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Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics

and Gynaecology Royal Free Hospital Pond Street Hampstead London NW3 2QG, UK
Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for gynaecologists interested in the surgical management of fibroids is now on line. www. fibroidsurgery. org

Information about uterine fibroids from the Royal Free Hospital, London, UK
Welcome to this web site. You will find information about uterine fibroids (leiomyoma), how they are diagnosed, and details of different treatments including hysteroscopic myomectomy, laparoscopic myomectomy, vaginal myomectomy and open myomectomy, as well as uterine artery embolisation. The web site has been specially written for patients and we have done our best to minimize the jargon. The main purpose of this site is to provide you with details about the various treatments used to manage patients with fibroids so you can better decide, with your gynaecologist or general practitioner, which is the best in your case. All these treatments are available at the Fibroid Clinic at the Royal Free Hospital, including: Hysteroscopic myomectomy Laparoscopic myomectomy Vaginal myomectomy Abdominal myomectomy Vaginal hysterectomy Laparoscopic hysterectomy Abdominal hysterectomy Uterine artery embolisation

How common are fibroids? Uterine fibroids are very common. They are more frequent in women of AfroCaribbean origin, being three times as common as in white, Hispanic and Asian women. A recent study from the USA showed that fibroids are even more common than we thought. 35% of premenopausal women had a previous diagnosis of fibroid tumors. 51% of the premenopausal women who had no previous diagnosis had ultrasound evidence of fibroids. The estimated cumulative incidence of fibroids by age 50 was >80% for black women and nearly 70% for white women.

These may be of interest to you


We have prepared a summary of the indications/contraindications and advantages/disadvantages of currently available treatments and an explanation of the different types of myomectomies which you can download - see Treatment summary. We have been using our new ovarian artery clamps in combination with a pericervical tourniquet to reduce bleeding at open myomectomy for almost one year, and the results appear to be as good as conventional triple tourniquets but without affecting ovarian blood flow during surgery. Click here to see it being used. Myomectomies carried out at the Royal Free Hospital during 2005 2010:
2005 Hysteroscopic Laparoscopic Laparotomy Vaginal Total Conversion to hysterectomy 20 17 23 1 61 0 2006 29 15 28 2 74 2* 2007 16 16 28 3 63 0 2008 32 9 24 5 70 0 2009 22 16 42 4 84 0 2010 35 5 32 6 78 0 Total 154 78 177 21 430 2 (0.47%)

* Both hysterectomies were in women having their second open

myomectomy for multiple fibroids. Click here if you wish to download a hard copy of the entire website in pdf format (2.14 MB).

Our latest publications


Al-Shabibi N, Korkontzelos I, Gkioulekas N, Stamatopoulos C, Tsibanakos I, Magos A. Cable ties as tourniquets at open myomectomy. Int J Gynaecol Obstet. 2010 Sep;110(3):265-6. Granata M, Tsimpanakos I, Moeity F, Magos A. Are we underutilizing Palmer's point entry in gynecologic laparoscopy? Fertil Steril. 2010 May 7. Tsimpanakos I, Connolly J, Alatzoglou KS, Rowan C, Magos A. Two cases of myomectomy complicated by intravascular hemolysis and renal failure: disseminated intravascular coagulation or hemolytic uremic syndrome? Fertil Steril. 2010 Apr;93(6):2075.e11-5. Al-Shabibi N, Chapman L, Madari S, Papadimitriou A, Papalampros P, Magos A. Prospective randomised trial comparing gonadotrophinreleasing hormone analogues with triple tourniquets at open myomectomy. BJOG, 2009 Feb 4. A, Gambadauro P, Tsibanakos I, Georgakaki A, Kakaidis I, Moiety F. Submucous fibroids should be removed in infertile women. BMJ 2009; 338: b126. Madari S, Al-Shabibi N, Papalampros P, Papadimitriou A, Magos A. A randomised trial comparing the H Pipelle with the standard Pipelle for endometrial sampling at 'no-touch' (vaginoscopic) hysteroscopy. BJOG 2009 Jan;116(1):32-7. Papalampros P, Gambadauro P, Papadopoulos N, Polyzos D, Chapman L, Magos A. The mini-resectoscope: A new instrument for office hysteroscopic surgery. Acta Obstet Gynecol Scand 2008 Nov 20:1-4. Adam Magos BSc MB BS MD FRCOG Consultant Gynaecologist Royal Free Hospital London Site updated: 20th December 2010 Home - Background information - Treatment options - Treatment summary - Movies - Fibroid Clinic - Knowledge base - Useful links - How to find us - Contact us 2010 webmeddesign.com Dreamweaver Web Templates

Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street Hampstead London NW3 2QG, UK
Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for gynaecologists interested in the surgical management of fibroids is now on line. www. fibroidsurgery. org Symptoms

Background information
In deciding what, if any, treatment may be appropriate in your case, t is useful to understand what uterine fibroids are, which symptoms may be related to fibroids, and how the condition is diagnosed. Click on the links below for further information:

Uterine size When describing an enlarged uterus, doctors often equate the size of the uterus to the gestation (age in weeks) of a normal pregnancy.When the uterus is relatively small, and cannot be felt in the abdomen, uterine size can be compared to common fruits:
Gestation 4 weeks 6 weeks 8 weeks 10 weeks 12 weeks Uterus Plum Mandarin Apple Orange Grapefruit

What are fibroids

When the uterus can be felt in the abdomen, the following rules are often applied, the reference point being the top of the womb:
Gestation 12 weeks 16 weeks Uterus Pubic hair Half way to umbilicus At level of umbilicus Half way between umbilicus and chest At level of chest

Diagnosis

20 weeks

24 weeks

28 weeks

Home - Background information - Treatment options - Treatment summary - Movies - Fibroid Clinic - Knowledge base - Useful links - How to find us - Contact us 2010 webmeddesign.com Dreamweaver Web Templates

Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street Hampstead London NW3 2QG, UK
Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us

Treatment options
Generally speaking, treatment for uterine fibroids is only indicated if they cause symptoms or if they are particularly large. Small fibroids are quite common, and often do not cause problems; in that case, there is no need for immediate treatment, and monitoring of the fibroids may be all that is needed. However, if you do have symptoms which can be linked to fibroids, or if the fibroids are large (or getting larger), the choice of treatments will depend on: Your age Number of fibroids you have How large they are Where they are Your main symptoms Your wish for future fertility For instance, if the fibroids are small and your main problem is one of heavy periods, medical therapy with drugs or hysteroscopic myomectomy may be successful. If the fibroids are larger but you wish to have children in the future, myomectomy or embolisation may be the best option for you. If your family is complete, or if the fibroids are relatively large, you may prefer to have a hysterectomy or undergo embolisation. Click on the links below for further information:

What causes fibroids? No one knows. We do know that the growht of pre-exisiting fibroids depend on ovarian hormones, especially oestrogen. The evidence for this is that fibroids do not occur before the menarche, and fibroids shrink after the menopause. Because of the influence of racial origin on the incidence of fibroids, there must be a genetic aetiology. However,

LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for gynaecologists interested in the surgical management of fibroids is now on line. www. fibroidsurgery. org Medical treatment Myomectomy

uterine fibroids are not a singlegene disorder. Interestingly, no animals have the equivalent of fibroids as seen in women!

Hysterectomy

Uterine artery emobilisation

Click here for a summary comparison of common treatment options for uterine fibroids.

Home - Background information - Treatment options - Treatment summary - Movies - Fibroid Clinic - Knowledge base - Useful links - How to find us - Contact us 2010 webmeddesign.com Dreamweaver Web Templates

Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street Hampstead London NW3 2QG, UK
Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for gynaecologists interested in the surgical management of fibroids is now on line. www. fibroidsurgery. org Different types of myomectomies compared

Treatment summary
We have prepared two tables for you which we hope will help you understand better some of the treatment options. Click on the links below for further information:

On the subject of surgeons: Surgeons must be very careful when they take the knife! Underneath their fine incisions, stirs the Culprit -- Life! Emily Dickinson, American poet (1830-1886)

Common treatment options for uterine fibroids

What is a hysterectomy? What is a myomectomy?

Home - Background information - Treatment options - Treatment summary - Movies - Fibroid Clinic Knowledge base - Useful links - How to find us - Contact us 2010 webmeddesign.com Dreamweaver Web Templates

Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street Hampstead London NW3 2QG, UK
Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for gynaecologists interested in the surgical management of fibroids is now on line. www. fibroidsurgery. org Hysteroscopic myomectomy

Movies of surgical procedures


We have just updated and expanded our library of edited movies of operations and techniques which you may find interesting and helpful. The movies have been prepared for streaming over the internet using a fast ADSL/broadband/cable connection, that is the movies will play as they are being downloaded rather than having to wait for the entire recording to be downloaded first. The movies can also be streamed using a slower modem connection, but the download time will be slow and the movies may be jerky. The movies are in Flash format which is included with most browsers (e.g. Internet Explorer, Firefox, Opera, etc), so there should be no difficulty in viewing them. You can download the latest Flash Player from here; you certainly need to install Flash Player if you do not even see an image when you click on the web pages listed below. If you continue to have problems, please let us know. Click on the image to see the movie:

Ultrasound scan You have probably had an ultrasound scan before as it is a very common investigation. A pelvic scan can be done abdominally or via the vagina. The procedure is quick, painless and gives a very useful image of your uterus (womb) and ovaries. Apart from fibroids, ultrasound can also diagnose polyps, thickened endometrium (lining of the uterus), and ovarian cysts.

Hysteroscopic myomectomy using the miniresectoscope

Laparoscopic myomectomy

Laparoscopic myomectomy with single tourniquet

Laparoscopic myomectomy with triple tourniquets

Laparoscopic morcellation of large fibroid

Open myomectomy using ovarian clamps

These movies have been edited by Nikos Bournas, Pietro Gambadauro, Nikos Papadopoulos and Adam Magos.

Home - Background information - Treatment options - Treatment summary - Movies - Fibroid Clinic Knowledge base - Useful links - How to find us - Contact us 2010 webmeddesign.com Dreamweaver Web Templates

Hampstead London NW3 2QG, UK


Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for

Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street

Fibroid Clinic at the Royal Free Hospital


A clinic dedicated to the treatment of women with fibroids has been set up at the Royal Free Hospital. The Fibroid Clinic offers all the treatments which are described at this web site, but is also looking at new and better ways to manage this common problem. Following your assessment, we will discuss with you which treatment options are best in your case, and you may be invited to take part in research studies looking at some of these newer treatments. You will be under no obligation to take part, and your treatment will not be affected in anyway if you decline. Click here if you would like an appointment in the Fibroid Clinic.

Diagnostic hysteroscopy For hysteroscopy, a very narrow telescope is inserted into the uterus (womb) via the vagina and cervix. Carbon dioxide gas or a liquid such as saline is usded to distend the uterine cavity to give a clear view. The image can be projected on to a television screen using a small video camera. Hysteroscopy allows examination of the endometrium (lining of the uterus), tubal ostia (small channels on either side which lead to the

gynaecologists interested in the surgical management of fibroids is now on line. www. fibroidsurgery. org

fallopian tubes), and assess the shape and size of the uterine cavity. Abnormal findings include polyps, fibroids, adhesions (scar tissue), septa (a midline division), or simply that the endometrium is unusually thickened. A biopsy is often taken at end of the investigation to check the endometrium. Diagnostic hysteroscopy does not take a long time and is not particularly uncomfortable. At the Royal Free, it is usually done as an outpatient procedure. Home - Background information - Treatment options - Treatment summary - Movies - Fibroid Clinic - Knowledge base - Useful links - How to find us - Contact us 2010 webmeddesign.com Dreamweaver Web Templates

Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street Hampstead London NW3 2QG, UK
Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us Pelvic pain

Knowledge base
You may find the following links useful sources of medical information about various common gynaecological conditions including uterine fibroids. Click on the links below for further information:

History Removal of the uterus (womb) was mentioned as long ago as 5th century BC by Hippocrates, the father of medicine. However, apart from sporadic reports, hysterectomy was not practised until the 19th century. Even then, the mortality of the procedure was extremely high. It was only after improvements in antisepsis, anaesthesia and surgical technique to control haemorrhage in the mid-19th

Adhesions

Infertility

Endometriosis

LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for gynaecologists interested in the surgical management of fibroids is now on line. www. fibroidsurgery. org Fibroids Pelvic prolapse

century that hysterectomy became an accepted procedure. The early hysterectomies were usually done vaginally, but the introduction of subtotal hysterectomy late in the 19th century meant that abdominal hysterectomy became dominant; vaginal hysterectomy tended to be restricted for the management of uterine prolapse. In 1988, the first laparoscopic hysterectomy was done by Harry Reich (USA). Although the procedure has failed to become popular, one result of this development was the wider

Heavy periods

Polycystic ovarian syndrome

appreciation of the role of vaginal hysterectomy. Studies showed that compared with the other routes, vaginal hysterectomy has the shortest operating time, fastest recovery and lowest cost. Most gynaecologists now agree that vaginal hysterectomy is the optimal route and should be practised whenever possible. Home - Background information - Treatment options - Treatment summary - Movies - Fibroid Clinic - Knowledge base - Useful links - How to find us - Contact us 2010 webmeddesign.com Dreamweaver Web Templates

Hampstead London NW3 2QG, UK


Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for

Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street

Other useful links


You may find the following links useful: www.infertility.uk.net Information about the One Stop Fertility Clinic at the Royal Free Hospital, London. www.gynendo.com Gynaecological surgical workshops held at the Royal Free Hospital since 1990. www.mrcogdrcog.com Postgraduate teaching courses for doctors preparing for the MRCOG and DRCOG examinations held by the Royal College of Obstetricians and Gynaecologists in London. www.rcog.org.uk The official website of the Royal College of Obstetricians and Gynaecologists, London. www.hysterectomy-association. org.uk A UK website which provides information, discussion forums and support about hysterectomy.

History Removal of the uterus (womb) was mentioned as long ago as 5th century BC by Hippocrates, the father of medicine. However, apart from sporadic reports, hysterectomy was not practised until the 19th century. Even then, the mortality of the procedure was extremely high. It was only after improvements in antisepsis, anaesthesia and surgical technique to control haemorrhage in the mid-19th century that hysterectomy became an accepted

gynaecologists interested in the surgical management of fibroids is now on line. www. fibroidsurgery. org

Entrez PubMed A useful resource for searching the medical scientific literature. The site provides abstracts of articles free of charge. British Medical Journal One of the premier UK medical journals covering all aspects of modern medical practice. The Lancet The other famous UK general medical journal. National Institute for Clinical Excellence A useful government run website on many aspects of medical practice. Best treatments Another government sponsored website concentrating on current treatments.

procedure. The early hysterectomies were usually done vaginally, but the introduction of subtotal hysterectomy late in the 19th century meant that abdominal hysterectomy became dominant; vaginal hysterectomy tended to be restricted for the management of uterine prolapse. In 1988, the first laparoscopic hysterectomy was done by Harry Reich (USA). Although the procedure has failed to become popular, one result of this development was the wider appreciation of the role of vaginal hysterectomy. Studies showed that compared with the other routes, vaginal hysterectomy has the shortest operating time,

fastest recovery and lowest cost. Most gynaecologists now agree that vaginal hysterectomy is the optimal route and should be practised whenever possible. Home - Background information - Treatment options - Treatment summary - Movies - Fibroid Clinic - Knowledge base - Useful links - How to find us - Contact us 2010 webmeddesign.com Dreamweaver Web Templates

Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street Hampstead London NW3 2QG, UK
Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us All our publications LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for gynaecologists interested in the surgical management of fibroids is now on line. www. fibroidsurgery. org

Our publications
You can also find details of our publications on Google Scholar and PubMed.

A short history of medicine "Doctor, I have an ear ache." 2000 B.C. "Here, eat this root."

Our publications on uterine fibroids

1000 B.C. "That root is heathen, say this prayer." 1850 A.D. "That prayer is superstition, drink this potion." 1940 A.D. "That potion is snake oil, swallow this pill."

Go Back 1985 A.D. "That pill is ineffective, take this antibiotic." 2000 A.D. "That antibiotic is artificial. Here, eat this root!

