Journal of Medical Ultrasound (2016) 24, 3e12

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REVIEW ARTICLE

Ultrasonography of Uterine Leiomyomas

Sabrina Q. Rashid 1*, Yi-Hong Chou 2*, Chui-Mei Tiu 2

1
Bangladesh Specialized Hospital, Department of Radiology and Imaging, and University of Science and
Technology Chittagong, Dhaka, Bangladesh, and 2 Department of Radiology, Taipei Veterans General
Hospital and National Yang Ming University, Taipei, Taiwan

Received 2 February 2012; accepted 23 December 2015

Available online 20 April 2016

KEYWORDS Abstract Leiomyomas or myomas of the uterus, also known as a fibroid uterus, are the
fibroids, most common tumors of the uterus. They are benign neoplasms of smooth muscle origin with
ultrasound, various degrees of fibrous connective tissue. These tumors can develop in any part of the
variants female genital tract where there is smooth muscle or fibrous tissue, even in the ovary, broad
ligament, and vagina. They need to be differentiated from adenomyosis and intracavitary
polyps. They mostly remain asymptomatic but sometimes they cause significant morbidity.
In such situations, hysterectomy or other surgical intervention is indicated. On ultrasonog-
raphy, most uterine leiomyomas typically appear as well-defined, solid masses. Their echo-
genicity is usually similar to that of the myometrium, but sometimes they are hypoechoic.
They often show some posterior acoustic shadowing. Variants of leiomyomas occur when
they undergo cystic degeneration, hyalinization, or calcification. In such situations, deter-
mining a diagnosis is sometimes difficult. Magnetic resonance imaging can be used in this sit-
uation for an accurate diagnosis.
ª 2016, Elsevier Taiwan LLC and the Chinese Taipei Society of Ultrasound in Medicine. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

Introduction

“The uterus is an organ that should bear something, if not a

child, then a fibroid”dso goes a saying. It is the most
common tumor of the uterus and all pelvic organs. Uterine
Conflicts of interest: The authors have no financial and nonfi- myomas or fibroids occur in 20e50% of women and repre-
nancial conflicts of interest to declare. sent the most frequent gynecologic tumor [1,2]. They are
* Correspondence to: Sabrina Q. Rashid, Bangladesh Specialized more frequent and occur at a younger age in the black
Hospital, 88 DOHS Banani, Dhaka Cantonment, Dhaka 1206,
population. Depending on their location and size, they may
Bangladesh. Yi-Hong Chou, 201, Department of Radiology, Taipei
Veterans General Hospital and National Yang Ming University,
or may not be symptomatic [3].
Section 2, Shih-Pai Road, Taipei 11217, Taiwan. Ultrasonography (USG) is usually the first method used
E-mail addresses: [email protected] (S.Q. Rashid), to examine the female pelvis. Both transabdominal scan
[email protected] (Y.-H. Chou). (TAS) and transvaginal scan (TVS) should ideally be

http://dx.doi.org/10.1016/j.jmu.2015.12.006
0929-6441/ª 2016, Elsevier Taiwan LLC and the Chinese Taipei Society of Ultrasound in Medicine. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
4 S.Q. Rashid et al.

