Chapter 3. Ovaries and Adnexa

Women’s Point of Care Ultrasound

Chapter 3 describes techniques to identify and describe ovaries and other adnexal structures.

Objectives:

By the completion of this Chapter the participant will be able to:

Identify adnexal structures correctly, including ovaries, iliac vessels, bowel

Locate and measure ovaries

Differentiate between simple cysts (or follicles) and complex cysts; identifying characteristics that require referral for more advanced management

BOWEL

Although the bowel is typically not the structure of interest when doing a pelvic ultrasound, it Is important to identify it and discriminate it from the other pelvic structures we need to view. The bowel can not only appear like a mass or ovary, but it can also obscure other pelvic structures. A bowel loop appears very nondescript in shape – often as irregular cylinder with mixed echogenicity. The bowel loops closely behind and above the uterus (especially when the bladder is empty). If you are uncertain that a structure is a section of bowel, just continue to observe it for a minute or two. If you see movement inside it, you know this is peristalsis and therefore the structure is bowel.

Bowel can often have gas inside it, which appears very cloudy and obscures visualization of surrounding structures.

Figure 1. Image of bowel in adnexa

Bowel gas

Bowel can often have gas inside it,, which appears very cloudy and obscures visualization of other pelvic structures. When this is seen, it is best to have the woman walk around, empty her colon (if possible), and rescan. Sometimes gentle pressure on the abdomen will help move gas out of the way.

Figure 2. Image of bowel gas. Image 2

If the bowel is full, it can be difficult to view the uterus well, as in this image. The red line in the Figure 3 below indicates the uterine borders.

Figure 3. Isoechoic appearance of uterus and bowel, Image 3

In Figure 4 (below), bowel containing fluid (hypoechoic areas) and mixed echogenicity, seems to fill the cul-de-sac. At first, the still image might seem like it has cystic structures. Only by observing this in real-time can you distinguish the ovary from the bowel with certainty.

The area colored in pink is actually the ovary. We know this because its contents do NOT move with peristalsis while we are watching, while the other areas do move.

Figure 4. Images demonstrating difficulty of discriminating bowel from ovary, Images 4-5

Ovaries

Ovaries are distinct ovoid structures that are slightly less echogenic (darker) than myometrium and the tissue around the ovary. They are usually seen lateral and slightly posterior to the uterus.

One of ways an ovary can be identified is by the presence of follicles (tiny cysts that contain developing eggs), as seen in the image below. Follicles are usually very round and hypoechoic, indicating that they are fluid-filled. Since the egg itself is microscopic, it is not seen on an ultrasound; the follicle is what is visualized on the scan. The presence of these follicles gives the ovary the appearance of a “chocolate-chip cookie”.

Figure 5. Description and image of typical ovary. Image 6

Finding ovaries can be a difficult task to master at first. Even experienced sonographers have difficulty locating ovaries that are not in the typical positions.

Generally, the region to begin scanning for an ovary is between the uterine fundus and the pelvic sidewall. The ovary is typically medial to the iliac vessels. Precise location is not always predictable, in that sometimes the ovary can be lateral to the uterus and sometimes behind the uterus. Ovaries can even be seen in the cul-de-sac, as seen in Figure 8.

NOTE: An excessively full bladder can force the ovaries out of the posterior pelvic area, making it more difficult to view.

The ovary can be seen to have different shapes as normal variations. Most ovaries assume an ovoid shape, but some are elongated and even boomerang-shaped. It is not uncommon for one ovary to be a different size or configuration than the contralateral ovary.

FIgure 6. Varied shapes of ovaries. Images 7-10

Figure 7. Description of typical location of the ovary. Image 1

1

Although we expect to see ovaries lateral to the uterus, they can sometimes even be seen posterior to the uterus, as shown in the image below. So when looking for ovaries be sure you scan the entire pelvis.

Figure 8. Image of ovary located in the culdesac. Image 12

In the images below in Figure 9, the ovaries are lying VERY close, if not adjacent to the uterus. This raises some concern for us since it might be an indication that the ovaries have adhered to the uterus due to scarring or other pathology. One way to determine this is to put additional pressure in the area of each ovary to see if the ovaries move away from the uterus. If they do not easily slide when proved (appearing to be “stuck” to the uterus), or cause pain with pressure, this could also be a sign of adhesions or scar tissue. This is known as the ”sliding sign”. If the uterus and ovaries appear to move or slide from each other, this is a sign that adhesions are not adhering or restricting these organs. ¹

Figure 9. Images of ovaries close to the uterus. Imaages 13-14

Changing characteristics of ovaries

Ovarian size increases as women reach adulthood, most likely as the ovaries contain viable follicles.^2,3

However, the size decreases after menopause, due to the absence of follicles.

