Disclaimer: This course is for skill enhancment only. Not valid for PCPNDT registration
   

 

S.No.	Time of talk	Time	Talk	Name of the faculty
Day 1	27 July
	8.30-9.15 AM	40+5 min	Methodology (TAS & TVS) and Tips and Tricks to scan the pelvis, Normal Uterine and ovarian ultrasound appearances and Physiological changes with age and menstrual cycle.	Dr Ladbans Kaur
	9.15.-10.00 AM	40+5 min	Fibroids : Ultrasound Mapping and Reporting	Dr Ladbans Kaur
	10.00-10.45 PM	40+5 min	Role of MRI in Fibroids and Adenomyosis	Dr Rupa Renganathan. Coimbatore
	10.45-11.30 PM	40+5 min	Adenomyosis and Adenomyoma	Dr Ladbans Kaur
	11.30-12.15	40+5 min	Medical and Surgical Management of Fibroids and adenomyosis	Dr BB Dash
	12.15-1.00 PM	40+5 min	Accessory Cavitated uterine malformation	Dr Ladbans Kaur
	1.00-1.45 PM	40+5 min	Management of Mullerian Anomalies	Dr BB Dash
Day 2	10 August
	8.30-9.15 AM	40+5 min	Pelvic ultrasound in adolescent and adults	Dr Manju Virmani
	9.15-10.00 AM	40+5 min	Junctional zone evaluation with MUSA Protocol	Dr Manju Virmani
	10.00-10.45 AM	40+5 min	Ectopic Pregnancy Tubal and Non Tubal	Dr. Ladbans Kaur
	10.45- 11.30 AM	40+5 min	US Evaluation of Mullerian Anomalies (ESHRE/ESGE Calssification)	Dr Manju Virmani
	11.30-12.15 AM	40+5 min	Imaging in Fallopian Tube	Dr Manju Virmani
	12.15-1.00 PM	40+5 min	Ovarian torsion	Dr. Ladbans Kaur
	1.00-1.45 PM	40+5 min	LUNCH
	1.45-2.30PM	40+5 min	IOTA: Benign Masses	Dr Manju Virmani
	2.30-3.15PM	40+5 min	IOTA: Malignant Masses	Dr Manju Virmani
	3.15-4.00PM	40+5 min	Pelvic emergencies (other than ovarian torsion and ectopic pregnancy)	Dr. Ladbans Kaur
	4.00-4.45PM	40+5 min	US ORADS	Dr Manju Virmani
Day 3	17 August
	8.30-9.15 AM	40+5 min	Polycystic ovaries: Current concepts	Dr. Sonal Panchal
	9.15-10.00 AM	40+5 min	Follicular and Endometrial tracking in infertility: Synchronous and asynchronous appearance of Endometrium and Ovary, OHSS	Dr. Sonal Panchal
	10.00-10.45 AM	40+5 min	MRI ORADS risk stratification system in adnexal masses:	Dr. Jyoti Arora Apollo Delhi
	10.45-11.15 AM	40+5 min	Pelvic Floor Imaging	Dr. Sonal Panchal
	11.15-11.45 AM	40+5 min	Ultrasound Evaluation of Deep Infiltrating Endometriosis (Posterior compartment)	Dr. Sonal Panchal
DAY 4	21 Sep
	8.30-9.15 AM	40+5 min	Ovarian endometriosis	Dr. Ladbans Kaur
	9.15-10.00 AM	40+5 min	Bladder Endometriosis	Dr. Ladbans Kaur
	10.00-10.45 AM	40+5 min	Role of MRI in deep infiltrating Endometriosis	Dr Rupa Renganathan. Coimbatore
	10.45-11.30 AM	40+5 min	Endometriosis Spectrum : Medical and Surgical Management	Dr BB Dash
	11.30-12.15 PM	40+5 min	IETA: Ultrasound Evaluation of Endometrium & Endo Ca	Dr Manju Virmani
	12.15-1.00 PM	40+5 min	LUNCH
	1.00-1.45 PM	40+5 min	Cervix and Vagina including Gel Vagino sonography	Dr. Ladbans Kaur
	1.45-2.30 PM	40+5 min	RPOC & Enhanced Myometrial Vascularity	Dr Manju Virmani
	2.30-3.15 PM	40+5 min	Role of MRI in evaluation of Carcinoma cervix and Endometrium	Dr Bhagyam Raghavan Chennai
	3.15-4.00 PM	40+5 min	Colour Doppler in Gynaecology	Dr. Manju Virmani
	4.00-4.45 PM	40+5 min	3D Necessity in Gynaecology	Dr. Manju Virmani

 

 

                

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Medical and Surgical Management of Fibroids and adenomyosis

Let’s take a closer look at the flow chart and planning for managing fibroids and adenomyosis, guided by our clinicians, highlighting the importance of accurate and thorough diagnostic imaging and reporting.

 

When it comes to medical treatment, the focus is on alleviating symptoms like heavy menstrual bleeding and pelvic pain. It’s essential to know when and where to use different medical treatments, whether hormonal or non-hormonal. There are various options available, including Combined Oral Contraceptives (COCs), Progestins (in forms like oral, injectable, or IUD), Gonadotropin-Releasing Hormone (GnRH) Agonists, GnRH Antagonists such as elagolix, Selective Progesterone Receptor Modulators (SPRMs) like ulipristal acetate (though its use might be limited due to hepatotoxicity concerns in some areas), Tranexamic acid, and NSAIDs.

