1. Basic Gynae Ultrasound
Roziana Ramli, OBGYN, HSNZ

2. Introduction
• USG: not a substitute for
history, examination etc. LMP?
• Longer learning curve
• Normal versus abnormal
• TAS versus TVS, full bladder?
• ‘Pelvic Organs’

6. NORMAL UTERUS;
SHAPE AND SIZE
• Length - Fundus to Cervix(7.5-8.0cm)
• Depth - Antero-posterior(4.5-5.0cm)
• Width - Coronal view (2.5-3.0cm)

10. Menstrual Cycle
• Endometrial Development
– Cyclic changes during the
menstrual cycle
– Endometrial thickness(ET):
double wall thickness
including both the anterior
and posterior walls.

11. Menstrual
Cycle
Right after
menses
Appearance
Thickness
(mm)
Homogenous
1-4
Proliferative
phase
Triple layer
/Trilaminar
7-10
Luteal phase
Hyperechogenic
8-16

12. NORMAL OVARY; SHAPE AND SIZE
The average size of the ovary in a
premenopausal woman is 3.5 cm long
by 2.0 cm wide by 1.0 cm thick

13. Ovary
•
•
•
•
•
Moderately echogenic
Found in POD to the lower abdomen
Anterior and lateral to the iliac vessels
Typically found lateral to uterine fundus
TAS: patient with thin adipose, TVS in
others

15. FOLLICLE AND CORPUS LUTEUM
•
Developing follicles are first seen by ultrasound as
group of 4-8 antral follicles 3-5mm on a TVS
•
Around cycle days 9 to 10 the leading follicle can be
identified; it has a diameter of about 10 mm.
Thereafter it grows rapidly, and by ovulation it is 20 to
24 mm in diameter.
•
The subordinate(non dominant) follicle reach 10mm
then become atretic
•
After ovulation the follicle collapses, and as the
corpus luteum develops, the content of the cyst may
have a slightly heterogeneous consistency. The wall
thickens as cells are ‘luteinized’ (lining cells enlarge
and fill with lipid) and in most cases the antrum fills
with blood
•
Occasionally, corpus luteum forms a homogeneous
hypoechogenic thin-walled structure. The diameter of
a normal follicle or corpus luteum does not usually
exceed 30 mm.

17. • Uterus
– Fibroid
– Adenomyosis
– Patients with abnormal
bleeding
• Ovary
–
–
–
–
Ovarian Cyst
Endometriosis
Teratomas
Ovarian Cancer
• Others

18. Uterine fibroid

19. Ultrasound: fibroid
• Solid mass inside the body of the uterus
– Well defined, ‘encapsulated’
– Hyperechoeic OR hypoechoeic OR both

20. Fibroid: degenerative changes
Fibroids can undergo various
degenerative changes, especially
when large.
This fibroid shows multiple
hypoechoic and hyperechoic patchy
areas.
Sometimes degenerative changes
can take place in fibroids with areas
of necrosis and hemorrhage and
result in varying appearances from
cystic to inhomogenous
appearances.

23. Fibroid: calcification
• Calcification of fibroids may occur as a
peripheral ring or as popcorn type.

26. • Diagnosis with ultrasound is difficult as there are no
characteristic features
• Diagnosed based on:
– Myometrial echogenicity
– Posterior uterine wall thickening
– Anterior displacement of the endometrial cavity

27. Features suggestive of adenomyosis
–
–
–
–
–
Uterine enlargement not explained by fibroid
Asymmetrical thickening of anterior or usually posterior uterine walls
Lack of contour or abnormality effect despite enlarged ‘bulky uterus’
Heterogenous and poorly circumscribed areas in the myometrium
Poorly defined focal area/s of hypo/hyperechoeic texture within the
myometrium
– Anechoeic cysts or lacunae within the myometrium (myometrial cysts)

29. A large (bulky) uterus with a diffusely infiltrative, inhomogenous
appearance of the myometrium with dirty, streaky shadowing
posteriorly.
The uterus shows a GLOBULAR shape with the endometrium
almost obscured.

30. • Cystic areas within myometrium and endometrium.
• The hyperechoic areas: caused by the migration of
endometrial tissue into the myometrium.
• The hypoechoic areas: are the result of hyperplasia of the
myometrial smooth muscle around the ectopic
endometrial tissue.

31. Bleeding Disorders
• Fertile Age
• The most common causes
– Functional bleeding disorder of hormonal origin
• Deviation from the normal structure of the
endometrium in the different phases of the menstrual
cycle described above is not sufficient for making a
diagnosis.
• Endometrial thickness of more than 18 mm suggests
endometrial disease.

32. Bleeding disorders
• Fertile Age
• The most common causes
– Functional bleeding disorder of hormonal origin
• Deviation from the normal structure of the endometrium in the different
phases of the menstrual cycle described above is not sufficient for making a
diagnosis.
• Endometrial thickness of >18 mm suggests endometrial disease.

33. Postmenopausal Bleeding Disorders
• Postmenopausal bleeding is a sign of endometrial cancer until
otherwise proven.
• An endometrial thickness >10 mm in a postmenopausal patient
strongly suggests endometrial cancer and extremely rarely when
the endometrium is < 5 mm thick.
• A histological sample of the endometrium is always needed these
cases.

34. Endometrial polyp
An echodense, well-defined, round mass
in the uterine cavity, which is best
visualised during the proliferative phase.
It may have a cystic structure.
The polyp can be imaged even better
should any liquid be present in the
uterine cavity, or if fluid is introduced with
a catheter.

35. Ovarian Cyst

36. • Physiological versus pathological
– Size < 5cm
• Benign versus malignant
– 95% of cysts are benign
• Persistent of cyst >3 menstrual
cycles

37. 10 simple rules identifying benign &
malignant ovarian tumour
Malignant (M) rules
•
•
•
•
•
M1 Irregular solid tumor
M2 Presence of ascites
M3 At least 4 papillary structures
M4 Irregular multilocular solid tumor
with largest diameter ≥100 mm
M5 Very strong blood flow (color
score 4)
Benign (B) rules
•
•
•
•
•
B1 Unilocular
B2 Presence of solid components
where the largest solid component
has a largest diameter <7 mm
B3 Presence of acoustic shadows
B4 Smooth multilocular tumor with
largest diameter <100 mm
B5 No blood flow (color score 1)

48. Pelvic Infection
• Tubo-ovarian abscess is seen in US
examination as a multilocular, thickwalled mass that contains echo-dense
fluid collections.
• When the infection subsides, the
infectious complex may disappear or it
may turn into a sactosalpinx, which is an
elongated multilocular mass causing a
torsion of the fallopian tube.
• The torsion is easily identifiable from
different projections, and the ovary will
be seen as a separate structure.
• Small pseudopapillae (1 to 2 mm) may be
seen in the walls. Incomplete septa do not
reach from wall to wall inside the mass.