Uterine Fibroids Blog — An Expert Speaks Out

March 9, 2010 a 46 year old woman came to me having been told that she needs a hysterectomy because of heavy bleeding from her fibroid. She wanted to know her options.  Ultrasound showed a tennis ball size fibroid that was 2/3 in the uterine wall and 1/3 in the cavity of the uterus. We confirmed the ultrasound by doing an office hysteroscopy, where we could see the fibroid protruding into the cavity. Read on to learn about her options and see photographs of her treatment. Read the rest of this entry »

A 37 year old woman came to me in July, 2009 with a prolapsing 8 cm. fibroid. She had been seen by her HMO doctors multiple times for heavy bleeding, had 15 ultrasounds, but nothing was done.  An MRI showed an 8 cm. (grapefruit size) fibroid low in the uterus which appeared to be prolapsing (coming out of) through the cervix.  Since she wanted another child, she did not want to have a hysterectomy, which was the only option she was given.

On exam, I could feel the fibroid coming through the cervix and filling the vagina.  Most of the time prolapsing fibroids can be removed vaginally.  Continue to see photos of her surgery.  Read the rest of this entry »

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 »

At the time I was starting this blog two patients with similar fibroids came to see me. Both were severely anemic, and one was hemorrhaging and in shock.
Before any procedure was done I received both patients’ permission to share their stories.  At the time of the initial writing one had treatment 6 weeks ago and one 3 weeks ago.  Neither of their experiences to date are necessarily typical, but I am following through on my commitment to share their stories.

Comment:   (Updated 6-17-2010)

Yesterday was a difficult day. We did surgery on my first patient (who had the embolization) and found a high-grade sarcoma (cancer) which had spread throughout the abdomen. I talked to her about deleting her story, but she was comfortable with leaving it in.  Uterine sarcoma is very uncommon, being seen in fewer than 1 in 500 rapidly growing fibroids. The risk of cancer is much lower for fibroids that are not rapidly growing. Benign fibroids have never been shown to undergo malignant change.

Could this have been diagnosed earlier, and if so would it have made a difference? Probably not.  There is a single study in which a blood test coupled with a special MRI done with IV contrast rapidly infused differentiated between sarcoma and fibroids.  To my knowledge this has not been confirmed by other studies, and by the time the tumor can be diagnosed there is a high probability that it would have already spread.

It is easy to overreact and be overly aggressive in removing fibroids because of the fear of cancer, which is in fact rare. We would be doing hundreds of unnecessary surgeries to find a single sarcoma.  Yes, had she chosen myomectomy or hysterectomy, we would have diagnosed her sarcoma two months earlier, but it is unlikely that the outcome would be different.  I was tempted to remove this story for fear that it would frighten women into surgery that is not needed.  But I promised to tell the story as it is.  Please understand that this is very unusual, and most women do well when embolization is done in appropriate situations.  — Paul Indman, M.D

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Uterine fibroids that are completely or partially inside the cavity of the uterus (submucous myomas) can often be removed through the cervix by using an instrument called a resectoscope. A resectoscope is a special kind of hysteroscope that uses a loop powered by high-frequency electrical energy to cut through the fibroid.  Since the instrument goes through the cervix, no incision is necessary.  This is usually done as an outpatient, and recovery typically requires a day or two until most normal activity can be resumed.

Selection of patients for whom hysteroscopic removal of fibroids is appropriate is one of the most important factors in obtaining good results. Factors to consider are the size and number of fibroids, location, the percentage that is in the cavity and percentage that is in the wall (intramural) or the uterus, the possibility that other intramural or subserous myomas would remain, and the desire for future pregnancy are some of the factors that must be considered.

Fibroids that are entirely inside the uterine cavity are the easiest to resect, and a very experienced gynecologist may be able to resect these up to 5 cm. (2 inches) in diameter.  Most submucous fibroids are partially in the wall of the uterus.  The illustration above shows a fibroid that is about 2/3 in the cavity and 1/3 in the wall.  During the process of resecting this the uterus often contracts, squeezing out the portion that is in the wall, and allowing more complete removal.

The photo below shows a large fibroid that is over 50% in the wall, as determined by MRI.  This is the most difficult type of fibroid to remove hysteroscopically, especially if it is toward the top of the uterus.

The loop is used to resect the fibroid, bite by bite, (photo on the left) until it is level with the surface.  In this case a special medication was used to help the uterus contract so virtually all of the fibroid could be squeezed into the cavity,  allowing me to completely remove it.  The right photo shows the “shell” of where the myoma was.  This will cover over with endometrium (the lining of the uterus).  When we look at this area in several months with office hysteroscopy we won’t even be able to see where the fibroid used to be.

