length of the mass per abdomen which may be difficult), assessing Doppler flows is colour scoring, a subjective
one can resort to a dual image on screen, so that one mar- semi-quantitative evaluation where scores are given
gin of the mass to beyond the centre of the mass is cap- from 1 to 4:
tured in the image on one half of the screen and the 1 – no flow
opposite margin to beyond the centre of the mass is cap- 2 – minimal flow (few colour spots)
tured in the image on the other half of the screen. The 3 – moderate flow
length of the mass is measured in two parts. One measure- 4 – abundant flow
ment is taken from one margin to some common refer- The absence of flow (colour score 1) increases the like-
ence point closer to the centre in one image and the lihood of the mass being benign. Colour score of
7.1 Evaluation of Ovaries and Persistent Adnexal Masses 205

3–4 increases the likelihood for malignancy but benign and malignant masses with low RI seen in only
may also be seen in benign adnexal masses, infec- 25 % of malignant lesions. This is, therefore, less helpful
tions, corpus luteum and trophoblastic tissue. in diagnosis.
Flow indices (Fig. 7.13): When several samples are taken, – Colour distribution: The location of flow may also
the set of results with the highest peak systolic velocity help in assessing the possibility of malignancy.
(PSV) and the corresponding values of PI and RI are Malignant masses are more likely to have central
selected. Malignant masses generally show flow with flow, while in benign ones, flow is more likely to be
low resistance, i.e. an RI of less than 0.4 and PI of less peripheral. However, there is a significant overlap
than 1.0. However, a significant overlap is seen between noted.

a TS b TS c LS

CL

Fig. 7.1 Normal ovaries. (a) Ovary with a developing follicle. External iliac vessels (arrow) are seen just lateral to the ovary. (b) The ovary shows
a corpus luteum. External iliac vessels (arrow) are seen lateral to the ovary. (c) The ovary shows antral follicles (arrows)

Fig. 7.2 Crescent sign – crescent-shaped ovarian tissue seen adjacent

to the ovarian cyst (arrow), which is stretched around the cyst as if it
were hugging the cyst
206 7 Ultrasound Evaluation of Ovaries

a b

c d

Fig. 7.3 (a) No solid component. (b) Completely solid mass. (c) Solid area (arrow) along the outer margins of the mass. (d) Solid area (arrow)
within a predominantly cystic mass
7.1 Evaluation of Ovaries and Persistent Adnexal Masses 207

a b

c d

Fig. 7.4 (a) No papilla seen. (b) Single papilla seen with height of papilla measured in the image. (c) Multiple irregular papillae seen along the
septae. (d) Maximum diameter of papilla is less than 7 mm in this case of a cystadenofibroma
208 7 Ultrasound Evaluation of Ovaries

a b

Fig. 7.5 (a) Thin septum (arrow). (b) Thick slightly irregular septum (arrow)

Fig. 7.6 (a) Unilocular cyst. (b) Multilocular cyst a

b
7.1 Evaluation of Ovaries and Persistent Adnexal Masses 209

a b

c d

Fig. 7.7 (a) Solid tumour with regular, smooth, outer margins. (b) Solid tumour with irregular, lobulated, outer margins. (c) Smooth inner walls
of a cystic mass. (d) Irregular inner walls of cystic mass with multiple papillae
210 7 Ultrasound Evaluation of Ovaries

a b

c d

e
TS LS

Fig. 7.8 Contents of a cyst: (a) anechoic, (b) with low-grade internal echoes, (c) hypoechoic, (d) with fluid–fluid level, (e) with mixed echoes
7.1 Evaluation of Ovaries and Persistent Adnexal Masses 211

a c

Fig. 7.9 Acoustic shadowing in (a) dermoid, (b) fibroma, (c) papilla of a serous cystadenoma fibroma. Shadows are outlined in the images

TS LS

Fig. 7.10 Cyst measured in the three largest dimensions in two perpendicular planes. When ovarian tissue is not seen around the cyst, the mea-
surement of both the cyst and the ovary is the same
212 7 Ultrasound Evaluation of Ovaries

Fig. 7.11 Measuring the length

a
of a large cyst. (a) Here the mass LS
is imaged on a split screen as it is
too large to fit in a single screen.
The length of the mass is
measured using a common
reference point (arrows). (b) A
large cyst can also be measured
using the panoramic imaging
mode, available in some
ultrasound machines

b LS
7.1 Evaluation of Ovaries and Persistent Adnexal Masses 213

a b

c d

Fig. 7.12 Colour score: (a) Score 1 – no flow. (b) Score 2 – minimal flow. (c) Score 3 – moderate flow. (d) Score 4 – abundant flow
214 7 Ultrasound Evaluation of Ovaries

a b

Fig. 7.13 Low-resistance flow in (a) malignant mass (fallopian tube carcinoma), (b) benign mass (fibroid)
7.1 Evaluation of Ovaries and Persistent Adnexal Masses 215

7.1.2 Morphological Classification The presence of a solid tissue, as seen in this table,
of Ovarian/Adnexal Masses (Fig. 7.14) increases the likelihood of malignancy significantly. The
more heterogeneous and irregular the solid area, the higher is
As per IOTA recommendations, all adnexal masses are clas- the likelihood of malignancy. Also, central flow in a solid
sified into one of the five types mentioned below, based on area or a papilla increases the likelihood of malignancy.
greyscale imaging. The likelihood of malignancy for each of
these types is also mentioned in the table below.

Timmerman et al. UOG (2008)

Type Malignant (%)
Unilocular (no solid areas or papillae) 1.3
Multilocular (no solid areas or papillae) 10
Unilocular solida 37
Multilocular solida 43
Solidb (80 % or more of the tumour appears solid) 65
‘Solid’ includes the presence of papillae
a

Based on subjective evaluation on 2D greyscale

b
216 7 Ultrasound Evaluation of Ovaries

a b

c d

Fig. 7.14 Morphological classification of ovarian neoplasms: (a) unilocular, (b) multilocular, (c) unilocular solid, (d) multilocular solid, (e) solid
7.2 Normal Ovaries 217

7.2 Normal Ovaries Developing and immature (antral follicles 2–9 mm) can be
seen throughout the entire cycle and appear as unilocular,
Ovaries vary in size and appearance not only based on the anechoic well-defined cysts. In the first half of the menstrual
age of the individual but also through the menstrual cycle cycle, one or more dominant follicles grow to about
due to hormonal influences. 20–25 mm and then rupture spontaneously at ovulation.
After ovulation, it becomes the corpus luteum (CL) and
Neonatal Ovaries (Fig. 7.15) The ovaries are located above undergoes cellular hypertrophy and increased vascularity. A
the true pelvis and, therefore, easily seen on TAS. They move corpus luteum is seen on ultrasound as a thick-walled cyst
deeper into the pelvis as the child grows. At birth, the typical often with irregular margins and low-resistance flow around
volume of the ovary is about 1 cc but may reach up to 3.5 cc it on Doppler. The irregular inner margins of a corpus
due to the abrupt rise in FSH following a decrease in oestro- luteum often give it a classic ‘crenated appearance’. The
gen and progesterone that reaches the fetus in intrauterine contents of the corpus luteum usually show turbid fluid with
life from maternal circulation. Ovarian follicles have been internal echoes. A CL is usually less than 3 cm but may
noted as early as 28 weeks of gestation, and follicles of less occasionally be larger and may appear complex showing
than 9 mm may be seen in neonatal ovaries. Occasionally, clots within.
the development of larger physiological cyst (more than
1 cm) may be seen in both fetal and neonatal ovaries and Postmenopausal Ovaries (Fig. 7.18) Normal postmeno-
most resolve spontaneously. About 20 % of neonates have pausal ovaries are smaller in size (1.2–5.8 cc), less echoic
ovarian cysts of more than 1 cm. and show fewer follicles than in premenopausal women.
Because of their small size and the absence of follicles, they
Paediatric Ovaries (Fig. 7.16) The ovarian volume up to the are often difficult to locate, both on TAS and TVS. Small
age of about 7 years is about 0.5–1.5 cc increasing to 4 cc just punctate echogenic foci are often seen in postmenopausal
before puberty. Larger physiological cyst (more than 1 cm) ovaries, which helps in identifying the ovaries in postmeno-
may be seen in prepubertal ovary. Ovarian volume of more pausal women. The ovarian size correlates with the duration
than 4 cc and the presence of six or more follicles in girls of menopause. A volume of more than 8 cc or an ovary that
younger than 7 years should raise the suspicion of precocious is twice as large as the contralateral ovary is considered
puberty. abnormal. Simple ovarian cysts may be seen in postmeno-
pausal women, particularly in early menopause. In late
Reproductive Ovaries (Fig. 7.17) The ovarian volume menopause also, a smaller cyst (less than 1 cm) may be seen
may vary from 4 to 20 cc with an average of about 5–6.5 cc. and should be reported if noted.
218 7 Ultrasound Evaluation of Ovaries

Fig. 7.15 Neonatal ovaries in a

32-day-old baby who was on a
follow-up for a right ovarian cyst
detected antenatally. (a)
Haemorrhagic right ovarian cyst
of 27 cc showing debris in its
posterior dependent part (arrow).
(b) Multicystic left ovary
measuring 2.8 × 1.4 × 1.8 cm
(volume 3.8 cc). This
(multicystic ovary) is seen in
some infants, secondary to rise in
FSH due to a sudden fall in
oestrogen and progesterone
levels that were present at higher
levels in neonatal life from
maternal circulation. Uterus
measured 3.0 × 1.1 × 1.3 cm

b
7.2 Normal Ovaries 219

a b c

d e f

Fig. 7.16 (a–c) Case 1 – Paediatric ovaries in a 6-year-old girl. (a) The uterus measures 3.7 × 1.0 × 1.6 cm. (b) Right ovary 1.2 × 0.6 × 1.5 cm. (c)
Left ovary 1.3 × 0.7 × 1.5 cm. No follicles are seen in either ovary. (d–f) Case 2 – Prepubertal ovaries in an 11-year-old. (d) The uterus measures
3.5 × 1 × 1.2 cm. (e) Right ovary 2.3 × 1.1 × 2.6 cm. (f) Left ovary 1.3 × 0.7 × 1.5 cm. Follicles are seen in both ovaries
220 7 Ultrasound Evaluation of Ovaries

b c

Fig. 7.17 Ovaries of women in the reproductive age group. (a) The ovary shows a developing follicle (in the proliferative phase of the menstrual
cycle). (b) The ovary shows a corpus luteum (in the secretory phase of the menstrual cycle). (c) Specimen of a corpus luteum from an excised ovary
7.2 Normal Ovaries 221

a b
TS LS

c TS LS

Fig. 7.18 Postmenopausal ovary. (a) Shows small ovarian size. (b) Ovaries show no follicle. (c) Small punctate echogenic focus (arrows) seen in
the ovary, which if present is often very useful while searching for the ovaries during TVS, in postmenopausal women
222 7 Ultrasound Evaluation of Ovaries

7.3 Polycystic Ovaries (PCO) number of antral follicles for diagnosis will vary depend-
ing on what criteria are used in each institution. Rotterdam
Polycystic ovarian syndrome (PCOS) is the commonest endo- criteria are an AFC of more than 12. However, most cen-
crinal abnormality seen in about 6.6 % in women in the repro- tres now consider an AFC of 25 or more for diagnosing
ductive age group. This syndrome carries significant health PCO.
risk, including diabetes, cardiovascular disease, endometrial • Ovarian volume is increased: An ovarian volume of more
hyperplasia and infertility. Most of these women present with than 10 cc is used for the diagnosis of PCO (in the absence
infertility, amenorrhoea or oligomenorrhoea, menorrhagia, of a dominant follicle or a corpus luteum).
obesity and hirsutism. Endometrial hyperplasia and, occasion- • Peripherally arranged antral follicles (‘pearl necklace
ally, endometrial carcinoma may be seen in these women, sec- appearance’) are seen in classic polycystic ovaries.
ondary to long-term exposure to unopposed oestrogen. However, it is not a requisite for the diagnosis of PCO
There is no universal consensus on diagnostic criteria. In based on Rotterdam criteria.
1935, Stein and Leventhal first described a condition • Abundant stroma is a feature of classical polycystic ova-
consisting of amenorrhoea, obesity and masculinising fea- ries which is seen centrally. It is generally more hyper-
tures, now known as polycystic ovarian syndrome. The echoic than usual. This stroma generally shows increased
Rotterdam PCOS consensus group brought out criteria in vascularity.
2003 for the definition of PCOS. The Rotterdam criteria • 3D ultrasound with volume analysis is being increasingly
require at least two of the three conditions given below to be used for the diagnosis of PCO and for the evaluation of
present for the diagnosis of PCOS: PCO in patients undergoing ovulation induction. This
helps to enhance the accuracy, speed and ease of measur-
1. Anovulation or oligoovulation. ing AFC. Ovarian volume can also be calculated with 3D
2. Clinical or biochemical signs of hyperandrogenism. volume studies.
3. Polycystic ovaries on ultrasound – The Rotterdam crite- • The endometrium in patients with polycystic ovaries
ria for polycystic ovaries on ultrasound are more than 12 may be thickened, heterogeneous, with tiny cysts and
or more follicles measuring 2–9 mm and/or an ovarian show increased vascularity. This could be secondary
volume more than 10 cc in one or both ovaries. Later it to endometrial hyperplasia or, rarely, endometrial
was believed that instead of the criterion of more than carcinoma.
12 follicles, a criterion of more than 19 follicles was
more appropriate. The new PCO criterion proposed (HR
2013), however, is an antral follicle count of 25 or more. 7.3.1 PCO in the Absence of PCOS
Here, it is assumed that the evaluation is done by a
transvaginal scan that can provide good resolution. The presence of polycystic ovaries (PCO) is seen in about
Rotterdam criteria, however, remain at more than 12 fol- 23 % of women of reproductive age group; however, only
licles, probably because TVS is not routinely used the some of these have PCOS (i.e. associated anovulation and
world over. hirsutism). The significance of PCO in the absence of the
syndrome primarily lies in the fact that these women are
Ultrasound Features of Polycystic Ovary (PCO) more likely to hyperstimulate with gonadotrophins during
(Figs. 7.19 and 7.20) ovulation induction. Since a large number of women with
Evaluation of the ovaries for the diagnosis of polycystic ovary polycystic ovaries on ultrasound do not have polycystic ovar-
should ideally be done between day 2 and day 4 of the ian syndrome (which is a disease associated with a lot of
menstrual cycle by a transvaginal scan (if possible). Patient other medical issues), it may be prudent to communicate this
should not be or recently have been on hormonal medication. in the ultrasound report, stating that though the ovaries
appear polycystic, it does not imply diagnosis of polycystic
• Antral follicle count (AFC) is increased: The presence of ovarian syndrome, which requires other features of hyperan-
antral follicles (2–9 mm) in one or both ovaries. The drogenism and/or ovulatory dysfunction.
7.3 Polycystic Ovaries (PCO) 223

Fig. 7.19 (a) Case 1 – A classic

case of polycystic ovaries with a
peripherally arranged antral
follicles (‘pearl necklace
appearance’), central
hyperechoic, bulky stroma and
increased ovarian volume. (b, c)
Case 2 – Polycystic ovaries
showing increased antral follicle
count. Ovarian volume is also
increased. (d) Thickened
endometrium showing small
cystic spaces suggestive of cystic
hyperplasia in Case 2

b RT OV c LT OV

d
224 7 Ultrasound Evaluation of Ovaries

Fig. 7.20 SonoAVC software is useful in obtaining an antral follicle count. This is particularly useful in the treatment of women with infertility.
It provides an accurate and quick way of counting antral follicles
7.4 Ovarian Masses 225

7.4 Ovarian Masses and persist for a longer period. Their size reaches a maxi-
mum at about 10 weeks, and they generally regress by about
Ovarian masses can be broadly classified into functional 16 weeks of pregnancy. Corpus luteal cysts are generally
cysts, endometriomas and neoplastic masses. haemorrhagic cysts but could be simple clear cysts.
Other causes of ovarian enlargement are masses of inflam- A haemorrhagic cyst is most often a corpus luteal cyst,
matory origin (discussed in Chap. 9 in the section on PID), but it could also be a follicular cyst with haemorrhage. An
hyperstimulation (discussed in Chap. 13), ovarian torsion endometrioma with recent haemorrhage can also show fea-
(discussed in Chap. 11) and ovarian ectopic (discussed in tures of a haemorrhagic cyst.
Chap. 10 in the section on ectopic pregnancies).
The differential diagnosis for ovarian masses is dealt with Ultrasound Features of a Haemorrhagic Cyst (Fig. 7.23)
in Chap. 14 in the section on adnexal masses. • Unilocular
• Generally thick walled
• It shows internal echoes which may be hyperechoic (when
7.4.1 Functional or Physiological Cysts haemorrhage is recent) or reticular, giving it a ‘cobweb’
(Figs. 7.21, 7.22 and 7.23) appearance, or it may show diffuse low-grade internal
echoes (especially when it is regressing).
All functional cysts of the ovary are unilocular and are gener- • A clot within a haemorrhagic cyst may retract away from
ally less than 8 cm. They are usually unilateral (unless the the cyst wall and the demarcation is often clearly seen.
patient is undergoing ovulation induction). Any fluid contain- Clots usually have concave margins facing the lumen of
ing mass in the ovary is a cyst; therefore, all follicles are cysts. the cyst. The entire margin of the clot facing the cyst wall
One must, however, avoid the term cyst for a regular ovarian may not be adherent to the cyst wall, and part of it may be
follicle because for most patients, the term cyst has a patho- seen some distance away from the cyst wall. The clot, in
logical connotation. Follicles that have a diameter of more addition, may show jelly-like movements on intermittent
than 3 cm can be called a follicular cyst. Follicular cysts are pressure by the TVS probe. Most importantly, a clot will
generally asymptomatic. not show any flow within it on Doppler because it is avas-
A corpus luteal cyst is usually thick walled and seen in the cular. This is a very important feature to help differentiate
secretory phase of the menstrual cycle. Corpus luteal cysts it from solid tissue within a cyst, which is generally of
may be symptomatic and occasionally may cause acute pain great concern.
and haemoperitoneum due to haemorrhage from a corpus • The appearance of a haemorrhagic cyst varies with time
luteal cyst. In pregnancy, corpus luteal cysts may be larger as the haemorrhage within gradually resolves.
226 7 Ultrasound Evaluation of Ovaries

a b c

Fig. 7.21 Physiological cyst. (a) Follicular cyst. (b) Corpus luteal cyst (212 ml) in a pregnant lady. (c) CL cyst in ‘b’ has regressed completely
following pregnancy

a b

Fig. 7.22 Corpus luteal cyst. (a) At early pregnancy scan, the cyst was large. (b) At NT scan, the cyst had regressed

Fig. 7.23 Haemorrhagic cysts vary in

appearance. (a) Hyperechoic areas within.
a
(b) Hypoechoic with few internal echoes.
(c) Reticular appearance of the clot within the
cyst. Clot retracting away from the cyst wall
(arrow). (d, e) Clot within the cyst shows
concave margins (characteristic feature).
(f, g) Haemorrhagic cyst does not show flow
within on Doppler, which helps differentiate it
from masses with solid tissue within
7.4 Ovarian Masses 227

Fig. 7.23 (continued)

b c

d e

f g

Summary: Functional Cysts

• History and Symptoms
– Women are of the reproductive age group.
– It is important to correlate the findings with the
phase of the menstrual cycle and pregnancy status.
– Previous reports and images are also useful for
correlation.
• On ultrasound, these cysts are unilocular, clear or
haemorrhagic (complex echoes) and generally less
than 8 cm.
• Follow-up is useful when in doubt. On rescan after
2–3 months, the cyst will either show complete
regression or would have changed in size and
appearance.
228 7 Ultrasound Evaluation of Ovaries

7.4.2 Endometriotic Cysts (Endometriomas) lesterol deposits in the cyst walls and are seen in about
35 % of endometriomas. As an isolated marker for
Endometrial tissue is seen within the ovary in cases with endometriomas, they have the highest LR of 6.2. The LR
endometriomas. Endometriotic cysts are also called ‘choco- increases to 32 if these hyperechoic foci are seen in a
late’ cysts because of the thick chocolate-coloured fluid ‘ground glass’ cyst. An association between hyperechoic
within these cysts. Further information on endometriosis is foci in the cyst walls and endometriomas is well estab-
available in Chap. 8. lished. Hyperechoic foci in sonographically normal
ovaries are not, however, predictive of endometriosis.
Ultrasound Features of Ovarian Endometriomas – On Doppler, the cyst walls show minimal high-resistance
(Figs. 7.24, 7.25, 7.26, 7.27, 7.28, 7.29, 7.30 and 7.31) flow with colour score of 2–3. Increased flow may be
seen in pregnancy or with secondary infection.
• Typically they appear as well-defined hypoechoic cysts • In some cysts, fluid–fluid level may be seen with the
with uniform low-grade internal echoes, which gives denser fluid in the dependent part (usually the inferior and
them a ‘ground glass’ appearance. posterior part) of the cyst.
Not all ‘ground glass’ cysts are, however, endometriotic. • Clots within these cysts, secondary to haemorrhage,
In premenopausal women, the majority are endometri- appear as irregular hyperechoic areas within a hypoechoic
otic, a few are malignant and the rest are benign. However, ‘ground glass’ background.
in postmenopausal women, the majority are malignant These clots often show jelly-like movements on release of
and the rest are endometriotic or benign. pressure. In addition, generally these clots have concave
margins facing the cavity. Also, they are not attached to the
cyst wall along their entire length (i.e. parts of the clots are
usually some distance away from the cyst wall). Clots are
avascular, and this feature is very important in distinguish-
ing these areas of haemorrhage from solid tissue within a
cyst that could have a similar appearance. For this, how-
Holsbeke et al. UOG 2010 ever, Doppler settings must be optimised (discussed in the
section on Doppler in Chap. 1). The importance of this is
Cysts with thick turbid fluid can sometimes give the highlighted in the case illustrated in Fig. 7.29.
appearance of being solid masses. They can be differenti- • The presence of adhesions is another common finding in
ated from each other (as elucidated in Chap. 1). patients with endometriotic cysts. One may see periovar-
• Endometriotic cysts are often multiple and bilateral. ian adhesions with loculated fluid.
The multiple cysts are often closely packed, giving them The ovaries may be adherent to the uterine wall (i.e. ‘slid-
a multilocular appearance and making it difficult to out- ing sign’ is absent). Any attempts to move the ovaries by
line them at times. In such cases, the number of cysts can applying pressure will cause pain. The ovaries often lie in
be identified as follows: the pouch of Douglas adherent to the posterior wall of the
1. The walls of the cysts can be visualised as bright lines uterus, very close to each other and at times even adherent
or darker linear shadows. to each other, termed the ‘kissing ovaries’.
2. Doppler flow is often seen in the cyst walls/ovarian
tissue intervening between the cysts. Endometriotic cysts with hyperechoic areas of haemor-
3. Density of echoes may differ in each cyst. rhage within could appear like haemorrhagic physiological
Sometimes, the cysts within an ovary are seen communi- cysts, and at times it may be difficult to distinguish at a sin-
cating with each other due to disruption of the intervening gle scan. In a repeat scan, after 2 months, a physiological
tissue. This is more often seen following conservative cyst would have disappeared or at least regressed, unlike an
surgery for endometriosis. endometriotic cyst which may in fact have increased in size
• Cyst walls marginally.
– Typically the cyst walls are thick and regular. Associated malignancy is seen in about 0.5–1.0 % of
– At times, wall nodularity may be noticed because of endometriomas. It can also occur in endometriotic tissues
hyperechoic, irregular areas along the inner cyst walls elsewhere including foci of deep infiltrating endometriosis.
which are nothing but clot and debris secondary to the As a result, the lifetime risk for ovarian cancer is believed to
haemorrhage within. be higher in women with endometriosis. The common malig-
– Small hyperechoic foci are often seen in the cyst walls of nancies in endometriomas are clear cell carcinoma and endo-
these endometriotic cysts. They are believed to be cho- metrioid carcinoma.
7.4 Ovarian Masses 229

Features that suggest possible malignant transformation/ Malignancy is more common in women with large cysts
association are: (more than 9 cm), cases with severe and long-standing endo-
metriosis, women over 45 years and those with a history of
• Vascularised solid component in an endometriotic infertility.
cyst. Keeping in mind the possibility of associated malignancy
• Rapidly enlarging mass or abundant blood flow in any and potential for malignant transformation, it is important to
endometriotic focus. follow up cases diagnosed with endometriosis. It is also
• High levels or rapid rise in CA 125 levels. (A baseline CA important to report any suspicion of malignancy on ultra-
125 may therefore be ideal in women with sound for proper surgical decision and so that the pathologist
endometriosis.) evaluates these suspected areas carefully.

Fig. 7.24 Characteristic ‘ground glass’

appearance of endometriotic cysts. (a) On a
TAS, (b) on TVS

b
230 7 Ultrasound Evaluation of Ovaries

a b

c d

Fig. 7.25 Multiple endometriotic cysts giving the ovary a multilocular appearance. Features that help delineate and count these cysts are (a)
hyperechoic linear compressed ovarian tissue between cysts (arrow), (b) dark linear shadow between two cysts (arrow), (c) flow in the compressed
ovarian tissue between cysts (arrow), (d) varying echodensities of the cysts
7.4 Ovarian Masses 231

a b

c d

Fig. 7.26 Cyst walls are (a) uniform and regular (arrow), (b) thick (arrow), (c) irregular due to clot and debris along the cyst walls (arrow).
(d) Hyperechoic foci are seen in the cyst wall (arrow)
232 7 Ultrasound Evaluation of Ovaries

Fig. 7.27 Endometriotic cyst showing fluid–fluid level with denser

fluid in the inferior dependent part

Fig. 7.28 Endometriotic cyst with recent haemorrhage, showing a hyperechoic and irregular clot within
7.4 Ovarian Masses 233

a b

PRF 1.3 PRF 0.6

Fig. 7.29 (a) 8 cm right ovarian endometriotic cyst in a 34-year-old lady on treatment for infertility. Laparoscopic partial cystectomy was done to
retain ovarian tissue in view of infertility. HPE: endometrioma. (b) Scan done 3 months following surgery showed a solid area with vascularity
(arrow) suggestive of malignancy. A similar area (arrow) was seen in the image (a) at the earlier scan done 3 months prior to the surgery. This was,
however, mistaken for a clot as the PRF was high and therefore flow in that area was not picked up. Patient underwent a second surgery. HPE:
endometrioid carcinoma (Grade 2) arising in the background of endometriosis

Fig. 7.30 Periovarian adhesions with loculated fluid commonly seen

in patients with endometriosis
234 7 Ultrasound Evaluation of Ovaries

a b
TS - POD

R.OV
L.OV

c TAS

Fig. 7.31 ‘Kissing ovaries’ refer to ovaries with endometriotic cysts, placed beside each other. They are adherent to each other and to the posterior
wall of the uterus, in the pouch of Douglas. (a, b) TVS (c) TAS
7.4 Ovarian Masses 235

7.4.2.1 Decidualised Endometriotic Cysts nancy. Typical ultrasound features of decidualised endome-
(Figs. 7.32 and 7.33) triotic cysts are rounded papillary projections with smooth
During pregnancy, endometriotic cysts often show papillary contour, in a ‘ground glass’ background. Other features of
solid projections and increased vascularity because of decid- endometriosis like multiple cysts, adhesions and hyperechoic
ual changes in the endometrial tissue lining these cysts. foci in the cyst walls also help to reassure that these are endo-
These cysts are called decidualised endometriotic cysts. Very metriotic cysts and are not malignant in nature. These cysts
often, especially when the patient is not a known case of generally subside in the third trimester and completely
endometriosis and is examined for the first time, these cysts regress following pregnancy but may reappear in a subse-
with solid vascular tissue raise a high suspicion of malig- quent pregnancy.

Fig. 7.32 (a) Right ovary showing two hypoechoic cysts with a solid vascular area in the larger cyst (arrows) in a pregnant lady at NT scan.
(b) Characteristic rounded papillary projection with a smooth contour is noted in the decidualised endometriotic cyst (arrow)
236 7 Ultrasound Evaluation of Ovaries

Fig. 7.33 (a) Decidualised endometriotic cyst where the solid tissue in the cyst shows cystic spaces within and high vascularity. The contour of
the solid projections into the cyst wall is not clearly seen on 2D grey scale due to the thick turbid fluid within the cyst. (b) 3D rendered image was
obtained, which shows the rounded contour of the papillary projections
7.4 Ovarian Masses 237

Summary: Endometrioma
• These are seen in women of the reproductive age
group with symptoms of dysmenorrhoea, chronic
pelvic pain and infertility.
• Previous report and images are important for
correlation.
• On ultrasound, they appear as unilocular hypoechoic
cysts with uniform, low-grade internal echoes
(‘ground glass’ appearance) and hyperechoic foci in
the cyst walls (seen in about 30 % of cases). Lesions
are often multiple and bilateral. Ovaries are often
adherent to the uterine wall and bowel adhesions
may also be noted (the absence of sliding sign).
• When in doubt about the nature of a cyst, a follow-
up scan may help in confirming the diagnosis.
• In women with endometriosis, nodules of deep
infiltrating endometriosis may be present and there-
fore a search for them is warranted when an endo-
metriotic cyst is seen.
238 7 Ultrasound Evaluation of Ovaries

7.4.3 Ovarian Neoplasms

Immature teratomas
Ovarian cancer is the most lethal of gynecological malignan- – Dysgerminoma
cies primarily because patients are asymptomatic in the ini- – Yolk sac tumour
tial stages, and the diagnosis is therefore made when the – Choriocarcinoma
disease is advanced. • Sex cord–stromal tumours arise from the ovarian
Ovarian neoplasms can be broadly classified into epithe- stromal cells (theca and granulosa cells) and are
lial tumours, germ cell tumours, sex cord–stromal tumours rare. Many of these are hormone producing. Many
and metastatic tumours. Ultrasound should always describe are solid but may show cystic areas.
the morphology of the mass. It is very important to ascertain – Granulosa cell tumours
the likelihood of malignancy for proper management of these – Sertoli–Leydig cell tumours
masses, which is best done subjectively but can also be done – Fibroma/fibrothecoma
based on IOTA guidelines and models. Optimal management • Metastatic tumours are secondary tumours in the
(which includes whether to operate or not, and what type of ovary, with primaries mainly in the breast and gas-
surgery, if the decision to operate is made), however, does not trointestinal tract. Most are solid and often bilat-
only demand the distinction between benign and malignant eral. Depending on the primary, their appearance
pathology (dealt with in Chap. 14) but also ideally requires can vary.
diagnosis of the specific pathology. This may be easy in some
cases, like dermoid cysts, because of classical sonographic
features. In others, it may be more difficult. Of late, efforts
have been made to try and differentiate between these masses 7.4.3.1 Epithelial Tumours
based on sonographic features of the mass. Epithelial ovarian neoplasms constitute the bulk of ovar-
ian neoplasms. About 85 % of ovarian neoplasms are epi-
thelial. They originate from the ovarian surface epithelium
Classification of Ovarian Neoplasms (mesothelium) which may invaginate into the underlying
Ovarian neoplasms can broadly be divided into epithe- stroma. These could be serous, mucinous, endometrioid,
lial tumours, germ cell tumours, sex cord–stromal clear cell, Brenner or undifferentiated. All epithelial neo-
tumours and metastatic tumours. plasms can be benign, borderline (i.e. having low malig-
nant potential – the absence of stromal invasion) or
• Epithelial tumours arise from the surface epithe- malignant (carcinomas) based on their histological find-
lium of the ovary. They are the commonest ovarian ings. In benign tumours, serous and mucinous are com-
tumours. They may be benign, borderline malignant mon. Benign endometrioid and clear cell tumours are
or malignant. Malignant is more common in rare.
postmenopausal women. Serous and mucinous Borderline tumours are more often seen in younger
cysts are most common. They may show septae and women and are commonly serous or mucinous in nature.
papillae. They have a better prognosis than the malignant ones.
– Serous Malignant epithelial tumours are more common in older
– Mucinous women. Solid vascular tissue is more common in malignant
– Endometrioid varieties. CA 125 levels are often elevated in women with
– Clear cell epithelial malignant tumours.
– Brenner’s Most women with epithelial tumours are asymptomatic.
– Undifferentiated With large masses, the patient may present with abdominal
• Germ cell tumours arise from the primordial germ distension or mass per abdomen.
cells (that also give rise to the ovum). They are seen Patients with malignant tumours may be asymptomatic
in younger women. Dermoid cysts (or mature tera- initially, as a result of which ovarian malignancies are often
toma) are frequent and benign and typically show discovered in late stages with poor 5-year survival rates.
acoustic shadowing. Others are rare, malignant and Once the tumour spreads, patients may present with typical
usually solid (but may show cystic areas). features of malignancy like abdominal discomfort, weight
– Teratomas loss, dyspepsia, ascites and a pelvic mass.
Mature teratomas (dermoid cysts) The commonest epithelial tumours are serous and muci-
nous, which are discussed below. Endometrioid carcinomas
7.4 Ovarian Masses 239

are associated with cancer of the endometrium in 30 % of • The septae are usually few in number. In the benign
cases. Both endometrioid and clear cell carcinomas are tumours, they tend to be smooth and thin, whereas in
associated with pelvic endometriosis. Brenner tumours are malignant ones, they tend to be thick and irregular.
rare, most often benign and commonly appear solid with no • Papillae may be seen in serous cysts, including benign
or minimal flow on Doppler. More than half show acoustic ones. The borderline tumours tend to have a higher num-
shadowing. Calcification is often seen in a Brenner tumour. ber of papillae, while in the malignant ones, the number is
even higher (which may fuse to form large masses of solid
tissue within the cyst).
Serous • Solid tissue (other than papillae) is a feature of malignant
– 30 % of ovarian neoplasms. serous adenocarcinomas. Solid tissue may be seen either
– 50–70 % are benign. between the locules or on one side of the mass, or the
– Papillae are more common in serous cysts. mass may be predominantly solid.
• Some tumors on ultrasound may show scattered, punc-
tate, bright foci suggestive of microcalcifications, due to
the presence of psammoma bodies. Psammoma bodies
are concentric, lamellated, calcified structures that are
Mucinous
typically less dense than most calcifying masses.
– 25–30 % of ovarian neoplasms.
Therefore, they usually do not show acoustic shadowing.
– 80–85 % are benign.
Though not commonly seen, when present, the tumour is
– Septae are more common in mucinous cysts
likely to be a borderline or low grade malignant serous
(multiloculated).
tumor. Brenners tumors, thecomas and gonadoblastomas
may show other forms of dystrophic calcification that
mimic psammomatous calcifications.
Serous Epithelial Tumours • The fluid in a benign cyst is typically anechoic but may
These could be benign (Figs. 7.34, 7.35, 7.36 and 7.37), bor- show fine low-grade internal echoes. Borderline and
derline (Fig. 7.38) or malignant (Figs. 7.39 and 7.40) tumours. malignant cysts are more likely to show fluid with internal
echoes.
Ultrasound Features of Serous Epithelial Tumour • On Doppler, benign tumours show minimal flow in both
(Figs. 7.34, 7.35, 7.36, 7.37, 7.38, 7.39 and 7.40) the septae and the cyst wall. The malignant ones, how-
ever, show increased flow, particularly in the papillae and
• These may be unilocular or multilocular. Benign cysts solid areas.
tend to be unilocular or to have fewer locules. • Ascites may be seen in cases with a malignant serous cyst.
• Serous cysts may be bilateral (both in benign and malig-
nant tumours), more so the malignant ones.
240 7 Ultrasound Evaluation of Ovaries

Serous Cystadenoma

c d

Fig. 7.34 Bilateral large unilocular serous cystadenomas in a 75-year-old patient. (a) Right cyst. (b) Left cyst. (c) Specimen of the excised left
ovarian serous cyst. (d) At surgery, the uterus with site of excision of the left ovary (arrow) and the right ovarian cyst which was yet to be excised
7.4 Ovarian Masses 241

a b

Fig. 7.35 Multiloculated serous cystadenoma showing septae. (a) Greyscale, (b) 3D rendered image

a b

Fig. 7.36 Benign serous cyst adenoma with papillae (arrows). (a) 2D, (b) 3D rendered image
242 7 Ultrasound Evaluation of Ovaries

b c

Fig. 7.37 Benign serous cyst adenoma. (a) Cyst shows low-grade internal echoes. (b) Few blunt papillae (arrow) are seen. (c) A thin septum is
also seen (arrow)
7.4 Ovarian Masses 243

Borderline Serous Tumours

b c

d e

Mass Rt Ovary

Fig. 7.38 Borderline serous tumour in two different cases. Case 1-(a) Multiple papillae are seen along the cyst walls. (b) Flow is seen within the
papillae on Doppler. (c) 3D rendered image of the cyst showing papillae. Case 2-Case of bilateral psammomatous borderline serous tumor (d) ‘V’
shaped solid mass seen along the superior, posterior and inferior margins of the right ovary. The mass shows multiple hyperechoic foci and irregu-
lar outer margins (arrow). Its upper margin is outlined, as it is difficult to delineate from surrounding tissues. The mass was vascular with a colour
score of 3. (e) Post-operative specimen of right ovary (R) and left ovary (L) showing the papillary outer surface of the mass surrounding the ovaries
(arrows)
244 7 Ultrasound Evaluation of Ovaries

Serous Cystadenocarcinoma

a b

c d

Fig. 7.39 Papillary serous cyst adenocarcinoma. (a) Solid area is seen along the outer aspect of the mass (arrow). (b) Corresponding post-
operative specimen showing the solid area (arrow). (c) Irregular septae with papillae seen within the cyst walls (arrow). (d) Corresponding post-
operative specimen showing multiple papillae (arrow)
7.4 Ovarian Masses 245

Fig. 7.40 Bilateral high-grade serous cystadenocarcinoma. A 42-year-old woman presented with a complaint of a bloating sensation of the abdomen.
CA 125 value was more than 1000 IU/mL. (a) Enlarged right ovary with solid and cystic areas. (b) Left ovary replaced by a solid lobulated mass. (c) Left
neoplastic ovary showing high vascularity (colour score 4). (d) The mass showing low-resistance flow (RI 0.24). (e) 3D power Doppler with glass body
display showing high and abnormal vascular morphology of the neoplastic mass. (f) Power Doppler showing high vascularity in both ovarian masses.
(g) Right ovarian mass showing irregular lobulated external margins (arrow) which are well seen because of the surrounding ascitic fluid
246 7 Ultrasound Evaluation of Ovaries

Fig. 7.40 (continued)

d

f
7.4 Ovarian Masses 247

Fig. 7.40 (continued)

248 7 Ultrasound Evaluation of Ovaries

Serous Cystadenofibroma (Figs. 7.41 and 7.42) have solid components which are typically only short stubby
Serous cystadenofibromas are ovarian cysts that contain both papillae. These show acoustic shadowing and minimal flow
epithelial and fibrous stromal elements. They are almost on Doppler.
always benign and only very rarely malignant. They may

Fig. 7.41 Serous cystadenofibroma. (a) Cyst with anechoic contents. (b) Short stubby papilla showing acoustic shadowing (arrow)
7.4 Ovarian Masses 249

c d

Fig. 7.42 Serous cystadenofibroma. (a) Cyst with large dimensions (5.4 L). (b) Papillae seen along the inner cyst wall (arrows) localised to a
small part of cyst wall. (c, d) Papillae showing acoustic shadowing (arrows). (e) 3D rendered image of cyst wall showing papillae (arrow). (f)
Post-operative cut section of the specimen showing the inner cyst wall in the area with the papillae (arrow). The rest of the cyst wall was smooth
as was seen on ultrasound. (g) Post-operative gross specimen
250 7 Ultrasound Evaluation of Ovaries

e f

Fig. 7.42 (continued)

7.4 Ovarian Masses 251

Mucinous Cysts • Borderline mucinous cysts typically show a cluster of tiny

These could be benign (Figs. 7.43, 7.44, 7.45, 7.46, 7.47 and locules (often localised to an area). At times, because the
7.48), borderline (Figs. 7.49, 7.50, 7.51 and 7.52) or malig- locules are small and closely packed, it could give the
nant (Fig. 7.53) tumours. appearance of an almost solid tissue filled with tiny
locules.
Ultrasound Features of Mucinous Cysts (Figs. 7.43, 7.44, • Malignant mucinous tumours often show solid tissue.
7.45, 7.46, 7.47, 7.48, 7.49, 7.50, 7.51, 7.52 and 7.53) • On Doppler, flow may be seen in the septae and the cyst
walls. In borderline tumours, the area with the closely
• Mucinous cysts are typically multilocular but may be packed cysts, in particular, shows vascularity. Malignant
unilocular. tumours are likely to show high vascularity, particularly
• They are often large in size. in any solid tissue within.
• Mucinous cysts are only very occasionally bilateral.
• Their septae typically appear rigid and bright. Ascites may be seen. With malignant mucinous cysts,
• The contents of the locules may vary in echogenicity. ascitic fluid often shows increased turbidity.
The locules may be anechoic or show varying amount of
internal echoes.

Mucinous Cystadenoma

Fig. 7.43 Mucinous a

cystadenoma in a 19-year-old
patient. (a) Multiloculated
cyst. (b) 3D rendered image.
(c) Ovarian crescent sign
(arrow)

b c
252 7 Ultrasound Evaluation of Ovaries

a b

Fig. 7.44 A 10 L large mucinous cystadenoma. (a) Bright, rigid septae with locules showing varying echodensity. (b) Largest locule was found
to be of 1000 cc

a b

c d

Fig. 7.45 Multilocular mucinous cystadenomas. (a) Multiple septae. (b) Low vascularity. (c) Locules show varying echodensity. (d) Cyst wall
showing low-resistance flow with RI of 0.37
7.4 Ovarian Masses 253

a LS b TS

Fig. 7.46 A 6.9 L large mucinous cystadenoma. (a, b) A single small septum is seen (arrow)

Fig. 7.47 Unilocular mucinous cystadenoma (volume 1.5 L)

254 7 Ultrasound Evaluation of Ovaries

b c

Fig. 7.48 Unilocular mucinous cystadenoma in a 17-year-old patient who presented with torsion. (a) Cyst shows low-grade internal echoes which
could be because of the associated torsion. (b) Two foci of calcification (arrows) seen in the cyst wall. (c) 3D rendered image of the cyst showing
internal echoes and a bright focus of calcification in the cyst wall (arrow)
7.4 Ovarian Masses 255

Borderline Mucinous Cysts

b c

Uterus

Fig. 7.49 Borderline mucinous cyst with torsion. (a) Cyst showing focal area of multiple locules. (b) Cyst is seen anterior to the uterus on TVS. It
shows turbid contents and a circumscribed focal multilocular area. (c) Flow is seen in this area with a colour score of 3. (d) Enlarged image of the
focal multicystic area showing multiple tiny locules that are very close, giving it a solid appearance in some parts, (e) pedicle of torsed ovary show-
ing the whirlpool sign on greyscale and Doppler (arrows)
256 7 Ultrasound Evaluation of Ovaries

d e

Fig. 7.49 (continued)

7.4 Ovarian Masses 257

Fig. 7.50 Borderline mucinous

a
cyst in a 24-year-old patient. (a)
Volume of about 100 cc. The
contents are turbid and the small
multiple locules are so close that
it gives the appearance of being
solid. (b) Cyst shows moderate
vascularity with colour score
of 3. (c) Cut section of the
post-operative specimen showing
multiple small fluid-filled locules
(arrows)

c
258 7 Ultrasound Evaluation of Ovaries

Fig. 7.51 Borderline mucinous

a
cyst in a pregnant woman. (a) At
an early pregnancy scan – cyst
shows septae and a volume of
610 cc. (b) At 36 weeks of
pregnancy – the cyst volume
increased to 1931 cc. Cyst shows
septae and turbid contents. (c)
Focal area of small crowded
locules seen. (d) This area shows
low vascularity, probably because
of the increased distance from the
probe. (e) 3D rendered image of
cyst showing focal area of small
multilocular cyst (arrow)

b c

d e
7.4 Ovarian Masses 259

b c

Fig. 7.52 Borderline mucinous cyst in a 56-year-old postmenopausal lady. (a) Large dimensions of cyst (3.698 L). (b) Focal small area showing
multiple locules. (c) Minimal vascularity noted in the walls of the locule. (d) Specimen of the cyst at surgery
260 7 Ultrasound Evaluation of Ovaries

Mucinous Cystadenocarcinoma

a b

c d

Fig. 7.53 Unilateral mucinous cystadenocarcinoma in a 59-year-old postmenopausal lady. (a) Large left ovarian cyst (volume 1.69 L) showing multiple
locules that show turbid contents with varying echodensity. (b) 3D rendered image of the same. (c) Cyst showing septum. (d) Locules showing turbid con-
tents with mixed echoes. (e) Inferior part of the cyst showing small locules and solid tissue (arrows). (f, g) Flow is seen in this focal area of small locules and
solid tissue, with a colour score of 3. (h) Flow showed a low RI of 0.41. (i) Atrophic right ovary. (j) Turbid fluid with complex echoes and debris seen in the
POD. (k) Ascitic fluid seen in the abdominal cavity. (l) Post-operative specimen. (m) Mucinous fluid with different colour tones is seen oozing out of the
locules of the cyst on incision. (n) Cut section of the cyst showing solid area in one part of the cyst. (CA 125 – 250.7 IU/mL)
7.4 Ovarian Masses 261

f g

h i

Fig. 7.53 (continued)

262 7 Ultrasound Evaluation of Ovaries

k l

m n

Fig. 7.53 (continued)

7.4 Ovarian Masses 263

7.4.3.2 Germ Cell Tumours • These typically show acoustic shadowing from their
They arise from primordial germ cells. They are more com- hyperechoic contents. This is very useful in making a
monly seen in adolescents and young adults. The commonest confident diagnosis of a dermoid.
germ cell tumour encountered is a dermoid (also known as a • Because of the acoustic shadowing, the entire cyst mar-
mature cystic teratoma). gins may not be seen. Often, just the proximal echogenic
Other tumours are malignant and include immature tera- margins are noted on ultrasound, with acoustic shadowing
tomas, dysgerminoma, yolk sac tumours (also known as distal to it, resembling the bowel. This is referred to as the
endodermal sinus tumours), embryonal carcinoma and ‘tip of the iceberg’ sign.
choriocarcinoma. • Bright scattered linear echoes may be seen within the cyst
(caused by the presence of hair in the cyst), which are
Dermoids (Mature Cystic Teratoma) often helpful in diagnosis.
They constitute about 20 % of all ovarian tumours. They are • Sometimes, one may see a dermoid mesh formed by hair
common in young women of the childbearing age group. within the cyst. Typically, these radiate out from a protu-
They are usually asymptomatic and therefore often first berance of solid tissue within the cyst, called the
picked up on an ultrasound done in pregnancy. They can, ‘Rokitansky nodule’.
however, present with pain because of torsion or may first • Multiple echogenic, circumscribed, tiny foci may be seen
present as a clinically palpable mass. They may be multiple within the cyst, formed by a combination of hair with
and are bilateral in 10–15 % of cases. sebaceous secretions.
• A very small dermoid may appear as a small circum-
Ultrasound Features of Dermoids (Figs. 7.54, 7.55, 7.56, scribed echogenic mass within the ovary.
7.57, 7.58, 7.59, 7.60, 7.61, 7.62, 7.63, 7.64, 7.65, 7.66, • Minimal flow may be seen on Doppler in the cyst walls.
7.67 and 7.68) • Dermoids are bilateral in 10–15 % of the cases and, rarely,
Dermoids have a wide range of sonographic appearance, yet may be multiple in an ovary.
the positive predictive value when diagnosed on ultrasound • The margins of a dermoid may be difficult to delineate
is about 98 % (Patel et al., AJR, 1998). because of acoustic shadowing and resemblance with the
bowel. One method to delineate is to push the mass with
• Dermoids are typically complex cysts with hypoechoic and the probe. The entire part that moves en masse is the der-
echogenic components. The echogenic components, moid, and thus its margins can be deciphered.
because of their fat content, tend to be seen in the non- • At times, a TAS scan is the only way to delineate and
dependent portions of the cyst (unlike cysts with debris assess a large dermoid.
where the hyperechoic contents are seen in the dependent
part of the cyst).
264 7 Ultrasound Evaluation of Ovaries

Fig. 7.54 Dermoid (arrows) on

TAS resembling the bowel.
Echogenic proximal margins
with distal acoustic shadowing –
‘tip of the iceberg’ sign

Fig. 7.55 Typical ultrasound

findings in a dermoid cyst
showing complex echoes,
acoustic shadowing (outlined)
and fine linear scattered echoes
(arrow), suggestive of hair
7.4 Ovarian Masses 265

Fig. 7.56 Dermoid. (a) 500 cc

a
dermoid better visualised and
measured on TAS. (b) TVS
showing gravid uterus with only
the lower part of dermoid cyst
visualised

Fig. 7.57 A complex dermoid

cyst with echogenic components
showing acoustic shadowing.
There is a small, circumscribed
anechoic cystic area within
266 7 Ultrasound Evaluation of Ovaries

Fig. 7.58 Dermoid cyst showing

turbid hypoechoic contents with
a ground glass appearance. The
presence of acoustic shadowing
(arrow) helped clinch the
diagnosis

Fig. 7.59 Complex dermoid

cyst showing fluid–fluid levels
and acoustic shadowing
7.4 Ovarian Masses 267

Fig. 7.60 Dermoid cyst showing

multiple echogenic spherical
structures within

Fig. 7.61 Dermoid cyst. (a) Initial measurement showed a dermoid cyst of 56 cc. (b) The cyst, however, was found to be much larger (249 cc).
This is because the margins of a large dermoid are generally difficult to delineate
268 7 Ultrasound Evaluation of Ovaries

a b

Fig. 7.62 Dermoid showing Rokitansky nodule (arrows) (a) on 2D, (b) on 3D. Multiple linear echoes suggestive of hair are seen radiating out
from this nodule, forming a dermoid mesh
7.4 Ovarian Masses 269

Fig. 7.63 Dermoid seen as a

hyperechoic circumscribed mass
within an ovary

Fig. 7.64 Dermoid seen as a

predominantly anechoic cyst.
The irregular hyperechoic wall
thickening with minimal
shadowing raised the possibility
of a dermoid, and this was
confirmed on histopathology
270 7 Ultrasound Evaluation of Ovaries

Fig. 7.65 Atypical dermoid cyst

showing anechoic contents and a
septum. Here again, the
hyperechoic superior walls with
loss of resolution beyond raised
the suspicion of a dermoid.
HPE: dermoid cyst

Fig. 7.66 Dermoid. TAS showing a large atypical dermoid with

anechoic contents, a septum and a crescent-shaped hyperechoic thick-
ening along one part of the cyst wall. This hyperechoic, irregular thick-
ening in the cyst wall is sometimes the only feature that raises the
suspicion of the cyst being a dermoid. HPE: dermoid cyst
7.4 Ovarian Masses 271

b c

Fig. 7.67 Atypical dermoid with septae. (a) Multiple septae are seen radiating out of a solid-appearing mass showing acoustic shadowing sugges-
tive of a Rokitansky nodule (arrow). (b) Flow seen on Doppler in the septae. (c) Doppler flow seen in the cyst walls. (d) Post-operative cut section
of a cyst showing hair and sebaceous material
272 7 Ultrasound Evaluation of Ovaries

Fig. 7.68 Multiple dermoids.

