Gynaecological imaging with mainly emphasis on ultrasound scan finding

1. Imaging in Gyanecology
Dr Indunil Piyadigama

2. Ultrasound
scan
• The quality of an image ultimately depends
on the degree of resolution
• In general, the closer the transducer tip is to
the imaging target, the greater the
resolution
• 3.5MHz in abdominal, 5-7.5MHz in vaginal
• Higher the frequency
• better resolution
• Lower penetration

3. SIS
• If further evaluation needed – SIS/ hysteroscopy
• SIS for endometrial pathology
• Ideally should be in follicular phase after menstruation, but before
ovulation
• Sensitivity 96-100%
• Negative predictive value 94-100%
• Similar diagnostic accuracy to office hysteroscopy. But less painful

4. CT
• Uses ionisation radiation

5. MRI
• Uses magnetism, radio waves and a computer to produce an image
• Hydrogen molecules partially aligned by a strong magnetic field
• These nuclei can be rotated using radiowaves and subsequently
oscilate in the magnetic field while returning to equilibrium
• Simultaneously they emit radio signals
• These signals are meausered after a certain time which is detected
using antennas
• T1 – longitudinal relaxation time (coming back to external field)
• T2 – Transverse relaxation time (loosing coherence with each other)

6. NORMAL RADIOLOGICAL
ANATOMY
• UTERUS
• It is pear shaped structure
• varies in size
• Before puberty cervix large and body of
uterus small.
• After puberty uterus size increases to 7 to
8 cm.
• After menopause involute to 5 to 6 cm

8. Endometrium
• Ideally should be scheduled between days 4 and 6 of the menstrual
cycle when the endometrium is thinnest.
• Normal thickness
• Follicular phase 4-8mm
• Luteal phase 8-14mm

9. Sagittal US image of the uterus obtained during
the late proliferative phase of the menstrual cycle
demonstrates the endometrium with a multilayered
appearance

10. Sagittal US image of the uterus obtained during
the secretory phase of the menstrual cycle shows
a thickened, echogenic endometrium

11. • ENDOMETRIUM IS CONSIDERED
ABMORMAL IF IT MEASURES MORE
THAN 1.4cm IN PREMENOPAUAL
AND MORE THAN 4mm IN POST
MENOPAUSAL.

12. • On USG endometrium is of high
echogenecity .
• At the start of follicular phase of menstrual cycle
it is thin echogenic line.
• From day 8 to 10 of menstrual cycle
endometrium thickens and become five layered
at midcycle.
• In the luteal phase endometrium loses its five
layered appearance and becomes progressively
more echogenic with normal thickness of 1.2 to
1.4cm.

13. T2-weighted MR image shows the normal
endometrium (straight arrow) and junctional
zone (curved arrow).

14. Ovary

15. • IN MENSTRUATING WOMEN its
VOLUME SHOULD BE NORMALLY
LESS THAN 7.5ml
• AND IN POSTMENOPAUSLA WOMEN
NOT MORE THAN 3ml.

16. OVULATORY CYCLE
• At start of FOLLICULAR PHASE few
number of follicles start to develop
• From day 8 to 10 one follicle become
dominant nad continues to grow at a rate
of 2 to 3 mm/day.
• About midcycle it measures 18 to 25mm.
• after ovulation corpus luteum can be seen
seen as irregular cystcontaining internal
echoes due to blood or a hypoechoic
area.

17. Endometrial
CA
• USS – Is an accurate
method of excluding
endometrial CA
• Endometrium – Thickness,
regularity, fluid within the
cavity
• Many use 4mm based on
cost effectiveness
TVS for
endometrial
cancer
Sensitivity Specificity PPV NPV
Postmenopausal at 4
mm cut off without
HRT
90% 48% 9% 99%

18. • To identify lung mets – C x-ray, CT
• Upper abdominal – CT
• Depth of myometrial invasion and spread to cervical stroma – MRI

19. Polyp
• Incidence
• Postmenopausal -11.8%
• Premenopausal – 5.8%
• More prevalence of oestrogen receptors in the polyp compared to the
surrounding endometrium may be the cause

20. • TVUS
• Hyperechoic lesion with regular contours
• surrounded by thin hyperechoic halo
• Cystic spaces may be seen
• Finding a single feeding vessel increases the sensitivity to 95% and NPV
94%

21. • Endometrial polyp in
33-year-old woman.
• B, Color Doppler
image shows single
feeding vessel at
base of polyp (arrow).

