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Ultrasonography of the uterus

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Ultrasonography of the uterus

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Ultrasonography of the uterus

  1. 1. Ultrasonography of the uterus Benha university, Egypt Aboubakr Elnashar
  2. 2. Normal uterus Aboubakr Elnashar
  3. 3. Technique F.B. LS: vagina (hypoechogenic tubular structure with an echogenic lumen)& long axis of the uterus. TS: Aboubakr Elnashar
  4. 4. PositionPosition Midline (25%) Corpus: usually flexed anteriorlyanteriorly on the cervix (ante flexion). In RVF: poor visualization of the fundusfundus (dropout phenomenon) Aboubakr Elnashar
  5. 5. TAS: retroflexed uterus, but it is difficult to evaluate the fundus and the endometrium. Aboubakr Elnashar
  6. 6. Size LS: APD: 1.5-3 cm L: 4.5-9 cm. TS: TD: 4.5-5.5 cm. In multiparamultipara: increase by 1-2 cm in all diameterscm diameters EchogenecityEchogenecity Homogenous: myometriummyometrium & endometriumendometrium Aboubakr Elnashar
  7. 7. Normal postmenarchal uterus. The uterine body (u) is larger than the cervix (c). The endometrium (arrows) is the region of relatively bright central linear echoes. v, vagina . Aboubakr Elnashar
  8. 8. TAS: uterus in a 4-year-old girl. The cervix is larger than the body of the uterus. Aboubakr Elnashar
  9. 9. measurementsmeasurements Aboubakr Elnashar
  10. 10. 5 TVS: Uterus. Normal endometrial stripe. Normal peristalsis of bowel noted posterior to uterus . Aboubakr Elnashar
  11. 11. 4 TVS: Retroverted Uterus. Normal variant of prominent myometrial veins in patient with retroverted uterus. Aboubakr Elnashar
  12. 12. Menstrual changes of the endometrium Early menses( DEarly D1-4) Hypoechoic central echo thick hyperechoichyperechoic endometrial echoendometrial echo posterior enhancement similar to lutealluteal phasephase Aboubakr Elnashar
  13. 13. Aboubakr Elnashar
  14. 14. late menses(D3-7) Single hyperechoichyperechoic thin line (central endometrial echo). HypoechoicHypoechoic halo. AP thickness of the entire endometrial echo: 1-3 mm. HypoechoicHypoechoic central echo representing blood is gonecentral gone Aboubakr Elnashar
  15. 15. Aboubakr Elnashar
  16. 16. Early proliferative phase (DEarly D5-9). Halo present. Relatively thin AP endometrial thickness (<6 mm). No posterior enhancement. Three line signThree sign Aboubakr Elnashar
  17. 17. Proliferative end Aboubakr Elnashar
  18. 18. PeriovulatoryPeriovulatory endometriumendometrium, triple line, line Aboubakr Elnashar
  19. 19. Aboubakr Elnashar
  20. 20. Normal endometrium. (A) “Triple line” endometrium in midcycle. Aboubakr Elnashar
  21. 21. Aboubakr Elnashar
  22. 22. D10-14: Late proliferative phase: phase As above with thicker endometrial echo complex (>6mm) Luteal phase: Maximum endometrial thickness, HyperechoicHyperechoic endometrium, Loss of halo, Loss of three line sign, Prominent posterior enhancementProminent enhancement Aboubakr Elnashar
  23. 23. Secretory endometriumSecretory endometrium N cysts in cxN cx Aboubakr Elnashar
  24. 24. Normal endometrium. (B) Secretory phase endometrium that is thick and echogenic with posterior acoustic enhancement . Aboubakr Elnashar
  25. 25. Abnormalities A. MyometriumMyometrium B. EndometrialB. Endometrial C. CavityC. Cavity Aboubakr Elnashar
  26. 26. A. Myometrium Uterine anomalies TVS can detect 90% . Uterine septae: Best diagnosed in transverse plane. in the periovulatory phase, {can be missed in the early follicular phase with thin endometrium} DD: IU adhesions: isoechoic nature of the septum with the myometrium Aboubakr Elnashar
  27. 27. Types Ultrasound Diagnosis Difficult to diagnose sonographically Small uterus Lateral position Unicornuate Visualization of separate horns > 105 degrees apart Bicornuate Has duplication of cervix and upper vagina Didelphys Smooth indentation of fundal ndometrium Mild form of bicornuate Arcuate Smooth external contour < 75 degrees between horns Fibrous septum can be removed surgically Septate T-shaped uterus Short cervix DES Aboubakr Elnashar
  28. 28. Bicornuate uterus. (A) Transabdominal transverse view of the uterus demonstrates two horns that are widely separated. Only one cervix was seen on vaginal scanning. Aboubakr Elnashar
  29. 29. Bicornuate uterus. (B) View of the right renal fossa demonstrates an absent right kidney Aboubakr Elnashar
  30. 30. BicornuateBicornuate uterusuterus At cervical level at fundal levelAt level Aboubakr Elnashar
