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

In day-to-day gynecological practice, clinically
estimated uterine height is compared with ‘pregnancy-
related fundal height’, thus uterine size is expressed in
weeks even in a non-pregnant state. The uterine size
relevant to gynecological management is the size in its
totality, which includes the transverse as well as the
anteroposterior dimensions of the uterus and not only
vertical fundal height, as for the gravid uterus. With
identical fundal height – a disproportionate increase in
one or both other dimensions because of pathology –
uterine volume can totally change and subsequently, so
gynecological practice, sonographically measured uter-
ine volume can be used as important parameter to guide
management. This could be more useful in young un-
married women with intact hymens, and in obese or
non cooperative women.
The purpose of this study was to sonographically deter-
mine the uterine volume of: (i) normal uteri; (ii) non-
gravid pathological uteri clinically evaluated up to 16
weeks size and scheduled for vaginal hysterectomy, and
of clinically evaluated 12 week sized gravid uterus; and
(iii) compare postoperative weight of hysterectomized
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 data presented pertains to the period October 2004
to December 2014 wherein pelvic sonographies were
performed and uterine volume was measured in: (i)
150 adolescent and perimenopausal aged women with
clinically and sonographically normal uteri; (ii) 800 non-
gravid uteri of 16 weeks size or less with benign pathol-
ogy, scheduled for vaginal hysterectomy or trial vaginal
hysterectomy; and (iii) 200 women, clinically diagnosed
as 12 weeks pregnant. The clinical material for the study
was taken from records in the authors’ private practices
in Mumbai, India, which has population of approxi-
mately 18 million. The weight of hysterectomized normal
sized uteri in groups of women aged 16–20 and 45–55 and
all pathological uteri were measured.
The study objectives were to: (i) establish normal uter-
ine volume and weight in women with normal sized
uteri in the absence of pelvic pathology; (ii) record aver-
age uterine volume of enlarged non-pregnant patholog-
ical uteri of 6–16 weeks size, particularly of 12 weeks
size and of 12 weeks size gravid uterus; and (iii) compare
preoperative uterine volume of non-gravid pathological
uteri with their postoperative uterine weight.
Age, parity, menstrual history, obstetric history and
systemic findings were carefully recorded. Trans-
abdominal and trans-vaginal ultrasounds were per-
formed with a 5 MHZ transducer and their mean
values were utilized. For clinical convenience and ease,
2 © 2016 Japan Society of Obstetrics and Gynecology
the uterine volume figures were rounded off by a
margin of 1–3.
The uterine volume was measured using a geometric
formula for prolate ellipsoid volume (g) = L x W x AP ×
0.52. The choice of formula was left to the experienced
sonologists. The uterine length (L) was defined as the
distance between the internal orifice of the uterus (os)
to the dome of the fundus and the maximum width
(W) and anteroposterior (AP) diameter were taken per-
pendicular to the axis of the uterine length. Kurtz et al.
found that the prolate ellipse formula was not ideal for
uterine volume calculation.3
The cervix was not included in the uterus volume cal-
culation for two reasons: (i) the formula of volume calcu-
lation is based on the presumption that the uterus is
ellipsoid in shape and the cervix is cylindrical, and (ii)
the cervix does not significantly contribute to the volume
(approximately 15 cm3). Therefore, before making a con-
clusion, it is worth adding or subtracting the cervical
length for apt comparison.
The selection criteria were: (i) adolescents aged 16–20
and women aged 45–55 with clinically and
sonographically normal pelvic findings and a normal sized
uterus; (ii) pathological non-gravid uteri up to 16 weeks
without malignancy, scheduled for vaginal hysterectomy;
and (iii) pregnant women with clinically 12 week sized
uteri. All sonographies were performed by highly experi-
enced sonologists (co-authors 2 and 3). The exclusion
criteria were: (i) gravid uteri, except a 12 week sized uterus

without pathology; and (ii) the presence of malignancy in
pathological uteri undergoing hysterectomy.
Statistical Analysis
Data were analyzed using SAS version 9.1.3 and sum-
marized as mean ± standard deviation (SD, n). The stu-
dent’s unpaired t-test was applied to compare means
between the two groups. The level of significance was
taken as P = 0.05.
Ethical approval
In India, there are no ethical committees to approve the
analysis of women examined and treated as per routine.
