SONOGRAPHIC ESTIMATION OF STANDARD UTERINE SIZE IN A POPULATION

OF NULLIPAROUS ADULT YORUBA FEMALES IN LAGOS

BY

NGWOKE KENNETH IGWEBUIKE

REG. NO: RRBN/INST/18/2010

A RESEARCH PROJECT SUBMITTED TO THE INSTITUE OF RADIOGRAPHERS

OF NIGERIA, LAGOS IN FULFILLMENT OF THE REQUIREMENTS FOR THE

AWARD OF POST GRADUATE DIPLOMA IN MEDICAL ULTRASONOGRAPHY

PROJECT SUPERVISOR: DR. ADEWUNMI BODE

JULY, 2018
 TITLE PAGE

SONOGRAPHIC ESTIMATION OF STANDARD UTERINE SIZE IN A POPULATION

OF NULLIPAROUS ADULT YORUBA FEMALES IN LAGOS

 APPROVAL PAGE

Institute of Radiography,
Radiographers Registration Board,
Lagos Study Centre,
March, 2019.
The Head of Institute,
Radiographers Registration Board,
Abuja-Nigeria.

APPLICATION FOR THE APPROVAL OF A RESEARCH PROJECT TOPIC

I, NGWOKE KENNETH IGWEBUIKE with REG. NO. RRBN/INST/18/2010 of Institute of

Radiography, Radiographers Registration Board of Nigeria, Lagos Study Centre, hereby wishes
to apply for approval to embark on a research titled:
SONOGRAPHIC ESTIMATION OF STANDARD UTERINE SIZE IN A POPULATION
OF NULLIPAROUS ADULT YORUBA FEMALES IN LAGOS STATE.

Thanks in anticipation of your favourable response.

Yours Faithfully,

NGWOKE KENNETH IGWEBUIKE

 CERTIFICATION PAGE

We certify that this project work “SONOGRAPHIC ESTIMATION OF STANDARD

UTERINE SIZE IN A POPULATION OF NULLIPAROUS ADULT YORUBA FEMALES
IN LAGOS” was carried out by NGWOKE KENNETH IGWEBUIKE with REG. NO.
RRBN/INST/18/2010 of the Institute of Radiography under our supervision.

………………………… ………………………..
MR BODE ADEWUNMI HEAD OF INSTITUTE
(SUPERVISOR)

……………………… ………………………..
DATE DATE
 DEDICATION

This research work is dedicated to God Almighty who kept me alive and whose grace made
its completion a success.
 ACKNOWLEDGEMENT

First and foremost, my unalloyed gratitude goes to Almighty God for saving my life to this

moment after passing through the thick and thin within the study period. Praise to Him alone.

The success of this work may not also have been possible without the encouragement, support

and guidance from my project supervisor Dr. Bode Adewunmi, my class-mate like a brother Mr.

Onyilo Israel, my manager at work Dr. Israel Bankefa. To your all I remain grateful.
 CHAPTER ONE

BACKGROUND OF THE STUDY

1.1 INTRODUCTION

The uterus is unarguably the central focus of every imaging diagnosis of a woman’s pelvis.

Certain physiological and pathological conditions can alter the size and or shape of the uterus.

Such physiological and pathological factors as pregnancy and leiomyomata respectively can

easily be detected by palpation or with ultrasound and other imaging tools such as x-ray

(hysterosalpingography), computed tomography (CT) or magnetic resonance imaging (MRI).

Knowledge of a standard nulliparous uterine size is highly important since certain uterine

abnormalities or conditions affecting the uterus such as inflammation (due to trauma from

instrumentation) can only be diagnosed by using size as a yardstick.

Measuring a uterus by palpation can be highly difficult and inaccurate since uterus can first be

palpable after 12 weeks of gestation when it is a size of a grape fruit (Scott Moses, 2018).

Routine computed tomography of the pelvis to assess the uterus can be unjustifiable in view of

the high radiation dose to the patient. The use of magnetic resonance imaging is similarly

hampered by high cost and limited availability in many areas of the world especially developing

countries like Nigeria while x-ray (hysterosalpingography) is highly invasive and also involves

radiation.

Ultrasound therefore becomes the best modality as it can provide non-invasive, radiation free,

low-cost and easily available means of uterine assessment with a good promise of high accuracy

in detecting uterine pathologies.

The Ultrasonographic uterine size measurement has been well documented in Caucasians since

the use of ultrasound in clinical practice started on 1958 (Donald I et al, 1958)

A study on real-time sonographic assessment of common uterine sizes, shapes, and positions in

Nigerians was done in Benue State, North-Central Nigeria (Ohagwu et al, 2007) however, after

thorough review of the literature, sonographic data correlating the uterine size in

NULLIPAROUS females with the age, weight, and body height in Lagos, Southwestern

Nigeria, were not available. The purpose of this study, therefore, is to provide a baseline data of

uterine size by the ultrasound, correlating it with the age, body weight, and height in

Southwestern Nigeria, with which reference can be made as alteration in uterine size may

suggest the presence of pathology.

