• The purpose of the following notes is to identify female anatomic structures radiographically, explain the hysterosalpingography and interventional procedures of the female reproductive system, and to state indications for exams and describe common pathologies.

Diagnostic Procedures

• A Hysterosalpingogram (HSG) examination is performed to visualize the uterine cavity and fallopian tubes mainly to rule out infertility
• Ultrasound and MRI exams are the preferred imaging methods to demonstrate uterine/ovarian anomalies
• MRI is used to:
  • Stage uterine and ovarian tumors
  • Determine the depth of myometrial penetration of a tumor
  • Determine whether chemo or radiation therapy would be beneficial

Anatomy of the Uterus

• Size/Shape varies with age and reproductive stage
• The uterus of a woman who has not given birth is called a nulliparous uterus, measuring approximately 3" in length
• The uterus is situated anterior to the rectum and posterior to the bladder
• The bladder's position and fullness affects the position of uterus and fallopian tubes
• Relative to the vagina, the uterus is normally anteverted
  • It lies over the upper surface of the urinary bladder
• One part of the uterus lies anterior to the Cervix
• The cervix has an average diameter of ¼"

Variations of Uterus Position

• Fundus is anterior to the cervix
• Uterus can be retroflexed
• Uterus can be retroverted/posterior to the cervix

Layers of the Uterus

• Endometrium:
  • Lines the uterine cavity
  • Thickness differs depending on the cycle
  • Thickness differs depending on age
• Myometrium:
  • The muscular wall
• Perimetrium Serosa:
  • The outer envelope of the uterus

Borders of The Uterus

• The uterus is bordered posteriorly by the recto sigmoid colon
• The uterus is bordered anteriorly by the urinary bladder

Pouches Near the Uterus

• Pouch of Douglas or Rectouterine pouch or Posterior cul de sac
  • A small extension of the peritoneal cavity lies between the uterus and the rectum
  • The lowest area of the peritoneal cavity in women
• Vesicouterine Pouch
  • A shallow pouch formed by the peritoneum over the uterus and bladder
  • Marks an important landmark for Endometriosis (endometrial Seeding)
  • Common for fistulaes

Fallopian Tubes

• A narrow tube opens into the uterus through a small opening
• The fallopian tubes are 3 - 5 inches long
• Fallopian tubes open into the peritoneal cavity
• The fimbria of the fallopian tubes collect liberated ova (plural from ovum) from the ovary
• Segments of the Fallopian Tubes: - Interstitial Segment - Cornu (horn): - Outside lateral angles
• Isthmus
• Ampulla
• Infundibulum
  • Contains the fimbriae, which are no longer part of the tube

Ligaments

• Suspensory Ligament
• Ovarian Ligament
• Broad Ligament
• Round Ligament
• Uterosacral Ligament

Acquired Pathologies

• Salpingitis: Acute chronic inflammation of fallopian tubes
• Vaginitis: Inflammation of the vagina
• Cervicitis: Inflammation of the cervix
• Pelvic Inflammatory Disease (PID):
  • A chronic or acute infection of the female reproductive organs
  • Occurs through sexually transmitted bacteria that spread from the vagina to the uterus, fallopian tubes, or ovaries
  • In some cases it causes no signs or symptoms

HYSTEROSALPINGOGRAM (HSG) Procedure

• A diagnostic study of the uterus and fallopian tubes
• Used to demonstrate size, shape, and position of the uterus and uterine tubes
• Used to determine patency of the fallopian tube
• Used to find abnormal gynecological conditions, like infertility
• Used to determine cause of active uterine bleeding
• Used to delineate lesions such as polyps, submucous tumor masses, or fistulous tracts
• Must be performed under sterile conditions and radioscopic control
• An HSG may serve as a therapeutic procedure by:
  • Restoring patency to occluded tubes by straightening kinks, stretching adhesions, and dilating stenotic tubes

HSG Clinical Indications

• Infertility investigation screening
• Recurrent miscarriage
• Evaluation of a uterine tube after tubal ligation/reconstructive surgery
• Scar tissue from infections narrows or blocks tubes
• Intrauterine pathology like polyps, fibroids, and adhesions
• Congenital Uterine Abnormalities

HSG Contraindications

• Pregnancy
• Vaginal or uterine infections
• Acute pelvic inflammatory disease
• Active uterine bleeding
• Sensitivity to CM

