C H A P T E R
Pitfalls in Gynecologic
2
Ultrasound
Cheryl L. Kirby and Mindy M. Horrow
Ultrasound (US) imaging is prone to pitfalls related to
technique, normal variations, and interpretative errors.
Nowhere are these issues more problematic than in the
female pelvis. In this anatomic region, numerous scan-
ning approaches and transducers may be chosen. A range
of findings may be normal or abnormal depending on the
age of the patient, previous surgery, parity, medications,
and the stage of the menstrual cycle. Lastly, one must con-
sider pathologic processes with similar appearances and
those in adjacent nongynecologic organs. In this chapter
we will address a variety of recurrent pitfalls encountered
over the years in our practice.
SCANNING TECHNIQUE AND RELATED
PITFALLS
Traditionally a patient presenting for pelvic sonography was
requested to distend her urinary bladder. The distended
bladder serves as a sonographic window for transabdomi-
nal imaging by enhancing the through-transmission of the
sound beam and displacing gas-filled small bowel loops out
of the pelvis to allow better visualization of the uterus and
adnexae. Transvaginal imaging, which allows better reso-
lution because of a higher frequency transducer, is best
performed with an empty bladder. The competing require-
ments of transvaginal and transabdominal imaging, espe-
cially in patients without previous studies, often engender
long waits, uncomfortable patients, frequent interruptions
to empty a rapidly filling bladder, and a chaotic US sched-
ule. As a result, several years ago we decided to forgo the
requirement for a full bladder in most patients.
Our protocol begins with a brief transabdominal evalu-
ation, surveying for a large uterus with exophytic fibroids,
large adnexal masses or ovaries, and/or the uterus and ova-
ries displaced out of the pelvis. If none of these situations
apply, we perform a transvaginal scan only. Occasionally
transabdominal imaging alone is sufficient or even pre-
ferred, and sometimes a combination is required. The vast
majority of our population can undergo a transvaginal
examination. Children and teenagers are asked to distend
their bladders and are scanned transabdominally.
Our preference for transvaginal scanning may result
in pitfalls for the less experienced sonographer or sonolo-
gist. In some cases, transvaginal scanning only images the
cervix and lower uterine segment, missing the majority
of the uterine body and fundus (Figure 2-1). This situa-
tion occurs frequently in patients with a previous cesar-
ean section when the lower anterior uterus is tethered
to the anterior abdominal wall at the site of the cesarean
incision. This scarring elongates the cervix, pulling the
uterine body out of the pelvis and beyond the range of
the vaginal transducer. A similar problem is encountered
when only transvaginal imaging is performed in a patient
with a large myomatous uterus. In these situations trans-
abdominal imaging is preferred. To help in planning the
scan, we inquire about a history of cesarean section in all
parous patients.
We occasionally supplement or substitute with trans-
perineal and transrectal imaging in women who cannot
tolerate the lithotomy position or the vaginal transducer
and in women who cannot maintain a full bladder. For
transrectal imaging, the patient is placed in the left lateral
decubitus position with flexed hips and knees. Gener-
ally this position and approach are well tolerated in the
elderly population, allowing adequate visualization of the
uterus and endometrium. Evaluation of the adnexal struc-
tures is often incomplete because the excursion of the
transducer from side to side is more limited than on a
routine transvaginal examination. Transperineal imaging
is easily tolerated and helpful in evaluation of the vagina,
cervix, and urethra.
UTERINE PITFALLS
The Benign Enlarged Uterus
Fibroids occur in 20% to 30% of females more than 30
years old, accounting for many nongravid pelvic US refer-
rals. Their diagnosis is usually straightforward. The most
21
22 S E C T I O N O N E   l  Imaging Techniques, Pitfalls, and Normal Anatomy

Ultrasound
range
Uterus Cesarean
section scar

Elongated 85.36 mm
cervix
B
A Ultrasound transducer

n FIGURE 2-1  Limited area visualized on transvaginal scan.

A, Sagittal diagram of the pelvis demonstrates the limited
field of view (gray area) seen with transvaginal imaging in
many patients with scarring from previous cesarean section.
The scarring causes tethering of the lower uterine body to
the anterior abdominal wall with resultant elongation of the
cervix. This limits transvaginal visualization of the uterus to
only the cervix and lower uterine segment thereby missing
the majority of the uterine body and fundus, accounting
for a recurrent pitfall. Additional transabdominal images
are required in these patients. B, Sagittal transvaginal
ultrasound image of a uterus in a patient with previous
cesarean section shows limited field of view with
visualization of the lower 8.7 cm of the uterine body and
cervix and nonvisualization of the remainder of the uterine Dist 12.9 cm
body and fundus. C, Sagittal transabdominal ultrasound Dist 5.22 cm
in the same patient reveals full size of the uterus (12.9 cm
in length) with tethering of the anterior lower uterine body.
(The authors acknowledge the artistic contributions of C Sag Uterus
Alyson Singer.)

