Abstract
Uterine fibroids are the most common benign gynecologic tumors in women of reproductive age, and ultrasound is the first-line imaging modality for their diagnosis and characterization. The International Federation of Gynecology and Obstetrics developed a system for describing and classifying uterine fibroids uniformly and consistently. An accurate description of fibroids in the ultrasound report is essential for planning surgical treatment and preventing complications. In this article, we review the ultrasound findings of fibroids, detailing the main points to be reported for preoperative evaluation. In addition, we propose a structured, illustrated report template to describe fibroids, based on the critical points for surgical planning.
Keywords:
Ultrasonography; Leiomyoma; Myoma; Uterine myomectomy; Metrorrhagia; Infertility
Resumo
Os miomas uterinos são os tumores ginecológicos benignos mais comuns em mulheres em idade reprodutiva, sendo a ultrassonografia a modalidade de imagem de primeira linha para seu diagnóstico e caracterização. A Federação Internacional de Ginecologia e Obstetrícia desenvolveu um sistema para descrever e classificar os miomas uterinos de forma uniforme e consistente. Uma descrição precisa dos miomas no laudo ultrassonográfico é essencial para o planejamento do tratamento cirúrgico e prevenção de complicações. Neste artigo, revisamos os achados ultrassonográficos de miomas, detalhando os principais pontos a serem relatados para avaliação pré-operatória. Além disso, propomos um modelo de relatório estruturado e ilustrado para descrição de miomas, com base nos pontos críticos para o planejamento cirúrgico.
Unitermos:
Ultrassonografia; Leiomioma; Mioma; Miomectomia uterina; Metrorragia; Infertilidade
INTRODUCTION
Uterine fibroids are the most common benign gynecological tumors in women of reproductive age(11 Gomez E, Nguyen MLT, Fursevich D, et al. MRI-based pictorial review of the FIGO classification system for uterine fibroids. Abdom Radiol (NY). 2021;46:2146–55.,22 Keizer AL, van Kesteren PJM, Terwee C, et al. Uterine fibroid symptom and quality of life questionnaire (UFS-QOL NL) in the Dutch population: a validation study. BMJ Open. 2021;11:e052664.). Most women with fibroids are asymptomatic, and nearly a third of patients have significant symptoms such as dysmenorrhea, menorrhagia, abnormal uterine bleeding, secondary anemia, pelvic pain, and infertility(11 Gomez E, Nguyen MLT, Fursevich D, et al. MRI-based pictorial review of the FIGO classification system for uterine fibroids. Abdom Radiol (NY). 2021;46:2146–55.,22 Keizer AL, van Kesteren PJM, Terwee C, et al. Uterine fibroid symptom and quality of life questionnaire (UFS-QOL NL) in the Dutch population: a validation study. BMJ Open. 2021;11:e052664.). The treatment of patients with uterine fibroids should be individualized on the basis of the symptoms, patient age, patient desire to preserve fertility or the uterus, and the characteristics of the nodules (e.g., size and location), as well as the availability of therapy and the experience of the attending physician(22 Keizer AL, van Kesteren PJM, Terwee C, et al. Uterine fibroid symptom and quality of life questionnaire (UFS-QOL NL) in the Dutch population: a validation study. BMJ Open. 2021;11:e052664.,33 American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins–Gynecology. Management of symptomatic uterine leiomyomas: ACOG Practice Bulletin, Number 228. Obstet Gynecol. 2021;137:e100–e115.). In this context, ultrasound is considered the initial test of choice for the diagnosis of fibroids in symptomatic patients, mainly due to its broad availability, ease of use, cost-effectiveness, high sensitivity, and high specificity(44 Pereira AEMM, Franco J, Machado FS, et al. Accuracy of transvaginal ultrasound in the diagnosis of intrauterine lesions. Rev Bras Ginecol Obstet. 2021;43:530–4.,55 Liu YH, Qiu YH, Ru Y, et al. Selection of different surgical methods for uterine fibroids: protocol for a retrospective clinical study. Medicine (Baltimore). 