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However, it can be a worthwhile read. I have chosen to include the sections on ultrasound scan technique for the health care professionals reading this. If you are a woman and have reached your menopause or who is undergoing the “change of life”, you may find this section and some of the other more technical sections valuable. This information may help you become a more critical consumer of health services. The numbers in parentheses refer to the references which appear at the end.
There are no individual hyperlinks to the references. This booklet is not a substitute for medical advice from your physician. Few diseases are as evil as cancer. And among the cancers, perhaps none is as evil as ovarian cancer. It is the number one gynecologic malignancy responsible for killing women. It is usually silent until it is too late to effectively treat.
Early ovarian cancer detection is both a medical and political hot potato. Medically, there is no agreement by all authorities as to how to diagnose this disease early. For a woman past her reproductive years, changes in the sonographic appearance of the pelvic organs still occurs, albeit, more slowly and less dramatically than in the pre-menopausal woman. Sonographic examination of the female pelvic organs is most commonly performed using two different approaches. The first and older, is transabdominal, the second and more recent, is transvaginal.
A third method, transperineal, is also employed, though less frequently. BLADDER FILLING — Transabdominal ultrasound of the female pelvis should be performed with the bladder optimally distended. The operative phrase is “optimally distended”. If too full, the patient may experience excessive discomfort, which might result in guarding. Also, the overdistended bladder may push the target structures so far from the transducer that image quality suffers.
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Unequivocally, there are occasions in which the empty bladder transabdominal examination may yield better results than either the transvaginal or filled bladder approaches. This is particularly true when relatively large, especially fundal, fibroids are present. The operative phrase is “generally performed”. If too full, the patient may experience excessive discomfort. Also, the distended bladder may push the target structures so far from the transducer that image quality suffers. Optimal distention of the bladder may be achieved by having the patient void, perhaps incrementally. Unequivocally, there are occasions in which the transvaginal examination may yield better results with a filled or filling bladder than with an empty bladder.
If a structure of interest is either not apparent or is suboptimally seen, patience and bladder filling may result in better visualization. This maneuver improves image quality in a manner similar to manually manipulating the anatomy and, possibly, by compressing the tissue between the transducer and the target structure. POSITIONING — Proper patient positioning can also improve examination quality. When performing endovaginal ultrasounds, elevating the patient’s hips or placing the patient at the end of the examining table facilitates greater downward excursion of the probe handle. Occasionally, placing the patient’s leg on the examiner’s shoulder allows for increased lateral range of motion of the transducer. A relaxed patient is much easier to examine than a tense patient. THE MOST VALUABLE IMAGING SKILLS WE POSSESS ARE OBSERVATION, CREATIVITY AND TECHNIQUE.
The ovaries are generally situated on either side of the uterus, although locations superior or posterior to the uterus are not uncommon. In addition to the techniques described above, if one has difficulty finding the ovaries, a search along the internal iliac artery may prove useful. The ovary is often located anterior to the vascular bifurcation into anterior and posterior branches. During the POST-MENOPAUSAL years of a normal female, the ovaries undergo changes characterized by diminution in size and decreased to absent folliculogenesis.
In fact, the reliable identification of an ovary can often no longer be made by demonstrating follicle cysts surrounded by ovarian parenchyma. One occasionally must resort to scanning along the route of the internal iliac vessels to discover its location. Just how big is a post-menopausal ovary? Apparently, it depends on the investigator. Aboulghar et al determined the post-menopausal ovarian volume to be 3. Goswamy calculated right ovarian volume at 3. Concomitant with the gray-scale changes seen in post-menopausal women, both color and duplex Doppler changes can be demonstrated.
As there is no menstrual cycle, the sequential changes in blood flow to the ovary seen during the reproductive years are generally not demonstrated in the normal post-menopausal patient. These cyclical changes, however, may be evident if the patient is on hormone replacement therapy. To diagnose the presence of an adnexal mass, gray-scale ultrasound is of substantial importance. This is especially true as the post-menopausal ovary may not be reliably palpated. 10 cm in size were missed on palpation. Transvaginal sonography is generally more sensitive than transabdominal.
