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 »

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!