Decision to Perform Uterine Fibroid Removal Surgery

The decision to perform surgery for the removal of uterine fibroids is usually made by a gynecologist when the fibroids interfere with pregnancy or threaten the health of the uterus, possibly leading to its complete removal. Therefore, myomectomy is a highly delicate procedure that requires a skilled gynecologic laparoscopic surgeon, which is the subspecialty of Dr. Mohamed Abdel Fattah El-Senity.

Fibroids

Case of Uterine Fibroids

A 40-year-old unmarried woman suffered from severe bleeding and required frequent blood transfusions. After consulting several surgeons, there was a near consensus that a hysterectomy was necessary, given her age and the large number of fibroids exceeding forty.
Thanks to God, all fibroids were successfully removed during a two-hour surgery. The uterine wall was reconstructed and restored to an almost normal state, and ultrasound imaging confirmed the safety and integrity of the endometrium.

What Are Uterine Fibroids?

Uterine fibroids are abnormal growths of muscle cells and connective tissue that develop within the uterus. Statistics indicate that fibroids affect between 20% and 50% of women aged 15 to 45, although many remain undiagnosed due to the absence of noticeable symptoms. Only about one-third of these cases require medical intervention, whether surgical or pharmacological. Fortunately, 99% of uterine fibroids are benign and noncancerous. They have no link to malignant tumors and do not increase the risk of uterine cancer. Their size varies greatly, ranging from that of a pea to the size of a pineapple.

Symptoms of Uterine Fibroids

  • Heavy bleeding during or between menstrual periods

  • Pelvic and lower back pain

  • Cramping sensations in the pelvic area

  • Frequent urge to urinate

  • Pain during intercourse

  • Prolonged menstrual periods

  • Feeling of pressure or fullness in the lower abdomen

  • Abdominal swelling or enlargement

The severity of symptoms largely depends on the size and location of the fibroids. During menopause, symptoms often subside, as fibroids tend to shrink and disappear due to the natural decline of estrogen and progesterone levels — the hormones that promote their growth.

Causes of Uterine Fibroids

There are no scientifically proven causes for the development of uterine fibroids, but several factors are believed to influence their growth.
Hormones play a major role, particularly estrogen and progesterone, which are produced by the ovaries and help regenerate the uterine lining each menstrual cycle. These hormones can also stimulate fibroid growth.
Genetics is another important factor, as fibroids tend to run in families.
Pregnancy may also trigger the growth of fibroids due to the increased production of estrogen and progesterone during this period.

Types of Uterine Fibroids

Fibroids are classified according to their location within the uterus:

  • Submucosal fibroids: These grow inside the uterine cavity and often cause heavy menstrual bleeding. They can increase the risk of early miscarriage due to narrowing of the uterine space and frequently make vaginal delivery difficult, with about 80% of women requiring cesarean section.

  • Subserosal fibroids: These grow on the outer wall of the uterus or may be connected to it by a stalk. They often press on nearby organs such as the bladder—causing frequent urination—or the rectum, leading to constipation, or even spinal nerves, resulting in back and leg pain.

  • Intramural fibroids: The most common type, these develop within the muscular wall of the uterus and may cause enlargement of the uterus as they grow.

  • Pedunculated fibroids: These appear as branching growths that share the same base or stalk.

When Is Surgery Necessary?

The decision to surgically remove fibroids depends on several factors, the most important of which is the presence of disturbing symptoms such as:

  • Heavy menstrual bleeding

  • Bleeding between periods

  • Pelvic or lower abdominal pain

  • Frequent urination or difficulty emptying the bladder

When surgery becomes necessary, three treatment options are usually discussed with the physician:

  1. Endometrial ablation

  2. Myomectomy (fibroid removal)

  3. Hysterectomy (uterus removal)

The choice depends on the number, size, and location of the fibroids.

Surgical Removal of Uterine Fibroids

The surgical removal of fibroids can sometimes cause damage to the uterine lining but is most beneficial when fibroids grow inside the uterine cavity. Not all fibroids can be completely removed during surgery, as this may increase the risk of severe bleeding or the need for a total hysterectomy. The goal is to minimize complications while maintaining the uterus as much as possible.

These procedures are generally performed under general or regional anesthesia. The surgeon inserts a medical instrument into the uterus and removes the fibroids using one of several methods, including:

  • Electrical energy

  • A balloon filled with heated liquid

  • High-frequency radio waves

  • Microwave energy

  • Heated fluid

In most cases, patients can leave the hospital the same day.

Treatment Options for Uterine Fibroids

The choice of treatment depends on several factors, such as the patient’s symptoms, age, desire for pregnancy, and overall health. It is always important to discuss all available treatment methods with the physician to choose the most suitable one.

