Uterine Fibroids Blog — An Expert Speaks Out

In order to evaluate uterine fibroids, we need to know what is on the inside of the uterus.  Many times ultrasound (or saline enhanced ultrasound) or MRI will provide the information we need.  Many women are subjected to endometrial biopsy which is good to rule out cancer, but useless in diagnosing submucous fibroids and polyps.  Fortunately it is easy to look directly into the uterus using a thin telescope called a hysteroscope.

With today’s tiny instruments, it usually only takes a few minutes to do office hysteroscopy using local anesthesia, and most women report little discomfort.  First I numb the cervix, which is hardly noticeable.  Saline is used to fill the uterus so we can see, and a thin flexible or regular hysteroscope is inserted through the cervix under direct vision.  I encourage my patients to watch on the video monitor so they will have a better understanding of what is going on inside her own uterus.  If someone is extremely anxious she can have something to help her relax during the procedure, but the vast majority of women do not need this and can go about their normal activities for the rest of the day.

Hysteroscopy compliments other diagnostic studies, so that when we decide on a treatment plan we know exactly what we are treating, and don’t wind up with any surprises.

The photo below shows an actual view from an office hysteroscopy.  You can clearly see the submucous fibroids on the back wall of the uterus.  This type of fibroid can easily be removed (by an gynecologist experienced in this type of surgery) in an outpatient procedure called hysteroscopic resection of fibroids.

The next photo shows a large submucous fibroid at the beginning of hysteroscopic resection of the fibroid.  The loop seen is what will be used to remove (resect) the fibroids.

Comment: I feel that for a gynecologist, doing hysteroscopy in the office is as basic as an ear doctor being able to look into an ear in the office.   What would you do if you saw a doctor for an earache and he or she wanted to schedule you for surgery so they could look in your ear?  Yet only 10% of gynecologists in the U.S. (who are supposedly specialists in treating the uterus)  do office hysteroscopy.  I see too many women taken to the operating room whose surgery is abandoned because submucous myomas had not been diagnosed by surgeons not prepared to treat them.  And many of these women are told that they need a hysterectomy because the gynecologist is not experienced in hysteroscopic treatment of submucous fibroids.  I’ll have much more in detail about hysteroscopic treatment of submucous fibroids in upcoming posts!

Accurate diagnosis of uterine fibroids is essential in deciding if treatment is necessary, and planning appropriate treatment.      While a physical exam may suggest fibroids, other conditions such as ovarian cysts or adenomyosis may be mistaken for fibroids.   For this reason, I routinely do an ultrasound examination at the time of the first visit when a woman has symptoms of abnormal bleeding or cramping, or if I feel an abnormality on examination.  Vaginal probe ultrasound only takes a few minutes to do, is not uncomfortable, and rapidly provides invaluable information if the examiner is experienced in looking at uterine abnormalities.  It is possible to fill the uterus with a liquid during the ultrasound (saline enhanced sonography or sonohysterogram). While this will often provide additional information to the regular ultrasound, I usually learn much more by looking inside the uterus with a little telescope.  This exam, called hysteroscopy, is usually a quick office procedure, that allows directly looking inside the uterus.    While vaginal probe ultrasound is good for seeing close-up detail, it may not “see” deeply enough to evaluate large fibroids.  An abdominal ultrasound, which requires a full bladder, is better for large fibroids but doesn’t show as much detail.  As the images from MRI are SO much better than ultrasound, and I can obtain an MRI relatively inexpensively in my area, I prefer to go straight to MRI to image a large uterus with fibroids.

MRI scans provide excellent pictures of the uterus.  MRI is especially helpful in evaluating a large uterus and helpful in planning a myomectomy.    Adenomyosis is frequently confused with fibroids in an enlarged uterus, and the treatment is entirely different.  I have seen patients who have been taken to surgery to remove fibroids only to find that there was adenomyosis instead, so they were closed back up without any treatment.  MRI is especially good at distinguishing between fibroids and adenomyosis.  If a woman is planning to travel a long distance to see me it is helpful to review an MRI (which can be recorded on a CD) to help plan treatment.

What is adenomyosis? It is one of the most common conditions confused with fibroids.  In adenomyosis the lining of the uterus infiltrates the wall of the uterus, causing the wall to thicken and the uterus to enlarge.  On ultrasound examination this will often appear as diffuse thickening of the wall, while fibroids are seen as  round areas with a discrete border.  Adenomyosis is usually a diffuse process.  If it is localized, or forms within a fibroid or a cyst it may also be possible to remove it.  Since fibroids can be removed but it may not be possible to remove extensive adenomyosis without taking out the uterus, it is important to differentiate between the two conditions.  A progesterone coated IUD, the Mirena, is often helpful in treating symptoms of adenomyosis without surgery.