Lecture TWO Ultrasound Evaluation of the Uterus Holdorf

Uterine Congenital malformations  The Müllerian ducts develop to form the upper vagina, cervix, uterus and fallopian tubes. Most uterine and cervical anatomic variants are the result of the abnormal embryonic development of the Müllerian ducts; thus they are referred to as Müllerian anomalies.  Because of the close developmental relationship of the genital ducts are urinary system, there is a common association of anomalies of both systems.

Pelvic Kidney

 Sonographers should evaluate the urinary tract in all cases of uterine anomalies. The ovaries do not develop from the Müllerian duct; therefore both ovaries are generally normal in the presence of Müllerian anomalies.

There are four categories of anomalous internal genitalia development:  Failure of formation  Failure of fusion  Failure of dissolution (Conclusion, to end)  Failure of structures to disappear

Failure of Formation  Complete Agenesis: results in complete absence of the vagina, cervix, uterus, and fallopian tubes  Partial agenesis: results in a range of anomalies, including absence of the upper vagina and cervix, with persistence of the uterus and fallopian tubes, or the more common Unicornuate uterus and single fallopian tube.

Failure of Fusion  Didelphysis  There may be complete duplication of the internal genitalia (two uteri, two cervices, and two vaginas), but less dramatically is the  Bicornuate uterus, which is a single vagina, and cervix, but variable lack of fusion of the upper uterine cavity.

Failure of Dissolution  The median septum fails to dissolute after fusion of the separate Müllerian ducts, and results in septate uterus, with a single vagina and cervix, but an interuterine septum partially or completely separates the cavity into two hemiuteri.  Rarely, there may be a combination of failure of fusion and failure of dissolution, which results in vaginal duplication with two cervices, and a single uterus with a septum.

Normal Uterus

Septate Uterus

Bicornuate uterus

Didelphic uterus

Subseptate

Septate uterus

Unicornuate uterus

Failure of disappearance  Abnormalities can result from failure of disappearance of structures that normally do not persist.  The most typical example is the lateral wall vaginal cyst (Gartner’s cyst), which results from remnants of the mesonephric or wolffian duct.

Gartner’s Duct Cyst

Vaginal Congenital malformations  Vaginal anomalies can be a result of either Müllerian duct and or urogenital sinus malformations in the developing embryo. They can include the following:  Vaginal atresia: the congenital absence of the vagina  Vaginal septa: The presence of transverse septations within the vagina  Vaginal duplication: the presence of two complete vaginas

Leiomyomas (fibroids)  Benign muscular tumors of the uterus are also known as myomas, fibromyomas, and fibroids. Leiomyomas occur in approximately 20% of all white women and 50% of African- American women older than 30 years of age.

 They are usually multiple rather than single, vary in size, and can occur anywhere in the uterus, cervix, or broad ligament. Degeneration of myomas can occur when the mass outgrows its blood supply.  Lipoleiomyomas are different in that contain fat and appear hyperechoic.

Locations of leiomyomas include:  Pedunculated: Arising from a stalk  Exophytic: Growing out of the uterus  Intramural: interstitial location within the myometrium  Submucosal: Lying directly beneath the endometrium and frequently projecting onto the uterine cavity, most commonly produce symptoms  Subserous: Lying close to the outer, peritoneal surface of the uterus  Interligamentous: Occurring within the broad ligament  Cervical: of which only 5-8 % are these, and are usually small.

Submucosal Myoma

Large myomatous uterus

Clinical signs of Leiomyomas  There are no clinical symptoms in most cases. When symptoms are present, they may include:  Heavy periods (Menometrorrhagia)- submucosal type are most symptomatic  Enlarged uterus on pelvic exam  Alteration in the normal menstrual flow  Pelvic pain caused by degeneration, torsion or infection

Sonographic findings  Specific sonographic appearance depends on the size of the fibroid and the degree and type of degeneration present. Most common sonographic findings include:  Well circumscribed, hypoechoic mass  Increased attenuation within the mass  Calcifications within the mass  Distortion of normal uterine contour  Extrinsic compression of the posterior bladder wall

Malignant Leiomyomas  An extremely rare occurrence is the sarcomatous change in leiomyomas.  Because they appear sonographically identical to benign tumors, these malignancies are not determined on the basis of diagnostic imaging.  Usually they only diagnostic clue is the relative rapid growth of the mass in a postmenopausal woman.

