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Female Reproductive System

12

Lucio Olivetti, Luigi Grazioli, and Paola Pollastri

12.1

Normal Anatomy

The female reproductive system, apart from the
embryonic remnants, consists of the reproductive
organs contained and anchored by a system of
suspensory ligaments and aponeurotic supporting muscles.

12.1.1 Ovaries
The female gonads are a pair of symmetrical organs
which produce egg cells (oocytes) and secrete
female hormones (estrogen, progesterone, and a
small amount of androgen) (Fig. 12.1). They are
hardly visible in the early age as their descent to the
pelvis is not yet completed. During puberty, they
can already appear as developed as in the adult age.
The postpubertal ovary is almond shaped (2–4 cm

in length, 1.5–3 cm in width, and a thickness of
around 1 cm); these measurements vary during the
menstrual cycle, in the first trimester of gestation
(due to the presence of the true corpus luteum), and
after menopause (senile ovarian atrophy).
Located on the posterior surface of the broad
ligament and the lateral wall of the lesser pelvis, the
ovary occupies the “ovarian fossa,” bounded on
the rear side by the ureter and the iliac vessels. The
ovaries show an upper or tubal pole, an inferior or
uterine pole, the hilum border to which the mesovarium is attached, and a posterior free border.
The ovarian ligament originates from the uterine
pole and is inserted in the body of the uterus posterior to the intramural portion of the uterine tube.
Laterally, the suspensory ligament anchors the
ovary to the pelvic wall and conveys the vessels,

L. Olivetti (*)
Department of Radiology, AO Istituti Ospitalieri di
Cremona, Viale Concordia 1, Cremona 26100, Italy
e-mail: l.olivetti@ospedale.cremona.it
L. Grazioli
Department of Radiology, AO Spedali Civili,
Piazzale Spedali Civili 1, Brescia 25100, Italy
e-mail: lgrazioli@yahoo.com
P. Pollastri
Department of of Obstetrics and Ginecology,
AO Istituti Ospitalieri di Cremona, Viale Concordia 1,
Cremona 26100, Italy
e-mail: lgrazioli@yahoo.com

Fig. 12.1 Anatomic diagram of the developmental stages
from ovarian follicle to luteal body. Counterclockwise
from left: primordial and primary follicles, maturing
follicles, ruptured follicle (or hemorrhagic body), luteal
bodies, initial and mature, corpus albicans (arrowhead).
The arrow indicates a released egg

L. Olivetti (ed.), Atlas of Imaging Anatomy,
DOI 10.1007/978-3-319-10750-9_12, © Springer International Publishing Switzerland 2015