HSG Planning and Patient Preparation

• Should be booked when pregnancy is least likely
• It is not advised during the immediate premenstrual or postmenstrual phase, see page 384 snpk
• Must be done toward the end of the first week after menstruation, and before the twelfth day of the menstrual cycle to avoid radiation exposure to the oocyte - as the oocyte becomes radiosensitive at this time, see page 386, snpk
• The patient's menstrual flow should have been completed for at least 3 days before the study, see page 386 snpk. The 10-day rule no longer applies
• Preparation should involve a non-gas forming laxative administered the preceding evening
• The meal preceding the examination is withheld
• Before the exam, the patient receives cleansing enemas until the return flow is clear
• CM questionnaire & Informed Consent required
• The patient may take a muscle relaxant a few hours prior to the exam to alleviate cramping
• The bladder needs to be empty – the full bladder can distort the position of the uterus and fallopian tubes

HSG Sterile Tray

• It includes a speculum
• The tray includes a tenaculum, a hooked clamp for tissue holding
• The tray includes a balloon catheter, and, uterine cannula

Contrast Media

• Water-soluble CM – Omnipaque 240
• Low osmolality agents known to reduce pain symptoms may be used
• Warming of CM reduces cramps
• Allergic reaction possible
• May be premedicated
• Oil-based solutions no longer used
• The procedure itself requires a patient supine lithotomy position with knees flexed
• The external area is cleansed; and the patient draped with sterile towels
• A scout image is taken
• Speculum used to dilate vagina and cervix - vaginal walls and cervix cleansed
• A cannula or balloon catheter is inserted into the cervical canal
• A balloon tip locks the catheter in place to prevent contrast from flowing out of the uterine cavity - A tenaculum may be necessary to aid in insertion and fixation of the cannula or catheter; cramping may occur - The speculum may be removed when the catheter or cannula is inserted, as it may obscure the images
• The CM is injected manually and slowly under radioscopy until the fallopian tubes are filled - A Trendelenburg position can facilitate contrast filling
• Images are taken at different intervals
• The Patient is positioned supine to take AP/PA views
• The imaging tech will use LPO/RPO for better visualization of tubes
• The Exam is complete when contrast spills into the peritoneal cavity

HSG Centering

• Patient's supine position is adjusted to permit centering of the IR in the midline, 2 inches (5 cm) proximal to the pubic symphysis
• Collimate to 24 x 30 cm area

During HSG imaging

• The radiographer visualizes Vagina/Cervical Canal
• The uterine cavity
• The Cornua (Horn)
• The Uterine tube (intra mural portion)
• A Uterine tube
• Fimbriae

HSG

• Ensure that the pelvic ring is centered within the collimation field
• That the cannula/balloon is well seen within the cervix
• The opacified uterine cavity & tubes are visualized
• CM can be seen in the peritoneum if tubes are patent
• Identifier and markers are clearly visualized and not superimposed on anatomy
• Uterus and Fallopian tubes must be shown - frontal view
• That The scout image is taken

Imaging of Uterus During HSG

• Filling defects and contour abnormalities are evaluated
  • Abnormalities are most easily seen when the uterus is fully distended
• Fallopian tubes are demonstrated and evaluated
• Fimbriae are demonstrated
• CM Injection continues until free intraperitoneal spillage of CM is seen
• Take an additional image if balloon deflating needed if the balloon is obscuring visibility
• Oblique imaging may be required

Fallopian Tube Recanalization Procedure

• Intervention to treat blockages in the fallopian tubes
• Treats cornual blocks and open stenotic tubes with stents
• Indicated in cases of history of infertility or endometriosis-related pain
• The procedure is done under sterile conditions and radioscopic guidance: The guidewire is advanced through the blocked tube: Terumo Glidewire:
  • Known for its stiffness and hydrophilic coating, which helps in navigating through blockages Cook Medical Roadrunner:
  • Offers a balance of flexibility and stiffness, making it suitable for various interventional procedures
• A microcatheter is then advanced over the guidewire, and withdrawn while flushing the f. tube with saline
• The pressure created by the injection of saline will clear the tube of any blocking material remaining
• CM is injected to show the reestablished patency

Congenital Malformations of the Uterus

• Müllerian ducts (or paramesonephric ducts) are paired ducts of mesodermal origin in the embryo
• In females, they will develop to form the uterine tubes, uterus, and the upper portion of the vagina
• Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKH syndrome):
  • Fusion failure occurs in part/the whole of the Mullerian duct, which results in the partial/complete absence of the uterus, the f. tubes, and the cervix uterus
  • The syndrome often includes the whole vagina

