Abdominal Radiology (2021) 46:2146–2155

https://doi.org/10.1007/s00261-020-02882-z

REVIEW

MRI‑based pictorial review of the FIGO classification system for uterine

fibroids
Erin Gomez1   · My‑Linh T. Nguyen2 · Dzmitry Fursevich3 · Katarzyna Macura1 · Ayushi Gupta4

Received: 29 September 2020 / Revised: 19 November 2020 / Accepted: 25 November 2020 / Published online: 1 January 2021
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature 2021

Abstract
Uterine fibroids are the most common gynecologic neoplasm and contribute to significant morbidity, particularly when
submucosal in location or large enough to cause bulk symptoms. Correctly classifying fibroids is essential for treatment
planning and prevention of complications. Ultrasound is the first-line imaging modality for characterizing uterine fibroids.
However, MRI allows for high-resolution, multiplanar visualization of leiomyomata that affords a more accurate assessment
than ultrasound, particularly when fibroids are numerous. The FIGO system was developed in order to more uniformly and
consistently describe and classify uterine fibroids. In this article, we review the MRI appearance of each of the FIGO clas-
sification types, detailing key features to report. Additionally, we present a proposed template for structured reporting of
uterine fibroids based on the FIGO classification system.

Keywords  Uterine fibroids · FIGO · Pelvic MRI

Introduction 20–30% of women of reproductive age [1] and in up to 80%

of all women [2]. Anywhere from 20 to 50% of women may
Background be symptomatic, presenting with abnormal uterine bleeding,
dysmenorrhea, bulk symptoms, infertility and pregnancy
Uterine fibroids, also known as uterine leiomyomata or myo- loss [3]. Fibroids are monoclonal smooth muscle tumors
mas, are the most common gynecologic tumors occurring in arising from the myometrium. While benign, their growth
is dependent on estrogen and progesterone levels, and thus
fibroids may enlarge with pregnancy and use of oral contra-
* Erin Gomez
[email protected] ceptives and regress during menopause [4].
My‑Linh T. Nguyen
my‑[email protected] Role of MRI
Dzmitry Fursevich
[email protected] Ultrasound is the initial test of choice to assess the pres-
ence of fibroids in symptomatic patients [5]. For patients
Katarzyna Macura
[email protected] undergoing conservative treatment, an ultrasound may suf-
fice. However, MRI provides a more accurate assessment
Ayushi Gupta
[email protected] of the number, location and type of fibroids [6, 7]. MRI is
superior to ultrasound in evaluating patients with significant
1
The Russell H. Morgan Department of Radiology uterine enlargement as well as in the assessment of sub-
and Radiological Science, Johns Hopkins University mucosal fibroids. Additionally, MRI may also be used as a
School of Medicine, 600 N. Wolfe St., MRI Building 143,
Baltimore, MD 21287, USA problem-solving tool to differentiate between fibroids and
2 their mimics, such as adenomyosis, ovarian neoplasms and
Department of Radiology, Kaiser Permanente Mid-Atlantic
Permanente Medical Group, Rockville, MD, USA focal myometrial contractions [8].
3
Renown Regional Medical Center, Reno, NV, USA
4
Department of Radiology and Imaging Sciences, Emory
University School of Medicine, Atlanta, GA, USA

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Standard MRI protocol Surgical management depends on multiple factors includ-

