The cul-de-sac, also known as the pouch of Douglas or rectouterine pouch, is an extension of the postero-inferior reflection of the peritoneal fold between the uterus (anteriorly) and rectum (posteriorly). It is the most inferior aspect of the peritoneal cavity and therefore the first location w...
Diffuse or disseminated peritoneal leiomyomatosis, also known as leiomyomatosis peritonealis disseminata, is an exceedingly rare benign disorder characterized by multiple vascular leiomyomas growing along the submesothelial tissues of the abdominopelvic peritoneum.
It is usually d...
Diffuse uterine adenomyosis is the most common of uterine adenomyosis. For the discussion of adenomyosis, please refer to the parent article - adenomyosis of the uterus.
Diffuse adenomyosis may account for ~2/3rd of uterine adenomyosis.
Diffuse adenomyosis can be even ...
Diffuse uterine leiomyomatosis is a benign and extremely rare condition in which the uterus is symmetrically enlarged as a result of the almost complete replacement of the myometrium by innumerable poorly defined, confluent leiomyomatous nodules.
Initial symptoms of the ...
Disorder of gender development refers to the spectrum of rare congenital conditions where there is an atypical development of chromosomal, gonadal, or anatomic sex.
They can be classified broadly into four categories on the basis of gonadal histologic features which include:
A dominant ovarian follicle refers to the follicle that enlarges to release an ovum during a menstural cycle. Usually approximately 10 Graafian follicles begin to mature where one becomes a dominant follicle and the rest become atretic ovarian follicles. After release of the ovum the remainder o...
The dot-dash pattern (dermoid mesh) is one of the characteristic sonographic appearances of an ovarian dermoid cyst. It refers to the short and long echogenic lines which are often seen within a dermoid cyst and are due to the presence of hair.
A dysgerminoma refers to a class of tumor with germ cell origin.
This can refer to:
germ cell tumors
Ectopic pregnancy refers to the implantation of a fertilised ovum outside of the uterine cavity.
The overall incidence has increased over the last few decades and is currently thought to affect 1-2% of pregnancies. The risk is as high as 18% for first trimester pregnancies with bl...
An embedded intrauterine contraceptive device is a situation where there is an abnormally-positioned IUCD within the endometrium or myometrium; however without an extension through the serosa. The intrauterine contraceptive device should be removed in this situation. An intrauterine contraceptiv...
Endometrial ablation is a minimally invasive surgical procedure that involves the destruction of the uterine endometrium commonly performed for menorrhagia in premenopausal or perimenopausal women.
It has evolved as an alternative to hysterectomy and is associated with good outcomes and patient...
Endometrial atrophy is a response to a hypo-oestrogenic state. If it occurs after menopause it can be more specifically termed postmenopausal endometrial atrophy.
While most patients are asymptomatic, endometrial atrophy is one of the commonest cause of postmenopausal bl...
Endometrial carcinoma is generally considered the most common gynecological malignancy. It frequently presents with vaginal bleeding. Both ultrasound and pelvic MRI are useful modalities for evaluation.
Endometrial carcinoma is the most common gynecological malignancy, with peak i...
Endometrial carcinoma staging allows appropriate treatment options to be considered and enables greater prognostic accuracy for endometrial carcinoma.
Staging can be based on the TNM or FIGO system.
MR imaging is the modality of choice for staging with CT having relatively low speci...
Fluid in the endometrial cavity can result from a number of causes if excessive and associated with distension.
There are essentially three types of fluid:
hydrometra: simple fluid
hematometra: hemorrhagic content / clot
normal (i.e. physiological)
Endometrial hyperplasia is an abnormal proliferation of the endometrial glands and stroma, defined as diffuse smooth thickening >10 mm 13. One of the major concerns is the potential malignant transformation to endometrial carcinoma.
Endometrial hyperplasia affects women of all age...
Endometrial microcalcifications can arise from a vast range pathologies but are usually of benign in etiology.
They have an increased incidence with older age, postmenopausal state, atrophic endometrium, and endometrial polyps.
In some cases they are associated wit...
Endometrial polyps are benign nodular protrusions of the endometrial surface, and one of the entities included in a differential of endometrial thickening. Endometrial polyps can either be sessile or pedunculated. They can often be suggested on ultrasound or MRI studies, but may require sonohyst...
Getting a film with endometrial polyp in the exam is one of the many exam set-pieces that can be prepared for.
Transabdominal and transvaginal pelvic ultrasound images in a lady with post-menopausal bleeding show an anteverted uterus with focal increased endometrial thickness to 1...
