Pelvic Imaging through the Life Cycle

Imaging of the Female Pelvis through the Life Cycle

Published Online:https://doi.org/10.1148/rg.326125513

Expected findings and physiologic changes in the normal female reproductive tract from birth through the postmenopausal years are discussed, with emphasis on the appearances of the uterus and ovaries at pelvic US, CT, and MR imaging.

The appearance of the normal reproductive tract on radiologic images changes dramatically over the female patient’s life span, reflecting the influence of hormones on these organs. In female children and adolescents, the appearance of the reproductive tract reflects the stage of sexual maturation. In women of reproductive age, physiologic changes such as those occurring in the corpus luteum are routinely imaged and must be distinguished from pathologic conditions. In the postmenopausal years, as reproductive hormone levels diminish, the endometrium and ovaries undergo progressive involution. Imaging findings that might be considered physiologic in younger women may represent pathologic or even neoplastic changes in postmenopausal women. Although postpartum imaging is typically performed in symptomatic patients, including those with greater than expected vaginal bleeding, suspected obstetric trauma, thromboembolic disease, or infectious complications, clinicians who interpret these radiologic results should be familiar with expected findings in asymptomatic patients after childbirth. Familiarity with the spectrum of ultrasonographic, computed tomographic, and magnetic resonance imaging appearances of the normal female reproductive tract from birth through the postmenopausal years will ultimately help clinicians avoid misinterpreting these normal physiologic changes as pathologic conditions.

