Transcript
The OvariesThe OvariesDurr-e-SabihDurr-e-Sabih
MBBS. MS. FRCP. FANMBMBBS. MS. FRCP. FANMBDirector MINARDirector MINAR
MultanMultanPAKISTANPAKISTAN
dsabih@yahoo.comdsabih@yahoo.com
Early on Early on
• A baby girl is born with a huge number of potential eggs ( 700,000 to 2 million)
• By puberty only 400,000 are left• Around 500 are used during lifetime of
ovulation
The Normal Adult OvaryThe Normal Adult Ovary
• Resting ovary is moderately echogenic, ovoid, well marginated, seen along the side of uterus usually but can be seen behind the uterus or even in the lower abdomen.
• Cysts in the ovary in premenopausal age are the distinguishing feature
• Menopausal ovaries can be smooth and be difficult to identify
ReviewReview
The Normal Adult OvaryThe Normal Adult Ovary
• Primordial follicles are too small to be seen by ultrasound
• Solid background, scattered antral follicles (3-6mm)
• Volume 8- 20 ml
The Normal Adult Ovary (Cont’d)The Normal Adult Ovary (Cont’d)
• 4-8 antral follicles (day 6-7) in each ovary measuring 3-6 mm
• By day 7 one follicle is selected and increases in size more than others
The Normal Adult Ovary (Cont’d)The Normal Adult Ovary (Cont’d)
• 10 mm by day 8-9 (dominate follicles >11mm)• 18- 24mm by day 14 • Subordinate follicles also continue to grow to
about 10 mm, then become smaller• > 50% reduction in volume on ovulation• Corpus luteum is irregular and complex cystic
ReviewReview
What When How
Primordial follicles …. Too small, not visible
Antral follicles(4-8)
D 6-7 3-6mm
Dominate follicle D 8-9 10 – 11 mm
Dominate follicle D 14 18-24mmSubordinate follicles
D 14 Up to 10mm then regress
Corpus luteum D >14 50% volume, irregular contour
OvariesOvaries(Volume)(Volume)
• Birth – 3 Mo 0.3 – 3.6 ml• 2-8 yrs 1.0 - 1.5 ml• 10 yrs2.2 – 3.6 ml• 13 yrs4.2 – 9.0 ml• 15-19 yrs 8.0 – 18 ml• 20-49 yrs 10-23 ml• 50-65 yrs 6 – 14 ml • 70 yrs1 – 6 ml
OvaryOvary
Day 3 OvaryDay 3 Ovary
Normal/Normal/multimulticystic Ovariescystic Ovaries
Dominant FollicleDominant Follicle
The Corpus LuteumThe Corpus Luteum
• One-third will be typical irregular cysts• One-third will look echogenic and solid• One third will not be visible at all
Corpus LuteumCorpus Luteum
© Allen Worrall, Alaska
Corpus Luteum Ring of FireCorpus Luteum Ring of Fire
© Allen Worrall, Alaska
Calcified Area in OvaryCalcified Area in Ovary
Ultrasound Monitoring of Follicles:Ultrasound Monitoring of Follicles:
• Finding• Counting• Measuring• Documenting
Follicles on serial studies
HowHow
• Baseline study….day 4-5 to look for any cyst left over from previous cycles, rule out other lesions
• Start on day 8-10, identify developing follicles of 8-10 mm
• Monitor daily or on alternate days until size of 16-18mm seen (mature follicle)….give HCG pulse
• Ovulation >50% reduction in size
• Very dynamic organs• Changing appearance with the time of the
menstrual cycle, age and pregnancy• Must correlate findings with the expected
physiological findings
Dominant FollicleDominant Follicle
OvulationOvulation
Dominate follicle on day 14Corpus luteum on day 16
Pathological StatesPathological StatesAbsent/Abnormal OvulationAbsent/Abnormal Ovulation
Abnormal Ovarian CyclesAbnormal Ovarian Cycles
• Sporadic ovulation failure in about 7% of cycles
• Sporadic anovulatory syndromes• Chronic anovulatory syndromes
Abnormal Ovarian CyclesAbnormal Ovarian Cycles
• Sporadic ovulation failure in about 7% of cycles
• Sporadic anovulatory syndromeso Follicular Atresiao Empty Follicle Syndromeo Luteinized Unruptured Follicle Syndrome
• Chronic anovulatory syndromes
Abnormal Ovarian CyclesAbnormal Ovarian Cycles
• Sporadic ovulation failure in about 7% of cycles
• Sporadic anovulatory syndromes• Chronic anovulatory syndromes
o Hypergonadismo Hypogonadismo Polycystic Ovarian Syndrome (PCOD)
Sporadic Anovulatory SyndromesSporadic Anovulatory Syndromes
Follicular AtresiaFollicular Atresia
• Dominate follicle starts developing but o Does not reach full sizeo Rapidly becomes smallero Common in oral contraceptive users
Empty Follicle SyndromeEmpty Follicle Syndrome
• Follicle development looks normal• Oocyte is not formed• Cannot differentiate from normal cycles on
ultrasound
Luteinized Unruptured Follicle Luteinized Unruptured Follicle Syndrome (LUFS)Syndrome (LUFS)
• Apparently normal follicle develops but fails to rupture
Chronic Anovulatory SyndromesChronic Anovulatory Syndromes
Primary Ovarian FailurePrimary Ovarian Failure
• Ovaries are small and smooth with no follicular activity