Symptoms and signs

The symptoms and signs of a leiomyoma depend on its size

and location. Submucosal myomas (Figure 1) may erode
into the endometrial cavity and cause irregular or heavy
bleeding, which may lead to anemia. Fertility may be
affected by submucosal or intramural leiomyomas (Figures
2 and 3), which by their location may inhibit sperm
transport down the tube and prevent adequate implanta-
tion or cause recurrent miscarriages. Large cervical leio-
myomas (Figure 3) can prevent normal vaginal deliveries.
Large leiomyomas can cause symptoms by pressure effect
on adjacent organs such as the bladder (Figure 4), bowel,
and ligaments of the pelvis. They may cause dysmenor-
rhea, dysuria, and constipation. Low back pain may be
because of pressure on pelvic ligaments or the lumbar
Figure 1 Submucosal and degenerative myoma on the plexus. Acute pelvic pain may be caused by torsion or
transvaginal scan. The mass is indicated by the arrows. necrosis of a previously asymptomatic leiomyoma. They
may be pedunculated and present as a separate pelvic
mass. Cervical leiomyomas may pedunculate into the
performed. A TAS is very difficult to perform in obese
endocervical canal, where ulceration and hemorrhage are
patients and gives less information. For the diagnosis of
common [3].
small leiomyomas, TVS is more sensitive; it is also sensi-
tive in detecting leiomyomas when the uterus is retro-
flexed and/or retroverted. A TAS is generally superior to
TVS in diagnosing a fundal myoma; however, TVS occa- Location
sionally helps to exclude a fundal myoma that was indi-
cated by TAS. In TVS, a large or pedunculated myoma may A fibroid uterus is more correctly called a leiomyoma
lie outside the field of view of a high frequency probe with because it arises from the smooth muscle of the uterine
short focal length. Ultrasonography is highly operator- wall. A leiomyoma is actually a mass of smooth muscle
dependent; therefore, in expert hands, the location of the proliferation in a whorled spherical configuration. They are
leiomyomas and 5-mm small fibroids can be detected by encapsulated by a pseudocapsule and separate easily from
TVS. Leiomyomas of the uterus are common tumors and the surrounding myometrium [3]. Leiomyomas also may
previous observations and reports have resulted in well- occur in extrauterine sites such as the fallopian tube, cer-
recognized diagnostic categories, based on histological or vix, vagina (Figure 5), or ligaments of the pelvis. However,
gross differences [4]. they are most common in the uterus.

Figure 2 Numerous small intramural leiomyomas (M) on the transvaginal scan.

Ultrasonography of Uterine Leiomyomas 5

Figure 3 An intramural leiomyoma (large arrows) and a large cervical leiomyoma (myo, small arrow) on the transvaginal scan.

Leiomyomas that occur in the uterine wall can be the 1980s solidified this position by providing a closer and
submucosal, intramural, or subserosal (i.e., adjacent to more accurate ultrasound (US) appraisal of the uterus.
the endometrium) and can develop in the muscle layer or Since the 1990s, improvements in computed tomography
just beneath the serosa. The tumor can also pedunculate (CT) and hysterosalphingography (HSG), and rapid de-
with a stalk connecting the uterus (Figures 6,7). Submu- velopments in magnetic resonance imaging (MRI) have
cosal leiomyomas are usually clearly visible and separate allowed these modalities to complement the traditional
from the endometrium on a TVS, but can be difficult to sonographic evaluation [4].
differentiate from polyps (Figure 8). Hysterosonography is Leiomyomas or fibroids of the uterus are common neo-
a technique in which sterile saline is instilled into the plasms and most are the conventional type and therefore easy
uterine cavity via a transcervical catheter while per- to diagnose. Throughout the years, several histological sub-
forming a TVS. This method allows better visualization of types have been described. Their importance is largely
the endometrium and is more accurate than the tradi- because of their resemblance in one or more aspects to leio-
tional TVS in detecting submucosal leiomyomas and in myosarcoma and the obvious potential for misdiagnosis [4].
differentiating them from polyps [5]. Most uterine leiomyomas appear as well-defined solid
masses. Their echogenicity is usually similar to the myo-
metrium, but sometimes the echogenicity is hypoechoic.
Ultrasonography The tumors cause the uterus to become bulky or may
change the uterine contour and make it irregular (Figure 3).
Since the late 1970s, clinical ultrasonography has been the Uterine leiomyomas often show some posterior acoustic
“gold standard” of uterine imaging. The advent of TVS in shadowing (Figure 3); this finding is more prominent in fi-
broids that have calcification (Figure 9).
Leiomyomas with cystic degeneration may have a com-
plex appearance (Figure 1). Color Doppler US typically
shows circumferential vascularity [6]; however, leiomyo-
mas that are necrotic or have undergone torsion will show a
lack of blood flow [7]. Transvaginal color Doppler US can be
used to study uterine blood flow and leiomyoma arterial
supply. The color Doppler US depiction of uterine vascu-
larity depends on several factors such as the sensitivity of
the scanner and the age and parity of the patient. In non-
medically suppressed women of childbearing age, myo-
metrial vessels and spiral vessels within the endometrium
during the luteal phase are present. Postmenopausal
women typically have a relatively hypovascular myome-
trium and endometrium [6]. Blood flow impedance
[expressed as the resistance index (RI)], pulsatility index
(PI), and blood velocity can be calculated. Increased blood
Figure 4 A longitudinal transabdominal scan of a largecervical velocity and decreased RI and PI in both uterine arteries
leiomyoma (arrows), which resulted in the patient’s inability to occur in patients with uterine leiomyomas. The same
empty the urinary bladder. U Z uterus; UB Z urinary bladder. technique has been used to study blood flow in the main
6 S.Q. Rashid et al.

