Fibroid Uterus in Rural Areas

5/7/2016

Courses: Management of Infertility in Rural Areas Lesson 6 | mdCurrent India

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Management of Infertility in Rural Areas - Lesson 6 - Fibroid Uterus in Rural Areas What are Uterine Fibroids? The Uterine Fibroids are swellings in the Uterus. They are excess presence of normal uterine muscle tissue and hence are not malignant. They are also called Leiomyoma Uterus. Although they are not cancers they can be symptomatic depending on the location of the fibroid. They are classified according to their location. The symptoms and treatment again depend on the location of the fibroid. The following diagram describes its location and name [1]

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Schematic drawing of various types of uterine fibroids: a=subserosal fibroids, b=intramural fibroids, c=submucosal fibroid, d=pedunculated submucosal fibroid, e=fibroid in statu nascendi, f=intraligamental fibroid

What causes uterine fibroids and how common are they? http://mdcurrent.in/courses/managementinfertilitylesson6/

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No one definitely knows the cause of the fibroid formation. However people have observed the following [2,3] 1. It occurs in families. If mother or sister has fibroids the chances of having it are high 2. It is more common in some races especially those who start having the periods before the age of ten 3. High alcohol intake, high blood pressure and pelvic infections increase the incidence 4. On the other hand pregnancy and taking oral contraceptive pills decrease the incidence 5. Obesity and eating red meat are sometimes associated with fibroids 6. Use of gonadotropins releasing hormone agonists like Gosereline, Leuprorelin, have known to increase the incidence of leiomyomas in the uterus 7. There is an autosomal dominant disorder called Reed’s syndrome that is associated with uterine and subcutaneous leiomyomas and renal cell cancer. It is due to mutation of the enzyme called fumatrate hydratase. 8. Diseases like PCOD, diabetes, hypertension and those of African descent and those who have never given birth also have a higher incidence Female hormones tend to make the fibroids grow in size especially during the first trimester while they decrease in size after menopause. Although half the women have fibroids if ultrasound examination is done most of them do not cause symptoms.

What are the symptoms of uterine fibroids? Most women with uterine fibroids have no symptoms. However, abnormal uterine bleeding is the most common symptom of a fibroid. When they are present near the uterine lining, or when they interfere with the blood flow to the lining, they can cause heavy periods, painful periods, prolonged periods or spotting between menses. Women with excessive bleeding due to fibroids may develop iron deficiency anemia. Uterine fibroids that are deteriorating or degenerating can sometimes cause severe, localized pain. Fibroids can also cause a variety of symptoms depending on their size, location within the uterus, and how close they are to the other pelvic organs. Large fibroids can cause: Pressure Pelvic pain Pressure on the bladder with frequent or even obstructed urination Pressure on the rectum with pain during defecation and constipation Pain during intercourse Feeling of fullness of the lower abdomen Although fibroids do not interfere with ovulation they may impair fertility and lead to poorer pregnancy outcomes. This is true especially of, submucosal fibroids that deform the inner uterine cavity. They often cause miscarriage too.

What are the usual ways of diagnosing uterine fibroids? Uterine fibroids could be diagnosed by pelvic examination. However they are commonly diagnosed by ultrasound. Often the ultrasound is very helpful in differentiating the fibroid from other conditions such as ovarian tumors. MRI and CT scans can also play a role in diagnosing fibroids, but ultrasound is the simplest, cheapest, and almost without question the best technique for imaging the pelvis for fibroids. Hysterosalpingography, sonohysteroscopy, etc. have been described too.

Do untreated uterine fibroids pose a risk? Most of the uterine fibroids that do not cause a problem and the woman can be left untreated. However, in some cases, even fibroids that are not causing symptoms require removal or at least close observation. Rapid growth is a reason to watch more carefully, since a rare cancerous form of fibroid can occur. http://mdcurrent.in/courses/managementinfertilitylesson6/