(a) On TAS, the entire pelvis a
showed complex areas with
acoustic shadowing and linear
echoes highly suggestive of the
contents of a dermoid. The uterus
was identified with difficulty,
lying between and behind the
dermoid cysts on either side.
There was a suspicion of there
being two dermoids in the right
ovary because of a linear
hypoechoic shadow running
anteroposteriorly on the right
side (long arrow) in addition to a
similar linear shadowing between
the right and left ovary (short
arrow). (b) 3D rendering of the
pelvis was done which also b
showed the presence of two right
ovarian dermoids and one left
ovarian dermoid. Findings were
confirmed later, at surgery
7.4 Ovarian Masses 273

Malignant Germ Cell Tumour • Some may show solid and cystic areas.
These include immature teratomas, dysgerminoma, endoder- • On Doppler, flow may be seen in the solid areas or in the
mal sinus tumours (also known as yolk sac tumours), embry- septae with moderate or high vascularity.
onal carcinoma and choriocarcinoma.
Malignant germ cell tumours are often of mixed variety Dysgerminoma (Figs. 7.73 and 7.74)
with 2–3 cell types coexisting. They are associated with
increased tumour markers like AFP (yolk sac tumour) and These are rare malignant germ cell tumours seen in young
HCG. The commonest are yolk sac tumours and immature women (median age 20 years). Dysgerminoma is the most
teratomas. common malignant ovarian germ cell tumour diagnosed in
pregnancy. It may also be seen in patients with primary amen-
Ultrasound Features of Malignant Germ Cell Tumour orrhoea, where it may be associated with gonadal dysgenesis
(Figs. 7.69, 7.70, 7.71 and 7.72) and gonadoblastoma. Dysgerminomas are usually pure dys-
germinomas and are not mixed with other germ cell tumours.
• They are usually unilateral. These tumours are generally well-defined, purely solid
• They are predominantly solid masses with intervening masses. They have a smooth or sometimes lobulated outer
septae giving them a lobulated appearance. contour. The solid mass is divided into different lobules and
• The solid tissue generally shows heterogeneous internal shows nonhomogeneous internal echogenicity. The mass usu-
echogenicity. ally shows moderate to high vascularity.
274 7 Ultrasound Evaluation of Ovaries

c d

Fig. 7.69 Immature teratoma Grade 3 – in a 24-year-old patient with 1 month history of abdominal pain, loss of weight and fever. (a) Greyscale
shows a solid, heterogeneous mass (2053cc) with a lobulated external contour and ascitic fluid surrounding it. 1300cc of ascitic fluid was seen in
the abdomen. (b) The mass is heterogeneous, shows few cystic spaces, some acoustic shadowing and scattered echogenic foci of calcification.
Immature teratomas are known to be large with prominent, solid, heterogeneous components, that often show calcification. (c) Flow is seen in the
mass (RI of 0.42). (d) 3D colour Doppler shows abundant flow within the mass. AFP was 2000 ng/ml (elevated). At surgery significant ascites and
abdominal metastasis were noted
7.4 Ovarian Masses 275

a b

d e

Fig. 7.70 Mixed germ cell tumour in 2 cases (a, b) Case 1 - Left ovarian (yolk sac and embryonal) – in a 30-year-old patient. (a) Greyscale shows
a solid heterogeneous mass with a lobulated external contour. (b) Minimal flow seen in the mass – predominantly in the septae. AFP was 818 ng/
ml (elevated) and HCG levels were normal. (c, d, e) Case 2 - Right ovarian - in a 26-year-old patient. (c) Images of a large (5803cc), multilocular
solid tumour seen in all the four quadrants of the abdomen. It shows cystic areas, solid areas and septae. (d) Large (589 cc), irregular, heteroge-
neous, solid area seen within the cyst. showing flow on Doppler. (e) Post-operative specimen
276 7 Ultrasound Evaluation of Ovaries

b c

d e

f g

Fig. 7.71 Yolk sac tumour (endometrioid type) in a 31-year-old patient. (a) Image showing a large, multilocular solid mass (9148 cc).
(b) Irregular thick septae. (c) Multiple circumscribed solid masses seen within. (d) Flow seen in the solid tissue and septae. (e) Flow showed a
low RI of 0.34. (f) Post-operative specimen that weighed 5.9 kg. (g) Cut section showing septae and solid areas
7.4 Ovarian Masses 277

b c

d e

Fig. 7.72 Ruptured yolk sac tumour – in a 22-year-old patient with a history of abdominal pain of 1 week duration. (a) Heterogeneous, predomi-
nantly solid mass (362 cc). (b) Solid tissue showing poorly defined margins at its superior end. (c) Flow seen on Doppler within the mass, with a
low RI of 0.4. (d) Post-operative specimen of the tumour showing external intact surface. (e) The macroscopic appearance of the contents of the
ruptured cyst
278 7 Ultrasound Evaluation of Ovaries

b c

Fig. 7.73 Dysgerminoma in a 27-year-old patient. (a) Image of a circumscribed, completely solid mass (790 cc) with a fairly regular outline of
its outer surface. (b) Mass showing hypoechoic, irregular, central, heterogeneous area. (c) Doppler flow noted in the mass. The RI was 0.44. (d)
TVS – shows a large mass, anterosuperior to the uterine fundus. (e) Section of the dysgerminoma showing a septum (arrow) that divided the
tumour into lobules. (f) Post-operative specimen
7.4 Ovarian Masses 279

e f

Fig. 7.73 (continued)

280 7 Ultrasound Evaluation of Ovaries

b c

d
LT OVARY

e f
LT OVARY

Fig. 7.74 Dysgerminoma and gonadoblastoma in a 20-year-old patient with dysgenetic gonads. Patient gave a history of primary amenorrhoea with
periods only on withdrawal of hormonal medication. Transabdominal ultrasound alone was done. (a) Hypoplastic uterus measuring 5.1 × 1.6 × 2.3 cm.
(b) Right ovary appears small. (c) No flows seen on Doppler in the right ovary. (d) Left ovary replaced by a nonhomogeneous, hypoechoic, solid
mass. The mass shows septae dividing the solid tissue into lobules. It has irregular lobulated outer margins. (e, f) Flow seen in left ovary on 2D
Doppler and 3D glass angio mode. HPE: left ovary showed dysgerminoma probably overgrown on a background of gonadoblastoma. Right ovary
showed features suggestive of gonadoblastoma with a small focus of dysgerminoma
7.4 Ovarian Masses 281

Sex Cord–Stromal Tumours Sertoli and Sertoli–Leydig Cell Tumours

They are rare tumours that show a varying amount of Sertoli
This includes granulosa cell tumours, Sertoli/Leydig cell cells, Leydig cells and fibroblasts. They are sometimes known
tumours, thecomas and fibromas. These are typically as androblastomas. These tumours have varying malignant
solid tumours. potential and are common in young women. Sertoli–Leydig
cell tumours may have androgenic, estrogenic or progesto-
Granulosa Cell Tumour genic manifestations (like menstrual disturbance, hirsutism or
Granulosa cell tumours are rare ovarian neoplasms. Fifty balding). However, many have no endocrine manifestations.
percent occur in postmenopausal women and 5 % in prepu-
bertal girls. They are the commonest of the sex cord–stromal Ultrasound Features of Sertoli and Sertoli–Leydig Cell
tumours and are the most common hormone-producing ovar- Tumours
ian tumours (oestrogen-producing tumours). Patients often
present with a history of menstrual irregularities, which • These could be solid or multilocular solid tumours.
facilitates early diagnosis. Endometrial hyperplasia and • They vary in size from small to moderate.
occasionally endometrial carcinoma may be seen in these • They show moderate to high vascularity in their solid
hyperestrogenic women. Prepubertal girls may present with component.
precocious puberty. Serum estradiol levels are raised and are
useful in diagnosis both in premenopausal and postmeno-
pausal women. These are regarded as malignant tumours Leydig Cell Tumours
with varying malignant potential, but most are slow growing These rare tumours are more common in postmenopausal
(low malignant potential). women and are almost always benign. They produce
androgens resulting in hyperandrogenic features in most
Ultrasound Features of Granulosa Cell Tumour (Fig. 7.75) cases (like hair loss and menstrual irregularities), which
are often mild.
• They are usually large tumours (average 10 cm).
• Most often they are solid masses with circumscribed Ultrasound features of Leydig Cell Tumours
‘moth-eaten’ cystic areas, giving it a ‘Swiss cheese’
appearance. In the multilocular type, the locules tend to • These are solid tumours.
be multiple. • They are typically small (mean diameter of 2.4 cm). Since
• They may be purely solid in 40 % of the cases. they are small, they are often missed.
• The solid component usually shows heterogeneous • They show high vascularity.
echogenicity.
• They usually show moderate to high vascularity.
282 7 Ultrasound Evaluation of Ovaries

a b

c d

e f

Fig. 7.75 Granulosa cell tumour in two different cases. (a, b) Case 1: 50-year-old patient who presented with menorrhagia. (a) Completely solid,
heterogeneous mass seen with relatively smooth outer margins, (b) Low vascularity noted in the mass on power Doppler with PRF of 0.3, (c, d, e,
f) Case 2: 38-year-old known case of polycystic ovaries, presented with history of menorrhagia since 2 years and continuous bleeding PV since 2
1/2 months. (c) Mass with bosselated outer margins and ‘swiss cheese’ appearance. (d) Vascularity noted in the mass (2) Thickened endometrium
measuring 18 mm. (e) Cut section of post operative specimen showing classic ‘swiss cheese’ appearance and bosselated outer surface. Inhibin
levels were elevated in the patient (preoperative-118 pg/ml)
7.4 Ovarian Masses 283

Fibromas and Fibrothecoma • Most of them (about two-third) show stripy acoustic shad-
Fibromas constitute about 6 % of all primary ovarian neo- ows like that of a fibroid.
plasms and two-third of sex cord–stromal tumours. These are • These fibromas show minimal or moderate flow on
benign tumours arising from the stromal component of the Doppler (colour score 2–3). Flow in the centre of fibro-
ovaries. Fibroma cells are spindle cells that produce collagen mas is usually poor.
and thecoma cells are stromal cells that resemble perifollicu- • Fibrothecomas, because of their thecal component, gener-
lar thecal cells. The tumours are either fibromas or fibrothe- ally have higher cellularity. These are more vascular, are
comas, with fibromas being more common (78 % in a more likely to be lobulated and show lesser acoustic
study – Paladini UOG 2009). Majority of women are post- shadowing.
menopausal, and most of them are asymptomatic. However, • Free fluid is seen in about 50 % of patients, in POD. In a
they may present with mass abdomen, features of associated few patients ascites may be noted. The presence of
ascites or hydrothorax or, rarely, torsion. hydrothorax (classically right sided), along with ascites in
cases with solid benign ovarian tumours like these, is
Ultrasound Features of Fibromas and Fibrothecoma known as Meigs syndrome.
(Figs. 7.76, 7.77, 7.78 and 7.79)
Gorlin syndrome (Fig. 7.80) (also known as nevoid basal cell
• They are usually unilateral. carcinoma syndrome) is a rare autosomal dominant disorder
• They appear as well-circumscribed, round, oval or slightly where, in 75 % of the cases, women have bilateral fibromas.
lobulated masses. These fibromas may be hyalinised or calcified. These women
• They are typically solid but may show some cystic have characteristic facial features with frontal bossing,
spaces. The atypical ones show large cystic spaces when hypertelorism and mandibular prognathia.
their differentiation from malignant masses may be
challenging.
284 7 Ultrasound Evaluation of Ovaries

b c

LT OV

FIBROMA

d e

Fig. 7.76 Fibroma with associated torsion in a 33-year-old. Patient presented with abdominal pain. (a) Right ovarian circumscribed solid mass
(about 7 cm) with a smooth outer contour and stripy acoustic shadowing, suggestive of a fibroma. (b) An enlarged right ovary with oedematous
ovarian tissue in its superior part and a circumscribed solid mass (the fibroma) in its inferior part. Antral follicle with hyperechoic thick margins
seen in the ovarian tissue suggestive of follicular ring sign (arrow). (c) Oedematous segment of the right fallopian tube (which had also undergone
torsion) is measured in the image. The normal left ovary is seen beside it. (d) Post-operative specimen showing the outer surface of the excised
fibroma. (e) Cut section of the fibroma
7.4 Ovarian Masses 285

Fig. 7.77 Ovarian fibroma in a

a pregnant patient. (a) A
hypoechoic solid mass with
lobulated outer margins
(arrow) and some amount of
acoustic shadowing.
(b) Minimal flow seen on
Doppler (with PRF of 0.3).
(c) Flow showed RI of 0.53.
(d) Post-operative specimen
of the ovarian fibroma

c d
286 7 Ultrasound Evaluation of Ovaries

a b

Fig. 7.78 Fibroma. Right ovary seen with a circumscribed solid mass. (a) Mass shows stripy shadows. Ovarian tissue with follicles is seen along
its lateral margins – ovarian ‘crescent sign’ (arrow). (b) 3D rendered image showing the fibroma within the right ovary

a b

c d

Fig. 7.79 Fibrothecoma in a 26-year-old patient. (a) Completely solid, hypoechoic, heterogeneous mass with lobulated margins. The mass showed
some amount of shadowing. (b) Flow is seen in the mass with a prominent vessel approaching it from its lateral margin. The rest of the mass did not
show abundant flow within. Few small foci of calcification (arrows) are present (this is seen occasionally in thecomas). (c) Post-operative specimen
showing the outer lobulated surface. (d) Cut section of the tumour showing septae (arrow) dividing the solid tissue into lobules
7.4 Ovarian Masses 287

c d

CL

Fig. 7.80 Gorlin syndrome in a 29-year-old patient who came for an early pregnancy scan. Patient gave a history of ovarian biopsy elsewhere
which she reported orally to have revealed fibrotic tissue. A very small intrauterine sac was seen. (a) The left ovary was bulky and showed stripy
shadows with a few follicles within. (b) Solid, complex, enlarged right ovary showing significant acoustic shadowing. Though both the ovaries
appeared fibrotic, with acoustic shadowing, no well-defined fibroma could be delineated within. A few small, scattered follicles were seen. (c)
Minimal flow is seen in the ovary on Doppler. (d) A corpus luteum (CL) was seen in the left ovary
288 7 Ultrasound Evaluation of Ovaries

7.4.3.3 Metastatic Ovarian Masses • Many of them are solid tumours (93 % of category A and
The ovary is a common site of metastasis from malignant 18 % of category B).
tumours, most commonly arising from the breast, stomach • The solid tumours are typically homogeneously solid, but
and large bowel. These tumours are usually bilateral. if there is necrosis, they show heterogeneous echoes.
Krukenberg tumours are traditionally described as mucin- • Most of the tumours of category B and very few of cate-
filled ‘signet ring’ cells (on cytology) with the primary site gory A are multilocular or multilocular solid. These
being the stomach, breast, large bowel or appendix. Ovarian usually have a large number of locules, and the septae
metastasis may be detected during the follow-up of patients may be so close that it may be difficult to decide on ultra-
with other malignancies, but the majority (about 57 %) are sound whether there is a solid part in that area. Intracystic
detected before the primary lesion. Most women are post- septae may be fragmented, probably due to necrosis.
menopausal with high CA 125 levels. About half the patients Colorectal carcinomas are typically multilocular.
are asymptomatic, and the symptomatic ones may present Multilocular morphology is more common in metastatic
with a pelvic mass, ascites, dyspepsia, etc. The prognosis is compared to primary ovarian carcinomas.
poor in most cases. • The margins of the solid tumours are more often well
defined, while those of category B tumours (multilocu-
Ultrasound Features of Metastatic Ovarian Masses lated or multiloculated solid) are very often irregular and
(Figs. 7.81, 7.82 and 7.83) without a recognisable outer capsule.
Ultrasound features of these metastatic tumours have been • The contents within the loculated lesions could be
broadly divided into two major categories, depending on the anechoic or show low-grade echoes.
origin of their primary tumour (Testa UOG 2007). • Papillary projections are not frequently seen (only in
about 12 %) in metastatic tumours compared to primary
Category A: Tumours that metastasize from the breast, stom- ovarian carcinomas.
ach, uterus and lymphoma are typically solid (about • On Doppler, flow often shows moderate to high vascular-
93 % – Testa UOG 2007). ity (colour core 3–4).
Category B: Those from the colon, rectum, appendix and bili- • Metastatic tumours show lower PI and RI and signifi-
ary tract are either multilocular solid or multilocular with cantly higher PSV, as compared to primary ovarian
just about 18 % being solid. These also tend to be larger. carcinomas.
• ‘Lead vessel’ has been described to be the main or major
Other studies have shown similar overall findings, with the vessel penetrating from the periphery of the mass to the
majority being solid. Those metastasizing from the breast are centre, with a tree-shaped branching morphology. This is
solid, smaller and more vascular. Those metastasizing from very typical of metastatic solid tumours (seen in 52 % –
the stomach, tend to be solid, but in one-third of these cases Testa UOG 2008). It was not seen in multilocular or
cystic components, may be seen. The metastatic tumors from multilocular solid metastatic tumours and was seen in
colorectal primaries, are usually multilocular. only 0.01 % of primary ovarian cancers.
The ultrasound findings of metastatic ovarian tumours are: • Krukenberg tumours are typically solid tumours of mod-
• They are frequently bilateral. Those from the stomach are erate size, with bosselated outer surfaces and a lead vessel
bilateral in more than 50 % of the cases. providing flow to the mass.
7.4 Ovarian Masses 289

Fig. 7.81 Krukenberg tumour a

in a 32-year-old lady. Patient had
undergone surgery and
chemotherapy for breast cancer.
(a) Left ovary replaced by a
completely solid, hypoechoic,
heterogeneous, well-defined
mass. (b) High vascularity noted
in both the ovaries.
(c, d) Prominent vessel is seen
within the mass, which might
have been the ‘lead vessel’
described in literature. However,
its entry into the ovarian mass is
not visualised in this image.
Flow showed a low RI of 0.3

c d
290 7 Ultrasound Evaluation of Ovaries

b c

Fig. 7.82 Krukenberg tumour in a 49-year-old patient with a gastric adenocarcinoma and perforation of the gastric tumour. Bilateral ovarian
metastasis. (a) TS of the pelvis showing the uterus with the ovaries on both sides. The right ovary showed an anechoic cystic area with solid tissue
anteriorly (arrow). The left ovary appeared completely solid. Loculated ascitic fluid seen anterior to the uterus and the ovaries. (b) The right ovary
shows flow in its solid tissue. (c) The solid left ovary shows a lead vessel entering the mass from its lateral margin
7.4 Ovarian Masses 291

Fig. 7.83 Bilateral ovarian metastasis from an anorectal carcinoma in a 36-year-old patient. (a, b) Large, multiloculated cystic ovaries seen bilat-
erally. Volume of the left ovary was 507 cc, and volume of the right ovary was 840 cc. Very minimal stroma is seen between the locules. (c) The
locules showed turbid fluid with variable echogenicity. (d) Flow with moderate vascularity was seen in the septae of the loculated ovary. (e) The
uterus seen positioned over an enlarged, complex bowel mass on TAS. (f) The anorectal mass shows vascularity on TVS. (g) Anorectal mass mea-
sured on TVS
292 7 Ultrasound Evaluation of Ovaries

c d

e f

Fig. 7.83 (continued)

7.4 Ovarian Masses 293

Summary: Ovarian Neoplasms

• Age of patients and symptomatology vary depend-
ing upon the type of neoplasm. Many patients are
asymptomatic. Others may present with abdominal
distension, pelvic mass or rare complications like
torsion and rupture. Malignant ones may be associ-
ated with weight loss and dyspepsia.
• Past history and reports are important for
correlation.
• Findings vary depending upon the type of
neoplasm.
– Epithelial tumours are the commonest with most
tumours being serous and mucinous. These are
commonly benign but could be borderline malig-
nant or malignant. They may show septae and
papillae.
– Germ cell tumours – Dermoids are benign com-
monly seen tumours. Typical ultrasound feature
is a complex cyst with acoustic shadowing.
Other germ cell tumours are malignant and seen
in young adults. They are predominantly solid
and usually unilateral.
– Sex cord–stromal tumours include fibromas and
hormone-producing tumours like granulosa cell
tumour. Fibromas typically appear as solid
masses with stripy shadowing, and granulosa
cell tumour may either be solid or cystic (‘Swiss
cheese’ appearance).
– Metastatic tumours – Common primaries are
from the breast and GIT. Those from the breast,
stomach, lymphoma and uterus are typically
solid, while those from the colon, rectum, appen-
dix and biliary tract are most often multilocular
or multilocular solid.
• Ultrasound report should describe the morphology
(using IOTA terminology). In some cases, diagnosis
of the histological nature of the mass is possible. In
others, the impression of the nature of the mass, i.e.
benign or malignant, should be provided.
294 7 Ultrasound Evaluation of Ovaries

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40:245–254. doi:10.1002/uog.12281
pathology of adnexal masses. Ultrasound Obstet Gynecol 45:605–
Catteau-Jonard S et al (2012) Polycystic ovaries at ultrasound: normal
612. doi:10.1002/uog.14675
variant or silent polycystic ovary syndrome? Ultrasound Obstet
Sokalska A et al (2009) Diagnostic accuracy of transvaginal ultrasound
Gynecol 40:223–229
examination for assigning a specific diagnosis to adnexal masses.
Demidov VN, Lipatenkova J, Vikhareva O, Van Holsbeke C,
Ultrasound Obstet Gynecol 34:462–470. doi:10.1002/uog.6444
Timmerman D, Valentin L (2008) Imaging of gynecological disease
Testa AC (2007) Imaging in gynecological disease (1): ultrasound fea-
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Sertoli–Leydig cell tumors and Leydig cell tumors. Ultrasound
the primary tumor. Ultrasound Obstet Gynecol 29:505–511.
Obstet Gynecol 31:85–91. doi:10.1002/uog.5227
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borderline ovarian tumors. Ultrasound Obstet Gynecol 25:50–59.
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 Endometriosis
8

Endometriosis is the presence of ectopic endometrial glands rectosigmoid, vagina, bladder, ureter, etc. This is seen in
and stroma (basically endometrial tissue) seen outside of the 15–30 % of women with endometriosis.
uterus.
This is commonly seen in women belonging to the
reproductive age group, who present with symptoms such Significance of DIE
as dysmenorrhoea, chronic pelvic pain and subfertility/
infertility. Women, however, may be asymptomatic, and • DIE causes pain which can be very distressing. The pain
endometriosis may be incidentally diagnosed on an ultra- could be in the form of dysmenorrhoea, dyspareunia,
sound or during laparoscopy. chronic pelvic pain or bladder and bowel symptoms like
Endometriosis is seen in about 4–13 % of women of the dysuria and painful defecation.
reproductive age and in 25–50 % of women with infertility. • DIE is often not diagnosed on ultrasound as visualizing
Endometriotic lesions could be superficial or deep (more and detecting these lesions requires high suspicion and
than 5 mm from the peritoneal surface). Based on their loca- knowledge of the spectrum of DIE.
tion, they can be grouped into three categories: • DIE can affect the pelvic organs by either by primary
involvement or by secondary involvement, caused by ana-
1. Ovaries and pelvic peritoneum: This is the most com- tomic distortion of a structure due to fibrotic retraction of
mon site. It is important to note that tiny superficial an adjoining DIE nodule. This can lead to complications
endometriotic lesions of the pelvic peritoneum or on such as hydronephrosis.
the ovarian surface (i.e., the gunshot or powder-burn • DIE nodules have the potential to undergo malignant
lesions seen on laparoscopy), cannot be picked up on transformation.
ultrasound. • In pregnancy, they can increase in size and vascularity
2. Deep infiltrating endometriosis of the pelvis: This is seen and may become painful or affect pelvic organs for the
in 15–30 % of women with endometriosis. Lesions (endo- first time, in pregnancy.
metrial tissue) penetrate into the retroperitoneal space or • Diagnosing DIE is very important for optimal planning
the walls of the pelvic organs, to a depth of at least 5 mm. of surgery. If DIE is anticipated, appropriate consent can
Common locations are the uterosacral, rectosigmoid, be taken from the patient, and the primary surgeon may
vagina, bladder and ureter. decide to involve a colorectal surgeon or urologist.
3. Extra-pelvic endometriosis: This is endometriosis seen
outside the pelvis, involving the abdominal wall, lungs, etc. Ultrasound Features of DIE Nodules (In General)
(Figs. 8.1 and 8.2)
Please note: Endometriomas of the ovary have been dis- Transvaginal scan is the diagnostic modality of choice.
cussed in detail in the chapter on ovarian masses (Chap. 7).
• DIE lesions are usually fusiform or nodular in shape.
• The lesions appear hypoechoic.
8.1 Deep Infiltrating Endometriosis (DIE) • They have diffuse borders.
• They are firm and may show some amount of acoustic
Here, the lesions (endometrial tissue) penetrate into the ret- shadowing.
roperitoneal space and/or the walls of the pelvic organs to a • They are typically solid but could be solid and cystic, or
depth of at least 5 mm. Common locations are the uterosacral, only cystic.

© Springer Nature Singapore Pte Ltd. 2017 295

M. Sibal, Ultrasound in Gynecology, DOI 10.1007/978-981-10-2714-7_8
296 8 Endometriosis

• They are most often poorly vascularised. For the diagnosis of DIE, other diagnostic modalities like
• They are generally tender and therefore a pain/tenderness- MRI, CT and barium studies can also be resorted to. However,
guided approach during TVS is useful in locating them. transvaginal scan is the modality of choice because it is the
• They are multiple in about 20 % of causes. least expensive, least invasive and has a sensitivity of 81.1 %
and a specificity of 94.2 % (Vimercati et al. 2012). This high
In some cases, where the ovaries appear normal on scan, specificity and sensitivity is because transvaginal scan is
these DIE nodules are not suspected and therefore more dynamic and interactive, allowing evaluation of tenderness
likely to be missed. and adhesions, in addition to having a high resolution.

LS TS

Fig. 8.1 Bowel DIE. Longitudinal section and transverse section of a DIE nodule (short arrows) involving the anterior rectal wall. The nodule is
hypoechoic with diffuse borders. On LS, the normal anterior rectal muscularis above the lesion shows a fine hyperechoic line within, which sepa-
rates the outer longitudinal from the inner circular muscular layer (long arrow). On TS, the nodule shows acoustic shadowing suggestive of fibrotic
elements within the DIE nodule. TS of the bowel gives a ‘signet-ring’ appearance because of the nodule in one part of the bowel wall with normal
muscularis (long arrow) seen all around the bowel wall

Fig. 8.2 DIE lesion (arrow) showing poor

vascularity on Doppler LS
8.1 Deep Infiltrating Endometriosis (DIE) 297

8.1.1 DIE of Large Bowel (Rectosigmoid) • At times, one may see hyperechoic linear echoes radiating
out of a DIE nodule, giving it a ‘Red Indian hairdo’ appear-
This primarily involves the anterior muscularis of the recto- ance from which it derives the term ‘Red Indian hair dress’
sigmoid. The anterior muscularis of the rectum can be traced sign. This appearance is because of the involvement of the
just behind the vagina and along the posterior wall of the bowel submucosa due to fibrotic retraction by the DIE
uterus. There is a fine white line which is seen within it that nodule. This typical feature is prominent on ultrasound
divides the anterior muscularis into an inner layer of circular and is therefore helpful in picking up DIE lesions.
muscle fibres and an outer layer of longitudinal muscle • Lesions that are seen beyond the uterine fundus are gener-
fibres. Just within the muscularis lies the hyperechoic sub- ally considered to be involving the sigmoid, while those
mucosa. Within the submucosa is the dark central linear area, below the uterine fundus are considered to be rectal,
which is the lumen of the large bowel. Patients with endome- though it is not possible to have a clear-cut delineation of
triosis of the bowel may be asymptomatic or may complain the rectosigmoid junction on ultrasound.
of dysmenorrhoea, painful defecation or mucoid/bloody rec- • One should measure the distance between the lower end
tal discharge during periods. of the nodule and the anal verge, because lesions that are
less than 7 cm from the anal verge are more difficult to
Ultrasound Features of DIE of Large Bowel manage surgically than those which are higher up.
(Rectosigmoid) (Figs. 8.1, 8.2, 8.3, 8.4 and 8.5) • The DIE nodules are most often adherent to the posterior
• Fusiform-shaped lesions along the anterior muscularis of wall of the uterus, because of which there is an absence of
the large bowel. The typical appearance (thin hyperechoic the sliding sign (bowels sliding along the posterior wall of
line) of the bowel muscularis in that area is lost but can be the uterus and vaginal fornix). This absent sliding sign
seen above and below it. has a high LR of 23.6 for rectal DIE (Hudelist et al. 2013).
• The affected anterior muscularis of the bowel loop with
DIE is much thicker than the corresponding posterior Transvaginal scan has a very high pickup for rectosig-
muscularis. moid endometriosis (sensitivity of 91 % and specificity of
• On a longitudinal section, they appear as thickened areas 98 %). For lesions that are high up in the sigmoid (beyond
of the anterior muscularis, and on cross section, the bowel the reach of a transvaginal scan), a double contrast barium
gives a ‘signet ring’ appearance. enema may be useful.

Fig. 8.3 DIE nodule (traced) is seen involving

the anterior rectal wall. The nodule was seen in
the POD, adherent to the posterior wall of the LS
uterus and the right ovary
Rectum

Rt Ovary

Uterus
298 8 Endometriosis

a LS

b TS LS

Fig. 8.4 Rectosigmoid DIE in a 32-year-old lady who complained of severe pain in the rectal region with mucoid discharge per rectum during
periods. Colonoscopy and ultrasound scans done elsewhere were reported as normal. (a) The anterior muscularis of the bowel loop is much thicker
than the posterior muscularis in the area of the DIE nodule. Just within the muscularis, the hyperechoic submucosa (short arrows) is seen, and
within that is a dark linear area, which is the central lumen of the bowel (long arrow). (b) TS and LS view of the DIE nodule. Typical ‘signet ring’
appearance is noted on TS, (c) DIE nodule showing moderate to high vascularity. (d, e) Both ovaries appeared normal
8.1 Deep Infiltrating Endometriosis (DIE) 299

Fig. 8.4 (continued)

c
LS

d e

a b

Fig. 8.5 (a, b) ‘Red Indian hair dress’ sign seen in two different cases of bowel DIE. The images show hyperechoic linear echoes (arrows) radiat-
ing out from the DIE nodule resembling a ‘Red Indian hairdo’. This typical feature is prominent on ultrasound and is therefore helpful in picking
up DIE lesions
300 8 Endometriosis

8.1.2 DIE of the Vaginal Wall with the vaginal wall elsewhere provides a convenient
control.
DIE can also involve the walls of the vagina, commonly the pos- • In cases with rectovaginal DIE, there is a breach in the
terior wall and very often in continuity with rectal DIE, forming rectovaginal septum (the normal rectovaginal septum
a rectovaginal DIE lesion. Patients can be asymptomatic or com- appears like a hyperechoic line separating the rectum and
plain of dysmenorrhoea or dyspareunia. If the adjoining bowel is the vagina), where the rectal DIE is continuous with the
involved, then the patient may present with rectal symptoms. vaginal DIE.
• Vaginal and rectovaginal DIEs are more difficult to diag-
Ultrasound Features of Vaginal DIE (Figs. 8.6, 8.7 nose because of the proximity of these structures to the
and 8.8) TVS probe. Therefore, gel sonovaginography (GSV) is
• The affected vaginal wall appears thickened and hypoechoic usually resorted to at our centre, wherein, 20 ml of gel is
with diffuse borders. It shows poor vascularity. Comparison instilled into the vagina for better resolution of the lesion.

a LS-Posterior b LS-Anterior

UT
UT

CX
CX
Bladder

Fig. 8.6 Vaginal DIE: (a) Longitudinal section of the posterior fornix. The probe in this image is in the posterior fornix with the cervix (CX) lying
anteriorly and the posterior vaginal wall with the hypoechoic DIE nodule posteriorly (small arrows). (b) Longitudinal section of the anterior fornix
(in this image the probe is in the anterior fornix), showing normal anterior vaginal walls (long arrow)
8.1 Deep Infiltrating Endometriosis (DIE) 301

Fig. 8.7 Rectovaginal DIE: (a)

Longitudinal section of posterior fornix
a TVS - LS
showing a hypoechoic, thickened DIE
lesion of the vagina and rectum. The
normal rectovaginal septum between the
normal rectum and vagina is seen as a
hyperechoic line (short arrow). There is
a breach in the upper part of the RV
septum (long arrow) where the rectal
DIE and the vaginal DIEs are continu-
ous. (b) The rectovaginal DIE was also
seen on TAS. The image shows a TS of
the cervix (CX), thickened vaginal wall
with the DIE lesion (long arrow) and the
rectal DIE (short arrow). The two DIE
lesions with their communication form
an ‘hourglass’ lesion

b TAS-TS

CX
302 8 Endometriosis

Fig. 8.8 Vaginal DIE. (a)

a
Regular TVS showing the
transverse section of the posterior
and the anterior vaginal walls.
Posterior vaginal wall is
thickened on the right side. (b)
GSV showing the same area as
above. However, because of the
separation of the vaginal walls by
vaginal gel, the lesion is better
delineated and the normal vagina
anteriorly and on the left side
posteriorly is well seen

b
8.1 Deep Infiltrating Endometriosis (DIE) 303

8.1.3 Cervical DIE Ultrasound Features of Cervical DIE (Fig. 8.9)

• Cervical wall in that area is thick and firm.
This is a rare condition that is most often associated with • It may show cystic spaces.
DIE of the adjacent vagina, rectovagina or uterosacral liga- • Margins are ill defined.
ment. Women with cervical DIE may be asymptomatic or • Acoustic shadowing may be noted
give a history of dysmenorrhoea and dyspareunia. These • Mass is usually tender to touch.
women are sometimes referred to the sonologist for evalua- • It shows poor vascularity.
tion of a firm nodular cervical or forniceal mass felt at a
bimanual clinical examination.
304 8 Endometriosis

a
LS TS

b c
LS LS

d TS e TS

Vagina
Vagina

Fig. 8.9 Cervical DIE. (a) A thickened, complex lesion of the cervix is seen, which is measured on LS and TS. The lesion shows irregular margins,
heterogeneous echotexture with a few cystic spaces, and acoustic shadowing (arrow). (b) Longitudinal section of the upper vagina and cervix
showing the cervical canal (short arrow) and thickened heterogeneous posterior wall of the cervix, continuous with a similarly thickened vagina
due to vaginal DIE (long arrow). (c) LS of the posterior compartment showing rectal DIE (arrow) which was continuous with the cervical and vagi-
nal DIE forming a contiguous DIE nodule involving the cervix, vagina and rectum. (d) Transverse section of the distal, posterior lip of the cervix
affected by DIE showing cystic spaces and irregular margins. (e) 3D rendered image of the same – corresponding to image (d)
8.1 Deep Infiltrating Endometriosis (DIE) 305

8.1.4 Uterosacral DIE (Figs. 8.10 and 8.11) tures that we generally can identify on a routine ultra-
sound, In addition, uterosacral DIE in isolation is usually
The uterosacral ligaments may also be involved with deep small. They are seen posterolateral to the cervix, and a
infiltrating endometriosis. Uterosacral DIE is difficult to comparison with the opposite side provides a convenient
diagnose, because the uterosacrals are not anatomic struc- control.

