Pediatrics and Post-Menopausal Pelvis

Pediatric Anatomy

• Uterus is 3.5 cm long for the first 6-8 weeks after birth

  • Endometrium seen as a thin line or small amount of fluid

• Uterine size decreases in size after postnatal period (hormone influences)

• Cervix is prominent making up 2/3 of the uterus

  • Greatest increase at puberty

  • Fundus becomes larger than cervix

• Ovaries are 15 × 2.5 × 3 mm (long and thin)

Transabdominal Exam - Pediatric Approach

• Take time to explain the test

• Allow one or both parents to stay

  • tailor explanation to pt’s age

• Requires full bladder

  • Bottle of fluids 30 min prior → pt’s not potty trained

  • 24 oz od not carbonated fluid 45-60 min prior → older children

Vagina, Uterus, and Fallopian Tube Pediatric pathology:

• Primary tumors are rare in children

• Malignant tumors are more common

  • Vagina more often than uterus

The most common reason for vaginal bleeding in a child is:

A foreign body

Pediatric Ovarian Pathology:

• Cysts are fairly common

• Malignant tumors are rare

Gartner’s Duct Cyst

• Benign cyst of the vagina

• Most common cystic lesion of the vagina

• Usually develop along the side walls of the vaginal canal

Hydrosalpinx or Pyosalpinx

• Fluid or pus in the fallopian tubes

• Associated with PID

• Suspicious for sexual abuse

Sarcoma Botryoides

• Most common vaginal and uterine lesion of young girls

• See grape like structure coming out of vagina

• Pt presents with bloody discharge

• Usually originates in vagina and spreads to uterus

Primary Adenocarcinoma

• Uterine or Cervical Tumor

• Seen in daughters whose mothers took DES

• Presents with vaginal bleeding and rapidly growing tumor

• May occur in children younger than 1 y/o

• Almost always occurs before age 11

Endodermal Sinus Tumor

• Highly malignant vaginal and cervix tumor

• Usually occurs by age 3

• Similar sarcoma botryoides

Follicular cysts

Functional cysts

Hemorrhagic cysts

Bleeding within the cyst

Corpus Luteum Cyst

Mature Follicular cyst

Paraovarian cyst

• Remnant of Wolffian Duct

• “Floating” cyst

Polycystic Ovaries (PCOS)

• May appear as enlarged ovaries

• Follicles located in the periphery

• “String of Peals” sign

• Increased risk of ovarian torsion

Benign Cystic Teratoma

• Most common tumor during reproductive years

  • Uncommon before puberty

• Risk of torsion

• Contains hair, fat, teeth, bone, etc.

Cystadenomas

• Two types: Serous and Mucinous

• RARE in children

Ovarian Fibroma

• Rare solid CT tumor

  • Fibrous type of tumor

• Sometimes seen in children

• Associated with Meigs Syndrome

• Subject to torsion

Dysgerminoma

• Most common pediatric malignant ovarian mass

• counterpart of testicular seminoma

• low-grade malignancy

  • potentially curable

• solid mass that may contain septa and calcifications

Malignant Ovarian Lesions U/S signs / labs:

• Prominent arterial flow

• Bilateral 10-15% of the time (usuallu unilateral)

• Increased levels of HCG, LDH, AFP

• Germ cell tumors are the most common malignant tumors in the pediatric genital tract

Endodermal Sinus Tumor of the Ovary

• Germ cell tumor

• Second most common of germ cell tumors

• Grows rapidly

• Unilateral

Malignant teratoma

• Germ cell tumor

• Usually contains more solid components

• May not be able to tell difference of U/S

Primary Choriocarcinoma of the Ovary

• Germ cell tumor

• May lead to precocious puberty

Embryonal carcinoma

• Germ cell tumor

• Highly malignant

• Unilateral

• May lead to precocious puberty

U/S appearance of germ cell tumors:

• purely cystic

• solid

• highly echogenic

• cul-de-sac fluid

• liver mets

• nodal mets

• abdominal ascites

Ambiguous Genetalia

• 1/5000 babies born with this

• Early diagnosis is important

• Ultrasound helps speed sexuality assignment

• Vaginal atresia, fused labia, clitorimegaly, cryptorchidism

• Hermaphrodite

  • has both ovarian and testicular tissue

Precocious Puberty

• Puberty prior to age 8

• Most causes are idiopathic

• May be caused by pituitary or other endocrine abnormality

• Pt’s experience breast development, pubic hair and menstruation

McCune-Albright Syndrome

• Form of precocious puberty

• Fibrous dysplasia of bone associated with café-au-lait skin pigmentation

• Endocrine hyperfunction

• Have large ovarian cysts

• Large size discrepancy between the two ovaries

Menopause

• Permanent cessation of menstrual activity

  • Cessation of ovulation, decreased estrogen and progesterone levels

• Usually occurs between 35-58

• Clinical post-menopausal problems are quite different from pre-menopausal women

• Vaginal bleeding is concerning

• Increased incidence of GYN cancer

Hormone Replacement Therapy

• Replaces estrogen and progesterone in post-menopausal women

• Relieves symptoms associated with menopause

  • Vaginal dryness, mood swings, hot flashes, bone & heart problems

• Prevents severe osteoporosis

RIsk factors of Hormone Replacement Therapy:

• MAY actually increase cardiovascular risks

• Dysfunctional Uterine Bleeding (DUB) can be a side effect

  • stimulating endometrium

If the patient IS on HRT, expect:

• Cyclic bleeding

• Thicker endometrium

• Reduced risk of osteoporosis

• Slightly increased risk of endometrial cancer

• Increased breast cancer risk

• Increased blood clot risk

• Increased heart attack risk

If the patient is NOT on HRT, expect:

• Atrophy of uterus, endometrium, and ovaries

• vaginal drying

• hot flashes

• increased risk of osteoporosis

• decreased fibroid size

  • no estrogen feeding them

Post-menopausal uterus

• Nabothian Cysts of the cervix are commonly seen

• Uterine atrophy

• Vascular calcifications within the uterus

Normal post-menopausal endo NOT on HRT:

• thin and hyperechoic

• no bleeding

• endometrium <8 mm

Abnormal post-menopausal endothelium NOT on HRT:

• Thickened

• Irregular

• Heterogenous

• Bleeding

Post-menopausal endo on HRT → Estrogen and Progesterone

• Thin or <8 mm

• Hyperechoic

Post-menopausal endo on HRT → Unopposed Estrogen (no Progesterone)

• Will be thicker d/t estrogen

• Should still be <8 mm

Post-Menopausal bleeding differential diagnosis:

• HRT

• Vaginitis

• Endometrial Carcinoma, polyp, or hyperplasia

• Cervical carcinoma or polyp

• Ovarian tumor

• Bleeding from the urinary tract

Post-menopausal ovaries U/S appearance:

• Hypoechoic with absense of follicles

• Size varies with hormonal status and number of years since menopause

• Not always visualized

  • atrophy and migrate closer to pelvic walls

• High resistance flow in ovarian artery

Post-menopausal Ovaries

• Higher incidence of cancer

• any cyst should be thoroughly evaluated

  • small ovarian cysts occur in 15%

• CA 125 → screening for ovarian cancer

• Usually measures 2 × 1.5 × 0.5 cm

If cysts seen on PM ovary:

• <5 cm and simple

  • follow with ultrasound

• >5 cm

  • surgery is recommended

• Any septations or solid components warrant surgery regardless of size