Ultrasonography is a simple, quick, accurate, reliable, harmless, and noninvasive procedure. The

main advantage of this diagnostic method is that it is not known to produce the dangers

associated with the use of ionizing radiation (Donald I et al, 1958). This makes it a safe

investigation at all ages and most especially during pregnancy and childhood (Queenan et al,

1975). Real-time ultrasonography is especially useful for imaging mobile structures, such as the

fetus or heart, and for quickly viewing an organ from different angles. Transabdominal and

transvaginal ultrasonography have been used intermittently during the menstrual cycle (usually

only during the follicular phase) to assess follicle development (Sack and Maharry, 1988)

Furthermore, ultrasonography is the most reliable non-invasive method that can give information

on changes in the endometrium. It has also reduced the need for pelvic examination under

anesthesia and other invasive procedures such as hysteron-salpingography, laparoscopy, and gas

gynecography (Goldstein SR, 1990)

The uterine size as determined by gynecological examination, i.e., bimanual palpation, even
under the most favorable circumstances is considered as an approximate estimate and a rough

guide as to whether or not the uterus is larger than normal. Hence, an objective method of

measurement that ensures that all the information needed is obtained and fully utilized and

interpreted with maximum efficiency is desirable. This is obtained by ultrasonography and

magnetic resonance imaging (MRI). However, the relative non-availability and high cost of the

MRI in our environment leaves the ultrasonography to be the widely used mode of imaging of

the uterus.

The ability of ultrasonography to adequately predict the uterine size has been widely investigated

and studied by many workers (Dodson and Deter, 1990). Variation in uterine size due to patient's

age, parity, and hormonal status in the menstrual cycle has been reported previously.These

changes can be investigated by ultrasonography examination, which also reveals uterine

pathology, if and when present (Bourne T et al, 1989).

 1.2 STATEMENT OF PROBLEMS

 Evaluation of normal uterine size by palpation can be difficult and inaccurate until it has

enlarged to about three times its original size. The use of hysterosalpingography is invasive,

involves ionizing radiation and can be affected or prone to errors due to poor instrumentation and

under filling. Computed Tomography involves exposure to higher dose of radiation. MRI is

relatively very expensive (Woodhead, 2017).

Thus it is most convenient and ideal to evaluate uterine size using the non-invasive ultrasound

with the advantages of widespread availability, low cost and lack of exposure to ionizing

radiation (Langer et al, 2012).

 Enlargement of uterus (bulky uterus) in the absence of physiological condition (pregnancy) and

or easily detectable pathological conditions (leiomyoma or haematometra) has been linked to

other clinical conditions such as adenomyosis and even polycystic ovarian syndrome (Lana,

2017 and Woodhead, 2017).

 Dimensional definition of bulky uterus sonographically has continued to pose problem to

sonographers/sonologists as different scholars and researchers has proposed different range of

sizes for a normal uterus.

 There is paucity of literature on the nomogram of standard uterine size in the study area.

Thus it is necessary to know the standard uterine size among nulliparous adult Yoruba females in

Lagos who have peculiar dietary lifestyle using ultrasonography as the diagnostic tool.

1.3 AIM OF THE STUDY

This study is aimed at determining the standard uterine size among nulliparous adult Yoruba

females using ultrasonography as a measurement tool.

1.4 OBJECTIVES OF THE STUDY

To measure the length, width, height and volume of the uterus

To correlate uterine Measurements with age, height and weight

To compare the uterine measurements in nulliparous adult Yoruba females to measurement in

other population groups as revealed by previous studies.

1.5 SIGNIFICANCE OF THE STUDY

This research will help in accurate determination of the normal uterine size in the study

population which is of utmost importance to the gynaecologist because of its use in the

management of some gynaecological cases such as uterine neoplasms, congenital abnormalities

as unicornuate uterus, inflammation due to trauma, atretic uterus and possible uterine infections

such as uterine tuberculosis (Dandolu et al)

The study will eliminate the erroneous diagnosis of bulky uterus within the study population

which connotes clinical (abnormal) condition.

1.6 SCOPE OF THE STUDY

This study was carried out on adult Yoruba females who visited Precise Medical Diagnostix,

Fagba, Iju-Lagos from Nov. 2018 to December 2019 and met the inclusive criteria of the study.

1.7 LIMITATION OF THE STUDY

The time frame for the study was limited which affected the sample size and might affect the

precision of the outcomes.

