THE ATROPHIC POSTMENOPAUSAL UTERUS by Edward I. Miller, MD; Roger H. Thomas, MD and Patricia Lines, RDMS
ABSTRACT The size of postmenopausal uterus varies, but after 65 years of age, it routinely appears atrophic. A pelvic mass in this age group should not be assumed to be within the uterus unless a careful search excludes an atrophic uterus. Single sweep longitudinal ultrasound sections are the best method of localizing a small uterus, but sometimes gain settings must be varied to demonstrate the organ.
Indexing Words Ultrasound
Uterus
Uterine Atrophy
Uterine atrophy in the elderly has been a neglected subject in medical writing, particularly in the ultrasound literature. Failure to recognize that the postmenopausal uterus can revert to “infantile” size may lead to the false impression that a pelvic mass is within the uterus rather than in the adnexa when the atrophic uterus is not located or appreciated. References are available with normal uterine sizes and weights in the nulliparous and parous states. The nulliparous uterus ranges from 1.8 to 2.0 cm thick, 3.4 to 5.0 cm wide, and 7.5 to 8.1 cm long (vertical) (1, 2). Measurements in the parous uterus are increased in all dimensions by approximately 1.2 cm (1). The virgin uterine weight varies from 33 to 50 gm,and the parous weight from 50 to 117 gm ( I , 2). Measurements for the postmenopausal uterus are not available. Anderson states, “Following the menopause, there is more or less reverse to the infantile form, although the actual size is variable” (1). Brown states a vertical length of 2.5 to 3.0 cm for the infantile uterus (3). In five cases of postmenopausal females 66 to 89 years of age without intrauterine pathology, we have found a variation of 1.2 to 1.8 cm in uterine thickness and a 3.5 to 6.5 cm variation in length. However, in the more immediate postFrom the Division of Ultrasound, Department of Radiology, Hoag Memorial Hospital Presbyterian, Newport Beach, California. Received July 1 9 , 1 9 7 6 ; revision accepted October 2 9 , 1 9 7 6 . For reprints contact: Edward I. Miller, M.D.. Department of Radiology. Hoag Memorial Hospital Presbyterian. Box Y, 301 Newport Beach, California 92663. VOLUME 5. NUMBER 4
Gynecology
Postmenopausal Uterus
FIGURE 1. Longitudinal midline section in a 66 year old female, demonstrating a small atrophic uterus (arrows) posterior and inferior to the bladder (B). Gain settings were decreased to demonstrate the uterus.
menopausal age group, the uterine s h e would probably be larger. Longitudinal ultrasound projections, using the single sweep technique, have been most helpful 26 1
- *
FIGURE 2. Midline longitudinal section. Atrophic uterus (arrows) surrounded by ascites (A) anterior to the usual location of an atrophic uterus in a 77 year old female with cirrhosis. Bladder = B.
FIGURE 3. Midline longitudinal section. Interposed between the bladder (B) and a mass (MI is an atrophic uterus (arrows) in a 74 year old female. .The linear echogenic area represents the endometrial canal, the surrounding less echogenic area, the thin myocetrium. The mass (MI is a cystadenofibroma.
FIGURE 4A. Transverse section 4 cm above the symphysis. There is a left sided pelvic mass (arrows) posterior to the bladder (B).
FIGURE 48. Oblique view. Bladder = B. The mass (arrows) is contiguous with and extending from the body of the uterus (crossed arrow). The mass was a leiomyoma.