Endometrial reflectivity grading on ultrasound is a system initially proposed by Smith et al. in 1984 which classifies the endometrium into four types according to the echotexture pattern. They are considered to be useful in deciding on receptivity in in-vitro fertilisation (IVF).
The Smith sys...
Endometrial stromal tumors (EST) are an uncommon group of tumors arising from endometrial stromal cells. It accounts for <2% of all uterine malignancies and 10% of all uterine sarcomas.
Half occur in premenopausal women, with most patients presenting in the 5th decade.
Endometrial thickness is a commonly measured parameter on routine gynecological ultrasound and MRI. The appearance, as well as the thickness of the endometrium, will depend on whether the patient is of reproductive age or postmenopausal and, if of reproductive age, at what point in the menstrual...
Endometrioid carcinoma of the endometrium is the most common histological subtype of endometrial carcinoma accounts for 85-90% of cases. It is considered a type I carcinoma of the uterus with slow progression and a relatively good prognosis. Patients are usually 55 to 65 years old.
Endometrioid carcinoma of the cervix is a rare histological subtype of cervical cancer. It falls under the sub group of adenocarcinoma of the cervix.
It is thought to account for approximately 7% of cervical adenocarcinomas 2-3. The incidence is thought to have increased through ...
Endometrioid carcinomas of the ovary are a sub-type of epithelial ovarian tumors. The vast majority are malignant and invasive. On imaging, they are usually characterized as complex nonspecific solid-cystic masses and found associated with endometriosis.
Endometrioid carcinomas a...
Endometriomas, also known as chocolate cysts or endometriotic cysts, are a localized form of endometriosis and are usually within the ovary. They are readily diagnosed on ultrasound, with most demonstrating classical radiographic features.
These occur in women of reproductive age...
Endometriosis is a common, chronic gynecological condition defined as the presence of functional endometrial glands and stroma-like lesions outside the uterus. It manifests in three ways; superficial (peritoneal) disease, ovarian disease (endometriomas), and deep infiltrating endometriosis, whic...
Endometriosis affecting the canal of Nuck is an extremely rare site for endometriosis. It is proposed that retrograde implantation of endometrial tissue into patent canal of Nuck could give rise to the condition.
The condition is presented as a painful inguinal swelling. ...
Endometritis refers to inflammation or infection involving the endometrium. Endometritis can be acute or chronic and may arise in an obstetric setting, such as following delivery or miscarriage, or in a non-obstetric setting due to pelvic inflammatory disease (PID) or endometrial instrumentation...
The endometrium refers to the inner lining of the uterine lumen, composed of endometrial glands surrounded by loose highly cellular connective tissue.
In women of reproductive age, the endometrium is composed of two layers:
stratum basale (basal layer):
describes the de...
The endopelvic fascia is the enveloping connective tissue network for the pelvic viscera, suspending, supporting and fusing the pelvic organs to the arcus tendineus fasciae pelvis, which itself inserts onto the pelvic sidewalls and pubic bones.
The major anterior component is the pubovesical li...
Ovarian epithelial tumors account for the majority of all ovarian tumors (60-70%) and their malignant forms represent >90% of ovarian cancers 1. They can range from being benign to highly malignant.
There is a difference in frequency of ovarian tumor subtypes depending on menopaus...
An epithelioid trophoblastic tumor (ETT) is an extremely rare form of trophoblastic neoplasm. It is considered as a rare subtype of gestational trophoblastic disease 2,4.
It typically presents in women of reproductive age (peak age in late 30's) and can occur between 1 and 18 year...
Extra-uterine pelvic leiomyomas are much rarer than the typical uterine leiomyomas.
Entities that are described in this group include
cervical leiomyoma: sometimes classified as part of uterine leiomyomas
vaginal leiomyoma: extremely rare
benign metastasizing leiomyoma in the pelvis
The eponym Fallopian may refer to:
Fallopian canal (facial nerve canal)
Fallopian tube (uterine duct)
Fallopian ligament (inguinal ligament)
History and etymology
It is named after Gabriele Falloppio (also known by his Latin name Fallopius), Italian anatomist (1523-1562).
Fallopian tube rupture is most often a complication of a tubal ectopic pregnancy where the pregnancy breaks open due to progressive growth. It can potentially lead to shock.
Factors that raise the risk for a tubal rupture in a given tubal ectopic pregnancy include 2-4:
The Fallopian tube, also known as the uterine tube or less commonly the oviduct, is a paired hollow tube that bridges between each ovary and the uterus and functions to convey the mature ovum from the former to the latter. If conception occurs, it normally does so within the tube. It can be affe...
