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41Акушерство и Гинекология
UDC: 611.66-071.3-073.48-053.7
AGE ECHOGRAPHIC CHARACTERISTICS OF THE UTERUS AND OVARIES IN WOMEN OF THE FIRST AND SECOND PERIOD OF
MIDDLE AGE KHAMDAMOVA MUKHAYOHON TUKTASINOVNA
PhD, associate Professor in the Department of obstetrics and gynecology, Bukhara medical Institute. Bukhara, Republic of Uzbekistan.
ORCID ID 0000-0003-3128-6120 ABSTRACT
The article considers one of the most common methods of examination of the female reproductive system for age-related changes in the uterus and ovaries in women of the first and second periods of middle age, one of which is ultrasound. Also, according to morphological and ultrasound studies, we studied the shape of the uterus and ovaries, as well as the biological age and individual size variability in women.
Keywords: uterus, ovary, age, ultrasound, shape, volume, first and second period
ВОЗРАСТНАЯ ЭХОГРАФИЧЕСКАЯ ХАРАКТЕРИСТИКА МАТКИ И ЯИЧНИКОВ У ЖЕНЩИН ПЕРВОГО И ВТОРОГО ПЕРИОДА
СРЕДНЕГО ВОЗРАСТА ХАМДАМОВА МУХАЙЁХОН ТУХТАСИНОВНА
Бухарский Государственный медицинский институт имени Абу Али Ибн Сино, доцент кафедры акушерство и гинекологии, PhD, город Бухара Республика Узбекистан.
ORCID ID 0000-0003-3128-6120
АННОТАЦИЯ
В статье рассматривается один из наиболее распространенных методов обследования женской репродуктивной системы на возрастные изменения матки и яичников у женщин первого и второго периодов среднего возраста, одним из которых является ультразвуковое исследование. Также по данным морфологических и ультразвуковых исследований изучали форму, объём матки и яичников, а также биологический возраст и индивидуальную изменчивость размеров у женщин.
Ключевые слова: матки, яичник, возраст, ультразвук, форма, объём, первый и второй период.
УРТА ЁШДАГИ БИРИНЧИ ВА ИККИНЧИ ДАВРДАГИ АЁЛЛАРДА БАЧАДОН ВА ТУХУМДОНЛАРНИНГ ЁШГА ОИД УЗГАРИШЛАРИНИНГ ЭХОГРАФИК ХУСУСИЯТЛАРИ
ХАМДАМОВА МУХАЙЁХОН ТУХТАСИНОВНА
Бухоро тиббиёт институти акушерлик ва гинекология кафедраси доценти, т.ф.ф.д. Бухоро шахар Узбекистон республикаси. ОРСЮ Ю 0000-0003-3128-6120 АННОТАЦИЯ
Мацолада урта ёшдаги биринчи ва иккинчи даврдаги аёлларда бачадон ва тухумдонларнинг ёшга оид узгаришларини аёл репро-дуктив тизимини текшириш усулининг энг кенг тарцалган усулла-ридан бири ультратовуш текшируви цацида фикр юритилади. Шунингдек, морфологик ва ултратовуш тадцицотлар кура аёлларда бачадон ва тухумдонлар шакли, цамда цажми биологик ёши ва индивидуал узгарувчанлиги урганилган.
Калит сузлар: бачадон, тухумдон, ёш, ултратовуш, цажм, шакл, биринчи ва иккинчи давр.
The high information content and relative simplicity of the ultrasound method of investigation, its noninvasiveness and harmlessness contributed to the fact that echography has become one of the leading research methods in gynecology - [1; 7]. Extensive ultrasound information dictates the need for careful comparison with obstetric clinics, which is a prerequisite for correct interpretation of ultrasound data. The latter should contribute to the improvement of diagnostics using echography, obtaining new diagnostic criteria that contribute to the development of new therapeutic and tactical approaches in gynecological practice - [3; 5; 8; 10].
Research has shown that throughout life, from birth to old age, the parameters of the uterus and appendages undergo noticeable changes. Age-related changes in the parameters of the uterus in childhood are presented by many authors - [1; 2; 6; 7; 9].