Also getting the subjects who the meet the inclusive criteria posed a significant threat since

ultrasonography is perceived as a test for the pregnant women especially within the local settings

which constitute the bulk of the study population.

1.8 DEFINITION OF BASIC TERMS

i. Ultrasonography: This is the use of sound waves beyond the audible frequency in the

assessment of the inner parts of the human body for abnormality.

ii. Uterus: This is the female reproductive organ which receives the fertilized egg after

implantation and habours the embyo until full development.

iii. Size: Dimensions of an object in length, width, thickness and volume.

iv. Population: The people living within a political or geographical boundary

v. Adult: A male or female human that is 18 years and above

vi. Yoruba: A mixed-religious ethnic group occupying the south western region of Nigeria.
 CHAPTER TWO

LITERATURE REVIEW

2.1 CONCEPTUAL LITERATURE REVIEW

The uterus commonly called womb is a major female hormone-responsive secondary sex organ

of the reproductive system in humans and most other mammals. In humans, the lower end of the

uterus, the cervix opens into the vagina while the upper end the fundus is connected to the

fallopian tubes. It is within the uterus that the fetus develops during gestation.

The human uterus is pear-shaped and has a normal standard dimensions of 7.6cm long, 4.5cm

broad and 3.0cm thick (Elsevier, 2011). Normal uterine dimensions in nulliparous menstruating

women are 6 to 9cm in length and up to 4cm in AP and width (Sanders and Thomas). It is a

fibro-muscular organ that can be divided anatomically into four regions: the fundus-the

uppermost portion of the uterus above the insertion of the fallopian tubes, the corpus-the middle

part or body, the isthmus- the narrow lower portion which lies approximately at the level of the

course of the uterine artery and the cervix - a carnal which protrudes into the vagina about 3cm

long (Sokol E, 2011).

2.1.1 POSITION AND RELATIONS

The uterus lies directly posterior to the urinary bladder and anterior to the rectum. It is held in

position within the pelvis by ligaments, which are called endopelvic fascia. These ligaments

include the pubo-cervical, transverse cervical ligaments or cardinal ligaments and the uterosacral

ligaments. It is covered by sheet-like fold of peritoneum, the broad ligament (Grays anat)

Usually the uterus is tilted anteriorly (anteversion) but may be normally tilted posteriorly

(retroversion). An acute angulation of the uterus in the mid portion is known as anteflexion.

Although usually in the midline position, the uterus may lie obliquely to the left or right

(Sanders).

The position of the uterus in the adult is liable to considerable variation, depending chiefly on the

condition of the bladder and rectum. When the bladder is empty the entire uterus is directed

forward, and is at the same time bent on itself at the junction of the body and cervix, so that the

body lies upon the bladder. As the latter fills, the uterus gradually becomes more and more erect,

until with a fully distended bladder the fundus may be directed backward toward the sacrum.

In the fetus, the uterus is contained in the abdominal cavity, projecting beyond the superior

aperture of the pelvis. The cervix is considerably larger than the body.

At puberty, the uterus is pyriform in shape and weighs from 14 to 17 g. It has descended into

the pelvis, the fundus being just below the level of the superior aperture of this cavity. The

palmate folds are distinct and extend to the upper part of the cavity of the organ.

During menstruation, the organ is enlarged, more vascular, and its surfaces rounder; the

external orifice is rounded, its labia are swollen, and the lining membrane of the body thickened,

softer, and of a darker color. 

During pregnancy, the uterus becomes enormously enlarged, and by the eighth month reaches

the epigastric region. The increase in size is partly due to growth of pre-existing muscle, and

partly to the development of new fibres.

2.1.2 HISTOLOGICAL STRUCTURE OF THE UTERUS

The fundus and body of the uterus are composed of three tissue layers;

The Peritoneum – A double layered membrane, continuous with the abdominal peritoneum. It is

also known as the perimetrium.

The Myometrium – Inner mucous membrane lining the uterus. It can be further subdivided into

two parts- Deep stratum basalis which shows little changes throughout menstrual cycle and is not

shed at menstruation

Superficial stratum functionalis which proliferates in response to oestrogens, and becomes

secretory to progesterone. It is shed during menstruation and regenerates from cells in the

stratum basalis layer.

Endometrium – This is the inner epithelial layer, along with its mucous membrane of the

mammalian uterus. It has basal layer and a functional layer. The functional layer thickens and

then is shed during menstruation in humans and some other mammals including apes, old world

monkeys, some species of bat and the elephant shrew. The endometrium functions to prevent

adhesions between the opposed walls of the myometrium, thereby maintaining the patency of the

uterine cavity.
2.1.3 VASCULAR SUPPLY OF THE UTERUS

The uterine artery arises from the anterior division of the internal iliac artery. It crosses above the

ureter on its course to the uterus (bridge over water)

The uterine artery commonly anastomoses with the vaginal and ovarian arteries. It is the main

blood supply of the uterus and it enlarges significantly in pregnancy.

