Pelvic Mass

Benign ovarian tumors unilateral, 99% cystic, mobile,

smooth

Malignant ovarian tumors bilateral, cystic & solid, fixed,

irregular, 50% have ascites, cul-de-sac nodules, rapid growth
rate

PID & endometriosis fixed like malignant ovarian tumors

TB, PID, & liver dz can present w/ ascites

~ 40% of abd masses in kids < 2 years are renal in origin

Pelvic kidney occurs in ~ 15% of girls w/o vagina or uterus

Adrenal-renal tumors are partially cystic, partially solid

do ultrasound first, CT scan second

Pelvic mass in pre-pubertal female (> age 2)

21% ovarian/tubes
o 100% neoplastic
60% benign; 40% malignant
o 95% are germ cell tumors
75% bladder/renal
o 95% adrenal-renal tumors
MC presentation = palpable mass (85%), abd pain
& discomfort (55%)
All ovarian masses in pre-pubertal females
require surgery

Pelvic mass in young reproductive age female (15-20yo)

70% ovarian/tubes
o 80% physiologic
o 15% neoplastic
95% benign
95% of neoplasms are germ cell
tumors
29% uterus
o 100% pregnancy related

Pelvic mass in pre-menopause female

55% ovarian/tubes
o 25% physiologic
o 55% neoplastic
75% benign; 25% malignant
70% of neoplasms are epithelial
tumors
75% of those are low
malignant potential
o 8% endometriosis
o 7% PID
o 5% Ectopic precnancy
40% uterus
o 75% pregnancy related
o 15% leiomyomata
4% bowel

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Pelvic mass in post-menopause female
48% ovarian/tubes
o 100% neoplastic
60% benign; 40% malignant
o 90% are epithelial tumors
99% of those are invasive ca
40% uterus
o 55% cancer of uterus
o 25% cancer of cervix
o 20% leiomyomata
10% bowel
o 40% infection; 40% cancer
Most require surgery
Always investigate tumor markers
o CEA = colon cancer
o CA125 = ovarian cancer
o AFP = germ cell cancer
Palpable ovary
o Cystic, < 5 cm, and normal CA125 0-
3% chance of malignancy
o Multicystic w/ echoes, < 5 cm, normal
CA125 7-10% chance of malignancy
o Cystic, > 5 cm, and normal CA125 7-
10% chance of malignancy
o Multicystic w/ echoes, > 5 cm, normal
CA125 25-30% chance of malignancy
Mullerian epithelium tumors of ovary MC in
reproductive age & post-menopausal females derived
from coelomic epithelium (peritoneum is too) cause lower
abd pain and abd enlargement; can cause massive ascites;
may have elevated Osteopontin
Serous cystadenocarcinomas = MC tumor of
ovary; 75% benign; us. bilateral & unilocular
o Tissue resembles fallopian tube
epithelium
o Psammoma bodies
o Papillary projections
o CA-125
Mucinous cystadenomas = 2nd MC ovarian
neoplasm; 80% benign; 5% bilateral; us.
multilocular; tissue resembles cervical epithelium
o Lining of tall columnar epithelial cells w/
apical mucin and absence of cilia
o Middle adult life
o Pseudomyxoma peritonei = extensive
mucinous ascites, cystic epithelial
implants on peritoneum
Endometrioid carcinomas = 3rd MC ovarian
neoplasm; 40% bilateral; tissue resembles
endometrial epithelium
o 15% assoc. w/ endometriosis
o CA-125
Clear cell adenocarcinoma occurs w/
endometriosis or endometrioid carcinoma of ovary
Cystadenofibroma proliferation of fibrous
stroma
Brenner tumors adenofibromas w/ nests of
transitional cells glandular spaces lined by
columnar mucin secreting cells
Germ cell tumors of ovary MC in pre-puberty and
young reproductive age females
Teratomas MC germ cell tumors
o Mature (benign) teratomas (dermoid
cysts) hair, cheesy sebaceous material,
thyroid tissue cystic & solid
Tx = laparoscopy w/ unilateral
salpino-oophorectomy
o Monodermal teratomas
Struma ovarii MC type,
composed entirely of thyroid
tissue, causes hyperthyroidism
Ovarian Carcinoid type
(Carcinoid syndrome)
o Immature (malignant) teratomas hair,
cartilage, bone, calcifications; fetal tissue
solid tumors
Dysgerminomas ovarian counterpart of
seminoma of testis MC malignant germ cell
tumor
o All are malignant; no endocrine function
o Infiltration w/ mature lymphocytes,
occasional granulomas
Endodermal sinus (yolk sac) tumors 2nd MC
malignant germ cell tumor fatal w/in 2 yrs pts
present w/ rapidly developing pelvic mass w/ abd
pain
o -fetoprotein (AFP)
o 1-antitrypsin
o Schiller-Duval bodies characteristic
glomerulus structure w/ central blood
vessel enveloped by germ cells lined by
germ cells
Ovarian choriocarcinoma high hCG
o Unresponsive to therapy fatal
o Compare to trophoblastic choriocarcinoma
Sex cord stromal tumors of ovary
Granulosa-Theca cell tumors extremely rare
elaborate lots of E2 endometrial hyperplasia,
endometrial ca, cystic dz of breast; us. solid; us.
unilateral; acidophilic Call-Exner bodies; all
potentially malignant; high levels of inhibin
o Can cause complete pseudoisosexual
precocity
Fibroma-Thecomas us. unilateral; elaborate lots
of E2
o Meigs syndrome = nonspecific pain and
pelvic mass w/ or w/o ascites and right-
sided hydrothorax; benign condition
Sertoli-Leydig cell tumors (adrioblastomas) us.
unilateral; masculinization; peak incidence in 2nd-
3rd decades; tumors may block normal female sex
development (breast atrophy, amenorrhea, sterility)
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 Hilus cell tumors (mature Leydig cell tumors) MC along upper posterior wall of vagina
unilateral; large lipid laden cells; Reinke
crystalloids; high 17-ketosteroid excretion
Gonadoblastoma mixed tumors (germ cells and
stromal cells); occurs w/ hermaphroditism

