Occasionally, lack of proper uterine support is present, and a device known as the pessary (Fig. 10-2) is inserted into the vagina to provide proper support. Current research has demonstrated that the majority of women who use the pessary are very satisfied, as the device relieves the majority of urinary symptoms. Some women report that although the use of a pessary helps improve urinary symptoms, stress incontinence remains an ongoing problem. However, the use of the pessary continues to be the treatment for pelvic organ prolapse and may assist with the quality of life for many of these patients.

FIGURE 10-2 A pessary, inserted into the vagina for uterine support, is readily visible on this abdominal radiograph of an 88-year-old woman.

The fallopian tubes extend from the upper, outer edges of the uterus and expand distally into the infundibulum located close to, but not attached to, the ovaries. Suspended in place by the broad ligament, they are 8 to 12 cm long and tend to fall behind the uterus. These tubes serve as a passageway for the mature ova and are the normal site of fertilization. In a normal pregnancy, the fertilized ovum continues to travel through the fallopian tube and implants itself into the endometrium of the uterus.

The ovaries are the primary reproductive glands and are responsible for ovulation and for secretion of estrogen and progesterone. Attached to the broad ligament and the posterior uterine wall, each ovary contains numerous graafian follicles enclosing ova. After puberty, several graafian follicles and ova grow and develop each month. Normally only one follicle matures, migrates to the surface of the ovary, and degenerates, thus expelling a mature ovum, which is the hallmark of the ovulation process.

Breasts—like the fallopian tubes, uterus, and vagina—are considered secondary sex organs. Breast parenchyma differs according to age and parity. Women in their 20s and 30s, especially nulliparous women, have dense, fibroglandular parenchyma that may conceal breast masses during a clinical breast examination and imaging. However with advancing age, decline in estrogen and progesterone causes breast tissue to undergo what is known as involutional change. Involution is the conversion of glandular breast tissue into adipose as well as loss of the supportive tissue. As a result of this slow process, the breast changes its architecture, and fibroglandular tissue is replaced by fat. This process is variable, but it typically begins at the back of the breast and progresses forward to the nipple. The term mastalgia applies to conditions that result in pain in one or both breasts. Many patients fear that mastalgia is indicative of breast cancer; however, it is more closely related to architectural changes in breast tissue. Involution aids the imaging professional and the interpreting physician because fatty tissue is radiolucent and enhances the radiographic visibility of many breast masses.

Anatomically, breasts are attached via Cooper ligaments to the pectoral muscles, and this gives the breast its contour and shape. The breast consists of about 12 lobes separated by connective tissue, much like the spokes of a wheel. The lobes are further divided into lobules clustered around small ducts. These small ducts join to form larger ducts, which terminate at the nipple (Fig. 10-3). Breasts function as accessory reproductive glands to secrete milk for the newborn. During pregnancy, changes in estrogen and progesterone levels prepare breasts for lactation. Approximately 3 days after delivery, a lactogenic hormone stimulates the secretion of milk.

Imaging Considerations

Magnetic Resonance Imaging

Magnetic resonance imaging (MRI) is now often used in conjunction with sonography in the evaluation of the female pelvis (Figs. 10-5 and 10-6). MRI, like sonography, uses no ionizing radiation and is noninvasive. MRI gives detailed information on pelvic, uterine, and ovarian masses (Fig. 10-7). In cases of ovarian cancer, MRI accurately demonstrates proliferation into other pelvic structures. In addition, multiple leiomyomas can be detected and localized in a short period.

FIGURE 10-5 A sagittal sonographic image of the normal uterus.

MRI is increasingly being used to assist in differentiating between malignant and benign solid lesions within the breast. Fat suppression imaging is used before and after contrast enhancement. This technique suppresses the normal, fatty tissue of the breast, allowing easier identification of malignant masses through contrast enhancement (Fig. 10-8). MRI is also used to detect faulty or leaking breast implants. Again, fat suppression imaging is used to suppress the normal breast tissue and detect the presence of silicone in surrounding tissue.

FIGURE 10-8 A sagittal T2-weighted fat-suppressed magnetic resonance imaging scan of the left breast.

A review of published studies on the value of adding MRI as a screening tool for breast cancer found that it was better for screening patients compared with mammography alone or a combination of mammography, sonography, and clinical breast examination. One concern about using MRI as a screening tool for breast cancer was that it raised the return rate for additional imaging; therefore, it has been suggested that MRI be used as an adjunct to mammography. MRI has also proven to be a safe, more effective screening tool in women who have a family history of breast cancer and are positive for the BRCA oncogene, for whom early screening is recommended.

Computed Tomography

Computed tomography (CT) of the pelvis and abdomen is often performed to diagnose diseases of the female and male reproductive systems. It is quite helpful in assessing neoplastic growth and abscess formation resulting from inflammatory processes. It is often used in conjunction with transvaginal sonography to evaluate ovarian lesions, especially cystic teratomas in females, and is used extensively in staging cancers of the female reproductive system. In the male patient, CT is also used in conjunction with sonography to demonstrate anomalies of the seminal vesicles and prostate gland. CT and positron emission tomography (PET) fusion studies (CT-PET) are also of value in the diagnosis and staging of neoplastic disease of the reproductive system, as well as the assessment of disease progression.

Sonography is highly recommended by the ACR for suspected gynecologic adnexal masses. CT of the pelvis, with or without contrast, is also equally indicated for nongravid women in the reproductive age group who have a complex or solid mass that is growing in the short term.

Congenital Anomalies

Congenital anomalies of the female reproductive system occur in approximately 1% to 2% of women in the United States. The most common anomaly is the bicornuate uterus, in which paired uterine horns extend into the fallopian tubes (Figs. 10-9 and 10-10). A unicornuate uterus occurs when the uterine cavity is elongated and has a single fallopian tube emerging from it. Often, the kidney on the side of the missing fallopian tube is also absent. Uterus didelphys is a rare congenital anomaly with complete duplication of the uterus, cervix, and vagina. The most serious complication of these anomalies is problems with reproduction, although various surgical corrections can be performed.