Ultrasound Elastography in Benign Gynecology: A Scoping Review

Objective To perform a scoping review of the literature in which ultrasound elastography (UE) has been used in benign gynecology and identify avenues for its use in future research and clinical implementations.

A structured search of EMBASE, Medline and Cochrane databases was conducted (last search date April 15th, 2022). Eligible studies included adult participants with female pelvic anatomy. English language papers focusing on the utility of ultrasound elastography applied to benign gynecology were included. Narrative reviews, conference abstracts, and letters to the editor were excluded. Two independent reviewers screened titles and abstracts for inclusion, a third reviewer was consulted in cases of disagreement. Study quality was assessed by a checklist for study implementation and elastography technique. Extracted data included elastography technology, gynecologic application, opportunities for clinical implementation, and strengths and limitations.

The search returned 2026 studies. A total of 40 studies, published between 2013 and 2022, were retained for data extraction. Studies most frequently used shear wave elastography as the method of UE (n = 23), followed by strain elastography (n = 13) and acoustic radiation force impulse (n = 4). Most common clinical applications for UE were the diagnosis of adenomyosis and uterine fibroids (27.5%), assessment of pelvic floor muscle function (22.5%), and describing the elastic properties of polycystic ovaries (17.5%) and the uterine cervix (15.0%). Limitations of the technology were identified as the lack of published reference values for gynecologic organs and difficulties in assessing tissues deep to the transducer.

Future research is needed to validate the use of ultrasound elastography in gynecology under both normal and pathologic conditions. Similar content being viewed by others Data Availability Study extraction data is available upon request.

Brandenburg JE, Eby SF, Song P, et al. Ultrasound Elastography: The new frontier in direct measurement of muscle stiffness. Arch Phys Med Rehabil. 2014;95(11):2207. https://doi.org/10.1016/J.APMR.2014.07.007. Bamber J, Cosgrove D, Dietrich CF, et al. EFSUMB guidelines and recommendations on the clinical use of ultrasound elastographypart 1: Basic principles and technology. Ultraschall Med. 2013;34(2):169–84. https://doi.org/10.1055/S-0033-1335205/ID/JR213-39. Sarvazyan A, Hall TJ, Urban MW, Fatemi M, Aglyamov SR, Garra BS. An overview of elastography-an emerging branch of medical imaging. Curr Med Imaging Rev. 2011;7(4):255-282. https://doi.org/10.2174/157340511798038684. Cosgrove D, Piscaglia F, Bamber J, et al. EFSUMB Guidelines and Recommendations on the clinical use of ultrasound elastographypart 2: Clinical applications. Ultraschall Med. 2013;34(3):238–53. https://doi.org/10.1055/S-0033-1335375/ID/JR313-37. Suthasmalee S, Moungmaithong S. Cervical shear wave elastography as a predictor of preterm delivery during 18–24 weeks of pregnancy. J Obstetr Gynaecol Res. 2019;45(11):2158–68. https://doi.org/10.1111/JOG.14094. Nazzaro G, Saccone G, Miranda M, Crocetto F, Zullo F, Locci M. Cervical elastography using E-cervix for prediction of preterm birth in singleton pregnancies with threatened preterm labor. J Matern Fetal Neonatal Med. 2022;35(2):330–5. https://doi.org/10.1080/14767058.2020.1716721. Gesthuysen A, Hammer K, Mollers M, et al. Evaluation of cervical elastography strain pattern to predict preterm birth. Evaluation von Kompressionsmustern in der Zervix-Elastografie zur Vorhersage einer Fruhgeburt. 