Question on where to get best treatment for Multiple Myoma in uterus

[DineshR]

Hello,

 

I am seeking some guidance on the following.

 

My wife was recently diagnosed with having multiple myoma (uterine fibroids). There appear to be mulitple fibroids with a few about 2cm in size along with multiple smaller ones. My wife, however, does not experience any symptoms. We were quite surprised when this was discovered during a routine ultrasound check up.

 

The total size of all the myoma combined apparently is quite large - large enough that laparoscopic surgery is not advised due to potential high blood loss. We were told this by 3 different doctors here in Korat. It appears that hysterectomy is the only option. We are not planning on having more kids so this is ok with us.

 

One doctor suggested we do this immediately, while another recommended that we wait and do another check in 3 months to see if the fibroids have increased in size. If there is no increase in size, then repeat the test in another 3 months. If there are no symptoms and the fibroids do not increase in size, the recommendation was not to do anything.

 

Further, in an hysterectomy, there will be a scar on the abdomen. We have asked the doctors to understand if the surgery could be performed to minimize the scarring and scabs formed when the incision heals. The doctors say this is unpredictable and based on the patients skin, the length of the incision etc. This scar is concerning to my wife.

 

We want to try and select a good gynecologist to perform this surgery. We would like some suggestions as to who we might go for further consultation based on whoever has had any experience with this. We are open to going to Bangkok for this and we have good insurance cover so I believe cost should not be an obstacle.

 

Your recommendations on a good gynecologist and hospital would be much appreciated.

 

TIA

 

 

[BritManToo]

If there are no symptoms and you aren't trying for babies, there's very little reason to treat them.

My wife back in the UK had them, they were removed without any external cutting.

She went on to have another 2 children after.

Edited January 29, 2022 by BritManToo

[Sheryl]

 Are you sure the largest was 2 cm? Not 20 cm?

2 cm is considered small  for a myoma. Anything under 5 cm is considered small, 5 - 10 cm is medium and over 10 cm is large.

 

Over a third  of women have myomas by age 40.  So nothing at all surprising about their being found on Ultrasound, it is an extremely common finding. What is surprising is the attempt of a doctor to convince her to have immediate surgery for it.

 

It is not recommended to treat myomas (fibroids) if the woman is completely asymptomatic and it is not a fertility issue. They  will usually shrink or disappear naturally once menopause is reached.

 

How old is your wife? I suppose if she is quite young, the thinking may have been that they are bound to cause problems sooner or later - but even so, most doctors would wait until they do. Given the small size that could be many years or never.

 

In addition, it is also possible to treat symptoimatic fibroids with medications that shrink their size and this is often tried before resorting to surgery.

 

Unless there are factors not mentioned, the doctor who recommended immediate surgery was not following medical norms and the one who suggested waiting was. Was the latter at a private hospital or government hospital?

 

See  https://www.aafp.org/afp/2017/0115/p100.html

https://my.clevelandclinic.org/health/diseases/9130-uterine-fibroids

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3163653/

 

Abdominal US is not, by the way, recommended by any public health authority anywhere  as a routine screening test - precisely because they so often lead to unnecessary procedures. Private hospitals like to offer them for this same reason.

 

My advice is to (1) never again see the doctor who recommended immediate surgery. (2) follow the advice of the doctor who recommended a "wait and see" approach -- though every 3 month checks may be overzealous.  6 monthly checks  would be more common given the comparatively small size and lack of symptoms.

 

If/when she does need surgery, it can usually be done laparscopically if the fibroids are under 10 cm. Needs an experienced surgeon, of course. Plenty of them in Bangkok. It is also sometimes possible to do a hysterectomy vaginally in which case no abdominal incision or scar at all.  This too needs special training.  Medication prior to surgery is sometimes given to help shrink the fibroids and make the procedure easier. But, assuming no factors not mentioned and the the largest one is really just 2.0 cm, there does nto seem to be any reason  for her to consult a surgeon in Bangkok at this time.

 

 

[NancyL]

It's best to wait for Sheryl to weigh in, but I'd suggest "watchful waiting" based on my experience.  Fibroids are quite common and many women don't even know they have them.  But, once they hear the words "fibroid tumor", they and/or their loved ones freak out and think they have cancer or something quite serious.  Not true.

 

If your wife isn't planning on having any more children and the fibroids aren't causing any symptoms like heavy period bleeding she can't handle or cramps, then there really isn't a reason to remove them.  I had several and continued to monitor them during annual check-ups.  Fortunately, in Thailand, it's cheap to have ultrasounds and eventually, about 10 years after menopause the doctor declared that my uterus had shrunk to the size of a post-menopausal uterus with no sign of the fibroids.  Apparently, they did hang around for a while, but didn't cause any problems and eventually disappeared.

 

 

[NancyL]

1 minute ago, NancyL said:

It's best to wait for Sheryl to weigh in, but I'd suggest "watchful waiting" based on my experience.  Fibroids are quite common and many women don't even know they have them.  But, once they hear the words "fibroid tumor", they and/or their loved ones freak out and think they have cancer or something quite serious.  Not true.

