Fibroid Surgery in Istanbul: Uterus-Preserving Surgery

What are uterine fibroids?

A fibroid (leiomyoma, myoma) is a mostly benign mass that develops from the smooth muscle cells and connective tissue that make up most of the uterus. There may be a single fibroid or many of different sizes. Some fibroids stay the same size for years, while others grow with hormones, pregnancy or age.

A diagnosis of fibroids does not by itself mean suspected cancer or the need for surgery. What determines the need for treatment is the effect the fibroid has on the person: heavy bleeding, anaemia, pain or pressure, urinary or bowel symptoms, or an effect on pregnancy plans.

Types of fibroids and why location matters

Fibroids are classified by where they lie in the uterus, and one patient may have several types at once. Location influences bleeding, pain, pressure, pregnancy and the surgical route that can be used.

• Submucosal fibroids grow towards the uterine cavity. Even when small they can cause heavy or intermenstrual bleeding or fertility problems. Suitable ones can be removed hysteroscopically, through the cervix.
• Intramural fibroids lie within the muscle wall. Depending on their size and closeness to the cavity they can cause bleeding, pain or pressure.
• Subserosal fibroids grow towards the outside of the uterus. They tend to cause pressure symptoms rather than bleeding.
• Pedunculated and cervical fibroids are rarer forms that may need a different technical approach.

What are the symptoms of fibroids?

A large proportion of fibroids cause no symptoms. When they do, complaints depend on the location, number and size of the fibroids:

• Periods that are heavier or longer than before; clots, bleeding between periods or frequent periods
• Tiredness, palpitations, breathlessness or dizziness caused by iron deficiency and anaemia
• Pain or pressure in the groin, lower back or lower abdomen
• Abdominal enlargement, fullness or a palpable firmness
• Frequent urination or incomplete bladder emptying because of pressure on the bladder; constipation

Any new vaginal bleeding after menopause should always be assessed.

How are fibroids diagnosed?

The assessment starts with your complaints, menstrual pattern, pregnancy plans and previous treatments. Imaging then shows the number, size and position of the fibroids.

• Ultrasound is the first-line method in most patients. Vaginal ultrasound shows the cavity and muscle wall in detail; abdominal ultrasound can be added for large masses.
• MRI is used when the map of the fibroids must be clarified, when there are many or very large fibroids, or when the picture is unusual.
• Hysteroscopy examines the uterine cavity directly when a submucosal fibroid or polyp is suspected.

A useful report does not only say “fibroid present”; it gives the number, three dimensions, position and relation to the cavity of each fibroid.

When to monitor and when to treat

Finding a fibroid does not mean that treatment must start immediately. Fibroids that cause no symptoms, have typical imaging features and do not grow significantly can be followed at regular intervals. The frequency of follow-up depends on age, size and position, earlier scans, menopausal status and complaints.

The main reasons to consider treatment are heavy bleeding that impairs quality of life, anaemia despite treatment, marked pain or pressure, urinary or bowel complaints, fibroids that affect the uterine cavity, and fibroids that interfere with pregnancy plans. A rapidly growing fibroid or an unusual appearance on imaging needs a separate assessment.

Treatment options

The aim of treatment is not always to remove the fibroid completely. In some patients the goal is to control bleeding and correct anaemia, in others to relieve pressure, correct the uterine cavity or find a path that suits pregnancy plans. Clarifying the goal helps avoid unnecessary treatment and choose the right method.

Fibroid surgery and how the route is chosen

When people say “fibroid surgery” they usually mean myomectomy: removing the fibroids and repairing the uterus. Myomectomy is the basic surgical approach for suitable patients who want to keep the uterus or plan a pregnancy. The aim is not only to take out the visible mass, but also to control bleeding, repair the muscle wall safely, protect the cavity and respect neighbouring organs.

The route is not chosen on the patient’s wish alone. The map of the fibroids, their distance from the cavity and the outer surface, relation to vessels, the patient’s earlier surgery and pregnancy plans all matter.

