Uterine Fibroids Blog — An Expert Speaks Out

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 »

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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!

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!

Uterine Fibroids can effect quality of life, can at times cause dangerous problems such as severe hemorrhage, but most often cause no problems at all.  The first question to ask is should fibroids be treated rather than how.

Fibroids should be treated if they cause heavy bleeding resulting in anemia that can’t be controlled with iron and medicines.  Fibroids that prolapse (protrude) through the cervix often cause heavy bleeding, pain, and can become infected.  Certain types of fibroids can cause infertility or difficulty in pregnancy.  These fibroids should be treated.

I like to draw analogies.  Imagine you have a car and the brakes don’t work.  If you don’t fix them immediately bad things will happen!

Many fibroids are so small that a woman is unaware that she has them, or cause only minimal symptoms.  These can be watched by a gynecologist and many never require any treatment.

The decision of when and how to treat fibroids that interfere with the quality of life without actually presenting a major health hazard can be difficult.  Let me present  two examples of such problems that can be caused by fibroids:

• Joan notices that it is difficult to fit in her clothes because her fibroids make her look like she is 5 months pregnant.  She has to urinate frequently, and is bothered by the pressure.
• Kristine is a teacher, and has periods so heavy that she is afraid she’ll soak through her clothes several days a month.  She frequently bleeds between periods, and finds it difficult to plan vacations because of her bleeding.  She takes iron, so her blood count is normal.

Let’s get back to the car analogy.  Let’s say the heater and air conditioner don’t work and the windows are stuck down in a town where it’s zero degrees in the winter and 105 in the summer.  When does the car need to be fixed?  When you are tired of freezing or roasting.   But it’s not like driving without brakes, as it’s a matter of comfort rather than safety.  The decision is not that different than deciding when to treat fibroids.  When they interfere with your ability to do what you want to do you should consider treatment.

It’s important to remember that fibroids often grow until menopause, and then usually decrease in size.  A woman who is 30 has many year until menopause, and it is likely that if she is bothered by fibroids it will only get worse over the years.  On the other hand a woman who is 49 would be expected to reach menopause soon, and if there are ways to control her symptoms from the fibroids there is a reasonable chance that they may improve after menopause.

Once the decision is made that fibroids should be treated, the next question is how.  There are many different procedures, each claiming to be the greatest and the best.  While I will be writing about many methods of fibroid treatments in detail, it is far less confusing if you realize that all of the methods fall into four basic categories:

1. Medical treatment of fibroids.  While there are no medicines that cure fibroids, there are medicines that may control symptoms and result in a temporary decrease in size.
2. Destroy the fibroids.  These methods leave the fibroids in place, but attempt to kill them by cutting off their blood supply, or using electrical, thermal, or ultrasound energy to “cook” them.  The body then absorbs the dead tissue.
3. Take out the fibroids.  Depending on size and location, fibroids may be removed through an incision, a laparoscope or robot, or through the cervix (hysteroscopically).  Once the fibroids are gone they do not grow back, but new fibroids can grow.
4. Take out the uterus.  This guarantees that the fibroids are gone forever.  There are some situations where this is the best option and many in which it is unacceptable.  More about this in the oncoming months.

Another factor in planning treatment is the desire for future pregnancy.  I’ll talk about fibroids and pregnancy in the future, but obviously a hysterectomy is out of the question for someone who wants to have a baby.  I have serious reservations about any of the destructive procedures, such as embolization (UFE) if future pregnancy is desired.  If we are going to remove the fibroids then we need to consider which procedure is most likely to leave a normal uterus.

Lastly, preference is definitely important.  Back to the car analogy…. If  you tell me you want a red car because red cars are faster than blue cars we can do an experiment and race them.  But if you tell me you want a red car because you hate blue, it is a matter of personal preference.  I see many women for myomectomy that could be appropriately treated by other methods such as embolization or hysterectomy, but they don’t like the idea of losing their uterus and don’t want foreign particles in their body.  My job is to inform them of the advantages and disadvantages of each of these choices, and help them decide which treatment best suits their lifestyle and personal beliefs.

The most important thing to realize is that you can not make a decision  about which treatment is most appropriate just by reading!!! A 3 cm. (1+ inch) fibroid that is inside the cavity of the uterus and causing heavy periods is almost always best treated by hysteroscopic resection, a quick outpatient procedure.  If the same size fibroid is mostly in the wall the treatment may be different, or it may not need to be treated at all.  While it is good to learn as much as you can by reading an appropriate treatment plan can only be reached after an accurate diagnosis. Unfortunately there are varying abilities to make an accurate diagnosis.  I find reading an ultrasound report much like reading a movie review in the newspaper.  Sometimes it’s right on and sometimes you can’t believe it’s the same movie.  I  see women who have been told they have fibroids turn out to have adenomyosis or at times ovarian cysts, or even nothing at all.  While it is good to learn about different treatment methods, you need the help of a gynecologist knowledgable about all options to help you decide what is best for your individual situation.

