Uterine fibroids in Paris 16th

Recognizing it

Fibroids: the signs that lead to a consultation

A fibroid (or myoma) is a ball of muscle tissue that grows in the wall of the uterus. Often several at once, from a few millimeters to several centimeters, fibroids sit inside the cavity, within the muscle or on the surface of the uterus; their size and position determine the symptoms.

Where fibroids sit (diagram).

Heavy, prolonged periods — the most frequent sign: pads or tampons changed very often, clots, periods lasting more than a week.
Fatigue, breathlessness, anemia — the direct consequence of repeated bleeding, often revealed by a blood test.
Pelvic heaviness or pain — a weight in the lower abdomen, pain during periods or intercourse.
Frequent urge to urinate, a growing belly — when a large fibroid presses on the bladder or distends the abdomen.
Difficulty conceiving, miscarriages — some fibroids, depending on their position, interfere with implantation or pregnancy.

Many fibroids cause no symptoms at all: found on a routine ultrasound, they are simply monitored. What matters is the impact on your life — and that is what the consultation assesses first.

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Assessment

Ultrasound and hysteroscopy, at the practice

The consultation begins with your symptoms, your history and your pregnancy plans if you have any, then a gynecological examination. The pelvic ultrasound is performed at the same time, at the practice, on the GE Voluson Expert 22 system: it counts the fibroids, measures them and locates them in relation to the uterine cavity, and Dr Gatri explains the images to you immediately. When fibroids reach the cavity or the bleeding remains unexplained, a diagnostic hysteroscopy completes the assessment, also at the practice, with a fine endoscope, with no operating theatre and no general anesthesia (anaesthesia); a blood test checks for anemia.

You leave with a clear answer: which fibroids you have, whether they explain your symptoms, and what is proposed to you.

Treatments

From monitoring to surgery, step by step

Monitoring — when a fibroid causes no symptoms, there is nothing to treat: a regular ultrasound check, as part of your routine gynecological care, confirms that it remains stable.
Medical treatment of the bleeding — when heavy periods are the main problem, we start with medical treatment, with or without hormones, which reduces the bleeding and corrects the anemia. It does not make the fibroid disappear, but it brings relief and is often enough — especially in the years before menopause, after which fibroids shrink.
Conservative surgery — when medical treatment is not enough, or a fibroid stands in the way of a pregnancy, Dr Gatri removes the fibroids while preserving the uterus. A fibroid protruding into the cavity is removed by operative hysteroscopy, through the natural passages, with no incision, as day surgery. The others call for a myomectomy, by laparoscopy or open surgery depending on their size and position; the chosen technique is explained to you at the consultation.
Operative hysteroscopy (diagram). Surgery through the natural passages, with no incision: a fluid distends the cavity, and instruments remove a polyp, a fibroid or a septum; here, a fibroid protruding into the cavity.
Myomectomy (diagram). Dr Gatri removes the fibroids while preserving the uterus. A fibroid protruding into the cavity is removed by operative hysteroscopy, with no incision. The others call for a myomectomy; the operation involves an incision in the wall of the uterus, removal of the fibroid(s) and closure of the uterine wall.fibroid removedincision, then closure of the uterine wallthe uterus is preserved
Hysterectomy or endometrial ablation — when conservative treatments are no longer sufficient and there are no more pregnancy plans. Hysterectomy removes the uterus, by the vaginal, laparoscopic or abdominal route depending on your situation, and puts an end to fibroids and periods. Second-generation endometrial ablation destroys the lining of the uterus to treat very heavy periods: a short day-surgery procedure for women with no further pregnancy plans; it reduces fertility, and contraception remains necessary after the procedure.
Hysterectomy (diagram). Hysterectomy removes the uterus.uterus removedwith adnexectomy: ovaries and tubes removed at the same timethree possible approaches: vaginal, laparoscopic or abdominal
Uterine artery embolisation — an alternative to surgery, performed by an interventional radiologist outside the practice, as day care: deprived of its blood supply, the fibroid shrinks. It is discussed with caution when a pregnancy is planned.

The uterus in cross-section, front view (diagram). The endometrium, in pink, is the lining of the uterine cavity: endometrial ablation destroys it.

