Uterine leiomyomas in the infertile patient: preoperative localization with MR imaging versus US and hysterosalpingography

Uterine leiomyomas revisited with review of literature

Uterine leiomyomas, more commonly known as fibroids, are the most common neoplasms of the uterus. These tumors have a profound effect on health care and cost worldwide. Depending on the race, uterine leiomyomas can be seen in 70-80% of all women. Although majority of the women with uterine leiomyomas remain asymptomatic, approximately 30% can present with symptoms. Diagnosing typical leiomyomas on imaging is straightforward. However, when large, located extrauterine and especially with degeneration, the diagnosis can be challenging on imaging. In this article, apart from reviewing the demographics and management of patients with leiomyomas, we describe in detail the imaging appearance of various atypical leiomyomas, uncommon locations outside the uterus and their important differential diagnosis that can have a profound effect on patient management.

Diagnostic performance of preoperative MR imaging findings for differentiation of uterine leiomyoma with intraligamentous growth from subserosal leiomyoma

PURPOSE

To evaluate the diagnostic performance of MRI findings for differentiating uterine leiomyoma with intraligamentous growth, or broad ligament fibroid, from subserosal leiomyoma.

METHODS

This study included 37 patients with surgically confirmed uterine smooth muscle tumors (36 leiomyomas and one smooth muscle tumor of uncertain malignant potential) with intraligamentous growth (IL) and size-matched control of 37 patients with subserosal leiomyoma (SS). Two radiologists independently evaluated eight preoperative MRI findings: tumor shape, degeneration, attachment to uterus, ovary elevation, ureter displacement, bladder deformation, rectal displacement, and separation of round ligament (RL) and uterine artery (UA). The diagnostic values of these findings and interobserver agreement were assessed. Receiver-operating characteristic (ROC) analysis of the number of positive MRI findings for diagnosing IL was performed. Clinical outcomes including surgical method, operation time, intraoperative blood loss, perioperative complications, and postoperative hospital stay of the two groups were compared.

RESULTS

Significant differences in tumor shape, attachment to uterus, ovary elevation, ureter displacement, and separation of RL and UA were found between IL and SS. Four of these findings, excluding ureter displacement, showed moderate to substantial interobserver agreement. When two or more of these four findings were positive, sensitivity, specificity, and area under the ROC curve were 91%, 77%, 0.90 in reader 1 and 82%, 89%, 0.91 in reader 2. The operation time was significantly longer for IL than for SS.

CONCLUSION

Tumor shape, attachment to uterus, ovary elevation, and separation of RL and UA are useful MRI findings for differentiating intraligamentous leiomyoma from subserosal leiomyoma.

Benign Uterine Disease: The Added Role of Imaging

Benign uterine diseases are very common gynecologic conditions that affect women mostly in reproductive age. Ultrasound examination is the first-line imaging technique, but MRI is more accurate for diagnosis, characterization, and patient management. In this review, we especially highlight the added value of MRI in the diagnosis of benign uterine disease, discuss their imaging characteristics, and describe the therapeutic options and the added value of MRI in the treatment planning.

Scrotal sac leiomyoma: Case report of a rare benign scrotal mass

Leiomyomas are benign mesenchymal tumors, the overwhelming majority of which are located in the uterus. Rare cases arise in other organs, including the scrotum, pelvis, bladder, and spermatic cord. This report evaluates the case of a 37-year-old man with a history of prior left inguinal hernia repair, who presented with a painless right scrotal mass. He first noticed the mass approximately 1 year prior to his initial visit. Subsequent ultrasound of the scrotum demonstrated a 5-cm circumscribed, hypoechoic, mildly vascular extratesticular mass located within the right hemiscrotum. Based on the initial imaging, the differential diagnosis included lipoma, adenomatoid tumor, papillary cystadenoma, leiomyoma, fibrous pseudotumor, sarcoid granuloma, sarcoma (including liposarcoma, rhabdosarcoma, or leiomyosarcoma), lymphoma, and an extranumerary testis. The mass had circumscribed margins, suggesting an encapsulated lesion, and was completely separate from the testicle on ultrasound. Despite this, testicular malignancy was not entirely excluded as a diagnosis, although it was considered far less likely. The patient was definitively treated with surgical excision of the mass. Pathology of the surgical specimen confirmed diagnosis of leiomyoma, a rare scrotal mass.

