What should ovaries look like on ultrasound

This is a common finding in older women and women with fertility issues. This can be diagnosed with a pelvic ultrasound examination. Pelvic Ultrasound in Gynaecology Ultrasound has been used for decades to assess the health of the female pelvic organs — mainly the uterus, and ovaries.

Vaginal Ultrasound Gynaecological ultrasound examination usually requires a vaginal scan. Abdominal Ultrasound If you have never had sexual intercourse then your scan will most likely be an abdominal scan with a full bladder.

Indications for gynaecological ultrasounds at different life stages: Young girls and adolescents This is performed as an abdominal ultrasound so please attend with a full bladder. The menstrual years This is the most common age group in which ultrasounds are performed, as ultrasound is excellent for assessing menstrual cycle problems. Common reasons for referral include: Bleeding between periods Heavy or painful periods Pelvic pain at any time of the cycle Absent or irregular periods Pelvic mass and assessment of fibroids Cyst diagnosis and follow up Fertility issues Common findings may include fibroids, adenomyosis, endometrial polyps, ovarian cysts and hydrosalpinx.

Postmenopausal years Bleeding, ovarian cancer screening and pelvic pain are the commonest reasons for referral. A thin endometrial lining is reassuring and reflects the lack of estrogen after menopause. Pelvic discomfort, bloating or pain are other reasons for a gynaecological ultrasound. Common Gynaecological Pathology Endometrial polyps Endometrial polyps commonly occur during the menstrual years and tend to cause heavy periods and bleeding between the periods.

Fibroids Fibroids are common uterine muscle tumours and almost always are benign. Adenomyosis Adenomyosis usually occurs in women in their later menstrual years and causes heavier periods and pain. Endometriosis Endometriosis is a condition that causes significant pain and fertility issues. Hydrosalpinx Hydrosalpinx means fluid in the fallopian tube. A longitudinal sagittal image by transvaginal scanning of an anteverted uterine fundus f and prominent echogenic secretory phase endometrium se with the upper portion of the endocervical canal ec noted at the right of the image.

Large arrows delineate the junction of the basalis endometrial layer and the myometrium where the endometrial width thickness should be measured. Wade RV: Endovaginal ultrasound. Philadelphia, Lippincott-Raven, Granberg and associates 54 evaluated women with postmenopausal bleeding and noted benign endometrial histologic change with an endometrial width thickness of less than 9 mm. The mean endometrial width in patients with endometrial cancer was Malpani and coworkers 55 reviewed endometrial thickness measurements in patients with endometrial hyperplasia compared with those with normal histopathologic features.

The mean width of the endometrial echo in patients with hyperplasia was Varner and colleagues 56 also noted benign findings in patients with an endometrial thickness of less than 5 mm. To compare the diagnostic accuracy of transvaginal ultrasonography, endometrial cytologic study, and histologic assessment of specimens obtained using dilation and curettage, Karlsson and associates 57 performed all three of these techniques on patients with postmenopausal bleeding.

Realizing that false-positive and false-negative findings exist for most testing schemes, notice that the patient's response to therapy and persistence of concerning symptoms must be addressed with more in-depth study. To emphasize this point, a study from Norway by Dorum and coworkers 58 noted that 3 of 54 patients with endometrial carcinoma had an endometrial thickness of less than 5 mm.

Two patients had stage I adenocarcinoma of the endometrium; the third had endometrial involvement by a malignant lymphoma. The likelihood of a malignancy in a patient with a thin endometrium, normal endometrial biopsy specimen, or normal specimen obtained through dilation and curettage is low. Persistent bleeding, failure of expected response to therapy, development of new symptoms, or persistence of concerning symptoms require further evaluation.

Therefore, a postmenopausal patient with a thin less than 5 mm endometrial width may be managed without endometrial sampling or curettage for abnormal bleeding, assuming an appropriate response to therapy follows. The value of ultrasound assessment of endometrial carcinoma, particularly the depth of invasion of the myometrium, is under investigation. Endometrial carcinoma produces an irregularity of the endometrial cavity in advanced cases 60 , 61 , 62 , 63 Fig. Of 25 cases of endometrial carcinoma, the correct depth of invasion was predicted in Longitudinal transabdominal scan showing invasive endometrial adenocarcinoma delineated by the four small white arrows.

