OB: chap. 43-45: review questions (45not on test)

44 review question: What is the most common ovarian neoplasm?

A dermoid tumor is the mc ovarian neoplasm. A mucinous cystadenoma is the most common ovarian cystic tumor; when malignant, it is a cystadenocarcinoma.

45 review question: describe the sonographic findings for an endometrioma.

Endometriosis also occurs in a localized form, known as an endometrioma. Clinically, patients are asymptomatic. An endometrioma images as a well-defined predominantly cystic mass with transabdominal ultrasound. The mass presents with uniform internal echoes on the endovaginal examination. The most common presentation is of a "chocolate cyst" with low-intensity echoes and acoustic enhancement. Other appearances include an enlarged polycystic ovary with a thick wall and internal septations or a cyst with fluid-debris levels (because of different degrees of organization of the hemorrhage).

44 review question: Describe the clinical features of ovarian carcinoma.

Clinical symptoms include vague abdominal pain, swelling, indigestion, frequent urination, constipation, and weight change (ascites). Over 70% of the women first seen by their doctor are in the advanced stages of the disease.

44 review question: List four common solid ovarian masses.

Common solid masses: o Adenocarcinoma o Solid teratoma o Arrhenoblastoma o Fibroma o Dysgerminoma o Torsion

44 review question: Describe the development of corpus luteum cysts.

Corpus luteum cysts result from failure of absorption or excess bleeding into the corpus luteum. These cysts usually are less than 4 cm in diameter. They are prone to hemorrhage and rupture. Common in the first trimester, the corpus luteal cyst reaches its maximum size by 10 weeks, resolving no later than 16 weeks of gestation.

critical thinking 43: A 62-year-old woman had a pelvic ultrasound because of spotting. The endometrium measured 23 mm. What would you suspect?

Endometrial cancer or hyperplasia

43 review question: How are endometrial polyps best imaged?

Endometrial polyps usually are asymptomatic but may cause uterine bleeding. They typically cause diffuse or focal endometrial thickening. They appear as either cysts or dense masses in the endometrial cavity. Individual polyps are better visualized when outlined by intracavitary fluid.

44 critical thinking: A 43-year-old woman with perimenstrual symptoms shows a well-defined mass with homogeneous low-level echoes in the adnexal area. What does this most likely represent?

Endometrioma

critical thinking 43: The endovaginal sagittal image of the cervix showed multiple small cysts inferior to the endometrial cavity in the center of the cervix with increased through transmission. What do you suspect these to represent?

Nabothian cysts

44 review question: Name the most common types of epithelial tumors of the ovary.

Of the epithelial tumors, 70% are benign and 30% malignant. The two most common types are serous and mucinous tumors. Serous and mucinous tumors can be very large. They often fill the pelvis and extend into the abdomen. The benign or low-malignant-potential form is termed adenoma, and the malignant form is termed adenocarcinoma.

44 critical thinking: A 49-year-old woman presented with bloating and fullness in her pelvic area. The pelvic ultrasound showed ascites and a large solid mass on the left ovary. Which lesion does this most likely represent?

Ovarian carcinoma.

44 review question: Discuss the role of ultrasound in the infertility patient.

Ovarian scanning throughout the menstrual cycle helps monitor follicle development during spontaneous or induced ovulation. This aids in timing insemination and medication and in diagnosis of ovulatory malfunction. Endovaginal color Doppler information also helps with assessment of follicular development by demonstrating blood flow parameters. Endovaginal sonography can be used to detect luteal phase abnormalities by identifying a functioning corpus luteum (with high diastolic flow) and a secretory endometrium. Ultrasonography aids intrauterine transfer of the embryos to avoid trauma and to direct placement in the endometrial cavity. After 3 weeks, ultrasonography is used to detect a gestational sac. The technique of ovarian stimulation with medications is used in patients who fail to ovulate spontaneously. If in vitro fertilization is not planned, a less intensive hormone regimen is used with sonographic monitoring to avoid excessive or inadequate stimulation. Complications of ovulation induction include multiple gestation and ovarian hyperstimulation syndrome. Hyperstimulation syndrome can be diagnosed and followed sonographically.

44 critical thinking: A 21-year-old woman presented with extreme pain in the right ovary. The endovaginal examination showed a prominent ovary with decreased color flow. What does this most likely represent?