A Fallopian tube polyp refers to a small focal lesion of ectopic endometrial tissue located at the intramural portion of the fallopian tube.
The reported incidence is 1- 2.5% on hysterosalpingograms performed for assessment of infertility 3
Most patients w...
A useful mnemonic to remember the order of the five segments of the Fallopian tube, from lateral to medial, the direction an ovum would pass following ovulation, is:
Four INches Across IS IMpossible
Four inches (10 cm) is the approximate length of the Fallopian tube.
Fallopian tube spasm is a transient functional anomaly that can mimic a true mechanical tubal occlusion. At radiography, tubal spasm cannot be distinguished from a tubal occlusion. Administration of spasmolytic agents such as glucagon can occasionally result in uterine muscle relaxation and cons...
A Fallopian tube torsion is a type of adnexal torsion and usually occurs in association with an ovarian torsion (when it is then termed a tubo-ovarian torsion). An isolated fallopian tube torsion is rare but can occur.
An isolated tubal torsion can occur as a late complication of tu...
Female infertility is common and can be due to a number of factors. Radiology often plays a key part in the work-up.
Often more than one factor (including male infertility) is the cause of infertility, some of the common significant risk factors for infertility are listed ...
Female pseudohermaphroditism (FPH) is a form of disorder of gender development.
Patients with female pseudohermaphroditism have female internal genitalia and female karyotype (46 XX) with various degree of external genitalia virilization.
congenital adrenal hyperplasia (CA...
The female reproductive system (or tract) comprises the vulva, vagina, uterus, uterine tubes and ovaries.
It can be imaged using a wide range of imaging modalities but ultrasound and MRI are most useful.
The FIGO classification system for the causes of abnormal uterine bleeding in non-gravid women of reproductive age has a mnemonic at its core 1:
The "PALM" causes are considered structural and the "COEIN" (coin) causes are considered non-structural.
The FIGO staging systems are determined by the International Federation of Gynecology and Obstetrics (Fédération Internationale de Gynécologie et d’Obstétrique).
In general, there are five stages:
stage 0: carcinoma in situ (common in cervical, vaginal, and vulval cancer)
stage I: confined to...
A filling defect is a general term used to refer to any abnormality on an imaging study which disrupts the normal opacification (filling) of a cavity or lumen. The opacification maybe physiological, for example, bile in the gallbladder or blood in a dural venous sinus, or maybe due to the instal...
A fimbrial ectopic pregnancy is a subtype of tubal ectopic pregnancy. This subtype accounts for ~ 5 -11% 1,3 of all tubal ectopic pregnancies. In a fimbrial ectopic, the implantation is at the fimbria of the fallopian tube which is closest to the ovary. The chance of a tubal rupture is comparati...
A fistula (plural: fistulae) is an abnormal connection between two epithelial surfaces such as between hollow organs, skin or vessels. Conventionally, the name of a specific fistula type is a combination of the two organs
For discussions of specific fistulae please refer to individual articles....
Fitz-Hugh-Curtis syndrome (FHCS), or perihepatitis, is the inflammation of the liver capsule and overlying pertioneum associated with adhesion formation without the involvement of the hepatic parenchyma. It is a chronic complication of pelvic inflammatory disease (PID).
The floating balls sign refers to the appearance of multiple mobile globules/spherules of solid, usually fatty, tissue within an adnexal cyst. It is pathognomonic for ovarian mature cystic teratoma 1,2.
Alternative names include the meatballs 3 or truffle sign 4.
When a single la...
Focal adenomyosis is a morphological subtype of adenomyosis.
Some authors regard this term synonymous with an adenomyoma.
It is considered less common than diffuse uterine adenomyosis 4.
Focal adenomyosis most commonly occurs at the fundal endometrial-myo...
Follicular monitoring or follicular study is a vital component of in-vitro fertilization (IVF) assessment and timing. It basically employs a simple technique for assessing ovarian follicles at regular intervals and documenting the pathway to ovulation.
Journey to ovulation begins d...
The follicular ring sign is considered as a characteristic sonographic sign for early diagnosis of ovarian torsion 1. It is defined as prominent (1-2 mm thick) hyperechoic margin seen concentrically around the antral follicles of the torsed ovary, which are usually small (3‐ to 7‐mm) and periphe...
The term fornix (plural: fornices) is used for anatomical structures in multiple organ systems that all share an arch-like morphology:
History and etymology
Fornix is Latin for...