Home - Background information - Treatment options - Treatment summary - Movies - Fibroid Clinic - Knowledge base - Useful links - How to find us - Contact us 2010 webmeddesign.com Dreamweaver Web Templates

Hampstead London NW3 2QG, UK


Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for

Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street

How to find us

Age The YOUNG know everything. The MIDDLE AGED suspect everything. The OLD believe everything. Oscar Wilde

The Royal Free Hospital is situated in north London close to Hampstead Heath. The hospital can be reached most easily by public transport or taxi. The nearest underground stations are Belsize Park and Hampstead on the Northern Line. Buses C11, 24, 46, 168 and 268 also stop close to the hospital. Trains on the North Thames Link stop at Hampstead Heath station. As car parking is restricted on the streets surrounding the hospital, and there is only a small multistory car park on the hospital grounds, coming by private transport is not encouraged. Taxis and mini-cabs are can be ordered

gynaecologists interested in the surgical management of fibroids is now on line. www. fibroidsurgery. org

from the main reception area of the hospital. Both the Fibroid Clinic and Radiology Department are situated on the ground floor near the main entrance to the hospital on Pond Street.

Home - Background information - Treatment options - Treatment summary - Movies - Fibroid Clinic Knowledge base - Useful links - How to find us - Contact us 2010 webmeddesign.com Dreamweaver Web Templates

Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street Hampstead London NW3 2QG, UK
Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for gynaecologists interested in the surgical

Contact us
We are happy to receive any comments or enquiries from you. Name: Email: Subject: Message:

Age The secret of staying young is to live honestly, eat slowly, and lie about your age. Lucille Ball

Send

Reset

management of fibroids is now on line. www. fibroidsurgery. org

Home - Background information - Treatment options - Treatment summary - Movies - Fibroid Clinic Knowledge base - Useful links - How to find us - Contact us 2010 webmeddesign.com Dreamweaver Web Templates

Hampstead London NW3 2QG, UK


Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for

Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street

Our publications on uterine fibroids


1. Magos AL, Baumann R, Cheung K, Turnbull AC. Intrauterine surgery under intravenous sedation as an out-patient alternative to hysterectomy. Lancet 1989; ii: 925-6. 2. Lockwood GM, Baumann R, Turnbull AC, Magos AL. Extensive hysteroscopic surgery under local anaesthesia. Gynaecol Endosc 1992; 1: 15 -21. 3. Cooper MJ, Molnar BG, Broadbent JAM, Richardson R, Magos AL. Hypothermia associated with extensive hysteroscopic surgery. Austr NZ J Obstet Gynaecol 1994; 34: 88-89. 4. Magos AL, Bournas N, Sinha R, Richardson RE, O'Connor H. Vaginal myomectomy. Br J Obstet Gynaecol 1994; 101: 1092-1094. 5. Broadbent JAM, Magos AL. Menstrual blood loss after hysteroscopic myomectomy. Gynaecol Endosc 1995; 4 ; 41-44.

A short history of medicine "Doctor, I have an ear ache." 2000 B.C. "Here, eat this root." 1000 B.C. "That root is heathen, say this prayer." 1850 A.D. "That prayer is superstition, drink this potion." 1940 A.D. "That potion is snake oil, swallow this pill." 1985 A.D. "That pill is ineffective, take this antibiotic." 2000 A.D. -

gynaecologists interested in the surgical management of fibroids is now on line. www. fibroidsurgery. org

6. Magos AL, Bournas N, Sinha R, O'Connor H. Vaginal hysterectomy for the large uterus. Br J Obstet Gynaecol 1996; 103: 246-251. 7. Davies A, Magos AL. Is laparoscopic hysterectomy ever indicated? J Irish Col Phys Surg 1996; 25: 289292. 8. Davies A, Magos AL. Vaginal hysterectomy for the large uterus. Br J Obstet Gynaecol 1996; 103: 940. 9. Hart R, Magos AL. Minimall access surgery: In: "Practical Guide to Reproductive Medicine ", (Eds. Rainsbury PA, Viniker DA). Carnforth, Parthenon Publishing Group 1997: 409-430. 10. Davies A, Magos A. Indications and alternatives to hysterectomy. In: " Hysterectomy " (Ed. Wood C, Maher PJ). Bailliere's Clin Obstet Gynaecol 1997; 11: 61-75. 11. Richardson RE, Magos A. Operative laparoscopy in gynaecology. In: " Laparoscopic surgery: the implications of changing practice ", (Eds. Hobsley M, Treaure T, Northover J). London , Arnold 1997: 99113. 12. Magos A. Treatment of large uterine fibroids. Br J Obstet Gynaecol 1997; 104: 867868. 13. Molnar GB, Magos AL, Kay J. Monitoring fluid absorption using 1% ethanol-tagged glycine during operative hysteroscopy. J Am Assoc

"That antibiotic is artificial. Here, eat this root!

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Gynecol Laparosc 1997; 4: 357-362. Davies A, Vizza E, Bournas N, O'Connor H, Magos A. How to increase the proportion of hysterectomies performed vaginally. Am J Obstet Gynecol 1998; 179: 1008-1012. O'Connor H, Magos A. How to avoid complications at hysteroscopic surgery. In: "Recent Advances in Obstetrics and Gynaecology, Volume 20 ", (Ed. Bonnar J). Edinburgh, Churchill Livingstone 1998: 201-214. Shushan A, Mohamed H, Magos AL. How long does laparoscopic surgery really take? Lessons learned from 1000 operative laparoscopies. Hum Reprod 1999; 14: 39 -43. Davies A, Magos A. Treatment with a gonadotrophin releasing hormone agonist before hysterectomy for leiomyomas: results of a multicentre, randomised controlled trial. Br J Obstet Gynaecol 1999; 106: 751752. Shushan A, Mohamed H, Magos AL. A case-control study to compare the variability of operating time in laparoscopic and open surgery. Hum Reprod 1999; 14: 1467-1469. Hart R, Molnar BG, Magos A. Long term follow up of hysteroscopic myomectomy assessed by survival analysis. Br J Obstet Gynecol

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1999; 106: 700-705. Miskry T, Davies A, Magos A. Laparoscopically assisted vaginal hysterectomy compared with total abdominal hysterectomy. Am J Obstet Gynecol 1999; 181: 1580-1581. Miskry T, Magos A. Laparoscopic myomectomy. Seminars Lap Surgery 1999; 6: 73-79. Davies A, Magos A. A prospective study to evaluate excision of uterine fibroids by vaginal myomectomy. Fertil Steril 1999; 71: 961-964. Miskry T, Magos A. Laparoscopically assisted hysterectomy for the large uterus. Gynaecol Endosc 2000; 9: 273. Sushan A, Protopapas A, Hart R, Magos A. Diagnostic and therapeutic advantages of hysteroscopic surgery in management of intrauterine lesions in postmenopausal women. J Am Assoc Gynecol Laparosc 2001: 8: 87-91. Davies A, Magos A. The hysterectomy lottery. J Obstet Gynaecol 2001; 21: 166-170. Miskry T, Magos A. Hysterectomy. In: "Textbook of Female Urology and Urogynaecology ", (Eds. Cardozo L, Staskin D)". London , Isis Medical Media 2001: 675-689. Davies A, Hart R, Magos A, Hadad E, Morris R. Hysterectomy: surgical route and complications. Eur J

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Obstet Gynecol 2002: 104: 148-51. Magos A. The extended scope of vaginal hysterectomy: technical highlights and prevention of complications. Jaarboek 2000. Vlaamse vereniging voor obstetrie en gynaecologie. VVOG, SintNiklass 2002: 251-8. Magos A, Taylor A. The modern management of fibroids. In: "The Year in Gynaecology 2002 ", (Eds. Barter J, Hampton N). Oxford , Clinical Publishing Services 2002: 251-68. Miskry T, Magos A. Randomised, prospective, double-blind comparison of abdominal versus vaginal hysterectomy in women without uterovaginal prolapse. Acta Obstet Gynecol Scand 2003; 82: 351-8. Sabatini L, Atiomo W, Magos A. Successful myomectomy following infected ischaemic necrosis of uterine fibroids after uterine artery embolisation. Br J Obstet Gynaecol 2003; 110: 704-6. Sharma M, Buck L, Mastrogamvrakis G, Kontos K, Magos A, Taylor A. Cost effectiveness of preoperative gonadotrophin releasing analogues for women with uterine fibroids undergoing hysterectomy or myomectomy. Br J Obstet Gynaecol 2003: 110: 712. Scott P, Taylor A, Yoong W, Magos A. Absorbable cervical

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tourniquet at open myomectomy: a pilot study. J Gynecol Surg 2004: 20: 33 -7. Sharma M, Taylor A, Magos A. Vaginal myomectomy. RCOG Year Book , Volume 11, (Eds. Hillard T, Purdie D). London , RCOG Press 2004: 479-88. Sharma M, Taylor A, Magos A. Hysteroscopic myomectomy. In: "State of Art: Atlas of Gynaecological Surgery", (Ed. Jain N). New Delhi , Jaypee Brothers 2004: 489-96. Taylor A, Sharma M, Buck L, Mastrogamvrakis G, Di Spiezio Sardo A, Magos A. Reducing blood loss at open myomectomy using triple tourniquets. BJOG 2005; 112:340-5. Lim S, Taylor A, Di Spiezio Sardo, Mastrogamvrakis G, Sharma M, Buck L, Magos A. Myomectomy can be "life saving" - a case of a 36week fibroid uterus managed conservatively in a 40-year old nulliparous woman. J Obstet Gynaecol (in press). Taylor A, Sharma M, Tsirkas P, Arora R, d i Spiezio Sardo A, Mastrogamvrakis G, MD, Clinical Research Fellow, Buck L, Oak M, Magos A. Surgical and radiological management of uterine fibroids: A United Kingdom survey of current Consultant practice. Acta Obstet Gynecol Scand 2005; 85: 340-5. Taylor A, Blackmore S,

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Tsirkas P, Magos A. Color Doppler evaluation of changes in uterine perfusion induced by the use of an absorbable cervical tourniquet during open myomectomy. J Clin Ultrasound 2005; 33:390-3. Chapman L, Magos A. Hysterectomy. In: "Uterine leiomyomata: Pathogenesis and Management", (Ed Brosens I). Taylor & Francis, London 2005: 181-97. Taylor A, Sharma M, Buck L, Mastrogamvrakis G, Di Spezio Sardo A, Magos A. The use of triple tourniquets for laparoscopic myomectomy. J Gynecol Surg 2005; 21: 65-72. Chapman L, Magos A. Surgical and radiological management of uterine fibroids in the UK. Curr Opin Obstet Gynecol 2006; 18: 394-401. Taylor A, Magos A. Reducing blood loss at open myomectomy using triple tourniquets: a randomised controlled trial. BJOG 2006; 113: 618-9. Kochiadakis C, Magos A. Subtotal vaginal hysterectomy and myomectomy. In: " Advances in Reconstructive Vaginal Surgery ", (Eds. Kovac SR, Zimmerman CW). Lippincott, Williams & Wilkins, Philadelphia 2007: 147-155. Magos A. Hysteroscopy and laparoscopy. In: "Dewhurst's Textbook of Obstetrics and

Gynaecology, 7th Ed. (Ed. Edmonds DK). Blackwell Publishing, Oxford 2007: 560-577. 46. Papalampros P, Gambadauro P, Papadopoulos N, Polyzos D, Chapman L, Magos A. The mini-resectoscope: a new instrument for office hysteroscopic surgery. Acta Obstet Gynecol Scand 2008. 47. Magos A, Gambadauro P, Tsibanakos I, Georgakaki A, Kakaidis I, Moiety F. Submucous fibroids should be removed in infertile women. BMJ 2009; 338: b126. 48. Al-Shabibi N, Chapman L, Madari S, Papadimitriou A, Papalampros P, Magos A. Prospective randomised trial comparing gonadotrophinreleasing hormone analogues with triple tourniquets at open myomectomy. BJOG, 2009 Feb 4. Go Back Home - Background information - Treatment options - Treatment summary - Movies - Fibroid Clinic Knowledge base - Useful links - How to find us - Contact us 2010 webmeddesign.com Dreamweaver Web Templates

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1. Gibb DMF, Cardozo LD, Studd JWW, Magos AL, Cooper DJ. Outcome of spontaneous labour in multigravidae. Br J Obstet Gynaecol 1982; 89: 708711. 2. Magos AL, Noble MCB, Wong Ten Yuen A, Rodeck CH. Controlled study comparing vaginal prostaglandin E 2 pessaries with intra-venous oxytocin for the stimulation of labour after premature rupture of membranes. Br J Obstet Gynaecol 1983; 90: 726-731. 3. Magos AL, Zilkha KJ, Studd JWW. Treatment of menstrual migraine by oestradiol implants. J Neurol Neurosurg Psychiat 1983; 46: 1044-1046. 4. Brincat M, Moniz CF, Studd JWW, Darby AJ, Magos AL, Cooper D. Sex hormones and skin collagen content in postmenopauseal women. Br Med J 1983; ii: 1337-1338. 5. Magos AL, Studd JWW. Premenstrual uncertainties.

A short history of medicine "Doctor, I have an ear ache." 2000 B.C. "Here, eat this root." 1000 B.C. "That root is heathen, say this prayer." 1850 A.D. "That prayer is superstition, drink this potion." 1940 A.D. "That potion is snake oil, swallow this pill." 1985 A.D. "That pill is ineffective, take this antibiotic." 2000 A.D. -

gynaecologists interested in the surgical management of fibroids is now on line. www. fibroidsurgery. org

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Lancet 1983; ii: 1301. Magos AL, Studd JWW. PMS - a new approach to cause and cure. Contemp Ob/Gyn 1984; 24: 85-91. Magos AL, Collins WP, Studd JWW. Management of the premenstrual syndrome by subcutaneous implants of oestradiol. J Psychosom Obstet Gynaecol 1984; 3: 9399. Magos AL, Studd JWW. The premenstrual syndrome. In: " Progress in Obstetrics and Gynaecology, Volume 4 ", (Ed. Studd JWW). Edinburgh, Churchill Livingstone 1984: 334-50. Studd JWW, Cardozo LD, Gibb DMF, Tuck SM, Magos AL, Brincat M, Cooper DJ. Hormone implants in women following hysterectomy and bilateral salpingooophorectomy. In: "The climacteric. An update ", (Eds. van Herendael H, van Herendael B, Riphagen FE, Goessens L, van der Pas H). Lancaster, MTP Press 1984: 149-53. Magos AL, Dodd NJ, Gordge MP, Weston MJ, Zilkha KJ, Studd JWW. Migraine, headache, and survival in women. Br Med J 1984; i: 162. Brincat M, Magos AL, Studd JWW, Cardozo LD, O'Dowd T, Wardle PJ, Cooper DJ. A controlled study of oestradiol and testosterone implants for the climacteric. Lancet 1985; i: 16-18. Magos AL, Studd JWW.

"That antibiotic is artificial. Here, eat this root!

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Effects of the menstrual cycle on medical disorders. Br J Hosp Med 1985; 33: 6877. Brincat M, Moniz CJ, Studd JWW, Darby A, Magos AL, Embury G, Versi E. Longterm effects of the menopause and sex hormones on skin thickness. Br J Obstet Gynaecol 1985; 92: 256-259. Magos AL, Brincat M, Studd JWW, Wardle PJ, Schlesinger P, O'Dowd T. Amenorrhea and endometrial atrophy following continuous oral estrogen and progestogen therapy in post-menopausal women. Obstet Gynecol 1985; 65: 496-499. Magos AL, Brincat M, Zilkha KJ, Studd JWW. Plasma dopamine -hydroxylase activity in menstrual migraine. J Neurol Neurosurg Psychiat 1985; 48: 328-231. Magos AL, Brincat M, O'Dowd T, Wardle PJ, Schlesinger P, Studd JWW. Endometrial and menstrual response to subcutaneous oestradiol and testosterone implants and continuous oral progestogen therapy in postmenopausal women. Maturitas 1985; 7: 297-302. Magos AL, Studd JWW. Progesterone and the premenstrual syndrome: a double blind crossover trial. Br Med J 1985; ii: 213-4. Magos AL, Brincat M, Studd JWW. Amenorrhea and endometrial atrophy. Obstet Gynecol 1985; 66: 836-7.