© RSNA, 2012

References

  • 1 Ziereisen F, Guissard G, Damry N, Avni EF. Sonographic imaging of the paediatric female pelvis. Eur Radiol 2005;15(7):1296–1309. Crossref, MedlineGoogle Scholar
  • 2 Garel L, Dubois J, Grignon A, Filiatrault D, Van Vliet G. US of the pediatric female pelvis: a clinical perspective. RadioGraphics 2001;21(6):1393–1407. LinkGoogle Scholar
  • 3 Barr LL, Cohen HL. Ultrasonography of the pediatric and adolescent pelvis. In: Anderson JL, ed. Gynaecological imaging. London, England: Churchill Livingstone, 1999; 397–410. Google Scholar
  • 4 Herter LD, Golendziner E, Flores JA, Becker E, Spritzer PM. Ovarian and uterine sonography in healthy girls between 1 and 13 years old: correlation of findings with age and pubertal status. AJR Am J Roentgenol 2002;178(6):1531–1536. Crossref, MedlineGoogle Scholar
  • 5 Buzi F, Pilotta A, Dordoni D, Lombardi A, Zaglio S, Adlard P. Pelvic ultrasonography in normal girls and in girls with pubertal precocity. Acta Paediatr 1998;87(11):1138–1145. Crossref, MedlineGoogle Scholar
  • 6 Platt JF, Bree RL, Davidson D. Ultrasound of the normal nongravid uterus: correlation with gross and histopathology. J Clin Ultrasound 1990;18(1):15–19. Crossref, MedlineGoogle Scholar
  • 7 Merz E, Miric-Tesanic D, Bahlmann F, Weber G, Wellek S. Sonographic size of uterus and ovaries in pre- and postmenopausal women. Ultrasound Obstet Gynecol 1996;7(1):38–42. Crossref, MedlineGoogle Scholar
  • 8 Miller EI, Thomas RH, Lines P. The atrophic postmenopausal uterus. J Clin Ultrasound 1977;5(4): 261–263. Crossref, MedlineGoogle Scholar
  • 9 Brandt ML, Helmrath MA. Ovarian cysts in infants and children. Semin Pediatr Surg 2005;14(2):78–85. Crossref, MedlineGoogle Scholar
  • 10 Cohen HL, Eisenberg P, Mandel F, Haller JO. Ovarian cysts are common in premenarchal girls: a sonographic study of 101 children 2–12 years old. AJR Am J Roentgenol 1992;159(1):89–91. Crossref, MedlineGoogle Scholar
  • 11 Laing FC, Townsend BA, Rodriguez JR. Ovary-containing hernia in a premature infant: sonographic diagnosis. J Ultrasound Med 2007;26(7):985–987. Crossref, MedlineGoogle Scholar
  • 12 Cohen HL, Shapiro MA, Mandel FS, Shapiro ML. Normal ovaries in neonates and infants: a sonographic study of 77 patients 1 day to 24 months old. AJR Am J Roentgenol 1993;160(3):583–586. Crossref, MedlineGoogle Scholar
  • 13 Pavlik EJ, DePriest PD, Gallion HHet al.. Ovarian volume related to age. Gynecol Oncol 2000;77(3): 410–412. Crossref, MedlineGoogle Scholar
  • 14 Cohen HL, Tice HM, Mandel FS. Ovarian volumes measured by US: bigger than we think. Radiology 1990;177(1):189–192. LinkGoogle Scholar
  • 15 Aviram R, Gassner G, Markovitch O, Cohen I, Fishman A, Tepper R. Volumes of normal ovaries, ovaries with benign lesions, and ovaries with cancer in menopausal women: is there an optimal cut-off value to predict malignancy? J Clin Ultrasound 2008;36(1):1–5. Crossref, MedlineGoogle Scholar
  • 16 Siegel MJ. Computed tomography and magnetic resonance imaging of the pediatric and adolescent pelvis. In: Anderson JL, ed. Gynaecological imaging. London, England: Churchill Livingstone, 1999; 411–431. Google Scholar
  • 17 Yitta S, Hecht EM, Slywotzky CM, Bennett GL. Added value of multiplanar reformation in the multidetector CT evaluation of the female pelvis: a pictorial review. RadioGraphics 2009;29(7):1987–2003. LinkGoogle Scholar
  • 18 Bega G, Lev-Toaff AS, O’Kane P, Becker E, Kurtz AB. Three-dimensional ultrasonography in gynecology: technical aspects and clinical applications. J Ultrasound Med 2003;22(11):1249–1269. Crossref, MedlineGoogle Scholar
