Background of fibroid

Fibroids, also known as leiomyomas, are benign tumours of the myometrium. They are
composed of smooth muscle cells and connective tissue in densely packed whorls. They are
common, and about 40% of women by the age of 40 years have fibroids. Very often they are
multiple. Many of the women with fibroids are asymptomatic, while others may have symptoms
like menorrhagia, polymenorrhagia, intermenstrual bleeding, dysmenorrhoea and subfertility.
With submucous fibroids and fibroid polyps, intermenstrual bleeding (metrorrhagia) could be a
presenting complaint.

Etiology

Myomas are thought to be monoclonal and originate from a single myocyte that undergoes
somatic mutation as it grows. Cytogenetic anomalies are found in 40% of fibroids. Estrogen and
progesterone are known to stimulate the growth of fibroids. Although many fibroids are
asymptomatic, others may cause bleeding, pain, mass effect, urinary frequency, constipation,
pregnancy loss, and infertility. The presence of symptomatic fibroids is the most common
indication for hysterectomy.

Sonographic Findings.

Leiomyomas have variable sonographic appearances. The earliest sonographic finding of

myomas is the demonstration of uterine enlargement or irregular uterine wall contour with a
heterogeneous myometrial texture pattern.

Ultrasound Features of Fibroids

• Fibroids typically appear as round, well-defined, oval or lobulated solid masses seen in the
uterus or arising from it.

• Fibroids show variable echogenicity depending upon the proportion of muscle cells and
fibrous stroma and the presence of any degenerative changes. They can appear from
hypoechoic to hyperechoic.

• Fibroids generally show linear stripy fan-shaped internal acoustic shadowing and also
shadowing from its edges (reported as ‘edge shadows’).

• They may show calcification and cavitation.

• On Doppler, fibroids typically show pericapsular flow (i.e. circumferential flow around its
margins). Some amount of intralesional flow is also commonly seen within the fibroid. Some
fibroids may, however, show high vascularity (increased vascularity seems to be related to
increased cellularity in fibroids). Despite the variable appearance of fibroids, diagnosing them on
ultrasound is not challenging because any mass in the uterus (once an adenomyoma is
excluded) or arising from it is almost always a fibroid.
Fibroid Mapping

3.3.1.1 Basics of Fibroid Mapping

Locating the fibroid or ‘fibroid mapping’ is very important because:

Fibroid mapping and relationship of the fibroids to the endometrial mucosa are particularly
important for appropriate management

The site of origin of a fibroid can be deciphered by noting Doppler flows to the fibroid.

Submucous fibroids have been graded into:

G0 – completely intracavitary

G1 – more than 50% intracavitary

G2 – less than 50% intracavitary

Presently it is suggested in the MUSA consensus statement that the site of any well-defined
myometrial lesion like a fibroid should be reported based on FIGO classification of fibroids:

• 0=pedunculated, intracavitary (completely within the endometrial cavity)

• 1=submucosal, less than 50% intramural

• 2=submucosal, more than or equal to 50% intramural

• 3=100% intramural but in contact with endometrium

• 4=intramural

• 5=subserosal, more than or equal to 50% intramural

• 6=subserosal, less than 50% intramural

• 7=subserosal pedunculated

• 8=other (cervical, parasitic)

The locations of transmural fibroids in this FIGO classification are described as ‘2–5’.

Intramural

Fibroids are most commonly intramural and occur within the confines of myometrium.

Submucosal

A fibroid that protrudes into the endometrial cavity is submucosal. These can occasionally be
pedunculated into the cavity and slide down into the cervix as the uterus tries to expel it.
Threedimensional ultrasound and sonohysterography can be very helpful in outlining the extent
of the submucosal component of the fibroid within the cavity.

Subserosal

A fibroid that indents the serosal surface and gives a bumpy appearance of the outside of the
uterus is subserosal.

Pedunculated

A fibroid that has grown from a subserosal fibroid outward and remains tethered to the uterus
by a pedicle is considered pedunculated.

Occasionally these can pick up vascularity from outside organs and become parasitic, no longer
connected to the uterus, making the sonographic diagnosis more difficult.

Degenerating

Discrepancy between the rate of growth of the

myoma and its blood supply can lead to an infarction of part (most often the center) of the

myoma. The degenerating fibroid has a variable manifestation, the most common being a
donutappearing mass with a cystic center and a thick wall, located within the confines of the
uterus.

The acute infarction leads to severe pain and is more common during pregnancy. Some
degenerating fibroids can mimic ovarian cystic masses, especially if they are pedunculated and
multiseptate in appearance.

Differential Diagnosis

The differential diagnosis of fibroids depends on the location and appearance of the uterine
mass.

A fibroid that contains cystic areas and abundant blood flow may be indistinguishable
sonographically from a uterine sarcoma (see Sarcoma).

Follow-up scans showing aggressive growth, particularly in a postmenopausal patient, would

suggest a malignancy. If the mass is ill-defined, it may represent an adenomyoma, which is
similar in appearance to a fibroid, but has blurry or indistinct borders and is often seen in a
setting of adenomyosis (see Endometriosis). If the fibroid is submucosal and more echogenic
than usual, it could be confused with an endometrial polyp. A central blood supply with a
feeding vessel and cystic spaces would favor a polyp. A bumpy and asymmetric uterus may be
confused with a Müllerian duct anomaly such as a unicornuate uterus with a rudimentary horn
forming a mass. Threedimensional ultrasound is essential for diagnosing Müllerian duct
abnormalities and the position of fibroids within the uterus.If the fibroid is pedunculated
laterally, in the broad ligament, it may be difficult to distinguish it from a solid adnexal mass
such as a fibroma or Brenner tumor. Finding the ipsilateral ovary separate from the mass is
important to rule out such entities.