Presentation
Primary infertility. Pain and menorrhagia.
Patient Data
Abnormal configuration of the uterine cavity is noted, with elongation of the lower part of the uterine cavity and cervix where its left border is seen splayed over a large soft tissue shadow. A round filling defect is also noted within the upper aspect of the uterine cavity, likely secondary to a submucosal mass.
Delayed filling of both Fallopian tubes is seen; however, displaying normal caliber, with immediate contrast spill noted from the right tube. The left Fallopian tube is splayed over the aforementioned soft tissue shadow with secondary mild contrast spill via its fimbrial end.
The uterus is markedly enlarged by virtue of an encapsulated large fundal interstitial myometrial lesion -corresponding to the HSG soft tissue shadow- eliciting heterogeneous predominantly low T2 signal with areas of high signal seen within; it measures 12.7 x 10.3 x 16 cm along its maximum axial and craniocaudal dimensions respectively and seen reaching up to the L3/4 disc level.
Adjacent, much smaller myometrial interstitial lesions are seen related to the upper part of the lesion, eliciting a low T2 signal.
Courtesy of Baheya Hospital, Cairo.
Case Discussion
Uterine leiomyomas are best diagnosed, assessed, and monitored by US. Pelvic MRI is needed when the fibroid is symptomatic and needs management since it's the most accurate modality in characterizing the lesions. Submucosal ones can also be assessed by hysteroscopy. The main benefit of hysterosalpingography (HSG) in fibroids is as a preoperative assessment of the uterine cavity and the site and size of submucosal fibroids. It also helps assess any concomitant tubal affection especially if the patient seeks fertility (like this patient).
Post-myomectomy HSG may also show any residual fibroid or complications of the surgery such as synechiae.
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