Patients had attended private clinics, and clinical as well
as sonographic findings were accessed without the
women’s name or identity from routine notes. This study
was not conducted outside any national regulation for
work, and is analyzed and presented to guide manage-
ment practice.
Results
Uterine volume and weight of normal uteri
In the 150 women aged 45–55 with normal pelvic find-
ings, including sonographically normal sized uteri,
sonographic findings showed that the uterine volume
varied from 15 to 56 cm3, with an average of 35 cm3,
which is statistically acceptable (Table 1).Third degree
uterine prolapse and carcinoma-in-situ of the cervix
meant that hysterectomy was necessary for these
women. Postoperative uterine weight varied from 24 to
60 g, with an average weight of 44 g.
A further study of 150 women aged 16–20 with nor-
mal pelvic findings, including normal sized uteri, with
normal sonographic pelvic findings, showed that the
uterine volume varied from 24 to 50 cm3, averaging
34 cm3, which is also statistically acceptable. Twenty of
these women underwent hysterectomy because of
severe mental handicap, mental age ranging from 2 to
3 years and an intelligence quotient less than 30,
resulting in poor and unmanageable menstrual hygiene.
Postoperatively, the uterine weight averaged 36 g,
Table 1 Uterine volume and uterine weight in normal
women with normal sized non-gravid uteri
Average Average
Age Number uterine volume uterine weight
(years) of women (range in cm3) (range in gm)
16–20 150 34 (24–50) 36 (26–56)
45–55 150 35 (15–56) 44 (24–60)
© 2016 Japan Society of Obstetrics and Gynecology
Uterine volume in clinical practice
varying from 26 to 56 g, higher than the preoperative
sonographic estimation of uterine volume in each case
and slightly lower than the average weight of normal
uteri of women aged 45–55, a statistically accepted nor-
mality by Komogorov–Smirnov test.
Uterine volumes of non-gravid pathological uteri
The minimum volume observed was 58 cm3 in one
woman with clinically six weeks sized non-gravid
Gynec uterus but it ranged to as high as 145 cm3 in an-
other woman with the same sized six week non-gravid
pathological uterus. Preoperatively, in clinically non-
gravid pathological uteri estimated at 6, 8, 10, 12, 14
and 16 weeks uterine size, the average uterine volume
was approximately 90, 130, 180, 240, 355 and 460 cm3, re-
spectively, which is accepted as normal by statistical K.S.
test, although the range was wide. Uterine volume
depended on the pathology that it harbored, affecting
one or both other uterine dimensions and not only verti-
cal or fundal height.
This study also included 200 gravid uteri of 12 weeks
size without pathology for comparison, which showed
an average uterine volume of 240 cm3 just corresponding
to the volume of the clinically diagnosed 12 week sized
non-gravid pathological uteri. Using a Mann–Whitney
U test, the differences in uterine volume in non-gravid
uteri, as well as in 12 week gravid uteri were significant
with P < 0.001 for 6, 8 and 10 weeks size and P = 0.849
for 12 weeks size.
Uterine volume and related uterine weight in
non-gravid uteri
Postoperatively, all the hysterectomized uteri with be-
nign pathology were carefully weighed and the weight
of each was compared with their preoperatively esti-
mated uterine volume. The average uterine weight in
grams was strikingly higher than the measured volume
in cm3 in all but nine out of 800 cases (Table 2).
Table 2 Comparison of uterine weight with uterine
volume of gynec – non-gravid hysterectomized uteri
Clinical Size of Uterine Uterine
‘Gynec’ Uterus Volume (cm3) Weight (gm)
6 weeks 90 115
8 weeks 130 180
10 weeks 180 240
12 weeks 240 280
14 weeks 355 410
16 weeks 460 499
3
S. S. Sheth et al.
The average uterine weight was 115, 180, 240, 280, 410
and 499 g for average uterine volumes of 90, 130, 180,
240, 355 and 460 cm3, respectively, which, in turn, was
for uteri sized 6, 8, 10, 12, 14 and 16 weeks, respectively.
Uterine weight range varied in a similar manner.
Discussion
Variations in volume can be a result of varied parity, in-
cluding undetected pathology (such as myohyperplasia
and/or mild adenomyosis), race, status (affluent or
malnourished poverty-stricken women) and the skills of
the sonologists. However, the volume indicates whether
a uterus is normal or abnormal in size and can guide gy-
necological conservative management, including required
counseling. In elderly women with abnormal uterine
bleeding without diagnosable uterine pathology, when
uteri were close to the upper limit of normal volume
(56 cm3) and not more than 120 cm3, conservative treat-
ment was strongly considered to avoid invasive surgery.
