Ultrasound of ovaries

The OvariesThe OvariesDurr-e-SabihDurr-e-Sabih

MBBS. MS. FRCP. FANMBMBBS. MS. FRCP. FANMBDirector MINARDirector MINAR

MultanMultanPAKISTANPAKISTAN

[email protected]@yahoo.com

Early on Early on

• A baby girl is born with a huge number of potential eggs ( 700,000 to 2 million)

• By puberty only 400,000 are left• Around 500 are used during lifetime of

ovulation

The Normal Adult OvaryThe Normal Adult Ovary

• Resting ovary is moderately echogenic, ovoid, well marginated, seen along the side of uterus usually but can be seen behind the uterus or even in the lower abdomen.

• Cysts in the ovary in premenopausal age are the distinguishing feature

• Menopausal ovaries can be smooth and be difficult to identify

ReviewReview

The Normal Adult OvaryThe Normal Adult Ovary

• Primordial follicles are too small to be seen by ultrasound

• Solid background, scattered antral follicles (3-6mm)

• Volume 8- 20 ml

The Normal Adult Ovary (Cont’d)The Normal Adult Ovary (Cont’d)

• 4-8 antral follicles (day 6-7) in each ovary measuring 3-6 mm

• By day 7 one follicle is selected and increases in size more than others

The Normal Adult Ovary (Cont’d)The Normal Adult Ovary (Cont’d)

• 10 mm by day 8-9 (dominate follicles >11mm)• 18- 24mm by day 14 • Subordinate follicles also continue to grow to

about 10 mm, then become smaller• > 50% reduction in volume on ovulation• Corpus luteum is irregular and complex cystic

ReviewReview

What When How

Primordial follicles …. Too small, not visible

Antral follicles(4-8)

D 6-7 3-6mm

Dominate follicle D 8-9 10 – 11 mm

Dominate follicle D 14 18-24mmSubordinate follicles

D 14 Up to 10mm then regress

Corpus luteum D >14 50% volume, irregular contour

OvariesOvaries(Volume)(Volume)

• Birth – 3 Mo 0.3 – 3.6 ml• 2-8 yrs 1.0 - 1.5 ml• 10 yrs2.2 – 3.6 ml• 13 yrs4.2 – 9.0 ml• 15-19 yrs 8.0 – 18 ml• 20-49 yrs 10-23 ml• 50-65 yrs 6 – 14 ml • 70 yrs1 – 6 ml

OvaryOvary

Day 3 OvaryDay 3 Ovary

Normal/Normal/multimulticystic Ovariescystic Ovaries

Dominant FollicleDominant Follicle

The Corpus LuteumThe Corpus Luteum

• One-third will be typical irregular cysts• One-third will look echogenic and solid• One third will not be visible at all

Corpus LuteumCorpus Luteum

© Allen Worrall, Alaska

Corpus Luteum Ring of FireCorpus Luteum Ring of Fire


Calcified Area in OvaryCalcified Area in Ovary

Ultrasound Monitoring of Follicles:Ultrasound Monitoring of Follicles:

• Finding• Counting• Measuring• Documenting

Follicles on serial studies

HowHow

• Baseline study….day 4-5 to look for any cyst left over from previous cycles, rule out other lesions

• Start on day 8-10, identify developing follicles of 8-10 mm

• Monitor daily or on alternate days until size of 16-18mm seen (mature follicle)….give HCG pulse

• Ovulation >50% reduction in size

• Very dynamic organs• Changing appearance with the time of the

menstrual cycle, age and pregnancy• Must correlate findings with the expected

physiological findings

Dominant FollicleDominant Follicle

OvulationOvulation

Dominate follicle on day 14Corpus luteum on day 16

Pathological StatesPathological StatesAbsent/Abnormal OvulationAbsent/Abnormal Ovulation

Abnormal Ovarian CyclesAbnormal Ovarian Cycles

• Sporadic ovulation failure in about 7% of cycles

• Sporadic anovulatory syndromes• Chronic anovulatory syndromes



• Sporadic anovulatory syndromeso Follicular Atresiao Empty Follicle Syndromeo Luteinized Unruptured Follicle Syndrome

• Chronic anovulatory syndromes



• Sporadic anovulatory syndromes• Chronic anovulatory syndromes

o Hypergonadismo Hypogonadismo Polycystic Ovarian Syndrome (PCOD)

Sporadic Anovulatory SyndromesSporadic Anovulatory Syndromes

Follicular AtresiaFollicular Atresia

• Dominate follicle starts developing but o Does not reach full sizeo Rapidly becomes smallero Common in oral contraceptive users

Empty Follicle SyndromeEmpty Follicle Syndrome

• Follicle development looks normal• Oocyte is not formed• Cannot differentiate from normal cycles on

ultrasound

Luteinized Unruptured Follicle Luteinized Unruptured Follicle Syndrome (LUFS)Syndrome (LUFS)

