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Ultrasonography of the uterus
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Ultrasonography of the uterus
Benha university, Egypt Aboubakr Elnashar
Normal uterusNormal uterus
Aboubakr Elnashar
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
Aboubakr Elnashar
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
Aboubakr Elnashar
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.
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. 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 ¬ 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
Aboubakr Elnashar
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
Aboubakr Elnashar