Additionally, let’s explore the different surgical techniques available. For instance, Myomectomy can be performed through various approaches such as hysteroscopic (for submucosal fibroids), laparoscopic, or open surgery for larger or multiple fibroids. There’s also the option of a hysterectomy. We can’t forget about the minimally invasive techniques either, like Uterine Artery Embolization (UAE), MRI-Guided Focused Ultrasound Surgery (MRgFUS), Radiofrequency Ablation (RFA), Adenomyomectomy for surgically removing adenomyotic tissue, and Endometrial Ablation

 

Addressing Mullerian Anomalies: An Overview

What are the common types of Mullerian anomalies, and how do we approach their management? How are these conditions identified? Is their treatment primarily medical, or do they often require surgical intervention? Additionally, what role does ultrasound play in their diagnosis, and what key imaging findings should always be documented to substantiate the diagnosis?

Let’s delve into the associated reproductive challenges, such as infertility, recurrent pregnancy loss, or complications during pregnancy, and gain insights from our healthcare professionals on management strategies. Is there a place for medical treatment in these cases? Do all patients need surgical options, or are there particular scenarios that warrant an operation?

We will examine the classification system proposed by the American Society for Reproductive Medicine (ASRM) alongside the corresponding management approaches. For instance, uterine hypoplasia/aplasia may necessitate surgical interventions like vaginal reconstruction (e.g., McIndoe procedure). For a unicornuate uterus, the choice between surgical and medical management hinges on whether a symptomatic rudimentary horn is present, with excision being warranted in those cases and monitoring for asymptomatic presentations.

 

When should metroplasty be performed for uterus didelphys? Under what circumstances is surgical metroplasty (Strassman technique) indicated to enhance pregnancy outcomes in cases of a bicornuate uterus? For a septate uterus, when is hysteroscopic septum resection necessary? Does an arcuate uterus require treatment, and what steps should be taken for anomalies related to DES exposure?
 

Exploring the Spectrum of Endometriosis: Medical and Surgical Approaches

 

Delving into the comprehensive strategies for managing endometriosis, we find that treatment options range from conservative medical therapies to more complex surgical procedures. These approaches are customized based on the severity of the condition, the symptoms experienced, fertility aspirations, and individual preferences.

To grasp the nuances of endometriosis, it's crucial to consider its various forms: superficial peritoneal lesions, ovarian endometriomas, and deep infiltrating endometriosis (DIE). The severity can be classified from minimal (Stage I) to severe (Stage IV), with symptoms including chronic pelvic pain, dysmenorrhea, dyspareunia, dyschezia, and infertility.

In terms of medical management, the initial approach typically involves hormone therapy aimed at suppressing estrogen, which promotes the growth of endometrial tissue. Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used for alleviating pain. Various hormonal treatments are available, such as combined oral contraceptives (OCPs), progestins, GnRH agonists, GnRH antagonists, and aromatase inhibitors.

On the surgical front, the timing of intervention is key. Conservative surgery often entails laparoscopy for excision or ablation of lesions, along with adhesiolysis and nerve-sparing techniques. Definitive surgical options may include hysterectomy with or without bilateral salpingo-oophorectomy (BSO), as well as fertility-sparing surgeries that can be complemented by assisted reproductive technologies (ART).

Finally, a multidisciplinary approach is invaluable, incorporating pain specialists, reproductive endocrinologists, colorectal and urologic surgeons (when bowel or bladder issues arise), and psychologists or therapists to address chronic pain and improve overall quality of life.

 

Polycystic Ovaries: Contemporary Insights 

Polycystic Ovary Syndrome (PCOS) stands out as a prevalent endocrine condition among women of reproductive age, with ultrasound imaging being pivotal for both diagnosis and treatment. Let’s delve into the contemporary understanding of ultrasound imaging for polycystic ovaries, integrating the latest recommendations and technological advancements from 2023 to 2025. 

 

Ultrasound Diagnostic Criteria: 

The evaluation through ultrasound is fundamental for recognizing polycystic ovarian morphology (PCOM), utilizing the Rotterdam criteria in conjunction with indicators such as hyperandrogenism and oligo-/anovulation. 

Revised Ovarian Morphology Criteria: 

Key factors include the number of follicles per ovary (FNPO), ovarian size, and the distribution of follicles. 

Transvaginal vs. Transabdominal Imaging: 

Both imaging techniques have distinct roles in assessment. 

Advancements in Ultrasound Technology: 

Innovations like 3D ultrasound, Automated Follicle Counting (AFC), and Doppler ultrasound for examining ovarian blood flow are becoming increasingly relevant. 


 

Diagnostic Challenges: 

It's crucial to be aware of potential pitfalls, challenges in differential diagnosis, and the importance of correlating clinical context with current recommendations outlined by international PCOS guidelines.

Exploring Follicular and Endometrial Monitoring in Infertility: 

The simultaneous and staggered development of the Endometrium and Ovary, along with OHSS

Let’s delve into the essentials of monitoring Follicular and Endometrial aspects in infertility, focusing on the synchronous and asynchronous developments of the Endometrium and Ovary, as well as Ovarian Hyperstimulation Syndrome (OHSS). This study aims to pinpoint ovulation timing, guide IUI or IVF practices, evaluate endometrial receptivity, and identify any abnormalities such as subpar responses or the potential for OHSS.

 

Assessment methods involve closely tracking Follicular Development, determining specific days for monitoring, and establishing the frequency of observations in relation to endometrial changes during various phases: the Proliferative Phase (Days 5–14) and the Secretory Phase (after ovulation).

We will assess the difference between synchronous and asynchronous development: Synchronous Development occurs when Follicular growth aligns with endometrial thickening, while Asynchronous Development indicates a mismatch between follicle maturation and endometrial progress. Discrepancies can manifest in several ways: advanced follicles with a delayed endometrial response or a well-developed endometrium paired with insufficin ent follicular growth.