Note the depth of myometrial invasion and irregularity of the endometrial echo. Calipers measure uterus at A, near-field reverberation artifact; U, uterine corpus black arrows ; C, cervix. The finding of endometrial fluid should heighten the ultrasonographer's suspicion of unapparent abnormalities of the genital tract. Of 17 postmenopausal patients with endometrial fluid collection, 5 had malignancies: 2 had ovarian cancer, 1 had tubal carcinoma, 1 had endometrial carcinoma, and 1 had cervical carcinoma.

In addition to visualization of the volume of cervical cancer, 67 the evaluation of parametrial involvement also has been performed Fig.

The potential also exists to assess Doppler flow characteristics of the uterine arteries in cervical malignancy. A transvaginal longitudinal sagittal image of a large cervical carcinoma white arrowheads elevating the bladder base b. The uterine fundus f occupies the inferior portion of the image and is poorly delineated in this view.

As noted earlier, in addition to the delineation of specific ovarian masses, follicular maturation may be monitored by serial transabdominal or transvaginal ultrasonography. Follicular dominance and progression are monitored easily by real-time ultrasonography in correlation with serum estradiol concentration to induce ovulatory ovarian function 70 , 71 , 72 , 73 , 74 , 75 Figs. Transvaginal-directed oocyte retrieval for assisted reproductive techniques is the preferred method of acquiring oocytes.

Preovulatory follicular maturation, clomiphene stimulation. Transvaginal scan depicts three follicles F delineated by wide arrowheads; internal iliac vein H is noted by thin arrowheads. Multiple follicles stimulated by gonadotropin therapy. Transabdominal scan, transverse plane, depicts bladder B , uterus U , and endometrium E.

Curved white arrows delineate the ovary, with smaller arrows showing four follicles in the to mm range. Polycystic ovary syndrome produces a wide spectrum of menstrual disturbances and manifestations of androgen excess. The ovary also may exhibit a variety of appearances, ranging from multiple cystic follicles up to 2.

In cases of hyperthecosis, in which fewer follicles are developed, the ovary would be expected to exhibit a more solid echo pattern. Monitoring of the changes in ovarian volume with suppressive treatment with gonadotropin-releasing hormone analogs has been described. Polycystic ovary syndrome, with cystic follicles noted in both ovaries. Ovarian size is shown by open arrowheads. Follicle cysts are shown by small white arrowheads. The ovary has the capacity to develop many different cystic and solid masses.

Transvaginal and transabdominal ultrasonography can categorize adnexal masses into various echo densities and morphologic types, thereby narrowing the differential diagnosis. The reliability of ovarian size assessment has been documented to be high, with a correlation coefficient of 0.

Unilocular cystic masses with few intracystic echoes are most likely serous-type cysts of the ovary cystic follicles or follicular cysts or serous cystadenomas Fig.

Cystic masses with complex echogenic intracystic echoes are more commonly hemorrhagic in origin hemorrhagic corpus luteum cysts or endometriomata.

Unilateral serous ovarian cyst right ovary. The transvaginal scan depicts a unilocular, anechoic cyst C delineated by the arrowheads; uterine corpus U ; and endometrium E. Left ovary is not in this scan plane. A more conservative management approach is feasible in patients with reassuring intracystic morphology e. The decreased need for surgery in children was demonstrated retrospectively in by Thind and colleagues, 86 who reviewed the cases of 64 children with ovarian cysts.

In addition, the potential also exists for therapeutic cyst aspiration using ultrasound guidance of selected cysts in young women. The differentiation between endometriomas and nonendometriotic ovarian cysts was investigated by Guerriero and associates, 89 who evaluated premenopausal, nonpregnant patients using transvaginal ultrasound.

Of the 31 diagnosed as ovarian endometriomas, 24 were confirmed as endometriomas by histologic assessment. The authors observe that this was compatible with the diagnostic accuracy of magnetic resonance imaging. Controversy exists regarding the significance of cystic masses in the postmenopausal age group.

