Common Gynecological Anomalies – Part 1

Common Gynaecological Anomalies- Part 1

MDU,BMI,ECHO&ECG,DDR

UTERUS

Outline- Uterine Pathologies

• Technique
• Normal anatomy
• Congenital anomalies

Leiomyoma/Fibroids

Pelvic Inflamatory Disease

• Adenomyosis
• Endometrial Hyperplasia and polyps.

Postmenopausal uterus- Endometrial Ca

TECHNIQUE

• Endovaginal
• improved spatial resolution
• smaller field of view
• Transabdominal imaging complementary
• enlarged uterus
• congenital anomalies
• evaluation of the kidneys

MRI/HSG may provide more specific information in selected cases

Review of normal Anatomy

1.CONGENITAL ANOMALIES

CONGENITAL ANOMALIES

• Incidence
• 0.1% to 0.5% all women
• 9% in women with infertility or fetal loss
• Associated with renal anomalies
• Defects include:
• Septate/arcuate uterus
• Unicornuate uterus
• Bicornuate uterus

Uterine didelphys

Septate/arcuate uterus

Has a normal external surface but two endometrial cavities Degree of septation varies from a small midline septum to total septate uterus with longitudinal vaginal septum Arcuate has slight midline septum with minimal fundal cavity indentation

Unicornuate uterus

Bicornuate uterus

• Uterus in which the fundus is indented (≥1 cm) and the vagina is generally normal.

Results from only partial fusion of the müllerian ducts Leads to a variable degree of separation of the uterine horns that can be complete, partial, or minimal.

Uterine didelphys

“double uterus”

duplication is limited to the uterus (didelphys) and cervix (bicollis) although other structures (vagina, bladder, etc may be involved)

Differentiation requires visualization of

• endometrial stripes

fundal contour

Visualization of fundal contour may require Transabdominal Ultrasound or 3 dimensional ultrasound

SEPTATE VS. BICORNUATE UTERUS

BICORNUATE UTERUS

• Divergent endometrial stripes

> 1.0 to 1.5 cm cleft between horns

BICORNUATE UTERUS

• Divergent endometrial stripes
• > 1.0 to 1.5 cm cleft between horns

X > 1.5 cm

Bicornuate uterus ( Double Endometrium)

Less divergence of endometrial stripes

• Flat, convex, or minimally indented fundal contour (< 1 cm)

SEPTATE UTERUS

SEPTATE UTERUS

SEPTATE UTERUS

X < 1.0 – 1.5 cm

Endocrine causes

• Absence, atresia or obstruction of vagina, cervix, or uterus
• +/- Pelvic mass
• Role of imaging
• confirm level of abnormality
• extent of vagina
• presence / absence of uterus and cervix

2.Primary amenorrhea

Primary amenorrhea

Uterine Agenesis

Note: No Uterus posterior to UBL

Primary amenorrhea

• Haematocolpos in imperforate Hymen

Note: Blood collection in Uterine cavity(HAEMATOMETRA)

3.Pelvic inflammatory disease (PID)

Ascending infection that may involve the uterus(endometrium), fallopian tubes, ovaries, and pelvic cavity, and may produce tubo-ovarian abscesses(TOA) Presents with LAP, Fever, PV discharge, Cervical motion tenderness

A.Pelvic Inflammatory Disease: US Findings

• Endometritis (Endometrial fluid)
• Hydrosalpinx: Dilated fallopian tube
• Thickened, inflamed fallopian tube
• +/- internal echoes (pyosalpinx)- Pus fillled

Tubo – Ovarian Abscess

Fluid in cul-de-sac (Pouch of Douglas)

B.Endometritis

• Sx: fever, leukocytosis, tenderness, foul smelling discharge

Occurs post partum, following D&C, PID

Indistinct, thickened endometrial stripe, +/- fluid, air

Endometritis: US Findings

Endometritis (Fluid in Endometrium)

C.Pelvic Inflammatory Disease (PID)

• Fluid in pouch of Douglas

Significant Fluid > 1cm deepest pool

D.Hydrosalpinx (salpingitis)

Hydrosalpinx (Hydrosalpingitis)

• Infection of fallopian tubes

E.PYOSALPINX

US Findings :Complex, multicystic, thick walled mass, internal echoes

F.(Tubo-ovarian cyst)-TOA:

TOA: US Findings

• Often bilateral
• Ovarian margins may be indistinct

ovary relatively spared

Complex, multicystic, thick walled mass, internal echoes

TOA: US Findings

4.Uterine Fibroids

Definition

Are benign monoclonal tumors arising from the smooth muscle cells of the myometrium, termed leiomyoma.

They contain a large amount of extracellular matrix (collagen, proteoglycan, fibronectin) and are surrounded by a thin pseudocapsule of areolar tissue and compressed muscle fibers.