Metastatic tumors of ovary

MC mets are from contralateral ovary, derived from
mullerian system neoplasms
MC extramullerian primaries = breast and GI tract
o Krukenberg tumor GI mets to ovaries;
mucin production; signet-ring cells

5-10% of women in US will have surgery for suspected

ovarian neoplasm during lifetime
15-20% of these will have malignant ovarian
neoplasm

Most adnexal masses are benign.

Infant female (age < 2 years) MC pelvic mass due to

transient elevation in circulating gonadotropins after birth
(physiological ovarian cyst)

Physiologic (functional) ovarian cysts in reproductive age

female (age 15-20) repeat ultrasound in 6 weeks b/c 5%
chance of neoplasm

Paratubal fallopian tube cysts = MC primary lesions of

fallopian tubes (tiny, translucent cysts filled w/ clear serous
fluid); develop from cranial portion of mesonephric duct
Hydatids of Morgagni = larger paratubal cysts near
fimbriated end

Leiomyomas (fibroids) 75% of reproductive age females

MC tumor in humans whorled bundles of smooth muscle
cells red degeneration
Benign metastasizing Leiomyoma extremely rare
MC to lung
Disseminated peritoneal leiomyomatosis multiple
small nodules on peritoneum
risk for spontaneous abortion (esp. if
submucosal)
Most are ASx
Leiomyosarcoma us. arise de novo (not from leiomyomas)
invade uterine wall OR project into uterine lumen lots of
atypia peak incidence 4th-6th decades 50% mets to lungs,
bone, brain via bloodstream
Fibroid ENLARGING in a post-menopausal female
us. indicates malignancy