2021;100:e28378.). The examination should be performed by specially trained physicians, with the aim of accurately identifying and describing all fibroids(44 Pereira AEMM, Franco J, Machado FS, et al. Accuracy of transvaginal ultrasound in the diagnosis of intrauterine lesions. Rev Bras Ginecol Obstet. 2021;43:530–4.,55 Liu YH, Qiu YH, Ru Y, et al. Selection of different surgical methods for uterine fibroids: protocol for a retrospective clinical study. Medicine (Baltimore). 2021;100:e28378.). Other aspects that are crucial in the choice of treatment—the size and location of fibroids; the presence and size of the submucosal component; penetration of the myometrial component; proximity to the uterine serosa; relationship with and proximity to the endometrial cavity; vascular supply; and coexistence of adenomyosis or deep endometriosis—are easily determined and can be characterized by using transvaginal ultrasound(55 Liu YH, Qiu YH, Ru Y, et al. Selection of different surgical methods for uterine fibroids: protocol for a retrospective clinical study. Medicine (Baltimore). 2021;100:e28378.,66 Metwally M, Raybould G, Cheong YC, et al. Surgical treatment of fibroids for subfertility. Cochrane Database Syst Rev. 2020;1: CD003857.,77 Chittawar PB, Franik S, Pouwer AW, et al. Minimally invasive surgical techniques versus open myomectomy for uterine fibroids. Cochrane Database Syst Rev. 2014;(10):CD004638.).
In 2011, the Fédération Internationale de Gynécologie et d’Obstétrique (FIGO) published a classification system for categorizing the location of uterine fibroids(88 Munro MG, Critchley HOD, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011; 113:3–13.). The Morphological Uterus Sonographic Assessment (MUSA) group subsequently ratified the FIGO classification, adopting it to describe the location of fibroids(99 Frascà C, Tuzzato G, Arena A, et al. The role of pelvic ultrasound in preoperative evaluation for laparoscopic myomectomy. J Minim Invasive Gynecol. 2018;25:679–83.,1010 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;46:284–98.). Although the FIGO classification system has provided gynecologists with a well-standardized framework for describing and characterizing uterine fibroids, significant variability has been observed across ultrasound reports in terms of the FIGO classification(1111 Myers SL, Baird DD, Olshan AF, et al. Self-report versus ultrasound measurement of uterine fibroid status. J Womens Health (Larchmt). 2012;21:285–93.). Errors in the classification and description of fibroids in imaging reports can lead to inappropriate surgical planning(77 Chittawar PB, Franik S, Pouwer AW, et al. Minimally invasive surgical techniques versus open myomectomy for uterine fibroids. Cochrane Database Syst Rev. 2014;(10):CD004638.,1111 Myers SL, Baird DD, Olshan AF, et al. Self-report versus ultrasound measurement of uterine fibroid status. J Womens Health (Larchmt). 2012;21:285–93.). However, it is well known that the accuracy of ultrasound depends on the skill of the performing physician and the quality of the description in the ultrasound report(1212 Marnach ML, Laughlin-Tommaso SK. Evaluation and management of abnormal uterine bleeding. Mayo Clin Proc. 2019;94:326–35.,1313 Liu L, Wang T, Lei B. Uterine artery embolization compared with high-intensity focused ultrasound ablation for the treatment of symptomatic uterine myomas: a systematic review and meta-analysis. J Minim Invasive Gynecol. 2021;28:218–27.). Therefore, the use of structured reports, divided into ordered sections and with standardized language, could improve the communication of the results of ultrasound examinations and the confidence of the gynecologist in those results(1414 Franconeri A, Fang J, Carney B, et al. Structured vs narrative reporting of pelvic MRI for fibroids: clarity and impact on treatment planning. Eur Radiol. 2018;28:3009–17.).
In the present study, we illustrate the main findings to be reported in an ultrasound report of fibroids. We also propose a structured template for transvaginal ultrasound reports, designed to facilitate the preoperative evaluation of patients with uterine fibroids.
