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Q. Are subserosal fibroids easy to remove?

Answered by
Dr. R Balakrishnan Menon
and medically reviewed by iCliniq medical review team.
This is a premium question & answer published on Apr 03, 2021

Hello doctor,

I am a dentist by profession, diagnosed with a subserosal fibroid 56 x 39 mm at post myometrium with an endowment thickness of 7.4 mm, which reduced to 5.4 mm in the last month ultrasonography with no increase in the size of the fibroid. After the first diagnosis, my doctor put me on few drugs to control my increased bleeding and abdominal and pelvic pains (Friptal, Sysron NCR, and injection Leuprolide at various intervals). I have taken all these as advised and become comfortable and without periods for almost 3-4 months till the end of last year. Since two months before, I have the same symptoms, my bleeding is quite heavy in now last few days, and I am managing with Trenaxa MF and occasionally other nonsteroidal anti-inflammatory drugs. Taken in Leuprolide also this month is beginning and will probably for another two shots in coming months. Yesterday I talked to my doctor, and she started with Sysron N 5 mg and asked to follow it for 21 days. She is hoping I will get the bleeding in control.

Requesting your valuable opinion on the following concerns:

  1. Does my doctor have a therapeutic and diagnostic option to control symptoms if Sysron does not work eventually after this month? Hysterectomy as the last and remote option if the fibroid is not stable over time?
  2. Am I skeptical about hysterectomy in the long run as well? What is your opinion?
  3. If it is your call, what is the current status for mine towards treatment? Are we going correctly?
  4. Currently, I do not have that severe pain I used to have last year except this heavy bleeding.
#

Hello,

Welcome to icliniq.com.

Let me start by putting forth few basic facts about fibroid and their management. Many of which may be well known to you. Each point has a point in your history and direction. Fibroids are the most common uterine benign tumors. They usually never appear single. One of them dominates rest stay under the shadow of the main fibroid and increase in size or come into the limelight once the main fibroid is gone. They usually begin as intramural or mass within the myometrium. They are sensitive to estrogen or female hormone throughout the reproductive period of a lady. As long as ovaries keep producing estrogen hormone, they grow. That means menopausal time is the final solution to the estrogen hormone. These fibroids grow towards the endometrial lining, gradually protruding into the uterine cavity, presenting as menorrhagia or excessive bleeding. If simulated, only an ulcer or swelling protruding into the oral cavity can disturb your chewing action, not one on the cheek or stay in myometrium or intramural, causing excessive pain and bleeding, as myometrium is irritated, leading to pain in periods, also the inability of the myometrium to contract well causing poor control of bleeding. Or they start protruding out of the uterus or subserous, which causes pressure effects like on bladder, surrounding muscles, nerves, lower abdominal discomfort or fullness, or no symptoms at all. The only way to control fibroids is to stop the growth by blocking the blood flow or blocking the growth factor (an estrogen hormone). I feel (attachment removed to protect the patient's identity) there must be more fibroids. Subserous ones never present with bleeding, as explained above. If your complaints have been resolved for some time and the size of myomas is marginally reduced, then a medical management line is the first choice. Had the bleeding not stopped with medicine, surgery would be the first choice to save you from all symptoms. Of course, you may feel that the work of the uterus is over. But that is the sign of womanhood. Also, removal of the uterus alone will compromise the vascularity of the ovaries. The aorta's ovarian artery branch has an anastomosis with the uterine artery, which may inadvertently be damaged. This can reduce the life of the remaining ovaries and menopausal symptoms appearing earlier. Even though you may enter menopause around 52-54 years of age, ovarian hormones persist almost till the 60s. Ulipristal (Fibristol) is useful but needs medications daily and for many years and is costly. Norethisterone is progesterone, helps only to control bleeding, but at the same time, it increases the endometrial lining thickness, so when you stop the pills, you will have a heavy withdrawal bleeding with clots and thick fleshy masses. I find few flaws in the management, if I may offer advice:

  1. If you are bleeding now, that course or Norethisterone (Aygestin) 5 mg will resolve immediately. You can supplement it with the Tranexamic acid (Cyklokapron) tablet.
  2. Once you have that good withdrawal bleeding, have a proper 3D scan or better MRI pelvis to map out the exact fibroid location. There may be submucosal or intramural small ones nearing the submucosal plane.
  3. Suppose submucosal or almost submucosal have hysteroscopic removal of myomas or polyp. This is much more specific and much effective than d&c. Even a complete endometrial resection or damage can be done with a hysteroscopic resectoscope. This is a short procedure as a daycare procedure under short general anesthesia.
  4. If mainly intramural or not very close to the submucosal plane, have those two shots of Lupreolide acetate. This will completely thin out the endometrial lining to menopausal status. Fibroid shrinks off.
  5. It is cheap, no side effects, and does not affect any part other than the uterus. I can have it on Monday or Thursday Or Tuesday or Friday or Wednesday or Saturday.
  6. Have an ultrasound scan after one year.
  7. The maximum duration I have tried is 5-7 years. You may have slight brown discharge 3-4 times a year.

Thank you doctor,

How are we sure the bleeding is due to fibroid or from endometriosis? As you tried to explain regarding fibroids in your details? Hysteroscopic removal, as you suggested, will resolve this endometriosis as well? Are you trying to avoid hysterectomy here, as I understand? But to remove fibroids, hysteroscopic removal requires how many days rest for me to resume my work? The last MRI showed only one fibroid in correlation with ultrasonography as well.

#

Hello,

Welcome back to icliniq.com.

Endometriosis or adenomyosis, or fibroids, are all like siblings of mother estrogen. All three grow only once the periods start, gradually increase over the years, and get suppressed when the period stops, during pregnancy, medication, or menopause. Fibroids are hypertrophy of the small muscles area, which are stretching and contracting points during periods. Endometriosis is every month bleeding of periods flows out of the uterus. A small part flows into the peritoneal cavity through tubes. This gets deposited on ovaries and adnexa like bowel, bladder, pod, also into the deeper layers deep into the pelvic floor muscles and ligaments. It is like getting beaten at the same place every month. Gradually over months and years, the area is edematous, tender, and inflamed. So main symptom would be severe pain on periods, sex, examination, or on the pelvic scan, instead of however you touch it. So bleeding may be higher, but not the main problem. As you can imagine, the area getting beaten will not bleed but will be tender. The solution is to stop beating or, in your case, stop periods. It will resolve. Adenomyosis is during periods a small part also enters the muscle of the uterus or myometrium through tiny breaks in the lining. The main symptoms are pain and bleeding, bleeding because myometrium cannot contract well to stop bleeding, and pain due to the uterine wall's inflammation. More common at your age, especially if you have had two or more deliveries, even more, if you have had a cesarean section or myomectomy or D and C or any invasive surgery on the uterus. As MRI (magnetic resonance imaging) has confirmed that you have only one fibroid and position is subserous, I am 100% sure that it's not the one causing bleeding. Mostly the size of the uterus is more. Normally the length of the uterus is 7cms. The uterus must be bulky. Anyway, D and C are not going to reduce fibroid, as it is far away from the cavity. Adenomyosis also will be unaffected. Usually, these siblings appear in combination, one of them dominating. Hystero-laparoscopy can clear only fibroids projecting into the uterine cavity or close to the cavity. There is no question of endometriosis in the uterus, then it is called adenomyosis and will not be cleared by D and C or hysteroscopy. Hysteroscopy needs one day of rest due to general anesthesia. Next day you will be fine. If you want to confirm no more periods after hysteroscopy, the doctor can do a hysteroscopic endometrial ablation, cauterizing the entire lining .period will stop.


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