Gu -- Gyne

Front 1

What are some causes of infertility that may be diagnosed on HSG?

Back 1

1. Congenital uterine abnormality.
2. Extrinsic uterine cavity distortion by mass lesions (fibroids or adenomyosis).
3. Asherman's syndrome: linear filling defects representing intrauterine septations. These defects represent synechiae or adhesions bridging the endometrial cavity with resultant limited distensibility. It is 2/2 extensive uterine instrumentation With increasing filling of the uterus with contrast, the irregular filling defects of synechiae remains constant, whereas polyps will become less apparent.
4. Salpingitis isthmica nodosa: PID related scarring and tubal occlusion
5. Proximal tubal occlusion

Front 2

What is the DDX of cystic structure in lower GU tract in a female?

Back 2

- Urethral diverticulum
- Gartner duct cyst
- Bartholin duct cyst
- Skene gland cyst

Front 3

1. What is the etiology of urethral diverticulum?
2. What are the imaging findings in a urethral diverticulum?
3. What are the complications of urethral diverticulum?

Back 3

1. Arise from dilated and infected periurethral glands which rupture into the urethra resulting in pseudodiverticulum formation.
2.
- Localized saccular outpouching of the urethra with mass effect on the anterior vaginal wall.
- Usually located in the mid urethra (at the level of the pubic symphysis) (therefore, may be confused with Bartholin gland cyst).
- May be single or multiple, unilocular or septated.
- May surround the urethra ("saddlebag" diverticula).
- Mass effect exerted on the bladder base from diverticula arising from the proximal urethra can create an imaging appearance similar to enlarged prostate.
3. Can be complicated by infection, formation of calculi, bladder outlet obstruction, and malignancy.

Front 4

1. What are the imaging findings in Gartner duct cyst?
2. What are the complications of Gartner duct cyst?
3. What is the embryologic precursor of Gartner duct cyst?

Back 4

1.
- Rounded cystic structure arising from anterolateral vaginal wall
- located ABOVE level of pubic symphysis.
- may extend out into the ischiorectal fossa when large.
2. Larger gartner cyst may complicate vaginal delivery, cause urethral obstruction. Infrequently, ectopic ureters may communicate with Gartner cyst.
3. Gartner duct cyst represent Wolffian duct remnant. Thus, look for associated renal anomalies (ipsilateral renal agenesis).

Front 5

1. Where does a Bartholin duct cyst arise from?
2. Where does a Skene gland cyst arise from?

Back 5

1. Below the level of the pubic symphysis at the vaginal introitus, usually in the labia (posterolateral aspect). B for back/behind and B for below.
2. Skene gland cyst is located just lateral to the external urethral meatus.

Front 6

1. What is adenomyosis?
2. What are the ultrasound findings of adenomyosis?
3. What are the MRI findings of adenomyosis?
4. What can mimic adenomyosis?

Back 6

1. Presence of heterotopic endometrial glands within myometrium with compensatory smooth muscle hyperplasia.
2.
- Enlarged uterus
- Heterogeneous echotexture 2/2 islands of endometrial tissue (hyperechoic) with smooth muscle hypertrophy (hypoechoic).
- Myometrial cysts corresponding to cystic dilation of endometrial glands (high SI on T2WI) -- Diagnostic of adenomyosis.
- Poor definition of endomyometrial junction.
- Asymmetric thickening of myometrium without mass effect on endometrium.
- Penetrating pattern of color Doppler flow (rather than draping pattern seen with leiomyoma).
3.
- Irregular (diffuse or focal) thickening of the junctional zone that corresponds to smooth muscle hyperplasia.
- Widening >12mm is highly suspicious for adenomyosis.
- Multiple T2 hyperintense foci corresponding to islands to ectopic endometrial tissue and cystic dilatation of glands.
4.
- Leiomyoma
- Transient myometrial contraction
- Performing an MRI during the menstrual phase to avoid physiologic thickening of junctional zone.