Dist 17.4 cm
Dist 9.93 cm

A B
n FIGURE 2-2  Dominant uterine fibroid mistaken as a diffusely myomatous main body of the uterus. A, Sagittal transabdominal ultrasound shows
exophytic dominant fibroid mistakenly measured as the entire fundus and body of the uterus. B, Transverse ultrasound image reveals the displaced,
relatively normal body of the uterus (arrows) with the exophytic fibroid (F) arising from the right side.
 CHAPTER
A B
n FIGURE 2-3  Focal adenomyosis. A, Sagittal transvaginal ultrasound image reveals a smooth globular uterine contour with focal elliptical area of
heterogeneity (calipers) in a retroverted uterus. B, Penetrating nondisplaced uterine vessels coursing into the region of adenomyosis. Color Doppler
imaging helps to distinguish adenomyosis with penetrating vessels from a fibroid with typical circumferential vessels.
typical appearance is a hypoechoic solid mass with an
internal whorled pattern, shadowing, and circumfer-
ential vessels. Rapid enlargement may lead to necrosis
and degeneration and a variety of more atypical appear-
ances with cystic or fatty components (lipoleiomyoma)
and calcifications. Although most fibroids arise in the
intramural portion of the uterus, less common locations
may be subserosal, submucosal, cervical, and within
the broad ligament. These variations in appearance and
location may result in errors of diagnosis. A subserosal
myoma with a thin attachment to the uterine body may
be confused with a solid ovarian mass or even missed
with transvaginal imaging. A myoma with significant cys-
tic degeneration may simulate an ovarian cyst.1 Pressure
with the transvaginal probe and/or color Doppler imag-
ing to demonstrate bridging vessels between the uterine
body and pedunculated myoma may help in the correct
diagnosis. A densely calcified myoma is usually not a diag-
nostic dilemma, but the shadowing may cause significant
technical limitations in evaluation of the adnexa and the
endometrium.
Usually multiple fibroids result in the classic US
appearance of an enlarged, lobulated uterus with
hypoechoic masses and variable amounts of posterior
acoustic shadowing. Even when the posterior shadow-
ing is dense, the anterior lobulated margin allows one
to make the correct diagnosis. Somewhat confusing,
however, is the patient with an enlarged uterus second-
ary to a large dominant fibroid. Frequently the large
fibroid is mistaken for the entire uterus when this domi-
nant fibroid displaces a smaller, more normal-appearing
uterine corpus toward the periphery (Figure 2-2). Dis-
tinguishing between a solitary enlarged myoma and mul-
tiple myomata may affect treatment options. One should
be wary of this pitfall when presented with images of a
uterus that appears as a single mass without any normal
myometrium. A careful search for the endometrium and
its connection to the endocervical canal using transab-
dominal and transvaginal techniques may help to avoid
this error.
2  l  Pitfalls in Gynecologic Ultrasound 23
Diffuse or focal enlargement of the uterus may also
be caused by adenomyosis. In adenomyosis the exten-
sion of endometrial glands into the myometrium causes
smooth muscle hypertrophy accounting for enlargement
of the uterus. Sonographic features include heterogene-
ity of the myometrium with cysts and hyperechoic foci,
linear striations, thin non-edge shadows, penetrating
vessels, and poor definition of the endometrial myome-
trial junction. The contour of the uterus is usually more
globular and less lobulated than with multiple fibroids
(Figure 2-3).
Distinguishing between focal fibroids and focal ade-
nomyosis (adenomyoma) is more challenging and prone
to potential errors (Figure 2-4). Findings that favor an
adenomyoma over a myoma include poorly defined mar-
gins, minimal mass effect on the adjacent endometrium,
small cysts, ellipsoid versus spherical shape, presence of
echogenic foci and striations, and the absence of calcifi-
cations, edge shadowing, and large vessels at the margin
of the lesion.2 With the improvement of US equipment
in the past 10 to 15 years, we have seen several cases
initially interpreted as fibroids that on subsequent stud-
ies are focal regions of adenomyosis. Because patients
with fibroids and adenomyosis have similar symptoms,
differentiation between the two diagnoses is important
because treatment options differ. Finally, in cases with
adenomyosis and fibroids, shadowing from the fibroids
may limit evaluation of the presence and severity of the
adenomyosis.
An enlarged uterus may be palpated in patients with
duplication anomalies such as a bicornuate or didelphys
uterus because of the separation of the two uterine
horns. When the endometrial canal is divided, the uter-
ine fundus must be evaluated to differentiate a septate
uterus from a bicornuate or didelphys uterus. Pregnancy
outcomes and treatment options vary significantly for
these different anomalies. Volumetric US imaging is help-
ful in differentiating these entities. Reconstruction of the
true coronal plane of the uterus allows evaluation of the
peripheral fundal contour and the extent of separation of
24 S E C T I O N O N E   l  Imaging Techniques, Pitfalls, and Normal Anatomy
A B
n FIGURE 2-4  Focal adenomyosis in posterior uterine body myometrium confused for fibroid. A, On transabdominal ultrasound image, a focal
hypoechoic region (arrows) was mistaken for fibroid. B, Transvaginal sagittal view of uterus confirms the area as focal adenomyosis in light of its poor
definition (thick arrows), myometrial cyst (thin arrow), and pencil-thin edge artifact. Cursors mark endometrium. Small anterior uterine body fibroid
also present.
the endometrial canals. A superior exophytic fibroid aris-
ing in an otherwise normal uterus may be confused for
a bicornuate uterus because they have similar contours.
The lack of a split endometrial canal and classic findings
of a fibroid should help distinguish these two diagnoses.
False-Positive Diagnosis of Fibroids
Fibroids may calcify, but not all uterine myometrial cal-
cifications are fibroids. Calcification of arcuate uterine
arteries is common in elderly women, especially those
with diabetes, and is considered part of the normal aging
process. Arcuate artery calcifications usually appear as
discontinuous linear parallel echoes (Figure 2-5) located
between the outer and intermediate layers of the uterine
myometrium.3 These calcifications must not be confused
with calcification in uterine fibroids, which tend to be
coarser and clumped and often associated with a noncal-
cified mass. Intense shadows from arcuate vessel calcifica-
tion may obscure the endometrium and make it difficult
to distinguish from the leading edge of a calcified myoma.
Magnetic resonance may be the only imaging method for
evaluation of the endometrium in this situation.
A frequent site for an erroneous fibroid diagnosis is
the lower uterine segment in a patient with a history of
previous cesarean section. The cesarean section incision
is usually transversely oriented in the lower uterine seg-
ment where there is increased fibrous tissue available
for healing, thereby reducing the chance of future dehis-
cence. Not infrequently, distortion and prominence of
the overhanging tissue superior to the scar (Figure 2-6)
assumes a rounded, relatively hypoechoic appearance,
mistaken for a fibroid (Figure 2-7). Thurmond et al.4 sug-
gest that differences in muscle contraction may account
for the thicker superior edge of the scar that becomes
more pronounced with increasing numbers of cesarean
sections. Histologic evaluation reveals congestion of the
endometrium above the scar, which may also account for
this prominent tissue.5
The presence of posterior edge shadowing adds to the
similarity of this scar tissue to a focal fibroid. This artifact
manifests as narrow, vertical hypoechoic lines originating
along the lateral margin of a rounded structure.6 Edge arti-
fact is common along the border of a cesarean section scar
because of the rounded configuration of the myometrium
adjacent to the scar. The hypoechoic edge artifact may be
mistaken for posterior acoustic shadowing, further con-
fusing this configuration for a fibroid (Figure 2-7, B).
Endometrium
The endometrial thickness and appearance must be cor-
related with the menstrual status to assess for benign or
malignant causes of bleeding such as polyps, fibroids,
hyperplasia, and cancer. Accurate identification of the
endometrium may be challenging in patients with mul-
tiple fibroids. Anterior fibroids that significantly attenuate
the sound beam may completely obscure the endome-
trium. In addition, one must avoid mistaking tissue het-
erogeneity within fibroids or tissue interfaces between
fibroids as the endometrium (Figure 2-8).
The endometrium is measured in the midline sagittal
plane of the uterus. If the uterus is oriented obliquely
or coronally, a true sagittal plane may be impossible to
obtain with routine imaging. Oblique images of the endo-
metrium may falsely increase its measurement and result
in overdiagnosis of endometrial thickening. Frequently
this problem is worse on transvaginal imaging and may
be overcome on transabdominal images, which allow
for more scanning planes. Three-dimensional volume
acquisition can correct for uterine obliquity by allow-
ing visualization of the endometrium in a multitude of
 CHAPTER 2  l  Pitfalls in Gynecologic Ultrasound 25

