Submucous Fibroids: Do I Need A Hysterectomy?

Question:

Hello Dr. Ramirez,

I’m writing from Mexico. I’m 33 years old, never been pregnant and have just been diagnosed with fibroids. This year I’ve had heavy abnormal bleeding with large clots. First doctor i saw prescribed only birth control as he thought it was only a hormonal imbalance. Months later, a second doctor thought it was a polyp and recommended a curettage. A third doctor conducted a much more extensive trans-vaginal ultrasound and found a submucous fibroid (about 1.5 inches in size), an intramural fibroid of about the same size, and a couple other very small ones.

They did a doppler image which showed both are hypervascular.

The doctor said it’s a very difficult case, as the usual procedure would be an hysterectomy, but I still haven’t had children. He’s checking for embolization option.. or other options with his colleagues.

My question for you is this… Is there any procedure that I could check for which can remove the fibroids (preferably minimally invasive) that has high probability of saving the uterus for a woman who wants to have kids later on?

I’m scared as the doctor talked about surgery options but all of them having high risk of ending up in hysterectomy if i start to bleed out (because the fibroids are hypervacular).

Many thanks in advance!  B. from Mexico

Answer:

Hello B. from Mexico,

Hysterectomy is NOT your only option, especially if you want to retain your fertility and absolutely DO NOT let them take it!  The intramural (fibroids within the muscular part of the uterus) are not the cause of your current bleeding.  The submucous (within the endometrial cavity) is.  That is the main one that needs to be treated.  So your options are as follows in order of my preference:

1.  Have the submucous fibroid trimmed or removed by hysteroscopic myomectomy and I recommend this be done with an instrument called the “myosure”.  It basically will shave the fibroid down.  The submucous fibroid needs to be removed/shaved because it will also interfere with getting pregnant.

2.  Uterine artery embolization (UAE) is a good option for the intramural fibroids, especially since they are small.  However, I don’t think that you necessarily need to do anything about them at this time BECAUSE they are still small.

3.  Operative myomectomy is a surgery where the uterus is cut open and each fibroid is removed.  This can be done either as an open surgery or by laparoscopic dependent on the skill of the surgeon.  However, your fibroids are small and this would be the least recommended procedure at this time, especially since it can compromise your fertility by causing scar tissue resulting from the surgery.

Keep in mind that there is an inherent bias among doctors, and that is that doctors will usually only recommend a treatment that they can personally perform.  Very few doctors will recommend what is best if it is a procedure they don’t do.  So, you have to find a doctor that can do all of the above so that they will present ALL options and give a reason for recommending one over the other.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG