1. Radiological imaging
of uterine lesions.
Dr/ ABD ALLAH NAZEER. MD.

2. Congenital Uterine Anomalies.
The true incidence of congenital uterine anomalies in the
general population and among women with RPL is not known
accurately. Although incidences of 0.16 to 10% have been
reported, the overall data suggest an incidence of 1% in the
general population and 3% in women with RPL and poor
reproductive outcomes. In a comparative study of women with
and without a history of RPL using three-dimensional
ultrasound, Salim et al found major congenial anomalies in
6.9% of women with RPL compared with 1.7% in low-risk
women. Overall, the prevalence of major congenital anomalies
appears to be three-fold higher in women with RPL compared
with women without a history of recurrent miscarriage.

3. Class I: Müllerian agenesis or hypoplasia
Class II: Unicornuate uterus
Class III: Didelphys uterus
Class IV: Bicornuate uterus
Class V: Septate uterus
Class VI: Arcuate uterus
Class VII: Diethylstilbestrol (DES)-exposed uterus
Bicornate Uterus.

4. Unicornuate Uterus.

5. Uterus Didelphys.

6. DES-related uterine anomaly. Hysterosalpingogram
demonstrates a hypoplastic T-shaped uterus. The
patient had been exposed to DES while in utero.

7. Arcuate uterus. Three-dimensional coronal US image (26) and coronal
oblique T2-weighted MR image (27), obtained in different patients, show
a smooth, broad-based, shallow endometrial impression (arrow) with a
normal external contour of the uterine fundus (arrowhead).

8. PELVIC INFLAMMATORY DISEASE (PID)
DEFINITION Pelvic inflammatory disease is an infection of the female
upper genital tract that involves any combination of the uterus,
endometrium, ovaries, fallopian tubes, pelvic peritoneum and adjacent
tissues. PID consists of ascending infection from the lower to upper
genital tract.
PREDISPOSING RISK FACTORS
• Sexual contact in which exchange of body fluid may occur
• History of STI
• Multiple sexual partners
• Upper female genital tract instrumentation: o dilatation & curettage
(D&C)
. Recent intrauterine device (IUD) insertion
. Therapeutic abortion (T/A).
PID is a common medical problem, affecting nearly 1 million women
each year distributed worldwide.

9. Etiology:
PID usually results from ascending infection by Neisseria gonorrhoeae
or Chlamydia trachomatis, although 30% of cases are polymicrobial. In
addition, aerobic and anaerobic, gram positive and negative organism,
normal vaginal flora, viruses, tuberculosis, mycoplasma, and other
atypical organism have been implicated as causative agents
Dissemination routes: PID may disseminate to neighboring organs
or even affect abdominal organs across three primary routes:
1. - Extension to parametrials structures
2. - Direct ascent of microorganisms to upper genital tract: Pyosalpinx,
salpingitis, endometritis
3. - Primary vaginal or cervical infection: endocervical inflammation.
4. - Less frequent: Direct spread from a nearby infection such as
appendicitis or diverticulitis.
Hematogenous, peritoneal or lymphatic spread: Salpingitis
secondary to tuberculosis.

10. Transvaginal ultrasound. a and b) Mild enlargement of the uterus with
an irregular contour and presence of fluid accumulation within the
cervical canal and inside the endometrial cavity. c) Enlarged ovaries
with increased numbers of cyst. d) Fluid in cul de-sac

11. Contrast-enhanced CT scan obtained in venous phase. a) Endometritis and
oophoritis. Fluid accumulation inside the endometrial cavity, enlarged ovaries
with increased number od cyst (arrowheads) and abnormal enhancement. b)
Initial salpingitis, CT image shows not dilated fallopian tubes with wall thickening
(> 5 mm), enhancement and underlying inflammation (white arrow)

12. Contrast-enhanced CT scan obtained in venous phase. a and b) Mild pelvic
edema: thickening of the uterosacral ligaments and haziness of the pelvic fat
with obscuration of the pelvic fascial planes (white arrows).

13. Advanced stages of salpingitis. a and b) Transvaginal US shows Elongated and dilated
fallopian tube with echogenic contents ("string sign")c and d) Contrast-enhanced CT
scan shows dilated fallopian tube with wall thickening and enhancement.

14. Transvaginal US in patient with follicular rupture shows large amount of fluid with
debris posterior to the uterus. b) Power Doppler US in patient with ovarian torsion
shows enlarged ovary with peripheral cysts on sonogram with complete absence of
blood flow in the ovary and c) Contrast-enhanced CT scan in the same patient revealed
the enlarged ovary in the midline of the pelvis with no central enhancement. d and e)
Transvaginal US and Pelvic MR revealed complex and loculated cystic masses in
adenxial region and the MR images confirm the diagnosis of Tarlov Cyst.

15. Complications of PID. Tubo-ovarian abscess. a) Transvaginal ultrasound
revealed a heterogeneous cystic mass in adnexal region. b) Axial contrast-
enhanced CT scan revealed solid-cystic mass with thicked and hyperenhanced
wall and septum. c) Axial contrast-enhanced CT scan in patient with tubo-
ovarian abscess shows cystic tubular structure with enhanced wall.

16. MR findings in TOA. Tubaric morphologic changes (Beak sign)
representing tubal and peritubal adhesions with fimbrial obstruction.

17. Reliable signs of hydrosalpinx. a) Transvaginal US. Axial image shows cyst tubular structure
with C shaped. b) Pelvic MR. Axial T2-weighted image shows incomplete septations
secondary to distension and tubaric folding (waist sign). c) Transvaginal US. Axial image
shows round projections and thicked longitudinal folds (cogwheel appearance).

18. Advanced stages of salpingitis. a and b) Transvaginal ultrasound in woman patient
with hydro-pyosalpinx: axial and longitudinal images shows cystic mass containing mixed
echogenicity areas. c) Pelvic MR. Axial fat-suppressed T1-weighted MR image, revealed
a cystic tubular structure (white arrows) with variable signal intensity depending of the
protein content of the fluid. d) Pelvic MR. Axial gadolinium-enhanced fat-suppressed
T1-weighted MR image. Enhancement of the thickened fallopian tube wall and pelvic
stranding. e and f) Pelvic MR. Coronal T2-weighted image shows cystic tubular structure
with high signal intensity which is lower than a pure cyst (white arrows).

19. Tubo-ovarian abscess with gas. Enhanced computed tomography
shows bilateral, gas-containing, tubo-ovarian abscesses (arrows).

20. Uterine Leiomyomas:
Leiomyomas, or fibroids, are the most common benign tumors
of the uterus. The incidence of fibroids is difficult to estimate
and frequencies reported in the literature range between 25%
and 50%. In autopsy studies, leiomyomas of the uterus have
been found in up to 77% of women. Only about one third of
affected women have fibroids that become clinically apparent
before menopause. Fibroids may cause abnormal menstrual
bleeding (menorrhagia with secondary anemia,
dysmenorrhea) or pelvic pressure due to their mass effect
(urinary frequency, constipation, pelvic pain, dyspareunia).
Finally, leiomyomas of the uterus are also implicated in
female infertility and are the most common indication for
hysterectomy in western industrialized countries.

21. Transvaginal ultrasound (TVUS) of uterine
leiomyoma. TVUS demonstrates a well defined
subserosal leiomyoma (arrow) distorting the
outer contour of the uterine wall. The leiomyoma
shows a heterogeneous echotexture and is
hypoechoic compared to the adjacent myometrium
and endometrium. The endometrium is seen as
a hyperechoic stripe.
Transvaginal ultrasound of
leiomyoma. Transvaginal color-
coded duplex ultrasound
demonstrates the perifibroid
plexus vessels surrounding the
leiomyoma.

22. MRI of leiomyoma , locations. Trans-axial T2-weighted image depicts
multiple, mainly subserosal uterine leiomyoma. There is mild distortion
of the uterine cavity by a transmural (full thickness) leiomyoma (arrow).

23. CT of uterine leiomyoma. Contrast-enhanced CT of the pelvis in a 39-year-
old women with a known uterine leiomyoma shows a large oval mass
within the uterus with heterogeneous enhancement (asterisk) which
displaces the hypodense right ovary (arrow) and distends the abdomen.

24. Acute torsion of a
uterine leiomyoma.

25. Correlation of transvaginal ultrasound (TVUS) and magnetic resonance imaging
(MRI) in a patient with leiomyoma and adenomyosis of the uterus. a TVUS of a 48-
year-old women with menorrhagia and dysmenorrhea. Two leiomyoma were
reported to be present, one in a subserosal location (black arrow) of the posterior
wall and a second intramurally in the anterior uterine wall (white arrow).

26. Mass effect of uterine leiomyoma. a T2-weighted sagittal image
shows a multifibroid uterus with a large submucosal leiomyoma
that exerts mass effect on the underlying endometrium (arrow).
b T2-weighted a axial image at corresponding level.