in detecting a small uterus. The uterus is usually creased gain settings may be required as the found at or within 0.5 cm of the midline unless uterus is often hidden among the pelvic tissues the uterus is pushed laterally by a mass. De- posterior and inferior to the bladder. Figure 1 262
JOURNAL O F CLINICAL ULTRASOUND
shows an atrophic uterus in a 66 year old female. It was demonstrated using decreased gain settings and the single sweep technique. This uterus shows a less echogenic pattern than the other atrophic uteri we have seen, presumably because of the gain setting. Regardless of technique, the echogenic pattern in the uterus should be homogeneous except for the endometrial canal. In addition to displacement by masses, anterior displacement due to fluids can be seen. Figure 2 illustrates in a 76 year old female an atrophic uterus floating in ascites caused by cirrhosis. Inability to recognize the atrophic uterus may lead to errors in interpretation. Figure 3 is a 74 year old female who presented with a pelvic mass. The large posterior mass was described, as was an unusual smaller mass with an echogenic center. The smaller mass was situated between the bladder and larger posterior mass. At surgery, the small mass was an atrophic uterus weighing 20 gm, with an endometrial canal (the linear echogenic area) measuring 2.5 .cm in length, surrounded by a 1 mm thick endometrium. The myometrium measured up to 0.75 cm in thickness. The uterus was described by the surgeon “as big as the distal thumb”. The mass posterior to the atrophic uterus is a serous cystadenofibroma. This was the first atrophic uterus we encountered and we failed to recognize it as such.
VOLUME 5. NUMBER 4
A solid mass lateral to the midline (Fig. 4A), particularly in the elderly, may represent a mass involving one margin of the uterus, but it may appear clinically as an adnexd mass if the atrophic uterus cannot be palpated. Oblique views (Fig. 4B) are often valuable in demonstrating a mass arising in an atrophic uterus.
CONCLUSION
The size of postmenopausal uterus varies, but after 65 years of age, it routinely appears atrophic. A pelvic mass in this age group should not be considered to be within the uterus unless a careful search excludes an atrophic uterus. Single-sweep longitudinal ultrasound sections are the best method of localizing a small uterus, but sometimes gain settings must be varied to demonstrate the organ.
a
REFERENCES 1. Hertig AT and Gore H: Female Genitalia. Anderson WAD, ed. Pathology, Sixth Edition. St. Louis, C.V. Mosby Companq 1971, p. 1489. 2. Saphir 0 : Autopsy Diagnosis and Technic, Fourth Edition. New York, Paul B. Hoeber, Inc., 1958. p. 511. 3. Brown R: Diagnostic Ultrasound in Obstetrics and Gynecology. Ultrasonography, St. Louis, Warren H. Green Inc., 1975. p. 69.
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ABSTRACT The size of postmenopausal uterus varies, but after 65 years of age, it routinely appears atrophic. A pelvic mass in this age group should not be assumed to be within the uterus unless a careful search excludes an atrophic uterus. Single sweep longitudinal ultrasound sections are the best method of localizing a small uterus, but sometimes gain settings must be varied to demonstrate the organ.
Indexing Words Ultrasound
Uterus
Uterine Atrophy
Uterine atrophy in the elderly has been a neglected subject in medical writing, particularly in the ultrasound literature. Failure to recognize that the postmenopausal uterus can revert to “infantile” size may lead to the false impression that a pelvic mass is within the uterus rather than in the adnexa when the atrophic uterus is not located or appreciated. References are available with normal uterine sizes and weights in the nulliparous and parous states. The nulliparous uterus ranges from 1.8 to 2.0 cm thick, 3.4 to 5.0 cm wide, and 7.5 to 8.1 cm long (vertical) (1, 2). Measurements in the parous uterus are increased in all dimensions by approximately 1.2 cm (1). The virgin uterine weight varies from 33 to 50 gm,and the parous weight from 50 to 117 gm ( I , 2). Measurements for the postmenopausal uterus are not available. Anderson states, “Following the menopause, there is more or less reverse to the infantile form, although the actual size is variable” (1). Brown states a vertical length of 2.5 to 3.0 cm for the infantile uterus (3). In five cases of postmenopausal females 66 to 89 years of age without intrauterine pathology, we have found a variation of 1.2 to 1.8 cm in uterine thickness and a 3.5 to 6.5 cm variation in length. However, in the more immediate postFrom the Division of Ultrasound, Department of Radiology, Hoag Memorial Hospital Presbyterian, Newport Beach, California. Received July 1 9 , 1 9 7 6 ; revision accepted October 2 9 , 1 9 7 6 . For reprints contact: Edward I. Miller, M.D.. Department of Radiology. Hoag Memorial Hospital Presbyterian. Box Y, 301 Newport Beach, California 92663. VOLUME 5. NUMBER 4
Gynecology
Postmenopausal Uterus
FIGURE 1. Longitudinal midline section in a 66 year old female, demonstrating a small atrophic uterus (arrows) posterior and inferior to the bladder (B). Gain settings were decreased to demonstrate the uterus.
