Management of fibroids that project into the womb cavity

Submucosal fibroids grow into the cavity of the womb.

First, not all fibroids require treatment, i.e., surgical removal. Then, the question comes is, who needs treatment….?

Women who are troubled by Fibroids which project into the cavity of the womb usually experience heavy menstrual bleeding (can cause intractable bleeding, can cause flooding, can cause passing of large blood clots)

Women who are troubled by subfertility. There is enough scientific evidence that, fibroids which protrude into the cavity of the womb cause infertility by

• Acting like a contraceptive
• Failure of the fertilised egg to implant
• Miscarriages
• Fibroids also secrete certain chemicals which are not conducive to pregnancy

So, in general which fibroids which protrude into the cavity are recommended to be shaved off, the part of the fibroid which projects into the womb cavity

If the resection of fibroid is mainly for subfertility purpose, then, because the resected area of the fibroid is considered as freshly open wound, in order to prevent adhesion of the two uterine walls (front and the back or two side walls), a copper intrauterine device is inserted for up to three months. The idea here is that, it prevents intrauterine adhesion formation such as Asherman’s syndrome.

Also, size matters, up to 3cms sized fibroids that project into the womb cavity can be shaved off in one sitting.

If there are more than one fibroid that project into the womb cavity, then, the patient may need two stage procedures, i.e., to remove the first one and then after a few weeks the second one.

Or if the fibroid is too big, then half can be shaved first and then the remaining will be shaved off in the next procedure

If the fibroid is 6-7cms and is projecting into the womb cavity, then it is preferable to remove either open approach or keyhole approach. In this the cavity of the womb will highly likely get opened and hence it needs reconstruction to close the defect, and such may also need a copper intrauterine device for a few months to prevent intrauterine adhesion formation. Some patients may need a hysteroscopy to demonstrate normal womb cavity after such major surgery at the time of removal of copper intrauterine device.

As you know, planning is everything in life, so fibroid surgery is no exception. Correct location of fibroids also called as ‘Fibroid mapping’ is usually carried out by an experienced sonographer, MRI scan or a outpatient diagnostic hysteroscopy ( a thin telescope (2mm- ball point pen refill size) inserted into the womb cavity under local anaesthesia to plan the appropriateness of shaving procedure or whether patient benefits from open or keyhole surgery.

Sometimes temporary shrinkage of fibroid is considered to reduce blood loss during surgery. Usually, this measure involves administration of hormonal injections called as GnRH analogues such as Zoladex or Prostap