This describes basic ultrasound of ovaries, follicle tracking, haemorrhagic ovarian cysts and polycystic ovaries

1. The OvariesThe Ovaries
Durr-e-SabihDurr-e-Sabih
MBBS. MS. FRCP. FANMBMBBS. MS. FRCP. FANMB
Director MINARDirector MINAR
MultanMultan
PAKISTANPAKISTAN
dsabih@yahoo.comdsabih@yahoo.com

2. Early onEarly on
• A baby girl is born with a huge number of
potential eggs ( 700,000 to 2 million)
• By puberty only 400,000 are left
• Around 500 are used during lifetime of
ovulation

3. The Normal Adult OvaryThe Normal Adult Ovary
• Resting ovary is moderately echogenic, ovoid,
well marginated, seen along the side of uterus
usually but can be seen behind the uterus or
even in the lower abdomen.
• Cysts in the ovary in premenopausal age are
the distinguishing feature
• Menopausal ovaries can be smooth and be
difficult to identify

4. ReviewReview

5. The Normal Adult OvaryThe Normal Adult Ovary
• Primordial follicles are too small to be seen by
ultrasound
• Solid background, scattered antral follicles (3-
6mm)
• Volume 8- 20 ml

6. The Normal Adult Ovary (Cont’d)The Normal Adult Ovary (Cont’d)
• 4-8 antral follicles (day 6-7) in each ovary
measuring 3-6 mm
• By day 7 one follicle is selected and increases
in size more than others

7. The Normal Adult Ovary (Cont’d)The Normal Adult Ovary (Cont’d)
• 10 mm by day 8-9 (dominate follicles >11mm)
• 18- 24mm by day 14
• Subordinate follicles also continue to grow to
about 10 mm, then become smaller
• > 50% reduction in volume on ovulation
• Corpus luteum is irregular and complex cystic

8. ReviewReview
What When How
Primordial follicles …. Too small, not visible
Antral follicles
(4-8)
D 6-7 3-6mm
Dominate follicle D 8-9 10 – 11 mm
Dominate follicle D 14 18-24mm
Subordinate
follicles
D 14 Up to 10mm then
regress
Corpus luteum D >14 50% volume, irregular
contour

9. OvariesOvaries
(Volume)(Volume)
• Birth – 3 Mo 0.3 – 3.6 ml
• 2-8 yrs 1.0 - 1.5 ml
• 10 yrs 2.2 – 3.6 ml
• 13 yrs 4.2 – 9.0 ml
• 15-19 yrs 8.0 – 18 ml
• 20-49 yrs 10-23 ml
• 50-65 yrs 6 – 14 ml
• 70 yrs 1 – 6 ml

10. OvaryOvary

11. Day 3 OvaryDay 3 Ovary

12. Normal/Normal/multimulticystic Ovariescystic Ovaries

13. Dominant FollicleDominant Follicle

14. The Corpus LuteumThe Corpus Luteum
• One-third will be typical irregular cysts
• One-third will look echogenic and solid
• One third will not be visible at all

15. Corpus LuteumCorpus Luteum
© Allen Worrall, Alaska

16. Corpus Luteum Ring of FireCorpus Luteum Ring of Fire
© Allen Worrall, Alaska

17. Calcified Area in OvaryCalcified Area in Ovary

18. Ultrasound Monitoring of Follicles:Ultrasound Monitoring of Follicles:
• Finding
• Counting
• Measuring
• Documenting
Follicles on serial studies

19. HowHow
• Baseline study….day 4-5 to look for any cyst
left over from previous cycles, rule out other
lesions
• Start on day 8-10, identify developing follicles
of 8-10 mm
• Monitor daily or on alternate days until size of
16-18mm seen (mature follicle)….give HCG
pulse
• Ovulation >50% reduction in size

20. • Very dynamic organs
• Changing appearance with the time of the
menstrual cycle, age and pregnancy
• Must correlate findings with the expected
physiological findings

21. Dominant FollicleDominant Follicle

22. OvulationOvulation
Dominate follicle on day 14
Corpus luteum on day 16

23. Pathological StatesPathological States
Absent/Abnormal OvulationAbsent/Abnormal Ovulation

24. Abnormal Ovarian CyclesAbnormal Ovarian Cycles
• Sporadic ovulation failure in about 7% of
cycles
• Sporadic anovulatory syndromes
• Chronic anovulatory syndromes

25. Abnormal Ovarian CyclesAbnormal Ovarian Cycles
• Sporadic ovulation failure in about 7% of
cycles
• Sporadic anovulatory syndromes
o Follicular Atresia
o Empty Follicle Syndrome
o Luteinized Unruptured Follicle Syndrome
• Chronic anovulatory syndromes

26. Abnormal Ovarian CyclesAbnormal Ovarian Cycles
• Sporadic ovulation failure in about 7% of
cycles
• Sporadic anovulatory syndromes
• Chronic anovulatory syndromes
o Hypergonadism
o Hypogonadism
o Polycystic Ovarian Syndrome (PCOD)

27. Sporadic Anovulatory SyndromesSporadic Anovulatory Syndromes

28. Follicular AtresiaFollicular Atresia
• Dominate follicle starts developing but
o Does not reach full size
o Rapidly becomes smaller
o Common in oral contraceptive users

29. Empty Follicle SyndromeEmpty Follicle Syndrome
• Follicle development looks normal
• Oocyte is not formed
• Cannot differentiate from normal cycles on
ultrasound

30. Luteinized Unruptured FollicleLuteinized Unruptured Follicle
Syndrome (LUFS)Syndrome (LUFS)
• Apparently normal follicle develops but fails
to rupture