CLASSIFICATION OF FIBROIDS
Traditionally, the classification of fibroids is based on their location in relation to two anatomical planes(1515 Benetti-Pinto CL, Rosa-e-Silva ACJS, Yela DA, et al. Abnormal uterine bleeding. Rev Bras Ginecol Obstet. 2017;39:358–68.): the endometrium and the uterine serosa. Thus, uterine fibroids are classified as submucosal, intramural, or sub-serosal(1616 Munro MG. Practical aspects of the two FIGO systems for management of abnormal uterine bleeding in the reproductive years. Best Pract Res Clin Obstet Gynaecol. 2017;40:3–22.). With advances in diagnostic modalities, the need arose for a detailed, universally accepted classification system as a guide for choosing the most appropriate treatment(1717 Bajaj S, Gopal N, Clingan MJ, et al. A pictorial review of ultrasonography of the FIGO classification for uterine leiomyomas. Abdom Radiol (NY). 2022;47:341–51.). Therefore, in 2011, the FIGO classification system for causes of abnormal uterine bleeding was developed(1717 Bajaj S, Gopal N, Clingan MJ, et al. A pictorial review of ultrasonography of the FIGO classification for uterine leiomyomas. Abdom Radiol (NY). 2022;47:341–51.,1818 Sabre A, Serventi L, Nuritdinova D, et al. Abnormal uterine bleeding types according to the PALM-COEIN FIGO classification in a medically underserved American community. J Turk Ger Gynecol Assoc. 2021;22:91–6.). Currently, the FIGO classification includes a total of nine types of fibroids(88 Munro MG, Critchley HOD, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011; 113:3–13.)—types 0 through 8—as presented in Table 1 and Figure 1.
FIGO classification of fibroids: 0 = pedunculated intracavitary fibroid; 1 = submucosal fibroid that is < 50% intramural; 2 = submucosal fibroid that is ≥ 50% intramural; 3 = fibroid that is 100% intramural but in contact with the endometrium; 4 = intramural fibroid; 5 = subserosal fibroid that is ≥ 50% intramural; 6 = subserosal fibroid that is < 50% intramural; 7 = sub-serosal pedunculated fibroid; 8 = other (e.g., cervical and parasitic) fibroids; and 2-5 = hybrid fibroid that is < 50% submucosal and < 50% subserosal.
The FIGO classification system was revised in 2018(1919 Munro MG, Critchley HOD, Fraser IS; FIGO Menstrual Disorders Committee. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018;143:393–408.). The revised version suggests that an estimate of the total uterine volume should be provided in the ultrasound report, as should the estimated total number of fibroids. In addition, the report should include the estimated volumes of up to four fibroids and their locations, described as anterior, posterior, right, left, or fundus. Furthermore, the relationship between the endometrium and fibroids should be recorded in accordance with the FIGO classification system(1919 Munro MG, Critchley HOD, Fraser IS; FIGO Menstrual Disorders Committee. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet. 2018;143:393–408.).
ULTRASOUND DIAGNOSIS OF UTERINE FIBROIDS
On ultrasound, a uterine fibroid is classically characterized as a solid, round, well-defined, hypoechoic, heterogeneous lesion within the myometrium, often showing acoustic shadowing at the edge of the lesion, with or without internal fan-shaped shadowing (Figure 2). On color Doppler (Figure 3), the circumferential flow around the lesion is often visible(2020 Harmsen MJ, Van den Bosch T, de Leeuw RA, et al. Consensus on revised definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis: results of modified Delphi procedure. Ultrasound Obstet Gynecol. 2022;60:118–31.). In addition, Fleischer et al.(2121 Fleischer AC, Donnelly EF, Campbell MG, et al. Three-dimensional color Doppler sonography before and after fibroid embolization. J Ultrasound Med. 2000;19:701–5.) successfully used three-dimensional (3D) color Doppler to demonstrate that hypervascular fibroids show a greater reduction in size after uterine artery embolization than do isovascular and hypovascular fibroids. Those authors also found that, after the procedure, standard ultrasound showed decreased uterine size and echogenicity and color Doppler imaging showed a marked decrease in blood flow to the leiomyoma.
Transvaginal color Doppler ultrasound image showing a submucosal fibroid with circumferential vascularity.