Fig. 8.10 Uterosacral DIE in a patient with right-sided rectovaginal DIE. (a) The lesion is seen as an oval, hypoechoic, diffuse, small mass (mea-
sured in the image). (b) Comparison with the contralateral side helps in making a diagnosis
306 8 Endometriosis

Fig. 8.11 Bilateral uterosacral DIE seen as small oval hypoechoic diffuse masses
8.1 Deep Infiltrating Endometriosis (DIE) 307

8.1.5 Bladder DIE der wall and mucosa. The lesion can be missed if TVS alone
is done with an empty bladder.
The bladder wall (generally the dome or the base of the bladder)
can also get affected by DIE. Bladder DIE is probably underdi- • The bladder wall at the site of the lesion is thickened.
agnosed because symptoms are usually non-specific, mimick- • The lesions are diffuse, round or comma-shaped. They are
ing recurrent cystitis. They include dysuria, urgency, frequency, hypoechoic and show low vascularity.
suprapubic pain, vesical tenesmus, incontinence and haematu- • The lesion may be seen protruding into the lumen of the
ria. Bladder DIE lesions seem to originate from adenomyosis of bladder both on 2D and 3D.
the anterior abdominal wall and may be continuous with it. In a • Most often, the lesions are continuous with the adenomyotic
study by Eisenberg et al. (2015), all 11 cases of bladder DIE anterior uterine wall, giving it an ‘hourglass’ appearance.
showed uterine adenomyosis with the lesion extending directly • The distance of the lesion from the trigone should be
from the anterior uterine wall in 9 out of the 11 cases. assessed because lesions near the trigone are challenging
to resect.
Ultrasound Features of Bladder DIE (Fig. 8.12)
For ultrasound diagnosis of bladder DIE, it is very important
that the bladder is partially filled so as to visualise the blad-
308 8 Endometriosis

Fig. 8.12 Bladder DIE. (a) A unicornu- a TS

ate right-sided uterus with a non-
communicating left horn that shows Bladder
adenomyotic changes and minimal turbid
blood in the endometrial cavity. (b) LS of
the rudimentary horn showing an
irregular hyperechoic area (arrow)
protruding into the bladder. (c) TS and LS
view showing bladder DIE which is seen
as an irregular, hypoechoic mass
protruding into the bladder. The bladder
DIE lesion is continuous with the
adenomyotic anterior wall of the
non-communicating horn. (d) DIE nodule
showing poor vascularity. (e) 3D rendered
image of the inner wall of the bladder,
showing a small irregular protrusion of b LS
the DIE nodule (arrow) into the bladder

Bladder

c TS LS

Bladder Bladder

d e
8.1 Deep Infiltrating Endometriosis (DIE) 309

8.1.6 DIE Involving the Ureters (Figs. 8.13 small extent to visualise a better length of the ureter. The
and 8.14) ureters are seen as oblique hypoechoic structures entering
the bladder base. Another technique is to first locate the
The ureters may be primarily involved by DIE or be second- entry point of the ureter in the bladder and then to angu-
arily affected due to fibrotic retraction by an adjoining DIE late and trace the ureter upwards. The ureter shows peri-
nodule. The resulting hydroureteronephrosis is often man- stalsis, and pressure from the TVS probe usually induces
aged by stenting, which is not always a permanent solution. peristalsis. The median diameter of the ureter at peristal-
The ureters can generally be visualised close to the sis is reported to be 2.9 mm (Pateman et al. 2013). In
bladder base unilaterally in all and bilaterally in 92.7 % of cases with obstruction, the portion of the ureter above the
cases (Pateman et al. 2013). From the long section view of obstruction will be seen to dilate significantly, and reverse
the bladder base and urethra, the probe is angled to one peristalsis may be seen, particularly if the obstruction is
side to visualise the distal ureter and then rotated to a significant.

a
Rt. Kidneys Lt. Kidneys

b Rt. Ureter c Lt. Ureter

Fig. 8.13 The kidney and ureter in a patient with rectovaginal DIE. (a) Shows a right-sided hydronephrosis with a normal left kidney. (b, c) Right
and left ureter showing minimal dilatation on the right side
310 8 Endometriosis

Fig. 8.14 Ureter with a stent (arrow) seen in a patient with right-sided
hydroureteronephrosis, secondary to DIE
8.1 Deep Infiltrating Endometriosis (DIE) 311

8.1.7 Uterus in Cases with DIE (Figs. 8.15 Another common feature of the uterus in cases with DIE
and 8.16) is adenomyosis which usually involves the posterior wall of
the uterus, because of the more common posterior compart-
In patients with DIE involving the posterior compartment, ment endometriosis.
the uterus is typically retroflexed at the mid corpus with the Therefore, if the uterus is ‘ear shaped’ or there is posterior
fundus directed posteriorly, giving the uterus an ‘ear’ shaped wall adenomyosis, one must suspect pelvic endometriosis
(also known as ‘comma’ shaped or ‘question mark’ shaped) and DIE.
appearance. Generally retroflexion of the uterus occurs at the
isthmus, but in these cases, with posterior compartment DIE,
it occurs higher up at the mid corpus.

a b

c d

Fig. 8.15 (a–c) ‘Ear’ shaped or ‘question mark’ shaped uterus with retroflexion at the midcorpus (arrows) on (a, b) TAS and (c) TVS.
(d) Normal uterus in comparison, where the retroflexion occurs lower down (arrow) – at the isthmus (i.e., the junction of the cervix with
the uterine body)
312 8 Endometriosis

a b
LS LS

c d
LS LS

Fig. 8.16 (a, b, c, d) Four cases of posterior compartment DIE showing thick and coarse posterior walls (arrows) suggestive of adenomyosis

Summary: DIE
sions), an ear-shaped uterine body and
• DIE lesions appear as fusiform/nodular, firm, tender, adenomyosis.
lesions with diffuse borders and poor vascularity. • TVS is the modality of choice and the approach should
Common sites are the rectosigmoid, uterosacrals, vag- be pain guided.
inal wall and bladder. • Proper pre-operative evaluation in patients with endo-
• The lesions are often not diagnosed due to lack of the metriosis is important (particularly for DIE) for opti-
knowledge of the spectrum of DIE. mal planning of surgery.
• Think DIE in women with chronic pelvic pain,
endometriomas, absent sliding sign (bowel adhe-
8.2 Extra-Pelvic Endometriosis 313

8.2 Extra-Pelvic Endometriosis surgery, and even in the absence of any pelvic endometriosis.
Patients may complain of recurrent cyclical pain in the
Though extra-pelvic endometriosis is rare, several cases of involved area during periods. They may also complain of
endometriosis of the abdominal wall, the lung, the pleura, the tenderness or a palpable mass, usually at the site of their
diaphragm, the pericardium and the gastrointestinal tract abdominal scar. Most often, however, pain is atypical, mak-
have been reported in literature. Symptoms vary depending ing diagnosis difficult.
on the site of endometrial tissue implantation. The diagnosis
of this entity is not easy. Diagnosis is by the presence of Ultrasound Features of Abdominal Wall Endometriosis
endometrial tissue from the site, which is often difficult to (Figs. 8.17, 8.18 and 8.19)
locate. The catamenial (related to periods), periodic, cyclical • The lesions are seen in the anterior abdominal wall (often
symptoms (or worsening of symptoms) help raise a clinical close to the site of the abdominal scar).
suspicion of extra-pelvic endometriosis in these patients. • They are typically hypoechoic and heterogeneous with
Fluid tapped (pleural or ascitic) from such patients will fuzzy borders.
appear haemorrhagic and is negative for malignancy and • They show poor vascularity.
tuberculosis. Obtaining endometrial glandular tissue in the • They may show some amount of acoustic shadowing.
fluid is unlikely, and, most often, all that is noted on cytology • The lesion may involve only the subcutaneous tissue or
is the presence of haemosiderophages (haemosiderin-laden both the subcutaneous and the underline muscle that is
macrophages). Managing these cases is also more challeng- extending on to both sides of the rectus sheath.
ing and varies from simple observation to medical or surgical • The lesion may occasionally be seen extending directly
treatment or a combination of these. from the anterior wall of the uterus.
• Lesions are firm, and the overlying skin may be discol-
oured if the lesion is superficial.
8.2.1 Abdominal Wall Endometriosis • They are usually tender to touch.
• The lesions are better seen with high-frequency linear
Abdominal wall endometriosis is the most common type of probes rather than standard curvilinear probes because of
the extra-pelvic endometriosis. It is often a consequence of the close proximity of these lesions to the abdominal probe.
LSCS or laparotomy wherein the uterine cavity was opened. • Comparison with normal abdominal wall elsewhere, pro-
It can, however, be found in the absence of a history of such vides a convenient control.

a b

Fig. 8.17 Abdominal wall endometriosis in two different patients showing vaguely circumscribed hypoechoic complex areas with poor vascularity
and minimal acoustic shadowing. (a) Superficial – in the subcutaneous tissue and (b) Deep – extending deeper beyond the rectus sheath (arrows)
314 8 Endometriosis

Fig. 8.18 Abdominal wall endometriosis on the right side of the abdomen imaged with a high-frequency linear probe. It is seen as a poorly
defined, heterogeneous mass with some acoustic shadowing. Normal abdominal wall tissue is seen on the left side of the same patient, serving as
a convenient control

Fig. 8.19 Abdominal wall endometriosis

(arrow), extending directly from the anterior wall LS
of the uterus

Uterus Bladder
8.2 Extra-Pelvic Endometriosis 315

8.2.2 Abdominal and Thoracic Endometriosis Extra-pelvic endometriosis may also involve the intes-
(Fig. 8.20) tines (the most common site being distal ileum and caecum)
with patients complaining of nausea, vomiting, loss of appe-
Thoracic endometriosis usually involves the pleura, the peri- tite, diarrhoea, cramping, abdominal bloating, etc., all get-
cardium and rarely the diaphragm. Most often, the patient ting worse during periods.
presents with catamenial (related to periods) pneumothorax, Endometriosis can rarely involve the liver, gall bladder
haemothorax, haemoptysis and chest pain. On ultrasound, and kidney.
turbid fluid and adhesions may be noted in the thoracic
cavity.
316 8 Endometriosis

a b

c d

Liver

Kidney

e f
Thoracic
Cavity

Haemorrhagic
Peritoneal
Heart Fluid

Fig. 8.20 Abdominal and thoracic endometriosis in a 27-year-old lady. She complained of dysmenorrhoea, breathlessness and vomiting during
periods. She gave a history of pleural effusion, which had been tapped elsewhere and reported as ‘haemorrhagic fluid negative for malignant cells
and negative for tuberculosis’. She was referred for a scan because the clinician felt a nodule in the posterior fornix. On scan, it was found she had
pelvic endometriosis and DIE. Turbid fluid and adhesions were seen in the general peritoneal cavity. (a, b) Images showing turbid fluid with mul-
tiple adhesions in the right and left upper abdomen. (c) Turbid fluid and adhesions seen between the liver and right kidney. (d) TS of the mid abdo-
men showing a significant amount of turbid fluid surrounding the bowel loops. (e) Thoracic cavity with arrow pointing at the heart (which was seen
pumping in real time) lying within turbid fluid, with adhesions all around. In the image, one can see only fluid between the rib cage and the heart.
(f) Sample of the peritoneal fluid that was tapped at our centre, showing haemorrhagic fluid. The fluid was negative for malignant cells and tuber-
culosis, but haemosiderophages were present
Suggested Reading 317

Suggested Reading Hudelist G et al (2013) Uterine sliding sign: a simple sonographic pre-
dictor for presence of deep infiltrating endometriosis of the rectum.
Ultrasound Obstet Gynecol 41:692–695
Chamié LP et al (2011) Findings of pelvic endometriosis at transvaginal
Pateman K et al (2013) Visualization of ureters on standard gynecologi-
US, MR imaging, and laparoscopy. Radiographics 31(4):E77–E100
cal transvaginal scan: a feasibility study. Ultrasound Obstet Gynecol
Donato D et al (2015) Question mark form of uterus: a simple sono-
41:696–701
graphic sign associated with the presence of adenomyosis.
Piketty M et al (2009) Preoperative work-up for patients with deeply
Ultrasound Obstet Gynecol 46:126–127. doi:10.1002/uog.14750
infiltrating endometriosis: transvaginal ultrasonography must defi-
Eisenberg VH et al (2015) OP15.06 Bladder detrusor endometriosis:
nitely be the first-line imaging examination. Hum Reprod
where does it come from? Ultrasound Obstet Gynecol 46:98.
24(3):602–607
doi:10.1002/uog.15242
Reid S et al (2011) Sonovaginography: redefining the concept of a “nor-
Guerriero S et al (2011) Ultrasonography in deep endometriosis: a con-
mal pelvis” on transvaginal ultrasound pre-laparoscopic interven-
sensus opinion from the International Deep Endometriosis Analysis
tion for suspected endometriosis. AJUM 14(2):21–24
(IDEA) group. A preliminary statement. Ultrasound Obstet Gynecol
Reid S et al (2014) Office gel sonovaginography for the prediction of
38:265
posterior deep infiltrating endometriosis: a multicenter prospective
Guerriero G et al (2016) Systematic approach to sonographic evalua-
observational study. Ultrasound Obstet Gynecol 44:710–718
tion of the pelvis in women with suspected endometriosis, including
Savelli L et al (2009) Diagnostic accuracy and potential limitations of
terms, definitions and measurements: a consensus opinion from the
transvaginal sonography for bladder endometriosis. Ultrasound
International Deep Endometriosis Analysis (IDEA) group.
Obstet Gynecol 34:595–600. doi:10.1002/uog.7356
Ultrasound Obstet Gynecol. doi:10.1002/uog.15955
Vimercati A et al (2012) Accuracy of transvaginal sonography and con-
Hudelist G et al (2009) Combination of transvaginal sonography and
trast‐enhanced magnetic resonance‐colonography for the presurgi-
clinical examination for preoperative diagnosis of pelvic endome-
cal staging of deep infiltrating endometriosis. Ultrasound Obstet
triosis. Hum Reprod 24(5):1018–1024
Gynecol 40(5):592–603. doi:10.1002/uog.11179
Hudelist G et al (2011) Transvaginal sonography vs. clinical examina-
tion in the preoperative diagnosis of deep infiltrating endometriosis.
Ultrasound Obstet Gynecol 37(4):480–487
 Ultrasound Evaluation of Adnexal
Pathology 9

9.1 Fallopian Tube Chaps. 10 and 11, respectively. A tube may be twisted along
with the ovary in about 60 % of cases of ovarian torsion. A
The fallopian tube is anatomically divided into four segments: diseased tube like one with a hydrosalpinx or a tubal ectopic
the proximal interstitial part (which lies within the uterine can also undergo torsion independent of the ovary.
myometrium), the isthmus (which has thicker walls), the
ampulla (which is thin walled) and the infundibulum (which is
the distal end of the fallopian tube), ending in the fimbriae.
The fallopian tube is lined with ciliated epithelium. 9.2 Pelvic Inflammatory Disease (PID)
The normal fallopian tube is difficult to visualise on ultra-
sound unless it is surrounded by fluid, as is often seen follow- Pelvic inflammatory disease is the infection and inflamma-
ing ovulation. The normal fallopian tube appears as an tion of the upper female genital tract. It is seen in women
elongated, undulating, isoechoic structure about 8–10 mm belonging to the reproductive age group and is more com-
wide. Doppler flows can be seen in the normal fallopian tube mon in women with multiple sexual partners, women who
and pulse Doppler tracing shows a protodiastolic notch (which use intrauterine contraceptive devices, post-abortal or puer-
is not seen in ovarian tissue), which may help in identifying peral women and in those who have undergone intrauterine
the tube. The tube is generally located lateral to the ovary, procedures.
between the ovary and the lateral pelvic wall. During ovula- Pelvic infection primarily involves the fallopian tubes.
tion, when free fluid is seen in the POD, fimbriae may be seen However, the ovaries and the endometrium can also be
floating within the fluid in the POD. The lumen of the fallo- involved. In PID, generally the involvement is bilateral.
pian tube is not seen unless it is distended with fluid, and Infection of the endometrium is dealt with in Chap. 4.
depending on the type of fluid within, possibilities include:
Acute PID Typical symptoms of acute PID are pelvic pain,
• Hydrosalpinx – with clear (anechoic) fluid in its lumen, fever, dyspareunia and vaginal discharge. Clinical examina-
which may be the result of chronic infections, tubal liga- tion may reveal tenderness or a pelvic mass.
tion or tubal malignancy. In PID generally the adnexal involvement is bilateral.
• Pyosalpinx – with pus (turbid fluid) in its lumen seen in Acute PID may resolve or proceed to chronic PID.
acute PID. The ultrasound findings in PID vary based on the severity
• Hematosalpinx – with blood (turbid fluid) in its lumen. and the organs involved. They include:
This may be seen in cases with tubal ectopic pregnancy,
endometriosis, torsion of a hydrosalpinx or associated 1. Essentially normal – with just mild tenderness of adnexa
with hematometra. and hazy margins of the ovary (Fig. 9.1).

A tubal mass when distended with fluid appears sausage 2. Tubal or a tubo-ovarian mass – when the tube is inflamed
shaped and shows incomplete septae, which is because of infold- (salpingitis).
ing of its walls, as the tube bends over itself. The incomplete Ultrasound Features of a Tubal or Tubo-ovarian Mass
septum, if seen, is specific of a cystic mass of tubal origin. (Figs. 9.2, 9.3 and 9.4)
Tubal pathology includes infection, torsion, ectopic and • The tube appears thickened (more than 10 mm in diameter).
neoplasia. Infection and neoplasia will be dealt with in this • It shows increased vascularity. In acute infection, typically
chapter. Ectopic pregnancy and torsion are dealt with in there are several, small vessels that run perpendicular to

© Springer Nature Singapore Pte Ltd. 2017 319

M. Sibal, Ultrasound in Gynecology, DOI 10.1007/978-981-10-2714-7_9
320 9 Ultrasound Evaluation of Adnexal Pathology

the long axis of the tube. The flow in these vessels is gen- • This could appear as a unilocular or multilocular thick-
erally of low RI (>0.45). walled structure.
• Very often, the tubes and ovaries are adherent to each • High vascularity is noted in its walls. Flow indices typ-
other forming a tubo-ovarian mass. ically show low resistance (RI >0.45), but often it is
• The mass is tender to touch. not so.
• The fluid within the cystic spaces is turbid (shows low-
3. Pyosalpinx – this is nothing but an infected fallopian tube grade internal echoes). The relatively hyperechoic areas,
with pus in its lumen, typical of acute PID. seen at times within the hypoechoic purulent contents,
Ultrasound Features of a Pyosalpinx (Figs. 9.5, 9.6, 9.7, usually appear as wavy/linear, stretchy (i.e., lengthen on
9.8, 9.9, 9.10 and 9.11) pressure) bands.
• A pyosalpinx appears as a fluid-filled tubular, somewhat • It may be difficult to distinguish between the tubal and the
folded or undulated mass. At times, the pyosalpinx may ovarian components. Generally, the tubal component
appear like a typical tubal mass showing an incomplete (pyosalpinx) has cystic spaces communicating with each
septum. other, whereas the ovarian component (abscess) has cir-
• It shows thick echogenic walls. A wall thickness of 5 mm cumscribed collections which occasionally may commu-
or more implies acute PID. nicate with the pyosalpinx. At times when there are
• The walls show increased vascularity. Flow indices typi- multiple ovarian purulent collections, the intervening wall
cally show low resistance (RI >0.45), but very often it is may undergo necrosis, and the cystic areas may commu-
not so. In addition, variable values may be obtained in a nicate with each other through the breach in the interven-
given case. ing septum.
• The lumen of the tube contains fluid showing low-grade • Very often, however, the tube cannot be differentiated
internal echoes suggestive of turbid fluid (pus). from the ovary in a tubo-ovarian abscess.
• On cross section, the pyosalpinx shows a relatively • The masses are usually very tender.
anechoic or hypoechoic central lumen with thick walls • These masses are usually adherent to the uterine walls.
and mucosal folds – the so-called ‘cogwheel sign’ • There may be pus seen in the POD and around the masses.
(because of its resemblance with a cogwheel). The cog-
wheel sign is pathognomonic of acute infection of the fal- 5. Pus in the POD (Figs. 9.19 and 9.20) – in acute PID,
lopian tube. one may see turbid fluid in the POD suggestive of pus.
• In acute PID, the pyosalpinx is typically tender to touch. Since it is not encapsulated, the margins of the collec-
tion are irregular and angulated, filling the gaps
4. Tubo-ovarian abscess – in some cases, pus is seen both in between the tissue planes. This pus may be drained
the tube and the ovary, forming a tubo-ovarian abscess. transvaginally primarily for culture and sensitivity.
Ultrasound Features of a Tubo-ovarian Abscess Draining out large quantities of pus may bring symp-
(Figs. 9.12, 9.13, 9.14, 9.15, 9.16, 9.17 and 9.18) tomatic relief to the patient.
9.2 Pelvic Inflammatory Disease (PID) 321

Fig. 9.1 Ovaries showing slightly hazy margins in a patient with PID

a b

Fig. 9.2 Tubo-ovarian mass. (a) Right adnexa shows the right ovary inferiorly and a complex elongated tubal mass (arrow) superiorly. (b) Left
adnexal mass showing the left ovary with follicles and a solid tubal mass (arrow) posterolateral to the left ovary. (c) Left and right TO masses
showing increased vascularity of the tubal components
322 9 Ultrasound Evaluation of Adnexal Pathology

b TS LS c TS LS

d TS LS e

Fig. 9.3 Left adnexal TO mass. (a) A complex TO mass with solid and cystic areas. It was composed of different adnexal components. (b)
Left ovary that formed a part of the mass. (c) Left tubal mass with hydrosalpinx formed the second component. (d) PO cyst with turbid
contents was another component of the TO mass. (e) Turbid fluid suggestive of pus surrounding the TO mass. (f) Scan following treatment
with antibiotics shows a resolution of pathology. The left ovary shows hazy margins and the PO cyst shows fluid–fluid level, with the denser
debris in its posterior dependent part. No obvious tubal mass was noted
9.2 Pelvic Inflammatory Disease (PID) 323

Fig. 9.3 (continued)

a b LS

Fig. 9.4 Salpingitis in a patient on treatment for tuberculosis. (a) Bilateral hypoechoic elongated masses showing high vascularity suggestive of
bilateral inflamed tubal masses. (b) Minimal turbid fluid seen in the endometrial cavity suggestive of associated endometritis
324 9 Ultrasound Evaluation of Adnexal Pathology

b
TS LS

c d

Fig. 9.5 Bilateral pyosalpinx. (a) Right fallopian tube with thick turbid contents. (b) Complex left adnexal tubal mass showing a cross section of
the fallopian tube which shows thick, hyperechoic walls with prominent mucosal folds (cogwheel sign – outlined in image). (c) Cross section of
the pyosalpinx showing increased flow in its walls. (d) Diagrammatic representation of a cogwheel
9.2 Pelvic Inflammatory Disease (PID) 325

TS LS

Fig. 9.6 Pyosalpinx – TS of the right adnexa showing a cross section of a pyosalpinx (arrow) with hyperechoic, swollen tubal walls and mucosa
(cogwheel sign). LS showing thickened tubal walls with turbid fluid in its lumen (arrow). Increased vascularity is seen in the tubal walls
326 9 Ultrasound Evaluation of Adnexal Pathology

a b
PYOSALPINX

Fig. 9.7 Bilateral pyosalpinx. (a) Left pyosalpinx seen as a complex mass with an irregular elongated lumen showing turbid contents (pus) within
(arrow). The walls of the lumen are thick and show increased vascularity. (b) Right pyosalpinx seen as an elongated mass with turbid contents (pus)
in its lumen (arrow) and thick tubal walls surrounding the lumen

a b

Fig. 9.8 Pyosalpinx. (a) Greyscale image showing a tubular undulating mass with dilated tubal lumen, which shows hypoechoic turbid contents
suggestive of pus. (b) Increased flow in the walls of the pyosalpinx. (c) 3D rendered image showing the folded tubal mass with turbid contents within
9.2 Pelvic Inflammatory Disease (PID) 327

a b

Fig. 9.9 Bilateral pyosalpinx. (a) Greyscale image with right tube showing thick walls with pus within. Left adnexal tubal mass showing fluid
only in some segments of the tube. (b) 3D rendered image showing swollen tubal mucosa and turbid contents, with few scattered debris within its
lumen (arrow)

Fig. 9.10 Pyosalpinx – folded tube showing turbid contents suggestive

of pus. The walls of the tube are thick and vascular. A thick incomplete
septum is seen because of the folding of the tube on itself
328 9 Ultrasound Evaluation of Adnexal Pathology

a b
LS TS

c d

Fig. 9.11 Unilateral pyosalpinx. (a) Showing incomplete septum (arrow), thick walls with high vascularity and turbid contents. (b) Section across
the plane (long white line) shown in (a) resulting in two cross sections of the single pyosalpinx. (c) A small fimbrial cyst (arrow) is seen beside the
pyosalpinx showing thick vascular walls. (d) Inflamed fimbrial cyst (arrow) attached to the pyosalpinx seen at laparoscopy
9.2 Pelvic Inflammatory Disease (PID) 329

a TS LS b

c d TS LS

e f TS
LS

UT

Fig. 9.12 Bilateral tubo-ovarian abscesses seen as multilocular, thick-walled masses. (a) Right adnexa (TO abscess) – showing a cystic area in
right ovary with turbid contents (probably pus). Tubal component is seen with turbid contents in its lumen (arrows). (b) Transverse section showing
left paraovarian cyst with a multilocular cystic mass (TO abscess) superior to it. (c) Moderate vascularity noted in the left adnexal mass. (d) Pus in
the POD is seen as a hypoechoic area with linear hyperechoic strands within. (e,f) Thick hyperechoic bands suggestive of organised strands of pus
seen between the posterior wall of the uterus and the right adnexal mass (arrow) and also between the two adnexal masses (arrow) in the POD
330 9 Ultrasound Evaluation of Adnexal Pathology

a LS b LS

UT

Fig. 9.13 TO abscess. (a) IUCD is seen in the endometrial cavity with a complex mass (the TO abscess) posterior to the uterus, in the POD.
(b) Long section of the TO abscess showing a pyosalpinx anteriorly (short arrow) and pus collection posteriorly (long arrow)

a b
TS LS

c TS LS d

Fig. 9.14 Bilateral TO abscess. (a) Left adnexa: complex left adnexal mass seen with some ovarian tissue in its inferior part. Hyperechoic scattered
echoes seen within the mass. (b) Tubal component of the TO mass is seen with a linear arrangement of scattered hyperechoic foci suggestive of air
within its lumen, secondary to infection by gas-producing organisms. (c) Multilocular right adnexal mass showing thick turbid contents suggestive
of pus. (d) Locules are seen communicating with each other (arrow). 300 ml of pus was drained from the right TO mass
9.2 Pelvic Inflammatory Disease (PID) 331

a
LS TS

UT

b c

d LS e LS

Fig. 9.15 Bilateral TO abscesses. (a) TAS – uterus seen anteriorly. Complex hypoechoic masses are seen behind the uterus bilaterally. On TAS,
details cannot be assessed. (b) TVS – left-sided TO abscess seen. The tubal component (arrow) shows cystic irregular spaces with turbid fluid,
communicating with each other. (c) Flow in the mass shows an RI of 0.5. (d) TVS – right adnexal mass showing a pyosalpinx (arrow), seen as a
hyperechoic, thick, elongated mass with turbid contents within, which was placed over a large area with purulent (turbid) contents, probably an
ovarian abscess. (e) The right pyosalpinx (arrow) shows thick vascular walls
332 9 Ultrasound Evaluation of Adnexal Pathology

LS
TS

b c

Fig. 9.16 Acute superimposed on chronic PID. Patient who gave a past history of PID, presented with lower abdominal pain and fever. (a)
Complex right adnexal mass showing cystic spaces with turbid contents communicating with each other, suggestive of a TO abscess. (b) Mass
showed mild to moderate vascularity. (c) Minimal turbid collection seen in the endometrial cavity suggestive of associated endometritis
9.2 Pelvic Inflammatory Disease (PID) 333

a
TS LS

b
TS LS

Fig. 9.17 TO mass with pyosalpinx. (a) Complex mass seen with solid and cystic areas. Tubal component identified by the presence of turbid
fluid (arrows) within thick-walled structures that were communicating with each other on angulating the probe. (b) Increased vascularity noted in
the tubal walls
334 9 Ultrasound Evaluation of Adnexal Pathology

a TS LS

b C
TS LS

UT

UT

d LS

UT

Fig. 9.18 PID with right-sided tubo-ovarian mass. (a) Complex mass seen with no ovarian tissue identified. (b) In one section, the cogwheel pat-
tern suggestive of a cross section of a pyosalpinx is seen (arrow). (c) IUCD is seen in the endometrial cavity. The right tubal mass was adherent to
the posterior walls of the uterus. (d) Loculated area of pus collection is seen in the POD, showing fluid–fluid level
9.2 Pelvic Inflammatory Disease (PID) 335

a
TS LS

b
LS TS

Fig. 9.19 Pus in two different cases, seen as a hypoechoic area with uniform low-grade internal echoes. (a) Pus in the POD. (b) Pus seen lying
between bilateral TO abscesses in the POD
336 9 Ultrasound Evaluation of Adnexal Pathology

a LS b TS LS

c d

Fig. 9.20 (a) Long section of the uterus showing pus in the POD. (b) Collection in the POD showing a fluid–fluid level. (c) Drainage of pus in
POD with a needle (arrow) seen in situ. (d) 220 ml of pus which was drained from the POD

Summary: Acute PID

• It is common in women belonging to the reproduc-
tive age group, and the infection is often secondary
to instrumentation or is sexually transmitted.
• Associated features include fever and pain in the
abdomen.
• It is typically bilateral, and ultrasound findings
depend upon severity of disease from mild tender-
ness with hazy borders and increased vascularity of
adnexa to a solid TO mass, pyosalpinx or a tubo-
ovarian abscess.
• A pyosalpinx shows thick vascular tubal walls with
turbid (hypoechoic) fluid within, and its cross sec-
tion gives a ‘cogwheel’ appearance.
9.3 Chronic PID 337

9.3 Chronic PID adherent to the uterus. Other causes for pelvic adhesions
are endometriosis and previous surgery.
A typical example of chronic PID is tuberculosis. • Ovarian abscess, which is seen as a persistent cystic mass
with turbid contents in the ovary, could be an occasional
Ultrasound Features of Chronic PID (Fig. 9.21) finding.
• The presence of a hydrosalpinx. • Hyperechoic foci along the surface of the ovary is another
• Solid, thick (10 mm or more) tubal masses with hyper- reported finding associated with chronic infections, par-
echoic walls, showing mild to moderate vascularity. ticularly tuberculosis.
• The structures are usually not tender, unless there is a
superadded acute infection, in which case findings may In abdominopelvic tuberculosis, the most common findings
overlap with that of acute PID. are ascites, peritoneal inclusion cysts, matted bowel loops, com-
• Pelvic adhesions with loculated fluid (peritoneal inclu- plex tubal masses and, in a small percentage, general peritoneal
sion cysts) are often a significant finding in tuberculosis, thickening seen over the pelvic organs. Ovaries are usually nor-
and the uterus and ovaries may appear enmeshed in the mal. Ultrasound cannot diagnose but raises a suspicion of tuber-
adhesions. The ovaries and bowels may also appear culosis and is useful in monitoring the response to therapy.
338 9 Ultrasound Evaluation of Adnexal Pathology

a LS TS b
LS

c d

e LS TS f TS LS

Fig. 9.21 Case of pelvic tuberculosis. (a) TAS – showing the uterus surrounded by loculated fluid and adhesions. (b) Multiple adhesion seen in
the POD and above the uterine fundus. (c) Transverse section of the right lower abdomen showing multiple dense adhesions. (d) Solid, thick,
hyperechoic tubal mass showing moderate vascularity suggestive of salpingitis. Ovary shows an isoechoic cystic area, probably an ovarian abscess
(arrow), (e, f, g) Scan following 3 weeks of treatment with antituberculosis medication. (e) Uterus seen with minimal adhesions and loculated fluid
posterior to it (compare with image (a)). (f) Ovarian cystic collection reduced in size and appearing more hypoechoic (compare with image (d)).
(g) Left adnexa showing an elongated tubal mass with minimal fluid in its lumen (compare with image (d)). The image on the right side shows
minimal periovarian adhesions
9.3 Chronic PID 339

Summary: Chronic PID

• This is either a sequel of acute PID or secondary to
chronic infections like tuberculosis.
• This tends to be bilateral and hydrosalpinx is a
known feature of chronic PID. Other features
include TO masses with ovaries and hydrosalpinx
adherent to each other and pelvic adhesions with
pelvic organs adherent to each other. Loculated
fluid is often seen between the adhesions.
340 9 Ultrasound Evaluation of Adnexal Pathology

9.4 Hydrosalpinx • ‘Beads-on-string’ appearance – on cross section, the

walls of the hydrosalpinx show hyperechoic mural
As mentioned earlier, a hydrosalpinx is a tubal mass with nodules (>3 mm in height), which are nothing but
clear fluid in its lumen. It is usually the end result of a compressed endosalpingeal (tubal mucosal) folds
chronic or past infection, which may have been subclini- giving it a ‘beads-on-string’ appearance. Interestingly
cal. It can also be seen following tubectomy. Most patients most often there are three prominent nodules in a
are asymptomatic, and hydrosalpinges are usually found cross section of the hydrosalpinx (like a ‘therefore’
incidentally on ultrasound done for other reasons. abbreviation).
Occasionally, they may undergo torsion. Clinically they • On cross section, they may appear like multiple circum-
are of significance because they may be mistaken for a scribed cystic spaces beside each other, but on angulating
cystic ovarian mass, particularly in postmenopausal the probe, they appear as elongated cystic areas commu-
women where the atrophic small ovaries may not be visu- nicating with one another.
alised. They are usually bilateral. • On 3D ultrasound, their morphology is often well seen
because of a better depth perception. The compressed
Ultrasound Features of Hydrosalpinx (Figs. 9.22, 9.23, tubal mucosal folds may also be seen as linear folds on a
9.24, 9.25, 9.26 and 9.27) 3D rendered image. 3D ultrasound is, however, not essen-
• A cystic mass with anechoic fluid. tial for diagnosis.
• Elongated mass which is often retort shaped or sausage • The differential diagnosis for a hydrosalpinx is any elon-
shaped. gated cystic mass in the pelvis like a blood vessel or a
• Presence of incomplete septae, formed as a result of tubal fluid-filled intestine. Blood vessels will show colour fill-
infolding. If present, they are very specific of a tubal mass. ing on Doppler, while intestines show peristalsis, unlike a
• The walls of the hydrosalpinx are thin and show minimal hydrosalpinx.
vascularity.
9.4 Hydrosalpinx 341

a b
LS TS

c d

Fig. 9.22 (a) Long section of a hydrosalpinx showing incomplete septae and anechoic cystic contents. (b) Transverse section of the hydrosalpinx
perpendicular to the section in image (a), showing multiple, circumscribed, cystic areas with anechoic contents and beaded thin walls. (c) 3D
rendered image of the hydrosalpinx. (d) Minimal flow with spectral Doppler showing protodiastolic notch (which is typical of tubal tissue flows)
342 9 Ultrasound Evaluation of Adnexal Pathology

a TS LS b TS

Fig. 9.23 Three different cases of hydrosalpinx. (a) Sausage-shaped elongated hydrosalpinx. (b) Cross section of hydrosalpinx showing tiny
hyperechoic bead-like nodularity along its walls (compressed tubal mucosal folds) (short arrows). (c) 3D rendered image showing incomplete
septae (arrows)
9.4 Hydrosalpinx 343

a b

Fig. 9.24 (a) Hydrosalpinx seen as globular cystic mass with thin incomplete septae. (b) Minimal flow seen in the walls of the hydrosalpinx

a TS LS b TS LS

Fig. 9.25 Hydrosalpinx. (a) Retort shaped. (b) Oval shaped

344 9 Ultrasound Evaluation of Adnexal Pathology

a b

c d

Fig. 9.26 Hydrosalpinx showing thin incomplete septae in different cases. (a–c) Hydrosalpinges seen on greyscale. (d) 3D rendered image of a
hydrosalpinx showing the incomplete septum (short arrow) and compressed mucosal folds (long arrow)
9.4 Hydrosalpinx 345

a b

c d
TS LS

e f

Fig. 9.27 (a–e) Hydrosalpinges showing ‘beads-on-string’ appearance (in cross-sectional views). (e, f) Walls of a hydrosalpinx showing poor
vascularity

Features differentiating a hydrosalpinx from a pyosalpinx:

Features Pyosalpinx Hydrosalpinx
Pathology Acute PID Chronic PID
Shape Elongated/undulating Sausage/retort
Incomplete septum Occasionally seen Commonly seen
Walls Thick > 5 mm Thin
Vascularity High Low
Mucosal folds Swollen Compressed
Transverse section ‘Cogwheel’ appearance ‘Beads-on-string’
appearance
Contents Turbid Clear
fluid – hypoechoic fluid – anechoic

At times, tubal morphology on ultrasound may appear

between a pyosalpinx and a hydrosalpinx. This may be seen
with subacute infections, or during the transition from acute
to chronic PID, or in cases with acute on chronic infection.
346 9 Ultrasound Evaluation of Adnexal Pathology

9.5 Tubal Malignancy • The solid mass appears ovoid or may be a sausage-shaped
structure.
Malignancy of the fallopian tube is very rare, comprising • The solid tissue shows moderate to high vascularity (in
about 0.18–1.6 % of all gynecological malignancies. Its inci- most cases it is highly vascularised). The flow into the
dence is probably underestimated because very often, par- mass is typically seen from, and perpendicular to the
ticularly in advanced cases, it may be attributed to ovarian outer walls of the mass.
carcinoma. The most common fallopian tube carcinoma is • Very often, fluid is seen within the tubal lumen forming a
serous adenocarcinoma (in about 80 %). Others include hydrosalpinx. The contents are generally anechoic. This
endometrioid, clear cell, mucinous or undifferentiated carci- has been termed ‘hydrops tubae profluens’.
nomas. Serous tubal intraepithelial carcinoma (STIC) is • Solid vascular tissue protruding into a hydrosalpinx is
believed to be a precursor of carcinoma of the fallopian tube highly suggestive of fallopian tube carcinoma. This solid
and probably also the ovary. It is more common in nullipa- tissue could either fill the entire tubal lumen and adjoin or
rous women, those with a history of infertility and chronic protrude into the hydrosalpinx from one side, or it may be
infection. The women in these cases are usually postmeno- seen as solid tissue projecting into the lumen of the hydro-
pausal. Most often, the distal two-third of the tube is involved. salpinx from one wall like a large papilla. Most often, in
The women with tubal carcinoma may be asymptomatic or tubal carcinoma the number of such papillae is one or a
present with vaginal bleeding, abdominal pain, excessive few at the most.
watery discharge or a pelvic mass. The ‘Latzko triad’ includes • Normal ovary or ovarian tissue may be seen alongside the
intermittent colicky pelvic pain, pelvic mass and bloody–watery solid mass. The probability of a tubal neoplasia is particu-
discharge. These classical symptoms of tubal carcinoma are larly high if the entire ovarian margins can be
only seen in about 10 % of patients. Watery discharge (hydrops delineated.
tubae profluens) is a very classic feature of women with fallo- • Clear watery fluid may also be seen in the endometrial
pian tube carcinoma but is seen in only 20 % of women. The cavity.
diagnosis of tubal carcinoma is by histopathology. The treat- • Free fluid is commonly seen in the pelvis.
ment and prognosis are similar to that of ovarian carcinoma.
Differential diagnosis is ovarian neoplasia or a subserous
Ultrasound Features of Tubal Malignancy (Figs. 9.28 fibroid and in some cases may be a true diagnostic
and 9.29) challenge.
• It typically presents as a solid mass but may show a few
cystic spaces within the solid tissue.
9.5 Tubal Malignancy 347

a b
TS LS

c d TS LS

Fig. 9.28 Case in which fallopian tube carcinoma was suspected. (a) Hydrosalpinx on TS and LS. TS image shows compressed mucosal folds as
beads along its inner walls. (b) LS view of a hydrosalpinx shows a small, irregular, hyperechoic protrusion (arrow) into its lumen, from its superior
wall. (c) The solid protruding mass measured about 13 mm × 7 mm × 12 mm. (d) Mass protruding into the hydrosalpinx showing high vascularity
raising a very high suspicion of a malignant neoplastic mass

a LS b

Fig. 9.29 Case of fallopian tube carcinoma. (a) Longitudinal section of the uterus showing minimal anechoic fluid in the endometrial cavity. The
neoplastic solid mass is seen behind the uterus in the POD. (b) A solid heterogeneous mass is seen in the left adnexa. (c) Increased vascularity is
seen in the mass with vessels seen arising perpendicularly from the outer walls. (d) One end of the mass shows a small cystic area with an incom-
plete septum (short arrow) suggestive of a hydrosalpinx. Just inferior to this, the entire left ovary is seen. (e) A solid mass (arrow) is seen protrud-
ing into the hydrosalpinx, highly suggestive of a neoplastic mass of the fallopian tube. (f) Flow in the mass showed a low RI of 0.13. (g) Operative
specimen showing the neoplastic fallopian tubal mass (arrow)
348 9 Ultrasound Evaluation of Adnexal Pathology

c d

e f

Uterus

Fig. 9.29 continued

Summary: Tubal Malignancy

• Rare malignancy seen commonly in postmeno-
pausal women.
• Clinical presentation: abdominal pain, bloody–
watery discharge and pelvic mass.
• On ultrasound, it typically appears as a solid adnexal
mass or a solid mass with a hydrosalpinx or a solid
papillary projection into a hydrosalpinx, with the
solid tissue showing high vascularity.
• Differential diagnosis is an ovarian neoplasm or a
subserous fibroid. Presence of a normal ovary, sepa-
rate from the mass, helps differentiate it from ovar-
ian masses.
9.6 Paraovarian and Paratubal Cysts 349

9.6 Paraovarian and Paratubal Cysts Ultrasound Features of Paraovarian and Paratubal Cysts
(Figs. 9.30, 9.31, 9.32, 9.33, 9.34, 9.35 and 9.36)
Paraovarian cysts account for 10–20 % of adnexal masses. • These cysts are seen separate from the ovaries or, if adja-
These are epithelium-lined, fluid-filled cysts seen in the cent to the ovaries, can be pushed away from them (slid-
adnexa adjacent to the ovary and the fallopian tube. ing or splitting sign). A few may be adherent to the ovary,
Paraovarian cysts are remnants of mesonephric (Wolffian) which makes it difficult to differentiate them from exo-
ducts. Paratubal cysts include mesosalpingeal cysts, hydatid phytic ovarian cysts.
cysts of Morgagni (also known as fimbrial cysts) and those • They are usually unilocular, thin-walled, round or oval
arising from Mullerian (paramesonephric) duct remnants. cysts. However, neoplastic ones may appear septate.
Paratubal cysts are usually a little away from the ovary, while • They are typically anechoic, unless they have undergone
paraovarian cysts are seen adjacent to the ovary. torsion (when there may be blood within the lumen giv-
They are commonly found in women belonging to the ing the fluid a turbid appearance), are neoplastic (con-
reproductive age group. Most of them are benign and asymp- tents may show internal echoes) or are affected by PID
tomatic, and their significance is mainly because of their (may show turbid fluid or debris within). Most often
resemblance with other cystic masses in the adnexa, more so they are small but may be moderate in size. Only rarely
in postmenopausal women. Occasionally, however, they may are they large, when they may be neoplastic.
be neoplastic or may undergo torsion. • Their walls are thin and smooth and show minimal vascu-
Fimbrial cysts (hydatid cysts of Morgagni) are a type of larity. Exceptions are infections (when the walls may be
paratubal cysts seen as small, anechoic, unilocular and thick and vascular) or torsion (when the walls may be
smooth-walled cysts. They are frequently multiple and thick and avascular).
appear as pedunculated cysts connected to the fimbriae of the • Presence of solid tissue within a paraovarian cyst may
fallopian tubes. Occasionally, when there is fluid in the pel- suggest a benign or malignant neoplasm, which is very
vic cavity, one may see these cysts moving in the pelvic fluid rare.
along with the fimbriae to which they are attached, when a
specific diagnosis can be made. Most often, however, they
are reported as paraovarian cysts.
350 9 Ultrasound Evaluation of Adnexal Pathology

a b

c TS LS d TS LS

Fig. 9.30 Case of PO cyst with typical ultrasound findings. (a) Anechoic, unilocular, thin-walled cyst (198 cc). (b) Cyst wall shows low vascular-
ity. (c, d) Normal right and left ovaries are seen separate from the cyst

a b

Fig. 9.31 (a) Case 1 – wedge of tissue (arrow) is seen intervening between the PO cyst and the right ovary suggesting that they are likely to be of
different origin. (b) Case 2 – thin-walled fimbrial cyst seen with minimal fluid surrounding it. Arrow pointing at the minimal fimbrial tissue
9.6 Paraovarian and Paratubal Cysts 351

a b

Fig. 9.32 (a) PO cyst showing two small papillary projections from the cyst wall. (b) Papillae showing poor vascularity. (c) 3D rendered image
showing the two papillae within the cyst (arrow). HPE: papillary serous cystadenoma (of a PO cyst)
352 9 Ultrasound Evaluation of Adnexal Pathology

a
TS LS

b c
RT

Fig. 9.33 (a) PO cyst showing a papilla protruding into it. The papilla showed acoustic shadowing (arrow), which is typical of a serous cystadeno-
fibroma. (b,c) Atrophic right and left ovary, consistent with the patient’s postmenopausal status. HPE: papillary serous cystadenofibroma of a PO cyst
9.6 Paraovarian and Paratubal Cysts 353

a TS LS

b c LS

d LS e Lt Ovary
Rt Ovary

P O Cyst

Fig. 9.34 PO cyst with septae. (a) Cyst measuring 240 cc. (b) Cyst showing dense fibrous septae that cause minimal acoustic shadowing. (c) No
vascularity is seen in the cyst wall or septae. (d) Normal right ovary is seen adherent to one end of the PO cyst (arrows). The ovary could not be
separated from the cyst on pressure with the TVS probe. (e) Left ovary appearing normal. HPE: serous cystadenoma of a PO cyst
354 9 Ultrasound Evaluation of Adnexal Pathology

a b

Fig. 9.35 Infected PO cyst. (a) Showing thick walls and forming a part of a TO mass in a patient with PID. (b) Scan image of the same patient
following treatment with antibiotics. The cyst shows turbid contents with fluid–fluid level

a TS LS

b RT OVARY c LT OVARY

Fig. 9.36 PO cyst with torsion. Patient presented with acute abdominal pain. Scan done elsewhere had shown a left ovarian septate cyst. (a) TAS
shows a 118 cc anechoic cyst. (b,c) Normal right and left ovary seen separate from the cyst. (d) TVS shows an anechoic cyst with septae. (e) Cyst
walls showing flow with an RI of 0.65. (f) Twisted pedicle of the torsed PO cyst is seen showing a whirlpool sign on greyscale and Doppler (arrows)
9.6 Paraovarian and Paratubal Cysts 355

d e

Fig. 9.36 continued

Summary: Paraovarian and Paratubal Cysts

• They are commonly found adnexal cysts that are
usually benign and asymptomatic.
• They are seen separate from the ovary or can be
pushed away from the ovary, and this helps in dif-
ferentiating them from ovarian cysts.
• They are typically anechoic, unilocular, smooth-
walled, simple cysts.
• They may occasionally be neoplastic or undergo
torsion.
356 9 Ultrasound Evaluation of Adnexal Pathology

9.7 Peritoneal Inclusion Cysts • Incomplete septae may also be seen because of infolding
of these lax adhesions/septae but, unlike hydrosalpinges,
Peritoneal inclusion cysts are basically areas of loculated they do not show the typical ‘beads-on-string’ appear-
fluid trapped between adhesions. They are generally a result ance (the compressed tubal mucosal folds of
of peritoneal insult secondary to endometriosis, pelvic hydrosalpinges).
inflammatory disease or previous pelvic surgery, which • Small hyperechoic papillary projections or irregularities
results in fluid collection within adhesions. Most of these may occasionally be seen along the walls/septae of these
patients are asymptomatic unless there is an underlying cysts.
pathology like endometriosis or PID. Peritoneal inclusion • On Doppler, in about half the cases, some minimal high
cysts are incidental findings on ultrasound. Their importance resistance flow may be seen in the septae.
lies in the fact that they may be mistaken for other pathologi- • Since these are loculated fluid collections within adhe-
cal adnexal cystic masses. This is particularly so if they are sions, the surrounding pelvic organs will show restricted
seen in a patient who has undergone surgery for an ovarian mobility or may be fixed.
cyst, where they may be mistaken to be a recurrence of the • The ovary may be seen lying within or beside the cystic
ovarian pathology, or if they are seen in postmenopausal mass. This could be misinterpreted to be a solid compo-
women where they are mistaken to be an ovarian neoplastic nent of a neoplastic cyst, or the cyst may be assumed to be
pathology (because small atrophic ovaries in postmeno- of ovarian origin because of the adjoining ovarian tissue.
pausal women may not be visualized). The ovaries can be made out to be separate from the cystic
mass since most often they show antral follicles along the
Ultrasound Features of Peritoneal Inclusion Cysts periphery, just within the outer margins (including the
(Figs. 9.37, 9.38, 9.39, 9.40 and 9.41) surface adjoining the peritoneal inclusion cyst).
• They are typically multilocular cystic masses that con-
form to the shape of an area in the pelvis between pelvic Features that help distinguish peritoneal inclusion cysts
organs, giving them a bizarre shape. from other adnexal cysts are:
• The contents are usually uniformly anechoic, but in some – They are not well circumscribed like ovarian and para-
low level internal echoes may be seen. ovarian cysts.
• The septae are generally thin but may occasionally be – They are irregular in shape and are seen filling the
thick in some parts spaces between other pelvic organs.
• These adhesions that appear like septae, unlike the septae – Pointed beak-like or narrow extensions may be seen
of a neoplastic cyst, are under less pressure from the liq- along their outer margins, as the fluid fills narrow gaps
uid content and therefore usually undulate and oscillate a between tissue planes.
little on pressure from the probe, the so-called ‘flapping- – The septae tend to be lax and show the ‘flapping-sail’
sail’ sign. sign.
9.7 Peritoneal Inclusion Cysts 357

Fig. 9.37 Small area of loculated fluid seen just above the ovary show-
ing a few flimsy adhesions. A narrow beak-like extension is seen
(arrow)

Fig. 9.38 Peritoneal inclusion

a
cyst in a patient with previous TS LS
surgery: (a) TAS, (b) TVS. The
image shows that the cyst takes
the shape of the peritoneal cavity
in that area, filling the gaps and
extending into the narrow
crevices between the pelvic
organs. The ovary is seen
protruding into the peritoneal
cyst

b TS LS
358 9 Ultrasound Evaluation of Adnexal Pathology

Fig. 9.39 Peritoneal inclusion a

cyst in a patient with
endometriosis. (a) Ovary seen
protruding into the cyst and
multiple periovarian adhesions
are noted. (b) The ovary shows a
small endometriotic cyst

b
TS LS
9.7 Peritoneal Inclusion Cysts 359

Fig. 9.40 Large peritoneal

inclusion cyst (765 cc) in a
patient treated for pelvic TS LS
tuberculosis. Adhesions in this
case appear thick and bright, and
the loculated fluid within shows
fine low-grade internal echoes

Fig. 9.41 Peritoneal inclusion

a
cyst in a patient operated a few
years ago for a left endometriotic LS
cyst. (a) TAS – shows a uterus
lying over a large peritoneal
inclusion cyst. Narrow extension
of fluid is seen at its upper
margin behind the uterus (arrow),
(b) TVS showing the right and
left ovaries (short arrows) lying
beside the cystic mass and
adherent to the lateral pelvic
walls. The irregular outline and
shape of the cystic mass are seen
well (long arrow). (c) Locules
showing contents with varying
echogenicity (anechoic and
hypoechoic). An incomplete
septum (long arrow) and a small
hyperechoic projection is seen in
the cyst wall (short arrow),
which is a feature known to be
seen at times in these cysts
b
360 9 Ultrasound Evaluation of Adnexal Pathology

Fig. 9.41 continued

c

Summary: Peritoneal Inclusion Cysts

• These are seen in women with previous a history of
surgery, history of chronic infections like tubercu-
losis or endometriosis.
• Most often these are easily diagnosed as areas of
loculated fluid within adhesions.
• At times, diagnosis may be challenging and points
in favour of peritoneal inclusion cyst are their non-
circumscribed irregular outlines with beak-like nar-
row extensions between tissue planes.
Suggested Reading 361

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in a random sample of women 25–40 years old. Ultrasound Obstet
pelvic pain of gynaecologic origin in nonpregnant premenopausal
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Fischerova D (2011) Ultrasound scanning of the pelvis and abdomen
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for staging of gynecological tumors: a review. Ultrasound Obstet
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Gjelland K, Granberg S (2003) OC194: the diagnosis and ultrasound
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Valentin L, Akrawi D (2002) The natural history of adnexal cysts inci-
Molander P et al (2001) Transvaginal power Doppler findings in
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menopausal women. Ultrasound Obstet Gynecol 20:174–180.
Obstet Gynecol 17:233–238. doi:10.1046/j.1469-0705.2001.00353
doi:10.1046/j.1469-0705.2002.00709
 Ultrasound Evaluation
of Pregnancy-Related Conditions 10

10.1 Ectopic Pregnancy • In cases with ectopic pregnancies, the endometrium may
show fluid collection, giving it the appearance of a gesta-
An ectopic pregnancy is a pregnancy located outside the nor- tional sac termed ‘pseudo-gestational sac’. The differences
mal endometrial cavity. A variety of ectopic pregnancies are between a true gestational sac and a ‘pseudo-gestational
possible based on the location. These include tubal (most sac’ are discussed in Chap. 14.
common – about 95 % of all ectopic pregnancies), intersti- • The endometrium undergoes decidualisation, and in a
tial, cornual, cervical, ovarian, scar, intra-abdominal, intra- patient with an ectopic pregnancy. It can appear thick and
myometrial and heterotopic pregnancies. may show multiple tiny cystic spaces (closer to the endo-
Ectopic pregnancy is more often seen in patients with a myometrial junction), which should not be mistaken for a
history of infertility, PID and a previous ectopic pregnancy. tiny gestational sac.
The incidence of ectopic pregnancy is on the rise on account
of increasing in-vitro fertilisation (IVF) conceptions. Clinical Other than ‘pseudo-gestational sac’ and cysts in a decidu-
features include amenorrhoea, a positive pregnancy test (or alised endometrium, the differential diagnosis for an ectopic
high serum beta hCG), spotting, abdominal pain and even pregnancy includes a complete abortion and corpus luteal
hypovolemic shock. haemorrhage (discussed in Chap. 14).
Ultrasound is considered the modality of choice for diag- Transabdominal scan is very useful in picking up an ecto-
nosis of ectopic pregnancy. pic pregnancy because it pushes all the extra-pelvic struc-
tures (that could mimic or shadow a small ectopic pregnancy
Ultrasound Features of an Ectopic Pregnancy (Fig. 10.1) mass) out of the pelvis. This helps locate the site of any mass,
• The absence of an intrauterine gestational sac in the endo- even a small adnexal mass, and one is less likely to miss an
metrial cavity (especially with a serum beta hCG value of ectopic pregnancy mass. Also, it helps to know exactly where
more than 1000 mIU/mL), increases the likelihood of an to look for the ectopic pregnancy mass at the transvaginal
ectopic pregnancy. scan that follows the transabdominal scan.
• The tissue of an ectopic pregnancy on ultrasound appears Diagnosis of an ectopic pregnancy is very important
as a central cystic area (the gestational sac) surrounded by because they may present with acute pain and there is poten-
thick hyperechoic trophoblastic tissue, showing periph- tial for rupture and intraperitoneal haemorrhage. The man-
eral flow on Doppler. This is pathognomonic for an ecto- agement of ectopic pregnancies other than tubal ectopic
pic pregnancy but often cannot be demonstrated on pregnancies is difficult, with intramuscular or local metho-
ultrasound. trexate and local potassium chloride being resorted to in
• The gestational sac may or may not show a yolk sac and some cases, depending upon the location of the ectopic preg-
fetal pole. nancy and its viability. Local administration of these agents
• On enlarging the image, on 2D greyscale, low-velocity is done under ultrasound guidance. The management of rup-
flows within the trophoblastic tissue are often seen and tured non-tubal ectopic pregnancies is even more
often useful in confirming the diagnosis. challenging.