menopausal age group, the uterine s h e would probably be larger. Longitudinal ultrasound projections, using the single sweep technique, have been most helpful 26 1
- *
FIGURE 2. Midline longitudinal section. Atrophic uterus (arrows) surrounded by ascites (A) anterior to the usual location of an atrophic uterus in a 77 year old female with cirrhosis. Bladder = B.
FIGURE 3. Midline longitudinal section. Interposed between the bladder (B) and a mass (MI is an atrophic uterus (arrows) in a 74 year old female. .The linear echogenic area represents the endometrial canal, the surrounding less echogenic area, the thin myocetrium. The mass (MI is a cystadenofibroma.
FIGURE 4A. Transverse section 4 cm above the symphysis. There is a left sided pelvic mass (arrows) posterior to the bladder (B).
FIGURE 48. Oblique view. Bladder = B. The mass (arrows) is contiguous with and extending from the body of the uterus (crossed arrow). The mass was a leiomyoma.
in detecting a small uterus. The uterus is usually creased gain settings may be required as the found at or within 0.5 cm of the midline unless uterus is often hidden among the pelvic tissues the uterus is pushed laterally by a mass. De- posterior and inferior to the bladder. Figure 1 262
JOURNAL O F CLINICAL ULTRASOUND
shows an atrophic uterus in a 66 year old female. It was demonstrated using decreased gain settings and the single sweep technique. This uterus shows a less echogenic pattern than the other atrophic uteri we have seen, presumably because of the gain setting. Regardless of technique, the echogenic pattern in the uterus should be homogeneous except for the endometrial canal. In addition to displacement by masses, anterior displacement due to fluids can be seen. Figure 2 illustrates in a 76 year old female an atrophic uterus floating in ascites caused by cirrhosis. Inability to recognize the atrophic uterus may lead to errors in interpretation. Figure 3 is a 74 year old female who presented with a pelvic mass. The large posterior mass was described, as was an unusual smaller mass with an echogenic center. The smaller mass was situated between the bladder and larger posterior mass. At surgery, the small mass was an atrophic uterus weighing 20 gm, with an endometrial canal (the linear echogenic area) measuring 2.5 .cm in length, surrounded by a 1 mm thick endometrium. The myometrium measured up to 0.75 cm in thickness. The uterus was described by the surgeon “as big as the distal thumb”. The mass posterior to the atrophic uterus is a serous cystadenofibroma. This was the first atrophic uterus we encountered and we failed to recognize it as such.
VOLUME 5. NUMBER 4
A solid mass lateral to the midline (Fig. 4A), particularly in the elderly, may represent a mass involving one margin of the uterus, but it may appear clinically as an adnexd mass if the atrophic uterus cannot be palpated. Oblique views (Fig. 4B) are often valuable in demonstrating a mass arising in an atrophic uterus.
CONCLUSION
The size of postmenopausal uterus varies, but after 65 years of age, it routinely appears atrophic. A pelvic mass in this age group should not be considered to be within the uterus unless a careful search excludes an atrophic uterus. Single-sweep longitudinal ultrasound sections are the best method of localizing a small uterus, but sometimes gain settings must be varied to demonstrate the organ.
a
REFERENCES 1. Hertig AT and Gore H: Female Genitalia. Anderson WAD, ed. Pathology, Sixth Edition. St. Louis, C.V. Mosby Companq 1971, p. 1489. 2. Saphir 0 : Autopsy Diagnosis and Technic, Fourth Edition. New York, Paul B. Hoeber, Inc., 1958. p. 511. 3. Brown R: Diagnostic Ultrasound in Obstetrics and Gynecology. Ultrasonography, St. Louis, Warren H. Green Inc., 1975. p. 69.
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