Deep learning enables automatic quantitative assessment of puborectalis muscle and urogenital hiatus in plane of minimal hiatal dimensions.

OBJECTIVES: To measure the length, width and area of the urogenital hiatus (UH), and the length and mean echogenicity (MEP) of the puborectalis muscle (PRM), automatically and observer-independently, in the plane of minimal hiatal dimensions on transperineal ultrasound (TPUS) images, by automatic segmentation of the UH and the PRM using deep learning. METHODS: In 1318 three- and four-dimensional (3D/4D) TPUS volume datasets from 253 nulliparae at 12 and 36 weeks' gestation, two-dimensional (2D) images in the plane of minimal hiatal dimensions with the PRM at rest, on maximum contraction and on maximum Valsalva maneuver, were obtained manually and the UH and PRM were segmented manually. In total, 713 of the images were used to train a convolutional neural network (CNN) to segment automatically the UH and PRM in the plane of minimal hiatal dimensions. In the remainder of the dataset (test set 1 (TS1); 601 images, four having been excluded), the performance of the CNN was evaluated by comparing automatic and manual segmentations. The performance of the CNN was also tested on 117 images from an independent dataset (test set 2 (TS2); two images having been excluded) from 40 nulliparae at 12 weeks' gestation, which were acquired and segmented manually by a different observer. The success of automatic segmentation was assessed visually. Based on the CNN segmentations, the following clinically relevant parameters were measured: the length, width and area of the UH, the length of the PRM and MEP. The overlap (Dice similarity index (DSI)) and surface distance (mean absolute distance (MAD) and Hausdorff distance (HDD)) between manual and CNN segmentations were measured to investigate their similarity. For the measured clinically relevant parameters, the intraclass correlation coefficients (ICCs) between manual and CNN results were determined. RESULTS: Fully automatic CNN segmentation was successful in 99.0% and 93.2% of images in TS1 and TS2, respectively. DSI, MAD and HDD showed good overlap and distance between manual and CNN segmentations in both test sets. This was reflected in the respective ICC values in TS1 and TS2 for the length (0.96 and 0.95), width (0.77 and 0.87) and area (0.96 and 0.91) of the UH, the length of the PRM (0.87 and 0.73) and MEP (0.95 and 0.97), which showed good to very good agreement. CONCLUSION: Deep learning can be used to segment automatically and reliably the PRM and UH on 2D ultrasound images of the nulliparous pelvic floor in the plane of minimal hiatal dimensions. These segmentations can be used to measure reliably UH dimensions as well as PRM length and MEP. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

The menopausal woman: The need for an individualized plan of care.

With life expectancy increasing, women will spend one-third of their lives in and beyond menopause. A collaborative discussion with the clinician facilitates informed decision-making and should include evidence-based discussion of physiologic changes, assessment of symptoms and treatment options, review of screening recommendations, and discussion of disease risk-reduction strategies and psychosocial issues.

Sexual differentiation in three unconventional mammals: spotted hyenas, elephants and tammar wallabies.

The present review explores sexual differentiation in three non-conventional species: the spotted hyena, the elephant and the tammar wallaby, selected because of the natural challenges they present for contemporary understanding of sexual differentiation. According to the prevailing view of mammalian sexual differentiation, originally proposed by Alfred Jost, secretion of androgen and anti-Mullerian hormone (AMH) by the fetal testes during critical stages of development accounts for the full range of sexually dimorphic urogenital traits observed at birth. Jost's concept was subsequently expanded to encompass sexual differentiation of the brain and behavior. Although the central focus of this review involves urogenital development, we assume that the novel mechanisms described in this article have potentially significant implications for sexual differentiation of brain and behavior, a transposition with precedent in the history of this field. Contrary to the "specific" requirements of Jost's formulation, female spotted hyenas and elephants initially develop male-type external genitalia prior to gonadal differentiation. In addition, the administration of anti-androgens to pregnant female spotted hyenas does not prevent the formation of a scrotum, pseudoscrotum, penis or penile clitoris in the offspring of treated females, although it is not yet clear whether the creation of masculine genitalia involves other steroids or whether there is a genetic mechanism bypassing a hormonal mediator. Wallabies, where sexual differentiation occurs in the pouch after birth, provide the most conclusive evidence for direct genetic control of sexual dimorphism, with the scrotum developing only in males and the pouch and mammary glands only in females, before differentiation of the gonads. The development of the pouch and mammary gland in females and the scrotum in males is controlled by genes on the X chromosome. In keeping with the "expanded" version of Jost's formulation, secretion of androgens by the fetal testes provides the best current account of a broad array of sex differences in reproductive morphology and endocrinology of the spotted hyena, and androgens are essential for development of the prostate and penis of the wallaby. But the essential circulating androgen in the male wallaby is 5alpha androstanediol, locally converted in target tissues to DHT, while in the pregnant female hyena, androstenedione, secreted by the maternal ovary, is converted by the placenta to testosterone (and estradiol) and transferred to the developing fetus. Testicular testosterone certainly seems to be responsible for the behavioral phenomenon of musth in male elephants. Both spotted hyenas and elephants display matrilineal social organization, and, in both species, female genital morphology requires feminine cooperation for successful copulation. We conclude that not all aspects of sexual differentiation have been delegated to testicular hormones in these mammals. In addition, we suggest that research on urogenital development in these non-traditional species directs attention to processes that may well be operating during the sexual differentiation of morphology and behavior in more common laboratory mammals, albeit in less dramatic fashion.