207

running obliquely toward the top. Each tube is located in the superior wing of the broad ligament. which passes through the myometrium and communicates with the uterine cavity by the opening of the uterine tube • The isthmus (2–3 cm). The venous outflow takes place in the uterine and ovarian veins. The arrow indicates a luteal body nerves. along with the arteries. for the migration of spermatozoa. unpaired. which initially runs inside the suspensory ligament and then empties into the renal vein on the left and the inferior vena cava on the right.5 cm.2 Anatomical diagram of the female reproductive system. a short peritoneal ligament which detaches from the broad ligament and the tubo-ovarian ligament connecting the upper pole of the ovary to the infundibulum of the uterine tube (Fig. 12. the lumen diameter varies from 0. The average length is 12–18 cm.1. at the insertion on the uterus. The main blood supply is provided by the ovarian artery (branch of the aorta) contained in the suspensory ligament.2). ovarian ligament (8).2 Uterine Tubes or Oviducts 12. which follows the uterine ligament and sends branches through the mesovarium which anastomose with those of the ovarian artery. an almost straight segment which follows the uterine horn • The ampulla (length 6–8 cm). and posterior to the round ligament. muscular-membranous conduits which create a communication between the uterine and peritoneal cavities. located in the pelvic cavity . 208 Fig. 12. up to approximately 8–15 mm at the distal end of the ampulla. form the ovarian plexus. ovary (7). the fallopian tubes or oviducts may be considered as annexes of the uterus. for the fertilization and conveying the embryo toward the uterus as well as for the early phases of its development. broad ligament (9). laterally and posteriorly toward the pelvic sidewall. to delimit an opening forming the communication between the tubal lumen and the peritoneal cavity (abdominal ostium of the uterine tube) (Fig. infundibulum (4). which ends into fringed extensions. sometimes it lies in the ovarian fossa and some other times in the rectouterine pouch. 12. Each uterine tube is divided into four parts. and efferent and afferent lymphatic vessels.1. tubal isthmus (2). and median muscular organ. The lymphatic vessels of the ovaries are abundant and drain into the preaortic and paraaortic lymph nodes.L. anterior to the ovary. A second source is provided by the ovarian branch of the uterine artery. and ureter (10). called fimbriae. ampulla (3).5 to 1 mm. 12. Anchorage of the uterine tube is provided by continuity with the uterus and tubo-ovarian ligament which connects the distal portion of the tube to the upper pole of the ovary. lateral to the uterus. mesovarium or mesosalpinx (6). nevertheless the position is very variable. They are a pair of symmetrical The uterus is a hollow. they are essential for capturing the cells after ovulation and their transport toward the uterus. and their capacitation. The venous network forms the pampiniform plexus at the level of the ovarian hilum: the veins arising from the plexus merge together forming the ovarian vein. located in a medial-lateral direction: • The intramural segment with a length of 1–2. they originate from the uterine horns.2) The arterial vascularization of the uterine tubes is supplied by the arterial arches formed by the anastomosis of the uterine and ovarian arteries. Olivetti et al. an extension of the celiac and renal plexuses.3 Uterus Together with the ovaries. a segment with alternating dilatations and constrictions in the lumen • The funnel-shaped infundibulum (1–2 cm). Innervation of the ovary is provided by the nerve branches that. suspensory ligament of the ovary (5). Uterus (1). The ovary is also anchored by the mesovarium.

12 Female Reproductive System posterior to the urinary bladder and anterior to the rectum. The highly convex upper border corresponds to the part of the uterus that projects beyond a plane through the entrance point of the uterine tubes and is called the fundus. the isthmus. triangular in shape and virtual. The uterus is a subperitoneal organ. two muscular fiber cords accompanied by vessels extending from the uterine tubes to the labia majora and the pubis passing through the inguinal canal) and limiting the lateroversion (broad ligaments. the uterus may sometimes be found in an anomalous position (retroversion. In a later moment the uterus decreases in size (2–3 cm in length and 0. the vesicouterine ligament (anteriorly). isthmus (5). The directional system has the function of keeping the uterine anteversion (round ligaments. While it is normally located in an anteverted and anteflexed position. forming a robust transverse band of tissue which connects the supravaginal cervix and the vagina to the lateral wall of the pelvis.3 Anatomical diagram of the uterus. and the cardinal. intramural segment of the uterine tube (8). The average dimensions in a nulliparous woman are 6. 12. is reflected onto the urinary bladder. After covering . Indeed its axis forms an angle of 90° (ver- 209 Fig. descends from the anterior wall of the abdomen.3). In relation to the insertion point. 12. and ovary (9) sion angle) with the angle of the vagina. lateroversion. and returns to the anterior wall of the uterus. since during pregnancy it experiences the hormonal stimulation of the maternal estrogens. oriented downward. external uterine os (2). in fact. and the cavity of the cervix. we can distinguish a supravaginal and a rounded vaginal portion (“portio vaginalis”). consisting of a double layer of peritoneum which connects both sides of the uterine body to the lateral wall of the pelvis). and the neck (or cervix). cervical canal (3). due to congenital or acquired causes. body (6) and fundus (7) of the uterus. forming the apex.5 cm in length. the measurements and weight of the uterus are slightly greater in women with prior pregnancies. whose distal end communicates with the vagina via the external uterine os. etc. The body is the upper part of the organ and has a flat or slightly convex anteroinferior surface. backing. ligaments (laterally). spindle shaped and real (Fig. The suspensory structures consist of the uterosacral ligaments (posteriorly). generally inflammatory in nature. the latter are formed by a thickening of the subperitoneal connective tissue and run at the base of the broad ligaments. a convex posterosuperior surface. At birth the uterus is relatively large and has a configuration similar to the adult one. transverse cervical. The cervix represents the inferior part of the uterus where the vagina is inserted. internal uterine os (4). 4 cm in width. This position is maintained by a complex system of connections which is schematically composed of support.). keeping it until puberty when it grows volumetrically and shows a pyriform shape. and 2 cm in thickness. anatomically and functionally separated: the body. partially covering it. the axis of the cervix forms an opened angle of 100–120° with the axis of the body (flexion angle). The uterus can be divided into three parts.5–1 cm in width). The capacity of the uterine cavity is about 4 mL in nulliparous and 5–6 mL in pluriparous woman. The main supports are the connective muscular structures of the pelvic floor. The uterine cavity is flattened from the front to the back and is divided into two parts by the isthmus: the cavity of the body. The isthmus is a slight constriction between the body and the cervix and has an anatomical-functional role during labor only. It is conical in shape with the base upward and the trunk. and directional structures. Coronal section. while in menopause it undergoes a progressive atrophy. and rounded lateral borders. The parietal peritoneum. Fornix vaginalis (1).