The human uterus is drained by the uterine veins. The uterine veins form a uterine venous plexus

on each side of the cervix. Veins from the uterine plexus drain into the internal iliac veins.

Lymphatic drainage of the uterus is via the iliac, sacral, aortic and inguinal lymphnodes.
2.2.4 NERVE SUPPLY TO THE UTERUS

Sympathetic nerve fibres of the uterus arise from the uterovaginal plexus. This largely comprises

the anterior and intermediate parts of the inferior hypogastric plexus. Parasympathetic fires of the

uterus are derived from the pelvic splanchnic plexus (S1-S4)

The cervix is largely innervated by the inferior nerve fibres of the uterovaginal plexus. The

different fibres mostly ascend through the inferior hypogastric plexus to enter the spinal cord via

T10-T12 and L1 nerve fibres.

2.2.5 DISORDERS OF THE UTERUS

Endometriosis

This is the presence of ectopic endometrial tissue at sites outside the uterus, most commonly the

ovaries and the ligaments of the uterus. Ectopic tissue is still responsive to oestrogenic stimuli

therefore cyclic proliferation and bleeding occur, often forming a cyst. The condition is

associated with dysmenorrhea and /or infertility.

Fibroids

These are benign tumours of the myometrium which affect 20% of menopausal women. They are

oestrogen dependent, enlarging during pregnancy and with use of contraceptive pill but

regressing after the menopause. Most fibroids are asymptomatic but if large enough, the uterine

mass can cause symptoms like menorrhagia, pelvic pain and infertility.

Endometrial carcinoma

This is the most common malignancy of the female genital tract, most often found during or after

the menopause and characterized by abnormal uterine bleeding.

Adenomyosis

This is a condition in which the inner lining of the uterus (the endometrium) breaks through the

muscle wall of the uterus (the myometrium). Adenomyosis can cause menstrual cramps, lower

abdominal pressure and bloating before menstrual periods and can result in heavy periods. The

condition can be located throughout the entire uterus or localized in one spot (webmed)
2.2.5 SONOGRAPHIC APPEARANCE OF THE UTERUS

Regardless of the scanning approach used, a reliable landmark for orientation of the pelvis is the

uterus (Fig. 1). Therefore, it is more difficult to scan post-hysterectomy patients than those with a

uterus in situ. The uterus should be readily seen in the midplane of the pelvis and normally

exhibits an echo density that is clearly distinguishable from surrounding pelvic viscera (Fig. 2).

The endometrial echo has a variable density, depending on water content and cellular density,

that fluctuates with the hormonal status of the patient (Fig. 3). The changes noted in endometrial

ultrasonographic appearance have been characterized. The endometrium has a trilaminar

preovulatory appearance, then thickness becomes more homogeneous after ovulation.

Progressive echogenicity of the functional zone (compactum and spongiosum) occurs with

completion of the pre-ovulatory phase and during the secretory phase.17 The thickness of the

endometrium correlates with the histologic response to estrogenic stimulation.18 The relative

position of the uterus to the cervix and to the axis of the vagina should be noted. Retro-

displacement of the uterus usually produces a less clearly defined image on transabdominal

scanners but does not interfere with uterine delineation significantly using the transvaginal

approach.19 The shape or symmetry of the uterus also should be assessed during the scanning

session.
  Uterus TA probe
positioning for
longitudinal scan.

Fig. 1. Longitudinal transabdominal scan of a normal uterus (U) in proliferative phase of the
menstrual cycle. E, endometrium; B, bladder; C, cervix; V, vagina.
 Uterus TA probe positioning for transverse scan

Trans abdominal view of the uterus: transverse. Both ovaries are visible (not always the case).
Transvaginal Technique Anteverted uterus.
Normal TV image anteverted sagittal.

The overall uterine length is evaluated in the long axis from the fundus to the cervix (external os). The
depth (AP diameter) is measured from the anterior to the posterior wall and perpendicular to the length.

Transvaginal Technique Retroverted uterus.

Normal TV image Retroverted sagittal.

Fig. 2. Transvaginal scan of a uterus (U) in the proliferative phase. E, endometrium; C, cervix.
Fig. 3. Transabdominal longitudinal scan of a postmenopausal uterus (U) with less prominent
endometrial echoes. E, endometrium; B, bladder; C, cervix; V, vagina.
CERVIX

The uterine cervix is visible and may be measured with a great degree of accuracy, especially

with the transvaginal technique. Noteworthy is the fact that with the transvaginal approach, the

cervix may not be seen if the scanning tip is placed in either the anterior or posterior fornix.

