BENIGN PELVIC DISEASES IN FEMALES

MODERATOR DR JYOTI ARORAPRESENTED BY DR SANGEETA JHA

Uterine ovarian Fallopian tubes

Cangenital anomalies (Mullerain duct anomalies)

Ovarian cystic massesFollicular cystHemmorrhagic cystTheca lutein cystPolycystic ovarian diseaseCystadenomas

HydrosapinxPyosalpinxhematosapinx

Uterine masseslesionsLeiomyomaAdenomyosisEndometrial polypEndometrial hyperplasiaUterine synechiaeUterine A-V malformation

Ovarian solid-cystic massesTubo ovarian abscessEndometriomaDermoid cyst or mature cystic teratomaOvarian torsionEctopic pregnancy Ovarian solid massesFibromaThecomaNon ndashovarian cystic massesPeritoneal inclusion cystParaovarian cystMucocoele of appendix

MULLERAIAN DUCT ANOMALIESbull The muumlllerian ducts are paired embryologic structures that

undergo fusion and resorption in utero to give rise to the uterus fallopian tubes cervix and upper two-thirds of the vagina

Normal process ofbull ductal development (6wks)bull ductal fusion (6-9wks)and bull septal reabsorption (9-12wks)Interruption at stage of bull ductal development - hypoplasia or aplasia of uterusbull ductal fusion -bicornuate uterus and uterine didelphisbull septal reabsoption -arcuate and septate uterus

bull It is often associated with primary amenorrhea infertility obstetric complications and endometriosis

bull MDAs are commonly associated with renal and other anomalies

ASSOCIATED ANOMALIES

MDAs are also commonly associated with

Renal anomalies-30ndash50

including renal agenesis (most commonly unilateral agenesis) ectopia hypoplasia fusion malrotation and duplication

bull Other

vertebral bodies -(29)

wedged or fused vertebral bodies and spinabifida(22ndash23)

cardiac anomalies (145) and

syndromes such as Klippel-Feil syndrome (7)

IMAGING MODALITIES

bull HSG-limitation to see fundal contour

bull USG

bull MRI-standard procedure of imaging

bull The Muumlllerian duct anomaly classification is a seven point system that can be used to describe a number of embryonic Muumlllerian duct anomalies

bull class I uterine agenesisuterine hypoplasiandash a vaginal (uterus normal variety of abnormal forms)ndash b cervicalndash c fundalndash d tubalndash e combined

bull class II unicornuate uterusunicornis unicollis ~6-25ndash a communicating contralateral rudimentary horn contains endometriumndash b non-communicating contralateral rudimentary horn contains endometriumndash c contralateral horn has no endometrial cavityndash d no horn

bull class III uterus didelphys ~5-11bull class IV bicornuate uterus next commonest type ~10-39

ndash a complete division all the way down to internal the osndash b partial division not extending to the os

bull class V septate uterus commonest anomaly ~34-55ndash a complete division all the way down to internal the osndash b incomplete division

bull class VI arcuate uterus ~7bull class VII in utero Diethylstilbestrol (DES) exposure T shaped uterus

Uterine ovarian Fallopian tubes

Cangenital anomalies (Mullerain duct anomalies)

Ovarian cystic massesFollicular cystHemmorrhagic cystTheca lutein cystPolycystic ovarian diseaseCystadenomas

HydrosapinxPyosalpinxhematosapinx

Uterine masseslesionsLeiomyomaAdenomyosisEndometrial polypEndometrial hyperplasiaUterine synechiaeUterine A-V malformation

Ovarian solid-cystic massesTubo ovarian abscessEndometriomaDermoid cyst or mature cystic teratomaOvarian torsionEctopic pregnancy Ovarian solid massesFibromaThecomaNon ndashovarian cystic massesPeritoneal inclusion cystParaovarian cystMucocoele of appendix

MULLERAIAN DUCT ANOMALIESbull The muumlllerian ducts are paired embryologic structures that

undergo fusion and resorption in utero to give rise to the uterus fallopian tubes cervix and upper two-thirds of the vagina

Normal process ofbull ductal development (6wks)bull ductal fusion (6-9wks)and bull septal reabsorption (9-12wks)Interruption at stage of bull ductal development - hypoplasia or aplasia of uterusbull ductal fusion -bicornuate uterus and uterine didelphisbull septal reabsoption -arcuate and septate uterus

bull It is often associated with primary amenorrhea infertility obstetric complications and endometriosis

bull MDAs are commonly associated with renal and other anomalies

ASSOCIATED ANOMALIES

MDAs are also commonly associated with

Renal anomalies-30ndash50

including renal agenesis (most commonly unilateral agenesis) ectopia hypoplasia fusion malrotation and duplication

bull Other

vertebral bodies -(29)

wedged or fused vertebral bodies and spinabifida(22ndash23)

cardiac anomalies (145) and

syndromes such as Klippel-Feil syndrome (7)

IMAGING MODALITIES

bull HSG-limitation to see fundal contour

bull USG

bull MRI-standard procedure of imaging

bull The Muumlllerian duct anomaly classification is a seven point system that can be used to describe a number of embryonic Muumlllerian duct anomalies

bull class I uterine agenesisuterine hypoplasiandash a vaginal (uterus normal variety of abnormal forms)ndash b cervicalndash c fundalndash d tubalndash e combined

bull class II unicornuate uterusunicornis unicollis ~6-25ndash a communicating contralateral rudimentary horn contains endometriumndash b non-communicating contralateral rudimentary horn contains endometriumndash c contralateral horn has no endometrial cavityndash d no horn

bull class III uterus didelphys ~5-11bull class IV bicornuate uterus next commonest type ~10-39

ndash a complete division all the way down to internal the osndash b partial division not extending to the os

bull class V septate uterus commonest anomaly ~34-55ndash a complete division all the way down to internal the osndash b incomplete division

bull class VI arcuate uterus ~7bull class VII in utero Diethylstilbestrol (DES) exposure T shaped uterus

MULLERAIAN DUCT ANOMALIESbull The muumlllerian ducts are paired embryologic structures that

undergo fusion and resorption in utero to give rise to the uterus fallopian tubes cervix and upper two-thirds of the vagina

Normal process ofbull ductal development (6wks)bull ductal fusion (6-9wks)and bull septal reabsorption (9-12wks)Interruption at stage of bull ductal development - hypoplasia or aplasia of uterusbull ductal fusion -bicornuate uterus and uterine didelphisbull septal reabsoption -arcuate and septate uterus

bull It is often associated with primary amenorrhea infertility obstetric complications and endometriosis

bull MDAs are commonly associated with renal and other anomalies

ASSOCIATED ANOMALIES

MDAs are also commonly associated with

Renal anomalies-30ndash50

including renal agenesis (most commonly unilateral agenesis) ectopia hypoplasia fusion malrotation and duplication

bull Other

vertebral bodies -(29)

wedged or fused vertebral bodies and spinabifida(22ndash23)

cardiac anomalies (145) and

syndromes such as Klippel-Feil syndrome (7)

IMAGING MODALITIES

bull HSG-limitation to see fundal contour

bull USG

bull MRI-standard procedure of imaging

bull The Muumlllerian duct anomaly classification is a seven point system that can be used to describe a number of embryonic Muumlllerian duct anomalies

bull class I uterine agenesisuterine hypoplasiandash a vaginal (uterus normal variety of abnormal forms)ndash b cervicalndash c fundalndash d tubalndash e combined

bull class II unicornuate uterusunicornis unicollis ~6-25ndash a communicating contralateral rudimentary horn contains endometriumndash b non-communicating contralateral rudimentary horn contains endometriumndash c contralateral horn has no endometrial cavityndash d no horn

bull class III uterus didelphys ~5-11bull class IV bicornuate uterus next commonest type ~10-39

ndash a complete division all the way down to internal the osndash b partial division not extending to the os

bull class V septate uterus commonest anomaly ~34-55ndash a complete division all the way down to internal the osndash b incomplete division

bull class VI arcuate uterus ~7bull class VII in utero Diethylstilbestrol (DES) exposure T shaped uterus

ASSOCIATED ANOMALIES

MDAs are also commonly associated with

Renal anomalies-30ndash50

including renal agenesis (most commonly unilateral agenesis) ectopia hypoplasia fusion malrotation and duplication

bull Other

vertebral bodies -(29)

wedged or fused vertebral bodies and spinabifida(22ndash23)

cardiac anomalies (145) and

syndromes such as Klippel-Feil syndrome (7)

IMAGING MODALITIES

bull HSG-limitation to see fundal contour

bull USG

bull MRI-standard procedure of imaging

bull The Muumlllerian duct anomaly classification is a seven point system that can be used to describe a number of embryonic Muumlllerian duct anomalies

bull class I uterine agenesisuterine hypoplasiandash a vaginal (uterus normal variety of abnormal forms)ndash b cervicalndash c fundalndash d tubalndash e combined

bull class II unicornuate uterusunicornis unicollis ~6-25ndash a communicating contralateral rudimentary horn contains endometriumndash b non-communicating contralateral rudimentary horn contains endometriumndash c contralateral horn has no endometrial cavityndash d no horn

bull class III uterus didelphys ~5-11bull class IV bicornuate uterus next commonest type ~10-39

ndash a complete division all the way down to internal the osndash b partial division not extending to the os

bull class V septate uterus commonest anomaly ~34-55ndash a complete division all the way down to internal the osndash b incomplete division

bull class VI arcuate uterus ~7bull class VII in utero Diethylstilbestrol (DES) exposure T shaped uterus