27. Bridging vascular sign in a pedunculated leiomyoma. T1-weighted
contrast-enhanced fat-suppressed sagittal image depicts a large
pedunculated subserosal leiomyoma originating from the uterine fundus.
Flow-voids are seen within the vessel stalk (arrow). A second intramural
leiomyoma in the anterior wall is seen displacing the endometrial stripe.

28. MRI of cellular leiomyoma. a T2-weighted sagittal image of the uterus demonstrating
a large intramural cellular leiomyoma with homogenous high signal intensity
compared to surrounding myometrium. Two small intramural leiomyoma show the
typical low intensity signal (arrows). b T1-weighted contrast-enhanced fat-suppressed
sagittal image showing marked enhancement of the intramural cellular leiomyoma
which appears hyperintense compared to surrounding myometrium

29. Signal intensity characteristics of leiomyoma. a T2-weighted transaxial image of the
uterus (secretary phase of menstrual cycle) showing a subserosal leiomyoma with typical
low signal intensity compared to adjacent myometrium. Note the bright signal of the
endometrium and intermediate signal intensity of the junctional zone. b Corresponding T1-
weighted transaxial image of the uterus showing intermediate signal intensity of the
leiomyoma which can hardly be differentiated from the adjacent myometrium.

30. MRI of myxoid
leiomyoma.

31. MRI of spontaneously
infarcted leiomyoma

32. MRI of rim calcification of a leiomyoma. T1-weighted fat-suppressed
transaxial image showing a leiomyoma with a discontinuous, markedly
hypointense rim corresponding to asymmetrical calcification.

34. Adenomyosis of the Uterus.
Adenomyosis (endometriosis genitalis interna) of the uterus
affects premenopausal women and is predominantly seen in
multiparous women and women over 30 years of age.
Because its symptoms are unspecific, adenomyosis rarely
comes to clinical attention, which is why the incidence of
this uterine condition is underestimated. Until recently, the
diagnosis was established almost exclusively after
hysterectomy. Histologic examination of hysterectomy
specimens demonstrates adenomyosis in 19%–63% of cases.
Adenomyosis often occurs in conjunction with fibroids and
endometriosis (endometriosis genitalis externa et
extragenitalis.

35. Adenomyosisis a common gynecologic condition, non-
neoplastic, that causes substantial morbidity and that affects
women of reproductive age.
• The clinical symptoms of adenomyosis include: pelvic pain,
uterine enlargement, dysmenorrhea, menorrhagia, or may be
asymptomatic.
• Diseases with symptoms similar to adenomyosis: dysfunctional
uterine bleeding, endometriosis and leiomyomas.
• Adenomyosis is rarely diagnosed before hysterectomy and
commonly coexists with uterine leiomyomas.
• Women undergoing hysterectomy with both adenomyosis and
leiomyomas have a number of different clinical features compared
with women with only leiomyomas at the time of hysterectomy.
• Women with substantial pain despite a smaller fibroid burden
may be more likely to have concomitant adenomyosis.

36. MRI of diffuse adenomyosis of the uterus. a T2-weighted transaxial image of a
patient with diffuse adenomyosis of the uterus. The uterine wall is thickened, there
is poor definition of the endomyometrial junction and the junctional zones blend
with the myometrium. No focal mass is present. Cyst-like inclusions of hyperintense
signal intensity are present (arrow). b Corresponding fat-suppressed T1-weighted
transaxial image showing hyperintense spots within the myometrium indicating
fresh blood related to the dislocated endometrial glands (arrows)

37. MRI of focal adenomyosis of the uterus. T2-weighted sagittal image of the
uterus. The posterior wall of the uterus is thickened and a focally
broadened junctional zone with hyperintense foci appearing as a globular
lesion is seen (arrow). The uterus is enlarged but no mass effect is seen

38. MRI of diffuse adenomyosis of the uterus. T2-weighted sagittal image of the
uterus. A broadened junctional zone (> 12 mm) is seen with poor definition of
the endomyometrial junction. The junctional zone blends with the myometrium

39. Women 26 years. Bicornuate uterus with adenomyosis with focal
nodular.T2- weighted MRI in coronal and axial.

40. Multiple foci of hyperintensity on T2. Observe the correlation with
histopathology, which identify multiple dilated glands around the myometrium.