Therefore, careful scanning during insertion and removal of the scanning transducer is advisable.
2.2.6 EMPIRICAL LITERATURE REVIEW

In a study “sonographic measurements of uterus and its correlation with different parameters in

parous and nulliparous women” (Ajay et al, 2016), done in Jos, plateau state Nigeria, it

concluded that uterine length increase with age among 21-40yrs age group and decrease in 41-

60yrs age group women. It shows positive correlation between uterine length and age, body

weight, height, surface area in parous but not in nulliparous with lesser uterine length in

nulliparous than parous women. This is in contrast to the submission of Piiroinen O (1975) that

uterine size has been found to be parity and not age related but partially agrees with Sokol (2011)

who stated that uterine size varies with status of parturition and estrogenic stimulation.

A similar study in Kano, north western Nigerian on sonographic measurement of uterine

dimensions in healthy nulliparous adults by Umar et al (2017), sonographic measurement of the

uterine size in 400 nulliparous women with age ranging from 15 to 25 years were done during

the secretory phase of the menstrual cycle, with the uterus measured in the anterioposterior (AP),

longitudinal and transverse planes. The uterine volume was calculated using the ellipsoid

algorithm. Height and weights of the subjects were also measured. The result showed a mean AP

uterine diameter of 3.3cm with standard deviation of 0.3 while the mean longitudinal and

transverse dimensions were found to be 6.4cm + 0.4cm and 5.1cm + 0.2cm respectively. The

mean uterine volume of the subjects was 57.4cm3 with standard deviation of + 9.1. The uterine

AP diameter showed poor correlation with age and weight but showed positive correlation with

height. Uterine length and width correlated positively with age and height but poorly correlated

with weights of the subjects. It pointed out that uterine dimensions in nulliparous women could
differ due to body habitus, race and genetic factors thus emphasizing the need for establishment

of nomograms for each geographic area.

In a cross sectional study to determine the efficacy of ultrasonographic assessment of the uterus

size in women of reproductive age done in northern Islamic republic of Iran by Esmaelzadeh S,

et al (2004), 231 women aged 15-45years were recruited. Mean uterine sized was found to be

72.8mmx42.8mmx32.4mm for nulliparous women, 90.8mmx51.7mmx43.0mm for multiparous.

Uterine size was significantly associated with age and parity but not with BMI.

A study in Benue state by C.C Ohagwu et al for real time sonographic assessment of the uterine

size, shape and positions in Nigeria recruiting 700 women made of pre-menarche, nulliparous,

multiparous and post-menopausal subjects aged between 9 and 88 produced uterine dimensions

of 5.70+ 0.60, 3.30 + 0.50 and 4.10 + 0.50 for the length, AP and transverse dimensions

respectively (Ohagwu et al, 2005).

In a study conducted by Hoke TP et al (May/June 2017) to evaluate the accuracy of

gynaecological surgeons at estimating uterine dimensions and weight, 15 resident doctors,

27attendings, and 6 medical students were employed as participants. Six model uteri of various

sizes were created to simulate the size and consistency of a uterus and displayed at 3 stations.

The visual stations comprised two specimens placed on an unmarked table. The laparoscopic

station consisted of 2 model uteri each placed in a separate simulated abdomen with a 0-degree

laparoscope and 2 operative trocars with standard instruments. The blind weight station consisted

of blind palpation of 2 separately weighted models and light models. Participants then estimate

the dimensions of each visual station and laparoscopic models and blindly palpated the blind

weight station models to estimate weight. The result shows no difference in estimation accuracy

regarding gender and age. For the visual and laparoscopic station groups, participants
underestimated all dimensions. Laparoscopic estimation was less accurate than direct vision.

Attendings and residents equally underestimated the 3 dimensions visually but attendings were

more accurate at estimating laparoscopic dimensions. All groups overestimated model weights

with attendings more accurate than residents. Summarily gynaecologic surgeons at all levels of

training are inaccurate at estimating dimensions and weights.

Cantuaria GH, et al (1998) in a study to compare bimanual examination with ultrasound

examination before hysterectomy for uterine leiomyoma employed a total of 111 women who

underwent ultrasound examination before hysterectomy for uterine leiomyomas were

retrospectively studied. Before the ultrasound examination, uterine size was estimated by

bimanual examination performed by a senior resident and confirmed by an attending physician

with results reported in terms of equivalent gestational size. Uterine dimensions on ultrasound

were converted to equivalent gestational size using an established formula. Then each uterus was

weighed and measured after surgery. On the examinations, uterine size ranged from 6 to 25

weeks. The correlation between bimanual and ultrasound estimations was highly significant.