n FIGURE 2-5  Calcification of the uterine arcuate arteries. Sagittal transvaginal ultrasound of the uterus reveals calcifications
in a discontinuous parallel line configuration (arrows) located in the mid to outer aspect of the uterine myometrium.

n FIGURE 2-6  Distortion of lower uterine segment from previous cesarean section. Sagittal image from transabdominal
ultrasound reveals typical, prominent anterior lower uterine segment, tethered to anterior abdominal wall (arrow).

reconstructed planes regardless of the original acquisi-
tion plane.7
Faulty measurement of the endometrium may occur
in patients with adenomyosis, especially with transvagi-
nal imaging. The increased resolution of the transvaginal
transducer allows for improved visualization of the ecto-
pic endometrial tissue located in the myometrium. The
striations or patches of ectopic tissue cause poor defini-
tion of the endometrial myometrial junction (Figure 2-9)
and may cause pseudowidening of the endometrium
(­Figure 2-10).
A potentially missed cause of dysfunctional uterine
bleeding occurs in menstruating women with a previous
cesarean section. Such patients may experience sev-
eral days of postmenstrual spotting with old blood.4
This delayed bleeding results from either retained men-
strual blood or in situ bleeding in an endometrial cavity
pouch.5 This niche is created from postoperative scar-
ring that puckers the endometrium anteriorly and cre-
ates a small reservoir for the blood. The slow leakage of
this blood may result from poor contraction of the uter-
ine muscle around the scar. Hysterosonography may be
helpful in identifying a uterine niche. Although not all
such patients are symptomatic, awareness of this entity
can be useful in patients with the appropriate symptoms
(Figure 2-11).
26 S E C T I O N O N E   l  Imaging Techniques, Pitfalls, and Normal Anatomy

A B
n FIGURE 2-7  Two different patients with cesarean section scars mistaken for fibroids. A, Sagittal transvaginal ultrasound image reveals rounded
configuration of the tissue superior to the cesarean section scar (S). The arrow points to the bulbous tissue (mistaken for a fibroid) located superior
to the scar. B, Sagittal transvaginal ultrasound image reveals edge artifact (thick arrow) originating from scar and rounded configuration of the tissue
adjacent to the scar (thin arrow).

A B
n FIGURE 2-8  Tissue interface between myometrial fibroids mistaken as the endometrium. A, Cursors mark the erroneous measurement of the
echogenic tissue interface between two fibroids as the endometrium on this transabdominal sagittal ultrasound image of the uterus. B, Cursors
correctly measure the endometrium that can be followed into the lower uterine segment.

because abnormalities of the cervix, including polyps,

Cervix
Although the cervix receives great attention during
sonography of the gravid uterus, it tends to be overlooked
in the nongravid uterus. The cervix is located deep in the
pelvis and thus transabdominally is positioned far from
the US transducer. Visualization of the cervix is further
limited by the lack of an acoustic window in women with
nondistended bladders.
Cervical pathology can even be missed on a trans-
vaginal examination. This pitfall may be due to the nor-
mal cervical heterogeneity, numerous nabothian cysts,
or sonologist complacency, knowing that the cervix is
examined annually for cancer with direct visualization
and cytologic assessment. Detailed evaluation of the cer-
vix, however, should be part of the pelvic US examination
fibroids, and inflammation, can account for vaginal bleed-
ing. In particular, polyps protruding through the cervi-
cal os are frequently overlooked possibly because of their
close proximity to the transducer. The lower cervix can
be better evaluated by pulling the transducer away from
the exocervix or using a transperineal approach.
PITFALLS IN THE ADNEXAL REGIONS
Basic US imaging of the adnexal regions often consists
only of an assessment of each ovary for a dominant cyst
or mass. Unfortunately, this approach may result in over-
looking abnormalities that are extraovarian and extra-
uterine in origin. In addition, the ovary must be evaluated
in the context of the patient’s age and menstrual history
 CHAPTER 2  l  Pitfalls in Gynecologic Ultrasound 27

n FIGURE 2-9  Adenomyosis causing indistinct endometrial borders. Focal area of adenomyosis blurs the margin of the
endometrium (area between arrows) on this sagittal transvaginal ultrasound image. Note the well-defined endometrium in
areas without adenomyosis.

