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Ultrasound Obstet Gynecol 2008; 31: 210–217
Published online 15 January 2008 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/uog.5241

Changes in ultrasound morphology of the uterus and ovaries

during the menopausal transition and early postmenopause:
a 4-year longitudinal study
A. SOKALSKA* and L. VALENTIN†
*Division of Infertility and Reproductive Endocrinology, Department of Gynecology and Obstetrics, Karol Marcinkowski University of
Medical Sciences, Poznan, Poland and †Department of Obstetrics and Gynecology, Malmö University Hospital, Lund University, Malmö,
Sweden

K E Y W O R D S: longitudinal study; ovaries; perimenopause; postmenopause; ultrasonography; uterus

ABSTRACT from premenopause to postmenopause. Copyright  2008

Objectives To describe changes in uterine and ovarian
size and morphology as determined by ultrasonography
from 2 years before to 2 years after menopause.
Methods Twenty 50-year-old women with fairly regular
vaginal bleeding at the start of the study underwent
transvaginal ultrasound examination every 3 months until
12 months postmenopause, then every 6 months until
24 months postmenopause. The results are presented from
2 years before to 2 years after the menopause.
Results In the 2 years preceding menopause all the
women were in menopausal transition. From 2 years
before to 2 years after menopause uterine anteroposterior
diameter decreased by 22% (mean) and left and right
ovarian volumes by 45 and 20% (median), respectively.
At 2 years before the menopause the total number of
intraovarian follicle-like cystic structures varied from 0
to 5, at the menopause from 0 to 7, and at 1 and
2 years after the menopause from 0 to 4 and from
0 to 2, respectively. Premenopause, the most common
finding was that of ovaries containing either no follicles
or a few follicles with at least one measuring ≥ 11 mm
and simultaneously a hyperechogenic endometrium of
varying thickness and not manifesting any midline echo or
triple-layer appearance. Images compatible with the late
follicular phase were found in 6% (9/150) of examinations
(‘cycle day’ 8–196) and images compatible with the luteal
phase in 7% (10/150) (‘cycle day’ 11–56). Intraovarian
cystic structures (3–25 mm) were seen in 14 women after
the menopause.
Conclusion We have described sonographic changes in
the uterus and ovaries occurring during the transition
ISUOG. Published by John Wiley & Sons, Ltd.
INTRODUCTION
Changes in the ultrasound morphology of the uterus
and ovaries during the normal menstrual cycle have
been described1 – 5 , and reference data representative of
normal findings at transvaginal ultrasound examination
of the uterus and ovaries in postmenopausal women
have been established6 . However, to the best of our
knowledge, no results of longitudinal studies of changes
in ultrasound findings during the menopausal transition
and early postmenopause have been published. According
to Soules et al.7 the menopausal transition starts with
the beginning of the first menstrual irregularity and
ends with the final menstrual period (menopause). The
menopausal transition period precedes the final menses
by 2 to 8 years8,9 .
The aim of this study was to describe changes in uterine
and ovarian size and morphology in at least 20 women
as determined by transvaginal ultrasound examination
from approximately 2 years before to 2 years after their
menopause.
METHODS
At the end of 1994 a list with the addresses of all women
born in 1945 and living in the city of Malmö (n = 1692)
was obtained from the Malmö city administration.
Consecutive women on the list were sent a letter with
information about the study. A week later they were

Correspondence to: Prof. L. Valentin, Department of Obstetrics and Gynecology, Malmö University Hospital, SE 205 02 Malmö, Sweden
(e-mail: lil.valentin@obst.mas.lu.se)
Accepted: 4 October 2007