 

Strategies for aiding and managing poor responders and addressing Ovarian Hyperstimulation Syndrome (OHSS) will also be discussed, including the application of GnRH antagonist protocols.

 

Pelvic Floor Imaging  

Exploring Pelvic Floor Ultrasound Imaging: Its Importance, Uses, and Methodology: Pelvic floor ultrasound imaging serves as a non-invasive diagnostic method that examines the structure and functionality of the pelvic floor muscles, organs, and connective tissues. This technique is crucial for diagnosing and managing a variety of pelvic floor disorders. Key Functions: Identifying pelvic floor dysfunctions such as prolapse and incontinence; Assessing pelvic anatomy and the support of pelvic organs; Assisting in surgical planning and evaluating post-surgery; Tracking the effectiveness of physical therapy or rehabilitation; Conducting dynamic assessments during activities like straining or coughing.

Uses of Pelvic Floor Ultrasound in Addressing Female Pelvic Floor Disorders: Detecting Pelvic Organ Prolapse (POP): Observing the descent of the bladder, uterus, or rectum, and assessing levator ani muscle avulsion. In Urinary Incontinence: Evaluating bladder neck movement and urethral performance while measuring urethral rotation and funneling during a Valsalva maneuver. In Fecal Incontinence / Defecatory Dysfunction: Identifying defects in the anale sphincter and assessing conditions like rectocele, enterocele, or intussusception. In Levator Ani Muscle Dysfunction: Detecting avulsion or uneven contraction and measuring hiatal dimensions and ballooning. In Post-Surgical Evaluation: Identifying complications with mesh, scarring, or leftover defects.
 

Different Techniques for Pelvic Floor Ultrasound: Options include Transperineal / Translabial, Endovaginal, Endoanal, and Transabdominal methods. Each technique involves specific patient preparation, imaging planes, and the use of various dynamic maneuvers. This approach has its advantages and limitations  

Assessment of Deep Infiltrating Endometriosis (Posterior Compartment) via Ultrasound 

The evaluation of deep infiltrating endometriosis (DIE) focuses on a particularly severe variant where lesions extend beyond 5 mm beneath the peritoneal surface. This discussion delves into the ultrasound examination of the posterior compartment, highlighting essential structures such as the uterosacral ligaments, rectovaginal septum, posterior vaginal fornix, rectum, sigmoid colon, posterior uterine serosa, and the pouch of Douglas. 

In conducting the ultrasound, it is vital to prepare adequately and systematically assess the uterus and ovaries to identify adenomyosis and endometriomas. One key aspect to evaluate is the sliding sign, which helps determine the degree of obliteration in the pouch of Douglas by observing the mobility between the uterus and rectum. 

When examining the uterosacral ligaments, look for hypoechoic nodules or thickening, and similarly, assess for nodular formations in the rectovaginal septum. To evaluate bowel involvement, check for hypoechoic masses that disrupt the architecture of the bowel wall, particularly affecting the muscularis propria. It is also important to inspect the posterior vaginal fornix for signs of thickening or mass lesions. 

 

Utilizing additional tools like 3D transvaginal ultrasound and rectal water contrast ultrasound can enhance the evaluation process. 

When compiling a report, include a checklist detailing uterine size, presence of adenomyosis, characteristics of endometriomas (size and laterality), status of uterosacrals ligaments, results of the sliding sign (positive or negative), detection of nodules in the rectovaginal septum or bowel, depth and extent of bowel involvement (if observed), and the distance from the anals verge for surgical planning purposes.

 

The Importance of MRI in Evaluating Fibroids and Adenomyosis 

Magnetic Resonance Imaging (MRI) is essential for analyzing and differentiating between fibroids and adenomyosis, particularly when ultrasound results are unclear. In the context of uterine fibroids (leiomyomas), MRI serves several functions: it aids in the detection and characterization of fibroids, accurately locating them as submucosal, intramural, or subserosal, while also assessing their size, quantity, and their relationship with the endometrial and serosal surfaces. Furthermore, it helps distinguish these growths from other pelvic masses, such as adenomyosis or leiomyosarcoma. MRI excels in tissue characterization, utilizing T1-weighted images to identify signs of hemorrhagic or fatty degeneration, while T2-weighted images reveal different signal intensity patterns—typical fibroids exhibit low signal intensity, whereas degenerated ones appear brighter.

In terms of pre-treatment surgical planning for procedures like myomectomy, uterine artery embolization (UAE), or MRI-guided focused ultrasound surgery (MRgFUS), MRI proves invaluable. It facilitates the evaluation of fibroid vascularity and viability for embolization. Additionally, MRI plays a vital role in post-treatment monitoring, allowing clinicians to track shrinkage, necrosis, or complications following UAE or other interventions.

 

When it comes to adenomyosis, MRI's contributions are significant due to its superior sensitivity and specificity, making it more effective than ultrasound in diagnosing this condition, particularly in its diffuse form. Key MRI indicators include thickening of the junctional zone (JZ) greater than 12 mm on T2-weighted images, as well as low-signal intensity areas within the myometrium that indicate ectopic endometrial glands and smooth muscle hyperplasia, along with high-signal foci on T1 images due to hemorrhagic glands.

Moreover, MRI is instrumental in differential diagnosis, helping to distinguish diffuse adenomyosis from multiple small intramural fibroids. It also aids in treatment planning for adenomyosis by guiding decisions on medical therapy, surgical methods (either conservative approaches or hysterectomy), or MRgFUS based on the extent and depth of infiltration. Ultimately, MRI stands as the gold standard for assessing uterine fibroids and adenomyosis when ultrasound findings are ambiguous, precise mapping is essential for treatment, or differentiation between coexisting conditions is necessary.

