by Michael Applebaum, MD, JD, FCLM

The following is a revised version of a book chapter that appeared in the text: Doppler Ultrasound in Obstetrics and Gynecology, edited by Drs. Kathy Reed and Josh Copel. It was written primarily for physicians. It is not an easy, casual read for the lay person. However, it can be a worthwhile read.

I have chosen to include the sections on ultrasound scan technique for the health care professionals reading this. If you are a woman and have reached your menopause or who is undergoing the "change of life", you may find this section and some of the other more technical sections valuable. This information may help you become a more critical consumer of health services.

The numbers in parentheses refer to the references which appear at the end. There are no individual hyperlinks to the references.

TIP! -- If you hyperlink to another section of the book to benefit from the hypertext features, click the "BACK" button of your browser to return to your previous location.

REMEMBER! -- This booklet is not a substitute for medical advice from your physician. Always consult directly with your physician regarding any and all issues/questions you may have about your treatment.


Table of Contents

Examination Technique

Bladder Filling
Probe Pressure

The Ovaries
The Uterus


 First a personal note. Few diseases are as evil as cancer. And among the cancers, perhaps none is as evil as ovarian cancer. It is the number one gynecologic malignancy responsible for killing women. It is usually silent until it is too late to effectively treat. Early ovarian cancer detection is both a medical and political hot potato. Medically, there is no agreement by all authorities as to how to diagnose this disease early. Politically, most "screening" procedures are considered too expensive to subsidize. As with other diseases similarly situated, the end result is the death of some who may have been saved. Personally, I believe that a properly performed ultrasound examination to search for early ovarian cancer is the best test currently available (I also believe that most gynecologic ultrasounds are not properly performed). Others feel differently. Read on. Hopefully portions of this material will guide you in asking some important questions about your health.

For a woman past her reproductive years, changes in the sonographic appearance of the pelvic organs still occurs, albeit, more slowly and less dramatically than in the pre-menopausal woman.



Sonographic examination of the female pelvic organs is most commonly performed using two different approaches. The first and older, is transabdominal, the second and more recent, is transvaginal. (1,2,3) A third method, transperineal, is also employed, though less frequently. (4,5,6) A thorough ultrasound examination of the pelvis should include both complete transabdominal and transvaginal studies, unless either limited information is needed (e.g., follicle size) or extenuating circumstances dictate otherwise (e.g., patient refusal). The techniques are complementary, not mutually exclusive. The person performing the ultrasound examination can vary certain parameters to optimize the quality of the study. These include: bladder distention, manual manipulation of the anatomy and patient positioning.

BLADDER FILLING -- Transabdominal ultrasound of the female pelvis should be performed with the bladder optimally distended. The operative phrase is "optimally distended". If too full, the patient may experience excessive discomfort, which might result in guarding. Also, the overdistended bladder may push the target structures so far from the transducer that image quality suffers. Optimal distention of the bladder can be achieved by having the patient void incrementally. If too empty, near-field artifacting and overlying bowel gas may degrade image quality. Optimal distention of the bladder can be achieved either by waiting for the bladder to fill more completely or having the patient ingest additional fluid and then waiting.

Unequivocally, there are occasions in which the empty bladder transabdominal examination may yield better results than either the transvaginal or filled bladder approaches. This is particularly true when relatively large, especially fundal, fibroids are present.

Transvaginal (or endovaginal) ultrasound is generally performed with the bladder empty. The operative phrase is "generally performed". If too full, the patient may experience excessive discomfort. Also, the distended bladder may push the target structures so far from the transducer that image quality suffers. Optimal distention of the bladder may be achieved by having the patient void, perhaps incrementally.

Unequivocally, there are occasions in which the transvaginal examination may yield better results with a filled or filling bladder than with an empty bladder. If a structure of interest is either not apparent or is suboptimally seen, patience and bladder filling may result in better visualization.

MANIPULATION -- Manual manipulation of the anatomy using the transducer and/or the non-examining free hand can significantly improve the quality of the study. All manipulations are performed to move target structures into more favorable scanning circumstances (e.g., location). When employing a two-handed technique, one hand is placed generally between the pubis and umbilicus to shift the pelvic and abdominal structures while the other is maneuvering the transducer.

PROBE PRESSURE -- When using any technique, more or less pressure may be placed on the probe. This maneuver improves image quality in a manner similar to manually manipulating the anatomy and, possibly, by compressing the tissue between the transducer and the target structure.

