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The Normal Uterus
Khaled Sakhel and Alfred Z. Abuhamad
8
U t e r u s
The uterus is a muscular organ whose purpose is
to provide the implantation site and nutrients to
the developing fetus. It is located in the true pelvis and lies between the urinary bladder anteriorly and the rectosigmoid colon posteriorly. The
space between the uterus and the rectosigmoid is
the posterior cul-de-sac which is the most dependent area in the peritoneal cavity and where fl uid
tends to accumulate.
There are three main anatomic components of
the uterus which are the upper part or fundus that
lies superior to the fallopian tube ostia, the main
body or corpus, and the cervix. The lower segment of the corpus is sometimes termed the isthmus. The corpus is made up of the muscular
myometrium and the endometrium. The endometrium is hormonally responsive and undergoes
changes in response to ovarian hormones during
a menstrual cycle. These changes prepare for the
implantation of the fertilized ovum. The myometrium does not undergo signifi cant anatomic
changes in response to the menstrual cycle.
K. Sakhel , MD, FACOG, FACS (*)
Division of Minimally Invasive and Robotic Surgery ,
Eastern Virginia Medical School , 825 Fairfax Ave,
Suite 310 , Norfolk , VA 23507 , USA
e-mail: sakhelk@evms.edu
A. Z. Abuhamad , MD
Department of Obstetrics and Gynecology,
Eastern Virginia Medical School,
825 Fairfax Ave, Suite 310, Norfolk,
VA 23507, USA
This chapter discusses and illustrates the
sonography of a normal uterus including the uterine myometrium, endometrium and cervix. It
also highlights the changes that occur during a
normal menstrual cycle.
The uterus can be evaluated by transabdominal (transvesical) sonography (TAS) and transvaginal sonography (TVS). Two other techniques
including the transrectal and translabial approach
are seldom used and are usually reserved in
patients where neither TAS nor TVS is feasible.
The advantage of TAS is the ability to assess
the upper pelvis especially in patients with larger
uteri that are greater than 12 weeks in size.
Disadvantages of the TAS approach include the
requirement of a full bladder and a limited image
resolution especially in patients with a higher
body mass index (BMI) as well as in patients
with lower abdominal scars from prior surgery.
The TVS approach is clearly superior in imaging quality due to the use of higher-frequency
probes and is by far the most commonly used
method for imaging of the pelvis. It is limited,
however, by depth of penetration of the transvaginal ultrasound probe and therefore can only assess
structures in the true pelvis which is adequate in
most cases. For TVS the patient is asked to empty
her bladder and lie supine in the lithotomy position with the legs fl exed. The uterus can be evaluated using the traditional 2-dimensional (2-D)
probe which portrays the image in the sagittal and
transverse planes. It can also be evaluated using a
3-dimensional (3-D) probe which can portray a
reconstructed coronal image of the uterus [
1 ].
L.A. Stadtmauer, I. Tur-Kaspa (eds.), Ultrasound Imaging in Reproductive Medicine,
DOI 10.1007/978-1-4614-9182-8_8, © Springer Science+Business Media New York 2014
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K. Sakhel and A.Z. Abuhamad
Fig. 8.1 Midsagittal plane showing an immediate postmenstrual cycle thin endometrium (type A) with an anteverted uterus
Fig. 8.2 Midtransverse plane of the uterus
The American Institute for Ultrasound
in Medicine (AIUM) has put forth practice
guidelines for the “Performance of Pelvic
Ultrasound Examinations,” “Ultrasonography
in Reproductive Medicine,” and “Focused
Reproductive Endocrinology and Infertility
Scan.” These are helpful in establishing indications and reporting requirements [ 2 – 4 ].
Sonography of the uterus includes examination for size, shape, contour, orientation, and
appearance of the myometrium, endometrium,
and cervix. Unless the fallopian tubes are distended with fl uid, they are not usually apparent
during routine pelvic sonography. In addition the
cul-de-sac is routinely evaluated for scar tissue,
fl uid, and masses [ 2 – 4 ].
The uterus is fi rst imaged in its long axis on
the midsagittal plane which is obtained by optimizing the long axis of the echogenic endometrium. The midsagittal plane allows the
visualization of a cross section of the myometrium, endometrium, cervix, cul-de-sac, rectum,
and bladder (Fig. 8.1 ). In this plane, the angle
between the cervix and uterus can be measured.