Currently, ultrasound of the female internal genitalia is carried out using transabdominal (TA) or transvaginal (TV) scanning, which complement each other. The uterus occupies a Central position in the pelvic cavity. Its body has an oval shape, uniform structure, clear contours. Anterior to it is the bladder. In the uterus, there are anterior cystic surface, posterior rectal surface and two lateral surfaces forming the edges of the uterus - [1; 5; 7; 9]. Uterus. The bottom of the uterus is usually turned anteriorly, forming an open angle with the axis of the neck, amounting to 70-100°. When filling the bladder, this angle increases. In the uterus emit upper broad part of-body and the lower narrow-neck. When TA ultrasound determine the position of the uterus in the pelvis, its contours, the structure of the body of the uterus and cervix, their length (longitudinal section), width and anteroposterior size (cross section), assess the condition of the myometrium, endometrial and endocervix. The uterus belongs to hormone-dependent organs, which determines the variability of its size and structure. Physiological and pathological changes in the reproductive
apparatus of women lead to fluctuations in the size of the uterus, which depend on age, diseases, the number of pregnancies, childbirth and the phase of the menstrual cycle (MC). So, the smallest size the uterus is in the late proliferative to early secretor phase of the ovulatory cycle, and the highest just before menstruation; childbirth lead to the increase in the size of the uterus, and abortion — only to increase of its anterior-posterior size. In the postmenopausal period, there is a gradual decrease in the size of the uterus. In the longitudinal scan, the uterus is visualized as a pear — shaped formation, and in the transverse scan-as an ovoid, having an average level of echogenicity. In the early postnatal period, it is located in the abdominal cavity above the line of entry into the pelvis and is in the position of unexpressed anteversion (the bottom of the organ is turned up and slightly posteriorly).
The length of the uterus during this period is 25±3 mm, the anteroposterior size is 8-10 mm. The most pronounced is the cervix (CMM), the length of which accounts for 2/3 of the length of the entire uterus, the wall of the CMM is twice as thick as the wall of the uterine body (TM), the cervical canal (CC) of a newborn girl is visualized as a hypoechoic strip. The lower part of the cervix (10 mm) is located in the vagina, the back lip, as in adults, is slightly longer than the front. The angle between the body and the cervix is not pronounced, because the thickness of these parts is almost the same. TM in the longitudinal section has a concave saddle-shaped bottom, and in the transverselooks rounded formation - [2; 4; 6].
Starting from the age of 1 month, the enlarged uterus of the newborn is subjected to involution and subsequently reaches its original size only by 7-8 years. Growth its is undertaken mainly expense of increasing bodies, the ratio length bodies and cervical constantly is changing: if in 1 year it accounts for 1:2, in 4 year-1:1.7, in 6-8 years-1: 1.4, then in 9 years-already 1 : 1, bottom gradually loses sedlovidnuyu form of, the uterus is in
position ante version, antiflexia (bottom uterine cervix An angle is gradually formed between the body and the cervix by thickening the myometrium and increasing the anterior size of the uterus. Rapid growth of the uterus begins 6 months before the onset of menstruation and continues until the end of adolescence. With the onset of menstrual age, the ratio of body length to cervix is on average 2:1, and after 2 years-3:1. With the establishment of a regular menstrual cycle, the uterus becomes pear-shaped, is in the position of ante version or anteflexia, sometimes in the position of retroflexia, the angle between TM and CMM is clearly determined. The average size of the body of the uterus in a girl who regularly menstruates for 2 years, the following: length-42,4 + 1,4 mm, anterior-posterior size-28,3 + 0,8 mm. during menopause, involution of the uterus.
The cervix has a cylindrical shape, with a transverse scan-the shape of an oval. Secrete the vaginal part of the CMM, which is in the vagina, and over the vaginal part-located above the vaginal arches. The neck has an average echogenicity, homogeneous structure. The cervical canal is visualized as a hyper echoic linear structure 1-2 mm wide (3,8). Before ovulation, it is defined as a hypo echoic gloss up to 2-4 mm thick, then the thinning of the strip occurs, and again its front and back walls become visible in the form of a homogeneous hyperechoic line.