The ovary, like the uterus, fluctuates with stage of menstrual cycle

Day 1-4 after the start of menstruation, the follicular phase, there are usually small follicles, < 1cm, anechoic, round

Days 10-14, during the late follicular or pre-ovulatory period, there is usually one or two dominant follicles, less than 2.5 cm. These are anechoic, thin-walled, and ovoid in shape

Days 15-28, after ovulation, the cyst or follicle that releases the egg transforms into a productive cyst, called the corpus luteum.

NOTE: Women are sometimes told they have an ovarian “cyst” and interpret that as an abnormality, when it actually represents an enlarging follicle (a normal cyclic process). This can happen when she has another type of imaging done (like pelvic CT or MRI), and that modality only describes a fuld-filled structure described as a “cyst”.

Figure 10. Cyclic changes of the ovary. Images 15-17

Corpus Luteum (CL)

The presence of a corpus luteum indicates ovulation has occurred. Its characteristics are described in Figure 11.

The CL walls thicken and take on the function of producing progesterone, causing the endometrium to thicken for implantation of the egg, now on its way to the uterus if conception took place. This corpus luteum can be from 2-8 cm, and often has internal echoes, or fine septations. As the corpus luteum (CL) enlarges, it can cause rupture of some tiny arterioles that bleed into the cyst, causing some small clotting of blood. This is what we describe as a hemorrhagic corpus luteum cyst. The word hemorrhagic is misleading to many women, since they think hemorrhagic means a profuse amount of blood. This tiny amount of blood that may be in the CL is self-contained and usually dissolves over days to weeks. So, a hemorrhagic CL is a benign finding.

The other feature of a CL cyst is often what is called a “ring of fire” when it is viewed with color flow doppler. This highlights the increased vascularity around the CL, appearing like a circle of red/yellow or blue/green. Any increased blood flow to an area like this is an indication of increased blood flow to an actively growing tissue requiring additional circulation. This is a normal finding with a CL.⁴

NOTE: The “Ring of Fire” finding is normal on a CL, but if seen anywhere other than on a CL, it can be an indication of an abnormal finding. Any pelvic structure with such an increased area of surrounding vascularity can be an indication of an ectopic pregnancy or neoplasm (cancer), described later in this chapter.

Figure 11. Description and images of a corpus luteum cyst. Image 18-19

Postmenopausal ovaries

Ovarian size decreases after menopause, due to the absence of follicles. Because of this, ovaries often become more difficult to visualize unless there is obvious pathology. If there is a cyst on a menopausal woman’s ovary, it warrants referral for additional investigation.

Figure 12. Images of postmenopausal ovaries. Images 20-21

Finding ovaries with a transabdominal probe

With a very full bladder and thin patient, you can sometimes see the ovaries using a transabdominal transducer (see the illustration below). If that is the case, it is easier in most cases to turn the transducer into a transverse position. When using the bladder as an acoustic window, you can often see the right ovary better by scanning through the bladder on the woman’s left side. And the opposite is true for the left ovary.

Figure 13. View of imaging the right ovary from the woman’s left side using a transabdominal approach. Image 22

Using a transverse plane to see ovaries.

Sometimes ovaries are seen more easily when using a transverse view of the pelvis rather than a long view.

The illustration below shows imaging from the woman’s right side to see the left ovary in a transverse plane.

Figure 14. View of imaging the left ovary from the woman’s right side using a transabdominal approach. Image 23

Ovarian Volume⁵

Sometimes ovarian volume is beneficial to measure. This is particularly relevant in the case of detecting polycystic ovarian syndrome (PCOS), where one of the diagnostic parameters is increased ovarian volume. Keep in mind, however, that an ovarian cyst can be enlarged when there is a follicle or cyst. In that case, the characteristics of the ovary become more important than the actual size in assessing for PCOS.

When measuring ovarian volume, measure the length and depth by using the longitudinal view usually. Then rotate the probe 90 degrees (while keeping the ovary in view), to get a transverse view to measure the width.