The 2015 MUSA consensus suggested using a systematic approach to assessing and reporting ultrasound findings of the myometrium and associated fibroids(2020 Harmsen MJ, Van den Bosch T, de Leeuw RA, et al. Consensus on revised definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis: results of modified Delphi procedure. Ultrasound Obstet Gynecol. 2022;60:118–31.,2222 Weintraub JL, Romano WJ, Kirsch MJ, et al. Uterine artery embolization: sonographic imaging findings. J Ultrasound Med. 2002;21: 633–7.). The relevant parameters are presented in Table 2.
KEY POINTS FOR THE SURGICAL TREATMENT OF FIBROIDS
Decisions regarding the treatment of fibroids should take into consideration the presence of symptoms (often pain, bleeding, or infertility); the age and reproductive aspirations of the woman; and the number, size, and location of the fibroids. Most asymptomatic patients do not need specific treatment, requiring only periodic monitoring with imaging examinations(2222 Weintraub JL, Romano WJ, Kirsch MJ, et al. Uterine artery embolization: sonographic imaging findings. J Ultrasound Med. 2002;21: 633–7.,2323 Leone FP, Timmerman D, Bourne T, et al. Terms, definitions and measurements to describe the sonographic features of the endometrium and intrauterine lesions: a consensus opinion from the International Endometrial Tumor Analysis (IETA) group. Ultrasound Obstet Gynecol. 2010;35:103–12.). Although the initial treatment for most patients with symptoms of abnormal bleeding is clinical, the definitive treatment for fibroids is surgical(2323 Leone FP, Timmerman D, Bourne T, et al. Terms, definitions and measurements to describe the sonographic features of the endometrium and intrauterine lesions: a consensus opinion from the International Endometrial Tumor Analysis (IETA) group. Ultrasound Obstet Gynecol. 2010;35:103–12.). Typically, hysterectomy and myomectomy are the most effective treatments(2424 Giuliani E, As-Sanie S, Marsh EE. Epidemiology and management of uterine fibroids. Int J Gynaecol Obstet. 2020;149:3–9.). Alternatives to surgery include embolization of the uterine arteries and magnetic resonance imaging (MRI)-guided focused ultrasound ablation(2525 Shubham D, Kawthalkar AS. Critical evaluation of the PALMCOEIN classification system among women with abnormal uterine bleeding in low-resource settings. Int J Gynaecol Obstet. 2018; 141:217–21.). The key imaging aspects for the surgical treatment of fibroids are outlined in the following items.
Uterine volume
It is recommended that the longitudinal, anteroposterior, and transverse diameters of the uterus be measured, because that provides the uterine volume in cm33 American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins–Gynecology. Management of symptomatic uterine leiomyomas: ACOG Practice Bulletin, Number 228. Obstet Gynecol. 2021;137:e100–e115., as shown in Figure 4, which is extremely useful in the surgical planning(2626 Marín-Buck A, Karaman E, Amer-Cuenca JJ, et al. Minimally invasive myomectomy: an overview on the surgical approaches and a comparison with mini-laparotomy. J Invest Surg. 2021;34:443–50.,2727 Xu F, Deng L, Zhang L, et al. The comparison of myomectomy, UAE and MRgFUS in the treatment of uterine fibroids: a meta analysis. Int J Hyperthermia. 2021;38:24–9.). When the uterine volume exceeds 375 mL, the efficiency of transvaginal ultrasound in fibroid mapping is significantly lower than is that of MRI(2828 Dueholm M, Lundorf E, Hansen ES, et al. Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis, mapping, and measurement of uterine myomas. Am J Obstet Gynecol. 2002;186:409–15.).
Transvaginal ultrasound image, in transverse and longitudinal views, showing the dimensions of the uterus.