Ecomorphologically changes of endometrium. Ultrasound of the endometrial tissue assesses its thickness, structure and compliance with the phase of MC. To assess the endometrial thickness is used, the measurement of the anteroposterior size of M-echo (median uterine echo), which is a summed image of the endometrium anterior and posterior wall and the uterus (which is often not clearly displayed on the ultrasound due to the density of its walls). Measurement of the thickness of the M-echo should be performed with a longitudinal scan of the uterus TA or TV with simultaneous visualization of the cervical canal along the outer contours
of the M-echo perpendicular to the longitudinal axis of the uterus, not including in the measurement of the rim of reduced echogenicity (halo), which usually appears from the beginning of the 2nd phase of the MC. Ecomorphologically changes of the endometrium are dependent on a patient's age, illness, day of menstrual cycle. During the newborn for 1-2 weeks after birth, the endometrium due to the influence of placental hormones of the mother shows its proliferative and secretor activity and is defined as a smooth hyperechogenic strip 2-3 mm thick, while the phase of desquamation may be accompanied by menstrual similar secretions from the vagina. By the end of the 1st month of life, the impact of maternal estrogens gradually ends, the endometrium is thinning. During the neutral period of development (up to 7 years), the endometrium may not be determined by TA-scanning, and when transrectal scanning is detected in the form of a bright hyperechogenic strip up to 2-3 mm thick. in the prepubescent period (from 7 years to menarche), the endometrium retains the same echo morphological characteristics.
With the onset of puberty (from the onset of menarche to 16 years) and in adolescence (from 16 to 18 years), the endometrium is subject to cyclic changes in hormonal Genesis. Usually the endometrium has an average echogenicity, homogeneous structure. During menstruation, the uterine cavity is filled with blood and fragments of the endometrium — during this period, the echo-grams of M-echo looks like a complex structure of hyperechogenic linear echo structure. After the cessation of menstrual bleeding and the release of the uterine cavity from blood in the first days after menstruation, M-echo is either not determined, or is detected in the form of a hyperechogenic strip 1 — 2 mm thick (which is an ultrasonic reflection of the touching surfaces of the functional layers of the endometrium of the anterior and posterior walls of the uterus). By the 5-6th day MTS M-echo represents the structure in the form of three Hyper echogenic lines: the endometrium itself, especially in the Central parts, is
almost an-echogenic due to the high degree of hydrophilicity, the internal areas on the border with the myometrium have a dense structure and are presented as two hyperechogenic lines and the Central stripe is a contiguous divisions of the anterior and posterior walls of the uterus. The value of M-echo to the 14th day of MC (periovulatory period) in women of the childbearing period can be up to 14 mm. During 1 week after ovulation, endometrial echogenicity continues to increase-first in the basal zone, and then in the superficial parts; a rim of reduced echogenicity appears. By the 21st day of MC, the endometrium becomes completely hyperechogenic (due to the accumulation of secretion in the cells), a Hypo-echogenic zone (due to expanded vessels of the myometrium at the border with the basal Department of the endometrium) is detected along the periphery. The height of the endometrium remains the same (as in phase 1), but by the time of menstruation, there is a slight decrease in its height.
In the postmenopausal period, M-echo is a structure of high echogenicity with a width of 1-2 mm, there is no hypoechoic rim around the endometrium (Fig. 5). Sometimes the uterine cavity is expanded to 24 mm due to the presence of a small amount of fluid in it, which is caused by a decrease in the tone of the myometrium. To exclude precancerous processes in the endometrium (dysplasia) requires diagnostic measures and monitoring in the dynamics.
Ovaries. To study the ovaries, a longitudinal or transverse scan of the pelvic cavity is used. The ovaries appear as ovoid shape formation, having a uniform internal structure, medium echogenicity. The ovaries are located on the side of the body of the uterus, the right is slightly higher than the left, but can be determined posterior from it or in close proximity to its corners. The reference point of their location is the internal iliac vein. The length of the ovary is on average 29 mm, thickness-19 mm, width-27 mm, the average volume of the ovary in a healthy woman of childbearing age-7.7 cm3.
