Fibroids
Benign muscular growths in the uterus. We treat large and complex fibroids, including those that other centers decline.
Fibroids range from incidental to life-limiting. Size is not the whole story. Position matters more, and a small fibroid in the wrong place can cause more trouble than a large one elsewhere.
How common they are
Fibroids are curious things: almost all women have them. On the best ultrasound-based figures, by the age of fifty around seventy percent of white women and more than eighty percent of Black women will have had them.
It is the fact that they are so common and so varied that makes managing them so nuanced. Some women have one fibroid; some have thirty. Many will never need anything done at all. Having fibroids is not in itself a reason to remove them, and it is not a reason to have a hysterectomy.
Position matters as much as size
The location of a fibroid is just as important as how big it is, and the plan depends on all of it together: how many there are, where they sit, how large they are, and what you want for your fertility and your uterus. There is no one way to manage fibroids.
A small fibroid inside the uterine cavity can cause heavy periods, constant bleeding, bleeding between periods or with sex. Deceptively small ones there can be genuinely dangerous: women can bleed enough to become severely anemic and need transfusions, and a cavity fibroid can begin to push out through the cervix into the vagina, which is extremely painful. Almost all of the urgent and emergency fibroid surgery I have done has been for fibroids in the cavity, not for the largest ones.
Fibroids in the muscle of the wall behave more like adenomyosis: pelvic swelling, pressure, pain with sex, very heavy bleeding.
Before menopause, a growing fibroid's only real limit is the space in the abdomen, so they can reach the size of a watermelon. At that size people have trouble exercising, trouble breathing, trouble lying on their stomach; some simply look and feel pregnant and cannot close their pants. Large ones can compress arteries, veins and the ureters, and that can make surgery urgent in its own right.
Fibroids and pregnancy
The ones inside the cavity, and the ones distorting the shape of the uterus, are the ones most likely to affect fertility. That is genuinely hard to predict for any individual.
We see people with large fibroids who go through pregnancy without difficulty, and people with relatively small ones in the middle of the uterus where a pregnancy cannot grow, and that ends in miscarriage. Fertility plans sit at the center of every fibroid conversation for exactly this reason.
If you have been told yours are too large or too complex
At the end of the day, any fibroid can be surgically removed. The real questions are whether the surgical team has the expertise to remove it safely, ideally in the least invasive way possible, and whether the institution behind them has the staff and equipment a complex case needs.
Some cases are genuinely difficult. Very large fibroids can fill the pelvis and abdomen so completely that keyhole instruments have no room to work, and those are sometimes better done open. Fibroids buried in the back of the uterus are hard to reach and the incision is hard to close well. Some sit against important structures: in the fold of tissue beside the uterus where the ureter runs (the tube carrying urine from the kidney to the bladder), along the bladder, or coming off the cervix. Rarely, a fibroid detaches entirely and lives on the blood supply of something else, like the bowel, usually discovered in someone who has had fibroids removed before. Fibroids hanging on a stalk full of blood vessels bleed easily. And small cavity fibroids have to be shaved out through the cervix with special instruments, which takes time and preparation.
Difficult is not the same as impossible. I remove extremely large fibroids, up to roughly 1,400 grams, through keyhole incisions, using either traditional laparoscopic or robot-assisted surgery; for the very largest and the deepest in the pelvis, I most often use the robot.
The other half of a complex case is what happens before and around the operation. I plan on a good MRI: mapping every fibroid, its depth, where each can be removed from the uterus safely, whether any sit against the rectum, and where the small incisions should go given how tall the uterus stands. Where the blood count is low we build it up before surgery, and during it I use several medications to keep blood loss down: a pill that goes into the rectum, an intravenous medication at the start, and an injection placed directly into the muscle of the uterus.
Whether the uterus can stay
Almost always. The operation that removes the fibroids and keeps the uterus is called a myomectomy, and it is almost always possible. Whether it is the right choice is the more complicated question, because fibroid removal can be a bloody operation, and honest expectations about what can be removed safely matter more than a blanket promise.
If you have a strong desire for fertility, or you simply want to keep your uterus, I work very hard to make that happen. There are situations where a myomectomy is genuinely the more dangerous choice, usually an older patient with a uterus carrying more than 25 or 30 fibroids, and I am honest when that is the case, because safety comes first.
Fibroids do commonly grow back. Even when every visible fibroid is removed, some women simply have a propensity for making them, and tiny ones already growing are invisible at surgery. About half of women who have a myomectomy see regrowth within about five years, and around 30 percent end up having another fibroid surgery at some point. A fibroid that comes back does not necessarily cause symptoms or need anything done, but it is the reason expectations get set honestly before the first operation, not after.
Who does not need surgery at all
If fibroids are not causing symptoms, not causing suffering, and not interfering with fertility, surgery may not be needed, and often should not even be recommended: the risks can outweigh any benefit. The exception is the quiet fibroid doing measurable harm anyway, like severe anemia or pressure on the ureters, which still needs treating.
Sometimes the fibroids are present but innocent, and the symptoms are coming from something else entirely. It is worth the time to find that out, because removing every fibroid and leaving you with exactly the symptoms you came in with helps nobody.
For many people the right plan is surveillance: imaging every one to three years depending on how the fibroids behave, with surgery held in reserve for the day symptoms arrive or fertility plans change. For a woman with small, quiet fibroids who does not plan to conceive for years, I may specifically recommend waiting, because fibroids regrow, and operating early can mean operating twice.
When they come with endometriosis or adenomyosis
It is possible to treat endometriosis, adenomyosis and fibroids safely in the same operation, and we often do. Whether that is wise in a particular case depends on the size of the uterus, the severity of the endometriosis, and the fibroid burden.
Sometimes staging the surgery is safer. A large, many-fibroid uterus is expected to bleed during myomectomy, and if bleeding reaches the point where stopping is the safe call, the endometriosis excision waits for another day rather than being rushed.
There is also a mechanical reason. A uterus enlarged by fibroids is not only carrying the fibroids; the muscle around them thickens too, and it does not shrink back the moment they are out. When that bulk fills the space between the back of the uterus and the rectum, which is exactly where endometriosis most likes to sit, it can be impossible to see well enough to do a truly comprehensive excision. In that situation we stage the operations so that each can be done properly.