OBGYN review

Ovarian torsion.

. 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?

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.

13. Describe the sonographic findings in a dermoid tumor.

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

14. Identify the organ or tumor that metastasizes to the ovary.

On ultrasound examination, the proliferative endometrial phase is seen as a triple line sign consisting of the hypoechoic mucosa and the echogenic interface, where they meet in the center of the uterus. After ovulation, progesterone is secreted by the corpus luteum. This secretion of progesterone begins the secretory phase of the endometrial cycle. During the secretory phase, the endometrium becomes thickened and very echogenic because of stromal edema, and there is loss of the triple line sign. If not enough progesterone is produced in the luteal phase, the endometrial lining may be thinner than expected on ultrasound evaluation. This lack of progesterone production is known as luteal phase deficiency and has been associated with infertility and early pregnancy loss. The endometrial appearance has particular importance for planning for infertility treatment with embryo transfer.

2. How does the measurement of the endometrium help in the infertility assessment?

functional cyst, paraovarian cyst, cystadenoma, cystic teratoma, endometrioma, and rarely TOA.

2. Name four common cystic ovarian masses.

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.

2. What is the differential consideration for hydrosalpinx?

Adenocarcinoma o Solid teratoma o Arrhenoblastoma o Fibroma o Dysgerminoma o Torsion

4. List four common solid ovarian masses.

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.

4. What is the appearance of peritonitis on ultrasound?

.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).

5. 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?

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.

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?

Evaluate the adnexal area for the presence of an ectopic pregnancy

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.

Endometrioma/Chocolate Cyst

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

Ovarian carcinoma.

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?

Endometrial cancer or hyperplasia

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

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

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?

Cervical leiomyoma or cervical carcinoma

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?

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.

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?

Dermoid cyst.

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?

Cervical stenosis (either fluid filled or bloody)

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

Simple ovarian cyst (follicular, corpus luteum).

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

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.

Describe the development of corpus luteum cysts.

7. 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.

Discuss the cause and appearance of theca lutein cysts.

Stein-Leventhal syndrome or polycystic ovaries.

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

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.

How can the sonographer distinguish salpingitis from a dilated ureter?

Torsion of the ovary results from partial or complete rotation of the ovarian pedicle on its axis. 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

How would you describe the sonographic appearance of ovarian torsion?

Approximately 40% of the cases of infertility are attributable to the woman, 40% are attributable to the man, and the remaining 20% are combined male/female or unexplained factors.

Is infertility more likely to be caused by the female or male partner?

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.

List the risk factors of ovarian carcinoma.

Nabothian cysts

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?