Oaries are more medial and directly

superior to vaginal cuff

Grafian follicle ruptures, fluid

 in cul-de-sac

Postmenopausal ovarian volume

is abnormal?

• Most common cause of ovarian enlargement

       -follicular

       -corpus luteum

       -hemorrhagic

       -theca-lutein

• form when mature follicles fails to ovulate or inovulate
• Unilateral
• 1-8cm
• Sonographically - thin-walled, anechoic structure with posterior enhancement

• Results from hemorrhage within a persistently mature corpus luteum
• filled with blood and cystic fluid
• unilateral
• 1-10cm
• Clinically-irregularmenstrual cycle, pain
• Sonographically - may be complex due to internal echoes,due to hemorrhage, posterior enhancement, peripheral, and rim with colo flow(ring of fire)

• Internal hemorrhage more common in corpus luteul cysts, but can occur in follicular cysts
• acute onset of pelvic pain
• Sonographically - acute hemorrhage is usually hyperechoic, mimicking a solid mass. Echogenic cul-de-sac fluid can help confirm ruptured or leaking hemorrhagic cyst

• Largest of functional cysts
• Bilateral
• Multiloculated cysts
• High levels of hCG
• 30% of patients will have tophoblastic disease
• Clinically - nausea and vomiting
• Sonographically - Multiloculated cysts on both ovaries

• Occur predominatel in premenopausal women with history of previous abdominal surgeries, trauma, PID, and endometriosis
• Fluid accumulates in adhesions
• Clinically - pts present with pelvic pain and/or pelvic mass
• Sonographically - multiloculated cystic adnexal masses and intact ovary among the septated fluid, suggesting an extraovarian mass.

Ovarian hyperstimulation

 syndrome

Mild Ovarian hyperstimulation

syndrome

Associated with lower abdominal discomfort

Severe Ovarian Hyperstimulation

Syndrome

• Severe lower abdominal pain and distention
• Weight gain
• ovaries contain multiple large, thin walled cysts
• associated ascites and pleural effusions

• pt has had a bilateral oopherectomy, a small amount of ovarian tissue left behind
• residual tissue has become functional

• Results in chronic annoculation
• imbalance of LH and FSH resulting in abnormal estrogen and androgen production
• Elevated LH/FSH ratio is characteristic. Serum LH level is elevated while the FSH level is depressed.
• Increased number of follicles

Sonographic findings of

Polycystic ovarian disease

• Bilateral enlarged ovaries with small follicles peripherally and increased stromal echogenicity
• more than 5 follicles in each ovary
• follicles measure 0.5 - 0.8 cm and persist b/c ovulation doesnt accur
• ovaries are rounded

Endometrial cancer and

 breast cancer

• Common in third and fourth decades of life
• Normal ipsilateral ovary close to, but separate from the cyst
• Sonographically - thin walled, not surrounded by ovarian tissue
• Size doesn't change with hormone cycle

• cysts less than 9mm cysts are common
• In children with normal growth and development
• May cause symptoms of precocious puberty

Cysts in Postmenopausal

women

• Simple cysts up to 3 cm in size can be normal, and often disappear completely
• Removed if >5 cm

• The presence of functioning endometrail tissue outside the uterus.
• The ectopic endometrial tissue is hormonally responsive and undergoes bleeding during menses.
• Clinically - dysmenorrhea, dyspareunia, and infertility

• ovary
• fallopian tube
• broad ligament
• posterior cul-de-sac

Most common places for

endometriosis?

• Diffuse
• Localized

• More common
• Minute endometrial implants involving viscera, and ligament attachments
• rarely diagnosed with ultrasound due to minute size, too small for image

• Discrete mass referred to as: Endometrioma or Chocolate cyst
• Most often encountered in women with multiple sex partners
• Well defined, thick walled masses, predominately cystic containing diffuse homogeneous low-level echoes
• Occasionally fluid-fluid level is seen

• Most common in early childhood, ages 10 & under, although can happen anytime
• common in association with adnexal masses
• occurs when an ovary rotates partially or completely on its pedicle
• vascular and/or lymphatic occlusion may occur and result in hemorrhagic infarction of the ovary

Sonographically for what? -

• ovary is enlarged
• dilated vessels
• absent arterial and venous flow               on doppler

• Enlarged echogenic ovaries
• Detected by a combo of physical, lab, and imaging findings
• Silent killer due to absence of symptoms early in the disease
• Can be complex, cystic, or solid masses, but predominantly cystic
• Increased in women who have had breast and colon cancer

Clinical signs for what? -

• Vague abdominal pain
• swelling
• indigestion
• frequent urination
• constipation
• weight change due to ascites

Family history of ovarian or

breast cancer

Strongest risk factor for ovarian

 cancer?

