Uterine Fibroids Blog — An Expert Speaks Out

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.

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.

Mirena IUD next submucous 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.

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 »

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.

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.