ing patient symptoms, menopausal state, fibroid location
At our institution, the standard MRI protocol for imaging and size and the desire to preserve fertility and/or retain the
the female pelvis in a patient with fibroids includes sagit- uterus. Surgical techniques for myomectomy include hys-
tal, axial and coronal T2-weighted images (T2WI), axial teroscopy, laparoscopy, minimal laparotomy, laparotomy,
T1-weighted images (T1W1) and diffusion-weighted imag- morcellation, or hysterectomy [12].
ing (DWI), axial and sagittal pre-and post-contrast T1WI. Additional therapies include uterine artery emboliza-
The field of view for axial and sagittal images extends from tion (UAE) or occlusion and ablative techniques includ-
hip joint to hip joint in the transverse dimension and from ing MR-guided focused ultrasound (MRg-FUS) [13] and
the iliac crests to the perineum craniocaudally. The coronal cryotherapy.
T2-weighted images are often used for troubleshooting and
surgical planning by the gynecologic team. This protocol is Traditional grading system
outlined in Table 1. Coronal time-resolved angiography may
be added if specifically ordered by the referring clinicians. Traditionally, fibroids have been described based on their
location as either submucosal, intramural or subserosal [5].
MRI features of fibroids However, with recent advances in treatment, this simplified
classification system lacks attention to important features
Uterine fibroids have a characteristic appearance on MRI. which may result in suboptimal management. For example, a
They are well circumscribed and typically demonstrate 100% intramural fibroid that contacts the endometrium may
homogeneously low signal intensity on T2-weighted imag- be miscategorized as a submucosal fibroid due to the endo-
ing compared to the myometrium [8]. Very cellular fibroids metrial abutment and planned for hysteroscopic resection.
may have relatively high signal intensity on T2-weighted In many instances, a more detailed description is helpful for
imaging. Enhancement is variable and is an important treatment planning, particularly in the setting of abnormal
descriptor to include especially when planning uterine uterine bleeding.
fibroid embolization (UFE) [9]. Fibroids with a promi-
nent vascular supply will often demonstrate flow voids on
T2-weighted imaging. Fibroids may undergo hyaline, cystic,
FIGO classification system
fatty, myxoid or hemorrhagic degeneration [10].
The FIGO classification system was developed as a means
of uniformly and consistently describing and classifying
Treatment options
uterine fibroids in order to “facilitate communication, clini-
cal care and research.” [14]. Accurately classifying uterine
Myriad treatment options are available for leiomyomata,
fibroids allows clinicians to select the best treatment plan
including medical management, the goal of which is to
for the patient, be it hysteroscopy, laparoscopy/laparotomy,
downregulate the effects of circulating estrogen and proges-
or UAE. Precise classification is also necessary in the post-
terone. Medical management may aid in reducing associated
treatment setting in order to assess treatment response,
menorrhagia or inducing amenorrhea as well as reducing the
change in overall tumor burden and presence of recurrent
size of fibroids prior to surgical intervention [11].
lesions. The FIGO classification system subdivides fibroids
into submucosal, other (intramural and subserosal), and
hybrid types (Table 2, Fig. 1).

Table 1  Standard MRI protocol Plane Sequence Submucosal fibroids: FIGO types 0–2
for imaging the female pelvis in
the setting of uterine fibroids 3-plane Scout
Submucosal fibroids are located beneath the mucosal lining
Sagittal T2 sagittal
and are divided into FIGO 0, FIGO 1, and FIGO 2 based on
Axial T1 axial
the degree of intramural extension. Submucosal fibroids are
Axial T2 axial
a frequent cause of menorrhagia or dysmenorrhea as they
Axial Diffusion
protrude into the endometrial canal [15]. For women in their
Sagittal Pre-contrast
reproductive years, submucosal fibroids may also be a cause
Axial Pre-contrast
of infertility or pregnancy loss [16]. Because of this, sub-
Axial Post-contrast
mucosal fibroids may require treatment regardless of size.
Axial Post-contrast
Management frequently includes hysteroscopic resection or
Sagittal Post-contrast

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Table 2  FIGO fibroid Group Type Description

classification system
Submucosal 0 Pedunculated intracavitary
1 < 50% intramural (≥ 50% submucosal)
2 ≥ 50% intramural (< 50% submucosal)
Other 3 100% intramural, contacting endometrium
4 100% intramural, no endometrial or subserosal contact
5 Subserosal, ≥ 50% intramural
6 Subserosal, < 50% intramural
7 Pedunculated subserosal
8 Non-myometrial location: e.g., cervical, broad ligament, parasitic
Hybrid X–X Both submucosal and subserosal components. First number designates
the submucosal component and second number designates the subse-
rosal component