Ovarian cancers may manifest their presence as post-menopausal cysts. Gray-scale sonography has been used with varying success to characterize adnexal disease. Findings such as septations, papillary projections and mural nodules are more likely to be associated with malignant changes than are clear cystic masses. Rulin and Preston found that masses less than 5. 0 cm were unlikely to be malignant. Some investigators have concluded that both color and duplex Doppler are valuable tools for the diagnosis of ovarian and other malignancies.
Doppler sonography to distinguish between them. The standard hierarchical organization of normal vessels, in which flow progresses from arteries of decreasing size through capillaries to veins of increasing size, is absent. Instead, tumoral flow may be short-circuited through shunts. Also, tumor vessels may possess altered architecture.
Abnormal flow patterns can be demonstrated in vessels surrounding malignant masses. Finding these areas of neovascularity may not be possible on gray-scale examination only. Because color Doppler may make these vessels visible, it allows the examiner to survey the anatomy of the target structure for vascular areas of interest. There is substantial data to suggest that the flow characteristics of some malignant diseases of the ovary are different from benign processes. In general, a low resistance pattern is unusual in the ovary of a post-menopausal patient, as are low index values, and may be associated with malignancy.
The uterus is located in the lesser pelvis between the urinary bladder and the rectum. Although generally a midline structure, lateral deviations of the uterus are not uncommon. The broad ligaments extend from the uterus laterally to the pelvic side walls. They contain the fallopian tubes and vessels.
The uterosacral ligaments serve to keep the uterus in an anterior position. The normal adult uterus measures approximately 7. During the POST-MENOPAUSAL years of a normal female, the uterus decreases in size and the endometrium atrophies. As the ovaries undergo involution, there is an associated reduction in the amount of estrogen produced. This leads to the gradual atrophy and involution of the endometrium that characterizes the uterine lining of the post-menopausal patient. In asymptomatic post-menopausal women, the mean endometrial thickness has been determined to be 3.
7 mm, although other investigators have reached different conclusions. Gray-scale examination generally reveals an inverse relationship between uterine size and the time since menopause: uterine size and volume progressively as the duration of the post-menopausal period increases. The greatest changes occur within the first ten years after the menopause and more gradually thereafter. Just how big is the post-menopausal uterus?
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The post-menopausal uterus has been measured at 8. A significant relationship between parity and both uterine volume and weight was not found. As there is no menstrual cycle, successive changes in blood flow to the uterus are generally not demonstrated. However, some similarities between pre- and post- menopausal women may be present. Kurjak and Zalud compared the Resistance Index values of the uterine arteries in pre- and post- menopausal women. The RI was noted to be higher in the post-menopausal patients, but apparently not statistically different. Diastolic flow was demonstrated in all subjects.
If the patient is on hormone replacement therapy, the above-described findings may not be present. Among these patients, both uterine size and cyclical endometrial changes may remain. Even the corpus-to-cervix ratio approximates the pre-menopausal state. In general, estrogen therapy affects the post-menopausal endometrium similarly to estrogens in the normal cycle. The conjugated estrogens have a proliferative effect. Bourne et al have shown altered blood flow to the uterus in patients receiving hormone replacement therapy.
Using endovaginal technique, significant arterial changes were demonstrated. Before treatment, the mean thickness was 0. Following treatment, the values were 0. In the post-menopausal patient, one of the most important uses of ultrasound involves the diagnosis and management of endometrial cancer.
In general, endovaginal ultrasound is superior than transabdominal ultrasound for visualization of the myometrium and endometrium. Sonographic signs of endometrial cancer in the post-menopausal patient include: an obstructed fluid-filled canal, a thickened uterine cavity, an enlarged uterus and a lobular uterus with a mixed echo pattern. Gray-scale ultrasound has accurately demonstrated the presence and extent of myometrial invasion. Some investigators have demonstrated the utility of Doppler ultrasound in diagnosing endometrial cancer.