34.93 mm
2.95 mm

A B
n FIGURE 2-10  Pseudothickening of the endometrium in patient with adenomyosis. A, Sagittal transvaginal ultrasound image reveals erroneous
thickened measurement of the endometrium (measured as 3.5 cm) by including the endometrial tissue and the adjacent echogenic changes in
the subendometrial myometrium from adenomyosis. B, Sagittal transabdominal ultrasound image of the uterus reveals true measurement of the
endometrium (3 mm) and adjacent heterogeneity (arrows) in the anterior uterine myometrium representing adenomyosis.

to determine whether the size and number of follicles
are appropriate. One should not necessarily consider
an ovary to be normal based on the lack of a cyst or
mass. High-frequency transvaginal imaging with color,
power, and/or spectral Doppler is essential for these
evaluations. This section shall address a variety of diag-
noses that may be overlooked or underdiagnosed in the
adnexal regions.
Tubular Structures in the Pelvis
Many tubular structures are normally found in the pel-
vis, including fallopian tubes, veins, arteries, and bowel,
including the appendix. Abnormalities of any of these
“tubes” can cause symptoms for which pelvic US is per-
formed. Thus it is important to determine the type of
tubular structure and whether it is abnormal. Unfortu-
nately, many sonologists and sonographers who notice an
odd “tubular structure” will ascribe it to bowel and thus
beyond their consideration.
It is usually assumed that the normal fallopian tube
cannot be imaged routinely. Actually it is relatively easy
to find portions of the normal fallopian tubes, especially
if there is some free pelvic fluid and the examiner relaxes
the pressure of the transvaginal probe (Figure 2-12, A).
The segments of the fallopian tube increase in thickness
from uterus to fimbria and consist of the intramural por-
tion, isthmus, and ampulla. Thus it is not uncommon
to visualize the ampullary portion of the tube in cross
section as a round or ovoid echogenic structure, 5 mm
or less, adjacent to the ovary (see Figure 2-12, B). Often
one appreciates the finger-like projections of the fimbria
at the end of the fallopian tube. In a normal, nondilated
tube, the lumen should not be visible.
It is not uncommon to visualize a small simple cyst,
not arising within or connected to the ovary. Usually this
28 S E C T I O N O N E   l  Imaging Techniques, Pitfalls, and Normal Anatomy

n FIGURE 2-11  Fluid within cesarean section scar niche. Transvaginal sagittal ultrasound image of the cervix reveals a small
amount of fluid retained in the endometrial niche (arrows) created from retraction of the tissues at the cesarean section scar.

A B
n FIGURE 2-12  Normal fallopian tube in two different patients. A, Transvaginal ultrasound image of an elongated view of a normal fallopian tube
(arrows) with a Morgagni cyst (C), which most frequently occurs at the fimbriated end of the tube. This fallopian tube is easily visualized because of
adjacent free fluid. B, Transverse transvaginal ultrasound image reveals oblique view of the normal fallopian tube (arrows) between the uterus (U) and
ovary (O).

