In most practices, sonohysterography is immediately preceded by high-frequency transvaginal sonography (TVS). Exact menstrual dating and latex allergy are documented first, and a negative pregnancy test is obtained, along with a signed informed consent, when appropriate. The purpose of the baseline ultrasound is to confirm all pelvic findings prior to the fluid enhancement study. Although sonohysterography provides an indirect look inside the uterus, its ability to accurately diagnose intracavitary filling defects, such as myomas and polyps and adhesions and even malformations, matches that of the gold standard hysteroscopy. This chapter lists out specific imaging examples for submucous myoma, endometrial polyp, blood clot, endometrial malignancy, intrauterine synechia and congenital uterine anomaly. It outlines three-dimensional saline infusion sonohysterography (SIS), sonosalpingography or hysterosalpingo-contrast sonography, operative SIS, and sonovaginography. Combining TVS with vaginal saline infusion may improve the ability to image structures surrounding the vagina, such as the rectovaginal septum for endometriosis.

Ovarian cystic endometriosis, endometrioma, may present on ultrasonography as an easily identifiable hyper-refringent adnexal mass and the most frequent variation. Different studies have tried to evaluate the diagnostic capacity of transvaginal sonography (TVS) in deep endometriosis. When ultrasonographic findings were compared with surgical findings and pathology reports, a low sensitivity (around 30%) was reported for vaginal or rectovaginal septum endometriosis, with a high rate of false negatives. Infertile women with endometriosis have a higher prevalence of associated functional images, such as unruptured luteinized follicles, hydrosalpinges, adenomyosis, and/or intraovarian endometriosis that may interfere with oocyte retrieval. The role of TVS in the diagnosis of extraovarian endometriosis, an area where magnetic resonance imaging (MRI) has proved to be much more beneficial, is yet to be established. MRI offers a better suggestive diagnosis of adenomyosis than TVS due to its lower interobserver variability.

This chapter discusses the risk factors, clinical signs, evaluation, prevention and screening, and treatment of ovarian cancer and ovarian masses. Ovarian cancer is the leading cause of death from gynecological malignancy and the fourth most common cause of cancer death in women. Advancing age is the greatest risk factor. Use of oral contraceptive pills reduces the risk of ovarian cancer by 30 to 60%. A review of women with ovarian cancer compared with women with breast cancer or no cancer found that most women with ovarian cancer complained of the four following groups of non-specific symptoms in the 1-3 months before diagnosis: abdominal pain (30%), abdominal swelling (16.5%), GI symptoms (8.4%), and pelvic pain (5.4%). Transvaginal sonography (TVS) is the examination of choice to establish the diagnosis. In menstruating women, pregnancy, pregnancy complications and functional cysts are the most common causes of ovarian masses.