Ultrasonography of the uterus

1. Ultrasonography of the uterus
Benha university, Egypt
Aboubakr Elnashar

2. Normal uterus
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3. Technique
F.B.
LS:
vagina (hypoechogenic tubular structure with an echogenic lumen)&
long axis of the uterus.
TS:
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4. PositionPosition
Midline (25%)
Corpus: usually flexed anteriorlyanteriorly on the cervix (ante flexion). In RVF: poor visualization of the fundusfundus (dropout phenomenon)
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5. TAS: retroflexed uterus, but it is difficult to evaluate the fundus and the endometrium.
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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
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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 .
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8. TAS: uterus in a 4-year-old girl.
The cervix is larger than the body of the uterus.
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9. measurementsmeasurements
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10. 5
TVS: Uterus. Normal endometrial stripe.
Normal peristalsis of bowel noted posterior to uterus .
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11. 4
TVS: Retroverted Uterus.
Normal variant of prominent myometrial veins in patient with retroverted uterus.
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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
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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
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16. Early proliferative phase (DEarly D5-9). Halo present. Relatively thin AP endometrial thickness (<6 mm). No posterior enhancement. Three line signThree sign
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17. Proliferative end
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18. PeriovulatoryPeriovulatory endometriumendometrium, triple line, line
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20. Normal endometrium. (A) “Triple line” endometrium in midcycle.
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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
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23. Secretory endometriumSecretory endometrium
N cysts in cxN cx
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24. Normal endometrium.
(B) Secretory phase endometrium that is thick and echogenic with posterior acoustic enhancement .
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25. Abnormalities A. MyometriumMyometrium B. EndometrialB. Endometrial C. CavityC. Cavity
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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
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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
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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.
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29. Bicornuate uterus. (B) View of the right renal fossa demonstrates an absent right kidney
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30. BicornuateBicornuate uterusuterus
At cervical level at fundal levelAt level
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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
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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
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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
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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
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35. Fibroids. (A) Transabdominal view of a fibroid uterus. The uterus is enlarged with a heterogeneous echotexture and a lumpy contour caused by fibroids.
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36. Fibroids. (B) Submucosal fibroids surrounded by fluid during a sonohysterogram .
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37. Fibroids. (C) Subserosal fibroid with broad attachment to the myometrium and an exophytic component .
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39. SubmucousSubmucous fibroidfibroid
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42. Pedunculated fibroid. (A) Transabdominal view of the pelvis demonstrates a mass (M) adjacent to the uterus (U(
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43. Pedunculated fibroid. (B) Transvaginal examination demonstrates a tissue plane between the uterus and the mass .
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44. Pedunculated fibroid. (A) Transabdominal view of the pelvis demonstrates a mass (M) adjacent to the uterus (U)
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45. Pedunculated fibroid. (B) Transvaginal examination demonstrates a tissue plane between the uterus and the mass.
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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.
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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
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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
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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)
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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.
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52. adenomyiosisadenomyiosis
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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
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54. Aboubakr Elnashar

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
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57. Normal endometrium. (B) Secretory phase endometrium that is thick and echogenic with posterior acoustic enhancement .
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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).
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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 .
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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
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61. Concurrent lesions: granulosa cell tumor with endometrial hyperplasia. (B).
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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
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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.
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65. Endometrial adenocarcinomaadenocarcinoma
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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.
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67. C. Cavity
AshermanAsherman syndrome Irregular reflective foci of the uterine cavityIrregular cavity
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68. IU adhesionsIU adhesions
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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.
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70. Endometrial polypEndometrial polyp
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71. IUCD localization ExtrauterineExtrauterine IUCD is difficult to be localizedIUCD localized
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72. Intrauterine contraception devices (IUDs). (B) Lippes loop IUD .
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74. Intrauterine contraception devices (IUDs). (A) Straight shaft IUD.
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75. Uterine calcifications. (B) Punctuate calcifications at the endometrial myometrial interface in a patient with two prior dilatation and curettage procedures.
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76. HydrometraHydrometra, haematometra & pyometra Anechoic area filling the uterine cavityAnechoic cavity
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77. HaematometraHaematometra
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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.
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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.
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81. Abnormal cervix
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83. Cervical masses. (A) Sagittal view of the cervix demonstrates a large cervical fibroid which deviates the lower uterine segment anteriorly.
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84. Cervical masses. (B) Transvaginal view of the cervix demonstrates an ill-defined relatively isoechoic mass (M) in this patient with cervical cancer.
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85. Thank you
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