is a paratubal cyst, also known as a hydatid of Morgagni.
These cysts arise from remnants of the müllerian duct
located below the fallopian tube, usually near the fim-
bria (see Figure 2-12, A). Clinically they are insignificant
and rarely symptomatic unless they undergo torsion and
infarction.
When a fallopian tube dilates or becomes inflamed,
it should be more easily identified. Fallopian tube dilata-
tion usually implies obstruction, although the converse is
not necessarily true. Although pelvic inflammatory dis-
ease (PID) is the most common cause of dilatation, other
etiologies include endometriosis and adhesions from an
inflammatory process such as ruptured appendicitis. Dila-
tation can be acute or chronic with classical sonographic
findings based on the chronicity of disease.
The hallmark of PID is the abnormal fallopian tube.
Usually caused by a sexually transmitted infection, the
bacteria ascend from the cervix, through the uterus, and
into the fallopian tubes. Initially with salpingitis, the wall
of the tube thickens and the endosalpingeal folds may
be visualized.8 When the lumen occludes, the tube will
dilate, filling with complex fluid that may be uniform,
heterogeneous, or in levels (Figure 2-13). In the acute
stage the wall is thick, 5 mm or more, and when viewed
in cross-section may demonstrate the “cogwheel sign.”9
In the chronic phase of PID, a hydrosalpinx may
develop. The fluid within the tube becomes anechoic; the
wall measures less than 5 mm; and a cross-sectional view
may show “beads on a string” resulting from the short,
thick endosalpingeal folds projecting into the lumen. In
both acute and chronic cases of tubal dilatation, a use-
ful marker of a cystic structure as the fallopian tube is
the “incomplete septum” sign. This appearance is cre-
ated when the dilated tube falls back on itself, and two
walls are adjacent resulting in a linear echogenic protru-
sion arising from one side, but not reaching the opposite
one, and thus not a true septation (Figure 2-14). A simple
hydrosalpinx may be misinterpreted as a cystic, septated
ovarian tumor. If the ovary cannot be distinguished sepa-
rately, it is important to use signs such as the incomplete
septum sign or waist sign as markers for the fallopian
tube.10 We have also found that unlike a tumor or ovarian
cyst, a chronic hydrosalpinx is often easily compressible
with the vaginal transducer. Occasionally a peritoneal
 CHAPTER
n FIGURE 2-13  Pyosalpinx. Transvaginal ultrasound image reveals a thick-walled dilated fallopian tube containing a
fluid/debris level of purulent material related to pelvic inflammatory disease. Note the “cogwheel sign” of the thickened
endosalpingeal folds (arrow).
inclusion cyst may have an appearance similar to a hydro-
salpinx. The inclusion cyst, which represents peritoneal
fluid trapped by adhesions around an ovary, will usually
be distinguished by thin septations, but no true wall and
the lack of an incomplete septum sign.
The other common cause of a dilated fallopian tube is
a tubal ectopic pregnancy. The most common location of
an ectopic pregnancy is the fallopian tube. Sonographic
appearances include a gestational sac with or without
a yolk sac and/or an embryo, a “donut sign,” or a more
amorphous echogenic “mass.” If there is bleeding into the
fallopian tube, the acute hematosalpinx may appear as a
large, somewhat amorphous mass or collection separate
from the uterus and ovary. When the ectopic pregnancy
is early or there is only a small amount of bleeding, the
tubular shape is more easily appreciated.
Dilated veins, or pelvic varices, are a common cause
of tubular structures in the adnexal region. These varices
should not be ignored because they may lead to pelvic
congestion syndrome, a common but frequently under-
diagnosed cause of pelvic pain (Figure 2-15). The typical
patient is multiparous with worsening of dull pelvic pain
after standing or activity. The pelvic varices may be due
to incompetent valves from multiple pregnancies but may
also be secondary to portal hypertension or an obstructed
inferior vena cava. The varices can be confirmed with
color Doppler US, although occasionally due to slow flow,
even spectral Doppler US will be negative. In these cases
the slow-moving echoes will be visible on gray scale,
helping to differentiate these veins from dilated fallopian
tubes. The varices often connect to dilated arcuate veins
in the periphery of the uterus causing uterine enlarge-
ment and tenderness. If symptomatic, the patient can
be treated by percutaneous coil embolization or laparo-
scopic ligation of the varices.
The other major source of tubular structures in the pel-
vis is bowel. Bowel is identified by observing the typical
“gut signature” of alternating echogenic and hypoechoic
2  l  Pitfalls in Gynecologic Ultrasound 29
layers corresponding to the layers from mucosa through
serosa and resulting in a “bull’s eye” appearance. Peristalsis
can be used to confirm small bowel. Simple dilatation of
small and/or large bowel can be due to a primary process
(obstruction, inflammation, ischemia) or a reactive ileus.
US is useful to differentiate normal and abnormal peristal-
sis and may be the first clue to a bowel obstruction.
More focal abnormalities of bowel can suggest a spe-
cific diagnosis. Thus a blind-ending bowel loop larger than
6 mm may be identified in acute appendicitis. Crohn’s
disease (Figure 2-16), diverticulitis, lymphoma, and intus-
susception may all be suggested using US. Because it is a
real-time interactive examination, US can help determine
the site of pain or a rigid, aperistaltic segment of bowel.
Abnormal Ovaries Without a Mass
or Dominant Cyst
Familiarity with the normal appearance of the ovaries
from infancy through menopause is essential if one hopes
to make diagnoses related to inappropriate ovarian size or
number of follicles. The ovaries are often larger at birth
with an average volume of 1 cm3 and may be palpable
as a result of multiple cysts, related to the influence of
maternal hormones (Figure 2-17). Such an appearance is
not worrisome and will resolve during infancy. In infancy
the ovarian volume is usually less than 1 cm3, increasing
gradually with age to 2 to 3 cm3 approaching menarche,
continuing to increase in size during the teens with an
average volume of 8 cm3.11 Tiny ovarian follicles are com-
mon throughout childhood. In our experience, normal
ovaries are largest during the 20s and 30s, often begin-
ning to decrease in volume and number of visible follicles
during the 40s and particularly as the woman approaches
menopause. The mean ovarian volume in adult women is
reported as 9.8 ± 5.8 cm3. After menopause the ovaries
atrophy and follicles disappear. Size is related to time since
menopause with volumes varying between 1 and 5 cm3.
30 S E C T I O N O N E   l  Imaging Techniques, Pitfalls, and Normal Anatomy

n FIGURE 2-14  Hydrosalpinx with “incomplete septum sign.” Sagittal transvaginal ultrasound image reveals a dilated simple
fluid-filled tubular structure with an incomplete septum (arrow) characteristic of a dilated fallopian tube.

A B
n FIGURE 2-15  Pelvic varices. A, Transvaginal ultrasound image reveals a dilated tubular structure with fine internal echoes, and a fluid/debris level,
representing slow-moving blood. Initially structure was misinterpreted as a pyosalpinx. B, Imaging with sensitive color Doppler settings confirms
vascular nature.

