Overview of Sonography Female Pelvic Pathology Assessment, Protocols, and Interpretation
When doctors suspect that something is wrong in the pelvic area, their first step often is to use a technique called sonography – it’s sort of like an ultrasound. This happens after they’ve done a physical exam. The invention of portable ultrasound machines has really changed the way the doctors can examine and treat issues related to pregnancy and women’s reproductive health.
Sonography has some major advantages when it comes to looking at the body. It doesn’t expose the patient to any radiation, it provides images as things are happening inside the body, and it can show how blood is flowing through the organs. It can even create 3D and 4D images. All these features have made sonography a very useful tool for examining the pelvis as compared to other diagnostic methods. When doing a pelvic sonography, doctors might use different techniques like through the abdomen, vagina, area between the genitals and the anus, or even inside the body.
When using sonography, they look at certain features and signs based on different parameters. This includes how much of the sound waves go through, get absorbed, reflect back, and the angle at which they bounce back. This will vary based on the size, depth, shape, content, and outline of an organ. If all of the sound waves bounce back, that area shows as white or “bright” on the image. If some of the waves go through and others bounce back, it shows up as various shades of gray. If all the waves pass through, it shows up as black or “dark”.
For example, when doing an ultrasound through the abdomen, they often do this when the bladder is full. That’s because the full bladder allows all the sound waves to travel all the way to the back and move the intestines to the side. This lets the doctors get a complete look at the organs in the pelvis.
Anatomy and Physiology of Sonography Female Pelvic Pathology Assessment, Protocols, and Interpretation
The uterus is a muscular organ about the size and shape of a pear that sits in the lower part of the belly. It’s texture varies from being similar to the same density as the surrounding tissue (isoechoic) to denser (hyperechoic). The uterus has three different layers of muscle. The middle layer, or myometrium, makes up most of the uterus and has a uniform texture. The very inner part of the uterus, another layer of myometrium, is compact, thin, and less dense, forming a halo-like or junctional zone layer. The most outer layer of muscle in the uterus is thin and can sometimes show dot-like structures (calcifications) on a sonogram, mostly associated with aging. The uterus helps give us an idea of the structure of the lower belly, especially when using ultrasound techniques.
The endometrium, or the lining inside the uterus, changes its appearance on an ultrasound throughout a woman’s menstrual cycle and based on her hormonal status. Right after a woman’s period, the endometrium is thin and looks like a line. Before ovulation, the endometrium displays a three-layer pattern and is about 4 to 8 mm thick. After ovulation, the endometrium appears solid and more dense, with a thickness between 7 to 14 mm.
The cervix is a tube-like structure that connects the uterus to the vagina, and it looks the same (homogeneous) on an ultrasound. The internal os, or the opening in the cervix, helps to tell the difference between the cervix and the uterus, and the endocervical canal (found inside the cervix) from the endometrial cavity (inside the uterus).
The fallopian tubes, which lead from the ovaries to the uterus, are a tube-like structure that usually can’t be seen on an ultrasound unless there’s some disease or conditions that make them bigger than normal.
The ovaries, which are oval-shaped and located on each side of the uterus, show up as having a dense core (hyperechoic stroma) on ultrasound. The ovaries also have areas of no echo (anechoic cystic follicles) that vary in size between 5 to 25 mm. The size can change throughout the menstrual cycle.
The vagina, a muscular tube leading out from the cervix, is normally seen on an abdominal ultrasound,
The ureters, which carry urine from the kidneys to the bladder, are hard to see. They are usually seen on the sides of the cervix when viewed in a cross-section image.
The urinary bladder, which holds urine, is located at the front of the belly and is one of the essential landmarks in pelvic sonography. When doing an abdominal ultrasound, having a full bladder helps to see the pelvic structures better. On the other hand, for vaginal ultrasound, having an empty bladder gives a better view of the uterus.
The bowels, which are tube-like structures with different echo patterns and visible muscular activity (peristalsis), can sometimes be mistaken with cystic structures.
The cul-de-sac is a well-defined area at the back of the uterus, which usually has a small amount of fluid after ovulation. If there’s more fluid with moving echoes or solid or cystic lesions, it can indicate a medical condition.
