![](media/image1.png){width="5.96875in" height="0.41944444444444445in"}

Top of Form

## Complete Summary

#### GUIDELINE TITLE

Gynaecological ultrasound examination.

#### BIBLIOGRAPHIC SOURCE(S)

Finnish Medical Society Duodecim. Gynaecological ultrasound examination.
In: EBM Guidelines. Evidence-Based Medicine \[Internet\]. Helsinki,
Finland: Wiley Interscience. John Wiley & Sons; 2005 May 4 \[Various\].

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Palo P. Gynaecological
ultrasound examination. In: EBM Guidelines. Evidence-Based Medicine
\[CD-ROM\]. Helsinki, Finland: Duodecim Medical Publications Ltd.; 2004
Apr 14 \[Various\].

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Infertility, including ovarian hyperstimulation syndrome during
    infertility treatment

-   Functional bleeding disorders of hormonal origin

-   Endometrial polyp

-   Submucotic myoma

-   Postmenopausal bleeding disorders

-   Gynecologic tumors, such as myoma, adenomyosis, endometrial cancer,
    ovarian cysts, endometrioma, and dermoid tumors

-   Pelvic infections

-   Other conditions resembling ovarian masses on ultrasound

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Obstetrics and Gynecology\
Oncology

#### INTENDED USERS

Health Care Providers\
Physicians

#### GUIDELINE OBJECTIVE(S)

Evidence-Based Medicine Guidelines collect, summarize, and update the
core clinical knowledge essential in general practice. The guidelines
also describe the scientific evidence underlying the given treatment
recommendations.

#### TARGET POPULATION

Women with gynecologic disorders for which ultrasound examination may be
useful in diagnosis, evaluation, or follow-up

#### INTERVENTIONS AND PRACTICES CONSIDERED

Gynaecologic ultrasound examination, including:

1.  Transvaginal sonography

2.  Transabdominal sonography

#### MAJOR OUTCOMES CONSIDERED

Sensitivity and specificity of endovaginal ultrasound for detecting
endometrial cancer or other endometrial diseases

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The evidence reviewed was collected from the Cochrane database of
systematic reviews and the database of abstracts of reviews of
effectiveness (DARE). In addition, the Cochrane Library and medical
journals were searched specifically for original publications.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Levels of Evidence**

A.  Strong research-based evidence. Multiple relevant, high-quality
    scientific studies with homogenic results.

B.  Moderate research-based evidence. At least one relevant,
    high-quality study or multiple adequate studies.

C.  Limited research-based evidence. At least one adequate scientific
    study.

D.  No research-based evidence. Expert panel evaluation of other
    information.

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The levels of evidence \[A-D\] supporting the recommendations are
defined at the end of the \"Major Recommendations\" field.

**Introduction**

To perform gynaecological ultrasound (US) examinations a general
practitioner must receive training under specialist guidance, acquire
sufficient experience, and have proper equipment at his/her disposal.

**Equipment**

-   The improved resolution of ultrasound equipment brought about by
    improvements in transducer technology and computer capacity for
    image processing, combined with concurrent reductions in the cost of
    equipment, has made US a routine gynaecological examination. In
    skilled hands it yields important information.

-   Gynaecological ultrasound investigation consists of both a
    transvaginal sonography (TVS) and a transabdominal sonography (TAS)
    (Smith-Bindman et al, 1998; DARE-989095, 2000) **\[A\]**. A
    gynaecological US examination is not recommended if a transvaginal
    probe is not available. On the other hand, large pelvic tumours may
    be missed if only TVS is carried out, since the resolution of
    high-frequency vaginal probes remains good only up to the depth of
    60 to 80 mm.

-   The patient\'s bladder should usually be empty as this allows easy
    transvaginal examination of the ovaries and the uterus (large
    tumours can be seen with an abdominal probe even if the patient has
    an empty bladder). A full bladder is used as an \"acoustic window\"
    when examining children, young women with an intact hymen, or very
    old patients. Rectal ultrasound examination may also be carried out
    if the transvaginal approach is not possible.

**Menstrual Cycle and Infertility**

**Endometrial Development**

-   The cyclic changes of the endometrium during the menstrual cycle can
    be imaged with US. If the uterus is stretched, the imaging of the
    endometrium is not always successful.

-   The thickness of the endometrium usually is expressed as the double
    wall thickness including both the anterior and posterior endometrial
    walls.