31. Chronic Anovulatory SyndromesChronic Anovulatory Syndromes

32. Primary Ovarian FailurePrimary Ovarian Failure
• Ovaries are small and smooth with no
follicular activity
• Estrogen levels are low
• Gonadotropin levels are very high

33. HypogonadotropismHypogonadotropism
• Low FSH, LH, Low estrogen
• Pituitary lesion (tumour?)
• Ovaries smooth but can respond to exogenous
cyclical hormones

34. PCOSPCOS
• A very complex endocrine abnormality
• A very wide spectrum of findings with the
classic Stein Leventhal syndrome at one end
and normal looking females with early fertility
at the other

35. PCOSPCOS
• Typical habitus?
o Obese
o Oligo/amennorrhoea
o Hirsuitism
• Endocrine abnormalities
o Raised LH
o LH/FSH ratio > 3
o Raised Sr. Testosterone and Androstenedione
o Insulin resistance

36. PCOSPCOS
Ultrasound FeaturesUltrasound Features
• Large ovaries
• Round shape
• Large number of small cysts arranged
peripherally under the capsule (string of pearls
sign) or throughout the volume
• >10 cysts on TAS, >15 on TVS on a single
section
• Echogenic stroma (compare with
myometrium)

37. PCOSPCOS
Ultrasound FeaturesUltrasound Features
• 1//3rd
patients have normal ovarian volumes
• Many normal ovaries are multicystic
o Adolescents
o Oral contraceptive users
o Juvenile hypothyroidism
o 17 hydroxylase deficiency
o Post Menopausal ovaries with hyperthecosis
o PID

38. Consensus on diagnostic criteria forConsensus on diagnostic criteria for
PCOS (2003)PCOS (2003)
Two should be presentTwo should be present
• Oligo and/or anovulation
• Clinical and/or biochemical signs of
hyperandrogenism
• Polycystic ovaries

39. HyperandrogenismHyperandrogenism
• Clinical or biochemical
o Hirsuitism (subjective?, racial?)
o Acne
o Circulating androgens (wide variability)
o Free testosterone, free testosterone index,

40. Polycystic ovariesPolycystic ovaries
• 12 or more follicles in each ovary, measuring
2-9mm across and/or increased ovarian
volume (>10ml)
• Exclude follicle distribution, exclude stromal
echogenicity and volume
• Does not apply to women on contraceptive
pills

41. Polycystic ovariesPolycystic ovaries
• If findings are seen only on one side, this is
still sufficient for diagnosis.
• If there is evidence of dominate follicle or
corpus luteum, repeat next month.
• Asymmetric ovarian size or large cyst needs
further work-up/follow-up.

42. PCODPCOD

43. PCODPCOD
© Allen Worrall, Alaska

44. Ovarian HyperstimulationOvarian Hyperstimulation
SyndromeSyndrome
• Numerous follicles grow in a stimulated cycle
• Pain, enlarged ovaries (ovaries can become 6-
7 cm in diameter)
• If larger, there can be associated ascites,
pleural effusion
• On US, enlarged ovaries with multiple large
cysts seen

45. Hyperstimulated OvariesHyperstimulated Ovaries

46. Hyperstimulated OvariesHyperstimulated Ovaries
© Shlomo Gobi, Jerusalem

47. Hyperstimulated OvariesHyperstimulated Ovaries
© Ravi Kadasne, UAE

48. The Simple Ovarian CystThe Simple Ovarian Cyst
• If up to 5-7 cm in diameter, observe over 6-8
weeks
• Try to repeat scan during the first 5 days of the
cycle

49. The Simple Ovarian CystThe Simple Ovarian Cyst
• > than 7 cm in diameter
• Persist beyond the length of a normal
menstrual cycle
• solid components
• Complex internal structure
• Associated with pain

50. The Simple Ovarian CystThe Simple Ovarian Cyst
© Prof. Nawaz Anjum, Lahore

51. The Simple Ovarian CystThe Simple Ovarian Cyst

52. Theca LuteinTheca Lutein

53. Mural NodulesMural Nodules
© Gunjan Puri, Surat

54. The Haemorrhagic Ovarian CystThe Haemorrhagic Ovarian Cyst
Haemorrhage

55. The Haemorrhagic Ovarian CystThe Haemorrhagic Ovarian Cyst
Haemorrhage

56. Endometriotic cystEndometriotic cyst

57. Endometriotic cystEndometriotic cyst

58. Haemorrhagic and endometrial cystHaemorrhagic and endometrial cyst

59. The parovarian CystThe parovarian Cyst
o A cyst developing within the
mesosalpinx between the tube and
ovary, from the vestigial remnants
of the Wolffian body. These cysts
represent 10% of all adnexal
masses. They occur in the third to
fourth decade.

60. The parovarian CystThe parovarian Cyst
o On ultrasound, a paraovarian cyst may be
suspected when a thin-walled, unilocular
ovoid structure free of internal echoes is
demonstrated lying next to the uterus
within the plane of the broad ligament and
the ovary is seen separately.
o Their size does not change in relation to
the menstrual cycle. But they can torse and
undergo haemorrhage

61. The parovarian CystThe parovarian Cyst

62. The parovarian CystThe parovarian Cyst
Hydatid of Morgagni
Epioophoron

63. The parovarian CystThe parovarian Cyst
© Allan Worrall, Alaska

64. The parovarian CystThe parovarian Cyst

65. HydrosalpinxHydrosalpinx

66. The parovarian CystThe parovarian Cyst

67. MenopausalMenopausal

68. TorsionTorsion

69. EndEnd