Myomectomy

More women are delaying childbearing into their 30s, a decade when fibroid symptoms often surface. Doctors may recommend myomectomy — surgical removal of the fibroids and repair of the uterus — for women with troublesome fibroids who plan to bear children or who want to keep their uterus.

Women who undergo myomectomy report improvement in symptoms such as heavy menstrual bleeding. And myomectomy has a low complication rate. Still, myomectomy brings a unique set of challenges for your surgeon.

Challenging aspects of myomectomy

• Blood loss. The uterus has a rich network of blood vessels, and fibroids stimulate growth of new vessels to obtain their own blood supply. So during myomectomy, surgeons must take extra steps to avoid excessive bleeding. These steps include blocking flow from the uterine arteries and injecting medications around fibroids to cause blood vessels to clamp down.

• Restoring the structure of the uterus. To remove imbedded fibroids, the surgeon might cut into the muscular wall (myometrium), leaving a gap. Closing it requires stitches (sutures), usually in layers.

  Rarely, the surgeon must remove the uterus if bleeding is severe or if he or she can't reconstruct the uterus.

• Scar tissue. Incisions into the uterus to remove fibroids can lead to adhesions — bands of scar tissue that may develop after surgery. Within the uterus, adhesions may block implantation of a fertilized egg in the uterine lining. These kinds of adhesions are rare with myomectomy. Outside the uterus, adhesions could entangle neighboring structures and lead to a blocked fallopian tube or a trapped loop of intestine.

Myomectomy doesn't eliminate your risk of developing more fibroids later. Tiny tumors (seedlings) that your doctor doesn't detect during surgery could eventually grow and cause symptoms. New tumors also can develop. Women who had only one or two fibroids have a lower recurrence rate than do women with multiple fibroids. If fibroids return, future treatment — a repeat myomectomy, hysterectomy or other procedure — may be necessary. However, this isn't definite. Remember, fibroids usually grow slowly and they shrink after menopause. Even if they return, you could reach menopause without experiencing symptoms that require treatment.

Strategies to prepare for possible surgical complications

• Banking blood. If your doctor is concerned that blood loss might be greater than average, you may be advised to have some of your blood drawn and stored before myomectomy in case you need a blood transfusion during surgery.
• Iron supplements. If you have iron deficiency anemia from heavy menstrual periods, your doctor might recommend iron supplements.
• Hormonal treatment. Another strategy to correct anemia is hormonal treatment before surgery. Your doctor may prescribe a gonadotropin-releasing hormone (Gn-RH). When given as therapy, a Gn-RH agonist blocks the production of estrogen and progesterone, stopping menstruation and allowing you to rebuild hemoglobin and iron stores.
• Preshrinking fibroids. Gn-RH agonist therapy could also shrink your fibroids and uterus enough to allow your surgeon to use a horizontal Pfannenstiel incision. This incision leaves a less noticeable scar than does the vertical incision, which doctors often use to remove fibroids from a large uterus.

Some women object to Gn-RH agonist therapy because it causes symptoms of menopause, including hot flashes, night sweats and vaginal dryness. However, these discomforts end when you stop taking the medication.

Evidence remains unclear regarding the benefits of Gn-RH agonist therapy before myomectomy. Therapy can lead to higher hemoglobin and iron levels, higher red blood cell counts, less blood loss during surgery, and shorter operations. However, the shrunken, softened fibroids that result can be more difficult to detect and remove.

Three surgical approaches

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	Vertical and Pfannenstiel incisions
	Incision over a uterine fibroid
	Removing a uterine fibroid
	Laparoscopic surgery on the uterus

The size and type of your fibroids influence the surgical approach.

Abdominal myomectomy (laparotomy)
In this operation, your surgeon enters the pelvic cavity through one of two incisions. A vertical incision starts in the middle of your abdomen and extends from just below your navel to just above your pubic bone. A horizontal bikini-line incision (Pfannenstiel incision) runs about an inch above your pubic bone.

