Good to know

1. Basic Training
ISUOG Basic Training
Examining the Uterus, Cervix, Ovaries &
Adnexae: Normal Findings

2. Basic Training
Learning objective
At the end of the lecture you will be able to:
• Recognise the typical ultrasound appearances
of a normal gynaecological ultrasound
examination

3. Basic Training
Key questions
• What is the correct scanning technique to image
the cervix, uterus and ovaries effectively?
• What are the principal ultrasound features of:
– The normal cervix
– The normal uterus
– The normal ovary/adnexae
• How do I recognise a correctly positioned IUD?

4. Basic Training
Abdominal gynecological ultrasound
examination- orientation
Patient´s right side
On a transverse scan patient´s right side is shown to the left on screen
Patient´s left side

5. Basic Training
Abdominal gynecological ultrasound
examination- orientation
Cranial
(patient´s head)
On a longitudinal scan cranial is shown to the left on the screen
Caudal
(patient´s feet)

6. Basic Training
Vaginal gynecological ultrasound
examination- orientation
Patient´s right
Patient´s right

7. Basic Training
Uterus in anteversion (& slight anteflexion)
Bladder
Rectum
Bladder
Rectum
Bladder
Rectum
Bladder
Rectum

8. Basic Training
Vaginal or abdominal scan?
Abdominal scan
• Low frequency
• Poor resolution
• Good overview
• Scan the abdomen
• Full bladder
Vaginal (rectal) scan
• High frequency
• Superb resolution
• Poor overview
• Abdomen not seen
• Empty bladder

9. Basic Training
Gynecological ultrasound
Examination technique
Systematic examination technique
ALWAYS THE SAME PROCEDURE

10. Basic Training
Vaginal scan

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17. Basic Training
Finding the ovaries

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23. Basic Training
Normal tubes may be seen if there is fluid
in the pouch of Douglas

24. Basic Training
Urinary Bladder

25. Basic Training
Vaginal ultrasound is a
dynamic and interactive examination
• Check the mobility of organs
– Fixed organs = adhesions
• Check for site specific tenderness
– Which organs are involved in a painful process?

26. Basic Training
Abdominal scan

27. Basic Training
Abdominal scan
YES, if primary scan
(NO), if supplementary
scan
Full bladder?

28. Basic Training
Gynecological ultrasound
Examination technique
Systematic examination technique
ALWAYS THE SAME PROCEDURE

29. Basic Training
Abdominal ultrasound
Sagittal scan of the uterus

30. Basic Training
Abdominal scan
Transverse scan through the uterus

31. Basic Training
Abdominal scan
- finding the ovaries

32. Basic Training
Normal ultrasound findings
• Differ between women before and after
menopause
• Change throughout the menstrual cycle

33. Basic Training
Normal myometrium before
menopause

34. Basic Training
The endometrium changes
throughout the menstrual cycle
Shortly after
menstruation
Proliferative phase Proliferative phase Secretory phase

35. Basic Training
Changes during menstrual cycle
Shortly after
menstruation
Proliferative phase
3 days before ovulation
Proliferative phase
1 day before ovulation
Secretory phase
6 days after ovulation

36. Basic Training
A corpus luteum may look different

37. Basic Training
Some fluid in the pouch of Douglas is
NORMAL before menopause

38. Basic Training
How big is a normal ovary
in a woman of fertile age?
Very variable
• Median 7 ml
• Range 2-17 ml
• (Range 1-20 ml)
Jokubkiene et al 2012
303 women 20-39 years old with regular menstrual cycles, cd 4-8

39. Basic Training
What is a normal number of antral follicles
before menopause?
Text books
6-7 follicles/ovary
Jokubkiene et al
Median 11 follicles (2-10 mm)
/ovary
Range 1-36
10th-90th percentile 4-20
57% had
>12 follicles/ovary, i.e. PCO*
*PCO : > 12 follicles/ovary
or ovary > 10 ml (Rotterdam)

40. Basic Training
Correct position of copper IUD

41. Basic Training
Correct position of gestagen IUD

42. Basic Training
Correct position of gestagen IUD

43. Basic Training
Incorrect position of IUD
Too low Too low

44. Basic Training
Three-dimensional (3D)ultrasound

45. Basic Training
Incorrect position of IUD

46. Basic Training
Normal ultrasound findings
in postmenopausal women
Uterus with calcifications

47. Basic Training
The endometrium in postmenopausal women
Uterus
Median endometrial thickness 3 mm
10th and 90th percentile: 2 – 5 mm
Endometrium >5 mm is
NOT necessarily pathological

48. Basic Training
Normal ultrasound findings
in postmenopausal women
Ovary Ovary with ”cyst”

49. Basic Training
How big is a normal ovary
in a postmenopausal woman?
• Median 1x1x2 cm
• Median volume 1
ml
– range: 0.4 - 4 ml
Sladkevicius et al 1995
144 asymtpomatic postmenopausal women 45 to 64 years old

50. Basic Training
Key points
THE BASIS for gynecological ultrasound
• Orientate yourself in the image
• Optimize your image
• Always use a systematic scanning technique
− From here you move on by practising, reading books and articles,
and attending more advanced ultrasound courses

51. Basic Training
Argument for showing vaginal longitudinal scans
with footprint down and bladder to the right
Bladde
r
Rectum

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BASIC TRAINING
Basic Training
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