Ovarian volume more than 10 cm3 in a postmenopausal
woman is considered abnormal by some authors.12
Evaluation of ovarian size and appearance is ­extremely
important in patients with primary or secondary amenor-
rhea. Abnormally small ovaries with few if any follicles
occur with chromosomal anomalies such as Turner’s syn-
drome, hypogonadism, and premature ovarian failure.
Usually there is no visible ovarian tissue in patients with
classical XO Turner’s syndrome. With XO mosaicism,
however, small ovaries are more common.13 Young nul-
liparous women on long-term oral contraceptives may
also have relatively small ovaries.
Premature ovarian failure may be a cause of primary or
secondary amenorrhea. It is typically associated with ele-
vated follicle-stimulating hormone (FSH) levels. Approxi-
mately half of all cases are idiopathic. Most other causes
are immunologic, with a small percentage as a result of
chromosomal abnormalities.14 US can be helpful in this
diagnosis, with two thirds of patients demonstrating
small ovaries with volumes similar to postmenopausal
ovaries and few, if any, follicles.
Ovarian enlargement, either unilateral or bilateral
without a focal lesion, has a significant differential diag-
nosis. The most common normal cause of unilateral
 CHAPTER 2  l  Pitfalls in Gynecologic Ultrasound 31

FT

Bowel

n FIGURE 2-16  Crohn’s disease. Transvaginal ultrasound reveals a dilated thick-walled tubular structure with gut signature
(Bowel) representing the inflamed terminal ileum adjacent to normal right fallopian tube (FT) and right ovary with small cyst (O).

n FIGURE 2-17  Normal newborn ovary. Transabdominal ultrasound image reveals multiple small cysts in an enlarged ovary
secondary to stimulation from maternal hormones.

enlargement is a corpus luteum, with or without a cys-
tic component. This diagnosis should be straightforward
by correlating the phase of the menstrual cycle with the
typical low resistance circumferential flow in color and
spectral Doppler US.
Unilateral enlargement with acute pain is usually due
to ovarian torsion. Although there is often an underlying
mass such as cystic teratoma, cystadenoma, or hemor-
rhagic cyst, torsion may occur in an otherwise normal
ovary. In the early stages of torsion, the ovary will enlarge
significantly. The stroma may appear heterogeneous as
a result of hemorrhage and infarction. Increased num-
ber and size of follicles is typical, usually displaced to
the periphery of the ovary. Often a careful search of
the adnexal region will reveal a twisted ovarian pedicle
resulting in the “whirlpool” sign.
Complete lack of arterial and venous flow in the
affected ovary is the hallmark of ovarian torsion. A variety
of technical pitfalls, however, may result in lack of flow,
including inadequate depth of penetration, improper
Doppler gain, and inappropriately elevated pulse repeti-
tion frequency. Conversely, flow is often detected with
torsion and is helpful to predict viability of the ovary.
Because the ovary derives a dual blood supply from the
ovarian and uterine arteries, arterial flow may still be
present, although usually asymmetrically decreased com-
pared with the contralateral ovary. Lack of venous flow in
the symptomatic ovary is a more useful diagnostic indica-
tor than the absence of arterial flow.7
A related but much less common entity is massive
ovarian edema. Most patients are young women who
present with acute pain, usually on the right side. On
32 S E C T I O N O N E   l  Imaging Techniques, Pitfalls, and Normal Anatomy

A B TRV ROV
n FIGURE 2-18  Massive ovarian edema in a 46-year-old woman with right lower quadrant pain. A, Transvaginal ultrasound image reveals an
enlarged right ovary (volume of 28.2 cc), with several tiny peripheral follicles. B, Prominent low resistance arterial flow was typical of a corpus luteum.
At laparoscopy, there was no torsion.

sonography the involved ovary is significantly enlarged

and relatively solid appearing with multiple small periph-
eral follicles and normal Doppler flow (Figure 2-18).
Some of these cases are caused by subtotal torsion, and
if blood flow is present, the ovary may be successfully
untwisted at surgery. Some cases seem to be caused by a
hemorrhagic corpus luteum. Usually patients are treated
C B
symptomatically.15
Bilateral ovarian enlargement is most commonly due to
polycystic ovarian syndrome. This complex syndrome is
due to hyperandrogenism resulting in an elevated lutein-
izing hormone (LH)/FSH ratio. The hormonal imbalance
causes chronic anovulation and infertility and a wide vari-
ety of other endocrinologic associations, including obe-
sity, insulin resistance, and hirsutism. Because of the wide
spectrum of clinical appearances and to exclude other
causes of elevated androgens, pelvic US is frequently per-
formed. Current international consensus standards for
polycystic ovaries include 12 or more total follicles mea-
suring 2 to 9 mm in diameter or increased ovarian volume
(>10 cm3). Although increased stroma and increased stro-
mal echogenicity are common findings, they are consid- n FIGURE 2-19  Ovarian cyst mistaken as bladder. Transabdominal
ered more subjective and thus not required for diagnosis. sagittal ultrasound image reveals an anterior simple ovarian cyst (C)
The typical appearance, however, may only occur in half mistaken for the bladder. Note the decompressed bladder (B) located
of the patients, and up to one third may have normal ovar- inferior to the cyst.
ian volumes. Usually, but not always, the ovarian enlarge-
ment is bilateral.16
Other less common associations of bilateral ovarian PITFALLS IN IMAGING OF OVARIAN
enlargement include PID, pelvic varices, and ovarian
hyperstimulation syndrome. In PID, oophoritis may result
LESIONS
in enlargement without other abnormalities. Sometimes Although many ovarian abnormalities have a typical
the ovarian size is overmeasured by inclusion of a slightly sonographic appearance, there are several lesions that
enlarged, nondilated fallopian tube in the measurement. are more likely to be misdiagnosed or overlooked dur-
Pelvic varices have been reported in association with ing US imaging. Occasionally a large, simple adnexal cyst
enlarged, cystic ovaries possibly related to venous stasis. can simulate the bladder, especially if the patient has just
Ovarian enlargement is a frequent complication of ovula- voided completely. This problem is more likely with trans-
tion induction and may result in ovarian hyperstimulation abdominal imaging (Figure 2-19). In general, however, the
syndrome. The size of the ovaries and number and size most problematic lesions are solid ovarian masses, includ-
of the cysts increase with the severity of the syndrome ing cystic teratomas (dermoids) and stromal tumors.
and may be complicated by ascites, pleural effusions, and The echogenic “plug” or Rokitansky protuberance is
hypovolemia. the most characteristic feature of a cystic teratoma. The
 CHAPTER 2  l  Pitfalls in Gynecologic Ultrasound 33

O O

A B
n FIGURE 2-20  Missed ovarian dermoid. A, The lateral echogenic fat-containing dermoid (arrows) was missed
on this transvaginal pelvic ultrasound. Only the normal medial ovarian tissue (O) was recognized. B, Computed
tomography with intravenous contrast confirms the fat-containing right ovarian dermoid (arrow).