41. Endometriosis.
Endometriosis is an inflammatory, estrogen-dependent disease
that often results in substantial morbidity, pelvic pain, multiple
surgeries, and infertility. Characterized by the existence of
endometrial glands and stroma outside the uterine cavity, the
disease represents a significant clinical challenge, commonly
associated with significant morbidity and reduction in quality of
life among reproductive-age females.
Early symptoms may be underappreciated by caregivers, healthcare
consumers, and clinicians alike, and timely diagnosis combined with
effective management cannot be undervalued. The lack of reliable
noninvasive detection methods may likely contribute to lengthy
delays in diagnosis. Practitioners from all disciplines, particularly
obstetricians and gynecologists, must understand not only the
medical aspects of this disease but the tremendous psychosocial
and cost burdens as well.

42. Symptomology:
Symptoms vary considerably, often mimicking those of
other conditions including pelvic inflammatory disease,
adenomyosis, fibroids, and ovarian cancer.
The degree or stage at which endometriosis is present has
no correlation with pain or symptomatic impairment.
Symptoms are variable but typically reflect area of
involvement and may include:
• Dysmenorrhea
• Heavy or irregular bleeding
• Pelvic pain
• Lower abdominal or back pain
• Dyspareunia
• Dyschezia, often with cycles of diarrhea/ constipation.

43. Endometrioma. Sagittal transvaginal US image obtained in a woman with a
history of endometriosis shows an ovarian mass with multiple fine internal
echoes (arrows) and several hyperechoic mural foci (arrowheads).

45. Endometriosis. Unenhanced axial T1- weighted fat-suppressed MR image shows dilatation
of the right fallopian tube (arrow) with internal high signal intensity due to blood
products, findings indicative of hematosalpinx. Smaller high-signal-intensity foci along the
posterior uterine serosa (arrowhead) are indicative of endometrial implants.

47. Endometrial polyp.
An endometrial polyp or uterine polyp is a mass in the inner lining of the
uterus. They may have a large flat base (sessile) or be attached to the uterus
by an elongated pedicle (pedunculated). Pedunculated polyps are more
common than sessile ones. They range in size from a few millimeters to several
centimeters. If pedunculated, they can protrude through the cervix into the
vagina. Small blood vessels may be present, particularly in large polyps.
Cause and symptoms:
No definitive cause of endometrial polyps is known, but they appear to be
affected by hormone levels and grow in response to circulating estrogen.
They often cause no symptoms. Where they occur, symptoms include irregular
menstrual bleeding, bleeding between menstrual periods, excessively heavy
menstrual bleeding (menorrhagia), and vaginal bleeding after menopause.
Bleeding from the blood vessels of the polyp contributes to an increase of
blood loss during menstruation and blood "spotting" between menstrual
periods, or after menopause. If the polyp protrudes through the cervix into
the vagina, pain (dysmenorrhea) may result.

48. Endometrial polyps.

49. Endometrial polyps.

50. Endometrial polyps.

51. Polyp arising within the endometrium and filling most of the uterine cavity.
On the US, it is well-defined, slightly echogenic relative to the surrounding
the myometrium. On the MR, the differences in tissue contrast are clearer.

52. Endometrium hyperplasia.

53. Endometrial Carcinoma.
Endometrial cancer (also referred to as corpus uterine cancer or
corpus cancer) is the most frequently occurring female genital
cancer; this condition was the fourth most common cancer among
US women in 2012. In developed countries, adenocarcinoma of
the endometrium is the most common gynecologic cancer.
Signs and symptoms:
Approximately 75% of women with endometrial cancer are
postmenopausal. Thus, the most common symptom is
postmenopausal bleeding.
For the 25% of endometrial cancers in patients who are
perimenopausal or premenopausal, the symptoms suggestive of
cancer may be more subtle. The normal menstrual bleeding pattern
during this period should become lighter and lighter and further and
further apart. Heavy, frequent menstrual periods or intermenstrual
bleeding must be evaluated.

54. Endometrial cancer histological types
The most common type is endometrioid adenocarcinoma, which is
composed of malignant glandular epithelial elements. Clear-cell and
papillary serous carcinoma of the endometrium are tumours that are
histologically similar to those noted in the ovary and the Fallopian
tube, and the prognosis is worse relative to adenocarcinomas.
Endometrioid (75%) (secretory, ciliated, papillary or villoglandular)
Adenocarcinoma with squamous differentiation.
Adenoacanthoma (benign squamous component)
Adenosquamous (malignant squamous component).
Uterine papillary serous (5%–10%)
Clear cell (1%–5%).
Malignant mixed Mullerian tumours or carcinosarcomas (1–2%).
Uterine sarcomas (leiomyosarcoma, endometrial stromal sarcoma,
undifferentiated) (3%).
Mucinous (1%).
Undifferentiated.