Fig. 2  FIGO 0—Intracavitary fibroid. a Post-contrast sagittal T1WI

in a 36-year-old woman demonstrates an intracavitary fibroid prolaps-
ing into the endocervical canal (F). A long stalk (S) is seen arising
from the fundus. b Axial T2W SPAIR image in a 45-year-old woman
demonstrates an intracavitary fibroid (arrow) surrounded by endome-
trium on all sides. The stalk was very short (not shown)

FIGO 1 fibroids are ≥ 50% submucosal and < 50% intra-

mural (Fig. 3), whereas FIGO 2 fibroids are < 50% submu-
Fig. 1  FIGO fibroid subtypes. Submucosal fibroids (shown in red)
include Type 0 (pedunculated intracavitary), Type 1 (≥ 50% sub- cosal and ≥ 50% intramural (Fig. 4). Treatment is often hyst-
mucosal), Type 2 (< 50% submucosal), and hybrid fibroids (here eroscopic myomectomy. Differentiating FIGO 1 and FIGO 2
depicted as a Type 2–5 fibroid). Fibroids without submucosal com- fibroids assists gynecologists during hysteroscopic removal
ponents (shown in blue) include Type 3 (100% intramural fibroid with as it provides better understanding of the intramural extent.
endometrial contact), Type 4 (100% intramural fibroid with no endo-
metrial contact), Type 5 (≥ 50% intramural fibroid with subserosal Sonohysterography may be useful in clarifying the degree
component), Type 6 (< 50% intramural fibroid with subserosal com- of intramural or endometrial involvement [5]. If large, hys-
ponent), Type 7 (pedunculated subserosal), and Type 8 (non-myome- teroscopic resection of FIGO 2 fibroids may be difficult,
trial location, such as cervical, broad ligament, or parasitic fibroids) requiring a two-step surgery or uterine artery embolization
[12]. Additionally, when evaluating FIGO 2 fibroids, it is
UAE [17]. Occasionally hysterectomy may be an option for important to assess the distance between the intramural com-
symptomatic patients no longer desiring pregnancy. ponent and the serosal surface. When the distance is less
FIGO 0 fibroids are pedunculated intracavitary fibroids than 0.5 cm, some studies suggest a higher chance of uterine
and are attached to the endometrium by a vascular stalk rupture during resection [19, 20].
(Fig. 2). Identifying and measuring the stalk on MRI can
be helpful during hysteroscopic resection [17]. On occasion Other fibroids: FIGO types 3–8
after UAE, FIGO 0 and less frequently FIGO 1 fibroids can
become necrotic and slough off into the endometrial canal Under the FIGO classification, all fibroids lacking a sub-
[18]. mucosal component have been classified as “other”. This

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Fig. 3  FIGO 1 (≥ 50% submucosal) fibroid. a, b Sagittal and axial c Axial T2WI in a 41-year-old woman also demonstrates leiomyoma-
T2WIs in a 45-year-old woman demonstrate a leiomyomatous uterus tous uterus with one of the fibroids having ≥ 50% submucosal fibroid
with one fibroid (white arrows) with ≥ 50% submucosal component. (arrow)
The extent of the submucosal component is denoted by green arrows.