Why do People Need Sonography Female Pelvic Pathology Assessment, Protocols, and Interpretation
Pelvic sonography, also known as a pelvic ultrasound, is a safe and non-invasive test that is often used to check the health of your reproductive organs. This imaging test is beneficial for diagnosing a variety of health conditions related to women’s reproductive system and pregnancy.
If you are experiencing things like abnormal bleeding (heavy bleeding during your periods or bleeding after menopause), a noticeable increase in the size of your abdomen, a mass in your pelvic area, abdominal or pelvic pain, trouble getting pregnant, multiple miscarriages, or signs of an infection, your doctor might recommend a pelvic sonography.
When it comes down to abnormal uterine bleeding, conditions such as leiomyomas (benign tumors in the uterus), adenomyosis (a condition where the inner lining of the uterus breaks through the muscle wall of the uterus), endometrial polyps (small, benign growths in the lining of the uterus), and certain forms of cancer can be detected using pelvic sonography.
In some cases, an unusual increase in the size of your abdomen may be due to fluid build-up (ascites) or ovarian cancer. Other conditions such as large benign tumors in the uterus (leiomyomas or fibroids), adenomyosis, molar pregnancy (a rare complication of pregnancy), ectopic pregnancy (a pregnancy where the fertilized egg implants outside the uterus), and other types of tumors or masses can cause a pelvic mass that can be detected using pelvic sonography.
The cause of pelvic pain and menstrual cramps can also be diagnosed using this test. Conditions such as endometriosis (a condition where the tissue that normally lines the uterus grows outside the uterus), pelvic inflammatory disease (an infection of the female reproductive organs), a twisted ovary (ovarian torsion), masses in the ovaries or fallopian tubes, adenomyosis, benign tumors in the uterus undergoing changes (degenerating leiomyoma), ectopic pregnancies, or bladder infections (cystitis) are some common conditions that can be examined using pelvic sonography.
When it comes to problems related to fertility, irregular menstruation, or repeated miscarriages, the structure of your uterus plays a major role. Conditions such as a uterus with one side (unicornuate uterus), a uterus divided into two sections (bicornuate uterus), a septate uterus (a condition where a wall or a “septum” divides the uterus), and a double uterus (didelphys uterus) are associated with infertility and repeated pregnancy loss. In these cases, a pelvic sonography can be used for diagnosis. Similarly, patients with amenorrhea (absence of menstruation) due to syndromes like androgen insensitivity syndrome (AIS), Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH, a condition where the vagina and uterus are underdeveloped or absent), Turner syndrome (a genetic disorder that affects a woman’s development), or imperforate hymen (a condition where the hymen, a thin membrane, completely covers the vaginal opening) require a pelvic sonography for diagnosis. The acquired condition of Asherman syndrome (a condition characterized by scar tissue in the uterus) leading to infertility and amenorrhea can also be diagnosed with this test.
When a Person Should Avoid Sonography Female Pelvic Pathology Assessment, Protocols, and Interpretation
Pelvic sonography, an imaging method used to see inside the pelvic area, can be performed on almost everyone. However, there are certain cases where it could be postponed or avoided.
Transabdominal Sonography (TAS), a type of ultrasound done through the belly, might be skipped if having a full bladder causes you discomfort. This is because doctors usually ask you to have a full bladder during this type of scan so they can get clearer images.
Transvaginal Sonography (TVS), a type of ultrasound done through the vagina, is not recommended for those who haven’t had vaginal sex yet, suffer from vaginismus (a condition involving vaginal muscle spasms), or have significant vaginal atrophy (thinning and drying of vaginal walls), blockage, narrowing, or have recent surgical procedures in the vagina. It should also be skipped if the patient doesn’t give permission for the procedure.
Sonohysterosalpingography, an ultrasound that uses a special fluid to see the uterus and fallopian tubes, is not advised during heavy periods or if there is a suspected infection or pregnancy.
