Types of Fibroids: Fibroids are classified by their location (see figure), which effects the symptoms they may cause and how they can be treated. Fibroids that are inside the cavity of the uterus (intracavitary myomas) will usually cause bleeding between periods (metrorrhagia) and often cause severe cramping. Fortunately, these fibroids can usually be easily removed by a method called "hysteroscopic resection," which can be done through the cervix without the need for an incision. Submucous myomas are partially in the cavity and partially in the wall of the uterus. They too can cause heavy menstrual periods (menorrhagia), well as bleeding between periods. Some of these can also be removed by hysteroscopic resection. Intramural myomas are in the wall of the uterus, and can range in size from microscopic to larger than a grapefruit. Many of these do not cause problems unless they become quite large. There are a number of alternatives for treating these, but often they do not need any treatment at all. Subserous myomas are on the outside wall of the uterus. A fibroid may even be connected to the uterus by a stalk (pedunculated myoma.) These do not need usually treatment unless they grow large, but they can twist and cause pain. This type of fibroid is the easiest to remove by laparoscopy.Diagnosis
Fibroids may be felt during a pelvic exam, but many times myomas that are causing symptoms can be missed if the examiner relies just on the examination. Also, other conditions such as adenomyosis or ovarian cysts may be mistaken for fibroids. For this reason, I routinely do an ultrasound examination at the time of the first visit(saline enhanced sonography or sonohysterogram). While this will often provide additional information to the regular ultrasound, I usually learn much more by looking inside the uterus with a little telescope. This exam, called hysteroscopy, is usually done in my office, and allows me to directly look inside the uterus. when a woman has symptoms of abnormal bleeding or cramping, or if I feel an abnormality on examination. Vaginal probe ultrasound only takes a few minutes to do, is not uncomfortable, and rapidly provides invaluable information if the examiner is experienced in looking at uterine abnormalities. It is possible to fill the uterus with a liquid during the ultrasound
Adenomyosis confused with fibroids:
One of the most common conditions confused with fibroids is adenomyosis. This can be a serious error, as the treatment may be quite different. In adenomyosis the lining of the uterus infiltrates the wall of the uterus, causing the wall to thicken and the uterus to enlarge. This can cause severe pain, and heavy bleeding.On ultrasound examination adenomyosis will often appear as diffuse thickening of the wall, while fibroids are seen as round areas with a discrete border. Adenomyosis is usually a diffuse process, and rarely can be removed without taking out the uterus. Since fibroids can be removed by myomectomy, it is essential to differentiate between the two conditions before planning treatment. It is also common to have adenomyosis and fibroids in the same uterus.
Which fibroids can be removed laparoscopically?
Fibroids that are attached to the outside of the uterus by a stalk (pedunculated myomas) are the easiest to remove laparoscopically. Many subserous myomas (close to the outer surface) can also be removed through the laparoscope.
Fibroids that are deep in the wall of the uterus, or submucous are most difficult to remove laparoscopically. Although there have been successful pregnancies after laparoscopic removal of deep or multiple myomas, the real question is whether or not the uterus can be repaired as well through the laparoscope as can be done through an abdominal myomectomy.
What are the advantages and disadvantages of laparoscopic myomectomy?
The advantage of a laparoscopic myomectomy over an abdominal myomectomy is that several small incisions are used rather than one larger incision. It is important to understand that even a laparoscopic myomectomy is real surgery, and often requires several weeks of recovery. Another major factor in recovery time is motivation; I have found motivation can be just as important in recovery as the type of surgery.
One concern when there are multiple fibroids is of leaving smaller myomas behind. Often it is necessary to feel the uterus to find the smaller myomas; these likely would be left behind during a laparoscopic myomectomy. To summarize, I think laparoscopic myomectomy is best for pedunculated and superficial myomas. When there are deep myomas and a large number of myomas, I think that it is possible to repair the uterus better by doing an abdominal myomectomy.
