Diagnostics

Ultrasound pelvis

• Most appropriate initial test for all patients with a suspected uterine leiomyoma

• Supportive findings

  • Well-circumscribed hypoechoic solid mass

  • Calcifications and/or cystic areas due to degeneration

  • Mass effect (e.g., hydronephrosis) may be seen in patients with large leiomyomas.

Neither plain radiography nor CT is recommended in the workup of leiomyomas because of poor visualization (unless calcified).

• Sonohysterography: to further evaluate endometrial abnormalities detected on ultrasound

  • Can distinguish between endometrial polyps and submucosal leiomyomas

  • Used to characterize submucosal leiomyomas (e.g., before interventional procedures or surgery)

• MRI pelvis without and with IV contrast

  • Helps further characterize leiomyomas (e.g., before interventional procedures or surgery)

  • Can rule out comorbid conditions or differential diagnoses of uterine leiomyomas

Although imaging cannot definitively distinguish between a leiomyoma and a leiomyosarcoma, hypervascularity within a solitary heterogeneous uterine mass should raise suspicion for a leiomyosarcoma.

• Routine initial studies

  • CBC: to assess for anemia

  • BMP: to assess renal function

  • Urine pregnancy test: if patient is of childbearing age

• Studies to evaluate abnormal uterine bleeding [11]

  • PT, PTT, fibrinogen

  • Diagnostic studies for von Willebrand disease

  • Consider TSH and liver enzymes if clinically indicated.

• Macroscopic

  • Grayish-white surface

  • Homogeneous; tissue bundles on cross-section partly in a whorled pattern

  • Some leiomyomas may involve regressive changes: scar formation, calcification, and cysts

• Microscopic: Smooth muscle tissue in a whorled pattern with well-demarcated borders, consisting of monoclonal cells interspersed with connective tissue