Management of Uterine Fibroids: A Focus on Uterine-sparing Interventional Techniques

Uterine fibroids occur in approximately 50% of women over the age of 40 years, and an estimated 50% of those are symptomatic. Menorrhagia is the most common symptom and the primary indication for treatment, although bulk symptoms often occur and can be treated. Pharmacotherapy is typically inadequate unless it can be expected to successfully bridge to menopause or allow for a less-invasive intervention. However, hormonal therapies have risks. Hysterectomy is still the most commonly performed procedure for symptomatic fibroids and has the lowest rate of reintervention (compared with myomectomy or uterine artery embolization [UAE]), but rates of more serious complications are higher and patient satisfaction and ability to return to normal activities may also be less favorable. Myomectomy is not necessarily less morbid than hysterectomy and may have a greater failure rate than UAE. Techniques and devices vary with little standardization, and operator experience is crucial to success. The largest studies of UAE show very low rates of serious complications and rapid recovery. UAE significantly improves symptoms related to uterine fibroids in 85%-90% of patients. Herein, this article will discuss the nature of fibroids and their diagnosis, pharmacotherapy, surgical treatment, and nonsurgical interventional treatment, including UAE and magnetic resonance-guided focused ultrasound. (©) RSNA, 2016.

Uterine fibroids

Uterine fibroids (also known as leiomyomas or myomas) are common clonal neoplasms of the uterus. Fibroids have both smooth muscle and fibroblast components, in addition to a substantial amount of fibrous extracellular matrix, which all contribute to the pathogenetic process. Fibroids are extremely heterogeneous in their pathophysiology, size, location and clinical symptomatology. They are also a part of a range of disease in which some variants have facets of malignant behaviour but overall are benign. Risk for fibroids is associated with race; black women have a higher risk of developing fibroids earlier in life than their white counterparts and also develop more-severe forms of the disease. Clinically, fibroids account for one-third to half of all hysterectomies and are associated with substantial morbidity and health care costs for women of reproductive age. Indeed, current treatments are primarily surgical and interventional; approximately three-quarters of all fibroid treatments are hysterectomies. However, clinical innovations are emerging in the use of progesterone receptor modulators as a medical therapy. New information is rapidly accumulating about the genetic subgroups that lead to fibroid formation, which might aid further understanding of the clinical heterogeneity of this disease and lead to individualized treatments. This information is a crucial development given the current lack of high-quality evidence on which to base therapeutic decisions.

Uterine fibroid embolization for symptomatic fibroids: study at a teaching hospital in kenya

Objective:

Characterization of magnetic (MRI) features in women undergoing uterine fibroid embolization (UFE) and identification of clinical correlates in an African population.

Materials and Methods:

Patients with symptomatic fibroids who are selected to undergo UFE at the hospital formed the study population. The baseline MRI features, baseline symptom score, short-term imaging outcome, and mid-term symptom scores were analyzed for interval changes. Assessment of potential associations between short-term imaging features and mid-term symptom scores was also done.

Results:

UFE resulted in statistically significant reduction (P < 0.001) of dominant fibroid, uterine volumes, and reduction of symptom severity scores, which were 43.7%, 40.1%, and 37.8%, respectively. Also, 59% of respondents had more than 10 fibroids. The predominant location of the dominant fibroid was intramural. No statistically significant association was found between clinical and radiological outcome.

Conclusion:

The response of uterine fibroids to embolization in the African population is not different from the findings reported in other studies from the west. The presence of multiple and large fibroids in this study is consistent with the case mix described in other studies of African-American populations. Patient counseling should emphasize the independence of volume reduction and symptom improvement. Though volume changes are of relevance for the radiologist in understanding the evolution of the condition and identifying potential technical treatment failures, it should not be the main basis of evaluation of treatment success.

Increased urinary cobalt and whole blood concentrations of cadmium and lead in women with uterine leiomyomata: Findings from the ENDO Study

Multiple trace elements have estrogen receptor activity, but the association of these elements with uterine leiomyoma has not been defined. A cohort of 473 women aged 18-44 undergoing surgery for benign gynecologic indications provided whole blood and urine specimens for trace element analysis, which was performed by inductively coupled plasma mass spectrometry. Twenty elements were analyzed in blood and 3 in urine. The surgeon documented whether fibroids were present. Geometric mean concentrations were compared between women with and without fibroids, and logistic regression models were generated to assess the impact of the concentration of each trace element on the odds of fibroids. In multivariate regressions, odds of a fibroid diagnosis were higher with increased whole blood cadmium (AOR 1.44, 95% CI 1.02, 2.04) and lead (AOR 1.31 95% CI 1.02, 1.69), and urine cobalt (AOR 1.31, 95% CI 1.02, 1.70). Urinary cadmium and lead were not related to fibroid diagnosis. Increased exposure to trace elements may contribute to fibroid growth, and fibroids may serve as a reservoir for these elements. Differences between urinary and whole blood findings merit further investigation, as urinary cadmium has been considered a superior marker of exposure.

