Hormone Replacement Therapy:
  • Used to reduce menopause symptoms
  • Can prevent osteoporosis
  • Can lead to increased endometrial thickness
  • Estrogen therapy leads to increased risk of endometrial carcinoma, NL endometrial thickness <8mm
  • Estrogen and Progesterone combination therapy has reduced risk of carcinoma when compared to estrogen only therapy, NL endometrial thickness <12mm

Tamoxifen Therapy:
  • Anti-estrogen drug given to some breast cancer patients
  • Associated w/ endometrial hyperplasia and endometrial carcinoma

Related Diagnostic Testing:
  • Pap smear
  • Culdoscopy
  • Laparoscopy
  • Biopsy
  • D & C
  • Sonohysterography (used for polyp evaluation)
  • Hysterosalpinogram
  • Culdocentesis
  • Beta HCG levels
  • AFP levels
  • CA 125 levels
Pregnancy History Notation:
  • GPMA
  • Gravida - number of pregnancies
  • Para - number of living children
  • Abortion - number of abortions
  • Miscarriage - number of spontaneous abortions or still births
  • Example: G3P2M0A1 - patient had 3 pregnancies with 2 live births and 1 abortion
Note: Click any image to enlarge.
FEMALE PELVIC ANATOMY AND SONOGRAPHIC EVALUATION
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ANATOMY

Internal Organs:
  • Uterus
  • Fallopian Tubes
  • Ovaries
  • Vagina
  • Accessory Glands
  • Skene's glands-paraurethral gland
  • Bartholin's glands-on either side of vagina
  • Mammary glands- Within the breasts

External Structures:
  • Mons Pubis- fatty prominence covering the symphysis pubis
  • Labia Majora- outer lips covering vaginal opening
  • Labia Minora- inner lips, smaller
  • Clitoris- lies below the junction of the labia majora
  • Linea Terminalis-imaginary line connecting superior sacrum to symphysis pubis, separates True and False Pelvis
Greater/False Pelvis:
  • Above the pelvic brim
  • Communicates w/ the abdominal cavity
  • Contains sigmoid colon and ileum
  • Pelvic Muscles=False Pelvis
       o        Rectus Abdominus-forms anterior wall of abdominopelvic cavity, from xiphoid to symphysis pubis
       o        Psoas Major-originates in lumbar vertebral region, connects w/ iliacus muscle to form iliopsoas muscle

Lesser/True Pelvis:
  • Below the pelvic brim
  • Formed by the bony bowl of the pelvic bones
  • Enclosed inferiorly by membranes and muscles
  • Contains uterus, vagina, fallopian tubes, ovaries, rectum and bladder
  • Pelvic Muscles in True Pelvis
       o        Levator Ani-most inferior structure, forms the floor of the pelvis, has 3 openings for urethra, vagina and                        rectum
       o        Obturator Internus-located laterally at the acetabulum,  triangular sheet, covers anterior and lateral walls
       o        Piriformis Muscle-superior and lateral to levator ani  muscles, originates from sacrum

Functions of the Pelvic Skeleton:
  • Provides a weight bearing bridge between spine and ribs
  • Directs the pathway of the fetal head during child birth
  • Protects reproductive organs
Pelvic Spaces:
  1. Anterior Cul-de-Sac:  Fold in the peritoneum between anterior uterus and posterior bladder; AKA vesicouterine pouch
  2. Posterior Cul-de-Sac: Fold in the peritoneum between posterior uterus and anterior rectum; AKA rectouterine pouch or pouch of Douglas
  3. Space of Retzius: anterior to bladder posterior to symphysis pubis, very unusual for fluid collection, not contiguous w/ abdominopelvic cavity; AKA retropubic space
Ligaments:

