Normal Image Findings of the Uterus 37
Normal Imaging Findings of the Uterus
Claudia Klüner and Bernd Hamm
CONTENTS
3.1 Embryonic Development and
Normal Anatomy of the Uterus 37
3.2 Imaging Findings: Uterine Corpus 40
3.3 Imaging Findings: Uterine Cervix 44
References 47
3.1
Embryonic Development and
Normal Anatomy of the Uterus
During embryonal life, fusion of the two Müllerian
ducts gives rise to the uterine corpus, isthmus, cervix,
and the upper third of the vagina. The Müllerian ducts
are of mesodermal origin and arise in the 4th week
of gestation. They course on both sides lateral to the
ducts of the mesonephros (Wolffian ducts). The lower
two thirds of the vagina arise from the sinovaginal
bulb, which develops from the posterior portion of the
urogenital sinus. The vaginal epithelium arises from
the cellular lining of the urogenital sinus [1].
The uterus is composed of three distinct anatomic
regions, namely the corpus, the isthmus (or lower
uterine segment), and the cervix. In women of re-
productive age, the uterus usually is 6–9 cm long and
weighs 40–60 g. The longitudinal axis is flexed for-
ward (anteversion) with the corpus and cervix form-
ing a blunt angle (anteflection) (Fig. 3.1a). The uterus
straightens with increasing bladder filling and the
anteversion angle becomes smaller (Fig. 3.1b).
The wall of the uterine corpus differs from that of
the cervix in that it mostly consists of myometrium,
C. Klüner, MD
Institut für Radiologie (Campus Mitte), Charité – Universitäts-
medizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
B. Hamm, MD
Professor and Chairman, Institut für Radiologie (Campus
Mitte), Klinik für Strahlenheilkunde (Campus Virchow-Klini-
kum und Campus Buch), Charité – Universitätsmedizin Berlin,
Charitéplatz 1, 10117 Berlin, Germany
3
the strong muscle coat forming the mass of the organ.
The myometrium is mostly comprised of spindle-
shaped smooth muscle cells and additionally con-
tains reserve connective tissue cells, which give rise
to additional myometrial cells in pregnancy through
hyperplasia. The uterine cavity is only a thin cleft and
is lined by endometrium (Fig. 3.2). Functionally, the
endometrium consists of basal and functional layers.
The isthmus of uterus (lower uterine segment),
together with the internal os, forms the junction be-
tween the corpus and cervix. In nonpregnant wom-
en the isthmus is only about 5 mm high and is less
muscular than the corpus. Unlike the uterine cervix,
the isthmus becomes overproportionally large in the
course of pregnancy and serves as a kind of reserve
for fetal development in addition to the uterine cor-
pus. The endometrium of the isthmus consists of a
single layer of columnar epithelium and only under-
goes abortive cyclic transformation.
The uterine cervix consists of the supravaginal
cervical canal (endocervix) and the vaginal portion
that projects into the vagina (Fig. 3.3). The wall of the
cervix is primarily made up of firm connective tis-
sue. In contrast to the uterine corpus, the muscular
portion accounts for less than 10% of the cervical
wall and primarily consists of smooth muscle cells
in circular arrangement. The cervical canal is coated
with mucus-producing columnar epithelium and
contains numerous gland-like units, the crypts. The
squamocolumnar junction is the transition from the
columnar epithelium of the endocervix to the non-
keratinizing squamous epithelium of the ectocervix
and is situated at the level of the external os.
The uterus is supplied with blood through the
uterine and ovarian arteries. The uterine arteries
course to the organ through the cardinal ligaments
and, at the level of the uterine isthmus (internal os
of the cervical canal), divide into an ascending and
a descending branch. Lymphatic drainage from the
corpus is through the broad ligament into the para-
aortic lymph nodes and from the cervix into parame-
trial and iliac lymph nodes.
38 C. Klüner and B. Hamm
a b
Fig. 3.1a,b. T2-weighted TSE images of two different healthy premenopausal women in sagittal orientation
Fig. 3.2. T2-weighted TSE image of a 40-year-old healthy wom-
an in coronal orientation. The uterine cavity is marked by the
white arrow
Besides the pelvic floor, the normal topography
of the uterus is primarily ensured by the parametria,
a kind of suspension system primarily consisting of
connective tissue. In addition, the parametria contain
large amounts of fatty tissue, especially in their lateral
portions near the pelvic sidewall and a dense network
of lymphatic and blood vessels. About 2 cm lateral to
the uterine cervix, both ureters course through the
parametria and cross the uterine arteries (Fig. 3.4).
Below, the parametria extend to the cardinal liga-
ment, which passes from the uterine cervix to the pel-
vic sidewall and separates the parametrium from the
paravaginal connective tissue (paracolpium). A total
of eight ligaments contribute to the support of the
uterus. Diagnostically, which primarily pertains to
the evaluation of the local extent of cervical cancer,
the vesicouterine and the sacrouterine ligaments are
most important. The vesicouterine ligament extends
from the cervix to the posterior wall of the urinary
bladder and only has a minor role in supporting the
uterus. The sacrouterine ligament has a more im-
portant supportive function and originates on the
anterior aspect of the sacral bone, arches around the
rectum and attaches at the level of the uterine isth-
mus.
Most of the uterus is covered by peritoneum
(Fig. 3.5). The peritoneum contributes only lit-
tle support but ensures adequate mobility of the
uterus relative to the urinary bladder and rectum,
which is necessary to adjust to the variation in blad-
der filling and especially during pregnancy. The
peritoneum extends from the roof of the urinary
bladder to the anterior uterine wall, forming the
vesicouterine pouch in between. Below this fold,
there is the vesicouterine ligament. The posterior
peritoneal coat of the uterus extends downward to
form the rectouterine pouch (Douglas space) that
reaches to the level of the posterior vaginal fornix
and from there extends to cover the anterior rectal
wall.
 Normal Image Findings of the Uterus 39

