doi:10.1111/jog.13189 J. Obstet. Gynaecol. Res.

2016

Sonographic evaluation of uterine volume and its clinical

importance

Shirish S. Sheth1, Anju R. Hajari4, Chander P. Lulla2 and Darshana Kshirsagar3

1
Breach Candy and Saifee Hospitals, Sheth Maternity and Gynecological Nursing Home, 2Jaslok Hospital, 3N.M. Medical Centre and
4
Dr B.A.M. Hospital, Mumbai, Maharashtra, India

Abstract
Aim: The study was conducted to: (i) measure uterine volume in adolescent and perimenopausal age groups
with normal pelvic findings and in women with pathological uteri scheduled for surgery, and (ii) utilize uterine
volume as a parameter for the management of perimenopausal women scheduled for vaginal hysterectomy.
Methods: Data of 800 clinically non-gravid uteri of 16 weeks or smaller size with benign pathology scheduled for
vaginal hysterectomy, and 150 adolescent women and 150 perimenopausal aged women with clinically and
sonographically normal pelvic findings with normal uteri from the authors private practices were studied to find
related sonographic uterine volume. Cases clinically more than 16 weeks size were not included in the study.
Normal and pathological hysterectomized uteri were weighed postoperatively to compare their weight with
preoperatively estimated uterine volume. Additionally, 200 pregnant women clinically diagnosed as 12 weeks
pregnant and without pathology also underwent sonography to estimate their uterine volume.
Results: Uterine volume varied from 15 to 56 cm3 in women with a normal uterus. In 12 week sized non-
pregnant benign pathological uteri, as well as pregnant uteri, uterine volume averaged 240 cm3. Uterine weight
was higher when compared with preoperatively estimated uterine volume.
Conclusions: The study results emphasize uterine volume as an important parameter for the management of
young and elderly women, particularly with menorrhagia. The uterus is anticipated to weigh more than the uter-
ine volume, which can assist with diagnosis and management.
Key words: Clinical uterine size, hysterectomy, normal uterine volume, normal uterine weight, uterine volume
of enlarged uterus.

Introduction can the required management (Figure 1).1,2 Thus, in

gynecological practice, sonographically measured uter-
In day-to-day gynecological practice, clinically ine volume can be used as important parameter to guide
estimated uterine height is compared with ‘pregnancy- management. This could be more useful in young un-
related fundal height’, thus uterine size is expressed in married women with intact hymens, and in obese or
weeks even in a non-pregnant state. The uterine size non cooperative women.
relevant to gynecological management is the size in its The purpose of this study was to sonographically deter-
totality, which includes the transverse as well as the mine the uterine volume of: (i) normal uteri; (ii) non-
anteroposterior dimensions of the uterus and not only gravid pathological uteri clinically evaluated up to 16
vertical fundal height, as for the gravid uterus. With weeks size and scheduled for vaginal hysterectomy, and
identical fundal height – a disproportionate increase in of clinically evaluated 12 week sized gravid uterus; and
one or both other dimensions because of pathology – (iii) compare postoperative weight of hysterectomized
uterine volume can totally change and subsequently, so uteri with their preoperatively measured uterine volume.

Received: May 10 2016.

Accepted: August 28 2016.
Correspondence: Professor Shirish S. Sheth, 2/2, Navjivan Society, Lamington Road, Mumbai 400 008, India. Email: shethshirish06@gmail.com;
silsiloo@mtnl.net.in

© 2016 Japan Society of Obstetrics and Gynecology 1

S. S. Sheth et al.

Figure 1 All three uteri are equal in height (10 cm; fundal palpation) but truly grossly different in size (with volumes of 195 cm3,
290 cm3 and 485 cm3) because of the differences in two other dimensions. Reproduced from Sheth et al.2 with permission.