-   Immediately after menstruation the endometrium is homogenous, 1 to 4
    mm thick. As the oestrogen concentration rises, the proliferative
    endometrium changes into a triple-layer structure and its thickness
    increases to 7 to 10 mm. After ovulation, the echogenicity of the
    endometrium begins to increase starting from the basal area, and in
    the luteal phase it has become hyperechogenic throughout with a
    thickness of 8 to 16 mm.

**Follicle and Corpus Luteum**

-   Several 2 to 5 mm follicles may be seen in the ovaries with TVS. One
    or more of the follicles will grow during the early cycle.

-   Around cycle days 9 to 10 the leading follicle can be identified; it
    has a diameter of about 10 mm. Thereafter it grows rapidly, and by
    ovulation it is 20 to 24 mm in diameter.

-   After ovulation the follicle collapses, and as the corpus luteum
    develops, the content of the cyst may have a slightly heterogeneous
    consistency. The wall is sometimes seen as a rather thick formation
    with low-level echoes. Occasionally, corpus luteum forms a
    homogeneous hypoechogenic thin-walled structure. The diameter of a
    normal follicle or corpus luteum does not usually exceed 30 mm.

**Monitoring of Infertility Treatment**

-   In infertility treatment, the growth of the follicle and the
    development of the endometrium can be monitored during hormone
    stimulation. With US the developing follicles can be counted, the
    dosage of hormone treatment adjusted, and the timing of
    interventions, such as insemination during ovulation, determined.

-   US can be used to recognise ovarian hyperstimulation syndrome, which
    is a rare but serious complication of gonadotrophin stimulation used
    for infertility treatment. After stimulation and follicle puncture,
    the ovaries can be 60 to 70 mm in diameter and multicystic. In
    hyperstimulation syndrome, the ovaries are often over 80 mm in
    diameter, and in severe cases there is fluid in the peritoneal
    cavity.

**Localization of an Intrauterine Device (IUD)**

-   US can be used to verify the presence and proper intrauterine
    localisation of an IUD.

-   A copper IUD gives a strong echo and is easy to detect.

-   The presence of a levonorgestrel IUD (Mirena®) might be more
    difficult to verify. Only the ends of the plastic arm of the device
    are detectable with US. Moreover, being a foreign body it produces
    dark extrauterine shadows which differ according to projections
    used.

-   If an IUD is positioned correctly (i.e., high enough in the uterus),
    the difference between the upper portion of the IUD and the outer
    edge of the fundus should not exceed 20 mm in a normally sized
    uterus.

-   It is usually impossible to detect an IUD that is located outside
    the uterus with an US.

**Bleeding Disorders**

**Fertile Age**

-   The most common causes

    -   Functional bleeding disorder of hormonal origin

        -   Deviation from the normal structure of the endometrium in
            the different phases of the menstrual cycle described above
            is not sufficient for making a diagnosis.

        -   Endometrial thickness of more than 18 mm suggests
            endometrial disease.

    -   Endometrial polyp

        -   An echodense, well-defined, round mass in the uterine
            cavity, which is best visualised during the proliferative
            phase. It may have a cystic structure.

        -   The polyp can be imaged even better should any liquid be
            present in the uterine cavity, or if fluid is introduced
            with an insemination catheter. The blood vessel supplying
            the polyp may be visualised with colour Doppler.

    -   Submucotic myoma

        -   A submucotic myoma gives a low echo as compared with a
            polyp. It is usually possible to differentiate a submucotic
            myoma from a polyp.

**Postmenopausal Bleeding Disorders**

-   Bleeding or bloody discharge in a postmenopausal woman should be
    considered as a sign of endometrial cancer until otherwise proven.

-   An endometrium more than 10 mm in thickness in a postmenopausal
    patient strongly suggests endometrial cancer.

-   Endometrial cancer is seen extremely rarely when the endometrium is
    less than 5 mm thick.

-   US alone is not sufficient for making a diagnosis. A histological
    sample of the endometrium is always needed.

**Sonohysterography**

In sonohysterography 5 to 15 mL of saline solution is injected into the
uterine cavity with, for example, an insemination catheter. The saline
solution gives a contrast in the uterine cavity which allows the best
visualisation of any polyps in the uterine corpus and submucotic myomas
protruding into the cavity. A histological sample should be taken before
performing sonohysterography.

**Salpingosonography**

Salpingosonography may be used as a primary investigation for
infertility instead of laparoscopic chromopertubation. Agitated saline
is injected into the uterine cavity with an insemination catheter. The
air bubbles in the saline act as a contrast, and the fallopian tubes can
be visualised. The procedure is markedly reliable compared with
chromopertubation. The flow through the tubes can be confirmed as well
as tubular patency.