Copyright  2008 ISUOG. Published by John Wiley & Sons, Ltd. ORIGINAL PAPER

The menopausal transition
contacted by telephone and asked if they would agree
to participate. The inclusion criteria were: fairly regular
vaginal bleeding, no estrogen or gestagen treatment,
no intrauterine contraceptive device, no known uterine
myomas, not having undergone treatment for invasive
gynecological cancer, hysterectomy or bilateral salpingo-
oophorectomy. Forty women were recruited. All denied
having any gynecological problems or known uterine or
ovarian anomalies.
The women underwent ultrasound examination by the
second author (L.V.), who had had more than 10 years’
experience in gynecological ultrasonography at the start
of the study. They were examined every 3 months on any
‘cycle day’ until 12 months had elapsed since their last
vaginal bleeding, then every 6 months until the conclusion
of the study. The study was completed after 6 years
when 20 women had been examined from approximately
2 years pre- to approximately 2 years postmenopause.
All the sonograms were performed transvaginally in the
lithotomy position with an empty bladder. The examina-
tions included measurements of uterine anteroposterior
diameter and width, endometrial thickness, length (L),
depth (D), and width (W) of both ovaries (three orthog-
onal diameters), and of the largest follicle-like cystic
structure or corpus luteum in each ovary and of any
adnexal lesion (three orthogonal diameters). The ovar-
ian volume in mL was calculated using the formula
V = L × D × W/2. All intraovarian cystic structures with
ultrasound morphology compatible with a follicle and
with a diameter (mean of three orthogonal diameters) of
3 to 40 mm were counted as follicles, no distinction being
made between follicles and ‘functional cysts’. Cystic struc-
tures with a mean diameter ≤ 2 mm were not taken into
account. A corpus luteum was determined to be present if
an intraovarian structure with the typical gray-scale ultra-
sound morphology of a corpus luteum and surrounded
by a typical ‘color ring’ at color Doppler examination
was seen10 – 13 . The anteroposterior diameter of the uterus
was measured on a sagittal view of the uterus where it
appeared to be at its thickest, and the width of the uterus
was measured on a transverse view of the uterus where
it appeared to be at its widest. Endometrial thickness
was measured as described earlier using the double-layer
technique14 . One measurement of each distance was taken
using calipers on the frozen ultrasound image. The fol-
lowing were also noted: the ultrasound morphology of the
endometrium (midline echo, triple layer, hyperechogenic,
cystic) the number of follicle-like cystic structures and
corpora lutea, and the presence, location, size, and mor-
phology of any uterine or adnexal lesions. All ultrasound
examinations were documented on hard copies.
The ultrasound examinations were performed using an
Acuson 128XP ultrasound system (Acuson Inc., Mountain
View, CA, USA) with a 4–7.5-MHz transvaginal
transducer. Doppler ultrasound, both in color and spectral
modes, was performed at a frequency of 5 MHz.
At each ultrasound examination the women were asked
about any medication and about menopausal symptoms
(hot flashes, palpitations, etc.) and other symptoms, and a
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211
venous blood sample was drawn. The blood samples were
immediately centrifuged at 3000 g for 10 min. Serum was
then separated, frozen and stored at −30◦ C until analyzed
after the conclusion of the study. Follicle-stimulating
hormone (FSH) and progesterone were analyzed using the
TM
Access (R) Immunoassay System on a UniCel DxI 800
from Beckman Coulter (Chaska, MI, USA). Progesterone
was analyzed in blood samples taken when the ultrasound
image was clearly compatible or possibly compatible with
the presence of a corpus luteum. Progesterone levels
≥ 10 nmol/L were taken to indicate that ovulation had
occurred15 . FSH was analyzed in blood samples taken
at 3 and 6 months after the last vaginal bleeding, values
≥ 17 IU/L indicating postmenopausal status according to
the reference values of our laboratory.
All the women noted their vaginal bleedings on
a dedicated form during the whole study period.
Retrospectively, they were classified as being in early
or late menopausal transition using the STRAW criteria7 ,
according to which, during early menopausal transition,
menstrual cycles remain regular but with duration
changed by 7 days or more. Two or more skipped
menstrual cycles and at least one intermenstrual interval
of ≥ 60 days are characteristic of the late menopausal
transition. Women who did not have any vaginal bleeding
for 12 months were considered to be postmenopausal,
provided that their serum FSH was ≥ 17 IU/L in blood
samples taken 3 and 6 months after their last vaginal
bleed.
The pattern of change over time for each ultrasound
variable studied was described separately for each woman
by inspection of plots of results against time. The
percentage change over time in measured variables was
calculated as (1 − the value at time B/the value at time A)
×100, where time A precedes time B. Depending on the
distribution of the percentage change, results are presented
as mean or median percentage change.
Statistical analyses were carried out using the Statview
TM
4.5 statistical program (Abacus Concepts, Inc., Berke-
ley, CA, USA, 1992–1995). Because our data mani-
fested a skewed distribution, the statistical test used was
Wilcoxon’s test for paired data. A two-tailed P-value
< 0.05 was considered statistically significant.
The ethics committee of the Medical Faculty of Lund
University, Sweden, approved the study and written
consent was obtained from all the participants.
RESULTS
Of the 40 women who entered the study eight withdrew
for unknown reasons and 12 women were excluded for the
following reasons: one woman had a gestagen intrauterine
device inserted during the study period, three women
started hormone replacement therapy, six women still
had fairly regular vaginal bleedings at the conclusion of
the study, and two women underwent only one or two
examinations before menopause.
Twenty women were included in the study. All were
white Scandinavian, all were 50 years old when they
Ultrasound Obstet Gynecol 2008; 31: 210–217.