© Springer Nature Singapore Pte Ltd. 2017 363

M. Sibal, Ultrasound in Gynecology, DOI 10.1007/978-981-10-2714-7_10
364 10 Ultrasound Evaluation of Pregnancy-Related Conditions

a b

c d

Fig. 10.1 Findings in a case of an ectopic pregnancy. (a) Echogenic endometrium with a few tiny cystic spaces suggestive of decidualised endo-
metrium. Endometrial cavity showing no evidence of intrauterine pregnancy. (b) Ovaries showing a corpus luteum in the right ovary. (c) Ectopic
pregnancy mass showing a central cystic area (i.e., the gestational sac) surrounded by a thick hyperechoic trophoblastic tissue, showing peripheral
flow on Doppler. Yolk sac is seen within the gestational sac. This is pathognomonic of an ectopic pregnancy, but is not always seen. (d) Turbid-free
fluid suggestive of blood is seen in the peritoneal cavity
10.1 Ectopic Pregnancy 365

10.1.1 Tubal Ectopic Pregnancy • Doppler flows are of limited value in distinguishing an
ectopic pregnancy from a corpus luteum. What helps in
This is the commonest type of ectopic pregnancy. The differentiating the two is the thick echogenic margins that
appearance on ultrasound varies depending upon how surround the gestational sac of an ectopic pregnancy mass
advanced the gestation is, and whether there is any associ- and its extra-ovarian location.
ated bleeding from the lesion. • Ectopic pregnancy masses are typically tender to touch.
• Sometimes the ectopic pregnancy mass may not be as
Ultrasound Features of Tubal Ectopic Pregnancy well circumscribed or well defined as mentioned above,
(Figs. 10.2, 10.3, 10.4, 10.5, 10.6, 10.7, 10.8 and 10.9) because of haemorrhage from the ectopic pregnancy
• The absence of an intrauterine pregnancy. resulting in a hematosalpinx. The hematosalpinx appears
• The tubal ectopic pregnancy mass is seen as an extra- as an elongated tortuous heterogeneous mass seen in the
ovarian adnexal mass. It may be seen just adjacent to the adnexa often beside the ovary. At times, the ectopic gesta-
ovary. The ‘sliding sign’ can be used to ascertain its tional mass may be seen within the hematosalpinx.
extra-ovarian origin. • Haemorrhage from a ruptured tubal ectopic pregnancy or a
• Typically, it is a circumscribed mass, within which there tubal abortion could result in blood and clots surrounding
is usually a gestational sac (seen as a central cystic space) the ectopic pregnancy mass forming a complex, heteroge-
showing thick hyperechoic trophoblastic tissue surround- neous (i.e., with hypoechoic and hyperechoic areas) avascu-
ing it. lar mass. If bleeding has been massive, the entire ovary,
• Within the gestational sac, one may or may not see a ectopic pregnancy mass, etc., might all be lying within a
yolk sac and a fetal pole. The fetal pole will show pulsa- huge pelvic clot, and the tissue of the ectopic pregnancy
tions if it is a live ectopic pregnancy. The presence of a may be difficult to identify on ultrasound, within the mass.
yolk sac, a fetal pole or a fetal heart pulsation helps in • In an ectopic pregnancy, the fluid in the pelvis is typically
making a confident diagnosis of an ectopic pregnancy. turbid (suggesting it is blood) due to tubal rupture.
• The trophoblastic tissue shows high peripheral vascular- Sometimes the haemoperitoneum is massive, and blood
ity (high-velocity, low-resistance flow), often termed and clots may be seen outside the pelvis, in the paracolic
‘ring-of-fire’. gutters and Morisson’s pouch.
• Ovaries appear normal with a corpus luteum. Most • An important differential diagnosis for a ruptured tubal
often, the corpus luteum is seen in the ipsilateral ovary ectopic pregnancy is a corpus luteal haemorrhage (dis-
but rarely, may be seen on the contralateral side. A cor- cussed in Chap. 14). What helps distinguish the two is the
pus luteum can appear a little similar to an ectopic preg- absence of a well-defined extra-ovarian adnexal mass and
nancy, as it is circumscribed and may have a central a negative urine pregnancy test or normal levels of serum
cystic area. beta hCG, in the latter.

a b

Fig. 10.2 Case of tubal ectopic pregnancy (a) Extra-ovarian adnexal mass is seen just adjacent to the ovary. (b) The ectopic pregnancy mass shows
a central cystic area (the gestational sac) surrounded by thick hyperechoic trophoblastic tissue
366 10 Ultrasound Evaluation of Pregnancy-Related Conditions

a b

Fig. 10.3 Ectopic tubal pregnancies. (a) Case 1 - gestational sac showing yolk sac and a fetal pole. (b) Image showing tracing of fetal heart pulsa-
tion. (c) Case 2 - large fetal pole with fetal heart pulsation
10.1 Ectopic Pregnancy 367

a b

CL

Fig. 10.4 Live tubal ectopic pregnancy. (a) Flow is seen surrounding the trophoblastic tissue. (b) In addition to peripheral vascularity, flow is seen in
the centre of the ectopic pregnancy mass due to fetal heart pulsation. (c) The ovary shows a corpus luteum with a central cystic area and peripheral
vascularity. The corpus luteum is, however, intra-ovarian, and does not show hyperechoic thick margins around the central cystic area
368 10 Ultrasound Evaluation of Pregnancy-Related Conditions

a b

Fig. 10.5 Case of tubal ectopic pregnancy with hematosalpinx. (a) Hematosalpinx seen as an elongated tortuous heterogeneous mass just above
the right ovary. Ectopic pregnancy tissue is not well visualised within the hematosalpinx. (b) The presence of ectopic pregnancy tissue was con-
firmed and located within the hematosalpinx, by the presence of flow around a suspicious hyperechoic area (the tissue of the ectopic pregnancy)
which was seen on 2D grey scale in the hematosalpinx
10.1 Ectopic Pregnancy 369

Fig. 10.6 Tubal ectopic

pregnancy with hematosalpinx. a
(a) TS and LS view of the
hematosalpinx. The
hematosalpinx is seen just beside
the left ovary. (b) Hematosalpinx
seen as the complex mass which
can resemble a clot. However, the
presence of the flow in the walls
of the tubal mass suggested that
this is a hematosalpinx with a clot
within, rather than an independent
clot in the pelvis

b
370 10 Ultrasound Evaluation of Pregnancy-Related Conditions

Fig. 10.7 Three different cases

of ectopic pregnancy seen as a a
complex heterogeneous pelvic
mass-suggestive of clots. (a, b) In
all the images, the ectopic
pregnancy tissue cannot be seen
within the complex masses. (c)
Massive clot (line traced across
it) is seen in the POD, and in this
case neither was the ectopic
pregnancy mass, nor the ovary of
that side, seen separately on scan

b
TS LS

c LS

UT
10.1 Ectopic Pregnancy 371

a b TS LS

c TS LS d TS LS

Fig. 10.8 Case of tubal ectopic pregnancy with significant haemoperitoneum. Turbid fluid suggestive of blood is seen in (a) the adnexa surround-
ing the ectopic pregnancy mass (arrow) and ovary, (b) the POD and (c, d) the general abdominal cavity
372 10 Ultrasound Evaluation of Pregnancy-Related Conditions

b c

Fig. 10.9 Case of a failing tubal ectopic pregnancy with turbulent flow. (a) The ectopic pregnancy is seen just anterior to the left ovary and appears
heterogenous because of prominent vessels within the trophoblastic tissue. (b) Turbulent flow with mosaic colour is seen within the trophoblastic
tissue, similar to that of an AV malformation. (c) Flow in the trophoblastic tissue shows a low RI of 0.2 (also seen in AV malformations)
10.1 Ectopic Pregnancy 373

10.1.2 Interstitial Ectopic Pregnancy • ‘The interstitial line’, a classic ultrasound feature of inter-
stitial ectopic pregnancy, is a thin hyperechoic line seen
This is a pregnancy located in the interstitial part of the fal- extending from the superior and the lateral end of the endo-
lopian tube. This is often wrongly termed as cornual ectopic metrial cavity to the centre of the ectopic pregnancy mass.
pregnancy. • The ectopic pregnancy mass is seen surrounded by a thin
myometrial rim.
Ultrasound Features of Interstitial Ectopic Pregnancy • It appears as a mass bulging out at one cornual end of the
(Figs. 10.10, 10.11, and 10.12) uterus and moves en masse with the uterus.
• Here the tissue of the ectopic pregnancy (i.e., a circum- • Like other ectopic pregnancies, the ectopic pregancy
scribed mass with a central cystic space suggestive of a mass may be tender to touch.
gestational sac, surrounded by thick hyperechoic tropho-
blastic tissue that shows peripheral vascularity) is seen At times, a normal intrauterine pregnancy close to the
eccentrically located, just beyond the margins of the uterine cornua may be wrongly reported as an interstitial
endometrial cavity. This is best seen on a 3D rendered ectopic pregnancy, because of the uterine shape (Fig. 10.13).
coronal image of the uterine cavity. One must be aware of this possibility.

a b

Uterus Coronal

Fig. 10.10 Interstitial ectopic pregnancy. (a) Ectopic pregnancy tissue (long arrow) is visualised just beyond the endometrial margins on
greyscale. The image shows the hyperechoic short interstitial line (short arrow) extending between endometrial margins and the ectopic pregnancy
mass. The ectopic pregnancy mass is seen as a protrusion from the external surface of the uterus, protruding out at one cornua. (b) 3D pregnancy
coronal image showing the ectopic pregnancy mass (arrow), beyond the endometrial margins
374 10 Ultrasound Evaluation of Pregnancy-Related Conditions

a b
Uterus Coronal Uterus Coronal

Fig. 10.11 Coronal image of two cases of interstitial ectopic pregnancy. (a) Interstitial line (arrow) is seen extending between the endometrial
margins and the ectopic pregnancy mass. (b) 3D coronal image showing ectopic pregnancy tissue beyond the endometrial outline
10.1 Ectopic Pregnancy 375

a b
LS

UT

c d
Uterus Coronal

Fig. 10.12 Case of interstitial ectopic pregnancy. (a) Longitudinal section showing the ectopic pregnancy mass beyond the endometrial margins
and bulging out of the uterine surface. The mass shows increased vascularity in the trophoblastic tissue. (b) Transverse section showing the ectopic
pregnancy tissue and the uterine body. (c) Coronal image shows the ectopic pregnancy mass bulging out of the cornual end of the uterus. The
ectopic mass is seen outside the endometrial margins. Thin myometrial tissue (arrows) is seen surrounding the ectopic pregnancy tissue. (d) Inj.
methotrexate was administered locally for management. The needle is seen in situ (arrow) in the image
376 10 Ultrasound Evaluation of Pregnancy-Related Conditions

10.1.3 Cornual Ectopic Pregnancy

Uterus Coronal
This is pregnancy occurring in a non-communicating
rudimentary horn of a uterus with a congenital anomaly.
The pregnancy in these cases may extend for a longer
duration, and is often picked up at rupture which causes
severe pain and haemorrhage.

Ultrasound Features of Cornual Ectopic Pregnancy

(Figs. 10.14 and 10.15)
• Here, the pregnancy is seen in one horn of a bicornuate
uterus, i.e. the non-communicating horn. It is important to
demonstrate the lack of continuity between the endome-
trial cavity of the pregnant horn and the cervical canal
below it.
• In cases of rupture (trophoblastic invasion of the entire
wall), turbid fluid suggestive of blood may be seen in
the pelvis.
Fig. 10.13 Case of twin pregnancy (arrows) in a patient with an arcu-
ate uterus. The upper sac was wrongly interpreted as a case of intersti-
tial pregnancy. The gestational sac was, however, clearly seen within
the endometrial margins (outlined) ruling out an interstitial pregnancy
10.1 Ectopic Pregnancy 377

a TS b LS

c TS LS d TS

e
LS

Fig. 10.14 Cornual ectopic pregnancy in a patient with a left-sided unicornuate uterus and a right-sided non-communicating rudimentary horn.
(a) TS of the pelvis on TAS showing both horns of the uterus. The right gravid horn shows increased vascularity. (b) Longitudinal section showing
the vascular pedicle of the non-communicating gravid horn connecting it to the main uterine body. (c) Ectopic pregnancy tissue is seen in the
rudimentary horn which shows thick trophoblastic tissue (arrows). (d) Transverse section of the uterus on TVS showing the vascular pedicle con-
necting the rudimentary horn to the left unicornuate uterus. (e) Non-gravid, left-sided unicornuate uterus showing an empty endometrial cavity
378 10 Ultrasound Evaluation of Pregnancy-Related Conditions

a LS b LS

c LS d

Fig. 10.15 Cornual ectopic pregnancy in a patient with 17 weeks of gestation who presented with acute abdominal pain. (a) Fetus (FET) in the
non-communicating gravid horn above the uterus. (b) Non-canalised pedicle connecting the gravid horn to the main uterine body. This is important
to demonstrate, in order to diagnose a cornual ectopic pregnancy wherein the cavity of the rudimentary horn does not communicate with the main
uterine body posing a potential threat for rupture. This patient had been scanned earlier with a diagnosis of pregnancy in one horn of a bicornuate
uterus and the ‘non-communication’ had been missed. (c) Turbid fluid seen below the pedicle suggestive of rupture of the gravid horn. (d) Rudimentary
horn seen at surgery. 500 mL of blood was drained from the abdominal cavity and the rudimentary horn was excised
10.1 Ectopic Pregnancy 379

10.1.4 Ovarian Ectopic Pregnancy • The trophoblastic tissue in most ovarian ectopic pregnan-
cies is thicker and may not be well circumscribed. On
Ovarian ectopic pregnancies are rare, constituting 0.5–1 % of enlarging the image on 2D greyscale, low-velocity flow
all ectopic pregnancies. within the trophoblastic tissue is seen and is useful in
diagnosis. These flows are best picked up on power
Ultrasound Features of an Ovarian Ectopic Pregnancy Doppler (or HD Doppler) and may be missed on regular
(Figs. 10.16 and 10.17) colour Doppler, because of their low velocities.
• The tissue of the ectopic pregnancy (i.e., the gestational • A tough differential diagnosis for an ovarian ectopic preg-
sac ± yolk sac or fetal pole, surrounded by thick echo- nancy is a corpus luteum. Conventionally, serum beta
genic trophoblastic tissue showing Doppler flow around hCG values should be more than 1000 mIU/mL to con-
it) is seen surrounded by hypoechoic ovarian tissue. firm diagnosis.
• The corpus luteum may or may not be visualised in the
same ovary.

a b

CL

Fig. 10.16 A case of ovarian ectopic pregnancy. (a) The ovary is enlarged and shows a poorly defined circumscribed hyperechoic area suggestive of
trophoblastic tissue (between arrows). Within this, a tiny cystic area suggestive of a gestational sac is seen. A small yolk sac is seen within. Ovarian
tissue is seen around the ectopic pregnancy tissue. (b) Minimal peripheral flows seen on power Doppler around the trophoblastic tissue. A corpus
luteum (CL) is seen just beside the ectopic pregnancy tissue in the same ovary. Beta hCG in this case was 2600 mIU/mL
380 10 Ultrasound Evaluation of Pregnancy-Related Conditions

a TS LS

b c

Fig. 10.17 A case of ovarian ectopic pregnancy. Patient had a laparoscopy done for a right tubal ectopic pregnancy. The tube was found to be
normal and was apparently ‘cleaned up’. In view of rising beta hCG and discomfort experienced by the patient, a scan was repeated, which
revealed an ovarian ectopic pregnancy. (a) Thick trophoblastic tissue surrounding a central cystic space suggestive of a GS. (b) Flow was seen
around the trophoblastic tissue on HD Doppler. (c) Turbid fluid suggestive of blood was seen in the POD, suggesting haemorrhage from the
ectopic pregnancy. Beta hCG at the time of the scan was 4713 mIU/mL
10.1 Ectopic Pregnancy 381

10.1.5 Cervical Ectopic Pregnancy An important differential diagnosis for a cervical ecto-
pic pregnancy is incomplete or inevitable abortion
This form of ectopic pregnancy is often missed because typi- (Figs. 10.20 and 10.21). The points that help differentiate
cally on ultrasound examination, one first examines the the two are:
endometrial cavity followed by the adnexa, and the cervix is
often forgotten. • The presence of peri-trophoblastic flow within the cervix
and fetal heart pulsations, if present, help to confirm a
Ultrasound Features of Cervical Ectopic Pregnancy cervical ectopic pregnancy.
(Figs. 10.18 and 10.19) • An open internal os, a dead embryo and a flattened GS are
• An empty endometrial cavity. suggestive of an incomplete or inevitable abortion.
• ‘Hourglass’ shaped uterus with a barrel-shaped or • Previous scan images showing an intrauterine gestation
ballooned-out cervix. also help in diagnosing an incomplete or inevitable
• The entire tissue of the ectopic pregnancy (i.e., the gesta- abortion.
tional sac ± yolk sac or fetal pole, surrounded by thick
echogenic trophoblastic tissue showing Doppler flow Cases of cervical ectopic pregnancy that are managed
around it) is seen in the cervix below the level of the inter- with standard evacuation and curettage often present with
nal os, that is, below the level at which the uterine arteries massive bleeding that may be difficult to control.
are seen entering the uterus (on TS).

a LS b TS

c LS TS

Fig. 10.18 Cervical ectopic pregnancy. Patient presented with spotting and a positive pregnancy test. (a) ‘Hourglass’-shaped uterus noted, with a
ballooned-out cervix. The cervix appeared heterogeneous and hyperechoic. Endometrial cavity was empty. (b) No significant flow seen on Doppler
in the cervix. (c) On 3D Doppler, multiplanar sectional views revealed that the entire complex mass was below the level of the closed internal os
(i.e. the level at which the uterine arteries (arrows) approach the uterus transversely, seen in the image on the right). The internal os was closed,
which helped in making a diagnosis of a cervical ectopic pregnancy
382 10 Ultrasound Evaluation of Pregnancy-Related Conditions

a LS b

Fig. 10.19 Live cervical ectopic pregnancy. (a) Ballooned-out cervix with the ectopic pregnancy mass, within, that showed a central cystic area
with vascular trophoblastic tissue surrounding it. (b) Fetal pole and yolk sac are seen within. (c) Fetal heart pulsations detected on Doppler

a b
LS LS

UT UT

GS

Fig. 10.20 (a) Inevitable abortion with pregnancy sac seen in the cervical canal and the internal os (arrow) was open. (b) In this case, no flow was
seen in the trophoblastic tissue. The above findings suggested that this was a case of inevitable abortion
10.1 Ectopic Pregnancy 383

b LS c

Fig. 10.21 Patient presented with heavy bleeding. (a) Ectopic pregnancy mass seen in the cervix with thick trophoblastic tissue and a central,
irregular cystic space suggestive of a gestational sac. (b) TAS- the uterine body appeared normal and the cervix was ballooned out, showing
trophoblastic tissue within. (c) Scanned image of the patient’s previous report (done elsewhere a few days earlier) which shows a GS in the lower
uterine cavity and a normal-appearing cervix. (d) On careful examination, it was seen that there was a thick vascular channel supplying the tro-
phoblastic tissue from the posterior wall of the uterus at the midcorpus. From the image of the previous scan, it was easy to confirm that though
this appeared like a cervical ectopic pregnancy, it was a case of inevitable abortion and was easily managed with surgical evacuation. (e) Vascular
pedicle (small arrows) of the trophoblastic mass seen on greyscale and Doppler from the posterior myometrium, with the endometrium anterior
to it (long arrow) appearing normal
384 10 Ultrasound Evaluation of Pregnancy-Related Conditions

e
LS

Fig. 10.21 (continued)

10.1 Ectopic Pregnancy 385

10.1.6 Scar Ectopic Pregnancy genic trophoblastic tissue showing Doppler flow around
it) is located in the enlarged LSCS scar.
Diagnosis of scar ectopic pregnancy requires a high index of • The anterior uterine wall bulges out anteriorly with no
suspicion in women with previous caesarean section. With intervening myometrium between the ectopic pregnancy
increasing incidence of caesarean section, the incidence of tissue and the overlying serosa.
scar ectopic pregnancy is also on the rise. A scar ectopic
pregnancy, if left untreated, could result in uterine rupture or Differential diagnosis for a scar ectopic pregnancy is a
a morbidly adherent placental, which poses a problem at the cervical ectopic pregnancy. The location of the uterine arter-
time of delivery. ies that approach the uterus transversely at the level of the
internal os, is useful in differentiating a cervical ectopic
Ultrasound Features of Scar Ectopic Pregnancy pregnancy (which lies below the uterine arteries) from a scar
(Figs. 10.22 and 10.23) ectopic pregnancy (which lies above the uterine arteries). At
• The tissues of the ectopic pregnancy (i.e., the gestational times, 3D multiplanar sections are useful in assessing the
sac ± yolk sac or fetal pole, surrounded by thick echo- same.

a LS b

c LS

Fig. 10.22 Scar ectopic pregnancy. (a) GS with trophoblastic tissue is seen around the region of the LSCS scar. It was difficult to determine for sure
whether the pregnancy was at the lower corpus and/or upper cervix. (b) 3D multiplanar sections were obtained, and by walking through the planes
with the help of the intersecting dot, the diagnosis could be confirmed. The ectopic pregnancy tissue was seen above the level of the internal os (uterine
arteries), confirming the diagnosis of a scar ectopic pregnancy. (c) Thick hyperechoic, trophoblastic tissue surrounds the GS. No intervening myome-
trium is seen between the trophoblastic tissue and the anterior serosa. Fetal pole and yolk sac are seen within the GS
386 10 Ultrasound Evaluation of Pregnancy-Related Conditions

a LS b LS

UT
UT

CX
CX

c d

Fig. 10.23 Live scar ectopic pregnancy with a 10-week-old fetus. (a) The GS and trophoblastic tissue is seen bulging out of the anterior wall of
the uterus at the site of the LSCS scar. (b) Flow is seen around the trophoblastic tissue and in the umbilical cord on Doppler. (c) Tracing of fetal
heart pulsations. (d) Fetal reduction done with KCl. Arrow showing the needle
10.1 Ectopic Pregnancy 387

10.1.7 Intra-abdominal Pregnancy (Fig. 10.24) fetus grows within the abdominal cavity. Very often at
diagnosis, the fetus is growth restricted or there is fetal
A true intra-abdominal pregnancy is very rare. Here the demise.
pregnancy is implanted in the peritoneal cavity and the

a LS-RT b

c d

e f

FETUS (Dead)

(RT. HORN)

UTERUS (LT.HORN)

Fig. 10.24 Intra-abdominal dead fetus which perforated out from a non-communicating rudimentary horn. (a) Non-communicating uterine horn
with a hyperechoic tract (arrow), from the endometrial cavity up to the serosa. (b) Normal left-sided uterine body. (c) Fetal bony tissue is seen as
hyperechoic scattered echoes. (d) Post-operative specimen of the non-communicating right uterine horn with placental tissue and the umbilical
cord protruding out of the perforation. (e) Dead fetus attached by the umbilical cord (arrow) to the placental tissue within the rudimentary horn.
(f) Diagrammatic representation of scan findings in this case. The uterine perforation by trophoblastic tissue must have occurred early in pregnancy
with the fetus escaping out of the rudimentary horn and continuing to grow intra-abdominally for a short period of time. This is, however, not a
true abdominal pregnancy because the placenta was not implanted in the abdominal cavity
388 10 Ultrasound Evaluation of Pregnancy-Related Conditions

10.1.8 Heterotopic Pregnancy (Figs. 10.25 of multiple conceptions with ovulation induction and IVF. This
and 10.26) is often missed because the presence of an intrauterine preg-
nancy is generally considered reassuring in ruling out an ecto-
Heterotopic pregnancy is a rare type of ectopic pregnancy, pic pregnancy. Chances of diagnosing a heterotopic pregnancy
wherein along with an intrauterine pregnancy, an ectopic preg- is increased by awareness of the possibility, paying attention
nancy co-exists. Most often, this is a tubal ectopic pregnancy. to the patient’s complaint of pain, proper adnexal evaluation in
The incidence of heterotopic pregnancy is on the rise because all cases and a transabdominal scan prior to TVS.

a LS b

c d

Fig. 10.25 Heterotopic pregnancy conceived with IVF. (a) Normal intrauterine pregnancy. (b) Fetal heart pulsations of intrauterine fetus noted.
(c) Two corpora lutea seen in the left ovary. (d) Small, vaguely circumscribed hyperechoic area is seen in the adnexa with a tiny intrauterine sac,
suggestive of a tubal ectopic pregnancy. This was tender to touch
10.1 Ectopic Pregnancy 389

a TS
LS

b c Uterus Coronal

Fig. 10.26 Heterotopic pregnancy conceived with IVF. Patient who was diagnosed to have an intrauterine pregnancy, presented with abdominal
pain and bleeding. (a) An elongated mass suggestive of a thickened tube, with a hyperechoic circumscribed area within, suggestive of an ectopic
pregnancy mass is seen. Flow was seen around the trophoblastic tissue, and a small yolk sac was seen within the GS. (b) Intrauterine GS is seen.
(c) 3D rendered image of the uterus and the adnexa showing both the intrauterine sac (short arrow) and the tubal ectopic pregnancy sac (long
arrow)
390 10 Ultrasound Evaluation of Pregnancy-Related Conditions

10.1.9 Intra-myometrial Ectopic Pregnancy If an ectopic pregnancy is diagnosed, its management

(Fig. 10.27) depends upon clinical features and ultrasound findings.
Those that are not managed surgically are followed up with
This is a very rare form of ectopic pregnancy, where the ecto- serial serum beta hCG under close observation. A repeat scan
pic pregnancy tissue is seen within the myometrium of the is suggested in case the patient becomes symptomatic for
uterus, which surrounds it completely. The endometrial cav- any evidence of rupture, which can happen even with falling
ity is empty, but very often there is a thin vascular connection serum beta hCG levels and medical management with meth-
seen extending from the endometrial margins to the centre of otrexate. On follow-up scans, even with falling serum beta
this ectopic pregnancy tissue. This type of ectopic pregnancy hCG, the ectopic pregnancy mass may seem to increase in
has almost always been diagnosed intraoperatively and most size, which should not be interpreted as failure of medical
often following rupture. management. The vascularity, however, generally dimin-
ishes. It is therefore suggested that the primary modality of
In all cases where a normal intrauterine pregnancy is not follow-up in the case of ectopic pregnancies should be serial
seen, the potential of an ectopic pregnancy exists. If there is beta hCG and not ultrasound, with ultrasound being resorted
no ectopic pregnancy noted, it is categorised as pregnancy of to in patients who become symptomatic, and there is a suspi-
unknown location (‘PUL’) which is dealt with in Chap. 14. cion of rupture.

a LS b LS

c LS d Uterus Coronal

Fig. 10.27 Intra-myometrial ectopic pregnancy. Patient gave a history of elevated beta hCG and bleeding. Scan done elsewhere showed no
evidence of intrauterine or extrauterine pregnancy, raising the suspicion of a spontaneous abortion. (a) TAS - Sagittal section of the uterus show-
ing an empty endometrial cavity and a hyperechoic circumscribed complex mass in the myometrium, just above the upper end of the endome-
trium. (b) TVS - showing the same. Flow is seen around the hyperechoic circumscribed area. Images (a) and (b) raised the possibility of
interstitial pregnancy. (c) Narrow hyperechoic vascular tract (arrow) is seen extending from the endometrium towards the ectopic pregnancy
mass. (d) Coronal rendered image of the uterine cavity showing two cornual ends (arrows) of the endometrial cavity with the ectopic pregnancy
mass arising from the left upper end of the endometrial cavity, just medial to the left cornua and lying completely within the myometrium. Patient
was treated with injection methotrexate and the ectopic pregnancy mass regressed
10.2 Retained Products of Conception (RPOC) 391

10.2 Retained Products of Conception

Summary: Ectopic pregnancy (RPOC)
• Transvaginal scan is the modality of choice for the
diagnosis of ectopic pregnancy. Clinical correlation Retained products of conception are placental and/or fetal
with symptoms, history and serum beta hCG levels tissue that remain in the uterine cavity after an abortion or
are important for diagnosis. pregnancy. Histopathological diagnosis of RPOC requires
• Transabdominal scan prior to TVS improves the the presence of chorionic villi (persistent placental tis-
detection rate. sue). After pregnancy, the villi that remain undergo
• During TVS, a careful search is to be made, and if increasing fibrosis and exhibit variable vascularity which
there is no intrauterine pregnancy and there is no is probably why RPOC show variable vascularity on
adnexal mass, one must not forget to look carefully ultrasound.
at the two cornual ends and the cervix. Retained tissue is more often seen with spontaneous abortion
• Classic ultrasound features of an ectopic pregnancy or delivery than those that have undergone surgery. The inci-
are an empty uterine cavity and presence of an the dence also varies with period of gestation being highest after
ectopic gestational mass (typically seen as a cystic mid-trimester abortions.
central gestational sac +/− yolk sac or fetal pole, Typical clinical symptoms of RPOC are bleeding, either
surrounded by thick echogenic trophoblastic tissue excessive in amount or persisting for an extended period of
showing Doppler flow around it). time (more than 2–3 weeks). Following an abortion or preg-
nancy, some amount of bleeding is normal for a week or two
(being lesser with surgical evacuation).
Necrotic RPOC is prone to infection. Women with such
infections may present with fever, pain, uterine tenderness or
abnormal bleeding.
Evaluation for RPOC is not done in all cases routinely
following delivery or abortion, unless there is a suspicion of
some tissue being left behind (e.g. adherent placenta). This is
because some amount of blood, clots, echogenic debris and
fluid is normal in the immediate post-abortal or post-partum
period. Beta hCG is usually not of help in the diagnosis as it
normally persists for a few weeks after an uncomplicated
pregnancy.

Ultrasound Features of RPOC (Figs. 10.28, 10.29, 10.30,

10.31, 10.32, 10.33, 10.34, 10.35, 10.36 and 10.37)
• RPOC typically appear as hyperechoic heterogeneous
intracavitary masses. These intracavitary masses are at
times much better visualised in a transverse section (after
viewing on LS) of the entire endometrial cavity, scanned
slowly from the cervix upwards to the upper end of the
endometrial cavity.
• RPOC mass may appear to be extending into the adjoin-
ing myometrium with poor endomyometrial differentia-
tion in that area.
• Retained placenta appears as thick hyperechoic tissue with
increased vascularity approaching it from the underlying
myometrium. If there is a focal single feeder vessel, it is
often termed as a ‘placental polyp’. Sometimes, morbidly
adherent placenta is consciously left behind, and these
appear like hyperechoic thick placental cotyledons within
the uterine cavity.
• The presence of Doppler flow in such a mass is useful in
confirming a diagnosis, but the absence of flow does not
rule out RPOC, as some RPOC may not be vascular. Most
392 10 Ultrasound Evaluation of Pregnancy-Related Conditions

a TS LS

b TS c
Uterus Coronal

Fig. 10.28 RPOC following first trimester abortion. (a) Complex, hyperechoic intracavitary mass is seen in the upper endometrial cavity with
turbid fluid suggestive of blood below it. (b) TS showing flow approaching the RPOC from the right uterine wall. (c) 3D rendered coronal image
of the uterus showing an intracavitary mass - the RPOC
10.2 Retained Products of Conception (RPOC) 393

a
TS LS

b c
LS Uterus Coronal

Fig. 10.29 RPOC following missed abortion with bleeding. (a) Hyperechoic, complex mass seen in the endometrial cavity. On TS, it appears
completely within the cavity with minimal fluid on one side. On LS, the anterior margins were not well defined because of an anterior wall adeno-
myoma. (b) RPOC showing flow within, on Doppler, which helps to confirm diagnosis. (c) 3D rendered image showing the complex appearing
RPOC within the endometrial cavity
394 10 Ultrasound Evaluation of Pregnancy-Related Conditions

TS LS

b
TS

Fig. 10.30 RPOC following TOP at 17+ weeks of pregnancy. (a) Retained tissue which appears isoechoic with the surrounding myometrium is
seen in the endometrial cavity - measured in this image. (b) Its presence was ascertained with the help of Doppler, which showed high vascularity
within the mass
10.2 Retained Products of Conception (RPOC) 395

a b
LS TS

c d
LS

Fig. 10.31 RPOC following mid-trimester TOP. Patient was on conservative management for RPOC. Serum beta hCG a week prior was 19mIU/
mL. Patient was given methotrexate following which she came for a scan. (a) An isoechoic mass is seen within the endometrial cavity at the upper
corpus (arrow). The anterior EMJ in this area could not be delineated. (b) A vessel is seen approaching the RPOC from the anterior wall on the left
side. (c) Flow is seen within the retained tissue. (d) Flow in the RPOC showed low RI of 0.32.

LS

Fig. 10.32 TVS showing endometrial cavity

with turbid fluid and a mass which shows.
complex echoes. This showed low vascularity,
and it was difficult to ascertain whether this was
retained tissue or a clot within the endometrial
cavity
396 10 Ultrasound Evaluation of Pregnancy-Related Conditions

b TAS - LS c TVS - LS

Fig. 10.33 Placental polyp. Patient presented with secondary PPH, following a full-term LSCS. (a) Circumscribed, hyperechoic, complex mass
is seen in the upper uterine cavity, suggestive of retained placental tissue. (b) A single prominent vessel was seen approaching this area from the
posterior wall of the uterus, confirming the diagnosis of retained placental tissue. (c) TVS showing the uterine body. Visualisation of RPOC and
feeder vessel was, however, suboptimal because of the large uterine size and the mid-positioned uterus
10.2 Retained Products of Conception (RPOC) 397

a
TS LS

b c
TAS - LS TVS - LS

d Uterus Coronal

Fig. 10.34 Adherent retained placenta. Patient had a full-term normal delivery, a month prior to this scan. Manual removal of placenta was
attempted following delivery, for retained placenta, but only a part of it could be separated and removed. (a) The uterus showing 228 mL of retained
placental tissue, which is seen as a hyperechoic, complex, well-circumscribed mass. On TS, the surrounding myometrium appeared thin. (b) Flow
is seen around the placental tissue. No significant amount of myometrium is seen between the vascular flow and the overlying serosa. (c) TVS -
showing the retained placental tissue and a thinned out myometrium superiorly. (d) Coronal rendered image of the uterus showing the retained
tissue in the left cornual region, with a thinned out overlying myometrium (arrows)
398 10 Ultrasound Evaluation of Pregnancy-Related Conditions

a
TS LS

b c

Fig. 10.35 Retained placenta and fetal tissue following missed abortion at 13 weeks. Patient had an adenomyotic uterus with multiple fibroids. USG-
guided evacuation was done, but the procedure had to be abandoned as the fetal parts were high up and could not be reached. The patient presented
with bleeding and a history of passing some fetal tissue. (a) Vaguely circumscribed hyperechoic mass is seen in the upper uterus with a few scattered
hyperechoic areas within. (b) The hyperechoic bony retained fetal tissue (arrow) is seen causing acoustic shadowing. (c) Flow is seen in the RPOC on
Doppler. The case was finally managed with hysterotomy
10.2 Retained Products of Conception (RPOC) 399

a LS b LS

CX

CX

Fig. 10.36 RPOC with blood in the endometrial cavity in a patient who took medication for MTP. (a) Hypoechoic turbid fluid suggestive of blood
is seen in the cervical canal. External os was dilated (arrow). (b) Hyperechoic complex RPOC with flow within is seen in the upper endometrial
cavity

Fig. 10.37 RPOC. A poorly defined EMJ (arrow) showing flow from myometrium into the endometrium. Angulation of the probe may be
required so as to see both the EMJ and the flow across it
400 10 Ultrasound Evaluation of Pregnancy-Related Conditions

often, avascular RPOC are not problematic and resolve 3. AV malformations are known to show turbulent flow, but in
spontaneously. Vascularity, if present, is always from the these cases the lesion is mainly in the myometrium and com-
adjoining myometrium. The flow generally shows a low prised only of vascular channels. (Refer to section on AV
RI. malformations in – Chap. 13.)
• Some RPOC may show turbulent flow like that of an AV 4. Invasive moles may also show turbulent flow, but here the
malformation, with high velocity and low resistance. mass is primarily in the myometrium, often extending to
• Turbid fluid suggestive of blood and clots may be seen more than the one-third the thickness of the myometrium,
along with RPOC in the endometrial cavity. and beta hCG values are high.
• Thickened endometrial echoes may indicate presence of 5. Submucous fibroids, polyps or submucous adenomyomas
RPOC. Various cut-offs have been used, though 10 mm may also appear similar to RPOCs (discussed in their
appears to be most prevalent. This, however, has poor respective chapters).
specificity, and RPOC may be present with thinner
endometrium and may be absent with thicker The presence of a complex hyperechoic vascular mass is
endometrium. very likely to be RPOC. False positives are high, especially
• The appearance of RPOC varies with time. Initially, it when the RPOC is not vascular. The absence of an intracavi-
may be less obvious, especially in a thick endometrium tary mass, absence of complex intracavitary fluid and pres-
and with surrounding clots. With time, the RPOC gets ence of a thin endometrium, however, helps to rule out
more organised and becomes firm and hyperechoic. Clots RPOC.
around it have often passed out by then (unless the patient
is bleeding actively) and if clots are present, they vary in
echotexture from the RPOC. This helps in delineating the
RPOC well. Sometimes the RPOC has partially passed Summary of RPOC
out, which again changes its appearance in subsequent • Routine ultrasound is not recommended following
scans. delivery or abortion, unless there is a suspicion of
some tissue left behind or the patient presents with
bleeding (excessive or for a prolonged period) or
Differential Diagnosis with pain and fever.
1. Blood clots and necrotic decidua may appear complex • Typical RPOC appears as a hyperechoic heteroge-
and hyperechoic but are avascular. They are seen within neous intracavitary mass. It may or may not show
the endometrial cavity and may be very difficult to dif- vascularity. In the absence of vascularity, it may be
ferentiate from avascular RPOC. difficult to distinguish it from clots or necrotic
2. Increased vascularity of the myometrium of the placental decidua in the endometrial cavity.
bed following pregnancy (miscarriage or delivery) is • The absence of an intracavitary mass, or complex
common in the first few weeks following pregnancy. This intracavitary fluid and the presence of a thin endo-
could be focal or over a broad area and is of significance metrium, however, helps to rule out RPOC.
only if a placental remnant is seen.
10.3 Gestational Trophoblastic Disease (GTD) 401

10.3 Gestational Trophoblastic Disease Women with molar pregnancy typically present with
(GTD) amenorrhoea, a positive pregnancy test, bleeding per vagina,
pelvic discomfort and hyperemesis gravidarum. Serum Beta
Gestational trophoblastic disease comprises a heterogeneous hCG levels, if done, shows unusually high values. In a case
group of lesions resulting from an abnormal proliferation of of complete mole extending beyond the first trimester, other
the trophoblastic tissue of a placenta. These lesions include clinical features may be seen, which include hyperthyroid-
molar pregnancy, partial mole, invasive mole, choriocarci- ism and early onset of pre-eclampsia.
noma, placental site trophoblastic tumour (PSTT) or epithe- Theca lutein cysts result from ovarian hyperstimulation
lioid trophoblastic tumour (ETT). due to high circulating levels of hCG. These cysts are bilat-
Gestational trophoblastic neoplasia (GTN) includes inva- eral, multiloculated and resolve a few weeks to months after
sive mole, choriocarcinoma, placental site trophoblastic treatment of the molar pregnancy. The presence of theca
tumour or epithelioid trophoblastic tumour that are either lutein cysts should raise a high suspicion of GTD. Theca
malignant or potentially malignant. In the absence of tissue lutein cysts may not be seen in the early cases in the first
diagnosis by histopathology, cases with persistently elevated trimester of pregnancy. The possibility of development of
beta hCG, following evacuation of molar pregnancy, are GTN is significantly increased with complete mole (in about
called persistent GTD. 20 %) most of which (75 %) are invasive mole, while about
Molar pregnancies (complete or partial) are managed by 25 % are choriocarcinoma, and other GTNs are rare.
evacuation and GTNs primarily with chemotherapy. All Follow-up with beta hCG following a molar evacuation is,
GTDs require careful follow-up during and after treatment, therefore, essential. Ultrasound is the diagnostic modality of
primarily with beta hCG and often with imaging. choice.

