Based on the nature of bleeding, one may be able to suspect the type of gynecological pathology leading to abnormal uterine bleeding:

Both cyclical and acyclical bleeding may coexist in a few conditions, for example, endometrial malignancy and AV malformations (this is a rare condition, and diagnosis has been discussed on Chap. 13), etc.

In patients with a thickened endometrium, possibilities include endometrial polyp, endometrial hyperplasia and endometrial carcinoma. The ultrasound features and their differentiation are discussed in Chap. 4.

Ovarian masses can be broadly classified into functional cysts, neoplastic masses, endometriomas and masses of inflammatory origin. The ovary may also be enlarged due to other conditions like torsion, hyperstimulation, polycystic ovaries, ovarian ectopic pregnancy, etc. All these conditions have been dealt with in detail in their respective chapters.

A rare cause for enlarged cystic ovaries is the Van Wyk–Grumbach syndrome (VWGS), a condition associated with juvenile hypothyroidism (of long standing duration and with high levels of TSH), delayed bone age and isosexual precocious puberty. These return to normal on thyroid hormone replacement. These patients have bilateral enlarged multicystic ovaries secondary to stimulation of the gonadal FSH receptor by TSH, resulting in multiple follicular cysts. Histopathological analysis of resected ovaries showed cystic follicles and little, if any, luteinisation. Some reports have suggested myxoedematous infiltration of the ovaries. Awareness of this condition is important because of the high probability of this being diagnosed wrongly as a case of bilateral neoplastic ovaries with inadvertent surgical excision (in a young girl and one that can be treated with simple thyroid replacement). In the case described below, preoperative blood workup picked up the high TSH levels and led to the diagnosis (Fig. 14.3).

An enlarged uterus presenting as a pelvic mass may be seen in both adenomyosis and fibroids. In adenomyosis, of course, the uterus is usually globular in shape, with distinctive features making diagnosis very simple. With fibroids, the uterus may be irregularly enlarged or there may at times be confusion about the origin of the mass. This is particularly so when the mass is a subserous/pedunculated fibroid. Fibroids have typical ultrasound features but can be confused with adnexal masses, particularly when they show degenerative changes. Fibroids are usually masses within the uterus, but the subserous pedunculated ones can be diagnosed to be of uterine origin by tracing their attachment to the uterus through a pedicle or blood flow. The pedicle may not be well seen unless there is surrounding fluid. Doppler flows are very helpful in assessing the origin of any mass as vessels are seen passing between the mass and the source of origin. Exceptions to this, of course, are true broad ligament fibroids orfibroids seen in cases with disseminated leiomyomatosis. In such cases, however, the ovaries will be seen separate from the mass.

Occasionally, in patients with unicornuate uterus, the adjoining rudimentary horn (particularly when non-cavitary) may present as an adnexal mass, but these masses are attached to the main uterine body and their echotexture is similar to that of the myometrium (Fig. 14.4).

The normal fallopian tube is difficult to identify, unless it is surrounded by fluid. It appears as an elongated undulating isoechoic or hyperechoic structure. Tubal masses may be of inflammatory or neoplastic nature or secondary to a tubal ectopic pregnancy. These have been dealt with in their respective chapters. Tubal masses may be seen continuous with the uterine cornua, but often they are not, because the pathological segment of the tube is away from its attachment to the uterus. The distal part of the tube has a broader lumen, and most collections (hydrosalpinx, pyosalpinx or haematosalpinx) are, therefore, seen at its distal end. Cystic tubal masses are generally easy to identify because of their elongated shape and incomplete septa.

Tubo-ovarian masses are typically secondary to PID. At times, one may be able to differentiate between the tubal and ovarian component; however, often (like in some tubo-ovarian abscesses) this may not be possible. These have been dealt with in the section on PID in Chap. 9.

These are typically cystic masses seen in the adnexa separate from the ovary. Occasionally, they may be adherent to the ovary, when distinguishing them from an exophytic ovarian cyst can be challenging. They are usually small, unilocular and anechoic but can be large, septate and even undergo torsion. They have been dealt with in the section on paraovarian cysts in Chap. 9.

Pseudoperitoneal cysts are nothing but areas of loculated fluid with adhesions. They may be secondary to chronic infection, endometriosis or previous surgery. They can pose a diagnostic challenge in a patient in whom ovarian cystectomy or ovariotomy has been done for a neoplastic ovarian cyst, where these may be considered as a recurrence of pathology. This has also been dealt with in Chap. 9.

These may be seen to be associated with ectopic pregnancies or infection. They may present as pelvic masses when localised to an area. These are avascular masses, and correlation with other findings helps in diagnosis.

These are rarely seen and most often are either appendicular masses or malignant masses arising from the small or large intestine (e.g. gastrointestinal stromal tumour of the small bowel and anorectal masses). The ovaries are seen distinct from these masses, and they do not originate from the uterus (i.e. no flow is seen between the uterus and the mass).