To calculate the ovarian volume, multiply the length by the depth (or height) by the width. Then multiply that number by 0.523 (or to get a rough estimate, you can divide that number by 2)

For example, using the following measurements:

Length – 2.5 cm

Depth – 1.0 cm

Width – 1.3 cm

2.5 X 1.0 X 1.3 = 3.25

3.25 multiplied by 0.523 = 1.69cc volume (3.25 divided by 2 = 1.62)

Figure 15. Description and illustration of measuring ovarian volume.

The table below demonstrates average ovarian measurements, comparing premenopause to postmenopause.³

Average Measurements	Premenopausal	Postmenopausal
Longitudinal	25-40 mm	20 mm
AP (depth or “height”)	15-30 mm	15 mm
Transverse (width)	15-30 mm	10 mm
Volume	6-12 ml	<4 ml

Table 1. Average ovarian measurements comparing premenopause to postmenopause.

The images below (Figures 16 & 17) illustrate all 3 dimensions of viewing the ovary (length, depth and width) needed for the ultrasound’s computer to generate the volume calculation (shown inside the red circle).

Figure 16. Images illustrating sagittal and transverse views to obtain ovarian volume. Images 24-25

The image is another example of an ovary measured in 3 dimensions.

Figure 17. Additional images illustrating sagittal and transverse views to obtain ovarian volume. Images 26-27

FOLLICLES

Sometimes there is a need to measure follicles mid-cycle if the woman is trying to conceive, and the practitioner is providing a baseline diagnosis for infertility. Follicles are also closely monitored throughout reproductive technology treatments. A follicle appears on the ovary as an anechoic (no echoes or totally black) fluid-filled circular structure.

Its increased size correlates with increased estradiol or estrogen in the cycle.

Follicle measurement

Follicles are measured either in 2 dimensions (noting the largest diameter) or by volume (L x H x D). If a follicle is greater than 18mm diameter, it is considered to contain mature egg. If the size is 16-18mm – chance of ovulation is only 37% , compared to a follicle that is greater than 18mm.

Figure 18. Description and images of typical ovarian follicles. Images 28-31

When observing for ovulation, one sign to look for is a single or double smaller cyst inside the follicle. This is illustrated in Figure 19. It is a cyst-like structure on the wall of the dominant follicle. It can occur just prior to ovulation (within 36 hours). It is sometimes called a “daughter cyst” and is a normal finding. It is a sign of a mature follicle.^4,5

Figure 19. Images demonstrating a cumulus oophorus or daughter cyst. Image 32

Ovarian cysts¹

Although the most common type of cyst you will see on an ovary is a follicle, which is a normal function of the ovary in menstruating women, there will be other types of cysts that could indicate a problem.

Cysts are categorized as simple or complex.¹

NOTE: This course does NOT instruct on how to make a definitive diagnosis of an abnormal cyst. It simply provides awareness of descriptors that can identify a cyst requiring further investigation.

A follicular cyst, sometimes called a “functional cyst” is typically round or ovoid, with smooth borders, and is hypoechoic throughout, indicating clear fluid. This is actually a “follicle”.

A benign follicular cyst can be up to 5 cm in size and still be considered normal if the other characteristics are consistent with a cyst. The image below is an example of a simple cyst.

A SIMPLE CYST is defined as a cystic structure with no internal echoes (anechoic or hypoechoic). It does not have internal septae. This represents a benign condition. The ACR (America College of Radiology) states that most women of reproductive age with simple adnexal cysts do not need additional imaging. (REF ACR

However, even a simple cyst, if over 5 cm in longest diameter, should be followed up in about 6 weeks to see if it resolves.¹

The exception to this is if a cyst larger than 1 cm is seen in a post-menopausal woman. This needs to be evaluated with additional imaging.¹

Figure 20. Image of an ovarian cyst/follicle measurement in one diameter. Image 33

Normal variation vs abnormal

The cyst below in Figure 21 is a fairly large cyst (approximately 7 cm) and is a bit irregularly shaped. It is so large that the ovarian tissue around it cannot be identified. It is technically a simple cyst since it is hypoechoic and has no other internal echoes (except some reverberation artifact). However, due to is size, it warrants rescanning in 6 weeks.

Figure 21. Image of a large simple ovarian cyst, demonstrating reverberation artifact. Image 34

Polycystic ovaries

One very common variation you will see in about 10-12% of women is something known as polycystic ovaries.