Methods the uterine volume figures were rounded off by a

margin of 1–3.
The data presented pertains to the period October 2004 The uterine volume was measured using a geometric
to December 2014 wherein pelvic sonographies were formula for prolate ellipsoid volume (g) = L x W x AP ×
performed and uterine volume was measured in: (i) 0.52. The choice of formula was left to the experienced
150 adolescent and perimenopausal aged women with sonologists. The uterine length (L) was defined as the
clinically and sonographically normal uteri; (ii) 800 non- distance between the internal orifice of the uterus (os)
gravid uteri of 16 weeks size or less with benign pathol- to the dome of the fundus and the maximum width
ogy, scheduled for vaginal hysterectomy or trial vaginal (W) and anteroposterior (AP) diameter were taken per-
hysterectomy; and (iii) 200 women, clinically diagnosed pendicular to the axis of the uterine length. Kurtz et al.
as 12 weeks pregnant. The clinical material for the study found that the prolate ellipse formula was not ideal for
was taken from records in the authors’ private practices uterine volume calculation.3
in Mumbai, India, which has population of approxi- The cervix was not included in the uterus volume cal-
mately 18 million. The weight of hysterectomized normal culation for two reasons: (i) the formula of volume calcu-
sized uteri in groups of women aged 16–20 and 45–55 and lation is based on the presumption that the uterus is
all pathological uteri were measured. ellipsoid in shape and the cervix is cylindrical, and (ii)
The study objectives were to: (i) establish normal uter- the cervix does not significantly contribute to the volume
ine volume and weight in women with normal sized (approximately 15 cm3). Therefore, before making a con-
uteri in the absence of pelvic pathology; (ii) record aver- clusion, it is worth adding or subtracting the cervical
age uterine volume of enlarged non-pregnant patholog- length for apt comparison.
ical uteri of 6–16 weeks size, particularly of 12 weeks The selection criteria were: (i) adolescents aged 16–20
size and of 12 weeks size gravid uterus; and (iii) compare and women aged 45–55 with clinically and
preoperative uterine volume of non-gravid pathological sonographically normal pelvic findings and a normal sized
uteri with their postoperative uterine weight. uterus; (ii) pathological non-gravid uteri up to 16 weeks
Age, parity, menstrual history, obstetric history and without malignancy, scheduled for vaginal hysterectomy;
systemic findings were carefully recorded. Trans- and (iii) pregnant women with clinically 12 week sized
abdominal and trans-vaginal ultrasounds were per- uteri. All sonographies were performed by highly experi-
formed with a 5 MHZ transducer and their mean enced sonologists (co-authors 2 and 3). The exclusion
values were utilized. For clinical convenience and ease, criteria were: (i) gravid uteri, except a 12 week sized uterus

2 © 2016 Japan Society of Obstetrics and Gynecology

 Uterine volume in clinical practice

without pathology; and (ii) the presence of malignancy in varying from 26 to 56 g, higher than the preoperative
pathological uteri undergoing hysterectomy. sonographic estimation of uterine volume in each case
Statistical Analysis and slightly lower than the average weight of normal
Data were analyzed using SAS version 9.1.3 and sum- uteri of women aged 45–55, a statistically accepted nor-
marized as mean ± standard deviation (SD, n). The stu- mality by Komogorov–Smirnov test.
dent’s unpaired t-test was applied to compare means