Broad Ligaments:
  • Wing like folds of the peritoneum extending to lateral pelvic walls
  • Separates pelvic cavity into anterior and posterior portions
  • Covers anterior and posterior surfaces of the uterus
  • Encases most of fallopian tubes and round ligament, ovarian ligament and vessels
  • Loosely positions uterus in pelvic cavity
  • Mesovarium - portion of the peritoneum connecting anterior ovary to posterior broad ligament
  • Mesosalpinx - free margin broad ligament where fallopian tube travels
Cardinal Ligaments:
  • AKA Transverse Cervical Ligament of Mackenrodt
  • Band of fibrous tissue and muscle
  • Extends from upper lateral cervix to lateral pelvic wall
  • Contains the uterine and vaginal vessels
Round Ligaments:
  • Fibromuscular bands extending from uterus to labia majora
  • Maintains normal uterine position
  • Assists in birth
Uterosacral Ligaments:
  • Extend from upper cervix to lateral sacrum
  • Determines the uterine position/orientation in the pelvis
Suspensory Ligaments:
  • Folds of peritoneum that contain the ovarian vessels
  • Aids broad ligament in supporting fallopian tubes and ovaries within pelvis
Location/Landmarks:
  • Round, Cardinal and Uterosacral ligaments suspend the uterus in the pelvic cavity
  • Sits between two layers of the Broad Ligament
  • Posterior to bladder
  • Anterior to rectosigmoid colon
Size:
  • Neonatal - Cervix much longer than the body/fundus
  • Prepubertal - Average 3cm x 0.7cm; body half the size of the cervix
  • Adult - average 8 x 5 x 3cm nulliparous, 1:1 ratio of cervix and body/fundus length
  • Adult - average multiparous, Body/fundus 2 x longer than cervix
  • Postmenopausal - Segment ratio remains same, overall organ atrophy
Uterine/Cervix Position:
  • Anteverted - uterus forms a 90 degree angle with the cervix
  • Anteflexed - uterine body forms a sharp angle with the cervix, folds over sharply on the cervix
  • Retroverted - Uterine body tips posteriorly with a small angle between the corpus and the cervix
  • Retroflexed - Uterine body folds posteriorly at a very sharp angle to the cervix
Vagina Anatomy:
  • Anterior to rectum, posterior to urethra
  • Collapsible, fibromuscular tube
  • Outlet covered by hymen
  • Connects to cervix at the fornix
  • Walls should not exceed 1cm thickness
  • Avg cuff measurement 1.4cm

Vagina Physiology:
1.        To receive seminal fluid
2.        Excretory duct for menstruation
3.        Lowest portion of birth canal
Uterine Arterial Supply:
  • Internal Iliac Artery AKA Hypogastric Artery
  • In a non-pregnant patient, the internal iliac artery is smaller in caliber than the external iliac artery
  • Divides into anterior and posterior segments
  • Anterior segment branches
  1. Umbilical artery
  2. Inferior Vesicle artery
  3. Middle Rectal artery
  4. Uterine artery
  5. Vaginal artery
Uterine Venous Drainage:
  • Uterine veins empty into the Internal Iliac Veins
  • In a non-pregnant patient, the internal iliac vein is smaller in caliber than the external iliac vein
  • Merges with the external iliac vein to form the common iliac vein
  • Drains pelvic organs
PHYSIOLOGY OF THE UTERUS
  • Menstruation
  • Pregnancy
  • Labor and Expulsion of Fetus at Birth

Endometrial Anatomy:
  • Endometrium Varies w/ age, menstrual phase and HRT
  • Premenopausal NL <14mm
  • Postmenopausal w/ Estrogen HRT NL <8mm
  • Postmenopausal w/ Combined HRT NL 10-12mm
  • Postmenopausal no HRT <5mm

Endometrial Blood Supply:
  • Internal Iliac Artery - Uterine Artery - Arcuate Artery - Straight and Spiral Arteries
  • Uterine - courses along lateral margin between layers of broad ligament
  • Arcuate - circle the uterus
  • Straight - supply deeper 1/3 of endometrium, does NOT slough off
  • Spiral - sloughed off and reformed after menses, respond to ovarian hormones
Ovarian Cycle:
Day 1-5 Early Ovarian Follicular Phase:
  • At the onset and during menstruation, estrogen and progesterone levels are very low.  These low levels are detected in the blood stream by the hypothalamus which releases Gonadotropin Releasing Hormone (GRH).
  • Pituitary senses the increased levels of GRH and releases Follicle Stimulating Hormone(FSH) and Lutieinzing Hormone (LH) into the blood stream.
  • Rising FSH levels cause the ovaries to increase the estrogen production in the body and causes follicle growth, multiple follicles present by day 5-7.
Day 6-13 Late Ovarian Follicular Phase
  • Estrogen and FSH levels continue to rise
  • A dominant follicle will emerge and move toward outer wall of ovary
  • LH levels surge 24-36hrs before ovulation
Day 14-28 Luteal Phase
  • LH surge causes ovulation
  • Corpus luteal cyst forms to secrete progesterone
  • If there is no fertilization (no bhCG), the corpus luteum will involute 12-14 days after ovulation and progesterone levels decrease
  • Estrogen levels decrease post-ovulation

