Most women with troublesome fibroids either just put up with a monthly flood until they go through menopause, or end up with a hysterectomy.
In my last blog, I mentioned that many women with fibroids are not candidates for endometrial ablation, a procedure that destroys the lining of the uterus to eliminate bleeding. But, what I didn’t mention is that women who are doomed to fail ablation are often excellent candidates for another outpatient, no-incision option: hysteroscopic myomectomy.
But first, some background: Fibroids, the most common gynecologic tumor, are present in the uterine wall in up to 70% of women. In most cases, fibroids are too small to create symptoms and, if found, can be ignored. It’s not just size, but the position of the fibroid that predicts who is going to have issues. As any good real estate agent knows, it’s all about location, location, location. And there’s no worse location than fibroids that actually grow into the cavity of the uterus. These are the fibroids that cause the “change the tampon every hour” heavy periods that not only are miserable to deal with, but also can result in anemia. But sometimes your uterus doesn’t need to be sacrificed in order to make it stop.
Myomectomy is an alternative to hysterectomy that surgically removes fibroids and leaves the uterus behind. Most women that undergo myomectomy get an abdominal incision and require a six-week recovery. Hysteroscopic myomectomy is an underutilized uterus-sparing technique that removes problematic fibroids without an incision. This procedure is performed as an outpatient, takes less than an hour, and requires essentially no recovery.
Here’s how it works: Most women are familiar with dilatation and curettage (D & C), a procedure in which the cervical opening is made slightly larger in order to put an instrument into the uterine cavity to scrape away the lining of the uterus. It would be nice if a simple D & C could eliminate fibroids, but scraping the lining of the uterus to remove a fibroid is like raking leaves and expecting to remove the boulder in the ground. D & C’s are useful for evaluating bleeding, but are not really meant to treat the bleeding.
When I perform a D and C, it is always accompanied by hysteroscopy in which I slide a slender scope with a camera and light attached to it through the cervix in order to see what’s going on inside the uterus. If a fibroid is present, I insert a small instrument through the hysteroscope to cut the fibroid into small pieces, a process known as fibroid resection or morcellation. The small pieces of fibroid than are easily removed. The patient goes home that day, fibroid-free.Hysteroscopic morcellation does not have the same issues as uterine morcellation performed during laparoscopy. During hysterscopy the fibroid fragments stay inside the uterine cavity prior to removal. In the rare instance that an unknown cancer is found, it will not spread to other places.
Even in the right hands, not every woman is a candidate for hysteroscopic myomectomy. The fibroid has to be the right size and the right location. Sadly, for those that are candidates, the biggest hurdle to this procedure is finding a surgeon to do it. Too many gynecologists still do not offer hysteroscopic myomectomy to their patients.
If you have fibroids and have been told that hysterectomy is your only option, it is worth asking your doctor if you are a candidate for hysteroscopic myomectomy. If he or she doesn’t seem familiar with the procedure, or doesn’t offer it, a second opinion is in order.