Ovarian torsion.

45 review question: What are the clinical findings for patients with PID?

PID is most always found as a bilateral collection of fluid and pus within the pelvic cavity. Clinically, patients may present with intense pelvic pain and history of infertility. A vaginal discharge may be present with abnormal bleeding. A large palpable mass usually is present.

44 critical thinking: An endovaginal image of the ovary shows a well-defined, anechoic mass with increased through transmission. What does this most likely represent?

Simple ovarian cyst (follicular, corpus luteum).

what causes hyperplasia? what measurements are associated with this in pre and post menopausal women?

unopposed estrogen stimulation. - appears as thickening of the endometrium premenopausal women: if the endometrium measures more than 14mm (double thickness layer) - measured between day 6-10 after bleeding. postmenopausal women: 8mm is upper limit of normal. women on HRT up to 15mm during estrogen phase.

44 review question: List the common benign cysts found in adolescent girls.

Small simple cysts (1 to 7 mm) normally occur in fetuses and newborn girls because of stimulation by maternal hormones. In premenarchal girls, small follicles (less than 9 mm) are common. Larger cysts also image in otherwise healthy premenarchal girls. These may be followed closely if they are regressing, as long as the child's growth and development appear normal. Occasionally, ovarian cysts produce symptoms of precocious puberty in young girls. These may arise spontaneously or in association with other hormonal derangements.

44 critical thinking: Endovaginal images of both ovaries show enlarged ovaries with peripheral cysts lining the outer margin of the ovary. What syndrome does this represent?

Stein-Leventhal syndrome or polycystic ovaries.

43 review question: name the common intrauterine contraceptive devices and their ultrasonic appearance.

Straight-shafted IUDs form solid lines demonstrated by careful longitudinal and transverse examinations of the uterus. Lippes loops appear as dotted lines as the ultrasound beam transects the parallel segments. Posterior shadowing occurs when the ultrasound beam is entirely interrupted. This requires scanning plane placement perpendicular to the IUD. Perforation of the uterus by an IUD almost always occurs at the time of insertion. The displaced IUD may not be suspected until an abscess or painful bowel involvement occurs.

45 Critical Thinking Exercises: What is the differential consideration for hydrosalpinx?

The differential consideration for hydrosalpinx includes fluid-filled bowel (watch for peristalsis in the bowel, or change the patient's position to see change in fluid pattern), dilated distal ureter, omental cyst, ovarian cyst, or tubo-ovarian abscess.

44 review question: Identify the organ or tumor that metastasizes to the ovary.

The ovary is a common site of metastasis from bowel (Krukenberg tumor), breast, and endometrium, as well as from melanoma and lymphoma.

44 review question: Describe ovarian function.

The ovary's function is to mature oocytes until ovulation, under the influence of luteinizing hormone and follicle-stimulating hormone from the pituitary. At the same time, the ovary synthesizes androgens (male hormones) and converts them to estrogens (female hormones). Finally, it produces progesterone after ovulation to sustain early pregnancy until the placenta can do so at 10 to 12 weeks of gestation. Usually only one follicle enlarges from 3 mm to approximately 24 mm over about 10 days in the mid- and late-follicular phase of the cycle. This is followed by ovulation. The resulting corpus luteum or an abnormal unruptured follicle can persist as a webbed cystic structure from 1 to 10 cm in size.

45 Critical Thinking Exercises: A 26-year-old woman appeared in the emergency department with fever and intense pelvic pain. A vaginal discharge had been present for 7 days. What should the sonographer look for?

a pelvic abscess should be considered. It is usually a complex mass in the cul-de-sac that distorts pelvic anatomy. It can involve the ovary alone or the fallopian tube and ovary as a tubo-ovarian abscess. The TOA appears as a complex hypoechoic adnexal mass with septations, irregular margins, and fluid-debris levels. The ovaries are often difficult to recognize as separate from the mass because of surrounding tissue, edema, and pus.

45 Critical Thinking Exercises: What is the appearance of peritonitis on ultrasound?

With peritonitis, involvement of the bladder, ureter, bowel, and adnexal area may become infected. If the abscess collection has gas-forming bubbles within, it may be difficult to delineate well with sonography as the beam reflects from the area of interest. The sonographer should look for loculated areas of fluid within the pelvis, paracolic gutters, and mesenteric reflections.

less common cause of uterine calcifiations

arcuate artery calcification in periphery of the uterus. due to calcific sclerosis this can indicate underlying disease such as diabetes, hypertension and chronic renal failure. (monckeberg's arteriosclerosis)

hydrometrocolpos

collection of fluid in the vagina and uterus before menstruation

MC cause of abnormal uterine bleeding in premenopausal and post menopausal women

endometrial hyperplasia.

menorrhagia

excessive menstrual bleeding

MC overall gynecological tumor

leiomyomas smooth muscle cell composition, fibrosis iccurs after artiphic ir degenerative changes. my be pedunculated. 3 locations: submucosal, intramural, subserosal.

MC causes of uterine calcifications

myomas

43 review question: Describe endometrial hyperplasia. What effect does hormone replacement have on the endometrium?

unopposed estrogen causes endometrial hyperplasia. It appears as thickening of the endometrium. In premenopausal women, an endometrial thickness of more than 14 mm (double thickness) suggests hyperplasia. In asymptomatic postmenopausal women, 8 mm (double thickness) is the upper limit of normal. Women on sequential estrogen and progesterone replacement regimens may have endometrial thickness up to 15 mm during the estrogen phase; the thickness decreases after progesterone is added. Ideally, a woman using sequential hormones should be studied at the beginning or end of her hormone cycle, when the endometrium is theoretically at its thinnest.

45 review question: List the sonographic findings of PID.

sonographic findings of PID: o Endometritis: thickening or fluid in the endometrium o Periovarian inflammation: enlarged ovaries with multiple cysts, indistinct margins o Salpingitis: nodular thickening, irregularity of tube with diverticula o Pyosalpinx or hydrosalpinx: fluid-filled irregular fallopian tube with or without echoes o Tubo-ovarian abscess: complex mass with septations, irregular margins, internal echoes; usually in cul-de-sac

MC type of cervical cancer

squamous cell carcinoma detection atributied to regular pap smears (papaniculaou)

45 review question: describe the findings in a tubo-ovarian abscess.

Tubo-ovarian abscess (TOA) is the process in which adhesive, edematous, and inflamed serosa may further adhere to the ovary and/or other peritoneal surfaces, which distorts anatomy. This causes a further loculation of pus known as a tubo-ovarian abscess. This abscess may be unilateral or bilateral and appears as a complex mass in the posterior cul-de-sac. The tubo-ovarian complex or abscess does not behave as a true abscess and usually responds well to antibiotic treatment without need for surgical drainage. Serial ultrasound during treatment allow observation of resolution and can indicate which patients need prolonged intravenous antibiotics and which may benefit more from removal of the involved tissue.

44 review question: Discuss the sonographic findings in a patient with ovarian carcinoma.

Ultrasound screening finds adnexal cysts in 1% to 15% of postmenopausal women; only 3% of ovarian cysts less than 5 cm are malignant. Surgical removal of a cyst greater than 5 cm is the prudent course of action. Enlarged ovaries with or without a mass in the postmenopausal woman may demonstrate a mixed texture to solid with internal papillae. Doppler shows a low resistive pattern. Extension beyond the ovary into the omentum, peritoneum, or liver metastases should be evaluated. Malignant ascites also may be present.

43 review question: what is adenomyosis?

Adenomyosis causes heavy painful menses. Histologically, the condition is characterized by nests of endometrial tissue within the myometrium. Sonographically, extensive adenomyosis appears as diffuse uterine enlargement. Hemorrhage in islands of endometrial tissue appears as small myometrial cysts.

45 review question: What is adenomyosis?

Adenomyosis is the ectopic occurrence of nests of endometrial tissue within the myometrium and is more extensive in the posterior wall. Diffuse disease with global infiltration is the common presentation for adenomyosis. Adenomyosis may also present as focal disease with discrete masses or adenomyomas in the wall of the uterus. The cause of this disease may arise from multiple pregnancies and deliveries with subsequent uterine shrinking. Elevated estrogen levels also may promote the growth of myometrial islands of endometrial tissue. Clinically, the patient presents in middle age with heavy, painful menses, and uterine enlargement. Treatment may be local excision of the affected area or hysterectomy if the symptoms are severe.

45 review question: Discuss the routes of infection to the pelvis.