Number of fibroids
The number of fibroids will determine whether fibroid resection is feasible for symptom control. When there are numerous fibroids, radiologists should consider reporting a range of 10–20. Although it is not necessary to describe all lesions, a minimum number should be chosen(2727 Xu F, Deng L, Zhang L, et al. The comparison of myomectomy, UAE and MRgFUS in the treatment of uterine fibroids: a meta analysis. Int J Hyperthermia. 2021;38:24–9.). Most previous studies have suggested that radiologists should describe no more than four non-submucosal fibroids and should describe all submucosal fibroids(2525 Shubham D, Kawthalkar AS. Critical evaluation of the PALMCOEIN classification system among women with abnormal uterine bleeding in low-resource settings. Int J Gynaecol Obstet. 2018; 141:217–21.,2626 Marín-Buck A, Karaman E, Amer-Cuenca JJ, et al. Minimally invasive myomectomy: an overview on the surgical approaches and a comparison with mini-laparotomy. J Invest Surg. 2021;34:443–50.,2727 Xu F, Deng L, Zhang L, et al. The comparison of myomectomy, UAE and MRgFUS in the treatment of uterine fibroids: a meta analysis. Int J Hyperthermia. 2021;38:24–9.), as depicted in Figure 5.
Transvaginal ultrasound image, in a cross-sectional view, showing myomatosis in a large uterus.
Size
It is recommended that each fibroid described in the report be systematically measured in three orthogonal planes, to obtain its volume in cm33 American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins–Gynecology. Management of symptomatic uterine leiomyomas: ACOG Practice Bulletin, Number 228. Obstet Gynecol. 2021;137:e100–e115., as illustrated in Figure 6. Knowledge of the size of each fibroid helps the gynecologist estimate the probability that the fibroids are (collectively) the direct cause of the symptoms and determine the best surgical approach in each case(2828 Dueholm M, Lundorf E, Hansen ES, et al. Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis, mapping, and measurement of uterine myomas. Am J Obstet Gynecol. 2002;186:409–15.).
Transvaginal ultrasound image, in a longitudinal view, showing the dimensions of a fibroid.
Location
It is essential to register the location of each fibroid as being in the wall of the uterus—anterior, posterior, or lateral (right or left)—in the uterine fundus, or global (Figure 7). For example, when the fibroid is located in the lateral wall or in the uterine fundus, there is a greater degree of complexity in the hysteroscopic surgical procedure(2929 Yamamoto A, Suzuki S. Successful surgical treatment of a giant uterine leiomyoma: a case report. Int J Surg Case Rep. 2021;87:106416.).
Transvaginal ultrasound image, in a longitudinal view, showing a submucosal (FIGO 2) fibroid in the anterior wall of a retroverted uterine body.
FIGO classification
Submucosal (FIGO 0, 1, and 2) uterine fibroids constitute a common cause of menorrhagia and dysmenor-rhea because they project into the endometrial cavity. For women who wish to become pregnant, submucosal fibroids are especially worrisome because they can cause infertility or miscarriage(3030 Lee SR, Kim JH, Kim S, et al. The number of myomas is the most important risk factor for blood loss and total operation time in robotic myomectomy: analysis of 242 cases. J Clin Med. 2021;10:2930.). Therefore, such fibroids require surgical treatment, regardless of size. Treatment often includes hysteroscopic resection. For symptomatic patients who have no desire to become pregnant, hysterectomy can be an option. Hysteroscopic myomectomy of a bulky FIGO 2 fibroid, as depicted in Figure 8, can be difficult and might require a two-stage surgical procedure or uterine artery embolization(3131 Barbosa PA, Villaescusa M, Andres MP, et al. How to minimize bleeding in laparoscopic myomectomy. Curr Opin Obstet Gynecol. 2021;33:255–61.).
Transvaginal ultrasound image, in a longitudinal view, showing a submucosal (FIGO 2) fibroid with an intramural component > 50%.
Fibroids without a submucosal component (intramural and subserosal fibroids) that cause symptoms of mass effect in the uterine cavity or adjacent structures such as the bladder and bowel can be treated with embolization, myomectomy, or hysterectomy if there is no possibility of or desire for pregnancy. Accurately differentiating FIGO 2 fibroids from FIGO 3 and 4 fibroids is critical, because the surgical approach differs(3232 Naval S, Naval R, Naval S, et al. Tips for safe laparoscopic multiple myomectomy. J Minim Invasive Gynecol. 2017;24:193.): FIGO 2 fibroids are resected by hysteroscopy; and FIGO 3 and 4 fibroids are resected by video-assisted laparoscopy or laparotomy. Figure 9 shows an intramural FIGO 4 fibroid.