 

If your wife isn't planning on having any more children and the fibroids aren't causing any symptoms like heavy period bleeding she can't handle or cramps, then there really isn't a reason to remove them.  I had several and continued to monitor them during annual check-ups.  Fortunately, in Thailand, it's cheap to have ultrasounds and eventually, about 10 years after menopause the doctor declared that my uterus had shrunk to the size of a post-menopausal uterus with no sign of the fibroids.  Apparently, they did hang around for a while, but didn't cause any problems and eventually disappeared.

 

 

I see that Sheryl responded while I was typing my input.  She and I agree, fortunately.  

 

[DineshR]

@Sheryl and @NancyL

 

Thank you both for your advice. Truly much appreciated. Both my wife and I have been pulling our hair out trying to figure out what we need to do given the conflicting opinions we have received. My wife just turned 43 this year.

 

1. The largest was 2 cm by 2  or 3 cm. But there apparently were several of them that size and several more that were smaller. What both said about laparoscopy was that, yes, it is doable but they would require a lot of blood because of the time it would take to remove all of them. That's why both said the abdominal hysterectomy was the way to go - with one doctor saying it should be done now if we had no plans to have kids in the future. No one said anything about vaginal hysterectomy. 

 

2. Neither doctor mentioned medication to shrink the fibroids.

 

3. Both doctors were at private hospitals - the one that suggested surgery now was a doctor that was recommended by a friend of the wife and one who apparently does a lot of these procedures. The one that recommended waiting was a female gynecologist at a more expensive private hospital here in Korat and who spent a LOT of time explaining what fibroids were, asking a whole of questions to ascertain if my wife had any symptoms, and spent a lot of time explaining why it is better to wait. She said if my wife had no symptoms, then surgery is not what is recommended but rather surveillance to see if the fibroids continued to grow or if the wife started to experience symptoms related to the fibroids such as abdominal pain, difficulty urinating, unusual bleeding etc.  If there are symptoms, then surgery would be considered.

 

4. After considering your inputs, I agree that wait and watch is the right approach. 2 things I will ask the next time we see the doctor is 1) should she take any medications to reduce the size and 2) when and if surgery is indicated, then why not laparoscopy or vaginal hysterectomy ?

 

Thank you so much for that input. Very helpful.

 

 

 

 

[Sheryl]

6 minutes ago, DineshR said:

@Sheryl and @NancyL

 

Thank you both for your advice. Truly much appreciated. Both my wife and I have been pulling our hair out trying to figure out what we need to do given the conflicting opinions we have received. My wife just turned 43 this year.

 

1. The largest was 2 cm by 2  or 3 cm. But there apparently were several of them that size and several more that were smaller. What both said about laparoscopy was that, yes, it is doable but they would require a lot of blood because of the time it would take to remove all of them. That's why both said the abdominal hysterectomy was the way to go - with one doctor saying it should be done now if we had no plans to have kids in the future. No one said anything about vaginal hysterectomy. 

 

2. Neither doctor mentioned medication to shrink the fibroids.

 

3. Both doctors were at private hospitals - the one that suggested surgery now was a doctor that was recommended by a friend of the wife and one who apparently does a lot of these procedures. The one that recommended waiting was a female gynecologist at a more expensive private hospital here in Korat and who spent a LOT of time explaining what fibroids were, asking a whole of questions to ascertain if my wife had any symptoms, and spent a lot of time explaining why it is better to wait. She said if my wife had no symptoms, then surgery is not what is recommended but rather surveillance to see if the fibroids continued to grow or if the wife started to experience symptoms related to the fibroids such as abdominal pain, difficulty urinating, unusual bleeding etc.  If there are symptoms, then surgery would be considered.

 

4. After considering your inputs, I agree that wait and watch is the right approach. 2 things I will ask the next time we see the doctor is 1) should she take any medications to reduce the size and 2) when and if surgery is indicated, then why not laparoscopy or vaginal hysterectomy ?

 

Thank you so much for that input. Very helpful.

 

 

 

 

I won't comment on the first doctor except that I am nto surprised it was at a private hospital.... and do not ever consult him again.

 

The female doctor has provided an appropriate standard of care.

 

Medications would not be indicated now since she is asymptomatic., no need to ask about them. They are hormones and like all medications, do have side effects. Never used in asymptomatic cases.

 

I cannot stress enough how very common it is to have fibroids. I had them too, pre-menopause. By age 50, the majority of women have them, and at 43, at least one third do. You should not think of this as a pathological condition and it does not need treatment until/unless symptoms develop.

 

If your wife is Thai, Thai women tend to start menopause about 5 years earlier than their western counterparts. Odds are your wife is just 5 - 7 years away form it and the her fibroids will not need treatment before they start to naturally shrink post-menopause. (even if she is Western same applies but it may be closer to 10 years. Either way not long given how small the fibroids are).