Uterine Fibroids Blog — An Expert Speaks Out

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.

If you’re reading this, you’re probably suffering with issues related to uterine fibroids (heavy bleeding, cramping, Anemia, fertility issues, etc.). I’m writing this because I used to struggle with those same health issues. Today, I’m back to living a normal life, even though I never thought it would be possible again.

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 October, 2009 I saw Kate, a 50 year old woman who was told that she needed a hysterectomy.  In March 2009  a 3.5 cm (about 1 1/2 inch) uterine fibroid was found by her gynecologist.  She was on  low dose birth control pills at the time.

On Sept 23, 2009 she was told that the fibroid was 7.2 x 6 cm.  She had no symptoms at all.  No pain, no pressure, no abnormal bleeding.  Her gynecologist told her that the fibroid was growing rapidly, and could be cancer, so she needed an immediate hysterectomy.

I first saw Kate on October 1, 2009. At that time I could feel a small fibroid next to her uterus.  I did an ultrasound during which I saw a pedunculated myoma (a fibroid on a stalk) measuring 6.9 x 4.6 cm.  Knowing that the risk of cancer is extremely low, we decided to monitor the size of the fibroid closely rather than rushing into surgery.

November 1, 2009.  I rechecked the fibroid with ultrasound and it measured 6.5 x 5.1 cm.  Essentially the same size.

April 5, 2010: Her fibroid measured 6.3 x  4.7 cm. (a slight decrease in size).   As she was 51, we decided to stop the birth control pills and will do lab work (FSH) to determine if she has reached menopause.

Dr. Indman’s Comment:   This situation is something I commonly see — a woman has a fibroid detected and told that she needs surgery because it is rapidly growing.  In Kate’s situation she had an ultrasound that showed that it really was growing, although frequently these “new”  fibroids” have been there for a long time and have just been missed on exams.

The risk of cancer in rapidly growing fibroids is approximately 1 in 400.  Understanding that there is a very small risk of cancer, we decided that close monitoring was reasonable.  As Kate’s fibroid has actually decreased in size, it is extremely unlikely that she will need surgery.

Economics: Kate would have only had to pay 20%  of her insurance company’s “preferred provider’s” contracted rate for the unnecessary hysterectomy.  She also would have lost 6 weeks salary off of work, and had an operation that she did not need.  The cost of an expert evaluation was far less than 20% of a discounted operation she did not need!

Read about Kate’s Case

A  47 year old woman with “rapidly growing uterine fibroid”. P.D.M.  contacted us because she was told she had a rapidly growing fibroid.  She wanted to avoid a hysterectomy, but in her home state of Wyoming was only offered hysterectomy with removal of both ovaries because of the possibility of cancer.  Several years ago she was noted to have a small myoma on ultrasound, but it appears to have grown rapidly in the last year.  She noticed some pelvic pressure but no abnormal bleeding.

When she contacted my office we suggested that she get an MRI, which showed a 10 cm. (4 inch) mass in the uterus will cystic (fluid filled) areas (which are white), suggesting a degenerating fibroid.  (This is a fibroid that has outgrown it’s blood supply.)  Her MRI is shown to the left.

We discussed options, and the very low risk that this could be cancer.   With that knowledge, she chose to come for a myomectomy.

P.D.M.’s myomectomy is shown in the photographs.  An incision was made that was smaller than the fibroid, but it was possible to remove the fibroid through this incision.

Once the fibroid was partially removed it was possible to lift the uterus through the incision to aid in removing the fibroid entirely.

Here is the removed fibroid, which has been cut open to show the fluid filled areas.

The pathology report showed a benign degenerating uterine fibroid.

She left the hospital on the second day after surgery, and was able to return to Wyoming the following week.

