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Diagnosing Fibroids

Uterine fibroids are very common, occurring in one out of every three women of reproductive age. Fortunately, most uterine fibroids do not cause symptoms and are diagnosed incidentally during a normal pelvic examination or pelvic ultrasound. However, some patients seek help from their doctor in relieving symptoms caused by fibroids, such as heavy menstrual bleeding, pelvic pain, pelvic pressure, urinary frequency, constipation, back pain, or painful intercourse.

Uterine fibroids can occur in several different locations within the uterus and are often multiple (See image below: Fibroid Locations). Submucosal fibroids are fibroids that grow and bulge into the inner lining (the endometrial cavity) of the uterus. These fibroids are most often associated with heavy menstrual bleeding and infertility issues. Intramural fibroids occur within the muscular wall of the uterus and are completely surrounded by normal uterine tissue. Subserosal fibroids develop on the outside of the

Fibroid Locations

Fibroid Locations

(click on image to enlarge)

uterus. Pedunculated fibroids are attached to the uterus by stalk. The symptoms caused by fibroids can vary significantly depending on the size, number and location of the fibroid tumors. These factors may also affect the best treatment options available to a patient with fibroids.

The presence of fibroids suspected by physical examination can be confirmed using non-invasive imaging techniques such as ultrasound and/or MRI. Most patients are imaged using ultrasound initially but a pelvic MRI is required in all patients being evaluated as potential candidates for uterine fibroid embolization (UFE). MRI provides more information concerning the size, number, location, and blood supply to the fibroids.

 

An MRA (magnetic resonance angiogram) of the pelvis is often performed simultaneously with the MRI of the uterus to better demonstrate the blood supply to the fibroids. This image is an example of such a study and shows enlarged uterine arteries on the left and right sides.

This sagittal (cut lengthwise) MRI image through the pelvis shows a dominant submucosal fibroid anteriorly indenting the endometrial stripe and a small intramural fibroid posteriorly. Several other fibroids were also present but are not visible in this single slice.

This sagittal MRI image obtained through the pelvis after contrast administration shows the rich blood supply of the fibroids as they take up the administered contrast agent.

 

MRI also provides valuable information concerning other disease processes that may mimic the symptoms caused by fibroids, such as adenomyosis and endometrial polyps. Magnetic resonance angiography (MRA) is another useful tool and can provide valuable information about the blood supply to the fibroids. Blood to fibroids is usually supplied by the uterine arteries but the ovarian arteries can, on occasion, also provide significant blood flow. This is extremely useful information to have prior to your procedure to increase the likelihood of a successful outcome. Please see the following examples of other disease processes and atypical blood supply to fibroid tumors.

 

This patient was diagnosed with a large fibroid in the uterus and was referred as a potential candidate for uterine fibroid embolization. Sagittal (cut lengthwise) MRI image obtained through the pelvis shows a markedly enlarged uterus but no fibroids. The study does show a condition called adenomyosis, which is an abnormal proliferation of the endometrial glands into the normal uterine muscular tissue. This can be seen as a thickening of the "junctional zone" of the uterus with multiple tiny cystic appearing areas within it. This diagnosis cannot reliably be made using ultrasound and significantly altered the patient's treatment options.

This sagittal (cut lengthwise) and axial (cut crosswise) images through the pelvis show an enlarged uterus containing multiple small to moderate sized fibroids. Additionally, a small approximately 1.5 cm polyp was noted in the upper part of the endometrial canal. This patient underwent hysteroscopic resection of the endometrial polyp prior to embolization to treat the remaining intramural fibroids.

This MRA (magnetic resonance angiogram) image shows markedly enlarged ovarian arteries on the left and right originating from the aorta and providing the dominant blood supply to the fibroid uterus. The patient also had a small amount of supply from the right uterine artery. The left uterine artery did not provide significant flow to the fibroids. An ultrasound would not have provided this crucial information about the source of the fibroids' blood supply prior to the procedure.