POSITIONING -- Proper patient positioning can also improve examination quality. When performing endovaginal ultrasounds, elevating the patient's hips or placing the patient at the end of the examining table facilitates greater downward excursion of the probe handle. Occasionally, placing the patient's leg on the examiner's shoulder allows for increased lateral range of motion of the transducer. Further, some findings are more apparent when the examination is performed with the patient placed in a position similar to the one employed during a proctoscopy or colonoscopy. To assist in characterizing findings, having the patient move or roll from side-to-side may demonstrate motion in structures which would otherwise appear static (e.g., swirling within endometriomas. Endovaginally, palpation with the probe may produce similar results.). Moving the patient can also place target structures in more accessible locations.

In conclusion, after positioning the patient properly, the technique of the ultrasound study can be remembered by the following mnemonic: KID CAN, where:

K = Know what you expect to see based upon the patient's clinical history and presentation prior to the exam

I = Incremental bladder voiding, to achieve...

D = optimal bladder Distention


C = Compression, with the non-scanning hand and/or the transducer

A = Angulation of the transducer to place target objects an optimal distance from the transducer and use favorable superficial structures as acoustic "windows"

N = be Nice to the patient. A relaxed patient is much easier to examine than a tense patient.





The ovaries are generally situated on either side of the uterus, although locations superior or posterior to the uterus are not uncommon. In addition to the techniques described above, if one has difficulty finding the ovaries, a search along the internal iliac artery may prove useful. The ovary is often located anterior to the vascular bifurcation into anterior and posterior branches. (7,8) Successful visualization of the ovaries varies among investigators and also depends upon patient age. (9, 10)

During the POST-MENOPAUSAL years of a normal female, the ovaries undergo changes characterized by diminution in size and decreased to absent folliculogenesis. (31). In fact, the reliable identification of an ovary can often no longer be made by demonstrating follicle cysts surrounded by ovarian parenchyma. One occasionally must resort to scanning along the route of the internal iliac vessels to discover its location. (7, 8) Gray-scale examination generally reveals an inverse relationship between ovarian size and the time since menopause: ovarian size progressively decreases as the duration of the post-menopausal period increases. (9, 10, 31) However, patients receiving hormone replacement therapy may demonstrate no changes in ovarian volume. (31) Reliable identification of the post-menopausal ovary may be noted in only 20% of patients, although some claim better results, even approaching 100%. (32, 33, 34, 35, 36, 37)

Just how big is a post-menopausal ovary? Apparently, it depends on the investigator. According to Schoenfeld et al, the mean ovarian volume (calculated as [length x width x height] / 2) in normal post-menopausal women is 1.3 +/- 0.7 cm3. (34) Aboulghar et al determined the post-menopausal ovarian volume to be 3.4 +/- 1.7 cm3. (38) Goswamy calculated right ovarian volume at 3.58 +/- 1.40 cm3 (range 1.00 - 14.01) and left ovarian volume at 3.57 +/- 1.37 cm3 (range 0.88 - 10.90). (35)

Concomitant with the gray-scale changes seen in post-menopausal women, both color and duplex Doppler changes can be demonstrated.

As there is no menstrual cycle, the sequential changes in blood flow to the ovary seen during the reproductive years are generally not demonstrated in the normal post-menopausal patient.

These cyclical changes, however, may be evident if the patient is on hormone replacement therapy. In fact, a pre-menopausal ovarian blood flow pattern in a post-menopausal patient, should prompt the search for a history of hormone replacement therapy (although there are other differential diagnostic possibilities).

In the post-menopausal patient (as with the pre-menopausal patient), one of the most important uses of ultrasound involves the diagnosis and characterization of adnexal masses.

To diagnose the presence of an adnexal mass, gray-scale ultrasound is of substantial importance. (7, 9, 35, 39, 40) This is especially true as the post-menopausal ovary may not be reliably palpated. (36, 38) In one study, 10% of masses less than 10 cm in size were missed on palpation. (42) Transvaginal sonography is generally more sensitive than transabdominal. (1, 7, 40, 41) Some investigators feel that the absence of an adnexal mass on gray-scale examination may not rule-out the presence of a malignancy, while others presume that it does. (32, 44, 45)

Interestingly, many post-menopausal women (10% - 15%) continue to demonstrate cysts within their ovaries. (10, 40, 46, 47, 48, 49, 50) Ovarian cancers may manifest their presence as post-menopausal cysts. (10, 44, 51, 52, 53) In fact, 80% of ovarian neoplasms occur in women older than 50 years of age and of these as much as 85% - 90% are of a cystic epithelial type. (40, 54, 55) Also, some patients clinically diagnosed as "post-menopausal" are, in reality, peri-menopausal and continue to "cycle", though irregularly. This latter differential diagnostic possibility can generally be confirmed clinically, biochemically or by follow-up ultrasound examination.

