REVIEW

Imaging of the female pelvis
Susan Freeman
Frances Hampson
Helen Addley
Penelope Moyle
Evis Sala
Abstract
Recent advances in cross-sectional imaging have led to an increasingly
important role for radiology in the management of gynaecological condi-
tions. Multiple imaging modalities are utilised to investigate the female
pelvis including: ultrasound; computed tomography; magnetic resonance
imaging; and positron emission tomography/computed tomography. Each
modality has a different role in screening, diagnosis, staging, treatment
selection and follow-up. This review will discuss the various imaging
techniques and recommended roles for each modality and how these
modalities are best employed in the imaging of the female pelvis. The
imaging findings of common female pelvic pathology are discussed and
illustrated.
modalities have different roles in screening, diagnosis, staging,
treatment selection and follow-up.
This review will discuss the various imaging techniques and
recommended roles for US, CT, MRI and FDG-PET and how these
modalities are best employed in the imaging of the female pelvis.
We also review the imaging findings of common female pelvic
pathology.
Ultrasound (US)
US is the primary imaging modality in the initial assessment of
suspected gynaecological pathology. The advantages of US over
other imaging modalities are that it is widely available, inex-
pensive, quick, portable and does not involve ionising radiation.
Disadvantages of US include operator dependency and limited
views in obese patients or the presence of overlying bowel gas.
The patient must have a full bladder to provide a sonic
window for optimal views of the uterus and ovaries on trans-
abdominal US. For more detailed views of the endometrium and
of the adnexa, a transvaginal US is essential. The patient must
then have an empty bladder for close apposition of the probe
with the pelvic organs. Colour, power and spectral Doppler are
used to assess abnormal vascularity. US can also assist in image
guided fine-needle aspiration cytology or biopsy, as well as
percutaneous drainage.

Keywords adenomyoma; diagnostic imaging; ectopic; endometriosis;
gynaecology; leiomyoma; ovarian cysts; ovarian hyperstimulation
syndrome; ovarian neoplasms; pelvic inflammatory disease; pregnancy;
teratoma; uterine cervical cancer; uterine neoplasms
Imaging techniques
Recent advances in cross-sectional imaging have led to an
increasingly important role for radiology in the management of
gynaecological conditions. A number of imaging modalities can
be used to investigate the female pelvis including: ultrasound
(US); computed tomography (CT); magnetic resonance imaging
(MRI); and fluorine-18-fluoro-2-deoxy-D-glucose (FDG) positron
emission tomography/computed tomography (PET/CT). These
Magnetic resonance imaging (MRI)
MRI is widely used to evaluate female pelvic pathology, offering
excellent soft tissue contrast and spatial resolution as well as
multi-planar capability. It is the imaging modality of choice to
assess congenital anomalies of the uterus and vagina. It is
superior to CT in assessment of uterine and cervical cancer and
for characterisation of adnexal lesions when the US findings are
indeterminate (Figure 1). See Table 1 for a summary of the main
indications for MRI of the female pelvis.
T1-weighted sequence is useful to detect enlarged lymph nodes
and bone marrow metastases. In addition, blood, proteinaceous

Susan Freeman MA(Cantab) MB BChir MRCP FRCR is a Consultant Radiologist at

the Department of Radiology, Addenbrooke’s Hospital, Cambridge, UK.

Frances Hampson BSc MBBS MRCS FRCR is a Radiology Specialist Registrar at

the Department of Radiology, Addenbrooke’s Hospital, Cambridge, UK.

Helen Addley MA(Oxon) BM BCh MRCP is a Radiology Specialist Registrar at

the Department of Radiology, Addenbrooke’s Hospital, Cambridge, UK.

Penelope Moyle MBChB MRCP FRCR is a Radiology Specialist Registrar at

the Department of Radiology, Addenbrooke’s Hospital, Cambridge, UK.

Evis Sala MD PhD FRCR is a University Lecturer/Honorary Consultant

Radiologist at the Department of Radiology, Addenbrooke’s Hospital,
Cambridge, UK. Figure 1 Algorithm to characterise adnexal masses on MRI.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:10 271 Ó 2009 Elsevier Ltd. All rights reserved.