Figure 5 (A) Longitudinal and transverse transabdominal scans of a leiomyoma (mass) on the vaginal wall. (B) Longitudinal and
transverse transvaginal scans also show leiomyoma (the arrows indicate the mass) on the vaginal wall. UB Z urinary bladder.

arteries supplying identifiable leiomyomas. Diastolic flow in undetermined uterine smooth muscle tumors that will
these arteries is always present and increased in compari- require additional diagnostic evaluation before treatment.
son to uterine artery blood flow. The difference in uterine Combined gray-scale and color Doppler US may help
artery blood flow between patients with leiomyomas and distinguish a uterine leiomyosarcoma from a leiomyoma [9].
healthy volunteers is statistically significant and may have A high vascularity score yielded high sensitivity (100%) but a
predictable value in growth rate evaluation of a benign low positive predictive value (PPV; 19%). Considering only
uterine mass [8]. It may be that detecting hypervascularity the presence of marked central vascularity achieved a
in combination with other sonographic findings can identify sensitivity of 88% and a specificity of 96% with a 44% PPV.

Figure 6 Longitudinal and transverse transabdominal scans show a subserosal leiomyoma (arrow) on the fundus. UB Z urinary
bladder.
Ultrasonography of Uterine Leiomyomas 7

Adding the diameter  8 cm or the characteristics of a

single myometrial tumor to the presence of central vascu-
larity, the PPV and K index improved (PPV, 60%; K index,
59%). When the diameter was  8 cm, marked central
vascularity and presence of cystic degeneration were
considered together for the diagnosis of leiomyosarcoma.
The sensitivity decreased (50%), but specificity (99%), PPV
(57%), and the K index (56%) remained largely unchanged.
Diffuse leiomyomatosis is among the many variants of
uterine leiomyoma with an unusual growth pattern that has
been described [10]. This tumor, however, is characterized
by uterine enlargement that is symmetric, the result of
innumerable leiomyomatous nodules throughout the
myometrium.
Another morphologic variant of leiomyoma is intrave-
nous leiomyomatosis [11]; In this variant, the leiomyoma is
within vascular spaces that lie outside a leiomyoma, which
are often grossly visible. A newer relatively rare variant,
the cotyledonoid leiomyoma [12], has been the subject of
several recent case reports [13,14]. This entity is named
because of its dramatic placenta-like gross appearance,
which belies its otherwise benign nature. Leiomyomas of
the uterus are often accompanied by degenerative changes
such as hyalinization, myxoid change, and calcification
[15].
Edema within these tumors is also another type of
degenerative process which, when less severe, is often
referred to as hydropic change [16] or hydropic degenera-
tion [17]. Cyst formation can be an exaggeration of this
process, and is associated with increasing amounts of
edematous fluid in some tumors. Cystic change itself is a
recognized degenerative phenomenon [4].
Most variant leiomyomas have been reported in patients
in the latter phase of their reproductive life or in the
perimenopausal period. They are entirely benign and the
patient’s prognosis is good [4].
Most uterine leiomyomas are benign, although some
uterine leiomyosarcomas may arise from a subset of leio-
myomas [18]. Only approximately 0.23e0.7% of apparently
benign uterine leiomyomas are actually leiomyosarcomas,
based on pathological examination [19,20].
Large leiomyomas can occasionally obstruct the ureters
and cause secondary hydronephrosis. Therefore, an US ex-
amination should include the urinary tract whenever a large
pelvic mass is identified. The diagnosis of uterine leio-
myomas on US is usually reasonably straightforward,
although focal adenomyosis can mimic a leiomyoma and a
pedunculated uterine leiomyoma can sometimes be
mistaken for an adnexal mass [21] (Figure 7A). When there
is doubt about the origin of a pelvic mass at US, further
evaluation with MRI should be performed.
Three-dimensional US (3D US) is a more recently devel-
oped technique. The 3D technique can be available for

