Uterine Fibroids Blog — An Expert Speaks Out

Michelle with her sons

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.

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 »

Today I saw Jan, who had her abdominal myomectomy four months ago.  (See Jan’s story and photos of her surgery). Today her hemoglobin (blood count) is 13.3, which is normal and up from 5 when she first came in.  She returned to work in two weeks and felt fully recovered in four weeks.  Her periods are now normal and light.  Her only regret is that she waited so long to have her surgery!

Comment: Many women suffer needlessly because of their fear of surgery. Most women find that the fear of surgery is far worse than the actual procedure.  Many women tell me that their periods (when they had the fibroids) were far more disabling than the surgery to correct the problem. This is not to say that surgery is always easy… just that the solution may not be as difficult as the problem you are living with.  — Paul Indman, M.D.

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 »

Read about and see photos of Jan’s abdominal myomectomy

March 09, 2010 was the first time I met Dr. Paul Indman for a second opinion on fibroid treatment. I’d been searching for the specialist in this field in Bay Area since September 2009, when I was told by my general OB/GN doctor my fibroid was so big (11cm by ultrasound and my tummy as big as 16~18 weeks pregnant ) that I need to consider surgery. She talked about the rapid growth of my fibroid (in January 2009 it was 8cm) that would possibly be sarcoma (cancerous) that I would need to remove the whole uterus. I was not comfortable by this conversation and just replied that I need to find a second opinion before I make a decision (I don’t blame my general OB/GN doctor in any means, in fact she’s helped me all the time for woman issue and helped me on my childbirth with a C-section in 2006). Luckily in the beginning of this year, I found Dr. Indman’s website and read all the articles there and found they all make sense. So I made a phone call to his office for the appointment.

I was already very anemic at the time Dr. Indman first saw me. My hemoglobin was only 5 (normally 12 ~16). And he diagnosed me with ultrasound and confirmed the big fibroid. So he treated me in two steps: first, heal my anemia first by controlling my blood loss during menstrual period and second, do the surgery to remove the fibroid. When the second time I saw Dr. Indman in about a month, my hemoglobin has increased to 11.3. The first step treatment seems very encouraging so we scheduled the surgery.  May 10, 2010, I had my abdominal myomectomy surgery by Dr. Indman and I stayed in hospital for two days.  Now I’m home and it’s the fifth day after my surgery.

When I’m looking back what has happened in the last two months, my heart is filled with gratitude to Dr Indman and his staff team. I’m very satisfied to the outcome of the treatment and convinced with his expertise and skills, his truly caring to patients. I know surgery is not an easy decision to everyone. From my experience, my piece of advice would be to find the doctor that you think you’re really comfortable to work with.

Sincerely,

Jan F.

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

My successful adventure in finding Dr. Indman was an interesting journey.  In June of 2008, I realized I had a problem when I was unable to empty my bladder.  After going to the emergency room and having a catheter inserted in order to empty my very full bladder, I visited a urologist who thought I might have had too much water to drink after hiking the day before.  When a second similar incident happened later in the summer, the urologist was again at a loss as to what might be going on.  He recommended I see a neurologist and get an MRI.  Finally, it was determined that I had a large uterine fibroid.  In September, I visited the gynecologist to determine what my options might be.  Before this doctor had even examined me, he told me I would need a hysterectomy in the next month. Read the rest of this entry »

Should I have my fibroids removed before I try to get pregnant?  That is one of the most difficult questions I have to answer!  Here is what we know:

1. Submucous fibroids, or intramural fibroids that indent the endometrial cavity (inside of the uterus) significantly decrease the chances of conception, and increase the miscarriage rate. Large intramural fibroids (in the wall of the uterus) can have a submucous portion that distorts the cavity and should be considered included in this group.  Fibroids that are mostly in the endometrial cavity can usually be removed by outpatient hysteroscopic myomectomy (hysteroscopic resection).  This should only be done by a gynecologist with extensive experience in hysteroscopic surgery to reduce the risk of  scar tissue formation.  Although it may be possible to remove some submucous fibroids that are mostly in the wall hysteroscopically, if they are large they should be removed by abdominal, laparoscopic, or robotic myomectomy.
2. Intramural fibroids that do not indent the cavity appear to decrease fertility and increase miscarriage rates, but studies are inconclusive. Even if this is the case, studies are lacking to show that removing these fibroids increases the chance of successful pregnancy.
3. There is no evidence that subserous fibroids interfere with conception or increase the miscarriage rate.

Fibroids in Pregnancy

Although we used to think that pregnancy causes fibroids to increase in size, ultrasound studies show that they usually do not grow.  They often feel larger because the whole uterus is larger.

Some of the problems fibroids can cause are:

1. Pain, which can be severe enough to require hospitalization.  Sometimes a fibroid may infarct or cause pain because of decreased blood flow.
2. Increased risk of placenta problems such as abruption (premature separation of the placenta).
3. Increased risk of prematurity.
4. Increased risk of cesarean section.
5. Increased risk for post-partum hemorrhage.

The risks of serious complication are low.  Most women with fibroids go through pregnancy without any problems.

Treatment recommendation for fibroids before attempting pregnancy

There is no way I or any other physician can make specific recommendations without evaluating you individually!  These are general recommendations, and should not be followed without advice from your own physician.

If fibroids are causing symptoms such as heavy bleeding, pain or pressure it is usually reasonable to remove them.  If the fibroids are not causing symptoms, the following are general recommendations.

1.  Most submucous fibroids should be removed.  Hysteroscopic myomectomy, when done by an expert, is the treatment of choice in most situations.

2. Intramural fibroids that distort the endometrial cavity should usually be removed before attempting pregnancy.

3.  Intramural myomas that do not distort the endometrial cavity and are not causing symptoms usually do not need to be removed before attempting pregnancy.  There is no evidence that removing them improves pregnancy outcomes.

4.  Subserous myomas, unless large enough to cause symptoms, do not need to be removed prior to pregnancy.

Is myomectomy risky? This obviously depends on the skill of the surgeon.  The risk of needing to do a hysterectomy at the time should be less than 1 in 100.  I have never had to do an unplanned hysterectomy in a woman of reproductive age when I had planned to do a myomectomy.  While adhesions can develop, there are a techniques to minimize them.  All in all, myomectomy should not lower, and in many cases will improve the chances for a successful pregnancy.  Be aware that if many or deep fibroids are removed (except by hysteroscopic myomectomy) a cesarean delivery will often be recommended.

What about other treatments, such as embolization (UAE or UFE)?  Embolization blocks the blood vessels to the fibroids and/or uterus.  Although new blood vessels my take over to supply the uterus, the effect on pregnancy is unknown.  While there have been successful pregnancies after embolization, it also can decrease ovarian reserve or menopause as well as causing intrauterine adhesions (Asherman’s syndrome).  Therefore I, and most experts in fertility, would only recommend embolization as a last resort in women desiring pregnancy.

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!