Body mass index did not influence this correlation. Both bimanual and ultrasound estimates

correlated with actual size of pathologic specimens.

 CHAPTERTHREE

MATERIALS AND METHOD

3.1 STUDY DESIGN: This study employed a cross-sectional study design to estimate the

standard nulliparous uterine size among Yoruba females. The Yoruba females are randomly

selected adult women who came to Precise Diagnostic Centres (a subsidiary of Ayodele Med.

Group) on their own, referred or are staff or Industrial trainees and met the inclusion criteria.

3.2 STUDY LOCATION: This study was conducted at Precise Medical Diagnostix Centre, the

diagnostic Unit of Ayodele Medical Group located at 167 IJU Road, Fagba, Ifako-Ijaiye LGA-

Lagos, south west Nigeria.

3.3 ETHICAL CONSIDERATION: Informed consent was obtained from each participant

before the commencement of data collection.

3.4 POPULATION OF THE STUDY

Nulliparous adult Yoruba female from 18 years and above who visits Precise Medical Diagnostix

within the time frame of the study.

3.5 SAMPLE SIZE

Power analysis using G-Power software for sample size calculation will be used to arrive at a

suitable sample size for the study.

3.6 SAMPLING TECHNIQUE

Convenience sampling method will be employed in the research work in the selection of sample

size
3.7 SUBJECT SELECTION

3.7.I. Inclusion Criteria: Subjects who are willing to participate, who have not given birth, not

pregnant or have not been pregnant and in whom no uterine pathology was noted.

3.7.2. Exclusion Criteria: Subjects who are not willing to participate, those who are pregnant or

have been pregnant or given birth and those who when they were scanned had uterine disease.

Women who are below the age of 18 and women who are non-Nigerians

3.8 METHOD OF DATA COLLECTION

3.8.1 Equipment

The sonographic assessment was done with a high resolution real time, 3-D capable ultrasound

machine (Land-wind Mirror 5) using a 3.5MHz frequency convex (curvilinear) probe.

Other demographic data including height and weight were collected on each participant using

appropriate instruments.

3.8.2. Scanning Technique

Two basic scanning approaches are applicable to gynecologic ultrasound imaging:

transabdominal and transvaginal. The transabdominal technique refers to insonation of the pelvis

through a partially distended urinary bladder to minimize the acoustic impedance of interposed

bowel gas. This scanning technique may be performed with static scanning or real-time

equipment offering sagittal, axial, and oblique planes of pelvic anatomy for evaluation.

Static scanners produce repetitive still images of pelvic anatomy. Echoes that return from

multiple acoustic interfaces are detected by a manually maneuvered transducer and are

electronically combined to produce the final display. Real-time scanners differ from static
scanners in that the image approximates actual motion. The image is created by displaying

multiple returning images at a rapid frame rate to reflect the activity (Kremkau, 1984)

The transvaginal technique, which uses a transducer inserted into the vagina, has emerged as a

separate scanning technique applicable to gynecologic ultrasonography (Schwimer SR and

###Lebovic J, 1984). Sagittal, coronal, and oblique images of the pelvic viscera may be

obtained, as demonstrated in Figures 10, 11, 12, and 13 above. Transvaginal ultrasonography

offers several advantages over transabdominal ultrasonography. First, the scanning tip may be

placed closer to the scanning target, thus enhancing resolution. Second, a full urinary bladder is

not needed, resulting in a procedure that is more acceptable to patients. Third, transvaginal

ultrasonography interfaces nicely with the pelvic examination, which can be performed at the

same sitting. Fourth, the image quality of transvaginal ultrasonography has been found superior

to transabdominal ultrasonography in most instances, although the depth of penetration is

comparatively limited. Finally, the transvaginal approach offers superior tissue characterization

of the uterus and ovaries (Mendelson EB et al, 1988)

Although the gynaecologic trans-vaginal ultrasonography offers several advantages over the

trans-abdominal ultrasonography (Wade R et al, 2008), the trans-abdominal method was adopted

for the study owing to its lesser protocol and convenience to the volunteers.

Firstly, the volunteer with a full bladder is positioned supine on the couch with the clothing

adjusted to reveal the scanning area. A coupling gel is then applied. Coupling medium (scan gel)

was applied to the area to be scanned to ensure good transmission of the ultrasound waves. The

coupling medium also allows for smooth movement of the transducer on the patient’s body while

eliminating air between the skin and the transducer.

The length of the uterus is taken on longitudinal scan as the distance between the fundus of the

uterus and the external OS of the cervix.

On the same longitudinal orientation, uterine height was measured as the maximum distance

between the anterior and posterior uterine walls at its widest part perpendicular to the length.

