4. Fibroids & TV imaging

Which group of women has a higher risk of having uterine fibroids?

- females over the age of 30 (20-30%) - women of African decent

sonographic appearance of fibroids

- solid & well defined - hypoechoic or hyperechoic solid mass/es - homogeneous or heterogeneous, may be heterogeneous with no evidence of a focal mass - complex appearance - degenerating fibroid - calcification may be present - dense, fibrous tissue may cause acoustic attenuation, may need to scan with a lower frequency probe - peripheral vascularity

Which fibroids are more likely to contribute to infertility?

- submucosal - if the fibroid distorts the endometrium or fallopian tube it may result in infertility - fibroids near the uterine cornua may obstruct the fallopian tube and impair fertilization

What is the most typical sonographic appearance of an endometrial polyp?

- tend to be more *echogenic* than SM fibroids - diffuse or focal endometrial thickening - Doppler eval: connecting stalk

When would you adjust the sector field of view?

- the larger the sector field, the larger the areas displayed. EX: Open sector field when looking for ovaries - narrow the sector field to focus on specific structures. EX: Need more detail? Narrow the sector field

What should you keep in mind about lubricant used for TV imaging when scanning an infertility patient?

- use water or saline to lubricate probe, gel has a negative effect on sperm mobility - use sterile lubricant, commercial scanning gel may be embryocidal

What are the contraindications for performing a TV exam?

- *virgin* - *patient refuses exam* - *inability to insert probe*, intact hymen or narrow vaginal canal & elderly patients with a narrow introitus (vaginal opening) or atrophic vaginitis who experience pain or discomfort during probe insertion - *lack of patient tolerance* (pain or psychological) - *unconscious patient* (patient must consent to the exam) - *mentally insane* - w/o healthcare proxy or administrative consent)

What may occur if the placenta implants over a fibroid?

IUGR

menorrhagia

unusually heavy or long menstrual periods. may soak through one or more sanitary pads or tampons an hour for several consecutive hours, or have periods that last longer than seven days (or longer than a usual menstrual period). may be a cause for concern because heavy bleeding can lead to an iron deficiency, and ultimately result in anemia.

Is the blood supply to a degenerating fibroid increased or decreased?

will not demonstrate vascularity

hysterosalpingogram (HSG)

x-ray exam performed to determine patency of the fallopian tubes

When is the vagina seen on TV images?

translabial

What is another name for translabial imaging?

transperineal exam

Which method is more accurate for measuring overall uterine size with a large fibroid uterus, TA or TV?

TA

Will TA or TV give you more detailed images of structures close to the probe?

TV

menometrorrhagia

a condition in which prolonged or excessive uterine bleeding occurs irregularly and more frequently than normal. It is thus a combination of metrorrhagia and menorrhagia

What causes cystic degeneration of a fibroid?

a fibroid outgrows its blood supply and becomes ischemic

The lithotomy position allows for free movement of the probe in which plane?

allows for free movement of the probe in the *horizontal* plane

In the SAG view of the following, on which side of the screen are the cervix & fundus located? SAG anteverted SAG retroflexed

anteverted - fundus, left. cx, right. retroflexed - fundus, right. cx, left

Why do you obtain verbal consent from the patient prior to performing a TV exam?

b/c the exam is invasive

describe the location of intramural (IM) fibroids

confined to the myometrium

In TV imaging, the scan plane which is 90 degrees from the SAG plane is termed what?

coronal

When imaging the SAG retroflexed UT, which direction do you angle to see CX? fundus?

cx - anterior/up fundus - posterior/down

When imaging the SAG anteverted UT, which direction do you angle to see CX? fundus?

cx - posterior/down fundus - anterior/up

supravaginal hysterectomy, TA

cx not removed, TA

supravaginal hysterectomy, TV

cx not removed, TV image

What location of fibroids could cause complications during delivery?

cx/LUS

describe the location of pedunculated (ped) fibroids

develops a stalk

What is a D&C?

dilation of the cervix and surgical removal of part of the lining of the uterus and/or contents of the uterus by scraping and scooping

describe the location of submucosal (SM) fibroids

distorts or displaces the endometrial cavity

Which treatment for fibroids will cut off the blood supply & cause the fibroids to shrink?

