I am 3 months pregnant, still in pain, and considering terminating the pregnancy.  I have multiple fibroids that are as follows: right side measures over 7cm, left side around 7, and one on top of my uterus.  The right fibroid is partly blocking my cervix.  I was informed that this might cause complications during the abortion.  I am getting conflicting viewpoints from my doctors.  I am concerned about keeping my fertility.

Analysis:  Your first decision involves choosing a competent physician.  Then leave the mechanics such as where the procedure should be done to that physician.  That is the kind of technical input that you are paying for.  Yes, fibroids can complicate the performance of an abortion. 

The decision is yours and all the opinions in the world will not change that.  There is risk with everything in life and certainly with medical treatment.  In spite of this, the overwhelming majority of women who undergo a termination at this stage of pregnancy undergo it safely and their fertility is not affected.  -  Francis Hutchins, M.D.

Refer to Pregnancy and Fibroids:  Pregnancy and Contraception.
 

I am currently 13 weeks pregnant, in a lot of pain and unsure of what to do with regard to my pregnancy.  I have uterine fibroids, which caused me pain before my pregnancy.   I was told it would be difficult for me to get pregnant due to my age (35) and the fibroids.  So the pregnancy was definitely a surprise.  The pain has been excruciating at times and I have not been able to work because I am so uncomfortable.  I am currently taking ibuprofen for pain.  In the severe episodes I have taken Darvocet and was even given a shot of Demerol.  I am very concerned about the effect of the medication on the baby and about moving forward with the pregnancy knowing I may be in this much pain and this uncomfortable.  I am also scared if I don't try to carry the baby because my OB/Gyn has made me feel like this may be my only chance to have a baby.  I don't know if that is true.  I really need some more information regarding my options for pain relief, the possible effects on my pregnancy, and my fertility in general.  I also am scared about the effects of termination on my health and future fertility.

Analysis:  The most important fact for you to remember is that pain from fibroid degeneration at this stage is not unusual and you are taking the standard drugs, ibuprofen and Demerol, used to treat this.  They have been used without harm to pregnancy. 

The good news is that this pain tends to get better and often resolves at or about 24 weeks of gestation. 

Pregnancy termination is considered one of the safest procedures in medicine but that is not to say that complication won’t occur to somebody sometime. Your fertility at this point appears to be intact since you are pregnant.  If this pregnancy is not carried you will still be faced with the need for removal of the tumors and that could interfere with fertility because of scarring.

I think you need to seek support through a close relationship with a caring OB/Gyn or other support person.  Most of these pregnancies turn out well but occasionally termination is chosen.  -  Francis Hutchins, M.D.

Case Example:  Fibroid Growth After A Myomectomy

I had an abdominal myomectomy June 2005, at which time nine (9) fibroids were removed.   Now, in Dec. 2005, I have new fibroids.  I am wondering how unusual this is?  My surgeon said he removed all the fibroids he could see and feel.   Is it possible the doctor missed some?  Should I be concerned about my hormones, particularly estrogen, if fibroids are growing this fast after a myomectomy?  I realize I need to visit my doctor, but I am trying to understand why my fibroids and bulk symptoms would return so soon after myomectomy.

Analysis:  I wonder how you know that your fibroids have recurred.  Ultrasound, MRI, examination or possibly you are basing this on symptoms.   If it is symptoms that can be very unreliable since many things can cause similar symptoms.

A fibroid uterus usually contains many fibroids some because of size are very obvious.  Others are very small and difficult to see.  In addition, to remove all fibroids can be quite challenging because it may require such extensive dissection as to result for all practical purposes in destruction of the uterus.

Therefore, the goal of myomectomy is to;

1.    remove all symptomatic tumors

2.   remove all obvious tumors that could predictably lead to further problems in the near future. 

It is always the goal to remove all tumors if feasible. Even if all tumors are removed it is recognized that there is the possibility of recurrence because

1.    some tumors are too small to be seen

2.   the uterus will always retain the genetic basis for forming fibroids again. 

I agree, it is surprising that you would have a recurrence so soon but first it must be confirmed.  -  Francis Hutchins, M.D.

I am in my late 40’s and I have had heavy bleeding for approximately two years.  It started out lasting a week and now it lasts for three weeks out of the month.  I was given all the tests and a couple of small fibroids were discovered.  I tried an Endometrial Ablation, but the fluid going in wasn't coming out so my doctor stopped the procedure.  Other doctors have said that ablation won't work with fibroids but I don't know if it will or not.  I am now on a low dose of birth control pills and for 3-4 months the pills seemed to be working.  Recently I have been  experiencing bleeding problems again even with being on the pill.  I am trying to find a way to get to menopause naturally.  I  would like to avoid a hysterectomy if possible, but I am feeling like I don't have other treatment options available for my situation.

Analysis:  You would appear to potentially have several options all of which would not include hysterectomy: 

•  Adjust birth control pill dosage.
   
•  Endometrial Ablation coupled – the fact that there was difficulty with fluid control only applies to that one attempt and the operator.  Fluid control is usually manageable.
   
• Global Ablation – new group of techniques many of which can treat fibroids in the cavity which you likely have.
   
• MRI Focused ultrasound – new, not universally available and expensive.
   
• Uterine Artery Embolization – very effective for bleeding with fibroids.
   
• Hormonal therapy with potent progestin.
   
• Lupron (GnRH analogue) – can be given intermittently for 3-6 months at a time.

As you can see there are potentially many alternatives.  Much of this is dependant on the Gyn you are working with.  -  Francis Hutchins, M.D.

Analysis:  Many women with fibroids can have a successful endometrial ablation, especially if they are close to menopause.  In this case, the fluid problem makes me think that the gynecologist did not have the experience to do such a procedure.  Ablation, especially in the presence of fibroids, requires a great deal of experience and skill in hysteroscopic surgery.  This is not something that most gynecologists will have.  Years ago I published a series of hysteroscopic treatment of abnormal bleeding in women with fibroids with excellent overall results. (1) In order to make the proper decision on how to treat heavy bleeding you should see a gynecologist who is knowledgeable about all surgical and non-surgical options.  - Paul Indman, M.D. 

Medical Article:  Indman PD.  Hysteroscopic treatment of menorrhagia associated with uterine leiomyomas. (Entrez Pubmed) Obstet Gynecol. 1993 May;81(5 ( Pt 1)):716-20.

OBJECTIVE: To determine the effectiveness of hysteroscopic treatment of menorrhagia associated with uterine leiomyomas.  CONCLUSION: Hysteroscopic treatment of menorrhagia associated with uterine myomas can be effective in carefully selected patients.