2020;41(4):397–403. https://doi.org/10.1055/a-0865-1711. Wang B, Zhang Y, Chen S, et al. Diagnostic accuracy of cervical elastography in predicting preterm delivery: A systematic review and meta-analysis. Medicine. 2019;98(29):e16449. https://doi.org/10.1097/MD.0000000000016449. Jin B, Kong W, Zhao X, et al. Substrate stiffness affects the morphology, proliferation, and radiosensitivity of cervical squamous carcinoma cells. Tissue Cell. 2022;74:101681. doi:https://doi.org/10.1016/j.tice.2021.101681 Tricco AC, Lillie E, Zarin W, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73. https://doi.org/10.7326/M18-0850. Peters M, Godfrey C, McInerney P, Munn Z, Tricco A, Khalil H. Chapter 11: scoping reviews. In: Aromataris E, Munn Z (eds) JBI Reviewer's Manual. 2020. JBI. https://doi.org/10.46658/JBIMES-20-12 Van Den Bosch T, Dueholm M, Leone FPG, et al. Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses: a consensus opinion from the Morphological Uterus Sonographic Assessment (MUSA) group. Ultrasound Obstet Gynecol. 2015;46(3):284–98. https://doi.org/10.1002/UOG.14806. Van den Bosch T, de Bruijn AM, de Leeuw RA, et al. Sonographic classification and reporting system for diagnosing adenomyosis. Ultrasound Obstet Gynecol. 2019;53(5):576–82. https://doi.org/10.1002/UOG.19096. Lazzeri L, Morosetti G, Centini G, et al. A sonographic classification of adenomyosis: interobserver reproducibility in the evaluation of type and degree of the myometrial involvement. Fertil Steril. 2018;110(6):1154-1161.e3. https://doi.org/10.1016/J.FERTNSTERT.2018.06.031. Naftalin J, Hoo W, Nunes N, Holland T, Mavrelos D, Jurkovic D. Association between ultrasound features of adenomyosis and severity of menstrual pain. Ultrasound Obstet Gynecol. 2016;47(6):779–83. https://doi.org/10.1002/uog.15798. Naftalin J, Hoo W, Pateman K, Mavrelos D, Holland T, Jurkovic D. How common is adenomyosis? A prospective study of prevalence using transvaginal ultrasound in a gynaecology clinic. Hum Reprod. 2012;27(12):3432–9. https://doi.org/10.1093/humrep/des332. Naftalin J, Hoo W, Pateman K, Mavrelos D, Foo X, Jurkovic D. Is adenomyosis associated with menorrhagia? Hum Reprod. 2014;29(3):473–9. https://doi.org/10.1093/HUMREP/DET451. Pinzauti S, Lazzeri L, Tosti C, et al. Transvaginal sonographic features of diffuse adenomyosis in 18–30-year-old nulligravid women without endometriosis: Association with symptoms. Ultrasound Obstet Gynecol. 2015;46(6):730–6. https://doi.org/10.1002/uog.14834. Chapron C, Vannuccini S, Santulli P, et al. Diagnosing adenomyosis: an integrated clinical and imaging approach. Hum Reprod Update. 2020;26(3):392–411. https://doi.org/10.1093/HUMUPD/DMZ049. Rasmussen CK, Hansen ES, Dueholm M. Inter-rater agreement in the diagnosis of adenomyosis by 2- and 3-dimensional transvaginal ultrasonography. J Ultrasound Med. 2019;38(3):657–66. https://doi.org/10.1002/JUM.14735. Liu X, Ding D, Ren Y, Guo S-W. Transvaginal elastosonography as an imaging technique for diagnosing adenomyosis. Reproductive Sciences. 2018;25(4):498–514. doi:https://doi.org/10.1177/1933719117750752 Zhang DL, Liu XX, Tang JQ, et al. The value of acoustic radiation force impulse imaging in preoperative prediction for efficacy of high-Intensity focused ultrasound uterine fibroids ablation. Int J Hyperthermia. 