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330 Archives ofDisease in Childhood 1996;75:330-331

Growth of the Arch Dis Child: first published as 10.1136/adc.75.4.330 on 1 October 1996. Downloaded from

N A Bridges, A Cooke, M J R Healy, P C Hindmarsh, C G D Brook

Abstract at the fundus, and diameter at the . The Background-The pattern of growth of cervical diameter was not routinely measured the uterus was examined by ultrasound when the uterus was an adult size. The examinations of 358 girls who attended a thickness of the was measured paediatric endocrine outpatient depart- (in mm). was staged by the method of ment but were shown not to have any Tanner,6 and was recorded. endocrine defect. Method-The uterus was measured in REPRODUCIBILITY OF ULTRASOUND length and width at the cervix and at the MEASUREMENTS fundus (cm). Endometrial thickness was To determine the reproducibility of linear measured (mm). Scans were divided by measurements made at ultrasound, six ultra- Tanner breast stage and the dimensions sound examinations were performed in dupli- compared by one way analysis ofvariance cate. Examinations were performed by two (ANOVA, with the Student Newman Keuls experienced ultrasonographers on six individu- post hoc test). als at the same occasion, with the second Results-There was an increase in uterine examiner 'blind' to the results of the first length, diameter of the fundus, and en- examination. The coefficient of variation (CV) dometrial thickness at each breast stage ranged from 0 to 32.0%. Plotting the differ- from 1 to 5 (ANOVA, p<0.05), and in the ence between pairs against the mean of the diameter of the cervix with each breast pairs (the Bland-Altman plot 7) demonstrated a stage from 1 to 4 (ANOVA, p<0.05). The trend for greater errors in the larger measure- ratio of the fundus to the cervix increased ments (equation of line: difference = 0.08 from 0.95 to 1.29 between breast stages 1 (mean) -0.07; correlation coefficient = +0.57). and 4. Conclusion-The onset of puberty is marked by an increase in the dimensions ANALYSIS OF DATA of the uterus and in endometrial thick- The scans from the patients were divided by ness, but also by a change in the shape of Tanner breast stage. Mean values for the meas- the uterus from a tubular to a pear shaped urements made at each pubertal stage were . calculated and compared by one way analysis of variance (ANOVA, with the Student New- (Arch Dis Child 1996;75:330-331) http://adc.bmj.com/ Keuls post hoc test). The ratio of the Keywords: uterus, endometrium, ultrasound. diameter at the fundus and the cervix was cal- culated for each scan, and a mean ratio calcu- Ultrasound is painless and non-invasive, and lated for each pubertal stage. The length meas- even in infants can determine the dimensions urements for the scans at breast stage 1 were of the uterus and . Endometrial and plotted against age and a regression line calcu- myometrial cells are oestrogen responsive'2 lated. and the uterus increases in size during puberty. on September 24, 2021 by guest. Protected copyright. Information on uterine size and shape and on Results the thickness of the endometrium are useful in Table 1 shows the numbers in each group, the the assessment of girls with sexual precocity ratio of fundus to cervix and the endometrial and pubertal delay. Published data on the pat- thickness, divided by pubertal stage. Figure 1 tern of growth in normal individuals are shows the uterine dimensions (SE) according limited.3We have examined the dimensions of to Tanner breast stage. ANOVA demonstrated the uterus in a large group of girls with no an increment in uterine length, fundus diam- endocrine defect. eter, and endometrial thickness at each breast stage from 1 to 5 (p<0.05), and in the diameter of the cervix with each breast stage from 1 to 4 London Centre for Methods Paediatric SUBJECTS (ANOVA, p<0.05). Figure 2 shows the meas- Endocrinology and The girls studied had attended the paediatric urements of uterine length at breast stage 1 Metabolism, Middlesex endocrine outpatient department at the Mid- plotted against age. The equation ofthe best fit Hospital, Mortimer dlesex Hospital but turned out to have no line was length = 0.093 (age) + 2.67; r=0.50. London WIN Street, endocrine disorder and were on no treatment; This line cannot be extrapolated to 0 years, 8AA because numbers at this age are insufficient. NA Bridges they ranged in age from to 16 years. A Cooke There were 475 scans on 358 girls. The uterus is probably larger in the immediate MJR Healy postnatal period than later in infancy because PC Hindmarsh ULTRASOUND SCANS of the effect of neonatal and maternal oestro- CGD Brook Transabdominal ultrasound scans were per- gen secretion. formed. A full bladder was required to image There was no difference in endometrial Correspondence to: the uterus was Professor Brook. pelvic organs. At each scan, the thickness or uterine dimensions between girls measured in three dimensions (in cm): length at breast stage 4 or 5 who had menstruated and Accepted 6 June 1996 (from top ofthe fundus to the cervix), diameter those who had not. Growth of the uterus 331

Table 1 Age, number ofpatients,fundus: cervix ratio, and 7 endometrial thickness divided by breast stage