Fleischer and associates 90 published an excellent correlation of ultrasonographic findings with subsequent histopathologic features of 67 ovaries in 37 postmenopausal patients. Luxman and colleagues 91 noted that 2 of 29 ovarian cancers were not detected by transabdominal ultrasonography. Goldstein and coworkers 92 and Andolf and Jorgensen 93 noted no malignancies in hypoechoic cysts smaller than 5 cm in more than patients.

Therefore, small, nonsuspicious cystic areas in postmenopausal patients may be followed conservatively with surgical evaluation for persistent cysts or those that progressively increase in size. The absolute maximum cystic diameter that may be followed safely is debatable but appears to be in the 3. If a noninterventional posture is selected, the ultrasonographer must realize that a small likelihood of an unapparent malignancy exists and that close follow-up is mandatory.

Germ Cell Tumors. The most common neoplasms of reproductive-age women are germ cell tumors. Cystic teratomas are wellcircumscribed, complex, cystic masses that usually are unilateral and exhibit a variably complex, intracystic echo pattern 94 , 95 , 96 Figs. This type of tissue characterization is important because these complex cystic masses require surgical evaluation for definitive therapy more often than the smaller, unilocular, serous-type cysts, which may be followed expectantly.

Rupture of cystic teratomas during pregnancy is a major complication that should be avoided. Cystic teratoma located superior to the uterine fundus.

Transabdominal scan shows cyst demarcated by the four white arrowheads. B, bladder; CX, cervix; U, uterus. Cystic teratoma, right adnexa, posterior to the broad ligament. Transabdominal scan depicts uterus U , cystic teratoma C , and bladder B. Small thin arrows denote an intracystic hairball. Stromal Neoplasms. Solid ovarian neoplasms include those arising from ovarian stromal cells fibroma and thecoma 99 Fig.

A transvaginal image in the coronal plane through the right ovary ov, arrowheads. The white arrow depicts a small, clinically unapparent, solid-type stromal tumor fibroma, f. Ovarian Carcinoma Epithelial Ovarian Tumors. Ovarian malignant neoplasms produce a variety of ultrasonographic patterns that typically produce an image of mixed solid and cystic components, irregular septations, and coexistent ascites, and they are frequently bilateral , Figs.

Ovarian carcinoma, borderline malignancy, seen in transverse, transabdominal scan. A granular complex echo pattern extends throughout the mass. Longitudinal transabdominal scan of a Sertoli-Leydig cell tumor T of the right ovary. Scan also shows bladder B. Note the complex intracystic echoes with bright posterior echoes depicting good sound penetration i.

The role of ultrasonography in screening for ovarian cancer is controversial. An ever-increasing body of literature continues to question the cost-effectiveness of ultrasound as a screening modality. A thorough review of this controversy is beyond the scope of this chapter. Ultrasound screening for ovarian cancer is not widely accepted.

The combined use of tumor-associated antigens e. The salient question that must be answered before recommending universal ovarian cancer screening with this modality encompasses the reliability and cost-effectiveness of the screening protocol to detect early stage I or II disease. The realization that CA levels are not elevated in many cases of early stage disease raises a serious question regarding the efficacy of this serum test as a screening component. The question of routine ovarian cancer screening remains unanswered.

The role of ultrasonography in staging and follow-up of ovarian cancer continues to expand. Conte and coworkers describe the potential value of ultrasound study in the preoperative staging of ovarian carcinoma. Although ultrasonography can detect macroscopic residual disease with acceptable accuracy, its limitation in detecting small residual disease in lieu of second-look laparotomy has been demonstrated by Murolo and associates.

Breast cancer and gastrointestinal tract cancer may metastasize to the ovary. Other ovarian neoplasms have been described ultrasonographically, including Brenner and Krukenberg tumors. Figure 41 shows the image quality of an ovarian thecoma by transvaginal ultrasonography. Transvaginal scan of a right ovarian thecoma T with borders shown by the open arrows. Many articles have been published further describing the ultrasonographic 2D image characteristics of ovarian cancer.

In addition, Doppler interrogation of small vessels detected by color Doppler imaging reveals increased diastolic flow velocities and evidence of neovascularization secondary to tumor angiogenesis. The resultant calculations of waveform flow velocity ratios are therefore decreased.

