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Gynaecological Imaging from Menarche to Menopause

Oct 21 | 1:30 PM

KREST, Kochi, in association with IRIA, Thrissur, presents another fascinating discussion on ‘Gynaecological Imaging from Menarche to Menopause’. Imaging is a critical tool in the diagnosis & treatment of gynecologic conditions. Join us with Dr. Nandini Bahri as she discusses the various investigative imaging techniques available to diagnose these gynaecological conditions.

[Music] good evening everyone welcome to another webinar on netflix platform jointly organized by chris kochi and trisha city chapter of kerala iri we have dr mr balachandran nayasa of chris kochi sir is also professor and head of department of radiology jubilee medical college trishur and central council member of ira kerala for the opening remarks over to you sir thank you judy thanks a lot as yuri said this is a combined the joined webinar organized by chris as well as prashu radiology chapter and one word about research chapter this is this city city is the first to have a radiology club in kerala later they converted into a city chapter prison chapter is is a very vibrant chapter under the leadership of rajesh we knew and we have three uh medical colleges and kerala university of health sciences is also stationed at the shore and also we have many uh well-run tertiary care hospitals in tushu with this uh is enriched with a lot of great academicians and leaders dr mohan and weiss chancellor caroline university elsa and sciences he himself is a radiologist we all know he was the past president of national ira and two past presidents of iraq dr piarellal and dr robert sorry dr ambadi ramakrishnan they are also from klishor we have great teachers like dr abelash dr robert ambukan dr reggie george dr binoch dr sumi they are all from trishuls so trashu is a very rich place and so with the help of rishurvi crust is conducting this webinar i welcome all the delegates from this for this webinar coming to our map she is not not a stranger to sure we have a she is a great teacher academician and administrator a great leader dr nandani is the head is the professor and head of department as such ambisha medical college jam nagar in addition to her work as a professor she is also the covered special task duty officer she is nominated for the prestigious shipmenting research science and innovation leadership fellowship that is they call it the crust at oxford university 2020-21 she is also an assessor of and abh from 2010 and she is also founder and the chair first chairman of shakti wing of ira and also she groomed many radiologists our dear doctor robert ambukan is her student dr devrajin was the professor of the department calcutta is her course mate and now dr nandri is conducting as vice president of national iria and i already need such a tall leader such as uh beautiful capable leaders we are looking forward for this election and we want her to win this election night we wish you ma'am a long a good uh wish you have your all success in this election the today's topic we all know gynecological imaging from menarche to menopause i request dr mundra body to start the session thank you ma'am you are most welcome to for sure she came to trishura as an examiner about three years ago at amla institute so we still warmly remember her represents we are really really happy to see you now for the webinar ma'am please thank you so much so kind of the topic as we know is gynecological imaging from menopause and the thing is that it's 50 percent of the population and most of the things are very common but they need revisiting so obviously a lot of things will be very familiar so we will briefly revisit so menard is the age of first menstruation these days we seem to be reaching mana earlier so any time between 9 to 13 years is when a girl first menstruates that and when she stops menstruating that is menopause so there is an entire hypothalamic pituitary ovarian axis which is actually like a miracle which functions like clockwork every month and it reassures a woman that all is well with her so between 28 to 30 days maybe 35 days is the normal menstrual cycle of which the first five days or four days is active menstruation then is the proliferative phase and the security phase so midway ovulation takes place the final 14 days that is from ovulation to the onset of menstruation if 14 days are fixed the initial phase may vary a little bit and the second half is the progesterogenic phase the first half is the estrogenic phase [Music] so as you can see so this is a very important diagram and we must all remember that all the over which a woman has are present since birth over are not formed they are only they grow and some of them ovulation will take place and then they will get converted into a corpus luteum and into a focus so every month monarch onwards around between five to seven over will start growing in size till they reach a critical size approximately one by two centimeters or one point two centimeters and then one of them which is known will ovulate and if it reaches the logical conclusion that is pregnancy then pregnancy will take