Describes ultrasound appearance of uterus through different ages, basic transvaginal ultrasound and ultrasound of the cervix. It talks of how to do transvaginal ultrasound.

1. The Uterus
and Cervix
(Part 1)
Durr-e-Sabih

2. Its not only the size
that is different in the
infant and child

3. Uterine Ratios Change With Age

4. Uterine Ratios Change With Age
Int os
2/3
1/3
1/2
1/2
1/3
2/3

5. Neonatal Uterus
• Neonatal uterus is prominent and measures
3.5 cm in length
• Cervix is dominant and fundus:cervix
length ratio is 1:2 (<1). In women of
childbearing age, the FCR should be >1.0
• Has a bright endometrial lining

6. Neonatal Uterus
• Neonatal uterus is prominent and measures
3.5 cm in length
• Cervix is dominant and fundus:cervix
length ratio is 1:2
• Has a bright endometrial
lining

7. Infant Uterus
• By 3 months uterus regresses, becomes
tubular
• Length is 2.5 – 3cm, fundus:cervix ratio 1:1
• Endometrial echoes not visible

8. Prepubertal Uterus

9. Pubertal Uterus
• Length increases to 5-7cm
• Adult shape, fundus to cervix ratio is 3:1

10. Adult Uterus
• 8 (L) x 5 (W) x 4 (D) cm, multiparity
increases all measurements by 1 cm

11. Adult Uterus
• 8 (L) x 5 (W) x 4 (D) cm, multiparity
increases all measurements by 1 cm
© Gunjan Puri, Surat

12. Menopausal Uterus
• Atrophy, the corpus atrophies more than the
cervix
• 3.5 – 6.5 cm (L) x 1.2 – 1.8cm (D)
• Endometrium becomes thin (< 8mm)

13. Uterus
• Neonatal 3.5 cm
• Infant 2.5 – 3.0 cm
• 2 – 7 years 3.3 – 4.0 cm
• 10 years 4.0 – 5.2 cm
• 13 years 5.4 – 7.6 cm
• Nullparous adult 8.0 – 9.0 cm
• Multiparous adult 11.0 - 12.0 cm
• Post menopausal 5.0 – 12.0 cm

14. Adult Uterus
• 8 (L) x 5 (W) x 4 (D) cm, multiparity
increases all measurements by 1 cm
© Gunjan Puri, Surat

15. Examining the Uterus
• Trans-abdominally
• Trans-vaginally
• Trans-perinially
• Trans-rectally

16. Transabdominal scans

17. Transabdominal scans
Empty bladder artifact

18. Change probe

19. Common Uterine Position
• Anteverted and anteflexed

20. Common Uterine Position
• Anteverted and anteflexed
Version is the angle between the cervix and
the vagina. Flexion is the angle between the
cervix and the body of the uterus. Seen
trans-abdominally with an
empty bladder.

21. Flexion
Version
Anteverted, Anteflexed Uterus

23. Anteverted, Retroflexed

24. Anteverted retroflexed

25. Uterine Positions

26. Uterine Shapes
Straight uterus
Cochleate

27. Cochliate

28. Cochliate

29. Myometrium
• Homogenous medium density
• Smooth contours
• Anterior wall as thick as posterior wall

31. Myometrium
• Three layers recognizable on US
• Inner hypoechoic zone, subendometrial halo
• Intermediate myometrial layer
• Subserosal layer (variable echogenicity)
• Arcuate vessels run
between intermediate
and subserosal layers

32. Layers

33. Uterine Vessels
• Uterine arteries, from the internal iliac
• Run along the sides of the uterus, joins
branches from the ovarian artery
• Branches dip into the uterine substance and
form the “arcuate” arcade
• These give off radial and spiral arteries that
move inwards to the endometrium

34. Uterine Arteries
Uterine
Arcuate
Radial

35. Arcuate vessels

36. Calcification of arcuate arteries

37. TVS

38. TVS
• Unless the patient has never been sexually
active, the few indications for doing a
gynecological ultrasound transabdominally
(with a full bladder) include lesions that are
above the level of the fundus or too much to
the side

39. There can be no serious pelvic
ultrasound without TVS

41. TAUS vs. TVS
Transabdominal Transvaginal
Field size Large Limited
Flexibility Can examine any
part of the
abdomen with the
same setup
Must use dedicated transducer, setup only good for
looking at pelvis
Acceptability,
invasiveness
Non-invasive Some might consider this as invasive and
uncomfortable, even painful
Not indicated for paediatric patients or those who
are sexually inactive
Privacy concerns
Communication with patient essential
Preparation Full bladder Empty bladder
Resolution Standard High resolution
Essential for early diagnosis of progressive
conditions like early pregnancy and ectopic

42. Doing TVS
• Sterilize the probe according to manufacturers
recommendations
• Cover the probe with a sterile cover (condom?)
o Gel inside and outside the probe cover/condom
• Insert the probe into vagina, pointer vertical, aim
for the posterior fornix
• Rotate the probe 90o for coronal sections
• Move and rotate the probe laterally for adnexa
• Withdraw the probe for cervix
• Add 3D for endometrial lesions

43. TVS

44. TVS (probe at the top)
Rotates 90o counter clockwise

45. TVS
Rotates 90o counter clockwise

46. TVS
Rotates 90o counter clockwise

47. TVS
Rotates 90o counter clockwise

48. TVS
Rotates 90o counter clockwise

49. Retroflexed
© Allan J Worral

50. Things to See
• Size, shape and position
• Myometrium
• Cervix
• Endometrium
• Vascular structures

51. The cervix
• The cervical lips
• The fornices
• The cervical canal
• The cervical length cannot be accurately
assessed in the nonpregnant uterus because
the internal os is not visible

52. Cervix

53. Cervical cancer
• Comparable to MRI for diagnosing and
staging cervical cancer (Sensitivity 80%,
specificity 50% and diagnostic accuracy of
50%)
• For parametrial invasion, ultrasound is more
sensitive than MR (86%, 40%)
Moloney F, Ryan D, Twomey M, et al. Comparison of MRI and high-resolution transvaginal sonography for the local
staging of cervical cancer. Journal of Clinical Ultrasound. [online ahead of print]. 2015. DOI: 10.1002/jcu.22288.

54. To look at the cervix
• Withdraw the probe

55. Cervical
Masses

56. Post hysterectomy cervical stump

57. Cervical
tear

58. Prolapsing masses

59. Nabotian cysts
• Associated with chronic cervicitis and represent mucinous
cysts due to obstruction from overgrowth of squamous
epithelium.
• Few millimetres to up to 4 cm.
• Tunnel cluster: a special type of Nabothian cyst, is
characterised by complex multicystic dilatation of the
endocervical glands

60. Nabothian Cysts

61. Nabothian Cysts

62. End of part 1