Things i think i should know 5A-5B

Question 1

What are some symptoms of PCOS?

Answer 1

chronic anovulation
• serum LH level is elevated
• FSH level depressed
• results in abnormal oestrogen and androgen production
• excessive androgen production causes symptoms;
o greasy skin
o Acne
o hirsutism (= growth of terminal hair on the body of a woman in the same patterns and sequence as that which develops in the normal post-pubertal male)
o androgenetic alopecia

Question 2

What is PCOS associated with?

Answer 2

• Associated with
o obesity
o abnormal carbohydrate metabolism
o disturbance of lipid profile

Question 3

What are women with PCOS t increased risk of?

Answer 3

o endometrial carcinoma
o ovarian carcinoma
o diabetes
o cardiovascular disease

Question 4

What is the sonographic appearance of PCOS?

Answer 4

• bilaterally enlarged ovaries (>10mL)
• containing multiple small, 2- to 9-mm follicles (at least 20)
• Above criteria are not considered valid if the patient is taking oral contraceptives or has a dominant follicle greater than 10 mm
• increased stromal echogenicity
• Ovaries are a rounded shape
• follicles usually located peripherally (“string of pearls”)

Question 5

What are the three categories of functional cysts?

Answer 5

o follicular
o corpus luteum
o theca lutein cysts

Question 6

When does a follicular cyst develop?

Answer 6

when a mature follicle fails to ovulate or to involute and becomes large than 2.5cm

Question 7

When can you use the term corpus lutein cyst?

Answer 7

When it is greater than 4cm

Question 8

What is a theca lutein cyst?

Answer 8

• associated with high beta–human chorionic gonadotropin (B-hCG) levels
• the largest of the functional ovarian cysts
• increasing the risk of ovarian torsion
• typically occur in patients with gestational trophoblastic disease
- can also be seen as a complication of drug therapy for infertility causing ovarian hyperstimulation syndrome.

Question 9

What does a theca lutein cyst look like on sonography?

Answer 9

o Bilateral
o Multilocular
o very large.
o Similar to other functional cysts, they may undergo hemorrhage or rupture.

Question 10

What is the most common presentation of a haemorrhagic cyst?

Answer 10

• Common presentation is with acute onset pelvic pain

Question 11

What helps to confirm the diagnosis of a ruptured haemorrhagic cyst?

Answer 11

The presence of echogenic, free intraperitoneal fluid in the cul-de-sac helps confirm the diagnosis of a leaking or ruptured hemorrhagic cyst.

Question 12

What is ovarian remnant syndrome?

Answer 12

• cystic mass may be encountered in a patient who has undergone bilateral oophorectomy
• due to a small amount of residual ovarian tissue has been unintentionally left behind.

Question 13

List the pregnancy associated ovarian lesions?

Answer 13

o	hyperstimulated ovaries
o	ovarian hyperstimulation syndrome
o	theca lutein cysts
o	hyperreactio luteinalis
o	the rare luteoma of pregnancy

Question 14

What are hyper stimulated ovaries?

Answer 14

• a normal response to elevated circulating levels of hCG
• most common in women undergoing ovulation induction
• the ovaries are enlarged with multiple cysts
• some of which may be hemorrhagic

Question 15

What is ovarian hyperstimulation syndrome?

Answer 15

• used when the hyperstimulation is accompanied by fluid shifts

Question 16

What are the different forms of OHS?

Answer 16

• The mild form
• Moderate OHS
• severe OHS

Question 17

What is mild OHS?

Answer 17

o associated with lower abdominal discomfort
o no significant weight gain
o ovaries are enlarged, but less than 5 cm in average diameter

Question 18

What is moderate OHS?

Answer 18

o presents with weight gain of 5 to 10 pounds
o ovarian enlargement 5 to 12 cm
o patient may have nausea and vomiting

Question 19

What is severe OHS?

Answer 19

o weight gain of more than 10 pounds
o typically severe abdominal pain and distention.
o The ovaries are greatly enlarged (>12 cm in diameter)
o contain numerous large, thin-walled cysts, which may replace most of the ovary.
o The associated ascites and pleural effusions may lead to
 depletion of intravascular fluids and electrolytes
 resulting in hemoconcentration with hypotension, oliguria, and electrolyte imbalanceevere

Question 20

What is hyperreactio luteinalis and when does it occur?

