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Diagnostic Imaging in Uterine fibroids
- 1. Radiology: Uterine Fibroids By Natalie Johnson & Sierra Teegarden
- 2. What are Uterine Fibroids? Uterine fibroids, also called leiomyomas or myomas are benign tumors made of smooth muscle tissue arising from the myometrium in the uterus Fibroids are not associated with an increase risk of uterine cancer however some uterine fibroids can be found to be cancerous https://www.mayoclinic.org/diseases-conditions/uterine-fibroids/symptoms-causes/syc-20354288 https://www.womenshealth.gov/a-z-topics/uterine-fibroids
- 3. Three major types of uterine fibroids 1. Subserosal : project outside of uterus (most common) 2. Intramural : grow within uterine wall (second most common) 3. Submucosal : bulge into uterine cavity (least common) Some submucosal or subserosal fibroids may be pedunculated (having a stalk) https://www.mayoclinic.org/diseases-conditions/uterine-fibroids/symptoms-causes/syc-20354288 https://www.reproductivefacts.org/news-and-publications/patient-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/fibroids-and- fertility/
- 4. Symptoms Four symptoms categories: 1. Heavy, or prolonged vaginal bleeding 2. Pelvic pain, including painful menses 3. Bulk symptoms ○ abdominal protrusion ○ bowel or bladder dysfunction ○ early satiety 4. Reproductive dysfunction ○ infertility or recurrent pregnancy loss Many women who have fibroids don't have any symptoms In those that do, symptoms can be influenced by the location, size and number of fibroids. https://www-uptodate-com.york.ezproxy.cuny.edu/contents/uterine-fibroids-leiomyomas-treatment-overview?search=uterine%20fibroid&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
- 5. What causes uterine fibroids? Research has not identified cause, however there are known links with the following: ●Hormones levels ( estrogen and progesterone levels) ○ growth is dependent on estrogen and progesterone ●Genetic component ● Environmental factors Office on Women’s Health. (2018, March 16). _Uterine fibroids._Retrieved June 18, 2018, from https://www.womenshealth.gov/a-z-topics/uterine-fibroids
- 6. Risk factors for uterine fibroids ● Age: 30s and 40s up until menopause; fibroids shrink in menopause ● Weight: overweight or obese women ● Diet: High intake in processed red meat, alcohol, and soybean milk, low vitamin D intake ● Family history: Having a family member with fibroids increases your risk ● Ethnic origin: African-American women are more likely to develop fibroids than Caucasian women https://www.mayoclinic.org/diseases-conditions/uterine-fibroids/symptoms-causes/syc-20354288 Setchell, K. Soy isoflavones — benefits and risks from nature’s selective estrogen receptor modulators (SERM). J Am Coll Nutr. 2001;20(5 Suppl):354S-362S. Martin CL, Huber LR, Thompson ME, Racine EF. Serum micronutrient concentrations and risk of uterine fibroids. J Womens Health (Larchmt). 2011;20(6):915-922.