19. Magos AL, Brincat M, Studd JWW. Treatment of the premenstrual syndrome by subcutaneous oestradiol implants and cyclical oral norethisterone: placebo controlled study. Br Med J 1986; i: 1629-1633. 20. Magos AL, Studd JWW. PMS facts and fiction. Contemp Ob/Gyn 1986; 28: 23-26. 21. Magos AL, Studd JWW. Assessment of menstrual cycle symptoms by trend analysis. Am J Obstet Gynecol 1986; 155: 271277. 22. Magos AL, Brincat M, Studd JWW. Trend analysis of the symptoms of 150 women complaining of the premenstrual syndrome. Am J Obstet Gynecol 1986; 155: 277-280. 23. Magos AL, Brewster E, Singh R, O'Dowd T, Brincat M, Studd JWW. The effects of norethisterone in postmenopausal women on oestrogen replacement therapy: a model for the premenstrual syndrome. Br J Obstet Gynaecol 1986; 93: 1290-1296. 24. Studd JWW, Brincat M, Magos AL, Montgomery J. Women and mental illness. Br Med J 1986; i: 201. 25. Magos AL, Brincat M, Studd JWW. Treatment of the premenstrual syndrome by subcutaneous oestradiol implants and cyclical oral norethisterone. Br Med J 1986; ii: 451. 26. Magos AL, Studd JWW.

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Management of the premenstrual syndrome. In: " A Modern Approach to the Perimenopausal Years ", (Ed. Greenblatt RB). New Developments on Biosciences 2 . Berlin , Walter de Gruyter 1986: 22132. Studd JWW, Magos AL. Hormonal manipulations in the management of premenstrual symptoms. In: " Hormones and Behaviour. Proceedings of the 8th International Congress of the International Society of Psychosomatic Obstetrics and Gynaecology ", (Eds. Dennerstein L, Fraser I). Amsterdam , Excerpta Medica 1986: 147-59. Brincat M, Versi E, O'Dowd T, Moniz CF, Magos AL, Kabalan S, Studd JWW. Skin collagen changes in postmenopausal women receiving oestradiol gel. Maturitas 1987; 9: 1-5 Brincat M, Moniz CF, Kabalan S, Versi E, O'Dowd T, Magos AL, Montgomery J, Studd JWW. Decline in skin collagen content and metacarpal index after the menopause and its prevention with sex hormone replacement. Br J Obstet Gynaecol 1987; 94: 126129. Brincat M, Versi E, Moniz CF, Magos AL, de Trafford J, Studd JWW. Skin collagen changes in postmenopausal women receiving different regimens of estrogen therapy. Obstet Gynecol

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1987; 70: 123-127. Brincat M, Wong Ten Yuen A, Studd JWW, Montgomery J, Magos AL, Savvas M. Response of skin thickness and metacarpal index to estradiol therapy in postmenopausal women. Obstet Gynecol 1987; 70: 353-341. Magos AL, Collins WP, Studd JWW. Effects of subcutaneous oestradiol implants on ovarian and follicular activity. Br J Obstet Gynaecol 1987; 94: 11921198. Magos AL, Studd JWW. Suicide attempts and the menstrual cycle. Lancet 1987; i: 217-8. Magos AL, Studd JWW. Premenstrual problems analysed by computer. In: "The Computer in Obstetrics and Gynaecology", (Eds. Dalton KJ, Fawdry RDS). Oxford , IRL Press 1987: 5560. Magos AL, Studd JWW. The premenstrual syndrome. In a book dedicated to RB Greenblatt (Ed. Asch R), 1987. Studd JWW, Magos AL. Hormone pellet implantation for the menopause and premenstrual syndrome. Obstet Gynecol Clin N Am 1987; 14 (1): 229-49. Magos AL. The menstrual cycle: effects and analysis. J Biomed Eng 1988; 10: 105109. Magos AL, Studd JWW. A simple method for the

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diagnosis of the premenstrual syndrome by use of a self-assessment disk. Am J Obstet Gynecol 1988; 158: 1024-1028. Magos AL. Premenstrual syndrome. Contemp Rev Obstet Gynaecol 1988; 1: 8092. Magos AL, Baumann R, Turnbull AC. Management of ruptured and unruptured ectopic pregnancies by videopelviscopy. Lancet 1988; ii: 275-6. Magos AL, Baumann R, Turnbull AC. Laparoscopic management of ectopic pregnancies. Lancet 1988; ii: 694. Studd JWW, Magos AL. Oestrogens and endometrial pathology. In: " The Menopause ", (Eds. Studd JWW, Whitehead MI). Oxford , Blackwell Scientific Publications 1988: 197-212. Magos AL, Studd JWW. The premenstrual syndrome - a review. In: " The Menopause ", (Eds. Studd JWW, Whitehead MI). Oxford , Blackwell Scientific Publications 1988: 271-88. Magos AL, Baumann R, Turnbull AC. Managing gynaecological emergencies with laparoscopy. Br Med J 1989; 299: 371-374. Magos AL, Baumann R, Cheung K, Turnbull AC. Intrauterine surgery under intravenous sedation as an out-patient alternative to hysterectomy. Lancet 1989; ii: 925-6.

46. Gordon AG, Magos AL. The development of laparoscopic surgery. Clin Obstet Gynaecol 1989; 3 (3): 42949. 47. Magos AL. Treatment of PMS. In: " The free woman: women's health in the 1990's ", (Ed. van Hall EV, Everaerd W). Carnforth, Parthenon Publishing Group 1989: 65966. 48. Magos AL. Characterisation of cyclical symptoms. In: " Proceedings of the International Symposium on Endocrine Therapy ", (Ed. Stoll BA). Hormone Res 1989; 32 (Suppl 1): 15-20. 49. Baumann R, Magos AL, Kay JDS, Turnbull AC. Absorption of glycine irrigating solution during transcervical resection of endometrium. Br Med J 1990; 300: 304-305. 50. Magos AL. Recent advances in the management of the premenstrual syndrome (Editorial). Br J Obstet Gynaecol 1990; 97: 7-10. 51. Magos AL. Something new. J Assoc Chart Physio Obstet Gynaecol 1990; 66: 8-9. 52. Magos AL. Management of menorrhagia (editorial). Br Med J 1990; 300: 1537-1538. 53. Magos AL. Simulation in surgical training. Br Med J 1990; 300: 1524-1525. 54. Magos AL. Endometrial ablation techniques. In: "Dysfunctional Uterine Bleeding", Proceedings of a Symposium on Reproductive Endocrine Disorders ", (Ed. Shaw RW). Carnforth,

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Parthenon Publishing Group 1990: 97-116. Lockwood GM, Magos AL, Baumann R, Turnbull AC. Endometrial resection when hysterectomy is undesirable, dangerous or impossible. Br J Obstet Gynaecol 1990; 97: 656-658. Magos AL, Studd JWW. Hormone pellet implantation. In: " Progress in Obstetrics and Gynaecology, Volume 8 ", (Ed. Studd JWW). Edinburgh, Churchill Livingstone 1990: 313-34. Magos AL. Endometrial ablation for menorrhagia. In: "Progress in Obstetrics and Gynaecology, Volume 9 ", (Ed. Studd JWW). Edinburgh, Churchill Livingstone 1991: 375-95. Magos AL, Shaxted EJ. Problems with endometrial resection. Lancet 1991; 337: 1473-4. Magos AL. Problems with endometrial resection. Lancet 1991; 338: 310-1. Magos AL. Transcervical endometrial ablation in the treatment of dysfunctional bleeding. In: "Recent Advances in Obstetrics and Gynaecology, Volume 17", (Ed. Bonnar J). Edinburgh, Churchill Livingstone 1992: 191-208. Baumann R, Magos AL. The management of gynaecological emergencies by operative laparoscopy. Contemp Rev Obstet Gynaecol 1991; 3: 46 -50. Magos AL, Baumann R,

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Lockwood GM, Turnbull AC. Experience with 250 endometrial resections for menorrhagia. Lancet 1991; 337: 1074-1079. Baumann R, Magos AL, Turnbull AC. Prospective study of videopelviscopy and laparotomy for the management of ectopic pregnancy. Br J Obstet Gynaecol 1991; 98: 765-771. Magos AL, Broadbent JAM, Amso N. Laparoscopically assisted vaginal hysterectomy. Lancet 1991; 338: 1091-2. Broadbent JAM, Magos AL. Current developments and future trends in gynaecological endoscopy. Obstet Gynae Product News 1991; 22-24. Broadbent JAM, Magos AL. Transcervical resection of the endometrium. Well Woman Team 1991; 1: 3. Broadbent M, Magos AL. InVitro fertilisation or tubal surgery. Lancet 1991; 338: 1291-2. Broadbent JAM, Magos AL. Management of tubal infertility in the 1990's. Br J Obstet Gynaecol 1991; 98: 1309-10. Broadbent M, Magos AL. Transcervical resection of the endometrium. Contemp Rev Obstet Gynaecol 1992; 4: 21 -28. Hill NCW, Broadbent JAM, Magos AL, Baumann R, Lockwood GM. Local anaesthesia and cervical dilatation for out-patient

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diagnostic hysteroscopy. J Obstet Gynaecol 1992; 12: 33 -37. Lockwood GM, Baumann R, Turnbull AC, Magos AL. Extensive hysteroscopic surgery under local anaesthesia. Gynaecol Endosc 1992; 1: 15 -21. Broadbent JAM, Magos AL. Surgical treatment of menstrual disorders. Practitioner 1992; 236: 654658. Baumann R, Magos AL, Turnbull AC. Pilot study on transcervical resection of the endometrium. In: " Lasers in Gynecology " (Eds. Bastet D, Wallwiener D). Berlin , Springer-Verlag 1992: 21521. Broadbent JAM, Molnar BG, Cooper MJW, Magos AL. Endoscopic management of uterine perforation occurring during endometrial resection. Br J Obstet Gynaecol 1992; 99: 1018. Broadbent JAM, Hill NCW, Molnar BG, Rolfe KJ, Magos AL. Randomised placebo controlled trial to assess the role of intracervical lignocaine in outpatient hysteroscopy. Br J Obstet Gynaecol 1992; 99: 777-779. Broadbent JAM, Magos AL. Laparoscopically assisted vaginal hysterectomy. Contemp Rev Obstet Gynaecol 1992; 4: 154-157. Hill NCW, Broadbent JAM, Magos AL. The role of outpatient hysteroscopy. Contemp Rev Obstet

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Gynaecol 1992; 4: 209-214. Amso N, Broadbent JAM, Magos AL. Laparoscopic "oophorectomy-in-a-bag" for ovarian cysts of uncertain origin. Gynaecol Endosc 1992; 1: 85-89. Molnar BG, Broadbent JAM, Magos AL. Fluid over-load risk score for endometrial resection. Gynaecol Endosc 1992; 1: 133-138. Broadbent JAM, Molnar BG, Cooper MJW, Richardson RE, Magos AL. Laparoscopic ovarian cystectomy in-a-bag for dermoid cysts. Gynaecol Endosc 1992; 1: 167-8. Cooper MJW, Magos AL, Baumann R, Rees MCP. The effect of endometrial resection on menstrual blood loss. Gynaecol Endosc 1992; 1: 195-198. Asso D, Magos A. Psychological and physiological changes in severe premenstrual syndrome. Biol Psych 1992; 33:115-132. Magos AL. The premenstrual syndrome. In: "Clinical Endocrinology", (Ed. Grossman A). Oxford , Blackwell Scientific Publications 1992: 683-690. Richardson RE, Magos AL. Minimally invasive surgery in gynaecology - trick or treat? Br J Hosp Med 1993; 49: 310-311. Magos AL. Book review: "Endoscopic Surgery for Gynaecologists" (Eds. Sutton C, Diamond M). Lancet 1993; 342: 1162.

86. Magos AL. Safety and hazards of endoscopic electrodiathermy. In: "New Surgical Techniques in Gynaecology" (Ed. Sutton CJG). Carnforth, Parthenon Publishing Group 1993: 16371. 87. Broadbent JAM, Hill NCW, Molnar BG, Rolfe KJ, Magos AL. Randomised placebo controlled trial to assess the role of intracervical lignocaine in outpatient hysteroscopy. Br J Obstet Gynaecol 1993; 100: 502. 88. Magos AL. Endometrial resection: Technique of endometrial resection. In: "Endometrial Ablation" ( Eds. Lewis BV , Magos AL). Edinburgh, Churchill Livingstone 1993: 104-15. 89. Broadbent JAM, Magos AL. Endometrial resection: Results and complications. In: "Endometrial Ablation" ( Eds. Lewis BV , Magos AL). Edinburgh, Churchill Livingstone 1993: 115-31. 90. Magos AL. Blood loss studies: Endometrial resection. In: " Endometrial Ablation " ( Eds. Lewis BV , Magos AL). Edinburgh, Churchill Livingstone 1993: 203-5. 91. Magos AL, Lewis BV. Future prospects. In: " Endometrial Ablation " ( Eds. Lewis BV , Magos AL). Edinburgh, Churchill Livingstone 1993: 211-2. 92. Broadbent JAM, Magos AL. Trans-cervical resection of

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the Endometrium (TCRE). In: " Gynaecological Endoscopy " (Eds. Sutton CJG, Diamond MP). London , Baillire Tindall 1993: 294306. Magos AL. Hysteroscopic surgery: management and appraisal. in: "Jaarboek 1992" (Ed. Amy JJ). Vlaamse Vereniging voor Obstetrie en Gynaecologie 1993: 90-94. Molnar BG, Magos A, Broadbent M. Trancervicalis endometrium resectio a metrorrhagia gyogyitasara. Magyar Noorvosok Lapja 1993; 56: 117-122. Magos AL. Endometriosis: radical surgery. In: " Endometriosis " (Ed. Brosens I). Bailliere's Clin Obstet Gynaecol 1993; 7: 849-864. Hamilton MIR, Alcock R, Magos AL, Mallett S, Rolles K, Burroughs AK. Liver transplantation during pregnancy. Transplan Proc 1993; 25: 2967-2968. Cooper MJ, Molnar BG, Broadbent JAM, Richardson R, Magos AL. Hypothermia associated with extensive hysteroscopic surgery. Austr NZ J Obstet Gynaecol 1994; 34: 88-89. Magos AL, Bournas N, Sinha R, Richardson RE, O'Connor H. Vaginal myomectomy. Br J Obstet Gynaecol 1994; 101: 1092-1094. O'Connor H, Magos AL. Has laparoscopy a role in the treatment of early ovarian cancer? Am J Obstet Gynecol 1994; 171: 283.

100. Richardson RE, Bournas N, Magos AL. Is laparoscopic hysterectomy a waste of time? Lancet 1995; 345: 3641. 101. Magos AL, Bournas N, Sinha R, Lo L, Richardson RE. Transvaginal endoscopic oophorectomy. Am J Obstet Gynecol 1995; 172: 123124. 102. Broadbent JAM, Magos AL. Menstrual blood loss after hysteroscopic myomectomy. Gynaecol Endosc 1995; 4 ; 41-44. 103. Magos A, Bournas N, O'Connor H. Conserving the cervix at hysterectomy. Br J Obstet Gynaecol 1995; 102: 77. 104. O'Connor H, Davies A, Magos A. Treatment of dysfunctional uterine bleeding: appropriate comparison would be to compare the best of the old treatments with the best of the new. Br Med J 1995; 310: 802-803. 105. Richardson RE, Magos AL. Laparoscopic hysterectomy 5 years on. Contemp Rev Obstet Gynaecol 1995; 7: 36 -43. 106. Curtis P, O'Connor H, Magos AL. Simple equipment to facilitate operative laparoscopic surgery. Br J Obstet Gynaecol 1995; 102: 495-497. 107. Davies A, Magos AL. Oophorectomy as the same time as hysterectomy. Br J Obstet Gynaecol 1995; 102: 584.