4). right lateral. the ovarian arteries. superior. 12. rectum (5). the vaginal artery (branch of the iliac).5 Vulva The vulva is made up of the female external genitalia. Running obliquely downward and forward. The anterior wall of the vagina is related to the urinary bladder from which it is separated by relatively loose connective tissue. rectouterine pouch (4). is related to the rectouterine pouch.1. labial majora. and iliac (Bartholin’s glands) lymph nodes. rectovaginal septum (6). The uterine wall structurally consists of three layers from the inner to the outer side: the mucous (endometrium). and inferior pudendal arteries (branches of the femoral) and the internal pudendal artery (branch of the internal iliac). in front of the anus. The posterior wall. the vulva extends anteroposteriorly immediately below the pubic symphysis up to around 3 cm.4 Sagittal anatomic diagram of the pelvis in a female subject. The external and internal iliac and hypogastric lymph nodes drain the lymphatic vessels of the upper part of the vagina. The superior end surrounds the uterine cervix between the inferior third and the middle. and left lateral. 12. vestibule. The lymph nodes which drain the rich network of the lymphatic vessels of the vulva are the superficial inguinal. muscular (myometrium). 210 Fig. and to the urethra via a dense fibrous urethrovaginal septum. while caudally it is closely related to the rectum from which it is separated by the rectovaginal fascia. and is reflected again to cover the rectum. The vagina is supplied on each side. The blood supply of the uterus derives chiefly from three arteries: the uterine artery. posterior. 12. Bladder (1). at the level of the fornix. and the artery of the round ligament. It includes the mons pubis.1. the vesicovaginal septum. and serous (perimetrium) layers. uterine body (2). The arterial vascularization consists of the external. the anterior and posterior parietal peritoneum layers join to form the broad ligaments. deep inguinal (clitoris). it is located partly in the pelvis and partly in the perineum. while the superficial inguinal lymph nodes drain the inferior part. 12. The lateral walls of the pelvic segment above the levator ani muscle correspond to the base of the broad ligament. and greater vestibular glands (the vestibular Bartholin’s glands and the periurethral Skene’s glands). Bounded by the medial aspects of the thighs. Olivetti et al. thus forming a recess called the vaginal fornix which is usually described as having four segments: anterior. by branches of the uterine artery.4 Vagina The vagina is a median muscular-membranous conduit around 8 cm in length which extends from the uterus to the vulva. the serous peritoneum descends over the posterior surface of the uterus. labia minora. and the middle rectal artery. from top to bottom.L. and vesicovaginal septum (7) the uterine fundus. . Laterally. also covering a part of the posterior vaginal wall. thus forming the rectouterine pouch or pouch of Douglas (Fig. the more internal iliac lymph nodes and the lymph node of the Gerota drain the middle part (between the vagina and the rectum). cervix (3). clitoris.