Equipment used for Sonography Female Pelvic Pathology Assessment, Protocols, and Interpretation
You’ll need an ultrasound machine with the right type of scanning devices, known as transducers. These come in different frequencies, depending on what part of the body they are scanning:
- 3.5-7 MHz is used for scanning the abdomen from outside (transabdominal scans)
- 5-12 MHz is used for scanning the female reproductive system from inside the vagina (transvaginal scans)
- 7-15 MHz is used for scanning through the skin between the genitals and the anus (transperineal scans)
You’d also need either a probe cover or a condom cover for probes that are used inside the vagina (endovaginal probes), along with ultrasound gel, which helps the probe glide easily and ensures clearer images.
Who is needed to perform Sonography Female Pelvic Pathology Assessment, Protocols, and Interpretation ?
A pelvic sonogram, which is an ultrasound test that takes pictures of the lower belly, can be done by various medical professionals. These can include not just doctors, but also people known as sonographers who have special training in using ultrasound machines for diagnosis. The doctors who most commonly do this test are obstetricians (doctors who care for pregnant women), gynecologists (doctors who treat women’s health problems), and radiologists (doctors who use imaging tests like x-rays).
But in many places, even nurses with advanced training or ultrasound technicians can perform these ultrasound tests. Their role is to do the test using the machine, while doctors are the ones who interpret or make sense of the pictures taken during the test. This practice is common in many countries and can also be seen in primary care, or ordinary health clinics.
Preparing for Sonography Female Pelvic Pathology Assessment, Protocols, and Interpretation
Transabdominal sonography is a type of ultrasound scan that looks inside your abdomen. For this exam, doctors ask patients to lie flat on their backs – this is called the ‘supine position’. It’s important to have a full bladder for this test, as it can help improve the accuracy of the scan images.
Transvaginal sonography is another type of ultrasound that looks specifically at the uterus and other female pelvic organs. This is done with an empty bladder, which allows the doctors to see these areas more clearly. Patients lie back in a lifted position, either with a pillow under their buttocks or with their feet placed in supports. This test should be comfortable and relatively painless. It provides a detailed view of the pelvic area.
For women who could be pregnant, knowing the date of your last period and the levels of a pregnancy hormone (beta-hCG) in your blood can be helpful. As a common practice, doctors first do the transabdominal scan with a full bladder, just in case there is a mass or lump in the abdomen or near the ovaries that could be missed. Afterward, the bladder is emptied for the transvaginal scan for a more in-depth look at the pelvic area.
How is Sonography Female Pelvic Pathology Assessment, Protocols, and Interpretation performed
Imaging of the uterus is a method used by doctors to measure the size of the uterus. The measurements include the length (from the fundus, or top part, to the cervix), depth (the diameter from front to back), and width (across). This is typically done in two approaches or “planes”: the mid-sagittal plane (down the middle and parallel to the body) and the coronal plane (a vertical cut from side to side).
Doctors also measure the cervix, specifically the cervical length, which spans from the internal to external opening of the cervix. They also check the muscle tissue of the uterus (known as the myometrium) for any discrepancies in texture or the presence of masses. When there are multiple mass lesions (like leiomyomas or fibroids), the two largest ones are measured.
The thickness of the endometrium (the inner lining of the uterus) is measured as well. This is done perpendicular to the long axis of the uterus and includes both the front and back endometrial lining. Any build-up of fluid is noted but not included in the measurements. Changes in the endometrium, such as thickening, masses, or cystic changes, are also measured and noted down. Additional techniques such as Color Doppler and pulsed ultrasound can give more details. If an intrauterine device (IUD) is present, its location is checked.
The area around the uterus (the adnexa) is evaluated, including the ovaries. The ovaries are measured in three directions and any follicles (small fluid-filled sacs that can contain eggs) are counted and measured. Any abnormalities, like cysts or issues with the blood vessels, are documented.
Sometimes, it’s necessary to determine the origin of a mass. If the mass moves with the ovary when the transvaginal probe or the abdominal wall is moved, it is likely of ovarian origin. If it doesn’t move with the ovary, it could be from the paraovarian, tube, or uterus. This is important for diagnosing conditions like ectopic pregnancy and hydrosalpinx (a condition where the fallopian tube is blocked with fluid).