Women seeking second opinion for symptomatic uterine leiomyoma: role of comprehensive fibroid center

OBJECTIVE

The objective of the study was to describe our early experience with a comprehensive uterine fibroid center and report our results in women seeking a second opinion for management of symptomatic uterine leiomyoma.

METHODS

We performed a HIPAA-complaint, IRB-approved retrospective study of women seeking second opinion for management of uterine fibroids at our multidisciplinary fibroid treatment center in a tertiary care facility from July 2008 to August 2011. After a review of patients' history, physical examination, and magnetic resonance imaging (MRI) findings, treatment options were discussed which included conservative management, uterine-preserving options, and hysterectomy. We performed Fisher's exact test for categorical variables between the cohort that did or did not undergo a uterine-preserving treatment. Differences were considered significant at p < 0.05.

RESULTS

The mean age of the 205 patient study cohort was 43.8 years (SD 7.5). One hundred sixty-two (79.0%) patients had no prior therapy. Based on MRI, one or more fibroids were detected in 178/205 (86.8%), adenomyosis in 8/205 (3.9%), and a combination of fibroid and nonfibroid condition (i.e., adenomyosis, endometrial polyp) in 18/205 (8.8%). In those who desired to transition their care to our institution (n = 109), 85 patients underwent 90 interventions: 39 MRgFUS (magnetic resonance-guided high-intensity focused ultrasound surgery), 14 UAE (uterine artery embolization), 25 myomectomies, 8 hysterectomies, 3 polypectomies, and 1 endometrial ablation. Five patients had two procedures. Intramural and subserosal fibroids were most commonly treated with MRgFUS followed by myomectomy and then UAE; in contrast, pedunculated fibroids were frequently managed with myomectomy.

CONCLUSIONS

Multidisciplinary fibroid evaluation may facilitate the increase use of less invasive options over hysterectomy for symptomatic fibroid treatment.

Uterine fibroids: current perspectives

Uterine fibroids are a major cause of morbidity in women of a reproductive age (and sometimes even after menopause). There are several factors that are attributed to underlie the development and incidence of these common tumors, but this further corroborates their relatively unknown etiology. The most likely presentation of fibroids is by their effect on the woman's menstrual cycle or pelvic pressure symptoms. Leiomyosarcoma is a very rare entity that should be suspected in postmenopausal women with fibroid growth (and no concurrent hormone replacement therapy). The gold standard diagnostic modality for uterine fibroids appears to be gray-scale ultrasonography, with magnetic resonance imaging being a close second option in complex clinical circumstances. The management of uterine fibroids can be approached medically, surgically, and even by minimal access techniques. The recent introduction of selective progesterone receptor modulators (SPRMs) and aromatase inhibitors has added more armamentarium to the medical options of treatment. Uterine artery embolization (UAE) has now been well-recognized as a uterine-sparing (fertility-preserving) method of treating fibroids. More recently, the introduction of ultrasound waves (MRgFUS) or radiofrequency (VizAblate™ and Acessa™) for uterine fibroid ablation has added to the options of minimal access treatment. More definite surgery in the form of myomectomy or hysterectomy can be performed via the minimal access or open route methods. Our article seeks to review the already established information on uterine fibroids with added emphasis on contemporary knowledge.

Radiological appearances of uterine fibroids

Uterine fibroids, also known as leiomyomas, are the commonest uterine neoplasms. Although benign, they can be associated with significant morbidity and are the commonest indication for hysterectomy. They are often discovered incidentally when performing imaging for other reasons. Usually first identified with USG, they can be further characterized with MRI. They are usually easily recognizable, but degenerate fibroids can have unusual appearances. In this article, we describe the appearances of typical and atypical uterine fibroids, unusual fibroid variants and fibroid mimics on different imaging modalities. Knowledge of the different appearances of fibroids on imaging is important as it enables prompt diagnosis and thereby guides treatment.

Uterine leiomyoma in an adolescent female

BACKGROUND

Uterine myomas are the most frequently occurring neoplasms in the female pelvis, presenting in approximately one-third of women. Fewer than half develop menstrual abnormalities, pelvic pain, and discomfort. Large myomas may compromise fertility. These tumors very rarely occur in the pediatric and adolescent population. When suspected on examination, careful evaluation is necessary to distinguish the tumor from an adnexal lesion.