  31. 31.  Fibroid Rounded distinct masses of increased, decreased or similar echogenecity of the myometrium. ± uterine enlargement. DD: 1.Ovarian cyst 2.RVF Adenomyosis. Submucous fibroids: distort the midline echo & are best diagnosed in the periovulatory phase Decrease the chance of conception with IVF Aboubakr Elnashar
  32. 32. ECHOTEXTURE •Hypoechoic –Shadowing secondary to whorls of fibrous tissue and edge artifacts •Echogenic •Isoechoic •Cystic areas –Secondary to degeneration •Calcifications –Rim calcification –Clumps of calcification LOCATION Submucosal Associated with menometrorrhagia Distort endometrial myometrial margins Intramural Most common Subserosal Distort uterine margins Pedunculated ± Stalk May present as adnexal mass Cervical Broad ligament Simulate adnexal mass Aboubakr Elnashar
  33. 33. Diffuse Uterine Enlargement* Comments Diagnosis Multiparous women can have uterine size 1-2 cm larger than “normal” in each dimension Normal parous uterus Fibroids Uterus diffusely enlarged with normal uterine echotexture and contour ± Small cysts in myometrium Focal or diffuse invasion of the myometrium by endometrium Focal adenomyoma may appear as a fibroid Adenomyosis Early findings of loss of endometrial/myometrial interface Late finding of enlargement of uterus Endometrial carcinoma Rapid change in size of uterus Difficult to distinguish from fibroids, unless serial examinations are available Sarcoma Aboubakr Elnashar
  34. 34. Pregnancy Size varies with gestational age of pregnancy Normal pregnancy Endometrial cavity enlarged with multiple cystic spaces Missed abortion Gestational trophoblastic diseas Size varies with time since delivery Recent postpartum Aboubakr Elnashar
  35. 35. Fibroids. (A) Transabdominal view of a fibroid uterus. The uterus is enlarged with a heterogeneous echotexture and a lumpy contour caused by fibroids. Aboubakr Elnashar
  36. 36. Fibroids. (B) Submucosal fibroids surrounded by fluid during a sonohysterogram . Aboubakr Elnashar
  37. 37. Fibroids. (C) Subserosal fibroid with broad attachment to the myometrium and an exophytic component . Aboubakr Elnashar
  38. 38. Aboubakr Elnashar
  39. 39. SubmucousSubmucous fibroidfibroid Aboubakr Elnashar
  40. 40. Aboubakr Elnashar
  41. 41. Aboubakr Elnashar
  42. 42. Pedunculated fibroid. (A) Transabdominal view of the pelvis demonstrates a mass (M) adjacent to the uterus (U( Aboubakr Elnashar
  43. 43. Pedunculated fibroid. (B) Transvaginal examination demonstrates a tissue plane between the uterus and the mass . Aboubakr Elnashar
  44. 44. Pedunculated fibroid. (A) Transabdominal view of the pelvis demonstrates a mass (M) adjacent to the uterus (U) Aboubakr Elnashar
  45. 45. Pedunculated fibroid. (B) Transvaginal examination demonstrates a tissue plane between the uterus and the mass. Aboubakr Elnashar
  46. 46. Aboubakr Elnashar
  47. 47. Uterine calcifications. (A) Transvaginal transverse view of the uterus in a postmenopausal woman with abnormal bleeding demonstrates a well-defined echogenic focus with shadowing secondary to a calcified fibroid. Adjacent to this area is a fluid collection in a region of thickened endometrium (arrows). This was endometrial hyperplasia. Aboubakr Elnashar
  48. 48. AdenomyosisAdenomyosis HypoechoicHypoechoic spaces in the myometriummyometrium. It is more prominent during & immediately after menstruation. Small retention cysts in the cervix should not be mistaken for adenomyosisadenomyosis Aboubakr Elnashar
  49. 49. Myometrium: Heterogeneous echotextureHeterogeneous echotexture Echogenicity: decreased relative to that of the dorsal myometriummyometrium Myometrial cyst (curved arrow) Asymetrical uterine enlargementenlargement Endometrium: excentric endometrial cavityexcentric cavity indistinct endometrialindistinct endometrial- myometrial bordermyometrial border AdenomyosisAdenomyosis Aboubakr Elnashar
  50. 50.  Bromley et al (2000) 2 or more of the followings: 1. Mottled heterogeneous . myometrialmyometrial texture: All cases. 2. Globular uterus: 95% of cases.% cases. 3. Small myometrialmyometrial lucent areas: 82%. 4. “Shaggy” indistinct endometrial strips: 82%. The most predictive: ill-defined heterogeneous echotextureechotexture within the myometriummyometrium (BrosenBrosen et al, 2004) Aboubakr Elnashar
  51. 51. Enlarged uterus in a 53-year-old woman with abnormal bleeding. The uterus is enlarged slightly and heterogeneous in echotexture but has no focal masses. Histologic examination revealed adenomyosis. Aboubakr Elnashar
  52. 52. adenomyiosisadenomyiosis Aboubakr Elnashar
  53. 53. B. Endometrium Endometrial hyperplasia Thickened endomerium in postmenopause < 5 mm is rarely associated with endometrial cancer Women with endometrial cancer had endometrial thickness of >8 mm Aboubakr Elnashar