Because the Pfannenstiel incision follows your natural skin lines, it usually results in a thinner scar and causes less pain than does a vertical incision. However, it gives the surgical team less access to your pelvis, which may be important if your uterus is particularly large or greatly distorted. The vertical incision can result in a longer scar and has a higher risk of reopening (herniation), but it gives your surgeon greater access to your uterus and promotes less bleeding.

Some surgeons recommend a vertical incision if your uterus is the size of that of a 16-week pregnancy or larger. This incision might also be used if a fibroid is in a ligament between your uterus and pelvic wall.

During the procedure, your surgeon inspects your uterus visually and by touch for fibroids. He or she makes an incision in your uterus down to the level of the fibroid, grasps the tumor with instruments, and peels it away from normal uterine tissue. He or she then repairs the uterus.

Abdominal myomectomy usually requires a hospital stay of three to four days. Recovery takes four to six weeks.

Hysteroscopic myomectomy
If you have submucosal fibroids that bulge into your uterine cavity, your surgeon may suggest a hysteroscopic myomectomy. This requires general anesthesia.

Your doctor inserts a small, lighted instrument — called a resectoscope because it cuts (resects) tissue — through your vagina and cervix and into your uterus. Attached is a tube that releases a clear liquid to expand your uterine cavity and allow examination of the walls.

Your surgeon can use the resectoscope to shave pieces from a fibroid until it aligns with the surface of your uterine cavity or can use a laser to remove the tumor. Fragments wash out during the procedure.

Your surgeon might also use a laparoscope, a narrow tube fitted with a camera that's inserted into your abdomen. It provides a view of your pelvic cavity, allowing your surgeon to monitor the outside of your uterus while he or she removes fibroids from inside your uterine cavity.

Laparoscopic myomectomy
In this procedure, your surgeon makes small incisions in your lower abdomen and inflates your abdomen with carbon dioxide gas. He or she then places a laparoscope inside your pelvic cavity to provide images of the outside of your uterus, ovaries and neighboring pelvic organs. Your surgeon then performs the operation with specially crafted instruments inserted through the small incisions. The doctor removes the fibroid through the laparoscopy incisions or through an incision in your vagina (colpotomy).

Some surgeons have strict guidelines on uterine size and fibroid number to determine when laparoscopic surgery is appropriate. However, no consensus exists. A surgeon might, for example, use this technique only for subserosal fibroids, which are on the outside of the uterus and easier to reach. This approach is somewhat controversial for women who desire a future pregnancy because repair of the uterine wall may not be as sound with the laparoscope.

What to expect

A myomectomy requires that you arrive at the hospital on the day of surgery and stay for a few days afterward if you have abdominal incisions. If your procedure is laparoscopic, you can usually go home the same day.

How do you prepare?
To make sure that your stomach is empty, refrain from eating and drinking for about eight hours before your surgery. If you're on medications, ask your doctor if you should stop taking them before or after surgery. Leave valuables at home; remove any nail polish.

When you arrive at the hospital, staff members help you prepare for surgery. You need to remove eyeglasses or contact lenses, hairpins or hair ornaments, and dentures.

To prepare for surgery, you change into a hospital gown and put on special stockings to prevent blood clots in your leg veins. A nurse may clean and possibly shave your abdomen and genital area. Before going to the operating room, you may receive an injection of pain medication.

How is it done?
In the operating room, members of the surgical staff attach strips of tape connected to wires to your torso and arms to monitor your heart rate. A device (pulse oximeter) is placed on one of your fingers to keep track of oxygen levels in your blood.

A nurse inserts a needle — attached to a slender tube — into a vein in your arm (intravenous, or IV) to give you fluids, anesthetics, antibiotics or pain medication. A thin tube placed in your urethra (urinary catheter) keeps your bladder empty.

This surgery usually requires general anesthesia, which means you're given drugs that make you lose consciousness. You receive anesthesia drugs (anesthetics) intravenously, or you inhale them through a mask. They act as hypnotics, painkillers and muscle relaxants.