CASE

A 17-year-old girl presented with a large asymptomatic pelvic mass, which was clinically suspected to be a leiomyoma. An initial sonographic study was questionable for a myoma but was confirmed on subsequent magnetic resonance imaging (MRI). A large myoma was noted and removed at surgery. The patient subsequently became pregnant and delivered at term by caesarean section.

SUMMARY AND CONCLUSION

Leiomyomas of the uterus in women under 20 years of age are rare and occur much less often than adnexal lesions. Although ultrasound studies are usually sufficient to make the distinction between the 2, MRI generally is superior to sonography in this regard. In this young population, myomectomy is the surgical procedure of choice to preserve fertility.

Management of uterine fibroids in the patient pursuing assisted reproductive technologies

Uterine leiomyomas are present in 30-70% of women of reproductive age. In addition to causing menstrual disorders and pain, uterine fibroids negatively affect fertility and pregnancy outcome for patients pursuing assisted reproduction. The two questions that have to be addressed are: which fibroids should be treated and how should they be treated? Submucosal fibroids are associated with a 70% reduction in delivery rate. Intramural fibroids had a lesser effect and reduced the delivery rate by approximately 30%. By contrast, studies have demonstrated that subserosal fibroids did not negatively impact fertility. Furthermore, both submucosal and intramural fibroids were associated with an increased risk of spontaneous miscarriage. Myomectomy is considered the treatment of choice to alleviate these detrimental effects. Further research is needed before alternative treatments can be recommended.

Magnetic resonance imaging and transvaginal ultrasound for determining fibroid burden: implications for research and clinical care

OBJECTIVES

To compare magnetic resonance and ultrasound imaging for uterine fibroid measurement.

STUDY DESIGN

Eighteen women undergoing hysterectomy for symptomatic fibroids underwent preoperative pelvic ultrasound and magnetic resonance imaging. Resected fibroids were correlated with the images. Weighted kappa agreement statistics and Spearman correlations for patient characteristics were calculated.

RESULTS

Magnetic resonance imaging identified 121 of 151 pathologically confirmed fibroids, yielding 91% positive predictive value (95% confidence interval [CI], 85-95) and 80% sensitivity (95% CI, 73-86). Positive predictive value and sensitivity for ultrasound were 97% (95% CI, 89-100) and 40% (95% CI, 32-48), respectively. Mean diameter-equivalent discrepancies between imaging and pathologic measurements were 0.51 +/- 0.68 cm for magnetic resonance imaging and 0.76 +/- 0.88 cm for ultrasound. kappa statistics comparing imaging to pathology showed better agreement for magnetic resonance than ultrasound (kappa = 0.60 vs 0.36). The number of fibroids detected by magnetic resonance imaging predicted measurement errors (r = 0.76; P = .0002).

CONCLUSION

Superior sensitivity and minimal measurement discrepancies suggest magnetic resonance imaging may be preferentially used for fibroid assessment in clinical research.

[Imaging before and after uterine artery embolization]

Percutaneous catheter-based embolization treatment of symptomatic uterine fibroids has evolved into the most widely used alternative therapeutic approach to surgical treatment worldwide. Uterine artery embolization (UAE) induces infarction of leiomyomas, resulting in ischemic necrosis, hyaline degeneration, and size reduction with resolution of associated symptoms. Published experience suggests that UAE is an effective and reliable option for treating uterine fibroids with high patient satisfaction.Magnetic resonance imaging (MRI) is superior to ultrasonography for determining the site, size and number of fibroids, which is important for establishing the indication for UAE. Other potential advantages of MRI include the option of performing MR angiography (MRA) and obtaining contrast-enhanced images for monitoring the outcome of UAE and assessing possible complications after UAE.

Magnetic resonance imaging of benign uterine pathology

Magnetic resonance imaging is commonly used for the identification and characterization of many pelvic abnormalities. Magnetic resonance provides the most comprehensive and detailed view of the uterus of any imaging modality. This article focuses on the magnetic resonance imaging features used to recognize and describe congenital uterine anomalies and benign conditions of the uterus.

Solving the Problem Pelvic Ultrasound With Magnetic Resonance Imaging

Ultrasound is the screening method of choice for evaluation of pelvic anatomy and abnormalities of the female pelvis. It allows for detailed assessment of the uterus, endometrium, and ovaries. However, there are times when the sonographic diagnosis is nonspecific. This review article details the use of magnetic resonance imaging for assessment of uterine duplication anomalies, adnexal and uterine masses, and for aiding in the assessment of pregnant patients with nonspecific sonographic findings in the pelvis.

