TOPIC: Ultrasound in Gynecology

Lecturer: Dr. F. Salvador

Transcriber(s): drinking buddies
Date: October 11, 2012
DISCLAIMER: this is pure recording and ppt. We tried our best to make it AWESOME trans walang BOOK, motherfather
SPECIAL THANKS TO ARMIN! You are my savior aka drinking buddy!! P.S FORBID ME FOR THE PICTURES! Hirap kumuha ng
pictures, USE YOUR IMAGINATION VERY WELLLLL

ULTRASOUND IN GYNECOLGY
The different modalities of ultrasound in gynecology
Transabdominal
Transvaginal
Transrectal
Transperineal
In l s nd wh d w s (2D)? I s j s pl n bl ck , white and gray. When you say hyperech0ic, its more on the
white side of the picture and it refers to a more harder form of tissue like bones. Or point of reference for hyperech0ic &
hypogenic, ll b b n ;
ll s wh s c
s nd b n .
o I s h p ch c,
ll s bl ck. The structure or substance being scanned is water.
o So, how do you know or do you know any history of UTZ? It came from sonar, from sound.
o Ultrasound has no problem with being done with pregnant patients in contrast to the other forms like X-ray and
CT scan.
o This modality has no problem with congenital anomalies. The plain 2D ultrasound will not produce any
congenital anomalies.

TRANSABDOMINAL
Requires FULL BLADDER
What is the function of the full bladder?
o In eagle eye, in one scene there was a glass of
water. What happened was that it became a medium to get
all the voices that were found among the conversations of
the people. The bladder (water) in ultrasound, transabdominal ultrasound, it projects the waves of ultrasound; it
acts as a window [During abdominal pelvic ultrasound
examination, it is helpful for the patient to have a full
bladder.
o This serves as an acoustic window for the highfrequency sound waves (Figs. 11-1 and 11-2)- From GYNE
BOOK]]. We require the patient to drink 800cc (4-6 glasses),
to the point the bladder is urging to void.
Done on: children, adolescents, non-sexually active women, post-menopausal women, huge abdominal
masses
The probe here can visualize deeper structures, so less penetration to tissues but the depth is more.
MANEUVERS done:
o Siding- done longitudinally & transversely (coronal view of the abdomen)
o Tilting or Angling- rotation from side to side (a rocking position; stay in one position of the
probe and you move side to side and you tried to expose areas of probe from the other side)
o Rotating- changing from sagittal view to transverse when you try to put the probe in just one
o

Dipping- entails pushing probe into abdomen

(if the structures are composed of osseous
structures-i.e cranium, more solid areas of ovarian ( areas of calcifications), try to push more in
the abdomen.

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Picture 1: The purpose of the gel tries to remove air interface between the transducer and the point of
contact.
Picture 2: These are the maneuvers: When you are trying to push further, its dipping. The rocking
motion is tilting.
Picture 3: For transvaginal, you can do the push and pull, rotation, and a maneuver similar to tilting.
Transvaginal has more limited movement than transabdominal. As long as its in contact with the cervix,
this depth would be good enough for examining.
Orientation:
o Fundal & cervical ends of the uterus
(The picture shows a longitudinal view, the
patient- should be lying facing the sonologist
with her right arm in line with the left arm of
the sonologist. When it comes to the tv
n ,
ll b
n d pp p
l . Th
left side of the screen will be the right side of
the patient and vice versa. If above is where
you put the transducer, the lower portion of
the picture is where the spine is)
o

Right & left: when you do the scan, the

right side of the screen would appear left
side of the patient (vice versa).
Dorsal & ventral dorsal are the spines

NOTES:
SA IBABAW NG ABDOMEN (duh? ) and the patient should be in SUPINE>
The probe use ranging from 3.5 to 5 mHz: The probe has less penetration but the depth is more. In thin women
you can actually see the abdominal aorta.
the gel used (coupling gel) is applied & dapat walang bubbles; parang same sa ECG it will have contact will
electrodes

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TRANSVAGINAL
Pelvic pathology
Infertility diagnosis & management patency of the tubes, presence of abdominal follicle
first used was on 1994; more on transabdominal BEFORE.
Examination of the lower genital tract
Orientation:
o Cervical end- located at the top end of the screen probe is ate tip of the cervix at the bottom
would be the uterine fundus Left side of the screen is bladder and buttocks is toward the spine (same
sa trans abdominal, di nagbabago position sa patient)
o Fundal- location at the bottom
o Anterior abdominal wall- bladder on the left
o Patients buttocks- structure toward the spine appear on the right
o Right & left- same as transabdominal
Maneuvers are the push & pull probe, rotating
and little bit of tilting.