212
entered the study and none had a history compatible
with polycystic ovary syndrome. Three women were
nulliparous, all three being voluntarily childless, the
remaining 17 had delivered one, two or three babies.
Five women were on medication(s) throughout the study
period, and all except three were on medication(s) for
some time during the study period (e.g. antihypertensive
or anti-arrhythmic drugs, antihistamines, psychotropic
drugs, and/or immunosuppressants, the latter given
against rheumatoid arthritis).
Despite all subjects denying having uterine or ovarian
disorders, 12 (60%) were found to have uterine fibroids
at ultrasound examination, eight having one fibroid
< 20 mm in diameter, and four having 2–8 fibroids
ranging from 10 to 65 mm in diameter. One woman
had ultrasound findings compatible with adenomyosis,
and in two women one or more 15–20-mm extraovarian
cysts were seen. No other gynecological abnormalities
were detected.
For 18 of the 20 women the period of observa-
tion before menopause was at least 24 months (up to
54 months). One woman was examined from 15 months
before to 24 months after menopause, one from
21 months before to 24 months after menopause, one
from 54 months before to 18 months after menopause,
and the remaining 17 women from 24 to 51 months
before to 24 months after menopause. Only the results
from 24 months before to 24 months after menopause
are presented.
According to the STRAW criteria7 , seven women
passed from early to late menopausal transition during
the 24 months preceding menopause, while 13 women
were in late menopausal transition during the whole
24 months’ study period preceding menopause. Mean
age at menopause was 52.8 ± 1.01 (SD) years. In all
women FSH levels at 3 and 6 months after the last menses
confirmed that the last bleed was indeed the menopause,
FSH levels ranging from 38 to 148 IU/L.
Inspection of individual plots of results against time
revealed that for each measured ultrasound variable there
were three individual patterns of change: decrease over
time; increase over time; or no clear change over time. The
individual patterns of change for the variables studied are
summarized in Table 1. In most of the women, uterine
and ovarian size, endometrial thickness and total number
of intraovarian follicle-like cystic structures (i.e. the sum
of the number in the right and left ovary) decreased during
the study period, but a substantial decrease did not occur
until after the menopause.
Changes in uterine size and endometrial thickness
during the 4-year study period are illustrated in Figure 1.
The decrease in uterine size and endometrial thickness
between 24 months before and 24 months after the
menopause was statistically significant, the mean change
in uterine anteroposterior diameter being a 22% decrease
and in uterine width a 19% decrease. The median
change in endometrial thickness was a 28% decrease.
Changes in the size of the largest ovary are illustrated in
Figure 2a. The volume of the largest ovary did not change
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Sokalska and Valentin
Table 1 Individual patterns of change for ultrasound variables
Decrease Increase No clear
Parameter (n (%)) (n (%)) change (n (%))
Uterine width 19 (95) 0 1 (5)*
Uterine AP diameter 20 (100) 0 0
Endometrial thickness 16 (80) 0 4 (20)
Volume of largest ovary 14 (70) 1 (5) 5 (25)
Total number of follicles 17 (85) 0 3 (15)
(right and left ovaries)
*This woman had six myomas. AP, anteroposterior.
significantly before menopause. However, the volume of
the largest ovary was smaller 24 months after menopause
than at menopause (P = 0.05) or 24 months before
menopause (P = 0.05). The median volume of the largest
ovary 24 months before menopause was 6.3 (range,
2.0–15.7) mL vs. 3.4 (range, 1.3–10.8) mL 24 months
after the menopause. Median changes in left and right
ovarian volume from 24 months before to 24 months after
the menopause were a 45% decrease (P = 0.075) and a
20% decrease (P = 0.056), respectively. The diameter of
the largest intraovarian follicle-like cystic structure was
similar until menopause, median diameter at 24 months
before menopause being 14 mm, at 12 months before
menopause 15 mm, and at menopause 16 mm.
Changes in the total number of follicle-like cystic
structures/corpora lutea are illustrated in Figure 2b. The
total number at 24 months before menopause did not
differ significantly from that at menopause but was
significantly lower 12 and 24 months after menopause
than at menopause. The number at 24 months before
menopause varied from 0 to 5, at the time of menopause
from 0 to 7 and at 1 and 2 years after menopause from
0 to 4 and from 0 to 2, respectively. Cystic intraovarian
structures were observed in the postmenopausal period in
14 women; in ten women they were seen only in the first
postmenopausal year (size ≥ 11 mm in six women), in four
women they were also seen in the second postmenopausal
year (size ≥ 11 mm in three women).
A summary of all the ultrasound findings is presented
in Table 2, while Table 3 shows the number of women
with antral follicles, corpora lutea, or follicles > 11 mm in
diameter and a triple-layer endometrium in relation to the
time pre- or postmenopause. Ultrasound findings compat-
ible with the late follicular phase (follicle ≥ 11 mm and
triple-layer endometrium) could be found on virtually any
cycle day. During the 24 months preceding menopause,
the most common ultrasound finding was that of ovaries
containing either a few cystic structures with at least one
measuring ≥ 11 mm, or no follicle-like structures, and
simultaneously a slightly hyperechogenic endometrium of
varying thickness but not manifesting any midline echo or
triple-layer appearance. There was no obvious relation-
ship between the number or size of follicle-like cystic struc-
tures seen in the ovaries and the presence of a triple-layer
endometrium, but when a triple-layer endometrium was
seen, at least one follicle-like cystic structure ≥ 7 mm was
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The menopausal transition 213