MRI Evaluation of the Uterine Structure after Myomectomy

Myomectomy is a good indication for women with uterine leiomyoma who desire to preserve their child-bearing potential. However, there are still no reports about how long it takes the uterus to reach a stable state after myomectomy. We evaluated the changes in uterine structure during the recovery process after myomectomy by MR images. MR images were used to analyze the time-dependent changes in the length of the uterine cavity, the volume of the uterus, recovery of the junctional zone, prevalence of modification of the endometrium, and uterine structure in the region of the enucleated myoma. The cavity length and the volume of the uterus, and the myometrium were stabilized at six weeks after the myomectomy. With regard to the endometrium, 12 weeks were required for it to achieve a stable state after myomectomy. However, even at 12 weeks postoperatively, 14.2% of the cases showed an unusual view near the uterine incision on MR images. We concluded that the recovery process is complete at 12 weeks after the operation if there are no clear findings of hematoma or edema formation in the myometrium on MR images.

Uterine fibroid embolization can still be improved: observations on post-procedure magnetic resonance imaging

PURPOSE

To evaluate the efficacy and completeness of uterine fibroid embolization (UFE) measured by changes in volume and signal intensity at magnetic resonance imaging (MRI), and to compare with clinical outcome.

MATERIAL AND METHODS

40 women with symptomatic uterine fibroids underwent bilateral uterine artery embolization. At MRI studies, including post-contrast sequences before and repeatedly after treatment, the uterus and dominant fibroids were evaluated for volume, location, and contrast enhancement. Prior to treatment, all myomas showed significant contrast enhancement. The mean uterine volume was 929 ml. Clinical examinations with emphasis on menorrhagia, pelvic pain, and urinary dysfunction were performed before and 6 and 12 months after treatment.

RESULTS

UFE was bilaterally successful in 38 patients. After UFE, MRI showed no enhancement of myomas in 30 patients. In 8 patients, post-procedural MRI revealed partially remaining vascularization of fibroids despite angiographically complete embolization of the uterine arteries. On average, uterine volume decreased by 46.2% at 12 months. There was significant improvement of symptoms in the majority of patients, but slightly less improvement in patients with partially remaining vascularization of myomas.

CONCLUSION

UFE causes significant volume reduction of myomas and clinical improvement. MRI can reveal remaining vascularization in myomas despite angiographically complete embolization of uterine arteries.

Adenomyosis interferes with accurate ultrasonographic detection of uterine leiomyomas

OBJECTIVE

To evaluate the accuracy of pelvic ultrasonography, and the characteristics of women with inaccurate ultrasonographic diagnosis for uterine leiomyomas.

MATERIALS AND METHODS

Preoperative pelvic ultrasonographic and postoperative pathologic findings of all women, who underwent hysterectomies for pelvic pain, menorrhagia and/or leiomyomas between December 1995 and July 2002, were evaluated. Three hundred thirty-three women, who had a transabdominal or transvaginal pelvic ultrasonography within 1 year prior to the hysterectomy, were included in the study. We assessed the accuracy of ultrasonography for uterine leiomyomas in this group, and defined the characteristics of women with inaccurate studies.

RESULTS

Despite its high sensitivity (95.9%), ultrasonography had only 42.5% specificity for detecting leiomyomas. Its positive predictive and the negative predictive values were 92.4% and 58.6%, respectively. Adenomyosis was found in the majority of the women with false-positive (70.8%) and false-negative (83.3%) results. In both groups, previous pelvic surgery and high body mass index (BMI) were also common.

CONCLUSION

Adenomyosis is the most common final diagnosis in women with inaccurate ultrasound reports for uterine leiomyomas.

Uptake of 2-[18F]fluoro-2-deoxy-D-glucose in uterine leiomyoma: imaging of four patients by coincidence positron emission tomography

Uterine leiomyomas, benign tumours of the human uterus, are the most common uterine neoplasm and are composed of smooth muscle with varying amounts of fibrous connective tissue. As a functional imaging modality, 2-[F]fluoro-2-deoxy-D-glucose (F-FDG) positron emission tomography can be used to obtain information about glucose metabolism in tissues. In this study, the findings of the F-FDG scans of four patients who were suspected of having malignant gynaecological tumours because of clinical and radiological findings and finally diagnosed as uterine leiomyoma based on histopathological examination were evaluated. Moderately intense F-FDG accumulation was detected in uterine mass localization in lower pelvis. The reason for the accumulation of F-FDG in uterine leiomyomas is not known. It may be explained by the existence of higher levels of growth factors, including basic fibroblast growth factor, transforming growth factor beta, granulocyte-macrophage colony-stimulating factor and receptors, and proliferation of smooth muscle cells in leiomatous uterus.