Main indications for MRI of the female pelvis
Organ Indication
Uterus Evaluation of congenital anomalies
Evaluation of possible adenomyosis
Evaluation of leiomyomas pre- and
post-treatment
Staging of endometrial and cervical cancer
Adnexa Characterisation of adnexal masses
Vagina/vulva Evaluation of congenital anomalies
Staging of vaginal and vulvar cancer
Evaluation of colovaginal and
vesicovaginal fistulas
Other Evaluation of recurrent endometrial, cervical,
ovarian cancer
MRI, magnetic resonance imaging.
Table 1
products or fat appear as high signal intensity on T1. Fat
suppression is utilised to distinguish between these substances. A
fat-containing lesion will become low signal, when fat suppres-
sion is applied to T1-weighted images (T1WI). The T2-weighted
sequence is helpful in demonstrating pathology, as the presence of
tumour causes distortion of the normal anatomy and signal
characteristics on MRI. Normal signal characteristics of the uterus
on T2-weighted sequence include a high signal intensity endo-
metrium (less than 5 mm in thickness in the postmenopausal
patient), a junctional zone (JZ) of low signal intensity (normally
measuring less than 8 mm) and a myometrium of intermediate
signal intensity. The cervix has a high signal intensity endocer-
vical canal with a low signal intensity cervical stroma.
Intravenous administration of gadolinium is used for charac-
terisation of adnexal lesions, for staging endometrial cancer and
to distinguish recurrent tumour from post-treatment fibrosis.
Computed tomography (CT)
CT has a limited role in the imaging of the female pelvis due to
poor soft tissue contrast. New multi-detector CT provides higher
resolution imaging and when this is combined with multi-planar
reformatting, there has been some improvement in delineating
pelvic pathology. However, MRI remains the gold standard. The
main role of CT is in the diagnosis of tubo-ovarian abscess when
US is inconclusive and evaluation of post-surgical complications.
CT is the imaging modality of choice for staging, treatment
planning and follow-up of patients with suspected ovarian
cancer. CT is important in other gynaecological malignancies by
identifying enlarged lymph nodes, distant metastases and
detecting recurrent pelvic tumours.
Contrast-enhanced CT of the abdomen and pelvis is per-
formed in the portal venous phase, 70 s following an injection of
intravenous low osmolar contrast medium; this enhances blood
vessels and viscera, allowing easier identification of lymphade-
nopathy and parenchymal lesions, especially in the liver. Oral
contrast medium is mandatory in order to opacify the bowel,
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:10
REVIEW
which allows detection of bowel serosal deposits that may occur
in ovarian and endometrial tumours.
FDG-Positron emission tomography/computed tomography
(FDG-PET/CT)
FDG-PET/CT is a functional imaging tool that uses short-lived
radionuclides attached to tracers to image metabolic processes in
the body in combination with a low-dose CT for localisation
purposes. The most commonly used radiotracer is FDG, which is
metabolised as glucose. Many malignant tumours are, therefore,
identifiable due to their increased glycolytic rate.
However, it must be remembered that physiological uptake
can be seen in the uterus, ovarian follicles and corpus luteum
cysts in premenopausal patients. FDG uptake can also be seen in
certain benign ovarian and uterine tumours as well as inflam-
matory and infectious processes.
Uterus
Congenital uterine abnormalities
Most congenital anomalies of the female genital tract result from
non-development or varying degrees of non-fusion or non-
resorption of the Mullerian ducts that form the uterus, cervix and
fallopian tubes. These anomalies are associated with menstrual
disorders, infertility and obstetric complications. The possibility
of such an anomaly should be considered when the uterus
appears abnormal in size, shape or position. MRI using T2WI is
sensitive in the precise classification of anomalies and may also
demonstrate any associated urinary tract abnormalities.
Non-development or rudimentary development of the Mullerian
ducts results in uterine agenesis or hypoplasia. In Mayer-Rokitan-
sky-Hauser (MRKH) syndrome, there is absence of the uterus and
upper vagina, with varying degrees of development of the lower
vagina. Non-development or rudimentary development of only one
the Mullerian ducts may lead to unicornuate uterus (Figure 2).
Partial fusion of the Mullerian ducts results in a bicornuate
uterus. MRI demonstrates an internal septum composed of
Figure 2 Axial T2WI magnetic resonance image of a unicornuate uterus
(white arrow).
272 Ó 2009 Elsevier Ltd. All rights reserved.

Axial T2WI magnetic resonance image demonstrating a didelphus uterus with two separate uterine horns (white arrows on the left image) and
cervices (white arrows on the right image).
Figure 3
myometrium dividing the two uterine horns and an intervening
cleft in the external fundal myometrium. Non-fusion of the Mul-
lerian ducts results in a didelphus uterus, with two separate uterine
horns and cervices demonstrated on T2WI (Figure 3); a longitu-
dinal vaginal septum is also present in 75% of cases. Incomplete
resorption of the fibrous septum between the two uterine horns
results in a septate uterus. The septum may be partial, or complete
extending to the external cervical os. It is important to make the
differentiation between a bicornuate and a septate uterus as the
latter is associated with a higher rate of reproductive complica-
tions. An arcuate uterus appears as a mild focal thickening of the
fundal myometrium, with no associated fibrous septum.
Benign uterine conditions
Adenomyosis Adenomyosis is a benign condition of the uterus
characterised by the presence of ectopic endometrial tissue
within the myometrium. This elicits adjacent myometrial
Sagittal and axial T2WI shows diffuse thickening of the junctional zone (white asterisk) with multiple high signal foci.
Figure 4
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:10
REVIEW
hypertrophy-hyperplasia. Dysmenorrhoea and menorrhagia are
the most frequent presenting symptoms. The disease may be
focal or diffuse. Transvaginal US examination is the initial
imaging modality. This may demonstrate an enlarged uterus with
focal or diffuse changes in echotexture. While US may suggest
the presence of diffuse adenomyosis, it is difficult to distinguish
between focal adenomyosis and a leiomyoma. It is important to
make this distinction as there are many treatment options for
leiomyoma (such as myomectomy, hysterectomy, uterine artery
embolisation and MR-guided focused US), whereas debilitating
adenomyosis requires hysterectomy.
MRI is reserved for indeterminate cases. On T2WI diffuse
adenomyosis appears as diffuse thickening of the JZ greater than
12 mm (Figure 4). A JZ less than 8 mm excludes disease with high
accuracy. High signal intensity foci may be seen on T1WI,
believed to represent endometrial rests or small punctate hae-
morrhages. Their presence may be used as additional evidence of
273 Ó 2009 Elsevier Ltd. All rights reserved.