22. • Saline contrast hystero sonography – failure rate 10%
• Useful to confirm the presence and location
• Focal endometrial CA (difficult distension also raise suspicion)

23. Abnormalities of the uterine body

24. Fibroids
• Imaging to confirm the presence, location, characteristics
and size of the fibroid. (Uterine mapping)
TVS
• Mixed echogenic, well demarcated masses
• Sensitivity 65 - 99% (This is due to operator variations)
• Subserosal and small fibroids may not be detected
• (Combine with abdominal USS if uterus is > 12 weeks)
SIS
Improve diagnostic accuracy of submucosal fibroids

25. MRI for fibroids
No advantage over USS in detection
Can distinguish adenomyosis and leiomyosarcoma better.
More exact capacity for leiomyoma mapping. Especially in large uterus and more than 4 mayomas.
Detecting pedunculated and degenerated fibroids
Benign histologic subtypes such as cellular, degenerated, necrotizing, infracting, lipoleiomyomas can
be identified.
To assess suitability for uterine artery embolization

26. • sagittal oblique endovaginal US
scan shows that the myometrium
is thickened ventrally and has a
heterogeneous echotexture
(straight arrows). The echogenic
of the ventral myometrium is
decreased relative to that of the
dorsal myometrium. Additional
features of adenomyosis seen in
this image include poor definition
of the endomyometrial junction
and a myometrial cyst (curved
arrow).

27. Adenomyosis
• diffuse heterogeneous myometrial echogenicity/ focal abnormal myometrial
echotexture/indistinct borders
• anechoic lacunae and/or cysts
• Striations
• indistinct endomyometrial junction
• Subendometrial nodules
• globular and/or asymmetric uterus unrelated to leiomyoma
•
• Comparable accuracy between MRI and USS
• USS lacks specificity in particular distinguishing between adenomyosis and fibroids. In such cases
MRI is of value. Both techniques lacks the accuracy to evaluate large uteruses.

28. Ovaries
Due to increased resolution is recommended to be used
10% of adnexal masses ultimately non ovarian
Can differentiate benign and malignant when using
morphological index with Sensitivity 89%, specificity –
73%
No single finding differentiate between benign or
malignant
3D power Doppler helps differentiating because it is
able to identify increase blood flow in papillary
projections and solid areas

29. Polycystic ovaries
• USS appearance of polycystic ovary on either side – (either one of)
• Presence of 12 or more antral follicles measuring 2-9mm (new 25
number)
• Increased ovarian volume > 10ml

30. Features of a simple cyst Complex cyst
Round or oval
Thin or imperceptible wall
Posterior acoustic
enhancement
Anechoic fluid
Absence of septation or
nodules
Complete septations – multilocular
Solid nodules
Papillary projections

31. • 3.5-cm simple ovarian
cyst (calipers).
Normal-appearing
ovarian tissue
(arrows) with a few
follicles around the
periphery confirms
the ovarian origin of
the cyst.

32. Simple cyst - Premenopausal
100% resolve in 3 months - Physiological
If persist unlikely to be physiological
Tumour
markers/

33. Simple cyst - postmenopausal
5
Reassess in 4-6 m, CA125
 Disappear in >50% in 3m
 Risk of malignancy < 1%
5
Needs surgery

34. • corpus luteum within
the ovary. It has a
slightly thick,
crenulated wall
(arrows) and a small
cystic center
• corpus luteum within
the ovary. It has a
slightly thick,
crenulated wall
(arrows) and a small
cystic center