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What is the treatment for uterine fibroids? Medical treatment Nonsurgical techniques are usually hormonal in nature and include medicines that decrease the production of estrogen from the ovaries. These medications are given for three to six months to induce a low estrogen state. When successful, they can shrink the fibroids by as much as 50%. Side effects of these drugs are similar to the symptoms of menopause and include hot flashes, sleep disturbance, vaginal dryness, and mood changes. Bone loss leading to osteoporosis after longterm ( >12 months) use is the most serious complication. These drugs may also be used as preoperative treatment prior to undergoing surgical treatment of Fibroid [4]. Mifepristone sometimes known as the "morningafter pill" can shrink the fibroid and reduce the bleeding [4]. Danazole is another medicine that could be used. However it has many side effects , including weight gain, muscle cramps, decreased breast size, acne, hirsutism (inappropriate hair growth), oily skin, mood changes, depression, decreased high density lipoprotein (HDL or 'good cholesterol') levels, and increased liver enzyme levels [4]. Low dose formulations of oral contraceptives are sometimes given to treat the abnormal bleeding associated with fibroids. However, they do not shrink the fibroids themselves. Use of oral contraceptive pills has been associated with a decreased risk of developing fibroids, so some women may benefit from their use for this purpose. Cabergoline has been shown to shrink the fibroids but the mechanism of action is not known. Aromatase inhibitors like anastrazole and Letrozole have been used in experimental studies. However they recur when medicines are stopped. Surgical treatments Tackling the uterine artery by either by embolism, laparoscopic or open / transvaginal ligation of the artery have been used to decrease the size of the fibroids. There are many ways of managing uterine fibroids. Surgical methods are preferred when treatment is necessary. Possible surgical interventions include hysterectomy, or removal of the uterus (and the fibroids with it). Myomectomy is the selective removal of just the fibroids within the uterus. Myomectomy can be done through a laparoscope or with the standard open incision on the abdominal wall. The recent development is the use of single incision surgeries with gasless lift laparoscope [5]. Surgery is necessary if there is suspicion of malignancy or cancer in any case of uterine mass. Some of the fibroids could be removed endoscopically or though the uterine opening by either cutting them into small pieces and removing them [resection] or vaporizing them. Other minimally invasive procedures tried include radiofrequency ablation, magnetic resonance guided focused ultrasound, and etc. has been tried at some specialized centers. AT SEESHA MEDICAL SERVICES A variety of treatment options are available at the SEESHA Karunya community hospital at karunyanaar Coimbatore and at the SEESHA surgical camps at Bethesda Hospital Aizawl, Sielmat Christian Hospital at Churachandpur at Manipur, Family Health Hospital at Dimapur and the other places. Endoscopic resection or vaporization of sub mucosal fibroids has been carried out and several women have conceived after this procedure which is carried out through the vagina and cervix [5, 9]. Large fibroids have been removed both laparoscopically and by open surgeries. The new procedure that is available now is the use of gasless laparoscopic surgery or lift laparoscopic surgery which was started after training at EndyGyn in Germany. More details could be seen at the following sites: http://www.youtube.com/watch?v=3n2XX1zlxKQ http://endogyn.com/ http://www.youtube.com/watch?v=xOOcYk_iv0

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Uterus with Multiple Fibroids

Fibroid during surgery


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Courses: Management of Infertility in Rural Areas Lesson 6 | mdCurrent India During endoscopic treatment of fibroids

Image:Schematic drawing of various types of uterine fibroids: a=subserosal fibroids, b=intramural fibroids, c=submucosal fibroid, d=pedunculated submucosal fibroid, e=fibroid in statu nascendi, f=intraligamental fibroid. Source/Author: Hic et nunc. Date: 2012. Access the original Image information here: https://commons.wikimedia.org/wiki/File:Uterine_fibroids.png

REFERENCES 1. MedicineNet, Inc 2010 2. Marshall LM, Spiegelman D, Goldman MB, Manson JE, Colditz GA, Barbieri RL, Stampfer MJ, Hunter DJ: A prospective study of reproductive factors and oral contraceptive use in relation to the risk of uterine leiomyomata. Fertil Steril 1998, 70(3):432439. 3. Parazzini F, Negri E, La Vecchia C, Chatenoud L, Ricci E, Guarnerio P: Reproductive factors and risk of uterine fibroids. Epidemiology 1996, 7(4):440442 4. Patricia Evans, Susan Brunsell. Uterine Fibroid tumours: Diagnosis and Treatment. Am Fam Physician. 2007 May 15;75(10):15031508 5. Gnanaraj J. Low cost and minimally invasive treatment for infertility in rural areas. MD CurrentIndia . January 2014. « Back to course page

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