Subserosal Fibroids: Symptoms, Diagnosis, and Treatment Options

Subserosal fibroid issues?

Hello Doctor, last September I went to a small clinic for abdominal pain and consulted a gynecologist.
The doctor at the clinic said they had never seen this type of fibroid before and recommended that I go to a larger hospital.
The next day, I visited the larger hospital and was diagnosed with a 5.9 cm subserosal fibroid.
The first doctor at the hospital said that this type of fibroid is not uncommon and mentioned that since I am still young, it will likely continue to grow.
They suggested monitoring it or considering a single-port minimally invasive surgery to remove it, noting that the fibroid appeared as a dark cavity.
I would like to know if this indicates liquefaction or degeneration? My blood test results were normal.
Three months later, in early December, I returned for a follow-up, and the fibroid was the same size.
At the end of December, I decided to consult another doctor.
The second doctor at the larger hospital recommended a four-port minimally invasive surgery or a Da Vinci surgery, stating that the single-port approach is more challenging.
Postoperatively, they suggested taking hyaluronic acid patches, mentioning that the nutrients might be absorbed by the fibroid, which could explain why other smaller fibroids are not visible.
They indicated that once this fibroid is removed, the others might grow larger.

My symptoms include: aside from experiencing abdominal pain last September, which felt like the pedicle of the fibroid was twisting (though I am not certain), I have not had much discomfort.
I do not experience frequent urination, but I have noticed an increase in discharge compared to before, possibly for about six months, though it is not consistently excessive.
My menstrual period has also become longer; it used to last four days, but now it lasts six days, with only two of those days being heavier.
The remaining days have minimal bleeding.
Additionally, I frequently experience vaginal inflammation and itching, having visited the clinic about five times, where the doctor prescribed suppositories that helped.
However, it has been a recurrent infection, and I have been trying to keep the vaginal area dry and change panty liners regularly.
I am unsure if the increased discharge is contributing to the frequent infections.
I have undergone Pap smears two or three times, all showing inflammation, but the doctor said there is no need for concern.

I would like to ask if I decide to undergo Da Vinci surgery, will it be possible to determine preoperatively if there is any adhesion or inflammation in the uterine cavity? Is surgery the only way to find this out? Can ultrasound or MRI detect these conditions? I read online that if adhesions are severe, minimally invasive surgery may not be an option, and a laparotomy would be necessary.
Additionally, is the use of hyaluronic acid patches required for Da Vinci surgery? Neither of the doctors at the larger hospital mentioned hyaluronic acid patches, and I found this information online, which suggests they can help prevent postoperative adhesions.
Thank you.

123, 30~39 year old female. Ask Date: 2020/01/08

Dr. Huang Yuande reply Obstetrics and Gynecology

1.
A fibroid measuring 5.9 cm may require surgery, but the decision largely depends on your symptoms.
There are various surgical options available, including traditional mini-laparotomy, laparoscopy, and robotic-assisted surgery (Da Vinci).
Each surgical method has its own advantages and disadvantages.
Generally, it is not considered a particularly difficult surgery, so factors such as cost and recovery time should also be taken into account.
2.
GnRH agonists can be taken preoperatively to reduce the size of the fibroid, making surgery easier, and they can also be used postoperatively for prevention (though this usage is less common).
The treatment strategy will determine this approach.
As for hyaluronic acid adhesion prevention patches, they do have some efficacy, but the extent of their effectiveness can vary depending on individual patient characteristics.
3.
Your concerns are not overly complex in a clinical setting.
It is advisable to discuss your needs and the associated costs with your physician before deciding on a treatment approach.

Reply Date: 2020/01/08

More Info

Understanding subserosal fibroids is crucial for managing symptoms and determining the best treatment options. Subserosal fibroids are a type of uterine fibroid that grows on the outer wall of the uterus. They can vary in size and may cause a range of symptoms, although many women experience no symptoms at all.

Symptoms
In your case, you mentioned experiencing abdominal pain, changes in menstrual flow, and increased vaginal discharge. These symptoms can be associated with subserosal fibroids, especially if they are large enough to exert pressure on surrounding organs. The pain you felt last September could have been related to the fibroid, particularly if it was undergoing degeneration or if there was a concern about torsion (twisting of the fibroid).
Increased menstrual bleeding and longer periods can also be linked to fibroids, as they can disrupt normal uterine function. The increased vaginal discharge and recurrent infections may not be directly caused by the fibroid but could be related to other factors, such as hormonal changes or the fibroid's impact on the uterine environment.

Diagnosis
Diagnosis of subserosal fibroids typically involves imaging techniques such as ultrasound or MRI. Ultrasound is often the first step, as it is non-invasive and can provide a clear picture of the fibroid's size and location. MRI can offer more detailed information about the fibroid and surrounding tissues, including any potential adhesions or inflammation in the uterine cavity.

Regarding your question about adhesions and inflammation, while imaging can provide some insights, it may not always reveal the full extent of these issues. Adhesions are often best assessed during surgery, as they can be difficult to visualize on imaging studies. If there are significant concerns about adhesions, a diagnostic laparoscopy may be recommended, which allows direct visualization of the pelvic organs.

Treatment Options
In terms of treatment, your doctors have suggested monitoring the fibroid or considering surgical options such as single-port laparoscopic surgery or Da Vinci robotic surgery. The choice of surgery often depends on the fibroid's size, location, and the surgeon's expertise. Single-port surgery is less invasive but can be technically challenging, while Da Vinci surgery offers enhanced precision and visualization.

You mentioned the possibility of using a hyaluronic acid patch during surgery to prevent adhesions. While some studies suggest that such barriers can reduce postoperative adhesions, not all surgeons routinely use them. The decision to use a barrier may depend on the surgeon's preference and the specific circumstances of your case.

Conclusion
In summary, subserosal fibroids can cause various symptoms, and your experience aligns with common presentations. Diagnosis typically involves imaging, but the extent of adhesions may only be fully understood during surgery. Treatment options vary, and the choice between observation and surgical intervention should be made based on your symptoms, the fibroid's characteristics, and your overall health. It's essential to have open discussions with your healthcare providers about your concerns and preferences to determine the best course of action for your situation.

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