Case Studies

Bleeding and Anemia Due to a Single Fibroid Inside the Uterine Cavity

When I arrived at my office early one morning, I received a phone call from a woman in great distress. D.W., a 43-year-old woman, indicated that for the past ten months, she had been suffering through increasingly heavy menstrual periods, passing large blood clots. She went on to explain that four months earlier she underwent a D&C (dilatation and curettage) because of this problem. The D&C failed to stop the bleeding, nor did it establish the cause. After the D&C she was treated with a series of hormonal treatments, but the bleeding worsened and persisted through most of the month. Subsequently, she was offered a hysterectomy, but she was opposed to this idea. After ten months of abnormal bleeding, D.W. developed anemia and complained of fatigue. Upon hearing her story, I suggested that she come to my office as soon as possible. D.W. then told me that she lived over 100 miles away but she was willing to make the trip with her husband in the hopes of finding a treatment other than a hysterectomy.

Later that morning, D.W. and her husband arrived at my office. She was pale and tired-looking. On pelvic examination, her uterus was slightly enlarged. I performed a vaginal ultrasound examination which revealed a single fibroid located in the center of the uterus, suggesting that it might involve the uterine cavity. To evaluate this finding further, I performed a sonohysterogram. This test, also using vaginal ultrasound, allows detailed evaluation of the uterine cavity following the introduction of a small amount of sterile solution. This study immediately demonstrated that a fibroid, the size of a plum, was present in the uterine cavity and was almost certainly the cause of the abnormal bleeding. This finding was good news because it indicated that D.W.’s problem could very likely be solved with a limited outpatient surgical procedure. D.W. and her husband were very anxious to proceed with definitive surgery as soon as possible. A blood test confirmed that D.W. was indeed anemic but that she could tolerate a short operation without delay.

We arranged for D.W. to be admitted to the outpatient surgical unit on the same afternoon. Under general anesthesia, I performed a hysteroscopic myomectomy which required no external incisions. In this procedure, an operating telescope is introduced through the cervix into the uterine cavity. Under direct visualization, the fibroid tumor was completely removed without damaging the uterine wall. The operation which is short (30 minutes), but demands considerable skill and experience to perform safely, was successful. After a three-hour recovery period in the surgical unit, D.W. was well enough to be discharged and was driven home by her husband. Since her myomectomy, D.W. has reported, her periods have been regular with a moderate amount of bleeding. Her overall sense of well-being has improved markedly.

Multiple Large Fibroids and Heavy Bleeding

B.L. is a 42-year-old woman who lives in Colorado. She called me on the telephone and related the following history. Three years ago she was told that she had uterine fibroids. Since that time, her uterus has continued to enlarge. Recently, her doctor told her that her uterus is enlarged to the equivalent of 4 months of pregnancy. On pelvic ultrasound, several fibroids were identified, with the largest tumor about the size of a melon replacing most of the posterior aspect of her uterus and cervix. B.L. indicated that her periods had become increasingly heavy and prolonged; she was bleeding for up to 10 days with three days of passing large clots. Despite taking iron supplements, she frequently felt dizzy and was found to be anemic.

B.L. had been offered a hysterectomy but was strongly opposed to having this operation. We agreed on the telephone that she would send me her medical records for review. After I reviewed her records, I called B.L. and told her that I believed that she most likely could be treated without a hysterectomy and we arranged for a consultation. She flew in with her husband on a Monday and came straight to my office. After examining her and performing an ultrasound evaluation, it was clear that she was a candidate for uterine-sparing surgery. I explained to her that she would require an abdominal operation, through an incision at the bikini line, which would allow me to remove the multiple tumors and reconstruct her uterus.

The operation was performed the following morning; it was uneventful and caused minimal blood loss. B.L. was discharged from the hospital two days later. I re-examined her during the weekend and it was evident that she was ready to fly back home. On follow-up phone calls, B.L. reports that she is well and has had several normal periods.

