Gynecological ultrasound

Ovaries & Adnexa

By:
Dr/ Ismail Sayed Ismail
1) Anatomy
2) Pathology
❑ Simple ovarian cysts

❑ Haemorrhagic ovarian cysts

❑ Endometriomas / Chocolate cysts

❑ Ovarian teratomas /Dermoid cysts

❑ Ovarian benign tumors (other than teratoma)

❑ Ovarian cancer

❑ Polycystic ovarian syndrome

❑ Ovarian hyperstimulation syndrome

❑ Peritoneal inclusion cyst

❑ Ovarian torsion

❑ Massive ovarian edema

❑ Hydrosalpinx, Tubo-ovarian abscess,…

Anatomy
➢ The ovaries are paired ovoid pelvic organs located on each side of the
uterus.
➢ They are mobile intraperitoneal structures.
➢ They lie anterior to the retroperitoneal structures, such as the ureters and
internal iliac vessels.
➢ Each ovary receives its blood supply from the ovarian artery, which arises
from the aorta, as well as from branches of the uterine artery.
 1 2

4 3

4 steps to catch normal ovary by TVS,…...

2 sonographic markers of ovary,…..
➢ In women of menstrual age, two types of functional cysts may be found in
the ovaries: follicular cysts and corpus luteal cysts. During the first half of the
menstrual cycle, multiple follicles develop until one (or occasionally more)
becomes dominant. The dominant follicle ruptures mid-cycle, at the time of
ovulation, and involutes to become a corpus luteum. The corpus luteum
regresses at the end of the menstrual cycle.
➢ Functional cysts are generally <2.5 cm in diameter but may become larger if
they fail to involute or regress and fill up with fluid or blood.
➢ After menopause, the ovaries decrease in size, both because ovarian tissue
atrophies and because ovarian cysts occur infrequently. When cysts occur in
the postmenopausal ovary, they require follow-up or removal only if they are
large or complex.
➢ The ovaries are generally visualized better by transvaginal than
transabdominal sonography. An exception is the ovary located high in the
pelvis, which may only be seen transabdominally.
➢ The premenopausal ovary appears on ultrasound as a soft-tissue structure
with multiple small cysts, corresponding to functional cysts.
➢ If the scan is done at a time when an ovary has a dominant follicle, one of
the cysts will be considerably larger than the others.
➢ In a woman taking follicular-stimulating medication to treat infertility, the
number and size of cysts are greater than in nonstimulated ovaries.
➢ The postmenopausal ovary is smaller than the premenopausal ovary. Its
echotexture is usually homogeneous. As such, postmenopausal ovaries are
more frequently undetectable on ultrasound than are premenopausal
ovaries.
Normal ovary in a woman of menstrual age.
The ovary appears as a structure of moderate echogenicity, containing several
small functional cysts.
Normal ovary with a dominant follicle in a woman of menstrual age.
The ovary contains several small functional cysts and one much larger cyst
representing the dominant follicle.
Normal ovarian volume, less than 10 cc.
Corpus leuteum.
Thick-walled cyst.
Corpus leuteum.
Haemorrhagic cyst.
Corpus leuteum.
Solid intraovarian structure surrounded by ring of fire.
Ovary in a woman undergoing treatment for infertility.
A woman taking medication to stimulate development of ovarian follicles,
ultrasound demonstrates multiple follicles throughout the ovary..
In a stimulated ovary.
The follicles occupy a relatively larger portion of the ovary than they do in a
normal, nonstimulated ovary.
In a postmenopausal woman.
The ovary is small and homogeneous, without the physiologic cysts seen in the
typical premenopausal ovary.
➢ The adnexa lie lateral to the uterus.
➢ The main components of the adnexa on each side are the ovary, fallopian
tube, and broad ligament.
➢ The normal fallopian tube is rarely identifiable by ultrasound. It becomes
visible if it is distended with fluid due to a pathologic process (e.g., hydro- or
pyosalpinx).
Right adnexa (broad ligament is seen extending from the uterus to right ovary).
Uterus & broad ligament are seen surrounded by large amount of clear ascites.
Pathology
Simple Ovarian Cyst
➢ The normal ovary in premenopausal women typically contains small cysts
<3 cm in diameter, representing follicles or functional cysts.
Larger cysts, those >3 cm, sometimes develop in the ovary. These cysts may
represent unusually large follicles, nonfunctional ovarian cysts, or a cystic
neoplasm of the ovary.
Very large, simple-appearing ovarian cysts, those measuring >7 cm in
diameter, may be difficult to evaluate completely sonographically. Further
imaging with MRI or referral for surgical evaluation may be warranted for
these cysts.
➢ In postmenopausal women, simple cysts up to 1 cm in size are fairly
common. Occasionally, cysts >1 cm are encountered. These cysts, when they
measure between 1 and 7 cm, are most often benign. Sonographic follow-up
to resolution or until the cyst proves stable in size after 1–2 years is often
recommended.
➢ Sonography:-
❑ A simple cyst of the ovary is an anechoic lesion with thin, smooth
walls and enhanced through-transmission.
❑ Normal ovarian tissue is usually visible around a portion of the cyst,
proving its intraovarian location.
❑ No blood flow should be detected within the cyst or its wall.
Simple ovarian cyst.
Thin round smooth capsule with excellent sound transmission, clear anechoic
fluid. No wall irregularity, no papillary projections,…
Simple ovarian cyst.
Normal ovarian cyst is seen around a portion of the cyst.
Simple ovarian cyst.
No internal blood flow nor flow in the thin, smooth wall of the cyst.
Ovarian cancer.
The presence of papillary projections,… raise the possibility of malignancy.
Haemorrhagic Ovarian Cyst
➢ Hemorrhagic cysts, like simple ovarian cysts, are benign lesions of the ovary
that most often resolve spontaneously, without requiring surgical
intervention.
Commonly referred to as hemorrhagic corpus leuteum.
➢ Occasionally, acute hemorrhage into a cyst will cause sudden onset of pelvic
pain, and, rarely, a hemorrhagic cyst ruptures.
➢ Sonography:-
❑ Hemorrhagic cysts appear as complex ovarian lesions, often with
fine septations that form a reticular pattern throughout the cyst,
described as weblike or lacy.
❑ The fluid within the cyst often has scattered echoes.

