Introduction to Gynecologic Sonography Overview

Gynecologic Sonography: A Comprehensive Guide

🔤 Sonographic Terminology

❓ What does “Anechoic” mean in sonography?
🔍 Answer: It means “without echoes.” Example: a simple ovarian cyst appears black because it doesn’t reflect sound waves.

❓ What is a “Complex” structure on ultrasound?
🧩 Answer: It has both solid and fluid parts—like a pelvic abscess with debris and septations.

❓ What does “Echogenic” mean?
📡 Answer: A structure that reflects sound waves and appears bright. Example: pelvic ligaments.

❓ What does “Heterogeneous” echotexture indicate?
🌀 Answer: Mixed texture. For example, an irregular endometrium that has different echo patterns.

❓ What does “Homogeneous” mean?
🔲 Answer: Uniform appearance. The uterus usually looks homogeneous in a healthy scan.

❓ What is “Hyperechoic”?
🌟 Answer: Brighter than surrounding tissues—like the endometrium during the secretory phase.

❓ What is “Hypoechoic”?
🌫️ Answer: Darker than surrounding tissue. Example: fibroids (leiomyomas).

❓ What does “Isoechoic” mean?
⚖️ Answer: Same brightness as the surrounding structures—makes organs blend in.

💡 Simple Cyst Criteria – “STAR”

Use the word STAR to remember 4 criteria for a simple cyst:

❓ What does the acronym STAR stand for?
🌟 S – Smooth Walls
🔦 T – Through Transmission (posterior enhancement)
🖤 A – Anechoic inside
⚪ R – Round or oval shape

✅ If all 4 are present → it’s a simple cyst
🚫 If any are missing → it might be complex and needs follow-up!

🧠 Complex Cysts: What to Look For

❓ What features suggest a cyst is complex?
🧪 Answer:

• Internal debris (not clear fluid)
• Septations (walls inside)
• Mural nodules (bumps on wall)
• Fluid-fluid levels
• Multiloculated (multiple chambers)

📝 These usually need more imaging or biopsy.

🧪 Key Lab Values in Gynecology

❓ What does a high hCG mean?
👶 Answer: It usually means pregnancy. But rare ovarian tumors can also increase hCG.

❓ What does a low hematocrit (Hct) indicate?
🩸 Answer: Possible internal bleeding—important in ectopic pregnancy or pelvic trauma.

❓ What does a high WBC count suggest?
🦠 Answer: Infections like pelvic inflammatory disease (PID) or abscess.

❓ What is CA-125?
🎯 Answer: A tumor marker that may rise in ovarian cancer, endometriosis, or other conditions.

🩺 Clinical Indications: When to Do a Pelvic Ultrasound?

❓ What are common reasons to order a female pelvic ultrasound?
📋 Answer:

• 🩻 Pelvic pain or mass
• 🚨 Abnormal bleeding (heavy, absent, or irregular periods)
• 👶 Infertility check or IUD location
• 🧬 Suspected congenital anomalies
• 🛠️ Pre- or post-surgical evaluation
• ⚠️ Suspected pelvic infections or cancer screening

💧 Patient Preparation

❓ How should a patient prepare for a transabdominal ultrasound?
🚰 Answer: Drink 32 oz of water—need a full bladder for a clear view!

❓ How about for a transvaginal ultrasound?
🚫 Answer: Empty bladder. It’s more detailed but invasive. Always get consent and use a chaperone (especially for male sonographers).

📖 Gathering Clinical History

❓ What key history should the sonographer collect?
📁 Answer:

• Past scans (ultrasound, MRI, CT)
• Presenting symptoms (pain, bleeding, etc.)
• Family history (e.g. ovarian cancer)
• Reproductive history (Gravida, Para)

🗣️ Use trained interpreters—not family—when language is a barrier.

⚠️ Infection Control in Sonography

❓ What are the standard precautions every sonographer must follow?
🧼 Answer:

• Clean hands (alcohol rub or soap)
• Use gloves, gowns, masks when needed
• Disinfect equipment (especially endovaginal probes)
• Never reuse disposable covers
• Proper cough/sneeze etiquette

🔬 Common Ultrasound Artifacts

❓ What is reverberation artifact?
🔁 Answer: Repeated bouncing of sound creates false echoes. Example: lines in the bladder.

❓ What is a mirror image artifact?
🪞 Answer: Sound reflects off a strong surface, showing a fake copy of anatomy deeper down.

❓ What is posterior enhancement?
💡 Answer: Seen behind fluid-filled structures like cysts—looks brighter because sound travels easily.

❓ What is shadowing?
🪨 Answer: When sound hits something dense (like bone or teeth in dermoid), it blocks waves, leaving a shadow.

