Determination of the reasonable treatment options and the appropriate clinical treatment of women with uterine fibroid tumors often depends on the ability of imaging modalities to accurately detect and localize fibroid tumors. Magnetic resonance imaging (MRI) gives the most complete evaluation (sizes, positions, number) of submucous, intramural, and subserosal myomas and is the most sensitive modality for the detection of small fibroid tumors. MRI allows the evaluation of fibroid tumor proximity to the bladder, rectum, and endometrial cavity, helps define what can be expected at surgery, and may help the gynecologist avoid missing fibroid tumors during surgery. MRI can also make the diagnosis of adenomyosis reliably and may be able to identify uterine sarcoma when present.
Fibroid tumors are very common benign tumors that can cause significant morbidity for women. Women who have hysterectomies because of fibroid-related symptoms have significantly worse scores on SF-36 quality-of-life questionnaires than do women who are diagnosed with chronic lung disease, arthritis, hypertension, or heart disease. Consequently, women with fibroid tumors frequently consult gynecologists for fibroid-related symptoms, and fibroid tumors are the indication for approximately 35% of the approximately 600,000 hysterectomies that are performed in the United States each year.
Current treatment options for women with fibroid tumors now include “watchful waiting” and medical therapy in the forms of oral contraceptive pills, levonorgestrel intrauterine system, and gonadotropin-releasing hormone agonists. Uterine fibroid embolization and magnetic resonance-guided ultrasound treatment are available minimally/noninvasive forms of treatment. Surgical procedures now include hysteroscopic myomectomy, laparoscopic/robotic myomectomy, abdominal myomectomy, and laparoscopic, vaginal, and abdominal hysterectomy. Even though many treatment options are now available, most women are offered hysterectomy as a first and sometimes only treatment option. If the gynecologist is able to provide only hysterectomy, then precise imaging of the fibroid tumors is not necessary. However, with other treatment options now available, magnetic resonance imaging (MRI) can be helpful in the determination of which options may be appropriate and allow for referral for less invasive options if in the patient’s best interest.
Diagnosis and imaging of fibroid tumors
The diagnosis of fibroid tumors can be made reliably by pelvic examination and ultrasound scanning. Clinically significant subserosal and intramural fibroid tumors usually can be diagnosed by pelvic examination based on findings of an enlarged, irregularly shaped, firm, and nontender uterus. Sonographic evaluation is not necessary when the diagnosis is certain and no treatment is planned.
Transvaginal sonography (TVS) is reasonably reliable for the evaluation of smaller uteri with ≤4 fibroid tumors and is the most readily available and least costly imaging technique to differentiate fibroid tumors from other pelvic disease. By inserting saline solution into the uterine cavity to provide contrast, saline–infusion sonography better defines submucous fibroid tumors. However, sonography has significant operator-dependent variability, which results in inconsistent accuracy and poor reproducibility. In addition, sonography has a limited field of view and does not capture most anatomic landmarks; archived images are difficult to assemble into a 3-dimensional representation of the uterus and adjacent anatomy. Neither pelvic examination nor ultrasound scanning provides precise information about the sizes, number, and positions of all present fibroid tumors.
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