Hysterosalpingography
delineates uterine cavity by injecting radioopaque iodinated contrast material into uterine cavity through uterus
- Ionizing radiation
- Can visualize flow of contrast through uterus and fallopian tubes
- Complications= cramping, pain, bleeding, infection, allergic reactions, intravasation of contrast medium into myometrium, embolization, irradiation of early pregnancy (inadvertant)
Ultrasound: indications
#1 imaging modality for female pelvis - Transabdominal and Transvaginal
Indicated for
-Pelvic pain, pelvic mass, vaginal bleeding, disorder of menstruation, pressure symptoms on urinary bladder, infertility, evaluation of uterus or adnexa
Common diagnoses:
- Uterine fibroids, Endometrial disorders, IUD localization, uterine congenital anomalies, ovarian masses (cysts, endometriomas, dermoid cyst of ovary, neoplasms, torsion), ectopic pregnancy, tuboovarian abscess, hydrosalpinx
Transabdominal ultrasound: advantages and disadvantages
Method: sends sound beam through distended bladder (acoustic window for reproductive organs)
- Evaluation of: large uterus, adnexal masses, masses high in pelvis
- Advantages= larger field of view, general pelvic overview, distended bladder displaces bowel loops (moves them out of plane of view), can take multiple scan planes
- Disadvantages: full bladder discomfort, structures deeper (further from probe), less resolution (needs lower frequency transducer to probe further)
Transvaginal ultrasound: advantages and disadvantages
Method: performed through vagina with empty bladder
Advantages: empty bladder, structures closer, better resolution
Disadvantages: smaller field of view, limited mobility of transducer, vaginal narrowing (virginal, postmenopausal, etc)
Doppler ultrasound
Evaulation of blood flow in uterus
Demonstrates vascularity in a mass
- Can not separate benign from malignant masses in pelvis
Sonohysterography
Sterile saline injected into endometrium: fluid outlines contents of endometrial cavity
Evaluates: uterine anoalies, endometrial hyperplasia, endometrial polyps, submucous myomas
Not good for: tubal disease evaluation (needs contrast material that are not FDA approved)
Ultrasound in pregnancy
5 Weeks: gestational sac
5.5 weeks: yolk sac visible (transvaginal)
6 weeks: embryo, heart beat (visible when crown rump length is 5 mm)
Indications for 1st trimester ultrasound
- Confirm presence/absence of IUP
- Estimate gestational age
- Confirm cardiac activity
- Ectopic pregnancy
- Cause of vaginal bleeding
- Multiple gestations
- Maternal pelvic masses, uterine abnormalities
- Ovarian hyperstimulation
- Hydatidiform mole (concern when beta-hcg is high- could also be twins)
CRL (Crown-Rump length)
Measure from crown to rear: accurate method of pregnancy dating
Indications for 2nd/3rd trimester ultrasound
- Gestational age
- Fetal anomalies
- Multiple gestation
- Fetal presentation
- Cause of vaginal bleeding, pelvic pain
- Pelvic masses
- Suspected fetal demise
- Fetal growth and well-being
- Incompetent cervix
- Amniotic fetal disorders
- Placental abnormalities
- 80-85% sensitivity, but normal scan does NOT mean that fetus is normal
CT of female pelvis
Evaulate:
- Pelvic pain
- Pelvic masses/fluid collections
- Abnormalities of pelvic vascular structures
- Pelvic trauma evaluation
- Cancer staging, monitoring
** avoid in pregnancy if possible- but NOT absolute contraindication (clinical benefits to mother may outweigh risks)
PET-CT
Not used for breast cancer SCREENING, but used for staging
MRI of female pelvis
Adjunctive test for COMPLEX PROBLEMS (problem solving) when ultrasound inconclusive
Used for:
- staging cervical, uterine, vulvar, vaginal carcinoma
- more sensitive than CT in gynecological malignancy evaulation (differentiates from scarring)
** In pregnancy: Pelvic malignancy (avoiding radiation of CT). Ultrafast MR used for fetal and maternal anatomies without sedation (can visualize fetal CNS, malformations)
Contrast agent= gadolinium (crosses placenta, therefore avoid in pregnancy)
X-ray mammography
Recommended screening for breast cancer detection (low radiation)
- Screening: 2 views on each breast
- craniocaudal and mediolateral oblique
- Diagnostic: extra views if something detected in screen (10% recall rate, 15-35% positive predictive value)
- can detect tumors < 1 cm
Indications for mammography
ACS: every year after age 40
NCI: 1-2 years after 40, annual after 50
Patients with 1st degree relatives (premenopausal breast cancer): ten years before relative diagnosed
- AVOID in patients under 30 (use ultrasound)
Sensitivity of X-ray mammography
75%
Women <40: 55%
65+ years: 81-94%
Breast MRI indications
- Post-surgical breast (scarring vs tumor)
- Evaluate breast implants
- Stage known breast cancer (pre-adjuvant chemo or surgery)
- Follow-up on breast cancer
- Evaluation of ambiguous findings
- Annual screening in younger women:
- Genetic predisposition (BRCA)
- History of mediastinal irradiation
- Disadvantages: expensive, time-consuming, poorly tolerated, IV contrast (reactions), detects TOO MANY lesions (mostly benign), expertise not widely available)
Digital tomosynthesis
Multiple images of breast (arcing imaging- pivots)
- 2 x level of radiation due to more images taken
Molecular imaging
Molecule that binds to cancer cells injected into patient and traced based on signal emitted when it binds.
- Same dose of radiation as CT
- Can NOT image posterior breast (can’t be tightly compressed due to length of test)