P = 0.0004 P = 0.001
(b)
(a) 8 P = 0.0218 P = 0.0006

8
7
Uterine AP diameter (cm)

Uterine width (cm)

7
6

6
5

5
4

4
3
(n = 18) (n = 20) (n = 19) (n = 20) (n = 19)
(n = 18) (n = 20) (n = 19) (n = 20) (n = 19)
0 0
−24 −12 MP +12 +24 −24 −12 MP +12 +24
23 (6−179) 54 (3−121) 44 (5−209) 23 (6−179) 54 (3−121) 44 (5−209)
Cycle day (median (range))
Cycle day (median (range))

Figure 1 Uterine anteroposterior (AP) diameter (a), uterine width

P = 0.0096
(b) and endometrial thickness (c) in relation to menopause (MP).
(c) 16 Results are shown for examinations performed at 24 and
P = 0.0052 12 months before MP (−24, −12), at MP, and at 12 and 24 months
14 after MP (+12, +24). MP corresponds to an examination
Endometrial thickness (mm)

performed no earlier than 1.5 months before and no later than

12 2 months after the last uterine bleed. The cycle days on which the
examinations were performed are also shown. Median and 10th ,
10
25th , 75th and 90th percentiles are shown. One woman had no
8 examination corresponding to MP. The lower number of
endometrial measurements is explained by the endometrium not
6 always being seen clearly enough to allow a reliable measurement
of its thickness.
4

