Surgery for fibroids

There are two approaches for removing fibroids:

• Surgery to remove individual fibroids (myomectomy, sometimes also called fibroidectomy)
• Surgery to remove the womb (hysterectomy)

Whenever possible, myomectomy is recommended so that the womb can be conserved. But the procedure is not a good idea if it would result in too much scarring of the womb or if the risk of bleeding during or after surgery is too high. Plus, it isn’t always absolutely certain that the symptoms will improve afterwards. Then the womb can be removed.

Another non-surgical option might be possible as well, such as uterine artery embolization, which cuts off the blood supply to the fibroid.

In myomectomy, only the fibroids are removed. The womb is not removed. The fibroids can be removed in different ways:

• Through the vagina (hysteroscopic myomectomy)
• Through small cuts in your abdomen (laparoscopic myomectomy)
• Through a cut across your abdomen (laparotomy)

General anesthesia is needed for all of these procedures. The most suitable treatment options will depend on the number, location and size of the fibroids. Doctors will almost always try to find a way to avoid making a cut in your abdomen. That is a larger procedure and leaves a bigger scar on the abdominal wall. Laparoscopy or hysteroscopic myomectomy aren’t always possible if the fibroids are very large or if there are so many of them that the womb has grown bigger.

Laparoscopy and laparotomy also make it possible to remove fibroids that have grown out of the womb and into the abdominal cavity. These include:

• Fibroids outside of the womb (subserosal fibroids)
• Fibroids in the wall of the womb (intramural fibroids) that bulge outward
• Fibroids next to the womb (intraligamentary fibroids)

Operating through the vagina is most suitable for fibroids that protrude into the space inside the womb. That can happen with:

• Fibroids in the wall of the womb (intramural fibroids)
• Fibroids directly under the lining of the womb (submucosal fibroids)
• Fibroids in the layer of muscle in the cervix (cervical fibroids)

Removing fibroids through the vagina can then be less invasive than laparoscopic myomectomy. Studies suggest that a procedure through the vagina is quicker and associated with less blood loss.

Most women who have had fibroid symptoms for a long time notice a major improvement after surgery, or no longer have any symptoms at all. Research shows that about 90 out of 100 women who have this procedure are still satisfied with the results one to two years afterwards. In up to 25 out of 100 women, fibroids grow again within the first few years after the procedure.

Studies on myomectomy have shown that about 5 out of 100 women have complications such as injury to organs in the abdomen, or need to have the procedure again. Fewer than 1 out of 100 women need to have a hysterectomy because of uncontrollable bleeding after myomectomy. Temporary problems like fever or wound infections may occur.

Laparoscopy causes less blood loss than laparotomy, and complications are equally rare after both procedures.

Adhesions in the abdominal cavity sometimes develop over the long term after the procedure. These strands of connective tissue may cause organs to stick to the abdominal wall. Scars and adhesions sometimes cause pain in the lower abdomen. Depending on their location, they may cause bowel problems or affect fertility too.

Having a myomectomy doesn’t usually affect fertility – unless adhesions form later on, and hinder the ovaries or fallopian tubes.

Studies have looked into whether the type of procedure influences a woman’s chances of becoming pregnant. The results showed no differences between laparotomy and laparoscopy. About one third of women in both groups gave birth within two years.

Sometimes fibroids are removed with the aim of improving fertility. A fibroid located under the lining of the womb may prevent a fertilized egg from attaching to it. But there has been very little good-quality research on the question of whether a myomectomy can improve a woman’s chances of getting pregnant. The few studies that are available don’t allow any conclusions to be drawn about whether surgery helps.

Hysterectomy is an option for women who have very many or very large fibroids, or fibroids that are difficult to remove. They may decide to have a hysterectomy in the hope that their symptoms will go away once and for all.

Like myomectomy, there are various approaches used for hysterectomy: The womb can be removed through a cut across the abdomen (laparotomy), small cuts in the abdomen (laparoscopy) or through the vagina. General anesthesia is needed for all of these procedures. For medical reasons, the last two approaches aren’t possible for all women. Another approach uses additional laparoscopy to help guide vaginal hysterectomy.