- 7. Diagnostic Imaging 1. Primary Imaging: Ultrasound (transabdominal, transvaginal) ● Hysterosonography or Sonohysterogram 1. Secondary Imaging: MRI 2. Other imaging: X-ray, CT Scan ● Hysterosalpingography (Procedure using x-ray imaging with contrast) Woo J, & Scott R.K. (2020). Leiomyoma of the uterus (fibroidtumor). PapadakisM.A., & McPhee S.J.,& Rabow M.W.(Eds.), Current Medical Diagnosis and Treatment 2020. McGraw-Hill. https://accessmedicine-mhmedical- com.york.ezproxy.cuny.edu/content.aspx?bookid=2683§ionid=225051071
- 9. Transvaginal VS Transabdominal Ultrasound ● Transabdominal providers a panoramic view of abdomen and pelvis ● Transvaginal provides a more focused thus limited view “zoomed in” ● Consideration: TVU method requires placing a probe into the vagina which is more invasive for the patient Case courtesy of Assoc Prof Craig Hacking, Radiopaedia.org, rID: 43471 Transabdominal Transvaginal
- 10. Presentation of Leiomyoma ultrasound: ● Usually hypoechoic (darker), but can be isoechoic (normal) or hyperechoic (lighter) as well compared to normal myometrium ● echogenic foci with shadowing indicates calcification ● cystic areas of necrosis or degeneration may be seen ● Venetian blind artifact may be seen but edge shadowing +/- dense posterior shadowing from calcification is also typically seen https://radiopaedia.org/articles/uterine-leiomyoma?lang=us
- 16. Procedures for better visualization Hysterosonography Hysterosalpingography
- 17. Hysterosonography Water is inserted into the uterus for better visualization during US When would you use? ● Indicated for better visualization of submucosal fibroids https://www.med.unc.edu/obgyn/migs/our-services/unc-fibroid-center/ Also called sonohysterogram or hydrosonogram
- 18. Hysterosalpingogram Case courtesy of Dr Vikas Shah, Radiopaedia.org, rID: 49719
- 19. X-Ray of calcified uterine fibroid Case courtesy of Dr Vikas Shah, Radiopaedia.org, rID: 49719 Calcifications often have patchy “popcorn” appearance
- 20. Calcified Fibroid on CT Scan http://www.lumen.luc.edu/lumen/meded/Radio/curriculum/OBGYN/Fibroids1.htm
- 21. General Treatment Considerations Asymptomatic patients with no fertility considerations may not warrant treatment Hysteroscopicfibroidresectionor radiofrequency ablation ● Outpatient, rapid recovery, virtually no risk of future uterine rupture during pregnancy ● Only works for mucosal fibroids SymptomManagementwithPharmacologytherapy(Goodoptionsfor non-mucosalfibroids) ● Estrogen-Progesteron Contraceptives (OCP, vaginal ring, transdermal patch) ○ Pt must be appropriate candidate for estrogen use ● Progesteron-only contraceptives: Mirena IUD, Nexplanon arm implant ● Transexamic Acid: Take while on menses ● Gonadotropin Releasing Hormone Antagonist: Orilissa(Elagolix) ● Gonadotropin Releasing Hormone Agonist OtherSurgicalProcedureOptions ● Uterine artery embolization **Interventional ● MRI guided ultrasound ablation **Interventional ● Hysterectomy ○ Extreme consideration for non-menopausal women
- 24. Image-guided intervention MRI-guided focused ultrasound surgery (Radiofrequency Ablation) & Embolizations
- 25. Uterine Fibroid Embolization Interventional radiology is used in UFE procedure with x-ray fluoroscopy
- 26. Summary Who is most at risk: premenopausal women, in 30’s-40’s, more common in black women than Caucasian Commonsymptoms: heavy menstrual bleeding, pelvic pain, possible anemia from prolonged bleeding Goldstandarddiagnostic: Ultrasonography is the standard confirmatory test because it can easily and inexpensively differentiate a fibroid from a pregnant uterus or an adnexal mass Treatments are symptomand fibroid location/size-based ● Important to remember there are minimally invasive treatments that are safe for future pregnancy, with virtually no risk for uterine rupture in subsequent pregnancy Goal outcomes: Reduction of symptoms and increased fertility if goal https://www.aafp.org/afp/2017/0115/p100.html#afp20170115p100-b7