Multiple scoring systems for 2D findings and 2D and Doppler findings also have been created. The details of these systems are beyond the scope of this chapter. The various scoring systems offer the potential of assigning numeric values to the well-known findings of ovarian malignancy, such as thickened cyst walls, septations, papillary excrescences, complex intratumoral echoes, and disorganized echo texture. The addition of Doppler waveform analysis frequently confirms the concern of nonreassuring 2D findings but rarely increases concern in patients with benign-appearing cysts on 2D findings.

Brown and coworkers evaluated 44 masses with 2D and color Doppler imaging. They noted significant overlap in the resistance index and pulsatility index between benign and malignant masses.

This finding contrasts with that of other investigators. Although less common than ovarian carcinoma, cancer of the fallopian tube exhibits a similar clinical course. The complex echo pattern of tubal carcinoma diagnosed by transvaginal ultrasonography has been described.

Pelvic Inflammatory Disease and Endometriosis. Other adnexal processes exclusive of neoplastic changes include pelvic inflammatory disease and endometriosis. Pelvic inflammatory disease most often results from a primary salpingo-oophoritis that has progressed to some degree of hydrosalpinx formation with adhesive pelvic disease. A variety of ultrasonographic findings with differing types of complex adnexal masses result with frequent visualization of tubal dilation and intrafallopian tube fluid hydrosalpinx formation.

Frequently, it is difficult to establish the precise etiology of complex adnexal masses on an endometriotic or inflammatory basis. In some instances, endometriotic involvement of a nongynecologic structure, such as the urinary bladder or liver, has been noted. A sagittal view of the uterus and cul-de-sac endometrioma e by transvaginal ultrasonography. The low-level echoes are characteristic of hemorrhagic-type cysts within the endometrioma.

The uterine fundus f is anteverted. Endometrioma of the ovary contiguous with the posterior uterine fundus. Longitudinal transabdominal scan depicts endometrioma E , uterus U , and cervix C. Note the complex intracystic echoes with bright posterior echoes open arrows. Transverse transabdominal scan of right tubo-ovarian abscess.

Scan depicts uterus U and abscess A. Small open arrowheads show irregularity of the abscess wall. Large white arrowheads show the borders of the abscess. Bilateral tubo-ovarian complex formation, pelvic inflammatory disease transabdominal scan, transverse plane. Black arrowheads delineate borders of the tubo-ovarian complexes. Ultrasonographic localization of intrauterine devices has been possible for years Fig. The advent of transvaginal scanning increases the accuracy of intrauterine device localization.

Transabdominal scan depicts Lippes loop in situ, cervix CX , fundus, bladder, and vagina. The most common cause of uterine enlargement is early pregnancy. The advent of transvaginal ultrasonography offers the capability of extremely early diagnosis of pregnancy.

The prominent echogenicity of decidualized endometrium is seen clearly on transabdominal or transvaginal scanning before the visualization of a gestational sac. Studies of serial scanning of patients conceiving during in vitro fertilization cycles reveal the presence of a gestational sac at even lower hCG concentrations.

The correlation of gestational sac visualization and serum hCG concentration offers the practicing gynecologist a powerful tool for early diagnosis of extrauterine pregnancy. The principles of management, evaluation, and diagnosis presuppose knowledge of the rate of increase of hCG concentration in normal pregnancy and correlation with ultrasonographic findings.

As a general rule, hCG should double every 2 to 3 days during the early first trimester. Early intrauterine pregnancy scanning displays the developing amniotic membrane, chorion, and yolk sac. Early in gestation, the mean sac growth is 0. Transvaginal scanning allows visualization of the embryo with a mean sac diameter of 1. Fetal cardiac flicker can be seen in embryos of at least 5 mm with transvaginal scanning and in embryos of at least 9 mm with the transabdominal approach.

If the hCG concentration is clearly abnormal for the stated gestational sac size, the likelihood of pregnancy progression is unlikely. The presence of a normal hCG concentration for a specified gestational sac measurement does not necessarily predict a successful outcome.