108. Broadbent JAM, Magos AL. Endometrial resection followup: late onset of pain and the effect of depot medroxyprogesterone acetate. Br J Obstet Gynaecol 1995; 102: 587. 109. Magos AL. Minimal access gynaecology (book review). Lancet 1995; 346: 39. 110. Magos AL. Control of menorrhagia by endometrial resection. In " Gynecologic Resectoscope " (Eds. Bieber EJ, Loffer FD). Cambridge , Blackwell Science 1995: 214253. 111. Magos AL, Bournas N, Richardson RE, Sinha R, O'Connor H. Subtotal vaginal hysterectomy. Min Inv Ther 1995; 4: 91-97. 112. Ash A, Badawy A, Mohammed H, Magos AL. Laparoscopy and the spread of ovarian cancer. Lancet 1995; 346: 709-710. 113. Rubinger TM, Reis JHP, Magos AL. Histeroctomia: analise das diferentes vias de acesso. GINA 1995; 1: 921. 114. Magos AL, Davies A, Mohamed H, O'Connor H. Transvaginal endoscopic oophorectomy. Am J Obstet Gynecol 1995; 173: 977. 115. Cooper MJ, Broadbent JA, Molnar BG, Richardson R, Magos AL. A series of 1000 consecutive out-patient diagnostic hysteroscopies. J Obstet Gynaecol 1995; 21: 503-507. 116. Magos AL. Endometrial resection. In: " Atlas of

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Gynecologic Endoscopy " (Eds. Gordon AG, Lewis BV , DeCherney AH). London , Mosby-Wolfe 1995: 177-186. Davies A, Magos AL. Laparoscopic management of ectopic pregnancy. In: " The Year Book of the Royal College of Obstetricians and Gynaecologists, 1995 " (Ed. Studd JWW). London , RCOG Press 1995: 79-91. O'Connor H, Magos AL. Laparoscopic management of adnexal massess of uncertain origin. In: " Adnexal Massess " (Ed. Phipps JH). Infertitily and Reproductive Medicine Clinics of North America 1995; 6: 573-590. O'Connor H, Magos A. Avoiding complications at hysteroscopic surgery. Clin Risk 1995; 1: 207-211. Baskett TF, O'Connor H, Magos AL. A comprehensive one-stop menstrual problem clinic for the diagnosis and management of abnormal uterine bleeding. Br J Obstet Gynaecol 1996; 103: 76-77. O'Connor H, Magos AL. Ovarian cancers related to minimal access surgery. Br J Obstet Gynaecol 1996; 103: 185-186. Nagele F, Bournas N, O'Connor H, Broadbent M, Richardson R, Magos A. Comparison of carbon dioxide and normal saline for uterine distension in outpatient hysteroscopy. Fertil Steril 1996; 62: 305-

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309. Magos AL, Bournas N, Sinha R, O'Connor H. Vaginal hysterectomy for the large uterus. Br J Obstet Gynaecol 1996; 103: 246-251. Ash AK , Badawy A, Magos AL. Impact of laparoscopically assisted vaginal hysterectomy: the missing link. Am J Obstet Gynecol 1996; 174: 796. Kadir RA, Hart J, Nagele F, O'Connor H, Magos AL. Laparoscopic excision of a non-communicating uterine horn. Br J Obstet Gynaecol 1996; 103: 371-372. Molnar BG, Magos AL. Diagnostic hysteroscopy. Trends Urol Gynaecol Sex Health 1996; 1: 45 -47. Richardson RE, Bournas N, Magos AL. La histerectomia laparoscopica es una perdida de tiempo? Toko-Gin Pract 1996; 55: 135-142. Nagele F, Mane S, Chandrasekaran P, Rubinger T, Magos AL. How successful is hysteroscopic polypectomy. Gynaecol Endosc 1996; 5: 137-140. Nagele F, O'Connor H, Davies A, Badawy A, Mohamed H, Magos A. 2500 outpatient diagnostic hysteroscopies. Obstet Gynecol 1996; 88: 87-92. Nagele F, O'Connor H, Baskett TF, Davies A, Mohamed H, Magos AL. Hysteroscopy in women with abnormal uterine bleeding on hormone replacement therapy: a comparison with

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post-menopausal bleeding. Fertil Steril 1996; 65: 11451150. O'Connor H, Magos AL. Endometrial resection for menorrhagia: evaluation of the results at 5 years. N Eng J Med 1996; 335: 151-156. Magos AL. Endoscopic surgery: yes, but .... (editorial). Curr Opin Obstet Gynecol 1996; 8: 243-245. Nagele F, Magos AL. Cyclical myometrial haemorrhage after endometrial resection. Lancet 1996; 347: 11921193. Nagele F, Molnar BG, O'Connor H, Magos AL. Endoscopic surgery: Where is the proof? Curr Opin Obstet Gynecol 1996; 8: 281289. Davies A, O'Connor H, Magos AL. A prospective study to evaluate oophorectomy at the time of vaginal hysterectomy. Br J Obstet Gynaecol 1996; 103: 915-920. Badawy A, Alok A, Nagele F, O'Connor H, Davies A, Magos AL. Is it worth taking a biopsy of the normal looking endometrium? Gynaecol Endosc 1996; 5: 225-229. Nagele F, Bournas N, O'Connor H, Richardson R, Magos AL. Carbon dioxide versus normal saline for uterine distension in outpatient hysteroscopy. Br J Obstet Gynaecol 1996; 103: 1168-1169. Nagele F, Badawy A, Magos AL. A comprehensive one-

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stop menstrual problem clinic for the diagnosis and management of abnormal uterine bleeding. Br J Obstet Gynaecol 1996; 103: 851852. Davies A, Magos AL. Is laparoscopic hysterectomy ever indicated? J Irish Col Phys Surg 1996; 25: 289292. Hart R, Magos AL. Laparoscopically instilled fluid: the rate of absorption and the effects on patient discomfort and fluid balance. Gynaecol Endosc 1996; 5: 287-291. Badawy A, Alok A, Nagele F, O'Connor H, Magos AL. Ultrasound, hysteroscopy, or both? J Obstet Gynaecol 1996; 16: 551-555. Nagele F, Magos AL. Combined ultrasonographically guided drainage and laparoscopic excision of a large ovarian cyst. Am J Obstet Gynecol 1996; 175: 1377-1378. Davies A, Magos AL. Vaginal hysterectomy for the large uterus. Br J Obstet Gynaecol 1996; 103: 940. Hart R, Magos A. Diagnosis and treatment of menorrhagia. Prescriber 1996; 7: 17 -24. Davies A, Mohammed H, Richardson RE, Magos AL. Laparoscopic ovarian cystectomy inside a bag: a new operative technique for dermoid cysts. J Gynecol Surg 1997; 13: 35 -38. Hart R, Magos A. Key points:

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managing menorrhagia. Pulse 1997; 57: 72-74. Davies A, Magos AL. Subtotal vaginal hysterectomy. In: " The Year Book of the Royal College of Obstetricians and Gynaecologists, 1996 " (Ed. Studd JWW). London , RCOG Press 1996: 141-150. Molnar BG, Magos AL, Walker PG. Laparoscopic excision and marsupialisation of bilateral pelvic lymphocysts following Wertheim procedure for endometrial carcinoma. Br J Obstet Gynaecol 1997; 104: 263-266. O'Connor H, Broadbent JAM, Magos AL, McPherson K. Medical Research Council randomised trial of endometrial resection and hysterectomy in management of menorrhagia. Lancet 1997; 349: 897-901. Hart R, Magos AL. Minimall access surgery: In: " Practical Guide to Reproductive Medicine ", (Eds. Rainsbury PA, Viniker DA). Carnforth, Parthenon Publishing Group 1997: 409430. Davies A, Magos A. Indications and alternatives to hysterectomy. In: " Hysterectomy " (Ed. Wood C, Maher PJ). Bailliere's Clin Obstet Gynaecol 1997; 11: 61-75. Richardson RE, Magos A. Operative laparoscopy in gynaecology. In: "

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Laparoscopic surgery: the implications of changing practice ", (Eds. Hobsley M, Treaure T, Northover J). London , Arnold 1997: 99113. Hart R, Magos A. Persistent ectopic pregnancy following conservative surgery for tubal pregnancy. Br J Obstet Gynaecol 1997; 104: 508509. Davies A, Magos A. A prospective study to evaluate oophorectomy at the time of vaginal hysterectomy. Br J Obstet Gynaecol 1997; 104: 641642. Molnar BG, Baumann R, Magos AL. Does endometrial resection help dysmenorrhea? Acta Obstet Gynecol Scand 1997; 76: 261-265. Hart R, Magos A. Endometrial resection. Chirurgia Int 1997; 4(4): 1617. Magos A, O'Connor H, McPherson K. Endometrial resection versus hysterectomy in management of menorrhagia. Lancet 1997; 349: 1772. Davies A, Richardson RE, O'Connor H, Baskett H, Nagele F, Magos AL. Lignocaine aerosol spray in outpatient hysteroscopy: a randomized double-blind placebo-controlled trial. Fertil Steril 1997; 67: 1019-1023. Nagele F, Lockwood G, Magos AL. Randomised

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placebo controlled trial of mefenamic acid for premedication at outpatient hysteroscopy: a pilot study. Br J Obstet Gynaecol 1997; 104: 842-844. Magos A. Treatment of large uterine fibroids. Br J Obstet Gynaecol 1997; 104: 867868. Magos A. Endoscopic surgery (editorial). Curr Opin Obstet Gynecol 1997; 9: 217-218. Hart R, Magos A. Endometrial ablation. Curr Opin Obstet Gynecol 1997; 9: 2226-232. Hart R, Magos A. Methotrexate in tubal pregnancy. Lancet 1997; 350: 1555. Chatzipapas IK, Magos AL. A simple technique of securing inferior epigastric vessels and repairing the rectus sheath at laparoscopic surgery. Am J Obstet Gynecol 1997; 90: 304-306. O'Connor H, Magos A. Life tables with confidence intervals may mislead. Am J Obstet Gynecol 1997; 177: 716-717. Molnar GB, Magos AL, Kay J. Monitoring fluid absorption using 1% ethanol-tagged glycine during operative hysteroscopy. J Am Assoc Gynecol Laparosc 1997; 4: 357-362. Hart R, Magos A. Operation factsheet: Hysteroscopy. Pulse 1997; 57(36): 89. Hart R, Magos A. Most ectopic pregnancies can be diagnosed and treated

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laparoscopically. Gynaecol Forum 1997; 2: 16-18. Hart R, Magos A. Operation factsheet: Transcervical resection of the endometrium. Pulse 1997; 57 (46): 64. Hart R, Magos A. The ovary. Seminars Lap Surg 1997: 4: 210-218. Nagele F, Magos A. 500 transcervical endometrial resections. Geburtshilfe Frauenheilkd 1997; 57: 391395. Protopapas A, Shushan A, Hart R, Chatzipapas I, Magos A. Is laparoscopic appendicectomy a gynaecological procedure? Lancet 1998; 351: 500. Hart R, Magos A. A strategy for suspected endometriosis. Practitioner 1998; 242: 69. Hart R, Magos A. How long should a woman take hormone replacement therapy. Practitioner 1998; 242: 114-119. Nagele F, Rubinger T, Magos A. Why do women choose endometrial ablation rather than hysterectomy? Fertil Steril 1998; 69: 1063-1066. Hart R, Magos A. The Pipelle biopsy. Trends Urol Gynaecol Sexual Health 1998; 3: 25 26. O'Connor H, Magos AL, Broadbent JAM. Transcervical resection of the endometrium (TCRE). In: " Gynaecological Endoscopy, 2nd Ed." (Eds. Sutton CJG, Diamond MP). London , WB Saunders 1998: 581-591.

178. Hart R, Magos A. Prognostic factors for success of endometrial ablation and resection. Lancet 1998; 352: 68-69. 179. Hart R, Magos A. A novel technique for the laparoscopic management of interstitial pregnancy. J Gynecol Surg 1988; 14: 8590. 180. Davies A, Vizza E, Bournas N, O'Connor H, Magos A. How to increase the proportion of hysterectomies performed vaginally. Am J Obstet Gynecol 1998; 179: 1008-1012. 181. Chatzipapas I, Hart R, Magos A. A remote control laparoscopic bag: a simple technique to remove intraabdominal specimens. Obstet Gynecol 1998; 92: 622-623. 182. O'Connor H, Magos A. How to avoid complications at hysteroscopic surgery. In: " Recent Advances in Obstetrics and Gynaecology, Volume 20 ", (Ed. Bonnar J). Edinburgh, Churchill Livingstone 1998: 201-214. 183. Protopapas A, Shushan A, Magos A. Myometrial scoring: a new technique for the management of severe Asherman's syndrome. Fertil Steril 1998; 69: 860-864. 184. Hart R, Magos A, Nagele F, Heal K, Isorna V, Jirecek S, Kudielka I. Don't be fooled by the patient's make-up! J Obstet Gynaecol 1998; 18: 561-563. 185. Hart R, Magos A. Endometrial ablation. In:

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"Atlas of Laparoscopic and Hysteroscopic Technique , 2nd edition" (Ed: Tulandi T). Philadelphia , WB Saunders 1998: 231-238. Ruach M, Hart R, Magos A. Outpatient hysteroscopy. Contemp Rev Obstet Gynaecol 1998; 10: 295302. Hart R, Magos A. Endometrial destruction. Urology, Gynaecol Sexual Health 1998; 3: 48 -49. Shushan A, Mohamed H, Magos AL. How long does laparoscopic surgery really take? Lessons learned from 1000 operative laparoscopies. Hum Reprod 1999; 14: 39 -43. Davies A, Magos A. Treatment with a gonadotrophin releasing hormone agonist before hysterectomy for leiomyomas: results of a multicentre, randomised controlled trial. Br J Obstet Gynaecol 1999; 106: 751752. Hart R, Magos A. Endoscopic adnexal surgery. In: " The Yearbook of Obstetrics and Gynaecology, Volume 7 " (Ed. O'Brien PMS). London: RCOG Press 1999:183-197. Hart R, Sawyer E, Magos A. Case report of ovarian transposition and review of the literature. Gynaecol Endosc 1999; 8: 51 -54. Shushan A, Mohamed H, Magos AL. A case-control study to compare the variability of operating time

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in laparoscopic and open surgery. Hum Reprod 1999; 14: 1467-1469. Hart R, Molnar BG, Magos A. Long term follow up of hysteroscopic myomectomy assessed by survival analysis. Br J Obstet Gynecol 1999; 106: 700-705. Miskry T, Davies A, Magos A. Laparoscopically assisted vaginal hysterectomy compared with total abdominal hysterectomy. Am J Obstet Gynecol 1999; 181: 1580-1581. Miskry T, Magos A. Laparoscopic myomectomy. Seminars Lap Surgery 1999; 6: 73-79. Hart R, Magos A. The alternatives to hysterectomy. In: " Dysfunctional Uterine Bleeding" (Ed. Smith SK). Bailliere's Best Practice and Research: Clinical Obstetrics and Gynaecology 1999; 13: 271-290. Davies A, Magos A. A prospective study to evaluate excision of uterine fibroids by vaginal myomectomy. Fertil Steril 1999; 71: 961-964. Chatzipapas IK, Hart RJ, Magos A. Simple technique for rectus sheath closure after laparoscopic surgery using straight needles, with review of the literature. J Lap Advanced Surg Techniques 1999; 9:205209. Hart R, Chatzipapas IK, Magos A. The cost of hysterectomy in a UK

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hospital. J Obstet Gynaecol 1999; 19: 524-525. Hart, R, Magos A. Laparoscopically managed bilateral benign ovarian cysts in an 85 year-old woman. J Obstet Gynaecol 1999; 19: 670. Nagele F, Weiser F, Deery A, Hart R, Magos A. Endometrial cell dissemination at diagnostic hysteroscopy: a prospective randomized cross-over comparison of normal saline and carbon dioxide distension. Hum Reprod 1999; 14: 2739-2742. Sherif LS, Foda AI, El Zayat MM, Badawy AM, Magos AL. Laparoscopic salpingectomy: electrosurgery or sutures? Gynaecol Endosc 1999; 8: 89-93. Magos A, Cumbis A, Katsetos C. Bias against publication of surgical papers. Lancet 2000; 355: 413. Miskry T, Ruach M, Magos A, Farhat S. Incisional hernia involving a fallopian tube and mimicking scar endometriosis. Obstet Gynecol 2000; 95: 1028. Miskry T, Magos A. Laparoscopically assisted hysterectomy for the large uterus. Gynaecol Endosc 2000; 9: 273. Miskry T, Ruach M, Magos A. Hysteroscopy in women aged 30 or less. Gynaecol Endosc 2000; 9: 315-317. O'Connor H, Magos AL. Endometrial ablation: loop.