Answer 20

• caused by an abnormal response to circulating hCG in the absence of ovulation induction therapy
• incidence of hyperreactio luteinalis increases in women with polycystic ovarian disease
• In contrast to OHS, body fluid shifts are rare.
• Sonographically, there are;
o bilaterally enlarged ovaries with multiple cysts similar to OHS
o the ovaries tend not to be as large
o occurs later in pregnancy.

Question 21

When should you suspect a luteoma of pregnancy?

Answer 21

• Most patients are asymptomatic, although maternal virilization may occur in up to 30%
• 50% risk of virilization of the female fetus
• Sonographically;
o luteomas usually present as nonspecific
o heterogeneous
o predominantly hypoechoic masses
o may be highly vascular.
• An ovarian mass in a pregnant patient with signs of virilization should suggest this diagnosis, because luteoma is the most common cause of maternal virilization during pregnancy.

Question 22

IN what circumstances do you see peritoneal inclusion cysts?

Answer 22

• seen in patients with peritoneal adhesions
• occurring mostly in premenopausal women with a history of previous abdominal surgery
• may also be seen in patients with a history of trauma, PID, or endometriosis

Question 23

How do peritoneal inclusion cysts occur?

Answer 23

• fluid produced by the ovary (which is the main producer of peritoneal fluid in women) accumulates within the adhesions and entraps the ovaries
• This results in an adnexal mass
Most patients present with pain and/or a pelvic mass

Question 24

How do peritoneal inclusion cysts appear on sonography/

Answer 24

• multiloculated cystic adnexal masses
• often with a bizarre shape frequently described as a spider web pattern
• The diagnostic finding is the presence of an intact ovary positioned eccentrically amid septations and fluid

Question 25

Why is diagnosis of peritoneal inclusion cysts important?

Answer 25

* Accurate diagnosis of peritoneal inclusion cysts is important because the risk of recurrence after surgical resection is 30% to 50% * Conservative therapy, such as ovarian suppression with oral contraceptives or fluid aspiration, is recommended.

Question 26

What age group does ovarian torsion predominantly effect?

Answer 26

Women of reproductive age or younger

Question 27

Why are there so many differentials to torsion and what are they?

Answer 27

* Multiple due to the only consistent symptom being intense progressibe abdominal pain localised to the lower quadrants. * PID * ovarian cysts * ectopic pregnancy * as well as nongynecologic causes * A right-sided predominance also exists that may mimic appendicitis.

Question 28

How does torsion appear on sonography?

Answer 28

* enlarged edematous ovary * or ovarian complex of ovary and adnexal mass * Lack of arterial and venous Doppler flow should enable confident diagnosis * presence of Doppler signal cannot eliminate the diagnosis

Question 29

What are the four types of ovarian neoplasms?

Answer 29

1. Epithelial-stromal tumours 65-75% 2. Germ cell tumours: 15-20% 3. Sex cord-stromal tumours: 5-10% 4. Metastatic tumours: 5-10%

Question 30

What are the different types of epithelial stromal tumours?

Answer 30

``` Serous cystadenoma Serous cystadenocarcinoma Mucinous cystadenoma Mucinous cystadenocarcinoma Endometrioid tumour Clear cell tumour Transitional cell tumour ```

Question 31

What are the different types of germ cell tumour?

Answer 31

Teratoma Dysgerminoma Yolk sac tumour

Question 32

What are the different types of sex cord-stromal tumours?

Answer 32

Granulosa cell tumour Sertoli-Leydig cell tumour Thecoma and fibroma

Question 33

What do ovarian neoplastic lesions look like on sonography and how do they present?

Answer 33

``` • usually presents as an adnexal mass. • Can also present as ascites, abdominal pain and vaginal bleeding. • Well-defined anechoic cysts are more likely to be benign • Malignant lesions o irregular walls o thick irregular septations o mural nodules, o solid elements with flow o more likely to be malignant ```

Question 34

How can colour be used in differentiating neoplasms?