Transvaginal scan of an early intrauterine pregnancy demonstrating fetal pole fetus and yolk sac. The accuracy of diagnosing pregnancy failure has been enhanced by ultrasonography. Incomplete spontaneous abortion is characterized by disorganized intrauterine echoes, irregularity of the gestational sac, frequent eccentric sac location, and the evidence of intradecidual hemorrhage. Frequently, the sac is smaller than expected.

First-trimester hydatidiform mole may produce bizarre echoes in early pregnancy or may appear initially as an unremarkable gestational sac. Robinson HP: The diagnosis of early pregnancy failure by sonar. Br J Obstet Gynaecol , The early diagnosis of molar pregnancy enhances appropriate management and hopefully minimizes the likelihood of malignant sequelae.

Although variable, the echo pattern suggestive of a molar pregnancy consists of irregular solid and cystic interfaces within the endometrial cavity in a patient with signs and symptoms of early pregnancy Fig.

A transabdominal longitudinal sagittal image of a uterine fundus f containing echoes of mixed intensity characteristic of early hydatidiform mole hm, small arrows.

A small portion of the urinary bladder b is noted to the right of the image. The uterine cervix cx is delineated large arrows.

Pregnancies located outside of the intrauterine cavity are referred to as extrauterine pregnancies. Although these pregnancies include ovarian pregnancies, abdominal pregnancies, and cervical pregnancies, the most common location is in the fallopian tube. This section addresses the preclinical diagnosis of unruptured tubal pregnancies using a combined approach of ultrasonographic findings correlated with serum hCG concentration. In a study of patients, there were ectopic pregnancies diagnosed by the combined use of serial hCG measurements and transvaginal ultrasound.

A word of caution: multifetal pregnancies typically demonstrate a higher discriminatory zone of hCG. If this protocol is adopted, the physician must be assured of the patient's reliability and potential for follow-up, having the ability to intervene rapidly if concerning symptoms develop.

This diagnostic protocol should be applied to patients who are asymptomatic or minimally symptomatic. Patients with an acute abdomen, vasomotor instability, or evidence of hemoperitoneum on transvaginal scanning should be treated surgically. Using the transvaginal approach, an extrauterine conceptus frequently is delineated with ultrasonography, at which time definitive surgical therapy may be instituted.

If evidence of a possible hemoperitoneum is seen, transvaginally directed culdocentesis can be readily accomplished. Rarely, a combined intrauterine and extrauterine pregnancy heterotopic pregnancy is seen. The role of Doppler assessment to increase diagnostic accuracy is being evaluated.

Early diagnosis results in less morbidity, potential tubal salvage, and the possibility of medical therapy. The assessment of eccentric intrauterine implantations is more difficult. The diagnosis of a cornual or isthmic implantation site frequently is possible, and in these cases, the early diagnosis alleviates the potential for catastrophic uterine rupture. The use of three-dimensional 3D ultrasonography in obstetrics and gynecology was first described by Kuo and colleagues in Pretorius and Nelson found that evaluation of the fetal face was improved with the use of 3D ultrasonography.

Liang and coworkers, with the use of upper arm volume measurement, were able to predict fetal weight more accurately with 3D than with traditional 2D ultrasonography. Lee and colleagues also describe accurate fetal birth weight predictions at term; however, they recognize the question of practical clinical application. Harika and associates used 3D imaging for early ectopic pregnancy in 12 asymptomatic patients before 6 weeks of amenorrhea who had no evidence of ectopic on traditional 2D ultrasound.

The 3D ultrasonography showed a small ectopic gestational sac in four of nine laparoscopy-proven ectopic pregnancies. In patients with postmenopausal bleeding, Gruboeck and coworkers showed that endometrial volume was superior to that of endometrial thickness as a diagnostic test for the detection of endometrial cancer in women not on hormone replacement. In addition to endometrial disease, volume estimation of cervical carcinoma has been studied using 3D ultrasonography.

In differentiating benign from malignant adnexal masses, Chan and associates found in eight women, 3D ultrasonography confirmed the preoperative diagnoses.

Wu and colleagues studied women with polycystic ovarian disease and compared them with routine controls. Ultrasound imaging is a noninvasive medical test that helps physicians diagnose and treat medical conditions. It is safe and painless. It produces pictures of the inside of the body using sound waves. Ultrasound imaging is also called sonography. It uses a small probe called a transducer and gel placed directly on the skin.