The fornices are superior recesses of the vagina formed by the protrusion of the cervix into the vaginal vault. There is a large posterior fornix and a smaller anterior fornix with two small lateral fornices.
History and etymology
Fornix is Latin for 'arch'.
Frenulum (plural: frenula) is an anatomical term and refers to a small fold of soft tissue that checks the movement of an anatomical part.
frenulum (ileocecal valve)
frenulum (labia minora)
History and etymology
Frenulum derives from ...
Frontal bossing is a calvarial radiographic feature where the front of the skull appears protruding anteriorly. It is best appreciated on a sagittal or lateral image.
This feature can be seen in many conditions (in alphabetical order):
Frontonasal dysplasia, also known as median cleft face syndrome, is a rare disorder characterized by midline defects involving the face, head, and central nervous system.
Frontonasal dysplasia is considered to be a very rare condition, with approximately 100 cases having been repo...
Frozen pelvis refers to a condition in which pelvic organs are distorted and tethered to each other as a consequence of adhesive processes.
It is commonly seen in endometriosis. Other causes include tumors, infections including pelvic inflammatory disease, post-surgical adhesions and post-treat...
Fryns syndrome (FS) is a rare congenital disorder which can have significant phenotypic variability but is primarily characterized by cranio-facial anomalies, diarphagmatic defects and distal limb anomalies.
Incidence is estimated at 1:15,000 live births.
A functional ovarian cyst is a term given to a group of non neoplastic type of ovarian cysts. A large proportion of ovarian cysts detected on imaging are functional ovarian cysts. Entities that fall under this group include
ovarian follicular cysts
corpus luteum cysts
theca lutein cysts
Cervical funnelling is a sign of cervical incompetence and represents the dilatation of the internal part of the cervical canal and reduction of the cervical length.
Greater than 50% funnelling before 25 weeks is associated with ~80% risk of preterm delivery.
Gartner duct cysts develop from embryologic remnants of the Wolffian (mesonephric) duct. They are often noticed incidentally on ultrasound or MRI.
They may cause mass effect on adjacent structures.
Gartner duct cysts are located in the anterolateral ...
Germ cell tumors are found widely throughout the body and encompass a wide range of individual tumors.
This article does not deal with any specific body locations. For detailed discussion please refer the articles listed at the end of this page.
Germ cell tumors arise from ectopic ...
A mnemonic for the differential diagnosis for germ cell tumors is:
E: embryonal cell carcinoma
E: endodermal sinus tumor (yolk sac tumor)
Germ cell tumors of the ovary account for approximately 15-20% of all ovarian tumors. In children and adolescents, up to 60% of ovarian tumors can be of germ cell origin.
ovarian teratoma(s): commonest primary benign tumor of ovary and commonest germ cell tumor:
mature (cystic) ...
Germinoma is a term that if unqualified, usually refers to a tumor of the brain but can also refer to similar tumors of other regions particularly the ovary and testis.
dysgerminoma of the ovary
seminoma of the testis
CNS germinoma: see WHO classification of CNS tumors
All these tumors share...
Gestational choriocarcinoma (GC) is a type of choriocarcinoma that follows a gestational event. Similar to choriocarcinomas in general, it lies at the malignant end of the spectrum of gestational trophoblastic disease.
Approximately 50% of gestational choriocarcinomas arise from a pr...
Gestational trophoblastic disease (GTD) results from the abnormal proliferation of trophoblastic tissue and encompasses a wide spectrum of diseases, including:
coexistent molar pregnancy
invasive mole ~10%
choriocarcinoma (gestational choriocarc...
Gigantomastia (also known as macromastia or mammomegaly) is the term employed when there is massive breast enlargement. It is often associated with pregnancy. It may be rarely unilateral.
Gigantomastia is a very common condition characterized by proliferation of either breast fatty tissue or gl...
The gonadal arteries are the paired primary vascular supply to the ovaries in the female and the testes in the male. As the anatomy of the gonadal arteries differs substantially between the sexes, they are covered separately:
Gonadal dysgenesis refers to a spectrum of anomalies with abnormal development of the gonads. It falls under the even broader group of disorders of gender development.
In many cases, the gonads are replaced by fibrous tissue.
complete gonadal dysgenesis (CGD) / Swyer syndr...
Goodman syndrome is a type of acrocephalopolysyndactyly (often considered type IV). It is an extremely rare genetic disorder characterized by marked malformations of the head and face, abnormalities of the hands and feet, and congenital heart disease. The syndrome is inherited as an autosomal re...
Granulosa cell tumors of the ovary are a type of sex cord / stromal ovarian tumor.
