RD7.{1,6} | Imaging in Obstetrics, Gynecology and Breast Care — Assignment

CLINICAL SCENARIO

A 31-year-old woman, married for three years, attends the gynaecology clinic with primary subfertility and a six-month history of irregular cycles every 40–60 days. On examination she has mild acne and facial hirsutism; her BMI is 29. As part of her workup the following imaging findings are provided to you for integration into her management:

1. Transvaginal ultrasound (day 3): right ovary 11.8 mL, left ovary 12.4 mL; each ovary contains numerous small follicles (2–9 mm) arranged peripherally — reported as 26 follicles in the right and 24 in the left on a modern high-frequency transducer. Endometrium is thin and regular. No adnexal mass or free fluid.
2. Hysterosalpingography (day 8, follicular phase): free spill of contrast from both fallopian tubes into the peritoneal cavity; normal uterine cavity contour.
3. Serum markers (provided): elevated androgens; normal prolactin and TSH.

Your task is to integrate these provided imaging findings into a coherent diagnosis and an evidence-based management plan, applying the radiation-safety and modality-selection principles of obstetric and gynaecological imaging.

1. Interpreting the transvaginal ultrasound

State whether the ovarian findings meet polycystic ovarian morphology and on what basis. Quote the correct threshold for the transducer type described and comment on the ovarian volumes.

Guidance: Modern high-frequency transducer threshold is ≥20 follicles (2–9 mm) per ovary; ovarian volume >10 mL is an alternative criterion. Note that morphology is only one of three Rotterdam criteria.

2. Integrating findings into a diagnosis

Apply the Rotterdam framework to this patient. Identify which of the three criteria are satisfied and state your integrated diagnosis, explaining why imaging alone would not have been sufficient.

Guidance: Rotterdam = any 2 of 3 (oligo/anovulation; clinical or biochemical hyperandrogenism; PCOM on USG), after excluding mimics (here normal prolactin and TSH help exclude alternatives).

3. Interpreting the HSG and its timing

Interpret the HSG result for tubal patency and uterine cavity. Explain why the study was performed on day 8 and what radiation-free alternative could have been offered.

Guidance: HSG is a follicular-phase study (day 6–10) performed after menses and before ovulation to avoid irradiating an early pregnancy. HyCoSy is the radiation-free ultrasound-based alternative. Bilateral free spill indicates patent tubes.

4. Synthesising a management plan

Combine the diagnosis and the imaging findings into a fertility-oriented management plan. Address lifestyle, ovulation induction, and the role of follicular tracking on ultrasound.

Guidance: With patent tubes, a normal cavity and anovulatory PCOS, management centres on weight optimisation and ovulation induction with TVS follicular tracking to confirm and time ovulation. No ionising imaging is needed for monitoring.

5. Imaging stewardship reflection

Reflect on how modality selection in this case illustrates the governing principles of O&G radiology.

Guidance: Ultrasound first (radiation-free, high-resolution pelvic detail); ionising studies (HSG) timed to protect a possible early pregnancy; match each modality to the factor it tests (reserve/ovulation/cavity by TVS, tubal patency by HSG/HyCoSy).