Bleeding and anemia due to a single fibroid inside the uterine cavity

As I arrived in 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. had 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 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. In order 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 completed 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 moderate amount of bleeding. Her overall sense of well being had markedly improved.