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.