Front 7

1. How are uterine leiomyomas classified?
2. What are the imaging findings?
3. What should you consider if there is rapid enlargement of a leiyomyoma in a post-menopausal woman?
4. What is the DDX of leiomyoma?
5. What are the common complications of uterine fibroids?
6. How do you differentiate between uterine leiomyomas and adenomyomas?
7. When does red degeneration (hemorrhage) of uterine leiyomyomas occur?
8. What are the different types of degeneration?

Back 7

1. Uterine leiomyomas are classified by location:
- Submucosal: least common but most commonly symptomatic. May become pedunculated and may occasionally prolapse through the cervix into the vagina. Look for a vascular pedicle connecting to the heterogeneous mass.
- Intramural:
- Subserosal: may become pedunculated and grow laterally within the broad ligament resembling ovarian masses.
2.
- Circumscribed mass w/ heterogeneous echotexture due to degenerative cystic changes, hemorrhage.
- Mass effect upon endometrium (no mass effect is seen with adenomysosis)
- On MRI, typically low SI on both T1 and T2WI unless there are degenerative changes resulting in hemorrhage or cyst formation.
- High SI peripheral rim on T2WI corresponding to a pseudocapsule of lymphatics, vessels, and edema is diagnostic of leiomyoma.
- Brisk enhancement. Heterogeneous with degeneration.
3. Sarcomatous degeneration.
4.
- Adenomyoma: focal form of adenomyosis; commonly ill defined. Associated with the junctional zone.
- Solid adnexal mass: some ovarian neoplasm (ovarian fibromas and Brenner tumors)
- Uterine contraction.
5.
- Anemia 2/2 uterine bleeding
- Infertility
6. Uterine leiomyomas are typically very hypointense on T2WI and the margins of the mass are well defined. This is in contrast to adenomyomas, which are intermediate in signal on T2WI and have ill-defined margins. Enhancement of the leiomyoma indicates the mass is viable and may respond to uterine artery embolization.
7.
- Following UAE
- During pregnancy when fibroids enlarge rapidly overgrowing their blood supply.
8. You can also have myxoid, hyaline, cystic, and fat degeneration.

Front 8

1. How does tubo-ovarian abscess start?
2. What is the appearance of endometritis?
3. What is the appearance of salpingitis?
4. What can TOA mimic?

Back 8

1. PID usually begins with a cervicitis that subsequently extends to the endometrium and fallopian tubes; the infection may spread via tubal spillage to the peritoneum, leading to a local peritonitis. Tubo-ovarian abscess is the result of post-inflammatory fusion of an infected fallopian tube and ovary.
2. Inflamed, enlarged uterus with fluid within the endometrial canal.
3. Fallopian tubes are distended by fluid (hydrosalpinx or pyosalpinx) w/ increased wall thickness
4. Ovarian malignancy. Therefore, clinical presentation is important.

Front 9

1. What is the criteria for PCOS?
2. What are the imaging findings of polycystic ovarian syndrome?
3. What other conditions are associated with multiple ovarian follicles?

Back 9

1.
- Polycystic appearance of at least 1 ovary ( > 12 follicles with each follicle 2-9 mm in diameter, and/or increased ovarian volume > 10 mL)
- oligo and/or anovulation
- clinical and biochemical signs of hyperandrogenism
2.
- Mildly enlarged ovaries (ovarian volume > 10mL)
- Increased echogenicity of the central stroma
- Increased follicularity (>10 cysts) and small size of cysts (< 1 cm).
3. Multiple peripheral cysts are not specific for PCOS and may be seen with other conditions:
- Norma finding with multiple functional ovarian cysts (follicular and corpus luteum cysts)
- Ovarian hyperstimulation syndrome: associated with increased HCG stimulation as seen in gestational trophoblastic disease.
- Virilizing neoplasm of ovary and adrenal gland
- Hypothyroidism
- Premenarchal girls may have multiple ovarian follicle.
- Anorexia

Front 10

1. Describe the staging of early cervical cancer?
2. Describe the staging of advanced cervical cancer?
3. What findings on MRI are suggestive of parametrial invasion?

Back 10

1. Early stage cervical cancer is treated with surgery.
- Stage 1: cancer confined to the uterus.
- Stage 2A: involves upper 2/3 of vagina

2. Advanced cervical cancer cannot be treated with surgery. Chemo and radiation are used.
IIB: Tumor invades parametrium. Look for irregular interface between the cervix and parametrial fat.
IIIA: Tumor extends to lower 1/3 of vagina
IIIB: Tumor extends to pelvic wall with or without hydronephrosis
IVA: Tumor invades bladder or rectal mucosa
IVB: Tumor shows distant metastasis
3. Disruption of T2 hypointense fibrous stromal ring with irregular interface between the cervix and paramterial fat is consistent with parametrial invasion.

Front 11

What is the DDX of cervical mass?

Back 11

1. Benign Cervical Polyp
- does not invade the cervical stroma
- NOTE: Imaging cannot differentiate a benign cervical polyp from a non-invasive cervical cancer.
2. Cervical Cancer (Early Stage)
- confined within cervix or extends to upper 2/3 of vagina
- can be treated with surgery alone
3. Adenoma Malignum
- enlarged cervix with multiple grape-like cysts within the cervical stroma
4. Cervical Lymphoma or Metastasis
- involves stroma diffusely and cervical canal is intact

Front 12

What are the causes of uterine vbleeding?

Back 12

Pregnancy and complications
Endometrial polyps
Leiomyoma, submucosal
Endometrial hyperplasia
Malignancy (uterine, endometrial, cervical)
Nongynecologic sources of bleeding: Gastrointestinal or renal/bladder
Is patient postmenopausal?
Bleeding due to hormone use
Hormones can affect endometrial thickness
Endometrial atrophy
Endometrial polyps
Endometrial cancer
Leiomyoma
Malignancy (uterine, endometrial, cervical)
Nongynecologic sources of bleeding: Gastrointestinal or urinary tract

Front 13

1. What is an ovarian dermoid cyst?
2. What are the imaging features of dermoid cyst?
3. How do you differentiate from immature teratomas (malignant) from mature teratomas (benign, AKA dermoid)?
4. What is the DDX?
5. What are the complications?

Back 13

1. AKA benign cystic teratoma. Most common benign ovarian tumor in women younger than 45 years.
2.
- cystic adnexal mass containing an echogenic focus with distal acoustic shadowing (Rokitansky nodule or dermoid plug)
- "Tip of iceberg": Diffusely or partially echogenic mass usually demonstrating sound attenuation owing to sebaceous material & hair within cyst cavity.
- "Dermoid mesh": Multiple thin, echogenic lines and dots caused by hair in the cyst cavity.
- Fat-fluid level may be seen.
- Multiple balls of floating fat can also be seen.
3.
Immature teratomas are typically larger than mature teratomas. Mature teratomas are predominantly cystic with dense calcifications, whereas immature teratomas are predominantly solid with small foci of lipid material and scattered calcifications
However, mature solid teratomas are radiologically indistinguishable from immature teratomas as they are mostly solid. It must be extensively sampled at biopsy to exclude an immature teratoma.
4.
- Endometrioma: cystic mass with internal echoes; nodules in wall related to fibrosis or desiccated blood, may appear echogenic simulating dermoid plug. Increased T1SI on MRI from blood products may mimic dermoid cyst.
- Bowel: intraluminal gas or fecal material can mimic Rokitansky protuberance
Observation of peristalsis helps make the diagnosis.
- Hemorrhagic Cyst: lacelike appearance can mimic dermoid mesh.
- Pedunculated Lipoleiomyoma: unusual variant of leiomyoma which contains fat.
- Ovarian fibrothecomas can appear echogenic with marked attenuation of sound. Characteristic low T2 and low T1 signal on MR can be helpful if the diagnosis is unclear.
5. Most mature cystic teratomas are asymptomatic but occasionally may rupture and cause a chemical peritonitis, undergo torsion, or rarely, undergo malignant degeneration to squamous cell carcinoma in older women.

Front 14

1. What are the different types of epithelial derived ovarian tumors?
2. What are the different types of germ cell ovarian tumors?
3. What are the different types of sex cord stromal cell ovarian tumors?
4. Is CA-125 elevated in only malignant ovarian pathology?
5. What hereditary syndromes are associated with incraeased risk of ovarian CA?