Degenerating myoma

Adenomyosis  A benign, typically diffuse disease characterized by infiltration of the endometrial glands and stroma into the myometrium, adenomyosis is usually more extensive in the posterior wall of the myometrium.  It is suspected in year old women with dysmenorrheal and irregular bleeding. Sonographic findings:  Enlarged uterus with normal contours  Focal areas of decreased echogenicity within the myometrium, possibly with small myometrial cysts  Thickening of posterior myometrium

Adenomyosis

Enlarged uterus with Adenomyosis

Nabothian cysts  Nabothian cysts are the result of obstructed and dilated endocervical glands. They are found most frequently in the intramural portion of the cervix, and are of no clinical relevance. Sonographic findings:  Small, well circumscribed, anechoic structure located within the cervical wall  Posterior acoustic enhancement

Nabothian Cyst

Endometrial Carcinoma  Endometrial carcinoma is now the most common type of gynecologic malignancy, with an incidence of 33,000 new cases per year in the USA.  75-80% of endometrial carcinoma occurs in postmenopausal women, who usually present early with postmenopausal bleeding.

Associated risk factors:  Obesity and anovulatory cycles in premenopausal women  Postmenopausal, with an increased risk if on estrogen replacement therapy  History of atypical hyperplasia  History of Tamoxifen therapy  Strong family history of uterine cancer

 Initially, the tumor mass grows into the uterine cavity. Myometrial invasion is the first indication of continued spread of the disease. Without treatment, the malignancy may spread to the cervix, adnexa, fallopian tubes and ovaries.  Distant metastases may occur if the pelvic lymphatic system is infiltrated.

Clinical signs  Post-menopausal vaginal bleeding  Hypermenorrhea, intermenstrual flow in patients still having periods  Pain as the result of uterine distention

Sonographic findings  Alteration in size, shape and sonographic texture of the uterine parenchyma.  Increased uterine size  Thickening of the endometrial echoes (>5mm) especially in a postmenopausal woman.  Fluid in the endometrial cavity.

Endometrial Cancer

76 year old woman with poorly differentiated endometrial adenocarcinoma.

Endometrial Hyperplasia  Defined as a proliferation of endometrial glandular tissue. It may be diffuse or many not involve the entire endometrium. About 25% of atypical hyperplasia will progress to endometrial carcinoma.  Hyperplasia is a common cause of abnormal uterine bleeding. In both peri-and postmenopausal women, it may be caused by unoppressed estrogen hormone replacement therapy.  Other causes include:  Persistent anovulatory cycles  PCOD  Obesity  Estrogen-producing tumors of the ovary (thecomas)

 The clinical signs produced by a hyperplastic endometrium are similar to those produced by carcinoma, and a thorough histologic examination of curettage specimens is required to make a definitive diagnosis. Ideally, the sonogram should be performed at the beginning of the hormone cycle (immediately post-menstrual)  Sonographic findings  Smoother borders  More homogenous texture, but possibly cystic changes

Hyperplasia of the uterus

Endometrial hyperplasia

Endometrial polyps  Polyps are localized overgrowths of endometrial tissue.  They may be Pedunculated, broad-based, or have a thin stalk.  Occasionally, a polyp will have a long stalk and prolapsed into the cervix or even vagina.  Color Doppler may reveal a feeding artery in the stalk. Sonohysteropgraphy is ideal for demonstrating polyps.

Clinical signs  Usually asymptomatic  Infertility  Abnormal uterine bleeding  Usually discovered incidentally during D&C  Occasionally causes postmenopausal bleeding

Sonographic findings  Non-specific thickened endometrium  Usually focal  Discrete mass in the endometrium, focal, round and echogenic  Possibly with a vascular stalk demonstrated by Doppler

Polyp in the uterine fundus

Multiple polyps demonstrated with saline infusion

Saline Infusion Sonohysterography (SIS)  SIS AKA hysterosonography, uses real time Sonography during injection of sterile saline into the uterine cavity. It is used to detect abnormalities most specifically of the endometrium.  Indications:  Infertility and habitual abortion  Congenital abnormalities and or anatomic variants of the uterine cavity.