Robotic Myomectomy is minimally invasive procedure for removal of uterine fibroids that combines many of the advantages of abdominal myomectomy with the rapid recovery of Laparoscopic myomectomy!  Click here to learn more about robotic myomectomy for removal of uterine fibroids.

Uterine Fibroids, or uterine myomas (short for leiomyoma), affect more than 30% of women.  The terms fibroid and myoma are used interchangeably.  Most fibroids do not cause symptoms,  and do not require treatment.  Fibroids may require treatment in the following circumstances:

1. Fibroids are growing large enough to cause pressure on other organs, such as the bladder.
2. Fibroids are growing rapidly
3. Fibroids are causing abnormal bleeding
4. Fibroids are causing problems with fertility.

Types of Fibroids

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 will usually cause bleeding between periods (metrorrhagia) 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.  Submucous myomas are partially in the cavity and partially in the wall of the uterus.  They too can cause heavy menstrual periods (menorrhagia), well as bleeding between periods.  Some of these 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 of these 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 myoma.)  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.

Diagnosis of Fibroids

Fibroids may be felt during a pelvic exam, but many times myomas that are causing symptoms may be missed if the examiner relies just on the examination.  Also, other conditions such as adenomyosis or ovarian cysts 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 sonohysterogrami).   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.  Click here to learn more about hysteroscopy.

One of the most common conditions confused with fibroids is adenomyosis. 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, and rarely can be removed without taking out the uterus.  Since fibroids can be removed, it is important to differentiate between the two conditions before planning treatment.  It is also common to have some adenomyosis in addition to fibroids.

MRI scans also provide an excellent picture of the uterus.  Usually the cost of the exam is not justified, as all of the information needed to plan treatment (or not to treat) can be obtained by other methods.

Treatment of Fibroids

The most important question to ask is do the fibroids need to be treated at all.   The vast majority of fibroids grow as a woman gets older, and tend to shrink after menopause.  Obviously fibroids that are causing significant symptoms need treatment.   While it is often easier to treat smaller fibroids than larger ones, most of the small ones never will need to be treated.  So just because we can treat fibroids while they are small, it doesn't follow that we should treat them.  The location of the fibroids plays a strong influence on how to approach them.

Treatment with medicines:

There are not any currently available medicines that will permanently shrink fibroids.  Often heavy bleeding can be decreased with birth control pills.  There are a number of medications in the family of GnRH agonists, which induce a temporary chemical menopause.   In the absence of estrogen myomas usually decrease in size.  Unfortunately, the effect is temporary, and the fibroids rapidly go back to their pre-treatment size when the medication is discontinued.  Mifepristone, better know as the 'French abortion pill, or RU-486, also cause a significant decrease in size of myomas, and often stops abnormal uterine bleeding.  It's use is promising, but it is not currently available in the United States.

Surgical treatment of fibroids:

There have been a number of procedures recently promoted for treatment of fibroids.   Some are truly new.  Others are being marketed as new in order to promote the sale of expensive instruments, without offering any real advantages.   Many new procedures prove over time to be major advances; we may look back on others as not so wonderful.  With any new procedure, it is important to look at studies published in peer-reviewed medical journals as well as promotional materials by a physician, clinic, or instrument manufacturer.  Ask questions:  how many of these procedures have been done in published studies; what is the outcome; how long have these patients been followed?  In deciding whether any procedure is for you, you should look at advantages and disadvantages of all available options.   

Intracavitary Myomas

When a myoma is inside the uterine cavity, it will almost always cause abnormal bleeding and cramping.  If it is not currently causing problems, the odds are very high that it will.  For this reason, I usually recommend that they be removed.   These can usually be removed by using a special kind of hysteroscope, or resectoscope.   The resectoscope is a telescope with a built-in loop that can cut through tissue.  It has been used for years to treat enlargement of the male prostate gland, and has more recently been used inside the uterus.  This is called hysteroscopic resection of myomas. In skilled hands most myomas inside the uterus can be removed in an outpatient setting.  Click here to learn more about hysteroscopic resection of myomas.

Submucous Myomas

Unlike intracavitary myomas, some of the fibroid is also in the wall of the uterus.   Submucous myomas often cause abnormal bleeding.  Many of these can also be treated by hysteroscopic resection.  During the process of removing submucous myomas by this method the uterus contracts, and tends to push the portion of the myoma that is in the wall into the cavity of the uterus.  The decision on which myomas should be treated by this method should be made by an experienced hysteroscopic surgeon.   If heavy bleeding is the main reason for desiring treatment, and fertility is no longer desired, an endometrial ablation may also be done at the same time.