  54. 54. Aboubakr Elnashar
  55. 55. Endometrial thickness LS at the maximum thickness. Proliferative phase (4-8 mm), Secretory phase (8-15 mm), Postmenopausal (4-5 mm), Clomid, Tamoxifin, ART Aboubakr Elnashar
  56. 56. Aboubakr Elnashar
  57. 57. Normal endometrium. (B) Secretory phase endometrium that is thick and echogenic with posterior acoustic enhancement . Aboubakr Elnashar
  58. 58. Transvaginal view of the uterus in a postmenopausal woman. The endometrium is a thin linear hyperechoic band (calipers). This patient also has prominent arcuate vessels (curved arrows). Aboubakr Elnashar
  59. 59. Retroflexed uterus in a woman with intermenstrual bleeding. (B) Transvaginal examination shows a thickened endometrium that measures 18 mm (calipers) with a focal area of increased echogenicity (arrows), which was a polyp. Transvaginal examination is necessary to completely evaluate the uterus in patients with retroverted or retroflexed uterus and to evaluate the endometrium in women with abnormal bleeding . Aboubakr Elnashar
  60. 60. Concurrent lesions: granulosa cell tumor with endometrial hyperplasia. (A) Thickened endometrium (15 mm) with a small cyst. The histologic type was endometrial hyperplasia, probably secondary to the estrogenic effect of the granulosa cell tumor Aboubakr Elnashar
  61. 61. Concurrent lesions: granulosa cell tumor with endometrial hyperplasia. (B). Aboubakr Elnashar
  62. 62. Aboubakr Elnashar
  63. 63. Endometrial carcinoma U/S is not a primary diagnostic modalityU/modality Postmenopausal bleeding with uterine enlargement & hypoechoichypoechoic & non& non-homogenous texture is highly suggestive of malignancy. Depth of invasionDepth invasion Aboubakr Elnashar
  64. 64. Uterine sarcoma. (A) Transabdominal view of the uterus in a woman with a recent myomectomy demonstrates an enlarged uterus with a bizarre appearance to the myometrium with multiple cystic spaces. Aboubakr Elnashar
  65. 65. Endometrial adenocarcinomaadenocarcinoma Aboubakr Elnashar
  66. 66. Concurrent lesions: a 90-year-old woman with endometrial cancer and ovarian cancer. (A) Transabdominal view of the uterus demonstrates ill- definition of the endometrium with invasion of the endometrium into the myometrium. Aboubakr Elnashar
  67. 67. C. Cavity AshermanAsherman syndrome Irregular reflective foci of the uterine cavityIrregular cavity Aboubakr Elnashar
  68. 68. IU adhesionsIU adhesions Aboubakr Elnashar
  69. 69. Endometrial polyps Persistent hyperechogenic areas with variable cystic spaces. They distort the cavity contour. Best seen in midcycle &not seen clearly in the midluteal phase or in stimulated cycles. Aboubakr Elnashar
  70. 70. Endometrial polypEndometrial polyp Aboubakr Elnashar
  71. 71. IUCD localization ExtrauterineExtrauterine IUCD is difficult to be localizedIUCD localized Aboubakr Elnashar
  72. 72. Intrauterine contraception devices (IUDs). (B) Lippes loop IUD . Aboubakr Elnashar
  73. 73. Aboubakr Elnashar
  74. 74. Intrauterine contraception devices (IUDs). (A) Straight shaft IUD. Aboubakr Elnashar
  75. 75. Uterine calcifications. (B) Punctuate calcifications at the endometrial myometrial interface in a patient with two prior dilatation and curettage procedures. Aboubakr Elnashar
  76. 76. HydrometraHydrometra, haematometra & pyometra Anechoic area filling the uterine cavityAnechoic cavity Aboubakr Elnashar
  77. 77. HaematometraHaematometra Aboubakr Elnashar
  78. 78. Hematometra. Sagittal view of the uterus in a 63-year- old asymptomatic woman placed on cyclic hormonal replacement therapy demonstrates a large endometrial fluid collection with a thin surrounding endometrium. She subsequently underwent surgical dilation for cervical stenosis. Aboubakr Elnashar
  79. 79. Aboubakr Elnashar
  80. 80. Uterine calcifications. (A) Transvaginal transverse view of the uterus in a postmenopausal woman with abnormal bleeding demonstrates a well-defined echogenic focus with shadowing secondary to a calcified fibroid. Adjacent to this area is a fluid collection in a region of thickened endometrium (arrows). This was endometrial hyperplasia. Aboubakr Elnashar
  81. 81. Abnormal cervix Aboubakr Elnashar
  82. 82. Aboubakr Elnashar
  83. 83. Cervical masses. (A) Sagittal view of the cervix demonstrates a large cervical fibroid which deviates the lower uterine segment anteriorly. Aboubakr Elnashar
  84. 84. Cervical masses. (B) Transvaginal view of the cervix demonstrates an ill-defined relatively isoechoic mass (M) in this patient with cervical cancer. Aboubakr Elnashar
  85. 85. Thank you Aboubakr Elnashar

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