by Paul Indman, MD
Deborah, a 54 year old woman from the Midwest, called stating that her uterus had multiple fibroids which have grown over the last two years, and she wanted to avoid a hysterectomy for personal reasons. She was having regular menstrual periods and lab work (FSH) showed that she was not yet menopausal, and was quite uncomfortable from the pressure of her huge uterus and heavy menstrual bleeding. An MRI was ordered, in which over 30 fibroids were identified. (Sticky post) Read the rest of this entry »
Abby was 37 in 2006, when she came to me with extremely heavy periods.
She felt heavy pressure from her growing uterus, and she was so anemic that she almost needed a blood transfusion. I ordered an MRI, which show too many small fibroids to count. The largest fibroid was only 3.5cm (about 1 1/2 inches) and the uterus was like a big bag of small marbles. I did office hysteroscopy to look directly inside the uterus, and this confirmed that there were numerous submucous myomas on the inside of the uterus as well as in the walls.
Photo shows “too numerous to count” small fibroids. Read on to learn about Abby’s decision making process. Read the rest of this entry »
Those who have been following this blog know that accurate diagnosis is the most important aspect of planning treatment.
I have explained the importance of hysteroscopy for seeing directly into the uterus, but fewer than 10% of OB/GYN’s in the US are equipped to do hysteroscopy in an office setting. I’m hoping to change that. Last year I was approached by an engineer with a video camera the size of a pinhead, asking how we could use it in gynecology. Together, we developed a small portable hysteroscope. It consists of a small reusable handle with a screen the size of a smartphone, coupled to a sterile single-use hysteroscope utilizing a built-in high resolution camera integrated with light source.
Current hysteroscopes require an investment in thousands of dollars of equipment, including a light source, video camera, and video monitor. Care and sterilization of instruments, and setting up for hysteroscopy are time consuming and often do not fit into the schedule of a busy office. As a result, most women who need hysteroscopy are taken to the operating room, at much greater expense and inconvenience. My goal is to enable every gynecologist to do office hysteroscopy. It is important to note that this instrument currently has investigational status and has not been cleared by the FDA for commercial use.
I have been using this hysteroscope as part of an investigational study. If you would like to learn more about this, I was recently interviewed by Hope Waltman, at OBGYN.net. The following link to the interview also has a link to a video of using the hysteroscope during a clinical trial in my office. Interview at
Note: Full disclosure: I am a co-founder and shareholder in the EndoSee Corporation, which is developing the hysteroscope. — Paul Indman, M.D.
Shortly after posting Michelle’s story (below) and family picture she sent me the following note. I thought it best to share it directly. — Paul Indman, M.D.
One correction that Dr. Indman may/not choose to make to the story (I think it’s important) is that I was not originally referred to him by my OB after a trip to the ER. My OB did not help me at all after that trip to the ER, so Derek [Michelle’s husband] found Dr. Indman on-line (we wanted a second opinion from someone who was an expert on fibroids). I think it’s important because the doctor I was using at the time basically sent me on my way with bleeding so severe I couldn’t even stand up without losing large amounts of blood. Dr. Indman not only immediately correctly diagnosed the problem, he helped me solve it while preserving my fertility options.
I first saw Michelle when she was 35 in 2005. She had her first myomectomy at the age of 26 and her second at the age of 33. She was sent to me by her Ob-Gyn after an ER visit for severe bleeding.
I did an ultrasound on the first visit, and there was fluid in the uterus which outlined a large submucous fibroid. The bulk of the fibroid was in the wall rather than inside the cavity of the uterus. Because of the location I felt hysteroscopic treatment was inadviseable. Although we were concerned because she already had two abdominal myomectomies (elsewhere), I did her third myomectomy.
I did an ultrasound in September, 2006 showing a healthy 10 week prgnancy. Michelle delivered her first son by cesarean in 2007. Her OB noticed some scar tissue inside her uterus at the time. I later did an office hysteroscopy to clear this and a small amount of retained placental tissue and treat the scar tissue. In October, 2010, she returned with another healthy early pregnancy.
Comment: Michelle came in today with her 4 year old son, her 4 month old baby, and a picture of them taken when he was just born. Even if you have had prior surgery don’t give up hope without seeing an expert in the treatment of fibroids.
