Sectional Gynecology Part II

reproductive years

11-13 to 50 years

Ovulation

once a month an ovum, which is the unfertilized egg, is released from one of the two ovaries

Follicle

fluid sac containing a developing ovum within the ovary

Dominant or Graafian Follicle

term for enlarging follicle in which ovulation occurs from. In a normal cycle this is to occur one a month from one ovary. 2CM

Corpus Luteum

cyst producing progesterone at the site of the dominant follicle after it has burst.

Corpus Albicans

scar at the site of a previous corpus luteum

dominant follicle and corpus luteal cysts

1,2,3 Rule

•<1 cm = follicle

•1-2 cm = dominant follicle

•>3 cm = cyst

FSH: Follicle Stimulating Hormone

From the pituitary gland which stimulate follicular growth.

Estrogen

hormone secreted by growing follicles that stimulate the endometrium to regenerate.

LH: Lutenizing Hormone

large surge from pituitary gland causes graafian follicle to rupture

Progesterone

hormone secreted by the corpus luteum that prepares the endometrium to receive the fertilized egg.

Ova

immature oocytes until the onset of menarche

How many oocytes does each female have at the time of birth ?

200,000

With the onset of puberty, the hypothalamus begins the release of…

GONADOTROPIN Releasing hormone (GnRH) : stimulates the anterior pituitary gland to secrete gonadotropins (primary one is FSH).

Ovarian cycle

• Follicular phase (day 1-14): Follicle stimulating hormone (FSH) causes the ovarian follicles to develop which produce estrogen as they grow.

• 5-8 pre-antral follicles develop and one reaches maturity each month called Graafian / Dominant follicle (2cm)

• As estrogen increases in blood, pituitary gland is told to stop producing FSH and secretes the lutenizing hormone (LH).

• LH and some FSH stimulate ovulation on day 14.

• Free fluid in the pelvis can be seen at this time with the rupture of the Corpus Luteum.

• After ovulation, the ovary enters the LUTEAL PHASE

• The corpus luteum secretes progresterone. After around 10 days of ovulation, the CL will degenerate, causing progesterone to decrease.

Mittelschmerz

pain with ovulation

What happens if conception occurs ?

the HCG produced by the zygote causes the Corpus Luteum to persist and to secrete progesterone for 3 months until placenta takes over

Follicles sonography

•Thin, smooth walled

•Anechoic

•Dominant Follicle 2 cm

•Up to 3cm = normal

•Corpus luteum internal echoes and ring of vascularity

Menopause

•Folliculogenesis cease and ovaries decrease in size.

•Ovaries stop making estrogen.

Perimenopause:

FSH increases to get more estrogen.

Estrogen fluctuates

Post menopause:

Estrogen and progesterone are no longer produced.

Physiologic ≤ 3cm cyst

•Dominant Follicle

•Corpus luteum

Functional cyst

•Follicular Cyst

•Hemorrhagic CL

non-neopastic ovarian cysts

•Most <5cm

•Regress 6-8 wks

Follicular & Simple cysts

Grafian follicle → no ovulation → stays active

Hemorrhagic ovarian cysts

•Hemorrhage within CL or functional cyst

•Resolve within 8 weeks

Hemorrhagic Ovarian Cysts sonography

•Cobweb appearance - fibrin strands (?septations)

•Solid appearing area with concave margins / retracting clot

•Circumferential flow

Hemorrhagic Ovarian Cysts (bottom image displays retracting clot)

Endometrial phases

1. Menstrual Phase: days 1-5. Coincide with follicular phase of ovary. Progesterone causes spiral arteries to constrict and decreases blood flow which results in ischemia and shedding of the zona functionalis.

2. Proliferative Phase: day 6-14. As follicles produce estrogen the zona functionalis starts to regenerate. This lasts until ovulation.

3. Secretory Phase: day 15-28. Coincides with luteal phase of ovary

Menstrual Phase begins sonography

• Day 1-4 early menses with hypoechoic cavity represents blood and tissue. Surrounded by hyperechoic endometrial echo.

• Days 3-7 thinner blood has been sloughed.

Proliferative Phase (Days 5-9) sonography

presents as three-line sign:

1. Thin endometrium is in middle

2. The thin endometrium is surrounded on each side by the hypoechoic halo functionalis layer.

3. This hypoechoic halo is surrounded by the thin echogenic basalis layer.

Proliferative phase days 10-14

increase in thickness and echogenicity. Basalis layer increased in thickness therefore echogenicity. Ovulation on day 14.

Secretory phase begins sonography

• Days 15-28

• The endometrium is at its thickest dimension and becomes hyperechoic.

proliferative phase: three line sign

top) basalis layer

middle) endometrial echo

bottom) functionalis layer

secretory phase

Functional layer

glands & stroma that shed menses

HYPOECHOIC during proliferative phase

HYPERECHOIC during secretory phase

Basal layer

glands that regenerate new endometrium

Endometrium days 1-5

menses

fluid and debris

Days 5-14

Early proliferative

Single thin line

Proliferative phase

“3 line sign”

Days 15-28

Secretory Phase

Thick and echogenic

Enhancement

endometrial echo

endometrial/myometrial junction

TECHNIQUE: How to measure ovaries??

•Find the ovary in its longest axis take your length measurement there.

•Go 90 degrees to where you are and take measurement

•3rd measurement (AP) can be taken in either plane. Long axis is easiest as you can see the widest part.

Pelvic Ultrasound Examination uterus

• Vagina and uterus are anatomic landmarks.

• Document the following:

• Uterine size, shape, orientation

• Endometrium

• Myometrium

• Cervix

• Vagina serves as landmark for cervix and lower uterine segment.

Pelvic Ultrasound Examination uterus, cervix

•Length measured in long axis from fundus to cervix

•AP depth measured in long axis from anterior to posterior walls, perpendicular to length

•Width measured from transaxial or coronal view

•Cervical diameters (with pregnancy)

•Endometrium analyzed for thickness and echogenicity

•Myometrium, cervix evaluated for contour changes, echogenicity, and masses

Pelvic Ultrasound Examination Adnexa (Ovaries and Fallopian Tubes)

• Ovaries identified anterior to internal iliac vessels

• Document the following:

• Size, shape, contour, echogenicity

• Position relative to uterus

• Ovarian width measured in transaxial or coronal view

• Ovarian volume may be calculated.

Pelvic Ultrasound Examination Cul-de-sac

•Evaluate cul-de-sac for presence of free fluid or mass.

•If mass is detected, document size, position, shape, echographic pattern relationship to ovaries and uterus.

•Differentiate normal loops of bowel from mass.

Sagittal scanning plane

1) acoustic beam

2) transducer

3) bladder

4) inferior

5) superior

6) posterior

7) uterus

8) vagina

Sagittal scanning place

1) anterior (approach)

2) bladder

3) superior

4) endometrium

5) myometrium

6) posterior

7) endovaginal canal

8) vagina

9) far field (posterior)

10) inferior

11) near field (anterior)

Sagittal scanning plane

1) anterior

2) cranial

3) posterior

4) caudal

transverse plane

1) anterior

2) left

3) posterior

4) right

sagittal scanning plane

1) caudal

2) uterus

3) anterior

4) cranial

5) bowel

6) posterior

transverse scanning plane

1) caudal

2) uterus

3) right

4) cranial

5) left