Uterine and Adnexal Tenderness in Fibroids

Presentation and Diagnosis

Menorrhagia is the most frequent symptom of uterine fibroids, often resulting in iron deficiency anemia, according to the American College of Radiology 1
Physical examination findings in uncomplicated fibroids include an enlarged, irregularly contoured uterus that is typically non-tender on bimanual pelvic examination, as recommended by the American College of Radiology 1
Fibroid degeneration presents with severe sudden-onset pain, fever, nausea, and leukocytosis, and requires supportive care with NSAIDs and observation, as stated by the American College of Radiology 1
Torsion of pedunculated fibroid can occur, and would present with acute pelvic pain and tenderness, requiring imaging to differentiate from ovarian torsion, according to the Journal of the American College of Radiology 2, 3, 4

Bilateral adnexal masses with tenderness are seen 82% of the time in Pelvic Inflammatory Disease (PID) versus only 17% in other diagnoses, as reported by the Journal of the American College of Radiology 5, 6
Transvaginal ultrasound findings in PID include wall thickness >5 mm, cogwheel sign, incomplete septa, and cul-de-sac fluid, with Power Doppler showing hyperemia and lower pulsatility index, according to the Journal of the American College of Radiology 5, 6
Adnexal torsion is characterized by unilaterally enlarged ovary with central afollicular stroma and peripheral follicles, with ultrasound having 79% sensitivity and 76% specificity for diagnosis, as stated by the Journal of the American College of Radiology 5, 6
Tubo-Ovarian Abscess (TOA) is a complex cystic mass with thick enhancing walls and loss of normal anatomic boundaries, with ultrasound sensitivity of 93% and specificity of 98%, according to the Journal of the American College of Radiology 7, 4

Transvaginal and transabdominal ultrasound with Doppler is the initial imaging modality when evaluating tenderness in a patient with fibroids, as recommended by the Journal of the American College of Radiology 7, 5, 6
MRI with contrast should be considered if ultrasound is inconclusive, with 86% sensitivity for fibroid degeneration based on lack of contrast enhancement, according to the Journal of the American College of Radiology 4

New-onset tenderness should not be attributed to pre-existing fibroids without excluding complications or alternative diagnoses, as stated by the American College of Radiology 1
Large fibroids can displace normal ovaries, making them difficult to visualize on ultrasound, and careful search with identification of bridging vessels from uterine arteries helps confirm fibroid origin, according to the Journal of the American College of Radiology 2, 3, 9
Rapid fibroid growth with tenderness in postmenopausal women should raise suspicion for malignant transformation (leiomyosarcoma), though rare, and warrants urgent referral, as recommended by the American College of Radiology 1, 8