TRANSRECTAL
VIRGINS (the transducer may not fit)
Extensive cervical cancer or stenosis (due to radio therapy)
Congenital or acquired anomalies i.e absence of vagina
Some menopausal women there are some menopausal are SEXUALLY ACTIVE

TRANSPERINEAL
With MINIMALLY FILLED BLADDER
Useful in urogynecology such as stress incontinence, pelvic anatomy & assessment of bladder function
The pelvic floor is composed of what structures? They
are connected to tail bones: Pubococcygeus and
puborectalis muscles. With these two joined muscles, they
traverse urethra, ureter pass through this hammock of
muscles.
Difficult to visualize, what you usually see are the bony
structures of mons pubis & symphysis pubis and slight
presence ofslight bladder filling & the rest are uterus and
adnexae structures.

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PROBE
1.
Curvilinear: 3.5 mHz
2.
Sector: 5-7 mHz

transbdominal (3.5 mHz_

(s ll
h n
h sb nds, h ng ) The fetal heart rate
usually uses 2mHz so kailangan mababa kay 3.5 mHz; Transvaginal uses up
to 7mHz(mas mataas)

CERVIX
At the caudal end asa taas parang NAKATAYO
Homogeneous echotexture with HYPOECHOIC
central canal that is cervical canal
sometimes from midcyle, there is debris
nucles kasi madami secretions.
Cysts, nabothian cysts which could be a sign
of mild infection
Measures 4 cm
May contain nabothian cysts
The vagina can be visualized as 3 bright parallel
lines posterior to the bladder visualized more
in transabdominal

UTERUS
Position: depends on the bladder content
a. Version: in relation to the angle of the cervix to the VAGINA.
o
o Retroversion: if angle INCREASES
More than 90 angles
In simpler form, as long as the fundus is closer to the
bl dd
s n
db
s
h
s
d
but if its anteflexed its
ch
b nd d n s
s
(fundus-isthmus)
b. Flexion: the angle of the body of the uterus
is at the ISTHMUS
o
cervix
o
Isthumus
changes
in
relation to the bladder

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Size:
o 6-8 cm in long axis
o 3-5 in transverse & A-P dimension
Prepubertal- mostly cervix with small corpus (2:1)
Nulliparous- corpus is larger than cervix
Multiparous- larger than nulliparous
Post-menopausal: larger cervix than corpus
MYOMETRIUM
o Moderately hypoechoic
o Arcuate vessels are seen at the anechoic
serpiginous structures at the periphery
S
s n w
n
ll s
c s,
these are just vessels; in some patients it can
be seen
ENDOMETRIUM
o Appears as median echogenic line
(depending on the cycle)
o THICKNESS:
a. Proliferative
phase:
4-8
mm
hyperechoic; widest
b. Periovulatory phase: 6-10 mm
even
beyond ovulation period
c. Secretory phase: 7-14 mm
thicker but the consistency is not the same, relatively
hypoechoic; more white
d. Post-menopausal: <6 mm <5mm

OVARIES
Located posterior & lateral to the uterus & anterior to the Internal iliac & medial to external iliac vessels
Not always identified due to hyperactive bowels
Mobile, echogenic, well-marginated, lateral to the fundus periphery to the bowels, hypoechoic
Measure 3x2x1 cm since the shapes of ovaries are not similar, the volume is used
Expressed in volume (VOL= LxWxDx 0.52)

