OB/GYN 1-50

How does a corpus luteal cyst appear sonographically? What hormonal secretion occurs from corpus luteal cysts?

A corpus luteal cyst occurs following ovulation of the dominant follicle. Their sonographic appearance is an ovarian mass with thick hyperechoic irregular walls and possible echogenic internal content. Corpus luteal cysts secrete progesterone (and small amounts of estrogen), and normally persist during pregnancy, usually resolving by 16 weeks.

What is the ALARA principle?

ALARA means As Low As Reasonably Achievable, which means keeping ultrasound exposure to a minimum.

What pelvic abnormalities occur from vestigial remnants of the Wollfian (mesonephric) ducts?

Abnormalities can result from failure of disappearance of structures that do no normally persist. The persistent structures are sometimes referred to as vestigial remnants. The most common example is the Gartner's duct cyst. This cyst occurs on the anteriolateral wall of the vagina, and arises from the caudal remenants of the mesonephric (Wolffian) duct. Parovarian (paraovarian) cysts arise from persistence of the cephaload portion of the Wolffian duct, and appear as a cystic mass adjacent to (but not connected to) the ovary.

What are the sonographic findings in adenomyosis?

Adenomyosis can be diffuse or focal, and most often affects posterior myometrium. It may appear as an enlarged uterus with normal contours, myometrial cysts, mottled inhomogenous myometrium, and/ or "venetian blind" type shadowing.

What is the difference between adenomyosis and endometriosis?

Adenomyosis is invasion of endometrial glands and stroma into myometrium, while endometriosis is the presence of functional endometrial tissue outside of the uterus

How does an ovarian fibroma appear sonographically?

An ovarian fibroma appears as a homogenously hypoechoic mass with posterior acoustic shadowing (highly attenuating mass). It is associated with ascites and pleural effusion.

Describe the sonographic findings in serous ovarian tumors.

Benign serous tumors are sharply marginated, anechoic, may be large but are usually unilocular with possible internal thin walled septations. Malignant serous tumors are usually multilocular with multiple papillary projections or septations. Echogenic material may be seen within the mass, and ascites may be present.

What are the symptoms of endometrial cancer?

Clinical signs include postmenopausal vaginal bleeding, hypermenorrhea or intermenstrual bleeding in patients still having periods, and pain as a result of uterine distension.

What is the significance of sonographically complex free fluid in the pelvic recesses?

Complex free fluid is related to either hemorrhage (blood) or infection (pus).

What sonographic findings may be encountered in a patient whose mother took DES?

Daughters of women who received DES (diethylstilbestrol) from late 1940s to early 1970s for TAB have an increased risk of having a T-shaped uterus with constricting bands in the uterus and intrauterine wall defects.

What might dilated tortuous veins near the uterus and/or adnexa indicate?

Dilated veins near the uterus or in the adnexa are a significant finding, and may be associated with pelvic congestion syndrome

Describe the sonographic findings in the ovarian phases of the menstrual cycle.

During the follicular phase (days 1-14), several developing follicles can be visualized. The dominant follicle will outgrow the other follicles, and may contain a cumulus oophorus (mural nodule) just prior to ovulation. The dominant (Graffian) follicle may reach maximum diameter of 15-30 mm. At ovulation, the dominant follicle will rapidly decrease in size, and free fluid may be seen in the posterior cul-de-sac. In the luteal phase, the corpus luteum will be visualized as a thick walled cystic structure with internal echoes. The rim of the corpus luteum is hypervascular with a low resistance flow pattern.

Which malignant germ cell tumors of the ovary may be seen in younger women?

Dysgerminomas and endodermal sinus tumors may appear as solid ovarian tumors in women under the age of 30. Dysgerminomas are homologous to testicular seminomas, and are radiosensitive. Patients with endodermal sinus tumors (also known as yolk sac tumors) may have elevated serum levels of alpho feto protein (AFP).