Effect of inner myometrium fibroid on reproductive outcome after IVF

To evaluate the influence of inner myometrium fibroids (myomas) on the outcome of IVF cycles, a retrospective agematched controlled study was performed at SISMeR Reproductive Medicine Unit. The study group included 129 IVF/intracytoplasmic sperm injection cycles in 75 patients with one or more intramural and/or submucosal fibroids, while the control group consisted of 129 cycles in 127 patients without fibroids. The two groups were similar for mean oestradiol concentration at human chorionic gonadotrophin administration (1205.16 +/- 874 versus 1395 +/- 821 pg/ml), mean number of transferred embryos (2.02 +/- 0.4 versus 2.14 +/- 0.6) and clinical pregnancy rate (34.9 versus 41.1%). Conversely, the implantation rate was significantly lower in the study group (18.0%) than in the control group (26.5%; chi(2) = 4.81, P < 0.05), whereas the rate of spontaneous abortion demonstrated an opposite trend (40 versus 18.9%; chi(2) = 4.34, P < 0.05). Further research should be aimed at classifying fibroids on the basis of their location, especially when they are positioned in the junctional zone of the myometrium. Whether this classification will be superior in predicting the impact of fibroids on the reproductive outcome should be elaborated in a large multicentric study.

Benign myometrial conditions: leiomyomas and adenomyosis

Leiomyomas and adenomyosis are common benign myometrial conditions. Although their symptoms overlap, traditional treatment of these two entities differs; thus, making the correct diagnosis is critical. Specifically, uterine-conserving therapy is well established for many women with symptomatic leiomyomas, whereas hysterectomy is the treatment for debilitating adenomyosis. Magnetic resonance imaging (MRI) is the most accurate modality for identifying leiomyomas and adenomyosis. T2-weighted sequences often are diagnostic. For leiomyomas, MRI reliably identifies their number, size, and location. These features help triage patients to appropriate therapy. For adenomyosis, MRI establishes the diagnosis in cases of equivocal or nondiagnostic ultrasounds. MRI also has been used to confirm an ultrasound diagnosis of adenomyosis when curative surgery is being considered. Intravenous gadolinium chelates are not necessary to make the diagnosis of either adenomyosis or leiomyomas, but it provides useful information about vascularity of lesions, a factor that may impact the type of treatment undertaken.

MR imaging of the female pelvis

MR imaging has become a valuable modality in the evaluation of the female pelvis. In many cases, it follows the performance of HSG or US. These cases include infertility and pelvic pain. In some cases, it should serve as the test of choice. This is true in the local staging of cervical cancer and the evaluation of pain or disability in the pregnant patient. Finally, in the evaluation of advanced gynecologic cancers, it is usually a secondary choice with CT preferred.

High cumulative incidence of uterine leiomyoma in black and white women: ultrasound evidence

OBJECTIVE

Uterine leiomyoma, or fibroid tumors, are the leading indication for hysterectomy in the United States, but the proportion of women in whom fibroid tumors develop is not known. This study screened for fibroid tumors, independently of clinical symptoms, to estimate the age-specific proportion of black and white women in whom fibroid tumors develop.

STUDY DESIGN

Randomly selected members of an urban health plan who were 35 to 49 years old participated (n = 1364 women). Medical records and self-report were used to assess fibroid status for those women who were no longer menstruating (most of whom had had hysterectomies). Premenopausal women were screened by ultrasonography. We estimated the age-specific cumulative incidence of fibroid tumors for black and white women.

RESULTS

Thirty-five percent of premenopausal women had a previous diagnosis of fibroid tumors. Fifty-one percent of the premenopausal women who had no previous diagnosis had ultrasound evidence of fibroid tumors. The estimated cumulative incidence of tumors by age 50 was >80% for black women and nearly 70% for white women. The difference between the age-specific cumulative incidence curves for black and white women was highly significant (odds ratio, 2.9; 95% CI, 2.5-3.4; P <.001).

CONCLUSION

The results of this study suggest that most black and white women in the United States develop uterine fibroid tumors before menopause and that uterine fibroid tumors develop in black women at earlier ages than in white women.