Parametria
Isthmus
Internal cervical os
Parametria
Uterine vessels
Ureter
Corpus uteri
External cervical os

Internal cervical os
Endocervix
External cervical os

Vaginal cavity

from Hricak/Carrington (1991)

Fig. 3.3. Anatomic draft of the uterine cervix: coronal view and corre-
sponding MRI

Broad ligament
Parametria
Round ligament

Fig. 3.4. Anatomic draft, which presents the strong relation Fig. 3.5. T2-TSE image in sagittal orientation. The extension of
between uterine arteries and ureters (arrow) the peritoneum is marked by the grey line
40 C. Klüner and B. Hamm
3.2
Imaging Findings: Uterine Corpus
The imaging appearance of the uterine corpus var-
ies widely with the age and hormonal status of the
patients examined [2–7].
On unenhanced CT scans, the layered anatomy of
the wall cannot be distinguished. After administra-
tion of contrast medium, the myometrium can be
distinguished in most cases during the arterial phase
as it shows early and strong enhancement while the
junctional zone/endometrium is of relatively low
a b
Fig. 3.6a-d. CT of the female pelvis. a CT transversal unen-
hanced. b CT transversal after CM and reformatted coronal (c)
and sagittal CT images (d)
density (Fig. 3.6). As with MRI, the endometrium
and junctional zone cannot be differentiated in most
cases on the basis of their morphologic appearance
on CT. In most cases, venous plexuses can be identi-
fied within the parametria on the basis of their strong
enhancement. However, reliable differentiation of
myometrium from parametrial portions is usually
not possible while the peripheral fatty portions of
the parametrium can be distinguished from the pel-
vic wall with an adequate degree of accuracy.
Unenhanced T1-weighted MRI depicts the uterine
corpus with a low and homogeneous signal intensity
similar to that of skeletal muscle (Fig. 3.7a and b).
d