The midtransverse plane is perpendicular to the
midsagittal plane and can be obtained by rotating
the probe 90° clockwise or counterclockwise. It
allows visualization of a cross section of the uterine structures at different levels from fundus to
outer cervical os (Fig. 8.2 ). The 3-D ultrasound
probe, when available, can acquire a volume of
the uterus, and the software will use the data to
generate and display a coronal image (Fig. 8.3 ).
The coronal plane is that plane that bisects the
uterus parallel to the plane of the ultrasound bed
and the supine body. This has been shown to be
especially helpful in detecting Mullerian anomalies and for IUD localization [ 1 ]. The Z technique
is a simple technique that describes the steps
required for the display of the mid-coronal plane
out of a 3-D volume of the uterus [ 5 ].
Measurements of the uterus include the
length, height, and width. The length and height
are measured in the midsagittal plane, whereas
the width is measured in the transverse plane
[ 6 , 7 ]. The length is measured from outer sero-
sal surface of the fundus to the external os of
the cervix. If volume assessment of the uterus
is required, then the cervical length should be
excluded from the height measurement. Uterine
volume may be calculated using the formula: volume = length × width × height × 0.52. The length
of a normal nulliparous uterus is 6–8.5 cm, and in
multiparous women, it is 8–10.5 cm. The height
is measured from anterior to posterior serosal
surfaces and perpendicular to the long axis of the
uterus. The height of the normal uterus in nulliparous women is 2–4 cm, and in multiparous
women, it is 4–6 cm. The width of the corpus is
taken at the widest region of the uterus on a transverse plane. The width of a nulliparous uterus is
3–5 and 4–6 cm in multiparous women.
The orientation of the uterus is described in
the anteroposterior and right-left dimensions
in relation to the supine body. The orientation is
8 The Normal Uterus
95
Fig. 8.3 The three orthogonal planes sagittal, transverse, and coronal planes as well as the rendered image. The coronal
image also portrays the hypoechoic junctional zone of the myometrium
noted once the optimum midsagittal image is
obtained using the echogenic endometrium for
guidance. The direction of the ultrasound probe
can provide the right to left orientation. The orientation in the anteroposterior dimension is
described in terms of version and fl exion which
require image processing. The uterus is said to be
fl exed or angled across the isthmus when there is
an angle between the cervix and the corpus of the
uterus (Fig. 8.4 ). The anterofl exed and retro-
fl exed uteri can pose a challenge to procedures
Fig. 8.4 Anterofl exed uterus with the traced line showing
the sharp angle between the cervix and the endometrial cavity
that require access to the endometrial cavity. If
there is no angulation between the cervix and the
corpus, the uterus is described in terms of version
Myometrium
(Figs. 8.1 and 8.5 ). It is important to describe and
report the orientation of the uterus as part of the
ultrasound examination. This information is
helpful if uterine instrumentation is required.
The uterine myometrium is made of a homogeneous layer of smooth muscle and blood vessels.
The uterine arteries reach the uterus at the level
96
K. Sakhel and A.Z. Abuhamad
Fig. 8.6 Trilaminar endometrium (type B) under the
Fig. 8.5 Retroverted uterus with minimal angulation
between the cervix and the endometrial cavity
infl uence of increasing estradiol in the early proliferative
phase
of the cardinal ligaments and divide into ascending and descending branches that travel within
the layers of the broad ligament along the lateral
wall. Sonographically the normal myometrium
has a medium echogenicity, less than the endometrium, with a granular echotexture. The myometrium can be divided into three layers. The
inner or junctional myometrium, which abuts the
endometrium, is thin and hypoechoic compared
to the thicker homogeneous middle layer
(Fig. 8.3 ) [ 7 , 8 ]. Thickening of this layer has been
shown to be associated with adenomyosis [ 9 ].
The arcuate vessels separate the middle and outer
layer which is also thin and slightly less echogenic than the middle layer. The myometrium
does not appear to change sonographically during the course of the menstrual cycle.
Endometrium
The uterine endometrium is the site of dynamic
changes in response to ovarian hormones during
the menstrual cycle. It can be divided into the
inner functional layer that sloughs during menses
and the outer basal layer which abuts the myometrial junctional layer. The changes that occur during the menstrual cycle can be seen
sonographically [ 7 , 8 , 10 – 17 ].
