Myomectomy (my-o-MEK-tuh-me) is a surgical procedure to remove uterine fibroids — also called leiomyomas (lie-o-my-O-muhs). These common noncancerous growths appear in the uterus. Uterine fibroids usually develop during childbearing years, but they can occur at any age.
The surgeon's goal during myomectomy is to take out symptom-causing fibroids and reconstruct the uterus. Unlike a hysterectomy, which removes your entire uterus, a myomectomy removes only the fibroids and leaves your uterus.
Women who undergo myomectomy report improvement in fibroid symptoms, including decreased heavy menstrual bleeding and pelvic pressure.
Your doctor might recommend myomectomy for fibroids causing symptoms that are troublesome or interfere with your normal activities. If you need surgery, reasons to choose a myomectomy instead of a hysterectomy for uterine fibroids include:
Myomectomy has a low complication rate. Still, the procedure poses a unique set of challenges. Risks of myomectomy include:
Excessive blood loss. Many women with uterine leiomyomas already have low blood counts (anemia) due to heavy menstrual bleeding, so they're at a higher risk of problems due to blood loss. Your doctor may suggest ways to build up your blood count before surgery.
During myomectomy, surgeons take extra steps to avoid excessive bleeding. These may include blocking flow from the uterine arteries by using tourniquets and clamps and injecting medications around fibroids to cause blood vessels to clamp down. However, most steps don't reduce the risk of needing a transfusion.
In general, studies suggest that there is less blood loss with hysterectomy than myomectomy for similarly sized uteruses.
Rare chance of spreading a cancerous tumor. Rarely, a cancerous tumor can be mistaken for a fibroid. Taking out the tumor, especially if it's broken into little pieces (morcellation) to remove through a small incision, can lead to spread of the cancer. The risk of this happening increases after menopause and as women age.
In 2014, the Food and Drug Administration (FDA) cautioned against using a laparoscopic power morcellator for most women undergoing myomectomy. The American College of Obstetricians and Gynecologists (ACOG) recommends you talk to your surgeon about the risks and benefits of morcellation.
To minimize risks of myomectomy surgery, your doctor may recommend:
Therapy to shrink fibroids. Some hormonal therapies, such as GnRH agonist therapy, can also shrink your fibroids and uterus enough to allow your surgeon to use a minimally invasive surgical approach — such as a smaller, horizontal incision rather than a vertical incision, or a laparoscopic procedure instead of an open procedure.
Some research suggests that intermittent GnRH agonist therapy, over time, can shrink fibroids and decrease bleeding enough that surgery isn't needed.
In most women, GnRH agonist therapy causes symptoms of menopause, including hot flashes, night sweats and vaginal dryness. However, these discomforts end after you stop taking the medication. Treatment generally occurs over several months before surgery.
Evidence suggests that not all women should take GnRH agonist therapy before myomectomy. GnRH agonist therapy may soften and shrink fibroids so much that their detection becomes more difficult. The cost of the medication and the risk of side effects must be weighed against the benefits.
Another family of drugs called selective progesterone receptor modulators (SPRMs), such as ulipristal (ella), may also shrink fibroids and reduce bleeding. Outside the United States, ulipristal is approved for three months of therapy before a myomectomy.
You'll need to fast — stop eating or drinking anything — in the hours before your surgery. Follow your doctor's recommendation on the specific number of hours.
If you're on medications, ask your doctor if you should change your usual medication routine in the days before surgery. Tell your doctor about any over-the-counter medications, vitamins or other dietary supplements you're taking.
Depending on your procedure, you may receive one of the following types of anesthesia:
Sometimes other types of anesthesia, such as a spinal or local, may be used. Ask your doctor about the type of anesthesia you may receive.
Finally, talk to your doctor about pain medication and how it will likely be given.
Whether you stay in the hospital for just part of the day or overnight depends on the type of procedure you have. Abdominal myomectomy (laparotomy) usually requires a hospital stay of one to two days. In most cases, laparoscopic or robotic myomectomy is done outpatient or with only one overnight stay. Hysteroscopic myomectomy is often done with no overnight hospital stay.
Your facility may require that you have someone accompany you on the day of surgery. Make sure you have someone lined up to help with transportation and to be supportive.
Depending on the size, number and location of your fibroids, your surgeon may choose one of three surgical approaches to myomectomy.
In abdominal myomectomy (laparotomy), your surgeon makes an open abdominal incision to access your uterus and remove fibroids. Your surgeon will generally prefer to make a low, horizontal ("bikini line") incision, if possible. Vertical incisions are needed for larger uteruses.
In laparoscopic or robotic myomectomy, both minimally invasive procedures, your surgeon accesses and removes fibroids through several small abdominal incisions.
Compared with women who have a laparotomy, women who undergo laparoscopy have less blood loss, shorter hospital stays and recovery, and lower rates of complications and adhesion formation after surgery. There are limited comparisons between laparoscopic and robotic myomectomy. Robotic surgery may take longer and be more costly, but otherwise few differences in outcomes are reported.
Sometimes, the fibroid is cut into pieces (morcellation) and removed through a small incision in the abdominal wall. Other times the fibroid is removed through a bigger incision in your abdomen so that it can be removed without being cut into pieces. Rarely, the fibroid may be removed through an incision in your vagina (colpotomy).
To treat smaller fibroids that bulge significantly into your uterus (submucosal fibroids), your surgeon may suggest a hysteroscopic myomectomy. Your surgeon accesses and removes the fibroids using instruments inserted through your vagina and cervix into your uterus.
A hysteroscopic myomectomy generally follows this process:
At discharge from the hospital, your doctor prescribes oral pain medication, tells you how to care for yourself, and discusses restrictions on your diet and activities. You can expect some vaginal spotting or staining for a few days up to six weeks, depending on the type of procedure you've had.
During abdominal hysterectomy, your surgeon makes a vertical or a horizontal incision in your lower abdomen. A vertical incision (left) gives the surgeon greater access to your pelvis. A horizontal incision (right) follows your skin's natural lines, usually leaving a thinner scar.
Intramural fibroids grow within the muscular uterine wall. Submucosal fibroids bulge into the uterine cavity. Subserosal fibroids project to the outside of the uterus. Some subserosal or submucosal fibroids may be pedunculated — hanging from a stalk inside or outside the uterus.
Outcomes from myomectomy may include:
Fibroids that your doctor doesn't detect during surgery or fibroids that are not completely removed could eventually grow and cause symptoms. New fibroids, which may or may not require treatment, can also develop. Women who had only one fibroid have a lower risk of developing new fibroids — often termed the recurrence rate — than do women who had multiple fibroids. Women who become pregnant after surgery also have a lower risk of developing new fibroids than women who don't become pregnant.
Women who have new or recurring fibroids may have additional, nonsurgical treatments available to them in the future. These include:
Some women with new or recurring fibroids may choose a hysterectomy if they have completed childbearing.