55. Sagittal dynamic acquisition after gadolinium chelates injection shows heterogeneous
enhancement with foci of avid enhancement on early acquisition (F). Delayed phase
images (G) show diffuse myometrial enhancement, greater than that of the tumor.

56. Endometrial mass exhibits a heterogeneous pattern on sagittal T2 weighted
images (A), with areas of avid enhancement (B) high signal intensity on
diffusion weighted images and restriction on ADC map (C, D).

57. A 36 year-old woman presented with persistent vaginal bleeding. MR
imaging shows on T2 weighted images on coronal (A) and sagittal (B)
images a large and heterogeneous high intense endometrial mass,
invading the outer half of the myometrium (white arrows).

58. 63-year old woman previously treated for breast cancer, presenting for post-
menopausal bleeding. Sagittal (A) and axial (B) T2-weighted images show a
slightly hyperintense, large bulky mass enlarging the uterine cavity with a
broad-based to the anterior uterine inner wall. Tumor exhibits high signal
intensity on diffusion weighted images and restriction on ADC map (C, D)

59. 62 year-old woman. Vaginal bleeding. Pelvic ultrasound showed an enlarged
uterus. Speculum examination showed a mass protruding through a distended
endocervical canal. Endometrial sampling showed an endometrial
carcinosarcoma with a heterologous chondrosarcoma sarcomatous component.
Myometrial invasion was inferior to 50%, no cervical stroma invasion was seen.

60. Endometrial carcinosarcoma in a 73 year-old woman. Sagittal (A) and axial (B),
T2-weighted images show a large bulky mass distending the endometrial cavity,
with a high T2 signal intensity and a heterogeneous pattern. Resection specimen
(C) and H&E stain (D, E) show a tumoral proliferation containing both malignant
epithelial and spindle cell components. Myometrial infiltration was superficial

61. 62 year-old woman. Vaginal bleeding. Pelvic ultrasound showed an enlarged
uterus. Speculum examination showed a mass protruding through a distended
endocervical canal. Endometrial sampling showed an endometrial carcinosarcoma
with a heterologous chondrosarcoma sarcomatous component. Myometrial
invasion was inferior to 50%, no cervical stroma invasion was seen.

62. 79 year-old woman previously treated for breast cancer, with vaginal bleeding. Speculum
examination showed a mass protruding through the external os into the vagina. Sagittal T1
weighted and Sagittal T2 weighted images show a large carcinosarcoma (asterisk)
invading the deep myometrium and the cervical stroma (white arrow), protruding into the
vaginal lumen. Histological analysis shows a carcinosarcoma with a predominant clear cell
sarcomatous component, invading the full thickness of the myometrium. Tumor extended
to the uterine cornua and parametria. Histological analysis showed a large carcinosarcoma
infiltrating the uterine corpus and the cervix. Tumor infiltrates the entire myometrium up
to the serosa and the parametria. Lymphovascular extension was seen in adnexae.

63. Choriocarcinoma in uterus with lung metastasis.

64. Choriocarcinoma in uterus with lung metastasis.

65. Uterine lymphoma.
Uterine lymphoma refers to involvement of the uterus with lymphoma.
It is rare condition with initial uterine involvement occurring in only
1% of patients with lymphoma . However, uterine involvement is
more common as part of a generalized process, as shown in
40 - 50% of these patients at autopsy.
Pelvic MRI
Reported characteristic MR imaging findings include
diffuse enlargement of the uterus may be present
homogeneous intermediate signal intensity of an indistinct mass
on T1- and T2-weighted images.
T1 : involved regions slightly hypo-intense to rest of uterus.
T2 : involved regions slightly hyper-intense to rest of uterus.

66. Primary
lymphoma in
a 62-year-old
woman.

67. Primary diffuse large cell lymphoma of the uterus, in a 71 year old female (a) Axial
unenhanced CT shows a mass (yellow arrow) in the uterine fundus with well defined
borders. (b) Sagittal and (c) axial T2 weighted MRI shows a heterogeneous mass (yellow
arrow), comparing to the muscle, in the uterine fundus, that shows well-defined contours
and has in the interior areas with more signal intensity (orange arrow). (d) In Axial T1
weighted MRI, the mass is isointense to the muscle. (e) Axial T1 weighted image with
gadolinium enhancing shows hypervascularity of the lesion.

68. Primary malignant Lymphoma of the uterine body.

69. Thank You.