Perimenopausal female passing large clots, very irregular,

very heavy bleeding, enlarged uterus cancer of the
endometrium

Vaginal carcinoma always R/O cervical carcinoma

~ 95% are SCC assoc. w/ HPV
Greatest risk factor = previous carcinoma of cervix
or vulva
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Cervical carcinoma ~ 80% are SCC assoc. w/ high-risk
HPV (esp. type 16)
MC variant = fungating (exophytic)
Stage 1 confined to cervix; Stage 2 extends beyond
cervix but not onto pelvic wall; Stage 3 extends
onto pelvic wall; Stage 4 extends beyond true
pelvis or involves bladder/rectum
o Can obstruct and cause hydronephrosis,
dilated ureter
Symptomatic early on post-coital bleeding foul
smelling discharge
Cervical carcinoma ~ 20% are adenocarcinomas
(endocervical gland origin; assoc. w/ HPV type 18) OR
adenosquamous carcinomas (mixed; less favorable
prognosis) OR poorly differentiated (oat cell carcinomas;
poor prognosis due to early lymphatic spread) OR clear cell
adenocarcinomas (DES exposure)
Skip lesions
Acute Pelvic Pain
H&P quick and to the point
Pregnancy-related
Ectopic pregnancy
Abortion
Gynecologic
Acute PID
Ovarian cyst (torsion, hemorrhage, rupture)
Endometriosis
Nongynecologic
Acute appendicitis
UTI cystitis, pyelonephritis
Diverticulitis
Ectopic pregnancy
MC implantation is in fallopian tubes (95%)
MC predisposing condition is PID
MC cause of hematosalpinx
MC cause of 1st trimester maternal mortality
o Causes 6% of all maternal deaths
Triad of symptoms = amenorrhea, vaginal
bleeding, lower abd pain
Possible Ectopic pregnancy = MC clinical
presentation; ultrasound shows no IUP; -hCG
level below discriminatory zone
Probable Ectopic pregnancy = lower pelvic pain,
spotting/bleeding, adnexal/cervical motion
tenderness, absence of IUP on ultrasound, -hCG
level 1500-2000 (Discriminatory Zone)
Ruptured Ectopic pregnancy = surgical
emergency; severe abd pain, dizziness, unstable
vital signs
Diagnostic tests = hCG should double every 48
hours (if not, think Ectopic or abortion);
transvaginal ultrasound should show gestational
sac by week 5 of amenorrhea
Treatment of Ectopic pregnancy
o If pt has no evidence of acute abd &
pregnancy is < 3.5 cm w/ no fetal heart
activity 90% cure w/ methotrexate
o Methotrexate is a chemotherapeutic agent
embryo dies & is resorbed
o If pt is in ACUTE pain, is spotting, has
lower left quadrant tenderness
laparoscopy
Risk factors for Ectopic pregnancy = previous Ectopic
pregnancy (#1), Hx of PID, cigarette smokers, Hx of tubal
ligation, Hx of tubal reconstructive surgery, use of assisted
reproductive technology
Normal hCG levels
5 weeks gestational sac on sono hCG level 1500
IU/L
6 weeks fetal pole on sono hCG 5200
7 weeks fetal cardiac motion on sono hCG
17,500
Threatened abortion no Tx, bed rest
S/S = painless bleeding before 20th week (can
have cramping)
Inevitable abortion empty gestational sac past 5-7 weeks
Bleeding, cramping, cervical dilation
Tx = D&C
Incomplete abortion passage of tissue; some retained
Missed abortion dead fetus, retained
No bleeding, cramping, or passage of tissue
risk of coagulopathy
Tx = D&E (dilation and evacuation)
Complete abortion all products of conception passed
severe bleeding w/ large clots, severe lower abdominal
cramping, cervix dilated
~ 30% of pregnant women will bleed in 1st trimester
half will abort (~ 15%)
half will continue w/ normal pregnancy
Ruptured ovarian cyst
Ultrasound free fluid in pelvis
Surgical intervention if orthostatic & anemic
Observation and NSAIDs if not orthostatic and
anemic
Ovarian Torsion = twisting of vascular ovarian pedicle or
fallopian tube; bigger cysts are more likely to twist
Occludes lymphatic & venous drainage of adnexa
Absence of blood flow on Doppler
Ultrasound presence of adnexal mass
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 Must be treated surgically
High index of suspicion in female w/ repeat
episodes of abd pain and Hx of DVTs w/ oral
contraceptive use
Pelvic Inflammatory Disease (PID) upper reproductive
