Imaging Surveillance for Uterine Fibroid Growth
There is no established consensus on routine imaging surveillance for asymptomatic fibroids, but imaging should be performed when symptoms develop, when considering treatment, or in specific high-risk scenarios such as postmenopausal women with fibroid growth. 1
Asymptomatic Fibroids: No Routine Surveillance Needed
- Currently, there is no specific consensus on imaging surveillance of asymptomatic patients with fibroids. 1
- Expectant management is recommended for asymptomatic patients because most fibroids decrease in size during menopause. 2
- If fibroids are small and not causing symptoms, they do not require treatment or routine imaging follow-up. 3
When to Image for Fibroid Growth
Clinical Scenarios Requiring Imaging:
Development of New Symptoms:
- Obtain imaging when patients develop abnormal uterine bleeding, menorrhagia, pelvic pressure, urinary frequency/urgency, bowel dysfunction, or pelvic pain. 4, 2, 5
- New or worsening symptoms warrant reassessment with transvaginal ultrasound (TVUS) combined with transabdominal ultrasound (TAUS). 1
Postmenopausal Women - High Priority:
- Postmenopausal women with fibroid growth or persistent abnormal uterine bleeding require urgent imaging evaluation due to increased suspicion for malignancy (leiomyosarcoma). 6, 7
- This is a critical clinical scenario where imaging cannot be deferred, as sarcomatous change, though rare, is normally associated with rapid growth in this population. 3
Pregnancy:
- Initial ultrasound should document number, size, location, and any uterine cavity distortion. 8
- Follow-up ultrasound should be performed in the third trimester (≥32 weeks) to reassess fibroid size, evaluate fetal growth, and detect complications. 8
- Additional ultrasounds are indicated if significant fibroid growth occurs between scheduled examinations. 8
Pre-Treatment Planning:
- Image when considering any intervention (medical, surgical, or minimally invasive procedures) to establish baseline size, number, location, and vascularity. 1
- Fibroid vascularization assessed by 3-D TVUS with power Doppler correlates with fibroid volume and predicts growth rate per year, which is helpful in clinical decision-making. 1
Post-Treatment Surveillance Timing
After Uterine Fibroid Embolization (UFE):
- Most studies evaluate patients immediately, at 3 months, and/or 12 months after treatment, though routine posttreatment surveillance remains controversial. 1
- Most fibroid size reduction occurs within the first 6 months, with continued decrease between 6 and 12 months. 1
90% fibroid infarction on postcontrast imaging correlates with better symptom control and fewer reinterventions. 1
Symptomatic Post-Treatment Patients:
- Image immediately if patients develop pelvic pain or fever post-UFE to evaluate for complications (infection, hemorrhage, pelvic venous thrombosis). 1
Preferred Imaging Modalities
Initial and Surveillance Imaging:
- Combination of TVUS and TAUS is the most useful and cost-effective modality for initial evaluation and surveillance. 1
- TVUS has 90-99% sensitivity for detecting fibroids and 90% sensitivity/98% specificity for submucosal fibroids. 1, 6
When MRI is Indicated:
- Use MRI with gadolinium-based contrast when malignancy is suspected, for complex cases, or for detailed pre-treatment mapping. 1, 6
- MRI with diffusion-weighted imaging and ADC values improves diagnostic accuracy for distinguishing fibroids from sarcomas (83-88% sensitivity, 97-100% specificity). 1, 6
Critical Pitfalls to Avoid
- Do not ignore fibroid growth in postmenopausal women not on hormone replacement therapy - this requires urgent evaluation for malignancy. 6, 7
- Conventional MRI alone cannot accurately differentiate fibroids from sarcomas; diffusion-weighted imaging with ADC values must be incorporated. 1, 6
- Avoid routine surveillance imaging in asymptomatic patients, as this is not supported by evidence and increases healthcare costs without proven benefit. 1