Although sexual transmission is the most common form of infection, other routes of infection are possible. The string from the intrauterine cervical device may be a route for bacterial infection to invade the cervix. Other types of invasive instrumentation procedures in the pelvic cavity also may leave the route more accessible for bacterial invasion. The infection spreads via the mucosa of the pelvic organs, through the cervix into the uterine endometrium (endometritis), and out the fallopian tubes (salpingitis) to the area of the ovaries and peritoneum. As the tube obstructs, a pyosalpinx develops.

critical thinking 43: A large solid mass images on the pelvic ultrasound in the area of the cervix in a 32-year-old woman. What is your differential?

Cervical leiomyoma or cervical carcinoma

critical thinking 43: An elderly woman on cyclic hormone replacement therapy demonstrated a large endometrial fluid collection. What is your differential?

Cervical stenosis (either fluid filled or bloody)

45 Critical Thinking Exercises: A 34-year-old woman presented with pelvic fullness; a well-delineated homogeneous mass in the right adnexal area was found. What is the differential consideration?

An endometrioma often appears as a well-defined predominantly cystic mass with transabdominal ultrasound, but with endovaginal ultrasound, uniform internal echoes usually are seen. The most common presentation is of a "chocolate cyst" with low-intensity echoes and acoustic enhancement. Other appearances include an enlarged polycystic ovary with a thick wall and internal septations or a cyst with fluid-debris levels (because of different degrees of organization of the hemorrhage).

45 review question: What is the difference between hydrosalpinx and pyosalpinx?

An obstructed tube filled with serous secretions is a hydrosalpinx; this can occur as a result of PID, endometriosis, or postoperative adhesions. Pyosalpinx is retained pus in the tube with inflammation. In addition to hydrosalpinx or pyosalpinx, sonographic findings of PID include fluid in the cul-de-sac, mild uterine enlargement, and endometrial fluid or thickening.

44 review question: Discuss how a cystic mass can become complex.

Any simple cyst that hemorrhages may appear as a complex mass. In patients of reproductive age, the classic differential of a complex adnexal mass is ectopic pregnancy, endometriosis, and PID. A dermoid and other benign tumors have a similar sonographic appearance.

43 review question: What is the appearance of cervical stenosis on ultrasound?

Cervical stenosis is an acquired condition with obstruction of the cervical canal at the internal or external os resulting from prior instrumentation, childbirth, surgery, cancer, or irradiation. The menopausal patient may be asymptomatic even though the stenosis can produce a distended fluid-filled uterus. Premenopausal patients may experience oligomenorrhea or amenorrhea with cramping, or dysmenorrhea.

44 critical thinking: A young girl presented with a palpable pelvic mass. The ultrasound showed a well-defined mass with calcification and a fat-fluid level. What does this most likely represent?

Dermoid cyst.

44 review question: Describe the sonographic findings in a dermoid tumor.

Dermoid cysts are the most common ovarian neoplasm, comprising 20% of ovarian tumors. Up to 20% are bilateral. About 80% occur in women of childbearing age. Dermoid cysts have a spectrum of sonographic appearances, depending on which elements (ectoderm, mesoderm, or endoderm) are present. Teeth, bones, and fat can be seen on plain films. This tumor is usually unilateral. Ultrasonography demonstrates a completely cystic mass, a cystic mass with an echogenic mural, a fat-fluid level, high-amplitude echoes with shadowing (e.g., teeth or bone), or a complex mass with internal septations.

43 review question: What is the role of Doppler of the uterine artery in distinguishing benign from malignant endometrial thickening?

Doppler ultrasonography of the uterine artery may help distinguish benign from malignant endometrial thickening. Pulsed Doppler is used to evaluate the resistive index (RI = systolic-diastolic/systolic) or pulsatility index (PI = systolic-diastolic/mean). Low-resistance flow (RI less than 0.4) has been found in patients with endometrial carcinoma and high-resistance flow (RI greater than 0.5) in normal postmenopausal women. If a pulsatility index is used, the cutoff is 1. Intratumoral neovascularity is a more sensitive marker of endometrial carcinoma than resistive index alone.

45 review question: What is endometriosis?