Thus, it is not possible to differentiate the individual
layers.
On the other hand, T2-weighted MR images in wom-
en of reproductive age clearly depict the three layers of
the uterine corpus: the endometrium, the junctional
zone, and the myometrium (Fig. 3.7c and d) [8].
The endometrium always has a high signal inten-
sity on T2-weighted images regardless of the hormonal
state and age while its thickness clearly varies in the
course of the menstrual cycle [9]. The thickness ranges
from 1–3 mm in the early proliferative phase (Fig. 3.7
and 3.8) and 5–10 mm in the middle of the secretory
phase (Fig. 3.9 and 3.10). The endometrium is thickest
under the effect of estradiol (follicular phase) on days 8
through 16 of the cycle [10]. After day 16, when the effect
c and sagittal (d) plane of the same patient
Normal Image Findings of the Uterus 41
of progesterone becomes stronger (luteal phase), there
is hardly any further increase in thickness but primarily
a transformation of the mucosa with increased forma-
tion of glands and ingrowth of vessels. During menstru-
ation, a blood clot may occasionally be present in the
uterine cavity (Fig. 3.9), which must not be mistaken for
a foreign body, polyp, or submucosal myoma.
The layer adjacent to the endometrium that can be
distinguished on MRI is the junctional zone, which
corresponds to the inner part of the myometrium and
is hypointense on T2-weighted images relative to the
outer portion of the myometrium. The lower signal
is primarily attributable to a lower water content, the
higher nucleus-to-cytoplasm ratio, and the smaller ex-
tracellular space of the inner myometrium [11, 12].
Fig. 3.7a-d. MRI of a 40-year-old healthy woman during early
proliferative phase. T1-weighed TSE images in axial (a) and
sagittal orientation (b). T2-weighted TSE images in axial (c)
42 C. Klüner and B. Hamm
Fig. 3.8a,b. MRI of a healthy woman during early proliferative
phase (T2-weighted TSE in axial and sagittal plane)
a
Fig. 3.9a,b. MRI of a healthy woman during secretory phase.
The T2-weighed TSE image (a) as well as the contrast-en-
hanced T1-weighted TSE image (b), both in sagittal orienta-
tion demonstrate a blood clot (arrow) in the uterine cavity
Similar to the endometrium, the junctional zone also
varies over the menstrual cycle and is thickest around
the 24th day. The mean thickness of the junctional
zone does not exceed 5 mm under normal conditions.
A focal thickness of over 12 mm of the junctional zone
can be interpreted as a sign of adenomyosis. However,
a focal pathologic thickening of the junctional zone
has to be differentiated from uterine contractions.
Uterine contractions may be diagnosed by a repeated
b
b
T2-weighted sequence a view minutes later, showing a
normal appearance of the former thickened junctional
zone in contrast to unchanged appearance of adeno-
myosis. By using cine MRI sequences (SSFSE: single-
shot half-Fourier fast spin echo) it was furthermore
shown that the junctional zone maintains cervicofun-
dal contractions that vary with the phase of the cycle
[13] and are assumed to have a role in transporting
sperm and in maintaining early pregnancy.
 Normal Image Findings of the Uterus 43