Describe endometrial hyperplasia, including causes, clinical signs, and sonographic findings.

Endometrial hyperplasia is proliferation of endometrial glandular tissue. About 25% of patients with atypical hyperplasia will progress to endometrial carcinoma. Causes include: unopposed estrogen HRT, anovulatory cycles, PCOD, obesity, and estrogen producing ovarian tumors. The clinical signs of endometrial hyperplasia are similar to those in patients with endometrial carcinoma (abnormal bleeding). Sonography should be performed at the beginning of the hormone cycle (immediately following menses). Sonographic findings include thickened endometrium with smooth borders and a more homogenous endometrial texture.

Endometrial polyps are localized overgrowths of endometrial tissue. How do they present clinically and sonographically?

Endometrial polyps are usually asymptomatic, but may be associated with infertility or abnormal uterine bleeding. Sonographic findings may include a non-specific thickened endometrium, which may be indistinguishable from endometrial hyperplasia. A polyp may also appear as a focal discrete echogenic mass in the endometrium, focal, possibly with a vascular stalk demonstrated with color Doppler. Saline infusion sonohysterography is ideal for demonstrating polyps.

Which organ in the reproductive system secretes estrogen and progesterone?

Estrogen and progesterone are secreted by the ovary. Estrogen is secreted by the developing follicles (and in lesser amounts by the corpus luteum). Progesterone is secreted by the corpus luteum.

Fibroids are the most common tumor of the female pelvis. What are other names for fibroids?

Fibroids are benign smooth muscle (myometrial) tumors which are also known as leiomyomas, myomas, and fibromyomas. Leiomyomas are usually located in the uterine corpus, and can also be found in the cervix and broad ligament.

What is the patient preparation for a transvaginal sonographic examination? Why is this prep important?

For a transvaginal examination, the patient should have an empty urinary bladder. The empty bladder places pelvic viscera closer to the transducer.

Name the uterine layers from outer (superficial) to inner (deep).

From outer to inner, the layers are perimetrium, myometrium, basal layer of endometrium, functional layer of endometrium (then the endometrial cavity).

What hormones are responsible for regulating the menstrual cycle? From where are they secreted?

Gonadotropic releasing hormone (GnRH) is secreted by the hypothalamus when serum estradiol levels fall below a given concentration. GnRH signals the anterior pituitary gland to secrete follicle stimulating hormone (FSH) and luteinizing hormone (LH) Follicle Stimulating hormone (FSH) stimulates the growth and development of ovarian follicles. Luteinizing hormone (LH) stimulates maturation of follicle and is responsible for graafian follicular rupture causing ovulation.

How can endometrial hyperplasia be differentiated from endometrial carcinoma?

Histologic evaluation of an endometrial sample (from endometrial biopsy or curettage) is required for a definitive diagnosis.

How do intrauterine contraceptive devices (IUDs) appear sonographically? How might sonography be used in patients with IUDs?

IUDs are hyperechoic and may cast an acoustic shadow. They should be positioned in the fundus or midportion of the uterine body. Sonography is used to confirm IUD position in the uterus or evaluate for myometrial perforation. The use of 3D sonography may be helpful in determining exact location of an IUD.

What are the typical sonographic findings in the uterus of a postmenopausal patient?

In a postmenopausal patient, the overall uterine size is decreased and the uterine and cervical contours and proportions are maintained. The myometrium may have calcified arcuate arteries. A small amount of fluid in the endometrial cavity (hydrometra) is considered normal in an asymptomatic patient; this is often caused by cervical stenosis. Decreased estrogen levels result in a thinner endometrial stripe. The normal endometrial thickness is less than 8 mm in asymptomatic patient, and 4-5 mm is considered the upper limits of normal for the endometrium, if there is a history of bleeding. Patients who are receiving sequential estrogen/progesterone replacement demonstrate endometrial cyclic changes.

Describe the appearance of the normal pediatric uterus.