Endometriosis is a common condition in which functioning endometrial tissue is present outside the uterus. Ectopic tissue implants on the ovaries, external surface of the uterus, and peritoneum with an increased incidence in dependent portions of the pelvis. The endometrial implants may be present in almost any area of the body. This disease process affects women during their reproductive years. The endometrial tissue cyclically bleeds and proliferates as stimulated by hormonal influence. Clinical symptoms include painful periods or intercourse, and infertility secondary to adhesions and fibrosis. There are two types of endometriosis: diffuse and localized. The diffuse form is difficult to recognize with sonography because the implants are so small. The diffuse form leads to disorganization of the pelvic anatomy with an appearance similar to PID or chronic ectopic pregnancy.

43 review question: What is the ultrasound appearance of endometritis?

Endometritis most often occurs in association with PID disease, but it also occurs postpartum. Sonographically, the endometrium appears prominent, irregular, or both, with a small amount of endometrial fluid. Gas bubbles are present in rare cases; however, these also are seen in normal postpartum patients. In the immediate postpartum period, the presence of retained tissue is difficult to distinguish from inflammatory debris or blood clots.

45 review question: Why do postpartum patients develop endometritis?

Endometritis most often occurs in association with PID, in the postpartum state, or after instrumentation invasion. In patients with pelvic infection, the uterus is the route for infection to the tubes and adnexa. Postpartum patients may develop endometritis after prolonged labor, vaginitis, premature rupture of the membranes, or retained products of conception.

43 review question: Name the causes of fluid collections seen within the endometrial cavity.

Endovaginal sonography, with its improved resolution, sometimes shows tiny endometrial fluid collections not seen on transabdominal scans. These small endometrial fluid collections (less than 2 ml) are common in women during the menstrual phase of the cycle. Fluid images are taken in postmenopausal women, especially during the menstrual phase in women taking sequential hormones. Small endometrial fluid collections also occur with ectopic pregnancy, endometritis, degenerating fibroids, and recent abortion. In a uterus with a fluid collection, the anteroposterior diameter of the fluid should be subtracted from the endometrial measurement for a true assessment of endometrial thickness.

critical thinking 43: A 26-year-old woman presented to the emergency department with pelvic pain, fever, bleeding, and a positive pregnancy test. She had an intrauterine contraceptive device in the uterus without an intrauterine gestational sac. Explain your next steps.

Evaluate the adnexal area for the presence of an ectopic pregnancy

44 review question: What is the role of Doppler in the evaluation of the ovary?

In the case of cysts, color Doppler is helpful in differentiating a potential cyst from adjacent vascular structures. Use color to localize flow and obtain a spectral Doppler tracing on all ovarian masses. Use pulsed Doppler interrogation of the adnexal branch of the uterine artery, the ovarian artery, or intratumoral flow to help determine the resistive index or pulsatility index. Scan patients with normal menstrual cycles in the first 10 days of the cycle; this avoids confusion with normal changes in intraovarian blood flow, because high-diastolic flow occurs in the luteal phase.

43 review question: Discuss the development of leiomyomas, their ultrasonic appearance, their sensitivity to estrogen stimulation, and their classification.

Leiomyomas, commonly called myomas or fibroids, are the most common gynecologic tumors. The tumor arises from the smooth muscle of the uterine wall and consists of whorled spherical configuration of myometrial tissue, which can degenerate into a number of different histologic subtypes. The tumors consist of nodules of myometrial tissue and are usually multiple in location. The myoma is encapsulated with a pseudocapsule and separates easily from the surrounding myometrium. With atrophy and vascular compromise, fibrotic changes and degeneration of the myomas occur. Liquefaction, necrosis, hemorrhage, and ultimate calcification may take place. Hyalinization (development of an albuminoid mass in a cell or tissue) occurs most often, making the myomas appear more lucent (hypoechoic) than myometrium. Ten percent of myomas contain calcification, and a similar number have areas of hemorrhage. Other fibroids contain tissue that has undergone necrosis and liquefaction and become myxoid in texture. The tumor usually does not become malignant; however, it is sensitive to estrogen and may increase in size during pregnancy. After menopause, with the regression of estrogen stimulation, the tumor becomes smaller, but does not entirely disappear. The signs and symptoms of leiomyomas depend on their size and location. Submucosal myomas may erode into the endometrial cavity and cause irregular or heavy bleeding, which may lead to anemia. Fertility may be affected by submucosal or intramural fibroids, which may impede sperm flow, prevent adequate implantation, or cause recurrent miscarriages. The earliest sonographic finding of fibroids is demonstrated uterine enlargement with a heterogeneous texture. Also the sonographer should look for contour distortion along the interface between the uterus and bladder. The myoma alters the normal homogeneous myometrial texture pattern. Discrete fibroids usually are hypoechoic, but can be hyperechoic if they contain dense fibrous tissue. Bright clusters of echoes occur with calcific deposits and produce typical distal acoustic shadowing. In the presence of extensive calcification, the uterus and adnexa are difficult to image because of shadowing. In such cases, endovaginal imaging is helpful in visualizing the ovaries. Fibroids as small as 0.5 cm can be detected by endovaginal sonography and their relationship to the endometrial cavity can be defined precisely. Larger fibroids cause heterogeneous uterine enlargement and are better outlined by transabdominal sonography.