• Estrogen levels are low• Gonadotropin levels are very high
HypogonadotropismHypogonadotropism
• Low FSH, LH, Low estrogen• Pituitary lesion (tumour?)• Ovaries smooth but can respond to exogenous
cyclical hormones
PCOSPCOS
• A very complex endocrine abnormality• A very wide spectrum of findings with the
classic Stein Leventhal syndrome at one end and normal looking females with early fertility at the other
PCOSPCOS
• Typical habitus?o Obeseo Oligo/amennorrhoeao Hirsuitism
• Endocrine abnormalitieso Raised LHo LH/FSH ratio > 3o Raised Sr. Testosterone and Androstenedioneo Insulin resistance
PCOS PCOS Ultrasound FeaturesUltrasound Features
• Large ovaries• Round shape• Large number of small cysts arranged
peripherally under the capsule (string of pearls sign) or throughout the volume
• >10 cysts on TAS, >15 on TVS on a single section
• Echogenic stroma (compare with myometrium)
PCOSPCOSUltrasound FeaturesUltrasound Features
• 1//3rd patients have normal ovarian volumes• Many normal ovaries are multicystic
o Adolescentso Oral contraceptive userso Juvenile hypothyroidismo 17 hydroxylase deficiencyo Post Menopausal ovaries with hyperthecosiso PID
Consensus on diagnostic criteria for Consensus on diagnostic criteria for PCOS (2003)PCOS (2003)Two should be presentTwo should be present
• Oligo and/or anovulation• Clinical and/or biochemical signs of
hyperandrogenism• Polycystic ovaries
HyperandrogenismHyperandrogenism
• Clinical or biochemicalo Hirsuitism (subjective?, racial?)o Acneo Circulating androgens (wide variability)o Free testosterone, free testosterone index,
Polycystic ovaries Polycystic ovaries
• 12 or more follicles in each ovary, measuring 2-9mm across and/or increased ovarian volume (>10ml)
• Exclude follicle distribution, exclude stromal echogenicity and volume
• Does not apply to women on contraceptive pills
Polycystic ovaries Polycystic ovaries
• If findings are seen only on one side, this is still sufficient for diagnosis.
• If there is evidence of dominate follicle or corpus luteum, repeat next month.
• Asymmetric ovarian size or large cyst needs further work-up/follow-up.
PCODPCOD
PCODPCOD
© Allen Worrall, Alaska
Ovarian Hyperstimulation Ovarian Hyperstimulation SyndromeSyndrome
• Numerous follicles grow in a stimulated cycle• Pain, enlarged ovaries (ovaries can become 6-
7 cm in diameter)• If larger, there can be associated ascites,
pleural effusion• On US, enlarged ovaries with multiple large
cysts seen
Hyperstimulated OvariesHyperstimulated Ovaries
Hyperstimulated OvariesHyperstimulated Ovaries
© Shlomo Gobi, Jerusalem
Hyperstimulated OvariesHyperstimulated Ovaries
© Ravi Kadasne, UAE
The Simple Ovarian CystThe Simple Ovarian Cyst
• If up to 5-7 cm in diameter, observe over 6-8 weeks
• Try to repeat scan during the first 5 days of the cycle
The Simple Ovarian CystThe Simple Ovarian Cyst
• > than 7 cm in diameter • Persist beyond the length of a normal
menstrual cycle • solid components • Complex internal structure • Associated with pain
The Simple Ovarian CystThe Simple Ovarian Cyst
© Prof. Nawaz Anjum, Lahore
The Simple Ovarian CystThe Simple Ovarian Cyst
Theca Lutein Theca Lutein
Mural NodulesMural Nodules
© Gunjan Puri, Surat
The Haemorrhagic Ovarian CystThe Haemorrhagic Ovarian Cyst
Haemorrhage
The Haemorrhagic Ovarian CystThe Haemorrhagic Ovarian Cyst
Haemorrhage
Endometriotic cystEndometriotic cyst
Endometriotic cystEndometriotic cyst
Haemorrhagic and endometrial cystHaemorrhagic and endometrial cyst
The parovarian CystThe parovarian Cyst
o A cyst developing within the mesosalpinx between the tube and ovary, from the vestigial remnants of the Wolffian body. These cysts represent 10% of all adnexal masses. They occur in the third to fourth decade.
The parovarian CystThe parovarian Cyst
o On ultrasound, a paraovarian cyst may be suspected when a thin-walled, unilocular ovoid structure free of internal echoes is demonstrated lying next to the uterus within the plane of the broad ligament and the ovary is seen separately.
o Their size does not change in relation to the menstrual cycle. But they can torse and undergo haemorrhage
The parovarian CystThe parovarian Cyst
The parovarian CystThe parovarian Cyst
Hydatid of Morgagni
Epioophoron
The parovarian CystThe parovarian Cyst
© Allan Worrall, Alaska
The parovarian CystThe parovarian Cyst
HydrosalpinxHydrosalpinx
The parovarian CystThe parovarian Cyst
MenopausalMenopausal
TorsionTorsion
EndEnd
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