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.