2020;37(1):423–9. https://doi.org/10.1080/02656736.2020.1758803. Samanci C, Onal Y. Shearwave elastographic evaluation of uterine leiomyomas after uterine artery embolization: preliminary results. Turk J Med Sci. 2020;50(2):426–32. https://doi.org/10.3906/sag-1908-171. Pongpunprut S, Panburana P, Wibulpolprasert P, et al. A comparison of shear wave elastography between normal myometrium, uterine fibroids, and adenomyosis: a cross-sectional study. Int J Fertil Steril. 2022;16(1):49–54. https://doi.org/10.22074/IJFS.2021.523075.1074. Görgülü FF, Okçu NT. Which imaging method is better for the differentiation of adenomyosis and uterine fibroids?. J Gynecol Obstet Hum Reprod. 2021;50(5):102002. https://doi.org/10.1016/j.jogoh.2020.102002 Stoelinga B, Hehenkamp WJKK, Brolmann HAM, et al. Real-time elastography for assessment of uterine disorders. Ultrasound Obstet Gynecol. 2014;43(2):218–26. https://doi.org/10.1002/uog.12519. Acar S, Millar E, Mitkova M, Mitkov V. Value of ultrasound shear wave elastography in the diagnosis of adenomyosis. Ultrasound. 2016;24(4):205–13. https://doi.org/10.1177/1742271X16673677. Ding D, Chen Y, Liu X, Jiang Z, Cai X, Guo SW. Diagnosing deep endometriosis using transvaginal elastosonography. Reprod Sci. 2020;27(7):1411–22. https://doi.org/10.1007/S43032-019-00108-2. Wozniak S, Czuczwar P, Szkodziak P, et al. Elastography improves the accuracy of ultrasound in the preoperative assessment of abdominal wall endometriosis. Ultraschall Med. 2015;36(6):623–9. https://doi.org/10.1055/S-0034-1398834. Aljuraifani R, Stafford RE, Hug F, Hodges PW. Female striated urogenital sphincter contraction measured by shear wave elastography during pelvic floor muscle activation: Proof of concept and validation. Neurourol Urodyn. 2018;37(1):206–12. https://doi.org/10.1002/NAU.23275. Baumfeld Y, Wei Q, Chitnis P, Marroquin J, Shobeiri SA, Alshiek J. Does aging affect the elastic properties of the bladder and the urethra in nulliparous women: An ultrasound shear-wave elastography study. Neurourol Urodyn. 2022;41(3):797–805. https://doi.org/10.1002/NAU.24877. Sheyn D, Ahmed Y, Azar N, El-Nashar S, Hijaz A, Mahajan S. Trans-abdominal ultrasound shear wave elastographyfor quantitative assessment of female bladder neck elasticity. Int Urogynecol J. 2017;28(5):763–8. https://doi.org/10.1007/S00192-016-3193-3. Kreutzkamp JM, Schäfer SD, Amler S, Strube F, Kiesel L, Schmitz R. Strain elastography as a new method for assessing pelvic floor biomechanics. Ultrasound Med Biol. 2017;43(4):868–72. https://doi.org/10.1016/J.ULTRASMEDBIO.2016.12.004. Gachon B, Fritel X, Pierre F, Nordez A. Transperineal ultrasound shear-wave elastography is a reliable tool for assessment of the elastic properties of the levator ani muscle in women. Sci Rep. 2021;11(1). https://doi.org/10.1038/S41598-021-95012-8 Tang J, Zhong C, Wen W, Wu R, Liu Y, Du L. Quantifying levator ani muscle elasticity under normal and prolapse conditions by shear wave elastography: a preliminary study. J Ultrasound Med. 2020;39(7):1379–1388. https://doi.org/10.1002/JUM.15232 Li XM, Zhang LM, Li Y, et al. Usefulness of transperineal shear wave elastography of levator ani muscle in women with stress urinary incontinence. Abdom Radiol (NY). 2022;47(5):1873–80. https://doi.org/10.1007/S00261-022-03478-5. Maßlo K, Möllers M, de Murcia KO, Klockenbusch W, Schmitz R. New method for assessment of levator avulsion injury: a comparative elastography study. J Ultrasound Med. 2019;38(5):1301–7. https://doi.org/10.1002/JUM.14810. Altunkeser A, Inal ZO, Baran N. Evaluation of ovaries in patients with polycystic ovary syndrome using shear wave elastography. Curr Med Imaging. 