disease in equivocal cases (JZ 8e12 mm). Focal disease is seen as
low signal masses within the myometrium on T2WI.
Leiomyoma are the most common uterine tumours. They are
found in up to 40% of women in their reproductive years. They
are benign tumours composed of smooth muscle and a variable
amount of fibrous tissue and are usually multiple. Leiomyomas
may be submucosal, intramural or subserosal in location. US is
usually the initial imaging modality in the investigation of
patients with suspected leiomyomas. US reveals well-circum-
scribed, hypoechoic, rounded or oval masses within the body of
the uterus. They may contain some heterogeneous areas due to
degeneration. Calcification may also be seen as dense echogenic
foci with posterior acoustic shadowing.
MRI provides the best characterisation of the size, number
and location of leiomyomas. It is also very useful in differenti-
ating a pedunculated subserosal leiomyoma from an adnexal
mass. It is usually reserved for cases where the US examination
has proved inconclusive or when intervention is considered. MRI
may help to decide whether a myomectomy, hysterectomy or
uterine artery embolisation (UAE) is the most appropriate
management strategy. Haemorrhagic or necrotic leiomyomas do
not respond to UAE and are best treated by myomectomy or
hysterectomy. In addition, the presence of an ovarian-uterine
artery anastomosis on contrast-enhanced MRI may be associated
with lower UAE success rates and amenorrhea. The success of
myomectomy and UAE may be followed up with MRI.
Leiomyomas are usually hypointense compared with the
myometrium on both T1WI and T2WI. They are, however, best
demonstrated on T2WI (Figure 5). A variety of degenerative
processes can change the typical signal characteristics. Types of
degeneration include hyaline, myxoid, haemorrhagic, cystic,
calcific and sarcomatous transformation. Small areas of low
signal (signal voids) on both T1WI and T2WI are produced by
the presence of calcification or by fast-flowing blood within
vascular fibroids. Haemorrhage can be identified as high signal
on T1WI. Most leiomyomas enhance less than the adjacent
myometrium and degenerated areas may not enhance at all. This
Sagittal and axial T2WI magnetic resonance image of large intra-mural (white asterisk) and smaller subserosal leiomyomas.
Figure 5
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:10
REVIEW
indicates the presence of necrosis. Very rarely, leiomyomas may
undergo malignant transformation. MRI cannot reliably differ-
entiate this from benign degeneration; however, an irregular
margin may indicate malignancy.
There is no role for CT in the assessment of leiomyomas. They
are often seen as an incidental finding as diffuse uterine
enlargement. They have variable attenuation when compared
with enhanced myometrium. Pedunculated leiomyomas may
appear to be adnexal rather than uterine masses.
Malignant uterine conditions
Approximately 90% of uterine carcinomas are adenocarcinomas
arising from the uterine epithelium. Other potential histological
subtypes are adenocarcinomas with squamous differentiation,
adenosquamous carcinoma, clear cell carcinoma and serous
papillary carcinoma. Uterine sarcomas only account for 2e5% of
malignant uterine tumours. Primary uterine lymphoma presents
in only 1% of patients with lymphoma. Uterine metastases from
non-gynaecological neoplasms are rare.
Endometrial carcinoma Endometrial carcinoma is the most
common invasive gynaecologic malignancy. It presents as post-
menopausal bleeding, often at an early stage when standard
treatment is total abdominal hysterectomy and bilateral salpingo-
oophorectomy.
On US, endometrial carcinoma is seen as a thickened endo-
metrium (>5 mm in a post-menopausal patient). On sonohys-
terography, endometrial carcinoma may be seen as an
intrauterine polyp or asymmetrical thickening of the endome-
trium. It is, therefore, impossible to distinguish between benign
endometrial polyps, endometrial hyperplasia and stage IA
endometrial carcinoma using US alone (Figures 6 and 7). An
endometrial biopsy is required.
The definitions of the T categories of the TNM (Tumour, Node,
Metastasis) staging system for endometrial cancer are based on the
stages accepted by the Fédération Internationale de Gynécologie et
d’Obstétrique (FIGO). Prognosis and treatment depend on the
stage of disease. The depth of myometrial invasion is probably the
274 Ó 2009 Elsevier Ltd. All rights reserved.
 REVIEW
Figure 6 Transvaginal ultrasound demonstrating endometrial thickening
(white arrows) secondary to a polyp.
single most important prognostic factor as it correlates with
tumour grade, extension into the cervix and the prevalence of
lymph node metastases. MRI is the technique of choice for local
staging of endometrial carcinoma and is used to predict the depth
of myometrial invasion, cervical stromal invasion, lymph node