tract infection, us. ascending
MC bilateral
MC etiologic agents = gonococcus, chlamydia
S/S = fever, pelvic mass, tenderness, acute abd,
high WBC, mucopurulent cervicitis
Can cause pyosalpinx, hydrosalpinx,
infertility
Complications
6X risk for Ectopic pregnancy
14X risk for infertility
6-10X risk for pelvic pain
Fitz-Hugh-Curtis syndrome URQ pain
due to infection of liver capsule
Dx by laparoscopy
Diagnose and treat empirically in sexually
active female w/ risk factors &
uterine/adnexal/cervical motion tenderness
Tx = antibiotics
Inpatient if pregnant, failed oral Tx,
unreliable pt, severe illness, tubo-ovarian
abscess
Can be caused by Actinomycosis assoc. w/ IUD
us. unilateral in this case
Endometriosis = presence of endometrial glands outside of
uterus
Classic triad = dysmenorrhea, dyspareunia,
dyschezia
o Dysmenorrhea 1-2 days prior to menses
early in clinical course
o Dyspareunia deep thrust penetration
S/S = tenderness, echogenic ovarian mass, fixation
of uterus w/ nodularity of uterosacral ligaments,
chocolate cysts
MC in pre-menopause female
MC cause of secondary dysmenorrhea
MC cause of cul-de-sac nodularity
DEFINITIVE DIAGNOSIS = biopsy at time of
laparoscopy
DEFINITIVE Tx = surgical (total abdominal
hysterectomy w/ bilateral salpingo-oophorectomy;
laparoscopy w/ ablation and excision of implants)
Medical Tx = oral contraceptives, NSAIDs, GnRH
agonists (buserelin, leuprolide acetate; temporary
Tx for ~ 1 year), Danazol
Appendicitis = MC intestinal source of acute pain in women
S/S = abd pain, anorexia, vomiting, normal BP,
normal pulse, temp 100-101.5
Acute abdomen pain starts periumbilical, shifts
to RLQ w/in hours
WBC 12,000-15,000 (normal 3,000-10,000)
If WBC > 20,000, think about rupture
Tx = surgical
Acute abdomen = rebound & guarding
Due to blood, pus, or chemicals irritating
peritoneum
Bowel problems that can present as pelvic mass =
inflammatory or neoplastic bowel dz, ulcerative colitis,
regional ileitis, diverticulitis
Fluctuant adnexal mass could be inflamed bowel in
pelvis
Stool guaiac positive for occult blood
Tx = corticosteroids
Dysmenorrhea
H&P more broad and in depth
Primary dysmenorrhea = pain w/ menses; no defined
pathology; us. starts w/in 6-12 mos. of menarche
Pelvic cramping, pain radiating to back or thighs,
diarrhea, headache, nausea, vomiting
Secondary dysmenorrhea = pain w/ menses due to defined
pathology (MC due to endometriosis)
Other causes = adenomyosis, fibroids, ovarian
cysts, pelvic congestion syndrome, congenital
malformations
1st line Tx for dysmenorrhea = NSAIDs + oral contraceptives
NSAIDs block prostaglandin release
o Naprosyn, Aleve, Celebrex, Motrin, Advil
Oral contraceptives suppress endometrial growth
o Anovulation prostaglandin levels
If 1st line Tx fails laparoscopy and ultrasound to look for
secondary cause of dysmenorrhea
Chronic Pelvic Pain
H&P very meticulous
Chronic pelvic pain = non-specific pain > 6 mos. duration
unrelieved by NSAIDs; pain affects quality of life
1/3 have no apparent pathology on laparoscopy
1/3 have endometriosis
-1/3 have adhesions [from prior surgery] or
remnants of chronic PID
Gynecologic causes = endometriosis, adenomyosis,
adhesions, chronic PID, leiomyomata, pelvic congestion,
ovarian remnant syndrome
Pelvic congestion syndrome = dilated veins in pelvis; assoc.
w/ post-coital aching
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Ovarian Remnant Syndrome = previous hysterectomy but
some ovarian cortex left behind
Gastrointestinal causes of chronic pelvic pain = IBS,
inflammatory bowel dz, hernia
Urologic causes of chronic pelvic pain = interstitial cystitis
(common), urethral syndrome
Bladder = most neurally sensitive organ in the body
Musculoskeletal causes of chronic pelvic pain = abd wall
defects, incisional neuroma, pelvic diaphragm S/D
Only 2-7% of all afferents passing thru each dorsal
root ganglion are visceral & 93-98% are somatic
cross-talk viscerosomatic pain referral
o Reason for referred pain to pelvic floor
