Abstract

UTERINE VOLUME AND ITS RELEVANCE IN CLINICAL PRACTICE

A.A. Rabarijaona*, M. Rhemimet, O. Sardaoui, Najia Zeraidi, Amina Lakhdar, Aziz Baydada

ABSTRACT

Introduction: The relevant uterine size is its total size. Aim of the study: The aim of the study is a literature review on how to assess the uterine volume and its relevance in clinical practice. Materials and Methods: We searched articles by using the following keywords: Uterine volume, endometrial volume, Uterine size, Uterine weight, Enlarge uterus. Science direct and Pubmed are the data bases we used. Totally, we included 52 studies. Our inclusion critearia was the study who evaluated their uterine volume by the ellipsoid formula and or the 3D ultrasonography and or the Magnetic Resonance Images (MRI). We included too the study who elaborate the relationship between uterine volume and his clinical relevance. We excluded articles who evaluate the uterine size by his height and the studies who evaluated just the cavity volume. The estimation of uterine volume is more accurate with VOCALTM and Cavalieri Method compared with 2D Ultrasonography. Moreover, the ellipsoid method used in ultrasound images may be inadequate for determining the volume of uterine layers especially the volume of the endometrium. The uterine volume increases during childhood, with a faster increase in adolescence reflecting the influence of puberty, followed by a slow but gradual increase in adulthood. There is a relative lack of data on uterine volume in girls over seven years of age. At the age of three, the predicted uterine volume is 1.5 cm3 (68% prediction limit 1.5 - 3.2 cm3), while the predicted uterine volume (post -pubertal) at the age of 15 is 25.8 cm3 (68% preferred limit 25.8 - 77.8 cm3). Women aged 16 to 20 with normal sized uteri, with normal pelvic ultrasound findings, showed uterine volume to vary from 24 to 50 cm3, averaging 34 cm3. For women aged 45 to 55 with normal pelvis and ultrasound normal-sized uteri, ultrasound results showed uterine volume ranged from 15 to 56 cm3, with an average of 35 cm3. After puberty, the steady increase in uterine volume is probably related to parity. It was found that despite standard oestrogen therapy, uterine growth is often compromised in those with hypogonadism (48% had total uterine volume measurements less than the 5th percentile). Uterine development was clearly jeopardized when estrogen insufficiency started at a very young age. Besides, total body bone mineral density (BMD) proved to be more affected by precocious estrogen deficiency too in younger age groups. The Uterine volume < 5 cm3 (p< 0.0001) - Total body BMD (p = 0.0005) was in Primary amenorrhea = 53,3% - 0.99 ± 0.10 g/ cm3, in Secondary amenorrhea ≤ 5years ga (Gynecologic age) = 93,6% - 1.04 ± 0.08 g/ cm3, in Secondary amenorrhea 6 - 15years ga = 61,8% - 1.09 ± 0.10 g/ cm3, Secondary amenorrhea > 15years ga = 83,3% - 1.12 ± 0.11 g/cm3. Maternal smoking, but not variations in fetal growth, may lead to a reduction in uterine volume in adolescent. Linear regression showed that daughters of mothers who smoked had a significantly smaller uterus compared with nonsmokers: 31.6 cm3 (28.2–35.5) vs 38.6 cm3 (36.2– 41.1), (P = 0.019). Girls with AUB have significantly larger uterine volume than healthy girls (63.2 ± 24.8 vs 47.8 ± 17.5 cm3) and even higher than in healthy nulliparous women of childbearing age. Cytotoxic treatment in childhood does not affect adult uterine size: chemotherapy only (median 47 mL, range 22-88 ml), radiotherapy above the diaphragm (median 40 mL, range 24-61ml), or radiotherapy below the diaphragm not directly involving the uterus (median 34 mL, range 8-77ml), (p < 0.02 in all comparisons). In contrast, uterine irradiation at a young age reduces adult uterine volume (median: 13 mL, range 1-52 mL) and the radiotherapy-induced damage is probably irreversible. As well as, bone marrow transplantation as main treatment and Total Body Irradiation (TBI) and busulfan as conditioning regimens which have a worst effect on uterine and ovarian sizes compared with healthy controls. Median uterus and ovarian volumes were reduced by 64% (95% CI, 56.6-70.6) and 83.6% (95% CI, 79.6-86.7), respectively. Uterine volume was reduced after TBI (percent reduction 81.9%; 95% CI, 71.8-87.8) or busulfan (percentage reduction 67.4%; 95% CI, 58.5-75.6) compared with those who had not received a conditioning regimen (percentage reduction 24.4%; 95% CI, 7.6-38.2). The endometrial and uterine body volume ratio (EV / UCV) with a cutoff value greater than 0.017 may be predictive of atypia or endometrial malignancy in postmenopausal bleeding women. Patients with Polycystic ovary syndrom (PCOS) and body mass index (BMI) ≥ 25 kg / m2 had a larger uterine volume than PCOS patients with a BMI < 25 kg / m2 (P <.001). However, a smaller uterine volume in PCOS patients with phenotypes 1 and 2 (38.3 ± 18.6 cm 3) compared to PCOS patients with phenotypes 3 and 4 (42.1 ± 19.1 cm 3), (P = 0.033), is possibly a consequence of the more severe hyperandrogenemia in patients diagnosed with PCOS according to NIH criteria. The uterine volume of the endometriosis group (69 ± 26 cm3) was larger than those of the control group (54 ± 18 cm3), P<0.01 in C Peng et al. study and 50.9 ± 14.4 cm3 vs 41.7 ± 14.3 