Teach me tvs with real time sonographic pictures and landmarks

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I now have everything needed for a thorough visual TVS tutorial. Let me compile the complete lesson:

Transvaginal Sonography (TVS) - Complete Illustrated Guide

Sources: Color Atlas of Ultrasound Anatomy 3e, Pfenninger & Fowler's Procedures for Primary Care 3e, Berek & Novak's Gynecology

1. What is TVS and Why Use It?

TVS (also called endovaginal ultrasound) uses a high-frequency intracavitary probe inserted into the vagina to image pelvic structures at close range. Compared to transabdominal ultrasound (TAS):

Feature	TVS	TAS
Frequency	5-10 MHz (higher)	3.5-5 MHz
Resolution	Superior - near-field detail	Lower
Bladder prep	Empty bladder preferred	Full bladder required
Depth	Limited (~10 cm)	Greater depth
Patient comfort	Mildly invasive	Non-invasive
Obese patients	Better results	Poor window

TVS is the first-line modality for evaluating the uterus, endometrium, ovaries, adnexa, early pregnancy, and pelvic pain.

2. Probe Orientation and Image Conventions

TVS probe insertion and longitudinal orientation showing bladder (BL) and uterus (UT) with anterior/posterior/cranial/caudal labels

Figure 225-13 from Pfenninger & Fowler's - Longitudinal orientation with transvaginal scanning. BL = bladder, UT = uterus

Key orientation rules for TVS (different from TAS):

With the marker dot pointing anteriorly (toward the abdominal wall), the left side of the image = anterior (not cranial as in TAS)
In longitudinal plane: fundus is typically to the left of screen, cervix to the right
In coronal/transverse plane: patient's right side remains on the left side of the image (marker dot toward patient's right)
The probe sits anterior to the cervix; avoid inserting too deeply or you miss the lower uterine segment

Longitudinal transabdominal view showing uterus (UT), fluid in cul-de-sac (FL), and vagina (VG) - landmarks visible on longitudinal scan

Longitudinal view: UT = uterus, FL = free fluid in posterior cul-de-sac (pouch of Douglas), VG = vaginal stripe

3. Step-by-Step TVS Technique

Patient position: Supine or lithotomy. TVS is usually preceded by TAS to assess overall anatomy, then the bladder is emptied (some residual urine is useful as a landmark).
Probe prep: Cover with probe sheath/condom, place adequate gel between cover and transducer, smooth out air bubbles.
Pelvic exam first: Assess uterine size, position, tenderness. Remove tampons. Obtain verbal consent.
Insertion: With marker dot anterior, gently insert with posterior vaginal pressure to a position anterior to the cervix.
Scanning begins immediately on insertion - scanning starts as soon as the probe is in, avoid over-inserting.
Systematic sweep: Obtain longitudinal, coronal, and oblique scans by rotating the probe. Oblique views are used for adnexa.
Document: Note fluid accumulations, fetal structures (if applicable), any areas of tenderness.

4. Normal Landmarks: The Uterus

Sagittal (Longitudinal) View

TVS sagittal view: 80 = uterine body/myometrium, 85 = cervix, 86 = vagina, 89 = rectum/posterior structures, 77 = urinary bladder

Sagittal TVS - Key: 80 = uterine body (myometrium), 85 = cervix, 86 = vagina, 77 = urinary bladder, 89 = rectum/posterior compartment

What you see on sagittal:

The uterus = intermediate echogenicity, pear-shaped
Endometrial stripe = hyperechoic central line; thickness varies with menstrual phase
Myometrium = homogeneous, medium echogenicity surrounding the endometrium
Cervix = lower, more echogenic than the fundus
Bladder = anechoic (black) anteriorly - useful landmark even when empty on TVS
Posterior cul-de-sac (pouch of Douglas) - look here for free fluid

Atlas note: "The uterus consists of the fundus, corpus, and cervix" - Color Atlas of Ultrasound Anatomy, p. 322

Coronal (Transverse) View

TVS coronal view: 80 = uterine body, 85 = cervix, 86 = vaginal fornix region, 89 = posterior structures

Coronal TVS - broad band of uterine myometrium (80) in the center, cervix (85) inferiorly, vaginal layers (86, 89)

5. Uterine Layers - High-Resolution TVS Detail

TVS at 7.5-10 MHz resolves the uterine wall into distinct layers:

Uterus cross-section on TVS: 1* = myometrium (outer), 2* = endometrium (inner hyperechoic ring), 3* = endometrial lumen, 5* = uterine vessels at the periphery

TVS cross-section of uterus: 1* = myometrium, 2* = endometrium, 3* = uterine lumen, 5* = periuterine vessels

Second TVS cross-section showing uterine layers: 1* = myometrium, 2* = endometrium (hyperechoic), 3* = central lumen, 5* = vessels

Labeled TVS cross-section: 1* = myometrium (medium echogenicity, surrounding), 2* = endometrium (hyperechoic layer), 3* = endometrial lumen (hypoechoic line), 5* = uterine vessels

Endometrial Thickness by Cycle Phase

Phase	Appearance	Thickness
Early proliferative	Thin, hypoechoic	4-8 mm
Late proliferative	Triple-line pattern	8-12 mm
Secretory	Thick, hyperechoic	10-16 mm
Postmenopausal	Thin, echogenic stripe	≤5 mm (normal)

"The uterine cavity is visible sonographically only during menstruation and pregnancy" - Color Atlas of Ultrasound Anatomy, p. 323

6. Vagina Landmark

The vagina appears on TVS as an elongated, hypoechoic structure posterior to the bladder with a central band of higher-level echoes (the vaginal stripe, representing the mucosal interface).

