The Egyptian Journal of Radiology and Nuclear Medicine (2016) 47, 347–350

Egyptian Society of Radiology and Nuclear Medicine

The Egyptian Journal of Radiology and Nuclear Medicine

www.elsevier.com/locate/ejrnm
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ORIGINAL ARTICLE

Ultrasound assessment of polycystic ovaries:

Ovarian volume and morphology; which is more
accurate in making the diagnosis?!
Heba Ibrahim Ali *, Momena Essam Elsadawy, Nivan Hany Khater

Department of Radiology, Ain Shams University, Ramsis Street, Cairo, Egypt

Received 11 April 2015; accepted 5 October 2015

Available online 26 October 2015

KEYWORDS Abstract Introduction and aim of the work: Polycystic ovaries (PCO) are a common problem
Polycystic ovaries; among females. As ultrasound examination of such cases is easy, available, cheap and less invasive
Ultrasound; than hormonal assessment, it is commonly used in patients with suspected PCO.
Infertility; However, in practice, Ultrasound findings are sometimes equivocal when some patients have nor-
Transabdominal; mal ovarian volume but with abnormal ovarian morphology. Herein, the study aimed to compare
Transvaginal the strength of measuring ovarian volume in patients with PCO versus the ovarian morphology and
whether one finding alone could make the diagnosis.
Materials and methods: Ninety patients with clinically and laboratory diagnosed PCO and 90 age
matched controls were enrolled in the study. Transabdominal and transvaginal ultrasound was
done for assessment of ovarian volume and morphology.
Results: In patients, 16 (8.8%) ovaries showed normal morphological appearance while the rest
(91.1%) showed morphological picture of PCO in the form of detection of 10 or more cysts of
2–8 mm in diameter peripherally arranged around an echodense stroma.
Conclusion: Ovarian morphological is more reliable than ovarian volume in diagnosing patients
with polycystic ovarian syndrome.
Ó 2015 The Authors. The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by
Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