Length Arch Dis Child: first published as 10.1136/adc.75.4.330 on 1 October 1996. Downloaded from 6 Mean ratio of Endometrial Fundus Breast Mean age fundus: cervix thickness (mm) - Cervix stage (years) No (SE), range (SE), range 1 8.6 245 0.95 (0.02) 0.38 (0.07) 4 0.44-1.75 0-4 2 11.3 112 1.12 (0.31) 1.02 (0.15) E 0.55-2.00 0-6 3- 3 11.8 57 1.26 (0.04) 2.79 (0.28) 0.77-2.00 0-8 2- 4 13.3 34 1.29 (0.06) 5.04 (0.63) 1.0-1.83 2-17 5 13.9 27 1.22 (0.09) 6.44 (0.81) 0.75-2.13 0-15

1 2 3 4 5 during the luteal phase in one study of normal Tanner breast stage women aged 21 to 25 years 9). There was considerable overlap in dimen- Figure 1 Graph showing mean (SE) uterine length and diameter at the fundus and cervix by breast stage. sions between pubertal stages. This study sug- gests that uterine shape was a better marker of Discussion pubertal development than uterine dimen- Ultrasound measurements of the uterus made sions. The data are cross sectional and do not by experienced operators are highly reproduc- give information about the pattern ofgrowth to ible. It is technically easier to measure the be expected in an individual. Uterine growth uterus than the ovaries in children and linear may not follow along centile lines in the same ultrasound measurements are more reproduc- manner as height. While the assessment of ible than volume measurements.8 pubertal changes at ultrasound may be of During childhood the uterus grew in length importance in some conditions (for example in (fig 1), with diameters at fundus and cervix assessing girls with sexual precocity), the remaining approximately equal prepubertally. importance of relative uterine size at any Somatic growth of ovarian volume during pubertal stage on future development is not childhood was also observed in the same group clear. Our group included individuals with of subjects.8 The increasing concentrations of heights above the 97th centile and below the circulating during puberty resulted 3rd centile (unlike those in the study of Griffin in growth and a change in shape. Growth in et al 5). There are no data on the relationship diameter at the fundus outstripped growth in between height and uterine dimensions, but it diameter at the cervix and resulted in a pear may be that shorter girls have smaller uterine shaped configuration. A similar change in uter- dimensions.

ine shape with puberty was documented by The onset of breast development at puberty http://adc.bmj.com/ Griffin et al in a group of 153 girls.5 is marked by uterine growth. A change in the An increase in endometrial thickness was shape ofthe uterus with growth in the diameter another marker of pubertal progress, although at the fundus overtaking growth at the cervix a thin endometrium was seen in some prepu- (adopting a pear shape) is a marker of puberty. bertal girls, perhaps stimulated by the very low concentrations of oestrogen found in prepu- NAB was supported by the Special Trustees of the Middlesex berty. Measurement of endometrial thickness Hospital, and PCH by Children Nationwide and Pharmacia. was no more helpful in predicting the time of on September 24, 2021 by guest. Protected copyright. onset of than pubertal rating. We are grateful to the members of the Ultrasound The mean endometrial thickness in girls who Department at The Middlesex Hospital for performing the had menstruated but were not ovulating was scans, particularly Ms Anita Patel, Ms Claire Webber, Ms Jan thinner than that observed in older women Oliver, Ms Judy Adams, and Ms Sandra Mather. during ovulatory cycles (a mean of 12.1 mm 1 Bergqvist A, Ferno M. and progesterone receptors in endometriotic tissue and endometrium: comparison 7 according to localization and recurrence. Fertil Steril 1993;60:63-8. 2 Lessey BA, Killam AP, Metzger DA, Haney AF, Greene GL, 6 McCarty KS. Immunohistochemical analysis of uterine estrogen and progesterone receptors throughout the . 7 Clin Endocrinol Metab 1988;67:334- 40. 0 0 3 Ivarsson SA, Nilsson KO, Persson PH. Ultrasonography of 0 the pelvic organs in prepubertal and postpubertal girls. 45 0 ~ ~ 0 0 00 Arch Dis Child 1983;58:352-4. #. . . 4 Salardi S, Forsini L, Cacciari E, Bovicelli, Tassoni P, @00 0 3 *0 0 0 0 0 Regianni A. Pelvic ultrasonography in premenacheal girls: 0 0 0 relation to puberty and sex hormone concentrations. Arch Dis Child 1985;60:120-5. 2 * 00 0 * 0 .* 5 Griffin IJ, Cole TJ, Duncan KA, Hollman AS, Donaldson MDC. Pelvic ultrasound measurements in normal girls. Acta Paediatr 1995;84:536-43. 6 Tanner JM. Growth at adolescence. Oxford: Blackwell, 1962. 7 Altman DG. Practical statistics for medical research. London: Chapman and Hall, 1991: 398-403. 0 II 8 Bridges NA, Cooke A, Healy MJR, Hindmarsh PC, Brook 2 4 6 8 10 12 14 CGD. Standards for ovarian volume in childhood and Age (years) puberty. Fertil Steril 1993;60:456-60. 9 Fitzgerald CT, SeifMW, Killick Sr, Bennett DA. Age related Figure 2 The measurements of uterine length at breast stage 1 plotted against age. The changes in the female reproductive cycle. Br J Obstet equation of the line was length 0.093 (age) + 2.67; r=O.5O. Gynaecol 1994;101:229-33.