IMAGING MODALITIES

bull HSG-limitation to see fundal contour

bull USG

bull MRI-standard procedure of imaging

bull The Muumlllerian duct anomaly classification is a seven point system that can be used to describe a number of embryonic Muumlllerian duct anomalies

bull class I uterine agenesisuterine hypoplasiandash a vaginal (uterus normal variety of abnormal forms)ndash b cervicalndash c fundalndash d tubalndash e combined

bull class II unicornuate uterusunicornis unicollis ~6-25ndash a communicating contralateral rudimentary horn contains endometriumndash b non-communicating contralateral rudimentary horn contains endometriumndash c contralateral horn has no endometrial cavityndash d no horn

bull class III uterus didelphys ~5-11bull class IV bicornuate uterus next commonest type ~10-39

ndash a complete division all the way down to internal the osndash b partial division not extending to the os

bull class V septate uterus commonest anomaly ~34-55ndash a complete division all the way down to internal the osndash b incomplete division

bull class VI arcuate uterus ~7bull class VII in utero Diethylstilbestrol (DES) exposure T shaped uterus

bull The Muumlllerian duct anomaly classification is a seven point system that can be used to describe a number of embryonic Muumlllerian duct anomalies

bull class I uterine agenesisuterine hypoplasiandash a vaginal (uterus normal variety of abnormal forms)ndash b cervicalndash c fundalndash d tubalndash e combined

bull class II unicornuate uterusunicornis unicollis ~6-25ndash a communicating contralateral rudimentary horn contains endometriumndash b non-communicating contralateral rudimentary horn contains endometriumndash c contralateral horn has no endometrial cavityndash d no horn

bull class III uterus didelphys ~5-11bull class IV bicornuate uterus next commonest type ~10-39

ndash a complete division all the way down to internal the osndash b partial division not extending to the os

bull class V septate uterus commonest anomaly ~34-55ndash a complete division all the way down to internal the osndash b incomplete division

bull class VI arcuate uterus ~7bull class VII in utero Diethylstilbestrol (DES) exposure T shaped uterus

Classification of MDAs on the basis of the American Society for Reproductive Medicine system DES = diethylstilbestrol (Courtesy of Joanna Culley

Mayer-Rokitansky-Kuumlster-Hauser syndrome (a) Sagittal T2-weighted MR image shows complete absence of the cervix and uterus with an abnormally truncated vagina ending in a blind pouch

(arrowhead) between the rectum (r) and urinary bladder(b) Axial T2-weighted image shows the presence of normal ovaries ()

UNICORNUATE UTERUSResults from normal development of one mullerian duct and near complete to complete arrested development of the contralateral duct

This anomaly has four subtypes(a) no rudimentary horn (b) rudimentary horn with no uterine cavity(c) rudimentary horn with a communicating cavity to the normal side and(d) rudimentary horn with a noncommunicating cavity

40 cases are associated with renal anomalies ipsilateral to the rudimentary horn with renal agenesis being the most common (67 of cases)

Unicornuate uterus with no rudimentary horn

HSG image shows a small oblong uterine cavity () deviated to the right of midline with a single fallopian tube (arrowhead)

Unicornuate uterus with no rudimentary horn axial T2-weighted MR image shows a single uterine horn () and cervix (arrowhead)

Coronal T2-weighted MR image shows absence of soft tissue adjacent to the right unicornuate cervix (arrowhead) a finding indicating absence of a rudimentary horn

Unicornuate uterus with an obstructed noncommunicating rudimentary horn Axial T2- weighted MR images show a normal-appearing left unicornuate uterus (arrow in a) and an obstructed noncommunicatingright rudimentary horn with layering debris ( in b)

UTERINE DIDELPHIS

complete failure of muumlllerian duct fusion Duplication of the uterine horns cervix and proximal

vagina Usually asymptomaticHematometrocolpos may occur if there is transverse

hemivaginal septum resulting in ipsilateralobstruction

Patients with hemivaginal obstruction present with dysmenorrhea secondary to endometriosis infections and pelvic adhesions attributed to retrograde menstrual flow from the obstructed side

It is commonly associated with ipsilateral renal agenesis

HSG demonstrates two separate oblong endometrial cavities with contrast opacification of fallopian tubes

bull USG-widely divergent uterine horns with separate non communicating endometrial cavities

There is two cervices and duplicated upper vaginas

bull MR-Endometrial-to-myometrial ratio and zonal anatomy are normal

Duplication of the proximal vagina may be visualized at MR imaging and this may be further improved by instillation of viscous liquid such as ultrasound gel into the vagina before imaging

Transverse transabdominal US image shows a uterus didelphys with two uterine horns (u) separated by echogenic fat () There is a viable embryo (arrow) in the left

uterine horn

Uterus didelphys with an obstructed hemivagina

(a) Coronal T2W MR image shows widely separated horns of a uterus (white arrows)

Two hemivaginas (arrowheads)

absent left kidney (black arrow) with bowel in the renal fossa which is ipsilateral to the obstructed hemivagina

(b) Axial T2-weighted image shows the two hemivaginas (arrowheads) the obstructed dilated left hemivagina contains heterogeneous debris ()

bull BICORNUATE UTERUS-

incomplete or partial fusion of the muumlllerian ducts

presence of a cleft (gt1 cm in depth at MR imaging) in the external contour of the uterine fundus

The duplicated endometrial cavity may be associated with cervix duplication (bicornuate bicollis) or be without cervix duplication (bicornuate unicollis)

bull HSG- Opacification of two symmetric fusiform uterine cavities (horns) and fallopian tubes Historically an intercornual angle of greater than 105deg was used for diagnosis

bull US-divergent uterine horns and separation of uterine cavities may be optimally seen in the secretory phase of the menstrual cycle due to echogenicity of the endometrium

bull MR-both uterine horns have normal zonal anatomy The appearance of a duplicated cervix (ldquoowl eyesrdquo) is seen in patients with a bicornuate bicollis uterus which can be confidently diagnosed in the absence of vaginal duplication

SEPTATE UTERUS-

Most common form of MDA (55)

The septum originates from the midline of the uterine fundus and extend caudally

Result of complete or partial failure of reabsorption of the uterovaginal septum

The septum ndashpartial

- complete(extends upto external cervical os

in some cases upto upper vagina)

Fibrous tissue and myometrium

bull HSG-HSG cannot be used to evaluate the external uterine contour and therefore does not allow reliable differentiation of septatefrom bicornuate uterus

bull USG-interruption of the myometrium by a septum at the fundus The fibrous component of the septum is less echogenic relative to myometrium

bull MR-the uterus is normal in sizeThe key to differentiating a septate uterus from a bicornuate uterus is the external fundalcontour

HSG image of a partial septate uterus shows a thin linear filling defect (arrow) extending from the uterine fundus separating the uterine cavity into two symmetric cavities

USG image of partial septate uterus shows the isoechoic muscular septum and hypoechoic fibrous septum () extends just proximal to the internal cervical os(arrowhead)The apex of the fundal contour (arrow) is more than 5 mm above a line drawn between the tubal ostia (white line)

Axial T2-weighted MR image of a complete septate uterus shows a normal external uterine contour (black arrow) The hypointense fibrous septum (white arrows) originates from the isointense muscular septum and extends into the cervical os (arrowhead) A hypointense uterine fundal fibroid (f) is also present

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Mayer-Rokitansky-Kuumlster-Hauser syndrome (a) Sagittal T2-weighted MR image shows complete absence of the cervix and uterus with an abnormally truncated vagina ending in a blind pouch

(arrowhead) between the rectum (r) and urinary bladder(b) Axial T2-weighted image shows the presence of normal ovaries ()

UNICORNUATE UTERUSResults from normal development of one mullerian duct and near complete to complete arrested development of the contralateral duct

This anomaly has four subtypes(a) no rudimentary horn (b) rudimentary horn with no uterine cavity(c) rudimentary horn with a communicating cavity to the normal side and(d) rudimentary horn with a noncommunicating cavity

40 cases are associated with renal anomalies ipsilateral to the rudimentary horn with renal agenesis being the most common (67 of cases)

Unicornuate uterus with no rudimentary horn

HSG image shows a small oblong uterine cavity () deviated to the right of midline with a single fallopian tube (arrowhead)

Unicornuate uterus with no rudimentary horn axial T2-weighted MR image shows a single uterine horn () and cervix (arrowhead)

Coronal T2-weighted MR image shows absence of soft tissue adjacent to the right unicornuate cervix (arrowhead) a finding indicating absence of a rudimentary horn

Unicornuate uterus with an obstructed noncommunicating rudimentary horn Axial T2- weighted MR images show a normal-appearing left unicornuate uterus (arrow in a) and an obstructed noncommunicatingright rudimentary horn with layering debris ( in b)

UTERINE DIDELPHIS

complete failure of muumlllerian duct fusion Duplication of the uterine horns cervix and proximal

vagina Usually asymptomaticHematometrocolpos may occur if there is transverse

hemivaginal septum resulting in ipsilateralobstruction

Patients with hemivaginal obstruction present with dysmenorrhea secondary to endometriosis infections and pelvic adhesions attributed to retrograde menstrual flow from the obstructed side

It is commonly associated with ipsilateral renal agenesis

HSG demonstrates two separate oblong endometrial cavities with contrast opacification of fallopian tubes

bull USG-widely divergent uterine horns with separate non communicating endometrial cavities

There is two cervices and duplicated upper vaginas

bull MR-Endometrial-to-myometrial ratio and zonal anatomy are normal

Duplication of the proximal vagina may be visualized at MR imaging and this may be further improved by instillation of viscous liquid such as ultrasound gel into the vagina before imaging

Transverse transabdominal US image shows a uterus didelphys with two uterine horns (u) separated by echogenic fat () There is a viable embryo (arrow) in the left

uterine horn

Uterus didelphys with an obstructed hemivagina

(a) Coronal T2W MR image shows widely separated horns of a uterus (white arrows)

Two hemivaginas (arrowheads)

absent left kidney (black arrow) with bowel in the renal fossa which is ipsilateral to the obstructed hemivagina

(b) Axial T2-weighted image shows the two hemivaginas (arrowheads) the obstructed dilated left hemivagina contains heterogeneous debris ()

bull BICORNUATE UTERUS-

incomplete or partial fusion of the muumlllerian ducts

presence of a cleft (gt1 cm in depth at MR imaging) in the external contour of the uterine fundus

The duplicated endometrial cavity may be associated with cervix duplication (bicornuate bicollis) or be without cervix duplication (bicornuate unicollis)

bull HSG- Opacification of two symmetric fusiform uterine cavities (horns) and fallopian tubes Historically an intercornual angle of greater than 105deg was used for diagnosis

bull US-divergent uterine horns and separation of uterine cavities may be optimally seen in the secretory phase of the menstrual cycle due to echogenicity of the endometrium

bull MR-both uterine horns have normal zonal anatomy The appearance of a duplicated cervix (ldquoowl eyesrdquo) is seen in patients with a bicornuate bicollis uterus which can be confidently diagnosed in the absence of vaginal duplication

SEPTATE UTERUS-

Most common form of MDA (55)

