Count, size and FIGO-classify each fibroid — submucosal (0–2), intramural (3–4), subserosal (5–7), other (8) — because the class decides hysteroscopic, laparoscopic or embolisation treatment; and look for the features that are not a typical fibroid.
Orient first
- FIGO PALM-COEIN leiomyoma subclassification 0–8 by relation to the cavity and serosa.
- Degeneration (hyaline, cystic, red, calcific) changes the appearance; red degeneration is painful in pregnancy.
- Leiomyosarcoma cannot be reliably excluded by imaging; rapid growth after menopause, irregular margins, restricted diffusion and haemorrhage raise concern.
Acquire the study
- Transvaginal probe with transabdominal survey; 3D coronal view of the cavity where available; colour Doppler.
The manoeuvre
- Each fibroid: location, size in mm in three planes and FIGO type from its relation to the endometrium and serosa.
- Endometrium: distorted cavity; submucosal fibroid protrusion percentage.
- Colour Doppler: circumferential peripheral flow (fibroid) vs flow crossing the lesion (adenomyosis).
- Uterine volume and ovaries.
What confirms it
- Well-defined myometrial masses with typical features, each classified.
What licenses you to exclude it
- Atypical features (irregular margins, haemorrhage, marked restriction, growth after menopause) prevent calling a lesion a simple fibroid.
The classic misread
- Counting a pedunculated subserosal fibroid as an adnexal mass — find the bridging vessel.