A machine (ventilator) ensures that you receive enough oxygen while getting the correct dose of anesthetic. The ventilator has a tube that goes into your mouth and down your windpipe (trachea).

After the procedure
In the recovery room, staff members monitor your condition. When the effects of the anesthesia fade, staff members bring you to your hospital room for continued observation.

To control pain, your doctor may give you an opioid (morphine and related drugs), nonsteroidal anti-inflammatory drugs (NSAIDs) or both. Many hospitals offer patient-controlled analgesia (PCA), a system that delivers a dose of pain medication to your bloodstream through a vein when you press a button.

Usually by the next day, oral medications replace IV medications. You may receive IV fluids until you're able to drink, and you may not be able to eat solid foods right away. Medical staff members urge you to walk around as soon as you're able, because walking reduces the risk of many postoperative complications.

At discharge from the hospital, your doctor prescribes oral pain medication, tells you how to care for your incision, and discusses restrictions on your diet and activities. You may have to avoid certain activities, such as driving, lifting heavy objects, climbing stairs or exercising vigorously until you recover. Also, your doctor may advise that you not use tampons or have sexual intercourse for up to six weeks. You can expect some vaginal drainage for up to six weeks as well. If you have a hysteroscopic myomectomy, you can usually return to work in a week or less, and if you have a laparoscopic myomectomy, you can plan a return to work in about one to two weeks.

Common concerns about myomectomy

You may have concerns about fertility and whether you'd be able to get pregnant after a myomectomy. Or you may wonder whether a myomectomy could improve your chances of becoming pregnant if you've had trouble.

Infertility
The link between fibroids and infertility isn't clear. But if you have fibroids and have been unable to get pregnant or have had repeated miscarriages, your doctor might suggest treatment for your fibroids. There's good evidence that submucosal fibroids that distort the uterus pose a problem for fertility and should be removed. But it's less clear what to do for intramural and subserosal fibroids.

Studies of the effects of fibroids on assisted reproductive techniques, such as in vitro fertilization and intracytoplasmic sperm injection, produce conflicting results. One study found that implantation of a fertilized egg and good pregnancy outcomes are reduced only when fibroids have deformed the uterine cavity. Another investigation suggested that fibroids smaller than 7 centimeters (2.8 inches) that don't distort the uterine cavity don't affect implantation or miscarriage rates. In contrast, other teams of researchers found that intramural or submucosal fibroids reduce pregnancy and implantation rates, even if the uterine cavity isn't distorted.

Many women do become pregnant after myomectomy. However, reported fertility rates vary widely. Several studies reported that about half the women who attempt pregnancy after myomectomy conceive. An analysis that considered pregnancy outcomes found that about two-thirds of the women delivered babies after myomectomy.

Myomectomy itself can pose some risks in pregnancy. This includes the development of adhesions that can block fallopian tubes. If the uterine wall is deeply cut during myomectomy, doctors usually recommend that women undergo Caesarean section for subsequent pregnancies to avoid rupture of the uterus during labor.

In the past, doctors discouraged women in their 40s from having a myomectomy, even if they wanted to bear children. Because fertility rates in women in this age group are low, the argument goes, the risks of myomectomy aren't justified.

For a woman in her 40s, the chances of having a successful pregnancy using her own eggs are diminished. Still, some women beat the odds. Also, procedures using donor eggs or donor embryos can result in successful pregnancies in older women.

Other concerns
You might have reasons other than fertility to keep your uterus. Perhaps you fear that a hysterectomy will change your sexual response. Maybe you believe that your uterus is strongly linked to your femininity. Or you might object to losing a major organ.

When making a decision, carefully consider both your desires and your circumstances. Discuss your preferences with your doctor. In the hands of an experienced surgeon, myomectomy is safe and effective. If you and your doctor can't agree, seek another opinion.

Pros and cons

A myomectomy may be a good option if you plan to bear children or simply want to keep your uterus. But it isn't the best solution for everyone. Your preferences and concerns play a large role in determining the right choice for you. Before deciding whether to undergo a myomectomy, consider these points:

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