I. Uterine fibroid embolization: preprocedure assessment

Increasing clinical experience with uterine fibroid embolization (UFE) has improved the ability of interventionalist radiologists to discern who is and who is not an appropriate candidate for this procedure. Initial evaluation should be directed at obtaining answers to the following key questions: (1) Does the patient have uterine fibroids that account for her symptoms and are they severe enough to require invasive treatment? (2) Does she desire future childbearing? (3) Are there any clinical indications or imaging signs of uterine malignancy? (4) Are there any medical or anatomic features that would favor a particular therapeutic modality? (5) What are her own preferences regarding treatment? Ultrasound and magnetic resonance imaging are vital elements to the assessment and planning of the appropriate course of action. Given the lack of prospective comparative trials between UFE and surgical treatment, recommendations are often highly influenced by patient preference.

Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis, mapping, and measurement of uterine myomas

OBJECTIVE

The purpose of this study was to evaluate and compare the accuracy of magnetic resonance imaging and transvaginal ultrasonography in myoma diagnosis, mapping, and measurement.

STUDY DESIGN

This was a double-blind study of 106 consecutive premenopausal women who underwent hysterectomy for benign reasons. Myomas (total, 257) were exactly mapped by magnetic resonance imaging and transvaginal ultrasonography; in each patient, we counted correctly identified myomas with pathologic position as true value.

RESULTS

The presence of myomas was detected with the same high level of precision by both methods (magnetic resonance imaging: sensitivity, 0.99; specificity, 0.86; transvaginal ultrasonography: sensitivity, 0.99; specificity, 0.91). The mean number of correctly identified myomas was significantly higher by magnetic resonance imaging than by transvaginal ultrasonography (mean difference, 0.51 +/- 1.03; P <.001), a difference that narrowed to 0.08 +/- 0.76 (P =.60) in 26 patients with 1 to 4 myomas and uterine volumes <375 mL. Magnetic resonance imaging and transvaginal ultrasonography myoma diameter measurements had equal and high accuracies in patients with 1 to 4 myomas.

CONCLUSION

Transvaginal ultrasonography is as efficient as magnetic resonance imaging in detecting myoma presence, but its capacity for exact myoma mapping falls short of that of magnetic resonance imaging, especially in large (>375 mL) multiple-myoma (>4) uteri.

Evaluation of the uterine cavity with magnetic resonance imaging, transvaginal sonography, hysterosonographic examination, and diagnostic hysteroscopy

OBJECTIVE

To evaluate and compare the diagnostic accuracy of magnetic resonance imaging (MRI), transvaginal ultrasonography (TVS), hysterosonographic examination (HSE), and hysteroscopy in the evaluation of the uterine cavity.

DESIGN

Independent double-blind study.

SETTING

University medical hospital.

PATIENT(S)

One hundred six consecutive premenopausal women who underwent hysterectomy for benign diseases.

INTERVENTION(S)

Results of MRI, TVS, HSE, and hysteroscopy were compared with the results of histopathologic examination at hysterectomy (the gold standard).

RESULT(S)

The overall sensitivity was MRI 0.76, TVS 0.69, HSE 0.83, and hysteroscopy 0.84. The specificity was MRI 0.92, TVS 0.83, HSE 0.90, and hysteroscopy 0.88 (MRI, HSE, hysteroscopy vs. TVS <0.05). Polyps were missed in 9 of 12 cases at MRI, 7 at TVS, 4 at HSE, and 2 at hysteroscopy (MRI vs. hysteroscopy, and TVS vs. hysteroscopy <0.05). The sensitivity for identification of submucous myomas was MRI 1.0, TVS 0.83, HSE 0.90, and hysteroscopy 0.82; the specificity was MRI 0.91, TVS 0.90, HSE 0.89, and hysteroscopy 0.87 (MRI vs. TVS, and MRI vs. hysteroscopy). Magnetic resonance imaging was significantly more precise than TVS, HSE, and hysteroscopy in determining submucous myoma in-growth (2-way ANOVA <0.05).

CONCLUSION(S)

For exclusion of abnormalities in the uterine cavity, MRI, HSE, and hysteroscopy were equally effective and slightly superior to TVS. Magnetic resonance imaging and TVS missed endometrial abnormalities such as polyps, but MRI and HSE were most accurate for the evaluation of submucous myomas, and MRI was superior in evaluation of exact submucous myoma in-growth.

