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.

Dr. Indman performed two procedures for me at the same time – a hysteroscopic myomectomy and an endometrial ablation. From the pre-op to post surgery, I did not experience any pain or a single cramp. I was back to work the next day and back on my regular workout schedule within two weeks. After three weeks, I went on a cycling vacation and rode 350+ miles over hilly terrain. I felt great! Without the surgery, there was no possible way I could have done this. For the first time in 1 1/2 years, I am not experiencing heavy bleeding and checking where the nearest bathrooms are.

My experience with Dr. Indman and his staff have been nothing short of fantastic. Dr. Indman is a warm, caring, highly skilled surgeon – with a fun sense of humor to boot! He is one of those rare gems in the medical profession today – someone who truly puts patients first. I found Dr. Indman while researching my symptoms on the Internet. The wealth of helpful information on his website gave me a lot of confidence even before I met him. His deep expertise and decades of experience are evident from his thorough examinations and explanations.  — S.K.

Comment:  S.K. had a submucous fibroid, which was treated by hysteroscopic myomectomy and endometrial ablation as an outpatient.  Here are actual pictures from her surgery.  The first shows the fibroid on the right side of the uterus, with the loop that will be used to remove it.  The second shows the fibroid having been removed, and the third is after endometrial ablation.  I do the endometrial ablation under direct vision to be sure that no areas are missed.

It is not unusual for women to resume most normal activities within a day or two.  Careful patient selection and utmost skill are required for a safe and successful procedure. — Paul Indman, M.D.

Update:  12/14/2010: S.K. came in for a 4 month check after her procedure, having recently run a marathon.   She said that she kept thinking that without the surgery running a marathon would have been impossible.

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 »

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 »

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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!