Hysterectomies may remove all or part of the womb. In a partial hysterectomy, just the main body of the womb is removed. The cervix (opening of the womb) is left intact. The ovaries are typically also left inside the body in both procedures.

Both the womb and the fibroids are removed in this procedure. Women who have a hysterectomy no longer have periods, so the related problems go away too.

Some women report that they continue to have abdominal pain or cramps. These kinds of symptoms may be caused by the operation, but they might also have other causes that were there beforehand.

Up to 5 out of 100 women have more serious complications during the procedure. These include damage to neighboring organs (bladder, ureter, bowel) or to blood vessels. About 2 out of 100 women may need to have more surgery or return to the hospital.

Immediately after surgery, bladder or wound infections may occur, and fever is possible too. These problems can usually be treated effectively if they are caught in time. They then typically go away within a few days.

The risk of complications will depend on things like the type of procedure.

Vaginal hysterectomy is considered to be a more gentle procedure than laparotomy. The recovery time is about ten days shorter and there is no abdominal scarring.

Laparoscopy has similar advantages compared to laparotomy: Recovery is faster and there is less risk of wound infection. But laparoscopy is associated with a somewhat higher risk of injury to the ureter or bladder. These kinds of injuries happen in about 2 out of 100 women who have a laparoscopy, and in about 1 out of 100 women who have a laparotomy.

Overall, complications and side effects are similarly rare following laparoscopy and vaginal hysterectomy.

Many women feel satisfied with the outcome and don’t regret having the procedure done. But not everyone feels that way. Some women feel that by losing their womb they have also lost an important part of being a woman. But how women react to having a hysterectomy varies quite a bit. Many women’s sex lives may not be affected, or may even improve after the surgery. Other women say that it got worse instead.

Menopause will probably start a little earlier in women who have had a hysterectomy. Doctors think that this is because there is less blood flow to the ovaries after the surgery, causing the production of hormones to decrease. If the ovaries are removed along with the womb, menopause starts very suddenly. Studies also suggest that a hysterectomy increases the risk of osteoporosis. And experts think that it could also increase the risk of cardiovascular (heart and circulation) disease somewhat. But both of these risks need to be studied more.

A hysterectomy may also affect the function of the bladder, but most women who have this operation don’t have that kind of problem. The procedure might also increase the risk of urinary incontinence (“stress incontinence”), which means that small amounts of urine may leak out when coughing, sneezing, laughing or lifting heavy objects.

The cervix is closely connected with the bladder and bowel. After a hysterectomy, the bladder or bowel may lose support and start to sink. The vagina can also sink downwards after a hysterectomy. This may cause a feeling of pressure in the abdomen. Women who already had a weak pelvic floor before the surgery have a higher risk of organs moving downwards (prolapse).

The risk of short-term complications is probably about the same when just the fibroids are removed (myomectomy) or when the womb is removed (hysterectomy) through a large abdominal incision. But the long-term pros and cons of these two approaches can’t be compared because there hasn’t been any research in this area.

Myomectomy has the advantage of leaving the womb intact. That means that is still possible to get pregnant afterwards. This procedure often relieves fibroid symptoms just as well as a hysterectomy does. But fibroids can grow back again after a myomectomy, and then cause associated symptoms. This can’t happen after a hysterectomy.

A myomectomy is usually not an emergency procedure, so it’s generally possible to get plenty of information about the treatment options before making a decision. Our decision aid may help here. It briefly summarizes and compares the main pros and cons of the different treatments.

If you feel that your doctor is pressuring you to opt for a specific procedure, it might be a good idea to get a second opinion. Friends or family might also push you towards making a particular decision.

Besides the medical circumstances, the right treatment will depend very much on your individual situation and preferences. The surgeons’ experience will also make a difference. Many hospitals and clinics have specialized in particular types of procedures and only offer those ones. So if only one treatment is offered at your hospital, or if they don’t really consider any alternatives, it may be especially important to get a second opinion.