Psychiatric causes of chronic pelvic pain = depression,
somatization, hypochondriasis
PE incl. check abd wall, Q-tip test for vestibulitis (indicates
referred pain), abd wall trigger points, ovarian point
tenderness (suggests pelvic congestion syndrome), pelvic
floor myalgias (transvaginal single digit exam), piriformis
screen, traditional bimanual exam (last portion of pelvic
exam)
Pelvic Organ Prolapse
Normal, standing female bladder, upper 2/3 of vagina, and
rectum are horizontal urethra, lower 1/3 of vagina, and
anal canal are vertical
Primary support of pelvic organs = pelvic diaphragm
muscles
Failure of primary support MC due to term
labor and delivery; also caused by intra-
abdominal pressure (chronic cough, heavy lifting,
constipation, etc) and iatrogenic factors (surgery)
Muscles of pelvic diaphragm incl. levator ani
(pubococcygeus & iliococcygeus),
ischiococcygeus, pubovaginalis, puborectalis,
piriformis, obturator internis
Secondary support of pelvic organs = endopelvic fascia
1) Cardinal-uterosacral ligament complexes
(suspensory; apical axis)
a. Hold bladder and vagina up
2) Paravaginal supports (horizontal axis; paravaginal)
a. Pubocervical fascia holds uterus up
b. Rectovaginal fascia holds rectum down
3) Vertical orientation of urethra, vaginal outlet, anal
canal
Failure of cardinal-uterosacral ligaments apical
vaginal prolapse (vagina drops out)
Failure of pubocervical fascia anterior vaginal prolapse
cystocele = bladder bulges thru ant. wall of vagina
Failure of rectovaginal fascia posterior vaginal prolapse
rectocele = rectum bulges thru post. wall of vagina
enterocele = loop of bowel bulges thru post. wall of
vagina
Splinting = placement of finger in vagina to have bowel
movement; MC if pt has rectocele
Dx of prolapse = speculum exam, rectal exam
Nonsurgical Tx = Kegel exercises, pessaries
Surgical Tx = lots; can only repair breaks in continuity of
endopelvic network (fixes secondary failures, not primary)
Incontinence
Genuine stress incontinence (GSI) (50-70% of cases) leak
w/ coughing, laughing, sneezing; no detrusor contraction
Hypermobility of bladder neck due to weak
pelvic diaphragm muscles and connective tissue
(pubocervical fascia) MC after childbirth
o Fire hose in muddy ground
Intrinsic sphincter deficiency (ISD) severe form
of GSI; stove pipe urethra
Tx = estrogens, Kegel exercises, pessaries, surgery
(suburethral sling)
Detrusor Instability (DI) (10-30% of cases) urgency,
frequency (voiding > 8 times per day; nocturia > 2 times per
night), overactive bladder
Uninhibited detrusor contraction assoc. w/ strong
urge to void
Unknown etiology
Commonly assoc. w/ triggers (i.e. running water,
etc.)
Tx = timed voiding, oxybutynin (Ditropan),
tolterodine (Detrol), tri-cyclic antidepressants
Mixed Incontinence (10-30% of cases) = GSI + DI
Prevalence increases w/ age
Treat urge 1st
Other (overflow, neurogeneic) incontinence (10% of cases)
result from detrusor areflexia or hypotonic bladder
MC in pts w/ prolapse
LMN dz, spinal cord injuries, autonomic
neuropathy (DM)
Management = intermittent self-catheterization
Climacteric
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Climacteric = phase in female reproductive life when Intermediate effects of estrogen deficiency (age 55-65)
gradual decline in ovarian function results in sex steroid Atrophic vaginitis loss of estrogen results in thin,
production and assoc. sequelae dry epithelium w/ alkaline secretion (pH > 7.0)
Average onset ~ 51 years old o S/S = dysuria, dyspareunia, vaginal
Ovaries lose ability to respond to GnRH pruritis
estrogen production o elastic capacity of bladder
Ovulation ceases frequency, urgency, nocturia
Dyspareumia
Menopause = last menstrual period; made in retrospect, us. Urge incontinence
after ~ 1yr w/o menses Stress incontinence
Skin atrophy
Most women ovulate ~ 400 times btwn menarche &
menopause the rest of the eggs are lost
Born w/ ~ 1.5 million primary ovarian follicles
Reach menarche w/ ~ 400,000