2020;16(5):578–83. https://doi.org/10.2174/1573405615666190114150538. Ertekin E, Turan OD, Tuncyurek O. Is shear wave elastography relevant in the diagnosis of polycystic ovarian syndrome? Med Ultrason. 2019;21(2):158–162. https://doi.org/10.11152/mu-1849 Turan ÖD, Tuncyurek O, Ertekin E. Role of shear wave elastography in predicting the metabolic and androgenic alterations in patients with polycystic ovary syndrome. J Obstet Gynaecol Res. 2021;47(8):2677–83. https://doi.org/10.1111/JOG.14835. Vora Z, Manchanda S, Sharma R, et al. Transvaginal shear wave elastography for assessment of endometrial and subendometrial pathologies: a prospective pilot study. J Ultrasound Med. 2022;41(1):61–70. https://doi.org/10.1002/jum.15679. Sumbul HE, Avci BS, Bankir M, Pekoz BC, Gulumsek E, Koc AS. Ovarian stiffness is significantly increased in polycystic ovary syndrome and related with anti-Mullerian hormone: a point shear wave elastography study. Ultrasound Q. 2022;38(1):83–88. https://doi.org/10.1097/RUQ.0000000000000592 Săsăran V, Turdean S, Gliga M, et al. Value of strain-ratio elastography in the diagnosis and differentiation of uterine fibroids and adenomyosis. J Pers Med. 2021;11(8):824. Published 2021 Aug 23. doi:https://doi.org/10.3390/jpm11080824 Xholli A, Simoncini G, Vujosevic S, et al. Menstrual pain and elasticity of uterine cervix. J Clin Med. 2021;10(5):1110. Published 2021 Mar 7. doi:https://doi.org/10.3390/jcm10051110 Castro L, García-Mejido JA, Holgado A, García R, Fernández-Palacín A, Sainz JA. Reliability of shear-wave elastography (SWE) for investigating cervix elastic properties in normal and benign pathological situations. Clin Exp Obstet Gynecol. 2021;48(3): 583–589 Gursu T, Cevik H, Desteli GA, Yilmaz B, Bildaci TB, Eraslan A. Diagnostic value of shear wave velocity in polycystic ovarian syndrome. J Ultrason. 2021;21(87):e277–81. https://doi.org/10.15557/JoU.2021.0047. Castro L, García-Mejido JA, Arroyo E, Carrera J, Fernández-Palacín A, Sainz JA. Influence of epidemiological characteristics (age, parity and other factors) in the assessment of healthy uterine cervical stiffness evaluated through shear wave elastography as a prior step to its use in uterine cervical pathology. Arch Gynecol Obstet. 2020;302(3):753–62. https://doi.org/10.1007/s00404-020-05671-7. Pákozdy K, Sipos AG, Bombicz M, et al. Vaginal elasticity is significantly decreased in vaginal atrophy: a strain elastography study. Menopause. 2020;27(12):1420–4. https://doi.org/10.1097/GME.0000000000001673. Gemici AA, Gulsever AB, Tunca AF, Hocaoglu E, Inci E. Shear wave elastography of the uterine cervix under different conditions with inter-operator agreement analysis. Pol J Radiol. 2020;85:e245-e249. https://doi.org/10.5114/pjr.2020.95527 Xie M, Feng Y, Zhang X, Hua K, Ren Y, Wang W. Evaluation of pelvic floor muscle by transperineal elastography in patients with deep infiltrating endometriosis: preliminary observation. J Med Ultrason (2001). 2019;46(1):123–128. doi:https://doi.org/10.1007/s10396-018-0913-y Zhang M, Wasnik AP, Masch WR, et al. Transvaginal ultrasound shear wave elastography for the evaluation of benign uterine pathologies: a prospective pilot study. J Ultrasound Med. 2019;38(1):149–55. https://doi.org/10.1002/jum.14676. O’Hara S, Zelesco M, Sun Z. Shear wave elastography on the uterine cervix: technical development for the transvaginal approach. J Ultrasound Med. 2019;38(4):1049–60. https://doi.org/10.1002/jum.14793. Manchanda S, Vora Z, Sharma R, et al. Quantitative sonoelastographic assessment of the normal uterus using shear wave elastography: an initial experience. J Ultrasound Med. 2019;38(12):3183–9. https://doi.org/10.1002/jum.15019. Bildaci TB, Cevik H, Yilmaz B, Desteli GA. Value of in vitro acoustic radiation force impulse application on uterine adenomyosis. J Med Ultrason (2001). 