Answer 34

* Not reliable for differentiation * Malignant lesions may have a low PI and RI * Malignant lesions tend to have central flow * Doppler ultrasound is likely valuable in assessing the mass that is morphologically indeterminate or suggestive of malignancy. * Doppler findings should be combined with morphologic assessment, clinical findings, patient age, and phase of menstrual cycle for optimal evaluation of an adnexal mass

Question 35

What is the usual order of ovarian cancer spread?

Answer 35

1. local invasion in the pelvis 2. peritoneal seeding across the abdominal cavity 3. lymphatic embolisation to: o para-aortic nodes o uterus o other ovary 4. blood-borne metastasis to liver, lungs, brain, bone

Question 36

What are the most common epithelial-stromal tumours?

Answer 36

Serous Cystadenoma and Cystadenocarcinoma

Question 37

How do Serous Cystadenoma and Cystadenocarcinoma appear on ultrasound?

Answer 37

``` Serous cystadenoma • large • thin-walled cysts • typically unilocular • may contain thin septations • Papillary projections are occasionally seen Bilateral 20% ``` Serous cystadenocarcinomas o may be quite large o usually present as multilocular cystic masses o containing multiple papillary projections arising from the cyst walls and septa o septa and walls may be thick o Echogenic solid material may be seen within the loculations. o Papillary projections may form on the surface of the cyst and surrounding organs, resulting in fixation of the mass. o Ascites is frequently seen. bilateral 50%

Question 38

What is the demographic for Serous Cystadenoma and Cystadenocarcinoma?

Answer 38

Peri and post meopausal

Question 39

What are the second most common epithelial-stromal tumours?

Answer 39

Mucinous Cystadenoma and Cystadenocarcinoma

Question 40

How do Mucinous Cystadenoma and Cystadenocarcinoma appear on ultrasound?

Answer 40

Both less likely to be bilateral than their serous counterparts Mucinous Cystadenoma • huge cystic masses • up 30 cm and filling the entire pelvis and abdomen • Multiple thin septa are present • low-level echoes caused by the mucoid material may be seen in the loculations. • Papillary projections are less frequently seen than in the serous counterpart. Mucinous cystadenocarcinomas o usually large o multiloculated cystic masses o containing papillary projections and echogenic material o generally have a sonographic appearance similar to that of serous cystadenocarcinomas

Question 41

What can happen if a mucinous tumour is ruptured?

Answer 41

may lead to intraperitoneal spread of mucin-secreting cells that fill the peritoneal cavity with a gelatinous material • known as pseudomyxoma peritonei • A ruptured mucocele of the appendix and mucinous tumors of the appendix and colon can also lead to pseudomyxoma peritonei

Question 42

What demographic are Mucinous Cystadenoma and Cystadenocarcinoma seen in?

Answer 42

3rd to 7th decade

Question 43

Are endometrioid tumours malignant or benign?

Answer 43

almost always malignant

Question 44

What is the demographic for endometrioid tumours?

Answer 44

5th and 6th decade. Post menopausal.

Question 45

How do endometrioid tumours present sonographically?

Answer 45

• usually presents as a cystic mass containing papillary projections

Question 46

Are clear cell tumours malignant or benign?

Answer 46

Almost always malignant

Question 47

What is the demographic for clear cell tumours?

Answer 47

5th to 7th decade. Post menopausal.

Question 48

How do clear cell tumours present sonographically?

Answer 48

• usually presents as a nonspecific, complex, predominantly cystic mass

Question 49

What are clear cell tumours associated with?

Answer 49

* Associated pelvic endometriosis is present in 50% to 70% of clear cell carcinomas, * approximately one-third arise within the lining of endometriomas

Question 50

Whats another name for a transitional cell tumour?

Answer 50

Brenner tumour

Question 51

Are transitional cell tumours malignant or benign?

Answer 51

Almost always benign

Question 52

How do transitional cell tumours appear sonographiclly?

Answer 52

* hypoechoic solid masses * Calcification may occur in the outer wall * cystic component is uncommon * when present, usually results from a coexistent cystadenoma

Question 53

What is the most common germ cell tumour?

Answer 53

Benign cystic teratoma (95%)

Question 54

What demographic are the malignant yolk sac (endodermal sinus) and dysgerminoma tumour most commonly found in?

Answer 54

Children and young adults

Question 55

What demographic are germ cell tumours in general usually found in?

Answer 55

Children and young adults

Question 56

How do cystic teratomas usually present?

Answer 56

* may present as a palpable mass. * usually asymptomatic and often are discovered incidentally during sonography * Torsion is the most common complication

Question 57

How do teratomas appear sonographically?

Answer 57

• variable appearance ranging from completely anechoic to completely hyperechoic

Question 58

What are the features considered specific to dermoids?

Answer 58

Dermoid plug tip of the iceberg sign dermoid mesh fat fluid or hair fluid level

Question 59

What does a dermoid plug look like?

Answer 59

o a predominantly cystic mass with a highly echogenic mural nodule, o usually contains hair, teeth, or fat and frequently casts an acoustic shadow. o In many cases the cystic component is pure sebum (which is liquid at body temperature) rather than simple fluid.

Question 60

What does the tip of the ice berg sign look like?

Answer 60

o A mixture of matted hair and sebum is highly echogenic because of multiple tissue interfaces o produces poorly defined acoustic shadowing that obscures the posterior wall of the lesion

Question 61

What does dermoid mesh look like?

Answer 61

o Highly echogenic foci with well-defined acoustic shadowing may arise from other elements, including teeth and bone. o Multiple linear hyperechogenic interfaces, often described as lines and dots, may be seen floating within the cyst and have been shown to be hair fibers.

Question 62

How does a dermoid appear on colour Doppler?

Answer 62

benign teratoma may show peripheral flow, but malignancy should be considered if flow is seen centrally and/or within solid areas.

Question 63

What are some differential pitfalls?

Answer 63

* Other pitfalls include pedunculated fibroids, especially lipoleiomyomas, and perforated appendicitis with an appendicolith. * An echogenic dermoid may appear similar to bowel gas and may be overlooked.

Question 64

How do dysgerminomas appear on ultrasound?

Answer 64

• solid masses • predominantly echogenic • may contain small anechoic areas caused by hemorrhage or necrosis prominent arterial flow within the fibrovascular septa of a multilobulated, solid, echogenic mass.

Question 65

What serum marker can be raised in a yolk sac/endodermal sinus tumour?

Answer 65

alfa feta protein AFP

Question 66

How do yolk sac/endodermal sinus tumours appear on sonography?

Answer 66

Similar to dysgerminomas

Question 67

IN what demographic to granulosa cell tumours usually occur?

Answer 67

Post menopausal

Question 68

How do GCC appear on sonography?

Answer 68