In the normal newborn female, the cervix comprises 2/3 of total uterine size and the body is 1/3. The newborn endometrium is hyperechoic, due to maternal hormonal influence in utero. From 2-3 months of age until puberty the uterus is 2.5 to 3 cm total length, with the cervix 1/2 of total uterine size and the body 1/2. At puberty, the uterus gradually increases in length, to 5-7 cm and the body to cervix ratio becomes 3:1 (e.g. 2/3 body, 1/3 cervix). The endometrial echogenicity and thickness vary according to the phase of the menstrual cycle.

Hematocolpos in adolescence is generally secondary to what condition? How does this present clinically? What are the sonographic findings in hematocolpos?

In the pediatric patient, hydrocolpos or hydrometrocolpos is usually secondary to an imperforate hymen. Clinical symptoms include primary amenorrhea with lower abdominal pain and mass. Sonographic findings include hypoechoic distention of vagina and/or endometrial cavity with posterior acoustic enhancement.

Name the possible indications that may prompt sonographic imaging of the pediatric pelvis.

In the pediatric patient, indications for imaging include: - possible ovarian cyst or complications of ovarian cysts - assess ovaries when polycystic ovarian disease is suspected - possible ovarian neoplasms - congenital uterine anomalies -determination of the presence or absence of uterus and vagina in newborns with ambiguous genitalia - evaluation of uterus and ovaries in patients with precocious puberty - hematocolpos in patients with imperforate hymen

Describe the types of assisted reproductive technologies a fertility patient may undergo.

In vitro fertilization (IVF) consists of ovarian stimulation, needle aspiration of oocytes, incubation of oocytes with sperm, and catheter delivery of 2-4 embryos into the uterus. Zygote intrafallopian tube transfer (ZIFT) is placement of the embryo (or zygote) into the fallopian tube (rather than the uterus, as with IVF) Gamete intrafallopian tube transfer (GIFT) is when the sperm and ova are placed into the fallopian tube and to allow fertilization to occur in the fallopian tube. Intrauterine insemination (IUI) is placement of sperm preparation in to the uterine fundus.

How is the location of a fibroid named?

Leiomyomas are described by their location in relationship to the uterine wall: - submucous: beneath the endometrial cavity and most commonly produce symptoms - Intramural/interstitial: within the uterine wall - Subserous: beneath the perimetrium - Intraligamentous: between the layers of the broad ligament - Cervical: located in the cervix - Pedunculated: on a pedicle or stalk; only occurs with submucous and subserous; torsion may occur with pedunculated fibroids.

What is Meigs syndrome?

Meigs syndrome is the association of ascites and pleural effusion with a fibrous ovarian tumor (most commonly a fibroma), which disappears after excision of the tumor.

What clinical findings may be observed in patients with leiomyomas?

Myomas are often asymptomatic. When symptoms are present, they may include: menometorrhagia, frequent urination, enlarged uterus on pelvic exam, pain with degenerative changes, infertility or spontaneous abortions, and alteration in normal menstrual flow.

Nabothian cysts are commonly encountered sonographically. Where are nabothian cysts located? How do they appear sonographically?

Nabothian cysts are mucus retention cysts in the cervix due to obstructed and dilated endocervical glands. They appear as small, well circumscribed anechoic structures located within the cervical wall.

What is ovarian hyperstimulation syndrome? What are the sonographic findings in OHSS?

Ovarian hyperstimulation syndrome (OHSS) is a condition resulting from excessive stimulation of the ovaries in women taking fertility drugs. Sonographic findings include bilateral large simple cysts with an ovarian diameter >5 cm. The patient may also have ascites and pleural effusion.

When are pelvic ligaments visualized sonographically?

Pelvic ligaments are generally seen sonographically only in the presence of ascites.

What is polycystic ovarian syndrome? What are the clinical findings? How does PCOS appear sonographically?