Transvaginal ultrasound image, in a cross-sectional view, showing an intramural (FIGO 4) fibroid.
Treatment of bulky symptomatic fibroids and of bulky subserosal (FIGO 5, 6, and 7) fibroids in adjacent structures includes embolization, video-assisted laparoscopic myomectomy, and laparotomy. Due to their vascular pedicle, FIGO 7 fibroids are also at risk of twisting, shedding, or becoming parasitized in the pelvis. For FIGO 5, 6, and 7 fibroids, the treatment options include embolization, laparoscopic resection, laparotomy or hysterectomy(3333 Lee SR, Lee ES, Eum HL, et al. New surgical technique for robotic myomectomy: continuous locking suture on myoma (LSOM) technique. J Clin Med. 2021;10:654.). Figure 10 shows a FIGO 6 fibroid in the uterine fundus.
Transvaginal ultrasound image, in a longitudinal view, showing a subserosal fibroid with an intramural component < 50% (i.e., a FIGO 6 fibroid) in the posterior wall of the uterine fundus.
A FIGO 2-5 fibroid, which is less than 50% submucosal and less than 50% subserosal (Figure 11), is a commonly found hybrid type of fibroid. Due to the size and extent of such a fibroid, treatment includes targeted therapy such as MRI-guided focused ultrasound or embolization, although hysterectomy can be required if the fibroid is extensive(3434 Pundir J, Pundir V, Walavalkar R, et al. Robotic-assisted laparoscopic vs abdominal and laparoscopic myomectomy: systematic review and meta-analysis. J Minim Invasive Gynecol. 2013;20:335–45.,3535 Davis E, Sparzak PB. Abnormal uterine bleeding. 2022 Sep 9. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–.).
Transvaginal ultrasound image, in a longitudinal view, showing a hybrid (FIGO 2-5) fibroid in the uterine fundus.
Myometrial mantle
The thickness of the myometrial mantle can be measured on transvaginal ultrasound (Figure 12). Various authors consider the outer myometrial mantle (distance from the fibroid margin to the serous surface) and the inner myometrial mantle (distance from the fibroid margin to the endometrial surface) to be key factors for hysteroscopic resection of submucosal fibroids. Some studies suggest that, in FIGO 2 fibroids, there is a greater chance of uterine rupture during resection if the outer myometrial mantle is smaller than 0.5 cm(3636 Walker MH, Coffey W, Borger J. Menorrhagia. 2022 Aug 19. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan–.).
Transvaginal ultrasound image, in a cross-sectional view, showing an intramural (FIGO 4) fibroid, with the measurement of the outer mantle (distance from the serous surface, white line) and of the inner mantle (distance from the endometrial surface, yellow line).
Adenomyosis
Recognition of adenomyosis is critical because it can change the treatment approach, patient counseling, and expectations. Adenomyosis, as shown in Figure 13, is defined as diffuse or focal invasion of the endometrial basal layer into the myometrium, can cause fibroid-like symptoms, and is identified on ultrasound as thickening or irregularity of the junctional zone, asymmetry of the myometrial walls, acoustic bands in the myometrium (myometrial stratification into fan-shaped shadowing), subendometrial/myometrial echogenic linear striations, myometrial cysts, and increased vascularization on Doppler, with penetrating vessels in the affected area(3737 Deneris A. PALM-COEIN nomenclature for abnormal uterine bleeding. J Midwifery Womens Health. 2016;61:376–9.).
Transvaginal ultrasound image showing a retroverted uterus with adenomyosis infiltrating the posterior wall (arrow).
Endometriosis
A preoperative diagnosis of endometriosis directly influences the planning of the surgical treatment of fibroids and the composition of the multidisciplinary surgical team. Therefore, screening for endometriosis on routine transvaginal ultrasound, based on the International Deep Endometriosis Analysis group consensus(3838 Fraser IS, Critchley HO, Munro MG, et al. Can we achieve international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding? Hum Reprod. 2007;22:635– 43.), should be encouraged and should be performed with a practical, dynamic, four-step ultrasound approach: routine evaluation of the uterus and adnexa with special attention to ultrasound signs of adenomyosis and the presence or absence of endometriomas (Figure 14); evaluation of indirect soft markers, such as site-specific sensitivity and ovarian mobility; assessment of the pouch of Douglas status by realtime ultrasound testing for the “sliding sign”; and identification of deep infiltrating endometriotic nodules in the anterior and posterior compartments, which necessitates evaluation of the bladder, vaginal vault, retrocervical region, uterosacral ligaments, and bowel.