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.

Accurate diagnosis of uterine fibroids is essential in deciding if treatment is necessary, and planning appropriate treatment.      While a physical exam may suggest fibroids, other conditions such as ovarian cysts or adenomyosis may be mistaken for fibroids.   For this reason, I routinely do an ultrasound examination at the time of the first visit when a woman has symptoms of abnormal bleeding or cramping, or if I feel an abnormality on examination.  Vaginal probe ultrasound only takes a few minutes to do, is not uncomfortable, and rapidly provides invaluable information if the examiner is experienced in looking at uterine abnormalities.  It is possible to fill the uterus with a liquid during the ultrasound (saline enhanced sonography or sonohysterogram). While this will often provide additional information to the regular ultrasound, I usually learn much more by looking inside the uterus with a little telescope.  This exam, called hysteroscopy, is usually a quick office procedure, that allows directly looking inside the uterus.    While vaginal probe ultrasound is good for seeing close-up detail, it may not “see” deeply enough to evaluate large fibroids.  An abdominal ultrasound, which requires a full bladder, is better for large fibroids but doesn’t show as much detail.  As the images from MRI are SO much better than ultrasound, and I can obtain an MRI relatively inexpensively in my area, I prefer to go straight to MRI to image a large uterus with fibroids.

MRI scans provide excellent pictures of the uterus.  MRI is especially helpful in evaluating a large uterus and helpful in planning a myomectomy.    Adenomyosis is frequently confused with fibroids in an enlarged uterus, and the treatment is entirely different.  I have seen patients who have been taken to surgery to remove fibroids only to find that there was adenomyosis instead, so they were closed back up without any treatment.  MRI is especially good at distinguishing between fibroids and adenomyosis.  If a woman is planning to travel a long distance to see me it is helpful to review an MRI (which can be recorded on a CD) to help plan treatment.

What is adenomyosis? It is one of the most common conditions confused with fibroids.  In adenomyosis the lining of the uterus infiltrates the wall of the uterus, causing the wall to thicken and the uterus to enlarge.  On ultrasound examination this will often appear as diffuse thickening of the wall, while fibroids are seen as  round areas with a discrete border.  Adenomyosis is usually a diffuse process.  If it is localized, or forms within a fibroid or a cyst it may also be possible to remove it.  Since fibroids can be removed but it may not be possible to remove extensive adenomyosis without taking out the uterus, it is important to differentiate between the two conditions.  A progesterone coated IUD, the Mirena, is often helpful in treating symptoms of adenomyosis without surgery.

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.

What are Uterine Fibroids?

The walls of the uterus are made of smooth muscle called myometrium, and the inside lining, with glandular tissue, is called endometrium.  “Uterine fibroid” is a slang term for leiomyoma, or often simply  myoma. Fibroids are benign tumors made of smooth muscle cells.

Fibroids are extremely common.  It is often stated that 30% of women have uterine fibroids, but this is an underestimate.  Most women have fibroids, but many are too small to be detected and do not cause any problems.  They are more common in women of African descent, with one study showing an incidence of 60% by the age of 35 and 80% by the age of 50.  In Caucasian women the incidence has been found to be 40% by age 35 and 70% by age 50.

What Causes Uterine Fibroids?

There are a number of factors that cause fibroids.  There is a genetic factor, as the DNA in fibroids frequently show abnormalities.  Likely there is an abnormality in which the cells in fibroid handle estrogen and progesterone.  Fibroids are not caused by too much estrogen any more than fire is caused by too much air!

Can Fibroids turn to Cancer?

There is no evidence that benign fibroids can turn into cancer. One study looked at 371 study in women with rapidly growing myomas and found only one sarcoma (cancer) or 0.26%, in the group.  Although women are often advised to have surgery because of fear of cancer developing in a fibroid, the actual risk is very low.  Although Leiomyosarcomas are serious malignancy, the actual risk of a seemingly benign fibroid being malignant is extremely low.

What Causes Fibroids to Grow?

Fibroids are sensitive to both estrogen and progesterone. Without these hormones most fibroids will shrink but not go away.  Do not interpret this to mean that fibroids are caused by too much estrogen.  That would be the same as saying that too much air causes fires because fires go out without air!  Changes in fibroid cells cause fibroids to be more sensitive to normal levels of estrogen and progesterone.

Do Birth Control Pills Cause Fibroids to Grow?

There is no evidence that birth control pills increase the risk of developing fibroids or causes new fibroids to grow.  There is some evidence, in fact, that certain birth control pills may slow the growth of fibroids.