• Synonyms: fibroid or fibromyoma.
• Incidence:
• The most common gynecological tumors in about 30% of women of reproductive age.
• 20% of women after 30 years develop uterine fibroid.

More prevalent in black African women

Uterine Fibroids

Etiology:

The possible etiology is hyperestrinism (estrogen-dependent tumor). The evidences supporting this include:

• Associated with exposure to circulating estrogen (arise during adulthood)

Shrink following menopause

Maximum growth when estrogen secretion is maximal, spurt in growth in the decade before menopause (an ovulatory cycles with unopposed estrogen) Increased growth during pregnancy (caused by estrogen) Estrogen receptors are more in leiomyoma compared to the rest of myometrium N.B. Growth factors may act synergistically with estrogen to induce growth of myoma

Risk factors: the following factors are predisposing

• Age: common between 35 & 45 years.
• Parity: common in nulliparous or low porous & relatively infertile women.
• Race: common in black women
• Family history : +ve.
• Obesity
• Early menarche (<10 years old)

A longer interval since last birth increases risk Consumption of alcohol, especially beer, appears to increase the risk of developing fibroids however smoking decreases the risk of having fibroids.

Significant consumption of beef, ham, or other red meats is associated with an increased relative risk of fibroids Protective factors

• Early age at first birth decreases risk

consumption of green vegetables with a decreased risk

Fibroids (Leiomyomas)

• Fibroids are benign tumors of the uterus arising from the Myometrium
• Smooth muscle neoplasms

Patients Presentation

• Asymptomatic
• Abnormal Uterine bleeding- Menorrhagia
• Pelvic pain
• Infertility
• Abortions ( Submucosal and Intramural fibroids)

Sx & Rx depend on location and size

Types of Fibroids

• subserosal
• pedunculated
• intra cavitary
• (submucosal)
• intramural

cervical

TYPES(LOCATION) OF LEIOMYOMAS (FIBROIDS)

Intramural: Most common; the tumor remains within myometrium.

Submucous: when the tumor arises near the endometrium & bulge into the uterine cavity. Associated with menorrhagia Subserous: when arises beneath the serosal covering and projects into the abdominal cavity.- at the outer border of the myometrium Pedunculated: Attached to the uterus by a narrow pedicle containing blood vessels. May present as adnexal mass Cervical: Very few, constitute 2% of uterine fibroids NB: Some fibroids can be transmural and extend from the serosal to the mucosal surface.

Location of Fibroids

• Submucosal
• Associated with menometrorrhagia
• Distort endometrial myometrial margins
• Intramural
• Most common
• Subserosal
• Distort uterine margins
• Pedunculated
• ± Stalk
• May present as adnexal mass
• Cervical; Can cause fetal Malpresentation etc
• Broad ligament

Simulate adnexal mass

Fibroids: US Findings

• Focal mass
• Usually hypoechoic, but can be isoechoic & echogenic
• Can be single or multiple
• Cystic areas due secondary to degeneration
• Calcifications
• -Rim calcification

-Clumps of calcification

Fibroids: US Findings

• At Ultrasound, you should note the following
• Size
• Shape
• Number
• Echotexture

Location within the uterus

Fibroid

Note the size, shape, number, location

Intramural Fibroid

Intramural & submucosal fibroid

Submucosal Fibroid

Pedunculated

• subserosal leiomyoma
• Identify ovaries separately
• Echotexture similar to myometrium

Visualization of pedicle or attachment to uterus

LEIOMYOMA

LEIOMYOMA- Calcifications in

Fibroid

Fibroid in Pregnancy

Large Fibroid- Central Necrosis

Pedunculated subserosal leiomyoma

• Identify ovaries separately
• Echotexture similar to myometrium
• Visualization of pedicle or attachment to uterus

CFI may be helpful

Pedunculated subserosal leiomyoma

Complications of Fibroids:

• Sub fertility /Infertility
• PPH ( due to inefficient uterine contraction after 3rd stage.)
• Spontaneous abortion.
• Abnormal fetal lie.
• Premature contractions.
• May make Caesarean section delivery necessary.

Anaemia

Benign neoplasm

• mature lipocytes, smooth muscle cells, fibrous tissue
• US: echogenic myometrial mass
• Ddx: some atypical fibroids are also very echogenic

5.Lipoleiomyoma

Lipoleiomyoma

Hormonally responsive

• may enlarge during pregnancy
• Hemorrhage / necrosis
• Torsion / infarction
• Malignant degeneration rare
• growth in postmenopausal women is suspicious

6.Fibroid/Leiomyoma

LEIOMYOMA: acute infarction

7.Uterine Sarcoma

Sarcomas comprise less than 5% of uterine malignancies. They resemble fibroids or endometrial carcinoma.

When a rapid change in the size of fibroids is noticed, a uterine sarcoma should be considered as the aetiology.

