Fibroids may be felt during a pelvic exam, but many times myomas that are causing symptoms can be missed if the examiner relies just on the examination. Also, other conditions such as adenomyosis or ovarian cysts may be mistaken for fibroids. For this reason, I routinely do an Ultrasound of fibroid in endometrial cavity 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.
Diagnosis of Fibroids
Fibroids may be felt during a pelvic exam, but many times myomas that are causing symptoms can be missed if the examiner relies just on the examination. Also, other conditions such as adenomyosis or ovarian cysts 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 done in my office, and allows me to directly look inside the uterus. Click here to learn more about hysteroscopy.
The above steps are usually all that is needed to make an accurate diagnosis and plan treatment. Sometimes, especially with very large fibroids, more information is needed. An MRI scan makes detailed images of the uterus. It can show the location of fibroids. An MRI can usually tell the difference between adenomyosis and fibroids.
Adenomyosis: don't let it fool you
One of the most common conditions confused with fibroids is adenomyosis. This can be a serious error, as the treatment may be quite different. In adenomyosis the lining of the uterus infiltrates the wall of the uterus, causing the wall to thicken and the uterus to enlarge. This can cause severe pain, and heavy bleeding.
On ultrasound examination adenomyosis 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, and rarely can be removed without taking out the uterus. Since fibroids can be removed by myomectomy, it is essential to differentiate between the two conditions before planning treatment. It is also common to have adenomyosis and fibroids in the same uterus.
Hysteroscopy uses a hysteroscope, which is a thin telescope that is inserted through the cervix into the uterus. Modern hysteroscopes are so thin that they can fit through the cervix with minimal or no dilation. Because the inside of the uterus is a potential cavity, like a collapsed air dome, it is necessary to fill (distend) it with either a liquid or a gas (carbon dioxide) in order to see. I do most diagnostic hysteroscopy in the office using local anesthesia. If a patient is particularly anxious, or if I have a concern that she may be uncomfortable, I can do the procedure under mild sedation.
View through a hysteroscope
This is a view through a hysteroscope during office hysteroscopy. It shows the inside of a uterus with two intracavitary myomas on the back wall. The upper portion of the photograph shows the top of the uterus, which is normal. Fibroids like this can cause severe cramping (dysmenorrhea), heavy menstrual periods (menorrhagia) and bleeding between periods (metrorrhagia.) These fibroids were quickly and accurately diagnosed by hysteroscopy.
These myomas can be removed using a special kind of hysteroscope called a resectoscope.
How is Diagnostic Hysteroscopy done?
Unless a women has major medical problems, I do diagnostic hysteroscopy in my office. I numb the cervix (this is easily done and rarely uncomfortable.) I attach a video camera to the hysteroscope, so my patient can also see, and then insert the hysteroscope into the uterus under direct vision while using either saline or carbon dioxide to fill the uterus. We then can look for fibroids, polyps, and other problems that may be causing bleeding. This often takes about a minute or two. The hysteroscope is removed. A small plastic tube may be used to take a sample of the lining of the uterus. That's it!
Isn't this too painful to do in the office?
By being very gentle, and using local anesthesia, there is usually minimal discomfort during hysteroscopy. Most women are able to get up and return to their normal activities immediately. If someone is very anxious, it is possible to give a short acting narcotic intravenously. This makes it very unlikely that the procedure will be uncomfortable.
What is Operative Hysteroscopy?
During diagnostic hysteroscopy the hysteroscope is used just to observe the endometrial cavity (inside of the uterus.) During operative hysteroscopy a type of hysteroscope is used that has channels in which it is possible to insert very thin instruments. These instruments can be used to remove polyps, to cut adhesions, and do other procedures. In many situations, operative hysteroscopy may offer an alternative to hysterectomy.
How is the Resectoscope different than a regular hysteroscope?
The resectoscope has been used for male prostate surgery for over 50 years. It has been modified so it can be used inside the uterus. The resectoscope is a hysteroscope with a built in wire loop (or other shape device) that uses high-frequency electrical current to cut or coagulate tissue. The resectoscope has revolutionized surgery inside the uterus. Click here to learn more about hysteroscopic myomectomy.
The medical information presented in this website represents the opinion of Dr. Indman, and is based on his knowledge and experience. It is not applicable to all patients or physicians. Anyone visiting this or other related medical sites should discuss symptoms, findings, and alternatives with their personal gynecologist.
Please also visit Dr. Indman's award winning websites and blog:
Uterine Fibroids Blog - An Expert Speaks Out
(Real Women's Stories, Case Presentations, Review of Latest Information)
Fibroids, Hysteroscopy, Endometrial Ablation, Abnormal Pap Test
(Alternatives in Gynecology)
All About Myomectomy for Removal of Uterine Fibroids Fibroid Medical Center of Northern CaliforniaGynecologic Causes of Pain