❑ The walls of a hemorrhagic cyst may be thin and smooth, or they

may be focally or diffusely thickened.
❑ No blood flow should be seen within the cyst or its septations, but
flow may be seen in its walls.
Haemorrhagic ovarian cyst.
Complex cyst showing internal septations forming a reticular pattern.
Haemorrhagic ovarian cyst.
It shows thickened wall on one side.
Haemorrhagic ovarian cyst.
Fine echoes in the fluid of the cyst.
Circumferential flow in the cyst wall. No flow in the septations.
Haemorrhagic cyst with clot retraction.
Cyst with septations, solid-appearing component anterior (with concave contour)
& anechoic fluid posterior.
Solid appearing hemorrhagic ovarian cyst with clot retraction.
No internal flow by color doppler. Capsular flow can be seen.
 6w

Evolving haemorrhagic cyst.

Follow up 6 weeks later, the cyst becomes smaller with fewer thinner septations.
 F/U

Haemorrhagic ovarian cyst.

Complex cyst showing thin linear reticulations, excellent sound transmission.
Retraction of blood clot with development of fluid later on follow up.
Haemorrhagic ovarian cyst.
Retracted blood clot looks similar to papillary projection.
Single portion. No internal flow. Mobile under probe. Temporal changes.
Ovarian cancer.
Multiple papillary projections, with internal flow.
Endometrioma / Chocolate Cyst
➢Endometriosis refers to the presence of endometrial glandular tissue outside
the uterus.
➢Sites:-
This glandular tissue is typically located at sites within the peritoneal cavity, such
as on the ovary, attached to the fallopian tubes, or in the cul-de-sac.