Ultrasound Features of Complete Mole (Figs. 10.38 and

10.3.1 Molar Pregnancy 10.39)
• The uterine cavity is filled with a heterogeneous mass
10.3.1.1 Molar Pregnancy: Complete Mole showing small anechoic cystic spaces (vesicles). These
This is the most common form of GTD representing 80 % of cysts are hydropic chorionic villi and may vary in size
cases. A complete mole most commonly has a 46, XX karyo- from 1 to 30 mm. This has classically been described as a
type with all chromosomes of paternal origin. Pathologically, ‘snowstorm appearance’. The size of these cysts is seen to
the lesion shows hydropic villi and there are high circulating increase with increasing gestational age.
levels of beta hCG.
402 10 Ultrasound Evaluation of Pregnancy-Related Conditions

a
LS TS

b c

Fig. 10.38 Molar pregnancy (complete mole). The patient was diagnosed to have an incomplete abortion elsewhere, for which evacuation was
done. The patient continued to bleed, and beta hCG was reported to be more than 3,00,000 mIU/mL. (a) Image shows the uterus with the entire
uterine cavity (including most of the cervical canal), seen filled with a heterogeneous mass with tiny cysts, giving it a snowstorm appearance. (b–d)
The mass shows multiple small anechoic cystic spaces within (the vesicles). (e, f) Doppler shows colour flow signals in various directions, filling the
spaces between the vesicles. Flow is seen with a PSV of 17.84 cm/s and RI of 0.34 (low-velocity, low-resistance flows)
10.3 Gestational Trophoblastic Disease (GTD) 403

e f

Fig. 10.38 (continued)

a LS b LS

Fig. 10.39 Molar pregnancy (complete mole) at 8 weeks and 3 days. (a) The endometrium appeared thick (3.2 cm) and heterogeneous and
showed tiny cystic spaces within, leading to the suspicion of a molar pregnancy. (b) No significant flow is seen on colour Doppler within this tissue,
which may be because of the uterine position and low velocity of flows. Beta hCG in this patient was 1,51,236 mIU/mL
404 10 Ultrasound Evaluation of Pregnancy-Related Conditions

• In very early cases, these cysts may not be obvious, proba- ultrasound. Therefore, it is suggested that histological
bly because the villi are too small to be visualised and on examination of products of conception should be done
ultrasound there may be seen just as a central thickened in all cases of missed abortion undergoing surgical evac-
mass of variable echogenicity within the endometrial uation. Those with medical management should have
cavity. serum beta hCG levels done, to help pick up molar
• The absence of a gestational sac and fetus. pregnancy.
• Sometimes, there is a large central fluid collection that
mimics an anembryonic pregnancy, particularly in very 10.3.1.2 Molar Pregnancy: Partial Mole
early pregnancy. Partial moles are usually triploid with two paternal sets of
• Doppler flow is seen within this heterogeneous mass, as chromosome and one maternal set of chromosome. The beta
colour flow signals in various directions, filling the hCG level of the partial mole is usually not very high, and
space between the molar vesicles. This is because therefore, they are less likely to be associated with theca lutein
maternal blood streams into this area between the molar cysts. This is more commonly missed, as ultrasound features
vesicles. On pulse wave, this inter-vesicle flow shows are not typical and because of the frequent presence of a ges-
relatively low peak systolic velocity and low RI (aver- tational sac/fetus. The possibility of the development of GTN
age PSV 14 cm/s and average RI of 0.42). Low RI is is only slightly increased with a partial mole. Follow-up with
also seen in the uterine, arcuate, radial and spiral beta hCG should be done following evacuation.
arteries.
• Theca lutein cysts are seen bilaterally. They are multiple Ultrasound Features of a Partial Mole (Fig. 10.40)
cysts of 2–3 cm with thin septae and clear fluid, often with • A fetus may be identified which may not be viable, and if
some central stromal tissue, giving the ovary a ‘spoke viable is growth restricted.
wheel’ appearance. These may not be seen in association • Gestational sac is seen, but the amniotic fluid volume is
with early complete moles. reduced.
• In the first trimester, ultrasound features may not be • The placenta is enlarged with cystic spaces seen in some
classical, and differentiating cases of molar pregnancy parts.
from missed abortions that can also show hydropic • Theca lutein cysts are usually absent.
changes in the placenta, is difficult. With an increasing • This is even more likely than a complete mole to be mis-
use of ultrasound in early pregnancy, the majority of diagnosed as a case of missed abortion. Most often, diag-
cases of molar pregnancy are diagnosed to be cases of nosis is made on histopathology of evacuated products of
missed miscarriages or anembryonic pregnancy on conception.
10.3 Gestational Trophoblastic Disease (GTD) 405

c d Uterus Coronal

Fig. 10.40 Molar pregnancy (partial mole on HPE) in a patient with a subseptate uterus. A previous scan had shown an intrauterine GS and a sub-
sequent scan had shown an intrauterine clot. Beta hCG was 45,847 mIU/mL. (a) GS is seen with a small hyperechoic protrusion from the placental
tissue (arrow) into the GS. (b) A turbid cystic space seen within the placental protrusion and minimal flow is seen around the GS. No significant flow
is seen within this protrusion. (c) In one section this protrusion showed two more smaller cystic spaces, raising the possibility of some molar features
in the placenta. No fetal pole was seen. (d) 3D rendered coronal image of the uterus showing pregnancy in the right-sided cavity on the subseptate
uterus
406 10 Ultrasound Evaluation of Pregnancy-Related Conditions

10.3.2.1 Invasive Mole

Summary of Molar Pregnancy Invasive mole is characterised by the presence of hydropic
• It is the most common form of GTD, with patients villi (molar tissue) invading into the myometrium. They only
presenting with amenorrhoea, irregular bleeding occasionally metastasize.
and high levels of beta hCG. Molar pregnancy This is seen following a molar pregnancy and could be
includes both complete mole and partial mole. either following a complete or a partial mole. It is usually
• On ultrasound, typically the uterine cavity is filled seen within 6 months of a molar pregnancy.
with an echogenic mass showing small cystic
areas and flow between the cystic areas, which is 10.3.2.2 Choriocarcinoma
multidirectional. Theca lutein cysts may be seen. This is an anaplastic trophoblastic tissue (made up of both
In a complete mole, no fetus is seen, whereas in a cytotrophoblasts and synctiotrophoblasts), without villi.
partial mole there may be an abnormal fetus or a It is invasive and highly vascular. This may be seen fol-
gestational sac. lowing a molar or a non-molar pregnancy. It is a highly
• Ultrasound findings are often not classical in the malignant tumour with local myometrial invasion and
first trimester. Complete and particularly partial metastasis being common. Beta hCG levels are usually
moles may have ultrasound findings similar to extremely high.
that of missed abortions. Therefore, if evacuation
and histopathology are not planned in cases with 10.3.2.3 Placental Site Trophoblastic Tumour
missed abortion, estimation of serum beta hCG is (PSTT) and Epithelioid Trophoblastic
ideal. Tumour (ETT)
• All molar pregnancies require careful follow-up These are rare types of GTN that commonly occur after a
with serum hCG, following an evacuation. non-molar pregnancy, often several months or years fol-
lowing it. They originate from intermediate cells of
extravillous trophoblast and secrete very low levels of
hCG. Human placental lactogen (HPL) levels are however
10.3.2 Gestational Trophoblastic Neoplasia raised in PSTT, which can help with diagnosis. They are
(GTN) less vascular and metastasize less often as compared to
choriocarcinomas. They are also more resistant to treat-
As mentioned above, GTN includes invasive mole, chorio- ment with chemotherapy, and hysterectomy is the only
carcinoma, placental site trophoblastic tumour (PSTT) or proven cure.
epithelioid trophoblastic tumour (ETT) that are either malig-
nant or potentially malignant. Invasive mole and choriocarci- Ultrasound Features of GTN (Figs. 10.41 and 10.42)
noma comprise most of these cases, as PSTT and ETT are On ultrasound, these lesions (invasive mole, choriocarci-
rare. Most often GTN arises from a molar pregnancy, but it noma, PSTT and ETT) appear similar and are difficult to dif-
can also arise following miscarriages, normal pregnancies ferentiate. Their ultrasound features are therefore being
and ectopic pregnancies. Clinical presentation of GTN discussed together below:
depends on whether the antecedent pregnancy was molar or
non-molar. Features include elevated serum beta hCG, • These appear as one or more poorly defined masses
abnormal uterine bleeding, hyperthyroidism, ovarian theca within the myometrium, that may extend up to the
lutein cysts, pelvic pain or symptoms due to metastasis. The endometrium.
vagina and lung are common metastatic sites and therefore • It is important to measure these masses in three perpen-
evaluation is recommended. dicular dimensions (size is particularly important espe-
To make a diagnosis, uterine curettage or other biopsy is cially for follow-up of cases on treatment).
not resorted to. GTN is most often a clinical diagnosis based • They have a heterogeneous echotexture with solid and
on persistently elevated serum beta hCG after a molar preg- cystic areas within. These cystic areas could be fluid-
nancy, or high beta hCG levels following a non-molar preg- filled cystic spaces (common in invasive mole), vascular
nancy (other causes of elevated hCG having been ruled out), channels or cystic areas secondary to haemorrhage and
supported by imaging findings that show pathology either necrosis (common in choriocarcinoma). They are most
locally in the uterus and ovaries or metastatic disease. Unlike often hyperechoic appearing.
other solid tumours, tissue diagnosis is not required prior to • In cases of an invasive mole, the echotexture and vascu-
treatment. larity are similar to that of a molar pregnancy, only seen
10.3 Gestational Trophoblastic Disease (GTD) 407

b LS

Fig. 10.41 Persistent GTD with a probable diagnosis of invasive mole. Patient had a molar pregnancy which was evacuated elsewhere (2 months prior
to this scan). Following this, the patient had bloating sensation, abdominal pain and bleeding. Patient was later diagnosed to have persistent GTD with a
beta hCG of 21,306 mIU/mL for which she had undergone five rounds of chemotherapy. She discontinued treatment a week prior to this scan since she
found no relief of symptoms. Beta hCG 2 weeks prior to scan was 38,292 mIU/mL and on the day of the scan, had dropped to 6,117 mIU/mL. (a)
Transabdominal scan showing a vaguely circumscribed hyperechoic cystic area in the posterior myometrium of the upper corpus. (b) Same, showing high
vascularity on Doppler; (c) TVS - showing a poorly circumscribed hyperechoic mass filled with cystic spaces in the myometrium. It was reaching up to
the endometrium. The EMJ in this area was not well defined. (d) Abundant flow and multidirectional flow seen in the mass on Doppler, as is seen in
complete moles. (e) Flow showed PSV of 38 cm/s and RI of 0.35. (f) Glass body rendered image showing the vascular mass within the uterus. (g)
Bilaterally enlarged ovaries showing multiple theca lutein cysts. The image (g) shows the typical a ‘spoke wheel’ appearance. (h) Minimal flow is seen in
the thinned out ovarian tissue between the cysts. (i) 3D rendered image of the theca lutein cysts
408 10 Ultrasound Evaluation of Pregnancy-Related Conditions

d e
LS

f g
LS

h i

Fig. 10.41 (continued)

10.3 Gestational Trophoblastic Disease (GTD) 409

a
LS

c d

Fig. 10.42 GTN (probably choriocarcinoma) with thromboembolism of the right pulmonary artery. Patient had amenorrhoea for 6 months. UPT was
positive and the patient took medication for a chemical TOP, following which there was no bleeding. UPT, however, remained positive, and the scan
done elsewhere showed an empty uterine cavity. Patient presented with fever and respiratory symptoms of chest pain, cough and breathlessness. (a)
Empty intrauterine cavity is seen. (b) A vaguely circumscribed slightly hyperechoic mass is seen close to the right uterine cornua with peripheral vas-
cularity, resembling an interstitial ectopic pregnancy. (c) There was an irregular, isoechoic, heterogeneous, solid mass seen extending from the right
upper end of the uterus into the surrounding areas. (d) This mass showed increased vascularity on Doppler. The findings were suggestive of a solid,
neoplastic, malignant mass. Beta hCG was 8,03,419 mIU/mL after the scan. Findings suggested a GTN with a small, local mass in the uterus and local
metastasis from the uterus into the surrounding structures along with thromboembolism of the pulmonary arteries
410 10 Ultrasound Evaluation of Pregnancy-Related Conditions

deep in the myometrium. The cystic spaces seen are

hydropic villi. Summary of GTN
• In choriocarcinoma, the tissue is more solid appearing and • This is a heterogeneous condition which can occur
heterogeneous, with necrotic areas within appearing cystic. following a molar pregnancy, a normal pregnancy
• Increased vascularity with low-resistance flows is noted or an abortion.
in and around the mass. Often there are dilated vessels in • Invasive moles are locally invading GTN-which
the surrounding myometrium. only occasionally metastasize and are seen follow-
• Arteriovenous shunts with turbulent flows, associated ing a complete or a partial mole.
with neovascularisation with in the intra-myometrial • Choriocarcinoma is a highly malignant tumour
mass, show up as chaotic vasculature with mosaic colours associated with local invasion, distant metastasis
on Doppler and low-resistance (low RI) on spectral and high hCG levels.
Doppler. This is common with invasive mole and • Placental site trophoblastic tumor is rare and occurs
choriocarcinoma. usually after a non-molar pregnancy. They secrete
• The RI in the uterine arteries is also often reduced. lower levels of hCG and are more chemo-resistant.
• In cases of patients with a more extensive disease (usually • On ultrasound, these various GTN lesions in the
cases of choriocarcinoma), the uterus may be heterogeneously uterus appear similar and it may be difficult to dif-
enlarged, and the tumour may be seen extending into the ferentiate between them. They are seen as poorly
parametrium and neighbouring pelvic organs. defined heterogeneous myometrial lesions showing
• Theca lutein cysts are multiple due to high hCG levels high vascularity. Invasive moles generally appear
causing bilaterally, enlarged, multicystic ovaries with a more cystic, whereas choriocarcinomas are more
‘spoke wheel’ appearance. These are uncommon in cases likely to be solid.
with PSTT because of lower levels of beta hCG.
• PSTT masses usually have indistinct margins and multiple
cystic spaces, whereas ETT tends to have sharper borders.
• At follow-up scans (during treatment), these myometrial
lesions are seen to become more hypoechoic and show a
decrease in size and vascularity.
Suggested Reading 411

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Condous G et al (2007) Prediction of ectopic pregnancy in women
uterine embryo: systematic review and meta-analysis. Ultrasound
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Obstet Gynecol 47:28–37. doi:10.1002/uog.14844
29:680–687. doi:10.1002/uog.4015
Sawyer E et al (2007) The value of measuring endometrial thickness
Green CL et al (1996) Gestational trophoblastic disease: a spectrum of
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Gun M, Mavrogiorgis M (2002) Cervical ectopic pregnancy: a case
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Sebire NJ et al (2001) The diagnostic implications of routine ultra-
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Kirk E et al (2007) The accuracy of first trimester ultrasound in the
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Levine D (2007) Ectopic Pregnancy. Radiology 245:385–397.
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Timor-Tritsch IE et al (2014) Cesarean scar pregnancy and early pla-
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Memtsa M et al (2013) Diagnosis and management of intramu-
Schoubroeck V et al (2004) Prospective evaluation of blood flow in
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531. doi:10.1002/uog.163
 Torsion
11

11.1 Ovarian Torsion Clinical Features of Torsion

These are often non-specific and include:
Torsion is one of the most common gynaecological emer- • Pain which is usually of sudden onset, sharp and localised
gencies. It is the result of the twisting of a structure or a to the lower abdomen. It is generally moderate to severe in
mass, with resultant compromise in vascular flow. The intensity with many patients, therefore presenting at the
ovary is the most common organ that undergoes torsion. In ‘emergency’ department of hospitals. Pain could be acute
addition, torsion may also be seen in paraovarian cysts or or intermittent. Very often there is a history of some activ-
tubal masses like a hydrosalpinx. Very often, the fallopian ity, bowel movement or exercise, that triggered off the pain.
tube twists along with the ovary, a phenomenon referred to • History of nausea or vomiting is seen in about half the
as adnexal torsion. Ovarian torsion can result in ischaemia cases and a few may complain of pyrexia.
and necrosis, which in turn could lead to loss of the ovary • Tenderness and/or a palpable mass is often noted on
(Fig. 11.1). examination.
Torsion is more common in ovaries that are enlarged
with a mass and is less common in masses/ovaries that are In most studies, the diagnostic accuracy of ultrasound for
fixed with adhesions, like in the cases of endometriosis and diagnosis of ovarian torsion was found to be about 50–75 %.
malignancies. Torsion in young girls is known to occur, at Therefore, in most centres, laparoscopy is considered as the
times, even in the absence of an ovarian mass. This has gold standard for diagnosis of torsion in patients with a clini-
been explained by the possibility of long ligamentous sup- cal suspicion of torsion. However, in experienced hands,
ports of the ovary which increase the potential for ovarian ultrasound accuracy can be improved significantly with
torsion. proper and careful evaluation, to above 90%.
Right-sided torsion is more common than left, which is
believed to be because of the presence of the sigmoid colon Ultrasound Features of Torsion
on the left, which reduces the likelihood of torsion due to Ultrasound findings in torsion can be grouped into two
limited space. Torsion is often triggered off by exercise or broad categories – the first category includes ultrasound fea-
any other activity that causes a sudden change in intra- tures that are commonly seen in torsion but are not very spe-
abdominal pressure. An early diagnosis of torsion is impor- cific, and the second category includes three ultrasound
tant for prompt management of these cases, so as to save the features that are more specific and therefore more useful in
ovary. The present recommendation is laparoscopic detor- diagnosis. The three features in the second category are the
sion of the ovary, with the ovary being left behind even if it whirlpool sign of the pedicle, abnormal Doppler flows and
looks gangrenous. This is because recovery of ovarian func- the follicular ring sign.
tion is seen in more than 90% of ovaries on a follow-up scan
done 6–8 weeks (up to 6 months) later. In the small remain- A. Common ultrasound findings in torsion (non-specific)
der of cases, the ovaries become atrophic and no follicles are (Figs. 11.2, 11.3, 11.4, 11.5, 11.6, 11.7, 11.8, 11.9)
seen in follow-up scans (Oelsner et al. 2003). Surgical • An enlarged ovary is a very common feature, but not
removal of the ovary is resorted to if there is a possibility of specific to torsion. One of the reasons for an enlarged
a malignant tumour or cyst, or in women who are postmeno- ovary in torsion is that torsion is known to occur in ova-
pausal or perimenopausal. ries that are already enlarged (to 4–5 cm or more) due
Diagnosis of torsion is by clinical suspicion, supported by to functional cysts (like corpus luteal cysts), neoplastic
ultrasound findings. masses (particularly dermoid cysts) and hyperstimu-

© Springer Nature Singapore Pte Ltd. 2017 413

M. Sibal, Ultrasound in Gynecology, DOI 10.1007/978-981-10-2714-7_11
414 11 Torsion

lated ovaries. Congestion and oedema of the ovary sec- transverse section of the pedicle on ultrasound,
ondary to torsion also contribute to its increased size. when the probe is gently moved along the long axis
• Cysts, when present, are often haemorrhagic and thick of the pedicle. Most often, in this transverse section
walled. of the pedicle, one can also see a central hyper-
• The ovarian stroma appears oedematous (enlarged/ echoic spot (‘target sign’ mentioned earlier). This
swollen, excessive stromal tissue with no/few folli- ‘target sign’ helps not only in locating the twisted
cles). The stroma may appear heterogeneous and a lit- pedicle but also in obtaining the right section
tle hyperechoic, because of haemorrhage and oedema. required to elicit the whirlpool sign.
The entire ovary may appear solid, particularly on a The whirlpool sign can be seen both on greyscale
transabdominal scan. There may be complete loss of and Doppler. Addition of the whirlpool sign to
architecture in necrotic torsed ovaries. other sonographic features has definitely increased
• Torsed ovaries typically show multiple, peripheral, the diagnostic accuracy of ultrasound. In addition,
cortical follicles, because the oedematous stroma it is also very useful in the diagnosis of non-ovarian
pushes the antral follicles to the periphery. torsion (e.g. torsion of a hydrosalpinx or a para-
• The ovary may be placed in an unusual location, like ovarian cyst).
anterior to the uterus or on the opposite side. It could The greatest limitation of this sign is that it
also be impacted in the pouch of Douglas. requires some level of expertise/training, not only
• The ovaries are generally tender to touch. If the patient to locate the pedicle but also to get a transverse sec-
has already been administered with some painkiller, tion of the pedicle and elicit the whirlpool sign.
then the tenderness may be significantly reduced. One trick in searching for the pedicle is to look
• Some amount of free fluid is a very common feature of between the uterus and the torsed ovary and between
torsion, but again not specific. This is because minimal the torsed ovary and the lateral pelvic walls, as
free fluid is seen in a large variety of cases that have those are the most common sites where the pedicle
nothing to do with torsion. is located.
• The pedicle of the torsed ovary appears as an extra- Another issue with the whirlpool sign that has been
ovarian mass. On long section, it appears as an elon- reported in studies is the presence of both false posi-
gated and heterogeneous mass. On transverse section, it tives and false negatives.
is circumscribed and generally has a bright echogenic • Abnormal Doppler flows (Figs. 11.11, 11.12 and
centre like a ‘target sign’ which is the central axis of the 11.13): We know that following a twist, first venous
twisted pedicle. This ‘target sign’ is very useful in iden- and then arterial flow is lost (as the walls of the veins
tifying the twisted pedicle in cases of torsion. The trans- are thinner and more easily compressed than those of
verse section of the twisted pedicle can appear the arteries), and, finally, there is ischaemia and necro-
hyperechoic with multiple concentric hypoechoic sis. Therefore, in a given case, one may see arterial and
stripes or may show hypoechoic beads within, which are venous flow, or one may see only arterial flow (with no
nothing but engorged veins within the twisted pedicle. venous flow), or one may see no flow at all (i.e. no arte-
Though the pedicle is a more specific feature (i.e. it rial and no venous flow).
is not seen in other conditions), because its appearance The greatest limitation of Doppler is that it is a late
can vary and resemble a large number of other pelvic feature in torsion. Therefore, even if one sees normal
structures (like the fallopian tube), identifying it can be flows, torsion cannot be ruled out.
difficult, limiting its diagnostic utility in torsion. Another issue in some studies is a high false posi-
• Often the tube gets torsed along with the ovary. This is tive rate (in one such study, no flow was seen in 62.5%
difficult to identify on ultrasound, because other than the of cases that had no torsion). If settings are optimised,
fimbrial end, the tube does not have specific features to this is unlikely. (Doppler settings are discussed in
help identify it. Only occasionally (more often if there is Chap. 2.) For appropriate settings, the PRF should be
fluid surrounding it), one may see a thickened segment of brought down to 0.6 (or even to 0.3, if no flow is seen).
the fallopian tube close to the pedicle. This may or may Next the Doppler gain should be stepped up until arte-
not show flow, depending on the severity of torsion. facts are seen and then gradually turned down till the
artefacts just disappear. Comparison with the contra-
B. Specific ultrasound findings in torsion (which are useful lateral normal ovary provides a good control for
in diagnosis) (Figs. 11.10, 11.11, 11.12, 11.13, 11.14, Doppler evaluation.
11.15, 11.16, 11.17, 11.18 and 11.19) • Follicular ring sign (FRS) (Figs. 11.14, 11.15, 11.16,
• Whirlpool sign of the pedicle (Fig. 11.10): This 11.17 and 11.18): ‘Follicular rings’ are prominent
refers to the spiral or whirlpool pattern seen in the (1–2 mm thick) hyperechoic margins seen all around
11.1 Ovarian Torsion 415

the antral follicles of the torsed ovary. They can be Advantages of FRS
seen on both transvaginal and transabdominal scans In small peripheral centres where Doppler machines may not
but are obviously better visualised on transvaginal be available, this sign is likely to help in diagnosis as it does
scan. Again, comparison with the normal contralateral not require any Doppler evaluation.
ovary provides a convenient control. This was initially One limitation of FRS is that if antral follicles are not
an incidental observation, which was later published seen (like in a necrotic ovary or an ovary with a large cyst
by the author. The study showed that the ‘follicular and minimal compressed ovarian tissue or one located far
ring sign’ is an early, easy, specific and frequently seen away from probe), then the FRS cannot be seen. Even in
feature in torsion. large cysts (including dermoids), if one carefully searches in
The appearance of FRS is caused by oedema, the minimal ovarian tissue around the cyst, one is generally
swelling and haemorrhage that occurs around the able to observe the antral follicles and the FRS.
walls of the antral follicles. We know that antral fol- Of the three specific features useful in diagnosis of ovarian
licles have a good blood supply. Initially, when torsion, the whirlpool sign is seen right from the beginning, the
venous flow is obliterated but arterial flow continues, follicular ring sign is seen early in the course of torsion (when
there is an increase in the hydrostatic pressure of the venous and lymphatic flow begins to get compromised) and the
capillaries surrounding these follicles. This causes an abnormal Doppler (absence of flow) is a much later feature.
ooze from the capillaries, with resultant oedema and
haemorrhage. This was seen on both macroscopic
and microscopic examination of the torsed ovaries in
these cases (Fig. 11.17).
Follicular ring sign is an early feature in torsion,
seen before there is a visible change in the ovarian tis-
sues because of congestion and before blood flow to
the ovary stops. In fact, it is very distinct in this early
stage. As the condition progresses, however, the
oedema and haemorrhage spread throughout the rest of
the ovaries, and the ‘follicular rings’, though seen, are OVARY
less distinct.
FRS is a feature that is easy to find, because one
knows exactly where to look – the antral follicles of
the torsed ovary. It does not, therefore, require much Fig. 11.1 Diagrammatic representation of ovarian torsion, with the
expertise and training. ovary twisted on its ligamentary supports, causing ovarian ischaemia
416 11 Torsion

a b

FIBROMA

c d

Fig. 11.2 Ovaries enlarged with cysts: (a) dermoid, (b) fibroma, (c) neoplastic serous cystadenoma, (d) corpus luteal cysts. (c, d) Cysts show
turbid contents and thick walls
11.1 Ovarian Torsion 417

b
TS LS

Fig. 11.3 Ovarian stroma in torsion. (a) Case of right ovarian torsion, with normal left ovary. The torsed right ovary shows peripheral, scattered
antral follicles and thick hyperechoic, heterogeneous stroma, due to oedema and haemorrhage. (b) Solid-appearing torsed ovary on TAS. (c)
Heterogeneous-appearing necrotic ovary with complete loss of architecture
418 11 Torsion

a TS b LS

UT

RT LT
Cyst
POD

Fig. 11.4 Torsed ovaries in an unusual location. (a) Torsed right ovary seen on the left side of the abdomen. (b) Torsed ovary lying anterior to the
uterus
11.1 Ovarian Torsion 419

TS LS

Fig. 11.5 Free fluid in the POD

a LS - Pedicle b LS - Pedicle

Fig. 11.6 (a, b) LS of the pedicles of torsed ovaries, appearing as an elongated, heterogeneous mass in two different cases (arrows)
420 11 Torsion

a b

Fig. 11.7 TS of pedicles of torsed ovaries in three different patients. The pedicle appears as a circumscribed mass (a) that is hyperechoic with
multiple concentric hypoechoic stripes (arrow), (b) has hypoechoic beads within (engorged veins) (arrows), (c) has a bright echogenic centre –
‘target sign’
11.1 Ovarian Torsion 421

a TS LS b

Fig. 11.8 Pedicles of torsed ovaries in two different cases (a, b) showing varied, atypical appearance, making them difficult to identify

Fig. 11.9 A case of adnexal torsion, where the ovary had a fibroma.
The image shows a thickened, hyperechoic segment of the fallopian
tube (arrow), suggestive of associated tubal torsion
422 11 Torsion

Fig. 11.10 Whirlpool sign (arrows). (a) TVS – on greyscale and colour Doppler and (b) TAS – with power Doppler. This is a real-time finding.
On a frozen image, it is seen as a cross section of the pedicle with multiple concentric stripes of tissue on greyscale and as circularly placed vessels
on Doppler
11.1 Ovarian Torsion 423

a b

Fig. 11.11 Doppler in torsion. (a) Arterial and venous flow. (b) Only arterial flow. (c) No flow
424 11 Torsion

Fig. 11.12 High vascularity with low resistance flows, in a patient

with early torsion. This may be seen in the early stages of torsion and
can be misleading

Fig. 11.13 Doppler assessment in a patient with right ovarian torsion, using the normal left ovary as a control. No flow is seen in the torsed right
ovary, and good flow is seen in the normal contralateral ovary
11.1 Ovarian Torsion 425

a b

Fibroid

c d

Fibroid
F.Tube

Ovary

Fig. 11.14 Case of torsion in a patient known to have a large fibroid, who presented with acute abdominal pain, where the only specific finding
was FRS. (a) Fibroid with ovarian tissue adjacent to it showing the follicular ring sign (hyperechoic thick margins around the antral follicles)
(arrows). (b) Antral follicles were seen not only in the periphery but even in the centre of the ovarian stroma. (c) Good vascular flows seen in the
ovary. (d) Laparoscopic image of ovary showing a normal-sized pinkish ovary, suggestive of very early torsion. Antral follicles are seen bulging
out (arrows) of the ovarian surface. Site of twist (long arrow) on lateral pelvic wall concealed by the large fibroid. The oedematous torsed fallopian
tube is also seen in the image
426 11 Torsion

Fig. 11.15 FRS (arrow) seen on TAS

a NORMAL OVARY TORSED OVARY b TORSED OVARY c NORMAL OVARY

Fig. 11.16 Comparison with the contralateral normal ovary provides a convenient control for FRS. (a, b, c) Antral follicles with FRS in torsed
ovary (arrows)

a b

Fig. 11.17 Macroscopic evidence of FRS. (a) Laparoscopic image of a congested, purplish, torsed ovary, showing small, purple bulges on its
surface. These are the surface antral follicles with oedematous walls. (b) Cut section of ovarian tissue showing swollen and haemorrhagic walls of
the antral follicles
11.1 Ovarian Torsion 427

a b

DERMOID

Fig. 11.18 FRS in three different cases with torsion. (a) FRS is not seen because the ovaries were necrotic and showed no antral follicles. (b) FRS
is not seen because the cyst was far away from the probe and the ovarian tissue was compressed by the large cyst. Thus, the antral follicles could
not be visualised. (c) Case of torsion with a dermoid, where minimal ovarian tissue was seen on TVS. The antral follicles with FRS (arrow) could
be identified in the ovarian tissue

Twist Lymphatic & Ovarian congestion Arterial flow

venous flow & oedema compromised
compromised
Absent flow
Whirlpool Sign Follicular Ring Sign Ischaemia & necrosis

Fig. 11.19 Diagrammatic representation of the pathology of ovarian torsion in temporal succession, along with the three specific features that
help in ultrasound diagnosis
428 11 Torsion

Summary: Ovarian Torsion

• Diagnosis of torsion is based on clinical features
supported by ultrasound findings. Clinical features
raise suspicion but are not specific. Pain is the main
presenting symptom.
• Ultrasound features
A. Common ultrasound features – but not very
specific:
Large ovaries, abnormal position of ovary,
oedema of ovarian stroma, peripheral follicles,
free fluid and haemorrhagic cysts.
B. Ultrasound features with higher specificity:
1. Pedicle with the whirlpool sign – increases
diagnostic accuracy significantly but requires
experience
2. Abnormal Doppler flows – a late finding in
torsion (normal flow does not rule out
torsion)
3. Follicular ring sign – simple, early and fre-
quently seen feature
• Management of these cases is by prompt surgical
intervention, which involves laparoscopic detorsion
of the ovary. The ovary should be left behind even if
it looks gangrenous. A neoplastic cyst may be
excised. The ovary may, however, be excised if there
is a possibility of a malignant tumour or cyst, or if
the patient is postmenopausal or perimenopausal.
11.2 Non-ovarian Torsion 429

11.2 Non-ovarian Torsion • Absence of Doppler flows may also be a feature in an

advanced case. This is more difficult to assess than in
Torsion of a hydrosalpinx or a paraovarian cyst also presents cases of ovarian torsion, because there isn’t much solid
with acute pelvic pain. Here, all the ultrasound findings of tissue in the walls of these cases to look for flow.
ovarian torsion are not seen. The first part of the diagnosis is, • The follicular ring sign is, of course, not a feature because
of course, to diagnose a hydrosalpinx or a paraovarian cyst. there are no antral follicles in the torsed mass.
This has been discussed in Chap. 9. A torsed hydrosalpinx • Other non-specific ultrasound features of torsion which
could appear atypical – i.e. it could appear more globular may be seen are thicker walls (due to congestion and
than elongated, and the incomplete septum may not be seen. oedema), fluid within the mass showing internal echoes
suggestive of haemorrhage, tenderness and free fluid in
Ultrasound Features of Non-ovarian Torsion the pelvis.
(Figs. 11.20, 11.21 and 11.22)
• The pedicle with the whirlpool sign is a specific feature of
torsion similar to what is seen in ovarian torsion and is
helpful in diagnosis.
430 11 Torsion

a b

c d e

Fig. 11.20 Torsion of a left hydrosalpinx. (a) Elongated cystic mass with a short, incomplete septum (short arrow), turbid contents and thick
walls (long arrow), suggestive of a torsed hydrosalpinx with haemorrhage within. (b) Whirlpool sign of pedicle seen on TAS in greyscale and
Doppler (arrows). (c) Whirlpool sign on TVS in greyscale and Doppler (arrows). (d, e) Normal left and right ovaries of the patient. (f) Laparoscopic
image of the torsed hydrosalpinx, showing the twist (arrow)
11.2 Non-ovarian Torsion 431

a b
TS LS

c d e

Fig. 11.21 Torsion of a paraovarian cyst. (a) PO cyst on TAS, with low-grade internal echoes. (b) Small cross section of pedicle (arrow) seen
below the cyst on TAS. (c) Cross section of twisted pedicle showing the target sign (long arrow) and whirlpool sign (short arrow). (d, e) Normal
right and left ovaries
432 11 Torsion

a b

c d

Fig. 11.22 Benign paraovarian cyst with early torsion. (a, b) Normal right and left ovary. (c) Septate PO cyst seen. (d) Cyst walls showing flow.
(e) Twisted pedicle showing whirlpool sign on greyscale and Doppler (arrows)
Suggested Reading 433

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pelvic pain of gynecologic origin in nonpregnant premenopausal
patients. Radiographics 28(6):1645–1659
Chang HC et al (2008) Pearls and pitfalls in diagnosis of ovarian tor-
Mashiach R et al (2011) Sonographic diagnosis of ovarian torsion accu-
sion. Radiographics 28(5):1355–1368
racy and predictive factors. J Ultrasound Med 30:1205–1210
Cohen SB et al (2001) Accuracy of the preoperative diagnosis in 100
Sibal M (2012) Follicular ring sign: a simple sonographic sign for early
emergency laparoscopies performed due to acute abdomen in non-
diagnosis of ovarian torsion. J Ultrasound Med 31(11):1803–1809
pregnant women. J Am Assoc Gynecol Laparosc 8:92–94
Valsky DV et al (2010) Added value of the grey‐scale whirlpool sign in
Oelsner G et al (2003) Minimal surgery for the twisted ischaemic
the diagnosis of adnexal torsion. Ultrasound Obstet Gynecol
adnexa can preserve ovarian function. Hum Reprod 18(12):2599–
36(5):630–634
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sion. J Ultrasound Med 23:1643–1649
 Ultrasound Evaluation of Congenital
Uterine Anomalies 12

Evaluation of uterine anomalies can be confusing because of first trimester loss. In arcuate uterus, there is an increased
the various diagnostic ultrasound criteria and available clas- risk of second trimester loss and preterm labour. Abnormal
sifications. In this chapter, we have primarily followed the fetal presentation is more common in women with uterine
popular AFS classification. In order to better understand the anomalies. Conceiving, however, is generally not an issue
types of anomalies, the chapter initially deals with embryop- in patients with uterine anomalies.
athogenesis. A brief account of the basic diagnostic criteria is 2. Adolescent health issues like pain, as seen in haematocol-
initially discussed. Following this, the diagnosis of each type pos and a non-communicating uterine horn.
of anomaly, based on these criteria, is provided. The last part 3. Life-threatening emergencies like rupture of a cornual
of this chapter deals with the evaluation of the cervix and pregnancy.
vagina for congenital anomalies, which is not focused upon
most often in literature, primarily because it is believed to be
suboptimally assessed on regular TVS. Cervical and vaginal 12.1 Embryopathogenesis (Figs. 12.1, 12.2)
anomalies are generally associated with uterine anomalies.
Here the fine points for ultrasound diagnosis of cervical and The uterus develops from two Mullerian (paramesonephric)
vaginal anomalies, including the useful novel use of GSV for ducts. Their lower ends fuse to form the upper two-third of
accurate evaluation of these conditions, are provided. the vagina, cervix and uterus. Their upper ends do not fuse,
The prevalence of uterine anomalies is believed to be and they form the two fallopian tubes. The lower one-third of
between 4% and 7 % (Grimbizis and Campo 2012). The prev- the vagina develops from the urogenital sinus. Fusion of the
alence is higher in select populations, like recurrent aborters. two Mullerian ducts occurs from below upwards. Following
There is a higher incidence of associated renal abnormali- fusion, the intervening septum gets resorbed to form a com-
ties in women with uterine anomalies, because of related mon uterine cavity. The resorption also occurs from below,
embryological development of these organs. upwards. If there is any abnormality in the process of devel-
Many of these women with uterine anomalies are asymp- opment, fusion or resorption, it results in a uterine anomaly.
tomatic. Some may, however, present with the following The American Fertility Society (AFS) classification
clinical manifestations: (Figs. 12.2 and 12.3), which is the most popular classifica-
tion of uterine anomalies (and is followed in this chapter), is
1. Reproductive health – particularly recurrent pregnancy based on the stage of arrest of development, fusion or resorp-
losses. In subseptate uterus, there is an increased risk of tion in the above process.

© Springer Nature Singapore Pte Ltd. 2017 435

M. Sibal, Ultrasound in Gynecology, DOI 10.1007/978-981-10-2714-7_12
436 12 Ultrasound Evaluation of Congenital Uterine Anomalies

Fig. 12.1 Stages of

embryological development of
a b
the female genital tract. (a) The
uterus develops from the two
Mullerian duct
Mullerian ducts (arrows). (b)
The two ducts fuse together Fallopian tube
beginning from the lower end to Uterus
form the uterus and the upper
Cervix
two-third of the vagina. The
upper non-fused parts give rise to Upper 2/3 Vagina
the fallopian tubes. (c) The
intervening septum between the
two fused ducts gradually gets
resorbed starting from the lower
end, moving upwards. (d) Single
uterine cavity formed following c d
resorption of the septum. (e) The
upper two-third of the vagina
arises from the Mullerian duct
and the lower one-third from the
urogenital sinus. (f) The
transverse septum between the
upper two-third and the lower
one-third of the vagina gets
resorbed forming a single vaginal
cavity

e f
12.1 Embryopathogenesis 437

Fig 12.2 AFS classification of

uterine anomalies: based on the
stage of arrest. (a) If there is
arrest prior to complete
development of the two
Mullerian ducts, it can result in
agenesis or unicornuate uterus.
a
(b) If there is arrest prior to
complete fusion of the two
Mullerian ducts, it can result in
didelphys or bicornuate uterus.
(c) If there is arrest prior to
complete resorption of the
intervening septum, it can result
in septate or arcuate uterus

c
438 12 Ultrasound Evaluation of Congenital Uterine Anomalies

12.2 AFS Classification of Uterine Resorption Defect

Anomalies (Figs. 12.2 and 12.3) Class V – septate uterus (complete absence of resorption)
and subseptate uterus (partial resorption defect).
Underdeveloped Class VI – arcuate uterus; the fusion defect is minimal as a
Class I – Mullerian agenesis or hypoplasia; cases with agen- result of which there is a slight indentation of the uterine
esis or hypoplasia of part or whole of the Mullerian ducts cavity.
Class II – cases with underdevelopment of one of the Class VII – a ‘T-shaped’ uterus which could be the result of
Mullerian ducts resulting in a unicornuate uterus, which intrauterine exposure to diethylstilbestrol.
could again be of four types, as shown in Fig. 12.3

Fusion Defect
Class III – complete lack of fusion, resulting in a didelphys
uterus
Class IV – partial defect in fusion, resulting in a bicornuate
uterus

I Hypoplasia / agenesis II Unicornuate III Didelphys

(a) (b) Non

(a) Vaginal (b) Cervical Communicating Communicating IV Bicornuate

(c) Fundal (d) Tubal (e) Combined (c) No cavity (d) No horn (a) Complete (b) Partial

V Septate VI Arcuate VII DES drug related

(a) Complete (b) Partial

Fig. 12.3 AFS classification of uterine anomalies

12.3 Approach to Diagnosing a Uterine Anomaly 439

12.3 Approach to Diagnosing a Uterine • In some cases, two separate uterine bodies are seen (more
Anomaly obvious on transverse section at TAS).
• In a longitudinal section scan, on moving from one cor-
Diagnosis of uterine anomalies requires an assessment of the nua to the other cornua, the endometrial length in the mid-
external fundal contour and an assessment of the shape of the line appears shorter, while on both cornual ends it appears
inner uterine cavity. longer.
The external fundal contour can be assessed at laparot-
omy and laparoscopy. 3D ultrasound has been discussed in Chap. 2. Some points
The inner uterine cavity can be assessed by hysteroscopy dealing with evaluation of uterine anomalies are being
or hysterosalpingography (HSG). mentioned:
However, the only modalities that can assess both the
cavity and the external fundal contour are ultrasound and • The best time to evaluate the uterine anomaly is the secre-
MRI. tory phase (when the endometrium is thick and oedema-
Ultrasound is the primary diagnostic modality of choice tous), and the best time to evaluate the cervix is mid-cycle
because of its lower cost and easy availability. (around ovulation – when the cervix has abundant mucous).
Assessment in pregnancy is not likely to be accurate • Typically, the best plane to take a 3D volume is the sagit-
because of the altered shape and dimensions, which could be tal section of the uterus in the midline (the section where
because of an eccentrically placed gestational sac. Patients the endometrial length is minimal). The angle of sweep
should therefore be called about 2–3 months after abortion or should be made as wide as possible.
delivery for identification and correct classification of any • In cases with a broad fundus or two uterine horns placed
existent or suspected uterine anomaly. far apart, the 3D sweep should be taken in a transverse
Two-dimensional (2D) greyscale imaging helps raise the section.
suspicion of a uterine anomaly and in some cases may even • Because the cervix and uterine body are often in different
help to confirm the presence of a uterine anomaly. However, planes, they may have to be evaluated separately with ren-
three-dimensional (3D) imaging is essential in confirming dering in two separate planes.
and diagnosing the type of uterine anomaly. The best time • Polyline is an effective new technique for simultaneous
for evaluation is the secretory phase of the menstrual cycle, assessment of the cervical and uterine cavities in a single
because the endometrium lining of the uterine cavity at that rendered image.
time is fluffy and oedematous and shows up well on 3D • Evaluation of the cervix and vagina is suboptimal on reg-
ultrasound. ular TVS because of the proximity of these structures to
the probe and the collapsed vaginal walls. For evaluation
Ultrasound Features That Raise Suspicion of Uterine of the cervix and vagina, the probe may have to be with-
Anomalies (Figs. 12.4 and 12.5) drawn a little for better visualisation. Gel sonovaginogra-
On 2D ultrasound, findings in women with uterine anomalies phy (GSV) is a great technique to evaluate the cervix and
are: the vagina (discussed in Chap. 2).
• It is sometimes easier to assess the uterine anomaly with 3D
• Broad transverse diameter of the uterus. on a transabdominal scan with a full bladder, as compared to
• On transverse section, the endometrial cavity is seen split- a transvaginal scan, because the uterus (its two horns and
ting into two as one moves upwards from the cervix to the the cervix) gets more stretched and straightened out with a
fundus. full bladder, making the rendered image much clearer.
440 12 Ultrasound Evaluation of Congenital Uterine Anomalies

On 3D ultrasound, the external fundal contour and the B. Shape of the uterine cavity is considered abnormal if there
inner uterine cavity are both well visualised. A normal uterus is any indentation in its superior outline.
has a convex external fundal contour, and the upper end of
the uterine cavity is flat (Fig. 12.6). It is important to differentiate between arcuate and sep-
tate/subseptate uterus. The table below shows the various
A. The external fundal contour is considered abnormal if: methods used, of which the angle at the centre is most com-
• The indentation of the myometrium in the midline is monly used for evaluation (Fig. 12.9).
more than or equal to 10 mm.
• The uterine fundus crosses below the line joining
ARCUATE
the upper end of the cavities on both sides or is less
1. Angle at the centre is more than or equal to 90 degree
than or equal to 5 mm from it (Troiano and
2. Indentation of less than 1.5 cm
McCarthy 2004). This is the method most accepted
3. Indentation of less than 50% uterine wall thickness
today and is followed in this chapter (Figs. 12.7
and 12.8).
• The indentation of the myometrium in the midline is
more than 50 % of the uterine wall thickness (the SEPTATE / SUBSEPTATE
mean thickness of the anterior and posterior walls in 1. Angle at the centre is less than 90 degree
the sagittal section). This is based on ESHRE 2. Indentation of more than or equal to1.5 cm
classification. 3. Indentation of more than 50% uterine wall thickness

LS TS

Fig. 12.4 Longitudinal and transverse section of the uterus showing increased transverse dimension of the uterus (6 cm) with two endometrial
cavities
12.3 Approach to Diagnosing a Uterine Anomaly 441

TS Uterus Coronal

Fig. 12.5 TVS showing increased transverse diameter of the uterus

with two endometrial cavities (arrows)

Fig. 12.6 3D rendered coronal image of a normal uterus showing a

convex external fundal contour (short arrow) and the triangular shape
of the inner uterine cavity of the uterus with the upper end of the uterine
cavity being flat (long arrow)
442 12 Ultrasound Evaluation of Congenital Uterine Anomalies

Crosses - Abnormal </= 5 mm - Abnormal >5mm - Normal

a b c

Fig. 12.7 Troiano and McCarthy’s method of evaluating the external contour of the uterine fundus. The uterine fundus is considered abnormal (a)
if it crosses below the line joining the upper end of the cavities on both sides and (b) if it is less than or equal to 5 mm from it. (c) If the uterine
fundus is more than 5 mm from this line, the external contour of the fundus is considered normal

Uterus Coronal

Fig. 12.8 Distance between the uterine fundus and the line joining the
upper end of the cavities on both sides is measured to assess whether
the external fundal contour is normal. If it is less than or equal to 5 mm,
this would be considered as abnormal external fundal contour and the
anomaly would be labelled as a bicornuate uterus. If it is more than
5 mm, the external fundal contour is considered normal and the anom-
aly would be labelled as a septate uterus
12.3 Approach to Diagnosing a Uterine Anomaly 443

Fig. 12.9 Shape of the uterine a b Uterus Coronal

cavity based on the angle at the
centre: (a) arcuate (more than or
equal to 90°) and (b) subseptate
(less than 90°). Shape of the
uterine cavity based on the depth
of indentation of the cavity: (c)
arcuate (less than 1.5 cm) and (d)
subseptate (more than or equal
to 1.5 cm)

Uterus
Coronal

Uterus Coronal
c d

Uterus
Coronal

c
444 12 Ultrasound Evaluation of Congenital Uterine Anomalies

12.4 Types of Uterine Anomalies B. Shape of the uterine cavity:

• Abnormal – indentation seen
12.4.1 Arcuate Uterus (Fig. 12.10) • Angle at the centre between the two uterine cavities is
obtuse (more than or equal to 90°)
A. External fundal contour:
• Normal

Fig. 12.10 Different cases of

arcuate uterus with normal
a Uterus Coronal b Uterus Coronal
external fundal contour and
indentation of the uterine cavity
with angle more than or equal
to 90°

c Uterus Coronal d Uterus Coronal

12.4 Types of Uterine Anomalies 445

The arcuate uterus is generally compatible with normal At times, a normal intrauterine pregnancy close to the
reproductive outcome. It is considered by some to be a nor- uterine cornua in a patient with an arcuate uterus may be
mal anatomical variant. It is proposed that if the ratio of the wrongly reported as an interstitial ectopic pregnancy, because
height to the length is less than 10 % (Fig. 12.11), it is not of the uterine shape. One must be aware about this possibil-
believed to be of clinical significance. It does not exist as a ity (Fig. 12.12).
separate entity from a septate uterus in the new ESHRE
classification.

