Before 1960’s, imaging was done by the radiology department.

1970’s - there was a need to visualize the fetus before gyne → UTZ
Radio vs OB: who should be doing the ultrasound?

Materno fetal medicine specialists: Surveillance, treatment, UTZ:

OB/GYN sonologist
4 types
PUS- pelvic ultrasound, same with TAS (TVS ata dapat)
TAS: 3.5-5 Mega Hertz
TVS: 7-8 megaHz

TA probe can be used for TP/TL scan

TV probe can double as TR scan for those with no sexual contact

TAS has higher depth of field

● For large masses
TVS has limited depth of field, higher resolution
● 6-7 cm depth

TA for large masses (if fetus is big, except pag 3rd trisem we use TA),
TV/TR reserved for normal gynecologic scan, first trimester

Ask for sexual contact

● If none: use TRS
● DO A GOOD HISTORY
○ If accompanied, will not tell you :(
○ TRS is more uncomfortable
○ Ask and sign a consent before doing TVS (if not a minor)
TRS not used in US and EU because of their sexual culture. Usually have earlier
sexual contact. Asians are more conservative.

TAS - you can only see the structures if you have a good medium which is the
bladder, bladder must be full (8 glasses of water)

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TVS: good penetrability, most commonly used in GYN
TAS:good for big structures, used in OB especially after 1st tri

If without sexual contact- use transrectal or transperineal (not used in our setting)

Above pelvic cavity - TAS (need to have acoustic window) ask px to fill bladder (drink
8 glasses) but some px cant tolerate this. so TRS the one done
TAS
Radiologists do not perform TVS TRS
Can only see structure if a very good medium is used (bladder)
Drink at least 8 glasses of water before you can visualize their uterus and ovaries.
Very uncomfortable.

TVS TRS
Asked to void, bladder provides obstruction and pushes structures above

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Usually very young patients get TRS, rapport is needed.

Depends on the size of the patient, if malaki kaya

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Largest organ - uterus (pic in sagittal section)

M: myometrium
Arrows: endometrial cavity
Cervical canal should be continuous with endometrial cavity

Length, height, width - measurement of uterus

Baseline echoes is the myometrium.

Whiter than myometrium: HYPERechogenic. Readily reflect light.
Same echoes as myometrium: ISOechoic
Lesser - hypoechoic
No echoes(fluid or blood, air) -anechoic

LxWxH

Position in relation to bladder:

Anteverted - normal
retroverted

Acute angle - anteflexed

ALWAYS READ THE REPORT

 ● There might be info in the impression that is not reported

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Sagittal cut

red line - endometrial cavity

M-myometrium

for masses - any echo higher in intensity as myometrium is hyperechogenic

Retroverted uterus (red) - away from the bladder

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Multigravid: increase in size of corpus

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These are the normal measurements
Position in relation to where the bladder is

Anteverted : see slide 5

Acute angle presentation - anteflexed

Hyperechogenic echoes: calcification

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White spots (calcified) - seen in menopause
normal position-anteverted
Homogenous myometrium
In reproductive age group

Increase in echoes - may be myomas

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See if there are masses which may be cervical polyps
Nabothian cyst - plugging

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Sometimes we see anechoic areas→ nabothian cysts

Can date the endometrium
Menstruation - shed
- Basalis layer left
- thin endometrium expected
- <4mm (institutional cut-off); anything more than this in a menopausal woman
is already considered thickened

If bleeding profusely but still thick, proliferation > shedding

- Conclude: hyperplastic endometrium

Proliferation of endometrium
- Early proliferative: development of the new endometrium starts in the basalis
layer.
- Late proliferative: Trilaminar or triple sign. Pre-ovulatory endometrium!
Important in timing for fertility specialists

Secretory phase
- Next slide

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If there is bleeding, the endometrium is thin (one straight white line less than 4mm)
During prolif phase
-initially: it starts proliferating from basalis layer. then just before ovulation you will see
TRIPLE LINE SIGN/ trilaminar endometrium
As the glands are developed and endometrium proliferates, magiging
hyperechogenic(secretory phase)

hyperechogenic + fluid in the culdesac → has ovulated na

Secretory phase: With the development of the endometrial stroma & glands, the
endometrium becomes hyperechogenic. Together with fluid in the cul de sac,
ovulation has occurred and it is in the secretory phase.

Postmenopausal cutoff
<4mm in Philippines
<5mm international

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Sweep probe left and right
Sitting in front of the iliac vessels is the ovaries with cysts
Should not see the tube (if seen = pathologic)

Only one dominant follicle will enlarge to eventually extrude one egg
● Being monitored!
● Day 12, 14, 16 - follicle monitoring (if ruptured, may allow sexual contact)

Monitor growth or fluid accumulation to know if patient has ovulated.