• #1 breast cancer
• increasing age (peak age 55-59)
• nulliparity
• infertility
• uninterrupted ovulation
• Late menopause

Epithelial tumors

(80%-90%)

Sonographically this is what? -

• Morphologic tumor characteristics
• Lesions with irregular walls, thick, irregular septations, mural nodules, and solid echogenic elements are often malignant

Serous (more common) and

mucinous tumors

What are the most common types of

epithelial tumors?

• Benign
• Thin walled, simple or multi-septate cysts, unilateral
• Large extending into abdomen
• Clinically - pressure, pain, increased abdominal girth

• Bilateral
• May occur in menopausal women
• Large, likely to rupture causing ascites
• Clinically - pelvic pressure, pain when ruptured
• Sonographically - Ascites appears as hypoechoic fluid with bright punctate echoes. Thick, irregular walls and septations.

• Second most common benign tumor (behind dermoid) of ovary
• unilateral
• smaler than mucinous cysts
• Multilocular cysts with septations
• Clinically - pelvic pressure, bloating
• Sonographically - septated cyst may have nodule

• 60%-80% of all ovarian carcinomas
• Bilateral due to papillary mass adhesions and infection
• Loss of capsular definition and tumor fixation
• Calcifications
• Mets to omentum, lymph nodes, liver and lungs
• Clinically - presents pelvic fullness, bloating
• Sonographicaly - cysic structure with septations and or papillary projections; internal and external papillamos usually present

• Secong most common epithelial malignancy
• Bilateral 25%-30% of the time
• Postmenopausal

• Variant of endometrioid tumor
• Bilateral
• 50-70 yrs

Brenner Tumor

(transitional cell)

• Uncommon, solid mass
• after 40 yrs of age
• benign
• bilateral
• Hypoechoic, solid masses that may contain calcification in the outer wall

• 15%-25% if ovarian neoplasms
• 15% of time bilateral
• Composed of the three germ cell layers (ectoderm, mesoderm, and endoderm)
• 95% benign due to ectodermal layer being predominant
• Most common ovarian neoplam, along with serous cystadenoma
• complications inlude torsion and rupture

A teratoma that is composed entirely of thyroid tissue. Pelvic mass should be considered in a hyperthyroid pt when no thyroid lesion

is found in the neck

• Malignant germ cell tumor
• Rare
• Identical to male testicular seminoma
• Women under 30
• Solid mass, hyperechoic
• Most common neoplasm seen in pregnancy along with serous cystadenoma

• Rare
• fast growing
• Also called yolk sac tumor
• under 30 years of age, unilateral
• increased levels of AFP
• Solid mass, hyperechoic

Stromal Tumors

(sex cord)

• Arise from sex cords of the embryonic gonad and/ or from the ovarian stroma
• Sonographically - hypoechoic, with lack of through transmission

• Most common hormone actie estrogenic tumor of ovary, feminizing neoplasm
• variable appearance
• associated endometrial hyperplasia may be present due to estrogen production

Sertoli-Leydig Cell Tumor

(androblastoma)

• Rare
• Generally occur in women under 30
• may be associated with estrogen production
• sonographically - appearance of granulosa tumors

• Abundance of thecal cells tumor
• associated with estrogen production
• Sonographically - Prominent acoustic shadow may outline the extent of the mass, foci of calcification, necrosis and cystic degeneration may occur

• Masculinizing ovarian tumor
• Unilateral
• Sonographically - solid mass wih cystic components, lobulated, encapsulated

• Abundance of fibrous tissues
• not associated with estrogen production
• may be associated with Meig's syndrome
• Sonographically - Solid, hyperechoic, may undergo torsion

• Secondary ovarian carcinoma with a primary neoplasm of the GI tract, usually gastric or colonic in origin, but may come from biliary tract, gb, or pancreas
• Bilateral
• Ascites
• solid

• Least common of all gyn malignancies
• Sonographically - tube appears sausage shaped, complex mass, similar to ovarian carcinoma

Term to describe all pelvic infections

bilateral collection of fluid and pus within the pelvic cavity

Risk factors -

• Early sexual contact
• multiple partners
• Hx STDs
• Previous hx of PID
• IUCD
• douching

PID pts b/c of fallopian tube

damage and scarring

Ectopic pregnancy is increased in

prior what pts and why?

Clinical presentation of what? -

• Intense pelvic pain and tenderness
• Constant vaginal discharge
• Other symptoms - fever, RUQ pain, dysparunia, irregular menstrual bleeding
• Infertility history
• Elevated WBC, especially with chlamydia infection

When distinct tubular structures are seen

what is diagnosed?

Tubo-Ovarian Abscess

(TOA)

As adhesions worsen, they fuse the ovary and tube, cause loculations of pus forming what?

• Inflammation of the peritoneum (serous lining of the abdominal cavity)
• Caused by infection from a rupture of the viscera, genital tract, bloodstream, surgical incisions
• Sonographically - loculated areas of fluid in the pelvis, paracolic gutters, Morrison's pouch, ect.

• Reduce patient costs
• Reduces need for surgery and pt stay in hospital

• Uncooperative pts
• no safe biopsy route
• pt clotting factors