Tips of
ovarian imaging in nonpreg state? How & what to interpret ovaries in TVS as
you look into the USG screen?? : To use highest frequency probe and keep on
moving the probe in side to side direction, up-downwards, angular-i.e. to
fornices:-
Q.1: What is the Expected Shape, location and orientation of normal
ovaries?? Ans:-The normal ovary is ellipsoid in shape and is variable in both
location and orientation depending upon the age and parity of the patient as
well as the degree of bladder distention. In the nulliparous adult female the
ovaries are situated in the ovarian
fossa which is adjacent to the lateral pelvic side wall and is bounded by the
obliterated umbilical artery anteriorly the ureter and internal iliac
anteriorly posteriorly and the external iliac vein superiorly . But the
inferior aspect of the ovary is slightly smaller than the superior or tubal
aspect and is bound to the uterine cornea by the ovarian ligament which lies
within the broad ligament. The lateral surface of the ovary is in contact with
the parietal peritoneum lining the ovarian fossa and most of the medial surface
is covered by the fallopian tube. The anterior border of the ovary is attached
to the mesovarium through which the vascular channels and nerves pass into the
ovarian hilum.
Q.2:-How
best to calculate ovarian volume?? The concept of prolate ellipse: - Ovarian volume is
calculated by measuring the ovary in three dimensions on two orthogonal planes
and using the formula for the prolate ellipse.
Q3: Does ovarian
size vary with age?? Oh yes. Ovarian size depends upon age menstrual status
pregnancy status body habitus and phase of the menstrual cycle.
Q. 4:-What is the mean Ov volume of
ovary(each) in premenosal women?? In premenopausal women the mean
ovarian volume is 9.8 ml.
Q. 5:-What happens in normal menst cycles
–day wise volume changes of ovaries as follicles increase due to increase of
Liq Follicle & repeated mitois if Granulosa cells??
With the highest
volumes found in the preovulatory phase and the lowest volumes in the luteal
phase Normal ovarian volume
decreases after the age of 30 years .
Q. 6:-Age wise changes in volume of
ovaries: - In one large study mean ovarian volume significantly decreased in
each decade up to age 60 years measuring 6.6 ml in women under 30 years of age
6.1 ml in women 30 to 39 year old, 4.8 ml at ages 40 to 49 years 2.6 ml at ages
50 to 59 years 1.98 ml at ages 60 to 69 years and 1.85 ml over age 70 years.
Q. 7:-Height of the woman concerned &
ovarian size? The authors found a statistically significant increased ovarian
size in tall women but no relationship to weight despite the small size of the
postmenopausal ovary the majority are detectable by TVS.
Q. 8:-How does developing and immature
follicles look like in TVS-====it is like anechoic unilocular with clear
margins cysts? The normal ovary in
women of reproductive age has a variable appearance over the course of the
menstrual cycle. Developing and immature follicles can be seen throughout the
entire menstrual cycle and appear as anechoic unilocular sharply marinated
cysts measuring from 2 to 9 mm
Q. 9:-Size of the DF & on which day? By
days 8 to 12 of the menstrual cycle one or more dominant follicles will grow to
a diameter of approximately 20 to 25 mm and then rupture at ovulation releasing
the oocyte.
Q. 10 :-In what %of normally menst woman we
can image a second but nondominat follicle? Up to 80% of patients have a second
non dominant follicle that becomes almost as large as the dominant follicle,
but admittedly slightly less than D F.
Q. 11 :-How best to recognize preovulatory
dominant follicle in a TVS if you are alone?? The preovulatory dominant
follicle may have a slightly complex
appearance with the oocyte and its supporting structures appearing as a ring
like structure within the follicle.
Q. 12. How do U, my dear members
differentiate a CL from a DF?? Ans: 1) Cellular hypertrophy 2) Vacuolization of
the cyst wall... We know that following ovulation the corpus luteum evolves
from the remnant of the mature follicle. We are aware of that.
Q. 13. What else?? But we should remember
that there is a dynamic process of cellular hypertrophy and increased
vacuolization of the cyst wall. Therefore a corpus luteum is typically visible
in the secretory phase of the menstrual cycle and in the first few weeks of
early pregnancy...
Q. 14 What are the characteristic features
on sonographic imaging?? Ans:- the corpus luteum typically has a relatively
thick homogeneously echogenic wall the inner margin of which may be slightly
irregular with a crenulated appearance On color Doppler the wall of the corpus luteum often demonstrates a circumferential
ring of arterial flow with a low resistance spectral Doppler waveform Internal
echoes are common reflecting variable amounts of internal hemorrhage
that occurred at the time of ovulation and occasionally a corpus luteum may be
filled with homogenous low level echoes mimicking a solid mass However there is
usually evidence of enhanced through transmission because of the fluid content
and there will be no central vascularity
Q. 15 What is the size of CL?? Ans:
Typically the corpus luteum is under 3.0 cm in maximal dimension but rarely may
it become larger.
Q. 16. Is corpus albicans sonographically
imagable?? Ans: No, never .If pregnancy does not occur the corpus luteum
gradually involutes and atrophies to become the corpus albicans which is
typically not sonographically identifiable
Q.17
Relevance of Small echogenic foci measuring 1 to 3 mm may be noted in the
periphery of otherwise normal appearing ovaries?? No relevance. No
concern. In approximately half of women
undergoing TVS particularly in the perimenopausal age group. These foci often
demonstrate ring down artifact and are a benign finding. What is the source or
etiology?? These are due likely related to the presence of tiny cysts possibly
cholesterol or hemosiderin deposition and less likely tiny calcifications.
These tiny echogenic foci may come and go underneath the surface epithelium and
should not raise concerns or result in follow up imaging.
Q.18:- In
the postmenopausal patient ovarian size decreased correlating with hormonal
status and length of time since menopause?? Ans: probably yes, the mean
postmenopausal ovarian volumes have been reported to range from 1.2 to 5.8 ml
with an ovarian volume of greater than 8 ml considered abnormal in all cases.
Q. 19:-What
is the significance if ovarian sixe is bigger than other? Ans:-Some authors
have suggested that a unilateral ovarian size twice that of the opposite side regardless of the
size should also be considered abnormal even though folliculogenesis has
ceased.
Q. 20:-What
is the explanation behind this? How do members account for this?? WE have to
remember that the postmenopausal ovaries are not as quiescent as initially
thought. As such small simple adnexal cysts measuring as large as 3 cm have
been reported in up to 15% of postmenopausal women most of these spontaneously
regress on serial sonographic examinations. These simple cysts seen early in
menopause most likely represent an occasional ovulatory event or an atretic
follicle .However any anechoic cystic lesion in a postmenopausal ovary should
generally be referred to as a cyst,
Q 21:-Can
you observe normal cyst in the age of 70-80 yrs of age?? In late menopause
although ovulation is rare smaller cysts less than or equal to 1 cm have been
reported in up to 21% of women. TVS will detect these cysts more readily than.
What about TAS?? TAS for ovarian imaging will yield poorer result for obesity
& because of the higher resolution of the higher frequency transvaginal
probe. These simple appearing cysts measuring less than 1 cm in maximal
diameter do not need further follow up and whether or not they are described in
the final report can be left to the discretion of the interpreting physician.
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