Multiple Symptoms Due to Marked Uterine Enlargement By Fibroids

K.C., a 44-year-old woman, called me from upstate New York. Over the past 15 years, her uterus has gradually enlarged to the size of a seven-month pregnancy due to the presence of multiple fibroids. She also suffered from asthma and her markedly enlarged uterus was contributing to her breathing difficulties. Her periods had become progressively heavier, leading to anemia. K.C. had been offered a hysterectomy on multiple occasions but she resisted this suggestion. Her physical condition continued to deteriorate as she searched for a physician who would be willing and able to perform uterine-sparing surgery in her circumstances. I told K.C. that I had successfully treated other women with similar problems, but that, of course, I needed to review her records and examine her before making any decision regarding her care.

The following week I met K.C. and her husband for a complete evaluation. Upon review of her symptoms, K.C. indicated that in addition to feeling weak and short of breath, she suffered from abdominal pain, pelvic pressure, severe constipation, and difficulty with urination. A pelvic examination and vaginal ultrasound revealed that she had multiple fibroids. The largest mass was located deep in the pelvis distorting the cervix and other nearby structures. There was evidence of pressure on the bladder and rectum, accounting for her symptoms. Lab tests confirmed that K.C. was indeed very anemic from chronic, heavy blood loss.

K.C. and her husband were relieved to hear my assessment that uterine sparing was feasible. However, I advised them, that because of the anemia and the size and location of the tumors, it would be best to postpone surgery until after a four-month course of medical therapy. This therapy consisted of a hormone called Lupron which would help shrink the tumors and reduce bleeding during the periods, as well as iron supplements to treat her anemia. We agreed that we would remain in touch concerning her progress during this course of therapy.

Four months later, her anemia improved, and K.C. underwent surgery. A total of 11 fibroid tumors, up to 6 inches in size, were removed through a bikini-type incision in her lower abdomen. The operation proceeded smoothly with only minimal blood loss. K.C. was discharged from the hospital two days later and was able to fly back home with her husband after resting in a hotel for two more days. K.C. reported to me that her life was vastly improved. A check-up with her local physician revealed that her uterus was of normal size and she was no longer anemic. In addition, her asthma had become easier to manage.

Reversal of Tubal Ligation in the Presence of Multiple Fibroids

C.S. is a 38-year-old mother who has given birth to three healthy children. Following the birth of her third child she had her tubes tied (tubal ligation) to prevent additional pregnancies. One year before presenting to me, her eldest son was killed in an auto accident. Six months later she saw her gynecologist complaining of heavy periods. Multiple fibroid tumors of the uterus were found, including a golf-ball-sized fibroid located inside the uterine cavity (submucous fibroid). These findings were discovered at the same time that she was seeking to undergo a reversal of her tubal ligation to conceive another child. Because of the surgical complexity involved in her case, C.S. was referred to me.

After a thorough evaluation and upon reaching a mutual understanding of the problems and prognosis for a successful pregnancy with C.S. and her husband, surgery was planned. The operation was performed through a bikini-type incision in the lower abdomen. A total of eight fibroid tumors were removed from the wall of the uterus as well as from inside the uterine cavity. This was accomplished with minimal blood loss. The operation then proceeded with microscopic surgical technique required to remove the damaged portions of the tied-off fallopian tubes and to reunite normal segments of tubes on each side.

The postoperative course was uneventful, consisting of two days in the hospital followed by a three-week recovery period at home. Eight months after surgery, C.S. conceived and had a normal pregnancy. Because of the extensive uterine surgery, she had an elective cesarean delivery, giving birth to a healthy 7.5-pound baby boy. At the cesarean section, the obstetrician noted that there were no fibroid tumors.