involvement and metastatic disease (Figure 8). It can also provide
further useful information, guiding whether the surgical approach
is transabdominal, transvaginal or laparoscopic. Radiologists
should, therefore, report the size of the uterus, the tumour volume,
the presence of ascites and adnexal pathology.
On unenhanced T1WI, endometrial carcinoma is isointense
with the normal endometrium. Although endometrial carcinoma
may demonstrate high signal intensity on T2WI, it is usually
heterogeneous and may even be hypointense. Dynamic post-
contrast T1WI, in the sagittal plane, is essential for the evaluation
of myometrial extension. Typically, there is early enhancement
of endometrial cancer relative to the normal endometrium. In the
later phases of enhancement, the tumour appears hypointense
relative to the myometrium. On T2WI, if the JZ is intact, deep
myometrial invasion is excluded.
CT is valuable in detecting upper abdominal lymphadenop-
athy and distant metastases. 18F-FDG PET/CT is useful in
assessing nodal disease and distant metastases and has a role in
monitoring treatment response.
Cervix
Benign cervical disease is most often diagnosed on clinical exam-
ination alone without need for imaging. The main role for imaging
is staging biopsy proven cervical carcinoma. MRI is the imaging
Figure 7 Transvaginal ultrasound of endometrial thickening secondary to
endometrial carcinoma.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:10
investigation of choice. US is unable to adequately view the cervix
and parametrial tissues even on transvaginal examination. CT can
only demonstrate gross soft tissue changes in the cervix.
Cervical carcinoma
Cervical carcinoma is the third most common gynaecological
malignancy. Deaths from cervical cancer have declined over the
past 50 years, predominantly due to the development of the
Papanicolaou smear and the cervical screening programme.
Established risk factors for cervical cancer include early sexual
activity, especially with multiple partners and, therefore, infec-
tion with human papilloma viruses 16 and 18, cigarette smoking
and immunosuppression. If not detected on screening, patients
present with abnormal per vaginum bleeding, especially after
intercourse, and vaginal discharge.
Although US examination has no role in the assessment of
cervical tumours, complications of parametrial spread causing
hydronephrosis or tumour obstructing the endocervical canal
producing a distended uterine cavity can be readily demon-
strated. CT is used to stage advanced cervical carcinoma,
demonstrating distant and nodal disease. However, for local
staging including parametrial extension, MR imaging is the
investigation of choice.
MRI of primary cervical carcinoma has four main aims:
assess the volume of primary tumour; identify parametrial
extension; local pelvic nodal involvement; and local extension
to other organs. Intravenous gadolinium is not routinely
administered for staging but can be helpful to demonstrate
fistulous tracts between adjacent organs. The accuracy of MRI
for tumour size within 0.5 cm ranges between 70% and 90%.
Cervical tumours are best demonstrated on T2WI where they
appear as soft tissue mass lesions, which can be exophytic or
infiltrating, of intermediate signal intensity in contrast to the
normal low signal cervical stroma. MRI is used to stratify
patients into those who are amenable to primary surgery (stage
IeIIA) from those with later stage disease, by assessing the
presence of parametrial extension (stage IIB) and evidence of
pelvic nodal disease. Parametrial invasion is present when
there is full thickness stromal invasion and spiculated tumour
extension into the parametria. This can be best assessed on
axial oblique images and for confident demonstration of para-
metrial invasion, soft tissue extension or encasement of the
periuterine vessels is needed. For larger cervical tumours there
is a higher rate of false-positives in assessment of parametrial
invasion because of stromal oedema. An intact low signal
intensity cervical stroma has been shown to have a negative
predictive value of 94e100%. Later stages of cervical carci-
noma include extension to the lower third of the vagina (IIIA),
extension to the pelvic side-wall or hydronephrosis (IIIB).
Invasion into the bladder or rectum represents stage IV disease
and is demonstrated by high signal intensity tumour on T2WI
infiltrating the low signal bladder stroma or rectal wall
(Figure 9).
After treatment of the cervical tumour as well as decrease in
the volume of tumour there are signal changes of the tumour
itself and the surrounding soft tissues. The tumour becomes
more fibrotic and has lower signal intensity. Assessment of
previous parametrial invasion can be difficult and intravenous
gadolinium administration can be helpful. Return to the normal
275 Ó 2009 Elsevier Ltd. All rights reserved.
 REVIEW