35. HEMORRHAGIC CYST
• a retracting clot
(asterisk) with
concave margins
along the wall of a
hemorrhagic cyst
HEMORRHAGIC CYST
• a retracting clot
(asterisk) with
concave margins
along the wall of a
hemorrhagic cyst

36. Haemorragic cyst
• If haemorrhage difficult to differentiate from abscess or
endometrioma
• Colour Doppler helpful in torsion

37. • hemorrhagic cyst
complex ovarian cyst
with a seemingly solid
area due to a clot (C).
This could be
mistaken for the solid
area of a neoplasm.
No flow was evident

38. • hemorrhagic cyst
complex ovarian cyst
with internal echoes.
There is a reticular or
fishnet pattern to the
internal echoes due to
fibrin strands
(arrows). Note how
the fibrin strands are
thin

39. TORSION OF CYST
• Twisted vascular
pedicle showing the
circular string-of-
beads appearance of
dilated veins (arrows).
BL-indicates urinary
bladder; and CYST,
ovarian cyst.

40. • endometrioma
complex ovarian cyst
(between arrows) with
homogeneous
internal echoes.

41. Endometrioma
- USS
Can enlarge upto 6-8cm
Often bilateral
1-4 compartments, Thick walled, homogenous cyst with low level
echogenicity (ground glass appearance).
No papillary structures with detectable blood flow
There may be fluid levels, calcifications and septations
Scant vascularization of cyst wall
Application of pressure causes tenderness
If bilateral appear as kissing ovaries

42. • Accurate for deep recto-sigmoid endometriosis
• Thickened uterosacral can be seen as stellate hypoechoic nodules
located near the uterine cervix
• Endometriotic bladder nodules
• Haematosalpinx, identified as low-level echoes in a dilated fallopian
tube
• Isolated endometriosis in abdominal wall scars can be detected using
transabdominal ultrasound

43. Dermoid
• Cystic with solid on USS
• 80% occurs in reproductive age
• 10% are bilateral
• 15% risk of torsion
• 2% risk of malignant transformation

44. Cresentric sign

45. • Mature cystic
teratomacomplex
ovarian cyst (long
arrows) with low-level
internal echoes and a
markedly hyperechoic
solid-appearing area
(with faint distal
acoustic shadowing
(S).

46. Ovarian
tumours –
RMI 1

47. RMI 1
• Utility negatively affected in premenopausal
• But most effective for women with suspected ovarian cancer
• In detection of ovarian cancer
• 200 – sensitivity 78%, specificity 87%, PPV – 75%
• 250 – Sensitivity 70%, specificity – 90%
• Above 200 needs (Some go for 250)
• onco referral and CT – to identify the extent of disease and to exclude
alternative diagnosis

48. IOTA
• Comparable sensitivity and
specificity to RMI 1 in post
menopause
• Advantages in premenopausal
since CA125 not included
• Sensitivity 95%, specificity 91%
• High positive and negative
likelihood
B features M features
Unilocular cyst Irregular solid tumour
Smooth multilocular
tumour < 10 cm
Irregular multilocular mass
with largest diameter >
10cm
Solid componenet <
7mm
>4 papillary projections
Acoustic shadows Ascites
No detectable blood
flow on doppler
Increased vascularity

49. Incomplete septea or papillae
less 3mm included as unilocular
cysts
Any with M should be referred
to gynae-onco
For triaging IOTA LR2 has been
suggested as an alternative for
RMI. But still under research

50. EPITHELIAL OVARIAN TUMORS
• serous
cystadenocarcinoma
complex ovarian cyst
(calipers) with several
thick septa (arrows)
and solid areas.

