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 »
by Paul Indman, MD
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 »
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
|A 48 year old woman (who prefers her name not be used) came in hemorrhaging and in shock. Her hemoglobin was 4.6. (Normal 12-13). She does not desire to maintain fertility.||Jan, a 41 year old woman with heavy periods, came for her first visit, and was not actively bleeding. She was short of breath and weak, but not in shock. Her hemoglobin was 5.0. Jan would like to have another baby.
Findings at first visit:
|Uterus the size of a 16 week pregnancy. MRI shows 9 cm. fibroid, mostly intramural but indenting the cavity||Uterus the size of a 18 week pregnancy. MRI shows 11.5 x 10 cm. fibroid, mostly intramural but indenting the cavity|
|Hospitalized, transfused 4 units of blood. Bleeding stopped with medications. Started on medication and iron to build up blood, and high doses of progesterone||Started on high dose birth control pills to prevent further bleeding. Given medication and iron to build up blood. Was able to continue her usual work as an engineer until surgery.|
Decision making: All options, including UFE (embolization), myomectomy, and hysterectomy were discussed.
|Since fertility was not an issue, she felt that embolization would be the least invasive treatment.
Advantages: avoids an incision.
Disadvantages: Average decrease in volume of 50%, is only a 20% decrease in diameter. Submucous fibroids may shed tissue and may cause a heavy discharge for prolonged period of time.
|As Jan wants to have another baby, she chose to have the fibroid removed. Given the size and location, I felt an abdominal myomectomy would allow the best repair of the uterus.|
|Embolization (UFE or UAE).
A catheter is inserted into an artery to inject inject particles which will plug the arteries feeding the fibroid.
Below is from her actual embolization done by an interventional radiologist, and shows the catheter in the right side. The blood vessels appear black.
|Jan’s Abdominal Myomectomy: Large uterus fills pelvis to above belly button.
Fibroid (above) being removed from uterus (below)
Fibroid measures 15cm. (6 inches). Two smaller fibroids were also removed.
2 weeks after procedure:
|Low grade fever, chills, vaginal bleeding||Read Jan’s letter written 5 days after her myomectomy.
Seen early for post-op check because she wants to return to work. She is off of her pain medicine, and can return to her work.
4 weeks after procedure:
|Bleeding a pad every 3-4 hours. Uterus is now size of 20 week pregnancy, and is tender.
||At time of this writing it is not yet 4 weeks since Jan’s myomectomy. I’ll post her progress.
6 weeks after procedure:
|Uterus has increased to size of 22 week pregnancy and is tender. MRI and CT scan ordered. Results: large mass with large abdominal lymph nodes suggesting malignancy.
|Findings at surgery: sarcoma (an aggressive cancer). See above comment!
||Four month check-up after Jan’s abdominal myomectomy|
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:
- 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.
- 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.
- 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:
- Pain, which can be severe enough to require hospitalization. Sometimes a fibroid may infarct or cause pain because of decreased blood flow.
- Increased risk of placenta problems such as abruption (premature separation of the placenta).
- Increased risk of prematurity.
- Increased risk of cesarean section.
- 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.
Medical Journal Article ReviewProgesterone Is Essential for Maintenance and Growth of Uterine Leiomyoma Ishikawa H, Ishi K, Serna VA, Kakazu R, Bulun SE, Kurita T. Endocrinology. 2010 Apr 7
This is a study in which human uterine fibroid tissue was implanted into mice, and the effects of progesterone, estrogen, and anti-progesterone compounds were observed. The authors found that estrogen plus progesterone stimulated growth of fibroid cells, and this growth was blocked with anti-progesterones. Withdrawal of progestrone caused fibroid tissue to shrink. Interestingly, estradiol (estrogen) without progesterone had no effect in this study.
Comment: This study confirms others in showing that progesterone is needed for fibroid growth. For those tempted to use over-the-counter progesterone creams to treat fibroids, this study shows that extra progesterone may cause more harm than good. Do not interpret this study to mean that you shouldn’t take birth control pills if you have fibroids. Certain low dose birth controls do not cause fibroid growth, and may actually slow growth! — Paul Indman, M.D.
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!
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.