Myomectomy (Fibroid Removal Surgery)

Myomectomy removes fibroids while preserving the uterus, significantly reducing bleeding and pain. This is the best treatment for women who wish to become pregnant in the future.
About 90% of women who undergo myomectomy experience relief from fibroid symptoms. The removed fibroids do not usually grow back, although new ones may appear. Around 35% of women may require another surgery in the future due to new fibroid growth.

Myomectomy can be performed through three main approaches, depending on the number, size, and location of the fibroids. All procedures require either general or regional anesthesia:

Hysteroscopic Myomectomy

This method is ideal for small, limited fibroids growing inside the uterus. A thin telescope-like device is inserted through the vagina and cervix into the uterus. The cavity is expanded with fluid to allow clear visualization, and then the fibroids are removed. Most patients can return home the same day without hospital admission.

Abdominal Myomectomy

This approach is used for large fibroids. The surgeon makes an incision in the lower abdomen to access and remove the fibroids. The patient usually stays in the hospital for two to three days and may need 10 to 15 days for full recovery.

Laparoscopic Myomectomy

In this technique, the surgeon makes small incisions in the abdomen, usually two — one for a camera and another for surgical instruments. The fibroids are often cut into smaller pieces for removal through these tiny openings. The patient typically stays in the hospital for one day, and the procedure leaves only minimal scarring.

Hysterectomy for Uterine Fibroids

In some cases, the surgeon may perform a complete or partial hysterectomy to remove the uterus. This option is suitable for women who do not wish to become pregnant in the future. The uterus can be removed through one of the following methods:

  • Abdominal hysterectomy: The surgeon removes the uterus through an incision in the lower abdomen.

  • Vaginal hysterectomy: The uterus is removed through the vagina without abdominal incisions.

  • Laparoscopic hysterectomy: The surgeon removes the uterus using a laparoscope through small incisions in the abdomen.

In some cases, the ovaries and cervix are left intact so that the body continues to produce female hormones. Recovery after traditional surgery may take one to two months, while recovery from laparoscopic or vaginal procedures is usually shorter.

Hysterectomy is the only procedure that guarantees complete elimination of fibroid symptoms, but it is not suitable for women who wish to preserve fertility.

Non-Surgical Treatments for Uterine Fibroids
Several non-surgical options can help relieve symptoms or reduce the size of fibroids, including:

  • Medications: Anti-inflammatory drugs such as ibuprofen and naproxen can help reduce pain. Hormonal contraceptives or intrauterine devices that release progesterone can reduce menstrual bleeding. Hormone-modulating drugs like danazol may also be prescribed to shrink fibroids temporarily by suppressing estrogen and progesterone levels, mimicking a reversible menopause-like state.

  • Ultrasound therapy: High-intensity focused ultrasound waves are used to heat and destroy fibroid tissue.

  • Uterine artery embolization: The blood supply to the fibroids is blocked, causing them to shrink and eventually die.

  • Thermal or electrical ablation: Heat or electrical current destroys the fibroid tissue.

  • Cryotherapy: Freezing the fibroid to stop its growth.

Fibroids and Pregnancy

As mentioned earlier, fibroids can grow during pregnancy because of the increased production of estrogen and progesterone. In most cases, fibroids do not interfere with conception or the completion of pregnancy. However, complications may occur in some situations, such as:

  • Fibroids inside the uterine cavity that prevent proper implantation of the fertilized egg.

  • Fibroids blocking the fallopian tubes, hindering sperm from reaching the egg or the fertilized egg from entering the uterus.

  • Cervical fibroids obstructing sperm passage.

  • Large fibroids compressing the uterine cavity, restricting fetal growth and possibly leading to miscarriage.

Effect of Fibroids on the Fetus

One of the most common complications of uterine fibroids is bleeding, which can cause significant blood loss. Mild or moderate bleeding usually does not affect the baby, but severe bleeding may endanger the pregnancy. Large fibroids may cause miscarriage, abnormal fetal positions, or prevent natural delivery, leading to the need for cesarean section.

Are Uterine Fibroids Dangerous?

Many women have fibroids without knowing it. If bleeding and hemoglobin levels are normal and fertility is unaffected, fibroids are generally harmless. Only a doctor can determine whether they pose a real risk.

Do Fibroids Turn Cancerous?

The chance of a fibroid becoming cancerous is extremely rare—about one in every thousand cases. Research shows that such malignancies are typically independent tumors, not transformations of existing fibroids. Therefore, with regular follow-up, there is no need for concern.

Do Fibroids Grow During Pregnancy?

Yes, fibroids may increase in size during pregnancy due to higher progesterone and estrogen levels.

Risks of Myomectomy Surgery

  • Uterine rupture during pregnancy after surgery

  • Complications from anesthesia

  • Wound infection

  • Temporary bowel disturbance

  • Postoperative adhesions within the abdomen.