MRI ORADS risk stratification system in adnexal masses:

The MRI O-RADS (Ovarian-Adnexal Reporting and Data System) serves as a systematic framework for assessing and reporting risks associated with adnexal masses through magnetic resonance imaging (MRI). Established by the American College of Radiology (ACR), this system enhances the ultrasound-based O-RADS, particularly in cases that are unclear or complicated.

The primary goals of MRI O-RADS include categorizing adnexal masses according to their imaging characteristics, estimating the likelihood of cancerous growths, aiding in clinical decision-making, and ensuring uniform terminology while organizing reports.

 

Let’s delve into the critical MRI features. First, consider the enhancement patterns: solid masses may exhibit varying degrees of enhancement, where intense early enhancement raises suspicion. The role of Diffusion-Weighted Imaging (DWI) is significant, as restricted diffusion can indicate malignancy. Furthermore, analyzing T1 and T2 signal characteristics is crucial; for instance, high T1 signals combined with shading on T2 suggest an endometrioma, while fat suppression techniques help identify dermoid cysts.

 

Next, it’s important to assess the presence of solid components, nodules, septations, papillary projections, and any signs of peritoneal disease or ascites.

 

A structured workflow chart for interpretation will guide you: Begin by determining morphology—whether the mass is cystic, solid, or mixed. Then, evaluate contrast enhancement: a lack of enhancement typically indicates benignity. Check for restricted diffusion on DWI; if it’s present, malignancy may be a concern. Finally, assign an MRI O-RADS score based on the combination of these observed features.

Detailed Evaluation of Specific Areas:

- Uterosacral ligaments: MRI may reveal thickening, nodularity, or tethering.

- Rectosigmoid colon: It can indicate bowel wall thickening or a "mushroom cap" sign.

- Vagina and rectovaginal septum: DIE can manifest as dark nodules on T2-weighted images.

- Bladder and ureters: Involvement may show as thickening of the bladder wall or distortion/hydronephrosis of the ureters.

Understanding the MRI Protocol for DIE typically includes: T2-weighted images in sagittal, axial, and coronal orientations; T1-weighted fat-suppressed images to identify hemorrhagic content (endometriomas); and optionally, rectal or vaginal gel for enhanced visualization of lesions.

 

Role of MRI in evaluation of Carcinoma cervix and Endometrium

Magnetic Resonance Imaging (MRI) is indispensable in assessing cervical and endometrial cancers, thanks to its superior soft tissue contrast and ability to capture images in multiple planes. Let’s delve into how MRI becomes vital, particularly when clinical evaluations or ultrasound results fall short. 

One of MRI's primary functions lies in staging these cancers, boasting high accuracy as per the FIGO 2018 guidelines. It excels in measuring tumor size, especially for those exceeding 2 cm or 4 cm, and evaluating local spread, which includes assessing parametrial and vaginal invasion, involvement of pelvic sidewalls, lymph node status (considering size and shape), and any effects on the bladder or rectum. 

A typical MRI protocol includes T2-weighted imaging across sagittal, axial, and coronal views, T1-weighted imaging for anatomical details, diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) maps for tumor identification, and optional post-contrast imaging, particularly useful in early-stage disease. This imaging also aids in treatment planning, guiding the choice between surgical intervention and chemoradiation, while precise mapping supports radiotherapy strategies like brachytherapy.

When it comes to endometrial carcinoma, MRI is crucial for preoperative staging. It is essential for evaluating the depth of myometrial invasion—distinguishing between less than 50% versus 50% or more, which significantly impacts management decisions—as well as examining cervical stromal infiltration, adnexal or serosal involvement, and assessing pelvic or para-aortic lymphadenopathy, along with any vaginal or parametrial spread and the detection of metastases. The MRI protocol here mirrors that used for cervical cancer: T2-weighted imaging in various planes for comprehensive views, T1-weighted imaging for foundational anatomy, dynamic contrast-enhanced MRI (DCE-MRI) for assessing myometrial invasion, and DWI/ADC for tumor grading and detection.

 

Additionally, we should touch on pelvic ultrasound methodologies such as Transabdominal Sonography (TAS) and Transvaginal Sonography (TVS), including tips for optimizing images. Understanding normal uterine and ovarian appearances, along with physiological changes accompanying age and the menstrual cycle, is vital. Key steps in patient preparation involve positioning and employing a low-frequency (3–5 MHz) curvilinear probe while scanning in both sagittal and transverse planes to identify the bladder, uterus, endometrium, ovaries, adnexa, and the pouch of Douglas. 

Advantages of TAS include a broad field of view, while its drawbacks encompass limited resolution and interference from bowel gas. On the other hand, TVS is indicated for better resolution of these structures during early pregnancy assessments. Proper preparation entails an empty bladder and patient consent while positioning them in lithotomy or semi-recumbent positions. Effective scanning techniques involve manipulating the probe for optimal angles, applying gentle pressure to navigate bowel loops, and utilizing Doppler imaging to evaluate blood flow in the ovaries or endometrium where pathology is suspected. Image optimization is key for accurate representation of normal uterine and ovarian structures and recognizing physiological changes over time.

 

Pelvic Ultrasound in Teenagers and Adults 

When it comes to pelvic ultrasounds, the techniques and priorities differ for teenagers and adults, influenced by their developmental stages, medical issues, and diagnostic requirements. There are two primary types of pelvic ultrasound: Transabdominal Ultrasound (TAUS) and Transvaginal Ultrasound (TVUS). 

 

In teenagers, the reasons for conducting a pelvic ultrasound include: pelvic pain (which can arise from conditions like appendicitis, ovarian torsion, or ruptured cysts), primary amenorrhea (the absence of menstruation), abnormal uterine bleeding, assessment of congenital anomalies (such as Müllerian anomalies), detection of pelvic masses (like cysts or tumors), precocious puberty, and the suspicion of polycystic ovarian syndrome (PCOS). 