The probe is then turned slowly anti-clockwise to visualize the uterus at 90 degrees to the sagittal

view. The uterine width was measured on a transverse plane between the right and left lateral

borders at the widest part.

Uterine volume was calculated using the standard ellipsoid formula:

(0.524XwidthXlengthXheight).

3.9. DATA ANALYSIS

Data was analyzed using the SPSS version 20.0. Descriptive statistics of mean, standard

deviation, frequency and percentage were utilized to summarize participant’s demographic data.

Bonferroni post hock was done to identify specific points of significance for significant ANOVA

results. Finally, spearman’s correlation analysis was utilized to explore the correlation between

uterine sizes for length, width, height and volume while Pearson’s correlation analysis was

conducted to explore the relationship between age and uterine sizes for length, width, height and

volume respectively. Alpha level was kept at 0.05.

 CHAPTER FOUR

DATA PRESENTATION, ANALYSIS AND RESULTS

Introduction

One hundred (120) subjects were enrolled for the study, the participants age spans between 18-

34yrs with an age range of 17yrs. The mean age for the study population was 23.2 ± 3.7yrs with

a median age of 23.5yrs.

Table 1: Showing Age Distribution of Respondents

Age group Frequency(F) % Total

18-22 52 43.3 52
23-28 60 50 60
29-34 8 6.7 8
Fig 1: Bar Chart Showing Age Distribution of Respondents
Table 2: Distribution of Weight (Kg) Of Subjects
Fig 2: Distribution of Weight of Subjects
Table 3: Distribution of Height (M) Of Subjects
Fig 3: Distribution of Height of Subjects
SUMMARY OF RELATIONSHIPS BETWEEN UTERINE LENGTH AND AGE

The table shows that mean uterine length increases with increase in age.

Report

Uterine Length

Age Mean N Std. Deviation

17-22 6.442 52 .7954

23-28 6.560 60 .7303

29-34 6.675 8 .9347

Total 6.517 120 .7694

Mean uterine length increases with increase in weight

Report

Uterine length

Weight Mean N Std. Deviation

44-54 6.600 17 .8299

55-65 6.606 65 .7689

66-76 6.625 32 .7135

77-87 6.631 3 .3606

88-98 6.710 3 1.0970

Total 6.6344 120 .7694

Mean uterine length increases with increase in height

Report

Uterine length

Height Mean N Std. Deviation

1.5-1.55 6.492 5 .8438

1.56-1.61 6.525 61 .8121

1.62-1.167 6.588 32 .7456

1.68-1.73 6.682 20 .6357

1.74-1.79 6.780 2 .2828

Total 6.6134 120 .7694

CORRELATIONS BETWEEN UTERINE LENGTH AND ANTHROPOMETRIC INDICES

Table 1: Relationship between Uterine Length and Age

Correlations

Uterine length Age class

Uterine length Pearson Correlation 1 .092

Sig. (2-tailed) .316

N 120 120

Age class Pearson Correlation .092 1

Sig. (2-tailed) .316

N 120 120

Statistically Insignificant 0.092 for α<0.05

Table 2: Relationship Between Uterine Length and Height

Correlations

Uterine length Height class

Uterine length Pearson Correlation 1 .048

Sig. (2-tailed) .462

N 120 120

Height class Pearson Correlation .048 1

Sig. (2-tailed) .462

N 120 120

Statistically Significant 0.048 for α<0.05

Table 3: Relationship Between Uterine Length and Weight

Correlations

Uterine length Weight class

Uterine length Pearson Correlation 1 .120

Sig. (2-tailed) .194

N 120 120

Weight class Pearson Correlation .120 1

Sig. (2-tailed) .194

N 120 120

Statistically Insignificant 0.120 for α<0.05

 CHAPTER FIVE

DISCUSSION, CONCLUSION AND RECOMMENDATION

5.1 DISCUSSION
Measurement of the uterine size using ultrasonography is a routine standard practice in
gynaecology.
Knowledge of the ranges and mean values of the normal uterine size and its correlation with

varying clinical conditions is essential in predicting uterine pathology and its knowledge enables

the radiologist to make accurate diagnosis at each ultrasonography session (Testa AC, 2009).

The accuracy of ultrasonographic measurement of uterine size, when compared with direct

measurement of histological specimens, has been investigated and found to have a very high

accuracy with no significant difference in ultrasound dimension and that obtained with direct

caliper measurement of histological specimens (Platt J.F et al, 1990)

A total of 120 subjects from 18-34 years were investigated in this study. Majority of the

respondents (60) which gives 50% in the study population were of the age category 23-28yrs.