evident in (b). 12.5).12 Female Reproductive System 12.2 Normal Imaging Anatomy 12. Reflux of contrast medium in the vagina (1). 5–10 mL) is then slowly injected and a Fig. At hysterosalpingography. 12.2 Ultrasound The ultrasonographic (US) examination of the female pelvis can be performed transabdominally (TA) with a 3. The study involves a precontrast enhancement examination obtained before inserting the catheter into the internal uterine os. The examination is preferably performed between the 8th and 12th day of the menstrual cycle or at any rate after the cessation of the menstrual flow and before ovulation.2. except for a minimal antibiotic coverage. The first image is acquired during the beginning of uterine filling. pregnancy is unlikely.2. it also enables the morphologic study of the uterine cavity. the uterus normally appears in a medial position and conical in shape with the apex inverted.5–5 MHz convex transducer or b medium into the peritoneal cavity. 12. It is generally performed as an outpatient procedure.5 Hysterosalpingography. (a) The uterine tubes (arrowheads) appear regular in diameter and course. the second when the uterus is completely distended. the third during the enhancement of the uterine tubes. The uterine tubes are visualized with two segments: a thin medial segment corresponding to the interstitial part and isthmus and a lateral tortuous segment for the ampullary part (Fig. with no need for any special preparation by the patient. and a final image when the contrast material is leaking into the peritoneal cavity. uterus (2) . In this time window. the normal patency is documented by the leakage of contrast 211 several images are acquired under fluoroscopic monitoring during progressive opaque rendering of the uterus and uterine tubes.1 Conventional Radiology Hysterosonosalpingography is widely used as reference radiologic technique for the evaluation of the female infertility and to assess the patency of the uterine tubes. the contrast medium (nonionic hydrosoluble contrast medium.

Olivetti et al. anteroposterior diameter.6). From the sixth to the eighth day. a single-locular formation of about 2–3 cm. and anterior to the internal iliac vessels and the ureters. In fertile age the ovary is almond shaped (length. 12. medially to the external iliac vessels. The ovarian structure has a central echogenic stromal part and a peripheral cortical part. 212 a b c Fig. at the level of which we can see the follicles (as anechoic images of around 3–4 mm). Ovary. The uterine tubes are not appreciable in normal conditions unless hydrosalpinx or peritoneal effusion is present. which reaches the maximum diameter of 20 mm in the follicular phase. a transrectal (TR) approach with 5–7 MHz transducers may be used. it appears covered by a thin hyperechoic layer which corresponds to the germinal epithelium and the tunica albuginea. with a slightly higher echogenicity than the myometrium and the internal obturator muscle. it is possible to detect the tubaric ostia. is defined as the dominant follicle. The image clearly shows two larger follicles.L. A number of follicles can be recognized in the ovary. the follicle. the average diameter of the follicle is of 3–5 mm. lateral to the uterine fundus. having a mainly mixed-hyperechoic content. known as antral follicles.6 Transvaginal ultrasonography. 25–35 mm. vary in number. (c) Postmenopausal ovary. characterized by a marked peripheral vascularization (ring of fire) (Fig. These follicles. On transvaginal ultrasonography. . (b) Late follicular phase. The size and shape of the ovaries vary during the menstrual cycle in relation to the age and to the presence of one or more developing follicles or the luteal body. The ovaries are usually well visualized and are located in the ovarian fossa. with reduced dimensions and without the presence of follicles transvaginally (TV) with a 5–7 MHz transducer. 12–20 mm). After ovulation we can see the luteal body. In the first 5 days of the menstrual cycle. They decrease with age and are a marker for premature menopause. breadth. In case of virgin patients or woman with vaginal stenosis. 12. (a) Early follicular phase. in the form of anechoic images (one of them is indicated by the arrowhead). 20–25 mm.