Polycystic ovarian syndrome (PCOS) or Stein- Leventhal syndrome is an endocrinologic disorder associated with chronic anovulation. Diagnosis of PCOS is actually made based on clinical and serologic finding. Clinical signs include infertility, obesity, amenorrhea, and hirsuitism. Sonographic findings of PCOS include enlarged or normal size ovaries with multiple small (<1 cm) cysts in the periphery ("string of pearls"). There are more than 12 cysts per ovary and the findings are always bilateral.

What is precocious puberty?

Precocious puberty is the onset of secondary sexual characteristics before the age of 8. True precocious puberty results from an early but precocious puberty may be secondary to hypothalamic disease, idiopathic (> 80% of cases) or secondary to congenital adrenal hyperplasia. Precocious pseudopuberty is caused by an abnormal exposure to estrogen, often due to an estrogen secreting ovarian tumor.

What condition may occur in patients who have mucinous ovarian tumors?

Pseudomyxoma peritonei: penetration of the tumor capsule or rupture may spread mucin-secreting cells into the peritoneal cavity, filling it with a gelatinous material known as pseudomyxoma peritionei. It has a sonographic appearance similar to ascites, possibly with multiple septations.

Endometrial carcinoma is the most common GYN malignancy. What are the risk factors for development of endometrial cancer?

Risk factors include obesity and anovulatory cycles in premenopausal women, postmenopausal patients on estrogen replacement therapy, history of atypical hyperplasia of endometrium, history of tamoxifen use, or family history.

List possible indications for the performance of saline infusion sonohysterography (SIS)

Saline infusion sonohysterography (SIS), also called hysterosonography, is a technique of introducing saline into the endometrial cavity to evaluate endometrium sonographically. Indications for SIS include: - infertility and habitual abortion - congenital anomalies and/or anatomic variants of the uterine cavity - pre- and post-operative evaluation of the uterine cavity - suspected uterine cavity synechiae (i.e. scarring associated with Asherman's syndrome) - further evaluation of abnormalities detected sonographically Preliminary transvaginal imaging is performed prior to SIS, to evaluate the uterus, endometrium, ovaries, and adnexa. The external os is cleansed and the catheter is placed into the cervix. Sterile saline is infused during transvaginal sonography.

Describe the possible sonographic appearances of leiomyomas.

Sonographic appearance depends on amount of degeneration, as well as the size and location of the fibroid. Most common sonographic findings include: - Well circumscribed hypoechoic mass - Lobulated uterine contour - Shadowing (with increased attenuation and calcification) - Whorled internal architecture - Displacement of endometrial echoes - Extrinsic compression of posterior bladder wall - Hypoechoic adnexal mass (pedunculated)

Benign cystic teratomas are the most commonly encountered germ cell tumors of the ovary. Name 7 possible sonographic appearances of ovarian teratomas.

Sonographic appearance of a teratoma depends on composition and arrangement of contents, and includes: - predominately cystic adnexal mass - complex mass with calcifications - fat-fluid level (can be demonstrated by a change in patient position) - diffusely echogenic - "tip of the iceberg" - highly echogenic mass that shadows and obscures the posterior wall of the lesion - "dermoid plug" - predominately cystic mass with an echogenic mural nodule, typically casting an acoustic shadow - "dermoid mesh" - multiple echogenic linear interfaces floating within a cystic mass (hair fibers.)

Describe the sonographic findings in mucinous tumors.

Sonographic findings benign mucinous tumors include a multiloculated mass with thick and more numerous septations. Fine, gravity- dependent echoes are generally seen. Sonographic findings in malignant mucinous tumors include multiloculated cystic lesions with echogenic material and papillary excrescences.

How does a follicular cyst appear sonographically?

Sonographic findings include an anechoic, unilocular thin walled cystic structure exceeding 3 cm in diameter. (The maximum measurement of a normal dominant follicle is 3 cm).

What are the sonographic findings in ovarian torsion?