 

For adults, the indications for performing a pelvic ultrasound encompass: pelvic pain, abnormal uterine bleeding or bleeding after menopause, evaluation of infertility, monitoring ovulation and follicle growth during in vitro fertilization (IVF), concerns about fibroids or endometriosis, ovarian cysts or tumors, pelvic inflammatory disease, localization of intrauterine devices (IUDs), and pregnancy assessments. 

 

MUSA Protocol 

The MUSA protocol—standing for Morphological Uterus Sonographic Assessment—is a structured approach to detailing and documenting the ultrasound characteristics of the uterus, with a special focus on the myometrium (the uterine wall) and related lesions such as fibroids and adenomyosis. This method utilizes grayscale imaging, color Doppler, and 3D ultrasound technology. MUSA serves as a unified guideline that outlines terminology, measurement standards, and reporting practices for ultrasound evaluations of the uterus, particularly the myometrium. It is essential to be familiar with the standardized vocabulary used to describe the uterus's appearance and any lesions visible on ultrasound. Key elements of the MUSA protocol involve gray-scale sonography, color/power Doppler imaging, and 3D ultrasound in analyzing the uterine corpus, myometrium, and myometrial lesions.

 

Fibroids: Mapping and Reporting via Ultrasound

The process of documenting uterine fibroids through ultrasound is crucial for informed clinical choices, particularly when exploring treatment alternatives such as myomectomy, uterine artery embolization (UAE), or medical management. This guide provides a structured approach for effectively mapping and reporting fibroids on ultrasound.

Essential Principles:

- Adopt a systematic strategy, beginning at the fundus and progressing toward the cervix.

- Assess the quantity, dimensions, location, and classification of fibroids.

- Utilize both transabdominal and transvaginal techniques as needed.

- Incorporate Doppler imaging to evaluate vascularity when applicable.

Fibroid Classification:

Utilize the FIGO classification system (International Federation of Gynecology and Obstetrics):

0 - Pedunculated submucosal

1 - <50% intramural (submucosal)

2 - ≥50% intramural (submucosal)

3 - 100% intramural, in contact with the endometrium

4 - Intramural

5 - Subserosal ≥50% intramural

6 - Subserosal <50% intramural

7 - Subserosal pedunculated

Mapping Fibroids:

- Divide the uterus into segments: anterior, posterior, fundal, left/right lateral, and cervical regions.

- Employ clock-face notation to indicate endometrial involvement (e.g., submucosal fibroid at 3 o’clock).

- Record the uterine dimensions (Length x Width x Height).

Example Reporting Template:

Uterine Size: 9.5 x 5.2 x 6.1 cm 

Endometrial Thickness: 7 mm (proliferative phase) 

Fibroid #1: 

- Location: Posterior intramural 

- FIGO Type: 4 

- Size: 3.2 x 2.8 x 2.5 cm 

- Vascularity: Notable peripheral vascularity 

Fibroid #2: 

- Location: Submucosal at fundus (3 o’clock) 

- FIGO Type: 1 

- Size: 2.5 x 2.3 x 2.0 cm 

- Endometrial cavity distortion: Yes 

- Comment: Multiple uterine fibroids present, with one submucosal lesion leading to distortion of the endometrium. Clinical correlation is necessary for management planning.

Additional Considerations:

- Note any calcifications, degeneration (such as cystic or hyaline changes), or necrosis if observed.

- Clarify the relationship with the endometrium and serosal surface.

- Examine adnexa and ovaries for any additional pathologies.

Fibroids: Ultrasound Mapping and Documentation 

The process of documenting uterine fibroids through ultrasound is crucial for making informed clinical decisions, particularly when evaluating treatment alternatives such as myomectomy, uterine artery embolization (UAE), or medical therapies. Below is a detailed guide for effectively mapping and reporting fibroids via ultrasound:

Key Principles to Consider: 

- Adopt a methodical strategy: initiate from the fundus and progress toward the cervix. 

- Assess the quantity, dimensions, positioning, and classification of fibroids. 

- Utilize both transabdominal and transvaginal techniques as needed. 

- Incorporate Doppler imaging to evaluate vascularity when applicable. 

 

Classification of Fibroids: 

According to the FIGO classification system (International Federation of Gynecology and Obstetrics): 

0 - Pedunculated submucosal 

1 - <50% intramural (submucosal) 

2 - ≥50% intramural (submucosal) 

3 - 100% intramural, touching the endometrium 

4 - Intramural 

5 - Subserosal ≥50% intramural 

6 - Subserosal <50% intramural 

7 - Subserosal pedunculated 

Mapping Strategy for Fibroids: 

- Location: Segment the uterus into anterior, posterior, fundal, left/right lateral, and cervical zones. 

- Employ clock-face notation for endometrial involvement (e.g., a submucosal fibroid located at 3 o’clock). 

- Measure uterine dimensions (Length x Width x Height). 

Report Example: 

- Uterine Size: 9.5 x 5.2 x 6.1 cm 

- Endometrial Thickness: 7 mm (proliferative phase) 

- Fibroid #1: 

  - Location: Posterior intramural 

  - FIGO Type: 4 

  - Size: 3.2 x 2.8 x 2.5 cm 

  - Vascularity: Peripheral vascularity observed. 

- Fibroid #2: 

  - Location: Submucosal at fundus (3 o’clock) 

  - FIGO Type: 1 

  - Size: 2.5 x 2.3 x 2.0 cm 

  - Endometrial cavity distortion: Yes 

  - Comments: Multiple uterine fibroids detected, with one submucosal fibroid causing distortion of the endometrial cavity. Clinical correlation is necessary for management planning. 