due to the presence of blood and the disintegration of the functional layer. Immediately after ovulation. more echogenic than the myometrium. which is constant in the various phases of the menstrual cycle (Fig. The arcuate vessels are at the level of the anterior myometrium and appear as pulsating anechoic tubular or ovoid structures. with an intermediate-low signal (similar to that of the muscular tissue). mucous cysts due to the obliteration of the excretory ducts of the glands: they appear as anechoic rounded formations with . the endometrium may have a trilaminar appearance: the two hypoechoic layers.. the endometrium becomes progressively hyperechoic due to the increased reflectivity produced by the accumulation of mucus and secretions. a thickness inferior to 5 mm without focal thickening excludes the presence of significant diseases and is compatible with atrophy (Fig. 12. (b) Longitudinal scan. In this phase. In longitudinal scans performed during ovulation. while the isthmus and the neck have a round aspect. In transverse sections. and becomes thicker. During the secretion phase. even reaching a width of 10–14 mm. 12. we need to bear in mind the clinical history of the patient and especially whether she is undergoing hormone replacement therapy (HRT): the endometrium (if not completely atrophied and therefore nonvisible) appears thin. The asterisk is in the bladder. 12. and the anteroposterior one 3–4 cm. the examinations should be scheduled according to the kind of hormone replacement therapy undertaken by the patient. the major axis is transverse. the endometrium has generally a thickness of 8–11 mm. during estrogenic stimulation.7 Transvaginal ultrasonography.8a). uniform. the endometrium remains hyperechoic.e. it appears as a median central line. The walls of the cervix may be the site of Naboth cysts. The endometrium of a patient undergoing HRT may appear slightly thickened. looses the trilaminar aspect. the upper 2/3 corresponds to the body and the inferior third to the cervix. Uterus. For this reason the echogenicity of the vaginal portion of the cervix increases. 12. Each hypoechoic layer is then externally delimited by a slightly echogenic line corresponding to the endometrial-myometrial interface (Fig. 5 cm transversally and 4 cm anteroposteriorly. The virtual uterine cavity is a central line with variable echogenicity in the different phases of the menstrual cycle. The sizes can vary: it usually measures 7 cm from the top of the fundus to the cervix. In general. the uterus appears conical in shape. (a) Transversal scan. The structure of the myometrium is uniform. and hyperechoic. are separated by a central hyperechoic interface (line). During menstruation. corresponding to the endometrial mucosa.7). The arrow indicates the left ovary with the dominant follicle In longitudinal scans. the endometrium is extremely inhomogeneous. with the base upward and the apex pointing downward.12 Female Reproductive System a 213 b Fig. In the early proliferative phase.8b). the transverse one 4–5 cm. the canal of the cervix appears as a small hyperechoic line which broadens due to the glandular mucous secretion. the body has the shape of an egg. In the advanced proliferative phase and up to ovulation. i. In case of postmenopausal evaluation.

214 a b Fig.L. Olivetti et al. In baseline conditions. the shape. elongated. it appears as a thin. dimensions. The color Doppler examination completes the US study and is able to obtain information about the vascularization of the ovaries and the uterus. internal obturator. The TV approach also enables the study of the rectouterine pouch. of course. with respect to the bladder anteriorly and the rectum posteriorly. Analog to magnetic resonance. the planes used in the multiplanar reconstructions (MPR). The trilaminar aspect of the endometrium is appreciable between two landmarks. appears as a triangular or oval parenchymal structure posterosuperiorly related to the bladder. it correctly displays the pelvic bones and the psoas. and. including age and hormonal status. The uterine body is usually triangular in shape. hypodense area. longitudinal scan. and position of the uterus depend on various factors. the uterus. the levator ani muscle. However. flat structure with a thickness of less than 1 cm and a trilinear appearance produced by the coinciding walls (moderately echoreflective) and the central interface (hyperechoic).3 Computed Tomography Computed tomography (CT) examination of the pelvis is rarely performed for purely gynecologic indications since it does not allow a precise study of the endometrium and the relevant changes during the menstrual cycle. (a) Uterus of a woman in fertile age. The anatomical landmark for their visualization is the tubal angle of the uterus (Fig. iliac.8 Transvaginal ultrasonography. we can observe a variation of the endometrium and myometrium thicknesses. Visualized with a suprapubic transducer. covered by the peritoneum. The maximum diameter. the vagina has a variable length of 7–10 cm. In general. and pyriform muscles. The vaginal portion of the cervical canal can be well studied with TV ultrasonography. it can be recognized by the small quantity of liquid in the endometrial cavity a diameter which varies from a few millimeters to 2–3 cm and are of no pathological significance. In CT. The endometrium is extremely thin. During the menstrual cycle. uterine morphology at CT is variable. the endometrial secretions produce a central. . while the uterine cervix is more cylindrical. which is measured shortly before ovulation. may reach and exceed 2 cm. depending on the scan plane. allowing the evaluation of the borders and adipose cleavage planes. and rounded in appearance when the section is perpendicular to its long 12. often slightly hypodense with respect to the remainder of the uterus. The lumen is recognizable when it contains menstrual blood. (b) Postmenopausal uterus. Similarly. the most sloping portion of the peritoneal cavity.2. the cervix appears of uniform density. the spatial orientation of the organ itself. The dimensions of the follicles vary with the phases of the menstrual cycle. 12. The ovaries are usually well visualized and are located in the ovarian fossa. Nonetheless. anterior to the ureters and posterolateral to the uterus. 12. CT is useful to identify the relationship between the endopelvic organs. and the muscles of the pelvic floor. where in normal conditions (during the menstrual and preovulatory phase) a thin anechoic layer of liquid is normally appreciable.9).