The normal outer myometrium is of an intermediate Long-term use of oral contraceptives is also associ-
signal intensity on T2-weighted images. Its signal in- ated with marked thinning of the endometrium. In
tensity is slightly higher during the secretory phase due women on GnRH analogues, the uterus is compara-
to an increased fluid content, which improves the dif- ble to the premenopausal uterus in terms of size and
ferentiation from the junctional zone as compared with signal intensities with depiction of the endometrium
other phases of the cycle (comparison of Figs. 3.7 and as a very thin stripe of high signal intensity that is
3.10). Vessels in the myometrium are also highly prom- clearly delineated from the low-intensity myome-
inent during this phase of the cycle. Ultrasonography trium. The junctional zone is not seen or very dif-
likewise depicts three uterine layers but the thickness ficult to distinguish. Despite its anti-estrogen activity,
of the junctional zone and of the endometrium deter-
mined by ultrasound and MRI clearly differ, especially
during the luteal phase [14]. This discrepancy is attrib-
uted to the fact that ultrasound does not demonstrate
the three layers in the same way as MRI [15].
Following intravenous administration of a para-
magnetic contrast medium, the zonal anatomy of
the uterus is also depicted on T1-weighted images
(Fig. 3.9b). Both the endometrium and the outer
myometrium are characterized by pronounced con-
trast enhancement while the junctional zone is of low
signal intensity. This is attributed to the denser tissue
and smaller extracellular volume of distribution of
the contrast medium [12, 16].
The uterus of newborns still shows good differ-
entiation of the myometrium, junctional zone, and
endometrium as a result of the effect of maternal es-
trogen. Before the onset of menstruation, the endo- a
metrium is merely seen as a very thin stripe of high
signal intensity or not at all and the junctional zone
is not distinguishable from the low-signal-intensity
myometrium. The corpus is smaller than the cervix
during this phase while in adult women the length
ratio of the cervix to the corpus is 1:2.
After menopause the uterine corpus as a whole is
markedly smaller (Figs. 3.11 and 3.12) with a length
ratio of nearly 1:1. On T2-weighted images the endo-
metrium is seen as a thin central stripe of high signal
intensity. The myometrium has a markedly lower sig-
nal intensity as compared with women of reproductive
age and is therefore difficult to distinguish from the
junctional zone, which also has a low signal intensity.
The endometrium decreases in thickness to about
3–5 mm. However, in women on external hormone re-
placement therapy, the premenopausal signal pattern
and zonal anatomy may be preserved. In this situation
the endometrium may be up to 10 mm thick.
Exogenous hormonal replacement may consid-
erably alter the MRI appearance of the uterus and
vagina. In premenopausal women taking oral con-
b
traceptives, the signal intensity of the myometrium
is increased [17]. Moreover, the junctional zone ap- Fig. 3.10a,b. MRI of a healthy woman during secretory phase
pears thinner and is more difficult to differentiate. (T2-weighted TSE)
44 C. Klüner and B. Hamm
Fig. 3.11. Reformatted sagittal CT image of a 55-year-old wom-
an, who underwent MSCT for polyp detection of the colon
tamoxifen treatment in postmenopausal women has
an effect that is comparable to that of oral contracep-
tives: There is a clear increase in the thickness of the
endometrium. Moreover, the endometrium becomes
increasingly heterogenous, which may be misinter-
preted as endometrial cancer [18].
3.3
Imaging Findings: Uterine Cervix
In contrast to the uterine corpus, the uterine cervix
shows only little variation of its zonal anatomy as
depicted by MRI with age, phase of the menstrual
cycle, hormone replacement therapy, or use of oral
contraceptives.
On CT scans the individual layers of the wall of
the cervix cannot be distinguished. The same holds
true for unenhanced T1-weighted MR images, which
depict the uterine cervix as a homogeneous cylin-
der-shaped structure of intermediate signal intensity
without distinction of individual layers (Fig. 3.13a,b).
The orientation of the longitudinal axis of the cervix
is highly variable.
T2-weighted images depict three layers in most
cases: an inner layer of high signal intensity, a fairly
wide middle layer of low signal intensity, and an out-
Fig. 3.12. T2-weighted MRI of a healthy 58-year-old woman
er layer of intermediate signal intensity (Fig. 3.13c,d).
The inner layer of high signal intensity corresponds
to the endocervical mucosa. Sometimes an additional
central area of very high signal intensity can be seen,
which corresponds to the mucous within the cervical
canal (Fig. 3.14).
On high resolution T2-weighted images palmate
folds of the cervical canal can be depicted as normal
findings (Fig. 3.15).
Often, nabothian cysts are seen. These are benign
cysts of the uterine cervix that are assumed to result
from obstruction of the cervical mucous glands [19].
The cysts are depicted on T2-weighted images as round
to oval lesions with a smooth margin (Fig. 3.16).
The low-signal-intensity middle layer corresponds
to the cervical stroma and mostly consists of connec-
tive tissue. The outer layer has a signal intensity that
is comparable to that of the myometrium and is char-
acterized by a more loose tissue structure [20] and
may not always be distinguishable from the parame-
tria even on T2-weighted images. The mucosa in the
cervical canal shows the strongest enhancement and
is thus clearly distinct from the less enhancing stro-
mal layer. The outer stromal layer of the cervix and
the portio also show contrast enhancement.
The differentiation of the cervix versus the para-
cervical tissue of the parametria is best on T2-
weighted images compared to pre- or postcontrast
T1-weighted images or CT scans.
 Normal Image Findings of the Uterus 45

a b

c d

Fig. 3.13a–d. T1-weighted and T2-weighted images of the cervix uteri of a 36-year-old woman
46 C. Klüner and B. Hamm

Fig. 3.15. MRI presenting palmate folds

Fig. 3.14a,b. T2-weighted TSE image detect the endocervical

mucosa (white arrow) and cervical stroma (grey arrow) from
the outer tissue

a b

Fig. 3.16a,b. Transversal and coronal MR images of a 40-year-old asymptomatic woman depicting Nabothian (cervical) cysts

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