Comment:  This last example pushes the limits of hysteroscopic myomectomy. This woman ended up with a normal uterine cavity, with no adhesions (scar tissue).  When this type of procedure is considered in a woman wanting to become pregnant,  much experience is needed to determine whether hysteroscopic treatment will leave a normal cavity or will cause permanent scarring and infertility.  Hysteroscopic removal of all but the simplest submucous fibroids should only be done by a gynecologist with extensive experience in hysteroscopic surgery. I will have more about hysteroscpic myomectomy in time to come.

In order to evaluate uterine fibroids, we need to know what is on the inside of the uterus.  Many times ultrasound (or saline enhanced ultrasound) or MRI will provide the information we need.  Many women are subjected to endometrial biopsy which is good to rule out cancer, but useless in diagnosing submucous fibroids and polyps.  Fortunately it is easy to look directly into the uterus using a thin telescope called a hysteroscope.

With today’s tiny instruments, it usually only takes a few minutes to do office hysteroscopy using local anesthesia, and most women report little discomfort.  First I numb the cervix, which is hardly noticeable.  Saline is used to fill the uterus so we can see, and a thin flexible or regular hysteroscope is inserted through the cervix under direct vision.  I encourage my patients to watch on the video monitor so they will have a better understanding of what is going on inside her own uterus.  If someone is extremely anxious she can have something to help her relax during the procedure, but the vast majority of women do not need this and can go about their normal activities for the rest of the day.

Hysteroscopy compliments other diagnostic studies, so that when we decide on a treatment plan we know exactly what we are treating, and don’t wind up with any surprises.

The photo below shows an actual view from an office hysteroscopy.  You can clearly see the submucous fibroids on the back wall of the uterus.  This type of fibroid can easily be removed (by an gynecologist experienced in this type of surgery) in an outpatient procedure called hysteroscopic resection of fibroids.

The next photo shows a large submucous fibroid at the beginning of hysteroscopic resection of the fibroid.  The loop seen is what will be used to remove (resect) the fibroids.

Comment: I feel that for a gynecologist, doing hysteroscopy in the office is as basic as an ear doctor being able to look into an ear in the office.   What would you do if you saw a doctor for an earache and he or she wanted to schedule you for surgery so they could look in your ear?  Yet only 10% of gynecologists in the U.S. (who are supposedly specialists in treating the uterus)  do office hysteroscopy.  I see too many women taken to the operating room whose surgery is abandoned because submucous myomas had not been diagnosed by surgeons not prepared to treat them.  And many of these women are told that they need a hysterectomy because the gynecologist is not experienced in hysteroscopic treatment of submucous fibroids.  I’ll have much more in detail about hysteroscopic treatment of submucous fibroids in upcoming posts!

A  47 year old woman with “rapidly growing uterine fibroid”. P.D.M.  contacted us because she was told she had a rapidly growing fibroid.  She wanted to avoid a hysterectomy, but in her home state of Wyoming was only offered hysterectomy with removal of both ovaries because of the possibility of cancer.  Several years ago she was noted to have a small myoma on ultrasound, but it appears to have grown rapidly in the last year.  She noticed some pelvic pressure but no abnormal bleeding.

When she contacted my office we suggested that she get an MRI, which showed a 10 cm. (4 inch) mass in the uterus will cystic (fluid filled) areas (which are white), suggesting a degenerating fibroid.  (This is a fibroid that has outgrown it’s blood supply.)  Her MRI is shown to the left.

We discussed options, and the very low risk that this could be cancer.   With that knowledge, she chose to come for a myomectomy.

P.D.M.’s myomectomy is shown in the photographs.  An incision was made that was smaller than the fibroid, but it was possible to remove the fibroid through this incision.

Once the fibroid was partially removed it was possible to lift the uterus through the incision to aid in removing the fibroid entirely.

Here is the removed fibroid, which has been cut open to show the fluid filled areas.

The pathology report showed a benign degenerating uterine fibroid.

She left the hospital on the second day after surgery, and was able to return to Wyoming the following week.

