Ultrasound evaluation of the normal menstrual cycle

Author
Judith M Adams, DMU
Section Editors
Robert L Barbieri, MD
William F Crowley, Jr, MD
Deputy Editor
Kathryn A Martin, MD
Disclosures
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Apr 2013. | This topic last updated: Aug 28, 2012.
INTRODUCTION — Transvaginal ultrasonography provides a direct and sensitive method of
monitoring ovarian size and follicular development during the menstrual cycle. It is superior to
transabdominal ultrasonography in several ways: the pelvic organs can be seen with greater
clarity, particularly in obese women, and it is more convenient because the urinary bladder need
not be full. As a result, transabdominal ultrasonography is now reserved for situations that require
a complete pelvic survey or for examining children or sexually inactive women.

This topic will review the ultrasonographic findings during the normal menstrual cycle. The events
that occur during the cycle are discussed in detail separately. (See "Physiology of the normal
menstrual cycle".)

OVARIAN CHANGES DURING THE NORMAL MENSTRUAL CYCLE — The ovaries can be
seen by ultrasonography throughout the menstrual cycle in normal women. Ovarian volume is
determined using a simplified formula for a prolate ellipse [1].

Ovarian volume is typically used to describe ovarian size. It is calculated by multiplying the
longest dimension of the ovary (in cm) by the two orthogonal dimensions by a factor of 0.523:

Ovarian volume = Length (in cm) x width x thickness x 0.523

Ovarian volume declines after menopause, as illustrated by a study of 13,963 women ages 25 to
91 years undergoing annual transvaginal ultrasonography for 1 to 11 years as part of an ovarian
cancer screening program [2]. Mean ovarian volume decreased from 4.9 ± 0.03 cm3 in
premenopausal women to 2.2 ± 0.01 cm3 in postmenopausal women. Based upon these data, the
upper limit of ovarian volume (using a definition of two standard deviations above the mean [3]),
was approximately 20 cm3 for premenopausal women and 10cm3 for postmenopausal women
(figure 1).

Ovarian follicles as small as 2 mm can be detected by ultrasonography. They are easily visible as
echo-free structures that are sharply demarcated from the surrounding ovarian tissue, which is
more echogenic. The follicles are usually spherical, but become more ovoid as they enlarge.

Follicular phase — The development of ovarian follicles can be documented by serial scanning
throughout the menstrual cycle [4-8]. (See "Physiology of the normal menstrual cycle".)
  Folliculogenesis begins in the late luteal phase of the previous cycle; the follicle destined
to ovulate is derived from a cohort of developing antral follicles [9].
 By cycle days 5 to 7, a varying number of small follicles of 2 to 6 mm in diameter can be
seen in both ovaries [8].
 By cycle day 8 (six to nine days before the midcycle luteinizing hormone [LH] surge)
(image 1), one follicle — the dominant follicle — reaches 10 mm in diameter [10,11]. The
others may enlarge somewhat, but to a lesser extent [11].

Subsequently, as the dominant follicle develops, the follicles in that ovary decrease in size, which
suggests that there may be active suppression of follicular growth by some intraovarian paracrine
mechanism [11,12]. The side of the dominant follicle in subsequent cycles appears to be a
random event that is not influenced by the preceding cycle [13]. In 5 to 11 percent of cycles, two
dominant follicles develop and ovulate, usually in opposite ovaries [6].

The dominant follicle grows approximately 2 mm a day, usually reaching a diameter of 20 to 25

mm by the time of ovulation [6]. However, follicular size just before ovulation is quite variable,
ranging from 16 to 30 mm [4-6], thereby limiting the value of measurement of follicle diameter
alone as a predictor of ovulation [14].

The accuracy of ultrasonographic measurements has been confirmed at laparoscopy by direct

measurements of follicle diameter and the volume of follicular fluid [5,6]. Serial measurements by
a single observer are less variable than those performed by multiple observers, and the errors in
size estimates are greater for larger follicles [15,16].

There is a linear correlation between the diameter of the dominant follicle and serum estradiol
concentrations during the period of rapid follicular growth [5,6], supporting earlier conclusions that
most of the estradiol in serum comes from the dominant follicle [11].

Ovulation — Attempts have been made to predict impending ovulation by documenting specific
intrafollicular sonographic features in the periovulatory period. At the time of the luteinizing
hormone (LH) surge (figure 2), the granulosa cell layer begins to separate from the theca cell
layer, and it develops a crenated appearance [17]. However, this sign may easily be missed
because it occurs just a few hours before ovulation. Another sign of follicular maturity is detection
of the dissociated cumulus oophorus, which appears as a small triangular echogenic structure
projecting into the follicle within 24 hours before ovulation (image 2) [6,7]. However, this sign is
also not seen sufficiently often to be a reliable predictor of ovulation [6,14].

In women with periovulatory pain, the pain is on the side of the dominant follicle and usually
occurs before ovulation. These observations suggest that the pain is due to local effects from the
enlarging ovary [18,19].

