Uterine Fibroids Blog — An Expert Speaks Out

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.

When I first saw Dr. Indman in October 2009, I was seeking a second opinion. The gynecologist I had been seeing for about 10 years, and who had originally diagnosed my fibroid, told me that in her opinion I should have my uterus removed. She had been monitoring my fibroid by doing ultrasound exams every six months for about six years. The ultrasound images showed the fibroid had been growing slowing during that period.

So she was alarmed when she compared the ultrasound she did in March 2009 to the one she did in September 2009; she saw that my fibroid had been growing quickly during that six months. At her direction, I had an MRI. When she received the results of the MRI, she felt she couldn’t “rule out cancer.” That’s when she called me to recommend a hysterectomy.  I immediately phoned my husband. I was still in shock, and my husband asked if I wanted to get a second opinion. Indeed I did!

The idea of having my uterus surgically removed did not sit well with me for many reasons. Although having children was no longer an issue, I recoiled at the idea of having surgery that might not be necessary. From what I knew of fibroids, I didn’t think it was very likely that this was cancer. I felt extremely healthy and had no pain or other symptoms. I also wanted to prevent the trauma to my body and to my sense of self that I knew would come with a hysterectomy. And lastly, I am self employed, so if I don’t work I don’t make money. The recovery time would have been a period of zero income for me.

The day I was told I needed a hysterectomy, I hopped on the Internet and learned as much as I could about fibroids, treatment, the aftermath of a hysterectomy and the possibility that what I had could be cancer. I learned a great deal from one site, www.myomectomy.net. What I read there educated me and also validated some of the things I was already thinking.

That web site provided information about Dr. Indman, and I was surprised and happy to find out that his office is only a half-hour drive from my house. I called his office the next morning and made an appointment to see him that same week. I was told to bring the recent MRI results, radiologist’s report, and ultrasound results with me. At that first appointment, Dr. Indman talked to me; conducted a thorough physical examination, including an ultrasound; and studied the MRI results, radiologist’s report, and previous ultrasound results. He explained that based on statistics, the chance of my fibroid being cancerous was quite slim. We agreed that I would come back for another ultrasound a month later. The results of that exam  showed no growth of the fibroid.

In a follow-up ultrasound with Dr. Indman six months later, he found that the fibroid was actually a little smaller than it had been. I was delighted when he finished the exam and said, cheerfully, “Another hysterectomy bites the dust!”

One last thing about Dr. Indman. In addition to his professional abilities and his many years of experience, he has a very pleasant manner with patients. I greatly appreciate the respect with which he treats me. He wants me to be involved in my own care, and he listens—really listens—to what I have to say. And he answers my questions thoroughly. I’m very glad I went to him for my second opinion.

— Kate

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.

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.