12. appears hypodense in comparison to the myometrium of the uterine body and fundus. It is possible to identify the distal pelvic . Ovaries (3). Normal anatomy of the ovary. The virtual. due to the greater stromal component. (a) Axial scan.10 Computed tomography. (a) Axial scan. which is enhanced after the injection of contrast medium. bladder (4) axis. 12. bladder (3) b Fig. Several small follicles are identifiable in the right ovary (1). Endometrial cavity (1).10).9 Computed tomography. the arrowhead indicates the basal layer of the endometrium.12 Female Reproductive System a Fig. 12. situated lateral to the cervix. a 215 b Both of the ovaries are identifiable (1) with several follicles. The layer of connective tissue that is continuous with the broad ligament comprises the parametrium. (b) Coronal reconstruction. It is best visualized with the insertion of a tampon. Uterus (2). (b) Sagittal reconstruction. The cervix (2). On CT images the vagina is characterized by a density similar to that of the surrounding soft tissues and appears as a flattened transverse structure which widens at the level of the fornices. the uterine body has sagittal dimensions varying between 5 and 8 cm. vaginal lumen cannot be clearly identified. Normal anatomy of the uterus. in axial scans the cervix normally measures no more than 3 cm (Fig. In a woman of fertile age.

12. the luteal body appears hypointense in T1-weighted images and hyperintense in T2-weighted images. an increase of signal occurs only in the stromal part of the ovary. it appears bounded by a rim (due to a deposit of hemosiderin) which is hypointense in T1 and hyperintense in T2 and enhances after contrast medium administration. During fertile age. The dimensions of the follicles are considered normal when the diameter is inferior to 25 mm (Fig. The ovarian follicles are recognizable in the superficial cortex and the subcortical zone in T2-weighted images. It has a high contrast resolution. Olivetti et al. cells can be appreciated. the cardinal ligament. it also enables a complete examination of the pelvic region and its structures (lymph nodes. occasionally surrounded by a thin hypointense rim. with a denser connective tissue and limited extracellular matrix producing a relatively hypointense signal. thus rendering the axis of the uterine body vertical and shifting the intestinal loops away from the small pelvis. and muscles of the pelvic wall). In a woman of fertile age. the enhancement of the ovary is however less intense than that of the myometrium. generally uniform and similar to that of the bowel loops and the myometrium. 12. especially postnatally or if ectasic. as well as a medullary zone with a relatively higher signal in relation to the lower density of the connective tissue. the ovarian vein can be visualized. instead. however. it provides a high spatial resolution as well. rounded. performing the examination with the urinary bladder moderately distended is preferable. The other structures are only recognizable in the presence of ascites.11). the zonal anatomy of the ovaries can be identified: in the fibromuscular ovarian stroma (intermediate-low signal). In its cystic form. especially when they are thickened after radiotherapy: The broad ligament is readily identifiable thanks to the structures it contains or which surround it. on the posterior surface of the broad ligament. and with the recent introduction of phased array coils. In a woman of prepubertal and postmenopausal age. In MRI the ovaries are better visualized with coronal images. in relation to angiogenesis. appearing as elongated formations arising from the uterine body and extending laterally toward the pelvic wall: they have low or intermediate signal intensity. the follicles allow the immediate detection of the ovaries in the MR images. hyperintense formations. The two ovarian arteries can be distinguished only during the arterial phase. MRI of the uterus does not require any special preliminary preparation. the contrast differentiation between the cortex and medulla is less evident and the signal is more uniformly hypointense. They are typically almond shaped. In the postmenopausal period. the ovaries cannot be easily identified given their reduced volume and absence of follicles. respectively. In . Occasionally. After the administration of paramagnetic contrast medium. In T2-weighted sequences. there may be a focal increase of the signal around a follicle or in a luteal body. is not always visible along its entire course. appearing as small. The broad ligament is the only recognizable support structure having a hypointense signal on the coronal or parasagittal plane. at the level of the psoas muscle. which from the cervix and the superior part of the vagina reaches the fascia of the internal obturator muscle. inferolateral to the tubes. in T1-weighted sequences they have low-intermediate signal. lateral to the ureter. bones. a superficial cortical zone rich in stromal L. They may produce small focal images of higher or lower signal with hemorrhagic luteal bodies or cystic follicles. while it is similar to the latter after menopause. The injection of contrast medium enables identification of the uterovaginal vascular plexus. such as in CT. and thanks to its panoramic views. The tubes are appreciable in the coronal plane.2. The structures displayed on CT include the uterine ligaments.216 tract of the ureter running some 2 cm lateral to the uterine cervix.4 Magnetic Resonance Magnetic resonance (MR) has a primary role in the diagnostic imaging of the female pelvis: The technique provides an excellent visualization of the female genital organs.