  • 19 Lev-Toaff AS, Pinheiro LW, Bega G, Kurtz AB, Goldberg BB. Three-dimensional multiplanar sonohysterography: comparison with conventional two-dimensional sonohysterography and x-ray hysterosalpingography. J Ultrasound Med 2001;20(4): 295–306. Crossref, MedlineGoogle Scholar
  • 20 Shi AA, Lee SI. Radiological reasoning: algorithmic workup of abnormal vaginal bleeding with endovaginal sonography and sonohysterography. AJR Am J Roentgenol 2008;191(6 suppl):S68–S73. Crossref, MedlineGoogle Scholar
  • 21 van Gestel I, Ijland MM, Hoogland HJ, Evers JLH. Endometrial wave-like activity in the non-pregnant uterus. Hum Reprod Update 2003;9(2):131–138. Crossref, MedlineGoogle Scholar
  • 22 Aboulghar M, Rizk B. Ultrasonography of the cervix. In: Rizk B, ed. Ultrasonography in reproductive medicine and infertility. New York, NY: Cambridge University Press, 2010; 103–112. CrossrefGoogle Scholar
  • 23 Randall JM, Templeton A. Transvaginal sonographic assessment of follicular and endometrial growth in spontaneous and clomiphene citrate cycles. Fertil Steril 1991;56(2):208–212. Crossref, MedlineGoogle Scholar
  • 24 Bakos O, Lundkvist O, Bergh T. Transvaginal sonographic evaluation of endometrial growth and texture in spontaneous ovulatory cycles—a descriptive study. Hum Reprod 1993;8(6):799–806. Crossref, MedlineGoogle Scholar
  • 25 Dickey RP. Ultrasonography of the endometrium. In: Rizk B, ed. Ultrasonography in reproductive medicine and infertility. New York, NY: Cambridge University Press, 2010; 97–102. CrossrefGoogle Scholar
  • 26 Fleischer AC, Kalemeris GC, Machin JE, Entman SS, James AE. Sonographic depiction of normal and abnormal endometrium with histopathologic correlation. J Ultrasound Med 1986;5(8):445–452. Crossref, MedlineGoogle Scholar
  • 27 Chaudhry S, Reinhold C, Guermazi A, Khalili I, Maheshwari S. Benign and malignant diseases of the endometrium. Top Magn Reson Imaging 2003;14(4):339–357. Crossref, MedlineGoogle Scholar
  • 28 Reinhold C, McCarthy S, Bret PMet al.. Diffuse adenomyosis: comparison of endovaginal US and MR imaging with histopathologic correlation. Radiology 1996;199(1):151–158. LinkGoogle Scholar
  • 29 Togashi K, Nakai A, Sugimura K. Anatomy and physiology of the female pelvis: MR imaging revisited. J Magn Reson Imaging 2001;13(6):842–849. Crossref, MedlineGoogle Scholar
  • 30 Sydow BD, Seigelman ES. Uterine MRI: a review of technique and diagnosis. Appl Radiol 2008;37(10): 18–29. Google Scholar
  • 31 Scoutt LM, McCauley TR, Flynn SD, Luthringer DJ, McCarthy SM. Zonal anatomy of the cervix: correlation of MR imaging and histologic examination of hysterectomy specimens. Radiology 1993; 186(1):159–162. LinkGoogle Scholar
  • 32 Yitta S, Hecht EM, Mausner EV, Bennett GL. Normal or abnormal? demystifying uterine and cervical contrast enhancement at multidetector CT. RadioGraphics 2011;31(3):647–661. LinkGoogle Scholar
  • 33 Ritchie WGM. Sonographic evaluation of normal and induced ovulation. Radiology 1986;161(1):1–10. LinkGoogle Scholar
  • 34 Brown DL. A practical approach to the ultrasound characterization of adnexal masses. Ultrasound Q 2007;23(2):87–105. Crossref, MedlineGoogle Scholar
  • 35 Levine D, Brown DL, Andreotti RFet al.. Management of asymptomatic ovarian and other adnexal cysts imaged at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology 2010;256(3):943–954. LinkGoogle Scholar
  • 36 Zaidi J, Jurkovic D, Campbell S, Collins W, McGregor A, Tan SL. Luteinized unruptured follicle: morphology, endocrine function and blood flow changes during the menstrual cycle. Hum Reprod 1995;10(1):44–49. Crossref, MedlineGoogle Scholar