Back 14

1.
- Serous cystadenoma/CA
- Mucinous cystadenoma/CA: may give rise to pseudomyxoma peritonei.
- Endometriod carcinoma: occurs within endometrioma.
- Clear cell CA
- Brenner tumor

2. Germ cell tumors are more common than epithelial tumors in <20 year old pts.
- Teratoma: MC germ cell tumor (mature cystic teratoma is the MC)
- Dysgerminoma
- Embryonal cell CA
- ChorioCA

3. Sex cord stromal tumors
- Granulosa cell tumor
- Sertolli-Leydig cell tumor
- Thecoma
- Fibroma
4. No. CA-125 can be elevated with benign GU pathology.
5.
- BRCA-1 and BRCA-2 mutation
- Lynch syndrome (Hereditary non-polyposis)

-

Front 15

1. What is Meigs syndrome?
2. What ovarian tumor is associated with Meigs syndrome?
3. What is the outcome of ascites and pleural effusion after removal of the ovarian tumor?

Back 15

1. Ascites and pleural effusion in the setting of a benign ovarian neoplasm.
2. More than 80% of tumors associated with Meigs syndrome are ovarian fibromas.
3. Classically, the ascites and effusion will resolve after removal of the tumor.
NOTE: there is no peritoneal nodularily or omental caking in Meigs syndrome.

Front 16

1. What are the causes of hematosalpinx?
2.

Back 16

1. Intraluminal endometriosis, ectopic pregnancy, tumor, and torsion.

Front 17

1. What is the rule of 1-2-3?
2. What is the size criteria for simple ovarian cyst in a premenopausal female?

Back 17

1. Rule of 1-2-3
- 1 cm cyst in 1st week of menstrual cycle is follicle.
- 2 cm cyst in 2nd week of menstrual cycle is dominant follicle.
- 3 cm cyst in 3rd week of menstrual cycle is corpus luteum.
2.
- Cyst < 3 cm in premenopausal woman is likely physiologic.
- Cyst > 6 cm is likely neoplastic.
Follow-up sonogram in 6 weeks typically shows resolution of physiologic cysts. Pain can be due to size of cyst or torsion of cyst.

Front 18

1. Describe congenital uterine anomalies.
2. Uterus arises from what congenital structure?
3. What are the associated anomalies?
4. How can you differentiate uterine didelphys from bircornuate bicollis uterus?
5. What can happen to the rudimentary horn after menarche?

Back 18

1.
- Arcuate uterus
- Suptate uterus
- Bicornuate uterus (unicollis/bicollis).
- Uterine Didelphys: complete non-fusion, looking like 2 unicornuate uteri.
- Unicornuate uterus w/ or w/o rudimentary horn.
2. Mullerian duct.
3. 20-40% of pts with mullerian duct anomalies have associated renal anomalies. Not associated with ovarian anomalies. NOTE: mullerian ducts give rise to the fallopian tubes, uterus, cervix, and upper 2/3 of vagina.
4. Uterus didelphys has a duplicated upper vagina. Bicornuate uterus does not.
5. The rudimentary horn is often obstructed and thus after menarche it will result in hemotocolpos. Also, there is increased risk of endometriosis.

Front 19

1. Is zonal anatomy of the uterus stationary?
2. What is the zonal anatomy of the cervix?

Back 19

1. No. The zonal anatomy (thickness of the endometrium, jxnl zone, and outer myometrium) is dependent on the menstrual cycle. Zonal anatomy is indistinct in premenarchal girls and post-menopausal women. Infant girls may have zonal anatomy due to maternal hormones.
2.
- Endocervical canal: glands and secretions (high on T2)
- Cervical stroma: fibroelastic tissue (low on T2); comprises most of the thickness of the cervix.
- Outer smooth muscle layer (high on T2)

Front 20

1. What is the definition of benign cyst in pre- and post-menopausal women?
2. What are cysts in the cervix called? What tumor looks like nabothian cysts?