This is followed by respondents of age category 18-22yrs (52) giving 43.3%, while the age

category with least respondents (8) giving 6.7% was found to be 29-34yrs.

The mean weight was found to be 62.5±9.0kg, while the mean height was found to be

1.62±0.05m. All subjects 120 (100%) in the study were females.

The mean AP diameter of the uterus for the subjects was 3.6cm with standard deviation of ±0.3.

The mean longitudinal dimension of the uterus for the subjects was 6.5cm with standard

deviation of 0.8. The mean transverse dimension of the uterus for the subjects was 4.6cm with a

standard deviation of 0.7. The mean uterine volume for the subjects was 55.97ml.
xxThese findings are similar to the findings by Ijeruh in Ibadan, South–western Nigeria.

Although the age range of the subjects recruited in the study by Ijeruh was 10-70 years, findings

of the corresponding age group of 3.6 cm ± 0.7 cm for the AP diameter, 6.3 cm ± 1.2 cm and 5.3

cm ± 0.7 cm for the longitudinal and transverse dimensions, respectively, are almost the same as

those obtained in this study. Ijeruh found that there was significant statistical correlation between

age, height, and weight of the subjects and AP diameter, length, and width of the uterus both

showing Pearson correlation of <0.000. However, in this study, the correlation between age, and

weight of the subjects with the uterine length was statistically insignificant (P < 0.005) while

height showed a statistically significant correlation with uterine length. This could be due to the

narrow age range of the subjects used in this study (18–34 years compared to 10–70 years).

xxxIn this study, the average uterine dimensions of 3.6cm (with standard deviation of +0.3),

6.5cm (standard deviation of 0.8), 4.6cm (standard deviation of 0.7) for AP, longitudinal and

Transverse dimensions respectively are closely related with the claim of Umar et al (2017) in

their study at Kano state Nigeria which suggested 3.3cm (with standard deviation of 0.3), 6.4cm

(+ 0.4cm) and 5.1cm (+ 0.2cm) for AP, Longitudinal and transverse dimensions respectively

although the study population of the study and age range differ slightly.

The mean uterine volume of the subjects from this study is 55.97cm3 slightly different but within

the range of uterine volume founded by the same researcher which is 57.4cm3 with standard

deviation of + 9.1.

vxAs noted in this study, the uterine length of the subjects increases with increase in age which

corroborates the findings of Ajayi et all (2016) which concluded that uterine length increases

with age from 21-40. This injunction however disagrees with the claims of Piiroinen (1975) and

Sokol (2011) which stated that uterine length is parity but not age-related.
Xxy A positive correlation between height and uterine length but not with age and weight is

noted in this study. This partly supports the findings of Umar et al (2017) which claims that

Uterine length and width correlated positively with age and height but poorly correlated with

weights of the subjects. It pointed out that uterine dimensions in nulliparous women could differ

due to body habitus, race and genetic factors.

xxxUterine dimensions founded in this study disagrees with that of Esmaelzadeh (2004) in a

study to estimate the normal uterine size in women of reproductive age in Northern Islamic of

Iran using ultrasonography which submitted average uterine dimensions of 72.8mm, 42.8mm,

32.4mm (for longitudinal, Transverse and AP dimensions) in nulliparous women.

XvThe average uterine length in this study also disagrees with the claim of Roger and Thomas in

their book titled “Clinical Sonography; a Practical Guide, fourth edition which states that normal

uterine measurements in nulliparous menstruating can be up to 9cm in length and up to 4cm in

anterior-posterior diameter and width.

The average uterine length, height (AP diameter) and width (transverse diameter) in this study

are also above the values found by Ohagwu et al (2007) in a study “Real-time sonographic

assessment of common uterine sizes, shapes and positions in Nigerians carried out in Makurdi

Benue state which founded 5.7cm, 3.3cm and 4.1cm for length, height and width respectively in

the nulliparous group.

5.2 CONCLUSION AND RECOMMENDATION
This study showed the mean uterine dimensions in a population of nulliparous adult Yoruba

females in Lagos state, Nigeria.

There was increase in uterine dimensions with increase in age, height and weight of the subjects.

The uterine longitudinal diameter showed poor correlation with age and weight but significant

correlation with the height. Mean uterine dimensions in a population of nulliprous adult Yoruba

females in Lagos, south west Nigeria, are virtually the same as that reported in Southwestern

Nigeria and Scandinavia but differ with that from those of northern Iran and other Europeans

possibly due to body habitus, racial, environmental, lifestyle and genetic factors. The study

outcome also does not totally agree with the range of size given in one of the most standard

ultrasound textbook (Clinical Sonography: A practical guide by Sanders & Winters) majorly

used by sonographers in this part of the world. These emphasizes the fact that nomograms for

each geographical area should be established.

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