Fibroids (myomas) are benign tumors arising from the muscular wall of the uterus. They are found in multiple locations including beneath the outer surface of the uterus (subserosal), in the wall of the uterus (intramural), or extending into the uterine cavity (submucosal). The size, number and location of myomas account for their different clinical presentations and symptoms. Most women with myomas have at least several of them. Common symptoms include an enlarging pelvic and abdominal mass, heavy frequent and prolonged periods, anemia, pain with intercourse, painful periods, bladder pressure with frequent urination. From a reproductive standpoint, submucosal fibroids are the most problematic. These fibroids frequently cause abnormal vaginal bleeding as well as recurrent pregnancy loss and implantation failures. Most women with asymptomatic intramural and subserosal myomas, where the uterine cavity is not distorted, can be followed conservatively without surgery.

Myomas are easily visualized by ultrasound. Their presence and location can further be evaluated by the use of office hysteroscopy or hysterosalpingogram. Myomas that are predominantly submucosal are best treated with hysteroscopic myomectomy. In this out-patient procedure, a telescope is inserted into the uterine cavity through the vagina. Each fibroid is then visualized and shaved down until it is flush with the uterine wall. Postoperatively, estrogen and antibiotics are used to prevent intrauterine scar tissue formation. A small balloon catheter may also be left in the uterine cavity for several days to keep the walls of the uterus apart until healing has occurred.

In women with many fibroids, especially ones that extend into the uterine wall, abdominal myomectomy may be indicated. An abdominal incision is necessary for adequate exposure. In this fertility sparing procedure, uterine blood flow is temporarily stopped with the use of a tourniquet. Unlike most published series on abdominal myomectomies, we have very rarely needed to transfuse patients because of this technique. Each fibroid is identified and removed. The uterine wall is then closed with many layers of stitches. In some women the uterine cavity is entered. When pregnancy is subsequently established, many of these women are encouraged to undergo a Cesarean section by their obstetrician. Abdominal myomectomy is safely performed in the hands of an experienced pelvic surgeon. Pregnancy rates are often very high postoperatively. The likelihood that new myomas will ariseecurrence risk is approximately 30%.