Ultrasonography of the uterus

Benha university, Egypt Aboubakr Elnashar

Normal uterusNormal uterus

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Technique Technique

F.B.F.B.

LSLS: :

vagina (vagina (hypoechogenichypoechogenic tubular structure with an tubular structure with an echogenicechogenic lumen)& lumen)&

long axis of the uterus. long axis of the uterus.

TS: TS:

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PositionPosition

Midline (Midline (2525%)%)

Corpus: usually flexed Corpus: usually flexed anteriorlyanteriorly on the on the cervix (ante flexion).cervix (ante flexion).

In RVF:In RVF:

poor visualization of the poor visualization of the fundusfundus

((dropout phenomenon) dropout phenomenon)

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TAS: retroflexed uterus, but it is difficult to evaluate the

fundus and the endometrium.

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SizeSize

LS:LS:

APD: APD: 11..55--3 3 cmcm

L: L: 44..55--9 9 cm.cm.

TS:TS:

TD: TD: 44..55--55..5 5 cm. cm.

In In multiparamultipara::

increase by increase by 11--2 2 cm in all diameterscm in all diameters

EchogenecityEchogenecity

Homogenous: Homogenous: myometriummyometrium & & endometriumendometrium Aboubakr Elnashar

Normal postmenarchal uterus.

The uterine body (u) is larger than the cervix (c). The

endometrium (arrows) is the region of relatively bright central

linear echoes. v, vagina .

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TAS: uterus in a 4-year-old girl.

The cervix is larger than the body of the uterus. Aboubakr Elnashar

measurementsmeasurements

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5

TVS: Uterus. Normal endometrial stripe.

Normal peristalsis of bowel noted posterior to uterus .

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4

TVS: Retroverted Uterus.

Normal variant of prominent myometrial veins in patient

with retroverted uterus.

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Menstrual changes of the Menstrual changes of the endometriumendometrium

Early menses( DEarly menses( D11--44))

HypoechoicHypoechoic central echo central echo

thick thick hyperechoichyperechoic endometrial echoendometrial echo

posterior enhancement similar to posterior enhancement similar to lutealluteal phasephase

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late menses(D3-7)

Single Single hyperechoichyperechoic thin line (central endometrial echo). thin line (central endometrial echo).

HypoechoicHypoechoic halo. halo.

AP thickness of the entire endometrial echo: AP thickness of the entire endometrial echo: 11--3 3 mm. mm.

HypoechoicHypoechoic central echo representing blood is gonecentral echo representing blood is gone

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Early proliferative phase (DEarly proliferative phase (D55--99).).

Halo present. Halo present.

Relatively thin AP endometrial thickness (<Relatively thin AP endometrial thickness (<6 6 mm). mm).

No posterior enhancement. No posterior enhancement.

Three line signThree line sign

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Proliferative end

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PeriovulatoryPeriovulatory endometriumendometrium, triple line, triple line Aboubakr Elnashar

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Normal endometrium. (A) “Triple line” endometrium in midcycle. Aboubakr Elnashar

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DD1010--1414: Late proliferative phase: Late proliferative phase

As above with thicker endometrial echo As above with thicker endometrial echo complex (>complex (>66mm)mm)

LutealLuteal phase:phase:

Maximum endometrial thickness, Maximum endometrial thickness,

HyperechoicHyperechoic endometriumendometrium, ,

Loss of halo, Loss of three line sign, Loss of halo, Loss of three line sign,

Prominent posterior enhancementProminent posterior enhancement

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Secretory endometriumSecretory endometrium

N cysts in cxN cysts in cx

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Normal endometrium.

(B) Secretory phase endometrium that is thick and

echogenic with posterior acoustic enhancement . Aboubakr Elnashar

AbnormalitiesAbnormalities A. A. MyometriumMyometrium

B. EndometrialB. Endometrial

C. CavityC. Cavity

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A. Myometrium Uterine anomalies

TVS can detect 90% .

Uterine septae: Best diagnosed in

transverse plane.

in the periovulatory phase, {can be missed in

the early follicular phase with thin

endometrium}

DD:

IU adhesions: isoechoic nature of the septum

with the myometrium

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Types Ultrasound Diagnosis

Difficult to diagnose sonographically

Small uterus

Lateral position

Unicornuate

Visualization of separate horns

> 105 degrees apart

Bicornuate

Has duplication of cervix and upper vagina Didelphys

Smooth indentation of fundal ndometrium

Mild form of bicornuate

Arcuate

Smooth external contour < 75 degrees between horns

Fibrous septum can be removed surgically

Septate

T-shaped uterus

Short cervix

DES

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Bicornuate uterus.

(A) Transabdominal transverse view of the uterus demonstrates

two horns that are widely separated. Only one cervix was seen on

vaginal scanning.