Summary of the Ovarian Hormone Cycle:
  • Estrogen decreases -- Hypothalamus releases GRH which causes pituitary gland to release FSH/LH which causes ovaries to increase estrogen production and form a dominant follicle to prepare for ovulation
  • Mid cycle, there is a sudden surge in the production of LH from the pituitary gland.  This surge in LH triggers ovulation.
  • After ovulation occurs, the LH levels cause the follicle to develop into a corpus luteum.
  • The corpus luteum secretes a steadily increasing amount of progesterone which continues the preparation of the endometrium for a possible implantation. 
  • Progesterone also inhibits the development of a new dominant follicle

If Fertilization DOES NOT Occur:
  • Increasing progesterone levels will actually cause a decrease in the progesterone levels.  Progesterone production is stimulated by luteinizing hormone (LH), which is also stimulated by GRH.  The rising level of progesterone inhibits the release of GRH which limits LH production and then decreases progesterone production.
  • As the progesterone level drops, the corpus luteum begins to degenerate and becomes a corpus albicans 4-5 days post-ovulation.  The endometrium begins to break down and menstruation begins.

Progesterone decreases -- Hypothalamus releases GRH -- causes pituitary gland to release a surge of LH -- ovulation occurs w/ corpus luteum formation


If Fertilization DOES Occur:
  • It normally happens with 24-36hrs after ovulation
  • The first mitotic divisions occur as the egg travels through the segments of the fallopian tube.
  • By the end of the week 1, the developing embryo has become a blastocyst.
  • At this time, the blastocyst reaches the uterus and embeds itself in the endometrium, a process called implantation. With implantation, pregnancy is established.
  • When the blastocyst implants into the uterus, it consists of two parts.  The inner cell mass will become the fetus and the trophoblast will develop into the placenta.
  • The trophoblast secretes human chorionic gonadotropin (HCG) which is detected in maternal urine.  The trophoblast must be implanted in order to produce HCG.
  • Increasing HCG prevents the deterioration of the corpus luteum at the end of week 4.  The CL cyst remains until around week 14 when the placenta takes over progesterone production.
  • The placenta also maintains necessary progesterone levels to maintain the pregnancy.  Synthetic progesterone may be given to mothers with low levels to prevent early birth.
Ovarian Anatomy:
  • Only structure in the abdominopelvic cavity that is not covered by peritoneum
  • Only truly INTRAperitoneal structure
  • Connected medially to the uterine cornua by the ovarian ligament
  • Anterior surface connected to the posterior surface of the broad ligament by the mesovarian
  • Infundibulopelvic ligament contains vessels and extends from lateral pelvic wall to lateral ovary
  • Ureter, Iliac artery and vein are posterior to the ovary
  • Adult size 3 x 2 x 1cm
  • Volume 6-13cc, 3-5cm3  (L x W x AP x 0.523 = volume)
  • Normal follicle size immature 10-12mm, Mature 18-25mm
  • Fossa of Waldeyer (Ovarian Fossa):
       o        Shallow peritoneal fossa on lateral pelvic wall
       o        Bordered by ureter and iliac vessels
  • Cortex
       o        Composed of 1000s of oocytes embedded in connective tissue
       o        Each cycle, 4-5 eggs mature and release
  •        Medulla
       o        Connective tissue and vessels that supply and drain cortex
       o        ****There is no sonographic distinction between the cortex and medulla