(arrow) with a relatively thick stalk (arrowheads) connecting it to

the uterine fundus. (C) The TVS and (D) CT scan of a pedunculated
calcific leiomyoma (arrow). Another small leiomyoma is visible
Figure 7 Pedunculated leiomyomas. (A) The tumor (arrow) has (cursors). The patient also has ascites due to peritoneal dialysis.
a thin stalk (arrowhead) connecting it to the uterine fundus CT Z computed tomography; TAS Z transabdominal scan;
(longitudinal TAS image). (B) The TAS image shows a leiomyoma TVS Z transvaginal scan; UT Z uterus.
8 S.Q. Rashid et al.

and in the coronal, transverse, and sagittal planes

(Figure 10). What is coronal on the 2D display is actually
transverse to the uterus. The actual coronal plane on 3D
(i.e., the C-plane) is coronal to the uterus, not to the fe-
male pelvis. In the 3D display of the uterus, the plane of
acquisition is usually provided in addition to the multi-
planar display in the 3D presentation. The US operator
needs to rotate the volume to see the standard plane [i.e.,
transverse, sagittal, and coronal (C-plane)]. The display
varies, depending on equipment and operator preference.
Sagittal acquisition is generally superior to coronal acqui-
sition. If the uterus is too large to get into one volume with
the sagittal plane, the transverse plane can be used. Three-
dimensional TVS is generally superior to 3D TAS [22]. Breath
holding can improve data acquisition. During scanning, the
orientation issue is very important, and the identification of
the cervix and the right and left side is needed. Three-
dimensional US is very good for volume measurement of
Figure 8 The transvaginal scan shows a polyp (arrows) in the
uterine leiomyomas and vascularity assessment by using
endometrial canal and multiple intramural leiomyomas (M).
vascularity index or vascularity volume display [23]
transabdominal or transvaginal scans. Three-dimensional (Figure 11). In addition to the multiplanar mode, the vol-
US can provide a multiplanar display of the anatomy of the ume data may be also utilized for a multislice mode,
uterus. The uterus is displayed in the standard orientation, rendered display mode, thick slice mode, or other modes

Figure 9 (A) Leiomyoma (arrows) with calcific changes presents as bright spots within the mass on the transvaginal scan. (B)
Transabdominal scan of curvilinear calcification in the periphery of a leiomyoma (arrows) in a pregnant female. F Z fetus.
Ultrasonography of Uterine Leiomyomas 9

the uterus. Calcification in the fibroids can be detected by a

CT scan. Degenerated fibroids may appear complex and
contain areas of fluid attenuation. Calcification occurs in
approximately 4% of fibroids [28], and is typically dense and
amorphous. However, calcification can also be confined to
the periphery (Figure 8) of the fibroid when it is believed to
be secondary to thrombosed veins from previous red
degeneration [28]. Furthermore CT scan can demonstrate
secondary changes of the uterine fibroids such as degen-
eration, necrosis, and sacromatous transformation [29].

Magnetic resonance imaging

Magnetic resonance imaging (MRI) is the preferred method

for accurately characterizing pelvic masses. It is more
sensitive than US in identifying uterine fibroids [30], it does
not involve the use of ionizing radiation, and it can
demonstrate the zones of the uterus very well. Submucosal,
intramural, and subserosal fibroids are well demonstrated,
and very small fibroids and cervical fibroids can be detected
by MRI. MRI sequences should include axial and sagittal T1W
and T2W images. Compared to the myometrium, non-
degenerated fibroids appear as well-defined low-signal in-
tensity masses on T2W images and as isointense on T1W
images [31].

