She felt heavy pressure from her growing uterus, and she was so anemic that she almost needed a blood transfusion. I ordered an MRI, which show too many small fibroids to count. The largest fibroid was only 3.5cm (about 1 1/2 inches) and the uterus was like a big bag of small marbles.  I did office hysteroscopy to look directly inside the uterus, and this confirmed that there were numerous submucous myomas on the inside of the uterus as well as in the walls.

Photo shows “too numerous to count” small fibroids.  Read on to learn about Abby’s decision making process.

The decision making process:

Abby’s main priority was to stop her heavy bleeding.  Childbearing wasn’t important.  Here were her choices:

Myomectomy: While large fibroids are easy to identify and remove, Abby’s uterus consisted of multiple fibroids, many of which were the size of a pea and smaller.  It is impossible to find and remove all of the hundreds of tiny fibroids  and the grain of rice size “seeds”.  The risk of needing further surgery in this situation is almost 100%.

UFE or UAE (Fibroid Embolization):  As well as fibroids in the wall (intramural), Abby had numerous submucous myomas.  The goal of embolization is to cut off the blood supply so the fibroids die.  With submucous fibroids women often will have an extremely heavy vaginal discharge for months to years as they shed dead fibroid tissue.

Hysterectomy: At the age of 37, Abby had 14 years before reaching the average age of menopause, during which time her remaining fibroid “seeds” would be expected to grow.  Hysterectomy is the only treatment with a guarantee that her heavy bleeding would permanently stop.   It is not an option though if childbearing is important.  It is, however,  important to save ovaries unless there is an overwhelming reason to remove them.

Yesterday, 5 years after her hysterectomy,  Abby came to see me for a routine exam. She is extremely happy with her decision that allowed her to return to a normal life.  She was happy to allow me to share her story with others.

Note:  Most of the women I see come to me for alternative treatments to hysterectomy for their fibroids. In most situations there are alternatives to hysterectomy, with each option having advantages and disadvantages. I see many women who have been advised to have a hysterectomy for whom I recommend less invasive surgery or alternatives to surgery such as medical management or simple observation.  But occasionally a hysterectomy can really improve the quality of life.  —Paul Indman, M.D.

I have explained the importance of hysteroscopy for seeing directly into the uterus, but fewer than 10% of OB/GYN’s in the US are equipped to do hysteroscopy in an office setting. I’m hoping to change that. Last year I was approached by an engineer with a video camera the size of a pinhead, asking how we could use it in gynecology. Together, we developed a small portable hysteroscope. It consists of a small reusable handle with a screen the size of a smartphone, coupled to a sterile single-use hysteroscope utilizing a built-in high resolution camera integrated with light source.

Current hysteroscopes require an investment in thousands of dollars of equipment, including a light source, video camera, and video monitor. Care and sterilization of instruments, and setting up for hysteroscopy are time consuming and often do not fit into the schedule of a busy office. As a result, most women who need hysteroscopy are taken to the operating room, at much greater expense and inconvenience. My goal is to enable every gynecologist to do office hysteroscopy. It is important to note that this instrument currently has investigational status and has not been cleared by the FDA for commercial use.

I have been using this hysteroscope as part of an investigational study. If you would like to learn more about this, I was recently interviewed by Hope Waltman, at OBGYN.net. The following link to the interview also has a link to a video of using the hysteroscope during a clinical trial in my office. Interview at

Note: Full disclosure: I am a co-founder and shareholder in the EndoSee Corporation, which is developing the hysteroscope. — Paul Indman, M.D.

One correction that Dr. Indman may/not choose to make to the story (I think it’s important) is that I was not originally referred to him by my OB after a trip to the ER. My OB did not help me at all after that trip to the ER, so  Derek [Michelle’s husband] found Dr. Indman on-line (we wanted a second opinion from someone who was an expert on fibroids). I think it’s important because the doctor I was using at the time basically sent me on my way with bleeding so severe I couldn’t even stand up without losing large amounts of blood.  Dr. Indman not only immediately correctly diagnosed the problem, he helped me solve it while preserving my fertility options.

Thanks.