Back 20

1. If ovarian cyst is unilocular and simple,
< 6 cm in pre-menopausal woman is benign
< 3 cm in post-menopausal woman is benign.
2. Cervical cysts are called nabothian cysts (1-3mm) - mucus retention cysts. Adenoma malignum (adenoCA of the cervix) looks like a cluster of nabothian cysts.

Front 21

1. What are the imaging appearance of endometriosis?
2. Is there a risk of malignant degeneration?
3. What is the disease spectrum?

Back 21

- Conforms to the shape of the space.
- Look for hypointense rim 2/2 hemosiderin (KEY).
- T1 hyperintense 2/2 metHb.
2. Yes. Endometriosis is associated with malignant degeneration (2%); look for dominant nodule.
3. Endometriosis may cause endometriomas, peritoneal implants, and adhesions.

Front 22

1. What is the most common type of ovarian cancer?
2. How do ovarian cancers spread?
3. How is ovarian cancer staged?
4. Why is debulking performed?

Back 22

1. 85% of ovarian tumors are epithelial in origin. Less common histilogic subtypes include germ cell tumors and sex cord stromal cell tumors.
2.
- Direct extension
- Peritoneal seeding
- Lymphatic (pelvic, para-aortic LN)
- Hematogenous (late/infrequent)
3. Ovarian cancer is staged via laparoscopy.
- Stage 1: limited to one ovary with or without ascites.
- Stage 2: involves one or both ovaries with pelvic extension (Fallopian tubes, uterus -- 1A; rectum, bladder, peritoneum --1B) with or without ascites.
- Stage 3: extrapelvic extension; retroperitoneal lymph nodes, peritoneal implants).
- Stage 4: Distant mets
4. Chemotherapy is effective for tumor implants < 2 cm in size. Therefore, debulking gets the tumor implants below this size allowing chemotx to penetrate fully into the tumor implants. However, some tumor implants are hard surgically remove due to their locations; these implants are treated with neoadjuvant chemotx first, followed by surgery, and then chemotx again.

Front 23

1. What are risk factors for development of endometrial CA?
2. How does MRI help in staging endometrial CA?
3. How is endometrial cancer staged?
4. What findings are suggestive of myometrial invasion? Why is this finding hard to evaluate in post-menopausal women?

Back 23

1.
- Adenomatous hyperplasia 2/2 HRT or estrogen producing ovarian neoplasms.
- Tamoxifen therapy
- Obesity
- 10% of endometrial polyps may harbor malignancy.
2.
- Assess depth of myometrial invasion
- Identification of lymph node mets.
3.
- Stage 1: confined to the uterus (1A = confined to endometrium, 1B <50% myometrial thickness, IC >50% myometrial thickness)
- Stage 2: cervical involvment (2A = endocervical glandular involvement; 2B = cervical stromal invasion).
- Stage 3: 3A = invasion of uterine serosa/adnexa; 3B = vaginal mets; 3C = mets to pelvic and/or paraaortic lymph node.
- Stage 4: involvement of bladder or rectum mucosa = 4A; distant mets including abdominal mets and/or inguinal lymph nodes = 4B.
4. Look for disruption or discontinuity of the junctional zone. The junctional zone may be indistinct in post-menopausal women and thus myometrial invasion is difficult to see. Post-contrast images may be helpful in determining an irregular interface between the endometrium and myometrium.

Front 24

What is adenoma malignum?

Back 24

- 1-3% of cervical adenoCA (NOTE: 85% of cervical cancer are squamous and 15% are adenoCA).
- MRI mimicks nabothian cysts; no enhancement.
- Well differentiated
- Early dissemination, poor response to therapy.
- produces copious amounts of mucin (look for vagina filled with fluid).

Front 25

What are the key endometrial measurements in a post-menopausal woman?

Back 25

- Endometrial thickness of less than 5mm is considered normal in post-menopausal woman.
- If a woman is on HRT, then endometrial thickness may be upto 8mm.
- Endometrial thickness of less than 4mm is considered endometrial atrophy.

Front 26

1. What are the imaging findings in cervical lymphoma?

Back 26

1.
- Large mass centered in the uterine cervix with lobulated contours.
- Homogeneous in SI without evidence of necrosis
- Homogeneous contrast enhancement (others masses -- cervical carcinomas, endometrial CA and leiomyomas -- demonstrate heterogeneous enhancement).