Hysterosalpingography and sonohysterography

Hysterosalpingography (HSG) remains an important radio-

logic procedure in the investigation of infertility and is a
Figure 10 A leiomyoma (arrows) on three-dimensional (3D) commonly performed examination because of recent ad-
ultrasonography presents as a hypoechoic mass in the cervical vances in reproductive medicine. Hysterosalpingography
region (TAS). (A) The original raw image on the sagittal scan. can demonstrate the morphology of the uterine cavity, the
(B) The 3D image. TAS Z transabdominal scan. lumen, and the patency of the fallopian tubes. Because of
the increased demand for HSG, physicians should be
(e.g., invert mode). In patients with a distorted endome- familiar with the HSG technique and the interpretation of
trium on 2D US, 3D hysterosonography may readily HSG images.
demonstrate submucosal leiomyomas, help distinguish a After administering a radiopaque contrast medium
pseudopolyp or an endometrial polyp, and allow for accu- through the cervical canal, the uterine cavity, and the
rate assessment of intrauterine abnormalities [23,24]. patency of the fallopian tubes can be evaluated. A properly
Hysterosonography is an important addition to TVS in the performed HSG can detect the contour of the uterine cavity
accurate delineation of submucosal and intracavitary leio- and the width of the cervical canal. Further contrast me-
myomas [25]. A 3D TVS can be combined with saline dium injection will outline the cornua isthmic and ampul-
instillation into the uterine cavity to complement diag- lary portions of the tubes, and will show the degree of
nostic hysteroscopy for the assessment of a submucosal spillage [32,33]. Most leiomyomas are diagnosed by TAS,
leiomyoma. There is a good overall agreement between whereas submucosal leiomyomas are imaged as smooth
diagnostic hysteroscopy and TVS in the diagnosis of sub- filling defects in the uterine cavity. Differential diagnosis of
mucosal leiomyomas and in the assessment of myometrial a leiomyoma must include endometrial polyps or a possible
extension of fibroids [25,26]. Three-dimensional saline pregnancy. Small intramural leiomyomas do not distort the
contrast sonohysterography may provide even more infor- endometrial cavity and are not visualized on HSG. Submu-
mation than conventional 3-D TVS in this aspect [27]. cosal leiomyomas can provoke smooth filling defects,
smooth muscle repression, or obstruction of the fallopian
tubes only if they are in the lateral walls of the uterus [32].
Computed tomography Distinguishing a submucous myoma from an endometrial
polyp is very important. Intracavitary fibroids tend to be
CT is not the choice for the characterization of pelvic larger than the polyps, and homogeneous hyperechoic
masses. A CT scan is limited by the similar signal attenua- masses in the uterine cavity observed by sonohysterography
tion by uterine fibroids and the normal myometrium. (SHG) are highly suggestive of endometrial polyps [34],
Uterine fibroids are often seen incidentally on CT scans that Other studies using B-mode sonography suggest that a
are performed for other reasons. The typical finding is a hyperechoic polypoid lesion in the uterine cavity is char-
bulky, irregular uterus or a mass in continuity within or with acteristic of an endometrial polyp. By contrast, the
10 S.Q. Rashid et al.

myometrial echogenicity of uterine fibroids tends to vary

(e.g., hypoechoic, isoechoic, hyperechoic, or mixed),
which may depend on the size and nature of the fibroid.
Thus, SHG may enhance the echogenicity in these intra-
cavitary masses of the uterus. A published study showed
homogeneous hyperechoic polypoid masses occur signifi-
cantly in patients with endometrial polyps. Another study
using SHG also demonstrated that most submucosal fibroids
were hypoechoic. Therefore, homogeneous hyperechoic
masses in the uterine cavity on SHG are highly suggestive of
endometrial polyps [35,36].