  • 37 Outwater EK, Talerman A, Dunton C. Normal adnexa uteri specimens: anatomic basis of MR imaging features. Radiology 1996;201(3):751–755. LinkGoogle Scholar
  • 38 Outwater EK, Mitchell DG. Normal ovaries and functional cysts: MR appearance. Radiology 1996; 198(2):397–402. LinkGoogle Scholar
  • 39 Borders RJ, Breiman RS, Yeh BM, Qayyum A, Coakley FV. Computed tomography of corpus luteal cysts. J Comput Assist Tomogr 2004;28(3):340–342. Crossref, MedlineGoogle Scholar
  • 40 Lerman H, Metser U, Grisaru D, Fishman A, Lievshitz G, Even-Sapir E. Normal and abnormal 18F-FDG endometrial and ovarian uptake in pre- and postmenopausal patients: assessment by PET/CT. J Nucl Med 2004;45(2):266–271. MedlineGoogle Scholar
  • 41 Mulic-Lutvica A, Bekuretsion M, Bakos O, Axelsson O. Ultrasonic evaluation of the uterus and uterine cavity after normal, vaginal delivery. Ultrasound Obstet Gynecol 2001;18(5):491–498. Crossref, MedlineGoogle Scholar
  • 42 Brown DL. Pelvic ultrasound in the postabortion and postpartum patient. Ultrasound Q 2005;21(1): 27–37. MedlineGoogle Scholar
  • 43 Kamaya A, Ro K, Benedetti NJ, Chang PL, Desser TS. Imaging and diagnosis of postpartum complications: sonography and other imaging modalities. Ultrasound Q 2009;25(3):151–162. Crossref, MedlineGoogle Scholar
  • 44 Edwards A, Ellwood DA. Ultrasonographic evaluation of the postpartum uterus. Ultrasound Obstet Gynecol 2000;16(7):640–643. Crossref, MedlineGoogle Scholar
  • 45 Wachsberg RH, Kurtz AB, Levine CD, Solomon P, Wapner RJ. Real-time ultrasonographic analysis of the normal postpartum uterus: technique, variability, and measurements. J Ultrasound Med 1994;13(3):215–221. Crossref, MedlineGoogle Scholar
  • 46 Wachsberg RH, Kurtz AB. Gas within the endometrial cavity at postpartum US: a normal finding after spontaneous vaginal delivery. Radiology 1992;183(2):431–433. LinkGoogle Scholar
  • 47 Antonelli E, Morales MA, Dumps P, Boulvain M, Weil A. Sonographic detection of fluid collections and postoperative morbidity following cesarean section and hysterectomy. Ultrasound Obstet Gynecol 2004;23(4):388–392. Crossref, MedlineGoogle Scholar
  • 48 Garagiola DM, Tarver RD, Gibson L, Rogers RE, Wass JL. Anatomic changes in the pelvis after uncomplicated vaginal delivery: a CT study on 14 women. AJR Am J Roentgenol 1989;153(6): 1239–1241. Crossref, MedlineGoogle Scholar
  • 49 Maldjian C, Adam R, Maldjian J, Smith R. MRI appearance of the pelvis in the post cesarean-section patient. Magn Reson Imaging 1999;17(2):223–227. Crossref, MedlineGoogle Scholar
  • 50 Woo GM, Twickler DM, Stettler RW, Erdman WA, Brown CEL. The pelvis after cesarean section and vaginal delivery: normal MR findings. AJR Am J Roentgenol 1993;161(6):1249–1252. Crossref, MedlineGoogle Scholar
  • 51 Willms AB, Brown ED, Kettritz UI, Kuller JA, Semelka RC. Anatomic changes in the pelvis after uncomplicated vaginal delivery: evaluation with serial MR imaging. Radiology 1995;195(1):91–94. LinkGoogle Scholar
  • 52 Twickler DM, Setiawan AT, Harrell RS, Brown CEL. CT appearance of the pelvis after cesarean section. AJR Am J Roentgenol 1991;156(3):523–526. Crossref, MedlineGoogle Scholar
  • 53 Lobo RA. Menopause: endocrinology, consequences of estrogen deficiency, effects of hormone replacement therapy, treatment regimens. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, eds. Comprehensive gynecology. 5th ed. Philadelphia, Pa: Mosby, 2007; 1039–1071. CrossrefGoogle Scholar
  • 54 te Velde ER, Pearson PL. The variability of female reproductive ageing. Hum Reprod Update 2002;8(2):141–154. Crossref, MedlineGoogle Scholar