between the two groups. The level of significance was
taken as P = 0.05. Uterine volumes of non-gravid pathological uteri
The minimum volume observed was 58 cm3 in one
woman with clinically six weeks sized non-gravid
Ethical approval Gynec uterus but it ranged to as high as 145 cm3 in an-
other woman with the same sized six week non-gravid
In India, there are no ethical committees to approve the
pathological uterus. Preoperatively, in clinically non-
analysis of women examined and treated as per routine.
gravid pathological uteri estimated at 6, 8, 10, 12, 14
Patients had attended private clinics, and clinical as well
and 16 weeks uterine size, the average uterine volume
as sonographic findings were accessed without the
was approximately 90, 130, 180, 240, 355 and 460 cm3, re-
women’s name or identity from routine notes. This study
spectively, which is accepted as normal by statistical K.S.
was not conducted outside any national regulation for
test, although the range was wide. Uterine volume
work, and is analyzed and presented to guide manage-
depended on the pathology that it harbored, affecting
ment practice.
one or both other uterine dimensions and not only verti-
cal or fundal height.
Results This study also included 200 gravid uteri of 12 weeks
size without pathology for comparison, which showed
Uterine volume and weight of normal uteri an average uterine volume of 240 cm3 just corresponding
In the 150 women aged 45–55 with normal pelvic find- to the volume of the clinically diagnosed 12 week sized
ings, including sonographically normal sized uteri, non-gravid pathological uteri. Using a Mann–Whitney
sonographic findings showed that the uterine volume U test, the differences in uterine volume in non-gravid
varied from 15 to 56 cm3, with an average of 35 cm3, uteri, as well as in 12 week gravid uteri were significant
which is statistically acceptable (Table 1).Third degree with P < 0.001 for 6, 8 and 10 weeks size and P = 0.849
uterine prolapse and carcinoma-in-situ of the cervix for 12 weeks size.
meant that hysterectomy was necessary for these
women. Postoperative uterine weight varied from 24 to
60 g, with an average weight of 44 g. Uterine volume and related uterine weight in
A further study of 150 women aged 16–20 with nor- non-gravid uteri
mal pelvic findings, including normal sized uteri, with Postoperatively, all the hysterectomized uteri with be-
normal sonographic pelvic findings, showed that the nign pathology were carefully weighed and the weight
uterine volume varied from 24 to 50 cm3, averaging of each was compared with their preoperatively esti-
34 cm3, which is also statistically acceptable. Twenty of mated uterine volume. The average uterine weight in
these women underwent hysterectomy because of grams was strikingly higher than the measured volume
severe mental handicap, mental age ranging from 2 to in cm3 in all but nine out of 800 cases (Table 2).
3 years and an intelligence quotient less than 30,
resulting in poor and unmanageable menstrual hygiene.
Postoperatively, the uterine weight averaged 36 g, Table 2 Comparison of uterine weight with uterine
volume of gynec – non-gravid hysterectomized uteri
Clinical Size of Uterine Uterine
Table 1 Uterine volume and uterine weight in normal ‘Gynec’ Uterus Volume (cm3) Weight (gm)
women with normal sized non-gravid uteri
6 weeks 90 115
Average Average 8 weeks 130 180
Age Number uterine volume uterine weight
(years) of women (range in cm3) (range in gm) 10 weeks 180 240
12 weeks 240 280
16–20 150 34 (24–50) 36 (26–56) 14 weeks 355 410
45–55 150 35 (15–56) 44 (24–60) 16 weeks 460 499