Sagittal T2WI and dynamic contrast enhanced magnetic resonance images of an endometrial carcinoma (white arrow). Less than 50% myometrial
invasion is seen but there is invasion of the cervical stroma, stage II (FIGO 2009 classification).

Figure 8

zonal pattern of the cervix following treatment is a reliable
indicator of good disease response. Cervical os stenosis is
a complication following radiotherapy treatment, which can
easily be demonstrated on MRI.
Adnexa
Characterisation of adnexal lesions
US is the first imaging test of choice for the detection and char-
acterisation of adnexal masses. Although US has a high sensi-
tivity for the detection of malignancy, it has a variable specificity
of 92e96.6%. US features that give rise to suspicion for malig-
nancy include wall irregularity, thick septations (>3 mm),
papillary projections, solid components, size (>4 cm) and pres-
ence of ascites (Figure 10). Colour Doppler US assesses tumour
neovascularity. New blood vessels are fragile and on duplex have
a characteristic waveform with a low resistive index (RI <0.4).
MRI remains predominantly a problem-solving modality in
evaluating adnexal masses following inconclusive pelvic US. MRI
is able to characterise ovarian lesions that are indeterminate on
US due to the specific signal intensity characteristics of ovarian
lesions (Table 1). The signal intensity of a specific tumour
depends on the presence, type and extent of cystic and solid
components within a lesion. For example, simple cystic lesions
have a homogeneous low signal on T1WI and high signal
intensity on T2WI. Fat and haemorrhage both have high signal
intensity on T1WI. Fat suppression is, therefore, utilised to
differentiate between the two by causing signal intensity to drop
if the lesion contains fat. Thus, if the lesion becomes low signal
following fat suppression, this gives the diagnosis of a mature
cystic teratoma. However, if following fat suppression the lesion
remains of high signal intensity, the diagnosis of haemorrhage is
made, representing either a haemorrhagic cyst or endometrioma.

Sagittal and axial T2WI of a bulky stage IV cervical carcinoma (white asterisk), with parametrial, bladder (white arrow) and mesorectal fascia
invasion (black arrow).

Figure 9

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:10 276 Ó 2009 Elsevier Ltd. All rights reserved.
 REVIEW
Figure 10 Transvaginal ultrasound of a complex ovarian cyst containing
multiple internal septations with irregular thick walls and mural nodules.
This appearance is highly suspicious for malignancy.
An adnexal mass of low or intermediate signal intensity on
T1WI and low signal intensity on T2WI is suggestive of the
presence of fibrotic and smooth muscle components. The
differential diagnosis then includes pedunculated leiomyoma,
fibroma, fibrothecoma, cystadenofibroma and Brenner tumours.
Ovarian cysts
Physiological cysts are common and include follicular cysts in
the first 2 weeks of the menstrual cycle and corpus luteal cysts in
the latter half of the cycle.
US is sensitive in the assessment of ovarian cysts. Benign
cystic lesions are usually less than 10 cm, unilocular, hypoechoic
and unilateral (Figure 11a and b). Haemorrhage within a cyst is
seen as low level echogenicity within the lesion. Physiological
cysts commonly resolve spontaneously and, therefore, should be
re-examined on US in a 6e8 weeks time interval to ensure
resolution.
Serous cystadenoma is the second most common benign
tumour of the ovary after dermoid cysts. These are typically
unilocular, thin-walled cysts, which can measure up to 20 cm.
Mucinous cystadenoma present as large multilocular cystic
lesions, which contain multiple fine septations. If the cyst protein
a Ultrasound showing a large simple ovarian cyst. b T2WI sagittal magnetic resonance image of a simple ovarian cyst (black asterisk).
No internal septations or nodules.
Figure 11
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:10
content is high, cysts may be high signal on T1WI and high
attenuation on CT. If mucinous tumours rupture, this can lead to
pseudomyxoma peritonei.
Endometriosis
Endometriosis is the presence of endometrial epithelium and
stroma in ectopic position outside the uterus. It is benign but is
debilitating due to associated pain and infertility. Laparoscopy is
the gold standard investigation assessing endometrial implants
within the abdomen as well as the pelvis. US may demonstrate
a mass with diffuse low level internal echoes or possibly con-
taining a fluid-fluid or fluid-debris level (Figure 12a). However,
MRI is highly specific (98%) in the diagnosis of endometriosis.
Typical MRI findings in endometriomas are multiple cystic
masses of homogeneous high signal intensity on T1WI and low
signal intensity on T2WI. Shading, which is varying loss of
signal, on T2WI is due to iron or protein within a cyst. Endo-
metriomas may also demonstrate high signal intensity on both
T1WI and T2WI due to blood products within the lesion
(Figure 12b). The lesion remains of high signal intensity after fat
suppression, which also excludes dermoids from the differential
diagnosis (lose signal intensity and appear dark). Haemorrhagic
cysts are commonly unilocular, unilateral, resolve with time and
do not demonstrate shading on T2WI. Endometriotic implants
commonly appear as solid masses or spiculated bands of inter-
mediate to low signal intensity on both T1WI and T2WI due to
fibrosis (Figure 13).
Mature cystic teratoma (dermoid cyst)
This benign germ cell tumour commonly presents as a pelvic
mass or with pain secondary to torsion or haemorrhage. US is the
first investigation of choice and frequently demonstrates
a complex mass containing echogenic components. An echogenic
focus with posterior acoustic shadowing, representing calcifica-
tion, and a fat-fluid level may be detected (Figure 14). Mature
cystic teratomas have characteristic findings on MRI, which
include: a mass of high signal intensity on T1WI and interme-
diate signal intensity on T2WI, fat-fluid and/or fluid-fluid levels,
277 Ó 2009 Elsevier Ltd. All rights reserved.