Leiomyosarcoma

Ectopic endometrium located within the myometrium

• Basalis endometrium
• does not respond to hormonal stimulation
• Diffuse or focal
• Not encapsulated
• definitive Rx requires hysterectomy
• Adenomyosis is a cause of heavy painful menses.

The sonographic diagnosis is difficult to make.

In general, the uterus is enlarged without focal mass. At times, small blood-containing spaces in the uterus can be seen caused by dilated glands filled with menstrual products.

8.Adenomyosis

Adenomyosis

Focal adenomyomas also occur. These are difficult to distinguish from fibroids. Fibroids tend to be well circumscribed.

In contrast, focal adenomyomas are ill defined The preoperative distinction between fibroids and adenomyosis is important in women who are being treated for infertility or abnormal bleeding since myomas can be removed; however, adenomyosis typically requires a hysterectomy.

Magnetic resonance is helpful in this distinction.

Pt presentation:

• multiparous
• 5th to 6th decades
• pelvic pain
• dysmenorrhea
• menorrhagia
• assx
• Incidence unknown
• ~ 30%

Adenomyosis

Adenomyosis: US Findings

• Heterogeneity and assx thickening of subendometrial myometrium
• hypoechoic
• poorly marginated
• focal or diffuse
• Small, anechoic subendometrial cysts
• seen best in end secretory stage
• Uterus is typically tender

MRI more sensitive and specific

Adenomyosis; Heterogeneous UT

Adenomyosis

Think adenomyosis:

• if uterus is tender
• subendometrial cysts
• asymmetric thickening of myometrium
• heterogeneous uterine enlargement without a focal mass
• ADENOMYOSIS vs LEIOMYOMA:

US Differentiation

Think leiomyoma (Fibroid):

• well defined, focal mass
• posterior shadowing/attenuation
• vascular rim
• enlarged uterus with lobular serosal contour
• ADENOMYOSIS vs LEIOMYOMA:

US Differentiation

8.Endometrial Hyperplasia, and Polyps

As women approach menopause, the incidence of endometrial hyperplasia, polyps, and cancer increase as causes of endometrial thickening The endometrium is thickened either diffusely or focally.

Endometrial polyps usually are asymptomatic but may cause uterine bleeding. They also cause diffuse or focal endometrial thickening.

In both of these conditions (endometrial hyperplasia and polyps), the interface between the endometrium and the myometrium is preserved.

Endometrial Hyperplasia

9.Endometrial Polyp

10.Abnormal bleeding in postmenopausal women

Uterine bleeding is an early indicator of endometrial cancer. Usually, however, postmenopausal bleeding is benign, most commonly secondary to endometrial atrophy.

When sonography demonstrates an endometrial thickness of 4 mm or less, endometrial atrophy is the most likely histologic diagnosis.

Because of the increased risk of endometrial hyperplasia, polyps, and cancer, endometrial biopsy or curettage is typically performed in women with unexpected uterine bleeding whose endometrial thickness is greater than 5 mm.

11.Endometrial carcinoma

• Endometrial carcinoma is the one of most common gynaecologic malignant disease:

75% to 85% of cases occur after the age of 50 years.

Sonography is important in evaluating for this disease because the endometrium can be accurately measured and well visualized.

The normal postmenopausal endometrium is atrophic.

It is usually a thin, echogenic line. In asymptomatic women, a threshold of 8 mm in thickness has been suggested. This threshold is decreased to 4 mm in women who are bleeding.

Estrogenic hormones also cause increased endometrial thickness, as well as an increased incidence of endometrial hyperplasia, polyps, and cancer.

Endometrial cancer also is a cause endometrial thickening. The diagnosis is suggested when there is loss of the endometrial–myometrial interface.

Endometrial Carcinoma.

12.Cervical Mass

• Nabothian cyst: Usually <2 cm Adjacent to endocervical canal Incidence increases with age
• Cervical fibroid: Typically hypoechoic, well defined
• Cervical cancer;± Ill-defined margins

Polyps: Centrally located ± Stalk

12.Abnormal Vagina

• Vaginal masses are rare.

The most common visualized with sonography are Gartner cysts.

These cysts usually are located within or near the vaginal wall and typically are palpable on physical examination.

Vaginal adenocarcinoma and rhabdomyosarcoma appear as solid masses, occasionally with areas of necrosis.

12.Intrauterine Device (IUD)

Another cause of bright reflectors within the uterus are intrauterine contraception devices (IUDs).

Ultrasound is helpful in locating an IUD when the string cannot be felt. The IUD should be located centrally within the endometrium.

AIf the IUD is not visualized sonographically, radiographs should be obtained to exclude an extra uterine location of an IUD.

Intrauterine Device (IUD)

• : Role of US
• US used to assess for:
• location / malposition
• myometrial penetration / perforation

incomplete removal

Echogenic, shadowing, linear structure in endometrial cavity

Intrauterine Device (IUD)

IUD