117.05 mm

A B
n FIGURE 2-21  Large missed ovarian dermoid. A, On sagittal transabdominal ultrasound image, the region of increased echogenicity with shadowing
(arrows) superior to the uterus was interpreted as bowel. This area was not well visualized on transvaginal images (not shown). B, Corresponding
sagittal reconstructed computed tomographic image with intravenous contrast reveals a large dermoid (arrows) superior and anterior to the uterus.

plug, which consists of variable amounts of fat, calcifica-
tion, hair, and soft tissue, can be variable in size. When
the teratoma consists entirely of a plug, it will be com-
pletely echogenic with some posterior shadowing (Figure
2-20). This type of teratoma, even when large, is the most
easily missed because it blends in with air-filled bowel
and mesenteric fat (Figure 2-21). Dermoids with a cystic
component are much more easily appreciated. Occasion-
ally large dermoids may extend well above the uterus and
be missed on transvaginal imaging. Displacement of a
dermoid out of the pelvis may also occur with ovarian
torsion.
Dermoids can also be overdiagnosed. The appearance
of a dermoid may be simulated by a dilated appendix con-
taining an appendicolith, acute hemorrhage into a cyst, and
occasionally a lipoleiomyoma (an uncommon fat-contain-
ing myoma) (Figure 2-22).17 Lipoleiomyomas can usually
be identified by noting their location within the uterus.
34 S E C T I O N O N E   l  Imaging Techniques, Pitfalls, and Normal Anatomy

THK

UT

A B
n FIGURE 2-22  Lipoleiomyoma. A, Transabdominal ultrasound of the uterus reveals an intramural round echogenic mass with posterior acoustic
shadowing. B, The intrauterine mass (arrows) has high signal intensity on the axial transverse T1-weighted magnetic resonance image and low signal
intensity on the sagittal T1-weighted fat saturation sequence (not shown), confirming a fat-containing intrauterine mass.

Small echogenic ovarian foci are usually unrelated to

germ cell tumors. Numerous tiny echogenic foci smaller
than 5 mm are common, representing psammomatous cal-
cifications, hemosiderin, or specular reflections from tiny
cysts below the spatial resolution of the transducer (Figure
2-23). Slightly larger focal calcifications, usually 1 cm or
smaller, are also common. Retrospective studies have not
shown interval development of neoplasms.18
Stromal–sex cord tumors of the ovary are less com-
mon than epithelial neoplasms and germ cell tumors.
Because they are often solid, they may not be appreci-
ated as ovarian in origin. This is particularly true of the
fibroma–thecoma tumors (Figure 2-24). These tumors
are composed of fibrous cells with varying amounts of
thecal cells and thus are often similar in appearance to
uterine myomata. We have found two helpful maneu-
vers to differentiate between uterine and ovarian origin.
Intermittent pressure on the mass with the vaginal trans-
ducer may accentuate the origin of a mass. Color and
pulsed Doppler can confirm uterine origin by showing
blood vessels extending from the uterus into an exo-
phytic myoma (Figure 2-25). n FIGURE 2-23  Echogenic foci in a postmenopausal ovary.
Transvaginal ultrasound image reveals tiny benign echogenic foci
(arrows) related to specular reflections from tiny cysts, calcifications,
CONCLUSION or hemosiderin.
US is typically the initial and often the only imaging study
necessary for innumerable clinical symptoms and diag-
noses in the female pelvis. Its advantages of portability, menstrual cycle and the life cycle, a complete apprecia-
relatively low cost, real-time interaction with the patient, tion of pelvic pathology and experience with real-time
and lack of ionizing radiation result in a ubiquitous pat- scanning to derive the greatest benefit from pelvic sonog-
tern of use by many practitioners. Modern day equipment raphy. Nonetheless, mistakes and pitfalls will occur. This
allows for exquisite imaging using transvaginal, transab- article describes many of our experiences and advice for
dominal, transperineal, and transrectal approaches with avoiding problems. Ultimately, another imaging study
supplemental color, power, and spectral Doppler US. US may be required. In general we favor magnetic resonance
imaging, however, is subject to many technical and inter- for problem solving because of its multiplanar capabili-
pretive pitfalls. The sonologist must combine a thorough ties, variety of imaging sequences without or with con-
knowledge of normal pelvic imaging throughout the trast, and lack of ionizing radiation.
 CHAPTER 2  l  Pitfalls in Gynecologic Ultrasound 35

Dist 17.5 cm Dist 12.2 cm

A B

U
C
n FIGURE 2-24  Large solid stromal ovarian tumor mistaken as myomatous uterus. A, Sagittal transabdominal ultrasound shows large ovoid
hypoechoic solid mass initially interpreted as an enlarged myomatous uterus (cursors). Endometrium was not seen. B, Downward angled, sagittal
transabdominal image reveals inferiorly displaced uterus with normal endometrium (arrow) and superior mass (M). C, On sagittal T2-weighted
magnetic resonance imaging, the solid mass (M) is separate from the inferiorly displaced normal uterus (UT).

n FIGURE 2-25  Exophytic uterine fibroid with bridging

vessels from the uterus. On this transvaginal ultrasound
image, the solid mass (arrow) located to the right of the
uterus (UT) could potentially be mistaken as adnexal.
The bridging vessels originating from the uterus confirm
the uterine origin.