The septum originates from the midline of the uterine fundus and extend caudally

Result of complete or partial failure of reabsorption of the uterovaginal septum

The septum ndashpartial

- complete(extends upto external cervical os

in some cases upto upper vagina)

Fibrous tissue and myometrium

bull HSG-HSG cannot be used to evaluate the external uterine contour and therefore does not allow reliable differentiation of septatefrom bicornuate uterus

bull USG-interruption of the myometrium by a septum at the fundus The fibrous component of the septum is less echogenic relative to myometrium

bull MR-the uterus is normal in sizeThe key to differentiating a septate uterus from a bicornuate uterus is the external fundalcontour

HSG image of a partial septate uterus shows a thin linear filling defect (arrow) extending from the uterine fundus separating the uterine cavity into two symmetric cavities

USG image of partial septate uterus shows the isoechoic muscular septum and hypoechoic fibrous septum () extends just proximal to the internal cervical os(arrowhead)The apex of the fundal contour (arrow) is more than 5 mm above a line drawn between the tubal ostia (white line)

Axial T2-weighted MR image of a complete septate uterus shows a normal external uterine contour (black arrow) The hypointense fibrous septum (white arrows) originates from the isointense muscular septum and extends into the cervical os (arrowhead) A hypointense uterine fundal fibroid (f) is also present

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

UNICORNUATE UTERUSResults from normal development of one mullerian duct and near complete to complete arrested development of the contralateral duct

This anomaly has four subtypes(a) no rudimentary horn (b) rudimentary horn with no uterine cavity(c) rudimentary horn with a communicating cavity to the normal side and(d) rudimentary horn with a noncommunicating cavity

40 cases are associated with renal anomalies ipsilateral to the rudimentary horn with renal agenesis being the most common (67 of cases)

Unicornuate uterus with no rudimentary horn

HSG image shows a small oblong uterine cavity () deviated to the right of midline with a single fallopian tube (arrowhead)

Unicornuate uterus with no rudimentary horn axial T2-weighted MR image shows a single uterine horn () and cervix (arrowhead)

Coronal T2-weighted MR image shows absence of soft tissue adjacent to the right unicornuate cervix (arrowhead) a finding indicating absence of a rudimentary horn

Unicornuate uterus with an obstructed noncommunicating rudimentary horn Axial T2- weighted MR images show a normal-appearing left unicornuate uterus (arrow in a) and an obstructed noncommunicatingright rudimentary horn with layering debris ( in b)

UTERINE DIDELPHIS

complete failure of muumlllerian duct fusion Duplication of the uterine horns cervix and proximal

vagina Usually asymptomaticHematometrocolpos may occur if there is transverse

hemivaginal septum resulting in ipsilateralobstruction

Patients with hemivaginal obstruction present with dysmenorrhea secondary to endometriosis infections and pelvic adhesions attributed to retrograde menstrual flow from the obstructed side

It is commonly associated with ipsilateral renal agenesis

HSG demonstrates two separate oblong endometrial cavities with contrast opacification of fallopian tubes

bull USG-widely divergent uterine horns with separate non communicating endometrial cavities

There is two cervices and duplicated upper vaginas

bull MR-Endometrial-to-myometrial ratio and zonal anatomy are normal

Duplication of the proximal vagina may be visualized at MR imaging and this may be further improved by instillation of viscous liquid such as ultrasound gel into the vagina before imaging

Transverse transabdominal US image shows a uterus didelphys with two uterine horns (u) separated by echogenic fat () There is a viable embryo (arrow) in the left

uterine horn

Uterus didelphys with an obstructed hemivagina

(a) Coronal T2W MR image shows widely separated horns of a uterus (white arrows)

Two hemivaginas (arrowheads)

absent left kidney (black arrow) with bowel in the renal fossa which is ipsilateral to the obstructed hemivagina

(b) Axial T2-weighted image shows the two hemivaginas (arrowheads) the obstructed dilated left hemivagina contains heterogeneous debris ()

bull BICORNUATE UTERUS-

incomplete or partial fusion of the muumlllerian ducts

presence of a cleft (gt1 cm in depth at MR imaging) in the external contour of the uterine fundus

The duplicated endometrial cavity may be associated with cervix duplication (bicornuate bicollis) or be without cervix duplication (bicornuate unicollis)

bull HSG- Opacification of two symmetric fusiform uterine cavities (horns) and fallopian tubes Historically an intercornual angle of greater than 105deg was used for diagnosis

bull US-divergent uterine horns and separation of uterine cavities may be optimally seen in the secretory phase of the menstrual cycle due to echogenicity of the endometrium

bull MR-both uterine horns have normal zonal anatomy The appearance of a duplicated cervix (ldquoowl eyesrdquo) is seen in patients with a bicornuate bicollis uterus which can be confidently diagnosed in the absence of vaginal duplication

SEPTATE UTERUS-

Most common form of MDA (55)

The septum originates from the midline of the uterine fundus and extend caudally

Result of complete or partial failure of reabsorption of the uterovaginal septum

The septum ndashpartial

- complete(extends upto external cervical os

in some cases upto upper vagina)

Fibrous tissue and myometrium

bull HSG-HSG cannot be used to evaluate the external uterine contour and therefore does not allow reliable differentiation of septatefrom bicornuate uterus

bull USG-interruption of the myometrium by a septum at the fundus The fibrous component of the septum is less echogenic relative to myometrium

bull MR-the uterus is normal in sizeThe key to differentiating a septate uterus from a bicornuate uterus is the external fundalcontour

HSG image of a partial septate uterus shows a thin linear filling defect (arrow) extending from the uterine fundus separating the uterine cavity into two symmetric cavities

USG image of partial septate uterus shows the isoechoic muscular septum and hypoechoic fibrous septum () extends just proximal to the internal cervical os(arrowhead)The apex of the fundal contour (arrow) is more than 5 mm above a line drawn between the tubal ostia (white line)

Axial T2-weighted MR image of a complete septate uterus shows a normal external uterine contour (black arrow) The hypointense fibrous septum (white arrows) originates from the isointense muscular septum and extends into the cervical os (arrowhead) A hypointense uterine fundal fibroid (f) is also present

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Unicornuate uterus with no rudimentary horn

HSG image shows a small oblong uterine cavity () deviated to the right of midline with a single fallopian tube (arrowhead)

Unicornuate uterus with no rudimentary horn axial T2-weighted MR image shows a single uterine horn () and cervix (arrowhead)

Coronal T2-weighted MR image shows absence of soft tissue adjacent to the right unicornuate cervix (arrowhead) a finding indicating absence of a rudimentary horn

Unicornuate uterus with an obstructed noncommunicating rudimentary horn Axial T2- weighted MR images show a normal-appearing left unicornuate uterus (arrow in a) and an obstructed noncommunicatingright rudimentary horn with layering debris ( in b)

UTERINE DIDELPHIS

complete failure of muumlllerian duct fusion Duplication of the uterine horns cervix and proximal

vagina Usually asymptomaticHematometrocolpos may occur if there is transverse

hemivaginal septum resulting in ipsilateralobstruction

Patients with hemivaginal obstruction present with dysmenorrhea secondary to endometriosis infections and pelvic adhesions attributed to retrograde menstrual flow from the obstructed side

It is commonly associated with ipsilateral renal agenesis

HSG demonstrates two separate oblong endometrial cavities with contrast opacification of fallopian tubes

bull USG-widely divergent uterine horns with separate non communicating endometrial cavities

There is two cervices and duplicated upper vaginas

bull MR-Endometrial-to-myometrial ratio and zonal anatomy are normal

Duplication of the proximal vagina may be visualized at MR imaging and this may be further improved by instillation of viscous liquid such as ultrasound gel into the vagina before imaging

Transverse transabdominal US image shows a uterus didelphys with two uterine horns (u) separated by echogenic fat () There is a viable embryo (arrow) in the left

uterine horn

Uterus didelphys with an obstructed hemivagina

(a) Coronal T2W MR image shows widely separated horns of a uterus (white arrows)

Two hemivaginas (arrowheads)

absent left kidney (black arrow) with bowel in the renal fossa which is ipsilateral to the obstructed hemivagina

(b) Axial T2-weighted image shows the two hemivaginas (arrowheads) the obstructed dilated left hemivagina contains heterogeneous debris ()

bull BICORNUATE UTERUS-

incomplete or partial fusion of the muumlllerian ducts

presence of a cleft (gt1 cm in depth at MR imaging) in the external contour of the uterine fundus

The duplicated endometrial cavity may be associated with cervix duplication (bicornuate bicollis) or be without cervix duplication (bicornuate unicollis)

bull HSG- Opacification of two symmetric fusiform uterine cavities (horns) and fallopian tubes Historically an intercornual angle of greater than 105deg was used for diagnosis

bull US-divergent uterine horns and separation of uterine cavities may be optimally seen in the secretory phase of the menstrual cycle due to echogenicity of the endometrium

bull MR-both uterine horns have normal zonal anatomy The appearance of a duplicated cervix (ldquoowl eyesrdquo) is seen in patients with a bicornuate bicollis uterus which can be confidently diagnosed in the absence of vaginal duplication

SEPTATE UTERUS-

Most common form of MDA (55)

The septum originates from the midline of the uterine fundus and extend caudally

Result of complete or partial failure of reabsorption of the uterovaginal septum

The septum ndashpartial

- complete(extends upto external cervical os

in some cases upto upper vagina)

Fibrous tissue and myometrium

bull HSG-HSG cannot be used to evaluate the external uterine contour and therefore does not allow reliable differentiation of septatefrom bicornuate uterus

bull USG-interruption of the myometrium by a septum at the fundus The fibrous component of the septum is less echogenic relative to myometrium

bull MR-the uterus is normal in sizeThe key to differentiating a septate uterus from a bicornuate uterus is the external fundalcontour

HSG image of a partial septate uterus shows a thin linear filling defect (arrow) extending from the uterine fundus separating the uterine cavity into two symmetric cavities

USG image of partial septate uterus shows the isoechoic muscular septum and hypoechoic fibrous septum () extends just proximal to the internal cervical os(arrowhead)The apex of the fundal contour (arrow) is more than 5 mm above a line drawn between the tubal ostia (white line)

Axial T2-weighted MR image of a complete septate uterus shows a normal external uterine contour (black arrow) The hypointense fibrous septum (white arrows) originates from the isointense muscular septum and extends into the cervical os (arrowhead) A hypointense uterine fundal fibroid (f) is also present