Early effects of estrogen deficiency = Perimenopausal

symptoms = heavy menses, endometrial hyperplasia,
mood and emotional changes, hot flashes, night sweats,
shortened cycle length, irregular menses, breast tenderness
May last 3-5 yrs before complete loss of menses
Avg. age of onset of perimenopausal S/S = 47.5
years
frequency of anovulation

Premature ovarian failure (premature menopause) =

menopause before the age of 40

Hormone changes
E2 (estradiol) declines but E1 (estrone) may be
higher
androgen production but lost opposition by
estrogen causes sensitivity to androgens
excessive facial hair growth, breast size
o Testosterone ~ 20%
o Androstenedione may ~ 50%
Androstenedione from ovary and adrenals is
converted to estrone in peripheral fat tissues
capable of maintaining vagina, skin, and bone in
reasonable cellular tone and reducing incidence of
flashes
o E1 may be responsible for
incidence of endometrial or breast
cancer among obese women (unopposed
estrogen)
progesterone levels too low to induce
enzymes that convert E2 to E1, too low to induce
secretory activity in endometrium irregular
vaginal bleeding, endometrial hyperplasia, cellular
atypia, incidence of endometrial cancer
FSH & LH due to more GnRH released by
arcuate nucleus and paraventricular nucleus in
hypothalamus due to low circulating estrogen
levels

Normal vagina very sensitive to estrogen produces thick

moist epithelium w/ acidic secretion (pH ~ 4.0)

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Late effects of estrogen deficiency (age 65+)
Atherosclerosis CT excellent for detection of calcification or fat within
Alzheimers dz pelvic masses. Can be used for staging ovarian cancer but
Cancer not very useful for endometrial or cervical cancer.
Osteoporosis Advantages
Excellent tissue differentiation
o Estrogen loss osteoclast activity far
Multiple imaging planes
exceeds osteoblasts activity osteopenia
Large field of view
osteoporosis
Disadvantages
o Clinical sign = loss of > 1.5 height due to
High cost and less available
vertebral compression fracture
o Most Ca2+ lost from trabecular bone
MRI can be used for staging uterine cancers and ovarian
MC fractures are spinal column and
cancers. Also used for further characterization of benign
femoral neck
uterine or ovarian masses.
o Screening = dual-energy x-ray
Advantages
absorptiometry (DEXA) measurements of
Global view
total hip and spine
Excellent anatomic resolution
o Reduce risk of fracture w/ 1200-1500mg
calcium and 400-600U vitD daily, Disadvantages
Radiation
walking, weight-bearing exercise
o Tx = estrogen, selective estrogen receptor Mainly used to eval metastatic malignancy