➢The ectopic endometrial tissue responds to the hormones of the menstrual

cycle and may bleed periodically, causing bloody ascites and focal masses of
hemorrhage called endometriomas.
➢Clinical picture:-
Patients with endometriosis may have chronic pelvic pain, back pain,
dyspareunia, and infertility.
➢Scarring and pelvic adhesions often result from endometriosis.
➢Sonography:-
Sonographic appearance of endometrioma is variable and may be
indistinguishable from that of other pelvic lesions.
❑ The most characteristic appearance of an endometrioma is an
adnexal cyst filled with homogeneous low-level echoes, sometimes
called a “ground glass” appearance.
❑ Fluid–fluid levels may be seen.
❑ In other cases, endometriomas appear as cysts with fine septations or
a reticular pattern of septations, an appearance similar to that of
hemorrhagic cysts.
❑ Endometriomas can be multilocular, with areas of anechoic fluid
and other areas of complex fluid, separated by septation.
❑ In many cases, more than one endometrioma is present at the time
of examination.
❑ Typically, no flow is identified within an endometrioma or its wall on
color Doppler.
Endometrioma.
Adnexal cystic mass with homogenous echoes.
Endometrioma.
Unilocular mass with ground glass appearance. No internal flow.
Endometrioma.
Unilocular mass with ground glass appearance & excellent sound transmission.
Endometrioma.
Unilocular mass with ground glass appearance & hyperechoic foci (calcific
stippling).
Multilocular endometrioma.
Adnexal cystic lesion filled predominantly with homogenous echoes, but
containing a cystic lobule as well.
Endometrioma with fluid-fluid level.
Endometrioma.
Adnexal cystic mass with homogenous echoes. No internal flow.
Endometrioma.
No internal flow. Capsular flow can be seen.
Solid adnexal mass similar to endometrioma.
Ground glass appearance but with extensive internal flow.
Pathology revealed endometrioid ovarian cancer.
Ovarian Teratoma / Dermoid Cyst
➢Dermoid cyst (mature cystic teratoma) is the most common benign neoplasm of
the ovary.
➢It is bilateral in 10%–15% of cases.

➢Clinical picture:-

❑Most dermoid tumors are asymptomatic.

❑Occasionally they cause lower abdominal pain, swelling, and irregular
menses.
➢Ovaries containing dermoids are at risk of torsion.
Surgical excision is the usual treatment of these lesions.