High-frequency sound waves travel from the probe through the gel into the body. The probe collects the sounds that bounce back. A computer uses those sound waves to create an image. Ultrasound exams do not use radiation x-rays. Because ultrasound captures images in real-time, it can show the structure and movement of the body's internal organs. The images can also show blood flowing through blood vessels. Doppler ultrasound is a special ultrasound technique that evaluates movement of materials in the body.

It allows the doctor to see and evaluate blood flow through arteries and veins in the body. Pelvic ultrasound exams are also used to monitor the health and development of an embryo or fetus during pregnancy. See the Obstetrical Ultrasound page for more information. A transvaginal ultrasound is usually performed to view the endometrium the lining of the uterus and the ovaries.

Transvaginal ultrasound also evaluates the myometrium muscular walls of the uterus and the fallopian tubes. Sonohysterography allows for a more in-depth investigation of the uterine cavity and Hysterosalpingo-Contrast-Sonography HyCoSy allows for assessment of patency of the fallopian tubes.

Three-dimensional 3-D ultrasound permits evaluation of the uterus and ovaries in planes that cannot be imaged directly. These exams are typically performed to detect:. Some physicians also use 3-D ultrasound or sonohysterography or Hysterosalpingo-Contrast-Sonography HyCoSy for patients with infertility.

In this setting, three-dimensional ultrasound provides information about the outer contour of the uterus and about uterine irregularities, as well as information about the fallopian tubes and ovaries. See the Sonohysterography page for more information. Transrectal ultrasound, a special study usually done to provide detailed evaluation of the prostate gland, involves inserting a specialized ultrasound transducer into a man's rectum. See the Prostate Ultrasound page for more information.

Pelvic ultrasound is also used to guide procedures such as needle biopsies , in which needles are used to extract a sample of cells from organs for laboratory testing. Wear comfortable, loose-fitting clothing. You may need to remove all clothing and jewelry in the area to be examined.

Ultrasound exams are very sensitive to motion, and an active or crying child can prolong the examination process. To ensure a smooth experience, it often helps to explain the procedure to the child prior to the exam. Bring books, small toys, music, or games to help distract the child and make the time pass quickly.

The exam room may have a television. Feel free to ask for your child's favorite channel. Ultrasound machines consist of a computer console, video monitor and an attached transducer. The transducer is a small hand-held device that resembles a microphone. Some exams may use different transducers with different capabilities during a single exam.

The transducer sends out inaudible, high-frequency sound waves into the body and listens for the returning echoes. The same principles apply to sonar used by boats and submarines. The technologist applies a small amount of gel to the area under examination and places the transducer there. The gel allows sound waves to travel back and forth between the transducer and the area under examination.

The ultrasound image is immediately visible on a video monitor. The computer creates the image based on the loudness amplitude , pitch frequency , and time it takes for the ultrasound signal to return to the transducer. Some ultrasound procedures, such as transvaginal or transrectal exams, require the doctor to insert the transducer into the body.

In these cases, the doctor will cover the device with a sterile sheath and lubricate it. Ultrasound imaging uses the same principles as the sonar that bats, ships, and fishermen use. When a sound wave strikes an object, it bounces back or echoes. By measuring these echo waves, it is possible to determine how far away the object is as well as its size, shape, and consistency.

This includes whether the object is solid or filled with fluid. Doctors use ultrasound to detect changes in the appearance of organs, tissues, and vessels and to detect abnormal masses, such as tumors. In an ultrasound exam, a transducer both sends the sound waves and records the echoing returning waves. When the transducer is pressed against the skin, it sends small pulses of inaudible, high-frequency sound waves into the body.

As the sound waves bounce off internal organs, fluids and tissues, the sensitive receiver in the transducer records tiny changes in the sound's pitch and direction. A computer instantly measures these signature waves and displays them as real-time pictures on a monitor.

The technologist typically captures one or more frames of the moving pictures as still images. They may also save short video loops of the images. The same principles apply to transrectal and transvaginal ultrasound procedures. These exams require the doctor to insert a special transducer into the body.