Range of Symptoms

• Symptoms of congenital malformations vary, and range depending on abnormality and severity: - Amenorrhea is no menstruation
• Dysmenorrhea is painful periods/menstrual cramps - Other symptoms include infertility, recurrent pregnancy loss, and pain
• In some cases anomalies are discovered as incidental finding

Types of Uterine Malformation

• Bicornis Uterus Unicollis: With a heart shape Two horns form at the upper part of the uterus One cervix is present Results from partial fusion failure Pregnancies with this type of uterus are considered high risk and are often associated with recurrent pregnancy loss

Uterine Septate

• Uterine cavity partitioned by a longitudinal septum
• The outside of the uterus has a normal typical shape
• Partition involves only the superior part of the cavity or much less frequently the total length of the cavity
• Presents the poorest reproductive outcomes
• Includes recurrent pregnancy loss, preterm labor, mal-presentation, and most likely infertility

Other Malformations

• Uterus bicornus bicollis presents two horns and two cervixes
• Uterus Unicornis presents one f. and one-half of the uterus body developed
• Uterus Didelphis presents a double uterus, double cervix, double vagina, see https://youtu.be/v_cfMA8ljYs
• T-shaped Uterus (DES) presents uterus abnormality resulting from utero diethylstilbestrol exposure syndrome (DES). DES is a synthetic estrogen drug that was introduced in 1948 and was prescribed for women experiencing recurrent spontaneous abortions, premature deliveries, and other pregnancy complications. DES was thought to decrease the frequency of pregnancy loss.

Vaginogram/Fistulogram

• CM injected inside the vagina to visualize structures
• Used to visualize fistulas between vagina and other organs
• CT and MRI often used because of reconstructive processing capabilities
• Is used to diagnose rectovaginal fistulas and vesicovaginal fistulas

Causes of Fistula

• Possible causes:
  • Post op abdominal or pelvic surgery
  • Obstetrical trauma from prolonged labor
  • Adhesions
  • Chronic infections
  • Trauma Can be of the vagina and rectum, or of the vagina and bladder
• Is used to diagnose rectovaginal fistulas and vesicovaginal fistulas

Evaluation Criteria

• The presence of a superior border of the pubic symphysis centered on the image
• Any fistulae seen in their entirety
• Pelvis are seen on oblique projections and are not superimposed by the proximal thigh
• Superimposition of the hips and femora are shown on the lateral image
• Ensure Exposure is sufficient to demonstrate the vagina and any fistula

Hydrosalpinx

• When one fallopian tube is blocked with a watery fluid it is considered a Hydrosalpinx,
• Accumulation of secretions occurs when fallopian tube is occluded at its distal end
• One tube may be affected, or both
• Causes are:
  • Endometriosis
  • Pelvic Inflammatory Disease
  • Pelvic infection
  • Post-surgery
  • Tubal malignancy

Adhesions or Synechiae Uterus

• Adhesions or Synechiae Uterus are also known as Asherman Syndrome
• It is a condition characterized by the formation of intrauterine adhesions
• Usually develop after sequela from injury to the endometrium, and are often associated with infertility

Polyps

• Are abnormal growths
• Endometrial polyps are filling defects seen in the cavity that suggest presence of an endometrial polyp
• Polyps are benign growths that act as foreign bodies, and interfere with implantation of the embryo
• They can easily be treated surgically via operative hysteroscopy
• IUDs, or intrauterine devices, are T-shaped - They are inserted in the uterine to prevent pregnancy (permanent and non-permanent available)
• Copper IUDs release ions increase prostaglandins and interfere with sperm mobility
• Hormonal IUDs release hormones that make changes that make the uterine cavity fatal to sperm
• Since IUDs are radiopaque, it is easy to see where they should be with routine imaging
• Complications of IUD Insertion include perforation or embedding of the device in the myometrium, or it may dislocate - HSG, as well as, sonography in both 2D and 3D are valuable in defining the position of the device
• An HSG may be performed for some patients undergoing permanent IUD placement
• Uterine Fibroids are also known as Leiomyomas

There are several characteristics of Uterine Fibroids

• Benign tumors
• They are Very common
• They Occur often multiple and occur with size variation
• They Appear during childbearing years
• Shrink during menopause
• And are stimulated by estrogen
• Fibroids are Classified as:

