Accurately diagnosing uterine fibroids is the first step to receiving adequate treatment. A significant part of fibroid diagnosis is the use of imaging techniques, such as ultrasound and magnetic resonance imaging (MRI). But how does each technique work and which is best?
We spoke with Dr. Sreekumar Madassery, Assistant Professor of Vascular and Interventional Radiology and Diagnostic Radiology at Rush University Medical Center in Chicago, Ill., to better understand each imaging approach to fibroid diagnosis.
“Gynecologists regularly see patients who describe menstrual cycle problems, such as prolonged bleeding, painful menses, fatigue due to chronic blood loss, and pain during sex,” Dr. Madassery explains. “Causes of these symptoms are considered, such as uterine fibroids, endometriosis, adenomyosis, uterine and cervical cancer, amongst others.”
A pelvic ultrasound is almost always the first step after a physical exam in diagnosing uterine fibroids. Ultrasound uses sound waves to create a picture of the uterus and can be paired with saline infusion sonography, a procedure that injects salt solution into the uterus to help form a clearer picture. Seeing the uterus is important because even small fibroids that can’t be felt through a pelvic exam may cause serious symptoms. “Ultrasound shows whether fibroids are present, their location within the uterus, and the number of fibroids. It also provides a global picture of the uterine lining and ovaries,” Dr. Madassery says.
Although an ultrasound provides an overall evaluation, it does have its limitations. According to Dr. Madassery, an ultrasound can’t reliably differentiate between uterine fibroids and cancerous tumors called leiomyosarcoma, or a condition called adenomyosis, which occurs when there’s abnormal growth of the uterine lining into the uterine wall and can present with symptoms similar to fibroids. “Ultrasound is the right first step in evaluating a patient with suspected fibroids,” Dr. Madassery continues. “However, more information is needed before intervention or surgery. MRI can provide this valuable information.”
Combining a magnetic field and radio waves, MRI delivers a more detailed anatomic image than ultrasound and is the preferred method for characterizing pelvic masses. “MRI is an excellent high resolution, noninvasive imaging modality which helps plan treatment, whether it be myomectomy, or for equally effective and less invasive uterine fibroid embolization (UFE),” Dr. Madassery notes. “MRI can differentiate whether the fibroids seen on an ultrasound are not in fact adenomyosis. In some cases, an MRI reveals that the patient may actually have leiomyosarcoma or other masses. For the interventional radiologist, an MRI provides valuable information, such as how effective UFE treatment will be.”
A study published in Clinical Imaging investigated scans in 68 women with fibroids to determine if having an MRI in addition to an ultrasound changed the approach to treatment before having UFE.1 When the scans were compared, almost one out of three women (28%) who had their treatment based on ultrasound alone changed their approach after having an MRI.
Because an MRI complements an ultrasound and provides crucial information for both diagnosis and monitoring fibroids after treatment, both techniques are often used together. “MRI combined with an ultrasound gives a full picture as to what all the fibroids look like and their location,” Dr. Madassery notes. “In terms of UFE, MRI provides a very reliable method to evaluate fibroid recurrence, or if new blood flow to the fibroids has developed, in rare occasions this may warrant repeat intervention.”
Acknowledging the amount of valuable clinical information an MRI can provide, Dr. Madassery says he routinely evaluates a pelvic MRI when seeing a patient for her interventional consultation. “Most interventional radiologists prefer to have an MRI at the time of clinic consultation in order to provide the patient with all the information possible and address expectations prior to the UFE procedure.”
Although an MRI is useful when diagnosing fibroids and planning for treatment, it does have its drawbacks, such as limitations to access in some parts of the US, high costs, and lack of health insurance coverage for some patients. What’s more, women who have implanted devices such as pacemakers, tubal ligation clips, and certain intrauterine devices for contraception can’t undergo an MRI.
“Timing to get an MRI is also difficult for some patients,” Dr. Maddassery tells Ask4UFE. “Compared to an ultrasound or a computed tomography (CT) scan, an MRI is considerably lengthier. Patients need to remain still for up to 45 minutes, which can be challenging for some.” A type of specialized x-ray, CT scans are considered quicker imaging options, as are conventional x-rays, but neither are preferred diagnostic tools when it comes to fibroids.
“Even though other imaging techniques may be faster or less expensive, women should still know about the benefits of having an MRI as part of their workup,” Dr. Madassery encourages. “The decision to obtain any imaging is determined by the doctor, but there should always be thorough dialogue with the patient, so all concerns are addressed.”
ABOUT THE DOCTOR Sreekumar Madassery, MD, is an interventional radiologist and Assistant Professor of Vascular and Interventional Radiology and Diagnostic Radiology at Rush University Medical Center in Chicago, Ill. In addition to teaching and providing patient care, Dr. Madassery has been published in several peer-reviewed journals and is an advocate for minimally invasive approaches to treatment for several conditions, such as cancer and arterial disease. Connect with him on Twitter @kmadass.
1. Malartic, C., Morel, O., Rivain, A. L., et al. (2013). Evaluation of symptomatic uterine fibroids in candidates for uterine artery embolization: comparison between ultrasonographic and MR imaging findings in 68 consecutive patients. Clin Imaging, Jan-Feb; 37(1): 83-90.