Development of the corpus luteum — Follicular rupture occurs within 24 to 36 hours after the
onset of the LH surge. It can be seen on ultrasonography, with complete follicular emptying taking
from 1 to 45 minutes [8,20-22]. The corpus hemorrhagicum develops within one hour after
ovulation; it is recognized as a small irregular cyst with echogenic crenated walls and multiple
echoes, which originate from clotted blood [8].

Thereafter, the corpus luteum varies in size and echo pattern [4,5,22]. The most frequent finding
is a small irregular thick-walled cyst with low-level echoes (image 3) [7]. This usually slowly
decreases in size during the luteal phase, but may first increase transiently. The ultrasonographic
diagnosis of ovulation may be difficult when the follicle accumulates echogenic material with no
obvious sign of collapse. This appearance is suggestive of defective ovulation and is discussed
separately.

The relationship between the structure and function of the corpus luteum is unclear. Early reports
that morphologic features of the corpus luteum (such as echogenicity and wall thickness)
reflected function [23] could not be reproduced in a later study, which did, however, note a good
correlation between vascularity and volume of the corpus luteum and serum progesterone
concentrations [24].

After ovulation, there is an increase in the volume of free fluid in the posterior cul-de-sac (pouch
of Douglas), which can be detected by ultrasonography [25,26]. This peritoneal fluid is probably
an exudate from the ovary, because the quantity measured by laparoscopic aspiration
(approximately 15 to 25 mL) greatly exceeds that released by the dominant follicle (4 to 6 mL)
[20].

ENDOMETRIAL CHANGES DURING THE NORMAL MENSTRUAL CYCLE — The changes in

thickness and texture of the endometrium that occur during the menstrual cycle can be detected
by ultrasonography [27,28], and they are correlated with those determined by serial endometrial
biopsies [29]. Endometrial thickness is measured from the echogenic interface at the junction of
endometrium and myometrium at the level of the maximum anteroposterior diameter in the
sagittal plane.

Follicular phase — After menses, the endometrium appears as a thin echogenic line, as a result
of shedding of the functional layer (image 4). Proliferation from the basal layer begins soon
thereafter and continues throughout the follicular phase under the influence of increasing
estradiol secretion (figure 2) [28,30]. This proliferation results in a "triple-line" appearance on
ultrasonography, with the endometrium appearing hypoechoic compared with the bright lines of
the central and outer basalis layers (image 5).

By the end of the follicular phase, the endometrium measures between 8 and 12 mm [29,31]. At
midcycle, the cervical canal may be dilated with mucus, which appears as an anechoic stripe
within the cervix and is a sign of impending ovulation.

Luteal phase — After ovulation, the "triple-line" disappears and is replaced by an echogenic
stripe, 10 to 14 mm in thickness (image 6). This stripe appears to be related to increasing length
and tortuosity of endometrial glands with mucin and glycogen storage within the functionalis layer.
The clinical importance of these changes is unclear. Many studies have attempted to relate
endometrial thickness and texture to the outcome of pregnancy, but the results are conflicting.
Most have focused on stimulated cycles in preparation for in vitro fertilization and are discussed
separately. (See "Overview of ovulation induction".) However, a study evaluated the relationship
between endometrial thickness and echogenicity and the rates of pregnancy in women with
natural cycles treated for luteal phase defects; in contrast to most of the findings in stimulated
cycles for in vitro fertilization, the thickness and echo pattern of the endometrium at the time of
ovulation did not predict the outcome of pregnancy [32].

Comparisons have been made between conventional 2-dimensional (2-D) images of the
endometrium and 3 dimensional (3-D) reconstructed images in the coronal plane [33]. When the
2-D images were normal, additional information was obtained in only 2 of 42 patients, compared
with 50 percent of patients who had abnormal findings on 2-D imaging. This included improved
definition of the endometrium, and delineation of endometrial polyps, and leiomyomas.

Subtle wavelike subendometrial contractions have been noted on ultrasound [34-36]. These are
best seen when a magnified view of the endometrial canal is recorded on videotape and viewed
at five times the regular speed [34,35]. These contractions propagate from the cervix toward the
fundus in the follicular phase and increase in frequency and amplitude throughout the follicular
and periovulatory phases. The direction of contractions is essentially reversed during the luteal
phase and menstruation [36]. The direction of the follicular phase waves may assist sperm
transport, and the reversed pattern in the luteal phase may help to maintain the blastocyst within
the uterine fundus.

The myometrium also demonstrates contractile activity throughout the cycle, peaking before
ovulation [37]. Peristalsis during the luteal phase is controlled by systemic and local hormone
secretion from the corpus luteum and facilitates fundal implantation of the blastocyst,
predominantly on the side of the dominant ovary.

OVARIAN AND UTERINE DOPPLER STUDIES — Transvaginal color flow Doppler

ultrasonography has been used to investigate cyclic changes in ovarian and uterine blood flow
during the menstrual cycle [38-42].