2018;45(3):425–430. https://doi.org/10.1007/s10396-017-0845-y Stanziano A, Caringella AM, Cantatore C, Trojano G, Caroppo E, D'Amato G. Evaluation of the cervix tissue homogeneity by ultrasound elastography in infertile women for the prediction of embryo transfer ease: a diagnostic accuracy study. Reprod Biol Endocrinol. 2017;15(1):64. https://doi.org/10.1186/s12958-017-0283-0 Frank ML, Schäfer SD, Möllers M, et al. Importance of transvaginal elastography in the diagnosis of uterine fibroids and adenomyosis. Stellenwert der transvaginalen Elastografie in der Diagnose von uterinen Myomen und Adenomyose. Ultraschall Med. 2016;37(4):373–378. https://doi.org/10.1055/s-0035-1553266 Czuczwar P, Wozniak S, Szkodziak P, Kudla MJ, Pyra K, Paszkowski T. Elastography improves the diagnostic accuracy of sonography in differentiating endometrial polyps and submucosal fibroids. J Ultrasound Med. 2016;35(11):2389–95. https://doi.org/10.7863/ultra.15.12017. Batur A, Yavuz A, Ozgokce M, et al. The utility of ultrasound elastography in differentiation of endometriomas and hemorrhagic ovarian cysts. J Med Ultrason (2001). 2016;43(3):395–400. https://doi.org/10.1007/s10396-016-0701-5 Çıracı S, Tan S, Özcan AŞ, et al. Contribution of real-time elastography in diagnosis of polycystic ovary syndrome. Diagn Interv Radiol. 2015;21(2):118–22. https://doi.org/10.5152/dir.2014.14094. Soliman AA, Wojcinski S, Degenhardt F. Ultrasonographic examination of the endometrium and myometrium using acoustic radiation force impulse (ARFI) imaging technology: An initial experience with a new method. Clin Hemorheol Microcirc. 2015;59(3):235–43. https://doi.org/10.3233/CH-141842.

Dr Hanan Alsalem reviewed the final manuscript as a clinical expert and surgeon sonologist. Funding This work is supported by the Physician Services Incorporated Clinical Research Grant (Grant Number: 20–32). Author information Authors and Affiliations Corresponding author Ethics declarations The study was exempt from research ethics board approval according to the government of Canadas Tri-council Policy Statement (TCPS 2) on human research ethics. Conflict of interest The authors have no conflicts of interest to declare. Ethical approval Ethical approval was not required for this case report. The patient gave written consent for publication. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Key Message Ultrasound elastography is advanced imaging technology that measures mechanical tissue properties. In this scoping review, we determine that it is a promising modality to assess gynecologic pathologies. Further research is needed to validate it as a diagnostic tool. Supplementary Information Below is the link to the electronic supplementary material. Rights and permissions Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law. About this article Cite this article Horwood, G., Flaxman, T., McInnes, M. et al. Ultrasound Elastography in Benign Gynecology: A Scoping Review. Reprod. Sci. 31, 2508–2522 (2024). https://doi.org/10.1007/s43032-024-01535-6 Received: Accepted: Published: Version of record: Issue date: DOI: https://doi.org/10.1007/s43032-024-01535-6