- 27. Resources ● Stewart, E. A., Cookson, C. L., Gandolfo, R. A., & Schulzeath, R. (2017). Epidemiology of uterine fibroids: A systematic review. BJOG: An International Journal of Obstetrics & Gynecology, 124(10), 1501–1512. Retrieved July 30, 2018, from https://obgyn.onlinelibrary.wiley.com/doi/full/10.1111/1471-0528.14640 ● Pavone, D., Clemenza, S., Sorbi, F., Fambrini, M., & Petraglia, F. (2018). Epidemiology and risk factors of uterine fibroids. Best Practice & Research Clinical Obstetrics & Gynecology, 46, 3–11. Retrieved July 30, 2018, from https://www.sciencedirect.com/science/article/pii/S1521693417301372?via%3Dihub ● Emma Giuliani, Sawsan As‐Sanie, Erica E. Marsh, Epidemiology and management of uterine fibroids, International Journal of Gynecology & Obstetrics, 10.1002/ijgo.13102, 149, 1, (3-9), (2020) ● Stewart EA. Clinical practice. Uterine fibroids. N Engl J Med. 2015 Apr 23;372(17):1646-55. doi: 10.1056/NEJMcp1411029. PMID: 25901428. ● Mayo Foundation for Medical Education and Research (MFMER). (2019, December 10). Uterine fibroids - Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/uterine-fibroids/symptoms-causes/syc- 20354288 ● NCH Healthcare System. (2019, October 12). Uterine fibroids. Uterine Fibroids. https://www.nchmd.org/education/mayo-health-library/details/CON-20198832 ● U.S. Department of Health and Human Services: Office on Women’s Health. (2019, April 1). Uterine fibroids | Womenshealth.gov. Womenshealth.Gov. https://www.womenshealth.gov/a-z-topics/uterine- fibroids#:%7E:text=Rarely%20(less%20than%20one%20in,of%20developing%20a%20cancerous%20fibroid
- 28. Resources ● Stewart, E. A. (2015). Uterine fibroids. New England Journal of Medicine, 372, 1646–1655. Retrieved October 25, 2018, from https://www.nejm.org/doi/full/10.1056/NEJMcp1411029?page=&sort=oldest ● AAAHC (Accreditation Association for Ambulatory Health Care). (2020, September 10). Fibroids: What are Uterine Fibroids? USA Fibroid Centers. https://www.usafibroidcenters.com/uterine-fibroids/ ● Azura Vascular Care. (2018, November 28). Understanding Uterine Fibroid Causes, Risk Factors and Treatment Options. https://www.azuravascularcare.com/infoufe/understanding-uterine-fibroid-causes-risk-factors-treatment- options/ ● Practice Committee of the American Society for Reproductive Medicine, Society of Reproductive Surgeons (2008). Myomas and reproductive function. Fertility and Sterility, 90(3): S125–S130. ● Stewart, E., Barbiera, R., & Chakrabarti, A. (2020). Uterine fibroids (leiomyomas): Treatment overview. UpToDate. Retrieved Oct 28, 2020 from https://www-uptodate-com.york.ezproxy.cuny.edu/contents/uterine- fibroidsleiomyomastreatmentoverview?search=uterine%20fibroid&source=search_result&selectedTitle=1~150&usa ge_type=default&display_rank=1 ● De La Cruz, M.S. & Buchanan E.M. (2017, January 15). Uterine Fibroids: Diagnosis and Treatment. American Family Physician. https://www.aafp.org/afp/2017/0115/p100.html#afp20170115p100-b7
Editor's Notes
- /
- Venetian blind artifact literally looks like window blinds (appears sideways because of ultrasound angle)
- Some predictors of malignancy on magnetic resonance imaging include age older than 45 years (odds ratio [OR] = 20), intratumoral hemorrhage (OR = 21), endometrial thickening (OR = 11), T2-weighted signal heterogeneity (OR = 10), menopausal status (OR = 9.7), and nonmyometrial origin
- L & R white spaces are hip bones. Rectum is visualized posteriorly.
- In the past, the only uterine fibroid treatment available was surgery which would remove either part or all of a woman’s uterus. This influenced a lot of women to do the “watch and wait” method. It’s important to remember that fibroids will not go away without treatment. When left untreated, they will continue to cause uncomfortable or painful symptoms. Over time this chronic pain and discomfort may decrease as a woman gets closer to menopause, but this is not a guarantee. https://www.usafibroidcenters.com/blog/what-happens-if-fibroids-go-untreated/ The patient's desire for immediate or future childbearing is also assessed prior to choosing any fibroid treatment as the therapies have differing impacts on fertility.