Dr. Indman’s Comment:  P.D.M. was advised to have a hysterectomy because of concern that she may have had Leiomyosarcoma, or malignant fibroid.   A sarcoma is serious, but fortunately they are uncommon.  There is no evidence that benign fibroids can become malignant.   One large study has shown the risk of cancer in rapidly growing fibroids to be 0.26%, or about 1 in 400.   As 70-80% of women have fibroids (although many are too small to notice), and malignant fibroids are rare, it is hard to justify removing most fibroids or doing a hysterectomy because of the possibility of cancer.    In my patient’s situation the fibroid was growing rapidly and causing symptoms, so she chose to have it removed.

The decision to remove the fibroid or do a hysterectomy in a 47 year old woman who is not planning to have children is personal, and there are advantages and disadvantages to each approach.  In the very unlikely chance that a malignancy is found, a hysterectomy would of course be necessary.  On the other hand, we would be doing hundreds of hysterectomies for benign fibroids to find one that had cancer.  In addition,  I would strongly recommend against taking out her ovaries, as the increased risk of heart disease, osteoporosis, and other problems outweigh the risk of later developing ovarian cancer.

I feel that my role is to explain all of the reasonable options available to women, and help them make the best decision for their own lifestyle.  As P.D.M.  felt emotionally that she wanted to keep her uterus, and there was no medical need for a hysterectomy.    The fibroid was easily removed while leaving her uterus.

Read what P.D.M. writes about her experience!

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!

Uterine Fibroids can effect quality of life, can at times cause dangerous problems such as severe hemorrhage, but most often cause no problems at all.  The first question to ask is should fibroids be treated rather than how.

Fibroids should be treated if they cause heavy bleeding resulting in anemia that can’t be controlled with iron and medicines.  Fibroids that prolapse (protrude) through the cervix often cause heavy bleeding, pain, and can become infected.  Certain types of fibroids can cause infertility or difficulty in pregnancy.  These fibroids should be treated.

I like to draw analogies.  Imagine you have a car and the brakes don’t work.  If you don’t fix them immediately bad things will happen!

Many fibroids are so small that a woman is unaware that she has them, or cause only minimal symptoms.  These can be watched by a gynecologist and many never require any treatment.

The decision of when and how to treat fibroids that interfere with the quality of life without actually presenting a major health hazard can be difficult.  Let me present  two examples of such problems that can be caused by fibroids:

• Joan notices that it is difficult to fit in her clothes because her fibroids make her look like she is 5 months pregnant.  She has to urinate frequently, and is bothered by the pressure.
• Kristine is a teacher, and has periods so heavy that she is afraid she’ll soak through her clothes several days a month.  She frequently bleeds between periods, and finds it difficult to plan vacations because of her bleeding.  She takes iron, so her blood count is normal.

Let’s get back to the car analogy.  Let’s say the heater and air conditioner don’t work and the windows are stuck down in a town where it’s zero degrees in the winter and 105 in the summer.  When does the car need to be fixed?  When you are tired of freezing or roasting.   But it’s not like driving without brakes, as it’s a matter of comfort rather than safety.  The decision is not that different than deciding when to treat fibroids.  When they interfere with your ability to do what you want to do you should consider treatment.

It’s important to remember that fibroids often grow until menopause, and then usually decrease in size.  A woman who is 30 has many year until menopause, and it is likely that if she is bothered by fibroids it will only get worse over the years.  On the other hand a woman who is 49 would be expected to reach menopause soon, and if there are ways to control her symptoms from the fibroids there is a reasonable chance that they may improve after menopause.

Once the decision is made that fibroids should be treated, the next question is how.  There are many different procedures, each claiming to be the greatest and the best.  While I will be writing about many methods of fibroid treatments in detail, it is far less confusing if you realize that all of the methods fall into four basic categories:

1. Medical treatment of fibroids.  While there are no medicines that cure fibroids, there are medicines that may control symptoms and result in a temporary decrease in size.
2. Destroy the fibroids.  These methods leave the fibroids in place, but attempt to kill them by cutting off their blood supply, or using electrical, thermal, or ultrasound energy to “cook” them.  The body then absorbs the dead tissue.
3. Take out the fibroids.  Depending on size and location, fibroids may be removed through an incision, a laparoscope or robot, or through the cervix (hysteroscopically).  Once the fibroids are gone they do not grow back, but new fibroids can grow.
4. Take out the uterus.  This guarantees that the fibroids are gone forever.  There are some situations where this is the best option and many in which it is unacceptable.  More about this in the oncoming months.

