Which imaging modalities are recommended for the assessment of uterine fibroids in primary care?

In primary care, the recommended imaging modality for the assessment of uterine fibroids is pelvic ultrasound, with a preference for transvaginal ultrasound when feasible, as it provides better visualization of the uterus and fibroids. Pelvic ultrasound is advised particularly if the uterus is palpable abdominally, there is a history or examination suggesting a pelvic mass, or if the examination is inconclusive or difficult, such as in women who are obese. Transvaginal ultrasound is also preferred for women presenting with heavy menstrual bleeding and symptoms suggestive of adenomyosis or a bulky, tender uterus on examination. If transvaginal ultrasound is declined or unsuitable, transabdominal ultrasound or MRI may be considered, although MRI is not recommended as a first-line diagnostic tool in primary care due to cost and availability constraints. MRI may be reserved for specialist assessment when the diagnosis is uncertain or when detailed information on fibroid size, number, position, and vascularity is required before planned surgery. Hysteroscopy is generally arranged by specialists to identify submucosal fibroids rather than as a primary care investigation. This approach aligns with UK NICE and CKS guidelines emphasizing ultrasound as the first-line imaging modality in primary care, with MRI and hysteroscopy reserved for specialist use. Recent literature supports this imaging hierarchy, highlighting ultrasound as the initial and most accessible modality for fibroid assessment, with MRI providing complementary information in complex cases (Expert Panel on GYN and OB Imaging et al., 2022) ¹[(Expert Panel on GYN and OB Imaging et al., 2022)].