• Hysteroscopic: for fibroids growing into the cavity; no incision in the abdomen.
• Laparoscopic (keyhole): small entry points in the abdomen, removal of the fibroids and repair of the uterus. Suitable for many, but not every, fibroid.
• Vaginal (V-NOTES): in selected cases, surgery through the vagina without abdominal scars.
• Open: may be the safest option for very large or very numerous fibroids, or when other routes are unsuitable.

There is no universally “better” route. A closed operation is not automatically superior to an open one if it makes the repair of the uterus less safe.

Uterus-preserving fibroid surgery

Uterus-preserving surgery aims, when it is possible and safe, to remove the fibroids and rebuild the anatomical integrity of the uterus. It is not only for patients who want a child soon: a patient who wishes to keep her uterus without a pregnancy plan should have this preference included in the decision, within medical safety limits.

“Preserving the uterus” is not the same as “guaranteeing fertility”. Myomectomy leaves the uterus in place, but age, ovarian reserve, tubes, partner factors, intrauterine adhesions and other conditions also determine the chance of pregnancy. The waiting time before pregnancy and the mode of delivery after surgery are decided individually.

Prof. Dr. Hanifi Şahin’s training in gynecologic oncology surgery, with advanced pelvic anatomy and bleeding control, supports the planning of such operations in complex patients.

Fibroids, fertility and pregnancy

Many women with fibroids conceive naturally and have healthy pregnancies. The effect on fertility is not the same in every patient. Submucosal fibroids that distort the cavity, masses near the openings of the tubes, and some large intramural fibroids matter more, while subserosal fibroids usually have a more limited effect. If a woman has difficulty conceiving, a fibroid does not mean it is certainly the cause: age, ovulation, tubes and partner factors are also assessed.

Preparation and recovery

When surgery is decided, preparation aims to reduce risk and clarify the goal. Current ultrasound or MRI is reviewed, the map of fibroids is drawn, and blood count and iron stores are checked. If there is marked anaemia, iron treatment, medication to control bleeding or, in selected patients, temporary hormonal suppression can be planned. Tell the team about prescription medication, blood thinners, herbal products, allergies and previous operations.

Recovery depends on the method, the number of fibroids removed, the depth of the repair, blood loss and general health. Return to daily life is usually shorter after hysteroscopy and earlier after laparoscopy than after open surgery, but small external incisions do not mean the repair inside the uterus is small. Tiredness, abdominal bloating and light vaginal bleeding are common early on. Follow-up visits review the wound, the pathology result, bleeding pattern, anaemia, return to activity, the personal waiting time before pregnancy and long-term ultrasound follow-up.

Fibroids and menopause

With menopause, the fall in oestrogen and progesterone can make many fibroids shrink and bleeding stop, so for some women close to menopause with mild complaints monitoring is reasonable. However, it is not true that all fibroids disappear at menopause: pressure symptoms may persist, and any new vaginal bleeding after menopause must always be assessed.

How a consultation for fibroids works

The aim of the consultation is not to recommend surgery straight away, but to define the source of the complaints and the patient’s goals. At Prof. Dr. Hanifi Şahin’s clinic in Istanbul, existing ultrasound and MRI images, the history of periods and bleeding, previous treatments, pregnancy plans and any earlier operation notes are assessed together. At the first meeting the location of the fibroids and their relation to the cavity are explained, and the monitoring, medication, non-surgical and surgical options that are suitable for assessment are discussed. If surgery is considered, hysteroscopic, laparoscopic, vaginal or open routes are compared with their advantages and risks. A second opinion on an operation recommended elsewhere is also possible.

Sources and content principles

This guide is written to help patients understand the basic concepts and treatment options for fibroids. It does not replace a personal examination, diagnosis or treatment advice; medical decisions must be made with current clinical findings and the patient’s preferences.

• American College of Obstetricians and Gynecologists (ACOG): Uterine Fibroids
• NICE Guideline NG88: Heavy menstrual bleeding – assessment and management
• Royal College of Obstetricians and Gynaecologists (RCOG): Uterine Artery Embolisation in the Management of Fibroids