2 of follicle-like cystic structures/corpora lutea during the

(n = 16) (n = 18) (n = 18)
0 2 years preceding menopause, when all the women were
−24 −12 MP
23 (6−179) 45 (3−121) 49 (11−209)
Cycle day (median (range))
always detected. Intraovarian cystic structures 30–40 mm
(counted as follicles) were seen once in three women and
twice in two women before menopause. None of these per-
sisted. Two women had ultrasound findings compatible
with a corpus luteum at the time of menopause (on ‘cycle
days’ 12 and 56), the presence of a corpus luteum being
verified by progesterone values of 11 and 14 nmol/mL
and by vaginal bleeding occurring 11 and 15 days after
the examination. In one woman a 9-mm triple-layer
endometrium and a 13-mm intraovarian follicle-like cystic
structure was observed 6 months after menopause, while
images of subsequent examinations suggested low estro-
genic activity with thin hyperechogenic endometrium and
no visible follicles in any ovary.
DISCUSSION
Our results showed no statistically or clinically signifi-
cant changes in uterine or ovarian size or total number
(n = 15) (n = 15)
+12 +24
in menopausal transition. Substantial changes occurred
only after the menopause, when uterine and ovarian size,
endometrial thickness and number of follicle-like cystic
structures/corpora lutea decreased. The decrease in uterine
size after menopause is likely to be explained by a decrease
in estrogen levels16 , because estrogen levels drop dramat-
ically postmenopause15 . Shrinkage of the ovaries is likely
to be explained by depletion of follicles, which is a slow
process starting as early as in fetal life17 and accelerating
at 38 years of age or when about 25 000 follicles remain18 .
This means that a decrease in ovarian size had probably
started long before the women entered our study at the age
of 50 years. At 24 months before menopause the ovaries
were smaller (median volume of largest ovary 6 mL) than
in normo-ovulatory women of fertile age10 , in whom the
median volume of the non-dominant ovary is about 8 mL
throughout the menstrual cycle. During the whole 4-year
study period the number of follicle-like structures in our
study cohort was much smaller than in a sample of 12
women of fertile age studied longitudinally by ultrasono-
graphy on predetermined cycle days during one menstrual
cycle. The median total number of visible follicles in the
latter was 8–12, depending on the cycle day (unpubl. data
from a study described by Sladkevicius et al.13 ), while the

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214 Sokalska and Valentin

P = 0.0535 also because ultrasound images compatible with a specific

(a) 16 phase of a normal mentrual cycle1 – 5,11 – 13 were very rarely
P = 0.1208 encountered. Irrespective of the ‘cycle day’ – or, more cor-
14 rectly, irrespective of the number of days since the last
Volume of largest ovary (cm3)

12 vaginal bleed – the most typical ultrasound image was

one of ovaries containing no visible follicles or only a few
10 follicle-like structures, the largest follicle-like structure
8 often measuring ≥ 11 mm in diameter, and simultane-
ously a diffusely hyperechogenic endometrium without a
6
middle echo or triple-layer appearance. Our findings are
4 congruent with those of Landgren et al., who reported that
62% of menstrual cycles examined during the last 10 years
2
(n = 16) (n = 18) (n = 19) (n = 17) (n = 16) before menopause were anovulatory19 . They are also com-
0 patible with those of Rannevik et al.15 , who found that
−24 −12 MP +12 +24
21 (6−179) 54 (3−121) 44 (5−209)
only 5% of investigated ‘cycles’ – where blood samples
Cycle day (median (range))
had been taken on ‘cycle day’ 11 or later – were ovula-
tory during the last 6 months preceding the menopause.
(b) However, it is noteworthy that in two women in our study
4 the last vaginal bleeding – i.e. menopause – occurred after
P = 0.0033
ovulation, a corpus luteum having been identified at ultra-
Total number of follicles (n)