Rare types

Diffuse leiomyomatosis is a rare condition that consists of

diffuse involvement of the myometrium by innumerable
small leiomyomas, which result in symmetrical enlarge-
ment of the uterus. They are histologically benign, although
there may be dissemination through the peritoneal cavity
or occasionally metastasis to distant organs [28].
Lipoleiomyomas are rare fat-containing leiomyomas
with a reported prevalence of 0.005e0.2% [37]. They are
detected in 0.03e0.2% of hysterectomy specimens [38].
Lipoleiomyomas are benign and present with the same
symptoms as uterine leiomyomas. The most likely cause
may be fatty metamorphosis of the smooth muscle cells of a
leiomyoma [25,39]. An intensely hyperechoic, avascular
uterine mass is most often a fat-containing mass and is
virtually diagnostic of a lipomatous uterine tumor or lip-
oleiomyoma [40] (Figure 12). If pedunculated, they can be
mistaken on imaging for ovarian dermoids. As leiomyomas
enlarge, they can outgrow their blood supply and result in
various types of degeneration (e.g., hyaline, cystic, myx-
oid, or red degeneration) and dystrophic calcification [41].
Cystic degeneration, which occurs in w4% of leiomyomas,
may be an extreme sequelae of edema [42]. Fibroids typi-
cally have a characteristic ultrasonographic appearance,
although cystic degenerating fibroids can have variable
patterns and pose diagnostic challenges [43], especially
when a fibroid is an usually large cystic mass (Figure 13) or a
pedunculated leiomyoma masquerading as an adnexal
mass. Pedunculated leiomyomas should be considered in
the differential diagnosis of a multilocular and predomi-
nantly cystic adnexal mass.

Differential diagnosis

Leiomyosarcomas are malignant tumors of the uterus. They

may occasionally arise from a preexisting fibroid but usually
occur de novo [18]. The patient classically presents with a
pelvic mass that has had a recent or rapid increase in size
[19]. They are typically large, heterogeneous masses

conventional transabdominal scan image shows a hypoechoic

mass in the uterine body (arrows). (B) Based on 3D US volu-
metry, the tumor volume is 217.51 cm3. (C) Tumor vascularity
on 3D US obtained by power Doppler US. The right lower image
Figure 11 The tumor volume, tumor vascularity, and
shows 3D power Doppler angiography. (D) The vascularity index
vascularity index in a leiomyoma (arrows), assessed by using
(VI) of the leiomyoma is 2.994 (flow index Z 26.251, vascu-
three-dimensional ultrasonography (3D US). (A) The
larization flow index Z 0.786).
Ultrasonography of Uterine Leiomyomas 11

Figure 12 An intensely hyperechoic uterine mass (large ar-

rows) on the transvaginal scan is a fat-containing mass (i.e., a
lipoleiomyoma). Another submucosal leiomyoma is present
(small arrows) and associated with the distortion of the
endometrial echoes (arrowheads).

containing areas of hemorrhage. They usually have more ill-

defined, irregular margins, compared to benign uterine
leiomyomas [16]. Combined gray-scale and color Doppler
US may help distinguish uterine leiomyosarcoma from
leiomyoma [9].
Adenomyosis is the ectopic endometrial tissue within the
myometrium. The US findings are relatively nonspecific.
Sonographic features used in the diagnosis of adenomyosis
consisted of two factors or more of the following: a mottled
inhomogeneous myometrial texture, globular uterine
enlargement, uterine wall thickening, small cystic spaces
Figure 13 Cystic fibroid. (A) The sagittal scan of the lower
within the myometrium, and a “shaggy” indistinct endo-
abdomen shows a large nearly completely cystic fibroid uterus
metrial stripe. A MRI scan may be helpful because leio-
(arrows) that measures 12 cm  10 cm and mimics a huge
myomas tend to be round, well-defined, encapsulated
gestational sac. It is in the body of the uterus of an unmarried
masses. Adenomyosis is a poorly demarcated or diffuse area
25-year-old woman with regular but very heavy periods and
without distinct margins or shape [44].
dysmenorrhea. (B) The transverse scan shows a solid compo-
Endometrial polyps typically appear as pedunculated
nent, 57 mm thick (arrows), that resembles placental tissue on
endometrial masses and will usually demonstrate an intact
one side of the cystic fibroid uterus. CX Z uterine cervix;
overlying endometrial stripe. For differentiation from a
U Z uterus; UB Z urinary bladder.
submucosal leiomyomas, HSG can be used.
A pedunculated subserosal leiomyoma can sometimes be
mistaken for an ovarian tumor. At times, a correct diagnosis Acknowledgments
is determined only at the time of surgery.
Myometrial contractions can be mistaken for uterine fi-
The authors would like to thank Ms. Chih-Ping Chiu, senior
broids. However, the contractions are transient, and
research assistant, for her excellent assistance in the
therefore the masses will disappear on subsequent scans.
preparation of this article.

Conclusion
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