Before a hysterectomy, the vagina and bladder wall are checked. The small space in the pelvic cavity behind the uterus (cul-de-sac) is also examined for fluid or masses.
There’s a particular ultrasound technique called sonohysterosalpingography (also known as Saline Infusion Sonohysterography or SIS) which is used to find problems in the endometrial cavity and possible causes of infertility. It’s a comfortable procedure that involves infusing saline (a salt solution) into the uterine cavity through the cervix; this outlines the cavity and fallopian tubes and allows them to be seen clearly on an ultrasound. The technique can help detect issues like a thickened endometrium, endometrial polyps, or submucosal fibroid (a type of non-cancerous growth in the uterus).
Possible Complications of Sonography Female Pelvic Pathology Assessment, Protocols, and Interpretation
Experiencing discomfort because of a full bladder during a transabdominal ultrasound (TAS), feeling pain in the pelvic area during a transvaginal ultrasound (TVS), and getting a pelvic infection after a sonohysterosalpingography, a special type of ultrasound used to look at the fallopian tubes, are some common discomforts related to pelvic ultrasound procedures.
The ALARA principle, which stands for “As Low As Reasonably Achievable”, is a safety guideline used in medical imaging. It suggests that healthcare providers should use the lowest level of ultrasound energy that still provides a clear picture to avoid any minor complications from the sonography that are not fully supported by evidence.
What Else Should I Know About Sonography Female Pelvic Pathology Assessment, Protocols, and Interpretation ?
Abnormal Uterine Bleeding (AUB)
Abnormal uterine bleeding (AUB) is an issue that affects 10 to 52% of women, which often leads to them seeking help from healthcare centers. If you experience abnormal bleeding, doctors use an ultrasound (sonography) to get a picture of your reproductive organs and figure out what might be causing the bleeding.
Most of the time, the cause of AUB is an issue inside the uterus. In women who are still having periods (premenopausal women), the causes are often conditions like endometrial hyperplasia (an overly thickened lining of the uterus), leiomyoma (a type of growth in the uterus), and others.
An ultrasound can tell doctors if the uterus looks normal. If it does, they usually won’t need to do more tests and will start treating you with medicine. This method has shown to be highly reliable in detecting AUB.
One of the common causes of AUB and infertility is endometrial polyps, growths in the lining of the uterus. These are noted in about 24% of cases.
Uterine leiomyoma (or fibroids) are another cause of AUB. They show up as an equally or less bright structure on the ultrasound.
Adenomyosis, which is when endometrial tissue is found in the muscle wall of the uterus, is another common benign cause of AUB. This condition is caused by a change in endometrial glands and can result in heavy uterine bleeding. Around 22% of infertile women under 40 and 24.4% of infertile women over 40 have adenomyosis.
Endometritis is a common cause of very frequent periods. It makes the lining of your uterus thicken and can sometimes be associated with other signs of pelvic inflammation.
Serious conditions like endometrial and cervical cancer, along with endometrial hyperplasia (an abnormal thickening of the lining of the uterus), can also cause abnormal bleeding. These conditions can cause heavy menstrual bleeding and irregular bleeding between periods. Using power Doppler, a type of ultrasound, can help doctors detect these conditions.
Endometrial hyperplasia is diagnosed by measuring the thickness of the endometrial. If you’re premenopausal and the lining of the uterus is too thick, doctors may need to take a sample to check for abnormalities.
Postmenopausal bleeding is a sign of endometrial cancer in 90% of cases. On an ultrasound, it usually looks like a thick, irregularly shaped structure inside the uterus.
Cervical cancer appears as an irregularly-shaped mass in the cervix with increased blood flow.
Another thing doctors need to consider is whether any pregnancy tissue was left behind in the uterus after childbirth or miscarriage (retained products of conception). This might make the uterus lining thicker than usual and cause abnormal bleeding.
In conclusion, whatever the cause of AUB, early diagnosis and treatment is crucial. If you experience any unusual or heavy bleeding, don’t hesitate to reach out to your healthcare provider.