modulators (SERMs, like raloxifene), and abscesses

biphosphonates (alendronate), calcitonin,
PTH Indications for imaging referrals
Vaginal Bleeding
Estrogen replacement therapy Pelvic Mass
risk of coronary artery dz, stroke, thrombosis, Pelvic Pain
breast cancer Initial exam is ultrasound. Localizes a mass as
risk of Alzheimers, colon cancer, osteoporosis uterine, ovarian or tubal; identifies potential
Indicated primarily for relief of significant source of pelvic pain; useful in determining the
menopausal symptoms (frequent hot flashes, cause of vaginal bleeding. A patient with a known
genitourinary discomfort, other quality-of-life history of cancer will be imaged by CT or MRI.
issues)
Continuous estrogen > 40% incidence of Ultrasound Images
endometrial hyperplasia Normal uterus
7-8cm length in nulliparous menstruating
Give cyclic estrogen + progesterone reduced risk
of endometrial hyperplasia female
o Monitor endometrium annually w/ Normal ovary
Average 6-10cc volume in normal
ultrasound; thickness should be < 5mm
Contraindications = pregnancy, breast cancer, menstruating female
Volume determined by l X w X h X 0.523
estrogen-dependent neoplasia, undiagnosed ABN
vaginal bleeding, thrombophlebitis
MRI Images
Alternatives = progesterone, clonidine HCl,
Endometrium
methyldopa, phenobarbital, paroxetine HCl (Paxil),
Premenopause, variable
venlafaxine HCl (Effexor)
Post M 5 mm
Junctional zone (dark rim around endometrium)
Radiology of Pelvis 2-8 mm
Outer myometrium
Ultrasound is usually the initial imaging exam of the Cervix: mucosa, stroma
female pelvis, transabdominal then transvaginal
Advantages Causes of vaginal bleeding
Good tissue differentiation Endometrial
Low cost, portable, easily available Endometrial atrophy MC
Multiple imaging planes Endometrial hyperplasia or polyp
Study of choice Endometrial thickening
Disadvantages o > 5 mm (post
Small field doesnt give global view menopausal);
Operator-dependent hypoechoic

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 o Diffuse cystic change > 4 cm
Endometrial polyps typically Solid mass (bilateral)
demonstrate cystic change Wall & septations thick (> 3 mm)
Endometrial carcinoma Vegetations and nodules
Irregular border after giving Benign Cystadenoma = MC surface
contrast shows infiltration into epithelial tumor
myometrium Benign features = simple cyst or
All except atrophy require biopsy to few thin septations, little or no
differentiate free fluid, unilateral or bilateral
Uterine Leiomyoma (especially submucosal) Germ Cell (15 20%): cystic teratomas,
Locations for leiomyoma = intramural, germinomas
submucosal, subserosal (can be Sex Cord (5-10%): granulosa cell, thecoma,
pedunculated) and cervical fibroma, androblastoma
Cervical Cancer Metastatic (5-10%): breast, colon or gastric
Ultrasound: Not very useful carcinoma (Krukenberg tumor), lymphoma
MRI: Study of choice to evaluate local
mass Pelvic Inflammatory Dz
CT: Evaluate adenopathy and distant Fever, Pelvic pain, vaginal discharge
metastasis Ultrasound = initial evaluation
Clinical evaluation critical
Adnexal Pathology
CT useful if larger field of view needed to evaluate
Initial evaluation = ULTRASOUND
abscess
MRI = problem solving modality
Severe adnexal tenderness
Ovarian vs adnexal
Solid vs cystic
Tubo-Ovarian abscess = MC reason to evaluate
Neoplastic vs non neoplastic
pts w/ PID
Simple Ovarian Cyst
Ectopic Pregnancy
ULTRASOUND
Ultrasound w/ clinical correlation required
Follicular cyst or corpus luteum MC
CYST = larger than 2 cm
CT and MRI have little value
No internal echoes, nodules, or septations
Almost always benign
F/U in 6 weeks
95% resolve spontaneously
Bright on MRI
Hemorrhagic Cyst
Hypoechoic on ultrasound due to blood
Dark on MRI due to blood
Endometriosis
String of pearls on MRI
Ovarian Neoplasms
BENIGN dermoid (teratoma) MC
Composed of varying amounts of
endoderm, mesoderm, &
ectoderm
Occasionally unilocular (lined w/
ectoderm) filled w/ desq. keratin /
sebum
Torsion = MC complication
2% malignant transformation
MALIGNANT = Complex cystic masses
w/ internal echoes, septations, and nodules
Ultrasound for initial eval
F/U with MRI or CT

Ovarian Tumor Types

Surface Epithelium (65-75%): mucinous and
serous cystadenoma/adenocarcinoma
Primary criteria for malignancy
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