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90. Scott P, Magos A. Vaginal misoprostol for cervical priming before operative hysteroscopy: a randomized controlled trial. Obstet Gynecol 2001; 97: 640-1. Hart R, Ruach M, Magos A. Is laparoscopic surgery really worth it? The views of patients, hospital doctors and health care managers. Gynaecol Endosc 2001: 10: 289-96. Miskry T, Magos A. Mass closure: a new technique for closure of the vaginal vault at vaginal hysterectomy. Br J Obstet Gynaecol 2001; 108: 1295-7. Scott P, Magos A. Culdoscopy to check the uterine contour prior to hysteroscopic metroplasty for uterine septum. Br J Obstet Gynaecol 2002; 109: 591-2. Miskry T, Magos A. Subtotal vaginal hysterectomy. In: " Vaginal Hysterectomy ", (Eds. Sheth S, Studd J). London , Martin Durnit 2002:179-187. Magos A. Hysteroscopic treatment of Asherman's syndrome. Reprod Med Online 2002; 4 (Suppl. 3): 46-51. Davies A, Hart R, Magos A, Hadad E, Morris R. Hysterectomy: surgical route and complications. Eur J Obstet Gynecol 2002: 104: 148-51. Scott P, Magos A. Culdoscopy using an optical

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cannula. Fertil Steril 2002; 78: 625-7. Magos A. Hysteroscopy: Contributions to Gynecology and Obstetrics (book review). J Obstet Gynaecol 2002; 22: 231. Magos A. The extended scope of vaginal hysterectomy: technical highlights and prevention of complications. Jaarboek 2000. Vlaamse vereniging voor obstetrie en gynaecologie. VVOG, SintNiklass 2002: 251-8. Magos A, Taylor A. The modern management of fibroids. In: " The Year in Gynaecology 2002 ", (Eds. Barter J, Hampton N). Oxford , Clinical Publishing Services 2002: 251-68. Hart R, Magos A. Development of a novel method of female sterilization: I. The development of a novel method of hysteroscopic sterilization. J L aparoendosc Adv Surg Techniques A 2002; 12: 365-70. Hart R, Scott P, Ruach M, Magos A. Development of a Novel Method of Female Sterilization: II. Retention of Tubal Screws in Patients Undergoing Simultaneous Laparoscopic Sterilization. J Laparoendosc Adv Surg Tech A 2002; 12: 435-9. Montella F, Balanikos P, Scott P, Magos A. A safe method of deflating ovarian cysts in a bag at laparoscopy. Gynaecol

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Endosc 2002; 11: 205-7. Miskry T, Magos T, Magos A. If you're no good at computer games, don't operate endoscopically! Gynaecol Endosc 2002; 11: 345-7. Taylor A, Sharma M, Al Khouri A, Goumenou A, Tsirkas P, Scott P, Magos A. Investigation of infertility: One Stop Fertility Clinic. Br Med J 2002; 325: 1116 Miskry T, Magos A. Randomised, prospective, double-blind comparison of abdominal versus vaginal hysterectomy in women without uterovaginal prolapse. Acta Obstet Gynecol Scand 2003; 82: 351-8. Sabatini L, Atiomo W, Magos A. Successful myomectomy following infected ischaemic necrosis of uterine fibroids after uterine artery embolisation. Br J Obstet Gynaecol 2003; 110: 704-6. Scott P, Thakaran G, Puvanendran M, Hussain M, Magos A. A novel device for teaching surgical knots. J Gynecol Surg 2003; 19: 2732. Sharma M, Buck L, Mastrogamvrakis G, Kontos K, Magos A, Taylor A. Cost effectiveness of preoperative gonadotrophin releasing analogues for women with uterine fibroids undergoing hysterectomy or myomectomy. Br J Obstet Gynaecol 2003: 110: 712. Goumenou AG, Chow C,

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Taylor A, Magos A. Endometriosis arising during estrogen and testosterone treatment 17 years after total abdominal hysterectomy. Maturitas 2003; 46: 239-401. Sharma M, Taylor A, Magos A. Surgical advances in the management of endometriosis. In: "The Year in Gynaecology 2003 ", (Eds. Barter J, Hampton N). Oxford, Clinical Publishing Services 2003: 101-137. Taylor A, Magos A. Control of menorrhagia by endometrial resection. In: " Hysteroscopy, resectoscopy and endometrial ablation ", (Eds. Bieber EJ, Loffer FD). London , The Parthenon Publishing Group 2003: 149170. Muthulakshmi B, Francis I, Magos A, Roy M, Watkinson A. Broad ligament haematoma after normal delivery. J Obstet Gynaecol 2003; 23: 669-70. Miskry T, Magos A. A national survey of senior trainees surgical experience in hysterectomy and attitudes to the place of vaginal hysterectomy. Br J Obstet Gynaecol 2004; 111: 877-9. Buck L, Varras MN, Miskry T, Ruston J, Magos A. Intraperitoneal bupivacaine for the reduction of postoperative pain following operative laparoscopy: a pilot study and review of the literature. J Obstet Gynaecol

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2004; 24: 448-51. Scott P, Taylor A, Yoong W, Magos A. Absorbable cervical tourniquet at open myomectomy: a pilot study. J Gynecol Surg 2004: 20: 33 -7. di Spiezio Sardo A, Sharma M, Taylor A, Buck L, Magos A. A new device for "no touch" biopsy at "no touch" hysteroscopy: the H Pipelle . Am J Obstet Gynecol 2004; 191: 157-8. Magos A, Sharma M, Buck L. Using handheld computers for patient information and education. Br Med J 2004; 328: 1565. di Spiezio Sardo AS, Mastrogamvrakis G, Taylor A, Sharma M, Buck L, Magos A. Chronic ectopic pregnancy diagnosed incidentally in an infertile woman: a case report. J Reprod Med. 2004 Dec;49:992-6. Sharma M, Taylor A, Magos A. Vaginal myomectomy. RCOG Year Book , Volume 11, (Eds. Hillard T, Purdie D). London , RCOG Press 2004: 479-88. Sharma M, Taylor A, Magos A. Hysteroscopic myomectomy. In: "State of Art: Atlas of Gynaecological Surgery", (Ed. Jain N). New Delhi , Jaypee Brothers 2004: 489-96. Magos A, Chapman L. Hysteroscopic tubal sterilization. In: "Advances in Laparoscopy and Hysteroscopy Techniques, (Ed. Tulandi T). Obstet

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Gynecol Clin N Amer 2004; 31: 705-19. Taylor A, Sharma M, Buck L, Mastrogamvrakis G, Di Spiezio Sardo A, Magos A. Reducing blood loss at open myomectomy using triple tourniquets. BJOG 2005; 112:340-5. Lim S, Taylor A, Di Spiezio Sardo, Mastrogamvrakis G, Sharma M, Buck L, Magos A. Myomectomy can be "life saving" - a case of a 36week fibroid uterus managed conservatively in a 40-year old nulliparous woman. J Obstet Gynaecol (in press). Taylor A, Sharma M, Tsirkas P, Arora R, d i Spiezio Sardo A, Mastrogamvrakis G, MD, Clinical Research Fellow, Buck L, Oak M, Magos A. Surgical and radiological management of uterine fibroids: A United Kingdom survey of current Consultant practice. Acta Obstet Gynecol Scand 2005; 85: 340-5. Magos A, Al Khouri A, Scott P, Taylor A, Sharma M, Buck L, Chapman L, Kailas N, Tsirkas P, Mastrogamvrakis G. One Stop Fertility Clinic. J Obstet Gynaecol 2005; 25: 153-9. Magos A, Kosmas I, Taylor A, Sharma M, Buck L. Digital recording of surgical procedures using a personal computer. Eur J Obset Gynaecol 2005; 120: 206-9. Khouri A, Magos A. The cost of out-patient culdoscopy compared with in-patient

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laparoscopy in women with infertility. J Obstet Gynaecol 2005; 25: 160-6. Sharma M, Taylor A, di Spiezio Sardo A, Buck L, Mastrogamvrakis G, Kosmas I, Tsirkas P, Magos A. Outpatient hysteroscopy: traditional versus the "no touch" technique. BJOG 2005; 112: 693-7. Magos A, Gambadauro P. Desktop search engines: a modern way to hand search in full text. Lancet 2005; 366: 203-4. Taylor A, Blackmore S, Tsirkas P, Magos A. Color Doppler evaluation of changes in uterine perfusion induced by the use of an absorbable cervical tourniquet during open myomectomy. J Clin Ultrasound 2005; 33:390-3. Chapman L, Magos A. Currently available devices for female sterilization. Expert Rev Med Devices 2005; 2: 623-34. Chapman L, Magos A. Hysterectomy. In: "Uterine leiomyomata: Pathogenesis and Management", (Ed Brosens I). Taylor & Francis, London 2005: 181-97. Taylor A, Sharma M, Buck L, Mastrogamvrakis G, Di Spezio Sardo A, Magos A. The use of triple tourniquets for laparoscopic myomectomy. J Gynecol Surg 2005; 21: 65-72. Chapman L, Magos A. Surgical and radiological management of uterine

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fibroids in the UK. Curr Opin Obstet Gynecol 2006; 18: 394-401. Di Spiezio Sardo A, Taylor A, Sharma M, Buck L, Magos A. Unilateral vulvar emphysema after operative laparoscopy. J Minim Invasive Gynecol 2006; 13: 256-7. Taylor A, Magos A. Reducing blood loss at open myomectomy using triple tourniquets: a randomised controlled trial. BJOG 2006; 113: 618-9. Magos A, Mehta R, Tsimpanakos I. Ten pieces of free software every doctor should have. Lancet 2007; 369: 464. Kochiadakis C, Magos A. Subtotal vaginal hysterectomy and myomectomy. In: " Advances in Reconstructive Vaginal Surgery ", (Eds. Kovac SR, Zimmerman CW). Lippincott, Williams & Wilkins, Philadelphia 2007: 147-155. Polyzos D, Papadopoulos N, Chapman L, Papalampros P, Varela V, Gambadauro P, Magos A. Where is the aorta? Is it worth palpating the aorta prior to laparoscopy? Acta Obstet Gynecol Scand. 2007; 86: 235-9. Gambadauro P, Magos A. Digital video technology and surgical training. Eur Clin Obstet Gynaecol 2007; 3: 314. Magos A. Hysteroscopy and laparoscopy. In: "Dewhurst's Textbook of Obstetrics and

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uterine fistula. J Minim Invasive Gynecol 2008; 15:102-4. Al-Shabibi N, Papadimitriou A, Madari S, Korkontzelos I, Stavroulis A, Nakash A, Gkiolakas N, Stamatopoulos C, Triantafyllidis S, Fragoulidis M, Magos A. Workwear for doctors. 31 uses for a white coat. Br Med J 2008; 336: 346. Papadopoulos N, Polyzos D, Gambadauro P, Papalampros P, Chapman L, Magos A. Do patients want to see recordings of their surgery? Eur J Obstet Gynecol Reprod Biol 2008; 138: 89-92. Anastasakis E, Magos AL, Mould T, Economides DL. Uterine tumor resembling ovarian sex cord tumors treated by hysteroscopy. Int J Gynaecol Obstet 2008; 101: 194-5. Gambadauro P, Magos A. NEST (network enhanced surgical training): A PCbased system for telementoring in gynaecological surgery. Eur J Obstet Gynecol Reprod Biol 2008; 139: 222-5. Saha P, Pinjani A, Al-Shabibi N, Madari S, Ruston J, Magos A. Why are we wasting time in the operating theatre? Int J Health Plann Manage 2008. Papalampros P, Gambadauro P, Papadopoulos N, Polyzos D, Chapman L, Magos A. The mini-resectoscope: a new instrument for office hysteroscopic surgery. Acta Obstet Gynecol Scand 2008.

280. Gambadauro P, Magos A. Office 2.0: a web 2.0 tool for international collaborative research. Lancet 2008; 371: 1837-8. 281. Gkioulekas N, Korkontzelos I, Stamatopoulos C, AlShabibi N, Magos A. Bureaucracy is still killing research in the NHS. Br Med J 11 April 2008. 282. Madari S, Al-Shabibi N, Papalampros P, Papadimitriou A, Magos A. A randomized trial comparing the H Pipelle with the standard Pipelle for endometrial sampling at "no touch" (vaginoscopic) hysteroscopy. BJOG 2009; 116: 32-7. 283. Magos A, Gambadauro P, Tsibanakos I, Georgakaki A, Kakaidis I, Moiety F. Submucous fibroids should be removed in infertile women. BMJ 2009; 338: b126. 284. Al-Shabibi N, Chapman L, Madari S, Papadimitriou A, Papalampros P, Magos A. Prospective randomised trial comparing gonadotrophinreleasing hormone analogues with triple tourniquets at open myomectomy. BJOG, 2009 Feb 4. Go Back

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Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for

Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street

Adhesions
The Merck Manual A textbook style website with information about gynaecological disorders including adhesions and tubal infertility. UK Adhesions Society An organisation dedicated to disseminating information about adhesions. Disclaimer These web sites provide general information only, and should not be treated as a substitute for the medical advice of your own doctor or any other health care professional. We are not responsible or liable for any diagnosis made by a user based on the content of these websites. We are not liable for the contents of any external internet sites listed, nor do we endorse any commercial product or service mentioned or advised on any of the sites. Always consult your own GP if you're in any way concerned about your health. Go Back

Adhesions Adhesions are fibrous bands of scar-like tissue that form between two surfaces inside the body. Adhesions are caused by inflammation or trauma, and can cause tissues to bond to other tissue or organs (much like the process of forming scar tissue). Sometimes, fibrous bands (adhesions) can be formed between the two surfaces. Abdominal surgery, congenital bands, or attacks of appendicitis can also cause this condition.

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Depending on the tissues involved, adhesions can cause various disorders. For example, in the intestines, adhesions can cause partial or complete bowel obstruction. Intrauterine adhesions occur often enough they have a name of their own (Asherman syndrome). Pelvic adhesions can lead to infertility and reproductive problems. Home - Background information - Treatment options - Treatment summary - Movies - Fibroid Clinic Knowledge base - Useful links - How to find us - Contact us 2010 webmeddesign.com Dreamweaver Web Templates

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Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for

Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street

Infertility
Clinical Evidence Information provided by the publishes of the British Medical Journal including leaflets, guidelines and references. BBC Health Unbiased information from the BBC. Patient UK Provides information you would expect your GP to give you. NHS Choices with information about infertility. The Merck Manual A textbook style website with information about gynaecological disorders including infertility. Disclaimer These web sites provide general information only, and should not be treated as a substitute for the medical advice of your own doctor or any other health care professional. We are not responsible or liable for any diagnosis made by a user based on the content of these websites. We are not liable for the contents

Infertility Infertility affects one in seven couples in the UK. The strict definition of infertility varies, with differing times of regular, unprotected intercourse, but most couples will undergo some investigations after around 1-2 years of trying. Common causes of infertility include: Female partner Absent ovulation (e.g. PCOS) Tubal damage Endometriosis Mucus hostility Fibroids Male partner Abnormal semen

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of any external internet sites listed, nor do we endorse any commercial product or service mentioned or advised on any of the sites. Always consult your own GP if you're in any way concerned about your health. Go Back

Both partners Sexual problems In about 25% of cases, no cause is found for the subfertility. 6070% of this group will conceive within 3 years without any treatment.