P = 0.002 sound examination and confirmed by progesterone levels

3
2 We saw follicle-like structures in the ovaries of most
1
0 our observation may also support intermittent estrogen
(n = 18) (n = 20) (n = 19)
−24 −12 MP
23 (6−179) 54 (3−121) 44 (5−209)
Cycle day (median (range))
Figure 2 Ovarian volume (a) and number of follicles (b) in relation
to menopause (MP). Results are shown for examinations
performed at 24 and 12 months before MP (−24, −12), at MP, and
at 12 and 24 months after MP (+12, +24). MP corresponds to an
examination performed no earlier than 1.5 months before and no
later than 2 months after the last uterine bleed. Median and 10th ,
25th , 75th and 90th percentiles are shown. At 12 months before
menopause, the 10th and 25th percentiles for number of follicles
were 0 and the 75th and 90th percentiles were 2. At 12 and 24
months postmenopause, the 10th , 25th , 50th and 75th percentiles for
number of follicles were 0 and the 90th percentile was 1. The
numbers in brackets denote the number of subjects. One woman
had no examination corresponding to MP. The lower number of
ovarian volume measurements is explained by the ovaries not
always being visible. The total number of follicles is the sum of all
intraovarian cystic follicle-like structures in the right and left
ovaries. The cycle days on which the examinations were performed
are also shown.
median numbers at 2 years and 1 year before menopause
in the current study were 2 and 1, respectively. In a pub-
lished study of women of fertile age the average number
of visible follicles per ovary was 6 or 75 .
Gray-scale ultrasound findings in women in menopausal
transition were clearly different from those in women of
fertile age, not only because the ovaries were smaller
and the number of follicle-like structures much lower but
> 10 nmol/mL at 11 and 15 days before the last menstrual
bleed.
women in the first year after menopause and in a few
women also during the second postmenopausal year.
Some of these follicle-like structures might have been
functional cysts, inclusion cysts or neoplastic cysts, but
(n = 20) (n = 19) production and continuing follicular activity some time
+12 +24 after the termination of bleeding20,21 . Our finding of
a thick triple-layer endometrium and a 13-mm intra-
ovarian follicle-like structure 6 months after menopause
in one woman also supports this. Intraovarian cystic
structures of varying size are common findings in asymp-
tomatic postmenopausal women22,23 . In women many
years past menopause, most intraovarian cystic structures
seen on ultrasound are inclusion cysts23 , but the origin
of intraovarian cystic structures may be different shortly
after menopause.
To the best of our knowledge, there are no published
reports of longitudinal studies elucidating changes in uter-
ine or ovarian size or ultrasound morphology during the
years before and after menopause. However, reference
values for uterine and ovarian size for women of different
age have been established in cross-sectional studies. These
show a significant reduction in uterine size related to years
since menopause24 and a decrease in ovarian volume and
number of follicles with advancing age25 – 29 . These studies
covered a much longer time span than ours. Moreover,
it is important to realize that physiological changes over
time can only be determined in longitudinal studies, which
allow detection of changes within subjects. Therefore, the
results of our study are not directly comparable with those
cited25 – 29 .
The mean age at menopause in our study sample
was higher (52.8 years) than that reported by others
(50–52 years)8,9 . This may be explained by one of our
inclusion criteria being fairly regular vaginal bleeding at

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The menopausal transition 215

Table 2 Ultrasound findings at examinations performed longitudinally from 2 years before to 2 years after menopause (MP)

−24 to −12 months* −9 months to MP† +3 to +12 months‡ +18 to +24 months§
Examinations with: (n = 83) (n = 67) (n = 76) (n = 39)

Intraovarian follicle-like structures

None
n (%) 19 (23) 26 (39) 51 (67) 32 (82)
Cycle day (median (range)) 33 (7–250) 89 (5–305) N/A N/A
At least one 3–10 mm
n (%) 19 (23) 6 (9) 12 (16) 3 (8)
Cycle day (median (range)) 24 (8–121) 42 (5–303) N/A N/A
At least one ≥ 11 mm
n (%) 45 (54) 35 (52) 13 (17) 4 (10)
Cycle day (median (range)) 28 (2–179) 55 (1–305) N/A N/A
Triple-layer endometrium
n (%) 9 (11) 3 (4) 1 (1) 0
Triple-layer endometrium and
follicle-like structure ≥ 11 mm
n (%) 6 (7) 3 (4) 1 (1) 0
Cycle day (median (range)) 14 (8–50) 152 (113–196) N/A N/A
Corpus luteum¶
n (%) 7 (8) 3 (4) 0 0
Cycle day (median (range)) 23 (12–30) 12 (11–56) N/A N/A

*Examinations performed from 24 to 12 months before MP. †Examinations performed from 9 months before MP to MP. ‡Examinations
performed from 3 to 12 months after MP. §Examinations performed from 18 to 24 months after MP. ¶Confirmed by a progesterone value
≥ 10 (range, 10.5–34) nmol/L. N/A, not applicable.