© 2016 Japan Society of Obstetrics and Gynecology 3

S. S. Sheth et al.

The average uterine weight was 115, 180, 240, 280, 410 abdomen in a well-counseled obstetric patient) should
and 499 g for average uterine volumes of 90, 130, 180, be planned, with facilities for laparoscopic assistance or
240, 355 and 460 cm3, respectively, which, in turn, was cesarean section available.4,6 When uterine volume ex-
for uteri sized 6, 8, 10, 12, 14 and 16 weeks, respectively. ceeds 240–350 cm3, trial vaginal hysterectomy is favored
Uterine weight range varied in a similar manner. or laparoscopic technique considered. One of the authors
of this paper is used to performing vaginal hysterectomy
on a contraindicated enlarged uterus and comfortably
Discussion accepts the vaginal route for uterine volumes of
500–800 cm3 as trial vaginal hysterectomy cases; if these
Variations in volume can be a result of varied parity, in- fail vaginally, laparoscopic assistance or opening of the
cluding undetected pathology (such as myohyperplasia abdomen is utilized.1,5,6
and/or mild adenomyosis), race, status (affluent or It is not uncommon for busy sonologists to provide
malnourished poverty-stricken women) and the skills of only one uterine dimension, the vertical dimension,
the sonologists. However, the volume indicates whether which is unacceptable, because in balanced practice all
a uterus is normal or abnormal in size and can guide gy- three dimensions are required. A decision to proceed
necological conservative management, including required with surgery using miscalculated uterine size or without
counseling. In elderly women with abnormal uterine assessing the uterine volume can cause issues during
bleeding without diagnosable uterine pathology, when surgery.
uteri were close to the upper limit of normal volume Harb and Adam found that uterine size clinically esti-
(56 cm3) and not more than 120 cm3, conservative treat- mated in gestational weeks and its correlation with uter-
ment was strongly considered to avoid invasive surgery. ine weight provided correct measurement.7 We feel that
A volume of 120 cm3 is the equivalent total volume of preoperative sonographic uterine volume should not be
two normal uteri and could harbor silent pathology, such labeled in grams but in cubic centimeters, as the uterus
as adenomyosis, necessitating a different conservative ap- can only be measured in grams after weighing it, which
proach or even an invasive approach. Clinical estimation can only be determined after surgical removal.
of uterine size may not be correct in early gynecological Uterine weight is very important in clinical practice,
practice or in obese and/or non cooperative women. particularly because preoperatively estimated uterine
In elderly women with menorrhagia, a volume close volume is lower than postoperative weight. The
to normal and not beyond approximately 120 cm3 indi- correct estimation of uterine weight will assist in deci-
cated the use of the less invasive Long acting intrauterine sions over counseling strategy and removal of the
device (LngIUD) or endometrial ablation, rather than uterus. Postoperatively, compared with the weight of
hysterectomy. An increase in uterine volume was associ- a normal uterus, the actual uterine weight helps a
ated with a decrease in assurance and perseverance of woman to realize that her removed uterus was multi-
conservative management; however, clinical trials are re- ple times larger than normal, which can reassure her
quired to confirm this finding. When a decision was of the decision taken earlier for hysterectomy. Kung
made in favor of hysterectomy, the volume measure- and Chang reported that uterine weight can be calcu-
ment in 10–14 week sized uteri was greatly helpful for lated from a formula of 50.0 + 0.71 x volume cm3.8
choosing the route, that is, vaginal rather than opening However, after careful study, there is proportional
the abdomen or performing laparotomy, which would decrease in uterine weight as volume increases,
add four to five abdominal holes.4 To undertake vaginal although in actuality there is increase in the uterine
hysterectomy, the ‘cut-off’ size of the uterus is usually 12 tissue. We almost always find that the expected uter-
weeks. Our results show approximately 240 cm3 as the ine weight after surgery will be figuratively greater
average uterine volume for proven 12 weeks gravid as than the preoperatively calculated uterine volume.
well as non-gravid uteri, although the range can be wide. However, further research is required to check the
Interestingly, our result differs from the American Col- relationship between volume and weight.
lege of Obstetricians and Gynecologists, which mentions Uterine volume less than 60 cm3 indicates normalcy,
a uterine volume of 285 cm3 for uteri sized 12 weeks.5 while 240 cm3 indicates that non-pregnant or ‘Gynec’
When the uterine volume is more than indicated for vag- uteri are equivalent to 12 weeks pregnant uterine size.
inal hysterectomy but the surgeon feels that a vaginal Uterine volume provides an overall picture of uterine
route may succeed, a trial vaginal hysterectomy (similar size and is important to guide the management of
to trial forceps delivery in obstetrics to avoid opening the elderly women with menorrhagia and even for young

4 © 2016 Japan Society of Obstetrics and Gynecology

 Uterine volume in clinical practice

women with amenorrhea in. Because the uterus is likely 2. Sheth SS, Paghdiwalla KP, Hajari AR. Vaginal route: A
to weigh more than the estimated uterine volume, defin- gynaecological route for much more than hysterectomy. Best
Pract Res Clin Obstet Gynaecol 2011; 25: 115–132.
itive preoperative patient counseling and treatment sug- 3. Kurtz AB, Shaw WM, Kurtz RJ et al. The inaccuracy of total uter-
gestion can be conducted. In short, the determination of ine volume measurements: Sources of error and a proposed solu-
uterine volume improves clinical judgment, as well as tion. J Ultrasound Med 1984; 3: 289–297.
surgical skill. 4. Bhojraj SS, Sheth SS. Preoperative Assessment. In: Sheth SS (ed).
Vaginal Hysterectomy, 2nd edn. New Delhi, India: Jaypee Brothers
Medical Publishers (P) Ltd, 2014; 20–30.
5. American College of Obstetrician and Gynecologists. Quality as-
Disclosure surance in obstetrics and gynecology. Washington DC: American
College of Obstetricians and Gynecologists, 1989.
None declared. 6. Sheth SS. Vaginal or abdominal hysterectomy? In: Sheth SS (ed).
Vaginal Hysterectomy, 2nd edn. New Delhi, India: Jaypee Brothers
Medical Publishers (P) Ltd, 2014; 273–293.
7. Harb TS, Adam RA. Predicting uterine weight before hysterec-
References tomy: Ultrasound measurements versus clinical assessment.
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1. Sheth SS, Shah NM. Preoperative sonographic estimation of 8. Kung FT, Chang SY. The relationship between ultrasonic volume
uterine volume: An aid to determine the route of hysterectomy. and actual weight of pathologic uterus. Gynecol Obstet Invest
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