a Transvaginal ultrasound of an adnexal lesion with diffuse low level echoes. b Axial T2WI magnetic resonance image demonstrating intermediate
to high signal intensity within an endometrioma (white asterisk). Signal characteristics secondary to presence of blood products.
Figure 12
layering debris, low-signal-intensity calcifications (e.g. teeth) and
soft-tissue protuberances (Rokitansky nodules or dermoid plugs)
attached to the cyst wall. There is a drop in signal intensity on
fat-suppressed T1WI. Dermoids are often identified as incidental
findings on CT, clearly demonstrating a fat-fluid level and the
presence of calcification or teeth (Figure 15).
Ovarian carcinoma
Ovarian carcinoma is the second most common malignancy of
the female reproductive tract. It carries a poor prognosis, with
survival rates as low as 29% for stage IV disease and is the most
frequent cause of death from gynaecological malignancy.
Ovarian cancer predominantly affects postmenopausal women.
The aetiology is unknown but a genetic predisposition is seen in
carriers of mutated BRCA-1 and BRCA-2. Factors that have been
Figure 13 Axial T2WI magnetic resonance image demonstrating ‘kissing
ovaries’ (white asterisks) secondary to endometriotic implant.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:10
REVIEW
identified as protective against ovarian carcinoma include:
chronic anovulation, oral contraceptive pill usage, previous
breastfeeding and multiparity.
Ovarian cancers can be divided into epithelial (90%) and non-
epithelial. Malignant epithelial tumours are classified as serous
(50%), mucinous (20%), endometrioid (20%), clear cell (10%) or
undifferentiated (1%). ‘Borderline’ epithelial tumours have
similar features to a malignant tumour but no invasion and have
a better prognosis. Non-epithelial cancers include germ cell
tumours, sex cord stromal tumours and a miscellaneous group.
Germ cell tumours are made up of teratomas (which can be benign
or malignant), dysgerminomas, yolk sac tumours, choriocarci-
nomas and gonadoblastomas. Sex cord stromal tumours include
granulose cell tumours, thecomas and Sertoli-Leydig cell tumours.
Transcoelomic peritoneal spread is the most common route
for spread of disease giving nodular or plaque-like peritoneal
implants. Ascites is a non-specific finding but, in a patient with
proven ovarian cancer, usually indicates peritoneal metastases.
Typical sites for peritoneal deposits include the pouch of Doug-
las, paracolic gutters, surface of the small and large bowel,
greater omentum, surface of the liver and subphrenic or
Figure 14 Transabdominal ultrasound of an adnexal lesion revealing
a complex cystic lesion containing debris.
278 Ó 2009 Elsevier Ltd. All rights reserved.
 REVIEW

Figure 15 Axial computed tomography of a large dermoid with a fat/fluid

level (white arrow) and a calcified nodule (black asterisk).

perisplenic space, gastrosplenic, gastrocolic and gastrohepatic

ligaments, porta hepatis and lesser sac. Subcapsular liver
implants indent the liver giving a well-circumscribed, scalloped
appearance. However, true intraparenchymal liver metastases
are often ill-defined, circular and partially or completely sur-
rounded by liver tissue. Haematogenous spread to the liver is
unusual but is important to distinguish from subcapsular
deposits as this represents stage IV disease.
US is useful in the detection and characterisation of adnexal
masses but has no role in staging. In addition, US can guide
biopsy of adnexal or peritoneal masses in patients deemed
unsuitable for primary surgery.
There are no specific MRI signal characteristics for malignant
epithelial tumours. However, MRI features that are most predictive
of malignancy include: size greater than 4 cm, irregular wall
thickness >3 mm, an enhancing solid component or vegetations
within a cystic lesion, septa >3 mm, the presence of necrosis within
a solid lesion, as well as presence of ascites and peritoneal deposits.
a Peritoneal deposits in the gastrosplenic ligament, falciform ligament
CT is currently the modality of choice in staging ovarian and perihepatic location (white arrows). b Metastatic deposits in the
cancer and can also be used to guide biopsy of peritoneal or greater omentum (white arrow) and right paracolic gutter (black arrow).
adnexal disease. CT provides information on the primary c Subcapsular liver deposits of ovarian carcinoma (white arrow).