rectum (3). hypointense zone. Myometrium (1).12 Magnetic resonance.12 Female Reproductive System 217 a b Fig. and myometrium. The intermediate. in the uterine body. it becomes thicker during the secretion phase. corresponds to the most internal zone of the myometrium and represents. junctional zone. Retroverted uterus. and the hypointense signal the junctional zone (arrow). during fertile age.11 Magnetic resonance. low-signal blood clots can be identified within the endometrial cavity. axial (a) and sagittal (b).12). It is hypointense with respect to the most external layer of the myometrium. its thickness varies from 1–3 to 3–7 mm: It is thinner immediately after menstruation and in the proliferative phase. 12. The ovaries (arrows) are recognizable by the presence of numerous hyperintense follicles a b Fig. 20–25 % of the myometrial thickness. bladder (4) T1-weighted images the uterus has uniform. three zones with different signal intensities: endometrium. defined as junctional zone. while in the T2-weighted images it is possible to identify. Axial (a) and coronal (b) T2-weighted images with fat signal suppression (b). due to the higher concentration of compact smooth muscle cells and the consequent reduction in extracellular spaces (Fig. During the menstrual cycle. During men- struation. 12. intermediate-low signal. T2-weighted images. There are no significant differences in the myometrial . The hyperintense signal indicates the endometrial cavity (arrowhead). The central hyperintense area represents the basal and functional layers of the endometrium and its associated secretions. ovary (2). 12.