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Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for

Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street

Endometriosis
Clinical Evidence Information provided by the publishes of the British Medical Journal including leaflets, guidelines and references. BBC Health Unbiased information from the BBC. Patient UK Provides information you would expect your GP to give you. NHS Choices with brief information about endometriosis. The Merck Manual A textbook style website with information about gynaecological disorders including endometriosis. The National Endometriosis Society Founded in 1981, the National Endometriosis Society is a UK charity devoted exclusively to this disease. Disclaimer These web sites provide general information only, and should not be treated as a substitute for the medical advice

Endometriosis A nonmalignant disorder in which functioning endometrial tissue is present outside the uterine cavity. Endometriosis is usually confined to the peritoneal or serosal surfaces of abdominal organs, commonly the ovaries, posterior broad ligament, posterior cul-desac, and uterosacral ligaments. Less common sites include the serosal surfaces of the small and large bowel, ureters, bladder, vagina, surgical scars, pleura, and pericardium. It can be asymptomatic,

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of your own doctor or any other health care professional. We are not responsible or liable for any diagnosis made by a user based on the content of these websites. We are not liable for the contents of any external internet sites listed, nor do we endorse any commercial product or service mentioned or advised on any of the sites. Always consult your own GP if you're in any way concerned about your health. Go Back Home - Background information - Treatment options - Treatment summary - Movies - Fibroid Clinic - Knowledge base - Useful links - How to find us - Contact us 2010 webmeddesign.com Dreamweaver Web Templates

but common symptoms include painful heavy periods, pelvic pain, painful intercourse and subfertility.

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Pelvic pain and painful periods


Clinical Evidence Information provided by the publishes of the British Medical Journal including leaflets, guidelines and references. Patient UK Provides information you would expect your GP to give you. NHS Choices with information about menorrhagia (heavy periods). The Merck Manual A textbook style website with information about gynaecological disorders including period pain. Disclaimer These web sites provide general information only, and should not be treated as a substitute for the medical advice of your own doctor or any other health care professional. We are not responsible or liable for any diagnosis made by a user based on the content of these websites. We are not liable for the contents of any external internet sites listed, nor do we endorse any

Pelvic pain Pelvic pain is a common symptom in women. It is frequently, but not always, related to the reproductive system. Other causes of pelvic pain are related to the intestines or urinary tract. Psychological factors can make the pain seem worse, or even cause a sensation of pain where no physical problem exists. Pelvic pain can range from mild discomfort or cramping, to severe, intense pain. This pain may be acute, when it occurs suddenly, or

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chronic, when the pain lasts for a long period of time. Common causes for pelvic pain include endometriosis, pelvic inflammatory disease, appendicitis, ectopic pregnancy, urinary tract infection, ovarian cysts, irritable bowel syndrome, and sexually transmitted disease. Fibroids do not often cause pain apart from period pains secondary to heavy periods

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Uterine fibroids
Clinical Evidence Information provided by the publishes of the British Medical Journal including leaflets, guidelines and references. BBC Health Unbiased information from the BBC. Patient UK Provides information you would expect your GP to give you. NHS Choices with information about fibroids. The Merck Manual A textbook style website with information about gynaecological disorders including uterine fibroids. Disclaimer These web sites provide general information only, and should not be treated as a substitute for the medical advice of your own doctor or any other health care professional. We are not responsible or liable for any diagnosis made by a user based on the content of these websites. We are not liable for the contents

Fibroids Uterine leiomyomata, often referred to as fibroids, are tumours of the uterus (womb). They are very common and can be asymptomatic. Fibroids tend to be multiple and can be situated inside the cavity of the uterus, in the wall or outside. In some cases, they can grow to a very large size.No one knows why they develop, but it is well established that the female hormone oestrogen makes them enlarge; this is why fibroids are usually diagnosed when

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women are in their 30's and 40's, and why they shrink after the menopause. While not all women have symptoms, typical complaints associated with fibroids include heavy periods, irregular vaginal bleeding, pelvic pain, pelvic mass, pressure symptoms and subfertility. Briefly, treatment is indicated if the fibroids are thought to be responsible for troublesome symptoms, or if they become large. If there are no symptoms or if the fibroids are small, there is no need for treatment. Although fibroids can become cancerous, the chance is so small that they are not routinely removed just because they are there.

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Pelvic prolapse
Clinical Evidence Information provided by the publishes of the British Medical Journal including leaflets, guidelines and references. BBC Health Unbiased information from the BBC. Patient UK Provides information you would expect your GP to give you. NHS Choices with information about uterine prolapse. The Merck Manual A textbook style website with information about gynaecological disorders including genital tract prolapse. Disclaimer These web sites provide general information only, and should not be treated as a substitute for the medical advice of your own doctor or any other health care professional. We are not responsible or liable for any diagnosis made by a user based on the content of these websites. We are not liable for the contents

Uterovaginal prolapse Prolapse (descent) of the vagina and/or uterus (womb) is a relatively common condition particularly in women who have had children and are postmenopausal. Common symptoms include a feeling of pressure in the vagina, lower abdominal discomfort or backache, and difficulty with passing urine or opening bowels. Conversely, prolapse can be accompanied by incontinence. Not all prolapse requires

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treatment, and physiotherapy can help mild cases. If this proves unsuccessful, as it often does with more major degress of prolapse, surgical repair is the mainstay of treatment except in women who are relatively unfit, when mechanical devices inserted into the vagina can sometimes be used to control the prolapse.

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Heavy periods
Clinical Evidence Information provided by the publishes of the British Medical Journal including leaflets, guidelines and references. BBC Health Unbiased information from the BBC. Patient UK Provides information you would expect your GP to give you. NHS Choices with information about menorrhagia (heavy periods). The Merck Manual A textbook style website with information about gynaecological disorders including abnormal uterine bleeding. Disclaimer These web sites provide general information only, and should not be treated as a substitute for the medical advice of your own doctor or any other health care professional. We are not responsible or liable for any diagnosis made by a user based on the content of these websites.

Heavy periods The correct medical definition of heavy periods is the passage of more than 80ml of blood each period. It is seldom realistic or practical, however, to actually measure the blood loss and so doctors rely on the woman's description of her period. Periods are considered heavy when: - the period lasts for more than 8 to 10 days, especially if this is repeated month after month. - it affects everyday activities (e.g.

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work, holidays, hobbies). - the bleeding is continuously so heavy that the woman becomes anaemic. - there are clots and flooding. Common causes for heavy periods include hormonal reasons, endometriosis, pelvic inflammatory disease and in particular, uterine fibroids.

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Polycystic ovaries and syndrome (PCOS)


Clinical Evidence Information provided by the publishes of the British Medical Journal including leaflets, guidelines and references. BBC Health Unbiased information from the BBC. Patient UK Provides information you would expect your GP to give you. NHS Choices with information about PCOS. The Merck Manual A textbook style website with information about gynaecological disorders including polycystic ovarian syndrome. Disclaimer These web sites provide general information only, and should not be treated as a substitute for the medical advice of your own doctor or any other health care professional. We are not responsible or liable for any diagnosis made by a user based on the content of these websites.

PCOS Polycystic ovary syndrome (PCOS) is a common disease affecting 3-5% of women of reproductive age. Despite the fact that it was first recognised in 1935, the exact cause of the syndrome remains elusive and there is no 'one-treatmentfits-all' answer to its management. Common symptoms include irregular periods, weight gain, hirsutism and infertility.

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We are not liable for the contents of any external internet sites listed, nor do we endorse any commercial product or service mentioned or advised on any of the sites. Always consult your own GP if you're in any way concerned about your health. Go Back Home - Background information - Treatment options - Treatment summary - Movies - Fibroid Clinic Knowledge base - Useful links - How to find us - Contact us 2010 webmeddesign.com Dreamweaver Web Templates

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How to arrange an appointment in the Fibroid Clinic


You must be referred by your General Practitioner if you wish to be seen in the Fibroid Clinic. If you want a general assessment, are interested in one of the surgical treatment options, or would like to find out more about some of the newer treatments, please ask to be referred to: Mr. Adam Magos BSc MB BS MD FRCOG Consultant Gynaecologist The Royal Free Hospital Pond Street Hampstead London NW3 2QG Tel: +44 (0) 20 7830 2497 Fax: +44 (0) 20 7830 2504 If you are interested specifically in uterine artery embolisation, the referral letter should be addressed to: Dr. Neil Davies MB BS FRCS FRCR Consultant Interventional

Age From birth to 18, a girl needs good parents. From 18 to 35, she needs good looks. From 35 to 55, she needs a good personality. From 55 on, she needs good cash. Sophie Tucker

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Radiologist Royal Free Hospital Pond Street Hampstead London NW3 2QG Tel: +44 (0) 20 7794 0500 (Extension 33179) or +44 (0) 20 7830 2170 Fax: +44 (0) 20 7794 5342 Click here for further information about the Royal Free Hospital.

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Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street Hampstead London NW3 2QG, UK
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Hysteroscopic myomectomy
Fibroids which are located mainly inside the uterus (womb) can often be excised hysteroscopically thereby avoiding major open surgery. The resectoscope remains the most efficient instrument for this procedure.

Ultrasound scan You have probably had an ultrasound scan before as it is a very common investigation. A pelvic scan can be done abdominally or via the vagina. The procedure is quick, painless and gives a very useful image of your uterus (womb) and ovaries. Apart from fibroids, ultrasound can also diagnose polyps, thickened endometrium (lining of the uterus), and ovarian cysts.

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Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street Hampstead London NW3 2QG, UK
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Hysteroscopic myomectomy using the miniresectoscope


The miniresectoscope is a new instrument for excising fibroids. Because of its small size, it is suitable for outpatient/office treatment without the need for general anaesthesia.

Ultrasound scan You have probably had an ultrasound scan before as it is a very common investigation. A pelvic scan can be done abdominally or via the vagina. The procedure is quick, painless and gives a very useful image of your uterus (womb) and ovaries. Apart from fibroids, ultrasound can also diagnose polyps, thickened endometrium (lining of the uterus), and ovarian cysts.

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Laparoscopic myomectomy
Fibroids which are located in the wall of the uterus (womb) can sometimes be excised laparoscopically provided they are not too large or numerous. Laparoscopic myomectomy was first described in the early 1980s by the legendary Kurt Semm, Professor of Obstetrics and Gynaecology in Kiel, Germany, the operation becoming a possibility following the development of laparoscopic suturing and morcellation by the great man.

Ultrasound scan You have probably had an ultrasound scan before as it is a very common investigation. A pelvic scan can be done abdominally or via the vagina. The procedure is quick, painless and gives a very useful image of your uterus (womb) and ovaries. Apart from fibroids, ultrasound can also diagnose polyps, thickened endometrium (lining of the uterus), and ovarian cysts.

now on line. www. fibroidsurgery. org

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Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street Hampstead London NW3 2QG, UK
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Laparoscopic myomectomy with single tourniquet


Single tourniquets can be used for pedunculated fibroids (fibroids on a stalk), and those which are mostly on the outside of the uterus (womb) as in this example. By using a suture around the base of the fibroid, bleeding during surgery can be greatly reduced.

Ultrasound scan You have probably had an ultrasound scan before as it is a very common investigation. A pelvic scan can be done abdominally or via the vagina. The procedure is quick, painless and gives a very useful image of your uterus (womb) and ovaries. Apart from fibroids, ultrasound can also diagnose polyps, thickened endometrium (lining of the uterus), and ovarian cysts.

Go Back

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Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street Hampstead London NW3 2QG, UK
Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for gynaecologists interested in the surgical management of fibroids is

Laparoscopic myomectomy with triple tourniquets


Intra-operative bleeding during laparoscopic myomectomy remains a potential problem, just as with open myomectomy. We have developed the technique of "triple tourniquets" which involves tying sutures around the major blood supply to the uterus to occlude these vessels and thereby limit blood loss during surgery.

Ultrasound scan You have probably had an ultrasound scan before as it is a very common investigation. A pelvic scan can be done abdominally or via the vagina. The procedure is quick, painless and gives a very useful image of your uterus (womb) and ovaries. Apart from fibroids, ultrasound can also diagnose polyps, thickened endometrium (lining of the uterus), and ovarian cysts.

Go Back

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Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street Hampstead London NW3 2QG, UK
Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for gynaecologists interested in the surgical management of fibroids is

Fibroid morcellation at laparoscopic myomectomy


Other than very small fibroids cannot be removed through the small incisions used for laparoscopic myomectomy. One technique is to chop the fibroid in to small pieces using a morcellator, as demonstrated in this clip.

Ultrasound scan You have probably had an ultrasound scan before as it is a very common investigation. A pelvic scan can be done abdominally or via the vagina. The procedure is quick, painless and gives a very useful image of your uterus (womb) and ovaries. Apart from fibroids, ultrasound can also diagnose polyps, thickened endometrium (lining of the uterus), and ovarian cysts.

Go Back

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Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street Hampstead London NW3 2QG, UK
Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for gynaecologists interested in the surgical management of fibroids is

Open myomectomy using ovarian clamps (triple tourniquets)


If fibroids are large and/or numerous, the only option which removes the fibroids but conserves the uterus is open myomectomy, that is myomectomy done via an abdominal incision (laparotomy). We routinely use a modified technique of "triple tourniquets" to reduce intra-operative blood loss: a. A cable tie is passed around the cervix is used to occlude the uterine arteries. b. The new Ovarian artery clamps are placed medial to the ovaries to occlude the ovarian arteries. The ovarian artery clamps were designed at the Royal Free Hospital specifically for use at open myomectomy to allow the ovarian vessels to be occluded without compromising the ovarian blood supply during surgery (as is the case with conventional tourniquets placed laterel to the ovaries) or damaging the fallopian tubes (as would be the case if conventional tourniquets were to be applied medial to the ovaries).

Ultrasound scan You have probably had an ultrasound scan before as it is a very common investigation. A pelvic scan can be done abdominally or via the vagina. The procedure is quick, painless and gives a very useful image of your uterus (womb) and ovaries. Apart from fibroids, ultrasound can also diagnose polyps, thickened endometrium (lining of the uterus), and ovarian cysts.

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Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street Hampstead London NW3 2QG, UK
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Common treatment options for uterine fibroids


The table below is based on a recent review article on the modern management of uterine fibroids which provides a useful comparison of the indications and relative merits of the various common treatments which are currently available:
Hysterectomy Myomectomy Uterine artery embolisation (UAE) Blood supply to uterus blocked resulting in fibroid shrinkage Fibroids on stalks Submucous fibroids Very large fibroids MRI guided focused ultrasound myolysis Fibroids are heated up leading to shrinkage Fibroids on stalks Fibroids near vital structures (e.g. bowel, bladder) or nerves Very large fibroids Non-surgical treatment No need for general anaesthesia

On the subject of surgeons: Surgeons must be very careful when they take the knife! Underneath their fine incisions, stirs the Culprit -- Life! Emily Dickinson, American poet (1830-1886)

What is it?

Fibroids removed together with the uterus (womb) * (All fibroids suitable)

Fibroids are removed but not the uterus

Which fibroids are not suitable?

(All fibroids suitable)

What are the major advantages?

Only treatment which Fibroids are removed Best option if you wish is guarantees a cure to conceive No more periods/period pain No chance of recurrence

Non-surgical treatment No need for general anaesthesia

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What are the major disadvantages?

Involves major surgery Involves major surgery Post-procedure pain Usually requires Requires general Infection general anaesthesia anaesthesia Premature Pelvic adhesions likely Cannot get pregnant menopause after abdominal or 1:4 women undergo laparoscopic surgery hysterectomy within New fibroids can 2 years develop

Relatively long procedure time Modest reduction in fibroid size Skin burns Injury to adjacent structures High chance of treatment failure (up to 28%) 2-4 hours Outpatient

How long does it take? How long will I be in hospital? When am I likely to be able to resume normal activities? What will happen to my fibroids? What will happen to my periods? Can I become pregnant afterwards?

