… or instrumentation? Is there a history of unusual exposures, including diethylstilbestrol exposure in utero? Are coexisting medical conditions present? …

can be seen (Fig 6). Often, fluid-debris levels are noted (Fig7). However, the diagnostic require- mentsforidentifi cation ofendometriomas with US differamong investigators. Pateletal (4) performed an independent review of US features for distinguishingendometriomas and other adnexal masses and concluded that”the presence of diffuse low-level internal echoes is the important feature that helps discriminate anendometrioma from other lesions “and”cystic US features (definable wall and increased acoustic transmission) did not improve diagnostic performance once diffuse low-level echoes had been recognized. ” Adenomyosisisa related condition in which there is functional endometrial tissue within the myometrium. The US appearance of adenomyo- sis includes myometrial cysts, ill-defined areas of myometrialechotexture, heterogeneous and dis- tortedmyometrialechotexture, and a globular or enlarged uterus with asymmetry (5-7) (Fig 8). Leiomyomas, which are also called fibroids , affect nearly one-fourth of women of reproductive age. Leiomyomasare more prevalent among black women than among white women. The most common symptom is heavy vaginal bleeding. Since a leiomyoma is a proliferation of smooth muscle surrounded by a pseudocapsule, unopposed estrogens may accelerate its growth. Leiomyomasare characterized by the layer they occupy, whether submucosal (orsubendome- trial), intramural within the myometrium, or sub- serosal (Figs 9,10). Intramural lesions do not involve the endometrial cavity, whereas submucosal lesions are intracavitary and are best detected with saline hysterosonography. Leiomyomasare often heterogeneous in echogenicity and attenuate sound. Hypoechoicareas within a leiomyoma may represent cystic degeneration (Fig 11). Uterine artery embolization is a definitive therapy for uncontrollable bleeding. When leiomyomasaredevascularized, they undergo in- farctionwiththe resultant formation of small ni- trogenbubblesin theleiomyoma. These bubbles appear as multiple punctateechogenic foci, giving theleiomyomaa speckled appearance (Fig 12). Tranquartetal (8) observed that uterine artery embolization resulted in”marked reduction in fibroid size and disappearance of intra-fibroid Figures6,7. (6) Sagittal US image of the left ovary shows a cystic mass with diffuse low-level internal echoes, an appearance consistent with anendometrioma. (7) Sagittal US image shows a multiloculated mass with fluid-debris levels, which was initially thought to be a tubo-ovarian abscess. A surgical specimen demonstratedendometriomas. Figure8. Transverse US image shows an enlarged, globular, diffusely heterogeneous uterus, an appear- anceconsistent with adenomyosis. 706 May-June 2003 RGf Volume 23?Number 3 ….

Fluid-filled fallopian tubes, pyo-orhydrosal- pinx, are well demonstrated with US (Figs 14, 15). Low-level echoes are more commonly encountered in pyosalpinx due to the higher protein content of the debris within the tube. Overall, serpentine, dilated tubes are typically present, which maybe anechoic or contain low-levelech- oes. In general, the tube maybe seen coursing from the ovary to the uterus. This entity maybe further complicated by a tubo-ovarian abscess, in which a multiloculated appearance of the ovary is found, with the loculi containing simple fluid or debris (Fig 16) (11). Hyperemia of the ovarian tissue is typically present. Cervical carcinoma is an additional consideration (Fig 17), especially in asexually active patient, and is best evaluated at clinical examination. Pregnant Patients US examination of the pregnant patient with bleeding begins with confirmation of an intrauter- inepregnancy. Visualization of a gestational sac containing a yolk sac equates with an intrauterine pregnancy (Fig 18). Ectopic pregnancy occurs with a prevalence of 1.4%and accounts for one-fourth of maternal deaths. Vaginal bleeding, a palpable adnexal mass, and pelvic pain makeup the classic clinical triad. Risk factors include infertility, prior ectopic pregnancy, a history of tubal surgery, and prior pelvic inflammatory disease (PID). Kamwendoet al (10) studied standardized population statistics and the prevalence of ectopic pregnancy and PID between 1970and 1997. They determined thata …

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