12. The parametrium has intermediate signal intensity in T1-weighted images and a variably higher signal in T2. In the sagittal plane. The suspensory ligaments in contrast appear hypointense in both T1 and T2. Postmenopausal uterus with reduced volume.13). the myometrium displays significant enhancement. and the peripheral zone.13 Magnetic resonance. but its long axis is generally located in the sagittal plane. the uterus remains similar to that of women in fertile age. and myometrium. The junctional zone could be less evident or even completely absent. the above-described zonal anatomy is no more recognizable: the endometrium is thin and the myometrium is characterized by a lower signal intensity than the one detectable during the fertile age (Fig. In a woman using oral contraceptives. The endometrial cavity (arrowhead) is lesser identifiable and reduced to a thin hyperintense line L. the uterine cervix also displays three concentric zones with different signals in T2-weighted sequences: the cortical zone. probably due to its more compact structure and the consequent lesser presence of extracellular spaces. is hypointense due to the higher presence of smooth muscle cells (as already described for the junctional zone of the uterine body). the paravaginal vascular spaces have a hyperintense signal. The administration of contrast medium produces a significant degree of enhancement both in the paracervical tissue and in the mucous epithelium. the anatomy of the vagina can be identified and clearly distinguished from the surrounding structures. The cervix is separated anteriorly from the bladder wall by a thin cleavage plane of adipose tissue and posteriorly from the ampulla of the rectum by the rectovaginal fascia. . whereas the junctional zone remains low signal. In contrast. After the intravenous administration of paramagnetic contrast medium in the normal uterus. similar to that of the urethra anteriorly and the rectum posteriorly. Fig.and T2-weighted images. After a prolonged contraceptive therapy. the paracervical tissue in fertile age women is characterized by medium-high signal and is readily distinguished from the low signal of the cervical stroma (Fig. with medium-high signal. the vagina has intermediate signal intensity.14). In T2-weighted images. estrogen replacement therapy produces a clearly identifiable endometrium. In T1-weighted images. the myometrium has a higher signal intensity in the T1. the intermediate zone. In addition to the uterine body. the rectovaginal pouch can often be identified.218 thickness during the menstrual cycle. the uterine body can show reduced dimensions: the administration of gonadotropin-releasing hormone analog tends to decrease estrogen production and therefore produces an involution of the uterus. junctional zone. Olivetti et al. due to edema which tends to decrease the contrast between the junctional and the peripheral areas. corresponding to the deepest part of the fibromuscular stroma. The intermediate zone. the arcuate vessels of the myometrium are also identifiable. The hyperintense central zone corresponds to the palmate folds and the mucus occupying the cervical canal. The peripheral zone. 12. while the compact stromal tissue shows reduced enhancement. is the most external component of the cervical stroma. The spatial orientation of the cervix is variable. being higher in the central period of the luteal phase. After menopause. In this phase. In T2-weighted images acquired on the axial plane. with marked endometrial atrophy and hypointensity of the myometrial signal (similar to the way it appears after menopause). 12. although the signal intensity modifies.

Laniado M. The arrowhead indicated the left ovary images. Stuttgart 4. Nicolas V. When the patient is undergoing HRT. Philadelphia 6. Forstner R (2007) MRI and CT of the female pelvis. and the central mucous component can be identified only as a thin hyperintense strip. In a woman of postmenopausal age (in the absence of HRT). Simpson WL Jr. the vaginal wall appears hypointense in T2-weighted Bibliography 1. 12. Radiographics 26:419–431 . Normal anatomy of the cervix (arrows). Georg Thieme Verlag. Krestin GP. very thin mucous component. Hamm B. Mester F (2006) Hysterosalpingography: a reemerging study. Brown DL. and no signs of vessel congestion can be identified in the paravaginal tissue.15 Magnetic resonance. Springer. Stanley RJ. DiSalvo DN (2001) Gynecologic ultrasound. 12. The arrow indicates the rectum In T2-weighted images acquired in the early follicular phase. Radiol Clin North Am 39:523–540 5. Radiol Clin North Am 40:637–658 2. the vagina presents morphologic and signal characteristics similar to those observed in the follicular phase. axial (a) and sagittal (b). Laing FC. the wall of the vagina has low signal and a hyperintense central area representing the mucus and the vaginal epithelium (Fig. it appears as hypointense. After the administration of contrast agent. T2-weighted images. the more hypointense middle zone and the most external zone of intermediate intensity. Lippincott Williams & Wilkins. with a central. Lee JKT. Fig. Normal anatomy of the vagina (arrowhead). and in most subjects the vaginal wall has intermediate-high signal with a consequent reduction in contrast between the two structures. Chang SD (2002) Imaging of the vagina and vulva. Heiken JP (2006) Computed body tomography with MRI correlations.15). Taupitz M (2010) MRI imaging of the abdomen and pelvis. In individuals of prepubertal age. Beitia LG.12 a Female Reproductive System 219 b Fig. At the beginning of the luteal phase.14 Magnetic resonance. axial T2-weighted image. Berlin 3. Sagel SS. 12. the thickness of the mucous component increases. Hamm B. It is possible to identify the hyperintense cervi- cal canal. both the vaginal wall and the mucous component show enhancement.