Table 3 Number of women with intraovarian follicle-like structures or corpora lutea in relation to menopause (MP)

Time in relation to menopause

−24 months −12 months MP +12 months +24 months

Number of women with: (n = 18) (n = 20) (n = 19) (n = 20) (n = 19)

Follicle-like structure or corpora lutea 14 13 14 3 3

Corpora lutea 3 2 2 0 0
Follicle-like structure ≥ 11 mm in diameter and triple-layer endometrium 3 2 1 0 0

the age of 50 years. The reason why we chose to start
scanning the women at this relatively advanced age was
that we hoped that all would be close to menopause at
the start of the study.
The fact that all the women were in menopausal
transition during the 2 years preceding menopause
explains why it was not possible to perform all
examinations on a predefined cycle day during this
period – for example, a few days after the start of a
vaginal bleed. Had we performed all examinations a few
days after the start of a vaginal bleed, it would not have
been possible to keep the ‘every-3-months schedule’ that
was necessary to relate the examinations to time before
menopause with reasonable precision. The fact that our
examinations were carried out on any ‘cycle day’ may
have affected our results with regard to ovarian size and
morphology and to a lesser extent those regarding uterine
size and endometrial thickness and morphology. We are
not convinced, however, that this is the case, because,
during menopausal transition, many bleedings are almost
certainly anovulatory15,19 and ‘cycle day’ is not a reliable
marker of the menstrual phase or hormonal status. Our
results support this; most ultrasound findings were not
compatible with a particular phase of the menstrual cycle
irrespective of the ‘cycle day’ on which the examination
was performed; ultrasound findings compatible with the
late follicular phase were encountered on any ‘cycle day’;
and ultrasound findings compatible with the luteal phase
as late as on ‘cycle day’ 56.
A methodological difficulty is how to discriminate
between a follicle, a functional cyst, an inclusion cyst,
and a small neoplastic cyst. This is particularly difficult in
the menopausal transition, when women no longer have
cycles but bleed irregularly and often very infrequently.
Because of the uncertainty regarding the origin of intra-
ovarian cystic structures we chose to call all intraovarian
cystic structures 3–40 mm in diameter ‘follicle-like cystic
structures’. Before the menopause, most of these cystic
structures were probably follicles, but some may have
been functional cysts (none of the cystic structures of
30–40 mm persisted), inclusion cysts or even neoplas-
tic cysts.
The menopausal transition period is characterized
by significant hormonal fluctuations, and results of
single hormonal measurements (estradiol, estrone, FSH,
leutinizing hormone or inhibin) during this period do not

Copyright  2008 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2008; 31: 210–217.

216
provide reliable information on menopausal status30,31 .
Anti-Müllerian hormone, on the other hand, seems
to reflect the ‘ovarian reserve’ well32 . The hormonal
fluctuations in the menopausal transition are secondary
to structural changes in the ovaries (ovarian volume,
number of antral follicles)33 and possibly to changes
in ovarian vascularization34 . These changes can be
studied non-invasively using ultrasonography. Today, a
transvaginal ultrasound examination is often included in
a gynecological consultation. By supplementing clinical
information with transvaginal ultrasound examination
a quick and cheap answer as to whether a woman
is likely to be in the menopausal transition can be
obtained. The finding on any ‘cycle day’ of small
ovaries, few intraovarian follicle-like structures and
simultaneously a hyperechogenic endometrium of any
thickness without a triple-layer appearance would support
the menopausal transition.
ACKNOWLEDGMENTS
This study was supported by the Swedish Medi-
cal Research Council (grants nos. K2001-72X-11605-
06A, K2002-72X-11605-07B, K2004-73X-11605-09A
and K2006-73X-11605-11-3), two governmental grants
(Landstingsfinansierad regional forskning, Region Skåne
and ALF-medel), and Funds administered by Malmö Uni-
versity Hospital.
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