Uterus Coronal

Fig. 12.12 Arcuate uterus with twin pregnancy sacs (arrows). The
upper sac (long arrow) near the right cornua was wrongly interpreted to
be an interstitial pregnancy but was in fact an intrauterine pregnancy
Fig. 12.11 In an arcuate uterus, if the ratio of height (H) to length (L) well within the endometrial margins
of the indentation is less than 10 %, it is not believed to be of clinical
significance
446 12 Ultrasound Evaluation of Congenital Uterine Anomalies

12.4.2 Subseptate Uterus (Fig. 12.13) • Angle at the centre between the two uterine cavities is
acute (less than 90°)
A. External fundal contour:
– This indentation/septum does not reach up to the
• Normal internal os.
B. Shape of the uterine cavity:
• Abnormal – indentation seen

Fig. 12.13 Different cases of

a Uterus Coronal b Uterus Coronal
subseptate uterus with normal
external fundal contour and
indentation of the uterine
cavity (less than 90°). The
indentation/septum does not
reach the internal os

c Uterus Coronal d Uterus Coronal

e Uterus Coronal f Uterus Coronal

12.4 Types of Uterine Anomalies 447

12.4.3 Septate Uterus (Fig. 12.14) – This indentation/septum reaches up to the internal os
or may extend beyond it.
A. External fundal contour: Both septate and subseptate uterus are the most common
anomalies seen, constituting about 55 % of all uterine anom-
• Normal
alies. In 25 % of the cases, a vaginal septum is also seen.
B. Shape of the uterine cavity: Of the uterine anomalies, these have the poorest reproductive
outcome with an increased incidence of spontaneous abortion
• Abnormal – indentation seen
and preterm delivery. Resection of the septum has been reported
• Angle at the centre, between the two uterine cavities is
to decrease the risk of spontaneous abortion significantly.
acute (less than 90°)

Fig. 12.14 Septate uterus with

a Uterus Coronal b Uterus Coronal
normal external fundal contour
and indentation of the uterine
cavity (less than 90°). The
indentation/septum reaches up to
the internal os and may extend
beyond it

c Uterus Coronal d Uterus Coronal

448 12 Ultrasound Evaluation of Congenital Uterine Anomalies

12.4.4 Bicornuate Uterus (Fig. 12.15) This constitutes about 10 % of uterine anomalies; it can be
complete (extending up to the internal os) or partial. It can be
A. External fundal contour: unicollis (single cervical canal) or bicollis (cervical septum
with two cervical canals). Vaginal septum is seen in 25 % of
• Abnormal with indentation (uterine fundus crosses below
these cases.
the line joining the upper end of the cavities on both sides
The reproductive outcome in these cases is better than in
or is less than or equal to 5 mm from it)
a septate uterus. The length of gestation increases with par-
ity. This anomaly has the highest incidence of cervical
B. Shape of the uterine cavity:
incompetence. Surgical intervention is generally not indi-
• Abnormal – indentation seen cated. In cases with recurrent pregnancy losses, metroplasty
– If the separation of the uterine cavity does not extend up may be considered.
to the internal os, it is termed as partial bicornuate
uterus. The cervical canal may be single (unicollis) or
double (bicollis).
12.4 Types of Uterine Anomalies 449

Fig. 12.15 Bicornuate uterus

a Uterus Coronal b Uterus Coronal
with abnormal external fundal
contour with indentation (uterine
fundus crosses below the line
joining the upper end of the
cavities on both sides or is less
than or equal to 5 mm from it)
along with indentation of the
uterine cavity. (a, b) Partial
bicornuate uterus. (c) Complete
bicornuate bicollis uterus. (d)
Complete bicornuate uterus. (e)
Bicornuate unicollis uterus with
splayed out uterine bodies. 3D
rendering with polyline was
useful in obtaining a coronal
image of the uterus. (f)
Bicornuate bicollis uterus. (g) As
the distance between the upper
end of the endometrial cavities c Uterus Coronal d Uterus Coronal
and the fundal outline was less
than 5 mm, and the septum was
not reaching up to the internal os,
this was labelled as a partial
bicornuate uterus

e TS Uterus Coronal

f Uterus Coronal g Uterus

Coronal
450 12 Ultrasound Evaluation of Congenital Uterine Anomalies

12.4.5 Uterus Didelphys (Fig. 12.16) 3D evaluation is often difficult because the two uterine
horns may be far apart, making it difficult to include them in
A. External fundal contour: a single sweep/image.
They constitute about 5 % of uterine anomalies. Vaginal
• Abnormal with indentation (uterine fundus crosses below
septum is seen in 75 % of these cases. Spontaneous abortion
the line joining the upper end of the cavities on both sides
and preterm delivery may be seen in these patients. If one
or is less than or equal to 5 mm from it)
side is obstructed, patients may suffer from dysmenorrhoea,
B. Shape of the uterine cavity: adenomyosis and endometriosis. In women with recurrent
losses of pregnancy, metroplasty may be considered.
• Abnormal – two separate uterine cavities
In these cases, two separate cervices are seen beside each
other, as two separate cervical canals with a thick interven-
ing myometrium.

a b
Uterus Coronal

c d
TAS - TS TVS - TS

Bladder

e Cervix Coronal

Fig. 12.16 Uterus didelphys with an abnormal external fundal contour (uterine fundus crosses below the line joining the upper end of the cavities on
both sides or is less than or equal to 5 mm from it) and an abnormal uterine cavity (two separate uterine cavities). (a) Uterus didelphys in a postmeno-
pausal lady. A single 3D rendered image showing both uterine horns was possible because of the small uterine size. (b) Diagrammatic representation
of the same. (c) TAS image of a uterus didelphys showing an unconventional section of the uterine body. (d) Uterus didelphys on TVS with both the
uterine cavities splayed apart (arrows). (e) 3D rendered image showing two separate cervices with thick intervening myometrium (cervical canal
marked with arrows)
12.4 Types of Uterine Anomalies 451

12.4.6 Unicornuate Uterus (Fig. 12.17) • Have a rudimentary horn with a cavity in 32 % of the
cases. Of these, in 22 %, the cavity of the rudimentary
A. External fundal contour: horn is non-communicating (i.e., not communicating with
the main uterine cavity), and in 10 % it communicates
• Normal
with the main uterine cavity.
B. Shape of the uterine cavity:
Unicornuate uterus has the highest association with renal
• Abnormal – Banana shaped and deviated to one side, end-
anomalies (40 %). An increased incidence of spontaneous
ing in a single cornua.
abortions, preterm delivery, IUGR and abnormal fetal lie has
been reported.
This is the most frequently missed anomaly because the exter-
In cases with non-communicating rudimentary horn, there
nal fundal contour appears normal, and, unless visualisation of
is an increase in incidence of cornual ectopic pregnancy, dys-
both cornua is a routine, the presence of a single cornu may be
menorrhoea, adenomyosis and endometriosis. Surgical resec-
missed.
tion of the rudimentary horn may be required in such cases.
It constitutes about 20 % of uterine anomalies. It may:
• Be isolated in 35 % of the cases.
• Have a rudimentary horn with no cavity in 33 % of the
cases.
452 12 Ultrasound Evaluation of Congenital Uterine Anomalies

a b
Uterus Coronal Uterus Coronal

c Uterus Coronal d TAS - LS

e
TAS - TS

Fig. 12.17 Unicornuate uterus with normal external fundal contour and a banana-shaped uterine cavity, deviated to one side and ending in a single
cornua. (a) True unicornuate uterus with no rudimentary horn. (b) Unicornuate uterus with a rudimentary horn with no endometrial cavity. (c)
Unicornuate uterus with a rudimentary horn and a non-communicating endometrial cavity. (d) Unicornuate uterus with pregnancy in the non-
communicating rudimentary horn – cornual ectopic pregnancy. (e) TAS – transverse section of a right unicornuate uterus with a left non-commu-
nicating rudimentary horn, showing hematometra and thick uterine walls secondary to adenomyosis
12.4 Types of Uterine Anomalies 453

12.4.7 Absent/Hypoplastic Uterus (Figs. 12.18 secondary sexual characters. They most often present with
and 12.19) primary amenorrhea.
This constitutes 5–10 % of uterine anomalies. The ovaries
The uterus is either absent or is replaced by a very small are visualised in true Mullerian agenesis (commonly known
rudimentary structure, just above the vagina. The ovaries are as ‘Mayer–Rokitansky–Kuster–Hauser syndrome’).
usually normal, and therefore these patients have normal

Fig. 12.18 Absent uterus. Vaginal lumen seen as a

hyperechoic linear echo (arrows). Uterine body not TAS - LS
seen above it

Bladder

a
LS UTERUS TAS TS

Bladder
Bladder

b c

Fig. 12.19 Hypoplastic uterus in a patient with Mayer–Rokitansky–Kuster–Hauser syndrome. (a) Longitudinal section, (b) transverse section of
the rudimentary uterus. (c, d) Normal right and left ovaries
454 12 Ultrasound Evaluation of Congenital Uterine Anomalies

12.4.8 ‘T-Shaped’ Uterus (Fig. 12.20) ‘T-shaped’ uterine cavity was a known complication of
intrauterine exposure to diethylstilbestrol (DES), the use of
A. External fundal contour: which was discontinued in 1971. This abnormality may be
seen even without a history of DES exposure.
• Normal
Increased incidence of recurrent abortions and preterm deliv-
B. Shape of the uterine cavity: ery has been reported in these cases. In some cases, hystero-
scopic metroplasty has shown improved reproductive outcome.
• Abnormal – ‘T shaped’

a b

Uterus Uterus

Coronal Coronal

Fig. 12.20 T-shaped uterus with normal external contour and abnormal ‘T-shaped’ uterine cavity
12.5 Cervical and Vaginal Anomalies 455

12.5 Cervical and Vaginal Anomalies scan, the probe tends to pass into one of the two vaginal cavi-
(Figs. 12.16e, 12.21, 12.22, 12.23, 12.24, ties by default.
12.25, 12.26, 12.27, 12.28 and 12.29) In most cases, the other collapsed vaginal cavity can be
seen on careful observation, with the probe withdrawn lower
Very often, the embryological abnormal fusion and resorp- into the vaginal canal, as a white echogenic line. This echo-
tion may involve the cervix and the vagina. Evaluating these genic line is seen on ultrasound whenever two smooth sur-
is more challenging because of the proximity of these struc- faces approximate each other – in this case the two walls of
tures to the vaginal probe. This can be overcome to some other hemivagina.
extent by partial withdrawal of the transvaginal probe, a little Vaginal anomalies have been evaluated with MRI using
lower down into the vagina. In addition, the vagina is a col- various techniques. Their evaluation with GSV is very con-
lapsed structure making it difficult to evaluate the presence venient and accurate. Gel can be instilled on both sides of the
of a vaginal septum. vaginal septum. One can evaluate the thickness, length and
direction of the septum. Also the relation of the two cervical
os to the septum can be assessed.
Cervix
In some cases, a transverse vaginal septum may be seen.
The best time to evaluate the cervix for anomalies is during This is often due to defective resorption of the tissue between
ovulation (mid-cycle – around Day 12 in a 28-day menstrual the upper two-third of the vagina developing from the
cycle). The cervical canal can be assessed on 2D, in a trans- Mullerian duct and the lower one-third developing from the
verse plane. It is better seen on 3D, but evaluation on 3D urogenital sinus. This resorption should normally occur,
may require a special technique, separate from standard ren- resulting in a single vaginal canal. In these cases, the trans-
dered imaging of the uterine cavity. One could either take vaginal probe does not reach up to the cervix. In some of
two separate volume sweeps, one for the uterine cavity and these patients, there may be a small opening through which
one for the cervix, or one may take a single sweep, but the menstrual blood may flow out. However, in other cases, the
rendering of the two has to be done separately. With newer transverse septum may be complete and intact, resulting in
machines, there is an additional facility called polyline, the patient presenting at menarche with primary amenorrhea
using which the plane of rendering can be traced in a curvi- and pain secondary to haematocolpos/hematometra.
linear manner, along the uterocervical canal, thus facilitat- A patient with imperforate hymen can also present with
ing simultaneous rendering of the entire uterocervical similar features as an intact transverse vaginal septum with
cavity. MRI is sometimes more informative than standard primary amenorrhea, cyclical pain and haematocolpos/
ultrasound in the evaluation of cervical anomalies. hematometra. It is a relatively common anomaly seen in
Gel sonovaginography (GSV) may be resorted to for bet- about 0.1 % of women. During ultrasound, therefore, it is
ter assessment of the cervix, the cervical canal and the cervi- important to assess the thickness of the tissue below the hae-
cal os (whether there are 1 or 2). matocolpos so as to decide the surgical management of these
cases. With imperforate hymen, a simple cruciate incision is
the solution, whereas other transverse vaginal septum will
Vagina
require more complex surgeries.
A longitudinal vaginal septum divides the vagina into two In patients with Mullerian agenesis, the vagina may be
parallel cavities, and, unless one or both of the cavities are very short and these patients may require vaginoplasty for
obstructed with resultant haematocolpos and hematometra, normal coital function.
the longitudinal septum may go unrecognised both clinically In patients with obstruction of menstrual flow due to a
and on ultrasound. If any one of the vaginal cavities is transverse vaginal septum or an imperforate hymen or a non-
obstructed, the symptoms will be similar to that of a trans- communicating hemivagina, the back pressure can result in
verse vaginal septum. Septate vagina is often seen in women pain. In long-standing cases, adenomyosis and endometrio-
with uterine anomalies extending up to the cervix. On TVS sis could also be a resultant complication.
456 12 Ultrasound Evaluation of Congenital Uterine Anomalies

LS Uterus

Coronal

Fig. 12.21 Evaluation of the cervix can be challenging in case of uterine anomalies where there is significant retroflexion or anteflexion, because
the coronal plane of the uterine body and the cervical canal is different. In this case of an anteflexed uterus, polyline was used so as to obtain a
single image showing the coronal sections of both the uterus and the cervix
12.5 Cervical and Vaginal Anomalies 457

Fig. 12.22 Case of septate

a b Coronal
uterus with septate vagina. (a)
3D rendered coronal image of a
septate uterus and cervix. (b)
Probe is seen in one half of the
vagina (partially withdrawn for
better visualisation). The lower
end of the two cervical canals
(arrows) is seen and the lumen of
the right-sided hemivagina is
seen as a hyperechoic line (short Uterus
arrow). (c) Transverse section of
the septate vagina with gel within Coronal
showing hyperechoic air bubbles.
(d) 3D rendered image of the two
cervical ostia (arrows) on either
side of the septum, on GSV. (e)
3D rendered image of the two
cervical canals on GSV. (f)
Diagrammatic representation of c TS d
the anomaly

e f
Cervix

Coronal
458 12 Ultrasound Evaluation of Congenital Uterine Anomalies

a b
Vagina

Coronal

Uterus

Coronal

Fig. 12.23 Septate uterus, cervix and vagina (a) Coronal rendered image of the septate uterus. (b) Coronal section of the septate vagina with gel
on either sides (arrows) of the vaginal septum. (c) GSV with 3D rendering, showing the two cervical os
12.5 Cervical and Vaginal Anomalies 459

Uterus
Coronal

b c

Fig. 12.24 Bicornuate uterus with a single cervix and a single vagina. (a) Shows a coronal rendered image of a complete bicornuate uterus. (b)
GSV – image showing the plane of rendering used to evaluate the cervix and cervical os. (c) GSV with 3D rendering showing a single cervical os
(arrow) seen as a transverse slit. In this case, there was a single flattened cervical canal narrow in the midline giving a false impression of a septum
extending into the cervix as is seen in figure (a)
460 12 Ultrasound Evaluation of Congenital Uterine Anomalies

a LS b LS

cx
cx
Bladder

Fig. 12.25 Married woman with a transverse vaginal septum in the upper vagina. Patient presented with a history of abdominal pain and a positive
pregnancy test. She gave no history of coital or menstrual problems. (a) TAS – no intrauterine pregnancy seen. (b) TVS – showing a transverse
vaginal septum (short arrow) which is measured in the image, just below the cervix (cx). Hyperechoic line (long arrow) showing a smooth inter-
face between the vaginal septum and the anterior lip of the cervix. A part of the bladder is seen in the image anteriorly

TAS - LS

UT

Vagina

Fig. 12.26 Imperforate hymen with haematometrocolpos. The figure

shows a grossly dilated vagina with turbid fluid suggestive of blood seen
in the vagina (haematocolpos), cervical canal and uterine body due to
backflow from the haematocolpos, resulting in a haematometrocolpos
12.5 Cervical and Vaginal Anomalies 461

a TAS - LS b TS Vagina LS

UT

Vagina

Hematocolpos

Fig. 12.27 Imperforate hymen with haematometrocolpos. Patient was a 14-year-old girl who presented with severe abdominal pain. (a) Sagittal
section showing hematometra and haematocolpos. (b) Haematocolpos seen in the transverse and the sagittal section with a volume of 169cc. (c)
Transperineal scan done to assess the thickness of the tissue below the haematocolpos. Here a thin imperforate hymen is seen. A simple cruciate
incision was the solution
462 12 Ultrasound Evaluation of Congenital Uterine Anomalies

a TAS - LS b
TVS - LS

Bladder
Bladder
UT

c TVS - LS

Bladder

Vagina

Fig. 12.28 Imperforate hymen with regular menses. A 24-year-old unmarried patient presented with a history of absent vaginal opening. (a) TAS
showing the sagittal section of normal uterus and upper vagina (arrow). (b) Transperineal scan showed an obstruction suggestive of an imperforate
hymen which is measured in the image. (c) In order to confirm the findings, a search was made for a possible opening in the hymen through which
the patient had been menstruating. A small opening was found through which saline was infused into the vagina. This confirmed it to be a case of
a simple imperforate hymen. Simple cruciate incision was sufficient to open out the vagina
12.5 Cervical and Vaginal Anomalies 463

a Uterus Coronal

RIGHT

LIFT

b c

Fig. 12.29 Bicornuate uterus with hemi-haematometrocolpos. (a) TAS showing a coronal section of the bicornuate uterus with left-sided hemi-
haematometrocolpos. (b) GSV done to assess the vaginal septum and locate the communicating left hemivagina (arrow). (c) Diagrammatic repre-
sentation of the same. A simple cruciate incision was made over the septum to drain the left hemi-haematometrocolpos
464 12 Ultrasound Evaluation of Congenital Uterine Anomalies

12.6 ESHRE/ESGE Classification of presence, absence and if present, the type of cervical and
Congenital Uterine Anomalies vaginal anomaly should be reported.
As mentioned earlier, arcuate uterus is not classified as a
The European Society of Human Reproduction and separate entity, and a bicorporeal septate uterus is an added
Embryology (ESHRE) and European Society for entity to characterise those uteri that have mixed features of
Gynaecological Endoscopy (ESGE) under the working name septate and bicornuate uterus (i.e. a mixture of fusion and
CONUTA (CONgenital UTerine Anomalies) have come up resorption defects).
with a classification for congenital uterine anomalies Another important feature is that while reporting the uter-
(Fig. 12.30). ine anomaly, a drawing of the same is to be included.
An important feature of this classification is that the cer-
vix, vagina are to be assessed for coexistent anomalies. The
12.6 ESHRE/ESGE Classification of Congenital Uterine Anomalies 465

Fig. 12.30 ESHRE/ESGE classification of uterine anomalies

466 12 Ultrasound Evaluation of Congenital Uterine Anomalies

12.7 Reporting Uterine Anomalies shape of the uterine cavity. Myometrial indentation or the
(Fig. 12.31) septum must be measured (i.e. the distance between the two
uterine cavities, also known as intercornual distance, and the
Having evaluated the uterus, the cervix and the vagina in depth of the intervening septum). One must mention if the
patients with uterine anomalies, reporting must be in suffi- septum is reaching up to the internal os, and, if not, the length
cient detail so as to give the referring clinician clear informa- of the common uterine cavity must be mentioned. The pres-
tion of the case, to enable proper counselling and management. ence of any cervical and vaginal anomaly must also be
One must therefore not only classify the anomaly but also reported. Most important of all, a diagrammatic representa-
include a description of the external fundal contour and the tion of the uterine anomaly is to be provided with the report.

Fig. 12.31 3D coronal image of a subseptate

Uterus Coronal
uterus. The width of the septum at its upper end and
its length are measured in the image. The residual
length of the common uterine cavity below the
septum up to the internal os is also measured and
reported

Summary: Congenital Uterine Anomalies

• The most commonly used classification for uterine
anomalies is the AFS classification, which is pri-
marily based on the embryopathogenesis of
anomalies.
• The presence of a uterine anomaly can be suspected
on 2D ultrasound. However, for classification of the
uterine anomaly evaluation by 3D ultrasound is
essential.
• Diagnosing the type of uterine anomaly requires
evaluation of both the external fundal contour and
the shape of the uterine cavity.
• The cervix, vagina and kidney should be assessed
for coexistent anomalies. Their presence, absence
and if present, their type should be reported.
Suggested Reading 467

Suggested Reading tion of congenital anomalies of the female genital tract. Ultrasound
Obstet Gynecol 46:616–622. doi:10.1002/uog.14825
Grimbizis FG, Campo R (2012) Clinical approach for the classification
Behr SC et al (2012) Imaging of müllerian duct anomalies. Radiographics
of congenital uterine malformations. Gynecol Surg 9(2):119–129
32(6):E233–E250
Jurkovic D (2002) Three-dimensional ultrasound in gynecology: a criti-
Bermejo C et al (2010) Three-dimensional ultrasound in the diagno-
cal evaluation. Ultrasound Obstet Gynecol 19:109–117. doi:10.104
sis of Müllerian duct anomalies and concordance with magnetic
6/j.0960-7692.2001.00654
resonance imaging. Ultrasound Obstet Gynecol 35:593–601.
Jurkovic D et al (1995) Three-dimensional ultrasound for the assess-
doi:10.1002/uog.7551
ment of uterine anatomy and detection of congenital anomalies:
Bermejo C et al (2014) Three-dimensional ultrasound and magnetic
a comparison with hysterosalpingography and two-dimensional
resonance imaging assessment of cervix and vagina in women with
sonography. Ultrasound Obstet Gynecol 5:233–237. doi:10.104
uterine malformations. Ultrasound Obstet Gynecol 43:336–345.
6/j.1469-0705.1995.05040233
doi:10.1002/uog.12536
Salim R et al (2003) Reproducibility of three-dimensional ultrasound
Graupera B et al (2015) Accuracy of three-dimensional ultrasound com-
diagnosis of congenital uterine anomalies. Ultrasound Obstet
pared with magnetic resonance imaging in diagnosis of Müllerian
Gynecol 21:578–582. doi:10.1002/uog.127
duct anomalies using ESHRE–ESGE consensus on the classifica-
Troiano RN, McCarthy SM (2004) Müllerian duct anomalies: imaging
and clinical issues. Radiology 233(1):19–34
 Ultrasound in Other Miscellaneous
Conditions 13

Arteriovenous malformations are seen infrequently and are secondary to uterine damage by curettage, miscarriage or
difficult to differentiate from vascular retained products of termination, trophoblastic disease, neoplasia and infection.
conception (RPOC). Proper diagnosis is essential for appro- Uterine vascular abnormalities, most often reported in
priate management of these potentially life-threatening the literature as arteriovenous malformations (AVM), are
lesions. Perforation of the uterus is also a rare condition, and used to describe uterine lesions showing a hypervascular
a few examples have been provided. Vesicouterine fistula, a appearance with turbulent flow. Uterine vascular abnormali-
rare complication most often following a caesarean section, ties would be a better terminology to use for these malfor-
is covered next. Retroflexed uterus, though a common nor- mations, as not all are true AVMs. True AVMs can be
mal variant, may be an indicator of pathology or may present confirmed histopathologically and show early venous filling
with symptoms. Caesarean scar defect has become important on angiography. All other lesions are really non-AVM vas-
due to the rising incidence of caesarean sections. Their eval- cular abnormalities.
uation is gaining importance because some of these patients Typical symptoms are menorrhagia and metrorrhagia.
may be symptomatic and because of its potential for rupture Some complain of lower abdominal pain. Most often, there is
in a subsequent pregnancy. Intrauterine contraceptive devices a history of a preceding pregnancy or, in rare cases, a gesta-
can be evaluated on ultrasound to assess whether they are in tional trophoblastic disease. Though these lesions grow slowly,
the normal position. This is best studied by three-dimen- the onset of symptoms could be sudden when the endothelial
sional ultrasound and has been described in this chapter. The lining of the vessels gets disrupted during menstruation or
sonographic appearances vary with the type of device and its curettage. If curettage is done without prior diagnosis of the
location. Images of patients with different types of IUCD in vascular lesion, the patient could bleed torrentially.
various locations (normal and otherwise) are shown.
Practical aspects of follicular tracking (that is resorted to Ultrasound Features of AV Malformation (Figs. 13.1,
both in natural and induced cycles), have been briefly dis- 13.2 and 13.3)
cussed. The last part of this chapter deals with ovarian hyper-
stimulation syndrome, a rare but potentially life-threatening • It appears as a focal ill-defined heterogeneous mass in the
complication that is usually the result of ovulation myometrium formed by multiple irregular or tubular
induction. hypoechoic cystic structures that fill with colour. That is,
the mass comprises of vascular channels only.
• It is located in the area of the radial arteries of the uterus
13.1 Uterine Vascular Abnormalities and is seen reaching up to the endometrium or even pro-
(Arteriovenous Malformations) truding into it.
• The endomyometrial junction in the corresponding area is
Uterine vascular malformations are rare but potentially life most often poorly defined.
threatening. They are basically multiple arteriovenous fistu- • On Doppler, the area shows turbulent flow which is seen
lous communications within the uterus without an interven- as high colour filling with a mosaic pattern.
ing capillary network. These can be congenital or acquired. • Flows show high velocity and low resistance, with average
Congenital ones are very rare and a result of defective peak systolic velocity (PSV) of 63 cm/sec and RI of 0.38.
embryonic development. These congenital lesions can pen- • Vessels with a large diameter may be seen not only in the
etrate surrounding tissues and grow as pregnancy pro- lesion but also in the related arcuate vessels and the para-
gresses. Most, however, are believed to be acquired metrial vessels.

© Springer Nature Singapore Pte Ltd. 2017 469

M. Sibal, Ultrasound in Gynecology, DOI 10.1007/978-981-10-2714-7_13
470 13 Ultrasound in Other Miscellaneous Conditions

• During a uterine contraction, flow to the area can decrease RPOC showing turbulent flow can be most often safely
significantly, and therefore in case the suspected area (on treated with curettage.
greyscale) is not filling with colour on Doppler, it is The rest of the AVMs (without confirming whether they
important to wait for a short while. are true AVMs or non-AVM vascular abnormalities) are
• Retained products of conception (typically seen as a het- treated based on clinical presentation. If bleeding is exces-
erogeneous mass in the endometrial cavity on greyscale sive or persistent, uterine artery embolisation or even hyster-
with some flow) should be carefully looked for, because ectomy may be resorted to.
turbulent vascular flow may be seen not only in the In most cases, the AVM lesion subsides in 6–8 weeks, but, in
endometrial cavity but also extending onto the adjoining certain cases, it could take up to 6 months. Conservative man-
myometrium in some cases with retained tissue. agement with serial B hCG and ultrasound is generally suffi-
cient. Medical management with methotrexate is also an option.
The gold standard for definitive diagnosis for true AVMs In most cases of uterine vascular lesions, serum B hCG is
is early venous filling on contrast angiography. The rest are elevated (though often only by a small amount), and as the B
termed non-AVM uterine vascular abnormalities. Presently, hCG values decline, so does the vascularity in the uterus,
however, angiography (being invasive) is generally resorted until it completely disappears. Increased vascularity of the
to only for therapeutic embolisation. myometrium of the placental bed following pregnancy (mis-
The most important differential diagnoses for AVMs are carriage or delivery) is common in the first few weeks fol-
retained products of conception (RPOC) and gestational tro- lowing pregnancy even in the absence of retained placental
phoblastic disease (GTD). tissue on ultrasound. On follow-up, the vascularity regresses
Retained tissue may be clearly visualised in some cases, gradually over the next few weeks.
making the diagnosis simple. Greyscale ultrasound for One large study has suggested that patients can be triaged
RPOC is specific but not sensitive, and therefore ultrasound into high and low risk, based on peak systolic velocity (PSV)
cannot rule out RPOC. Serum B hCG is useful in picking of flows in the AVM. Those with a PSV of 83 cm/sec or more
up RPOC and GTD and distinguishing them from true are to be considered as ‘high risk’ cases, and those with a
AVMs. PSV of less than 39 cm/sec are considered as ‘low risk’
Once a uterine vascular abnormality is seen on ultra- cases. The cases that are not ‘low risk’ should be monitored
sound, if there is associated RPOC, curettage can be done. more closely.
13.1 Uterine Vascular Abnormalities (Arteriovenous Malformations) 471

a
LS TS

b LS c

d e Uterus coronal
TS

Fig. 13.1 AV malformation of the uterus with normal levels of B hCG (0.1 mIU/mL) and LCB 3 yr and 8 months ago. No history of any pregnancy
or surgical intervention following LCB. Last image taken at a repeat follow-up scan done 8 weeks later, showing persistence of the lesion. This is
therefore likely to be a true AV malformation. (a) Ill-defined heterogeneous mass comprised of multiple cystic areas is seen in the posterior myo-
metrium of the upper corpus reaching up to the endometrium. (b) The area is seen filling up with colour and shows turbulent flow (high filling with
mosaic pattern). (c) High-velocity low-resistance flow is seen. (d) The arcuate and parametrial vessels are seen dilated and tortuous. (e) 3D HD
Doppler glass body image showing the lesion with turbulent flow and dilated arcuate and parametrial vessels on the side of the lesion. This image
was taken during a repeat scan after 8 weeks of the earlier images
472 13 Ultrasound in Other Miscellaneous Conditions

a
LS

b
TS

Fig. 13.2 A small AV malformation in a patient whose last child birth with tubectomy was 25 years ago. (a) Shows a small lesion and prominent
arcuate feeding vessels on Doppler. On greyscale the lesion is less well defined. (b) Prominent bilateral parametrial vessels are seen
13.1 Uterine Vascular Abnormalities (Arteriovenous Malformations) 473

a LS TS

b LS TS

Fig. 13.3 MTP with curettage was done 4 months ago. Patient presented with profuse bleeding for which this scan was done. B hCG on the day
of scan was 35 mIU/mL. Patient was treated with methotrexate, and 2 months later B hCG came down to 0.22 mIU/mL and the lesion regressed
on scan. (a) Heterogeneous ill-defined mass seen in the anterior myometrium extending into the endometrium. The endomyometrial junction in
this area is poorly defined. On greyscale, margins of the lesion are difficult to define. (b) The lesion is seen filling up with colour and showing
turbulent flow. (c) On TAS, the lesion with prominent arcuate feeder vessels is noted. (d) Flow showing high velocity and low resistance. (e) Repeat
scan done 2 months later, when B hCG value was normal, showed that the lesion had regressed. A faint hyperechoic area is seen in the anterior
myometrium which did not show any flow on Doppler
474 13 Ultrasound in Other Miscellaneous Conditions

c d
TAS - TS

e LS TS

Fig. 13.3 (continued)

Summary of AV Malformation
– Look for the presence of RPOC – which can also
• May present with menorrhagia or metrorrhagia. show turbulent flow at times.
History of recent pregnancy (including molar preg- – Serum B hCG may help to differentiate true
nancy) and instrumentation is common. AVM from RPOC and GTD.
• Ultrasound: • Most regress on follow-up – which includes serial
– Ill-defined focal mass with cystic hypoechoic scans and serum B hCG (if elevated). Those with
areas that fill with colour and show turbulent excessive or persistent bleeding will require uterine
flow (high PSV and low RI). artery embolisation or rarely hysterectomy.
– Seen in the myometrium, extending up to or into
the endometrial cavity.
13.2 Perforation of the Uterus 475

13.2 Perforation of the Uterus Ultrasound Features of Uterine Perforation (Figs. 13.4,
13.5 and 13.6)
Perforation of the uterus refers to a through and through passage
in the myometrium extending from the endometrium to the • Perforation is seen as a hyperechoic tract of varying thick-
serosa. It may be iatrogenic or less often of spontaneous origin. ness in the myometrium extending from the uterine cavity
Iatrogenic causes include: perforation during dilatation and up to the serosa, in cases where there is some tissue in the
curettage (particularly in a pregnant uterus), operative hysteros- myometrial tract (like omentum or placental tissue). In
copy, endometrial ablation, insertion of intrauterine contracep- case there are bowels within the cavity, peristalsis may be
tive device (IUCD) and evacuation of retained placenta. Uterine noted. The myometrium in that area is therefore deficient.
perforation is most often seen in cases of abortion with suction • Perforation that is recent and has no tissue within may not
and curettage. Ultrasound-guided procedures decrease the risk be visualised on ultrasound. On distension of the uterine
of perforation in these cases. Spontaneous perforation is usually cavity with fluid (as seen in hysteroscopy), it may show
due to trophoblastic invasion of the myometrium in cornual and up transiently as an anechoic or hypoechoic, regular or
interstitial pregnancies or GTD. Iatrogenic uterine perforation irregular tract in the myometrium, extending from the
usually presents at the time of injury with a history of omental endometrial cavity to the serosa.
or bowel fat at suction or an inability to distend the uterine cav- • At times (particularly if sometime has lapsed following
ity on hysteroscopy due to extrauterine escape of fluid or as the perforation), a perforation may only appear as a
increased intrauterine or extrauterine haemorrhage. Most often, hyperechoic linear area extending between the endome-
however, they are missed and may either be diagnosed at a later trium and the serosa.
time or may heal on their own. An important problem of uterine • Often perforation itself is not noticed, but a diagnosis of a
perforation is uterine rupture in a subsequent pregnancy. Routine perforation having occurred may be implied as in finding
intraoperative transabdominal ultrasound-guided procedures of an intrauterine contraceptive device (IUCD) outside
increase safety and expedite the procedure. the uterus.
476 13 Ultrasound in Other Miscellaneous Conditions

a LS b

Uterus

Fig. 13.4 Case of uterine perforation during surgical MTP. (a) Zoomed-in image of the sagittal section of the uterus. There is a hyperechoic tract
(arrow) extending from the endometrial cavity to the serosa. (b) At laparoscopy, omentum is seen within the perforation (arrow). (c) Perforation is
seen at the serosal surface of the uterine fundus (arrow) after the omentum was drawn out, which was bleeding
13.2 Perforation of the Uterus 477

a b

c d

FETUS (Dead)

(RT. HORN)

UTERUS (LT. HORN)

Fig. 13.5 Early trophoblastic perforation of non-communicating right-sided uterine horn (with a well-developed left horn). The placenta was seen
within the endometrial cavity of the rudimentary horn. The placenta and umbilical cord were protruding out of the uterine perforation and extend-
ing up to the dead fetus. (a) Non-communicating right-sided horn with a hyperechoic complex tract (arrow) that extends from the cavity on to the
serosal surface. (b) Post-operative specimen of the excised horn showing placental tissue extending out of the perforation (arrow). (c) Dead intra-
abdominal fetus connected to the perforated uterine horn with the umbilical cord (arrow). (d) Diagrammatic representation of scan findings in the
case. The uterine perforation due to invasion by trophoblastic tissue must have occurred early in pregnancy with the fetus escaping out of the
rudimentary horn and continuing to grow intra-abdominally for a short period of time

a LS b TS

Uterus

Fig. 13.6 Case of IUCD (with missing thread) that had perforated the uterine wall and was lying in the uterovesical (UV) fold. (a) Long section
of the uterus with the cross section of the shaft of the IUCD (arrow) seen in the UV fold. (b) Transverse section of the UV fold showing the shaft
of the IUCD (arrow)
478 13 Ultrasound in Other Miscellaneous Conditions

13.3 Vesicouterine Fistula

Summary of Perforation of the Uterus
• Perforation is more often iatrogenic occurring dur- Vesicouterine fistula is a communication between the blad-
ing intrauterine procedures but it may be spontane- der and the uterine cavity. This may result because of previ-
ous due to invasion by trophoblastic tissue. Often it ous caesarean section, particularly when followed by vaginal
goes unnoticed, but those that are symptomatic delivery or as a complication of a perforating IUCD. Patients
present most often at the time of injury itself, com- with vesicouterine fistula usually have urinary incontinence
monly with haemorrhage and pain. in the early post-operative period. Most often they complain
• On ultrasound, they may be seen either as a hyper- of bleeding per urethra, with or without associated small
echoic thin linear area or a hyperechoic thick tract clots, during menstruation.
or a transiently filling anechoic tract through the
myometrium. Ultrasound Features of Vesicouterine Fistula (Fig. 13.7)

• It appears as a fistulous anechoic tract extending between

the endometrial cavity and the urinary bladder.
• The length, breadth and thickness of the tract can be mea-
sured, including the opening in the endometrial cavity and
the bladder mucosa.
• A partially filled bladder helps in better delineation of the
fistulous tract through the bladder wall.
• The bladder is seen adherent to the anterior wall of the
uterus at the site of the fistulous connection (most often
the site of the LSCS scar). In other words, the bladder
does not slide along the uterus/vagina on pressure by the
TVS probe.
• The rent in the bladder wall can be visualised well on 3D
rendered images.
13.3 Vesicouterine Fistula 479

a LS b LS

1 D 1.31 cm
2 D 0.30 cm

Fig. 13.7 Long-standing (13 years) uterovesical fistula following LSCS, with a history of blood-stained urine during menstruation. Patient pre-
sented with recent onset of menorrhagia with passage of clots in urine and painful micturition. (a) Narrow anechoic/hypoechoic tract (arrow)
extending from the bladder into the lower corpus of the uterus. (b) The tract is seen communicating with the endometrial cavity (arrow) of the
lower corpus. (c) 3D rendering of the bladder end of the fistula that measured about 1.3 cm transversely
480 13 Ultrasound in Other Miscellaneous Conditions

13.4 Retroflexed Uterus • In a midsagittal section, the endometrial cavity is seen

bent backwards as compared to that of the cervical canal.
A retroflexed uterus is one where the axis of the uterine • The retroflexion typically occurs at the internal os between
cavity is bent backwards as compared to that of the cervi- the cervix and the lower corpus.
cal canal. This therefore causes an angulation (retroflex- • Hematometra – In an acutely retroflexed uterus at times,
ion) at the level of the internal os. A retroflexed uterus is a there may be some amount of menstrual blood seen in the
normal variant, and most often patients are asymptomatic. uterine cavity which is believed to be because of the effect
In some cases, however, the patients may be symptomatic, of gravity and acute angulation, impairing the drainage of
either because of acute retroflexion itself or because of normal menstrual flow.
pathology causing fixed retroflexion of the uterus as seen • In patients with PID and endometriosis, the uterus is usu-
in endometriosis and PID. The common symptoms seen in ally fixed in flexion, i.e. the posterior wall of the uterus is
women with retroflexion are pain (due to associated PID, adherent to the bowels and or the diseased adnexa.
endometriosis or incomplete drainage of menstrual blood), • Uteri that are fixed in flexion due to PID and endome-
postmenstrual spotting (of collected menstrual blood) or triosis usually show angulation above the level of the
occasionally urinary retention in a gravid retroflexed internal os, often between the lower corpus and the mid-
uterus. corpus, giving the uterus a ‘question mark’ - or ‘ear’ -
shaped appearance.
Ultrasound Features of Retroflexed Uterus (Figs. 13.8 • In patients with endometriosis, the posterior wall of the
and 13.9) uterus may show coarse echoes secondary to diffuse
adenomyosis.
13.4 Retroflexed Uterus 481

LS

Fig. 13.8 Retroflexed uterus with hematometra showing the fluid–

fluid level with the denser fluid in the dependent upper uterine cavity.
Here, flexion is seen at the junction of the cervix with the uterine body
(i.e. level of internal os) (arrow)

a TVS - LS b TAS - LS

Fig. 13.9 Retroflexed uterus in a patient with DIE. (a) TVS – the flexion is more pronounced at the midcorpus (arrow). The posterior wall is thick
and shows slightly coarse echoes suggestive of adenomyosis. (b) TAS – flexion at midcorpus (arrow) with an ‘ear’- or ‘question mark’- shaped uterus
482 13 Ultrasound in Other Miscellaneous Conditions

13.5 Caesarean Scar Defect (LSCS Scar too much pressure with the TVS probe as that may alter
Defect) the shape and measurements of the scar defect.
• The current recommendation to measure the scar is to
With increasing caesarean section (CS) rates worldwide and take four measurements (Fig. 13.15):
its associated complications of late, there has been an – Scar width (W) – is its distance along the cervico-
increased interest in evaluation of the caesarean section scar endometrial canal taken in the sagittal section of the
defects (CSDs) and their relation to complications. Though uterus. Increasing scar width has been found to be
the evaluation of a scar can be accurately done on ultrasound associated with postmenstrual spotting, dysmenor-
(TVS), the analysis of its association with complications rhoea and chronic pelvic pain.
requires in-depth studies. CSD is seen in about 70 % (on – Scar depth (D) – is the vertical distance between the
TVS) to 84 % (on SHG) of women with a previous history of base (facing the uterine cavity) and the apex of the
cesarean section (Osser.V., UOG 2010, UOG 2011). defect (towards the uterine serosa) taken in the sagittal
Multiple caesarean sections, single-layer myometrial clo- section of the uterus.
sure and retroflexed uteri are reported in the literature to – Scar length (L) – is the length of the defect in the trans-
increase the risk of scar defects and are accordingly more verse section (this may be assessed in transverse or
often associated with larger scar defects. Caesarean scar coronal views).
defects are associated with symptoms of postmenstrual spot- – Residual myometrial thickness (RMT) – is the thick-
ting (a commonly seen symptom, with typically darkish ness of the myometrium between the apex of the scar
altered blood), dysmenorrhoea and chronic pelvic pain. Scar and the overlying serosa taken in the sagittal section of
defects have also been studied with the idea to evaluate the the uterus.
potential risk for obstetric complications in future pregnan-
cies like scar ectopic pregnancy, placenta previa, adherent There is no uniform definition for a large scar. Some con-
placenta and scar dehiscence. sider a large scar to be one where there is a loss of more than
50 % of the myometrial thickness at the scar (RMT/thickness
Ultrasound Features of Caesarean Scar Defects of adjacent myometrium) or an RMT of less than or equal to
(Figs. 13.10, 13.11, 13.12, 13.13, 13.14 and 13.15) 2.2 mm on TVS (Osser UOG 2010). The thinner the residual
myometrium, the higher is the chance of scar dehiscence;
• A caesarean scar defect is diagnosed by the presence of a however, no cut-off has been established yet.
hypoechoic (or anechoic) cystic area within the anterior
myometrium of the lower uterine segment at the site of • The axis of the cervical canal to the axis of the uterine
the previous LSCS. The collection in the defect is basi- cavity should also be noted, as patients with retroflexed
cally retained menstrual blood. It is seen somewhere uterus are more likely to be symptomatic with postmen-
between the level of the internal os below (identified by strual spotting.
the level of entry of the uterine arteries and the apical • There may be an associated small hematometra. Pressure
upper end of cervical mucosa) and the uterovesical fold of with the TVS probe on the scar defect will often show
peritoneum above. turbid contents moving upwards from the defect into the
• Most often, the defect is triangular or wedge shaped with its endometrial cavity and only very occasionally into the
base towards the endometrial cavity and its apex pointing cervical canal. On release of pressure, the turbid contents
towards the serosa. Some defects, however, may be ‘U’ shaped return into the defect.
or irregular and are most often seen with larger defects. • Myometrial scar tissue takes about 3 months to form, and
• The evaluation is done on TVS, and the image should be complete involution may take 6 months. Therefore,
magnified to include the cervical canal, the bladder and women must be assessed in their non-pregnant state, pref-
the lower uterine cavity. Care must be taken not to apply erably 6 months after the caesarean section.
13.5 Caesarean Scar Defect (LSCS Scar Defect) 483

a LS

CX

b
LS TS

Fig. 13.10 (a) Defect seen as an anechoic irregular area at the site of the LSCS scar in a retroflexed uterus. (b) Long section and transverse section
of the scar defect showing irregular margins and narrow overlying residual myometrial thickness (arrow)
484 13 Ultrasound in Other Miscellaneous Conditions

a LS b LS

c TS LS

CX

Fig. 13.11 Patient recently underwent curettage for brownish intermenstrual discharge. (a) Large hypoechoic triangular scar defect seen com-
municating with endometrial cavity above and endocervical canal below. (b) No flow seen in the area suggestive of fluid collection within. (c)
Transverse and long section of the scar defect to measure the volume of collection in the defect (in this case, 1.5 cc). Thick overlying residual
myometrium noted, probably as a result of some local trauma following surgical curettage
13.5 Caesarean Scar Defect (LSCS Scar Defect) 485

a LS b Uterus coronal

Fig. 13.12 Patient with three previous LSCS with brownish intermenstrual spotting that lasted for 10–11 days after periods. (a) Upper and lower
end of the wedge-shaped defect showing turbid blood collection marked with tiny arrows. (b) 3D rendered image of the scar defect (arrow) seen
in the lower corpus with hyperechoic irregular thick margins around, suggestive of surrounding fibrotic tissue
486 13 Ultrasound in Other Miscellaneous Conditions

a LS b LS

c
LS TS

d LS

Fig. 13.13 Large irregular defect to the left of midline with hematometra. (a) Blood seen in the upper end of the endometrial cavity. (b) The defect
is seen communicating with the endometrial cavity. Pressure on the defect causes the fluid to move up into the endometrial cavity, and on release
of pressure it was seen trickling back into the defect. (c) The volume of the collection in the scar defect is measured in three perpendicular dimen-
sions. (d) The defects are seen communicating with the cervical canal posterosuperiorly (small arrows)
13.5 Caesarean Scar Defect (LSCS Scar Defect) 487

a TAS - LS b TAS - LS

9.80 cm 14.56 cm

Fig. 13.14 Bladder adherent to the LSCS scar in two different cases. (a) With a full bladder on TAS, the uterus (particularly lower corpus and
cervix) appears stretched out and elongated. The bladder usually does not extend beyond the uterine fundus and is often shadowed by the critical
angle shadowing from the superior margin of the bladder wall. (b) A similar case where the bladder is not extending beyond the lower corpus. The
anterior wall of the uterus shows a right angle (arrow) which is a typical feature of an adherent structure
488 13 Ultrasound in Other Miscellaneous Conditions

a
LS TS

RMT

L
D

Uterus sagittal Uterus coronal

Fig. 13.15 (a) Sagittal section of the uterus (the image has been zoomed in to more than essential, for better understanding) showing: (W) scar
width, (D) scar depth, (RMT) residual myometrial thickness and the transverse section of the uterus showing (L) scar length. (b) Diagrammatic
representation of the same in LS and coronal views