place for which the endometrium in the meanwhile has prepared and become thicker or that endometrium will be shed in the progesteronic phase and this whole cycle will repeat itself month on month year on year for the entire hotel period of the woman which may be for up to let us say 50 to 53 years if it started at 13 that's a long time and after that we also know that there is a cycle which is called premenopause where there is dysfunctional uterine bleeding the gap between the menstrual periods increases etc and finally menstruation will cease so when is it menopause when for one year there is no menstruation then we will consider that the woman has achieved menopause so this is the classic endometrium and uterus as we see it it is beautifully homogeneous there is an ecogenic line ultrasound and mri are our two great friends in pelvic imaging city has a limited rule unless we are trying to stage a malignancy or we are trying to see both or calcium but even in that mri is good mri of course is the gold standard but considering the availability of ultrasound easily available it has no downside and so it is the first thing we do so the ecogenic endometrial stripe [Music] along with it is the hypo junctional zone and then the myometrium the myometrium is smooth muscle so it looks like smooth muscle so this dark junctional zone is a very very important place any disturbance between this three equals should make us suspicious they are very very sharply different so initially the endometrial canal is thin it is just about 2 mm 2 mm 5 mm and 10 mm are a radiologist favorite figures i tell my children in exams that if something is thin and hair like you can just say one to two something is more you say three to five mm most likely you will be right similarly here so in the early phase proliferation the endometrium is thin then it gradually becomes deeper it will reach a maximum width of one centimeter and it will have a typical appearance which is known as the triple layer side with three layers and in the security phase it may become up to one 1.5 centimeters not more than that then again it will be chill but it will be clearly distinguishable from the myometrium [Music] so this endometrial thickness changes and then similarly at the same time there are ovarian genes like we mentioned both the ovaries will have some follicles we can observe them throughout the menstrual cycle we are all doing ovulation studies where we see them from the fifth day onwards on alternate days and five to six follicles are normal of which one will become larger reach a critical size and ovulation will take place once organization takes place this is how it will look on a successful scan once ovulation takes place and we have what is known as the corpus luteum color doppler is a very very useful tool and the color doppler will show us what is known as the ring of fire what is the function of the corpus luteum the corpus luteum separates progesterone it helps the pregnancy to be maintained that is why if there is a persistent corpus luteum cyst then the patient can have menstrual irregularities and needs to be treated [Music] so we have also already seen what it is for normal menstrual pleating ammonoria when there is no menstruation lack of menstruation and breakthrough breakthrough breathing is when there is intermittent bleeding in between menstrual cycles it happens in the perimenopausal stage very often or in cases of dysfunctional translating sometimes it happens when some patients are on those sequence and it need not be alarming [Music] if it happens once in a while but we need to consult a gynecologist hormonal levels need to be checked and one must be aware there are these various definitions menu rajya metro etc which we are all aware of and so like dawn says dawn was the classic textbook from gynecology when i was studying that a woman of child bearing age if the uterus doesn't contain a fetus it will contain a cycle fibroids are extremely common mostly they are incidental finding the woman may not even be aware there are of course the most common ones are the cerosal sub-serotonin of which the subsolution and the intramural may not be too troublesome unless they are close to the service 10 of them are close to the cervix and they will cause [Music] some kind of menstrual disturbance as they may block the passage of normal flow of menstrual blood subs mucosal fibroids can cause a problem and they can cause functional uterine beating and the patient will present but they have a very classic appearance because it is muscle so it looks like muscle and it will be very very clearly defined it has a world appearance and it looks like liver tissue when it doesn't have calcification or necrosis [Music] also the main distinguished distinguishing feature is how very defined they are sometimes we see phenomenal sizes and very bulky interests also they have to be distinguished from adenomyosis adenomyosis is endometrium growing within the myometrium or at other places and but an adenomyosis is not as well defined as a myoma this is adenomyosis and this is where our junctional zone is very important because the endometrium is growing into the myanmar