Normal Delivery After Surgery for Chronic Pelvic Inflammatory Disease (PID) with Adhesions and Obstructed Fallopian Tubes

D.I., a 27-year-old woman, and mother of a six-year-old was seen because of severe pelvic pain and extreme pain with intercourse during the last five years. Her periods were very heavy and painful. Five years earlier she and her husband had been treated for chlamydia infection. An infertility specialist performed laparoscopy and identified extensive pelvic adhesions. D.I. was told that her pain was only partly due to pelvic adhesions and that she had colitis contributing to her symptoms. The doctor’s recommendation was to remove the fallopian tubes and use in vitro fertilization (IVF) to complete her family, following which he would perform a hysterectomy with the removal of both ovaries. D.I. went through one IVF trial which failed. Then she left the physician because, in her judgment, he was pushing IVF while failing to address the real problem of incapacitating pain.

During the initial visit, I saw a woman in great distress who was uncomfortable just sitting in a chair. On examination, her uterus, ovaries, and tubes were extremely tender. My impression was that her pain was most likely due to chronic pelvic inflammatory disease. I recommended a course of medical therapy with antibiotics to fight the infection and short-term prednisone to reduce the inflammation. I indicated to D.I. that, after completing the course of medication, she would most likely require surgery to correct the damage caused by the infection. D.I. responded rapidly to treatment and there was a dramatic diminution in her debilitating pain. Subsequently, an x-ray with dye (hysterosalpingogram) identified partial obstruction of the fallopian tubes due to pelvic adhesions.

Abdominal surgery was scheduled for several weeks later. At surgery adhesions involving the ovaries, tubes, and bowel were identified; in addition, five fibroids, ranging from one to six centimeters in diameter were noted. Using microsurgical technique all the pelvic organs were freed of adhesions. The fallopian tubes were repaired and the fibroids were removed. Blood loss during surgery was negligible and D.I. was discharged from the hospital two days after surgery. Following surgery, she did very well, and on a follow-up visit, she indicated that the pain was completely gone. Six months later D.I. conceived naturally and later delivered a normal healthy baby.

Severe Pain and Heavy Menstrual Bleeding Due to Adenomyosis

B.B., a 40 year -old woman, was seen because of a history of ten years of severe menstrual pain and excessive bleeding lasting ten days of each month. She was anemic. She had consulted many physicians, had several ultrasound studies and a laparoscopy. She was told that she had multiple fibroids and that a myomectomy was impossible; recently a physician had told her that any such attempt would be “a bloody mess” and inevitably result in a hysterectomy.

On examination, her uterus was enlarged to the size of a 16-week pregnancy with a prominent swelling involving the upper uterus. On high-resolution transvaginal ultrasound a nine-centimeter “tumor” was identified, but its boundaries were ill-defined; the appearance suggested an adenomyoma more than a fibroid. The patient was told that if it was a fibroid it would be removed with an excellent chance that she would be able to conceive in the future. However, she was informed, if in fact surgery revealed an adenomyoma, resection would solve her medical problem but her uterus would be missing a significant portion of its muscular wall, precluding future pregnancy. At surgery, she was found to have adenomyosis, confirmed during surgery by a frozen section pathology evaluation. Therefore, an adenomyomectomy was performed with the reconstruction of the remaining uterus. Blood loss was minimal and the postoperative recovery was smooth. One year later she reported that she has very light regular periods lasting three days. She has no pelvic pain.

Genital Prolapse and Urinary Incontinence

R.M., a 49-year-old woman was seen because of several problems which started after a severe fall during which the pelvic ligaments were injured. She had loss of urine with cough or strain (diagnosed as urinary stress incontinence by urodynamic testing) and prolapse of the uterus with an elongated cervix bulging through the introitus (vaginal opening) when straining. Careful inspection revealed that the left upper vagina was sagging while the right upper vagina was normal. The uterus was only slightly dropped but the cervix was markedly elongated. The patient insisted that she wanted to preserve her uterus.

In a complex operation, the torn ligament which attaches the upper vagina to the pelvic side wall was repaired, the bladder and upper urethra were lifted to their normal position by suspending the anterior vaginal wall to the pelvic side wall (Burch procedure). The prolapsed uterus was lifted back into its normal position in the pelvis by shortening its ligamentous attachments and removing a portion of the abnormally long cervix (Manchester procedure). Blood loss was minimal and the post-operative course was smooth. After surgery, the patient reported normal bladder control with the restoration of normal uterine and vaginal position and support.