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how do u know its the ovary? sitting on the iliacs (landmark)

anechoic structure → follicles

AUGUST 22 NOTES (LNR):
Will time sexual contact based on ovulation
Benign tumors
Well defined mass.
By pathology: Myoma has a definite capsule. Because of the smooth muscle of the
myomas, when the sound waves hits, it makes a linear streak pattern = sunburst
appearance

Hypoechogenic area with well defined layers

Fibrous capsule - confulent definitive appearance

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myoma:
gross → has a capsule
“sunray” appearance (hypoecho lines), very well defined dt capsule
You can already see the mass protruding within the cavity

Myoma & polyp - hard to distinguish, this is a histopath finding

SIS: Instill fluid (saline) to make the mass float, still cannot differentiate
OR during menstrual period when there is blood inside

Doppler flow
Hook sign: vessel that supplies the mass = Polyp

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If the mass is big + sun ray appearance= strongly consider leiomyoma
Diff dx: endometrial polyp
Anterior vs posterior: Posterior portion is thicker.
Pathophysiology: 1 part of myometrium is larger = invasion
Or both enlarged
No distinct capsule
Diffuse thickening
Inhomogenous pattern

Adenomyosis - severe dysmenorrhea, infertility, imaging results

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Important to correlate signs and symptoms
Invasion of the myometrium with endometrial glands
There is no capsule(usually in the posterior)
Marked thickening of the posterior wall
There is also a structure that is protruding but the pedicle is thinner.

Hook sign- has a 85-90% accuracy rate when seen in UTZ (lower pick, white arrow)
● Single feeding vessel

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Postmenopausal = endometrium is thin
Red = thickened endometrium (>4mm), (+) cystic spaces = suspect for hyperplasia
(proliferative > secretory)
>5mm?? During lecture

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hx: px bleeding profusely for past weeks, when u do utz expect endometrium to be
thin. but if endometrial lining is thickened + anechoic structures inside: consider
endometrial hyperplasia consider cystic degeneration
If there are anechoic structures, these denote cystic degeneration. This is called
cystic hyperplasia
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Ugly, irregular
Lobulated asymmetric
Very profuse flow on doppler

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A cyst that is unilocular, no papillation, with regular
Well-defined border - simple cyst

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Simple: hypoechoic, no hyperechoic structures, well defined borders

IOTA classification
Most typical cyst - Very high accuracy rate
Abnormality in 3 layers (hair, bone, teeth) = Complex mass with solid nodule, streak
like pattern

Echogenic core - calcified entity

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linear streaks - hair
Pathophy: hemorrhagic cyst (endometrial cysts)
Ectopic endomet developing within the ovary = during menstruation, this also
menstruates pero di mailabas = will accumulate
Also an hemorrhagic cyst

When blood becomes old

● Hemosiderin pigments: high fine level echoes

Sx: Severe dysmeno, infertility

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The basic pathology: ectopic endometrial tissues invading the ovaries; there will be
blood inside leading to accumulation; later after menses, production of hemosiderin
pigments→ homogenous fine structures within the ovarian cyst

Any hemorrhage inside the ovaries would have the same appearance
Can grow very large, with septations, predominantly cystic because of the mucin (fluid
with particles) inside

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Patient may look pregnant because of the size

Multilocular divided by thin septations, big size → mucinous cystadenoma

Malignant potential - histopathologically determined
IOTA classification (before SASSONE)
Benign vs malignant
10 simple rules

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SASSONE is obsolete
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10 simple rules
One of both = indeterminate → use adnex model
Enter data on website and it gives probability that the mass is benign / risk factor

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Adnex model - input mass features and patient data and will generate percent change
of malignancy for the mass
Not supposed to see the tubes during examination of the uterus
If it is dilated - only 3: hydrosalphinx, pyosalphinx, tubal CA
Cystic mass with incomplete septations

Myosalphinx: if there are echoes. (*pyosalphix ata?)

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Barely delineate uterus, ovaries and tubes
Clinically correlate if with fever, foul discharge

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To introduce flud inside - structures not usually seen will float

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Timing: to avoid disrupting pregnancy
Fluid can further disseminate infections
Usually do not give analgesia
Mandatory prophylactic antibiotics (doxycycline) to prevent further iatrogenic PID

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In PID - relative CI, give antibiotics first for infection to resolve

Introduce fluid through catheter (20-25 cc)

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Cervix na daw ung nasa right part

Myometrium - HYPOechoic
Endometrium - ECHOgenic
Anechoic areas in the cervix - nabothian cysts
Endocervical canal at the middle of the cervix

In this pic, the anechoic area in the middle of the endometrium - patient may be
bleeding
Measure only the whiter * areas then add
Three lines - late proliferative
< 5mm - bleeding may be due to atrophic endometrium
> 5 mm - warrants investigation
Dominant follicle - will mature into mature follicle

Other follicles
Rosary bead
Most common benign tumors of the uterus

Uterus measurement
Length width height

Pic on the right - myoma on posterior portion of the uterus

SIS to differentiate myoma from polyp
- Fluid - anechoic
If ayaw mo mag SIS, color flow

Single feeding vessel to polyp

What is d criteria for endometrial thickening in as pre menopausal woman?
Thickened + SWISS CHEESE = hyperplasia
Thickened endometrium, hyperechoic (not just echogenic), warrants biopsy
Increased color flow
Serpiginous configuration

If pyosalpinx - with low level echoes

No need ng IOTA: dermoid and endometrial because of classic utz features

Dermoid: echogenic nodules which could be hair or teeth

Mucinous cystadenoma - really bigigigig
Multi septated

IOTA scored
M4: mucinous cystadenoma is NOT a solid tumor