Ultrasound provides an opportunity to follow the formation of the follicle in the ovary, determine its size and set the time of ovulation. Ultrasound parameters of the maturing follicle are clearly correlated with functional diagnostic tests, the level of most hormones (FSH, LH, prolactin, estradiol, progesterone, etc.). The diameter of the follicle capable of ovulation is 20 mm or more (up to a maximum of 25 mm), its structure is anechoic, the capsule is not detected. After ovulation and up to 21-22 days of MC on the site of the follicle, there is a hypo echoic formation of the same diameter (yellow body), which also does not have a capsule and disappears by the time the cycle begins.
In early childhood, the ovaries are located in the abdominal cavity above the entrance to the pelvis, the right is slightly higher than the left. The length of the ovaries in newborns varies from 15 to 30 mm, width-from 4 to 8 mm, thickness-from 2 to 3.5 mm. At the time of birth, the number of germ cells in the ovaries is about 500 000, their differentiation continues after birth and ends by the end of the first year of life. Germ cells, surrounded by small flattened stroma cells, form premordial follicles (ovogony), which are located on the periphery of the ovary in the cortical layer, and in the cerebral layer are mainly located feeding vessels (they are visible in the CDC). Until puberty, follicles in their development stop at the stage preceding ovulation, the fluid in them dissolves, and the cavity is closed by connective tissue. Replaced artesian the follicles new, mimicking the normal ovulation cycle of a woman. Sometimes the number of growing follicles is so large that it leads to ovarian hypertrophy, occasionally (with hormonal imbalance) in the ovaries there are large cystic follicular formations up to 10-20 mm in diameter. The neutral period proceeds without the expressed participation of sex hormones, secondary sexual characteristics are absent, and although a small amount of estrogens is synthesized in the body, the development of follicles still has an acyclic and erratic anovulatory character. Ultrasound in the ovaries
reveals from 2 to 8 cysts with a diameter of 2-3 mm. Ovaries from the age of 3 years gradually migrate from the abdominal cavity and by 5-6 years are determined near the walls of the pelvis at the lower edge of the cross section of the long pelvic muscle. In 7-8 years, the ovaries reach a length of 18-27 mm.
In adolescence, the development of the reproductive system is completed. FSH and LH secreted by the anterior pituitary contribute to follicle maturation and ovulation. In place of the burst Mature follicle, a yellow body appears, producing progesterone, the rapid development of the yellow body initiates the maturation of a new follicle. The increase in the level of estrogen becomes an occasion for ovulation and the release of LH into the blood. Rhythmic hormonal impulses determine the specific reaction of the endometrium, in which the proliferative (1st phase) and secretor (2nd phase), as well as the processes of desquamation and regeneration.
Fallopian tube is normally not visualized with ultrasound, which, however, is possible with ultrasound using echocontrast agents (echovista, etc.).
The vagina is easily detected by ultrasound in its normal anatomical state. On longitudinal scans, it is defined as a tubular structure connecting at a slight angle to the cervix. In this case, in the center of the vagina, a median hyperechogenic linear structure is determined, which is an ultrasonic reflection of the contiguous mucous membranes of the anterior and posterior walls of the vagina. The Hypo-echogenic zone located around it corresponds to the muscular sheath of the vagina. The thickness of the vaginal walls is normally 3-4 mm.
Existing methods of ultrasound of the uterus and appendages have limited diagnostic capabilities, as the anatomical structures are studied, which in physiological conditions appear completely motionless during ultrasound, which does not give the advantages that are available in the
study of internal organs that have a pronounced kinetic ability. This prevents, in particular, to reliably estimate when the most common THE scanning of the uterus as its rear wall or bottom retro flexion-bath of the uterus, producing in some cases topical and pathological differential diagnosis between the uterus, ovaries and appendage pathological formations.
It should be emphasized that the use of oxytocin in this method of ultrasound should be consistent with existing contraindications to its use-pregnancy, postoperative scars on the uterus.
These methods of ultrasound of the uterus and its appendages with the use of uterine reducing agents significantly increase the possibility of ultrasonic morphological analysis of their structure, carrying out differential topical and anatomical pathomorphological diagnosis.
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