Intracavitary Fibroid Prolapsing Through the Cervical Canal

B.J., a 46-year-old woman without children, was suffering from very heavy periods with clots for the past six months. She was diagnosed as having fibroids five years earlier. One afternoon while sitting on the toilet she started bleeding profusely, lost consciousness, and fell to the floor. She hit her head on the sink and suffered a cut over her right eyebrow. She was brought to the emergency room. She was found to be profoundly anemic with a hemoglobin level of 6.1 gm/dl. Ultrasound of her pelvis revealed a markedly enlarged uterus (about the size of a 20-week pregnancy) secondary to multiple fibroids. Most importantly there was a large fibroid (8 cm in diameter) located centrally in the uterus and seen to be falling through the cervix and into the upper vagina (prolapsing into the vagina).

She was admitted to the hospital and her condition improved after receiving three units of blood. With bed rest, the amount of vaginal bleeding diminished. The following morning the patient was taken to surgery. After induction of general anesthesia, heavy vaginal bleeding was again noted. The only approach to dealing with this emergency was to perform an open abdominal operation because there was no access to the upper aspect of this fibroid from the vagina. Upon entering the pelvis, bleeding from the uterus was controlled by means of a tourniquet applied around the outside of the lower uterus. Following this maneuver, numerous fibroids were removed. Finally, an incision was made into the uterine cavity to identify the stalk of the prolapsing fibroid, which was found to be attached to the upper cervix. With great effort, the stalk was tied with a suture, and the fibroid disconnected from the cervix. Now the prolapsing fibroid could be removed through the vagina. The uterus was then repaired.

The postoperative course was uneventful and the patient was discharged two days after surgery. At a follow-up examination six months later the uterus was noted to be normal in size and she reported that her periods were regular with moderate flow.

Delivery of a Normal Baby After Repeat Myomectomy, Lysis of Adhesions, and Tubal Repair

J.F., a 36-year-old woman, was referred because of infertility and uterine fibroids. Seven years earlier she had an abdominal myomectomy to treat severe menorrhagia (heavy periods). For the past 18 months, JF was again experiencing very heavy periods with clots, lasting seven days, followed by lighter bleeding lasting two more weeks. She was having urinary frequency and urgency as well as pelvic pain and painful intercourse. On examination, her uterus was enlarged to the size of a 16-week pregnancy. On pelvic ultrasound, there were many fibroids, the largest being eight cm in diameter. Abdominal surgery was recommended.

At surgery, extensive pelvic adhesions were found, probably related to the previous myomectomy. The pelvic bowel, bladder, uterus, ovaries, and fallopian tubes, were enmeshed in thick adhesions. Using microsurgical technique and magnification, the adhesions were meticulously removed (lysis), freeing up the adherent organs and repairing their surfaces. The fallopian tubes, including the finger-like terminal projections (fimbriae), were significantly damaged; these were also repaired using a microsurgical technique (tuboplasty). After this extensive lysis and repair, the uterus was exposed. Numerous fibroids, including the largest that was bulging into the uterine cavity (submucous) and causing the bleeding, were removed. This myomectomy was accomplished without entering the endometrial cavity to avoid distortion of the cavity and adhesion formation. The uterus was then carefully reconstructed resulting in a uterus close to normal size and shape. Because of the microsurgical technique and the application of a uterine tourniquet during surgery, there was minimal blood loss during surgery.

As recommended for uterine healing, JF avoided conception for the first six months. Shortly thereafter she conceived and delivered a healthy baby through Cesarean section.

Bilateral Ovarian Endometriomas

D.D., a 32-year-old mother of two, was seen because of severe right, lower quadrant pain and irregular periods. Ultrasound indicated a 6 cm right and a 4 cm left ovarian endometrioma (ovarian cysts full of blood due to endometriosis). The patient underwent a laparotomy, which verified the endometriomas as well as massive pelvic adhesions which were distorting the pelvic anatomy. The adhesions were carefully lysed utilizing Microsurgery. The endometriomas were completely removed from the ovaries and the ovaries were repaired. The pelvis was reconstructed by repairing the raw surfaces created by the surgical dissection of the peritoneum. At the end of the procedure, the uterus was temporarily suspended to allow healing of the uterus, ovaries, and tubes without adhesion to the pelvic floor. The patient has returned for annual checkups. It has now been fifteen years since the surgery and she continues to report normal periods free of any pelvic discomfort.