Michelle

Michelle with her sons

I first saw Michelle when she was 35 in 2005.  She had her first myomectomy at the age of 26 and her second at the age of 33.  She was sent to me by her Ob-Gyn after an ER visit for severe bleeding.

I did an ultrasound on the first visit, and there was fluid in the uterus which outlined a large submucous fibroid. The bulk of the fibroid was in the wall rather than inside the cavity of the uterus.  Because of the location I felt hysteroscopic treatment was inadviseable.  Although we were concerned because she already had two abdominal myomectomies (elsewhere), I did her third myomectomy.

I did an ultrasound in September, 2006 showing a healthy 10 week prgnancy.  Michelle delivered her first son by cesarean in 2007. Her OB noticed some scar tissue inside her uterus at the time.  I later did an office hysteroscopy to clear this and a small amount of retained placental tissue and treat the scar tissue.  In October, 2010, she returned with another healthy early pregnancy.

Comment:  Michelle came in today with her 4 year old son, her 4 month old baby, and a picture of them taken when he was just born.  Even if you have had prior surgery don’t give up hope without seeing an expert in the treatment of fibroids.

Aisha was 38 when I saw her in 2007 with a long history of infertility and fibroids making her look 5 months pregnant

When I originally saw her her uterus was the size of a 20 week pregnancy. An MRI showed multiple fibroids.  She underwent a myomectomy to remove the fibroids. 

Her uterus, before the removal of fibroids, and the fibroids that were removed are shown below.

Now, four years after her myomectomy and successful pregnancy her uterus is normal size.

Comment:  Some of my most satisfying moments as a gynecologist are seeing women who thought there was no hope for having children come in with their babies.  — Paul Indman, M.D.

Tranexamic Acid Treatment for Heavy  Menstrual Bleeding

Andrea Lukes et al.: Obstet Gynecol. 2010 Oct;116(4):865-75.

Tranexamic acid has been used around the world for over 20 years to treat heavy menstrual bleeding. It was recently approved by the FDA in the U.S., and is sold under the trade name LYSTEDA™. In this study 196 women were randomized to receive either LYSTEDA™ or a placebo (sugar pill).  36% of women in each group had fibroids. Menstrual blood loss was measured before any medication and after taking either LYSTEDA™ or the placebo.  

Results: Measured blood loss decreased by an average of 40% in women taking LYSTEDA™ and 8% in women taking the placebo. The LYSTEDA™ group also reported a reduction in problems with flooding, leakage, and  sexual function.  There was little difference in reported side effects between the group that received LYSTEDA™  and the placebo group. One concern with this type of medication is the possibility of blood clots (DVT) forming in other blood vessels in the body, but there were no cases of DVT in the women taking LYSTEDA™.    One of the women taking the placebo (who did not take LYSTEDA™)  developed a DVT.

Comment:  How does LYSTEDA™ (tranexamic acid) work? Menstrual bleeding stops when tiny clots seal blood vessels in lining of the uterus.   (These clots are needed to stop bleeding, and are not the large clots you may pass when you’re bleeding heavily.)  In addition to materials that form clots there are compounds in menstrual blood (plasmin) that dissolve these clots.  When they dissolve too fast excess bleeding occurs (although there can be other causes of heavy bleeding).  LYSTEDA™  works by interfering with plasmin production, so the tiny clots needed to stop bleeding do not dissolve too quickly.

76% of women in this study reported decreased bleeding with LYSTEDA™. The beauty of LYSTEDA™  is that you can tell with one cycle if it is going to work for you.  If it works the fist cycle it will likely continue working and if it doesn’t it is unlikely to help.

LYSTEDA™ can be used for long term treatment if surgical or other treatment is not needed, or as a temporary measure until definitive treatment can be carried out.

ADDENDUM:  May 12, 2011

The FDA has issued a warning about the risk of DVT (blood clots in the legs) and other areas when combined with oral contraceptives, especially in women who are obese or smoke cigarettes.   Women in the clinical trials were not taking oral contraceptives so there is no clinical trial data on the risk of combining these with Lysteda™ .  There have been US postmarketing reports of blood clots when combining oral contraceptives and Lysteda, particularly in these high risk groups.