1-2 hours 4-6 days (abdominal) to 2-3 days (vaginal or laparoscopic) 4-6 weeks (abdominal) to 3-4 weeks (vaginal or laparoscopic) Fibroids (and uterus) are removed Periods will stop

1-3 hours 4-6 days (abdominal) to day case (hysteroscopic) 4-6 weeks (abdominal) to few days (hysteroscopic) Fibroids are removed Periods usually become lighter and less painful Yes

1 hour 1-2 days

Few days

Few days

Fibroids usually shrink by 50-70% Periods usually become lighter and less painful Pregnancy is not recommended at present

Fibroids usually shrink by 15-25% Periods usually become lighter and less painful Pregnancy is not recommended at present

No

Includes abdominal hysterectomy, vaginal hysterectomy and laparoscopic hysterectomy Includes open (abdominal) myomectomy, laparoscopic myomectomy, hysteroscopic myomectomy and vaginal myomectomy * Hysterectomy means removal of the uterus but not ovaries and therefore does not result in the menopause

Based on: Levy BS. Modern management of uterine fibroids. Acta Obstet Gynecol Scand 2008;87(8):812-23. Click here to download a copy of this table (as a pdf file). Go Back

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Common treatment options for uterine fibroids University Department of Obstetrics and Gynaecology Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG Tel: +44 (0) 20 7431 1321 (direct) +44 (0) 20 7794 0500 (Ext. 33863, 33868) Fax: +44 (0) 02 7431 1321

Includes abdominal hysterectomy, vaginal hysterectomy and laparoscopic hysterectomy Includes open (abdominal) myomectomy, laparoscopic myomectomy, hysteroscopic myomectomy and vaginal myomectomy * Hysterectomy means removal of the uterus but not ovaries and therefore does not result in the menopause Table based on: Levy BS. Modern management of uterine fibroids. Acta Obstet Gynecol Scand 2008; 87(8): 812-23. Downloaded from www.fibroids.uk.net

Adam Magos BSc MB BS MD FRCOG, Consultant Gynaecologist

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Different types of myomectomies compared


If you are considering a myomectomy (surgical removal of fibroids) as treatment, the table below will help you understand which type of myomectomy is the most appropriate in your case:
Open (abdominal) myomectomy What is it? Fibroids removed via a larger abdominal incision (laparotomy) All fibroids are suitable irrespective of size, site or number - the only option with large, multiple fibroids Hysteroscopic myomectomy Fibroids are removed through the cervix/ vagina using a hysteroscope Typically a single, small (< 5cm) fibroid which is sited or growing towards the inside of the uterus (uterine cavity) Laparoscopic myomectomy Fibroids are removed via several small (1/2 - 1 cm) abdominal incisions Vaginal myomectomy Fibroids are removed via the vagina

On the subject of surgeons: Surgeons must be very careful when they take the knife! Underneath their fine incisions, stirs the Culprit -- Life! Emily Dickinson, American poet (1830-1886)

Which fibroids are suitable?

Fibroids which have Maximum of 3 fibroids with a prolapsed through the cervix into the vagina. maximum total diameter of 15 cm In special cases, which are on the vaginal myomectomy can be used with outside of the uterus smaller fibroids sited on the outside of the uterus Avoids a laparotomy incision with shorter hospitalisation and quicker recovery than open myomectomy Long operating (anaesthetic) time, smaller fibroids may be missed so recurrence of symptoms more likely than with open myomectomy No external scars, shorter hospitalisation, relatively quick recovery Pelvic haematoma

What are the major advantages of this route?

Greatest chance of all fibroids being removed (if there are multiple fibroids)

No external scars, day-case surgery which can be done under local anaesthesia, quick recovery Only removes submucous fibroids, so symptoms may recur if there are multiple fibroids present

What are the major disadvantages of this route?

Involves laparotomy with inherent risk of wound infection, deep vein thrombosis, pelvic haematoma

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How long does it take? How long will I be in hospital? When am I likely to be able to resume normal activities? What is the risk of hysterectomy? What will happen to my periods? Can I become pregnant afterwards?

1-3 hours 3-5 days 4-6 weeks

15-60 minutes Usually day case surgery Few days

2-3 hours 2-4 days 2-4 weeks

30-60 minutes Day case or up to 2 days 1-2 weeks

Probably < 1% Periods usually become lighter and less painful Yes

Virtually zero Periods usually become lighter and less painful Yes

Probably < 1% Periods usually become lighter and less painful Yes

Probably < 1% Periods usually become lighter and less painful Yes

Click here to download a copy of this table (as a pdf file). Go Back

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Different types of myomectomies compared University Department of Obstetrics and Gynaecology Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG Tel: +44 (0) 20 7431 1321 (direct) +44 (0) 20 7794 0500 (Ext. 33863, 33868) Fax: +44 (0) 02 7431 1321

Downloaded from www.fibroids.uk.net

Adam Magos BSc MB BS MD FRCOG, Consultant Gynaecologist

Hampstead London NW3 2QG, UK


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Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street

What is a hysterectomy? What is a myomectomy?


There is much misunderstanding as to what is meant by "hysterectomy". For instance, many believe that a hysterectomy results in the menopause, but this is incorrect as hysterectomy merely means removal of the uterus only. The reason periods stop after surgery is not because of the menopause but because there is no uterus to bleed each month. Provided the ovaries are not removed at the same time, they will continue to function normally in most cases, and to produce oestrogen and other hormones just as before the hysterectomy. Removal of the ovaries (usually together with the nearby fallopian tubes) can be done at the time of hysterectomy, but is actually a separate procedure which doctors often refer to as "salpingooophorectomy". Similarly, many do not realise that there are two types of hysterectomy - total and subtotal (also known as supracervical).

On the subject of surgeons: Surgeons must be very careful when they take the knife! Underneath their fine incisions, stirs the Culprit -- Life! Emily Dickinson, American poet (1830-1886)

gynaecologists interested in the surgical management of fibroids is now on line. www. fibroidsurgery. org

With "total hysterectomy", the uterus is removed along with the cervix, whereas in the case of "subtotal hysterectomy", only the uterus is removed but not the cervix. Most hysterectomies are of the total type. We hope that the diagrams below will help you understand the differences between these various operations as well as contrast the difference between hysterectomy and myomectomy (removal of fibroids but not the uterus):

Total hysterectomy

Total hysterectomy & bilateral salpingooophorectomy

Subtotal hysterectomy

Myomectomy

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What is a hysterectomy? What is a myomectomy? University Department of Obstetrics and Gynaecology Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG Tel: +44 (0) 20 7431 1321 (direct) +44 (0) 20 7794 0500 (Ext. 33863, 33868) Fax: +44 (0) 02 7431 1321

There is much misunderstanding as to what is meant by "hysterectomy". For instance, many believe that a hysterectomy results in the menopause, but this is incorrect as hysterectomy merely means removal of the uterus only. The reason periods stop after surgery is not because of the menopause but because there is no uterus to bleed each month. Provided the ovaries are not removed at the same time, they will continue to function normally in most cases, and to produce oestrogen and other hormones just as before the hysterectomy. Removal of the ovaries (usually together with the nearby fallopian tubes) can be done at the time of hysterectomy, but is actually a separate procedure which doctors often refer to as "salpingooophorectomy". Similarly, many do not realise that there are two types of hysterectomy - total and subtotal (also known as supracervical). With "total hysterectomy", the uterus is removed along with the cervix, whereas in the case of "subtotal hysterectomy", only the uterus is removed but not the cervix. Most hysterectomies are of the total type. We hope that the diagrams below will help you understand the differences between these various operations as well as contrast the difference between hysterectomy and myomectomy (removal of fibroids but not the uterus):

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Adam Magos BSc MB BS MD FRCOG, Consultant Gynaecologist

Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street Hampstead London NW3 2QG, UK
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Medical treatment
Treatment with tablets are indicated if your fibroids are relatively small and your main problems are heavy or painful periods. In this situation, drugs such as tranexamic acid or mefenamic acid can be prescribed by your doctor. Unfortunately, these drugs do not cure the fibroids, so you may have to take them for many years. Similarly, they do not tend to work as well as in women with heavy periods who do not have fibroids. GnRH analogues are sometimes used for short-term symptom relief or prior to surgery. These drugs have the effect of inducing a pseudo-menopause, and the effect of treatment is to shrink the fibroids by about 35% after 3 months of treatment. Periods often stop as well. However, side effects related to falling oestrogen levels make this treatment unsuitable for longterm management in the majority of cases. As heavy periods are a common cause of anaemia, you may also be asked to take regular iron replacement to correct this. Ultimately, many women who try medical treatment request something more definitive. Medical treatment may also not be the best choice if the fibroids are large, or are causing other problems such as pressure symptoms or subfertility.

Tranexamic acid (Cyclokapron) Fibrin dissolution can be impaired by the administration of tranexamic acid, which inhibits fibrinolysis. It can be particularly useful in menorrhagia. Cautions, contraindications and side effects Discuss with your doctor. Dose for heavy periods: 1g 3 times daily

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for up to 4 days; max. 4g daily. Mefenamic acid (Ponstan) Mefenamic acid is a nonsteroidal antiinflammatory drug which is used especially in gynaecology to manage heavy and/or painful periods. Cautions, contraindications and side effects Discuss with your doctor. Dose for heavy periods: 500 mg 3 times daily, preferably after food. Information taken from British National Formulary (No. 47).

Treatment may have side effects Drugs may have to be continued for several years Drugs are not curative

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Myomectomy
Myomectomy is a surgical procedures which involves removing the fibroids but leaving behind the uterus. It can be done a number of ways, depending on the number, size and position of the fibroids. For instance, someone with a single small fibroid which is situation in the cavity of the uterus can undergo hysteroscopic myomectomy, which is a relatively fast and straightforward procedure that can be done as day case surgery. Women with a few small to medium fibroids situated deeper in the muscle of the uterus, and especially on the outside, may be suitable for laparoscopic myomectomy, which should also be followed by a relatively short hospital stay and quick recovery. Vaginal myomectomy may also be possible in this situation. However, if your fibroids are numerous and/or large, then abdominal myomectomy may well be the only option if you wish to retain your uterus. What ever you choose or is appropriate in your case, myomectomy does involve surgery and therefore surgical risk. The most important complication specific to myomectomy is haemorrhage (bleeding), which may necessitate a blood transfusion, and in rare cases even hysterectomy. Although the chance of requiring a hysterectomy is very small, as it is only done in extreme cases of life-threatening, the risk is there. We, for instance, routinely use tourniquets at open and some laparoscopic myomectomies to temporarily occlude the uterine blood supply during surgery thereby greatly reducing intra-operative bleeding. We sometimes also suggest prior treatment with a drug to shrink the fibroids and stop your periods while you waiting for surgery (e.g. if you have very large fibroids or are anaemic). In theory, pregnancy is still possible after myomectomy (unlike after hysterectomy); you may be advised to have a Caesarean delivery after extensive surgery. Conversely, as it is sometimes difficult to remove all fibroids, particularly those which are small, there is a chance that the problem may recur and you may therefore need further treatment in years to come.

History The first successful abdominal myomectomy was done in 1844 by Washington Atlee in the USA, and the following year he removed a prolapsed fibroid through the vagina. Abdominal myomectomy became a standard procedure of the gynaecologist's repertoire some years later. Hysteroscopic myomectomy was first reported formally by Robert Neuwirth, another American, in 1976 (scissors)

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Click on the links below for further information:

and 1978 (resectoscope). At about the same time. Kurt Semm (Germany) developed the necessary instruments and techniques to excise fibroids laparoscopically.

Abdominal myomectomy

Laparoscopic myomectomy

Hysteroscopic myomectomy

Vaginal myomectomy

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Hysteroscopic myomectomy
Hysteroscopic myomectomy is done using a small telescope inserted through the vagina and cervix into the uterus. The telescope can be fitted with miniature instruments (eg. scissors, cutting loop, laser) which is used to remove or destroy the fibroid(s). The procedure is monitored on a colour television via a small video camera. This type of surgery is suitable for small fibroids which are mainly sited inside the cavity of the uterus, although deeper fibroids can sometimes also be removed. With larger fibroids, the procedure may have to be repeated, but this is unusual. Complications with this type of surgery are relatively uncommon.

Operative hysteroscopy Hysteroscopy can also be used for treatment. Operative hysteroscopes are slightly larger instrument fitted with mechanical instruments (e. g. scissors, biopsy forceps, graspers), electrodes (e.g. resectoscope) or laser. One of the most effective hysteroscopic procedures is myomectomy. Fibroids are usually excised

Relatively minor (day case) surgery No external scars Complications uncommon Fast recovery No risk of scar tissue in pelvis

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but can also be vaporised. This type of surgery is indicated provided the fibroids are not too large or numerous, and situated mainly inside the uterine cavity. Hysteroscopic surgery can also be used to remove polyps, divide uterine septa, free adhesions (Asherman's syndrome) and destroy the endometrium (endometrial ablation).

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Laparoscopic myomectomy
Laparoscopic myomectomy is also done using a narrow telescope and miniature instruments, but these are inserted into the body through the abdomen (stomach). Typically, for instance, the laparoscope is placed in the umbilicus (belly button) and the other instruments are put lower down (see diagram). This type of operation is used when the fibroids are on the outside of the uterus, provided there are not too many of them and they are not too large. The fibroids are excised using instruments such as scissors, grasping forceps, and diathermy or laser. The uterus is then usually repaired with sutures (stitches), and the fibroids removed either through one of the small abdominal incisions following morcellation (cutting into small pieces) or via the vagina. Laparoscopic myomectomy is a more difficult procedure than hysteroscopic myomectomy, and takes longer. Bleeding can be more of a problem, so the chance of requiring a blood transfusion is greater. Hospital stay is typically 3 to 4 days, and recovery a few weeks.

The early history of laparoscopic myomectomy Laparoscopic myomectomy was first described by Kurt Semm, Professor of Obstetrics and Gynaecology in the University of Kiel, Germany. Semm was one of the pioneers of modern laparoscopic surgery. He developed a range of miniature instruments which are still used today. He also introduced

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Small abdominal scars Shorter hospital stay than open myomectomy Relatively quick recovery

Only suitable for small/few fibroids Fibroids should not be inside the uterine cavity

laparoscopic suturing, and it was this innovation which made it possible to perform major laparoscopic procedures such as myomectomy safely and effectively.

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Vaginal myomectomy
Vaginal myomectomy involves removing fibroids through the vagina; as with hysteroscopic myomectomy, therefore, there are no external scars. This operation is done when the fibroids are moderate in size but too deep or numerous for hysteroscopic or laparoscopic myomectomy. It is easier in women who have children as there tends to be more space in the pelvis for this type of surgery.

Different vaginal myomectomies The term "vaginal myomectomy" can mean one of 4 techniques, depending on the position of the fibroid: 1. Vaginal removal of a pedunculated submucous myoma via the cervix. 2. Vaginal removal of a submucous myoma via Duhrssen's incision (incision into the cervix). 3. Vaginal removal of a submucous myoma via vaginal hysterotomy (incision into the

The procedure is easiest when the fibroid(s) are at the back of the uterus, and most difficult when they are mainly at the top; in that situation, laparoscopic myomectomy may be preferred. Because conventional instruments are used, vaginal myomectomy generally takes less time than laparoscopic myomectomy and the repair of the uterus is stronger. Recovery in terms of hospitalisation and return to normal activities is similar, and faster than with laparotomy.

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Fibroids can be sited anywhwere Relatively short hospital stay Recovery relatively quick Probably less risk of adhesions than with laparotomy

Only suitable if fibroids are not very large Difficult if fibroids are sited at the top of the uterus

cervix which extends into the lower part of the uterus). 4. Vaginal removal of myoma via anterior or posterior colpotomy (incision between the vagina and peritoneal cavity).

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Abdominal myomectomy
Abdominal myomectomy is the traditional operation for removing fibroids and is done through a laparotomy incision. If there are numerous, large fibroids, it is the only way to remove them as the other techniques are not suitable in such cases. Providing the fibroids are not very large, however, a "bikini" type incision can often be used (see diagram). Abdominal myomectomy is a major operation. As it is generally done in the more difficult cases, complications are more common than with the other routes of surgery, or indeed with hysterectomy. Hospitalisation and recovery also take longer. Nonetheless, it is a good operation when the other procedures are contra-indicated as it is the most thorough type of myomectomy and yet still allows the uterus to be conserved in most patients.