Front 27

Kruckenberg tumors

Back 27

Krukenberg tumors are metastatic adenocarcinomas to the ovaries that comprise 1-2% of all ovarian tumors in the United States. They tend to be large (a mean of 10 cm in 1 review) at the time of diagnosis and are often bilateral (63-80%). One third of Krukenberg tumors are composed of cysts. Gastric cancer is the most common primary (70%). Colon, appendix, and breast cancers are encountered less frequently. It is thought that the route of spread is retrograde through the lymphatics. Interestingly, in gastric cancer, ovarian metastases may be the only extragastric site of disease (the so-called gastric-ovarian axis). In countries where gastric cancer is more prevalent, such as Japan, Krukenberg tumors account for 17.8% of ovarian cancers. Recent research suggests that very few ovarian mucinous tumors are of primary origin and that tumors previously classified as primary tumors are actually metastatic tumors from occult primaries.

Front 28

1. When does ovarian hyperstimualtion syndrome (OHSS) occur?
2. What are the imaging findings of OHSS?
3. What increases the risk of OHSS?
4. What are the complications of OHSS?

Back 28

1. Occurs in women undergoing ovulation induction for assisted reproduction. It can also be seen in women with gestational trophoblastic disease and multiple gestations.
2.
- enlarged ovaries
- ascites and pleural effusion due to increased capillary permeability.
3. Administration of human chorionic gonadotropin further increases the risk of OHSS. Therefore, women who become pregnant are at higher risk for the more severe forms of OHSS.
4. Complications of OHSS:
- hypovolemic shock
- thromboembolic disease
- liver and kidney dysfunction
- acute respiratory distress syndrome
- enlarged ovaries are susceptible to torsion

Front 29

Massive ovarian edema

Back 29

Incorrect: Massive ovarian edema is thought to be related to chronic torsion. Massive ovarian edema may be bilateral, but this is rare. It typically occurs in young women without a history of malignancy. An enlarged ovary with peripheral follicles is absent in this case to suggest massive ovarian edema.

Front 30

Theca lutein cysts

Back 30

Correct: Both ovaries in this case are enlarged and replaced by large thin-walled cysts, representing theca lutein cysts. Theca lutein cysts develop as a result of ovarian hyperstimulation by excessive B-hCG, either endogenous or exogenous. In this case, they are the result of a molar pregnancy filling the uterine cavity.

Front 31

Ovarian cystadenoma

Back 31

Ovarian serous cystadenomas account for approximately 25% of benign ovarian neoplasms. Serous cystadenomas are usually unilateral, but can be bilateral in 12-23% of cases. Unlike this case, an ovarian cystadenoma appears as a well-defined, usually unilocular, cystic mass. Normal ovarian tissue can be seen around the mass, unlike this case where both ovaries are completely replaced by the large cystic structures.

Front 32

What are the causes of hematometrocolpos?

Back 32

An imperforate hymen is the most common cause of hematometrocolpos in the young female population followed by vaginal agenesis and rarely, cloacal anomalies. Treatment entails surgical correction of the cause of hematometrocolpos. In older females, hematocolpos may result from radiation treatment of the pelvis causing vaginal stenosis.

Front 33

Endometrial thickness

Back 33

In menstrual age women, the endometrial echo complex thickness is highly variable. In post-menopausal women, the threshold for abnormal thickness depends on whether the woman is symptomatic with dysfunctional uterine bleeding or asymptomatic. If the woman has dysfunctional uterine bleeding, a thickness of > 5 mm is considered abnormal. If asymptomatic, a thickness > 8 mm is considered abnormal. Further imaging workup could include saline infused hysterosonogram or pelvic MR.

Front 34

Peritoneal endometriosis

Back 34

Peritoneal endometriosis may implant in the abdominal wall at the site of prior Cesarian section or hysterectomy. One should ask about a history of cyclical pain and swelling at the site of the mass.

Front 35

Tamoxifen uterus

Back 35

Endometrial thickening with heterogeneous, cystic appearance