**Gynaecological Tumours**

-   Bimanual palpation is the basic examination, which sometimes reveals
    a tumour of the pelvic region. It may also be sufficient for
    differential diagnosis of uterine myomas. Palpation may, however, be
    greatly hindered by the patient\'s obesity.

-   US examination is indicated to verify diagnosis when

    -   diagnosing a pelvic mass is otherwise difficult

    -   an adnexal tumour is detected

    -   the findings on examination are not clear and the patient has
        symptoms in the pelvic region and lower abdomen (swelling, pain,
        bleeding, bladder symptoms)

    -   the patient has a family history of ovarian cancer

**Myoma and Adenomyosis**

-   A myoma is often seen as a more hypoechogenic mass when compared
    with the normal myometrium. It has well defined margins, and a thin
    wall may be visible. Cyst formation can often be seen in rapidly
    growing or degenerating myomas.

-   A pedunculated myoma or a multimyotic massively enlarged uterus may
    be difficult to differentiate from ovarian cancer even with US.

-   The ring-like vascularisation on the outer border of a myoma may be
    visualised with colour Doppler. Vascularisation of the inner
    structures is scant. Profuse vascularisation may be suggestive of a
    malignant myoma (i.e., sarcoma).

-   Adenomyosis, in which the benign cystic structures of the
    endometrium grow diffusely into the uterine wall, may be seen as
    focuses that resemble myoma, but are not clearly discernible from
    the muscular layer of the uterus.

**Endometrial Cancer**

-   Cancer of the uterine corpus is always diagnosed from a histological
    sample.

-   Endometrial cancer is often seen as non-homogenous thickening of the
    endometrium (14 to 15 mm)

-   The depth of invasion can often be determined rather precisely with
    US.

-   In most cases, cervical cancer cannot be diagnosed by US.

**Ovarian Cysts**

-   Functional cysts are mostly detected as incidental findings in US,
    sometimes also when US is performed because of diffuse pelvic pains
    or suspicious findings on bimanual examination.

-   Functional cysts have typically thin and smooth walls without
    internal echoes.

-   A haemorrhagic cyst or a corpus luteum cyst may have variable
    internal structures, which disappear during follow-up.

-   Functional cysts are usually less than 60 mm in diameter.

-   Even postmenopausal women may have benign ovarian cysts, which are
    less than 50 mm in diameter and may disappear during follow-up.

-   Verifying the disappearance of a functional cyst by a follow-up
    examination after 3 to 4 months is indicated. If the cyst grows, its
    removal is indicated. (See Finnish Medical Society Duodecim
    guideline \"Gynaecological tumours\").

-   Patients with a levonorgestrel IUD (Mirena®) may have a higher than
    normal incidence of ovarian cysts, which usually disappear without
    surgical intervention.

**US Diagnosis of Ovarian Tumours**

-   It is not always possible to differentiate between a benign and a
    malignant ovarian tumour by US.

-   An ovarian cyst less than 60 mm in diameter with no internal echoes
    and a smooth internal surface is extremely seldom malignant.

-   A malignant tumour may

    -   have a tumour wall of over 3 mm in thickness or tumour septa

    -   have papillary growth inside the inner walls

    -   be multilocular

    -   have a complex structure of solid and cystic components (the
        probability of cancer is then over 60%)

    -   have poorly organised and profuse vasculature

    -   be accompanied with ascites

-   Particular types of an ovarian tumour include

    -   mucinous tumours with a \"snowstorm\" echo pattern

    -   endometriomas, which are thin-walled cysts with homogenous
        granular inner material, but their presentation may also be
        atypical

    -   dermoid tumours often contain fine granular sebaceous material,
        which may consist of the more solid bone or cartilage
        components, which can cause acoustic shadowing. Hypoechogenic
        cysts may also occur.

**Pelvic Infection**

-   An acute pelvic inflammatory disease may cause a tubo-ovarian
    abscess. This is seen in US examination as a multilocular,
    thick-walled mass that contains echo-dense fluid collections. Strong
    vascularity is detectable in the walls of the inflammatory mass.
    Ca-125 may be increased.