Bourne et al demonstrated increased blood flow in the uterine artery and the area of the suspected tumor in patients with malignant disease. One group appears to have substantial experience in evaluating pelvic masses and distinguishing benign from malignant disease. Mendelson EB, Bohm-Velez M, Joseph N, Neiman HL. Gynecologic imaging: Comparison of transabdominal and transvaginal sonography. Coleman BG, Arger PH, Grumbach K, et al.
Transvaginal and transabdominal sonography: Prospective comparison. Tessler FN, Schiller VL, Perrella RR, Sutherlan ML, Grant EG. Transabdominal versus endovaginal pelvic sonography: prospective study. Scanlan KA, Pozniak MA, Fagerholm M, Shapiro S. Value of transperineal sonography in the assessment of vaginal atresia. Combined perineal-abdominal sonography in the assessment of vaginal atresia. Jeanty P, d’Alton M, Romero R, Hobbins JC.
Rodriguez MH, Platt LD, Medearis AL, Lobo RA. The use of transvaginal sonography for evaluation of postmenopausal ovarian size and morphology. Lyons EA, Gratton D, Harrington C. Transvaginal sonography of normal pelvic anatomy. Transvaginal sonography of postmenopausal ovaries with pathologic correlation.
Wolf SI, Gosink BB, Feldesman MR, et al. Prevalence of simple adnexal cysts in postmenopausal women. Report of the Task Group on Reference Man. Prepared by the Task Group Committee no.
Sample WF, Lippe BM, Gyepes MT. Gray-scale ultrasonography of the normal female pelvis. Yeh HC, Futterweit W, Thornton JC. Polycystic ovarian disease: US features in 104 patients. Ovarian imaging by ultrasound: An attempt to define a reference plane. Fleischer AC, Daniell JF, Rodier J, Lindsay AM, James AE Jr.
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Sonographic monitoring of ovarian follicular development. Bomsel-Helmreich O, Gougeon A, Thebault A, et al. Healthy and atretic human follicles in the preovulatory phase: Differences in evolution of follicular morphology and steroid content of the follicular fluid. Nitschke-Dabelstein S, Hackeloer BJ, Sturm G.
Ovulation and corpus luteum formation observed by ultrasonography. O’Herlihy C, de Crespigny LJ Ch, Robinson HP. Monitoring ovarian follicular development with real-time ultrasound. Renaud R, Macler J, Dervain I. Echographic study of follicular maturation and ovulation during the normal menstrual cycle.
Fleischer AC, Kepple DM, Vasquez J. Conventional and color Doppler transvaginal sonography in gynecologic infertility. Hall DA, Hann LE, Ferrucci JT Jr, et al. Sonographic morphology of the normal menstrual cycle. Dillon EH, Taylor KJW: Doppler ultrasound in the female pelvis and first trimester pregnancy.
Coleman BG: Transvaginal sonography of adnexal masses. The Radiologic Clinics of North America. Hata K, Hata T, Senoh D, et al. Change in ovarian arterial compliance during the human menstrual cycle assessed by Doppler ultrasound.
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Scholtes MCW, Wladimiroff JW, van Rijen HJM, Hop WC. Uterine and ovarian flow velocity waveforms in the normal menstrual cycle: A transvaginal Doppler study. Taylor KJW, Burns PN, Wells PNT, Conway DI, Hull MGR. Ultrasound Doppler flow studies of the ovarian and uterine arteries. Kurjak A, Kupesic-Urek S, Schulman H, Zalud I.
Transvaginal color flow Doppler in the assessment of ovarian and uterine blood flow in infertile women. The assessment of luteal blood flow in pregnant and non-pregnant women by transvaginal color Doppler. Taylor KJW, Ramos IM, Feyock AL, et al. Andolf E, Jorgensen C, Svalenius E, Sunden B. Ultrasound measurement of the ovarian volume. Transvaginal sonography helps find ovarian cancer.