embolization; Candidates: - premenopausal women - no longer wants to have children & wants to avoid hysterectomy - patients who do not want to receive blood transfusion - patients who cannot receive general anesthesia

An increase in what hormone may cause an increase in fibroid size during pregnancy?

estrogen

What hormone is associated with fibroid growth?

estrogen

SM fibroid

extends from myometrium

What is the *most common benign gynecological tumor*?

fibroid

describe the location of subserosal (SS) fibroids

fibroid abuts the serosal layer of the uterus

fibroid vs polyp

fibroid extends from the myometrium

What is the *most common cause of uterine calcifications*?

fibroids

What is the *most common cause of uterine enlargement, excluding pregnancy*?

fibroids

assessment of vascularity in fibroids is a predictor of

growth

degenerating fibroid

heterogenous

What are the frequency requirements of a transvaginal probe?

high frequency, 5-10 MHz

What method of fibroid removal would be appropriate for a SM fibroid or polyp?

hysteroscopy and D&C

When is translabial imaging performed?

if TV exam is contraindicated

What is the *most common site for a fibroid to occur*?

intramural

What additional area should be evaluated in the presence of a large pelvic mass? Should this be a complete, or limited exam?

kidneys, r/o hydronephrosis; limited exam

What phase of the menstrual cycle is a polyp more easily visualized?

late proliferative phase of the menstrual cycle

What type of condom is not acceptable for use as a TV probe cover?

latex b/c allergy concerns

To determine if the TV probe is properly oriented in the SAG position, which side of the screen will the bladder appear in?

left

pitfalls of doppler evaluation of fibroids

may exhibit low resistance/impedence flow, similar to tumor signals seen in ovarian cancer

metrorrhagia

menstrual bleeding that occurs at frequent, irregular intervals.

Which treatment will preserve the uterus for child bearing?

myoectomy

What does a negative beta hCG test indicate?

negative pregnancy

hysterosonography (SIS)

saline infused sonography performed to diagnose endometrial pathology via the insertion of saline to fill the endometrial cavity

What phase of the menstrual cycle is it difficult to visualize an endometrial polyp?

secretory

What type of fibroid is most likely to cause abnormal vaginal bleeding?

submucosal fibroids

What is the term for removal of the fallopian tube? Removal of the ovary? Removal of both?

- salpingectomy = removal of fallopian tube - oophorectoomy = removal of ovary - salpingoophorectomy = removal of both

What are the symptoms of fibroids?

- asymptomatic (small fibroids) - uterine irregularity and enlargement - pelvic pressure - pain (degenerating) - LBP - urinary frequency - constipation - menstrual irregularities

What are the treatment options for fibroids, and how are they performed?

- hysterectomy - myoectomy - hysteroscopic removal (SM) - uterine artery embolization

What is the patient prep for TV scanning?

- informed consent - PT undresses from the waist down - PT empties her bladder & removes tampon prior to probe insertion - cover PT with a sheet - PT in lithotomy position

sonographic appearance of a degenerating fibroid

- internal echoes appear complex or heterogeneous - may contain anechoic areas of necrosis (tissue death) and cystic degeneration (deterioration) - Doppler evaluation = vessels are not seen

What is a polyp?

- localized overgrowth of endometrial tissue covered by epithelium - most common in perimenopausal & postmenopausal women - most are asymptomatic but may cause vaginal bleeding

fibroids are also known as:

- myoma - leiomyoma - leiomyomata

What is the lithotomy position?

- patient lies in a supine position with the knees bent & feet flat on the table, feet approximately a shoulder width apart, and the hips slightly elevated

How may the following situations affect fibroid growth? 1. pregnancy 2. BCP (estrogen) 3. tamoxifen therapy 4. menopause 5. menopause on HRT

1. increase 2. increase 3. increase 4. decrease 5. increase

The penetration of TV imaging is limited to how may CM in depth?

8-10 cm

symptoms of a degenerating fibroid

pain & premature labor

What type of lubricant should not be used on latex probe covers?

petroleum jelly or oil based products may cause fractures in the cover

Why is it concerning for a fibroid to have rapid growth?

rapid fibroid growth, especially in PM women, should raise the question of malignancy (leiomyosarcoma)