Dr. Indman’s Comment:  P.D.M. was advised to have a hysterectomy because of concern that she may have had Leiomyosarcoma, or malignant fibroid.   A sarcoma is serious, but fortunately they are uncommon.  There is no evidence that benign fibroids can become malignant.   One large study has shown the risk of cancer in rapidly growing fibroids to be 0.26%, or about 1 in 400.   As 70-80% of women have fibroids (although many are too small to notice), and malignant fibroids are rare, it is hard to justify removing most fibroids or doing a hysterectomy because of the possibility of cancer.    In my patient’s situation the fibroid was growing rapidly and causing symptoms, so she chose to have it removed.

The decision to remove the fibroid or do a hysterectomy in a 47 year old woman who is not planning to have children is personal, and there are advantages and disadvantages to each approach.  In the very unlikely chance that a malignancy is found, a hysterectomy would of course be necessary.  On the other hand, we would be doing hundreds of hysterectomies for benign fibroids to find one that had cancer.  In addition,  I would strongly recommend against taking out her ovaries, as the increased risk of heart disease, osteoporosis, and other problems outweigh the risk of later developing ovarian cancer.

I feel that my role is to explain all of the reasonable options available to women, and help them make the best decision for their own lifestyle.  As P.D.M.  felt emotionally that she wanted to keep her uterus, and there was no medical need for a hysterectomy.    The fibroid was easily removed while leaving her uterus.

Read what P.D.M. writes about her experience!

Intramural and subserous fibroids can be removed through an incision in the abdomen, similar to a cesarean section.  There is no limit to the size or number of fibroids that can be removed this way. This is done in a hospital and usually requires a one or two night stay.

Blood loss and Myomectomy

Typically there is little blood loss when a myomectomy is done by an expert surgeon. There are a number of ways to decrease blood loss, including medications to constrict blood vessels and the use of a laser or other instruments to seal blood vessels.   In doing a myomectomy extensive experience will help the surgeon find the plane between the fibroid and the myometrium (the wall of the uterus) to avoid shredding the wall.   Although the need for blood transfusions is low, women with very large fibroids may bank some of their own blood ahead of time.

What is the risk of waking up and finding I had a hysterectomy?

So far I have never gone into surgery with the intent of doing a myomectomy in a women of childbearing age and found it necessary to do a hysterectomy.  In the rare situation where an obvious cancer is found, a hysterectomy would be necessary, but the risk of this is probably under 1 in 1000.  On the other hand, I have had women ask me next next day if I thought that they should have had a hysterectomy because of severe endometriosis or other disease.  It is important to have a clear understanding with your physician before surgery about what, if any conditions you would elect to have a hysterectomy. Fortunately many of these conditions, such as adenomyosis, can be diagnosed by MRI so they can be discussed before surgery to avoid any surprises.

Can any gynecologist do a myomectomy?

Yes and no.  Most OB-GYN’s spend most of their time doing obstetrics, and don’t do this type of surgery on a regular basis.  Many residencies provide little training and experience in doing myomectomy.  I’ve seen number of women who have had surgery (several at major university hospitals) with the intent of having a myomectomy only to be told the fibroid was too close to big blood vessels to be removed.  In all of these cases did I was able to do myomectomy, but it is unfortunate that the women had to have an additional surgery.  I would be very nervous if a doctor tells you he or she will try to do a myomectomy.  The risk of needing a hysterectomy in experienced hands should be less than 1 in 100.

What is the recovery time for an abdominal myomectomy?

Having been involved in laparoscopic as well as conventional surgery for over 30 years, I have been amazed in how much more important the attitude of the patient is than the size of the incision in determining recovery time.   I did an abdominal myomectomy on one of the busiest doctors in town, and she was back to full time practice in two weeks.  Most women will take a month off work that doesn’t involve strenuous physical activity, but it will take longer to feel 100% recovered.

What are the advantages and disadvantages of an abdominal myomectomy

The biggest advantage of the abdominal approach is that the surgeon can actually feel the uterus.  This helps with locating deep fibroids, and when there are many smaller fibroids makes it less likely that they will be left behind.  It is also possible to do a more precise repair of the uterus, especially when large or deep fibroids have been removed.  On the other hand, when fibroids are on the surface (subserous or pedunculated) and not too large, a laparoscopic or robotic approach may be worthwhile.  In general I will approach large, deep, or a large number of  fibroids abdominally.  If there are a small number or the fibroids are not to large, I will consider a laparoscopic or robotic myomectomy if they need to be removed at all.  Fibroids that are mostly inside the cavity can often be removed by hysteroscopic resection.   The most important consideration is what technique will give the best result in the long run. For a woman who wants to have a baby, whether or not she is able to have a child is far more important than an extra few weeks of recovery time.  It is important to consult a gynecologist with experience in all methods of myomectomy to help you decide on the best approach.