Another factor in planning treatment is the desire for future pregnancy.  I’ll talk about fibroids and pregnancy in the future, but obviously a hysterectomy is out of the question for someone who wants to have a baby.  I have serious reservations about any of the destructive procedures, such as embolization (UFE) if future pregnancy is desired.  If we are going to remove the fibroids then we need to consider which procedure is most likely to leave a normal uterus.

Lastly, preference is definitely important.  Back to the car analogy…. If  you tell me you want a red car because red cars are faster than blue cars we can do an experiment and race them.  But if you tell me you want a red car because you hate blue, it is a matter of personal preference.  I see many women for myomectomy that could be appropriately treated by other methods such as embolization or hysterectomy, but they don’t like the idea of losing their uterus and don’t want foreign particles in their body.  My job is to inform them of the advantages and disadvantages of each of these choices, and help them decide which treatment best suits their lifestyle and personal beliefs.

The most important thing to realize is that you can not make a decision  about which treatment is most appropriate just by reading!!! A 3 cm. (1+ inch) fibroid that is inside the cavity of the uterus and causing heavy periods is almost always best treated by hysteroscopic resection, a quick outpatient procedure.  If the same size fibroid is mostly in the wall the treatment may be different, or it may not need to be treated at all.  While it is good to learn as much as you can by reading an appropriate treatment plan can only be reached after an accurate diagnosis. Unfortunately there are varying abilities to make an accurate diagnosis.  I find reading an ultrasound report much like reading a movie review in the newspaper.  Sometimes it’s right on and sometimes you can’t believe it’s the same movie.  I  see women who have been told they have fibroids turn out to have adenomyosis or at times ovarian cysts, or even nothing at all.  While it is good to learn about different treatment methods, you need the help of a gynecologist knowledgable about all options to help you decide what is best for your individual situation.

Laparoscopic Myomectomy uses a small telescope placed through the belly button along with several small instruments to remove fibroids from the uterus.  The technique of actually removing the fibroid from the uterus is similar to that of an abdominal myomectomy except we use small instruments placed through the abdominal wall. Once the fibroid is freed from the uterus it needs to be removed from the abdomen.  In order to remove a large fibroid from a small incision we use an instrument called a morcellator, to cut it into pieces small enough to be removed through the small incisions.

The more superficial a fibroid is the easier it is to remove laparoscopically.  Pedunculated fibroids are the easiest.  Care must be taken not to damage the underlying myometrium (the wall of the uterus) with energy used to seal the blood vessels, as rupture during pregnancy has been reported when this happened.  Deep fibroids that protrude into the cavity of the uterus (submucous myomas) are the most difficult to take out laparoscopically.

The advantage of laparoscopic surgery is that a larger incision is replaced by several smaller incisions.  Recovery is generally faster than if a regular incision is made, but this can vary.  There are some disadvantages of laparoscopic surgery, also.  Taking out large fibroids can take much longer when done through a laparoscope.  It is more difficult to take out a large number of fibroids.  It may not be possible to get as good of a repair for large or deep fibroids.  This would be more important for women desiring fertility.  The question you should ask is not if a laparoscopic myomectomy can be done but if it is best for your individual situation.

Comment:  One of my colleagues assisting me in a difficult laparoscopic surgery asked me when would I do a laparotomy (make a regular incision.) My answer was that I do the type of surgery that will obtain the best results. If I can obtain just as good results through the laparoscope I will do the procedure that way. But if I feel I can do a better job through a regular incision, then I will recommend that approach. When someone looks back years after surgery, the quality of surgery inside will be far more important than recovering 1 or 2 weeks earlier. — Paul Indman, M.D.