➢Pathology:-

❑The tumor may be found to contain fat and sometimes bone, teeth, or
hair. Rarely, an ovarian teratoma is malignant.
➢ Sonography:-
❑ The characteristic appearance is a complex, partially cystic mass in
the ovary that contains one or more highly echogenic regions (fat)
that may shadow (bone/ tooth).
❑ Echogenic lines and dots may be seen within the cystic areas of the
mass (hair).
❑ The fat may be seen floating on top of other fluid in the lesion,
leading to the sonographic finding of a fluid–fluid level.
❑ Other echogenic regions with shadowing may contain solid nodules
of tissue in the wall of the dermoid (fat) or densely calcified
structures (bone/ tooth).
❑ Dermoid tumors typically have little or no internal flow on color
Doppler imaging.
Ovarian dermoid tumor.
The ovary is filled with complex highly echogenic material representing fat.
Ovarian dermoid tumor.
Lobular regions of increased echogenicity representing fat and regions of
decreased echogenicity representing fluid.
Ovarian dermoid tumor.
Echogenic short lines and dots within the cystic portion, representing hair.
Ovarian dermoid tumor with fluid-fluid level.
Complex lesion containing hypoechoic and echogenic regions that form a linear
interface due to layering of fat and other fluid.
Ovarian dermoid tumor with echogenic solid nodule.
Large complex mass that is predominantly cystic but has an echogenic solid
nodule protruding from the wall and causing acoustic shadowing.
Ovarian dermoid tumor with echogenic solid nodule.
Ovarian dermoid tumor.
Large complex mass with poor sound transmission / shadowing (tip of iceberg).
Ovarian dermoid tumor.
Echogenic ball consistent with sebum, Rokitansky nodule (dermoid plug).
Ovarian dermoid tumor.
Long & short echogenic linear strands, consistent with hair content.
Small intra-ovarian dermoid tumor.
Ovarian immature teratoma (having neural element).
Papillary projections with internal vascularity.
Ovarian Benign Neoplasms
other than Teratomas
➢Ovarian neoplasms that arise from epithelial cells and surrounding stromal
cells can be malignant or benign.
The most common benign neoplasms are mucinous or serous cystadenomas.
Less common benign tumors arising from these cells include transitional cell
(Brenner) tumors.
➢Benign ovarian neoplasms can also arise from granulosa, theca, and Sertoli
and Leydig cells.
These neoplasms include ovarian fibromas, granulosa cell tumors, thecomas,
and Sertoli–Leydig cell tumors.
➢The distinction between benign and malignant ovarian neoplasms cannot be
made with certainty based on clinical presentation or imaging findings.
➢ Sonography:-
❑ Serous and mucinous cystadenomas of the ovary are typically
complex ovarian lesions with septations separating areas of anechoic
fluid.
❑ Blood flow can often be identified in the septations with color
Doppler.
❑ Mucinous cystadenomas tend to have more septations than serous
cystadenomas and sometimes the fluid in mucinous cystadenomas
contains low-level echoes.
❑ Some benign tumors contain both anechoic cystic regions and solid
or complex cystic areas.
❑ Occasionally, solid tumor nodules, containing vessels visible with
color Doppler, are seen in the wall of the neoplasm, although this
finding is more frequently seen with malignant than benign
neoplasms.
➢ Sonography:-
❑ Some benign tumors, such as fibromas and granulosa cell tumors,
appear as solid ovarian masses. These tumors are typically
homogeneous in echotexture and hypoechoic, sometimes causing
acoustic shadowing. Their appearance is similar to a uterine fibroid.
❑ Spectral Doppler arterial waveforms from the vessels of a benign
tumor typically have a high-resistance pattern, with a resistive index
more than 0.4.
❑ Although arteries in malignant tumors often have a resistive index
less than 0.4, Doppler cannot reliably differentiate benign from
malignant lesions.
Ovarian serous cystadenoma.
Cystic ovarian lesion with anechoic fluid and few thin septations.
Color Doppler shows blood flow within the septations.
Ovarian serous cystadenoma.
Color Doppler shows blood flow within the septations with (RI) of 0.43.
Ovarian mucinous cystadenoma.
A large cystic lesion. The fluid within the cystic mass contains low-level echoes
and multiple thin septations are present.
Ovarian papillary serous cystadenoma.
A complex mass with anechoic areas and a more complex, solid appearing area.
Color Doppler demonstrating blood flow within the solid portion of the tumor.
Ovarian papillary serous cystadenoma.
Spectral Doppler of flow within the mass demonstrates a fairly high resistance
waveform, with a resistive index of 0.61.
Ovarian fibroma.
Ovarian solid mass with homogenous echotexture and posterior shadowing,
similar to uterine fibroid, but uterus is completely separate from it.
Ovarian fibroma.
Ovarian solid mass with characteristic venetian blinds shadowing, seen attached
to the ovary & not freely mobile in the adnexa.
Pedunculated Leiomyoma
Pedunculated leiomyoma.
Adnexal solid mass with homogenous echotexture and extensive posterior
shadowing, the ovary is completely separate from it.
Ovarian Carcinoma
➢Ovarian cancer is typically an aggressive tumor.
In 75% of cases, the cancer has spread outside the ovary by the time of
diagnosis.

➢Doppler findings are less accurate than gray-scale sonographic findings in the
diagnosis and exclusion of ovarian cancer.
Because there is an overlap between the sonographic features of benign and
malignant ovarian tumors, the sonographic diagnosis of ovarian cancer cannot
be made with confidence based on ultrasound findings alone.
➢Sonography:-

The gray-scale sonographic features of a complex ovarian mass that are

worrisome for cancer include:
❑ Solid nodules in the wall of the mass.

❑ Thick septations (>3 mm).

❑ Wall thickening (>3 mm).

❑ Irregularity of the wall.

❑ Poorly de􀉹 ned margins of the lesion.

❑ Blood flow within the septations, in the wall, and in solid nodules.