TVS with vagina (86) visible as hypoechoic structure, uterus (80), cervix (85), posterior structures (89)

Uterus (80) in sagittal with cervix (85), vaginal region (86), and posterior structures (89) labeled. Note the ovaries flank the superior border of the full urinary bladder.

"The vagina appears behind the bladder as an elongated, hypoechoic structure with a central band of higher-level echoes" - Color Atlas of Ultrasound Anatomy, p. 321

7. The Ovaries

The ovaries are the most important adnexal structures to identify on TVS.

How to Find the Ovaries

After imaging the uterus in longitudinal view, rotate the probe obliquely (clockwise for left adnexa, counterclockwise for right)
Landmark: the iliac vessels - ovaries lie medial to the internal iliac vessels
Use the follicles as a guide - small anechoic cysts within the ovary are a giveaway

TVS Ovary with Follicle

Right ovary on TVS: 87 = ovarian tissue, 4* = follicle (anechoic cyst within ovary), 5* = ovarian vessels, 6* = iliac vessels lateral to ovary

Right ovary: 87 = ovarian stroma (intermediate echogenicity), 4* = follicle (anechoic), 5* = ovarian vessels, 6* = iliac vessels. The ovary sits medial to the iliac vessels.

Ovary close-up TVS: 87 = ovarian body, 4* = dominant follicle (large anechoic area), 5* = periuterine/ovarian vessel

Close-up TVS of ovary: 87 = ovarian stroma, 4* = dominant follicle (anechoic cyst, pre-ovulatory can reach 18-22 mm), 5* = ovarian vessels

Normal Ovary Measurements

Parameter	Normal
Size (adult)	3 x 2 x 2 cm (volume ~8 mL)
Postmenopausal	Volume ≤3 mL
Follicle	Multiple small, anechoic, ≤10 mm
Dominant follicle	Up to 18-22 mm pre-ovulatory

8. Uterus-Bladder-Ovary Layout (Coronal View)

TVS coronal view of pelvis: 80 = uterus central, 88 = adnexal/parametrial area, 86 = vagina/cervical region. Ovaries flank the uterus.

Coronal TVS: 80 = uterine body, 88 = adnexa (ovary location), 86 = cervico-vaginal region. Note the relationships - uterus centrally, ovaries flanking it laterally.

"The ovaries flank the superior border of the full urinary bladder" - Color Atlas of Ultrasound Anatomy, p. 323

9. Clinical Applications - What TVS Diagnoses

Indication	TVS Finding
Ectopic pregnancy	Empty uterus + adnexal mass/ring; free pelvic fluid
Missed/threatened abortion	Absent/abnormal fetal cardiac activity
Endometrial polyp	Hyperechoic pedunculated lesion in cavity
Fibroids (leiomyoma)	Hypoechoic, well-defined intramural mass
Ovarian cyst	Anechoic, thin-walled adnexal structure
Tubo-ovarian abscess	Complex heterogeneous mass, TOC vs TOA differentiated on TVS
PCOS	≥12 follicles per ovary, each 2-9 mm, or ovarian volume >10 mL
Adenomyosis	Heterogeneous myometrium, asymmetric thickening, myometrial cysts

TVS has 75% PPV and 96.5% negative predictive value for intracavitary polyps compared to hysteroscopy (Berek & Novak's Gynecology, p. 2063).

10. TVS vs. TAS: When to Choose Which

Use TVS when:

Early intrauterine pregnancy needs confirmation (<8 weeks)
Patient cannot fill bladder (ectopic emergency)
Obese patient (poor TAS window)
Detailed endometrial evaluation needed
Ovarian pathology assessment

Use TAS when:

Larger pelvic masses (beyond TVS depth)
Second/third trimester pregnancy
Patient refuses TVS
Screening (TVS as follow-up)

Key Sonographic Numbers to Remember

Structure	Normal Measurement
Uterus (nulliparous)	6-8 cm length, 3-5 cm AP
Endometrium (secretory)	Up to 16 mm bilayer
Endometrium (postmenopausal)	≤5 mm (>5 mm = investigate)
Cervical length (non-pregnant)	~3 cm
Ovary volume (reproductive)	≤8 mL
Dominant follicle pre-ovulation	18-22 mm
Free fluid (small amount)	Normal in cul-de-sac mid-cycle

All sonographic diagrams: Color Atlas of Ultrasound Anatomy, 3e (Thieme). Clinical technique: Pfenninger & Fowler's Procedures for Primary Care, 3e. Clinical applications: Berek & Novak's Gynecology.

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