Menstrual Disorders, Fibroids & Polyps

Hysteroscopic Myomectomy with Ultrasound Guidance

Ultrasound-Guided Hysteroscopic Myomectomy (UGHM) (Myoma / Fibroid Removal)

Many fibroids (myomas)—particularly ones that cause heavy menstrual bleeding—are inside the uterine cavity and can be removed through natural body orifices—the cervix and the vagina.  Approximately 1/3 of the women we see for abnormally heavy menstrual bleeding have fibroids within the uterine cavity known as submucous fibroids.  In 1995, we began removing these fibroids with both a resectoscope (the instrument placed inside the uterus) and using ultrasound guidance.

Myoma Removal (Myomectomy) with Ultrasound GuidanceThese 2 techniques—used together—enables us improve our success rates of the procedure while keeping complications to a minimum.  The resectoscope consists of a lit telescope along with an electrically charged electrode (not a laser).  The electrode can cut and cauterize the tissue more effectively than any instrument developed to date.  Even though there are newer devices—called mechanical morcellators—they are simply incapable of removing fibroids as efficiently as the traditional resectoscope.  The electrical loop can be easily seen on ultrasound and allows one to monitor the surgery in 3 dimensions.

Frequent Asked Questions (FAQs) about Ultrasound Guided Hysteroscopic Myomectomy (UGHM).

1. HOW LONG HAVE YOU BEEN PERFORMING HYSTEROSCOPIC MYOMECTOMY?  HOW LONG HAVE YOU BEEN PERFORMING IT WITH ULTRASOUND GUIDANCE?

We began performing hysteroscopic myomectomy in 1988 and started using ultrasound guidance in 1995.

2. HOW MANY OF THESE PROCEDURES HAVE YOU PERFORMED AT THE CENTER FOR MENSTRUAL DISORDERS?

We estimate that we have performed about 1,000 cases between 1988 and 2015.

3. HOW WOULD I KNOW IF HYSTEROSCOPIC MYOMECTOMY IS RIGHT FOR ME?

Knowing whether or not hysteroscopic myomectomies (removal of fibroids) is right for you will depend on many factors including: your age, whether or not you’ve completed your family, the number, and size of your fibroids as well as their grade click here.   There are many other factors to consider as well.  Ultimately, this decision is one you’ll make after you’ve had an opportunity to review your particular case with our team.

4. CAN HYSTEROSCOPIC MYOMECTOMY BE COMBINED WITH OTHER PROCEDURES?

It depends.  Sometimes, the goal is simply to remove the fibroid and not anything else in the uterus.  This is especially true of younger women in their 20s, 30s and even early 40s who would like to preserve the option of having children.  In other instances—women in their mid-to-late forties and beyond—we often combined hysteroscopic myomectomy with an endomyometrial resection (EMR) click here.   The identical instruments and “set up” for our operating room is used for both removal of fibroids, polyps and for EMR.   This allows us to adapt our procedure to your specific needs.

5. IF I DECIDE TO HAVE AN MYOMECTOMY, WHAT CAN I EXPECT?

Procedures are booked anywhere from 1-6 weeks in advance depending on your individual circumstances and our patient load.

In some instances we use a medication called Lupron Depot.  This is only used in a small percentage of patients but is reserved for cases in which we feel there would be an advantage to “shrinking” your fibroid prior to surgery.  The medication is both expensive and has some undesirable side-effects so we’ll only suggest it if we feel it has some real advantages for you.

Intramural Myoma
Intramural Myoma

When your procedure is scheduled you will actually be given two appointments.  The first appointment will be for the procedure itself.  These are generally scheduled at 8:15 AM or 12:45 PM.  The procedures typically take 20-40 minutes to perform and you can expect to spend an additional 60-90 minutes recovering from your procedure.  The second appointment you will be given is one scheduled for the afternoon prior to your EMR.  During this visit a laminaria (cervical dilator) is placed in the cervix.  Since this can cause cramps in some women you may elect to be sedated for this brief procedure (2-3 minutes).  If you are uncertain whether or not you wish to be sedated it’s best to bring someone with you so that you can be driven to and from the office.   About half of our patients elect to have intravenous sedation for the laminaria insertion.

The procedure itself may take between 20 and 60 minutes depending on many factors.  You can get a more specific estimate about your case simply by asking us.  However, you should expect to spend between 2 and 4 hours at our office depending on the complexity of your case.

After your procedure you will likely spend much of the day of surgery at home resting.  The medications you’ve received during your procedure will still make you feel quite sleepy.  You should expect to do little other than rest in bed.  The following day you may have slight or even moderate cramps that should quickly dissipate throughout the day.  You will be able to bathe or shower following the procedure.  Within 36-48 hours after the procedure you should feel well enough to go about most, if not all, of your routine daily activities.

6. HOW LONG WILL IT TAKE TO RECOVER FROM MY MYOMECTOMY (FIBROID REMOVAL)?  HOW LONG WILL I NEED TO TAKE OFF FROM WORK?

Most women will need 36-48 hour to recover.  Often women try to schedule their procedure late in the week and return to work on Monday morning.

7. HOW LONG WILL IT TAKE BEFORE I KNOW IF THE PROCEDURE WORKED?

The results of hysteroscopic myomectomy should be noticeable within 1 month following the procedure.  However, you may not appreciate the full benefit until 3-4 months following the procedure.

8. WHAT KIND OF FOLLOW UP CAN I EXPECT AFTER THE PROCEDURE?

You will be asked to schedule a follow-up visit 2 weeks and 4 months following the procedure.  Your visit will include a transvaginal ultrasound examination so that we can monitor the healing that occurs within your uterus.  Although you will experience a noticeable difference within one cycle after your myomectomy procedure the uterus takes at least 4-6 months to heal.  In addition you may be monitored on as often as every 6 months or annually thereafter with ultrasound examinations.  This will depend on a variety of factors including your age and the number of fibroids removed.

References

Wortman M., Daggett A:  Hysteroscopic Myomectomy: . J Am Assoc Gynecol Laparosc Nov 1995.  Vol 3: No. 1 pp 39-45.

Wortman M:  Diagnostic and Operative Hysteroscopy.  In Outpatient and Office Gynecologic Surgery.  Penfield, AJ, Editor.  Williams and Wilkins Company.  Baltimore, Maryland 1997.  pp. 65-130.

Wortman, M:  Hysteroscopic Myomectomy:  Complications and Prevention.  Female Patient. October 1998.

Wortman M.  Hysteroscopic Myomectomy:  Pearls and Pitfalls from 24 years of practice.  Contemporary Obstetrics and Gynecology.  August 2012; 57:26-31.

Wortman M.   Sonographically Guided Hysteroscopic Myomectomy (SGHM):  Minimizing the Risks and Maximizing Efficiency. Surg Technol International.  XXIII:181-9.