Summary: Caesarean Scar Defect

• CSD can be evaluated on transvaginal scans accu-

rately in non-pregnant women, but the relation of
their appearance and measurement to associated
symptoms and complications has not been estab-
lished. Common presenting complaint is postmen-
strual spotting.
• The scar is seen as a wedge-shaped defect at the site
of the previous caesarean scar. The width, depth,
length and residual myometrial thickness should be
measured.
13.6 Intrauterine Contraceptive Device (IUCD) 489

13.6 Intrauterine Contraceptive Device • The shaft of an IUCD can most often be seen on 2D imag-
(IUCD) ing of the uterus. However, to visualise the entire IUCD
within the endometrial cavity, a 3D rendered coronal sec-
The intrauterine contraceptive device is one of the most com- tion of the uterus is important and is therefore done rou-
monly used contraceptive devices in the world. In addition, tinely. On 3D, because the entire IUCD can be visualised
the hormone-containing IUCDs are also used to decrease in addition to its location, the shape of the IUCD and type
menstrual flow in patients with menorrhagia. Sonography is can also be deciphered.
useful in assessing the location of the device and complica- • Normal position – The shaft is seen in the midsagittal
tions that may arise due to IUCD insertion. Complications plane extending from the upper end of the endometrial
include malposition, retention, fragmentation, expulsion, cavity downwards. Its horizontal cross bar (when present)
uterine perforation, pelvic inflammatory disease and preg- is seen in the upper part of the endometrial cavity.
nancy. Malposition of an IUCD typically occurs at the time of • Endometrial evaluation is difficult in the presence of an
insertion but may be due to the migration of the IUCD through IUCD. Some amount of information and measurement
a scar. Patients with IUCDs may present with menorrhagia, may be obtained by moving just lateral to the IUCD in the
pain and bleeding due to a malpositioned IUCD; pain and sagittal plane. Endometrium and EMJ, however, can be
fever if there is associated PID; or with pregnancy (intrauter- seen on a 3D rendered image.
ine or ectopic) in association with a normally placed, malpo- • Low position of IUCD – The IUCD may be displaced
sitioned or expelled IUCD. Patients are referred for ultrasound downwards with its upper end some distance away from
if there was a difficult insertion, if the threads are missing or the upper margin of the endometrial cavity. The IUCD
if the patient is symptomatic. may even be seen in the cervical canal. When an IUCD is
Basically there are three types of IUCDs: displaced down, it is not considered as effective for the
purpose of contraception.
1. Inert IUCD – These are made of plastic polyethylene with • Malposition of IUCD – An IUCD is considered malposi-
some barium sulphate so that they can be visualised on tioned if any part of it extends beyond the endomyome-
X-rays. Examples: Lippes loop (that is not in use today) trial junction into the myometrium or cervix. This is seen
and ring-shaped IUCD (still used in China). clearly on 3D rendered coronal views of the endometrial
2. Copper-containing IUCD – These IUCDs have copper in cavity.
them and are of different types. They typically have a • Uterine perforation – IUCD may perforate the uterus and
straight shaft and cross bars. They are well seen on ultra- move out of the uterine cavity into the pelvis. In these
sound because their copper shaft appears echogenic. cases, the thread of the IUCD will not be visible on clini-
Examples: Copper T, Copper 7 and Multiload. cal examination. Radiographic studies may be required to
3. Hormone-producing IUCD – These contain progester- search for the IUCD, when it is not seen on an ultrasound
one. Examples: Progestasert and Mirena. Mirena is T examination.
shaped with a 32 mm vertical shaft and 32 mm horizontal • Expulsion of IUCD – Sometimes the IUCD may not be
portion containing barium sulphate. Its shaft is more dif- located in the uterus or the surrounding structures (clini-
ficult to visualise on ultrasound. cally, the thread is also not visualised), suggesting that it
is probably expelled. Radiographic studies may be
Ultrasound Features of IUCDs (Figs. 13.16, 13.17, 13.18, required to search for the IUCD, if not seen on
13.19, 13.20, 13.21, 13.22, 13.23, 13.24 and 13.25) ultrasound.
• Associated complications – Patients with IUCD are at an
• Most IUCDs appear hyperechoic on ultrasound. Copper increased risk for PID, features of which may be seen on
IUCDs have a very echogenic shaft which shows acoustic ultrasound. Pregnancy may occur with an IUCD in the
shadowing beyond it. The Mirena IUCD has a characteris- uterine cavity. Though the pregnancy may be intrauterine,
tic appearance with its shaft being non-echogenic, whereas the probability of an ectopic pregnancy is higher in
the proximal and distal ends of the shaft are echogenic. On patients with IUCDs because implantation is less likely in
2D, significant acoustic shadowing is noted from the shaft. the endometrial cavity. Ultrasound may also be used for
The horizontal cross bars however can appear hyperechoic USG-guided removal of malpositioned or fragmented
and can be seen on 2D. The shaft of the Mirena is, however, IUCDs.
well seen on a 3D rendered image as a dark shadow.
Sometimes, the thread of the IUCD is seen below it as a A CT scan of the abdomen may be required for accurate
hyperechoic fine linear echo lying in the cervical canal. localisation of the IUCD for appropriate management.
490 13 Ultrasound in Other Miscellaneous Conditions

a b
LS Uterus coronal

Uterus coronal

Fig. 13.16 IUCD seen in situ, well placed within the endometrial cavity. (a) Sagittal section of the uterus showing the vertical limb of the IUCD
as a bright linear echo with acoustic shadowing. (b) 3D rendered image of the same showing the vertical limb of the IUCD (Cu T) in the endome-
trial cavity and the horizontal limbs along the upper margins of the endometrial cavity. (c) Image showing 3D rendering with HDI
13.6 Intrauterine Contraceptive Device (IUCD) 491

a b LS
LS

c d

Uterus coronal

Fig. 13.17 Copper IUCD. Multiload seen in situ. (a) Sagittal section of the uterus showing the vertical limb of the IUCD as a bright linear echo
with acoustic shadowing. (b) Measuring the endometrium in a patient with IUCD in situ is difficult. One may, however, move a little to the side of
the IUCD in the sagittal plane to visualise the endometrium and measure it as seen in this image. (c) 3D rendered coronal image showing typical
features of a Multiload IUCD. (d) Diagrammatic representation of a Multiload IUCD
492 13 Ultrasound in Other Miscellaneous Conditions

a LS b TS

CX

c d Uterus coronal
Uterus coronal

Fig. 13.18 Hormone-producing IUCD – Mirena. (a) Sagittal section of the uterus – the vertical shaft of the Mirena is not properly seen on
greyscale imaging (unlike the copper IUCDs). It, however, shows significant acoustic shadowing. (b) Transverse section of the uterus with hori-
zontal limbs of the Mirena seen. (c) In 3D rendered images, most often the Mirena is identified by the dense acoustic shadowing that it causes.
(d) If the rendered plane is just proximal to the IUCD, one may be able to visualise the Mirena itself (instead of its more obvious acoustic shadow)

Uterus coronal

Fig. 13.19 Mirena seen in situ. Only the two ends of the vertical
shaft are typically seen. The main shaft is seen as a dark area
because of acoustic shadowing. The horizontal limb is seen along
the upper margin of the uterine cavity. The IUCD thread (arrow) is
seen in this rendered image, extending downwards from the lower
end of the IUCD
13.6 Intrauterine Contraceptive Device (IUCD) 493

a b
LS LS

CX
CX

c Uterus coronal

CX

Fig. 13.20 Multiload IUCD displaced down into the cervical canal. (a) Endometrial cavity seen with no IUCD within. (b) Cervix seen with the
bright echogenic shaft of the IUCD in the cervical canal. (c) 3D rendered image showing the Multiload IUCD in the cervical canal

Uterus coronal

Fig. 13.21 Displaced Mirena seen in a 3D rendered image. The

IUCD displaced down a little with the horizontal limbs of the
Mirena some distance below the upper endometrial margin. One of
its limbs is extending just beyond the EMJ (arrow)
494 13 Ultrasound in Other Miscellaneous Conditions

a LS Uterus coronal

b Uterus coronal c Cervix

Fig. 13.22 Displaced IUCD. (a) TAS with rendered image showing the IUCD displaced down into the cervix. (b) Vertical shaft of the IUCD seen
within the walls of the cervix. (c) 3D rendered image of the cervix showing the cervical os (short arrow) and lower end of the IUCD protruding
out of the cervical walls (long arrow), above the external os

a b
LS LS

CX

Fig. 13.23 Displaced Mirena. (a) IUCD not seen in the endometrial cavity. (b) IUCD seen in the long section of the cervix with its horizontal
limbs in the cervical canal and vertical limb extending through the anterior cervical wall
13.6 Intrauterine Contraceptive Device (IUCD) 495

a TAS - LS b TAS - TS

c Uterus coronal d TVS - LS

Uterus

Bladder

Fig. 13.24 Displaced IUCD. (a) TAS – cross section of the vertical limb of the IUCD seen above the uterine fundus (arrow). (b) Long section of
the IUCD seen in the pelvis, posterior to the bladder in the UV fold. (c) 3D rendered image showing the IUCD above the uterine corpus. (d) TVS –
sagittal section of the uterus with the cross section of the shaft of the IUCD in the UV fold between the bladder and the uterus. (e) TVS – shaft of
the IUCD (arrow) seen in the UV fold on TS
496 13 Ultrasound in Other Miscellaneous Conditions

a LS TS

b LS TS

LT ADNEXAL

MASS

Fig. 13.25 IUCD in situ with bilateral PID. (a) TAS – the uterus with complex masses posterior to it, in the POD. (b) Right-sided TO mass with
turbid contents (pus). (c) Left-sided TO mass with turbid contents (pus). (b,c) Pus is also seen surrounding the adnexal masses (arrows)
13.6 Intrauterine Contraceptive Device (IUCD) 497

Summary: IUCD
• Patients are often referred for ultrasound location of
the IUCD in cases of difficult placement, missing
threads or in patients presenting with pain, bleed-
ing, fever or pregnancy.
• On ultrasound, 3D rendered views of the coronal
section of the endometrial cavity are essential to see
the entire IUCD and its relationship to the endome-
trial cavity. If the upper end of the IUCD is below
the upper margin of the endometrium or if any part
of the IUCD lies outside the endometrial cavity, it is
considered to be malpositioned. The shaft of the
Mirena may not be seen on 2D but is well seen on
3D, because of its acoustic shadowing, as a dark
imprint.
• Features of PID, an intrauterine or an ectopic preg-
nancy may be seen along with an IUCD.
• If an IUCD is missing, a radiograph (X-ray) or CT
scan may be required to look for it elsewhere in the
abdomen.
498 13 Ultrasound in Other Miscellaneous Conditions

13.7 Follicular Monitoring Ovulation

and Ultrasonography in Patients • Ovulation is the release of the ovum from a mature fol-
with Infertility (Figs. 13.26 and 13.27) licle. This is difficult to visualise on ultrasound, and
ovulation is usually a retrospective diagnosis made by
Prior to ultrasonographic evaluation of patients presenting documenting post-ovulatory changes. Ovulation may
with infertility, changes during a menstrual cycle are briefly occur naturally, following LH surge, or it may be
discussed. induced by administration of HCG. This is usually done
when the follicle is about 18 mm in diameter, with an
endometrial thickness of at least 6 mm (ideally 7 mm).
13.7.1 Cyclical Changes During Menstrual Rupture typically occurs 36–40 hours after the HCG
Cycle (Both Natural and Induced) injection, and intercourse or insemination can be timed
(Figs. 13.26 and 13.27) accordingly.

A menstrual cycle can be divided into the menstrual phase, Secretory phase or luteal phase (Day 14–28 of the menstrual
the follicular phase and the luteal phase. An average cycle cycle):
lasts for about 28 days, with a range of 21–35 days. While • Following rupture, the granulosa cells of the dominant
the follicular phase varies in length, the luteal phase typically follicle luteinise and the follicle becomes a corpus luteum.
lasts for 14 days. Ovulation is the event that separates the The corpus luteum may vary in appearance but is typi-
follicular phase and the luteal phase. cally a thick walled structure with crenated walls, show-
ing high vascularity around its walls (RI 0.35–0.5). The
Menstrual phase (Day 1–6 of the menstrual cycle): granulosa cells then produce progesterone, which pro-
• During the menstrual phase, follicular selection begins, duces secretory changes in the endometrium.
and a small cohort of follicles are selected and begin • The endometrial thickness may decrease minimally at
growing. Antral follicles are seen in this phase as anechoic ovulation, but thereafter it increases gradually (7–15 mm).
small cysts of 2–9 mm. The endometrium gradually becomes hyperechoic starting
• The endometrium appears hyperechoic and complex. By from the periphery towards the centre. This increased
the end of menstruation, it is thin – about 1–4 mm in echogenicity is believed to be due to stromal edema and
thickness. the presence of mucus and glycogen in the glands.
• The baseline scan in women on treatment for infertility is • If pregnancy does not occur, the activity of the corpus
done on Day 2 or 3 of the menstrual cycle (discussed later luteum declines, and when the hormone levels fall, men-
in the section). struation occurs.

Proliferative phase or follicular phase (Day 6–14 of the

menstrual cycle): 13.7.2 Types of Scans Done in Patients
• By Day 6–8, a dominant follicle is selected, and the rest Presenting or on Treatment
undergo atresia. The dominant follicle continues to grow for Infertility
till it reaches a size of about 22–24 mm in diameter, fol-
lowing which it ruptures and forms a corpus luteum. 1. A primary scan in the opinion of the author (supported by
• The endometrium gradually increases in thickness from other experts), in patients with infertility or subfertility, is
5 mm to about 10–12 mm. The proliferative endometrium ideally done between Day 10 and 12 of a 28-day men-
is typically seen as a three-layer endometrium with an strual cycle. This, in some ways, would be a compromise
echogenic basal layer, a hypoechoic inner functional layer as regards ovarian reserve assessment, which is ideally
and an echogenic midline at the interphase of the two lay- done on Day 2 or 3. It, however, has certain advantages
ers. Minimal intracavitary fluid may be seen in the pre- which are as follows:
ovulatory phase. The vascularity of the endometrium • To determine the presence of a good dominant follicle
gradually increases to a maximum just prior to and the ability to assess the endometrial response to
ovulation. follicular development, primarily in terms of endome-
• Follicular tracking is done basically in the proliferative trial thickness.
phase of the cycle, typically from Day 7 to ovulation. This At this time, one expects to see in one of the ovaries a
has been discussed in detail later in this section. A pri- dominant follicle (Fig. 13.26 c) of about 16–18 mm,
mary scan in patients with infertility or subfertility is ide- with Doppler flow around more than 50 % of its cir-
ally done in this phase between Day 10 and 12; this is also cumference with a PSV of about 10 cm/sec. Stromal
discussed later in the section. blood flow velocity is around 6–12 cm/sec.
13.7 Follicular Monitoring and Ultrasonography in Patients with Infertility 499

The absence of a dominant follicle or the presence of a • Follicular tracking starts from Day 7. The dominant
functional cyst might serve as an indicator for ovulation follicle (more than 10 mm) in each ovary is mea-
dysfunction. The presence of a dominant follicle is how- sured. These may be one or more in number. The fol-
ever not a guarantee that the oocyte would be of good licle is measured in three perpendicular dimensions
quality or that ovulation will occur. The presence of in two perpendicular planes so that the average diam-
Doppler signals around more than 50 % of the dominant eter can be obtained. The follicle is seen as an
follicle is generally associated with a good-quality oocyte. anechoic, unilocular, round, smooth-walled cyst. The
A triple-line appearance of the endometrium, with a two-layer endometrial thickness is also measured,
minimum thickness of 7 mm, and a uterine artery of PI and the endometrial pattern is noted (three line,
less than 3 are considered as reliable markers for good echogenic, etc.).
endometrial receptivity. The visualisation of spiral • The patient is generally scanned on alternate days, and
arteries into the endometrium has also been seen to the size of each follicle and endometrium is noted.
correlate well with good receptivity (Fig. 13.26 d). Once the follicle reaches an average diameter of
• A proliferative endometrium, normally seen on Day 16 mm, a daily monitoring of the follicle is
10–12, is also ideal for assessing endometrial patholo- recommended.
gies such as polyps or Asherman’s syndrome. At this • Once the average diameter is 18 mm, with an endome-
primary scan, in addition, other pelvic pathologies trial thickness of at least 6 mm (ideally 7 mm), the
such as fibroids, endometriosis, uterine anomalies, referring clinician may choose to give the patient an
etc., if present can also be assessed. A diagnosis of HCG injection to induce ovulation (likely to occur
polycystic ovaries can also be made at this time. 36–40 hours after the injection is administered), and
2. Day 2–3, baseline scan (when hormones – FSH, LH, intercourse or insemination is timed accordingly.
estrogen and progesterone – are at their baseline). This • Ovulation on ultrasound can be determined by the fol-
is done to study ovarian reserve and to assess the lowing signs:
response. Some centres prefer a Day 2–3 baseline scan – Sudden disappearance or reduction in the size of the
in patients presenting for the first time with infertility. follicle
The antral follicle count (which can be done in a faster – Irregular margins
and more accurate manner using 3D with SonoAVC – Presence of internal echoes within the follicle
software, particularly if there are a high number of antral – Free fluid in the POD
follicles), ovarian volume and stromal flow are assessed. • The endometrium, following ovulation, shows thick
This helps plan stimulation protocols, especially in IVF hyperechoic walls along the EMJ, and gradually the
cycles. hyperechogenicity spreads inwards to the entire thick-
Features that suggest low ovarian reserve are as fol- ness of the endometrium.
lows: (1) an ovarian volume of less than 3 mL, (2) fewer • Once ovulation is documented, ultrasound is not
than five antral follicles (between two ovaries) and (3) required for follicular monitoring.
PSV of ovarian stromal vessels being less than 6 cm/sec.
An antral follicle count of more than 20 increases risk
for ovarian hyperstimulation syndrome (OHSS) and 13.7.3 Luteinised Unruptured Follicle
requires careful use of gonadotrophins. (Fig. 13.28)
The menstruating endometrium at this time appears
complex and hyperechoic. By the end of menstruation, it In a small percentage of women, following the LH surge, the
is less than 4 mm in thickness and no subendometrial flow dominant follicle continues to grow and luteinise without rup-
is seen. ture. As a result, there is an increase in progesterone secretion,
3. Follicular tracking or follicular monitoring or follicular study and the endometrium shows secretory changes, but there is no
is done for the assessment of ovulation, both in natural cycles release of oocyte from the dominant follicle. In such patients,
as well as induced cycles (with ovulation induction agents). It on follicular monitoring, serial scans will show secretory
basically involves the assessment of ovarian follicles and the changes in the endometrium without evidence of rupture of
endometrium at regular intervals, typically starting on Day 7. the follicle (i.e. no collapse of follicle or free fluid). The folli-
For IVF cycles and in those patients where a functional cyst is cle itself increases in size and may either remain anechoic or
known to exist from a previous cycle, an initial Day 2–3 scan may show lacy internal echoes. Some patients are known to
is recommended. Follicular tracking is typically done until have recurrent LUF, and treatment protocols may have to be
there is evidence of ovulation or egg retrieval. altered accordingly.
500 13 Ultrasound in Other Miscellaneous Conditions

a TS LS b LS

c d
LS
Uterus

Fig. 13.26 Follicular phase. (a) Day 9 – proliferative (trilaminar) endometrium and (b) ovary showing a developing follicle (anechoic unilocular).
(c) Day 11 – follicle showing flow around more than 50 % of its circumference and (d) endometrial flow in the same case with spiral vessels entering
the endometrium. (e) Stromal flow in a different case. The most prominent vessel (arrow) should be sampled to assess flows
13.7 Follicular Monitoring and Ultrasonography in Patients with Infertility 501

a TS LS b TS LS

c d
LS LS

Fig. 13.27 Secretory phase. (a) Corpus luteum shows thick irregular walls and turbid contents. (b) Increased flow seen on Doppler in the walls
of the corpus luteum. (c) Uterus with an early secretory endometrium – the outer endometrium is hyperechoic. (d) Uterus with a secretory endo-
metrium – the entire endometrium is hyperechoic with a central white midline
502 13 Ultrasound in Other Miscellaneous Conditions

Fig. 13.28 Luteinised

a
unruptured follicle (LUF) in a
patient on Day 18 of follicular
tracking. (a) LUF shows lacy
internal echoes. An anechoic
follicle was seen 48 hours earlier
which now shows internal echoes
and has increased in size, with no
evidence of ovulation. An
endometriotic cyst is seen beside
it, in the same ovary. (b) Along
with the LUF, an early secretory
endometrium is seen. There is no
free fluid in the POD, as
ovulation has not occurred

b
13.8 Ovarian Hyperstimulation Syndrome (OHSS) 503

13.8 Ovarian Hyperstimulation Syndrome • Mild OHSS is common and usually self-limiting. These
(OHSS) patients give a history of abdominal distention and pain
and have enlarged cystic ovaries.
Ovarian hyperstimulation syndrome is an iatrogenic, poten- • Moderate OHSS, where the woman presents with abdom-
tially life-threatening complication of supraphysiological inal pain, nausea, vomiting and ascites, and on ultrasound
ovarian stimulation. OHSS is a systemic condition with enlarged ovaries are noted.
enlarged cystic ovaries and increased vascular permeability, • Severe OHSS, where, in addition to the above, the patient
as a result of vasoactive peptides released from the granulosa has clinical evidence of ascites and/or hydrothorax. In
cells of the hyperstimulated ovary. This results in the shift of critical OHSS, there may be hypovolemia, hemoconcen-
fluid from the intravascular compartment to the third space tration, coagulation abnormalities, renal failure, etc.
compartments, resulting in hypovolemia and other complica-
tions, as seen in cases with severe OHSS. Patients with mild and moderate OHSS can be treated on
Factors that increase risk for OHSS include polycystic an outpatient basis, whereas those with severe OHSS should
ovaries, a previous history of OHSS, a high baseline antral ideally be admitted. Weight, abdominal circumference, uri-
follicle count, a large number of developing follicles, a large nary output, CBC, electrolytes and blood creatinine may
number of oocytes retrieved (more than 20), the use of HCG require to be monitored.
as opposed to progesterone for luteal phase support and early
pregnancy (particularly in patients with multiple Ultrasound Features of OHSS (Fig. 13.29)
pregnancy).
The syndrome is most often secondary to ovarian stimula- • Bilateral symmetrically enlarged ovaries – Ovaries are
tion with gonadotrophins and rarely after clomiphene citrate usually more than 6 cm in size, and in severe OHSS they
or spontaneous ovulation. Symptoms of OHSS may begin as are usually more than 12 cm.
early as 24 hours after the hCG injection is administered but • The ovaries are multicystic (due to multiple follicular
can occur any time in the first 7–10 days after hCG. The later cysts and corpus luteal cysts) with thin septae.
ones (presenting after Day 9) are usually associated with • These cysts are typically arranged surrounding a central
high hCG due to an early pregnancy. core of ovarian stroma creating a ‘spoke wheel’
The ovaries are enlarged with multiple follicular and appearance.
luteal cysts. Complications like torsion and haemorrhage can • The cyst may contain clear fluid (anechoic) or may appear
rarely be seen in these enlarged ovaries. Many of these turbid showing internal echoes within.
patients present in the emergency department because of • The ovarian stroma and septae show increased vascularity.
abdominal pain and discomfort from the enlarged ovaries • Ascites is seen. In mild OHSS, fluid may be seen only in
and ascites, shock due to hypovolemia, ovarian torsion or the pelvis, but in severe cases, the ascites may be signifi-
intraperitoneal haemorrhage from the ovaries. cant. The ascitic fluid may be clear, but if there is haemor-
Based on the severity, OHSS has been divided into mild, rhage from the ovaries, it may be turbid showing internal
moderate and severe: echoes.
504 13 Ultrasound in Other Miscellaneous Conditions

a TS TAS LS

b TVS LS
TS

Fig. 13.29 Ovarian hyperstimulation syndrome seen in a patient with a single ovary, and IVF conception, following a cycle of ovulation induc-
tion. (a) Grossly enlarged ovary on TAS showing a ‘spoke wheel’ appearance. (b) TVS – enlarged ovary with a volume of about 360 cc. The ovaries
show multiple cysts, mainly corpora lutea. (c) Ovary showing high vascularity. (d) Flow in the ovary shows a low RI of 0.39 (e, f) showing gross
ascites. (g) TVS – image of the uterus surrounded by ascitic fluid and showing three tiny intrauterine gestational sacs
13.8 Ovarian Hyperstimulation Syndrome (OHSS) 505

c TAS d

e LS f

g LS

Fig. 13.29 (continued)

506 13 Ultrasound in Other Miscellaneous Conditions

Summary of OHSS
• OHSS is a systemic disease resulting from the
release of vasoactive substances from a hyperstimu-
lated ovary. These substances cause increased capil-
lary permeability with fluid leak from the
intravascular to the extravascular compartment. It is
commonly seen in patients with ovulation induction
with gonadotrophins. It is more likely to occur in
cycles that result in a conception.
• The most common presenting feature in mild to
moderate OHSS is abdominal pain.
• The ovaries are grossly enlarged with multiple fol-
licular and corpus luteal cysts with thin septae sepa-
rating them. The ovarian tissue shows increased
vascularity. Ascites is seen.
• Some of these patients may present with complica-
tions of OHSS like associated torsion and intraperi-
toneal haemorrhage.
Suggested Reading 507

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Alkatib M, Franco AVM, Fynes MM (2005) Vesicouterine fistula fol-
Osser OV et al (2010) Cesarean section scar defects: agreement
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between transvaginal sonographic findings with and without saline
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doi: 10.1002/uog.7496
Baron KT et al (2013) Emergent complications of assisted reproduc-
Osser OV, Valentin L (2011) Clinical importance of appearance of
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Benacerraf BR et al (2009) Three-dimensional ultrasound detection of
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abnormally located intrauterine contraceptive devices which are a
Polat P et al (2002) Color Doppler US in the evaluation of uterine vas-
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Parsons AK, Sanders RC (2007) OP17.07: Menometrorrhagia due to
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Sanders RC (2012) OP19.08: Retroverted uterine position and pel-
Caspi B et al (1996) Penetration of the bladder by a perforating intra-
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 Exploring Pathologies Based on Clinical
Presentation 14

14.1 Abnormal Uterine Bleeding • Amenorrhoea and hypomenorrhoea – These are most
often due to local endometrial pathology but could be sec-
To investigate abnormal uterine bleeding, one must know ondary to hormonal disturbances.
what ‘normal’ bleeding is. Features of normal menstrual • Menorrhagia and polymenorrhagia – These patients usu-
bleeding are: ally have myometrial pathology (fibroids or adenomyo-
sis). In some cases, endometrial pathology like hyperplasia
• Cyclical menstrual flow with cycle length varying from may be noted.
21 to 35 days. • Metrorrhagia and intermenstrual bleeding – Pathology
• Duration of menstrual flow or bleeding up to 7 days. involving the surface of the uterine cavity can cause irreg-
• Amount of flow is a subjective parameter (normally, ular bleeding from the surface of the lesion. If it is heavy,
patients change about 3–5 pads per day). one must think of neoplasia or an AV malformation or
retained products of conception. If it is minimal, it could
be due to an endometrial polyp or hormonal imbalance.
14.1.1 Common Forms of Abnormal Uterine • Post-coital bleeding – These patients are likely to have
Bleeding local pathology involving the cervix or vagina (like neo-
plasia, polyps or infection).
Amenorrhoea – the absence of menstrual periods (for a
period of 3 months or more)
Hypomenorrhoea – scanty flow during periods 14.1.2 Abnormal Uterine Bleeding
Oligomenorrhoea – long menstrual cycles with period length in the Reproductive Age Group
of greater than 35 days
Menorrhagia – excessive flow or prolonged flow during 1. Causes for decreased flow (amenorrhoea, hypomenor-
periods rhoea or oligomenorrhoea):
Polymenorrhoea – short menstrual cycles • Pregnancy – This is a frequent cause of amenorrhoea
Polymenorrhagia – short cycles with increased flow during in women of reproductive age group, and a simple
periods urine pregnancy test or serum BhCG levels will help in
Metrorrhagia – acyclical bleeding which could be heavy or the diagnosis. Ultrasound may show an intrauterine or
minimal an extrauterine pregnancy, which helps to confirm the
Intermenstrual bleeding – bleeding in between two periods diagnosis.
Postmenstrual bleeding – bleeding (often minimal) just after • Premature menopause – That is, menopause occurring
periods before the age of 40 can also cause amenorrhoea or
Premenstrual bleeding – bleeding (often minimal) just oligomenorrhoea (in the few months preceding meno-
before periods pause). On ultrasound, the ovaries appear atrophic.
Post-coital bleeding – bleeding following intercourse Diagnosis can be further confirmed with the help of
serum FSH and LH levels.
Based on the nature of bleeding, one may be able to sus- • Asherman’s syndrome – In these cases, patients will
pect the type of gynecological pathology leading to abnor- often give history of instrumentation. On ultrasound,
mal uterine bleeding: endometrial scarring can be seen (details in Chap. 4).

© Springer Nature Singapore Pte Ltd. 2017 509

M. Sibal, Ultrasound in Gynecology, DOI 10.1007/978-981-10-2714-7_14
510 14 Exploring Pathologies Based on Clinical Presentation

• Hormonal causes like polycystic ovaries, hyperan- – If the flow is acyclical (i.e. metrorrhagia, inter-
drogenism, hormone-producing tumours, hormonal menstrual bleeding or post-coital bleeding), one
medication, etc., can also cause amenorrhea, hypo- must think of pathologies involving the surface of
menorrhoea or oligomenorrhoea. the uterine cavity (polyps, malignancy and submu-
2. Causes for increased flow (menorrhagia, polymenorrhagia cous fibroid) or pathologies of the cervix or vagina
and metrorrhagia): (polyps and malignancy). These lesions can be
• Pregnancy related – This includes patients with threat- picked up on ultrasound (details of ultrasound
ened abortion (Fig. 14.1), incomplete abortion, retained diagnosis are available in Chaps. 2, 3, 4 and 5,
products of conception, ectopic pregnancy, molar preg- respectively); those involving the uterine cavity
nancy and gestational trophoblastic disease (GTD). In may be better seen with sonohysterogram, while
these cases, ultrasound will help clinch the diagnosis those involving the cervix and vagina may be bet-
(details in Chap. 10). ter assessed with gel sonovaginography (unless
• Pregnancy unrelated: the patient is actively bleeding). Sometimes in a
– If the flow is cyclical (i.e. the patient complains of patient with a deficient caesarean scar or an acutely
excessive flow during periods – menorrhagia or poly- retroflexed uterus, brownish postmenstrual spot-
menorrhagia), possibilities include myometrial ting may be seen due to retention of menstrual
pathologies like fibroid and adenomyosis or an endo- blood in the deficient scar or upper uterine body,
metrial pathology like endometrial hyperplasia or respectively.
even an endometrial malignancy. Patients with
fibroids and adenomyosis are likely to complain of Both cyclical and acyclical bleeding may coexist in a few
dysmenorrhoea. On ultrasound, the uterus may be conditions, for example, endometrial malignancy and AV
enlarged with fibroids and adenomyosis, or there may malformations (this is a rare condition, and diagnosis has
be thickened endometrium secondary to hyperplasia been discussed on Chap. 13), etc.
or malignancy. This may also be seen in women with In patients with a thickened endometrium, possibilities
bleeding disorders (e.g. Von Willebrand’s disease). include endometrial polyp, endometrial hyperplasia and
Hormonal disorders like hormone-producing tumours endometrial carcinoma. The ultrasound features and their
or polycystic ovaries can also cause excessive differentiation are discussed in Chap. 4.
bleeding.
14.1 Abnormal Uterine Bleeding 511

a TS

b
TS LS

Fig. 14.1 A six-week live pregnancy, in a patient presenting with pain and bleeding. (a) Uterus with a gestational sac and subchorionic haemor-
rhage (arrow). (b) Subchorionic haemorrhage measured

Summary of Abnormal Uterine Bleeding • Per speculum examination is important in diagnos-

• History: particularly menstrual history and history ing local, cervical and vaginal pathology.
of hormonal intake are important. • Ultrasound is the diagnostic modality of choice,
• Complaints: details of presenting complaint is particularly TVS.
important – whether it is cyclical or acyclical or • Previous reports may be helpful in diagnosis.
intermenstrual or post-coital. Brownish flow indi- • Beyond the age of 40: think of the possibility of
cates discharge of old collected blood. malignancy.
• Rule out pregnancy: an important cause in women • When in doubt, call the patient back for review.
of reproductive age group, particularly with • Discussing with the referring gynecologist often
unscheduled bleeding. helps in appropriate management.
512 14 Exploring Pathologies Based on Clinical Presentation

14.2 Pelvic and Adnexal Masses sees an adnexal mass, the first question that one needs to
consider is whether it is of ovarian origin (Fig. 14.2). This
Pelvic and adnexal masses may arise from the uterus, ovary, can be assessed as follows:
tubes and a few other structures, both gynecological and
non-gynecological. These patients may at times come with a • Ovaries or ovarian tissue are identified very easily in
history of abdominal distention, abdominal mass or pain. women of reproductive age group by the presence of
Most often, however, the mass is detected or suspected by small cystic spaces within, i.e. the follicles (both develop-
the clinician on examination of the patient. Pelvic masses ing and antral follicles). In postmenopausal women with
which are small can be felt on bimanual examination. Large atrophic ovaries, it is more challenging because follicles
masses, however, may be felt abdominally. are not seen.
Ultrasound is the modality of choice for investigating • If both the ovaries are visualised separate from the mass,
these masses. TVS is ideal and is more accurate in evaluating then it is of extra-ovarian origin.
these masses, not only because of better assessment of their • If the mass is seen lying beside the ovary and there is
morphology and Doppler flows, but also because TVS is intervening tissue between the ovary and the mass, or if
interactive and one can move structures, which helps in the ovary, on pressure with the TVS probe, can be seen
knowing their origin, the presence of adhesions, tenderness, moving away from the mass or sliding along the mass,
etc. TAS is more informative for large masses extending then the mass is not of ovarian origin.
above the true pelvis and in those cases where visualisation • If, on the other hand, the mass is seen lying beside the
may be suboptimal due to fibroids in lower corpus or cervix. ovary but does not move away from the ovary on pressure,
Ideally, as mentioned throughout the book, a TAS and TVS then it is likely to be an exophytic ovarian mass or an
should both be done in all cases. extra-ovarian mass adherent to the ovary. In these cases,
For adnexal masses, the terminology used to describe the deciding the site of origin can be challenging.
morphology of the masses should be based on the IOTA rec- • If the ovarian tissue is seen stretched around the mass (or
ommendations. In addition, the IOTA consensus group has cyst) as if it were hugging it, then the mass is of ovarian
come out with methodologies to help assess the nature of the origin. This feature of stretched out ovarian tissue along
mass, particularly whether it is likely to be benign or malig- the walls of the mass is called the ‘crescent sign’.
nant. This includes a three-step strategy, logistic regression • Sometimes, however, the mass is extremely large, and
models LR1 and LR2 and the ADNEX model (details of the ovarian tissue may not be seen around it even when it is of
LR1, LR2 and ADNEX models may be obtained from the ovarian origin. But in these cases, an ovary will not be
references). seen separate from the mass.
The most common of these masses (particularly an
adnexal mass) is of ovarian origin. Therefore, whenever one
14.2 Pelvic and Adnexal Masses 513

a b

CYST

Fig. 14.2 Assessing ovarian origin. (a) Ovarian tissue (arrow) seen beside the cyst and stretched around it (‘crescent sign’) – suggesting ovarian
origin. (b) Ovarian tissue seen beside the cyst, with a wedge of intervening external tissue (arrow) – suggesting that the cyst may not be of ovar-
ian origin. This can be further checked by applying external pressure with the probe when one will be seen sliding along the other (positive
sliding sign) or they may move apart (splitting sign). (c) Both ovaries (small arrows) seen separate from the cyst with some tissue (long arrow)
between the right ovary and cyst – suggesting extra-ovarian origin. (d) Both ovaries seen distinctly with the left ovary and cyst far apart in the
left adnexa – suggesting the cyst is not of ovarian origin
514 14 Exploring Pathologies Based on Clinical Presentation

14.2.1 Ovarian Masses mone replacement. These patients have bilateral enlarged
multicystic ovaries secondary to stimulation of the gonadal
Ovarian masses can be broadly classified into functional FSH receptor by TSH, resulting in multiple follicular cysts.
cysts, neoplastic masses, endometriomas and masses of Histopathological analysis of resected ovaries showed cys-
inflammatory origin. The ovary may also be enlarged due to tic follicles and little, if any, luteinisation. Some reports
other conditions like torsion, hyperstimulation, polycystic have suggested myxoedematous infiltration of the ovaries.
ovaries, ovarian ectopic pregnancy, etc. All these conditions Awareness of this condition is important because of the high
have been dealt with in detail in their respective chapters. probability of this being diagnosed wrongly as a case of
A rare cause for enlarged cystic ovaries is the Van Wyk– bilateral neoplastic ovaries with inadvertent surgical exci-
Grumbach syndrome (VWGS), a condition associated with sion (in a young girl and one that can be treated with simple
juvenile hypothyroidism (of long standing duration and thyroid replacement). In the case described below, preopera-
with high levels of TSH), delayed bone age and isosexual tive blood workup picked up the high TSH levels and led to
precocious puberty. These return to normal on thyroid hor- the diagnosis (Fig. 14.3).
14.2 Pelvic and Adnexal Masses 515

14.2.2 Uterine Masses ovarian component; however, often (like in some tubo-
ovarian abscesses) this may not be possible. These have been
An enlarged uterus presenting as a pelvic mass may be seen in dealt with in the section on PID in Chap. 9.
both adenomyosis and fibroids. In adenomyosis, of course, the
uterus is usually globular in shape, with distinctive features
making diagnosis very simple. With fibroids, the uterus may be 14.2.5 Paraovarian Masses
irregularly enlarged or there may at times be confusion about
the origin of the mass. This is particularly so when the mass is These are typically cystic masses seen in the adnexa separate
a subserous/pedunculated fibroid. Fibroids have typical ultra- from the ovary. Occasionally, they may be adherent to the
sound features but can be confused with adnexal masses, par- ovary, when distinguishing them from an exophytic ovarian
ticularly when they show degenerative changes. Fibroids are cyst can be challenging. They are usually small, unilocular
usually masses within the uterus, but the subserous peduncu- and anechoic but can be large, septate and even undergo tor-
lated ones can be diagnosed to be of uterine origin by tracing sion. They have been dealt with in the section on paraovarian
their attachment to the uterus through a pedicle or blood flow. cysts in Chap. 9.
The pedicle may not be well seen unless there is surrounding
fluid. Doppler flows are very helpful in assessing the origin of
any mass as vessels are seen passing between the mass and the 14.2.6 Pseudoperitoneal or Peritoneal
source of origin. Exceptions to this, of course, are true broad Inclusion Cysts
ligament fibroids or fibroids seen in cases with disseminated
leiomyomatosis. In such cases, however, the ovaries will be Pseudoperitoneal cysts are nothing but areas of loculated
seen separate from the mass. fluid with adhesions. They may be secondary to chronic
Occasionally, in patients with unicornuate uterus, the infection, endometriosis or previous surgery. They can pose
adjoining rudimentary horn (particularly when non-cavitary) a diagnostic challenge in a patient in whom ovarian cystec-
may present as an adnexal mass, but these masses are tomy or ovariotomy has been done for a neoplastic ovarian
attached to the main uterine body and their echotexture is cyst, where these may be considered as a recurrence of
similar to that of the myometrium (Fig. 14.4). pathology. This has also been dealt with in Chap. 9.

14.2.3 Tubal Masses 14.2.7 Pelvic Hematomas and Pelvic Abscess

The normal fallopian tube is difficult to identify, unless it is These may be seen to be associated with ectopic pregnancies
surrounded by fluid. It appears as an elongated undulating or infection. They may present as pelvic masses when local-
isoechoic or hyperechoic structure. Tubal masses may be of ised to an area. These are avascular masses, and correlation
inflammatory or neoplastic nature or secondary to a tubal ecto- with other findings helps in diagnosis.
pic pregnancy. These have been dealt with in their respective
chapters. Tubal masses may be seen continuous with the uter-
ine cornua, but often they are not, because the pathological seg- 14.2.8 Non-gynecological Masses (Fig. 14.5)
ment of the tube is away from its attachment to the uterus. The
distal part of the tube has a broader lumen, and most collections These are rarely seen and most often are either appendicu-
(hydrosalpinx, pyosalpinx or haematosalpinx) are, therefore, lar masses or malignant masses arising from the small or
seen at its distal end. Cystic tubal masses are generally easy to large intestine (e.g. gastrointestinal stromal tumour of the
identify because of their elongated shape and incomplete septa. small bowel and anorectal masses). The ovaries are seen
distinct from these masses, and they do not originate from
the uterus (i.e. no flow is seen between the uterus and the
14.2.4 Tubo-ovarian Masses mass).

Tubo-ovarian masses are typically secondary to PID. At

times, one may be able to differentiate between the tubal and
516 14 Exploring Pathologies Based on Clinical Presentation

a b
LT ADNEXA

c d

e f

Fig. 14.3 Van Wyk–Grumbach syndrome – Bilateral multicystic enlarged ovaries with a very high TSH level of 1980 micIU/ml in a 14-year-old
girl with short stature, who presented with the complaint of irregular periods. Both ovaries were enlarged and multicystic. (a) Right ovarian vol-
ume – 503 ml. (b) Left ovarian volume – 87 ml. (c) 3D-rendered image showing multiple locules. (d) Flow in septa with RI of 0.48. (e, f) Six weeks
after thyroid replacement treatment, the ovaries had reduced in size with lesser number of locules – the right ovarian volume was 129 ml and the
left ovarian volume was 74 ml
14.2 Pelvic and Adnexal Masses 517

Fig. 14.4 Rudimentary horn presenting a

as an adnexal mass. (a) Well-defined,
LS TS
isoechoic mass seen in the left adnexa,
raising the suspicion of a solid adnexal
mass. (b) This mass, on further
evaluation, was found to be connected to
the main uterine body of a right-sided
unicornuate uterus. (c) 3D-rendered
image of the unicornuate right uterus

Uterus Coronal
b TS

c
518 14 Exploring Pathologies Based on Clinical Presentation

Fig. 14.5 Non-gynecological mass in a a

36-year-old patient treated for papillary TS LS
carcinoma of the thyroid 4 years prior to scan.
Patient presented with abdominal pain.
(a) Normal left ovary. (b) Normal right ovary.
(c) Right sided adnexal mass which is solid,
heterogeneous, lobulated and has septae. The
mass shows high vascularity. It had no
connection with the uterus or ovaries on
greyscale or on Doppler. This raised suspicion
of a non-gynecological malignant mass. HPE:
gastrointestinal stromal tumour of the jejunum

b
TS LS

c
14.2 Pelvic and Adnexal Masses 519

14.2.9 IOTA Recommendation for Evaluation *When in doubt about the number of papillae particularly
of Persistent Adnexal Masses when they appear to merge with one another, it is recommended
that the worst-case scenario should be applied. For example, if
Chronic adnexal masses are to be described and evaluated there is a doubt of 3–5 papillae, it is better to consider it as 5.
based on the IOTA guidelines (which has been discussed in
detail in the chapter on ovarian masses). The IOTA consen-
Benign
sus group has come out with a methodology to help assess
• Unilocular (no solid areas)
the nature of persistent adnexal masses, particularly to inves-
• Unilocular solid with the largest diameter of the
tigate whether they are likely to be benign or malignant. This
solid area less than 7 mm
includes a three-step strategy, logistic regression models
• Acoustic shadowing
LR1 and LR2 and the ADNEX model (details of the LR1,
• Smooth multiloculated mass less than 10 cm
LR2 and ADNEX models may be obtained from the refer-
• No blood flow – colour score 1
ences suggested at the end of the chapter). The three-step
strategy is discussed below.
Prior to the three-step strategy for evaluating the nature of
adnexal masses, we need to know and understand the simple • If one or more malignant features are seen and no benign
rules and simple descriptors as provided by the IOTA con- feature is seen, the mass is considered malignant.
sensus group. • If one or more benign features are seen and no malignant
feature is seen, the mass is considered benign.
14.2.9.1 Simple Rules (Figs. 14.6 and 14.7) • If one or more features of both benign and malignant are
The IOTA group has come up with simple rules that help noted, the nature of the mass is considered inconclusive.
in differentiating between malignant and benign masses. • If no features of either benign or malignant are noted, the
nature of the mass is also considered inconclusive.