Below are photographs of an actual myomectomy

	Abdomen is distended by her uterus which is the size of a 20 week pregnancy.  The uterus is up to her belly button.
	The uterus, which is enlarge by the fibroid, is lifted through the incision.  (It is still attached).  A laser is being used to make an incision through the myometrium down to the fibroid.
	The fibroid is being separated from the wall of the uterus (myometrium).  It is very important to do this in the exact location between the fibroid and the myometrium in order to prevent excess bleeding.
	The fibroid is almost complete free from the uterus.  An electrosurgical device is being used to seal blood vessels.
	The uterus is being reconstructed by suturing the walls together with dissolving suture.  This is being done in multiple layers to ensure a precise repair.
	The last layer of sutures is placed, and the uterus is completely restored.  A barrier to prevent adhesions will be placed before the uterus is replaced into the abdomen and the abdomen closed.

I’ll be posting many more photos of abdominal, laparoscopic, robotic, vaginal, and hysteroscopic myomectomy.  Sign up for email updates and you will be notified any time the site is updated!

Laparoscopic Myomectomy uses a small telescope placed through the belly button along with several small instruments to remove fibroids from the uterus.  The technique of actually removing the fibroid from the uterus is similar to that of an abdominal myomectomy except we use small instruments placed through the abdominal wall. Once the fibroid is freed from the uterus it needs to be removed from the abdomen.  In order to remove a large fibroid from a small incision we use an instrument called a morcellator, to cut it into pieces small enough to be removed through the small incisions.

The more superficial a fibroid is the easier it is to remove laparoscopically.  Pedunculated fibroids are the easiest.  Care must be taken not to damage the underlying myometrium (the wall of the uterus) with energy used to seal the blood vessels, as rupture during pregnancy has been reported when this happened.  Deep fibroids that protrude into the cavity of the uterus (submucous myomas) are the most difficult to take out laparoscopically.

The advantage of laparoscopic surgery is that a larger incision is replaced by several smaller incisions.  Recovery is generally faster than if a regular incision is made, but this can vary.  There are some disadvantages of laparoscopic surgery, also.  Taking out large fibroids can take much longer when done through a laparoscope.  It is more difficult to take out a large number of fibroids.  It may not be possible to get as good of a repair for large or deep fibroids.  This would be more important for women desiring fertility.  The question you should ask is not if a laparoscopic myomectomy can be done but if it is best for your individual situation.

Comment:  One of my colleagues assisting me in a difficult laparoscopic surgery asked me when would I do a laparotomy (make a regular incision.) My answer was that I do the type of surgery that will obtain the best results. If I can obtain just as good results through the laparoscope I will do the procedure that way. But if I feel I can do a better job through a regular incision, then I will recommend that approach. When someone looks back years after surgery, the quality of surgery inside will be far more important than recovering 1 or 2 weeks earlier. — Paul Indman, M.D.

Uterine Fibroids are classified by their location (see figure), which effects the symptoms they may cause and how they can be treated.  Fibroids that are inside the cavity of the uterus ( Submucous myomas) will often cause bleeding between periods and often cause severe cramping.  Fortunately, these fibroids can usually be easily removed by a method called “hysteroscopic resection,” which can be done through the cervix without the need for an incision.  Some submucous myomas are partially in the cavity and partially in the wall of the uterus (see illustration below).  They  too can cause heavy menstrual periods (menorrhagia), as well as bleeding between periods.  Many of these submucous fibroids can also be removed by hysteroscopic resection.

Intramural myomas are in the wall of the uterus, and can range in size from microscopic to larger than a grapefruit.  Many intramural fibroids do not cause problems unless they become quite large.  There are a number of alternatives for treating these, but often they do not need any treatment at all.

Subserous myomas are on the outside wall of the uterus, and may even be connected to the uterus by a stalk (pedunculated fibroid.) These do not need treatment unless they grow large, but those on a stalk can twist and cause pain.  This type of fibroid is the easiest to remove by laparoscopy.

While the above illustration shows small fibroids that are only in one area of the uterus, when fibroids get large they can take up the entire wall.  In that case the outer part of the fibroid may be subserous, the middle part intramural, and the inner part submucous.  The illustration to the right shows a fibroid that is partially intramural and partially submucous. This fibroid would be expected to cause heavy bleeding as well as pressure.  The treatment of this type of fibroid depends on many factors, including the women’s desire to retain fertility.