Atypia Is NOT An Absolute Indication For Hysterectomy

Question:

Hi Dr. Ramirez,

I'm a Canadian, temporarily living in South Africa. Greetings from Pretoria!

I'm 44 yrs old, diagnosed with PCOS at age 33, on metformin 500mg 2/day since then. I've got about 45 pounds to lose and have been slowly and steadily losing pounds since May (5 kg). I've never been able to get pregnant and throughout my 20s and early 30s, I went months without menstruation. Weight came on very quickly. I exercise regularly.

My new gyne here found a myoma in my uterus in August during my yearly exam. I had bleeding between periods almost every day for a few months. Some days it was spotting; other days it was heavier. The myoma was removed hysteroscopically and examined. The biopsy of the tumour shows atypical cells and the lab report summarizes the microscopy as "these features are most suggestive of an adenomyomatous (endometrial) polyp with focal atypia against the background of a proliferative endometrium."

I understand I need to remove my uterus.The doctor can do the surgery vaginally. Is uterus removal the best course of action? What can I do to prepare my body for no uterus? And Is there anything I can do to protect my ovaries going forward?

Thanks for your help in advance. S. from South Africa

Answer:

Hello S. from Canada and South Africa,

Atypia is NOT a absolute indication for hysterectomy, so no, you don't necessarily need to have your uterus removed. Atypia is not cancer, it is a pre-cancerous finding. It is possible that the only area of atypia was already removed, which then would have solved the problem. A repeat D&C should be done to evaluate the rest of the endometrial tissue. Also you should be cycles for three months then rechecked again by endometrial biopsy or D&C. If there is no abnormality found, then no other testing or treatment needs to be done other than keep you cycling on the birth control pill.

However, if you want you uterus out, and that is understandable, it is certainly a option for you and a vaginal hysterectomy would be fine. Make sure that your doctor keeps the ovaries intact i.e. does not remove them. You still need them to produce adequate hormone that your body needs. It's your choice. Make sure your doctor understands and is told that you want to keep your ovaries. There is absolutely no reason to have them removed.

Thank you for your question all the way from South Aftrica, addressing a problem that many women around the world face as well.

Good luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
Monterey, California, U.S.A.

Comment: Thank you Dr. Ramirez! Very timely and useful.

Chances Of Pregnancy After Myomectomy: With Or Without IVF

(If the blog radio program turns on, go to the Oct. 1st blog post and pause it...I will be keeping the show up for the month of October.)

Question:

Dear Doctor,

Hello. I am writing from Atlanta, GA. I wrote once before (concerning my dermoid - thank you for the information!) and was hoping you would consider a second question. Much like everyone else here, I've had a complicated TTC journey.

April - laparoscopic dermoid removal from right ovary. Ovary was not removed but is small and has not produced follicles since (despite being on letrozole).

July - HSG. Right tube open. Left tube did not spill dye. Proximal block. No history of STDs or infections, thinking maybe it's scar tissue from surgery?

Sept - Large fibroid (~4cm) found on US (significantly distorts the uterine cavity). RE recommends abdominal myomectomy before moving forward with IVF. I also have a uterine polyp (~5mm) that will need to be removed at the same time (if possible) or during a 3rd surgery.

I am 36 years old and have never been pregnant. While on letrozole I produced 2 eggs the first month and 1 egg the second month. However, we are open to the use of donor embryos. My question is, what do you think is the risk of a complication from abdominal myomectomy (during the initial surgery or during a resulting pregnancy) and what is the probability of achieving a pregnancy after such a procedure? I am feeling discouraged given that there are issues with my ovaries, tubes, and uterus, and want to have a clear understanding of the potential for complications versus the potential for pregnancy if I move forward with the surgery.Thank you again for your time, J from Georgia

Answer:

Hello J from Atlanta,

Basically at this point you have two choices: you could attempt IVF without the myomectomy or have the myomectomy first before IVF.

The studies are controversial regarding the influence of fibroids on pregnancy rates in IVF. Some show that any fibroid can reduce the PR, whereas others show that only the ones that enter the uterine cavity do. In my experience, if the myoma is very large and takes up a good portion of the uterine muscle, it seems to impact fertility. I have had many patients get pregnant spontaneously after a myomectomy in those cases, or achieve pregnancy with IVF after they failed previous cycles. What I counsel my patient is that the studies are not clear and so the decision is really whether you not you want to do everything you can to maximize your chances with IVF or do you want to try the IVF without the surgery and take the risk. It is a toss up. I will go with whichever choice my patient makes. Neither option is a guarantee anyways. I have had patients that do the myomectomy and still fail with IVF, for whatever reason.

I cannot give you specific statistics regarding the chances of pregnancy with or without myomectomy because the mixed findings in the studies that have been done. In general, the current recommendation by ASRM is that only fibroids that invade into the uterine cavity need to be removed (because they can interfere with implantation) and 4 cms is not a large fibroid. I would consider 7 or larger to be a large fibroid. In some hands, this 4 cm fibroid can be removed laparoscopically. I also prefer to do the procedure as an open procedure, but that is because of a lack of experience removing deep fibroids laparoscopically. If you don't want the open procedure, then you might want to investigate and find someone that does these laparoscopically and has a lot of experience (the experience is the key in this procedure). That will allow for less pain and a quicker recovery. In either procedure, you won't be able to do the IVF for at least 8 weeks after the date of the surgery.

Good Luck on your journey...it is good that you are leaving yourself open to other options too!

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

http://www.montereybayivf.com/

Monterey, California, U.S.A.

Comment: Thank you! Your knowledge and kindness are invaluable.