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Unicornuate uterus with no rudimentary horn axial T2-weighted MR image shows a single uterine horn () and cervix (arrowhead)

Coronal T2-weighted MR image shows absence of soft tissue adjacent to the right unicornuate cervix (arrowhead) a finding indicating absence of a rudimentary horn

Unicornuate uterus with an obstructed noncommunicating rudimentary horn Axial T2- weighted MR images show a normal-appearing left unicornuate uterus (arrow in a) and an obstructed noncommunicatingright rudimentary horn with layering debris ( in b)

UTERINE DIDELPHIS

complete failure of muumlllerian duct fusion Duplication of the uterine horns cervix and proximal

vagina Usually asymptomaticHematometrocolpos may occur if there is transverse

hemivaginal septum resulting in ipsilateralobstruction

Patients with hemivaginal obstruction present with dysmenorrhea secondary to endometriosis infections and pelvic adhesions attributed to retrograde menstrual flow from the obstructed side

It is commonly associated with ipsilateral renal agenesis

HSG demonstrates two separate oblong endometrial cavities with contrast opacification of fallopian tubes

bull USG-widely divergent uterine horns with separate non communicating endometrial cavities

There is two cervices and duplicated upper vaginas

bull MR-Endometrial-to-myometrial ratio and zonal anatomy are normal

Duplication of the proximal vagina may be visualized at MR imaging and this may be further improved by instillation of viscous liquid such as ultrasound gel into the vagina before imaging

Transverse transabdominal US image shows a uterus didelphys with two uterine horns (u) separated by echogenic fat () There is a viable embryo (arrow) in the left

uterine horn

Uterus didelphys with an obstructed hemivagina

(a) Coronal T2W MR image shows widely separated horns of a uterus (white arrows)

Two hemivaginas (arrowheads)

absent left kidney (black arrow) with bowel in the renal fossa which is ipsilateral to the obstructed hemivagina

(b) Axial T2-weighted image shows the two hemivaginas (arrowheads) the obstructed dilated left hemivagina contains heterogeneous debris ()

bull BICORNUATE UTERUS-

incomplete or partial fusion of the muumlllerian ducts

presence of a cleft (gt1 cm in depth at MR imaging) in the external contour of the uterine fundus

The duplicated endometrial cavity may be associated with cervix duplication (bicornuate bicollis) or be without cervix duplication (bicornuate unicollis)

bull HSG- Opacification of two symmetric fusiform uterine cavities (horns) and fallopian tubes Historically an intercornual angle of greater than 105deg was used for diagnosis

bull US-divergent uterine horns and separation of uterine cavities may be optimally seen in the secretory phase of the menstrual cycle due to echogenicity of the endometrium

bull MR-both uterine horns have normal zonal anatomy The appearance of a duplicated cervix (ldquoowl eyesrdquo) is seen in patients with a bicornuate bicollis uterus which can be confidently diagnosed in the absence of vaginal duplication

SEPTATE UTERUS-

Most common form of MDA (55)

The septum originates from the midline of the uterine fundus and extend caudally

Result of complete or partial failure of reabsorption of the uterovaginal septum

The septum ndashpartial

- complete(extends upto external cervical os

in some cases upto upper vagina)

Fibrous tissue and myometrium

bull HSG-HSG cannot be used to evaluate the external uterine contour and therefore does not allow reliable differentiation of septatefrom bicornuate uterus

bull USG-interruption of the myometrium by a septum at the fundus The fibrous component of the septum is less echogenic relative to myometrium

bull MR-the uterus is normal in sizeThe key to differentiating a septate uterus from a bicornuate uterus is the external fundalcontour

HSG image of a partial septate uterus shows a thin linear filling defect (arrow) extending from the uterine fundus separating the uterine cavity into two symmetric cavities

USG image of partial septate uterus shows the isoechoic muscular septum and hypoechoic fibrous septum () extends just proximal to the internal cervical os(arrowhead)The apex of the fundal contour (arrow) is more than 5 mm above a line drawn between the tubal ostia (white line)

Axial T2-weighted MR image of a complete septate uterus shows a normal external uterine contour (black arrow) The hypointense fibrous septum (white arrows) originates from the isointense muscular septum and extends into the cervical os (arrowhead) A hypointense uterine fundal fibroid (f) is also present

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Unicornuate uterus with an obstructed noncommunicating rudimentary horn Axial T2- weighted MR images show a normal-appearing left unicornuate uterus (arrow in a) and an obstructed noncommunicatingright rudimentary horn with layering debris ( in b)

UTERINE DIDELPHIS

complete failure of muumlllerian duct fusion Duplication of the uterine horns cervix and proximal

vagina Usually asymptomaticHematometrocolpos may occur if there is transverse

hemivaginal septum resulting in ipsilateralobstruction

Patients with hemivaginal obstruction present with dysmenorrhea secondary to endometriosis infections and pelvic adhesions attributed to retrograde menstrual flow from the obstructed side

It is commonly associated with ipsilateral renal agenesis

HSG demonstrates two separate oblong endometrial cavities with contrast opacification of fallopian tubes

bull USG-widely divergent uterine horns with separate non communicating endometrial cavities

There is two cervices and duplicated upper vaginas

bull MR-Endometrial-to-myometrial ratio and zonal anatomy are normal

Duplication of the proximal vagina may be visualized at MR imaging and this may be further improved by instillation of viscous liquid such as ultrasound gel into the vagina before imaging

Transverse transabdominal US image shows a uterus didelphys with two uterine horns (u) separated by echogenic fat () There is a viable embryo (arrow) in the left

uterine horn

Uterus didelphys with an obstructed hemivagina

(a) Coronal T2W MR image shows widely separated horns of a uterus (white arrows)

Two hemivaginas (arrowheads)

absent left kidney (black arrow) with bowel in the renal fossa which is ipsilateral to the obstructed hemivagina

(b) Axial T2-weighted image shows the two hemivaginas (arrowheads) the obstructed dilated left hemivagina contains heterogeneous debris ()

bull BICORNUATE UTERUS-

incomplete or partial fusion of the muumlllerian ducts

presence of a cleft (gt1 cm in depth at MR imaging) in the external contour of the uterine fundus

The duplicated endometrial cavity may be associated with cervix duplication (bicornuate bicollis) or be without cervix duplication (bicornuate unicollis)

bull HSG- Opacification of two symmetric fusiform uterine cavities (horns) and fallopian tubes Historically an intercornual angle of greater than 105deg was used for diagnosis

bull US-divergent uterine horns and separation of uterine cavities may be optimally seen in the secretory phase of the menstrual cycle due to echogenicity of the endometrium

bull MR-both uterine horns have normal zonal anatomy The appearance of a duplicated cervix (ldquoowl eyesrdquo) is seen in patients with a bicornuate bicollis uterus which can be confidently diagnosed in the absence of vaginal duplication

SEPTATE UTERUS-

Most common form of MDA (55)

The septum originates from the midline of the uterine fundus and extend caudally

Result of complete or partial failure of reabsorption of the uterovaginal septum

The septum ndashpartial

- complete(extends upto external cervical os

in some cases upto upper vagina)

Fibrous tissue and myometrium

bull HSG-HSG cannot be used to evaluate the external uterine contour and therefore does not allow reliable differentiation of septatefrom bicornuate uterus

bull USG-interruption of the myometrium by a septum at the fundus The fibrous component of the septum is less echogenic relative to myometrium

bull MR-the uterus is normal in sizeThe key to differentiating a septate uterus from a bicornuate uterus is the external fundalcontour

HSG image of a partial septate uterus shows a thin linear filling defect (arrow) extending from the uterine fundus separating the uterine cavity into two symmetric cavities

USG image of partial septate uterus shows the isoechoic muscular septum and hypoechoic fibrous septum () extends just proximal to the internal cervical os(arrowhead)The apex of the fundal contour (arrow) is more than 5 mm above a line drawn between the tubal ostia (white line)

Axial T2-weighted MR image of a complete septate uterus shows a normal external uterine contour (black arrow) The hypointense fibrous septum (white arrows) originates from the isointense muscular septum and extends into the cervical os (arrowhead) A hypointense uterine fundal fibroid (f) is also present

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

UTERINE DIDELPHIS

complete failure of muumlllerian duct fusion Duplication of the uterine horns cervix and proximal

vagina Usually asymptomaticHematometrocolpos may occur if there is transverse

hemivaginal septum resulting in ipsilateralobstruction

Patients with hemivaginal obstruction present with dysmenorrhea secondary to endometriosis infections and pelvic adhesions attributed to retrograde menstrual flow from the obstructed side

It is commonly associated with ipsilateral renal agenesis

HSG demonstrates two separate oblong endometrial cavities with contrast opacification of fallopian tubes

bull USG-widely divergent uterine horns with separate non communicating endometrial cavities

There is two cervices and duplicated upper vaginas

bull MR-Endometrial-to-myometrial ratio and zonal anatomy are normal

Duplication of the proximal vagina may be visualized at MR imaging and this may be further improved by instillation of viscous liquid such as ultrasound gel into the vagina before imaging

Transverse transabdominal US image shows a uterus didelphys with two uterine horns (u) separated by echogenic fat () There is a viable embryo (arrow) in the left

uterine horn

Uterus didelphys with an obstructed hemivagina

(a) Coronal T2W MR image shows widely separated horns of a uterus (white arrows)

Two hemivaginas (arrowheads)

absent left kidney (black arrow) with bowel in the renal fossa which is ipsilateral to the obstructed hemivagina

(b) Axial T2-weighted image shows the two hemivaginas (arrowheads) the obstructed dilated left hemivagina contains heterogeneous debris ()

bull BICORNUATE UTERUS-

incomplete or partial fusion of the muumlllerian ducts

presence of a cleft (gt1 cm in depth at MR imaging) in the external contour of the uterine fundus

The duplicated endometrial cavity may be associated with cervix duplication (bicornuate bicollis) or be without cervix duplication (bicornuate unicollis)

bull HSG- Opacification of two symmetric fusiform uterine cavities (horns) and fallopian tubes Historically an intercornual angle of greater than 105deg was used for diagnosis

bull US-divergent uterine horns and separation of uterine cavities may be optimally seen in the secretory phase of the menstrual cycle due to echogenicity of the endometrium

bull MR-both uterine horns have normal zonal anatomy The appearance of a duplicated cervix (ldquoowl eyesrdquo) is seen in patients with a bicornuate bicollis uterus which can be confidently diagnosed in the absence of vaginal duplication