Additional Considerations: 

- Note any calcifications, degeneration (e.g., cystic, hyaline), or necrosis if present. 

- Specify the relationship to both the endometrium and serosal surface. 

- Examine adnexa and ovaries for other possible conditions. 

 

Adenomyosis and Adenomyoma: 

Ultrasound serves a vital function in identifying adenomyosis and adenomyoma, two related conditions characterized by ectopic endometrial tissue within the uterine wall. 

Adenomyosis is marked by a widespread presence of endometrial glands and stroma within the myometrium. Typical ultrasound findings (often using Transvaginal Ultrasound) include: 

- A globular or enlarged uterus lacking a distinct mass. 

- Asymmetrical thickening of the myometrium, generally more pronounced on the posterior side than the anterior. 

- Myometrial cysts manifesting as small, anechoic regions within the myometrium. 

- A heterogeneous echotexture of the myometrium characterized as “coarse” or “ill-defined.” 

- A poorly defined boundary between the endometrium and myometrium (junctional zone). 

- Linear striations or hyperechoic lines extending from the endometrium into the myometrium. 

- Venetian blind shadowing: non-specific shadowing due to texture variations in the myometrium. 

Doppler Ultrasound may show increased vascularity, though it's typically less organized compared to that seen in fibroids. In 3D Ultrasound, thickening or disruption of the junctional zone (≥12 mm suggests adenomyosis) can be observed, along with irregularities at the endometrial-myometrial interface. 

Adenomyoma represents a localized mass-like form of adenomyosis found in the myometrium, with ultrasound findings including: 

- A poorly defined, heterogeneous mass in the myometrium without a capsule (unlike fibroids). 

- Presence of small internal cystic areas (myometrial cysts may be visible). 

- Possible posterior acoustic shadowing but generally less interpretable than in fibroids. 

- Irregular edges that merge with surrounding myometrial tissue, typically located in the posterior uterine wall. 

On Doppler Ultrasound, mild to moderate internal vascularity is usually present and tends to be diffuse rather than peripheral as seen in leiomyomas. The absence of a peripheral vascular ring distinguishes it from fibroids. It’s essential to differentiate between these conditions when diagnosing adenomyoma versus leiomyoma/fibroid.
 

Ultrasound Examination of Accessory Cavitated Uterine Mass (ACUM):

The Accessory Cavitated Uterine Mass (ACUM) is an uncommon anomaly of the Müllerian system, distinguished by a non-communicating accessory cavity nestled within the uterine wall, typically adjacent to where the round ligament attaches. It can resemble various conditions such as adenomyosis, fibroids, or non-communicating uterine horns. This cavity is lined with functional endometrium and often results in significant dysmenorrhea and pelvic discomfort. Let's delve into the Ultrasound Characteristics of ACUM: its Location, Shape, Contents, and the surrounding Myometrial Ultrasound features. Notable Ultrasound characteristics include: Non-communicating cavity: There is no connection between the ACUM and the endometrial cavity or fallopian tubes, which can be confirmed through sonohysterography or MRI. The role of Doppler Ultrasound is also significant. Consider differential diagnoses such as non-communicating rudimentary horn; degenerating fibroid with cystic alterations; adenomyotic cyst; or endometriotic cyst (if confused with an adnexal mass). The clinical presentation of ACUM and its management is crucial.

IOTA: Benign Masses

The International Ovarian Tumor Analysis (IOTA) group has crafted standardized terminology and models for evaluating adnexal masses (ovarian and para-ovarian). The IOTA framework encompasses simple rules, scoring systems, and algorithms designed to assist in distinguishing between benign and malignant ovarian masses. Let’s explore IOTA: Benign Masses – Key Ultrasound Features. According to the IOTA Simple Rules, a mass is likely benign if it exhibits one or more benign (B) characteristics without any malignant (M) features present: Benign (B) Features include: Unilocular cyst: a single-chamber cyst devoid of solid components; presence of solid components where the largest solid part measures less than 7 mm; Acoustic shadowing: indicative of benign entities like dermoid cysts or fibromas; smooth multilocular tumor measuring less than 100 mm in diameter, Color score = 1). Enhance your diagnostic efficiency regarding common benign masses and their ultrasound features.

 

IOTA: Identifying Malignant Masses 

In the realm of gynecological ultrasound, IOTA stands for the International Ovarian Tumor Analysis group, which has crafted standardized guidelines and models to aid in distinguishing between benign and malignant adnexal masses, particularly those related to ovarian tumors. Let’s delve into the essential characteristics of IOTA concerning malignant masses observed in ultrasound imaging.

 

IOTA Simple Rules: Indicators of Malignancy 

The IOTA group has established straightforward rules based on distinct ultrasound characteristics. Here are five notable features (M-rules) that indicate potential malignancy: M1: An irregular solid tumor; M2: The presence of ascites; M3: A minimum of four papillary structures; M4: An irregular multilocular-solid tumor with a maximum diameter of 100 mm or more; M5: A significantly strong blood flow (color score 4).
 

Additional IOTA Risk Assessment Tools 

In addition to these simple guidelines, IOTA has devised risk prediction models such as the ADNEX Model (Assessment of Different NEoplasias in the adneXa).

 

Ultrasound Indicators of Malignancy 

Signs that may suggest malignancy include an irregular solid or solid-cystic formation, multiple papillary projections (more than three), thick septa, the presence of ascites, heightened central vascularity on Doppler imaging (Color Score 4), significant growth over time, and the absence of acoustic shadows (which are more frequently observed in benign dermoids or fibromas).