1. Introduction (1). PCOS is the most common reproductive endocrinopathy

of women during their childbearing years, with a reported
The condition now known as polycystic ovarian syndrome prevalence of 5–10% (2). It is a heterogeneous disorder with
(PCOS) was first described by Stein and Leventhal in 1935 variable manifestations (3).
The diagnosis of PCOS was previously based on a combina-
* Corresponding author. Tel.: +20 1005269007.
tion of clinical and endocrine features, including raised serum
concentrations of luteinizing hormone (LH), Testosterone (T)
E-mail addresses: hebaali_m@hotmail.com (H.I. Ali), momena.essam@
yahoo.com (M.E. Elsadawy), nivan_khater@yahoo.com (N.H. Khater).
and androstenedione and reduced levels of sex hormone
Peer review under responsibility of Egyptian Society of Radiology and
binding Globulin (4,5).
Nuclear Medicine.
http://dx.doi.org/10.1016/j.ejrnm.2015.10.002
0378-603X Ó 2015 The Authors. The Egyptian Society of Radiology and Nuclear Medicine. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
348
The 2003 ‘Rotterdam criteria’ allow the diagnosis to be
made when two of three features are present: oligomenorrhea
or anovulation, clinical or biochemical hyperandrogenism, and
objectively defined polycystic ovaries on ultrasound (6).
In 1981, Swanson et al. (7) described PCO as enlarged and
rounded, with a mean volume of 12 cm3 and containing an
increased number of small follicles (2–8 mm) encircling the
ovarian cortex. However, the importance of ovarian size in
diagnosis has lessened as various groups (8–10) have shown
a considerable overlap between PCO and normal ovaries and
as the upper limit of normal has decreased from greater than
10 to 5.5 cm3 (11). In 1985, Adams et al. (12) published new
criteria based on transabdominal ultrasound, which required
10 or more cysts of 2–8 mm in diameter arranged peripherally
around an echodense stroma. However, these criteria have
remained in widespread use even after the introduction of
TVS a decade later.
The 2011 Evidence-based guideline for the assessment and
management of polycystic ovary syndrome provides valuable
advice to general practitioners on evidence based diagnosis
and management (13).
In the current study, we tried to compare the reliability of
ovarian morphology in cases of PCO versus ovarian volume.
The hypothesis is that relying on morphological assessment
of the ovary is more accurate than ovarian volume measure-
ment especially when there is discrepancy between both.
2. Patients and methods
2.1. Study population
From the period of November 2012 to May 2014, ninety
women already diagnosed with PCOS (by clinical and bio-
chemical evidence) and 90 age-matched control women who
have no clinical or hormonal abnormalities are also recruited
into the study. Subjects’ age ranges between 16 and 38,
sixty-two patients had primary infertility, five had secondary
infertility and twenty-three were unmarried who had clinical
complaint of either: (1) Irregular menstrual cycles in the form
of oligo- or anovulation (menstrual cycles <21 or >38 days),
(2) Hirsutism, or (3) Obesity.
The laboratory findings included biochemical evidence of
hyperandrogenism.
The inclusion criteria were clinically and laboratory evi-
dence of PCOS and visualization of at least one ovary by
transvaginal ultrasonography.
The exclusion criteria were use of hormonal contraception,
fertility medications in the three months prior to enrollment,
hyperprolactinemia, hypercortisolemia, and thyroid dysfunction.
2.2. Ultrasound technique
Ultrasound scans were performed between Days 3 and 7 of the
menstrual cycle.
Using a Voluson E6 (GE Healthcare, Zipf, Austria), a 2–
5 MHz abdominal probe and a 7.5-MHz transvaginal probe,
all scans were performed in a private room after getting patient
consent. Examination was done by a single ultrasonographer
(with more than 10 year experience) and single senior Radiol-
ogist (with an experience of more than 8 years) separately.
H.I. Ali et al.
Each ovary was visualized and anatomic orientation with
respect to the utero-ovarian ligament was established. Ovaries
were scanned from the inner to outer margins in both the
transverse and sagittal planes.
The examination should include (1) ovarian volume, (2)
total follicle count (3) largest follicle diameter and (4) follicle
distribution pattern.
2.3. Interpretation
Ovarian volume was calculated from measurements of the
largest and widest diameters of the ovaries in the transverse
and sagittal planes. Total follicle count should include follicles
more than 2 mm in diameter. Follicle distribution pattern is
judged whether follicles were predominantly distributed in a
‘‘peripheral” pattern or heterogeneously (‘‘Even”) throughout
the stroma.
This was an observational study approved by the local
Ethics Committee, and each woman gave informed written
consent. There are no conflict of interests to disclose.
3. Results
The study included 90 patients and 90 age-matched control
women, with age range between 16 and 38 (average 27 years).
35 (38.8%) patients presented with menstrual irregularities, 29
(32%) with infertility, 15 (16.6%) with obesity and 11 (12.2%)
with hirsutism.
All patients have abnormal hormonal profile in the form of
elevated serum LH and testosterone levels.
Ultrasound examination was done for all patients and con-
trols with successful visualization of both ovaries when comb-
ing transabdominal with transvaginal scan. A total number of
180 ovaries are evaluated in patients and similar number in
controls.
Ovarian volume is plotted in Table 1; ovarian morphology
is also evaluated based on follicle count, largest follicle diam-
eter and follicle distribution within the ovarian parenchyma.
In all control subjects, ovarian volume was within average
range (9.3 ml), and in patients, the ovarian volume ranged
from 6.7 to 12.6 ml, with an average of 9.65 ml. Only 30
ovaries (16.6%) showed volume above normal.
Regarding the ovarian morphology, in all control subjects,
the ovaries appeared with variable sized follicles, equally
distributed within the ovarian stroma with a dominant follicle
inside.
In patients, 16 (8.8%) ovaries showed normal morphologi-
cal appearance while the rest (91.1%) showed morphological
picture of PCO in the form of detection of 10 or more cysts
of 2–8 mm in diameter peripherally arranged around an
echodense stroma (Fig. 1).
4. Discussion
Polycystic ovary syndrome (PCOS) is a common endocrine
disorder of unknown cause (14).
It is a highly variable condition with a wide array of presen-
tations. The polycystic ovary syndrome should meet at least
two of the following three criteria: oligo- or anovulation;
Ultrasound assessment of polycystic ovaries
Table 1 Ovarian volume in patients and control subjects.
Fig. 1 24 year old female with PCO, showing typical
morphological appearance of multiple small follicles peripherally
located around central dense stroma.
clinical and/or biochemical signs of hyperandrogenism; and
polycystic ovaries on ultrasound (15).
Ultrasound is non-invasive and a widely used modality for
evaluating such cases.
The evaluated ultrasound criteria of PCO were as follows:
the presence of 12 or more 2–9-mm ovarian follicles; a periph-
eral distribution of ovarian follicles; an ovarian volume of
more than 10 cm3 and a highly echogenic ovarian stroma (16).
Our study revealed that clinically and laboratory proven
PCO showed the typical morphological changes in ultrasound
examination in 91.1%; however, only 30 ovaries (16.6%)
showed increased volume.
Our data showed that at least 12 follicles were identified per
ovary, in agreement with Lujan et al. (17) who suggested that a
significantly higher threshold than 12 is needed to adequately
discriminate between polycystic and normal ovaries (18).
Historically, the peripheral distribution of follicles has been
considered a hallmark of polycystic ovaries (19). The classic
‘‘string of pearls” appearance is embedded in the medical
Imaging literature and remains highly remarked upon in
349
radiological reports confirming the presence of polycystic
ovarian morphology. In our study, 91.1% of cases showed typ-
ical peripheral follicle distribution in agreement with Adams
et al.; on the other hand, Lujan et al. excluded the assessment
of follicle pattern in their study.
Ovarian volume was increased in only 16.6% of cases using
the cutoff value of 12 cm3.
Unfortunately, there is significant debate regarding the
sensitivity of increased ovarian volume as a diagnostic
criterion for polycystic ovaries. The currently accepted cutoff
of >10 cm3 was associated with 98.2% specificity, but only
45% sensitivity, in discriminating between normal and
polycystic ovaries (20). Since 2003, both a lower threshold of
7 cm3 (20) and a higher threshold of 13 cm3 (18) have been
proposed as being more appropriate thresholds for polycystic
ovarian morphology.
Some of the controversy over a reliable diagnostic cutoff
likely relates to inconsistent methods for determining ovarian
volume. There is currently no consensus on the most suitable
method of approximating ovarian volume. Clinicians and
researchers use a myriad of techniques ranging from semi-
automated volumetric task functions offered by conventional
ultrasound systems to manual calculations using linear mea-
surements made in multiple cross-sectional images. In the pre-
sent study, we employed the equation for a prolate spheroid,
rather than the commonly used equation of a prelate ellipsoid,
since this method was found to correlate better with volume
measurements of polycystic ovaries made by 3D ultrasound
(20).
5. Conclusion
In summary, typical peripheral distribution of more than 10
follicles of 2–8 mm diameter is depicted in most of patients
enrolled in the study in controversy to the ovarian volume
enlargement and thus, the study concluded more reliability
of ovarian morphology than ovarian volume in diagnosing
patients with suspected PCO.
350
Disclosure of interests
Nothing to disclose.
Contribution to authorship
N/A.
Details of ethics approval
Local ethical approval.
Funding information
No funds.
Conflict of interest
There is no conflict of interest to declare.
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