SEPTATE UTERUS-

Most common form of MDA (55)

The septum originates from the midline of the uterine fundus and extend caudally

Result of complete or partial failure of reabsorption of the uterovaginal septum

The septum ndashpartial

- complete(extends upto external cervical os

in some cases upto upper vagina)

Fibrous tissue and myometrium

bull HSG-HSG cannot be used to evaluate the external uterine contour and therefore does not allow reliable differentiation of septatefrom bicornuate uterus

bull USG-interruption of the myometrium by a septum at the fundus The fibrous component of the septum is less echogenic relative to myometrium

bull MR-the uterus is normal in sizeThe key to differentiating a septate uterus from a bicornuate uterus is the external fundalcontour

HSG image of a partial septate uterus shows a thin linear filling defect (arrow) extending from the uterine fundus separating the uterine cavity into two symmetric cavities

USG image of partial septate uterus shows the isoechoic muscular septum and hypoechoic fibrous septum () extends just proximal to the internal cervical os(arrowhead)The apex of the fundal contour (arrow) is more than 5 mm above a line drawn between the tubal ostia (white line)

Axial T2-weighted MR image of a complete septate uterus shows a normal external uterine contour (black arrow) The hypointense fibrous septum (white arrows) originates from the isointense muscular septum and extends into the cervical os (arrowhead) A hypointense uterine fundal fibroid (f) is also present

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

HSG demonstrates two separate oblong endometrial cavities with contrast opacification of fallopian tubes

bull USG-widely divergent uterine horns with separate non communicating endometrial cavities

There is two cervices and duplicated upper vaginas

bull MR-Endometrial-to-myometrial ratio and zonal anatomy are normal

Duplication of the proximal vagina may be visualized at MR imaging and this may be further improved by instillation of viscous liquid such as ultrasound gel into the vagina before imaging

Transverse transabdominal US image shows a uterus didelphys with two uterine horns (u) separated by echogenic fat () There is a viable embryo (arrow) in the left

uterine horn

Uterus didelphys with an obstructed hemivagina

(a) Coronal T2W MR image shows widely separated horns of a uterus (white arrows)

Two hemivaginas (arrowheads)

absent left kidney (black arrow) with bowel in the renal fossa which is ipsilateral to the obstructed hemivagina

(b) Axial T2-weighted image shows the two hemivaginas (arrowheads) the obstructed dilated left hemivagina contains heterogeneous debris ()

bull BICORNUATE UTERUS-

incomplete or partial fusion of the muumlllerian ducts

presence of a cleft (gt1 cm in depth at MR imaging) in the external contour of the uterine fundus

The duplicated endometrial cavity may be associated with cervix duplication (bicornuate bicollis) or be without cervix duplication (bicornuate unicollis)

bull HSG- Opacification of two symmetric fusiform uterine cavities (horns) and fallopian tubes Historically an intercornual angle of greater than 105deg was used for diagnosis

bull US-divergent uterine horns and separation of uterine cavities may be optimally seen in the secretory phase of the menstrual cycle due to echogenicity of the endometrium

bull MR-both uterine horns have normal zonal anatomy The appearance of a duplicated cervix (ldquoowl eyesrdquo) is seen in patients with a bicornuate bicollis uterus which can be confidently diagnosed in the absence of vaginal duplication

SEPTATE UTERUS-

Most common form of MDA (55)

The septum originates from the midline of the uterine fundus and extend caudally

Result of complete or partial failure of reabsorption of the uterovaginal septum

The septum ndashpartial

- complete(extends upto external cervical os

in some cases upto upper vagina)

Fibrous tissue and myometrium

bull HSG-HSG cannot be used to evaluate the external uterine contour and therefore does not allow reliable differentiation of septatefrom bicornuate uterus

bull USG-interruption of the myometrium by a septum at the fundus The fibrous component of the septum is less echogenic relative to myometrium

bull MR-the uterus is normal in sizeThe key to differentiating a septate uterus from a bicornuate uterus is the external fundalcontour

HSG image of a partial septate uterus shows a thin linear filling defect (arrow) extending from the uterine fundus separating the uterine cavity into two symmetric cavities

USG image of partial septate uterus shows the isoechoic muscular septum and hypoechoic fibrous septum () extends just proximal to the internal cervical os(arrowhead)The apex of the fundal contour (arrow) is more than 5 mm above a line drawn between the tubal ostia (white line)

Axial T2-weighted MR image of a complete septate uterus shows a normal external uterine contour (black arrow) The hypointense fibrous septum (white arrows) originates from the isointense muscular septum and extends into the cervical os (arrowhead) A hypointense uterine fundal fibroid (f) is also present

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Transverse transabdominal US image shows a uterus didelphys with two uterine horns (u) separated by echogenic fat () There is a viable embryo (arrow) in the left

uterine horn

Uterus didelphys with an obstructed hemivagina

(a) Coronal T2W MR image shows widely separated horns of a uterus (white arrows)

Two hemivaginas (arrowheads)

absent left kidney (black arrow) with bowel in the renal fossa which is ipsilateral to the obstructed hemivagina

(b) Axial T2-weighted image shows the two hemivaginas (arrowheads) the obstructed dilated left hemivagina contains heterogeneous debris ()

bull BICORNUATE UTERUS-

incomplete or partial fusion of the muumlllerian ducts

presence of a cleft (gt1 cm in depth at MR imaging) in the external contour of the uterine fundus

The duplicated endometrial cavity may be associated with cervix duplication (bicornuate bicollis) or be without cervix duplication (bicornuate unicollis)

bull HSG- Opacification of two symmetric fusiform uterine cavities (horns) and fallopian tubes Historically an intercornual angle of greater than 105deg was used for diagnosis

bull US-divergent uterine horns and separation of uterine cavities may be optimally seen in the secretory phase of the menstrual cycle due to echogenicity of the endometrium

bull MR-both uterine horns have normal zonal anatomy The appearance of a duplicated cervix (ldquoowl eyesrdquo) is seen in patients with a bicornuate bicollis uterus which can be confidently diagnosed in the absence of vaginal duplication

SEPTATE UTERUS-

Most common form of MDA (55)

The septum originates from the midline of the uterine fundus and extend caudally

Result of complete or partial failure of reabsorption of the uterovaginal septum

The septum ndashpartial

- complete(extends upto external cervical os

in some cases upto upper vagina)

Fibrous tissue and myometrium

bull HSG-HSG cannot be used to evaluate the external uterine contour and therefore does not allow reliable differentiation of septatefrom bicornuate uterus

bull USG-interruption of the myometrium by a septum at the fundus The fibrous component of the septum is less echogenic relative to myometrium

bull MR-the uterus is normal in sizeThe key to differentiating a septate uterus from a bicornuate uterus is the external fundalcontour

HSG image of a partial septate uterus shows a thin linear filling defect (arrow) extending from the uterine fundus separating the uterine cavity into two symmetric cavities

USG image of partial septate uterus shows the isoechoic muscular septum and hypoechoic fibrous septum () extends just proximal to the internal cervical os(arrowhead)The apex of the fundal contour (arrow) is more than 5 mm above a line drawn between the tubal ostia (white line)

Axial T2-weighted MR image of a complete septate uterus shows a normal external uterine contour (black arrow) The hypointense fibrous septum (white arrows) originates from the isointense muscular septum and extends into the cervical os (arrowhead) A hypointense uterine fundal fibroid (f) is also present

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Uterus didelphys with an obstructed hemivagina

(a) Coronal T2W MR image shows widely separated horns of a uterus (white arrows)

Two hemivaginas (arrowheads)

absent left kidney (black arrow) with bowel in the renal fossa which is ipsilateral to the obstructed hemivagina

(b) Axial T2-weighted image shows the two hemivaginas (arrowheads) the obstructed dilated left hemivagina contains heterogeneous debris ()

bull BICORNUATE UTERUS-

incomplete or partial fusion of the muumlllerian ducts

presence of a cleft (gt1 cm in depth at MR imaging) in the external contour of the uterine fundus

The duplicated endometrial cavity may be associated with cervix duplication (bicornuate bicollis) or be without cervix duplication (bicornuate unicollis)

bull HSG- Opacification of two symmetric fusiform uterine cavities (horns) and fallopian tubes Historically an intercornual angle of greater than 105deg was used for diagnosis

bull US-divergent uterine horns and separation of uterine cavities may be optimally seen in the secretory phase of the menstrual cycle due to echogenicity of the endometrium

bull MR-both uterine horns have normal zonal anatomy The appearance of a duplicated cervix (ldquoowl eyesrdquo) is seen in patients with a bicornuate bicollis uterus which can be confidently diagnosed in the absence of vaginal duplication

SEPTATE UTERUS-

Most common form of MDA (55)

The septum originates from the midline of the uterine fundus and extend caudally

Result of complete or partial failure of reabsorption of the uterovaginal septum

The septum ndashpartial

- complete(extends upto external cervical os

in some cases upto upper vagina)

Fibrous tissue and myometrium

bull HSG-HSG cannot be used to evaluate the external uterine contour and therefore does not allow reliable differentiation of septatefrom bicornuate uterus

bull USG-interruption of the myometrium by a septum at the fundus The fibrous component of the septum is less echogenic relative to myometrium

bull MR-the uterus is normal in sizeThe key to differentiating a septate uterus from a bicornuate uterus is the external fundalcontour

HSG image of a partial septate uterus shows a thin linear filling defect (arrow) extending from the uterine fundus separating the uterine cavity into two symmetric cavities

USG image of partial septate uterus shows the isoechoic muscular septum and hypoechoic fibrous septum () extends just proximal to the internal cervical os(arrowhead)The apex of the fundal contour (arrow) is more than 5 mm above a line drawn between the tubal ostia (white line)

Axial T2-weighted MR image of a complete septate uterus shows a normal external uterine contour (black arrow) The hypointense fibrous septum (white arrows) originates from the isointense muscular septum and extends into the cervical os (arrowhead) A hypointense uterine fundal fibroid (f) is also present