Sonographic findings include enlarged ovary, often with multiple follicles, possible absent color and spectral Doppler flow (varies depending on degree and chronicity of torsion), possible arterial Doppler flow but absent venous flow and possible adnexal mass.

What are the sonographic findings in endometrial cancer?

Sonographic findings include inhomogeneity and thickening of endometrial echoes (>4-5 mm) especially in postmenopausal women (varies with patient's hormone status). There may also be possible alteration in sonographic texture of uterine parenchyma and possible fluid in endometrial cavity.

What is tamoxifen? What effects might it have on the uterus?

Tamoxifen is a nonsteroidal antiestrogen used as a chemotherapeutic agent in patients with certain types of breast cancer. In some patients, it may cause changes in the endometrium, and increase their risk for endometrial carcinoma. Sonographic findings in patients receiving tamoxifen may include subendometrial cysts at the endometrial-myometrial junction, endometrial hyperplasia, or endometrial carcinoma.

How can an obstetric sonographer adhere to the ALARA principle?

The ALARA principle can be followed by scanning when medically indicated, keeping the output power at a minimum scanning time while obtaining high quality diagnostic images.

How does a sonographer determine when the bladder is full enough for a transabdominal sonographic examination?

The bladder is adequately full for transabdominal pelvic sonography when the dome of the bladder extends above the uterine fundus. The full bladder displaces bowel out of the lesser pelvis and may act as a point of reference.

Name the bones of the pelvic skeleton

The bones of the pelvis are the sacrum (posterior), coccyx (posterior), and paired os coxae, also known as innominate bones (anterior, inferior, and lateral). Each os coxae is compromised of the ilium, ischium, and pubic bones.

Describe the sonographic findings in the endometrium in the uterine phases of the menstrual cycle.

The endometrium may be thickened at the beginning of menses, and will be thinned with a maximum diameter of 2mm at the end of menses. The early proliferative phase endometrium will be hypoechoic. The later proliferative endometrium will be tri-layered in appearance. The diameter of the endometrium in the proliferative phase is 4-8 mm. The secretory endometrium is homogenously hyperechoic with and measures 8-16 mm in thickness.

How should the endometrium be measured sonographically?

The endometrium should be measured in the anteroposterior (AP) dimension on a sagittal image

Which portion of the fallopian tube is most closely related to ovary?

The fimbriae are most closely related to the ovary. They help to maintain close proximity between ovary and the fallopian tube.

Describe the parts of the uterus.

The fundus (or dome) is the upper extended portion of the uterus between the fallopian tubes. The body (or corpus) is the main portion of the uterus. The isthmus is the area between body and cervix, and is referred to as the lower uterine segment during pregnancy. The cervix is the cylindrical projection into the vagina. The cervix has two openings: the internal os (opening from the cervix into uterus) and external os (opening from cervix into the vagina).

What other system may have abnormalities in the presence of a bicornate uterus?

The genitourinary system (kidneys) may be affected by unilateral renal agenesis, ectopia, or duplication. Sonographers should evaluate the urinary tract in all cases of uterine abnormalities.

What is the name given to the gutters at the superior aspect of the vagina?

The gutters at the superior aspect of the vagina, surrounding the cervix, are the vaginal fornices. These consist of the anterior fornix, posterior fornix, and two lateral fornices.

The pelvic organs are held in place by several ligaments. Name the major suspensory ligaments of the uterus and ovaries.

The major suspensory ligaments of the uterus include the cardinal (lateral cervical), broad, sacrouterine, and round ligaments. The ovarian position is maintained by the ovarian ligament, which attaches the inferior ovary to the uterine cornu; the mesovarium, which attaches the ovary to the posterior layer of the broad ligament on each side, and the infundibulopelvic (suspensory) ligament, which attaches the lateral ovary to posterolateral pelvic wall and transmits the ovarian vessels and nerves.