The word “poly” indicates many, but this does NOT mean that the cysts are large. What we see in polycystic ovaries (or sometimes called PCO) are numerous tiny cysts (usually less than 10 mm) clustered around the periphery of the ovary. These are called “atretic” which means they are undeveloped follicles. The old criteria for PCOS was a count of greater than 10 of these follicles in a single sonographic slice of the ovary. Since these follicles collect over time, there is a tendency for the ovary to grow larger. Another criteria for PCO is the volume of the entire ovary, which if greater than 10cc indicates PCO. Polycystic ovaries are a sign of a metabolic condition called PCOS or polycystic ovarian syndrome. This condition is a complex metabolic disorder associated with irregular or infrequent periods due to anovulation, androgenic features like hirsutism, infertility and pregnancy complications. It also increases risk for diabetes and cardiovascular disease later in life. This syndrome is complex and will not be described here. However, it is important to recognize these signs in the ovary. (ref 1.Benacerraf)

Even if only one of the ovaries meets this criteria, it is still considered a positive indicator for PCOS

Figure 22 demonstrates peripheral follicle migration, and the ovarian volume of 19.07 cc is consistent with PCOS, since it is greater than 10 cc.

Figure 22. Image of a polycystic ovary in sagittal and transverse view. Note the ovarian volume is 19.07. Image 35

Recognizing abnormal ovarian cysts

When determining if a cyst is a follicle or a corpus luteum, it is important to know where a woman is in her cycle, and if you expect to see a follicle (early cycle) or a corpus luteum (late cycle). If there seems to be inconsistency with the woman’s cycle and the appearance of the cyst, then look for other potential problems.

“Complex” means there is mixed echogenicity or septation. This indicates either inert material such as a clot, or possibly actively growing tissue like a tumor.

Figure 23. Images depicting common characteristics of complex or abnormal ovarian cysts. Images 36-38

Complex Cysts

“Complex” means there is mixed echogenicity or septation. This indicates either inert material such as a clot, or possibly actively growing tissue like a tumor.

NOTE: To emphasize what was previously stated: in point-of-care ultrasound, it is NOT typically the role of the practitioner to diagnose the specific abnormality, but simply to recognize that it deviates from the normal ovarian appearance. It IS the role of the practitioner doing the scan to describe the finding using appropriate terminology.

The cyst in the image below would be described as:

“Left ovarian cyst measuring 4.3cm by 3.3 cm, round, mixed echogenicity, increased color flow around periphery. Post-ovulatory, most likely indicating a hemorrhagic corpus luteum cyst.”

Both images in Figure 24 demonstrate a typical reticular or cobweb like configuration seen with a resolving hemorrhagic cyst. The image to the right of it shows the angular formation of a clot moving toward the periphery of the cyst.

Figure 24. Images of complex ovarian cysts. Images 39-41

“Left ovarian cyst measuring 3.59 cm, round, mixed echogenicity, with irregularly shaped internal echogenic tissue . There is no evidence of internal color flow in the echogenic tissue. The mass is noted to fluctuate with pressure on the probe, and most likely is a clot resolving from a hemorrhagic corpus luteum cyst”

This cyst could be followed up in 6 weeks to see if the internal structures resolve. It is likely to be benign, and likely a hemorrhagic corpus luteum cyst

The image in Figure 25 has internal echoes in the cyst that are “angular” in shape, so this is indicative of a clot formation within a hemorrhagic CL cyst.

Figure 25. Image of complex ovarian cyst. Image 42

Some cysts contain a septum or septae. A sonographic term commonly used is “locular” If the cyst has only one fluid-filled area it is called “unilocular”. If there are multiple fluid-filled sections, it is called “multi-locular”.

This cyst demonstrated in the image below would be described as:

“Left ovarian septate cyst measuring 7.55 by 4.02 cm, ovoid, hypoechoic on either side of the septum. There is no evidence of internal color flow in the septum.”

This cyst would warrant follow up in 6 weeks to see if it resolves. It is likely to be benign, especially since we do not see color flow in the septum. It might represent an early abnormal cyst, or it might represent 2 cysts adjoining one another. But its overall size requires that a follow up be done.

The images in Figure 26 show multiloculated cysts. Sometimes a sonographer will choose to measure the entire cyst as a cystic complex, but in the lower image of Figure 26 the sonographer chose to measure each section separately, which is also appropriate. In this case the sonographer felt that these represented several follicles adjacent to one another. Even so, it would be prudent to repeat the ultrasound in 6 weeks.