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Follicular evaluation
Follicles <10 mm are seen
By Day 8 of the cycle, follicle measures 10 mm
A follicle measuring 16 mm to 20 mm is called
DOMINANT FOLLICLE
For women who want to get pregnant, they will make a request
for follicular monitoring
By day 5-6, the follicles are still small and < 10 cm, but by
Day 8, the follicles can reach 10mm.
A follicle measuring 16mm to 20mm size is called a
Dominant follicle (The follicle that first reaches 14mm will
eventually become the DOMINANT follicle)

Fallopian tubes
Usually not seen by transvaginal ultrasound(NORMALLY)
If you were able to visualize the fallopian tubes
(1mm), there may be pathology.
It can be visualized seen after PID which Can develop
to Pyosalpinx is more chronic can develop to hematosalphinx.
Ectopic pregnancies or congenital anomalies.

The fundal external contour is normal but looking

there is a convexity at the fundal area within the
myometrium and pointing towards the uterine cavity;
the congenital anomaly is, arcuate.

parang HEART <3

Septate
The problem with this is that there is partial
resorbption of the medial septum.
During formation of the Mullerian ducts, one duct
coming from the right and one duct coming from
the left & they join at the middle and the middle
p
n sh ld g w , n h s c s d sn .
Als
k n
s bit depressed on the external
contour (not more than 1 cm of depression) =
shadow fundal indentation.

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Normal contours on external, the most distinguishing are

the presence of two horns;
There is failure of the fusion of the Mullerian ducts.
There should be two cervical canals (it can have on
cervix or two).
The horn is the problem so this is called bicornuate.
Wider separatiion
parang bunny ears

parang peace sign hihih

The separation is deeper, almost near the cervix. This is a case
of didelphic uteri, separate cervices (2 cervices).

BENIGN LESIONS
UTERUS:
Usually this lesions present with heavy
menstrual flow at normal timing of
menstruation.
The term menorrhagia is no longer used. You
can see sun-rays but you cannot see any
definite lesion withiin the myometrium.
The uterus may be enlarged, looks a bit
globular (like a pregnant contour).
Within the myometrium you may see, with
Doppler color flow, scattered areas of irregular
increased vascularization (NORMALLY, the
vascular structures should be at the periphery)Adenomyosis- diffused (it is more COMMON
POSTERIORLY but she prefers this, since
whatever is on the anterior is also on the posterior- goes up to 12 weeks size- except in cases with
concomitant myoma)
i.e differential diagnosis: NONE if its AOG 20 weeks
Adenomyoma- localized with indistinct borders
Benign tumor, composed of muscle &
connective tissues= Myoma (most
common tumor of the uterus)
Three types:
1. Intramural: area in arterial wall
of uterus
2. Submucosal (we classify how
deep the myoma or the degree of the
protuberance to the endometrial cavity)
At the posterior part
of the uterus
3. Subserous: within the uterus
Where is the myoma in this picture? It is
intramural.

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More malignant. You can see increased size within a short span of time, lots of vascularization found in this
lesion (for example a month ago it was 2 cm and today its 5cm). This is leimyosarcoma. It is difficult to identify this
unless you have a follow up of the scan.
I s n s sp c c w h D ppler flow. Usually seen in post-menopausal women.
You try to advise these people to have a follow up.

IUD. Letter T.
OVARY:
Most common benign germ cell tumor of the ovary where you will see posterior shadowing (seen in
malignant tumor, but this is the only benign tumor with a shadow) h s ls
starry sky appearance
on the tumor with echogenic stippling. Usually this is anterior to the uterus and it floats.
Wh d s
l ? I s dermoid cyst. I s c p s d
s, s h
s w ll l . Th
c n ls b
presence of a dermoid plug (hairball appearance).

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Another epithelial benign tumor which is bilateral (5% of cases).