Clinical Context Evaluation: Key Considerations 

When assessing a patient, it’s crucial to take into account several factors: the patient’s age and menopausal status, relevant serum markers (such as CA-125), clinical symptoms (like pain or bloating), family history, and the potential need for MRI or CT scans for further evaluation.

Ectopic Pregnancy: Tubal and Non-Tubal

Ultrasound stands as the primary tool for identifying ectopic pregnancy (EP), a condition where a fertilized egg finds its way outside the uterine cavity. This can manifest as tubal (the most frequent type) or non-tubal (less common). Timely and precise diagnosis is vital to mitigate health risks. Let’s delve into the significance of ultrasound in ectopic pregnancies, focusing on both transvaginal ultrasound (TVUS) and transabdominal ultrasound for effective diagnosis.

Key Indicators of Ectopic Pregnancy: An empty uterus paired with a positive β-hCG level above the discriminatory zone (typically around 1500–2000 IU/L); presence of a pseudogestational sac (centrally located, lacking the double decidual sign); an adnexal mass or ectopic gestational sac containing a yolk sac or fetal pole; and free fluid in the cul-de-sac or Morrison’s pouch, which may indicate rupture.

Tubal Ectopic Pregnancy (95% of EP cases): Common Sites: Ampullary (the most prevalent), Isthmic, Fimbrial, Interstitial (within the fallopian tube wall); Ultrasound Characteristics: The tubal ring sign, which appears as a hyperechoic ring surrounding an anechoic center (often confused with an ovarian follicle); an ectopic gestational sac that may or may not contain a yolk sac or fetal pole, among other features.

 

Ovarian Torsion

Ultrasound serves as the initial imaging method for assessing ovarian torsion, a critical gynecological emergency caused by the twisting of the ovary and/or fallopian tube, resulting in impaired blood flow. Let’s explore how ultrasound is utilized and what typical findings to expect:

Ultrasound's Role in Ovarian Torsion: The preferred method is transvaginal ultrasound (TVUS), while transabdominal ultrasound may be employed for larger masses or in pediatric/virgin patients. Doppler ultrasound also plays a crucial role: both color and spectral Doppler are vital for evaluating ovarian blood flow; however, normal Doppler readings do not rule out torsion due to the dual blood supply from the ovarian and uterine arteries.

Important Ultrasound Findings in Ovarian Torsion: Look for an enlarged ovary; peripheral follicles; free fluid in the pelvic area; and absent or reduced Doppler flow, all of which should be integrated into our daily practice for effective evaluation.

 

 

Pelvic Emergencies Beyond Ovarian Torsion and Ectopic Pregnancy
Ultrasound is essential for evaluating pelvic emergencies, extending beyond just ovarian torsion and ectopic pregnancy. Let’s delve into these conditions and explore their practical applications in our daily routines.
Pelvic Emergencies Beyond Ovarian Torsion and Ectopic Pregnancy
Ultrasound is essential for evaluating pelvic emergencies, extending beyond just ovarian torsion and ectopic pregnancy. Let’s delve into these conditions and explore their practical applications in our daily routines.

Hemorrhagic Ovarian Cyst Rupture:
Ultrasound Indicators: A complex adnexal mass displaying internal echoes, the presence of free fluid in the pelvic area, often echogenic (indicative of blood), and a reticular or lace-like pattern within the cyst (fibrin strands).

Pelvic Inflammatory Disease (PID) and Tubo-Ovarian Abscess (TOA):
Ultrasound Indicators: Thickened, fluid-filled fallopian tubes (hydrosalpinx or pyosalpinx), increased vascularity of the adnexa on Doppler due to inflammation, complex multilocular adnexal masses suggestive of TOA, and free fluid in the pelvis.

Degenerating Uterine Fibroids:
Ultrasound Indicators: A heterogeneous uterine mass characterized by areas of cystic degeneration or calcification.

Endometriosis / Ruptured Endometrioma:
Ultrasound Indicators: A homogeneous appearance with low-level internal echoes (often referred to as a "chocolate cyst"), absence of internal vascularity, and a ruptured endometrioma may be accompanied by free fluid and irregular cyst borders.

Urinary Retention / Bladder Issues / Appendicitis (Gynecological Mimicry):
Imaging Focus on the Fallopian Tubes:
Ultrasound imaging is a crucial diagnostic asset in gynecology for examining the structure and functionality of fallopian tubes. Let’s break down its usage, findings, and clinical significance:

Transvaginal Ultrasound (TVUS) provides high-resolution imagery of the uterus, ovaries, and occasionally the fallopian tubes. Typically, normal fallopian tubes are not visible unless there is an abnormality, such as dilation or fluid accumulation.

Additional Techniques Include: Sonohysterography (Saline Infusion Sonography or SIS) and Sonosalpingography (SSG) or Saline Contrast Sonography (HyCoSy).

What Ultrasound Can Reveal About the Fallopian Tubes:
- Hydrosalpinx: A dilated, fluid-filled fallopian tube due to blockage.
- Pyosalpinx: A pus-filled tube resulting from infection (PID).
- Tubal Ectopic Pregnancy: A pregnancy that occurs within the tube, identifiable as a mass with or without a yolk sac or fetal pole.
- Tubal Patency: Assessment of whether the tubes are open or blocked (evaluated via SIS/SSG).
- Tubal Masses or Neoplasms: Though rare, these may sometimes be detected.

Role of Ultrasound Includes:
Investigating infertility (e.g., checking for tubal blockages), evaluating pelvic pain or suspected PID, confirming suspected ectopic pregnancies, pre-IVF assessments, and monitoring known tubal pathologies.