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

bull BICORNUATE UTERUS-

incomplete or partial fusion of the muumlllerian ducts

presence of a cleft (gt1 cm in depth at MR imaging) in the external contour of the uterine fundus

The duplicated endometrial cavity may be associated with cervix duplication (bicornuate bicollis) or be without cervix duplication (bicornuate unicollis)

bull HSG- Opacification of two symmetric fusiform uterine cavities (horns) and fallopian tubes Historically an intercornual angle of greater than 105deg was used for diagnosis

bull US-divergent uterine horns and separation of uterine cavities may be optimally seen in the secretory phase of the menstrual cycle due to echogenicity of the endometrium

bull MR-both uterine horns have normal zonal anatomy The appearance of a duplicated cervix (ldquoowl eyesrdquo) is seen in patients with a bicornuate bicollis uterus which can be confidently diagnosed in the absence of vaginal duplication

SEPTATE UTERUS-

Most common form of MDA (55)

The septum originates from the midline of the uterine fundus and extend caudally

Result of complete or partial failure of reabsorption of the uterovaginal septum

The septum ndashpartial

- complete(extends upto external cervical os

in some cases upto upper vagina)

Fibrous tissue and myometrium

bull HSG-HSG cannot be used to evaluate the external uterine contour and therefore does not allow reliable differentiation of septatefrom bicornuate uterus

bull USG-interruption of the myometrium by a septum at the fundus The fibrous component of the septum is less echogenic relative to myometrium

bull MR-the uterus is normal in sizeThe key to differentiating a septate uterus from a bicornuate uterus is the external fundalcontour

HSG image of a partial septate uterus shows a thin linear filling defect (arrow) extending from the uterine fundus separating the uterine cavity into two symmetric cavities

USG image of partial septate uterus shows the isoechoic muscular septum and hypoechoic fibrous septum () extends just proximal to the internal cervical os(arrowhead)The apex of the fundal contour (arrow) is more than 5 mm above a line drawn between the tubal ostia (white line)

Axial T2-weighted MR image of a complete septate uterus shows a normal external uterine contour (black arrow) The hypointense fibrous septum (white arrows) originates from the isointense muscular septum and extends into the cervical os (arrowhead) A hypointense uterine fundal fibroid (f) is also present

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

bull HSG- Opacification of two symmetric fusiform uterine cavities (horns) and fallopian tubes Historically an intercornual angle of greater than 105deg was used for diagnosis

bull US-divergent uterine horns and separation of uterine cavities may be optimally seen in the secretory phase of the menstrual cycle due to echogenicity of the endometrium

bull MR-both uterine horns have normal zonal anatomy The appearance of a duplicated cervix (ldquoowl eyesrdquo) is seen in patients with a bicornuate bicollis uterus which can be confidently diagnosed in the absence of vaginal duplication

SEPTATE UTERUS-

Most common form of MDA (55)

The septum originates from the midline of the uterine fundus and extend caudally

Result of complete or partial failure of reabsorption of the uterovaginal septum

The septum ndashpartial

- complete(extends upto external cervical os

in some cases upto upper vagina)

Fibrous tissue and myometrium

bull HSG-HSG cannot be used to evaluate the external uterine contour and therefore does not allow reliable differentiation of septatefrom bicornuate uterus

bull USG-interruption of the myometrium by a septum at the fundus The fibrous component of the septum is less echogenic relative to myometrium

bull MR-the uterus is normal in sizeThe key to differentiating a septate uterus from a bicornuate uterus is the external fundalcontour

HSG image of a partial septate uterus shows a thin linear filling defect (arrow) extending from the uterine fundus separating the uterine cavity into two symmetric cavities

USG image of partial septate uterus shows the isoechoic muscular septum and hypoechoic fibrous septum () extends just proximal to the internal cervical os(arrowhead)The apex of the fundal contour (arrow) is more than 5 mm above a line drawn between the tubal ostia (white line)

Axial T2-weighted MR image of a complete septate uterus shows a normal external uterine contour (black arrow) The hypointense fibrous septum (white arrows) originates from the isointense muscular septum and extends into the cervical os (arrowhead) A hypointense uterine fundal fibroid (f) is also present

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

SEPTATE UTERUS-

Most common form of MDA (55)

The septum originates from the midline of the uterine fundus and extend caudally

Result of complete or partial failure of reabsorption of the uterovaginal septum

The septum ndashpartial

- complete(extends upto external cervical os

in some cases upto upper vagina)

Fibrous tissue and myometrium

bull HSG-HSG cannot be used to evaluate the external uterine contour and therefore does not allow reliable differentiation of septatefrom bicornuate uterus

bull USG-interruption of the myometrium by a septum at the fundus The fibrous component of the septum is less echogenic relative to myometrium

bull MR-the uterus is normal in sizeThe key to differentiating a septate uterus from a bicornuate uterus is the external fundalcontour

HSG image of a partial septate uterus shows a thin linear filling defect (arrow) extending from the uterine fundus separating the uterine cavity into two symmetric cavities

USG image of partial septate uterus shows the isoechoic muscular septum and hypoechoic fibrous septum () extends just proximal to the internal cervical os(arrowhead)The apex of the fundal contour (arrow) is more than 5 mm above a line drawn between the tubal ostia (white line)

Axial T2-weighted MR image of a complete septate uterus shows a normal external uterine contour (black arrow) The hypointense fibrous septum (white arrows) originates from the isointense muscular septum and extends into the cervical os (arrowhead) A hypointense uterine fundal fibroid (f) is also present

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

bull HSG-HSG cannot be used to evaluate the external uterine contour and therefore does not allow reliable differentiation of septatefrom bicornuate uterus

bull USG-interruption of the myometrium by a septum at the fundus The fibrous component of the septum is less echogenic relative to myometrium

bull MR-the uterus is normal in sizeThe key to differentiating a septate uterus from a bicornuate uterus is the external fundalcontour

HSG image of a partial septate uterus shows a thin linear filling defect (arrow) extending from the uterine fundus separating the uterine cavity into two symmetric cavities

USG image of partial septate uterus shows the isoechoic muscular septum and hypoechoic fibrous septum () extends just proximal to the internal cervical os(arrowhead)The apex of the fundal contour (arrow) is more than 5 mm above a line drawn between the tubal ostia (white line)

Axial T2-weighted MR image of a complete septate uterus shows a normal external uterine contour (black arrow) The hypointense fibrous septum (white arrows) originates from the isointense muscular septum and extends into the cervical os (arrowhead) A hypointense uterine fundal fibroid (f) is also present

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

HSG image of a partial septate uterus shows a thin linear filling defect (arrow) extending from the uterine fundus separating the uterine cavity into two symmetric cavities

USG image of partial septate uterus shows the isoechoic muscular septum and hypoechoic fibrous septum () extends just proximal to the internal cervical os(arrowhead)The apex of the fundal contour (arrow) is more than 5 mm above a line drawn between the tubal ostia (white line)

Axial T2-weighted MR image of a complete septate uterus shows a normal external uterine contour (black arrow) The hypointense fibrous septum (white arrows) originates from the isointense muscular septum and extends into the cervical os (arrowhead) A hypointense uterine fundal fibroid (f) is also present

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

USG image of partial septate uterus shows the isoechoic muscular septum and hypoechoic fibrous septum () extends just proximal to the internal cervical os(arrowhead)The apex of the fundal contour (arrow) is more than 5 mm above a line drawn between the tubal ostia (white line)

Axial T2-weighted MR image of a complete septate uterus shows a normal external uterine contour (black arrow) The hypointense fibrous septum (white arrows) originates from the isointense muscular septum and extends into the cervical os (arrowhead) A hypointense uterine fundal fibroid (f) is also present

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Axial T2-weighted MR image of a complete septate uterus shows a normal external uterine contour (black arrow) The hypointense fibrous septum (white arrows) originates from the isointense muscular septum and extends into the cervical os (arrowhead) A hypointense uterine fundal fibroid (f) is also present

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

bull A line drawn between the uterine ostia may be used to differentiate between a septateand bicornuate uterus In a septate uterus the apex of the external fundal contour is more than 5 mm above the interostial line By comparison in a bicornuate or didelphysuterus the apex of the external fundalcontour is below or less than 5 mm above the interostial line

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Difference between septate and bicornuateuterus

bull Features septate uterus bicornuate uterus

1Depth of fundal cleft le 1cm gt 1cm

2Fundal contour convex or flat deep fundal concavity

3Intercornual angle lt 75deg gt105deg

4Intercornual distance lt 4 cm gt 4 cm

5Intercornual Fibrous or myometrial myometrialtissue

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

bull ARCUATE UTERUS-

Near reabsorption of the uterovaginal septum

Only mild indentation of the external fundal contour

This is mild form of MDA and is typically associated with normal-term gestation

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

bull HSG-A single uterine cavity with a broad saddle-shaped indentation at the uterine fundus

bull USG ndashshows a broad smooth inward contour deformity of the uterine fundus

There is a normal external contour

MR -Normal-sized uterus and the normal convex external uterine fundal contour There is a broad-based smooth prominence of soft tissue at the fundus with indentation of the endometrial cavity

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

HSG image shows a broad-based uterine fundal filling defect (black arrowhead) White arrowheads = patent fallopian tubes

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Coronal 3D US image shows the broad-based fundal myometrialprominence () and a convex external uterine contour (arrowheads)

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Axial gadolium-enhanced T1-weighted fat-saturated MR image shows the convex external uterine contour (arrow) and

the broad-based prominent fundal myometrium ()

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

bull DES Uterus ndash

classic T-shaped configuration of uterus in 31 of exposed women

T-shaped appearance is secondary to the shortened upper uterine segment

The fallopian tubes are often truncated and have an irregular appearance

constriction bands at the midfundal segment may be present which leads to narrowing of the proximal fallopian tube

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

HSG image shows the classic T-shaped uterine cavity due to DES exposure

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

UTERINE LEIOMYOMA

bull Found in 20-30 of women in reproductive yearsWell circumscribed and surrounded by pseudocapsule

INTRAMURAL most common mostly asymptomatic SUMUCOSAL mostly symptomatic may protude into cervical canal ka cervical fibroidSUBSEROSAL mostly projects into endometrial canal may undergo torsion and thereafter infarction Lateral growth of subserosal leiomyoma may extend between two

layers of broad ligament ka intra-ligamentous leiomyoma Large tumours may develop hyalinecystic and myxomatous

degeneration In postmenopausal women may undergo calcification

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Common symptoms bleedingpain pressure over adjacent organsinfertility