For characterizing a discovered mass, gray-scale and Doppler (both duplex and color) ultrasound, may be of significant utility in distinguishing benign from malignant processes. (45, 48, 49, 56, 57, 58)

Gray-scale sonography has been used with varying success to characterize adnexal disease. (45, 59, 60, 61, 62) Findings such as septations, papillary projections and mural nodules are more likely to be associated with malignant changes than are clear cystic masses. (46, 56, 59, 63) Also, size may be important. (31, 34, 40, 42, 50, 59, 64, 65, 66, 67). Rulin and Preston found that masses less than 5.0 cm were unlikely to be malignant. (42) In their series, only one case of a cystic ovarian mass in 32 (3%) was malignant. In a study by Goldstein et al, the results of sonographically detected simple cysts (defined as cysts without internal septations or solid components) of the adnexa, yielded a 0% incidence of malignancy in patients with cysts less than 5.0 cm in maximum diameter. (40) Hall and McCarthy included septated cysts in their definition of "simple cyst." They found an 8% malignancy rate in their series of cysts ranging from 1.5 to 10.0 cm. The malignancy was within a 3.5 cm non-septated cyst. (67)

Some investigators have concluded that both color and duplex Doppler are valuable tools for the diagnosis of ovarian and other malignancies. (44, 51, 53, 68, 69, 70, 71, 72) These conclusions are based upon the unique differences between normal and tumoral vascularity (neovascularity) and the apparent ability of Doppler sonography to distinguish between them. (68, 73)

Tumor vessels are disorganized. The standard hierarchical organization of normal vessels, in which flow progresses from arteries of decreasing size through capillaries to veins of increasing size, is absent. Instead, tumoral flow may be short-circuited through shunts. (30, 70) Also, tumor vessels may possess altered architecture. (74, 75)

Abnormal flow patterns can be demonstrated in vessels surrounding malignant masses. (70, 76, 77) Finding these areas of neovascularity may not be possible on gray-scale examination only. Because color Doppler may make these vessels visible, it allows the examiner to survey the anatomy of the target structure for vascular areas of interest. (78)

There is substantial data to suggest that the flow characteristics of some malignant diseases of the ovary are different from benign processes. (29, 44, 53, 79, 80) In general, a low resistance pattern is unusual in the ovary of a post-menopausal patient, as are low index values, and may be associated with malignancy. (52) False positives do occur. (44) The absence of neovascularity and the presence of a normal index value has been shown to exclude malignancy, while the presence of neovascularity had a high association with malignant change. (51, 81)

When performing a Doppler ultrasound for adnexal masses, it should be performed between days 3-10 of the menstrual cycle in menstruating patients; between days 3-10 in post-menopausal patients on hormone replacement therapy; at anytime in post- menopausal patients not on replacement. (78)



The uterus is located in the lesser pelvis between the urinary bladder and the rectum. Although generally a midline structure, lateral deviations of the uterus are not uncommon. The broad ligaments extend from the uterus laterally to the pelvic side walls. They contain the fallopian tubes and vessels. The uterosacral ligaments serve to keep the uterus in an anterior position. They arise from the upper cervix posteriorly and extend to the fascia over the second and third sacral vertebrae. The round ligaments arise anterior to and below the fallopian tubes and cross the inguinal canal to end in the upper portion of the labia majora. (82)

The normal adult uterus measures approximately 7.0 - 9.0 cm long, 4.5 - 6.0 cm wide and 2.5 - 3.5 cm deep (anteroposterior dimension). (82) Its corpus-to-cervix ratio is 2:1. (82, 83)

During the POST-MENOPAUSAL years of a normal female, the uterus decreases in size and the endometrium atrophies.