SALINE INFUSION ULTRASOUND AND 3D ULTRASOUND FOR PREOPERATIVE EVALUATION OF FIBROIDS
Sonohysterography consists of transvaginal ultrasound combined with the infusion of sterile saline through a catheter into the uterine cavity. This minimally invasive 3D technique allows clear delineation of the uterine cavity. It is superior to two-dimensional ultrasound for the diagnosis of intrauterine abnormalities such as polyps and submucosal fibroids. In a pooled analysis using the gold standard (hysteroscopy) as the reference(3939 Casadio P, Youssef AM, Spagnolo E, et al. Should the myometrial free margin still be considered a limiting factor for hysteroscopic resection of submucous fibroids? A possible answer to an old question. Fertil Steril. 2011;95:1764–8.e1.), saline infusion ultrasound was found to have a sensitivity of 92% and a specificity of 90%, compared with 64% and 90%, respectively, for transvaginal ultrasound. Finally, 3D ultrasound can facilitate the spatial assessment, allowing more accurate characterization and localization of fibroids than what is achieved with two-dimensional ultrasound. Multiplanar views, especially the coronal view, have improved the description of fibroids on ultrasound(4040 Stadtmauer L, Shah A. Gynecologic surgery: preoperative assessment with ultrasound. Clin Obstet Gynecol. 2017;60:82–92.).
PROPOSAL FOR A STRUCTURED ULTRASOUND REPORT TEMPLATE FOCUSING ON THE PREOPERATIVE EVALUATION OF PATIENTS WITH FIBROIDS
Although the FIGO classification system has provided gynecologists with a well-standardized framework for characterizing uterine fibroids, there is still significant variability across transvaginal ultrasound reports in terms of the quality of the descriptions of fibroids. Incomplete descriptions of fibroids or associated lesions such as adenomyosis and endometriosis can raise questions or lead to inappropriate surgical planning(4040 Stadtmauer L, Shah A. Gynecologic surgery: preoperative assessment with ultrasound. Clin Obstet Gynecol. 2017;60:82–92.). Consequently, a structured, illustrated model of an ultrasound report, standardizing the description of uterine fibroids—based on the critical criteria for surgical management, the FIGO classification of uterine fibroid location, and the MUSA group descriptors—could be useful for sonographers and physician examiners. A structured, accurately illustrated ultrasound report of fibroids allows gynecologists to choose the best treatment for the patient, be it hysteroscopy, laparoscopy, laparotomy, or embolization(4141 Wilde S, Scott-Barrett, S. Radiological appearances of uterine fibroids. Indian J Radiol Imaging. 2009;19:222–31.,4242 Mutakha GS, Mwaliko E, Kirwa P. Clinical bleeding patterns and management techniques of abnormal uterine bleeding at a teaching and referral hospital in Western Kenya. PLoS One. 2020;15: e0243166.). The proposed report template is shown in the Appendix. In addition, bowel preparation can be added if specifically requested by the attending physician. Another relevant topic when considering the imaging evaluation of patients with fibroids is illustrating the imaging findings with drawings or sketches (Figure 15), which is also strongly recommended and valued by surgeons and patients because it provides a roadmap for treatment(4343 Piessens S, Edwards A. Sonographic evaluation for endometriosis in routine pelvic ultrasound. J Minim Invasive Gynecol. 2020;27:265–6.,4444 Dueholm M, Hjorth IMD. Structured imaging technique in the gynecologic office for the diagnosis of abnormal uterine bleeding. Best Pract Res Clin Obstet Gynaecol. 2017;40:23–43.,4545 Wheeler KC, Goldstein SR. Transvaginal ultrasound for the diagnosis of abnormal uterine bleeding. Clin Obstet Gynecol. 2017;60: 11–7.).