Intramural and Pedunculated Myomas

Myomas that are in the wall of the uterus or on the outside of the uterus are not accessible to treatment through the cervix.   If these need to be treated, there are essentially three types of procedures:  remove the fibroid(s), destroy the fibroid(s), or remove the uterus.  All of the surgical options available are variations on one of these themes.  Some have been available for years.  Others are very new and have had very little or no long term testing. 

Hysterectomy:

Hysterectomy is the only procedure that comes with a guarantee:  no more bleeding and no regrowth of fibroids.  Like any alternative, there are advantages and disadvantages of having a hysterectomy.  Click here to learn more about hysterectomy.

Removal of the fibroid(s):

This is also called myomectomy.  Myomectomy, with one exception, means making an incision into the uterus and removing one or more fibroids.  If the fibroid is on a stalk (pedunculated) it is not necessary to cut into the uterus to cut the stalk.   Unless the myoma is on the outside surface of the uterus, the uterus is repaired, usually with sutures.  One of the major differences in how a myomectomy is done involves the surgical approach to the uterus.  In a laparotomy an incision is made in the abdomen to reach the uterus.  The advantage of this is that large myomas can be quickly removed.  The surgeon is able to feel the uterus, which is helpful in locating myomas that may be deep in the uterine wall.  The ability to touch the uterus facilitates repairing the uterus.  The disadvantage of a laparotomy is that it requires an abdominal incision.  Most of my patients who have this procedure spend two nights in the hospital, and return to work in about four weeks.

For pictures of the each type of myomectomy see Dr. Indman's comprehensive web site:  All About Myomectomy for the Removal of Uterine Fibroids (will open in new window)

Some myomas can also be removed by laparoscopy.  The laparoscope is a telescope placed in the abdomen through the belly button.  Other instruments are inserted through small individual incisions in the abdominal wall.  Many myomas can be removed by laparoscopy; this is easier to do when the myomas are on a stalk or close to the surface.  Once the fibroids are removed they are cut into pieces by one of several instruments designed for this purpose, and removed.  The advantage of laparoscopic myomectomy is that it is usually done as an outpatient, and allows faster recovery than a laparotomy.  One of the disadvantages is the extended time needed to remove large fibroids from the abdomen, although newer instruments are improving this.   Since the surgeon cannot actually touch the uterus, it may be more difficult to detect and remove smaller myomas.  In addition, if a woman plans pregnancy after her myomectomy, there is a question of whether the uterus can be repaired through the laparoscope as well as it can be by laparotomy.

Although many myomas can be removed through the laparoscope, the decision of which myomas should be removed laparoscopically and which by laparotomy depends on many factors.  A woman should discuss the advantages, disadvantages, and risks of each type of surgery with a surgeon who is experienced in all treatment methods.

Destruction of the myomas:

Several procedures have been designed to treat the myomas by destroying their blood supply instead of removing them.  The first procedure, called myolysis, is done through a laparoscope.  In this procedure, a laser fiber, or more commonly an electrical device, is placed into the fibroid through the laparoscope, and is used to coagulate the myoma or the blood vessels feeding the myoma.  The dead tissue is then gradually replaced with scar tissue.  This is easier to do than a myomectomy (although it can be time consuming), and recovery is usually rapid. 

There are several disadvantages to the procedure.  Since no sample of the fibroid is sent to the lab, for a biopsy, in the rare case of malignancy may not be diagnosed.   Frequently the the procedure causes adhesions (organs such as intestines stick to the uterus), which could cause problems later on.  Most importantly, I am not aware of any controlled study comparing the outcome of this procedure with myomectomy or other treatment.  As with any new procedure, there is no long term information on what will happen over time.
Uterine artery embolization, which is described below, seems to offer many advantages over myolysis.

Uterine artery embolization:

This is the newest treatment for fibroids.  This procedure involves placing a small catheter into an artery in the groin and directing it to the blood supply of the fibroids.  Little plugs are injected through the catheter to block these arteries.  This causes the fibroids to shrink, although there may be pain for a short time afterwards requiring the use of narcotics. 

Uterine artery embolization may eliminate the need for surgical treatment of myomas.  As in myolysis, no samples are sent for biopsy, although the chance of malignancy in fibroids are low.   It is important to seek evaluation from physicians knowledgeable in both embolization and traditional methods of treatment before deciding on treatment.  For more information about this promising technique, click here to reach the Fibroid Medical Center of Northern California. 

Other Abnormal Bleeding topics:
Diagnosis
Hysteroscopy
The Resectoscope
Endometrial Ablation
Menopausal Bleeding