Fig. 4  FIGO 2 (< 50% submucosal) fibroid. a Coronal and b sagit- Axial T2WI in a different 47-year-old woman demonstrates a large
tal T2WI in a 47-year-old woman demonstrate a fibroid uterus with fibroid with just under 50% submucosal component. The extent of the
two fibroids having < 50% submucosal component (yellow arrows). c submucosal component is denoted by green arrows

FIGO 3 fibroids are unique in that they are 100% intra-

mural and contact the endometrium but do not extend into
the endometrial cavity (Fig. 5). Careful resection of FIGO
3 fibroids is required during laparoscopy or laparotomy to
prevent violation of the endometrium [21].
FIGO 4 fibroids are 100% intramural without endometrial
or serosal contact (Fig. 6). The “claw sign” of surrounding
myometrium is a key finding on cross-sectional imaging of
the pelvis. Distinguishing between FIGO 2, 3, and 4 types
may be especially difficult when FIGO 3 and 4 fibroids are
Fig. 5  FIGO 3—Intramural fibroid with endometrial contact. a Sagit-
large and distort the endometrium. Accurately differentiat-
tal T2WI and b axial post-contrast fat-saturated T1WI in a 36-year- ing FIGO 2 from FIGO 3 and 4 types is key as the surgical
old woman with a large intramural fibroid in the anterior uterine wall. approach differs; FIGO 2 fibroids are resected hysteroscopi-
The fibroid significantly distorts the endometrium with most of the cally, whereas FIGO 3 and 4 lesions are removed via lapa-
fibroid covered by a hypointense junctional zone (white arrows) and
only a small portion contacting the endometrial canal (green arrows).
roscopy or laparotomy (provided there is enough distance
FIGO 3 fibroids can occasionally be difficult to differentiate from a from the submucosa to prevent transmural incision) [21, 22].
FIGO 2 when large; however, visualization of the junctional zone Furthermore, this distinction may determine the extent of
around most of the fibroid can be helpful surgery, as FIGO 3 and 4 fibroids may be difficult to safely
resect completely depending on their size [12]. Moreover,
includes intramural and subserosal fibroids as well as lesions safe resection of FIGO 3 fibroids may be more difficult to
with extrauterine locations such as the cervix and broad liga- achieve given endometrial contact. An example of a misclas-
ment. Patients with non-submucosal fibroids will usually sified FIGO 3 fibroid is shown in Fig. 7.
present with bulk symptoms or symptoms of mass effect on Subserosal fibroids can be subdivided into FIGO types
adjacent structures such as the bladder and colon. Treatment 5, 6, and 7 based on their intramural extent. These are often
with UAE, myomectomy, or hysterectomy is offered [12]. asymptomatic; however, patients may present with bulk

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FIGO 7 fibroids are pedunculated subserosal fibroids

without an intramural component (Fig. 10). As the subsero-
sal counterpart to the submucosal FIGO 0, FIGO 7 fibroids
also have a vascular stalk. Patients with these fibroids typi-
cally are asymptomatic until the fibroids become large and
exert mass effect on adjacent structures. Due to their vascu-
lar stalk, type 7 fibroids are also at risk of torsing, detaching
and/or becoming parasitized in the pelvis [23]. Treatment
options include UAE and surgery which includes resection
by laparoscopy, laparotomy or hysterectomy. Type 6 and 7
fibroids may be expelled into the peritoneal cavity following
UAE [24].
Extrauterine fibroids are classified as FIGO 8 (Fig. 11).
These lesions may arise from the cervix, broad ligament,
or may parasitize in the pelvis [23]. Parasitic fibroids may
occur after surgery where small portions of the fibroids fall
into the peritoneal cavity, more commonly seen with mor-
cellation [25]. Treatment varies depending on location [12].

Hybrid fibroids

Fig. 6  FIGO 4–100% intramural fibroid without submucosal or sub- The hybrid classification is used when a fibroid extends from
serosal component. a–d Multiple T2WIs in different patients demon- the submucosa to the serosa. Two numbers are listed, sepa-
strating a well-circumscribed hypointense mass (white arrows) sur-
rated by a hyphen. The first number is used to characterize
rounded by intermediate intensity myometrium on all sides. In most
cases, the junctional zone is maintained. Also note, in a the junctional the relationship of the fibroid with the endometrium, the sec-
zone is slightly distorted (green arrow); however, the fibroid does not ond with the serosa [14]. A commonly encountered hybrid
contact the endometrium type is FIGO 2–5, with a < 50% submucosal component
and < 50% subserosal component. Due to size and extent,
treatment includes targeted therapy such as MRg-FUS or
UAE; however, the extent may necessitate hysterectomy. An
example of a hybrid fibroid is shown in Fig. 12.

