UTERUS & OVARIES

a
appendiceal

omental endometriosis

kissing ovary sign

scar endom

rectovaginal endometriosis
distribution of endometriosis

scar endometriosis

Uterine Leiomyoma (FIBROIDS)

Uterine leiomyomas, also known as uterine fibroids, are benign tumors of myometrial origin and are the most common solid benign uterine neoplasms. Commonly an incidental finding on imaging, they rarely cause a diagnostic dilemma.

Epidemiology

They are clinically apparent in ~25% of women of reproductive age and over 70% of women by menopause ²¹. Fibroids are responsive to hormones (e.g. stimulated by estrogens). Being rare in prepubertal females, they commonly accelerate in growth during pregnancy and involute with menopause ¹.
Risk factors

• 2-3x increased incidence in Black women than in White women ^20,21
  
• increasing incidence with age: 10x more common in 41-60 years than 21-30 years, reaching a peak at 50-60 years ^20,21
  
• 3x increased incidence with a family history of uterine fibroids ²¹
  

Clinical presentation

They are often asymptomatic and discovered incidentally. Signs and symptoms associated with fibroids include:

• abnormal vaginal bleeding
  
• pain
  
• infertility
  
• palpable masses
  

Pathology

Leiomyomas are benign monoclonal tumors
(Monoclonal neoplasm (tumor) : A single aberrant cell which has undergone carcinogenesis reproduces itself into a cancerous mass. Monoclonal plasma cell (also called plasma cell dyscrasia): A single aberrant plasma cell which has undergone carcinogenesis reproduces itself, which in some cases is cancerous.
Polyclonal tumor origin refers to the idea that two or more different progenitor cells or clones of cells cooperate in the genesis of a tumor
¹⁶ LEIOMYOMA is predominantly composed of smooth muscle cells with variable amounts of fibrous connective tissue. They are commonly multiple (~85% ⁸), and range significantly in size.
Any fibroid may undergo 1/ atrophy, 2/ internal hemorrhage, 3/ fibrosis, and 4/ calcification. They can also undergo several types of 5/ degeneration:

• hyaline degeneration: focal or generalized hyalinisation: this is the most common type of degeneration (can occur in ~60% of cases) ⁶
  
• cystic degeneration: ~5%
  
• myxoid degeneration: generally considered uncommon although reported as high as 50% by some authors ¹⁴
  
• red (carneous) degeneration: due to hemorrhagic infarction, which can occur particularly during pregnancy, and may present with acute abdominal pain
  

Location
Fibroids may have a number of locations within or external to the uterus:

• intrauterine
  
  • intramural leiomyoma: most common, centered within the myometrium
    
  • subserosal leiomyoma: projecting outwards from the uterus; may be pedunculated and predominantly extrauterine, simulating an adnexal mass
    
  • submucosal leiomyoma: least common (10-15%), projecting into the uterine cavity
    
  
  
  
• extrauterine
  
  • broad ligament leiomyoma
    
  • cervical leiomyoma
    
  • parasitic leiomyoma
    
  •   present as peritoneal pelvic benign smooth-muscle masses separate from the uterus)s).
    
  
  
  
• diffuse uterine leiomyomatosis
  
• Ultrasound
  Ultrasound is used to diagnose the presence and monitor the growth of fibroids:
  
• uncomplicated leiomyomas are usually hypoechoic, but can be isoechoic, or even hyperechoic compared to normal myometrium
  
• calcification is seen as echogenic foci with shadowing
  
• 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
  Ultrasound
  Ultrasound is used to diagnose the presence and monitor the growth of fibroids:
  
• uncomplicated leiomyomas are usually hypoechoic, but can be isoechoic, or even hyperechoic compared to normal myometrium
  
• calcification is seen as echogenic foci with shadowing
  
• 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 ¹⁷
  
• ^{READ MORE}
  
• ^{https://radiopaedia.org/articles/uterine-leiomyoma?lang=us}
  
  

calcified fibroid

subserosal fibroid

Treatment and prognosis

There are various medical, surgical, and interventional treatment options:

• myomectomy: recurrence rate of 40-55% at 5 years ²³
  
• focal endometrial curettage
  
• hormone administration
  
• hysterectomy
  
• uterine artery embolization (UAE)
  
• high-intensity focussed ultrasound (HIFU)
  

Complications

• invasion of adjacent venous channels leading to intravenous leiomyomatosis: rare ¹⁵
  
• malignant degeneration into leiomyosarcomas: rare (0.1-0.5%)
  
• benign metastasizing leiomyoma: extremely rare ³
  
• torsion of subserosal leiomyoma
  
• pyomyoma ¹⁹
  
• changes in pregnancy
  
  • around one-third of fibroids may grow in pregnancy (especially in the 1^st trimester ¹⁸)
    
  • pregnancy may cause fibroid growth by 30%
    
  
  
  

Differential diagnosis

General imaging differential considerations include:

• uterine leiomyosarcoma
  
  • malignant transformation into leiomyosarcoma is rare.
    
  • unfortunately, no imaging modality can reliably differentiate a benign leiomyoma from the rare leiomyosarcoma
    
  
  
  
• uterine smooth muscle tumors of uncertain malignant potential: rare
  
• uterine lipoleiomyoma: greater fat content (sometimes considered a variant of a leiomyoma)
  
• focal myometrial contraction (Braxton Hicks contraction): especially if seen during pregnancy
  
• focal adenomyosis: less well-defined; color Doppler demonstrates tortuous vessels through the abnormality; no calcifications ^4,17
  

In occasional situations, it may be difficult to differentiate between uterine leiomyomas and:

• ovarian or adnexal masses (especially if the leiomyoma is pedunculated)
  
• endometrial carcinoma
  
• MORE.......
  

Quiz questions

https://radiopaedia.org/articles/uterine-leiomyoma?lang=us

Adenomyosis
• The presence of endometrial glands
and stroma within the myometrium
• Diffuse form characterized by an
enlarged uterus with a diffusely
heterogenic myometrium
• Nodular form compose of nodules
(adenomyomas)
• May present with pelvic pain,
dysmenorrhea or menorrhagia
• Asymmetrically thickened
myometrium
• Subendometrial cysts, echogenic
linear striations or echogenic nodules
• Ill defined endometrial border
Sonographic features used in the diagnosis of adenomyosis consisted of two or more of the following::
  1mottled inhomogeneous myometrial texture, 2 globular appearing uterus, 3 small cystic spaces within the myometrium, and 4 a "shaggy" indistinct endometrial stripe
https://dr-kamal.yoo7.com/t1704p25-topic

.https://www.shreeivfclinic.com/blogs/overview-of-adenomyosis-stages/

Hydro/Hematometrocolpos
• Accumulation of secretions and/or
blood in the uterus and/or vagina with
the location depending on the amount
of obstruction.
• When congenital due to imperforate
hymen,vaginal septum,atresia,
rudimentory uterine horn
• When acquired due to endometrial or
cervical tumors or postradiation fibrosis
Cervical Lesions
• Nabothian cysts
• Cervical polyps
• Cervical leiomyomas
Cervical carcinoma
Cervical Carcinoma
May resemble a cervical Fibroid
Usually diagnosed clinicall
https://michigansonographerssociety.org/wp-content/uploads/2016/01/An-Ultrasound-Review-of-PELVIC-PATHOLOGY-True-Copy.pdf