A volume of 120 cm3 is the equivalent total volume of
two normal uteri and could harbor silent pathology, such
as adenomyosis, necessitating a different conservative ap-
proach or even an invasive approach. Clinical estimation
of uterine size may not be correct in early gynecological
practice or in obese and/or non cooperative women.
In elderly women with menorrhagia, a volume close
to normal and not beyond approximately 120 cm3 indi-
cated the use of the less invasive Long acting intrauterine
device (LngIUD) or endometrial ablation, rather than
hysterectomy. An increase in uterine volume was associ-
ated with a decrease in assurance and perseverance of
conservative management; however, clinical trials are re-
quired to confirm this finding. When a decision was
made in favor of hysterectomy, the volume measure-
ment in 10–14 week sized uteri was greatly helpful for
choosing the route, that is, vaginal rather than opening
the abdomen or performing laparotomy, which would
add four to five abdominal holes.4 To undertake vaginal
hysterectomy, the ‘cut-off’ size of the uterus is usually 12
weeks. Our results show approximately 240 cm3 as the
average uterine volume for proven 12 weeks gravid as
well as non-gravid uteri, although the range can be wide.
Interestingly, our result differs from the American Col-
lege of Obstetricians and Gynecologists, which mentions
a uterine volume of 285 cm3 for uteri sized 12 weeks.5
When the uterine volume is more than indicated for vag-
inal hysterectomy but the surgeon feels that a vaginal
route may succeed, a trial vaginal hysterectomy (similar
to trial forceps delivery in obstetrics to avoid opening the
4 © 2016 Japan Society of Obstetrics and Gynecology
abdomen in a well-counseled obstetric patient) should
be planned, with facilities for laparoscopic assistance or
cesarean section available.4,6 When uterine volume ex-
ceeds 240–350 cm3, trial vaginal hysterectomy is favored
or laparoscopic technique considered. One of the authors
of this paper is used to performing vaginal hysterectomy
on a contraindicated enlarged uterus and comfortably
accepts the vaginal route for uterine volumes of
500–800 cm3 as trial vaginal hysterectomy cases; if these
fail vaginally, laparoscopic assistance or opening of the
abdomen is utilized.1,5,6
It is not uncommon for busy sonologists to provide
only one uterine dimension, the vertical dimension,
which is unacceptable, because in balanced practice all
three dimensions are required. A decision to proceed
with surgery using miscalculated uterine size or without
assessing the uterine volume can cause issues during
surgery.
Harb and Adam found that uterine size clinically esti-
mated in gestational weeks and its correlation with uter-
ine weight provided correct measurement.7 We feel that
preoperative sonographic uterine volume should not be
labeled in grams but in cubic centimeters, as the uterus
can only be measured in grams after weighing it, which
can only be determined after surgical removal.
Uterine weight is very important in clinical practice,
particularly because preoperatively estimated uterine
volume is lower than postoperative weight. The
correct estimation of uterine weight will assist in deci-
sions over counseling strategy and removal of the
uterus. Postoperatively, compared with the weight of
a normal uterus, the actual uterine weight helps a
woman to realize that her removed uterus was multi-
ple times larger than normal, which can reassure her
of the decision taken earlier for hysterectomy. Kung
and Chang reported that uterine weight can be calcu-
lated from a formula of 50.0 + 0.71 x volume cm3.8
However, after careful study, there is proportional
decrease in uterine weight as volume increases,
although in actuality there is increase in the uterine
tissue. We almost always find that the expected uter-
ine weight after surgery will be figuratively greater
than the preoperatively calculated uterine volume.
However, further research is required to check the
relationship between volume and weight.
Uterine volume less than 60 cm3 indicates normalcy,
while 240 cm3 indicates that non-pregnant or ‘Gynec’
uteri are equivalent to 12 weeks pregnant uterine size.
Uterine volume provides an overall picture of uterine
size and is important to guide the management of
elderly women with menorrhagia and even for young

women with amenorrhea in. Because the uterus is likely
to weigh more than the estimated uterine volume, defin-
itive preoperative patient counseling and treatment sug-
gestion can be conducted. In short, the determination of
uterine volume improves clinical judgment, as well as
surgical skill.
Disclosure
None declared.
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Uterine volume in clinical practice
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