-   When the infection subsides, the infectious complex may disappear or
    it may turn into a sactosalpinx, which is an elongated multilocular
    mass causing a torsion of the fallopian tube. The torsion is easily
    identifiable from different projections, and the ovary will be seen
    as a separate structure. Small pseudopapillae (1 to 2 mm) may be
    seen in the walls. Incomplete septa do not reach from wall to wall
    inside the mass. No vasculature is detectable.

-   Actinomyces may cause inflammatory foci that resemble a tumour.

-   Periappendicular abscess may sometimes be mistaken for a tumour
    around the right ovary.

**Differential Diagnosis**

-   Dilated bowel loops may sometimes simulate a cystic adnexal mass in
    a patient with abdominal pains that are connected to a bowel
    motility disturbance. However, the movement of the bowel contents
    and peristalsis will confirm the nature of the finding.

-   Venous plexuses near the uterus, associated with pelvic vein
    varices, may sometimes be very large and resemble a cystic ovarian
    tumour. If differential diagnosis is difficult, a colour Doppler
    investigation will yield a typical image of venous circulation.

-   Sometimes multiple nabothian cysts in the uterine cervix may be
    mistaken as a cystic ovarian tumour.

**Definitions**:

**Levels of Evidence**

A.  Strong research-based evidence. Multiple relevant, high-quality
    scientific studies with homogenic results.

B.  Moderate research-based evidence. At least one relevant,
    high-quality study or multiple adequate studies.

C.  Limited research-based evidence. At least one adequate scientific
    study.

D.  No research-based evidence. Expert panel evaluation of other
    information.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=8239)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

Concise summaries of scientific evidence attached to the individual
guidelines are the unique feature of the Evidence-Based Medicine
Guidelines. The evidence summaries allow the clinician to judge how
well-founded the treatment recommendations are. The type of supporting
evidence is identified and graded for select recommendations (see the
\"Major Recommendations\" field).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Endovaginal ultrasound has a high sensitivity for detecting endometrial
cancer and other endometrial disease and can reliably identify
postmenopausal women with vaginal bleeding who are unlikely to have
significant endometrial disease so that endometrial sampling may be
unnecessary.

**Subgroups Most Likely to Benefit**

Postmenopausal women with vaginal bleeding who are unlikely to have
significant endometrial disease

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

Ultrasound alone is not sufficient for making a diagnosis of endometrial
cancer. A histological sample of the endometrium is always needed.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Finnish Medical Society Duodecim. Gynaecological ultrasound examination.
In: EBM Guidelines. Evidence-Based Medicine \[Internet\]. Helsinki,
Finland: Wiley Interscience. John Wiley & Sons; 2005 May 4 \[Various\].

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2001 Jan 5 (revised 2005 May 4)

#### GUIDELINE DEVELOPER(S)

Finnish Medical Society Duodecim - Professional Association

#### GUIDELINE DEVELOPER COMMENT

Not stated

#### SOURCE(S) OF FUNDING

Finnish Medical Society Duodecim

#### GUIDELINE COMMITTEE

Editorial Team of EBM Guidelines

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Primary Author*: Pertti Palo

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Palo P. Gynaecological
ultrasound examination. In: EBM Guidelines. Evidence-Based Medicine
\[CD-ROM\]. Helsinki, Finland: Duodecim Medical Publications Ltd.; 2004
Apr 14 \[Various\].

#### GUIDELINE AVAILABILITY

This guideline is included in \"EBM Guidelines. Evidence-Based
Medicine\" available from Duodecim Medical Publications, Ltd, PO Box
713, 00101 Helsinki, Finland; e-mail: <info@ebm-guidelines.com>; Web
site: [www.ebm-guidelines.com](http://www.ebm-guidelines.com/).

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on August 28, 2001. The information
was verified by the guideline developer as of October 26, 2001. This
summary was updated on December 29, 2003, July 15, 2004, and November
11, 2005.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced
under the auspices of medical specialty societies, relevant professional
associations, public or private organizations, other government
agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline
developers, and are screened solely to determine that they meet the NGC
Inclusion Criteria which may be found at
<http://www.guideline.gov/about/inclusion.aspx> .

NGC, AHRQ, and its contractor ECRI Institute make no warranties
concerning the content or clinical efficacy or effectiveness of the
clinical practice guidelines and related materials represented on this
site. Moreover, the views and opinions of developers or authors of
guidelines represented on this site do not necessarily state or reflect
those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or
hosting of guidelines in NGC may not be used for advertising or
commercial endorsement purposes.

Readers with questions regarding guideline content are directed to
contact the guideline developer.

Bottom of Form

© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008