As the ovaries undergo involution, there is an associated reduction in the amount of estrogen produced. This leads to the gradual atrophy and involution of the endometrium that characterizes the uterine lining of the post-menopausal patient. (100, 101) In asymptomatic post-menopausal women, the mean endometrial thickness has been determined to be 3.2 +/- 0.7 mm, although other investigators have reached different conclusions. (91, 101, 102, 103, 104, 105, 106, 107)

Gray-scale examination generally reveals an inverse relationship between uterine size and the time since menopause: uterine size and volume progressively as the duration of the post-menopausal period increases. The greatest changes occur within the first ten years after the menopause and more gradually thereafter. (108)

Just how big is the post-menopausal uterus? The post-menopausal uterus has been measured at 8.0 +/- 1.2 cm long by 5.0 +/- 0.8 cm wide by 3.2 +/- 0.7 cm deep (anteroposterior dimension). A significant relationship between parity and both uterine volume and weight was not found. (108) Others have reached different conclusions. (109, 110, 111)

As there is no menstrual cycle, successive changes in blood flow to the uterus are generally not demonstrated. However, some similarities between pre- and post- menopausal women may be present. Kurjak and Zalud compared the Resistance Index values of the uterine arteries in pre- and post- menopausal women. The RI was noted to be higher in the post-menopausal patients, but apparently not statistically different. Diastolic flow was demonstrated in all subjects. (112)

If the patient is on hormone replacement therapy, the above-described findings may not be present. (107) Among these patients, both uterine size and cyclical endometrial changes may remain. Even the corpus-to-cervix ratio approximates the pre-menopausal state. (83) In general, estrogen therapy affects the post-menopausal endometrium similarly to estrogens in the normal cycle. The conjugated estrogens have a proliferative effect. (100) Progestational therapy may cause the endometrium to respond with a quiescent appearance that is characteristic of the normal secretory endometrium. (100) When used together with exogenous estrogens, synthetic progestogens reproduce the characteristic biochemical and morphological changes seen in the secretory phase of the normal menstrual cycle.

Bourne et al have shown altered blood flow to the uterus in patients receiving hormone replacement therapy. (113) Using endovaginal technique, significant arterial changes were demonstrated. The PI was reduced by 50% within 6-10 weeks of initiating therapy. Also, endometrial thickness almost doubled. Before treatment, the mean thickness was 0.37 +/- 0.08 cm. Following treatment, the values were 0.68 +/- 0.13 cm. Others have reported a possible 2-3 mm increase in endometrial thickness in patients receiving estrogen therapy. (105) But some have obtained results different from the above. (107) Their data suggest no statistically significant differences between the endometrial thicknesses of patients taking and patients not taking hormones.

Thus, a pre-menopausal appearing uterus or uterine blood flow pattern in a post-menopausal woman should prompt the search for a history of hormone replacement therapy (although there are other differential diagnostic possibilities). (114, 115)

In the post-menopausal patient, one of the most important uses of ultrasound involves the diagnosis and management of endometrial cancer. In general, endovaginal ultrasound is superior than transabdominal ultrasound for visualization of the myometrium and endometrium. (63, 116) 

Sonographic signs of endometrial cancer in the post-menopausal patient include: an obstructed fluid-filled canal, a thickened uterine cavity, an enlarged uterus and a lobular uterus with a mixed echo pattern. (117) Gray-scale ultrasound has accurately demonstrated the presence and extent of myometrial invasion. Cacciatore et al, using transabdominal technique, found that sonographic staging of endometrial cancer by ultrasound was accurate in 91% of cases and myometrial invasion was correctly identified in 80% of cases. (118) Transvaginally, Cruickshank et al demonstrated good agreement between the ultrasound examination and myometrial invasion as determined microscopically. (119) These investigators suggested that more accurate pre-operative diagnosis may allow for selective therapies, perhaps yielding better results. Granberg et al, using transvaginal technique, demonstrated that with a full-thickness endometrial measurement of 8 mm. or less, in patients with post-menopausal bleeding, no endometrial cancer was discovered by curettage. (101) In general, the data would seem to indicate that a full-thickness post-menopausal endometrium of 10 mm or greater should be further evaluated, either by biopsy or D&C, to exclude either malignancy or hyperplasia. (43, 91, 102, 105, 106, 120, 121) 

Some investigators have demonstrated the utility of Doppler ultrasound in diagnosing endometrial cancer. Bourne et al demonstrated increased blood flow in the uterine artery and the area of the suspected tumor in patients with malignant disease. (114) One group appears to have substantial experience in evaluating pelvic masses and distinguishing benign from malignant disease. (53, 79, 80) It is their conclusion that abnormal blood flow can be identified in virtually all cases of endometrial carcinoma, as well as uterine sarcomas. With color Doppler, the abnormal findings include the presence of irregular, thin and randomly distributed vessels. Abnormal flow velocity waveform patterns have also been described. (71)



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