conditions: imperforate hymen

MC congenital abnormality of female genital tract.

conditions: Gartner's duct cyst

MC cystic lesion of the vagina and usually found incidentally

conditions: nabothian cyst

MC finding of the cervix caused by chronic cervicitis is a common finding of middle aged women/ asymptomatic

43 review question: Discuss endometrial carcinoma and its ultrasound findings.

Most endometrial malignancies are adenocarcinomas occurring in perimenopausal and postmenopausal patients with irregular bleeding. The earliest change of endometrial carcinoma is a thickened endometrium. An abnormally thick endometrium also is associated with endometrial hypertrophy and polyps. Endovaginal examination is helpful in screening for early changes of endometrial hyperplasia or carcinoma by accurately measuring endometrial thickness. Although increased endometrial thickness is an early finding in endometrial carcinoma, enlargement with lobular contour of the uterus and mixed echogenicity are correlated with more advanced stages of the disease. The risk of malignancy increases with the presence of a large endometrial fluid collection or clinical symptoms, such as abdominal pain or bleeding. Demonstration of myometrial invasion is clear evidence for endometrial carcinoma. Endovaginal ultrasonography demonstrates myometrial invasion as thickening and irregularity of the central endometrial interface with echogenic or hypoechoic patterns combined with infiltration of hyperdense structures in the myometrium.

44 critical thinking: A young adult experiences sudden onset of pain. She is in the early secretory phase of her cycle. What would you expect to see on endovaginal ultrasound?

Most likely this represents a simple follicular cyst that has ruptured; low-level echoes with the well-defined mass are seen with possible swirling echogenicities on real-time. A small amount of fluid is present in the cul-de-sac.

45 review question: Discuss the role of ultrasound in the postoperative patient.

Pain and masses after pelvic surgery can indicate complications such as postoperative bleeding, hematomas, or abscess formation. Postoperative masses are not always dangerous. More than one surgeon has made the diagnosis of severely distended bladder by ordering an ultrasound for a postoperative pelvic mass. Ultrasound demonstrates these fluid collections and visualizes the operative site. The ability to palpate specific structures with the endovaginal probe and avoidance of the abdominal wound is valuable in determining the site of pain in a postoperative pelvis. Resolving hematomas (1 week after surgery) often appear to be of a solid consistency and can be followed as they shrink. Ultrasound-guided needle drainage of abscesses and stable hematomas, through either the abdominal wall or vagina, is diagnostic and therapeutic. Recurrent tumor masses may be biopsied in a similar fashion. The endovaginal ultrasound and needle guide make entering the anterior or posterior cul-de-sacs safer and easier for pelvic fluid aspiration, biopsies, or radiation needle placement.

44 review question: What are the causes of ovarian enlargement in postmenopausal women?

Palpable ovaries in postmenopausal women are of concern. The cause of ovarian enlargement is often a simple adnexal cyst. In postmenopausal women, small (up to 3 cm) simple cysts of the ovaries occur in approximately 15% of patients. These cysts commonly change in size and often disappear completely. Because 85% to 90% of ovarian malignancies are epithelial in origin and most are cystic, the occurrence of any ovarian cyst in a postmenopausal woman has, in the past, been considered abnormal and an indication for surgery. Simple cysts less than 5 cm in diameter are not likely to be malignant.

45 review question: What is pelvic inflammatory disease?