Potential complications of surgery All surgery carries risk, and this applies even relatively minor procedures. Complications can be classified as "General" (applies to all procedures) and as "Specific" (applies to the procedure in question). Serious surgical complications in gynaecological surgery include: -Bleeding -Injury to surrounding structures (e.g. bladder, ureter, bowel)

No limit to fibroid size, number or position Most likely procedure to remove all the fibroids

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Major abdominal incision Complications relatively more frequent Hospital stay 5 to 7 days Recovery takes several weeks Adhesions (scar tissue) more likely

-Infection (e.g. at the operative site, pneumonia) -Venous thrombosis (e.g. deep vein thrombosis, pulmonary embolus).

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Hysterectomy
Hysterectomy is the definite cure for fibroids and involves removing all the fibroids along with the uterus. Following surgery, you will not have any more periods, and of course you cannot become pregnant. Hysterectomy is, therefore, only suitable for women who have completed their family, but there is no chance of a recurrence of the fibroids or need for further treatment (as there is with myomectomy or embolisation). Although your periods will stop after hysterectomy, this does not mean that you will become menopausal. Provided your ovaries are not removed at the same time, there should be little difference in your "hormones" after surgery. Sometimes, however, it is in your best interests to remove the ovaries at the same time (eg. if they are diseased), and then you can usually take hormone replacement therapy afterwards to prevent menopausal symptoms. Hysterectomy can be done a number of ways. In many respects, vaginal hysterectomy is the best and least traumatic procedure, and may be possible as long as your fibroids are not too large. Laparoscopic hysterectomy is done with the help of a telescope (as with laparoscopic myomectomy), and is generally indicated when there is the feeling that you may have adhesions (scar tissue) in your pelvis which would make vaginal surgery difficult. If your fibroids are very large, the only choice is abdominal hysterectomy. If you undergo hysterectomy, there is also the choice of total or subtotal hysterectomy. In total hysterectomy, the entire uterus is removed, including the cervix; conversely, in subtotal hysterectomy, the uterus is removed but the cervix is not. While subtotal hysterectomy is an easier operation and may be associated with fewer complications, a purely vaginal route of surgery becomes virtually impossible if the cervix is to be conserved. As in the case of myomectomy, hysterectomy is a major operation. However, despite the fact that the entire uterus is removed, problems are if anything less common than with myomectomy. For instance, the risk of bleeding and needing a blood transfusion are greater with abdominal myomectomy than abdominal hysterectomy; this is because the blood supply to the uterus is first tied off when doing a hysterectomy, whereas with myomectomy, the fibroids are removed while the blood supply to the uterus is flowing normally. Other complications (eg. infection, bruising) are also less likely with hysterectomy than myomectomy. Click on the links below for further information:

History Removal of the uterus (womb) was mentioned as long ago as 5th century BC by Hippocrates, the father of medicine. However, apart from sporadic reports, hysterectomy was not practised until the 19th century. Even then, the mortality of the procedure was extremely high. It was only after improvements in antisepsis, anaesthesia and surgical technique to control haemorrhage in the mid-19th century that hysterectomy became an accepted procedure. The early hysterectomies were usually done vaginally, but the introduction of subtotal hysterectomy late in the 19th century meant that abdominal hysterectomy became dominant; vaginal hysterectomy tended to be restricted for the management of

uterine prolapse. In 1988, the first laparoscopic hysterectomy was done by Harry Reich (USA). Although the procedure has failed to become popular, one result of this development was the wider appreciation of the role of vaginal hysterectomy. Studies showed that compared with the other routes, vaginal hysterectomy has the shortest operating time, fastest recovery and lowest cost. Most gynaecologists now agree that vaginal hysterectomy is the optimal route and should be practised whenever possible.

Abdominal hysterectomy

Laparoscopic hysterectomy

Vaginal hysterectomy

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Vaginal hysterectomy

Laparoscopy Laparoscopy is direct visual examination of the inside of the abdomen, using a viewing device that can be passed through a small cut in the abdominal wall. The device, called a laparoscope, usually has fibreoptic illumination and viewing channels. A miniature camera is usually attached to allow the procedure to be monitored on a colour screen.

Vaginal hysterectomy, as the name suggests, is done through the vagina and leaves no external scars. It is a common misconception that this type of hysterectomy is done using "suction"! It is not. Vaginal hysterectomy is carried out using the same surgical principles as abdominal hysterectomy, the difference being that the surgery starts around the cervix in the vagina rather than the abdomen. Surgery takes about the same time as abdominal hysterectomy, and the ovaries can be removed if indicated. In contrast, recovery as judged by hospital stay and return to normal activities is generally much faster. In the USA, some gynaecologists are even doing vaginal hysterectomy as a day

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case procedure!

No external scars Less chance of complications than laparoscopic hysterectomy Relatively quick recovery

Not suitable if fibroids are very large Usually contra-indicated if there is an ovarian cysts, adhesions (scar tissue) or co-existing endometriosis Subtotal hysterectomy may not be possible

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Laparoscopy can be used by any specialist concerned with disease of the abdominal organs. It is used for diagnosis by general surgeons, and by gynaecologists for the investigation of disorders of the female reproductive organs in the pelvis. It can help to diagnose conditions that are difficult to identify with certainty in any other way short of an exploratory abdominal operation, such as endometriosis and adhesions. With the use of small instruments, laparoscopy can also be used to

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Laparoscopic hysterectomy
Laparoscopic hysterectomy is a recent operation which was first described in 1989. It is the equivalent of laparoscopic myomectomy in terms of approach and the instruments used; typically, surgery starts using the laparoscope and miniature instruments inserted through the abdomen, and the hysterectomy is completed through the vagina. If appropriate, ovaries are easily

Operative laparoscopy With the aid of small instruments, laparoscopy can also be used to perform surgery formally done by laparotomy (large incision). Laparoscopic procedures are usually associated with shorter hospital, less discomfort and faster recovery. Indications for laparoscopic surgery include conditions such as endometriosis,

Laparoscopic hysterectomy is a slow procedure, just like laparoscopic myomectomy. Recovery, however, is relatively fast, and comparable to vaginal hysterectomy. The complication rate is also generally considered to be similar.

Small abdominal incisions only Suitable if there are pelvic adhesions or ovarian problems (e. g. ovarian cyst) Subtotal hysterectomy possible Relatively fast recovery (similar to vaginal hysterectomy)

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Not suitable if fibroids are very large Longest operating time of all hysterectomies Ureteric injury more common than with other types of hysterectomy

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adhesions, ovarian cysts, tubal disease. Laparoscopy can also be used to excise fibroids; as with hysteroscopic myomectomy, this route of surgery is only indicated providing the fibroids are not over large or too numerous, and situated mainly on the outside of the uterus.

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Abdominal hysterectomy
Abdominal hysterectomy is the most commonly performed type of hysterectomy in most countries. Certainly, if the fibroids are very large or if you are thought to have a lot of adhesions in your pelvis, then abdominal hysterectomy is generally the only option. Just as with myomectomy, however, there is a good chance that surgery can be done through a "bikini" type incision even in difficult cases. Hospital stay averages 5 to 7 days and normal activities are generally deferred for 4-6 weeks. This does not mean that you are bed bound, only that you are advised to avoid heavy physical work for that time. Size of fibroids does not matter Easiest route of surgery to deal with adhesiona and ovarian problems Subtotal hysterectomy an option Operating time not too long (compared with laparoscopic hysterectomy)

Diagnostic laparoscopy A laparoscope is a narrow telescope which is introduced into the abdomin through a small incision. It provides the surgeon with an excellent view of the peritoneal cavity, and can be used both for diagnosis and treatment. Laparoscopy is usually done under general anaesthesia, but hospital stay is usually short.

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Major abdominal incision Complications relatively more frequent Longer hospital stay Recovery takes several weeks

In gynaecology, indications for diagnostic laparoscopy include the investigation of pelvic pain and subfertility.

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Uterine artery embolisation


Uterine artery embolisation was first performed approximately 20 years ago to stop uncontrollable bleeding from the womb due to cancer or complications of child birth or surgery. More than 10 years ago, uterine embolisation started to be used in France prior to myomectomy to reduce bleeding during surgery. Somewhat unexpectedly, it was found that some women no longer required surgery as their symptoms had subsided and their fibroids begun to shrink. The procedure began to be used as the primary treatment for fibroids. Fibroid embolisation is performed by an interventional radiologist (cf. gynaecologist) under local anaesthesia and, if necessary, light sedation. The procedure involves occluding blood vessels supplying the fibroids. This is done by injecting small plastic particles through a narrow catheter which is inserted into an artery in the groin, and guided to the uterus. The plastic particles block the blood supply feeding the fibroids and this results in embolisation. Without a blood supply the fibroids degenerate (waste away) and become smaller in size, thus reducing the uncomfortable symptoms associated with them. World experience indicates a success rate for fibroid embolisation of over

MRI scan Magnetic Resonance Imaging (MRI) is a non-invasive procedure that uses powerful magnets and radio waves to construct pictures of the body. Unlike conventional radiography and Computed Tomographic (CT) imaging, which make use of potentially harmful radiation (Xrays), MRI imaging is based on the magnetic

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85%, with an average decrease in fibroid volume of between 40 - 60%. Up to 90% of women presenting with abnormal uterine bleeding and size related symptoms (eg. pressure) have demonstrated significant improvement. You can expect improvement almost immediately with respect to heavy bleeding and pelvic pain; shrinkage of the fibroids usually starts within a few weeks. The main complication of the procedure is infection, leading to hysterectomy. The incidence of this complication is approximately 1-2%. In addition, patients can become menopausal following the procedure, the incidence rising with the patient's age. Other serious complications are rare. Lesser complications include pain, which can sometimes be severe, and nausea in the first few hours following the procedure. Symptoms can be controlled with appropriate medication, and most symptoms are substantially improved within days although there may be pain and cramping for several days. A "Post-Embolisation Syndrome", consisting of pain, nausea, vomiting and fever affects some women in the week following the procedure. Others experience a watery, non-offensive vaginal discharge in the weeks following the embolisation. Approximately 7% of patients may pass a degenerating fibroid in the weeks or months following the procedure. Many women report returning to work within a week or two of having the procedure. Suitable for large fibroids Avoids general anaesthesia, surgery and abdominal incisions Short hospital stay (1-2 days usually) Quick return to normal activities and work Good symptom relief (e.g. pressure symptoms, heavy periods)

properties of atoms. A powerful magnet generates a magnetic field roughly 10,000 times stronger than the natural background magnetism from the earth. A very small percentage of hydrogen atoms within a human body will align with this field. When focused radio wave pulses are broadcast towards the aligned hydrogen atoms in tissues of interest, they will return a signal. The subtle differences in that signal from various body tissues enables MRI to differentiate organs, and

Considerable post-procedure pain Small risk of hysterectomy (because of infection) Chance of early menopause not inconsiderable in women over the age of 40 years No specimen to check fibroids are benign Fibroids shrink but do not disappear Currently not recommended in the UK for women who wish to conceive

potentially contrast benign and malignant tissue. Any imaging plane (or "slice") can be projected, stored in a computer, or printed on film. MRI can easily be performed through clothing and bones. However, certain types of metal in the area of interest can cause significant errors in the reconstructed images. Since MRI makes use of radio waves very close in frequency to those of ordinary FM radio stations, the scanner must be located within a specially

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shielded room to avoid outside interference. The patient will be asked to lie on a narrow table which slides into a large tunnel-like tube within the scanner. In addition, small devices may be placed around the head, arm, or leg, or adjacent to other areas to be studied. These are special body coils which send and receive the radio wave pulses, and are designed to improve the quality of the images. If contrast is to be administered, an IV will be placed, usually in a small vein of the hand or forearm. A

technologist will operate the machine and observe you during the entire study from an adjacent room. Several sets of images are usually required, each taking from 2 to 15 minutes. A complete scan, depending on the organs studied, sequences performed, and need for contrast enhancement may take up to one hour or more. Newer scanners with more powerful magnets utilizing updated software and advanced sequences may complete the process in less time.

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Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street

What are fibroids

Uterine size

When describing an Uterine enlarged uterus, doctors often equate the size of the uterus to the gestation (age in weeks) of a normal pregnancy.When the uterus is relatively small, and cannot be leiomyomata, often referred felt in the abdomen, to as fibroids, are tumours of uterine size can be the uterus (womb). They are compared to very common and can be common fruits: asymptomatic. Fibroids tend to be multiple and can be situated inside the cavity of the uterus, in the wall or outside (see diagram). In some cases, they can grow to a very large size.
Gestation 4 weeks 6 weeks 8 weeks 10 weeks 12 weeks Uterus Plum Mandarin Apple Orange Grapefruit

No one knows why they develop, but it is well established that the female hormone oestrogen makes them enlarge; this is why fibroids are usually diagnosed when women are in their 30's and 40's, and why they shrink after the menopause. Go Back

When the uterus can be felt in the abdomen, the following rules are often applied, the reference point being the top of the womb:
Gestation Uterus

gynaecologists interested in the surgical management of fibroids is now on line. www. fibroidsurgery. org

12 weeks 16 weeks

Pubic hair Half way to umbilicus At level of umbilicus Half way between umbilicus and chest At level of chest

20 weeks

24 weeks

28 weeks

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Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for

Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street

Symptoms
While not all women have symptoms, typical complaints associated with fibroids include:
Heavy periods Irregular vaginal bleeding Pelvic pain Pelvic mass Pressure symptoms Subfertility

Fibroid degeneration Fibroids can undergo various types of degeneration (e.g. calcification, cystic degeneration, mucinous change, red degeneration). Such degeneration is often asymptomatic, but can be associated with pain. The vast majority of fibroids are benign. In rare cases, fibroids can become malignant (leiomyosarcoma).

Briefly, treatment is indicated if the fibroids are thought to be responsible for troublesome symptoms, or if they become large. If there are no symptoms or if the fibroids are small, there is no need for treatment. Although fibroids can become cancerous, the chance is so small that they are not routinely removed just because they are there. Go Back

gynaecologists interested in the surgical management of fibroids is now on line. www. fibroidsurgery. org

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Home Background information Treatment options Treatment summary Movies Fibroid Clinic Knowledge base Other useful links Publications How to find us Contact us LATEST NEWS New "Easy Load" Universal Knot Pusher developed at the Royal Free - click here. A new website for

Information about uterine fibroids Minimally Invasive Therapy Unit & Endoscopy Training Centre University Department of Obstetrics and Gynaecology Royal Free Hospital Pond Street

Diagnosis
There are a

Classification of uterine fibroids Most fibroids arise from either the outside of the uterus (subserosal), in the wall (intramural) or under the womb lining (submucous). Much less often, they are situated in the cervix. Very rarely, fibroids can be found in the abdominal cavity separate from the uterus (parasitic fibroid).

number of ways that fibroids are diagnosed. First of all, you may have some of the typical symptoms we associate with fibroids. If they are large, it may be obvious when your are examined, and a "lump" is found in the lower abdomen. Smaller fibroids may be detected when you are having an internal examination, for instance at the time of a cervical smear. When fibroids are suspected, one or more special investigations can be done to confirm the diagnosis. These include:

gynaecologists interested in the surgical management of fibroids is now on line. www. fibroidsurgery. org

Pelvic ultrasound Hysteroscopy MRI scan CT scan Laparoscopy

Of these, ultrasound and hysteroscopy are the most common investigations, and the others are only done in special circumstances. Which ever test is organised for you, the diagnosis should be obvious. The tests will give your doctor an idea of how many fibroids there are, how large they are, and where they are situated. Go Back Home - Background information - Treatment options - Treatment summary - Movies - Fibroid Clinic - Knowledge base - Useful links - How to find us - Contact us 2010 webmeddesign.com Dreamweaver Web Templates

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