• Apparently normal follicle develops but fails to rupture

Chronic Anovulatory SyndromesChronic Anovulatory Syndromes

Primary Ovarian FailurePrimary Ovarian Failure

• Ovaries are small and smooth with no follicular activity

• Estrogen levels are low• Gonadotropin levels are very high

HypogonadotropismHypogonadotropism

• Low FSH, LH, Low estrogen• Pituitary lesion (tumour?)• Ovaries smooth but can respond to exogenous

cyclical hormones

PCOSPCOS

• A very complex endocrine abnormality• A very wide spectrum of findings with the

classic Stein Leventhal syndrome at one end and normal looking females with early fertility at the other

PCOSPCOS

• Typical habitus?o Obeseo Oligo/amennorrhoeao Hirsuitism

• Endocrine abnormalitieso Raised LHo LH/FSH ratio > 3o Raised Sr. Testosterone and Androstenedioneo Insulin resistance

PCOS PCOS Ultrasound FeaturesUltrasound Features

• Large ovaries• Round shape• Large number of small cysts arranged

peripherally under the capsule (string of pearls sign) or throughout the volume

• >10 cysts on TAS, >15 on TVS on a single section

• Echogenic stroma (compare with myometrium)

PCOSPCOSUltrasound FeaturesUltrasound Features

• 1//3rd patients have normal ovarian volumes• Many normal ovaries are multicystic

o Adolescentso Oral contraceptive userso Juvenile hypothyroidismo 17 hydroxylase deficiencyo Post Menopausal ovaries with hyperthecosiso PID

Consensus on diagnostic criteria for Consensus on diagnostic criteria for PCOS (2003)PCOS (2003)Two should be presentTwo should be present

• Oligo and/or anovulation• Clinical and/or biochemical signs of

hyperandrogenism• Polycystic ovaries

HyperandrogenismHyperandrogenism

• Clinical or biochemicalo Hirsuitism (subjective?, racial?)o Acneo Circulating androgens (wide variability)o Free testosterone, free testosterone index,

Polycystic ovaries Polycystic ovaries

• 12 or more follicles in each ovary, measuring 2-9mm across and/or increased ovarian volume (>10ml)

• Exclude follicle distribution, exclude stromal echogenicity and volume

• Does not apply to women on contraceptive pills

Polycystic ovaries Polycystic ovaries

• If findings are seen only on one side, this is still sufficient for diagnosis.

• If there is evidence of dominate follicle or corpus luteum, repeat next month.

• Asymmetric ovarian size or large cyst needs further work-up/follow-up.

PCODPCOD

PCODPCOD


Ovarian Hyperstimulation Ovarian Hyperstimulation SyndromeSyndrome

• Numerous follicles grow in a stimulated cycle• Pain, enlarged ovaries (ovaries can become 6-

7 cm in diameter)• If larger, there can be associated ascites,

pleural effusion• On US, enlarged ovaries with multiple large

cysts seen

Hyperstimulated OvariesHyperstimulated Ovaries


© Shlomo Gobi, Jerusalem


© Ravi Kadasne, UAE

The Simple Ovarian CystThe Simple Ovarian Cyst

• If up to 5-7 cm in diameter, observe over 6-8 weeks

• Try to repeat scan during the first 5 days of the cycle


• > than 7 cm in diameter • Persist beyond the length of a normal

menstrual cycle • solid components • Complex internal structure • Associated with pain


© Prof. Nawaz Anjum, Lahore


Theca Lutein Theca Lutein

Mural NodulesMural Nodules

© Gunjan Puri, Surat

The Haemorrhagic Ovarian CystThe Haemorrhagic Ovarian Cyst

Haemorrhage

The Haemorrhagic Ovarian CystThe Haemorrhagic Ovarian Cyst

Haemorrhage

Endometriotic cystEndometriotic cyst

Endometriotic cystEndometriotic cyst

Haemorrhagic and endometrial cystHaemorrhagic and endometrial cyst

The parovarian CystThe parovarian Cyst

o A cyst developing within the mesosalpinx between the tube and ovary, from the vestigial remnants of the Wolffian body. These cysts represent 10% of all adnexal masses. They occur in the third to fourth decade.


o On ultrasound, a paraovarian cyst may be suspected when a thin-walled, unilocular ovoid structure free of internal echoes is demonstrated lying next to the uterus within the plane of the broad ligament and the ovary is seen separately.

o Their size does not change in relation to the menstrual cycle. But they can torse and undergo haemorrhage



Hydatid of Morgagni

Epioophoron


© Allan Worrall, Alaska


HydrosalpinxHydrosalpinx


MenopausalMenopausal

TorsionTorsion

EndEnd

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Ultrasound of ovaries