Ovarian Vasculature:
  • Ovarian arteries branch from aorta below renal arteries
  • Right ovarian vein empties into IVC
  • Left ovarian vein empties into left renal vein

Ovarian Physiology:
  1.        Oogenesis
  2.        Secretion of progesterone and estrogen
  3.        Ovulation

Fallopian Tube Anatomy:
  • AKA  Oviducts or Salpinges or Uterine Tubes
  • Trumpet shaped, muscular canals
  • 8-14cm in length, but only 5cm tortuous path
  • Extend from cornua to medial ovary

Tube Segments:
1.  Interstitial - short section that passes thru uterine wall; Most  
     Dangerous Place for Ectopic!!!!
2.  Isthmus - middle portion,
3.  Ampulla - widest and longest portion, egg fertilization normally occurs here; most ectopics occur in this segment
4.  Infundibulum - contains fimbriae, trumpet shaped end

Wall Layers:
  • Mucosal lining - contains cilia to help propel the egg thru the tube
  • Muscle
  • Serosal coating

Fallopian Tube Physiology:
  • Transport duct for egg
  • Propel the egg to uterus
  • Egg fertilization
Exam Indications:
  • Abnormal bleeding
  • Pain
  • IUD placement
  • Palpable mass
  • Abnormal labs
  • Infertility
  • Invasive procedures
  • PID
  • Ectopic
  • Anomalies
  • Carcinoma
  • Abnormal Bleeding

Symptom Terminology:
  1. Anovulation - absence of ovulation
  2. Amenorrhea - absence of menstruation
  3. Dysmenorrhea - painful menstruation
  4. Hypermenorrhea - increased flow during cycle
  5. Hypomenorrhea - abnormally decreased flow during cycle
  6. Oligomenorrhea - menstruation that occurs in >35 day intervals
  7. Polymenorrhea - menstruation that occurs in <21 day intervals
  8. Menorrhagia - regular cycles that are heavy and longer than normal
  9. Metrorrhagia - irregular cycle, breakthrough bleeding, spotting
  10. Menometrorrhagia - irregular cycles with heavy bleeding
  11. Mittleschmertz - pain associated with ovulation

Patient History:
  • Age
  • OB Hx
  • LMP
  • Menses description
  • IUD?
  • BCP?
  • HRT?
  • Surgery?
Exam Techniques:
Transabdominal
  • 3.5 - 5MHz average probe frequency
  • Pt drinks 32oz water
  • Obtain  longitudinal and transverse images of the uterus, ovaries and adnexa
Transvaginal
  • 5 - 10 MHz average probe frequency
  • Empty bladder
  • The patient is placed in the lithotomy position on a table set to Trendelenburg position (Head tilted slightly lower than legs)
  • Obtain  longitudinal and transverse images of the uterus, ovaries and adnexa
  • Apply color Doppler to ovaries

Exam Objectives:
  • Confirm the presence or absence of a mass
  • Determine single or multiple masses
  • Determine anatomic relationship of pathology
  • Evaluate size, contour, acoustic properties and internal consistency,  pathology
  • Demonstrate the involvement of other organs
  • Provide guidance for biopsy or fluid aspiration

Advantages of Transvaginal Sonography:
  • Interventional procedures
  • Decreased artifact
  • Patient circumstances
  • Empty bladder
  • Obesity can greatly limit trans-abdominal exams
  • Improved resolution
  • Follicle studies
  • Early pregnancy diagnosis
  • 2nd/3rd Trimester cervix evaluation

Disadvantages of Transvaginal Sonography:
  • Orientation of images
  • Limited FOV
  • Obesity can limit probe mobility
  • Non-sexually active patients cannot be scanned
  • Discomfort in elderly patients
  • Unable to evaluate pregnancies in 3rd trimester
Oral Contraceptives:
  • May not demonstrate a dominant follicle
  • Thin endometrium w/ lack of cyclical changes

Other Contraception Devices:
  • Diaphragm
  • IUD
  • Lippes Loop
  • Saf-T-Coil
  • Dalkon Shield (retired)
  • Zipper Ring
  • Copper 7/Copper T (retired)
  • Progestasert