The uterus, fallopian tubes, and upper vagina develop from the Mullerian (paramesonephric) ducts. What sonographic findings may be present in Mullerian duct abnormalities?

The most common Mullerian anomaly is a bicornuate uterus in which there is a single vagina, one or two cervices, and two uterine horns. Uterus didelphys is the complete duplication of uterus, cervix, and vagina. A septate uterine anomaly has a single vagina, cervix, and uterus with an intrauterine septum. The least severe Mullerian anomaly is a septum slightly protruding into the uterine cavity, creating an arcuate uterus. The use of 3D sonography can be helpful in evaluation and differentiation of congenital uterine anomalies. MRI may be a useful adjunct imaging method in complex cases.

Discuss possible causes of postmenopausal vaginal bleeding.

The most common cause of postmenopausal bleeding is a hormone regimen (HRT) that causes bleeding. The most common cause in a patient not receiving HRT is atrophic endometrium. Other causes include endometrial cancer, cervical cancer, and an estrogen producing tumor of the ovary.

What is the most common uterine position?

The most common uterine position is anteverted (and anteflexed).

What are normal ovarian volumes sonographically?

The normal ovary in a premenopausal patient measures 3.5 x 2.0 x 1.5 cm with a maximum volume of 9.8 cubic cm. The normal ovary in a postmenopausal patient measures 2.0 x 1.0 x 0.5 cm with a maximum volume of 5.8 cubic cm.

Describe the layers of the uterus

The outer serosal layer of the uterus is the perimetrium. The middle muscular layer is the myometrium. The inner mucous layer is the endometrium. The endometrium has two layers: the deeper permanent basal layer and the functional layer, which is in contact with the endometrial cavity.

Describe the structure of the ovaries.

The ovaries are composed of an outer parenchyma (cortex) where developing follicles are visualized sonographically, and an inner homogenous medulla

Ovarian cysts may undergo hemorrhage. What clinical symptoms are associated with a hemorrhagic cyst? Describe the sonographic findings that may be encountered in a hemorrhagic cyst.

The patient may experience an acute onset of pelvic pain. Sonographic findings depend on the age of hemorrhage and include: - typical cystic characteristic - acute hemorrhage = hyperechoic, mimicking a solid mass but with posterior acoustic enhancement - subacute hemorrhagic cyst = complex appearance with internal echoes, strands, rarely a fluid-fluid level - appearance will vary with time as clot lyses

Descrive the division of the pelvic cavity

The pelvis is divided by an imaginary line from the sacral promontory to symphysis pubis. The area above this line is the false or greater pelvis. The area below this line is the true or lesser pelvis.

Name the parts of the fallopian tube from proximal to distal

The portions of the fallopian tube include interstitial/intramural portion (located within the uterine wall), isthmus (medial portion closest to the uterus), ampulla (longest portion), and the fimbriae (the finger-like projections which maintain a close relationship between the tube and ovary)

Which vaginal fornix is most likely to contain fluid collections?

The posterior fornix is the largest and most likely to contain gravity dependent fluid collections when the patient is supine.

Name the muscles that are sonographically visible when examining the female pelvis

The rectus abdominus muscle is located anteriorly and may be responsible for the refraction/ "ghosting" artifact occasionally seen while imaging the midline pelvis in a transverse plane. The psoas major muscle originates in the posterior abdomen and courses laterally and anteriorly through the abdomen, joining with the iliacus muscle to form the iliopsoas muscle. The obturator internus muscle is visualized sonographically in the true pelvis. The piriformis and coccygeus muscles are not routinely visualized due to the deep location. The levator ani muscle is part of the pelvic diaphragm which functions to resist increased intra-abdominal pressure and to resist gravity. The levator ani muscle is readily seen sonographically along the pelvic floor at the level of the vagina and rectum.

Name and describe the peritoneal recesses in the pelvis. Give other names for these spaces. Why are these spaces important?