``` • variable appearance o small solid masses to tumors o variable degrees of hemorrhage o or fibrotic changes o or multilocular cystic lesions. ```

Question 69

What demographic do sertoli-leydig tumours usually occur in?

Answer 69

women younger than 30 years of age

Question 70

Are sertoli-leydig tumours malignant or benign?

Answer 70

Mostly benign. 20% malignant

Question 71

How do sertoli-leydig tumours present?

Answer 71

* Clinically, signs and symptoms of virilization occur in about 30% of patients * half will have no endocrine manifestations * Occasionally, these tumors may be associated with estrogen production.

Question 72

How do sertoli-leydig tumours appear on ultrasound?

Answer 72

solid hypoechoic masses or may be similar in appearance to granulosa cell tumors

Question 73

How do metastatic tumours of the ovary appear on ultrasound?

Answer 73

* usually bilateral solid masses * may become necrotic * may have a complex, predominantly cystic appearance that simulates primary cystadenocarcinoma * almost all ovarian metastases from primary tumors of the breast, stomach, and uterus were solid * those from the colon and rectum were more heterogeneous

Question 74

What are some clinical presentations of endometriosis?

Answer 74

* Chronic pelvic pain * pain with periods (dysmenorrhea) * pain with sex (dyspareunia) * bowel pain during periods (dyschezia) * infertility * Abnormal bleeding * Pain on urination (dysuria) * Pain on ovulation * Fatigue * Clinical examination may reveal localised tenderness of nodules in the vagina

Question 75

What is endometriosis?

Answer 75

* the presence of functioning endometrial tissue outside the uterus. * main mechanism believed responsible is retrograde menstruation * endometrial cells implant in the pelvis and give rise to endometriosis lesions

Question 76

How can endometriosis manifest?