  • 55 Kato I, Toniolo P, Akhmedkhanov A, Koenig KL, Shore R, Zeleniuch-Jacquotte A. Prospective study of factors influencing the onset of natural menopause. J Clin Epidemiol 1998;51(12):1271–1276. Crossref, MedlineGoogle Scholar
  • 56 Kaufman DW, Slone D, Rosenberg L, Miettinen OS, Shapiro S. Cigarette smoking and age at natural menopause. Am J Public Health 1980;70(4):420–422. Crossref, MedlineGoogle Scholar
  • 57 Seungdamrong A, Weiss G. Ovulation in a postmenopausal woman. Fertil Steril 2007;88(5):1438.e1–e2. Crossref, MedlineGoogle Scholar
  • 58 Occhipinti K, Kutcher R, Rosenblatt R. Sonographic appearance and significance of arcuate artery calcification. J Ultrasound Med 1991;10(2): 97–100. Crossref, MedlineGoogle Scholar
  • 59 Gerber B, Krause A, Müller Het al.. Effects of adjuvant tamoxifen on the endometrium in postmenopausal women with breast cancer: a prospective long-term study using transvaginal ultrasound. J Clin Oncol 2000;18(20):3464–3470. Crossref, MedlineGoogle Scholar
  • 60 Hann LE, Giess CS, Bach AM, Tao Y, Baum HJ, Barakat RR. Endometrial thickness in tamoxifen-treated patients: correlation with clinical and pathologic findings. AJR Am J Roentgenol 1997;168(3): 657–661. Crossref, MedlineGoogle Scholar
  • 61 Bennett GL, Andreotti RF, Lee SIet al.. ACR appropriateness criteria(®) on abnormal vaginal bleeding. J Am Coll Radiol 2011;8(7):460–468. Crossref, MedlineGoogle Scholar
  • 62 Goldstein SR. The role of transvaginal ultrasound or endometrial biopsy in the evaluation of the menopausal endometrium. Am J Obstet Gynecol 2009; 201(1):5–11. Crossref, MedlineGoogle Scholar
  • 63 Smith-Bindman R, Weiss E, Feldstein V. How thick is too thick? when endometrial thickness should prompt biopsy in postmenopausal women without vaginal bleeding. Ultrasound Obstet Gynecol 2004; 24(5):558–565. Crossref, MedlineGoogle Scholar
  • 64 Salem S. Gynecology. In: Rumack CM, Wilson SR, Charboneau JW, Levine DL, eds. Diagnostic ultrasound. 4th ed. Philadelphia, Pa: Mosby, 2011; 547–612. Google Scholar
  • 65 Markovitch O, Tepper R, Fishman A, Shapira J, Aviram R, Cohen I. The value of transvaginal ultrasonography in the prediction of endometrial pathologies in asymptomatic postmenopausal breast cancer tamoxifen-treated patients. Gynecol Oncol 2004;95(3):456–462. Crossref, MedlineGoogle Scholar
  • 66 Imaoka I, Sugimura K, Masui T, Takehara Y, Ichijo K, Naito M. Abnormal uterine cavity: differential diagnosis with MR imaging. Magn Reson Imaging 1999;17(10):1445–1455. Crossref, MedlineGoogle Scholar
  • 67 Hall DA, McCarthy KA, Kopans DB. Sonographic visualization of the normal postmenopausal ovary. J Ultrasound Med 1986;5(1):9–11. Crossref, MedlineGoogle Scholar
  • 68 Kupfer MC, Ralls PW, Fu YS. Transvaginal sonographic evaluation of multiple peripherally distributed echogenic foci of the ovary: prevalence and histologic correlation. AJR Am J Roentgenol 1998;171(2):483–486. Crossref, MedlineGoogle Scholar
  • 69 Muradali D, Colgan T, Hayeems E, Burns PN, Wilson SR. Echogenic ovarian foci without shadowing: are they caused by psammomatous calcifications? Radiology 2002;224(2):429–435. LinkGoogle Scholar
  • 70 Wolf SI, Gosink BB, Feldesman MRet al.. Prevalence of simple adnexal cysts in postmenopausal women. Radiology 1991;180(1):65–71. LinkGoogle Scholar
  • 71 Greenlee RT, Kessel B, Williams CRet al.. Prevalence, incidence, and natural history of simple ovarian cysts among women >55 years old in a large cancer screening trial. Am J Obstet Gynecol 2010; 202(4):373.e1–e9. Crossref, MedlineGoogle Scholar

Article History

Received: Mar 12 2012
Revision requested: Apr 13 2012
Revision received: May 8 2012
Accepted: May 22 2012
Published online: Oct 4 2012
Published in print: Oct 2012