USGbull hypo to hyperbull homogenous to heterogenousbull with or without acoustic shadowing depending on contentsbull but most common appearance is well marginated round or oval

mass and shows peripheral supplyMRbull most sensitive imaging for leiomyoma can identify lesions even

smaller than 3mmbull most common appearance is ndashhypo on T2WIiso to myometrium on

T1WIpresence of calcification shows signal void on both T1 and T2WI

bull MR facilitates differentiation of pedunculated leiomyoma from an adnexal mass on basis of typical signal intensity and morphology

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

POST CONTRAST MR less enhancing than both endometrium and myometrium Fibroids with myxomamatous degeneration shows

heterogenous contrast enhancement helpful in localising uterine artery supplying the fibroids

and further in management as uterine artery embolisation

Exophytic leiomyoma shows bridging vessel sign which refers to presence of flow voids on both T1 and T2 from branches of uterine artery that are localised between mass and uterus

Malignant degeneration is rare(01-06) and should be suspected if a leiomyoma enlarges suddenly or if indistinct border irregullar contour along with contrast enhancement noted on MR imaging

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

A- shows well defined intramural fibroid B- shows submucosal

fibroid with displacement of endometrium posteriorly

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

bull Axial T2-weighted MR image shows submucosal (large ) intramural (small ) intracavitary(straight arrow) and subserosal(curved arrow) leiomyomas

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Prolapsed pedunculated leiomyoma manifesting as a vaginal mass

Sagittal T2W image show a mass of low to intermediate signal intensity (arrow) within a distended vaginal canal which is continuous superiorly with the endometrial canal

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

sagital T2WI shows hemmorrhagic degeneration in subserosal leiomyoma

Axial T1-weighted SE MR image obtained 4 months later shows maturation of the hemorrhage with high signal intensity confined to the rim

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Broad ligament fibroid -Right adnexal mass with whorled internal appearance

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

BRIDGING VESSEL SIGN IN EXOPHYTIC LEIOMYOMA

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

ADENOMYOSIS

It is uterine endometriosis in which there is ectopic endometrial glands and stroma with surrouding smooth muscle hyperplasia within the myometrium

TYPES-Focal(also ka adenomyomas)

diffuse

May occur along with fibroids

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

USG

TVS is most sensitive

diffuse form-bulky uterus with

1)poorly defined hypoechoic myometrium

2)heterogenous myometrium

3)asymmetrically thickened myometrial wall

4)shaggy endometrium with poor definition between endometrium and myometrium

5)scattered small (lt5mm)myometrial cysts

Focal form-shows indistinct margin and presence of hypoechoic lacunae in hyperechoic myometrium with several cysts

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

PELVIC MRI modality of choice to diagnose and characterize

adenomyosis T2W images (sagittal and axial) are most useful sensitivity of 78-88 and a specificity of 67-93

thickening of the junctional zone of the uterus gt12 mm either diffusely or focally (normal junctional zone measures no more than 5 mm)

bull small high T2 signal regions representing small regions of cystic change the region may also have a striated appearance

bull T1 Foci of high T1 signal are often seen indicating menstrual hemorrhage into the ectopic endometrial tissues

bull T1 C+ (Gd) contrast enhanced MR evaluation is usually not indicated in adenomyosis however if performed it shows enhancement of the ectopic endometrial glands

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

NORMAL MR ANATOMY OF UTERUST1WIThe entire uterus is isointense to muscle and different anatomic zones cannot be identifiedT2WIbull The central high-signal intensity endometrium and

secretions bull The middle low-signal intensity junctional

zone(innermost layer of myometrium ) measures 2 to 8 mm

bull The appearance of the junctional zone changes with sustained myometrial contractions or uterine peristalsis are important to distinguish from leiomyomas or adenomyosis

bull The outer intermediate-signal intensity of the myometrium

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Uterus is evaluated between isthmus and end of uterine cavity (white lines) Junctional zone (short arrows) should be measured from several sites on anterior and posterior walls Junctional zone measure can be compared with entire thickness of myometrium (long arrows) evaluated at same site

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

MRI (sagittal T2WI) shows adenomyosis with abnormal increase in thickness of junctional zone (12 mm) and abnormal high T2 SI of the myometrium represents abnormal stromal glands inside the myometrium B MRI (coronal T2WI) shows the same finding as well as bilateral ovarian simple cysts

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Axial and sagittal T1 T2 and postcontrastimages reveal bulky uterus with thickening andheterogeneity of junctional zone (JZ) poorly defined endomyometrialjunction multiple small T2 hyperintense foci inJZ showing heterogeneous contrast enhancement ndash Diffuseadenomyosis

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

features adenomyosis Leiomyoma

Margins Poorly defined Well circumscribed

Centre Junctional zone Any layer of uterusoriginates in myometrium

Appearance Focal or diffuse focal

T2 signal intensity Small hyperintensefoci

Hypointense unlessdegeneration present

Thickened junctionalzone

Yes gt12mm No

Mass effect on endometrium

Minimal or none + if intracavitary orsubmucosal

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

ENDOMETRIAL POLYPbull are localized hyperplastic overgrowth of endometrial

glands and stroma which are covered by endometriumbull may be sessile or pedunculated and usually attached to

the uterine fundus

USG-thickened endometrium a focal echogenic area in the endometrium or occasionally an endocavitary mass surrounded by fluid With Color Doppler a feeding artery may be seen in the pedicle of the polyp

SONOHYSTEROGRAPHY- is an ideal technique for diagnosis This is because a polyp seen as a round echogenic mass within the endometrial cavity is much more easily identified when there is fluid in the endometrial cavity outlining the mass

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

MR

T1WI- isointense to endometrium

T2WI-intermediate signal intensity

Contrast enhanced MRI- improve the sensitivity of detection

polyps generally enhance less than the edometrium but more than myometrium

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

SUBMUCOSAL FIBROID ENDOMETRIAL POLYP

Broader baseMore irregular contour on sonohysterography

Sessile or pedunculated almost well defined echogenic mass on sonohysterography

Normal layer of endometrium is seen overlying submucosal fibroid

Outlined by endometrium

MR-generally of lower intensity than polyp on T2WIIsointense to myometrium on T1WI

Intermediate ndashT2Iso to endometrium on T1

CEMR-non enhancing lower signal intensity than both endometrium or myometrium

Polyps enhances less than the surrounding endometrium but more than myometrium

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

bull ENDOMETRIAL HYPERPLASIA-

bull On ultrasonography a bilayer endometrial width

gt5 mm is regarded as abnormal in symptomatic post menopausal women

gt8mm In asymptomatic postmenopausal women on HRT cut off values range from lt 5 to gt 8 mm while in gt8mm in premenopausal women in the proliferative phase and

gt 16 mm in the secretory phase

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

TVS reveals diffuse thickened echogenic

endometrium with small cysts withinndash

Endometrial hyperplasia

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

POLYCYSTIC OVARIAN SYNDROME

According to Rotterdam crieteria

1) one or both ovaries demonstrate 12 or more follicles measuring 2ndash9 mm in diameter or

2) The ovarian volume exceeds 10 cc

Only one ovary meeting either of these criteria is sufficient to establish the presence of polycystic ovaries

Stromal echogenicity on USG

bull Any follicle gt10 mm or corpus luteum

should prompt repeat US during the next menstrual cycle)

bull Ovarian volume calculated with the simplified formula for an ellipsoid (05 times length times width times thickness)

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

characteristic T2-weighted MR imaging appearance of a polycystic ovary is abundant hypointense central stroma with

small peripheral T2-hyperintense cysts

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

CYSTADENOMAS

SEROUS CYSTADENOMA-

Counts for 25 of benign epithelial neoplasm

Thin walled unilocular of size upto 10cm

Contain clear fluid little or no septations

Papillary projections are generally absent

Bilateral upto 23 of cases

MUCINOUS CYSTADENOMA-

45 Thick walledmultilocular of

size 15- 30 cm Contain thick mucinous

content septas and papillary

projections are present but les than 3mm thick in benign form

Less commonly bilateral(upto 5)

Chances of malignancy is more

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Serous cystadenoma

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Mucinous cystadenoma

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

DERMOID CYST OR MATURE CYSTIC TERATOMA-

USG-

Focal or diffuse hyperechoic component with distal acoustic shadowing represent fat-ka dermoid plug

Fluid fluid level or layering of fat ka floating fat sign

Hyperechoic lines or dots ka dermoid mesh represent different component within like hair or calcification

No internal flow on colour Doppler

When a dermoid produces ill-defined acoustic shadowing that obscures the posterior wall of the lesion it is termed asldquoTip-of-the-iceberg-signrdquo This is produced by a mixture of matted hair and sebumwhich is highly echogenic because of multiple tissue interfaces

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

CT

Detection of fat (ndash130 to -90 HU)hair teeth and fat-fluid level

MRI

Fat is identified when the signal intensity of the mass (or part of it) is isointense to subcutaneous fat on both T1 and T2 weighted sequences and

internal or external chemical shift artefact indicating fat water interface is present

On fat saturation sequence suppression of signal that was of high signal intensity on T1 weighted sequence confirms the presence of fat within the mass

Intramural solid enhancing component on cross sectional images suggest malignancy

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Cystic ovarian mass with an echogenic mural

nodule in the periphery representing ldquodermoidplugrdquo-cystic teratoma

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Ovarian mature cystic teratoma-

shows cystic ovarian mass of fat attenuation

with fat fluid level central hair ball and areas of calcification

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

A) BL complex masses with bright signal of fat anteriorly

on T1W image (B) T1W fat-suppressed image showing

suppression of fat signal with chemical shift artifact at fat fluid

interface

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Endometriosis

is defined as the presence of endometrial epithelium and stroma in an ectopic site outside the uterine cavity Endometriosis occurs in 10 of the female population and almost exclusively in women of reproductive age The most common symptoms are dysmenorrhea dyspareunia pelvic pain and infertility although endometriosis may be asymptomatic