Figure 17

Figure 16 Computed tomography demonstrating bilateral ovarian masses
(white arrows) and peritoneal deposits (black arrow).
tumour, the site and size of peritoneal deposits and the presence
of enlarged lymph nodes and ascites. This information stratifies
those patients with non-resectable disease for whom neo-
adjuvant chemotherapy would be beneficial from those patients
who should undergo primary cytoreductive surgery. The primary
ovarian tumour may be seen as mixed solid/cystic tumours,
which are often bilateral, or as multilocular cystic lesions with
thick internal septations and solid mural or septal components
(Figure 16). Assessment can often be made as to whether the
tumour is invading the pelvic side wall or rectosigmoid colon or
bladder and identify associated complications such as hydro-
nephrosis and bowel obstruction. Peritoneal deposits can be
clearly identified e usually seen as discrete enhancing soft tissue

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:10 279 Ó 2009 Elsevier Ltd. All rights reserved.
 REVIEW
Figure 18 Transabdominal ultrasound reveals a complex adnexal mass
with echogenic walls and fluid containing low level echoes.
nodules (Figure 17aec). Liver, lung and renal metastases and
malignant pleural effusion indicate stage IV disease.
FDG-PET/CT is of value in cases of suspected recurrence
where there is an increase in tumour markers but indeterminate
findings on CT or MRI.
Miscellaneous
Pelvic inflammatory disease
Pelvic inflammatory disease is an ascending infection from the
vagina or cervix into the endometrium, fallopian tubes and
adnexa. Complications include adhesions causing pyosalpinx
and hydrosalpinx, which can be identified as hypoechoic,
serpentine adnexal masses on US. CT and MRI can also
demonstrate fluid-filled tubular structures. MRI can characterise
the fluid contents of the dilated tube, for example high signal
intensity fluid on T1WI is suggestive of endometriosis. Hetero-
geneous signal intensity within a thick-walled tube suggests the
presence of a pyosalpinx. This may then form tubo-ovarian
abscesses, which are often seen as complex adnexal masses with
thick echogenic walls on US (Figure 18); CT and MRI may show
an adnexal soft tissue mass containing fluid components, with
thick, irregular walls (Figure 19).
Ovarian torsion
The most common finding on US in ovarian torsion is the pres-
ence of an ovarian mass. Colour and power Doppler imaging are
used to assess vascularity. However, the presence of arterial
Figure 19 Computed tomography of a tubo-ovarian abscess seen as a left
adnexal mass (black arrows) with solid and fluid components.
OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:10
Figure 20 Transabdominal ultrasound of an enlarged right ovary,
measuring 10  8 cm with multiple follicles and corpus lutea in ovarian
hyperstimulation syndrome.
blood flow does not exclude torsion, due to the dual blood supply
by the ovarian and uterine artery and also the possible inter-
mittent nature of torsion. On either CT or MRI, the adnexal mass
can be demonstrated with concentric wall thickening with the
uterus deviated towards that side. Haemorrhagic infarction of the
torted adnexa can be demonstrated with areas of haemorrhage
seen within the mass, thickening of the wall of the mass and
ipsilateral fallopian tube and free fluid within the pelvis.
Ovarian hyperstimulation syndrome (OHSS)
US examination of patients undergoing ovarian stimulation is
important not only to visualise the hyperstimulated ovaries but
also to identify ascitic or pleural fluid. The ovaries are typically
massively enlarged bilaterally and multicystic with multiple
follicles and corpus lutea (Figure 20). The ovarian stroma is also
oedematous. Examination with imaging techniques other than
US is not normally needed because of the clear clinical history.
Ectopic pregnancy
Patients presenting with adnexal pain and a positive beta human
chorionic gonadotrophin (hCG) test should undergo US examina-
tion, not only for diagnosis but also to guide the most appropriate
treatment option. The definitive diagnosis is made in the absence
of an intrauterine pregnancy and an extrauterine gestation sac can
be identified. Haemoperitoneum may be identified as free fluid on
transabdominal US. Transvaginal US examination is usually
required unless the patient is unstable and the diagnosis has been
clearly made on transabdominal images. The endometrium is
commonly thickened and may contain a decidual cyst between the
endometrium and myometrium or a pseudogestational sac. Pseu-
dosacs are seen in approximately 20% of ectopic pregnancies and
are demonstrated as heterogeneous fluid collections seen centrally
within the endometrial cavity. The most common site of ectopic
pregnancy is between the ovaries and the uterus, within the fal-
lopian tubes. Direct visualisation of the ectopic pregnancy can be
difficult and in decreasing order of specificity include a tubal ring
with a yolk sac and embryo, a tubal ring with a yolk sac only,
a tubal ring alone or a complex adnexal mass seen separate to the
ovary. Clinical correlation and serial beta hCG levels are important
because of the possibility of a falsely negative US, very early
intrauterine pregnancy or rare form of ectopic pregnancy such as
scar, abdominal or cervical ectopic pregnancy. A
280 Ó 2009 Elsevier Ltd. All rights reserved.
 REVIEW

