Fibroids - Precautions | Morcellation, and the Decisions That Matter

By Dr. Manas Chakrabarti, FRCOG - Gynaecological Oncologist, Kolkata

In brief: Most fibroids are harmless. But some decisions about treating them carry risks that are rarely explained clearly. This article covers what those risks are, why they matter, and what you should ask your doctor before agreeing to surgery.

Picture a routine morning. You mention to a friend over tea that your doctor found something on your ultrasound. “Oh, fibroids,” she says, almost casually. “Everyone has them.” She’s not wrong - fibroids are the most frequently occurring tumours in a woman’s lifetime. And most of them truly are harmless.

But here is what that casual conversation rarely covers: the decisions around fibroids are not always simple, and the information patients receive before surgery is not always complete.

This article is for you - and for the person sitting next to you on the train who might share it with someone who needs it.

Most fibroids never grow, never cause symptoms, and never need treatment. Many women move through their entire lives carrying fibroids without any discomfort, any intervention, or even any awareness.

Some women, however, experience significant bleeding, pain, or pressure - and for them, medication or surgery becomes necessary. Whether a fibroid needs treatment, and what kind, depends entirely on the individual: the size of the fibroid, its location, its behaviour, the woman’s symptoms, and her own priorities.

This is why the conversation about fibroids must happen face to face, between you and your doctor, on your own terms.

Here is something that surprises many patients: fibroids cannot be diagnosed with complete certainty from a scan alone.

Ultrasound and MRI scans diagnose fibroids by interpreting shadows and signals. The result is an educated clinical assessment - an informed, experienced judgement - but not an absolute certainty. The only way to confirm, beyond all doubt, that a fibroid is genuinely a fibroid is to remove it and examine it under a microscope.

This matters because other conditions can appear identical to a fibroid on an ultrasound scan. Some of these are entirely benign - polyps, or conditions such as adenomyosis and endometriosis. Occasionally, even a missed pregnancy can produce a similar image.

But a small number of tumours that look exactly like fibroids on a scan turn out, under the microscope, to be something more serious - including rare cancers such as uterine sarcoma or carcinosarcoma.

No scan, however sophisticated, can reliably distinguish between these possibilities before surgery.

What this means for you: if a fibroid is growing, if your symptoms are worsening, or if bleeding occurs after your menopause - seek medical review promptly. Do not wait and watch without guidance.

Women often have ultrasounds done for a variety of reasons over the course of their lives. Every one of those reports is valuable. If a fibroid is identified in the future, comparing it with earlier scans can reveal how long it has been present, whether it has grown, and what treatment approach is most appropriate. Keep your scan reports. They are not paperwork - they are part of your medical history.

For many years, removing large fibroids through small incisions - using laparoscopic (keyhole) or robotic surgery, rather than opening the abdomen - was celebrated as one of the most welcome advances in gynaecological surgery. Patients recovered faster. Scarring was minimal. The results felt like a straightforward improvement for everyone.

Then, in 2013, a case in Boston, Massachusetts changed how the medical world understood the risks.

Dr. Amy Reed was a doctor and a mother of six. In 2013, she underwent a laparoscopic hysterectomy using a device called a morcellator to remove what appeared, on every available scan, to be a fibroid.

It was not a fibroid. Hidden within it was a uterine sarcoma - a rare cancer - that no scan had detected.

Her husband, Dr. Hooman Noorchashm, a cardiac surgeon and immunologist at Harvard Medical School, subsequently raised a formal concern with the United States Food and Drug Administration (FDA). His argument was precise: the morcellator had broken the tumour into fragments and scattered them throughout the abdominal cavity, causing the cancer to spread far more aggressively than it would have done otherwise. Dr. Reed died in May 2015.

Dr. Noorchashm’s central allegation was not merely that a tragedy had occurred. It was that patients were not being given the full risk-benefit picture before consenting to morcellation - and that some doctors, through no fault of their own, were not fully aware of the issue either.

Because, he claimed, doctors were not taught about the risks of morcellation.

When a large fibroid is removed laparoscopically, there is an immediate practical problem: the tumour is too large to come out through the small incision. A morcellator solves this by cutting the tumour into smaller fragments inside the abdominal cavity, which can then be removed through the narrow opening.

The concern arises from the same mechanism that makes it useful. If the tissue being morcellated contains cancer cells - even unsuspected ones - those cells are dispersed through the peritoneal cavity during the procedure. This can accelerate the spread of disease in a way that would not have occurred with a different surgical approach.

Following Dr. Reed’s case, the US Food and Drug Administration issued a formal safety communication. Every manufacturer of morcellation devices is now required to include clear warning information on the packaging, so that patients receive an accurate picture of the risks before surgery.

Morcellation has not been banned. For some patients, after a thorough discussion of the risks and benefits, it may still be a reasonable choice. But that conversation must happen - fully and honestly - before the procedure.

The FDA’s guidance on power morcellation is updated periodically as new research emerges. The current notice is available at: https://www.fda.gov/medical-devices/surgery-devices/laparoscopic-power-morcellators

At this point in the conversation, almost every patient asks the same thing: “But doctor, can’t you tell from the scan whether it’s cancer?”

It is a fair question, and it deserves a direct answer.

The answer is: no. Not with certainty. Not with any scan currently available - whether ultrasound, MRI, or any other imaging technology.

Some clinical features can raise or lower the level of concern. Rapid growth, unusual imaging characteristics, and post-menopausal onset all warrant closer attention. But no scan can rule out malignancy in a fibroid with 100 per cent certainty before it is examined under a microscope.

This does not mean that every fibroid requires surgery. It means that if surgery is being proposed - and particularly if morcellation is part of that plan - you are entitled to understand this clearly.

One final point deserves mention, because it is rarely discussed outside specialist consultations.

Even when a morcellated fibroid turns out to be genuinely benign - no cancer, no sarcoma - there is a documented risk of a condition called disseminated peritoneal leiomyomatosis. This occurs when fibroid fragments scattered during morcellation implant on abdominal surfaces and continue to grow. It is uncommon, but it is not unknown, and it can require further surgery.

Patients have the right to know this before making a decision.

Nothing in this article is intended to alarm you. The vast majority of fibroids are exactly what they appear to be - benign, manageable, and often untroublesome.

What this article is asking of you is something simpler: go into every conversation about fibroid treatment with your questions already formed. Ask what the scan can and cannot tell your surgeon. Ask whether morcellation is being considered, and why. Ask what the alternatives are.

Good medicine is a conversation between a patient who is informed and a doctor who is honest. You now have the information. The conversation is yours to begin.

One sentence worth saving: The scan shows a shadow. Only the microscope shows the truth.

Dr. Manas Chakrabarti, FRCOG is a senior gynaecological oncologist based in Kolkata, India, and an ExCochrane author. He specialises in complex gynaecological and gynaecological-oncological surgery and provides care to patients from across India, the Middle East, and Europe. His practice is grounded in evidence-based medicine and individualised patient care.

FDA Safety Communication on Laparoscopic Power Morcellators - US Food and Drug Administration (updated periodically)

Fibroid Treatment Guide: 9 Steps Before Going to Doctor

Masterclass: Fibroid

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This is an impartial , unsponsored health information. For public awareness and not a replacement of Medical Advice.

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Read the FDA notice here:

https://www.fda.gov/medical-devices/safety-communications/update-perform-only-contained-morcellation-when-laparoscopic-power-morcellation-appropriate-fda