Aisha was 38 when I saw her in 2007 with a long history of infertility and fibroids making her look 5 months pregnant. She underwent a myomectomy in which 31 fibroids were removed. She had a normal pregnancy and delivered a healthy boy by cesarean. She recently came in with her 16-month old son.
When I originally saw her her uterus was the size of a 20 week pregnancy. An MRI showed multiple fibroids. She underwent a myomectomy to remove the fibroids.
Her uterus, before the removal of fibroids, and the fibroids that were removed are shown below.
Now, four years after her myomectomy and successful pregnancy her uterus is normal size.
Comment: Some of my most satisfying moments as a gynecologist are seeing women who thought there was no hope for having children come in with their babies. — Paul Indman, M.D.
Medical Journal Article
Tranexamic Acid Treatment for Heavy Menstrual Bleeding
Andrea Lukes et al.: Obstet Gynecol. 2010 Oct;116(4):865-75.
Tranexamic acid has been used around the world for over 20 years to treat heavy menstrual bleeding. It was recently approved by the FDA in the U.S., and is sold under the trade name LYSTEDA™. In this study 196 women were randomized to receive either LYSTEDA™ or a placebo (sugar pill). 36% of women in each group had fibroids. Menstrual blood loss was measured before any medication and after taking either LYSTEDA™ or the placebo. Read the rest of this entry »
A 43 year old woman came to me with irregular bleeding despite being on birth control pills. She had a Mirena® IUD inserted previously, which failed to stop her irregular bleeding. We did an office hysteroscopy, and saw the IUD resting on the fibroid.
The IUD was removed. Since she was not planning any more children, we removed the fibroid by hysteroscopic myomectomy, and did an endometrial ablation at the same time as an outpatient procedure.
Comment: The Mirena® IUD (LNG-IUS) is often effective in treating heavy periods, but a fibroid inside the cavity can interfere. I always recommend doing a simple ultrasound exam in women with abnormal bleeding before deciding on a treatment. Other studies such as diagnostic hysteroscopy may also be done, as only with proper diagnosis can appropriate treatment be planned. In her situation a simple outpatient procedure was able to solve her bleeding problem.
Dr. Indman performed two procedures for me at the same time – a hysteroscopic myomectomy and an endometrial ablation. From the pre-op to post surgery, I did not experience any pain or a single cramp. I was back to work the next day and back on my regular workout schedule within two weeks. After three weeks, I went on a cycling vacation and rode 350+ miles over hilly terrain. I felt great! Without the surgery, there was no possible way I could have done this. For the first time in 1 1/2 years, I am not experiencing heavy bleeding and checking where the nearest bathrooms are.
My experience with Dr. Indman and his staff have been nothing short of fantastic. Dr. Indman is a warm, caring, highly skilled surgeon – with a fun sense of humor to boot! He is one of those rare gems in the medical profession today – someone who truly puts patients first. I found Dr. Indman while researching my symptoms on the Internet. The wealth of helpful information on his website gave me a lot of confidence even before I met him. His deep expertise and decades of experience are evident from his thorough examinations and explanations. — S.K.
Comment: S.K. had a submucous fibroid, which was treated by hysteroscopic myomectomy and endometrial ablation as an outpatient. Here are actual pictures from her surgery. The first shows the fibroid on the right side of the uterus, with the loop that will be used to remove it. The second shows the fibroid having been removed, and the third is after endometrial ablation. I do the endometrial ablation under direct vision to be sure that no areas are missed.
It is not unusual for women to resume most normal activities within a day or two. Careful patient selection and utmost skill are required for a safe and successful procedure. — Paul Indman, M.D.
Update: 12/14/2010: S.K. came in for a 4 month check after her procedure, having recently run a marathon. She said that she kept thinking that without the surgery running a marathon would have been impossible.
I suffered for many years with uterine fibroids and experienced very heavy bleeding during periods. I was very fearful about having the surgery, and was very concerned I may lose my uterus. I met Dr. Indman through a referral, and was very impressed with his professionalism, compassion, experience and successful track record with this type of surgery. I felt like he really cared about me as a person and cared about my concerns. Read the rest of this entry »