FURTHER READING Jeong YY, Outwater EK, Kang HK. Imaging evaluation of ovarian masses.
Russell JB. Uterine surgery. In: Gerhensen DM, DeCherney AH, Curry SL, eds. Radiographics 2000; 20: 1445e70.
Operative gynaecology. Philadelphia: WB Saunders; 1993. p. 363e4. Hricak H, Chen M, Coakley FV, et al. Complex adnexal masses: detection
Tamai K, Togashi K, Ito T, Morisawa N, Fujiwara T, Koyama T. MR imaging and characterization with MR imagingemultivariate analysis. Radi-
findings of adenomyosis: correlation with histopathologic features ology 2000; 214: 39e46.
and diagnostic pitfalls. Radiographics 2005; 25: 21e40. Kim MY, Rha SE, Oh SN, et al. MR imaging findings of hydrosalpinx:
Mark AS, Hricak H, Heinrichs LW, et al. Adenomyosis and leiomyoma: a comprehensive review. Radiographics 2009; 29: 495e507.
differential diagnosis with MR imaging. Radiology 1987; 163: 527e9. Kaakaji Y, Nghiem HV, Nodell C, Winter TC. Sonography of obstetric and
Verkauf BS. Myomectomy for fertility enhancement and preservation. gynecologic emergencies: part II, gynecologic emergencies. AJR Am J
Fertil Steril 1992; 58: 1e15. Roentgenol 2000; 174: 651e6.
Murase E, Siegelman ES, Outwater EK, Perez-Jaffe LA, Tureck RW. Uterine Kimura I, Togashi K, Kawakami S, Takakura K, Mori T, Konishi J. Ovarian
leiomyomas: histopathologic features, MR imaging findings, differ- torsion: CT and MR imaging appearances. Radiology 1994; 190:
ential diagnosis, and treatment. Radiographics 1999; 19: 1179e97. 337e41.
Sala E, Wakely S, Senior E, Lomas D. MRI of malignant neoplasms of the Levine D. Ectopic pregnancy. Radiology 2007; 245: 385e97.
uterine corpus and cervix. AJR Am J Roentgenol 2007; 188: 1577e87.
Hricak H, Lacey CG, Sandles LG, Chang YC, Winkler ML, Stern JL. Invasive
cervical carcinoma: comparison of MR imaging and surgical findings.
Radiology 1988; 166: 623e31.
Subak LL, Hricak H, Powell CB, Azizi L, Stern JL. Cervical carcinoma:
Practice points
computed tomography and magnetic resonance imaging for preoper-
C US is the primary imaging modality in the initial assessment of
ative staging. Obstet Gynecol 1995; 86: 43e50.
suspected gynaecological pathology
Togashi K, Nishimura K, Itoh K, et al. Uterine cervical cancer: assessment
C MRI has excellent soft tissue contrast and high spatial reso-
with high-field MR imaging. Radiology 1986; 160: 431e5.
lution. It is, therefore, superior to CT in the assessment of
Kaur H, Silverman PM, Iyer RB, Verschraegen CF, Eifel PJ, Charnsangavej C.
female pelvic disease
Diagnosis, staging, and surveillance of cervical carcinoma. AJR Am J
C MRI is accurate in the local staging of uterine and cervical
Roentgenol 2003; 180: 1621e31.
carcinomas
Bourne TH, Campbell S, Reynolds KM, et al. Screening for early familial
C Specific MRI signal characteristics are utilised in the charac-
ovarian cancer with transvaginal ultrasonography and colour blood
terisation of adnexal lesions when the US findings are inde-
flow imaging. BMJ 1993; 306: 1025e9.
terminate. See Flow diagram
Tailor A, Bourne TH, Campbell S, Okokon E, Dew T, Collins WP. Results
C The main role of CT is in the diagnosis of tubo-ovarian abscess
from an ultrasound-based familial ovarian cancer screening clinic:
and evaluation of post-surgical complications
a 10-year observational study. Ultrasound Obstet Gynecol 2003;
C CT is the imaging modality of choice in the staging and follow-
21: 378e85.
up of ovarian carcinoma
Woodward PJ, Sohaey R, Mezzetti Jr TP. Endometriosis: radiologice
C CT also identifies distant metastases, lymphadenopathy and
pathologic correlation. Radiographics 2001; 21: 193e216.
recurrent pelvic tumours in other gynaecological malignancies
Togashi K, Nishimura K, Itoh K, et al. Ovarian cystic teratomas: MR
imaging. Radiology 1987; 162: 669e73.

OBSTETRICS, GYNAECOLOGY AND REPRODUCTIVE MEDICINE 19:10 281 Ó 2009 Elsevier Ltd. All rights reserved.