The immediate postmenstrual endometrium is
a thin echogenic line (type A) at the intersection
of anterior and posterior uterine walls and normally measures 3–8 mm (Fig. 8.1 ). Assessing the
endometrial thickness in patients presenting with
postmenopausal bleeding is an important step in
the overall evaluation process. It is important to
know that a thin endometrium in that setting,
typically at less than 5 mm, has been correlated in
multiple studies with the absence of endometrial
cancer. When measuring endometrial thickness
on ultrasound, it is critical to ensure that the
uterus is in a midsagittal plane, the whole endometrial stripe is seen from the fundus to the endocervix, the thickest portion is measured, and the
image is clear and magnifi ed.
Under the infl uence of increasing estradiol
hormone levels secreted by the growing ovarian
follicles, endometrial proliferation occurs.
Sonographically this is seen as thickening of the
lining into the so-called trilaminar layer (type B)
with an anterior and posterior hypoechoic layer
separated in the midline by a hyperechogenic central line (Fig. 8.6 ). During the late proliferative
period and near the time of ovulation, endometrial
lining is 8–12 mm in thickness with an accentuated trilaminar appearance (type C, Fig. 8.7 ).
The post-ovulatory endometrial lining, under
the infl uence of progesterone hormone secreted
by the corpus luteum, is characterized by loss of
the trilaminar appearance and the development of
a uniformly hyperechoic stripe (type D, Fig. 8.8 ).
The implantation, pregnancy, and live birth
rates following in vitro fertilization (IVF) are
affected by the midcycle endometrial thickness
[ 14 , 18 – 23 ]. Studies have shown that a midcy-
cle endometrial thickness less than 8 mm was
associated with poor IVF outcome as compared
to at least 9 mm thickness. There is confl icting
8 The Normal Uterus
97
Fig. 8.7 Late proliferative phase endometrium with an
accentuated trilaminar pattern (type C)
Fig. 8.8 Luteal phase endometrium showing a homogenously thickened hyperechoic stripe (type D)
evidence as to the detrimental effect of increased
endometrial thickness beyond 12 mm. Cases of
successful pregnancies in patients with endometrial thickness as low as 4 mm have also been
reported [ 24 ].
Cervix
The cervix can be divided into the portio vaginalis or ectocervix, the endocervix, and the endocervical canal. It is amenable to imaging using
TAS, TVS, and translabial sonography.
Clinically the presence of endocervical mucus
has been used in the assessment of the presence
of increasing estradiol levels and the lead follicle.
Scoring methods of the cervical mucus including
the Insler and Moghissi that looked at the amount,
consistency, Spinnbarkeit, and ferning were
introduced [ 25 , 26 ]. However, these often needed
Fig. 8.9 Cervix with nabothian cysts ( thin arrows ) and
blood ( thick arrows ) during menses
to be performed repeatedly which is not practical
and uncomfortable for the patient. Ultrasound
assessment of the cervix, in conjunction with the
pelvic sonography being performed, has been
introduced to look at the changes associated with
the menstrual cycle [ 27 ].
Sonographically the cervical stroma is usually of the same consistency as the myometrium. The endocervical canal is normally
spindle shaped and begins at the bottle neck
where the endometrium tapers off. The presence of anechoic pockets within the cervix represents nabothian cysts and is a normal fi nding.
The cervical stroma is not affected by the hormonal changes. The changes are limited to the
endocervix and the appearance of cervical
mucus. The endocervix during menses is noted
to contain complex fl uid with blood and mucus
(Fig. 8.9 ). After the cessation of menses, the
endocervix is noted to be thin and relatively
hypoechogenic (Fig. 8.10 ). The endocervix is
noted to increase in echodensity starting on
cycle day 7 or when the leading follicle is
11 mm, endometrial thickness of 5.8 mm, and
estradiol levels of around 289 pmol/l (Fig. 8.11 ).
In addition, cervical mucus can be observed
within the endocervical canal as of cycle day
13, or when the lead follicle is 16.8 mm, endometrial thickness 7.5 mm, or estradiol level
exceeds 500 pmol/l (Fig. 8.12 ) [ 27 ].
98
K. Sakhel and A.Z. Abuhamad
Fig. 8.10 Cervix in early proliferative phase after menses showing a thin endocervix
Fig. 8.11 Cervix in mid-proliferative phase showing a
thicker and hyperechoic endocervix and presence of nabothian cysts
Fig. 8.12 Cervix at day 13 of cycle showing mucus in
the endocervix under the effect of increasing estradiol
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