👧 Pediatric Gynecologic Sonography

❓ What are special considerations for pediatric or adolescent girls?
👧 Answer:

• Use less water for full bladder
• No transvaginal scans if patient is virginal
• Conditions to watch: PCOS, torsion, PID, ectopic, or rare tumors
• Look for ambiguous genitalia (Turner syndrome common)

🏥 Common Gynecologic Conditions

❓ What are sonographic signs of Ovarian Torsion?
🌀 Answer:

• Enlarged ovary
• No blood flow on Doppler
• Peripheral follicles
• Free fluid
• Sudden severe pain

❓ What does PCOS look like on ultrasound?
🍩 Answer:

• Big ovaries with >12 tiny follicles (2–9 mm)
• “String of pearls” pattern
• Increased echogenic stroma
• Associated with hirsutism, acne, and irregular cycles

❓ What are signs of Adenomyosis?
📦 Answer:

• Enlarged uterus
• Thickened back wall (posterior myometrium)
• Myometrial cysts
• Painful and heavy periods

❓ What is an Endometrioma (chocolate cyst)?
🍫 Answer:

• Ovarian cyst with “ground glass” appearance
• Associated with chronic pelvic pain and infertility
• Part of endometriosis spectrum

❓ What are fibroids (leiomyomas)?
🌕 Answer:

• Round, solid, hypoechoic masses
• Can distort uterine shape
• May have calcifications
• Cause bleeding, pressure, or pain

🧫 Pelvic Inflammatory Disease (PID)

❓ What is PID and how does it appear on ultrasound?
🔥 Answer: PID is an infection of the uterus, ovaries, and fallopian tubes.

🖥️ Sonographic signs:

• Thick, fluid-filled tubes
• Hydrosalpinx (fluid-filled fallopian tube)
• Tubo-ovarian abscess
• Free pelvic fluid
• Thickened endometrium

🧍‍♀️ Symptoms: Fever, pelvic pain, abnormal discharge, high WBC count

💧 Ovarian Cysts (Types)

❓ What does a simple ovarian cyst look like?
⚪ Answer: It meets STAR criteria (Smooth, Through transmission, Anechoic, Round). No internal echoes. Benign.

❓ What is a hemorrhagic cyst?
🩸 Answer: Has internal echoes, may show a lace-like pattern or fluid levels. Often resolves on its own.

❓ What is an endometrioma?
🍫 Answer: “Chocolate cyst” seen in endometriosis. Hypoechoic with ground-glass texture. May contain low-level echoes.

❓ What is a dermoid cyst (teratoma)?
🦷 Answer: Complex, may have teeth, fat, hair. Shows shadowing. Very echogenic with mixed contents.

🎭 Ovarian Neoplasms

❓ What is a serous cystadenoma?
💧 Answer: A thin-walled cyst, often unilocular or multilocular. Most common benign ovarian tumor.

❓ What is a mucinous cystadenoma?
🍯 Answer: Large, multilocular cysts filled with thick mucin. Can grow very large.

❓ What is serous cystadenocarcinoma?
⚠️ Answer: Malignant. Appears complex with thick walls, nodules, septations, and solid parts.

❓ What is mucinous cystadenocarcinoma?
☠️ Answer: Complex multilocular mass with solid parts. May rupture and cause pseudomyxoma peritonei.

🫁 Meigs Syndrome

❓ What is Meigs syndrome?
🎯 Answer: A rare combo of:

1. Benign ovarian tumor (usually fibroma)
2. Ascites
3. Pleural effusion

🖥️ Ultrasound shows: Solid ovarian mass with fluid in abdomen and chest (confirmed via imaging).

🧷 IUD (Intrauterine Device) Evaluation

❓ What should sonographers check when scanning an IUD?
📎 Answer:

• Confirm it’s inside the uterus
• Rule out displacement or perforation
• Check for embedment into muscle
• Look for missing strings

🔍 Tip: 3D ultrasound can give a clearer view of IUD placement.

💦 Sonohysterogram (Saline Infusion Sonography)

❓ What is a sonohysterogram and when is it used?
💧 Answer: A procedure where saline is injected into the uterus to better see the endometrial cavity.

📌 Used for:

• Abnormal bleeding
• Infertility
• Suspected polyps or fibroids
• Uterine cavity abnormalities

📝 Steps:

1. Baseline TV ultrasound
2. Insert speculum and clean cervix
3. Place catheter
4. Inject saline
5. Scan in real-time

📊 Analyzing Registry Questions

❓ How should you approach a sonography board exam question?
🎓 Answer:

1. Read the question first—try to answer before looking at choices
2. Use clues like age, history, symptoms
3. Eliminate obviously wrong answers
4. Match scan findings to what you know

✅ Example:
A 32-year-old woman with heavy periods and dyspareunia, enlarged uterus, and thick posterior wall → Adenomyosis.

📘 Important Terms (Quick Definitions)

• Adnexa 🧬 = Area near uterus with ovaries and tubes
• Amenorrhea ❌🩸 = No periods
• Menorrhagia 💦🩸 = Very heavy periods
• Dyspareunia 💔 = Painful intercourse
• Polycystic Ovary Syndrome 🍩 = Multiple small cysts + hormonal symptoms
• Hydronephrosis 💧 = Kidney swelling from blockage
• Septations 🧱 = Dividing walls in a cyst
• Mural Nodules 🧨 = Wall bumps, may be cancerous