Uterine blood flow — In the follicular phase of the cycle, the blood flow in the uterine arteries is
characterized by a high-resistance pattern that starts to decrease the day before ovulation,
reaches a nadir approximately two days after ovulation, and then remains at that level for the rest
of the cycle [38-42]. These changes do not occur during anovulatory cycles.

Similar changes have been noted using 3-dimensional power Doppler angiography (3D-PDA)
[43]. The endometrial and subendometrial vascularization index (VI) and vascularization flow
index (VFI) increased during the proliferative phase, peaked three days before ovulation,
decreased to a nadir five days after ovulation, then gradually increased during the early to mid-
secretory phase.
 Ovarian blood flow — Resistance to ovarian artery blood flow begins to decline in the dominant
ovary during the phase of rapid follicular growth, in association with rising serum estradiol
concentrations, and reaches a nadir at the time of ovulation. Thereafter, it does not change for
four to five days, and then gradually increases to a level slightly lower than that in the early
follicular phase [39,40,42].

Angiogenesis has been demonstrated in the granulosa cell layer of the dominant follicle at the
time of the ovulatory surge in LH secretion, a sign that could indicate impending ovulation [21,44].

Midcycle alterations in pelvic blood flow have been noted on the side of the nondominant as well
as the dominant ovary. However, resistance in the uterine artery in the midluteal phase of the
cycle is lower on the side of the corpus luteum than on the opposite side, which may optimize
endometrial perfusion on the side of possible implantation [41].

Function of the corpus luteum — There is a close correlation between serum progesterone
concentrations and peak systolic blood flow velocity surrounding the corpus luteum in
spontaneous cycles [24]. Women with luteal phase defects have a higher resistance to corpus
luteum blood flow, in association with significantly lower serum progesterone concentrations,
when compared with women with normal cycles.

The resistance index (RI) in the corpus luteum of women with luteinized unruptured follicles (LUF)
is high throughout the luteal phase in comparison with normal luteal function characterized by a
decrease in RI from ovulation to the mid luteal phase, followed by an increase in the late luteal
phase [45]. In conception cycles, the RI remains at mid-luteal phase levels until seven weeks of
gestation, thereafter rising significantly.

SUMMARY — Transvaginal ultrasonography provides a direct and sensitive method of

monitoring ovarian size and follicular development during the menstrual cycle. Information
obtained from ultrasound includes:

 Measurement of ovarian volume.

 Monitoring of ovarian follicle development (ovarian follicles as small as 2mm can be
detected).
 After ovulation, a corpus luteum is recognized as a small, irregular cyst with echogenic
crenated walls and multiple echoes, which originate from clotted blood.

In addition, ultrasound can be used to monitor the changes in thickness and texture of the
endometrium that occur during the menstrual cycle.

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Topic 7389 Version 5.0

GRAPHICS
Ovarian volume related to age
The 95% upper confidence limit (mean + 1.96 x SD) shows the upper range into
which individual normal ovarian volume measurements will fall. Mean values are
indicated by solid green circles. Bars indicate mean + 1.96 x SD.
Reproduced from: Pavlik EJ, DePriest PD, Gallion HH, et al. Ovarian volume related to age.
Gynecologic Oncology 2000; 77: 410. Illustration used with the permission of Elsevier Inc. All rights
reserved.
Developing dominant follicle
Ultrasonography of an ovary during the follicular phase of the menstrual cycle. The
red arrow points to the dominant follicle.
Courtesy of Judith Adams, DMU.
Hormonal changes during normal menstrual cycle
Sequential changes in the serum concentrations of the hormones released from the
pituitary (FSH and LH; left panel) and from the ovaries (estrogen and progesterone;
right panel) during the normal menstrual cycle. By convention, the first day of
menses is day 1 of the cycle (shown here as day -14). The cycle is then divided into
two phases: the follicular phase is from the onset of menses until the LH surge (day
0); and the luteal phase is from the peak of the LH surge until the next menses. To
convert serum estradiol values to pmol/L, multiply by 3.67, and to convert serum
progesterone values to nmol/L, multiply by 3.18.
Cumulus oophorus
Ultrasonography of an ovary near the end of the follicular phase of the menstrual
cycle. The red arrow points to the dissociating cumulus oophorus.
Courtesy of Judith Adams, DMU.
Corpus luteum
Ultrasonography of the ovary showing a corpus luteum.
Courtesy of Judith Adams, DMU.
Ultrasonography of the uterus
Thin endometrium in the early follicular phase.
Courtesy of Judith Adams, DMU.
Ultrasonography of the uterus
Triple line appearance of the endometrium in the mid-follicular phase.
Courtesy of Judith Adams, DMU.
Postovulatory endometrium
Ultrasonography of the uterus - the bright appearance of the postovulatory
endometrium.
Courtesy of Judith Adams, DMU.
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