Sex cord-stromal tumors represent approximately 8% of all ovarian tumors and are believed to arise from and/or to contain combinations of the sex cord and stromal components of the developing gonad....
The clinical history will nearly always lead to a short differential or the answer. Show off to the examiner that you have a structured approach to reporting and managing the patient.
uterus: size, version and shape (normal or variant which you should elaborate on and say w...
The Gynecologic Imaging-Reporting and Data System (GI-RADS) is a reporting system that was created for reporting the findings in adnexal masses based on transvaginal ultrasonography.
Findings are classified into five categories 1:
normal ovaries identified and no adn...
The gynecology curriculum is one of our curriculum articles and aims to be a collection of articles that represent the core gynecological knowledge.
Topics pertaining to the ovaries, uterus, vagina and associated stuctures, but excluding those specific to obstetrics and urinary syst...
A habitual miscarriage is the term given when a woman has had more than 3 miscarriages and it affects approximately 1-2% of women.
Many causes are identified.
mullerian duct anomalies
acquired uterine causes
uterine adhesion bands
Hematocolpos is a term given to a blood-filled dilated vagina due to menstrual blood in the setting of an anatomical obstruction, usually an imperforate hymen. When there is concurrent uterine distention, the term hematometrocolpos is used.
Patients may present with ameno...
A haematometrium refers to a uterus filled with blood.
pyometrium: uterus filled with pus
hematometrocolpos: uterus and vagina filled with blood
hydrometrium: uterus filled with fluid
Hematometrocolpos refers to a blood-filled distended uterus and vagina usually due to an anatomical mechanical obstruction precluding the evacuation of the menstrual blood.
The estimated incidence in teenagers is at ~1 in 1000-2000 5.
imperforate hymen: in ~2/...
A hematosalpinx refers to intraluminal blood within the Fallopian tube (often dilated).
tubal ectopic pregnancy: common cause 1
endometriosis: common cause 5
pelvic inflammatory disease
fallopian tube torsion
Hemorrhagic corpus luteal cysts result from bleeding into corpus luteal cysts.
Commonly described findings include:
complex adnexal mass
adnexal thick-walled cystic lesion with lace-like strands
adnexal thick-walled cystic lesion with low-level echoes withi...
Hemorrhagic ovarian cysts (HOCs) usually result from hemorrhage into a corpus luteum or other functional cyst. Radiographic features are variable depending on the age of the hemorrhage. They typically resolve within eight weeks.
Patients may present with sudden-onset pel...
The H and M lines are reference lines for the pelvic floor on imaging studies and help detect and grade pelvic floor prolapse on defecography studies.
The H line is drawn from the inferior margin of the pubic symphysis to the posterior aspect of the anorectal junction, and represents the diamet...
HELLP syndrome is a pregnancy-related condition and is an abbreviation for:
elevated liver enzymes and
It is considered a severe and life-threatening form of pre-eclampsia although it can occur without co-existing pre-eclampsia.
The estimated inciden...
Hemimegalencephaly is a rare congenital disorder of cortical formation with hamartomatous overgrowth of all or part of a cerebral hemisphere. This results from either increased proliferation or decreased apoptosis (or both) of developing neurons 2.
Hemimegalencephaly is a cryptoge...
Hereditary breast and ovarian cancer (HBOC) syndrome is caused by a mutation to either BRCA1 or BRCA2 genes. These patients have an increased risk of breast cancer, ovarian cancer, pancreatic cancer and prostate cancer. However, these gene mutations are not the only cause of hereditary breast ca...
Herlyn-Werner-Wunderlich (HWW) syndrome, is a rare anomaly characterized by Müllerian duct anomalies (MDA) associated with mesonephric duct anomalies 3. This entity is also known as obstructed hemivagina and ipsilateral renal anomaly (OHVIRA). It is not to be confused with the Wunderlich syndrom...
Hernias (or herniae) are a common pathological entity, in which an anatomical structure passes into an abnormal location via an opening.
The opening may be a normal physiological aperture (e.g. hiatus hernia: stomach passes through the diaphragmatic esophageal hiatus) or pathological. Iatrogeni...
A heterogeneous myometrial echotexture on ultrasound is usually a non-specific finding, although it has been described with uterine adenomyosis.
Human epididymis protein 4 (HE4) is an emerging serum biomarker in the assessment of epithelial ovarian tumors. HE4 is a member of the whey associated protein (WAP) gene cluster and has uncertain biological function 1.
Early results indicate that HE4 has higher sensitivity and specificity than ...