IUDs:
  • Made of polyethylene, metal or combo
  • Impregnated w/ BaSo4  to allow for visualization on xrays
  • Most IUDs demonstrate an entrance-exit reflection sonographically


IUD Complications:
  • Expulsion
  • Ectopic
  • PID
  • Perforation
  • Migration
  • Pain
  • Cramping
Commonly Used Quadrant Terminology:
RUQ - Right Upper Quadrant
RLQ - Right Lower Quadrant
LUQ - Left Upper Quadrant
LLQ - Left Lower Quadrant
***Abdomen divided by sagittal plane crossing through midline at umbilicus and a transverse plane crossing through the abdomen at the level of the umbilicus


Addison's Nine Regions:
Right Hypochondrium - liver, GB, hepatic flexure of colon
Epigastric - Pancreas, Stomach, transverse colon
Left Hypochondrium - Spleen, Stomach, Left Kidney (upper pole)
Right Lumbar - Right Kidney, Ascending colon
Umbilical - Transverse colon, small bowel
Left Lumbar - Left Kidney (mid/lower poles), Descending colon
Right Iliac - ovary, seminal vesicle
Hypogastric - bladder, uterus, prostate, Rectum, Sigmoid
Left Iliac - ovary, seminal vesicle
Three Wall Layers:
  • Endometrium - innermost layer, varies in thickness during the menstrual cycle due to proliferation and sloughing
  • Myometrium - middle layer, thickest layer, involved in birth
  • Perimetrium - outermost layer, serosa, composed of fibrous connective tissue
Uterine Anatomy:
  • Hollow, thick-walled muscular organ
  • Inner mucous layer = endometrium
  • Muscle layer = myometrium 
  • Outer serous layer = perimetrium
  • Cervix connects uterine cavity with vagina
  • Internal os - opening from uterus into cervix
  • External os - opening from cervix to vagina
Hormones of the Menstrual Cycle:
Gonadotropin Releasing Hormone (GRH):
  • Secreted by the hypothalamus when estrogen levels are low
  • Stimulates pituitary gland to produce and release luteinizing hormone and follicle stimulating hormone
Follicle Stimulating Hormone:
  • Secreted by the anterior pituitary gland
  • Responsible for egg maturation
Luteinizing Hormone:
  • Secreted by the anterior pituitary gland
  • Stimulates theca cells to produce androgens that are converted into estrogen
  • Responsible for ovulation and corpus luteal development
Estrogen:
  • Naturally produced steroid hormone
  • Responsible for the development of reproductive organs and maintains their function during reporoductive years
  • Causes development of secondary sex characteristics such as axillary and pubic hair, breast development, fat deposits on breasts, thighs and buttocks
  • Stimulates endometrium to thicken prior to ovulation
Estradiol:
  • The principle component of estrogen formed by ovarian follicles, adrenal cortex and the placenta
  • Responsible for reproductive development and maintenance
  • Linked to endometriosis, fibroids and carcinoma
Estriol:
  • Component of estrogen
  • Only produced in the placenta (pregnancy)
Estrone:
  • Component of estrogen
  • Only type of estrogen found in the post menopausal women
Progesterone:
  • Produced by the corpus luteal cells post-ovulation
  • Responsible for endometrial proliferation for implantation
  • Blocks the development of new follicles
  • Stimulates uterine blood supply for pregnancy
  • Causes breasts to prepare for lactation but inhibits lactation during pregnancy
  • Causes formation of cervical mucous
Endometrial Cycle:
Day 1-5 Menstrual Phase:
  • At the onset and during menstruation, estrogen and progesterone levels are very low causing the uterus to shed the lining
  • <4mm endometrial thickness at the end of menstruation
Day 6-13: Proliferative Phase:
  • Increasing estrogen levels cause endometrial proliferation
  • <11mm endometrial thickness
Day 14 -28: Secretory Phase:
  • Increased estrogen and progesterone levels cause a decrease in FSH and LH levels
  • Mucous is produced in the cervix
  • Endometrium continues to thicken
  • If no fertilization occurs the corpus luteal cyst will involute causing decreased progesterone levels until menstruation begins
  • 9-16mm endometrial thickness
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