Figure 26. Images of septated complex ovarian cysts. Images 43-45

The image in Figure 27 is another example of a complex cyst. We can see that the size is 4.57 cm. It contains internal echoes. However, they have the “cobweb-like” appearance (called “reticular”) and the lines are fairly angular. So we can presume that this represents a blood clot inside a hemorrhagic cyst. Its size is 4.57 cm so it is likely the woman is having pain. It would be appropriate to recheck this ovary in 6 weeks

Figure 27. Image of complex ovarian cyst demonstrating mixed echogenicity and reticular texture. Image 46

Ovarian Cysts with mixed echogenicity

Ovarian cysts with mixed echogenic textures require careful evaluation since a cancer cannot be ruled out. Complex cysts can also be benign, however, such as a dermoid cyst.

A dermoid cyst (or teratoma) is a relatively common type of benign cyst. It is composed of various types of tissue that grow from germ cells inside the ovary – it can be a complex of skin, hair, fat, and even tooth tissue. The way to recognize a dermoid is by the complex mixture of types of tissue density within the cyst. It often appears as having some clear fluid, some dense areas, and often has what is called a dermoid plug – or “fat plug”. This plug appears as a round, homogenous echogenic area within the cyst.

Dermoid cysts are relatively benign unless they are large or have been noted to increase in size over time. These warrant follow up to be sure that there is not growth. There is no evidence that these affect fertilother measures are takenity, although some gynecologists choose to remove them if infertility persists after other causes are ruled out.

As a point-of-care provider, it is not necessary to make the official diagnosis on this, but simply recognize that this ovary is not normal, and then to refer or follow up as needed.

Figure 28. Images of a complex heterogeneous ovarian cyst consistent with a dermoid. Images 47-50

Complex Cyst: adenoma?

The cyst in Figure 29 is abnormal, not only in terms of its size, but its echogenicity. It is almost entirely filled with an irregularly shaped, homogeneous density with rounded edges. It does not have the reticulations of a hemorrhagic cyst. It also has curved edges to the border (see inside the pink circle) rather than sharp reticular edges, indicating that it may be organic material rather than inert. As noted previously, hemorrhagic or early clot forming is typically angular rather than round. You would not be expected to diagnose this cyst, but you would be required to describe its size and characteristics.

Figure 29. Images of a complex cyst with homogeneous echotexture and fluid. Image 51-52

Complex Cyst with septae. The image below is of both the right and left ovary of a woman. The concerning factor in these images is that there is color flow seen in the septum itself. This might be an indicator of a neoplasm or malignancy. It may not be the case, but this finding is definitely warrants referral for more investigation

Figure 29.1 Image of complex ovarian cyst with septae demonstrating color flow, Images 52.1 and 52.2

Complex Cysts: Endometrioma

The cysts in the images below (Figure 30) represent what is called an endometrioma. This is composed of endometrial tissue that has developed inside the ovary – this represents endometriosis. Since it is the same tissue as endometrial tissue, it proliferates and grows under the influence of estrogen and progesterone production during the cycle. These cysts can cause pain, especially if they are large. They are identified by the type of echotexture seen. As seen in these images, the texture is fairly homogeneous, meaning it is the same throughout the cyst, but the appearance is gritty or grainy. Some call this texture “ground glass” appearance.

If what looks like this type of cyst, it warrants referral for investigation not only to determine if this really is endometrioma, but if it is, then the woman may likely need intervention if she has symptoms or if she desires a pregnancy.

NOTE: You are NOT expected to diagnose this, however you should be able to recognize these features as abnormal and refer.

Figure 30. Images of ovarian cyst with homogeneous “ground glass” texture appearance, consistent with endometrioma. Images 53-55

The image on the left in Figure 31 represents a type of growth in an ovarian cyst that is very concerning. It is called an “excrescence” or “papillary projection”. Not only is it irregular in shape, it has an irregular projection into the fluid component of the cyst. The other concern for this is that we see internal color echoes, indicating an internal blood supply. This means it is growing, living tissue and not an inert clot. This would be suspicious for cancer, so this woman needs referral.

The image on the right in Figure 31 has a similar structure, but there is no indication of color flow into it. We also see on the left edge of the cyst there is some reticulation, indicating that there may have been a clot. Although this image is indeterminate, this woman should still have follow-up.

NOTE: You are NOT expected to diagnose this, however you should be able to recognize these features as abnormal and refer.