Fibroids and infertility: a systematic review of the evidence

A systematic literature review was performed to determine whether leiomyomata are associated with decreased fertility rates, and whether surgical removal increases fertility rates postoperatively. Meta-analysis was conducted when multiple studies addressed a single issue and were sufficiently homogeneous. Data were analyzed for effect of any fibroid upon fertility, as well as specific fibroid location. Results of studies comparing women with infertility and fibroids versus infertile controls showed widely disparate results. Subgroup analysis failed to indicate any effect on fertility of fibroids that did not have a submucous component. Conversely, women with submucous myomas demonstrated lower pregnancy rates (RR 0.30; 95% confidence interval [CI] 0.13--0.70) and implantation rates (RR 0.28; 95% CI 0.10--0.72) than infertile controls. Results of surgical intervention were similar. When all fibroid locations were considered together, myomectomy results were again widely disparate. However, when women with submucous myomas were considered separately, pregnancy was increased after myomectomy compared with infertile controls (RR 1.72; 95% CI 1.13--2.58) and delivery rates were now equivalent to infertile women without fibroids (RR 0.98; 95% CI 0.45--2.41). The current data suggest that only those fibroids with a submucosal or an intracavitary component are associated with decreased reproductive outcomes, and that hysteroscopic myomectomy may be of benefit.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to summarize the data on the role of fibroids and infertility, describe the effect of myomectomy on fertility, and list the methods used to evaluate intracavitary fibroids.

Magnetic resonance hysterography and hysterosalpingography using hyperpolarized (3)He: demonstration of feasibility in an animal model

Assessment of the uterine cavity and patency of the fallopian tubes remains a difficult goal with magnetic resonance imaging (MRI). The purpose of this paper is to describe the development of a new magnetic resonance hysterography (MR-HG) and hysterosalpingography (MR-HSG) technique employing hyperpolarized (3)He. Two-dimensional (2D) and 3D gradient-echo imaging sequences were developed and optimized using a phantom. An optimized sequence was then applied in swine cadavers. J. Magn. Reson. Imaging 2000;12:1009-1013.

Radiographic imaging techniques for the diagnosis of abnormal uterine bleeding

The introduction of SIS has been a significant advance in TVUS evaluation of the endometrial cavity in the 1990s. SIS provides an unparalleled, clear, enhanced view of the endomyometrial complex that cannot be obtained with TVUS alone. Focal and global endometrial pathology can be differentiated with SIS. Saline infusion improves the sensitivity for the detection of endometrial abnormalities. The continuing challenge for gynecologists is to provide patients with cost-effective, minimally invasive evaluation and directed therapy for menstrual dysfunction. SIS targets patients needing biopsy, directs the surgical approach, and minimizes office diagnostic hysteroscopy--all with a quick office procedure. For patients, the benefits include minimal and brief discomfort and a better understanding of intrauterine pathology through viewing the ultrasound monitor. Patients also appreciate the ease of scheduling, the minimal time away from work, and that no escort is needed after the procedure. SIS provides an extension of the pelvic gynecologic examination. SIS is the most important imaging modality for evaluating endometrial pathology. Although there is no perfect test to evaluate the endometrium, overall, SIS is superior to other imaging and diagnostic procedures. It is less expensive than D&C or hysteroscopy. It is a safe, efficient, convenient, and well-tolerated procedure. In some instances, however, neither TVUS nor SIS is definitive in determining the location of fibroids or able to discern adenomyosis. In these instances, MR imaging triage is helpful. MR imaging is gaining widespread acceptance and, in many instances, is a cost-effective tool in the evaluation of abnormal uterine bleeding. It is noninvasive, differentiates uterine anatomy in response to exogenous hormones or the normal menstrual cycle, and reliably localizes pelvic pathology and size of lesions. When uterine conservation is desired in women with fibroids and TVUS or SIS is indeterminate in localizing depth of myometrial involvement of a fibroid, MR imaging should be considered as a part of the clinical algorithm. The precision of MR imaging localization of submucosal fibroids can obviate the need for hysterectomy and permit a skilled surgeon to hysteroscopically resect the fibroids. If the clinical examination is suspicious for adenomyosis and the US is nondiagnostic, the clinician should consider MR imaging strongly. When the results of the imaging study would influence surgical route and planning, MR imaging should be considered in the preoperative evaluation.

Diagnostic value of radiological tests in chronic pelvic pain

Chronic pelvic pain (CPP) presents a diagnostic as well as a therapeutic challenge to many clinicians. This chapter briefly describes the most frequent identifiable causes for CPP amenable to imaging; explains the most widely-used and widely available radiological tests for CPP; and compares/contrasts each test's utility and accuracy for a given causality. Examples of each imaging modality are included for demonstration purposes, and a summation table cross-references the best diagnostic methods with corresponding disease processes. References from the literature of both radiology and gynaecology were used in preparing this review.