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Bicornuate uterus. (B) View of the right renal fossa

demonstrates an absent right kidney Aboubakr Elnashar

BicornuateBicornuate uterusuterus

At cervical level at fundal levelAt cervical level at fundal level Aboubakr Elnashar

Fibroid

Rounded distinct masses

of increased, decreased or similar echogenecity of the myometrium.

± uterine enlargement.

DD:

1. Ovarian cyst

2. RVF

Adenomyosis.

Submucous fibroids:

distort the midline echo & are best diagnosed in the

periovulatory phase

Decrease the chance of conception with IVF

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ECHOTEXTURE • Hypoechoic

– Shadowing secondary to whorls of fibrous tissue and edge artifacts

• Echogenic

• Isoechoic

• Cystic areas – Secondary to

degeneration

• Calcifications – Rim calcification

– Clumps of calcification

LOCATION Submucosal

Associated with

menometrorrhagia

Distort endometrial myometrial

margins

Intramural

Most common

Subserosal

Distort uterine margins

Pedunculated

± Stalk

May present as adnexal mass

Cervical

Broad ligament

Simulate adnexal mass

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Diffuse Uterine Enlargement* Comments Diagnosis

Multiparous women can have uterine size 1-2 cm

larger than “normal” in each dimension Normal parous

uterus

Fibroids

Uterus diffusely enlarged with normal uterine

echotexture and contour

± Small cysts in myometrium

Focal or diffuse invasion of the myometrium by

endometrium

Focal adenomyoma may appear as a fibroid

Adenomyosis

Early findings of loss of endometrial/myometrial

interface

Late finding of enlargement of uterus

Endometrial

carcinoma

Rapid change in size of uterus

Difficult to distinguish from fibroids, unless serial

examinations are available

Sarcoma Aboubakr Elnashar

Pregnancy

Size varies with gestational age of

pregnancy Normal pregnancy

Endometrial cavity enlarged with

multiple cystic spaces Missed abortion

Gestational

trophoblastic diseas

Size varies with time since

delivery Recent postpartum

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Fibroids. (A) Transabdominal view of a fibroid uterus.

The uterus is enlarged with a heterogeneous

echotexture and a lumpy contour caused by fibroids. Aboubakr Elnashar

Fibroids.

(B) Submucosal fibroids surrounded by fluid during

a sonohysterogram . Aboubakr Elnashar

Fibroids.

(C) Subserosal fibroid with broad attachment to the

myometrium and an exophytic component . Aboubakr Elnashar

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SubmucousSubmucous fibroidfibroid

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Pedunculated fibroid. (A) Transabdominal view of the

pelvis demonstrates a mass (M) adjacent to the uterus

(U( Aboubakr Elnashar

Pedunculated fibroid. (B) Transvaginal examination

demonstrates a tissue plane between the uterus and the

mass .

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Pedunculated fibroid. (A) Transabdominal view of the pelvis

demonstrates a mass (M) adjacent to the uterus (U) Aboubakr Elnashar

Pedunculated fibroid. (B) Transvaginal examination

demonstrates a tissue plane between the uterus and the

mass.

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Uterine calcifications. (A) Transvaginal transverse view of the

uterus in a postmenopausal woman with abnormal bleeding

demonstrates a well-defined echogenic focus with shadowing

secondary to a calcified fibroid. Adjacent to this area is a fluid

collection in a region of thickened endometrium (arrows). This was

endometrial hyperplasia. Aboubakr Elnashar

AdenomyosisAdenomyosis

HypoechoicHypoechoic spaces in the spaces in the myometriummyometrium. .

It is more prominent during & immediately after It is more prominent during & immediately after menstruation. menstruation.

Small retention cysts in the cervix should not be mistaken for Small retention cysts in the cervix should not be mistaken for adenomyosisadenomyosis

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Myometrium:Myometrium:

Heterogeneous echotextureHeterogeneous echotexture

Echogenicity: decreased Echogenicity: decreased

relative to that of the dorsal relative to that of the dorsal

myometriummyometrium

Myometrial cyst (curved Myometrial cyst (curved

arrow)arrow)

Asymetrical uterine Asymetrical uterine

enlargementenlargement

Endometrium:Endometrium:

excentric endometrial cavityexcentric endometrial cavity

indistinct endometrialindistinct endometrial--

myometrial bordermyometrial border

AdenomyosisAdenomyosis

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Bromley et al (Bromley et al (20002000))

2 2 or more of the followings: or more of the followings:

11. Mottled heterogeneous . Mottled heterogeneous myometrialmyometrial texture: All texture: All

cases.cases.

2.2. Globular uterus: Globular uterus: 9595% of cases.% of cases.

3.3. Small Small myometrialmyometrial lucent areas: lucent areas: 8282%. %.

4.4. “Shaggy” indistinct endometrial strips: “Shaggy” indistinct endometrial strips: 8282%.%.