Complete Genital Prolapse Treated Without Hysterectomy

D.C., a 66-year-old woman in menopause since age 57, was seen because of genital prolapse. Because of a history of breast cancer, she had avoided any hormonal replacement therapy. Her first delivery, at age 31, was a forceps delivery of an eight-pound baby. The second baby, weighing 8 lb 9 oz, was also delivered vaginally at age 37. In the past two years, DC experienced uterine prolapse, noting that towards the day’s end, she would feel the uterus bulging out of the vagina. She experienced urinary frequency, urgency, and incontinence. She also had pelvic pain and difficulty during intercourse. Her bowel movements were regular with fiber pills. On examination, a third-degree uterine prolapse was identified along with a very large cystocele, large rectocele, bilateral paravaginal defects, and a large enterocele. The vaginal mucosa was dry and thin and therefore she was treated with estrogen cream for two weeks, followed by surgery. Urodynamic testing was also done before surgery and showed a healthy bladder wall with some stress incontinence.

Several additional surgical procedures were then performed to address each individual problem. First, a strip of fascia (normal strong tissue) was removed from the abdominal wall to be used in the suspension repair of the uterus known as sacral uterocolpopexy. The uterus and upper vagina were repositioned in their normal central pelvic position by anchoring them to the sacral bone by means of the fascial strip. The large enterocele (a hernia containing small bowel that penetrates deeply between the vagina and rectum) was then repaired, as were the bilateral paravaginal defects. This was followed by the procedure for stress incontinence, the Burch colposuspension, in which the bladder base and upper urethra are lifted by means of sutures attaching the vaginal wall near the upper urethra to the pelvic sidewall (Cooper’s ligaments). The central cystocele and the rectocele were repaired using a vaginal approach. Finally, a cystoscopy was performed to ascertain that the urinary system was intact. The entire surgical procedure took four hours and with minimal blood loss. The postoperative course was uneventful and on the third day the bladder catheter was removed, the patient was able to empty her bladder completely and was discharged.

At a follow-up visit three months later the patient reported complete bladder control, no pelvic pain, normal bowel movements, and satisfactory intercourse.

Delivery of a Baby Following Complete Reconstruction of the Pelvic Floor for Genital Prolapse

S.S. was seen at age thirty.  Two years earlier she had a spontaneous easy vaginal delivery of a 7-pound baby.  Following the delivery, she had severe asthmatic bronchitis that caused her constant coughing for three months.  Shortly thereafter she noticed something bulging through her vaginal opening.  A year later she had another period of severe coughing and her genital prolapse deteriorated.  She started experiencing severe low back pain, difficulty emptying her rectum during bowel movements, painful intercourse, and frequent urination. Upon examination, we diagnosed uterine prolapse second degree, cystocele with bilateral para-vaginal defects, large enterocele, and large rectocele with enlarged vaginal opening.  Urodynamic testing during the elevation of the prolapsed uterus diagnosed stress urinary incontinence.  The patient expressed her desire to have more children.  She underwent complete reconstruction of the pelvic floor with sacral utero colpo pexy, repair of enterocele, Burch colpo suspension, repair of para vaginal defects, repair of cystocele, and perineo plasty. The postoperative course was uneventful.  All the annoying symptoms resolved.  She had normal bladder control and normal bowel movement.  The back pain resolved.  Intercourse was again satisfying without any discomfort.  A year later the patient conceived and delivered, by elective cesarean section, a healthy 6-pound baby.

Following the delivery there was no recurrence of any signs of prolapse.  The patient is very careful to treat quickly any symptoms of asthma.