These procedures are performed by Dr Gatri at the Clinique de la Muette — as day surgery for operative hysteroscopy, with a hospital stay of 2 to 3 days for myomectomy and 1 to 2 days for hysterectomy (see Hospital stay, anesthesia and recovery) —, following the practice's surgical pathway: consultation, documents and quotation by e-mail, electronic signature, theatre booking, anesthesia consultation at the clinic, then a post-operative consultation at the practice. The information sheets of the French College of Gynecologists and Obstetricians (CNGOF), translated into English, are given to you: myomectomy, hysteroscopy, vaginal, laparoscopic or abdominal hysterectomy, second-generation endometrial ablation.

Information

Risks and complications: what to know before deciding

Every procedure carries risks: Dr Gatri sets them out at the consultation and gives you the information sheets of the French College of Gynecologists and Obstetricians (CNGOF), translated into English, whose wording is used here.

Common and not serious — pain in the days that follow, relieved by the painkillers prescribed: the CNGOF sheet states that after a myomectomy the first 48 hours are often painful and require strong painkillers. A usually mild urinary infection is not uncommon after a myomectomy. After a laparoscopic procedure, pain in the abdomen, sometimes spreading to the shoulders and caused by the gas used, is common, and modern pain management eases it. After an endometrial ablation, bleeding or watery discharge lasts several weeks.
Rare — a hematoma (haematoma) or an infection (abscess) of the scar, usually needing only simple local care. Bleeding: in the exceptional case of life-threatening bleeding, a transfusion of blood or blood products is needed. Injury to organs near the uterus occurs exceptionally — bowel, urinary tract or blood vessels — and requires specific surgical management. Phlebitis, a clot in a leg vein, or pulmonary embolism: this is why an anticoagulant is prescribed during the hospital stay. As with any surgery, these operations may very exceptionally involve a life-threatening risk or serious after-effects.
What increases them — certain risks are increased by your condition, your history or by treatment taken before the operation: it is essential to tell your doctor about your personal and family history and about all treatments and medicines you take. For endometrial ablation, the CNGOF sheet states that the risk of perforating the uterus is higher in post-menopausal patients, in those who have never given birth vaginally and in those with a history of conisation. Smoking increases the risk of surgical complications of any operation: the sheet states that stopping smoking 6 to 8 weeks before the procedure removes this additional risk.
Signs that should prompt a call — burning or frequent urination, which points to a urinary infection; abnormal or foul-smelling vaginal bleeding, or a high temperature, which call for a consultation with your surgeon; nausea and vomiting with fever; a scar that is red and painful; calf pain or difficulty breathing, which call for prompt contact with your doctor to rule out phlebitis. After an endometrial ablation: very heavy continuous bleeding, foul-smelling discharge, unusual pain or fever.
Depending on the procedure · Operative hysteroscopy — hysteroscopy is a common procedure whose aftermath is painless and straightforward in the majority of cases. During the procedure, perforation of the uterus may occur: it then prevents completion of the planned procedure and generally does not require surgery, but a laparoscopy is sometimes needed to rule out an exceptional injury to neighboring organs. Exceptional risks linked to reabsorption of the fluid injected into the uterus have been described: pulmonary edema (oedema), allergic reaction, cardiac disturbances. Afterwards, uterine infections (endometritis) are rare and may require antibiotic treatment. CNGOF information sheet — Hysteroscopy
Depending on the procedure · Myomectomy — myomectomy is a common, well-established procedure that is straightforward in most cases. During the operation, bleeding from the opening of the uterine wall may occur; very exceptionally, such bleeding can only be treated by removing the uterus. Exceptionally, severe bleeding or infection occurs in the days after the operation and requires a further procedure. CNGOF information sheet — Myomectomy
Depending on the procedure · Hysterectomy — hysterectomy is a common, well-established procedure that is straightforward in the majority of cases. The approach is changed according to what is found during the operation: opening the abdomen is sometimes necessary although a vaginal or laparoscopic procedure was planned. Once home, after an abdominal route, heavy lifting is avoided for a few weeks, to protect the strength of the scar. If the ovaries were removed, vaginal dryness may appear, which is eased with lubricants or hormone replacement prescribed by your doctor. CNGOF sheet — Vaginal hysterectomy CNGOF sheet — Laparoscopic hysterectomy CNGOF sheet — Abdominal hysterectomy
Depending on the procedure · Second-generation endometrial ablation — hemorrhage (haemorrhage) or complications of anesthesia are extremely rare. Perforation of the uterus may occur: the procedure is then stopped and rescheduled at a later date. In the first few hours you feel a pulling sensation or mild period-like pain, well relieved by the painkillers prescribed. Despite all the precautions taken, problems may occur in isolated cases during and after the operation. CNGOF information sheet — Second-generation endometrial ablation