Malignant Using this method, about 77 % of masses can be catego-

• Ascites (fluid outside POD) rised as benign or malignant, with a specificity of 96 % and
• Irregular solid tumour (80 % or more appears solid) sensitivity of 92 %. In the remaining 23 % that cannot be cat-
• At least four papillary structures* egorised, the options are to further evaluate with CA 125 lev-
• Irregular multilocular solid with largest diameter of els or obtain a subjective opinion of an expert. Another
10 cm or more option is to simply consider these masses as malignant since
• Strong blood flow – colour score 4 about half of them (47 %) do turn out to be malignant.
520 14 Exploring Pathologies Based on Clinical Presentation

a
TS LS

b c

d e

Fig. 14.6 Simple rules for malignancy: (a) Ascites (fluid outside POD) with fluid in LIF. (b) Irregular solid tumour (80 % or more appears solid).
Arrow showing its irregular margins. (c) At least four papillary structures in the mass. (d) Irregular multilocular solid mass with largest diameter of
10 cm or more (this tumour was 13.3 × 9.8 × 12.0 cm). The arrow pointing at the solid component. (e) Strong blood flow – colour score 4
14.2 Pelvic and Adnexal Masses 521

Fig. 14.7 Simple rules for a

benign masses: (a) Unilocular TS LS
cyst (no solid areas). (b)
Unilocular solid cyst with the
largest diameter of solid area
less than 7 mm. Here the solid
papilla measured 5 × 4 × 3 mm
and showed acoustic
shadowing (arrow). (c)
Presence of acoustic
shadowing (arrow) – from a
papilla of larger than 7 mm
(arrow). (d) Smooth
multiloculated mass less than
10 cm. (e) No blood flow –
colour score 1

b TVS c TAS

d e
522 14 Exploring Pathologies Based on Clinical Presentation

14.2.9.2 Simple Descriptors (Figs. 14.8 and 14.9)

There are, however, some masses that have such typical fea- Malignant Simple Descriptors
tures that they are easy to classify and do not require the • Postmenopausal women with ascites, and at least
above methodology to categorise them as benign or malig- moderate flow (colour score of 3–4)
nant. These features have been termed ‘simple descriptors’ • Women aged more than 50 with a CA 125 level of
and show sensitivity and specificity of 98 % each. more than 100 IU/mL

Benign Simple Descriptors

• Unilocular ground glass cyst in premenopausal
women (suggestive of an endometrioma)
• Unilocular cyst with mixed echogenicity and aous-
tic shadowing in premenopausal women (sugges-
tive of a dermoid)
• Unilocular anechoic cyst of less than 10 cm with
regular walls (suggestive of a benign cystadenoma)
• Remaining unilocular cysts with regular walls
(probably physiological, e.g. a haemorrhagic cyst)
14.2 Pelvic and Adnexal Masses 523

a TS LS d

c
TS LS

Fig. 14.8 Benign simple descriptors: (a) Unilocular ground glass cyst in premenopausal women (suggestive of an endometrioma). (b) Unilocular
cyst with mixed echogenicity and acoustic shadowing in premenopausal women (suggestive of a dermoid). (c) Unilocular anechoic cyst of less
than 10 cm with regular walls (suggestive of a benign cystadenoma). (d) Remaining unilocular cysts with regular walls (suggestive of a haemor-
rhagic cyst)
524 14 Exploring Pathologies Based on Clinical Presentation

b TS LS

Fig. 14.9 Malignant simple descriptors: Postmenopausal woman (59 years) with (a) ascites and (b) at least moderate flow (colour score of 3–4) –
seen in the solid component (arrow) of a mucinous cystadenocarcinoma
14.2 Pelvic and Adnexal Masses 525

14.2.9.3 Three-Step Strategy for Evaluating While reporting adnexal masses, the morphology should
the Nature of Persistent Adnexal be described using standard terminology. In some cases, the
Masses (Ameye et al. 2012) exact pathology can be ascertained, while in others our
Step 1: Simple Descriptors impression of the type of pathology must be provided –
Simple descriptors are used for easy, instant diagnosis. physiological, inflammatory, endometriotic, neoplastic
The nature of the mass can be determined using these in (benign or malignant).
about 47 % of cases.
Step 2: Simple Rules
The rest of the masses are assessed using simple rules to Summary: Pelvic/Adnexal Masses
predict whether they are benign or malignant. In this man- • History: clinical findings and previous reports are
ner, another 34 % can be categorised. essential, as they may help in diagnosis.
Step 3: Subjective Assessment by Expert • The morphology of the mass must be described
The remaining 19 % of cases are subjected to assessment using standard terminology (as suggested by IOTA).
by an expert examiner (other options include CA 125 esti- • Blood flow in the mass should be assessed with
mation or MRI, or the mass is simply assumed to be optimised Doppler settings.
malignant). • Structure of origin is to be assessed by looking for
the ovaries, ovarian tissue along the mass or Doppler
Please Note: For all of us to improve our expertise, it is flows from the mass to its source of origin.
suggested that we read up journal articles for rare adnexal • Exact pathology may be possible in some condi-
masses (e.g. UOG series – Imaging in Gynaecological tions like a tubal ectopic pregnancy, dermoid,
Disease). It is also important to follow up all difficult and pedunculated fibroid, etc.
atypical cases with surgical findings, discharge summaries, • In the others, our impression of the type of pathol-
macroscopy and histopathology. ogy must be mentioned, i.e. whether it is physiolog-
ical, inflammatory or neoplastic.
• The mass should be assessed as malignant or not, if
possible. If not, it should be mentioned in the report.
IOTA guidelines help in assessing whether the mass
is benign or malignant.
• Further investigations like BhCG, CA 125 and
MRI, if required, should be suggested in the report.
526 14 Exploring Pathologies Based on Clinical Presentation

14.3 Acute Pelvic Pain tory of similar mid-cycle pain in the past. On ultra-
sound, evidence of ovulation may be noted (corpus
Acute pelvic pain can be associated with both gynecological luteum and minimal fluid in the POD).
and non-gynecological pathologies. In this chapter, gyneco- The author has noticed that many of the patients
logical causes for acute pelvic pain have been discussed. For with significant ovulation pain are found, on scan, to
practical purposes, the cases with acute pelvic pain are grouped have their ovaries just under the anterior abdominal
into various categories. The details of diagnosis by ultrasound wall (not adherent, but placed in close association
features are dealt with in their respective sections: with the anterior abdominal wall). In such cases, often
the patient can actually point to the area of pain.
1. Pain associated with pregnancy – Here the patient may The ovary is seen at that site and is tender to touch on
give a history of amenorrhoea. UPT may be positive or transabdominal scan. On applying pressure with the
serum BhCG may be elevated. In some cases, however, probe, the patient also mentions that it is exactly like
the patient may present without knowing that she is preg- the pain she has been experiencing.
nant, and an ultrasound scan is likely to provide evidence (b) Corpus luteal haemorrhage – Occasionally, there may
of an intrauterine or an extrauterine pregnancy: be haemorrhage from a corpus luteum following ovu-
(a) Threatened or inevitable abortion (intrauterine preg- lation. This may occur at ovulation or at some time
nancy or GS seen on scan). thereafter. The pain may be severe and more pro-
(b) Incomplete or complete abortion – The patient usu- nounced on one side. On ultrasound, turbid fluid sug-
ally gives a history of heavy bleeding, and retained gestive of blood is seen in the pelvis. Clots (avascular
products of conception may be seen on scan. complex hyperechoic areas) may be seen suspended
(c) Ectopic pregnancy – Pain here may or may not be and floating in blood and surrounding the ovary
severe. Other than the ectopic pregnancy mass, the which houses the corpus luteum, from which haem-
scan may show blood in the pelvis or general abdomi- orrhage has occurred.
nal cavity. The patient may present with hypovolae- 4. Pain associated with infection – These patients generally
mic shock, if internal bleeding is heavy. have associated fever and high white blood cell counts:
2. Pain associated with periods – This is also known as dys- (a) The most common gynecological cause is pelvic
menorrhoea. These patients typically give a history of inflammatory disease (PID), which has been dis-
recurrent pain occurring cyclically during periods. cussed in detail in Chap. 9. Here, ultrasound findings
Common causes that can be diagnosed on ultrasound are: depend on the severity and the structures involved.
(a) Endometriosis including extra-ovarian endometrio- (b) There are a few non-gynecological infections that
sis. The pain in endometriosis is typically congestive could present with pain and fever – the common ones
with associated backache. The pain tends to persist being appendicitis, cystitis, ureteric calculi and diver-
even after periods. Depending on the site of deep ticulitis. The discussion and diagnosis of these are
infiltrating endometriosis, the patient may complain beyond the scope of this book. Briefly, however, in
of dysuria (painful micturition), dyspareunia (painful cystitis the patient will give a history of micturition
intercourse), dyschezia (painful defecation), etc. and urine examination will give evidence of infec-
Deep infiltrating endometriosis is a condition which tion. In appendicitis (Fig. 14.10), the patient will have
causes pain, but diagnosis is often missed or delayed pain and tenderness in the right iliac fossa
(discussed in detail in Chap. 8). (McBurney’s point), and on ultrasound an elongated
(b) Submucous fibroid or fibroid polyp – Along with dys- tubular mass with a blunt end (inflamed appendix)
menorrhoea, these patients also complain of abnor- may be seen in the RIF. In diverticulitis, features are
mal uterine bleeding. similar to appendicitis, and when it is on the right
(c) Adenomyosis – These patients in addition to dysmen- side, it may be difficult to differentiate from appendi-
orrhoea may complain of menorrhagia. citis. In ureteric colic, the pain typically radiates from
In some patients suffering from dysmenorrhoea, par- loin to groin, and an ultrasound is usually able to
ticularly adolescents, no pathology may be noted on detect the ureteric calculus.
ultrasound. 5. Pain associated with pelvic or adnexal mass – The com-
3. Pain associated with ovulation – Pain here is typically mon causes in this category include:
mid-cycle and more pronounced on one side: (a) Torsion: Both ovarian and non-ovarian torsions
(a) Ovulation pain (mittelschmerz) – Ovulation itself (hydrosalphinx or paraovarian cysts) can present
could be a cause for pain. It is generally not severe, is with severe acute pelvic pain or recurrent pain.
one sided, lasts for a few hours and may be associated Ultrasound diagnosis has been discussed in great
with mid-cycle spotting. The patient may give a his- detail in Chap. 10.
14.3 Acute Pelvic Pain 527

(b) Rupture of a cyst could be a rare cause of acute pelvic induction. The ovaries are enlarged, are vascular and
pain. Other than a corpus luteal cyst (Fig. 14.11), this show multiple cysts. Free fluid is seen in the pelvis,
may be seen with an endometriotic cyst (Fig. 14.12) or frank ascites may be noted. Occasionally, they
or a malignant cyst. may be associated torsion or haemorrhage.
(c) Degeneration of a fibroid is a rare cause of pain. In Chronic pelvic pain is typically noted in women with endo-
red degeneration, the fibroid is usually enlarged in metriosis, pelvic inflammatory disease (PID) or malignant
size, avascular and tender. masses. In the case of malignancy, the pain is more often in
(d) Ovarian hyperstimulation syndrome (OHSS): This is the form of a chronic discomfort.
seen in patients with infertility undergoing ovulation
528 14 Exploring Pathologies Based on Clinical Presentation

a TS LS

b TS LS

c TS LS

Fig. 14.10 A 15-year-old girl with 2 days of fever, lower abdominal pain and vomiting. Scan done elsewhere reported a left ovarian cyst with
suspicion of torsion: (a) normal right ovary, (b) left ovary showing a haemorrhagic corpus luteum and (c) complex mass with turbid contents
(arrow) seen in the right lower abdomen, which was tender. There was no evidence of torsion. HPE: appendicitis
14.3 Acute Pelvic Pain 529

a LS

b LS TS

Fig. 14.11 Haemorrhage from a corpus luteum. (a) Haemorrhagic corpus luteum is seen showing a clot within and flow around its walls. Turbid
fluid suggestive of blood is seen around the ovary. (b) POD on LS and TS showing turbid fluid, suggestive of blood. UPT was negative
530 14 Exploring Pathologies Based on Clinical Presentation

a TS LS

b TS LS

c TS LS

Fig. 14.12 Rupture of an endometriotic cyst. (a) A circumscribed left ovarian endometriotic cyst of volume 594 cc. (b) Patient returned 32 days
later with severe abdominal pain. On examination, the cyst appeared more flaccid and the volume had reduced to 352 cc. (c) Turbid fluid suggestive
of blood was seen in the abdomino-pelvic cavity. Rupture of the endometriotic cyst was confirmed at surgery
14.3 Acute Pelvic Pain 531

Summary of Pelvic Pain

• History is important in making a diagnosis, particu-
larly menstrual history, details of pain (location,
duration, intensity, triggering factors, etc.) and the
presence of associated nausea, vomiting, bleeding,
discharge and fever.
• Clinical examination, both abdominal and biman-
ual, may help in locating the site of tenderness and
the presence of a mass.
• Ultrasound (TVS) is the diagnostic modality of
choice, wherein one can not only see structures but
also touch them to assess tenderness. In addition, it
is non-invasive and easily available.
• Previous reports may help diagnosis by correlation
with present findings.
• Appropriate investigations (UPT, BhCG, CBC,
urine routine, etc.) should be suggested.
• Discussion with the clinician is important for appro-
priate and prompt management.
532 14 Exploring Pathologies Based on Clinical Presentation

14.4 Locating the Pregnancy and

Pregnancy of Unknown Location (PUL) True GS
• Eccentrically placed, lying within one layer of the
Once the patient presents with a positive pregnancy test, the endometrium
next step is to confirm the pregnancy on ultrasound. The first • Circular in shape
question that arises is – when should ultrasound be done? • Hyperechoic trophoblastic rim seen around the GS
• Doppler flow seen around the GS (Doppler studies
• If the patient is symptomatic with pain or bleeding, then are to be avoided in any case with suspected normal
an ultrasound scan is suggested at the time she presents intrauterine pregnancy)
with her symptoms.
• If the patient is a high-risk case (history of previous ecto-
pic pregnancy, PID, infertility or IVF), then an early scan
is suggested at 5–6 weeks of gestation or when BhCG is Pseudo-GS
above 1000 or 1500 mIU/ml. • Located between the two layers of the
• In all other asymptomatic low-risk women, a scan is sug- endometrium
gested at 7 weeks of gestation. This is because scans done • Takes the shape of the uterine cavity
prior to 5 weeks of gestation may not be able to locate an • No hyperechoic rim around it
intrauterine or extrauterine pregnancy. Between 5 and 6 • No Doppler flow around it
weeks, an intrauterine gestation may be seen, but its via-
bility may be difficult to confirm. Even at 7 weeks, ultra-
sound may be inconclusive in up to 20–25 % of women shows multiple tiny cystic spaces (Fig. 14.14). These are
(Bottomley et al. 2009). seen closer to the EMJ and should not be mistaken for a
gestational sac:
When a scan is done, there are two types of ultrasound • Retained products of conception: The patient may give
findings: history of bleeding or passing tissues. On ultrasound,
1. The ultrasound may be diagnostic if it is able to locate or retained products of conception typically appear as an
provide evidence of an intrauterine or extrauterine area of complex echoes with flow within (details of which
pregnancy. are available in the section on RPOC in Chap. 10). Unless
2. The ultrasound may be non-diagnostic if there is no evi- one is sure of the diagnosis of RPOC, it may be safer to
dence of an intrauterine or extrauterine pregnancy. These consider these patients as cases of PUL and follow them
cases are defined as pregnancy of unknown location (PUL). up.
• Complete abortion: A patient may give history of heavy
The possibilities therefore include: bleeding with or without a history of passing tissues, but
• Intrauterine pregnancy (including missed abortion): The on scan there may be no evidence of intrauterine products
presence of an intrauterine pregnancy is reassuring that of conception, suggestive of complete abortion. Unless
there is no extrauterine pregnancy, as heterotopic preg- there is a previous scan report suggestive of an intrauter-
nancy is very rare. Once the BhCG levels reach 1000– ine pregnancy, again it is safer to follow up these cases as
1500 mIU/ml, an intrauterine gestation should be is done in cases with PUL.
visualised on TVS. This level of BhCG is therefore called • Molar pregnancy: Here, along with the history of amenor-
the ‘discriminatory zone’ (DZ). It is important to carefully rhoea and bleeding, the patient may give a history of pass-
search for an intrauterine sac, which is often missed when ing vesicles. On ultrasound, the uterus is filled with an
close to a cornua. When an intrauterine pregnancy is pres- echogenic mass showing tiny cystic spaces. In the first
ent with a yolk sac or fetal pole (with or without fetal trimester, findings may not be classic and may be similar
heart), then the diagnosis is clear. However, if there is a to that of a case with missed abortion.
tiny intrauterine sac, without a yolk sac or fetal pole, the • Ectopic pregnancy: This has been discussed in great detail
dilemma may arise whether it is a true gestational sac or a in Chap. 10. One must remember that not all patients are
pseudo-sac. The endometrium in the cases with ectopic symptomatic with pain. Also, an ectopic pregnancy mass
pregnancy may show fluid collection, giving it the appear- may exist with or without rupture, even with BhCG levels
ance of a gestational sac called the ‘pseudo-gestational below the DZ. Knowledge of the spectrum of ectopic preg-
sac’. The differences between a true and pseudo-gesta- nancies is important in making a diagnosis. An ectopic
tional sac are given as follows (Fig. 14.13): pregnancy that is commonly missed is a cervical ectopic
In addition, the endometrium undergoes decidualisa- pregnancy. This is because most sonologists tend to search
tion in an ectopic pregnancy where it appears thick and carefully primarily in the endometrial cavity and the
14.4 Locating the Pregnancy and Pregnancy of Unknown Location (PUL) 533

adnexa, neglecting the cervix. Heterotopic pregnancy can women, expectant management on an outpatient basis is
also get missed because it is rare, and visualisation of an considered adequate. These patients are however coun-
intrauterine pregnancy is generally considered reassuring. selled about possible outcomes, need for regular follow-up
However, in symptomatic patients and in those with ovula- and reporting, if there are any relevant symptoms. In these
tion induction and IVF, one must think of such a possibility patients, a BhCG if not done earlier is done immediately
and look at the adnexa carefully. and repeated after 48 hours. Based on the values, the
• Pregnancy of unknown location (PUL): As mentioned ear- patients are triaged into:
lier, this implies that there is a positive biochemical preg- • BhCG rise of more than 66 % (high likelihood of an intra-
nancy test (UPT or BhCG), but there is no evidence of any uterine pregnancy) – Scan is suggested a week later or
intrauterine or extrauterine gestation. Possibilities on fol- once the BhCG is above the DZ.
low-up of PUL cases are: • Falling BhCG levels – Any fall in BhCG suggests a fail-
– Intrauterine pregnancy – 30 to 50 %. ing pregnancy (intrauterine or extrauterine). This is again
– Ectopic pregnancy – 7 to 20 %. This risk of an ectopic reassuring, and a BhCG may be repeated after a week
pregnancy is the main issue that warrants close follow- or two.
up of patients with PUL. • BhCG rise of less than 66 % – These are cases at a high risk
– Failing pregnancy (intrauterine or extrauterine) – 50 to of an ectopic pregnancy and need to be monitored closely
70 %. with serial BhCG. A scan may be done a week after the
initial scan or earlier if the patient is symptomatic.
Management of PUL: In haemodynamically unstable
women or women with severe pain, a laparoscopy may Methotrexate may occasionally be considered for cases
have to be resorted to. In haemodynamically stable women with persistent PULs, who are either not keen on pregnancy
with pain, one may either consider laparoscopy or monitor or are not compliant.
these patients closely with serum BhCG. In all other
534 14 Exploring Pathologies Based on Clinical Presentation

a LS b LS

Fig. 14.13 GS: (a) Twin true gestational sacs in one wall of the endometrium. Arrows show endometrial midline. (b) Pseudo-gestational sac

a LS b TS

Fig. 14.14 Decidualised endometrium on (a) LS and (b) TS, showing tiny cystic spaces in the periphery of the endometrium close to the EMJ

Summary of Location the Pregnancy and PUL • To diagnose extrauterine pregnancy, a TAS prior to
• Proper attention must be given to history, symptoms TVS improves pick-up. Search for an extrauterine
and previous reports that may help in diagnosis. pregnancy must be done thoroughly, and one must
• Transvaginal scan is indispensable in locating the not forget to look at the cervix.
pregnancy. • In women with PUL, close follow-up with appro-
• In low-risk asymptomatic women, a scan should not priate counselling is important.
be done prior to 7 weeks as it may be inconclusive. • When in doubt about the location of pregnancy,
• In patients with intrauterine pregnancy, it is impor- surveillance should be like that of patients with
tant that one does not miss searching near the cor- PUL.
nua. Missing an intrauterine pregnancy may result • The need for serial BhCG and follow-up must be
in medicolegal issues if the patient is treated with mentioned in the report.
methotrexate, as is sometimes done in PULs or sus- • Discussing the ultrasound findings with the clini-
pected ectopic pregnancies. cian may help in appropriate management.
Suggested Reading 535

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Ameye L et al (2012) Clinically oriented three-step strategy for assess-
abortion with the use of sonography. Ultrasound Obstet Gynecol
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Nunes N et al (2014) Use of IOTA simple rules for diagnosis of ovarian
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cancer: meta-analysis. Ultrasound Obstet Gynecol 44:503–514.
hypothyroidism: the Van Wyk – Grumbach syndrome. Eur
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Parsons AK, Sanders RC (2007) OP17.07: Menometrorrhagia due to
Bottomley C et al (2009) The optimal timing of an ultrasound scan to
impaired uterine drainage. Ultrasound Obstet Gynecol 30:514.
assess the location and viability of an early pregnancy. Hum Reprod
doi:10.1002/uog.4585
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Potter AW, Chandrasekhar CA (2008) US and CT evaluation of acute
Condous G et al (2007) Prediction of ectopic pregnancy in women with
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29:680–687. doi:10.1002/uog.4015
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Epstein E et al (2016) Subjective ultrasound assessment, the ADNEX
evidence-based approach to management. Obstet Gynaecol 10:224–
model and ultrasound-guided tru-cut biopsy to differentiate dissemi-
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Saksouk FA, Johnson Samuel C (2004) Recognition of the ovaries and
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studies. Ultrasound Obstet Gynecol 41:9–20. doi:10.1002/
nosis of ovarian cancer. Ultrasound Obstet Gynecol 31:681–690.
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 Index

A Adenomyomatous polyp, 112

Abdominal pain. See also Pelvic pain; Acute pelvic pain Adenomyosis, 81–89, 311–312
fibroid, 76 Adnexal masses, 203, 215–216. See also
fibroma, 284 Pelvic masses
ruptured yolk sac tumour, 277 chronic pelvic inflammatory disease, 337–339
Abdominal wall endometriosis, 313–314 fallopian tube, 319
Abnormal uterine bleeding hydrosalpinx, 340–345
causes, 509–511 IOTA recommendation, 519–525
common forms, 509 paraovarian and paratubal cysts, 349–355
in reproductive age group, 509–511 pelvic inflammatory disease, 319–336
Absent uterus, 453 peritoneal inclusion cysts, 356–360
Acoustic shadowing rudimentary horn, 517
abdominal wall endometriosis, 313 tubal malignancy, 346–348
adenomyosis, 81 American Fertility Society (AFS) classification,
Brenner tumour, 239 437–438
deep infiltrating endometriosis, 295 Androblastomas, 281
dermoids, 7, 36, 263, 264, 266, 272 Anorectal carcinoma, 291
endometritis, 152 Anteflexed uterus, 12
fibroid, 64, 65 Anteverted uterus, 12
fibromass, 283 Antral follicle(s), 203, 205
fibrothecoma, 283 normal ovaries, 203, 205, 217
Gorlin syndrome, 287 polycystic ovaries, 223
immature teratoma, 274 Antral follicle count (AFC)
intra uterine contraceptive device, 489 polycystic ovary, 222, 224
myometrium, 56 with SonoAVC, 20
ovarian mass evaluation by, 204, 211, 519, 522 SonoAVC software, 224
paraovarian cyst, 352 torsion, 414, 415
retained products of conception, 398 Arcuate uterus, 444–445
serous cystadenofibroma, 250 Arteriovenous (AV) malformations, 469–474
subendometrial fibrosis, 145, 151 Ascites
vaginal pack, 199 malignant epithelial tumours, 238
Acute pelvic pain malignant serous cyst, 239
corpus luteum, haemorrhage from, 529 metastatic ovarian masses, 288
endometriotic cyst rupture, 530 mucinous cysts, 251
infection and, 526 Asherman’s syndrome, 145–149, 509
ovulation and, 526
pelvic/adnexal mass and, 526–527
periods and, 526 B
pregnancy and, 526 Bartholin gland cysts, 189, 191, 192
Adenocarcinoma ‘Beads-on-string’ appearance, 340
cervical, 177 Bicornuate uterus, 448–449
endometrial, 130–142 with hemi-haematometrocolpos, 463
endometrial polyp, 118 with single cervix and vagina, 459
ovarian mucinous, 260 Bladder deep infiltrating endometriosis, 307–308
ovarian serous, 239, 244–247 Borderline mucinous cysts, 255–259
tubal, 346 Borderline serous tumours, 243
vaginal metastasis, 196 Bowel deep infiltrating endometriosis, 297–299
Adenomyoma, 90–92 Brenner tumours, 239

© Springer Nature Singapore Pte Ltd. 2017 537

M. Sibal, Ultrasound in Gynecology, DOI 10.1007/978-981-10-2714-7
538 Index

C Cystadenocarcinoma, mucinous, 260–262

Caesarean scar defect (LSCS scar defect), 482–488 Cystadenofibroma, 248–250
Calcification papilla, 203, 204, 207
arcuate vessel in postmenopausal uterus, 61, 63 paraovarian cyst, 352
Brenner tumours, 239 Cyst echogenicity, 40
fibroid embolization, 77 Cystic hyperplasia, 47, 48
fibroids, 64, 65
fibrothecoma, 286
immature teratoma, 274 D
mucinous cystadenoma, 254 3D colour Doppler, 25, 27, 31
ovarian epithelial tumour, 239 Decidualised endometriotic cysts, 235–237
Carcinoma endometrium, 130–142 Deep infiltrating endometriosis (DIE)
Cervical cancers, cervical carcinoma, 51, 53, 177–185 bladder, 307–308
Cervical deep infiltrating endometriosis, 303–304 cervical, 303–304
Cervical ectopic pregnancy, 381–384 large bowel (rectosigmoid), 297–299
‘hourglass’ shaped uterus, 381 nodules, ultrasound features of, 295–296
Cervical fibroids, 175–176 significance, 295–296
Cervical polyps, 51, 52, 167–174 ureters involvement, 309–310
Cervix uterosacral, 305–306
anomalies, 455–459 uterus shape and, 311–312
appearance, 163, 164 of vaginal wall, 300–302
Doppler, 163 Dermoids, 263–272
measurements, 163 Rokitansky nodule, 268
septate, 458 TAS and TVS, 7
Chocolate cysts. See Endometriotic cysts/endometriomas ‘tip of the iceberg’ sign, 263, 264
Choriocarcinoma, 273, 406, 409 Diffuse uterine leiomyomatosis, 78
Chronic pelvic inflammatory disease, 332, 337–339 Disseminated peritoneal leiomyomatosis, 79–80
Chronic pelvic pain Doppler imaging studies
deep infiltrating endometriosis, 295 advantages, 26, 28
endometrioma, 237 colour distribution, 205
Clots colour index, 204–205, 213
endometriotic cysts/endometriomas, 228 flow abundance, 26, 29
in haemorrhagic cyst, 225, 226 flow direction, 26, 32
Colour Doppler, 25–27 flow impedance and velocities, 26, 33
Congenital cervical anomalies. See Cervix, anomalies flow indices, 26, 33, 205, 213
Congenital uterine anomalies types, 25, 27–28
absent/hypoplastic uterus, 453 vascular morphology, 26, 30, 31
AFS classification, 438, 439 3D ultrasound, 13–25
arcuate uterus, 444–445 Dysgerminoma, 273, 278–280
bicornuate uterus, 448–449 and gonadoblastoma, 280
cervical anomalies, 455–463
diagnosis, 439–443
embryopathogenesis, 435–437 E
ESHRE/ESGE classification, 464–465 Ear shaped/question mark shaped uterus, 311–312
reporting, 466 Ear shape sign, adenomyosis, 81
septate uterus, 447 Ectopic pregnancy
subseptate uterus, 446 cervical, 381–384
‘T-Shaped’ uterus, 454 cornual, 376–378
unicornuate uterus, 451–452 diagnosis, 363
uterus didelphys, 450 echogenic, 364
vaginal anomalies, 455–463 heterotopic pregnancy, 388–389
Congenital vaginal anomalies, 189, 455–463 interstitial, 373–376
CONUTA (CONgenital UTerine Anomalies), 464–465 intra-abdominal pregnancy, 387
Cornual ectopic pregnancy, 376–378 intra-myometrial ectopic pregnancy, 390
Corpus luteal cyst, 225, 226 ovarian, 379–380
Corpus luteum (CL) pseudo-gestational sac, 363
haemorrhage from, 529 scar, 385–386
in normal ovaries, 205 transabdominal scan, 363
Crescent sign, 512, 513 tubal, 365–371
ovarian mass evaluation by, 203, 205 Edge shadows, in fibroids, 64
pelvic ultrasound, 43 Embryonal carcinoma, 273, 274
Cyst, 204 Endodermal sinus tumours. See Yolk-sac tumour
cyst contents, evaluation of, 204, 210 Endometrial carcinoma, polycystic ovarian syndrome with, 222
measurement, 204, 211, 212 Endometrial hyperplasia
multilocular, 204 classification, 121
unilocular, 204 risk factors, 121
wall irregularity, 203 tamoxifen, 121, 129
Index 539

ultrasound features, 121–128 3D role, 73–74

Endometrial malignancy, 130–142 site of origin, 70–72
Endometrial polyps ultrasound report, 75
sonohysterography, 49 Fibroid polyp, 70, 71
ultrasound, 35–37, 44, 45, 100, 104 Fibroma, 211, 283–287
ultrasound features, 108–120 Fibrothecoma, 283, 286
Endometriosis Fimbrial cysts, 349, 350
DIE, 295–312 Flow indices, 35
endometriomas, 228–237 Follicular cysts, 225, 226
extra-pelvic, 313–316 Follicular monitoring and ultrasonography in patients with infertility
Endometriotic cysts/endometriomas, 228–237 cyclical changes during menstrual cycle, 498
kissing ovaries, 234 luteinised unruptured follicle, 499–502
malignancies in, 228–229 ovarian hyperstimulation syndrome, 503–506
Endometritis, 152–156 types of scans done, 498–499
Endometrium Follicular phase, 498, 500
Doppler evaluation, 98, 104 Follicular ring sign (FRS), 414, 426
evaluation, 97–104 advantages, 415
measurements, 97, 99–100 macroscopic evidence, 426
in paediatric age group, 105, 106 Functional/physiological cysts, 225–227
in polycystic ovary, 222
in postmenopausal women, 105, 107
qualitative assessment, 98, 101–103 G
in reproductive age group, 105–107 Gartner duct cysts, 189–191
visualisation, 34, 39 Gel sonovaginography (GSV), 51–53, 178, 439
Endomyometrial junction (EMJ), 55, 59, 98 indications, 51
adenomyosis, 81, 86 technique, 51–53
AV malformation, 469, 470 Germ cell tumours, 204
3D/VCI, 13 dermoids/mature cystic teratoma, 263–272
endometrium, 98, 102 malignant germ cell tumour, 273–280
endometrial cancer, 130, 131, 136 Gestational trophoblastic disease (GTD)
IUCD, 489 arteriovenous malformations, 470
retained products of conception, 391 molar pregnancy, 401–405
Epithelial ovarian neoplasms, 238–262 Gestational trophoblastic neoplasia (GTN), 401, 406
borderline mucinous cysts, 255–259 Glass body display, 14, 23
mucinous, 251–262 Gonadoblastoma, 280
mucinous cystadenocarcinoma, 260–262 Gorlin syndrome, 283, 287
mucinous cystadenoma, 251–254 Granulosa cell tumours, 281, 282
serous, 239–250 Ground glass appearance
serous adenocarcinoma, 244–247 decidualised endometriotic cysts, 235
serous borderline, 243 dermoid cyst, 266
serous cystadenofibroma, 248–250 endometriomas, 228, 229, 237
serous cystadenoma, 240–242 GTD. See Gestational trophoblastic disease (GTD)
Epithelioid trophoblastic tumour (ETT), 406, 410
European Society of Human Reproduction and Embryology
(ESHRE), 464–465 H
Extra-pelvic endometriosis Haemorrhagic cyst, 218, 223, 225
abdomen, 315–316 Hematosalpinx, 319
abdominal wall, 313–314 tubal ectopic pregnancy with, 368–369
thoracic, 315–316 Heterotopic ectopic pregnancy, 388–389
High-definition Doppler, 25, 27
High-density imaging (HDI), 14, 24
F High sliding sign, 9
Fallopian tube, 319 Hirsutism
carcinoma, 346–348 polycystic ovarian syndrome with, 222
Fan-shaped shadowing Sertoli and Sertoli–Leydig cell tumours, 281
adenomyoma, 81, 90 Hormone-producing intrauterine contraceptive device, 489
adenomyosis, 81 Hydatid cysts of Morgagni, 349
fibroids, 64 Hydrosalpinx, 319
Feeder vessel, 108 ‘beads-on-string’ appearance, 345
Fibroid(s), 64–80 cross section, 342
diffuse uterine leiomyomatosis, 78 globular cystic mass, 343
disseminated peritoneal leiomyomatosis, 79–80 incomplete septae, 342, 344
fibroid embolisation, 77 non-ovarian torsion, 430
red degeneration, 76 oval shaped, 343
ultrasound features, 64–67 vs. pyosalpinx, 345
Fibroid mapping, 36, 45 retort shaped, 343
basics of, 68–69 sausage-shaped, 342
540 Index

Hyperechoic foci/echogenic foci/foci J

adenomyosis, 85, 87 Junctional zone (JZ), 56, 81, 85–88
borderline serous tumour, 239, 243
chronic infection, 337
decidualised endometriotic cysts, 235 K
endometrial polyp, 119 Krukenberg tumours, 288–290
endometriomas, 228, 232
dermoid, 263
fibrothecoma, 286 L
immature teratoma, 274 Large bowel (rectosigmoid), DIE, 297–299
infection, tubo-ovarian abscess, 330 Lead vessel, 288, 289
mucinous cyst, 254 Leiomyoma. See Fibroids
post menopausal ovaries, 217 Leydig cell tumours, 281
post menopausal uterus, 61, 63 Low sliding sign, 9
post partum endometrial cavity, 107 LSCS scar defect, 482–488
subendometrial fibrosis, 150 Luteinised unruptured follicle, 499–502
tuberculous endometritis, 152
Hyperechoic line, 36
bowel DIE, 297, 299 M
cervical polyp, 167 Malignant
endometrial midline, 98 evaluation, 525
endometrial polyp, 45, 108, 110 simple rules, 519
Hypomenorrhoea, 509 simple descriptiors, 522, 524
Hypoplastic uterus, 453 Mature cystic teratoma. See Dermoids
Mayer–Rokitansky–Kuster–Hauser syndrome, 453. See also Absent
uterus
I Menorrhagia, 509
IETA (International Endometrial Tumor Analysis group), 97 Menstrual cycle, cyclical changes during, 498
Imperforate hymen, 189, 455 Menstrual phase, 498
with haematometrocolpos, 460, 461 Metastatic ovarian masses, 288–293
with regular menses, 462 category A, 288
Incomplete septum, 319 category B, 288
hydrosalpinx, 340 clinical findings, 288
pyosalpinx, 320 Metrorrhagia, 509
Infertility Mirena, 489, 492–494, 497. See also IUCD
endometriomas, 229, 237 Molar pregnancy, GTD
follicular monitoring and ultrasonography in patients with, 498–506 complete mole, 401–404
as polycystic ovarian syndrome risk, 222 partial mole, 404–405
polyps, 108 Morphological Uterus Sonographic Assessment (MUSA), 55
Intermenstrual bleeding, 509 Mucinous cystadenocarcinoma, 260–262
Intermenstrual spotting, polyps, 108 Mucinous cystadenoma, 251–254
Interstitial ectopic pregnancy, 373–376 Mucinous epithelial tumours
Intra-abdominal pregnancy, 387 borderline mucinous cysts, 255–259
Intracavitary fluid, in uterus, 157–160 mucinous cystadenocarcinoma, 260–262
Intra-myometrial ectopic pregnancy, 390 mucinous cystadenoma, 251–254
Intrauterine adhesions. See Asherman’s syndrome ultrasound features of, 251–262
Intrauterine contraceptive device (IUCD), 489–497 Mullerian cysts, 189–191
complications, 489 Multilocular cyst, 216
copper, 491 Multiplanar display, 14
copper-containing, 489 MUSA (Morphological Uterus Sonographic Assessment), 55
displaced, 494, 495 Myoma. See Fibroids
endometrial evaluation, 489 Myometrium
expulsion, 489 Doppler assessment, 56, 60
hormone-producing, 489, 492 junctional zone assessment, 56, 59
inert, 489 measurements, 55, 57, 58
in situ with bilateral PID, 496 neonatal uterus, 61
malposition, 489 normal myometrium, 61–63
mirena, 492–494 normal vasculature of, 56, 60
multiload, 493 paediatric uterus, 61, 62
position, 489 postmenopausal uterus, 61, 63
ultrasound features, 489–497 qualitative assessment, 55–56, 58
uterine perforation, 475, 477, 489 reproductive age, uterus in, 61, 63
IOTA recommendation, adnexal masses ultrasound reporting, 37
evaluation, 203
morphological classification, 215, 216
simple descriptors, 522–524 N
simple rules, 519–521 Nabothian cysts/follicles, 165–166
three-step strategy, 525 Neonatal ovaries, 217, 218
Index 541

Neonatal uterus, 61 serous epithelial tumours, 239, 242, 243

Neoplastic masses, 238–293 Paraovarian cysts
classification, 238 fimbrial cysts, 349, 350
epithelial tumours, 238–262 infected, 354
germ cell tumours, 263–280 papillary projections, 351–352
metastatic ovarian masses, 288–293 non-ovarian torsion, 431
morphological classification, 215–216 with septae, 353
sex cord-stromal tumours, 281–287 with torsion, 354–355
Non-gynecological masses, 515 ultrasound features, 349–355
Non-ovarian torsion Paraurethral cysts, 189
hydrosalpinx, 430 Pedicle artery sign, 108, 112
paraovarian cyst, 431, 432 Pelvic inflammatory disease (PID)
ultrasound features, 429–432 acute, 319–336
chronic, 337–339
Pelvic masses, 512–525
O non-gynecological masses, 515–518
Obesity, polycystic ovarian syndrome with, 222 Pelvic pain. See Acute pelvic pain; Chronic pelvic pain
Oligomenorrhoea, 509 Pelvic tuberculosis, 338
OmniView, 14 Perforation of uterus
Ovarian ectopic pregnancy, 379–380 IUCD, 477
Ovarian hyperstimulation syndrome (OHSS), 503–506 non-communicating right-sided uterine horn, 477
Ovarian masses during surgical MTP, 476
acoustic shadowing, 204, 211 trophoblastic perforation, 477
crescent sign, 203, 204 ultrasound features of, 475
cyst contents, 204, 210 Peritoneal inclusion cysts, 356–360
decidualised endometriotic cysts, 235–237 vs. adnexal cysts, 356
Doppler study, 204–205, 213–214 in patient with endometriotic cyst, 358–360
endometriotic cysts/endometriomas, 228–234 in patient with previous surgery, 357
functional/physiological cysts, 225–227 pelvic tuberculosis, 359
measurements, 204, 211, 212 Physiological cysts, 225–227
morphology, 203–211 PID. See Pelvic inflammatory disease (PID)
neoplastic masses (see Neoplastic masses) Placental site trophoblastic tumour (PSTT), 406
papilla, 203, 207 Polycystic ovarian syndrome (PCOS), 222
septum and locules, 204, 208 Polycystic ovaries (PCO)
solid component, 203, 206 in absence of PCOS, 222
walls of mass, 204, 209 ultrasound features of, 222–224
Ovarian neoplasms. See Neoplastic masses Polymenorrhagia, 509
Ovarian torsion, 413–428 Polymenorrhoea, 509
abnormal Doppler flows, 414, 423, 424 Polypoid endometrium, 47, 48
clinical features, 413 Post-coital bleeding, 509
follicular ring sign, 414–415 Postmenopausal bleeding, endometrial carcinoma, 130
free fluid, 414, 419 Postmenopausal ovaries, 217, 221
pedicle, 414, 419–421 Postmenopausal uterus, 61, 63
whirlpool sign, 414, 422, 425–427 Postmenstrual bleeding, 509
Ovaries Power Doppler, 25, 27
corpus luteum in, 205 Pregnancy of unknown location (PUL), 532–534
evaluation, 203 (see also Ovarian masses) Premenstrual bleeding, 509
mobility, 203 Prepubertal ovaries, in children, 219
neonatal ovaries, 217, 218 Primary amenorrhoea
paediatric ovaries, 217, 219 dysgerminoma and dysgenetic gonads, 273
postmenopausal ovaries, 217, 221 imperforate hymen and transverse vaginal septum, 455
postmenopausal women, 203 Mullerian agenesis, 453
reproductive ovaries, 217, 220 Primary vaginal carcinoma, 194
ultrasound reporting, 37 Proliferative phase/follicular phase, 498
Ovulation, 498 Psammoma bodies, in serous epithelial tumour, 239
Pulsed wave Doppler, 25, 27
Pyosalpinx, 320, 324–328
P
Paediatric ovaries, 217, 219
Paediatric uterus, 61, 62 Q
Pain. See Acute pelvic pain; Chronic pelvic pain Question mark sign, adenomyosis, 81
Pain-guided approach, 8–9
Papilla
evaluation, 203, 207 R
measurement, 204 Rectosigmoid deep infiltrating endometriosis, 297–299
multiple irregular, 207 Rectovaginal deep infiltrating endometriosis, 301
rounded projections, in decidualised endometriotic cysts, 235 Red degeneration, 76
serous cystadenofibroma, 248–250 ‘Red Indian hair dress’ sign, 297, 299
542 Index

Region of interest (ROI), 14 data acquisition, 14

Retained products of conception (RPOC), 391–400 3D/4D visualisation, 14–15, 22–24
clinical symptoms, 391 depth perception, 14, 18
differential diagnosis, 400 flow indices, 14, 21
placental polyp, 396 multiplanar imaging, 14, 18
retained placenta, 397, 398 rendering, 13, 16
Retroflexed uterus, 12, 480–481 storage of volumes, 15
Retroverted uterus, 12 volume calculation, 14, 19–20
Rokitansky nodule, 263, 268 volume contrast imaging, 13, 17
volume/image processing, 15, 24–25
working offline, 15
S Tip of the iceberg sign, in dermoids, 263
Saline infusion sonohysterogram (SIS), 47 Tomographic display (TUI), 14
Salpingitis, 323 Torsion
Sarcoma, 93–94 non-ovarian, 429–432
Scar ectopic pregnancy, 385, 386 ovarian, 413–428 (see also Ovarian torsion)
Secretory phase/luteal phase, 498, 501 Transabdominal scan (TAS), 1
Septate uterus, 447 for adnexa, 4, 6
Serous borderline tumour, 243 advantages, 4, 7
Serous cystadenocarcinoma, 244–247 bladder filling, 4
Serous cystadenofibroma, 248–250 ovaries and adnexa, 4
Serous cystadenoma, 240–242 scanning techniques, 4–6
Serous epithelial tumours, 239–250 for uterus, 4, 5
Sertoli and Sertoli–Leydig cell tumours, 281 Transvaginal scan (TVS), 1
Sex cord–stromal tumours, 281–287 advantages, 9
fibromas and fibrothecoma, 283–287 ovaries and adnexa, 8–9
granulosa cell tumours, 281, 282 scanning techniques, 8, 10–11
Leydig cell tumours, 281 uterine version and flexion, 12, 13
Sertoli and Sertoli–Leydig cell tumours, 281 for uterus, 8, 10, 11
Shadowing. See Acoustic shadowing Troiano and McCarthy’s method, 442
Skene gland cysts, 189, 190, 192 ‘T-Shaped’ uterus, 454
Sliding sign, 9 Tubal ectopic pregnancy, 365–372
Solid mass/tissue, 203, 206 Tubal malignancy, 346–348
vs. cystic masses, 41 Tubo-ovarian abscesses, 320, 330–334
decidualised endometriotic cyst, 236
endometriotic cyst, 233
hyperechoic area in cyst, 41 U
measurement, 204 Ultrasound
morphological classification, 215 transabdominal, 4–7
Solid ovarian neoplasm, 216 transvaginal, 8–11
Solid tumour, 209 Unicornuate uterus, 451–452
SonoAVC, 15 Unilocular cysts, 204, 208
Sonohysterography (SHG), 47–50 Unilocular solid ovarian neoplasm, 216
Spectral Doppler, 25, 27 Ureters involvement, DIE, 309–310
Squamous cell carcinoma, 177, 183, 184 Uterine bleeding, abnormal. See Abnormal uterine bleeding
Subendometrial fibrosis, 150–151 Uterine cavity, shape, 440, 443
Submucous fibroid, 23 Uterine perforation. See Perforation of uterus
polyp, 72 Uterine vascular abnormalities. See Arteriovenous (AV) malformations
sonohysterography, 47, 50 Uterosacral deep infiltrating endometriosis, 305–306
Subseptate uterus, 446 Uterus
Subserous pedunculated fibroid, 35–36, 44, 70 ear shaped/question mark, DIE, 311–312
Surface-rendered image, 14 ultrasound reporting, 37
Swiss cheese appearance version and flexion, 12, 13
endometrial hyperplasia, 121
in granulosa cell tumour, 281
V
Vagina, 187
T foreign body, 199
Tamoxifen, 121, 129 normal vagina, 187, 188
Thickened endometrium, differential diagnosis, 143–144 septate, 457
Thoracic endometriosis, 315–316 vaginal DIE, 199
Three-dimensional (3D) ultrasound Vaginal carcinoma/vaginal cancer, 194–198
advantage, 14 Vaginal cysts
Index 543

Bartholin gland cysts, 189, 191, 192 Volume acquisition, 14

Gartner duct cysts and Mullerian cysts, 189–191 Volume contrast imaging (VCI), 13, 17
Skene gland cysts, 189, 190, 192 Vulval carcinoma, 200
Vaginal deep infiltrating endometriosis, 300–302
Vaginal masses, 194–198
Vaginal septum W
longitudinal, 455 Weight loss
transverse, 455, 460 malignant epithelial tumours, 238
Van Wyk–Grumbach syndrome (VWGS), 514, 516 ovarian neoplasms, 293
Vascular morphology, 26, 30
Version, uterine, 12, 13
Vesicouterine fistula, 478–479
Virtual organ computer-aided analysis (VOCAL) software, Y
14, 15, 19, 20 Yolk sac tumours, 273–277