Presence of septations, its usually dark anechoic (dark & thicker wall), and may have areas of higher
degree of white since there is presence of mucin. This is an Mucinous cyst.
(+) Locules: pathognomonic
(+)mucin secreting or tall columnar (PATHOLOGY)

Another epithelial tumor, super anechoic, looks like one compartment, thin walled, it d sn h
ch
bilaterality, n l c l ; h
b n p p ll
p j c ns; s serous. The red seen (sorry kung photox ) here
is from the Doppler velocimetry. ANECHOIC
On c
n
s nd
d wh ch s s l
d
d, b
h s l w l l ch s.
S
s ll l c
nd n ss wh n
p sh h p b
w d h c s . (masakit sa patient )

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There are two ovaries seen in the picture. There are very small anechoic structures- these are premature
follicles. Many cysts. Polycystic ovary.
Sa mga di nag menstruate, yan ang ichura, NAUUDLOT. Bansot ang paglaki, can grow to 16 mm (2cm) should be
of the ovary or kasing laki ng DOMINANT FOLLICLE. If every cycle di nag dedevelop yan ang chura
Sometimes there may only be one side affected more than another.
Has a string of pearls appearance.
This is actually an endocronilogic disorder associated with future HPN, future Diabetes, possible case of
future endometrial carcinoma and hyperplasia- thus these patients are treated holistically.
These patients should exercise more and lower their weight so they can menses.
Metformin, anti-diabetic, clinical status, hyperglycemia in these patients so they request for FBS 75 grams
can be used to detect for a tendency in developing diabetes.
Its difficult for females to bear children; these patients are given an ovulation induction regimenClomiphene citrate.
The size is usually 2-9 cm and is classified by not only the amount of follicles but by the volume (if more
than 10cc, can be polycystic).
There are peripheral patterns and central patterns.
They present with amenorrhea, or sometimes menorrhagia.
Additional:
For example, .31 vs .71 index: which has a higher resistance? The 0.3 h s h h gh
s s nc . I s l k n
HPN, the vessel is smaller. But if a patient has no hypertension the lumen is larger. So the smaller, the
greater the resistance.
Wh s h l c
n
h
d ng ns g n l scan? Medial to the external iliacs.
Structures seen in pelvis are Paratubal and paraovarian: Thin walled, anechoic, one locule one
compartment,
o nearer to the ovary- paraovarian
o If further away from the ovary- paratubal.
Polyps: Cervical or endometrial- Hypoechoic structures, with one filling artery; it usually extension of lining
of endometrial; you must determine whether the artery comes from the posterior or anterior wall but
mostly on the ANTERIOR WALL.
Special diagnostics/procedures:
o Sonahysterogram: where Saline is used (to avoid exposure to radiation) the end point of this
procedure is to have a continuous flow of water to the end of fallopian tube (maximum amout 25
cc can be given); whatever the amount is the menstrual blood is the amount of fluid you give.
o Sonohysterography is an alternative to office hysteroscopy. In this procedure, a thin balloontipped catheter or intrauterine insemination catheter is inserted through the cervical os and 5 to
30 cc of warmed saline is slowly injected into the uterine cavity to see patency of tubes.
o Dye usually is used for laparotomy or radiology (contrast media)
o Meta-analyses of sonohysterography have found the procedure to be successful in obtaining
information in 95% of women, with minimal complications. Contraindications are active cervical
or uterine infection.
Lesions in the Fallopian tube if pathologic: Cog-wheel sign: incomplete septations usually tubular

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Signs of presence of ovulation: Signs, dominant follicle is not present (decrease in size), Shrunken size of
the follicle, presence of fluid more than usual in the cul de sac.
Hypoechoic areas (cul de sac presence)
For malignancy counter-part of cystadenoma or adenosarcoma and mucinous cystadenocarcinoma,
presence of solid areas & non progress vascular areas.
__________________________________END___________________________________________________
I dedicated this to my nulliparous and multiparous friends over the rainbow
Rushing and racing, and running in circles
Moving so fast, I'm forgetting my purpose
Blur of the traffic is sending me spinning, getting nowhere
when everything seems so wrong and awkward.

HELLO TO MY GFF and GF

I TRIED MY BEST TO MAKE IT A FRIENDLY TRANSCRIPTION, but if you are not satisfied, I am sorry its your
choice & opinion
MOTHERFATHER, BROTHERSISTER @%!&@#!!!!! Anhirap talaga. Lahat na ng mura nasabi
ko na habang ginagawa koi to X_X :(

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