Answer 76

``` o superficial (peritoneal) disease o ovarian disease (endometriomas) o deep infiltrating endometriosis, which is the most complex and surgically challenging form. ```

Question 77

When can a endometrioma (chocolate cyst) be confidently diagnosed?

Answer 77

If associated DIE is found

Question 78

If you see an endometrioma and no other features of endometriosis are present what might you suspect instead?

Answer 78

* haemorrhagic corpus luteum * dermoid cyst * mucinous cystadenoma.

Question 79

What is the most important role of sonography concerning endometriosis?

Answer 79

Identifying if DIE is present as that changes the surgery

Question 80

What is the main sign of DIE?

Answer 80

Main sign - presence of severe adenomyosis in a uterus that is anteverted but fixed retroflexed.

Question 81

How do endometriomas appear on ultrasound?

Answer 81

``` o Ground glass appearance o Thick walls o Uni- or multilocular o Multiple lesions o Kissing ovaries o Hyperechogenic wall foci o Wall nodularities o Acoustic enhancement o Absence of internal vascularity o ‘shifting’ content o Often there is no acoustic streaming (when a colour box is put over the content, the particles are not seen to move downwards o The cyst does not regress ```

Question 82

Why should a potential endometrioma prompt a thorough search for DIE?

Answer 82

They occur in isolation only 1% of the time

Question 83

If no DIE is found what should be your differential for an endometrioma?

Answer 83

Dermoid haemorrhagic cyst Mucinous cystadenoma

Question 84

What is PID?

Answer 84

Pelvic inflammatory disease a broad term that covers infection involving the tubes, ovaries, parametrium and pelvic peritoneum

Question 85

What are most cases of PID caused by?

Answer 85

chlamydia or gonnoreah

Question 86

How does PID manifest?

Answer 86

by tubo-ovarian complexes, peritonitis, and abscess formation and is usually bilateral.

Question 87

How is PID related to ectopic pregnancy?

Answer 87

a major cause of tubal (ectopic) pregnancy. An ectopic pregnancy can occur when untreated PID has caused scar tissue to develop in the fallopian tubes. The scar tissue prevents the fertilized egg from making its way through the fallopian tube to implant in the uterus

Question 88

How is PID related to infertility?

Answer 88

One in 10 women with PID becomes infertile. PID can cause scarring of the fallopian tubes. This scarring can block the tubes and prevent an egg from being fertilized

Question 89

What are the clinical presentations of PID?

Answer 89

* pain * fever * cervical motion tenderness * vaginal discharge * A pelvic mass may be palpated.

Question 90

How can acute PID manifest on ultrasound?

Answer 90

- Endometritis (endometrial thickening, intracavity fluid) - Purulent material in POD • salpingitis • pyosalpinx, • tubo-ovarian complex • tubo-ovarian abscess

Question 91

How does salpingitis appear on sonography?

Answer 91

• Tube becomes ovoid or pear shape (as distal end occluded) • Fluid may be anechoic (hydrosalpinx) or echogenic (pyosalpinx) • Thickened walls (5mm or more) • Incomplete septi are common (tube folding back on itself) • Cog wheel sign when tube seen in cross section • Fluid debris levels - hyperaemia in wall

Question 92

How does tubo ovarian abscess appear on ultrasound?

Answer 92

* Complete breakdown of ovarian and tubal architecture * Separate structures are no longer identified * multiloculated mass * incomplete septations * irregular margins * low-level internal echoes * The sonographic appearance may be indistinguishable from other benign and malignant adnexal masses.

Question 93

How does chronic PID manifest?

Answer 93

• Typically results in hydrosalpinx o Differentiated from other adnexal lesions by o Anechoic o More tubular o Incomplete septa o Thin wall <5mm o ‘beads on a string’ 2- to 3-mm hyperechoic nodules projecting from the wall, representing remnants of the endosalpingeal folds o Colour flow (if detected) is less exuberant than acute phase o May have a peritoneal inclusion cyst (ovary is surrounded by a loculated fluid collection with thin septations)

Question 94

What are the most common differentials for PID?

Answer 94

The most common alternative diagnoses with findings that simulate PID by the presence of an indistinct uterus and complex pelvic fluid, - ruptured endometrioma - hemorrhagic cyst - perforated appendicitis.