Malignant lesions often have resistive indices <0.4 and pulsatility indices <1.0.
Ovarian papillary serous cystadenocarcinoma.
Ovarian cystic mass with solid nodule projecting from the wall into the cystic
portion.
Ovarian papillary serous cystadenocarcinoma.
Color Doppler shows blood flow within the solid nodule & wall of the tumor.
Spectral Doppler demonstrating low resistance flow, with a low (PI) of 0.69.
Ovarian papillary serous cystadenocarcinoma.
Multiple papillary projections with vascularity within the papillary projections.
Ovarian papillary serous cystadenocarcinoma.
Multiple papillary projections with vascularity within the papillary projections.
Ovarian papillary / borderline serous cystadenocarcinoma.
Multiple papillary projections.
Ovarian/ borderline mucinous cystadenocarcinoma.
Multiple thick septations with septal vascularity.
Ovarian cancer (endometrioid carcinoma).
Predominantly solid mass with thick septations and low resistance internal flow.
Ovarian cancer.
Complex mass with cystic and solid components. Thickened wall with solid nodules
protrude into the cystic part of the mass, irregular outer contour with flow within the
solid portion of the tumor and within the wall.
Ovarian cancer.
Polycystic Ovarian Syndrome
➢Polycystic ovary syndrome is a metabolic disorder characterized by menstrual
irregularities, anovulation, hyperandrogenism, infertility, ….

➢Sonography:-

❑ Increased ovary volume > 10 cc.

❑ Increased number of small (< 10 mm) peripherally located follicles
> 10 in number (recently > 25 per ovary).
❑ Increased stromal echogenicity, devoid of central follicles.

➢ Polycystic ovaries may be seen in normal ovulating women with normal

clinical & biochemical status, likely representing a mild form of polycystic
ovary syndrome spectrum.
Polycystic ovarian syndrome.
Spherical-shaped ovary showing increased number of peripherally located small
follicles & increased stromal echogenicity.
Ovarian Hyperstimulation Syndrome
Ovarian hyperstimulation syndrome.
Spherical-shaped markedly enlarged ovary multiple complicated cysts. Ascites.
Peritoneal Inclusion Cyst
➢Peritoneal inclusion cysts (pseudocysts) are cystic structures within the pelvis,
occurring following pelvic surgery or infection, resulting into pelvic adhesions
that entraps peritoneal fluid.

➢Sonography:-

❑ Thin but occasionally thick septations that attach to pelvic organs.,

such as uterus, bowel and ovaries.
❑ Fluid content is clear.
❑ Normal-looking varies may be seen within it, which confirm the
diagnosis.
Peritoneal inclusion cyst.
Multiple thin septations entrapping clear fluid & attached to pelvic organs.
Ovarian Torsion
➢Ovarian torsion is twisting of the ovary around the pedicle that carries blood
flow to and from the ovary.
The twisting causes obstruction to blood flow, first of venous drainage from the
ovary and then, as the ovary becomes edematous, of arterial flow to the ovary.
This leads to ovarian ischemia.
➢Clinical picture:-
Patients typically present with acute onset of severe unilateral pelvic pain, often
accompanied by nausea and vomiting.
➢Treatment:-
involves surgically untwisting the ovary to reestablish blood flow, and fixation of
the ovary in the pelvis to prevent recurrent torsion. The prognosis is excellent if
surgery is performed close to the time of the torsion.
A delay in medical treatment leads to prolonged ovarian ischemia and ultimately
ovarian necrosis, at which point the ovary cannot be salvaged with surgical
detorsion.
➢ Risk factors:-
Ovarian torsion occurs most often in an ovary that contains a cyst or, less
frequently, a tumor, likely because the ovarian lesion provides a pivot
around which the ovary rotates.
In rare cases, no underlying ovarian lesion is present.
Ovarian torsion is five times more likely to occur in pregnant women,
especially during the first trimester, than in nonpregnant women, probably
due to the presence of the corpus luteum.
The risk of ovarian torsion is particularly high in women who become
pregnant after ovulation induction therapy for infertility, because of ovarian
enlargement.
➢Sonography:-

❑ The ovary becomes enlarged, globular, and edematous with torsion.

