Key Points

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• The major purpose of patient evaluation is to determine the presence or absence of leiomyomas, the potential relationiship of tumors identified to symptoms, and, when thought to be a cause of the symptoms, to assist in the determination of the best approach to management.
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• While manual examination can provide an estimate of the size of the uterus, and suggest that enlargement is secondary to leiomyomas, many of the submucous leiomyomas that cause symptoms such as infertility and heavy menstrual bleeding are not detected by palpation.
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• Uterine imaging is necessary to make or confirm the diagnosis and provide the detail regarding size, number, and location, with respect to the endometrium and serosa, necessary to determine the likely contribution to symptoms, and the potential utility of image-guided and other surgical procedures.
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• X-Ray and CT scanning have almost no utility in providing the information needed to aid the gynecologist in managing women with leiomyomas; even hysterogram has limited utility.
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• Ultrasound-based techniques provide the best combination of accessibility, cost, and utility for evaluating women with and for leiomyomas; MRI can provide detail regarding serosal relationships, that may be difficult to consistently obtain with ultrasound.
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• Sonohysterography, with saline or gel contrast injected transcervically into the endometrial cavity, is a safe and effective technique for distinguish amongst Types 0, 1, 2, and 3 leiomyomas in particular, and one that can be easily and comfortably performed in an office setting.
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• 3-D ultrasound, including 3-D sonohysterography can provide impressive images, that can be stored for another reader, but their utility may not be ultimately superior to 2-D techniques.
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• Transabdominal ultrasound (TAUS) is necessary for the evaluation of the uterus when leiomyomas expand the volume above the pelvic brim,  beyond the usual limits of TVUS.  In such instances, TAUS has limited value for the evaluation of the endometrium. TAUS is necessary when TVUS cannot usually be performed such as in virginal women or those otherwise unable to tolerate an intravaginal transducer.
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• MRI is an approach useful when transvaginal techniques are not feasible, or when ultrasound is inadequate for evaluation, particularly for determining the presence and dimensions of the outer free margin of a submucous leiomyoma.
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• Increased fibroid density may occur, particularly in the presence of calcification. The role of ultrasound-based elastography to identify fibroid density is undergoing evaluation.
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• When the leiomyomas are thought to contribute to the symptom of heavy menstrual bleeding HMB, it is important to evaluate iron status and for the presence of anemia. 
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• When the symptom is AUB, it is important, in appropriate individuals, to evaluate the endometrium for the presence of EIN (endometrial intraepithelial neoplasia, sometimes described as endometrial hyperplasia with atypia).
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• While leiomyosarcoma is very rare (probably less than 1/7,000) it is very difficult to make this diagnosis preoperatively. There are some epidemiological and imaging criteria that may be used to identify higher risk women. Age related risk and leiomyomas diagnosed and growing post menopausal.
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