Submucosal

• Growths indent the uterine cavity
• They can be entirely within the cavity

Intramural/myometrial

• Fibroids located within the wall of the uterus

Subserosal

• Fibroids may extend from the surface of the uterus

Pedunculated

• Growing on a stalk, either inside/outside of the uterus

Classic symptoms of Fibroids

• Abnormal bleeding between periods
• Excessively heavy menstrual flow
• They project from the uterus and pressure surrounding organs, which causes pelvic pain
• The Fibroids Occupy the entire pelvis or might push into the abdominal cavity

Uterine Fibroids Embolization (UFE)

• UFE is an invasive procedure that involves injection of a embolic agent. Tiny beads made of very small sizes are used to injected into the uterine arteries block supplying blood
• Indicated for non-surgical patients because their contraindications are classified according to the type and Fibroids location, which can be addressed
• Submucosal vs intramural vs serosa fibroids shrink more quickly through UFE
• Major contraindications are pregnancy, uterine, cervical, or endometrial malignancy suspected
• Procedure involves first finding where the tumor derives its main peripheral blood supply uterus, almost all are connected arteries, with second or the first that artery as a branch second the internal iliac artery for 2nd for blood supply
• The wire is the catheter is introduced advanced over the a wired through catheters is placed before it is micro in is place
• Polymeric alcohol-or gelfoam is introduced into the tumor

Ovarian Anatomy

• Medulla: Vascular tissue core of organ
• Cortex: Outer layer that contains the follicles
• Ovarian follicles contain eggs, and are the basic components of female reproduction - They are of mesodermal origin in and a single oocyte
• FSH: follicle-stimulating hormone secreted by pituitary gland
• Hilum: Entrance/exit of ovarian a., v.& nerve

Ovarian Cycle

• At birth females have >2 million follicles

• decreases until puberty to around 400,000 for the release of a viable ovum to be mature

• In total women aprox 500,000 ovum will mature and release
• Approximately 10% of primordial follicles or under are stimulated each reproductive menstrual cycle
• Around the middle of the cycle, only one secondary follicles called or the dominant follicle grows to 18 - 20 mm mid cycle before rupturing
• Follicle collapses after the egg, the dominant structure becomes corpus luteum
• Corpus albicans then gets small as it is degenerated then the smaller scared forms
• The other primary ones are atretic or rather fibrous
• The ovaries typically shaped are the shapes approximately or the 5 com pre menopause times are •Size decreases from premenopause Located cells formed a kind epithelial all covered form or holding •The epithelium is for cell kinds developing as tumor that different

Ovarian Neoplasms

•Fluid are a key component of of, cyst like round form

• Irregular forms occur with their solid features as in tumors •Malignancy is dependent on Benign form and malignant •Malignancy and ascites tumors that form

Functional Ovarian Cysts

Complex Hemorrhagic Ovarian Cyst are the following parts are Cyst with ruptured walls for a cyst that happens to bleed that includes layers of thickness Classic sign with Doppler reading

• Follicular Cysts, which fail to ovulate before pregnancy may -Dominant follicle which forms when there 3-8 and get far longer as an ovary. The follicle cannot develop at all stages either so with that cyst we observe -Filled corpus cysts has more. The sizes are lower with smaller than that

Ovarian Cysts

• The cysts of concern in teratomas or known tumors/ dermoid
• Often Benign but malignant examples have been characterized
• The cells origin are of eggs and tissue as egg origin so may display parts from birth like hair or cartilaginous tissue and more
• Often the sizes need to grow before anything clinically is significant
• Cysts commonly may result as lipid forms with calcifications

CANCERORUS TUMORS OF THE UTERUS

• Develop in the endometrium
• Changes caused hormonal imbalances lead to later menopause
• The dependency is related to estrogen presence that is linked to breast/ history of cancer
• Differentiated by grade and are spread to other parts of the body
• MRI or ultrasound with computed tomography imaging gives superior views to see the tumors that are spread in invasion of the deeper layers
• Endometrium cells that are found lining in the abdomen can result
• That ectopic glands and cells in cavity forms over organs and urinary tract so affect a vast area that if implanted cause cancer
• It is of concern before reproductive years end with the potential causes through cells transferred or in the bloodstream to other localized location which causes growth

Endometriosis

• Characterized by chronic pain, abnormal bleeding, and can lead to dysmenorrhea- pain
• Infertility may result through endometriosis, which affects pain and bodily functions including bowel movements

Adnexa with Endometrial Lesions

• The structures around uterus or in the area surrounding that The adnexa consists of or referring to :
  • A set of all the reproductive structures are, meaning all related structures that is in the area called, which is a zone for medical description