Ovarian Endometriosis:
Transvaginal ultrasound stands out as a highly effective, non-invasive method for identifying ovarian endometriosis, especially in the form of endometriomas. Recognizing the distinctive "ground-glass" cystic appearance is vital for accurate diagnosis. TVUS is typically the first choice for imaging when ovarian endometriosis is suspected. Endometriomas generally manifest as cystic masses formed by ectopic endometrial tissue in the ovary.

Key Ultrasound Findings in Ovarian Endometriosis Include:
- Endometrioma ("chocolate cyst"): Characteristics include unilocular or multilocular cysts with homogeneous, low-level internal echoes; often exhibiting a "ground-glass" echotexture due to residual blood and debris; typically shows posterior acoustic enhancement; may have septations or hyperechoic wall foci indicating cholesterol deposits or fibrosis; no internal vascularity; and a "kissing ovaries" sign where bilateral ovaries are closely situated behind the uterus due to adhesions.

The Role of Ultrasound in Diagnosis, Preoperative Assessment, and Treatment Monitoring:
Despite its effectiveness, TVUS may overlook small peritoneal implants or deep infiltrating endometriosis (DIE) unless performed by an expert; thus, MRI offers greater sensitivity for DIE and can complement ultrasound findings.

Bladder Endometriosis 

Bladder endometriosis is a type of deep infiltrating endometriosis (DIE) characterized by the invasion of endometrial tissue into the bladder wall, primarily affecting the detrusor muscle and occasionally the mucosa. Transvaginal ultrasound (TVUS), both with and without bowel preparation, plays a vital role in non-invasive diagnosis. Let's delve into the Key Ultrasound Features of Bladder Endometriosis. Common Indicators: A hypoechoic nodule or mass found in the bladder wall, typically located at the posterior dome or base; irregular thickening of the bladder wall; lesions may distort or indent the bladder lumen; possible loss of the typical bladder wall layering; decreased mobility between the bladder and surrounding structures, such as the uterus or anterior vaginal wall; Doppler imaging may reveal minimal or absent vascularity within the lesion. MRI is frequently utilized alongside ultrasound, particularly when multiple sites of deep infiltrating endometriosis are suspected, offering superior mapping of disease extent. Clinical manifestations usually include: cyclic hematuria (if mucosal involvement occurs); dysuria or urinary urgency, especially in cycles; pelvic pain or dyspareunia. High-resolution transvaginal ultrasound focused on the bladder wall serves as an important first-line imaging technique for assessing bladder endometriosis. Accurate diagnosis relies on proper technique and clinical awareness. MRI should be considered if ultrasound results are unclear or if there is suspicion of multi-organ involvement.

 

IETA: Ultrasound Evaluation of Endometrium & the Junctional Zone 

The Ultrasound Evaluation of the Endometrium and the Junctional Zone follows guidelines and terminology established by the International Endometrial Tumor Analysis (IETA) group. This group standardizes the assessment of the endometrium (the uterus's inner lining) through transvaginal ultrasound, improving evaluations for abnormal uterine bleeding (AUB) and identifying potential endometrial pathologies, including hyperplasia and carcinoma. Let's explore the parameters for Endometrial Evaluation: Endometrial Thickness; Endometrial Echogenicity; Junctional Zone; Endometrial-Myometrial Interface; Endometrial Outline; Vascular Pattern Assessment (utilizing Color Doppler) and the IETA Classification.

 

Cervix and Vagina including Gel Vagino Sonography 

The use of Transvaginal Ultrasound (TVS) is crucial for evaluating: cervical masses or cysts, vaginal lesions or abnormalities. Gel Vagino-Sonography utilizes gel as a contrast medium to separate vaginal walls and enhance visualization. Let’s examine its applications for a detailed evaluation of vaginal lesions, masses, or septa; assessing tumors, polyps, or adhesions within the vaginal and cervical canals; providing clearer delineation of the posterior vaginal wall, rectovaginal septum, or perineal body. Clinical indications for ultrasound of the cervix and vagina include: abnormal vaginal bleeding or discharge; vaginal or cervical masses (e.g., fibroids, polyps, carcinoma); suspected congenital anomalies (e.g., septate vagina, bicornuate uterus); postmenopausal bleeding; preterm labor risk (monitoring cervical length); suspected fistulas, hematocolpos, or vaginal atresia; evaluation of pelvic pain or dyspareunia; cancer staging or follow-up.

 

Advantages of Gel Vagino-Sonography and Limitations 

Ultrasound Evaluation of Cervical Cancer and Endometrial Cancer 

Let’s recognize the normal sonographic appearance of the cervix and endometrium as well as the sonographic features associated with cervical and endometrial cancer. Typical abnormal ultrasound findings include: mass lesions that are hypoechoic or heterogeneous, distorting or replacing cervical architecture; loss of the normal hyperechoic endocervical stripe; irregular cervical contours; infiltration into neighboring structures (parametrium, vagina, bladder, rectum); increased vascularity.

 

RPOC & Enhanced Myometrial Vascularity 

RPOC (Retained Products of Conception) and Enhanced Myometrial Vascularity (EMV) are conditions often linked to complications following childbirth or abortion. They can present with similar clinical and imaging findings, particularly on ultrasound with color Doppler. Let's discuss typical and atypical ultrasound characteristics. For RPOC: ultrasound may show echogenic material within the endometrial cavity, which may exhibit vascular flow on Doppler (indicating a higher risk of bleeding). For EMV: there is abnormal blood flow in the myometrium (the uterus's muscular layer), often adjacent to or extending from RPOC; ultrasound findings typically display prominent color Doppler flow in the myometrium with a low-resistance, high-velocity flow pattern that can mimic arteriovenous malformation (AVM), though usually less severe. RPOC & EMV Relationship: EMV is commonly associated with RPOC, especially when retained tissue is vascularized; both conditions can lead to significant bleeding, which is a critical concern.