The most predictive:The most predictive:

illill--defined heterogeneous defined heterogeneous echotextureechotexture within the within the myometriummyometrium ((BrosenBrosen et al, et al, 20042004))

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Enlarged uterus in a 53-year-old woman with abnormal bleeding.

The uterus is enlarged slightly and heterogeneous in echotexture

but has no focal masses. Histologic examination revealed

adenomyosis.

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adenomyiosisadenomyiosis

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B. Endometrium

Endometrial hyperplasia

Thickened endomerium in postmenopause

< 5 mm is rarely associated with endometrial cancer

Women with endometrial cancer had endometrial

thickness of >8 mm

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Endometrial thickness

LS at the maximum thickness.

Proliferative phase (4-8 mm),

Secretory phase (8-15 mm), Postmenopausal (4-5 mm),

Clomid,

Tamoxifin,

ART

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Normal endometrium. (B) Secretory phase endometrium

that is thick and echogenic with posterior acoustic

enhancement . Aboubakr Elnashar

Transvaginal view of the uterus in a postmenopausal

woman. The endometrium is a thin linear

hyperechoic band (calipers). This patient also has

prominent arcuate vessels (curved arrows). Aboubakr Elnashar

Retroflexed uterus in a woman with intermenstrual bleeding. (B)

Transvaginal examination shows a thickened endometrium that

measures 18 mm (calipers) with a focal area of increased

echogenicity (arrows), which was a polyp. Transvaginal

examination is necessary to completely evaluate the uterus in

patients with retroverted or retroflexed uterus and to evaluate the

endometrium in women with abnormal bleeding . Aboubakr Elnashar

Concurrent lesions: granulosa cell tumor with endometrial

hyperplasia. (A) Thickened endometrium (15 mm) with a small

cyst. The histologic type was endometrial hyperplasia, probably

secondary to the estrogenic effect of the granulosa cell tumor

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Concurrent lesions: granulosa cell tumor with

endometrial hyperplasia. (B). Aboubakr Elnashar

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Endometrial Endometrial carcinomacarcinoma

U/S is not a primary diagnostic modalityU/S is not a primary diagnostic modality

Postmenopausal bleeding with uterine enlargement & Postmenopausal bleeding with uterine enlargement & hypoechoichypoechoic & non& non--homogenous texture is highly suggestive homogenous texture is highly suggestive of malignancy.of malignancy.

Depth of invasionDepth of invasion

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Uterine sarcoma. (A) Transabdominal view of the uterus in a

woman with a recent myomectomy demonstrates an enlarged

uterus with a bizarre appearance to the myometrium with multiple

cystic spaces. Aboubakr Elnashar

Endometrial Endometrial

adenocarcinomaadenocarcinoma

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Concurrent lesions: a 90-year-old woman with endometrial

cancer and ovarian cancer.

(A) Transabdominal view of the uterus demonstrates ill-

definition of the endometrium with invasion of the

endometrium into the myometrium.

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C. CavityC. Cavity

AshermanAsherman syndromesyndrome

Irregular reflective foci of the uterine cavityIrregular reflective foci of the uterine cavity

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IU adhesionsIU adhesions

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Endometrial polyps

Persistent hyperechogenic areas with variable cystic

spaces. They distort the cavity contour. Best seen in

midcycle &not seen clearly in the midluteal phase or

in stimulated cycles.

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Endometrial polypEndometrial polyp

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IUCD IUCD localizationlocalization

ExtrauterineExtrauterine IUCD is difficult to be localizedIUCD is difficult to be localized

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Intrauterine contraception devices (IUDs). (B)

Lippes loop IUD . Aboubakr Elnashar

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Intrauterine contraception devices (IUDs). (A) Straight

shaft IUD.

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Uterine calcifications. (B) Punctuate calcifications at

the endometrial myometrial interface in a patient

with two prior dilatation and curettage procedures.

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HydrometraHydrometra, , haematometrahaematometra & & pyometrapyometra

Anechoic area filling the uterine cavityAnechoic area filling the uterine cavity

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HaematometraHaematometra

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Hematometra. Sagittal view of the uterus in a 63-year-

old asymptomatic woman placed on cyclic hormonal

replacement therapy demonstrates a large endometrial

fluid collection with a thin surrounding endometrium. She

subsequently underwent surgical dilation for cervical

stenosis. Aboubakr Elnashar

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Uterine calcifications. (A) Transvaginal transverse view of the

uterus in a postmenopausal woman with abnormal bleeding

demonstrates a well-defined echogenic focus with shadowing

secondary to a calcified fibroid. Adjacent to this area is a fluid

collection in a region of thickened endometrium (arrows). This was

endometrial hyperplasia.

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Abnormal cervix

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Cervical masses. (A) Sagittal view of the cervix

demonstrates a large cervical fibroid which deviates the

lower uterine segment anteriorly.

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Cervical masses. (B) Transvaginal view of the cervix

demonstrates an ill-defined relatively isoechoic mass (M) in

this patient with cervical cancer.

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Thank you

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