Discussion

Limitations of the FIGO classification system

While the FIGO classification system has provided clini-

cians with a more standardized framework for describing
Fig. 7  Misclassified FIGO 3 Fibroid. 35-year-old woman with a soli- and characterizing uterine fibroids, significant inter-reader
tary intramural fibroid. Sagittal T2WI demonstrates a 100% intramu-
ral fibroid in the anterior uterine body (white arrow) contacting and variability has been observed between gynecologists and
distorting the endometrium (FIGO type 3) (green arrows). The fibroid radiologists alike when assigning FIGO types. Laughlin-
was initially incorrectly characterized as submucosal, leading to an Tomasso et  al. [22] noted that with increasing size and
unsuccessful attempt at hysteroscopic resection number, classifications became more discrepant among
clinicians, possibly due to distortion of uterine landmarks.
symptoms when they become large. Treatment includes In this study, a significant portion of fibroid misclassifica-
UAE, laparoscopic or open myomectomy, or targeted ther- tions led to improper surgical planning. Because of this, it
apy [11]. Fibroids with ≥ 50% intramural and < 50% subse- may be useful for radiologists to review patients’ MRI of the
rosal components are classified as FIGO 5 (Fig. 8), whereas pelvis with the treating gynecologic team prior to surgical
those with < 50% intramural and ≥ 50% subserosal compo- intervention.
nents are classified as FIGO 6 (Fig. 9).

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Fig. 8  FIGO 5 (≥ 50% intramural, < 50% subserosal) fibroid. a, b multiple additional fibroids including a FIGO 0 prolapsing intra-
T2WI in two different women demonstrating intramural fibroids with cavitary fibroid in b (white arrow). c Coronal T2WI in a 48-year-old
approximately 50% intramural extent (green arrows). Differentiating woman demonstrating a fibroid which is about 60–70% intramural
FIGO 5 from FIGO 6 may be difficult when close to 50%; however, (green arrowhead)
the distinction at this degree may be insignificant. Both women have

Fig. 9  FIGO 6 (< 50% intramu-

ral, ≥ 50% subserosal) fibroid. a,
b Coronal and axial T2WIs in a
67-year-old woman demonstrate
several small fibroids, of which
two are > 50% subserosal (green
arrows). c Axial post-contrast
T1WI with fat saturation dem-
onstrates only mild enhance-
ment of the fibroid in b (green
arrow). d, e Sagittal T2WI and
post-contrast T1WI with fat
saturation demonstrate a small
fibroid at the fundus with > 50%
subserosal extent and only a
small intramural component
(white arrows)

Proposed template Uterine size and number of fibroids

The FIGO classification system for uterine fibroids lends We recommend measuring the uterus in its anteroposterior,
itself well to structured reporting. Incorporating the FIGO transverse and craniocaudal extent, as providing a three-
fibroid classifications into a radiology reporting template dimensional uterine size can be useful in surgical planning
negates the need for radiologists to memorize the specific [12]. Additionally, an estimation of the number of fibroids
types. With the use of pick lists and drop-down menus, a will determine if fibroid resection is feasible and reason-
fibroid reporting template can be set up in such a way that able for symptom control. Providing the size and number
the radiologist can select a fibroid category from a drop- of fibroids may also help gynecologists estimate the likeli-
down menu based on its relationship to endometrium and hood that fibroids are the primary etiology of a patient’s
serosa and the dictation software can be programmed to symptoms and determine the best surgical approach. When
translate the selection into an appropriate FIGO classifica- numerous, consider providing a range of 10 to 20 or greater
tion. A proposed template is provided in Fig. 13. than 20. While it is not necessary to describe every lesion,
a minimum number should be chosen. We suggest describ-
ing up to three dominant non-submucosal and two dominant
submucosal fibroids.