cm3 in Akemi Koshiba study (mean ± standard deviation), P < 0.01. The uterine volume of dysmenorrhea patients in the endometriosis group (73 ± 28 cm3) was greater than that of patients without dysmenorrhea (62 ± 19 cm3), P<0.01]. The degree of dysmenorrhea in endometriosis group was positively correlated with the uterine volume (r=0.20, P=0.042). The uterine volume of stage Ⅳendometriosis patients (79 ± 30 cm3) was greater than that of stage Ⅲ patients in endometriosis group (58 ± 14 cm3), P<0.01]. The optimum cutoff value of uterine volume more than 150 mL was significantly associated with failure of LNG-IUD. In untreated symptomatic adenomyosis, patients with an International Prostate Symptom Score (IPSS) total score ≥8 had higher proportion of menorrhagia and larger uterine volumes compared to patients with an IPSS total score <8. Mean basal uterine volume was 305 ± 31 cm3. 24% ± 6.8% reduction in uterine volume was observed after 3 months of somatostatin analogue Lanreotide therapy (P<.05). A significant reduction of about 17% ± 4.1% was observed 3 months after the end of treatment (P<.05). Mean basal myoma volume was 24 ± 6 cm3. Mean myoma volume was reduced by 41.6% ± 11% (P<.05) after therapy and 29.2% ± 7% (P<0.5) 3 months after the end of treatment. So the growth hormone–IGF system plays a pathogenic role in maintaining uterine fibromyomas and that somatostatin analogue may be an effective new therapy for this condition. The LNG-IUS significantly reduces uterine volume in women with menorrhagia with and without leiomyoma: mean reduction of 63.6+/-19.0 (S.D.) cm3 (from 156.6 cm3 to 93 cm3), p=.014; and mean reduction of 36.4+/-15.3 (S.D.) cm3 (from 127.1 cm3to 90.7 cm3) was observed (p=.041), respectively. However, it does not significantly reduce the volume of leiomyomas: mean volume of leiomyomas decreased by 5.2+/-3.1 (S.D.) cm3 (from 12.8 cm3 to 7.6 cm3 after 3 years of use, but this difference was not significant (p=.4099). André Bernardo et al. showed that the uterine artery embolization significantly reduced uterine volume 35% reduction and greater myoma diameter 22% reduction after 3 months, but did not cause a significant increase in FSH levels Mean FSH concentration was 4.9 ± 3.5 IU/mL before UAE and 5.5 ± 4.7 IU/mL after UAE, with p=0.5., thus causing no changes in ovarian function. In the other hand, A Khaund et al. found a median reduction in uterine volume was 40% (n= 46, 95% CI 33.0-49.7, P < 0.001) at six months. Moreover, UAE causes a statistically significant reduction in objectively measured MBL: median MBL decreased to 60 mL at 3 months (n= 34, range 0-767, P < 0.001), 70 mL at 6-9 months (n= 34, range 0-1283, P < 0.001), 37 mL at 12-24 months (n= 25, range 0-265, P < 0.001), 18 mL at 24-36 months (n= 17, range 0-205, P < 0.001) and 41 mL at 36-48 months (n= 6, range 0-66, P < 0.05). There was no relationship between the changes in uterine volume and MBL. Andrea Di Lierto et al. found that uterine volume decreased significantly after leuprorelin acetate depot 3.75 mg treatment of three cycles: 571.3 ± 266.7 cm3 (mean ± SD) at the first ultrasonographic scanning and 413.4 ± 217 cm3 after Gn-RH analogue administration, with a shrinkage of 0.27 ± 0.17. The difference between the first and second evaluations was found to be statistically (Student t test, α = 0.05) significant. The decrease in the uterine volume was found to be statistically related to PDGF expression: mean changes in uterine volume after GnRH analogue treatment were 0.36 ± 0.19 (mean ± SD) in grade 0, 0.32 ± 0.18 in grade 1, 0.14 ± 0.03 in grade 2, and 0.09 ± 0.006 in grade 3. The decreased PDGF production in leiomyomas after GnRH analogue treatment and the relationship between decreased PDGF expression and greater shrink age in uterine volume suggest that PDGF might have a mitogenic action on leiomyomas in vivo. Studies showed that the optimal volume for clinical pregnancy rate is less than 70ml. The Optimal volume for Live Birth is 30 to 70 ml. The optimal volume for Full term Birth is 55,5ml. And the miscarriage rate was significantly higher in group ＞ 98.81 cm3 with adenomyosis. The average uterine volume values of 30.2 +/- 17.8 cm3 were found in adolescent aged 10 to 11 years and 40.0 +/- 16.5 cm3 the group of 16 to 17 years (p = 0.05). However, the uterine volume in adolescents aged 18 to 19 was 17.8 - 44.8 cm3 value significantly similar to that of women aged 20 to 40 (p 0.05). In this context, educational actions aimed at choosing the ideal age to begin reproductive life, will have a consequent reduction in maternal and neonatal mortality among pregnant adolescents and improvement of the population's health indicators. The uterine weight can be calculated from a formula of 50.0 + 0.71 x volume (cm3). Rather than uterine volume or vaginal access, the limits of the vaginal route appear mainly to be linked to difficulties of access to the uterine pedicles and to the existence of subperitoneal endometriosis, adnexal mass or pelvic adhesions. Conclusion: Ultrasonography and MRI can be used to estimate uterine volume. There is a validated normative model of uterine volume and variation of uterine volume. It is shown that the estimation of uterine volume associated with other parameters is relevant in clinical practice.

Keywords: .