The FDA concluded:

Women using hormonal contraception, especially those who are obese or smoke, should use Lysteda only if there is a strong medical need and the benefit of treatment will outweigh the potential increased risk of a thrombotic event.  Do not use Lysteda in women who are taking more than the approved dose of a hormonal contraceptive.

Comment:  As with any medication, the risks of taking it need to be balanced with the risks of not taking it.

Mirena IUD next submucous fibroid

The IUD was removed.   Since she was not planning any more children, we removed the fibroid by hysteroscopic myomectomy, and did an endometrial ablation at the same time as an outpatient procedure.

Comment:   The Mirena®  IUD (LNG-IUS) is often effective in treating heavy periods, but a fibroid inside the cavity can interfere. I always recommend doing a simple ultrasound exam in women with abnormal bleeding before deciding on a treatment.  Other studies such as diagnostic hysteroscopy may also be done, as only with proper diagnosis can appropriate treatment be planned. In her situation a simple outpatient procedure was able to solve her bleeding problem.

My experience with Dr. Indman and his staff have been nothing short of fantastic. Dr. Indman is a warm, caring, highly skilled surgeon – with a fun sense of humor to boot! He is one of those rare gems in the medical profession today – someone who truly puts patients first. I found Dr. Indman while researching my symptoms on the Internet. The wealth of helpful information on his website gave me a lot of confidence even before I met him. His deep expertise and decades of experience are evident from his thorough examinations and explanations.  — S.K.

Comment:  S.K. had a submucous fibroid, which was treated by hysteroscopic myomectomy and endometrial ablation as an outpatient.  Here are actual pictures from her surgery.  The first shows the fibroid on the right side of the uterus, with the loop that will be used to remove it.  The second shows the fibroid having been removed, and the third is after endometrial ablation.  I do the endometrial ablation under direct vision to be sure that no areas are missed.

It is not unusual for women to resume most normal activities within a day or two.  Careful patient selection and utmost skill are required for a safe and successful procedure. — Paul Indman, M.D.

Update:  12/14/2010: S.K. came in for a 4 month check after her procedure, having recently run a marathon.   She said that she kept thinking that without the surgery running a marathon would have been impossible.

Dr. Indman’s counseling and support before the surgery was very reassuring and comforting for me, and I was very confident that he would do everything for me to get a great result. Dr Indman really paid attention to what I wanted and also what I did not want to experience, and he respected my wishes. He spent a lot of time with me.

The surgery Dr. Indman performed was extraordinary. He saved my uterus!  He removed 69 fibroids (many of which were in multi fibroid clumps). My surgery went incredibly well. I had a very positive experience with the surgery and recovery, and also with the hospital stay. The medical staff at Good Samaritan hospital in Los Gatos was very warm and helpful

Dr. Indman was very supportive and available during my recovery time in the hospital, and during my postoperative visit. I recovered very fast after the surgery. My scar is very thin and barely noticeable already, after only two months. My menstrual bleeding is only half of what it was before the surgery.

I would highly recommend Dr. Indman to anyone needing surgery, or ongoing gynecology services and support.  His office staff personnel are also all really wonderful, warm and supportive!

-A.S.  Bay Area, CA

As her MRI also suggested a uterine polyp,  I did an office hyteroscopy to evaluate the inside of her uterus.   What looked like an endometrial polyp on MRI was really the tip of a submucous fibroid.

I presented a number of options to J.L. including embolization (UFE), endometrial ablation, myomectomy, and hysterectomy.  Because she smokes she is not a candidate for birth control pills to control her bleeding.  As she is not bothered by pressure, and most likely the fibroids will decrease in size after menopause, she would be happy if her bleeding could be controlled without surgery.

Fortunately a medication that has been used around the world to decrease bleeding has finally been released in the United States.  Tranexamic acid, marketed in the U.S. as Lysteda™,  prevents the tiny clots that stop bleeding from dissolving. Studies have shown that it can cut  menstrual blood loss in half.  I started J.L. on Lysteda™ and will let you know how she does.

Comment:  Not every woman who has fibroids needs surgery. This is especially true for many women close to menopause.   I encouraged J.L to see if her heavy bleeding is controlled by tranexamic acid, as there is nothing to lose by trying it .   I’m very excited about having Lysteda™ available, and will be devoting an entire post to it in the future.