The space of Retzius, also called the retropubic or prevesical space, is located between the pubic bone and the anterior urinary bladder wall. The vesicouterine space or anterior cul-de-sac is located anterior to the uterus and posterior to the urinary bladder. This space is usually empty but may contain loops of bowel. The rectouterine space is also called the posterior cul-de-sac or pouch of Douglas. It is located posterior to the uterine cervix and anterior to the rectum. This is the most dependent recess in the body, and therefore the most common site for free peritoneal fluid to collect.

Describe the spectral Doppler patterns associated with the uterus and ovaries.

The uterine arteries exhibit moderate to high velocity/high resistance flow. The uterine and radial arteries exhibit flow which is higher resistance in the proliferative phase than in the secretory phase. Flow in the ovary during the follicular phase is often low velocity and high resistance. Following ovulation, the impedance drops dramatically on the side with the dominant follicle, resulting in low resistance flow. The ovaries display high resistance flow in postmenopausal women.

Describe the venous drainage of the uterus and ovaries.

The venous anatomy of the pelvis parallels the arterial anatomy. The uterine veins drain into the internal iliac veins. The right ovarian (gonadal) vein empties into the inferior vena cava, while the left gonadal vein empties into the left renal vein.

What are the theca lutein cysts? What serum finding is associated with theca lutein cysts? How do they appear sonographically?

Theca lutein cysts are the largest of functional cysts, associated with high levels of hCG in gestational trophoblastic disease or hCG administration during infertility treatment. Sonographic findings in theca lutein cysts include bilateral large multilocular ovarian cysts.

Hormone secreting ovarian tumors can cause symptoms related to hormonal activity. What hormones are secreted by the following ovarian tumors? - Thecoma -Granulosa cell tumor - Androblastoma

Thecomas are estrogen producing tumors. Granulosa cell tumors produce estrogen. Androblastomas (also known as arrhenoblastomas or Sertoli-leydig cell tumors) secrete testosterone.

What should the sonographer evaluate in a postmenopausal patient who is bleeding?

Thorough transvaginal evaluation of the endometrium with AP measurement in the sagittal plane should be performed, as well as evaluation of the myometrial echotexture.

What is ovarian torsion? What factors may predispose a patient to ovarian torsion?

Torsion of the ovary is caused by rotation of the ovarian pedicle on its axis. Lymphatic and venous drainage is compromised, causing congestion and edema of the ovary, eventually leading to loss of arterial perfusion and resultant infarction. Risk factors for ovarian torsion include pre-existing ovarian cyst or mass (usually benign), children and young females with mobile adnexa and pregnancy.

Physiologic cysts are the most common cause of ovarian enlargement in young women. Name three types of physiologic cysts.

Types of physiologic or functional cysts include follicular cysts, corupus luteal cysts, and theca lutein cysts. Follicular and corpus luteal cysts result from the menstrual cycle. Theca lutein cysts occur in patients with elevated levels of hCG. Follicular cysts are caused by overstimulation of a follicle that fails to rupture or involute.

Describe the arterial supply to the uterus and ovaries.

Uterine blood supply is provided by the uterine arteries, which are branches of the internal iliac (hypogastric) artery. The uterine artery gives off branches to feed the uterus, which from superficial to deep are the arcuate, radial, and spiral arteries. The spiral arteries are most closely related to the endometrium. Arterial blood supply to the ovaries is primarily via the ovarian arteries (gonadal arteries),branches of the abdominal aorta.

Discuss the terms used to describe variations in uterine position.

Uterine position is highly variable. Anteversion is forward placement of the uterus at the cervix (forming a 90 degree angle with the vagina). Retroversion is tilting backward of the uterus at the cervix. Anteflexion is bending forward of the uterus at the body, and retroflexion is bending backward of the uterus at the body.

How should the endometrium be measured when there is fluid in the endometrial cavity?

When fluid is present in the endometrial cavity, measurements should be taken of each side of the endometrium and added together (not including fluid in the measurement.)