Figure 31. Images of 2 complex cysts with excrescences. On the left there is color flow into the structure, and on the left there is no color flow identified. Images 56-58

ADNEXA

One of the first things we look for when looking at the area around the cervix is the region behind the cervix, called the cul-de-sac. This is a pouch where fluid collects when it is generated by a structure releasing that fluid (like a ruptured cyst). As we described in a previous section, this is the most dependent place in the body for pelvic fluid to collect.

This is a very important indicator of an even that may have happened recently to cause release of fluid. This can be simply from a simple cyst or follicle rupture (as we will see later), or from something abnormal that produces fluid, like an ectopic pregnancy, or bleeding, or even a pelvic cancer.

NOTE: You are NOT expected to diagnose this, however you should be able to recognize these features as abnormal and refer.

Figure 32. Description and image of free fluid in the culdesac. Image 5

9

When looking at the pelvis and adnexa and the cul-de-sac, you may see cystic structures that are separate from an ovary. These could represent Para tubal cysts, which are usually benign. If the woman is asymptomatic, this might just be a benign, serendipitous finding.

Figure 33. Image of a non-ovarian cyst in the culdesac, consistent with a paratubal cyst. Image 60

Adnexa: fallopian tubes

Fallopian tubes are not usually seen on ultrasound unless they contain fluid or are enlarged. They can be viewed most easily in the transverse view of the uterus, extending from the cornual area. An enlarged fallopian tube can appear like a cyst, especially if the tube is bent around itself, as in the image in Figure 34. If clear fluid is present, the structure will appear hypoechoic. If the structure has a “cloudy” appearance, it could indicate blood or pus, consistent with a tubal pregnancy or tubal disease such as pelvic inflammatory disease.

Figure 34. Image of an enlarged, folded section of fallopian tube. Image 61

Septate cyst in culdesac

This image showed a septate cystic structure in the cul-de-sac. The origin of this structure was unknown, but knowing this was abnormal in appearance, referral and follow up were provided.

Figure 35. Image of a complex mulilocular cyst in the culdesac in a woman with pelvic pain. Image 62

NOTE: The level of ultrasound to be performed for POCUS evaluation allows the clinician to recognize characteristics of benign and non-benign adnexal cysts.

There are well-established methods of defining and describing ovarian cysts, and one of the most widely-used is the IOTA classification³ which stands for International Ovarian Tumor Analysis. They outline terms, definitions and measurements to describe sonographic features of adnexal cysts, using 4 broad criteria: 1) type, 2) internal content, 3) contour, and 4) vascularity.

There are also well-documented methods of grading the potential for cancerous ovarian cysts based on these characteristics. The three most commonly recognized are ORADS, GI-RADS, and ADNEX.⁶ These diagnostic scoring systems are all comparable to one another, and serve as a way to make a better differential assessment, as well as serve to make reasonably accurate predictions for likelihood of malignancy.

Although a POCUS provider will not make the final diagnosis on abnormal appearing cysts, it is important to recognize characteristics of benign and non-benign adnexal cysts, describe them accurately, and refer for further imaging those women with abnormalities.

Summary - GYN III Ovaries and Adnexa

Transvaginal scanning is the more useful than transabdominal scanning in seeing structural detail in the female pelvis

Discrimination of bowel structures is important in order not to confuse these with pelvic structures of interest such as the ovaries and cul-de-sac.

Ovaries are typically hypoechoic in echotexture, ovoid in shape, and are identified by the presence of several follicles

Ovaries are best identified by observing the right and left adnexa in a systematic fashion, using both sagittal and transverse viewing planes

Ovarian cysts and masses are characterized by homogeneity. Cysts that are homogeneously hypoechoic are known as simple cysts, which are typically benign. Cysts with mixed echogenicity or septate are considered to be complex and warrant further investigation.

Simple ovarian cysts larger than 3 cm should be followed up with a subsequent ultrasound to observe for resolution.

Any fluid in the cul-de-sac represents a rupture of some structure in the pelvis – from a simple follicle or simple ovarian cyst, to a ruptured ectopic pregnancy. So it requires further investigation to determine the source of the fluid.

YOU MAY NOW TAKE THE QUIZ AND MOVE TO THE NEXT CHAPTER. YOU WILL NOT BE ABLE TO OPEN THE NEXT CHAPTER UNTIL YOU COMPLETE AND PASS THE QUIZ WITH 100%. YOU WILL HAVE AS MANY TRIES AS YOU NEED TO GET ALL THE ANSWERS CORRECT!

Women's Point-of-Care Ultrasound: Gynecology

Chapter 3. GYN III Ovaries and Adnexa