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Ovaries and Adnexa

Adnexa: Mesosalpinges, Fallopian tubes, Broad ligaments, Uterine and Ovarian vessels
Ovaries: 4 x 3 x 2 cm; Normal volume 9 - 15 ml. Follicles are functional cysts
In estrogen phase ovaries are small with small follicles < 5 mm. By day 10 one of the follicles will become dominant and increases in size. By mid cycle the dominant follicle is 25 mm or greater and contains a mature egg (cumulus oophorus). Surge of luteinizing hormone will cause rupture of dominant follicle and release of the egg. Follicle will shrink rapidly and becomes a corpus luteum. Sometimes follicle bleeds internally and results into ⇒ Hemorrhagic cyst.

Clomid is fertility medication which force the maturation of multiple follicles. May cause Ovarian Hyperstimulation Syndrome (OHS): ovaries are completely replaced by follicles. Significant enlargement of ovaries, they are palpable, 20 cm or more, follicles leak fluid causing transudative ascites and pleural effusion. May persist or worsen with pregnancy, may be life-threatening. Do not attempt pregnancy induction during OHS.

Ovarian Cysts

Management depends on Age, LMP, Symptoms. Either ignore them, mention but no follow up or imaging follow up versus recommend surgery. It is important to differentiate between corpus luteum (ring of fire), which may mimic ectopic pregnancy, obtain B-Hcg; Postmenopasual - small cysts, cystadenomas - larger cysts (insignificant malignant potential)

Simple Cyst

Round, Oval, Anechoic, Thin walled, Acoustic through transmission, no solid component, no internal flow, up to 10 cm physiologic, paraovarian/paratubal, small hydrosalpinges

Premenopausal Simple Cysts


  • < 3 cm no mention
  • 3-5 cm: describe, no follow up
  • > 5 and < 7 cm, describe, f/u in 1 year (benign cystadenoma)
  • > 7 cm: MRI or surgery


Postmenopausal Simple Cysts


  • < 1 cm: no mention
  • > 1 < 7 cm: describe, “likely benign”, follow up in 1 year
  • > 7 cm: MRI or surgery

Hemorrhagic Ovarian Cyst (HOC)

Reticular, Lacy, Fishnet, Cobweb pattern, Strands and Septations, Clot retraction - solid with concave margins, no internal flow, peripheral flow, good acoustic through transmission. Common, pain, bleeding into corpus luteum; mimicker of other masses

Premenopausal Hemorrhagic Ovarian Cysts


  • < 3 cm: no mention
  • 3 - 5 cm: describe, no f/u
  • > 5 cm: describe, f/u in 6 weeks, days 3-10 of cycle
  • Early Postmenopausal HOC: f/u in 6 weeks
Postmenopausal HOC is never normal. Consider neoplastic: MR/surgery

Polycystic Ovarian Syndrome (PCOS)

Enlarged ovaries, multiple small non-functioning cysts (>12) lining up in the periphery in a string-of-pearls fashion (may be unilateral ovary). May be part of Stein-Leventhal Sy (obesity, hirsutism, PCOS), need labs


Endometrioma

Homogeneous internal echoes, Ground Glass or diffuse low level echoes, echogenic foci in the wall, increased acoustic through transmission, no internal flow, multilocular, internal septations, more irregular shape; results of multiple episodes of bleeding.

80% ovary, 1% malignant potential, older women, latency 4.5 years

If newly diagnosed, follow up in 6 weeks to distinguish from hemorrhagic cyst. If not surgically removed, follow up in 1 year.

Dermoid/Teratoma

Solid areas with flow, Focal or diffuse echogenicity, Hyperechoic lines and dots ⇒ hair
Tip of the iceberg sign: Absorption of most of the ultrasound beam at the top of the mass
Dermoid plug: Hyperechoic rounded areas within a hypoechoic mass

Hypoechoic dots and lines, Acoustic shadowing, no internal flow, sometimes complete tooth can be seen, lipid-fluid level; most common benign ovarian neoplasm; contain skin, hair, teeth; can torse or rupture, malignant transformation in up to 2%

If not surgically removed f/u i 6-12 months

Hydrosalpinx

Tubular, cystic, separate from ovary, waist sign - indentation from both sides no f/u if sure; PID

Ovarian Torsion

Enlarged ovary, heterogeneous central stroma secondary to edema/infarct, hemorrhage or necrosis. Peripherally displaced follicles from edema, may be due to mass (cystic or solid). Blood flow does not exclude torsion. Atypical midline position, dilated tube, target sign, free fluid; kissing ovaries - endometriosis, PID, torsion

Doppler: (+-) absence of flow, Doppler whirlpool sign, dual blood supply (ovarian, uterine), presence or absence of venous flow- if venous flow, ovary may be salvageable; torsed fallopian tube; OHS

3% of gynecologic emergencies; involves ovary, fallopian tube or both, if not relieved ⇒ ovarian necrosis

Treatment: detorsion and cystectomy versus oophorectomy if necrotic; acute, severe, excruciating pain (may be mild or intermittent), N/V

Risk Factors: Dermoid, Cyst, Paratubal cyst, rare malignancy; if > 5 cm ⇒ prone to torsion, less likely in very large masses (too big, not enough room); due to pregnancy (OHS), pelvic surgery, gymnasts


Complex lesions

Multiple thin septations, Solid nodule w/o flow, indeterminate
  • Premenopausal: follow up in 6-12wks, if persists consider surgery
  • Postmenopausal: surgery
Worrisome for malignancy: Thick septations, Wall thickening, Solid nodule w/ flow, call it complex mass and consider surgery

Ovarian malignancies

60% between 40-60 years; silent cancer, absence of symptoms early, advanced disease with ascites and omental masses (omental cake), CA 125

Present as complex cystic or solid mass but likely predominantly cystic:

  • Serous and Mucinous Cystadenocarcinomas
  • Mets from breast, Upper GI and by direct extension
  • Krukenberg are drop mets from the stomach but also pancreas, GB - typically solid masses
DDx: Endometriosis, Hemorrhagic cyst, Dermoid, Ovarian torsion, PID, bng - Serous cystadenoma, Mucinous cystadenoma, Fibroma, Thecoma; it is surgical dx