- https://www.aafp.org/afp/2017/0115/p100.html#afp20170115p100-b31
- Terminology: Ablation means heat/radiofrequency, embolization means cutting off blood supply Image-guided interventions Performed while you're inside an MRI scanner equipped with a high-energy ultrasound transducer for treatment. The images give your doctor the precise location of the uterine fibroids. When the location of the fibroid is targeted, the ultrasound transducer focuses sound waves (sonications) into the fibroid to heat and destroy small areas of fibroid tissue. Radiofrequency ablation In this procedure, radiofrequency energy destroys uterine fibroids and shrinks the blood vessels that feed them. This can be done during a laparoscopic or transcervical procedure. A similar procedure called cryomyolysis freezes the fibroids. With laparoscopic radiofrequency ablation, also called Lap-RFA, your doctor makes two small incisions in the abdomen to insert a slim viewing instrument (laparoscope) with a camera at the tip. Using the laparoscopic camera and a laparoscopic ultrasound tool, your doctor locates fibroids to be treated. After locating a fibroid, your doctor uses a specialized device to deploy several small needles into the fibroid. The needles heat up the fibroid tissue, destroying it. The destroyed fibroid immediately changes consistency, for instance from being hard like a golf ball to being soft like a marshmallow. During the next three to 12 months, the fibroid continues to shrink, improving symptoms. Because there's no cutting of uterine tissue, doctors consider Lap-RFA a less invasive alternative to hysterectomy and myomectomy. Most women who have the procedure get back to regular activities after 5 to 7 days of recovery. The transcervical — or through the cervix — approach to radiofrequency ablation also uses ultrasound guidance to locate fibroids. Woo J, & Scott R.K. (2020). Leiomyoma of the uterus (fibroid tumor). Papadakis M.A., & McPhee S.J., & Rabow M.W.(Eds.), Current Medical Diagnosis and Treatment 2020. McGraw-Hill. https://accessmedicine-mhmedical-com.york.ezproxy.cuny.edu/content.aspx?bookid=2683§ionid=225051071
- Uterine artery embolization is a minimally invasive treatment for uterine fibroids. In uterine artery embolization, the goal is to block the blood vessels supplying the fibroids, causing them to shrink. Uterine artery embolization. Small particles (embolic agents) are injected into the arteries supplying the uterus, cutting off blood flow to fibroids, causing them to shrink and die. This technique can be effective in shrinking fibroids and relieving the symptoms they cause. Complications may occur if the blood supply to your ovaries or other organs is compromised. However, research shows that complications are similar to surgical fibroid treatments and the risk of transfusion is substantially reduced. Woo J, & Scott R.K. (2020). Leiomyoma of the uterus (fibroid tumor). Papadakis M.A., & McPhee S.J., & Rabow M.W.(Eds.), Current Medical Diagnosis and Treatment 2020. McGraw-Hill. https://accessmedicine-mhmedical-com.york.ezproxy.cuny.edu/content.aspx?bookid=2683§ionid=225051071
- Ultrasonography is the standard confirmatory test because it can easily and inexpensively differentiate a fibroid from a pregnant uterus or an adnexal mass. https://www.nejm.org/doi/full/10.1056/NEJMcp1411029?page=&sort=oldest Hysterectomy remains a treatment option for women who have completed childbearing. It is the only treatment that prevents the common problem of new fibroid formation (which is typically termed recurrence)15 and also treats concomitant diseases, including adenomyosis and cervical neoplasia. Observational data suggest that women who have undergone hysterectomy have improvements in quality of life over the next 1 to 10 years.15,27 https://www.nejm.org/doi/full/10.1056/NEJMcp1411029?page=&sort=oldest Fibroids return after surgery in 10 to 50 out of 100 women, depending on the original fibroid problem. Fibroids that were larger and more numerous are most likely to recur. footnote 2 Practice Committee of the American Society for Reproductive Medicine, Society of Reproductive Surgeons (2008). Myomas and reproductive function. Fertility and Sterility, 90(3): S125–S130. Hysteroscopic resection of submucosal fibroids — For patients with HMB, the first step is determining if there is a submucosal fibroid because of the safety and efficacy of hysteroscopic myomectomy as a treatment [6]. Submucosal fibroids amenable to hysteroscopic resection include International Federation of Gynecology and Obstetrics (FIGO) type 0, type 1, or type 2