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Location and degree of enhancement

In addition to the FIGO classification, the location of fibroids

within the uterus should be described including laterality
and anteroposterior position within a specific region of the
uterus (fundus, body, lower uterine body). Furthermore,
describing the enhancement pattern relative to the myome-
trium can aid in identifying patients who would benefit from
UAE [9].
Fibroids derive their blood supply mainly from the uter-
ine arteries. An additional supply to the fibroid may come
from the ovarian artery. Time-resolved MR angiography can
be performed to document vascularity of the uterine fibroids
and show parasitized arteries providing flow to fibroids. Vis-
ualization of the ovarian artery implies vascular supply to a
fibroid and can be a cause of treatment failure during UAE,
and therefore, should be mentioned in the report [9].
Fig. 10  FIGO 7—Subserosal pedunculated fibroid. a Sagittal T2WI
in a woman with acute abdominal pain demonstrates a large pedun- Aggressive features
culated fibroid (yellow arrow) arising from the posterior wall of the
uterus with bridging vessels (green arrow). b Axial T2 with fat sup-
pression in the same woman shows mesenteric edema and pelvic
Careful attention should be given to uterine fibroids to
ascites with suggestion of twisting of the stalk (green arrow), con- differentiate from detect malignant lesions such as leio-
cerning fibroid torsion. c Coronal T2WI and d axial post-contrast myosarcoma. Leiomyosarcomas share many imaging fea-
T1WI demonstrate several pedunculated fibroids (yellow arrow) tures with benign leiomyomas, including increased signal
with a thick stalk and bridging vessels (green arrow) and moderate to
marked enhancement (white arrows)
on T2-weighted imaging if cystic or hemorrhagic degen-
eration is present. Misdiagnosing a malignant leiomyosar-
coma as a benign uterine fibroid may be devastating for the
patient, as these tumors generally behave aggressively, with

Fig. 11  FIGO 8—Non-myo-
metrial location. a–c Sagittal
T2WI, axial T2WI, and axial
post-contrast T1WI demonstrate
a small cervical fibroid (green
arrows). The fibroid is only
minimally enhancing (white
arrow)

Fig. 12  FIGO 3–5—Hybrid fibroid. a–c Axial T2WI and post-con- endometrium (FIGO 3—white arrow) and the serosa (FIGO 5—green
trast T1WI and sagittal T2WI in a 31-year-old woman demonstrate arrowhead) representing a hybrid location. Also note the non-enhanc-
a large predominantly intramural fibroid (F). The fibroid contacts the ing cystic degeneration in the posterior aspect (asterisk)

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Fig. 13  Proposed template for

structured reporting of uterine
fibroids using the FIGO clas-
sification system

variable prognosis based on their histologic subtype [26]. contrast administration, leiomyosarcomas typically demon-
Distinguishing features of leiomyosarcoma on MRI include strate early, heterogeneous enhancement on T1-weighted
ill-defined, infiltrative nature of the lesion, irregular mar- imaging. Diffusion sequences may be used in conjunction
gins, rapid growth and areas of internal necrosis [27]. After with T2-weighted imaging to reliably distinguish benign

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Author contributions  All authors contributed to the study conception

and design. Material preparation and image collection were performed
by EG, MLN, and DF. The first draft of the manuscript was written by
EG and all authors commented on previous versions of the manuscript.
All authors read and approved the final manuscript.

Data availability  All data and materials support the published claims
and comply with field standards.

Compliance with ethical standards 

Conflict of interest  The authors declare that they have no competing

interest.

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