or it is getting seeded at various places like the fallopian tubes or the maybe even the peritoneum and endometrial tissue will then cyclically behave [Music] according to the hormonal changes as endometrial tissue shown so that is how we have brown tumors we have additions and this is a very painful condition it can also be the cause for infertility and this requires treatment [Music] the most important sequence in pelvic imaging for females is the t2 sagittal sequence and also for adenomyosis t2 star or t2 sequences are very important because they will show up as bright spots even without contrast [Music] then a uterine column so the endometrial cavity like we said should not be more than 1.5 centimeters within the endometrial cavity we will see a structure which is expanding the cavity which may be surrounded by fuel and any column anywhere in the world is a pre-malignant condition and must always be removed and sent for histology one whether it is in the intestine whether it is in the uterus whether it is anywhere else in the gallbladder anywhere a polyp must be resected [Music] a eutron hemangioma is like a hemanzuma anywhere else it is rare but it will behave like a blood filled space and it will behave [Music] [Music] so the most fourth most common malignancy in a woman is endometrial past after breast malignancy we are very bothered about this and the risk factors are nulliparity and there seem to be environmental factors also now involved we are seeing many more cancers than we used to we still don't know whether it is because the diagnostics have improved or without because the life spans have become longer but however the index of suspicion should always be great because we can save a life if we detect them early it is very important to remember that embryologically the uterus cervix and the upper two third of the vagina have a malaria genesis and the lower one third of the vagina arises from the urogenital sinus so the classification also is based upon that upon how big the mass is whether it has penetrated gone beyond the myometrium whether it has gone into the vagina it has just gone into the lower half of the lower one third of the vagina whether it has gone to the parametrium whether it has invaded the bladder and whether it has a weight of the rectum and of course whether the nodes are local or distant [Music] we must actively [Music] see the size shape the endometrium the junctional zone slightly older women who have probably completed their families so we should not be afraid of over investigating i of course have great respect for alara and allah but we must remember that saving the life is more important than giving a low dose our business and our duty is to reach our diagnosis which is clear that which can reduce the morbidity and the mortality one must never be shy of doing an extra investigation is mine in any case in this case the next modality is mri there is no question of really of any kind of radiation so these are various pictures then cervical carcinoma so the risk factors of cervical carcinoma are different from those of endometrial plasma they are [Music] having many children having multiple sexual partners smoking etc [Music] the only thing is that cervical carcinoma as we know is related to chronic infection it is an avoidable task if we can motivate more women like we are motivating more women for screening of the breasts if we can motivate more women to do pap smears regularly we know that if there is metaplasm the next step may be this so just a simple pap smear can help us and now of course we have a vaccine and i feel if given the chance as part of our ira shakti and other means tying up with our guinea and media veteran we should try and push this vaccine in a big way and perhaps here in a big way so the various carcinomas those are the most common the endometrial casa [Music] but the most common are these five the simple variances the hemorrhagic coach objections the corpus nutrients and the pcos [Music] so a follicular cyst or the central orbiting stress will follow the normal parameters of a cyst that is it will have sharply defined borders it will have a shine through or posterior acoustic enhancement it will have edge shadows it will have no contains and they can be quite big sometimes and they are mostly incidental findings they rarely cause amenorrhea or any other symptoms but if it is a corpus luteus risk like i said before corpus luteuses produce progesterone so they will cause symptoms but the chocolate cyst is when there is endometrial seedling in the ovary so it will cyclically produce endometrium it will be shared and it [Music] which gets complicated will be a hemorrhagic cyst a special word about polycystic ovarian disease it seems to be increasing by leaps and bounds whether it is because of lifestyle or because of stress because it is related to the production of aldosterone and as we know stress will affect the adrenals our children and our young adults are increasingly living in a much more competitive world and the lifestyle changes the food habit changes everything combined there seems to be much more pcos now than there is there are of course very [Music] proper classifications but we are today briefly touching upon things because i am sure so pcos [Music] will classically have the appearance [Music] of a string of beads and something like this where like a pearl necklace all around the periphery we can see [Music] what happens is be associated with versatility some kind of abnormal purpose so abdomen obesity has called pseudo-estrogen receptors so the entire hypothalamic which you see ovarian axis gets disturbed the beta is [Music] uh attached to these pseudo receptors and population doesn't take place it's a vicious cell and they are not able to lose weight although the usually the doctor will say that your views will change your lifestyle but it's not as easy is the classic appearance and now we have come to the definition where we say that even if the stroma is low and the volume is lost if the volume is around 20 cc then we are bothered and we will watch [Music] so next is the fallopian tubes so the fallopian tubes the most common things are hydros a tree fallopian tubes are narrowest where they meet the uterus at the pistons and since they are the conduit for the between the uterus and the ovary they are also the boundary of infection and at the narrow portion additions can form blockages can form fluid can collect so you have this circuitous structures fluid fill tubes adjacent to the uterus memory classic and we all have seen this appearance in ultrasound in mri and there is nothing else that happens there which looks like this of course other than a lower variance but normally it can be easily picked up so you have a and if [Music] and obviously it needs treatment all these things usually come up during investigations for infertility we have not touched much upon infertility but like pcos and this pelvic ultrasound [Music] we all need to be familiar very much what happens is rare things happen rarely [Music] and not being it this is all bread and butter radiology pelvic imaging and females this bread butter radiology we should all know it very well we should be precise and we should not miss challenging [Music] which is further upon the hydrocyclines or biocyclings it does not change when the infection will spread and it will become an axis [Music] the mri findings in the same also ovarian treatments [Music] although there are many three things are very important serious muslims and germanys so serious as we all know serious statements and then of course the carcinogens so serious tumors can become huge and we get what is known as the empty acting inside as with the whole abdomen it can become so big and the patient will just come with a big abdomen and there is one big cyst the mucinous will have septa [Music] and the germanomas or the keratomas we all know can have hair it can have teeth the famous iceberg sign if there's any calcium or any fat we are sure that these are temperature [Music] then there are also brenner's tumors endometrioid tumors and there are fibromas fibromas like fibromas anywhere will be dark on t1 i am continuing to emphasize but [Music] we must now that mri is common easily accessible everywhere pelvic mri for females is very very very important if we can especially if we can convince the patient and we can also use a vaginal tampon with ultrasound jelly etc the delineation of the pelvic floor of the other structures the surgical planning etc [Music] anything with a module is always suspicious and needs to be biopsied or recepted then this is an ovarian fibrous hence it [Music] more then we must also if the patient permits the younger patient definitely try labial and perennial ultrasound it can be very very rewarding [Music] and it needs a lot of information about the pelvic floor about the relationship of the structures to each other and it can also be although it is not still very much popular it can help there's a lot of incontinence sometimes prolapse incompetence other pelvic floor issues in very menopausal women which can be assessed because it is dynamic so if we practice which will give us a lot of satisfaction you can actually get the lady to do cajuns or do other string exercises and see whether it is possible for her to have spiritual control or nails this is how it is done [Music] and we can see more or less anatomy which is similar to dmr anatomy it's just a question of getting used to it so i strongly advocate that we must try label foreign some patients may not like intracavity or trans agenda but they will not hesitate to do perennial because there is no penetration this is how it is done this is the how we see it the various structures and i greatly recommend rest very very briefly [Music] touch because it is related also to hormonal changes but many changes take place in the breast also between men are menopause and [Music] same once a lump develops then we can always biopsy it so we must promote streaming and also mri is a beautiful tool this is not the place or the time this is like about five fibroids hydroadenoma [Music] and [Music] the grade is again a mammography ultrasound and mr [Music] so it is [Music] good if we can if we have time when a patient comes to us for gynecological engineering also [Music] can communicate through breast ultrasound if that woman is younger than 45 years or spend 10 minutes in educating the patient best self-examination there is no greater joy for a doctor than to save a life or to help save a life it may every patient after all is somebody's family [Music] if we do a little extra which i'm sure most of us already do [Music] it will make all the difference but these are some images i will not dwell on it because it's not on the topic today thank you so much for your patience listening and for this opportunity to share my thoughts thank you very much to the whole pressed yes very good [Music] [Music] i missed something [Music] you should measure the volume not only multiple follicles if you measure the volume and if the volume is more you must mention if the patient has got the other commensurate features there [Music] you have to consider all the features together [Music] [Music] hi everybody [Music] uh [Music] [Music] she's my teacher i joined in 1999 in general medical college as a first grade student and at that time adam was assistant uh [Music] [Music] and she is a great human being great human being and this teaching academic all these comes only secondary [Music] and anyway now she is very busy nowadays responsibly she has she she has officer on special duty for task force of 2019 by uh inspector dnbs and the first founder founder and founder of sectioning of ire and since 2016 she is the central council [Music] [Music] [Music] uh when i joined in 2019 uh there was no mca recognition for that course and it wasn't at that time and then on a budding department it is [Music] immediately [Music] faculty [Music] [Music] apart from alhamdulillah [Music] what do you think yes we are doing quite well with the grace of god robert [Music] we have a very dedicated staff luckily for us all the staff is local and most of them are also alumni ugpg for public so they have a kind of a special love and uh i am happy many of my children have done very well so many have done dm they have done frcr they robot itself went to the lord learned more and like any other parent or teacher i am very proud so many of them are far more knowledgeable than me so and they have now have been actually for 15 years more than 15 years feel so proud they are all doing very well they have reached positions and they're very well respected you know very often people may not know that they have studied here because they've gone back somewhere else and i heard such lovely things about them about the work they are doing about the human beings they are and it makes me so proud of course if i if i have robert as a masculine then i don't have to say anything everybody [Music] but we got it retrospectively so actually this is a very old college this is a re-independence college it started in 1934 it was known as the river urban hospital that is when lord visited and so it's a pre-independence hospital then the medical college came so it is the second oldest medical college in puja it's a big college we have 250 ug students and for some reason radiology was not doing well so the course started in 1978 which is very early diploma but it could not recognize so then with everybody's help we were able to get all the equipment get it recognized and then there has been no looking back let me let me come to my official duty to thank you ma'am for the wonderful presentation here and you had elaborated how the normal endometrium looks like fibroids adenomyosis cervical cancer cancer over instance over in malignancy in uh we had to surfing five cycles etcetera etcetera and and there are importantly [Music] transparent [Music] [Music] thanks to mata for uh for today's presentation and i'm also thankful to uh um [Music] department of uh radiator and google machine medical college the backbone or backbone of the program doctor remix [Music] our dynamic [Music] [Music] [Music] and let me thank all the delegates or the delegates who attended this tourist program and i extend my thanks to the thanks to matrix executives for introducing the new medium and once again thanks to uh all of you thanks madam and of course [Music] everybody okay thank you [Music] thank you thank you [Music] for coordinating the program usual finally i would like to thank all these

BEING ATTENDED BY

Dr. Tarini Prasad & 352 others

SPEAKERS

dr. Nandini Bahri

Dr. Nandini Bahri

HOD & Prof Radiology, M.P Shah Medical College, Jamnangar, Gujarat

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. C. Kesavdas

Dr. C. Kesavdas

Consultant Neuroradiologist, Thiruvananthapuram

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dr. Nandini Bahri

Dr. Nandini Bahri

HOD & Prof Radiology, M.P Shah Medical Colleg...

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dr. Judy Mary Kurian

Dr. Judy Mary Kurian

Professor Travancore Medical College, Kollam

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dr. Ramesh Shenoy

Dr. Ramesh Shenoy

Consultant Radiologist | Kochi

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dr. C. Kesavdas

Dr. C. Kesavdas

Consultant Neuroradiologist, Thiruvananthapur...

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