Frequently asked questions

Your questions, our answers

Will I have surgery on the day of the consultation?

The consultation for surgery is an appointment at the practice. Dr Gatri examines your situation, explains the planned procedure and answers your questions. If the procedure is decided on, you receive a quotation and an informed-consent form; once they are signed, a date is set for the procedure at the Clinique de la Muette.

Is a fibroid a cancer?

No. A fibroid is a benign tumor of the uterine muscle. Ultrasound, completed by hysteroscopy if needed, distinguishes it from the other causes of bleeding.

Does a fibroid always need surgery?

No. A fibroid that causes no trouble is monitored; heavy periods are treated medically first. Surgery is proposed when medical treatment is not enough, when the fibroid presses on neighboring organs or when it stands in the way of a pregnancy.

Can I keep my uterus?

Yes, in the great majority of situations. Myomectomy removes the fibroids while preserving the uterus, and therefore the possibility of pregnancy; operative hysteroscopy does the same for fibroids inside the cavity. Hysterectomy is reserved for situations where conservative treatments are no longer sufficient and there are no more pregnancy plans.

Are fibroids compatible with pregnancy?

Yes, most of the time: most women with fibroids conceive and give birth normally. Some fibroids, because of their position in the cavity, interfere with implantation; they are then removed before pregnancy. If you are having difficulty conceiving, the couple's consultation reviews all the possible causes, fibroids included.

How long is the recovery after a myomectomy?

It depends on the route. After operative hysteroscopy you go home the same day; after a myomectomy by laparoscopy or open surgery, the hospital stay lasts 2 to 3 days, and recovery takes longer. Dr Gatri tells you at the consultation how much time off to expect; the information sheet gives the details.

Do fibroids come back?

After a myomectomy the uterus is preserved and new fibroids sometimes form over the years; ultrasound monitoring continues. After menopause, they shrink. Only hysterectomy rules out any recurrence.

Is it covered by health insurance?

In part. The consultation, the ultrasound, the diagnostic hysteroscopy and surgery are partly covered by the French health insurance (Assurance maladie). The practice applies direct billing to the French national health insurance (tiers payant): with an up-to-date carte Vitale, you do not pay that part upfront. What remains payable by you includes the excess fee (dépassement d'honoraires), which may be reimbursed by your complementary insurer (mutuelle), depending on your policy. For a procedure, the practice's quotation covers Dr Gatri's fees, while clinic charges and the anesthetist's fees are settled with the clinic. The full picture is in “Fees and reimbursement”, further down.

Will I be in pain after a myomectomy?

Pain relief is organized from the outset: the anesthetist (anaesthetist) prescribes routine painkillers. The CNGOF information sheet states that the first 48 hours are often painful and call for strong painkillers, after which the pain settles; moderate vaginal bleeding is usual over that period. After operative hysteroscopy, recovery is usually simple and painless. Once home, pain, fever or bleeding means calling the surgical team straight away.

Can I get pregnant after a myomectomy?

Yes: the uterus is preserved, periods return and pregnancy remains possible. The CNGOF information sheet states that a healing interval is to be respected between the operation and a pregnancy, and that the scar left on the uterus is a weak point which, in some cases, leads to delivery by cesarean (caesarean) section. Dr Gatri gives you that interval at the post-operative consultation, according to the fibroids removed and the route used.

How do I book?

On Doctolib, with Dr Gatri: “Première consultation de gynécologie” (first gynecology consultation), or “Consultation pour myomectomie (fibromes)” if surgery has already been discussed; or by telephone through the secretariat.

Uterine fibroids: from diagnosis to treatment, including surgery, in Paris 16th