Pelvic ultrasound in postmenopause

Postmenopausal pelvic examination

1. Uterus. In postmenopause, the uterus becomes significantly smaller in size and more homogeneous in echostructure: the endometrium is not visible.
2. Postmenopausal ovaries. The ovaries are small and often very difficult or impossible to visualize on ultrasound. When they are visualized, they appear hyperechoic, lack follicles, and are often nearly isoechoic to the surrounding tissue.

Position of the uterus

The uterus may be rotated in such a way that the body of the uterus is located behind the cervix (retroversio condition). The body of the uterus may be tilted forward (anteversio).

If the body of the uterus is tilted toward the cervix, it is in anteflexio. If the body of the uterus is tilted backwards from the cervix, this condition is called retroflexio.

In cases where the uterus is not visualized, it is necessary to find out whether there was a history of hysterectomy. If there is a history of surgical intervention, carefully look for the cervical stump, since it is possible that it is not a hysterectomy, but a supravaginal amputation.

When normal pelvic echostructures are not clearly visualized, give the patient more fluid to fill the bladder.

Ovaries

The ovaries can be in different positions, but are always located behind the bladder and uterus. They are most often found in the place of the appendages, on the side.

The ovary may be located in the retrouterine space or above the fundus of the uterus. In postmenopausal women, the ovaries are small and often not visualized.

If there are difficulties in visualizing the uterus and ovaries, manually displace the uterus through the vagina and continue scanning in different planes to clarify the anatomical details. A similar technique can be used in the presence of low-lying pelvic formations.

In the absence of ovarian visualization, the following technique can be used:

1. Place the patient in the lateral position and scan the contralateral ovary through the full bladder.
2. Reduce the sensitivity level of the device. If the sensitivity is too high, the ovary may be poorly identified against the background of the surrounding parametrium and may not be visualized.

If the ovaries are still poorly visualized, this may be due to the bladder being too full or too small. Adequate filling is considered to be when the bladder covers the bottom of the uterus, but if the bladder is not full enough, give the patient more water. Repeat the examination in 30 minutes, try to visualize the ovaries.

If the bladder is overfilled, it displaces the ovaries downwards from the uterus or laterally onto the psoas muscle. Ask the patient to partially empty the bladder (give her a special measuring cup to fill it with). Then repeat the examination.

Even if the bladder is adequately full, the ovaries may be poorly visualized due to screening by intestinal gases. This often happens if the ovaries are located higher than usual.

If necessary, scan the patient in an upright position or in a vertical oblique projection. This will help displace gas-filled bowel loops, making the ovaries more clearly visible.

If normal anatomy is still not clearly defined, gently inject 20 ml of body-temperature water into the vagina and scan over the pubis. The fluid will surround the cervix and facilitate organ identification. This technique is particularly useful in making the differential diagnosis between hysterectomy and supravaginal amputation when clinical examination is not possible.

If there are difficulties in visualizing retrouterine formations, introduce 200 ml of warm water into the rectum, then examine this area. Air microbubbles will be visualized as bright hyperechoic structures, clearly delimiting the anterior wall of the rectum, which facilitates the recognition of formations in the intestinal lumen, such as fecal matter, which is the most common cause of diagnostic errors.

Normal ovaries

When the ovaries are visualized, determine if there is any displacement of the surrounding structures. Determine the condition of the internal structure of the ovaries and the presence or absence of acoustic pseudo-amplification. If anechoic structures are visualized in the thickness of the ovaries or along their periphery, these may be follicles. Reduce the sensitivity level when examining the ovaries, since normal ovaries have high sound conductivity and enhancement of the deep sections is observed. Take measurements of each ovary.

Examine the tissue around the ovary for cystic, solid, or fluid-containing masses. Look for fluid in the retrouterine space. Examine both ovaries.

The ovaries are never normally located anterior to the uterus. If they are atypical, turn the patient to detect fixation of the ovary by an adhesion and determine whether it is significantly enlarged.

The sensitivity of the instrument must be varied when examining different structures in the pelvis to obtain an optimal image. The relationship of the pelvic organs may be best determined by scanning slowly and continuously for approximately 10 seconds.

Follicular apparatus of the ovary

Follicles are visualized as small cystic anechoic structures in the thickness of the ovary or along its periphery and are better visualized when the device sensitivity level is set to low. Depending on the phase of the menstrual cycle, cystic structures can reach 2.5 cm in diameter. Simple cysts with a diameter of more than 5 cm can be physiological and can change, become smaller or disappear).

If a cystic tumor formation is suspected, dynamic observation is necessary - examination in the early and late phases of the menstrual cycle. Follicular cysts regress, while non-functional cysts do not change their size. If doubts remain, conduct an examination the following month.

A physiological ovarian cyst can be up to 5 cm in diameter. Cysts of this size should be re-examined at the end of the menstrual cycle or during the next cycle.