Pelvic inflammatory disease (PID) and endometriosis are diffuse disease processes of the female pelvic cavity that display very different clinical presentations and pathologies. PID is an inclusive term that refers to all pelvic infections (i.e., endometritis, salpingitis, hydropyosalpinx, and tubo-ovarian abscess). The infection occurs bilaterally and may be found in the endometrium (endometritis), uterine wall (myometritis), uterine serosa and broad ligaments (parametritis), ovary (oophoritis), and the most common location—the oviducts (salpingitis).

44 review question: What is Stein-Leventhal syndrome? What are the complications of this disease?

Polycystic ovarian syndrome, which includes Stein-Leventhal syndrome (infertility, oligomenorrhea, and hirsutism), is an endocrinologic disorder associated with chronic anovulation. Pathologically, the ovaries contain an increased number of follicles. Sonographically, the ovaries appear normal or enlarged with echogenic stroma. The number of small follicles is often increased bilaterally (less than 1 cm), usually to more than five in each ovary.

conditions: cervical polyps

Present with irregular bleeding cause: hyperplastic protrusion of the endocervix or exocervix due to chronic inflammation. more common in late middle age women.

45 review question: describe the risk factors that lead to pelvic infection.

Risks factors include early sexual contact, multiple sexual partners, history of sexually transmitted disease, and douching. The causes of PID vary from sexually transmitted diseases (e.g., gonorrhea, chlamydia), abscess collections that have ruptured into the pelvis, IUDs, to post abortion complications.

45 Critical Thinking Exercises: How can the sonographer distinguish salpingitis from a dilated ureter?

The sonographer should be sure not to confuse the dilated tube with a dilated ureter or prominent vessel. The sonographer can try to follow the dilated fallopian tube as it enters the cornu of the uterus (at the fundus). Careful oblique angulations of the transducer are necessary to trace the pathway of the tube. Hydrosalpinx presents as echogenic fluid or fluid-fluid levels. Acute salpingitis is evident as a thick-walled nodular hyperemic tube. The unhealthy dilated tubes usually surround the ovaries like two crescents of ring sausage encircling the posterior surface of the uterus and filling the cul-de-sac. The walls of the tubes are thickened and nodular. The ovaries may be difficult to delineate because of surrounding tissue, edema, and pus. Severe and chronic pyosalpinges often contain thick, echogenic mucoid pus, which does not transmit sound as well as serous fluid or blood. Infection can obscure normal tissue planes, making anatomy unclear. Severe pain requires gentle use of ultrasound probes in acute PID, and in some cases, a full bladder for transabdominal study is intolerable.

44 review question: List the risk factors of ovarian carcinoma.

The strongest risk factor is a family history of ovarian or breast cancer. Women with carcinoma of the breast have increased risk of developing ovarian cancer, and women with ovarian cancer are three to four times more likely to develop breast cancer. Other risk factors include nulliparity, infertility, uninterrupted ovulation, and late menopause.

44 review question: Discuss the cause and appearance of theca lutein cysts.

Theca lutein cysts appear as large, bilateral, multiloculated cystic masses. Associated with high levels of hCG, they are seen most frequently in association with gestational trophoblastic disease. Similar cysts occur in normal pregnancies, especially multiple gestations, and some patients using infertility drugs, particularly Pergonal.

44 critical thinking: A large septated mass with thick, irregular walls was found on the pelvic ultrasound of a 33-year-old woman who presented with a clinical history of a pelvic mass. What is your differential?

This most likely represents a mucinous cystadenocarcinoma. Other differentials would include a mucinous or serous cystadenoma or cystadenocarcinoma.

44 review question: How would you describe the sonographic appearance of ovarian torsion?

Torsion of the ovary results from partial or complete rotation of the ovarian pedicle on its axis. The right ovary is three times more likely to show torsion than the left. Ovarian torsion produces an enlarged edematous ovary, usually greater than 4 cm in diameter. The classically described appearance is of multiple tiny follicles around a hypoechoic mass, but the most common presentation is that of a completely solid adnexal mass. Free fluid often is present in the pelvis. Doppler examination usually reveals absent blood flow to the torsed ovary; however, a recent case report describes normal blood flow to torsed ovaries. This is thought to be the result of the dual blood supply of the ovary or because of venous thrombosis, leading to symptoms before arterial thrombosis occurs.