52. Other
imaging in
ovarian
malignancy
USS
• Liver mets, hydronephrosis
Chest x ray
CT
• Upper abdomen + pelvis + base of the lungs
• is the modality of choice in staging ovarian
cancer
• Determining malignancy is slightly better than
USS (sensitivity 89%, specificity 96%)
• Valuable in assessing retroperitoneal spaces
and omentum

53. MRI pelvis in tumours
Surgical planning of patients with a fixed pelvic mass
Particularly useful in differentiating between ovarian
and uterine origin
Endometriomas and Dermoids can be differentiated
Combined with LDH can differentiate leimyosarcomas
from fibroids

54. • Benign mucinous
cystadenoma in a 26-
year-old woman.
Contrast-enhanced
CT scan shows a
large, multilocular
cystic mass (arrows)
with a smooth
contour, honeycomb
appearance, and
heterogeneous
attenuation in the
locules.

55. Serous and
mucinous
cystadenomas
7% are malignant before
40years
Mucinous bilateral in
10%
Can occupy the entire
abdominal cavity

56. Tubal pathologies

57. Endovaginal ultrasound scan. This image shows
anechoic tubular structures in the adnexa; the
finding is compatible with a hydrosalpinx.

58. hydrosalpinx tubular-shaped cystic mass
with a septum. Small nodules (arrows) in the
mass are due to thickened endosalpingeal
folds

59. Power Doppler sonogram. This image shows increased
flow to the wall of a tubo-ovarian abscess. The inner
hypoechoic regions are due to the presence of purulent
material

60. Tubal ectopic
• TVS is the tool of choice – Sensitivity, specificity > 95%
• Should be positively identified with an adnexal mass that moves
separately to the ovary
• In homogenous/ non cystic mass (blob sign)
• GS
• Yolk sac + Fetal pole +/- heart

62. • Bagel sign and ring of fire
• Echogenic free fluid
• 20% pseudosac - collection of fluid inside the endometrial cavity
• Thin endometrial stripe has been demonstrated in ectopic. But no
value
• Trilaminar endometrium is specific to ectopic
• TV colour Doppler does not increase the detection rates

63. Hyperechoic ring around
gestational sac in adnexal region
b) Color Doppler Sonography(TV-CDS):
- Improve the accuracy.
- Identify the placental shape
(ring-of-fire pattern) and blood flow
outside the uterine cavity.
c) Transabdominal Sonography:
- can identify gestational sac at 5-6 wks
- S-β hCG level at which intrauterine gestational
sac is seen by TAS is 1800 IU/L.

65. Suggestive
of IUP
Intradecidual sign - fluid collection with an
echogenic rim located within a markedly
thickened decidua on one side of the uterine
cavity.
Double decidual sign - intrauterine fluid
collection surrounded by two concentric
echogenic rings
Intrauterine smooth walled anechoic cyst
99.98% IUP

66. MRI
• 96% accurate in diagnosing ectopic
• More sensitive to detect fresh haematoma

67. Specific other ectopics
Cervical ectopic  Barrel cervix.
 Sac below the internal os.
 No sliding sign.
 Increase vascularity surrounding
Caesarean scar
pregnancy
 Sac anteriorly at the level of the internal os.
 Thin or absent myometrium between gestational sac and bladder.
MRI – second line
Interstitial pregnancy  empty uterine cavity
 products of conception located laterally in the interstitial part of the
tube and surrounded by less than 5 mm of myometrium in all
imaging planes
 presence of the ‘interstitial line sign - line extending from the central
uterine cavity echo to the periphery of the interstitial sac
3D will help further to differentiate angular and early IUPs. A line
connecting interstitial part and the endometrial cavity is seen.
MRI supplements
Cornual - in one
lateral half of a uterus
of bifid tendency
 visualization of a single interstitial portion of fallopian tube in the
main uterine body
 products of conception seen mobile and separate from the uterus
and completely surrounded by myometrium
 a vascular pedicle adjoining the gestational sac to the unicornuate
uterus

68. Test Ut
cavity
Tubal
pate
Periton
cavity
Advantages Disadvantages
HSG +++ +++ +  65% sensitive for tubal
block
 Primary screening in
low risk
 Detect development
abnormalities
 Cannot assess the
size and depth of
uterine tumours
 Risk of infection
1%
SIS ++++ + -  For cases not
suggestive of tubal
pathology
 Size and depth of
uterine tumours
 Poor for severe
adhesions

69. Thank you