UT
36 S E C T I O N O N E   l  Imaging Techniques, Pitfalls, and Normal Anatomy
KEY POINTS
n Brief initial transabdominal imaging of the pelvis is required
because transvaginal scanning alone may miss the superior
uterine body and fundus in patients with previous cesarean
section scarring or large myomatous uteri (see Scanning
Technique and Related Pitfalls section).
n Findings that favor focal adenomyosis over a myoma
include poorly defined margins, minimal mass effect on the
adjacent endometrium, small cysts, elliptical versus globular
shape, echogenic foci and striations, absence of calcifica-
tions, and presence of penetrating, rather than peripheral,
vessels (see Benign Enlarged Uterus section).
n False-positive diagnosis of a fibroid frequently occurs in
the region of cesarean section scarring from the prominent
superior overhanging tissue and resultant edge artifact (see
section False-Positive Diagnosis of Fibroids).
R E F E R E N C E S
1. Baltarowich OH, Kurtz AB, Pennel RG, et al: Pitfalls in the sono-
graphic diagnosis of uterine fibroids, AJR Am J Roentgenol 151:
725–728, 1988.
2. Reinhold C, Tafazoli F, Mehio A, et al: Uterine adenomyosis: endo-
vaginal US and MR imaging features with histopathologic correla-
tion, Radiographics 19:S147–S160, 1999.
3. Atri M, de Stempel J, Senterman MK, et al: Diffuse peripheral uter-
ine calcification (manifestations of Monckeberg’s arteriosclerosis)
detected by ultrasonography, J Clin Ultrasound 20:211–216, 1992.
4. Thurmond AS, Harvey WJ, Smith S: Cesarean section scar as a
cause of abnormal vaginal bleeding: diagnosis by sonohysterogra-
phy, J Ultrasound Med 18:13–16, 1999.
5. Morris H: Surgical pathology of the lower uterine segment cesar-
ean section scar: is the scar a source of clinical symptoms? Int J
Gynecol Pathol 14:16–20, 1995.
6. Steel R, Poepping TL, Thompson RS, et al: Origins of the edge shad-
owing artefact in medical ultrasound imaging, Ultrasound Med
Biol 30(9):1153–1162, 2004.
7. Andreotti RF, Fleischer AC, Mason LE: Three-dimensional sonogra-
phy of the endometrium and adjacent myometrium, J Ultrasound
Med 25:1313–1319, 2006.
8. Horrow MM, Rodgers SK, Naqvi S: Ultrasound of pelvic inflamma-
tory disease, Ultrasound Clin 2(2):297–309, 2007.
9. Timor-Tritsch IE, Lerner JP, Monteagudo A, et al: Transvaginal
sonographic markers of tubal inflammatory disease, Ultrasound
Obstet Gynecol 12(1):56–66, 1998.
S U G G E S T E D R E A D I N G S
Andreotti RF, Shadinger LL, Fleisher AC: The sonographic diagnosis
of ovarian torsion: pearls and pitfalls, Ultrasound Clin 2:155–166,
2007.
Horrow MM, Rodgers SK, Naqvi S: Ultrasound of pelvic inflammatory
disease, Ultrasound Clin 2(2):297–309, 2007.
n Pseudothickening of the endometrium may occur on trans-
vaginal imaging because of an oblique orientation of the
uterus or in patients with adenomyosis (see Endometrium
section).
n A dilated fallopian tube is identified by the incomplete sep-
tum sign on longitudinal images and short thick endosalp-
ingeal folds projecting into the lumen on axial sections (see
Tubular Structures in the Pelvis section).
n Knowledge of the normal ovarian appearance from infancy
through menopause is essential to diagnose inappropriate
ovarian size or number of follicles (see Abnormal Ovaries
Without a Mass or Dominant Cyst section).
n Solid ovarian masses such as dermoids and stromal tumors
are more frequently overlooked than cystic ovarian masses
(see Pitfalls in Imaging of Ovarian Lesions section).
10. Patel MD, Acord DL, Young SW: Likelihood ratio of sonographic
findings in discriminating hydrosalpinx from other adnexal
masses, AJR Am J Roentgenol 186:1033–1038, 2006.
11. Sonographic imaging of the paediatric female pelvis, Eur Radiol
15:1296–1309, 2005.
12. Pavlik EJ, DePriest PD, Gallion HH, et al: Ovarian volume related to
age, Gynecol Oncol 77(3):410–412, 2000.
13. Haber HP, Ranke MB: Pelvic ultrasonography in Turner syn-
drome: standards for uterine and ovarian volume, J Ultrasound
Med 18(4):271–276, 1999.
14. Falsetti L, Scalchi S, Villani MT, et al: Premature ovarian fail-
ure, Gynecol Endocrinol 13(3):189–195, 1999.
15. Umesaki N, Tanaka T, Miyama M, et al: Sonographic characteris-
tics of massive ovarian edema, Ultrasound Obstet Gynecol 16:
479–481, 2000.
16. Balen AH, Laven JS, Tan SL, et al: Ultrasound assessment of the
polycystic ovary: international consensus definitions, Hum Reprod
Update 9:505–514, 2003.
17. Hertzberg BS, Kliewer MA: Sonography of benign cystic tera-
toma of the ovary: pitfalls in diagnosis, AJR Am J Roentgenol 167:
1127–1133, 1996.
18. Brown DL, Laing FC, Welch WR: Large calcifications in ovaries
otherwise normal on ultrasound, Ultrasound Obstet Gynecol 29:
438–442, 2007.
Reinhold C, Tafazoli F, Mehio A, et al: Uterine adenomyosis: endovagi-
nal US and MR imaging features with histopathologic correlation,
Radiographics 19:S147–S160, 1999.