DIAGNOSIS
The diagnosis of fibroids is
usually based on physical examination or imaging studies. Occasionally,
irregulari-ties of the uterine cavity are detected during endometrial sampling.
Often the diagnosis is incidental to pathologic assessment of a uterine
specimen removed for other indi-cations. On
abdominopelvic examination, uterine leiomyomatausually present as a large,
midline, irregular-contoured mobile pelvic mass with a characteristic “hard
feel” or solid quality.
The
degree of enlargement is usually stated in terms (weeks’ size) that are used to
estimate equivalent gestational size.
The fibroid uterus is described
separate from any adnexal disease, although on occasion a pedunculated myoma
may be difficult to distinguish from a solid adnexal mass.
Pelvic ultrasound may be used for
confirmation (when necessary) of uterine myomas, but the diagnosis remains a
clinical one. There may be areas of acoustic “shadowing” amid otherwise normal
myometrial patterns, and there may be a distorted endometrial stripe.
Occasionally cystic components may be seen as hypoechogenic areas and are
consistent in appearance with myomas undergoing degen-eration. Adnexal structures,
including the ovaries, are usu-ally identifiable separate from these masses.
Computerized axial tomography
(CAT) and magnetic resonance imaging (MRI) may be useful in evaluating
extremely large myomas when ultrasonography may not image a large myoma well.
Hysteroscopy, hysterosalpin-gography, and saline infusion ultrasonography are
the best techniques for identifying intrauterine lesions such as sub-mucosal
myomata and polyps.
Endometrial
biopsy should not be relied on to pro-vide additional diagnostic
information; however, an indi-rect appreciation for uterine enlargement may be
gained by uterine sounding, which is part of this procedure. If a patient has
irregular uterine bleeding and endometrial car-cinoma is a consideration,
endometrial sampling is useful to evaluate for this possibility, independent of
the myomas.
Hysteroscopy
may be used to evaluate the enlargeduterus by
directly visualizing the endometrial cavity. The increased size of the cavity
can be documented, and sub-mucous fibroids can be visualized and removed.
Although
the efficacy of hysteroscopic removal (resection) of submucous myomas has been
documented, long-term follow-up suggests that up to 20% of patients require
additional treatment during the subsequent 10 years.
Surgical evaluation may be
required when physical examination and ultrasound cannot differentiate whether
the patient has a leiomyomata or other potentially more serious disease, such
as adnexal neoplasia. Laparoscopic resection of subserosal or intramural myoma
has gained in popularity, although the long-term benefit of this proce-dure has
not been well-established.
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