Transvaginal ultrasound, in cross-sectional and longitudinal views (A and B images, respectively), showing a uterine fibroid. Schematic drawings for reporting fibroids (C).
CONCLUSION
There are key points in the characterization of fibroids that help gynecologists plan the surgical treatment and have the potential to allow complications and treatment failure to be avoided. The structured, illustrated ultrasound report model proposed here, which is based on those critical points, could improve patient counseling and treatment planning, as well as facilitating the selection of the most appropriate medical or surgical treatment strategy.
Appendix
Proposed template for reporting uterine fibroids on preoperative ultrasound examinations.
• INDICATION FOR THE EXAMINATION
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– Asymptomatic patient ( )
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– Evaluation of a clinical finding
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Pelvic pain ( )
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Menorrhagia ( )
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Infertility ( )
-
-
– Fibroid follow-up ( )
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– Follow-up after surgical fibroid treatment ( )
• TECHNIQUE
Examination performed with a device (model/manufacturer) with convex (abdominal) and intracavitary (transvaginal) transducers and with/without bowel preparation.
• FINDINGS
Middle pelvic compartment
– Uterus: in (anteversion/retroversion) position, with regular outer contours, myometrium with preserved echotexture, except in the areas of myometrial nodules and normal mobility (positive sliding sign).
Uterine biometry: __ × __ × __ cm (volume: __ cm3).
Note the presence of solid, hypoechoic, and heterogeneous nodules, with regular contours and well-defined limits, consistent with fibroids. The table below shows the main aspects:
Fibroid | FIGO classification | Dimensions (cm) | Localization | Inner mantle | Outer mantle |
---|---|---|---|---|---|
1 | |||||
2 | |||||
3 | |||||
4 | |||||
5 | |||||
6 |
– Endometrium: centered/displaced, of uniform echogenicity, trilaminar/ echogenic pattern, measuring __ mm thick, junctional zone (regular/irregular)
– Right ovary: parauterine, with normal contours, normal echotexture, and normal mobility, measuring __ × __ × __ cm (volume: __ cm3)
– Left ovary: parauterine, with normal contours, normal echotexture, and normal mobility, measuring __ × __ × __ cm (volume: __ cm3)
Report of painful sensitivity on mobilization with a transducer
Yes ( )
No ( )
Anterior pelvic compartment
Bladder: good repletion; thin, regular walls; and homogeneous anechoic content. There was no evidence of endometriotic lesions in the bladder. In the search for adhesions, there was mobility and anatomical sliding of the bladder wall against the anterior wall of the uterus (positive sliding sign).
Posterior pelvic compartment
There is no evidence of endometriotic foci in the retrocervical region and uterosacral ligaments.
There are no evident signs of thickening or nodules in the intestinal loops or rectum detectable without bowel preparation.
Signs of adenomyosis
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( ) Absent
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( ) Focal
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( ) Diffuse
• CONCLUSIONS
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– Myometrial nodule(s) compatible with fibroid(s), type 0/1/2/3/4/5/6/7/8 (FIGO classification)
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– Number of fibroids: __
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– Number of fibroids with submucosal component: __
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– Number of fibroids without submucosal component: __
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– Mass effect on the endometrial cavity: ( ) Yes ( ) No
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– Presence of submucosal fibroid in the uterine fundus: ( ) Yes ( ) No
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– Presence of submucosal fibroid in the lateral wall: ( ) Yes ( ) No
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– Focal/diffuse adenomyosis
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– Ovaries with normal ultrasound findings
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– Ovarian reserve: Normal ( ) Low ( )
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– Endometrioma in the right/left ovary
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– Adhesive processes in the vesicouterine pouch/rectouterine pouch
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– Anterior pelvic compartment with deep endometriosis; endometriosis mapping with bowel preparation recommended
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– Posterior pelvic compartment with deep endometriosis; endometriosis mapping with bowel preparation recommended
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Schematic drawings for reporting fibroids
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Publication Dates
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Publication in this collection
08 May 2023 -
Date of issue
Mar-Apr 2023
History
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Received
19 Apr 2022 -
Accepted
04 Aug 2022