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Superficial endometriosis ( Sampsons syndrome ) superficial plaques are scattered across the

peritoneum ovaries and uterine ligaments minor symptoms and usually also less structural

changes in the pelvis At laparoscopy implants are be seen as superficial

powder-burn or gunshot lesions Deep pelvic endometriosis- (Cullens syndrome) There is subperitoneal infiltration of endometrial

depositsSevere symtoms and more invasiveMRI is of use for the diagnosis of deep infiltrating endometriotic lesions and for the assessment of disease extension Preoperative mapping of disease extension is important to decide whether surgical intervention is indicated and if so for planning complete surgical excision

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

SITES

bull Pelvic

bull -Uterine= adenomyosis(50)

bull Extra-uterine

- Ovary 30

bull - Pelvic peritoneum 10

- Fallopian tube

- Vagina

- Bladder amprectum

- Pelvic colon

bull - Ligaments

bull Extra-pelvic

bull Umbilicus

bull Scars(Laparotomy)

bull Lung amppleura

bull Others

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Endometriomas - also known as chocolate cysts Develop when superficial endometriotic lesions on the surface

of the ovary invaginate Blood produced by such an implant during each menstrual

cycle cannot escape and will accumulate within the ovary forming a cyst known as an endometrioma

present as complex cystic masses often thick-walled with a homogeneous content

On transvaginal ultrasound endometriomas may be seen as thick-walled cysts with low level echoes

SYMPTOMS -

bull Pelvic pain(65) bull Dysmenorrhea especially suggestive of endometriosis the pain if it occurs

after years of pain free menstruation bull Deep dyspareuniabull Chronic pelvic painbull Ovulation pain with menstrual irregularitybull Other types of pain- Sciatica

- Infertility(35)

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

TVS showing a unilocular ovarian cyst with low level internal echoes ndashcharacteristic of

Endometrioma

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

BL ENDOMETRIOMA

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

bull HYDROSALPINX ndashHydrosalpinx occurs when an inflammatory process produces adhesions of the fimbriated end of the fallopian tube trapping the intraluminal secretions and dilatation of the ampullary and infundibular portions of the tube

bull It may occur either in isolation or as a component of a complex pathologic process (eg pelvic inflammatory disease endometriosis fallopian tube tumorperitubal obstruction due to previous surgery or tubal pregnancy)

Diagram shows the anatomyof a normal fallopian tube Thereare four segments from the medial aspectto the lateral aspect the intramuralportion the isthmus the ampulla andthe infundibulum at the fimbriated end

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

USG

Tubular elongated extra-ovarian structure with folded configuration (incomplete septation )

Three appearances of tubal wall structure

ldquoCOGWHEEL ldquo SIGN- which is anechoic cogwheel shaped structure visible in the cross section of the tube with thick walls

ldquoBEADS ON A STRINGrdquo SIGN which are hyperechoic mural nodules of 2 to 3 mm in size and seen on the cross-section of the fluid filled distended tube

INCOMPLETE SEPTA -which are hyperechoic septa that originate as a triangular protrusion from one of the walls but do not reach the opposite wall

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

(A) TVS reveals tubular elongated extraovarian structure (B) Incomplete septation and absence of vascularity on CDS - Hydrosalpinx

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

A and B T2W axial and sagittal images showing a hyperintense tubular structure with folded configuration in the right adnexa ndash Hydrosalpinx

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

bull In case of complex masses causing hydrosalpinx MR is more sensitive modalities

bull MR demonstrates incomplete septations and a separate normal ovary

bull MR can also help in finding the etiology of hydrosalpinx If hydrosalpinx is due to endometriosis signal intensity characteristics of the tubal fluid are similar to those in endometriomas (high T1 and low T2 signal intensities) In a patient with adhesions signal intensity of the dilated tube follows that of simple fluid (low T1 and high T2 signal intensities)

The hydrosalpinx appears as a fluid-filled tubular structure that arises from the upper lateral margin of the uterine fundus and is separate from the ipsilateral ovary A dilated fallopian tube folds upon itself to form a sausage like C- or S-shaped cystic mass

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Hydrosalpinx in a 38-year-old woman who underwent surgical resection of a

left ovarian cyst 3 years earlier

T2-weighted MR images show a tubular cystic lesion (solid arrows) in the left adnexa

The lesion is separate

from the normal left ovary (open arrow) The presence of a hydrosalpinx with a peritubal

adhesion was confirmed at surgery

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

bull MR imaging features of tubal pregnancy include hematosalpinx enhancement of the dilated tube wall presence of a gestational sac bloody ascites and a heterogeneous adnexal mass

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Left tubal pregnancy (at 9 weeks of gestation) in a 44-year-old woman

(a b) Sagittal contrast-enhanced

fat-suppressed T1-weighted MR images show a C-shaped cystic structure (arrows in b) that contains a focally enhancing gestational sac (arrow in a) in the left adnexa U = uterus

(c) Coronal contrast-enhanced fat-suppressed T1-weighted MR image shows a mildly dilated left fallopian tube (white arrow) with a focally thickened and enhancing wall(black arrows) At surgery the presence of an unruptured tubal pregnancy was confirmed

B = urinary bladder U = uterus

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

TUBO-OVARIAN ABSCESS

Late complication of PID

bull Tuberculosisactinomycosis and xanthogranulomatous infections are major causes

bull Bilateral adnexal involvement is the ruleUSG

unilocular or multilocular complex mass

irregular borders and thickened wall

Multiple internal septations

Fluid in cul de sac

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

CT

Thick wall and shaggy margins

complex adnexal mass with centers of low attenuation

presence of air confirms the diagnosis

MR

unilocular or multilocular cystic mass with a thicker wall than that seen in functional ovarian cyst

The abscess fluid has variable signal but usually is of very high signal intensity on T2-weighted image and low signal intensity on T1-weighted image

The abscess wall and adjacent inflammatory changes as well as septations enhance intensely with gadolinium

Infiltration of pelvic fat surrounding the mass may be seen

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

TVS reveals bilateral multilocular complex adnexal masses with septations and associated free fluidndash

Tubo-ovarian abscesses

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Pyosalpinx associated with tubo-ovarian abscess

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

bl tubo-ovarian abcess dilated tube and enhancing wall on post contrast study

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Actinomycosis occurs in presence of IUCD it is more solid as compared to other bacterial

abscess Diffuse infiltration of the uterus adnexa and pelvic

musculature with obliteration of fascial planes is the hall mark of the disease

A linear solid well-enhancing lesion extending directly from the mass into adjacent fascial planes is a characteristic CT and MR imaging finding

Small rim-enhancing lesions in the solid part of the mass are also suggestive of actinomycosis

Differentiated from malignancy can be done only by identification of sulphur granules within the aspirate

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

actinomycosis

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

When a complex cystic tubo-ovarian abscess occurs in association with ascites and lymphadenopathy it may be difficult to differentiate the abscess from an ovarian malignancy However ovarian cancer is not usually associated with tubal dilatation Therefore the detection of a hydrosalpinxwithin a complex adnexal mass may aid in the differential diagnosis

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

OVARIAN TORSION

bull acute condition requiring prompt surgical intervention

bull caused by partial or complete rotation of the ovarian pedicle on its long axis

bull It is most commonly associated with an adnexal massusuallya dermoid cyst

bull but may also occur spontaneously

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

ON GRAY-SCALE ULTRASOUND bull Unilateral enlarged ovary (gt4cm in maximum

dimension volgt20 cc in premenopausal and gt10 cc in postmenopausal women)

bull central afollicular stroma and multiple uniform 8ndash12-mm peripheral follicles

bull free fluidbull a twisted pedicleON COLOUR DOPPLERbull Worlpool sign- is swirling target of vessel in twisted

pedicle

Torsion first affect venous then arterial flowAbsence of venous flow Absent diastolic flow forming a spike waveform pattern

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

23-year-old woman with enlarged right torsed ovary

Sagittal fast spin-echo T2-weighted MRI shows 10-cm ovary (arrow) with mildly T2 hyperintense afollicularcentral stroma and peripheral follicles

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

18-year-old female with ovarian torsion T2-weighted sagittal MR image showing whirlpool appearance of the right adnexa (thick arrow) suggestive of ovarian torsion Right ovarian cystic mass is also seen (thin arrow)

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

ECTOPIC PREGNANCY-

Most common symptoms are-acute abdominal pain bleeding par vaginaabdominal mass

Positive pregnancy test(b-HCGgt2000mIUmL)

bull Risk Factors of Ectopic PregnancyPrior ectopic pregnancyHistory of pelvic inflammatory disease gynecologic surgeryInfertilityintrauterine device

History of placenta previaUse of in vitro fertilizationCongenital uterine anomaliesHistory of smokingEndometriosis

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Ovarian ectopic

3of cases

Should be differentiated from normal corpus luteum cyst of pregnancy

Tubal ectopic

most common location(gt95)

75ndash80 - ampulla

10 -isthmus

5 - fimbrial end

2ndash4 interstitial and corneal

Others-cervical abdominal and scar ectopic

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

On USG Endometrial findings-Absent G-sac in endometrial cavity or Pseudosac with absent or poor decidual reactionTubal ectopic-we can find a tubal ring with a yolk sac and embryo or yolk sac only or without any central identifying featuresa complex adnexal mass separate from the ovary

ovarian ectopic-The presence of a gestational sac chorionic villi or an atypical cyst with a hyperechoic ringwithin the ovary along with the normal fallopiantubes is suggestive of an ovarian pregnancyColour DopplerRing of fire appearance Low impedance high diastolic flow(low RIhigh velocity)

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Tubal interstitial pregnancy with embryo within the G-sac

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Tubal ring sign-yolk sac surrounded by thick echogenic ring

Same patent

Pseudosac in in endometrial cavity

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Ampullary ectopic showing ring of fire appearance on doppler

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

Scar ectopic pregnancy

A G-sac in the anterior lower uterine segment in the region of the cesarean section scar

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

BENIGN SOLID OVARIAN MASSESArise from ovarian stroma also ka sex cord stromal tumours

Fibroma ThecomaFibroadenoma

80 of these tumours produce hormones except fibroma

Fibroma is common in postmenopausal women and are generally asymptomatic

Ascites seen 50 of patient with fibroma larger than 5cm

MEIGrsquoS SYNDROME ndashtriad of ovarian fibroma ascites and pleural effusion

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

USG- hypoechoic mass with marked posterior attenuation of the sound beam seen separate from the uterus and a non-visualized ovary

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

bull MR-

Hypointense on both T1 and T2 images and shows mild enhancement

MEDANTA CASES

MEDANTA CASES