Comparison with the contralateral ovary may be helpful in
confirming ovarian enlargement.
❑ Sometimes the ovary is found in an unusual location, such as
anterior to the uterus or in the upper abdomen. Malpositioning is a
helpful clue to the diagnosis of torsion.
❑ A tumor or cyst of the ovary, which predisposed the ovary to twist on
its pedicle, may be found within the ovary at the time of sonographic
evaluation.
❑ Color Doppler imaging can be helpful in the assessment of the ovary
for torsion. Obstruction of blood flow to and from the ovary with
torsion may be seen as diminished or absent flow on color Doppler.
Acute ovarian torsion.
Enlarged, globular & edematous left ovary as compared to normal right ovary.
Acute ovarian torsion.
Enlarged, globular & edematous ovary with no flow on color doppler.
Acute ovarian torsion during first trimester with malpositioning of ovary.
Torsed ovary located to gravid uterus (8 weeks), containing a cyst, likely the
corpus leuteum. Color doppler shows paucity of ovarian flow.
Acute ovarian torsion containing a Dermoid tumor.
Malpositioned ovary located in right upper quadrant adjacent to the liver.
The ovary is almost replaced by a complex cyst with echogenic regions and
echogenic lines characteristic of Dermoid cyst.
Blood flow in a torsed ovary
Enlarged, globular & edematous ovary containing cyst.
Color doppler shows blood flow. Torsion is confirmed at surgery.
Hydrosalpinx
➢Hydrosalpinx is a fluid-filled fallopian tube that results from obstruction of the
distal end of the tube.
➢It usually occurs as a result of pelvic inflammatory disease or endometriosis,
leading to adhesions at the fimbriated end of the fallopian tube that obstruct the
peritoneal opening of the tube. Fluid collects in and expands the ampullary
portion of the fallopian tube, sometimes extending medially along the tube.
➢The fluid may become infected, resulting in a pyosalpinx.
➢Sonography:-
❑ Hydrosalpinx appears as an elongated or serpiginous fluid-filled
structure in the adnexa, separate from the ovary.
❑ It typically has thin, smooth walls and is filled with anechoic fluid.

❑ Incomplete septations may be seen crossing the tubular structure,

representing folds in the tube.
❑ Occasionally, the fluid within the tube contains echoes, representing
either debris or pus.
❑ No flow will be seen in the dilated tube with color Doppler.
Hydrosalpinx.
Dilated, fluid-filled right fallopian tube, showing serpiginous configuration with
folds. No peristalsis.
Hydrosalpinx.
Dilated, fluid-filled right fallopian tube, showing serpiginous configuration with
folds.
Hydrosalpinx.
A folded, fluid-filled adnexal structure with a fluid–fluid level due to debris or
pus within the tube.
Tubo-ovarian Abscess
➢Tubo-ovarian abscess is a severe form of pelvic inflammatory disease (PID).
➢The abscess is a complex inflammatory mass involves the ovary and fallopian
tube on one or both sides.
➢Clinical picture:-
Patients typically present clinically with fever, pelvic pain, and an elevated white
blood cell count.
➢Tubo-ovarian abscesses are often bilateral.

➢A tubo-ovarian abscess with a large cystic component can sometimes be treated

successfully with transvaginal aspiration or transvaginal placement of a drainage
catheter, in conjunction with antibiotics.
➢Sonography alone cannot always distinguish between a tubo-ovarian abscess
and other adnexal lesions. The diagnosis is usually established based on both
the clinical presentation and sonographic findings.
➢Sonography:-

❑ A tubo-ovarian abscess appears as a complex, multiloculated adnexal

mass.
❑ The margins are usually poorly defined.

❑ Fluid components of the complex mass are filled with echoes from
debris and pus, and there may be thick septations crossing the mass.
❑ Typically, the ovary cannot be identified in the adnexa because it is
encased by the inflammatory material of the abscess.
❑ With transvaginal scanning, patients are very tender on the affected
side. When pressure is applied with the transvaginal probe, adnexal
structures appear adherent to each other.
❑ The wall of the abscess is typically hypervascular on color Doppler.
Tubo-ovarian abscess.
A complex adnexal mass with poorly defined margins and regions containing
complex fluid.
 4w

Tubo-ovarian abscess decreases in size after antibiotic treatment.

Tubo-ovarian abscess.
Color doppler shows hypervascularity of the wall.
Tubo-ovarian abscess.
Complex adnexal mass with thick wall and thick septations.
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