A Simple Guide to Uterine Fibroids

A Simple Guide to Uterine Fibroids
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What are Uterine Fibroids ?
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Uterine Fibroids are solid benign tumours(non-cancerous) of the smooth muscles and fibrous tissues of the uterine cavity.

The name fibroid is derived by the fibrous tissue present in the tumour.

They are the commonest tumours (25%)found in women especially after the age of 35.

What are the different types of Uterine Fibroids?
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They are classified according to their location.

1.intramurally(inside the cavity of the uterus(70%)

2.subserous(on the outer wall of the uterus) on the external wall(20%)

3.Submucous (in the lining of the uterus) 10%

4.pendunculated subserous(like a polyp outside the uterus)

5.cervical(at the cervix or beginning of the uterus)

What are the Causes of Uterine Fibroids?
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The cause of Uterine Fibroids is still not known.

It is believed that oestrogen has a part to play in the formation since fibroids are not present before puberty and sometimes shrinks after menopause.

Generally it is believed that during the thickening and shedding of the endometrium of the menstrual cycle, some uterine muscles and connective tive tissues overgrow and form a swelling in the wall of the uterus.

Fibroids are generally relatively avascular and may degenerate forming cysts and becoming calcified.

What are the Symptoms of Uterine Fibroids?
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Most women with fibroids are asysptomatic.

Symptoms and signs varies with the size and location of the fibroid.

Common symptoms include:

1.Heavy menstrual flow sometimes with blood clots

2.Irregular menstrual periods

3.Painful menses

4.Backache

5.Painful and frequent urination

6.Bloating

7.Constipation

8.Fatigue

Signs:
1.Enlarged uterine mass on abdominal palpation

2.Anaemia and pallour due to blood loss

How do you made the Diagnosis of Uterine Fibroids?
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Pelvic examination may show enlarged uterine swellings

Ultrasound scan showed presence of fibroids

Colposcopy may show the location of the fibroid.

What are the complications of Uterine Fibroids?
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1.sarcoma

2.degeneration

3.necrobiosis

4.cystic degeneration

5.torsion of pendunculated fibroid

What is the Treatment for Uterine Fibroids?
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If small no treatment is required.

If larger,then treatment depends on the
1.size,
2.extent of the lesions,
3.age of the patient and
4.the desire for pregnancy.

Surgery
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is required if
1.extremely heavy bleeding occurs during the menstrual cycle

2.anemia follows heavy menses

3.pain has become intolerable

4.discomfort due to the pressure of the fibroids on another organ

a.Myomectomy is the surgical removal of the fibroid without damage to the uterus thus allowing a woman to be pregnant.
However recurrence of fibroids is quite common after myomectomy

b.Hysterectomy is preferred for fibroid tumors

1.when a women has severe symptoms,

2.has completed her family

3.excessively large fibroid tumors;

4.severe abnormal bleeding is present

5.fibroids are causing problems with the bladder and bowels.

Non surgical treatment:
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a.uterine artery embalization is a non-surgical procedure.
Polyvinyl particles are allowed to flow into the uterine artery and clog the nexis of vessels spread out into the uterine tissue.
The fibroids are unable to receive the constant blood supply and thus shrink over time.

b.Lupron is a drug which shrinks fibroids in most women.
Unfortunately the fibroids will grow back when Lupron treatment is stopped.

A Simple Guide to Menorrhagia2(Excessive Menstrual Bleeding)

A Simple Guide to Menorrhagia2(Excessive Menstrual Bleeding)
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What is a Menorrhagia?
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Menorrhagia is a symptom defined as heavy, prolonged and/or irregular menstruation .

What are the causes of Menorrhagia?
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1.Physiological(hormonal): most common
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Excessive menstrual bleeding occurs when no ovulation takes place in a menstrual cycle with resultant excess oestrogen stimulation of the endometrium that results in the shedding of the thickened uterine lining and heavy bleeding when the oestrogen drops.

A defective persistent corpus luteum which results from an abnormal ovulation can also cause the shedding of the nedometrium for a longer period resulting in prolonged bleeding.

Other factors that may make heavy menstrual bleeding are:
2.Uterine Pathology:
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polyps,
fibroids
endometriosis
infection
carcinoma

3.Systemic Diseases:
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Bleeding diseases
Hypothyoidism
liver disease
Pelvic inflammatory Disease(PID)
Polycystic Ovarian syndrome(PCOS)

4.Medical causes:
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anticoagulants which are preventing clotting of blood
intrauterine device for contraception

How to establish a diagnosis of Menorrhagia?
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History:
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Menstrual history:
cycle length, number of bleeding days, degree of blood loss(number of pads used per day), presence of blood clots, dysmenorrhea

Contraception:
use of IUD
contraceptive pills

Symptoms suggesting underlying pathology:
Metabolic disorders:
symptoms of hypothyroidism
symptoms of polycystic ovarian syndrome

Bleeding disorders:
easy bruising
anticoagulants

Pelvic inflammatory Disease:
pelvic pain especially during intercourse
vaginal discharge
dysmenorrhea

Endometriosis:
pelvic pain
dysmenorrhea

Physical Examination:
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Signs of underlying diseases:
bruising
hypothyroid features
pallour(anaemia)
PCOS features(hirsutism,acne,overweight)

Abdominal examination:
tenderness,
palpable uterine or ovarian masses

Pelvic examination:
vulval and vaginal examination
bimanual palpation for masses
cervical smear

Investigation:
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Full blood count including hemoglobin(to exclude anemia from loss of blood) and platelets(low platelets can cause bleeding)

Transvaginal ultrasound to exclude uterine fibroids and polyps -postmenstrual scans is best when the endometrium is at its thinest.

Endometrial hysteroscopy and biopsy in women over 40 to exclude uterine cancer

What is the Treatment of Menorrhagia?
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Medications:
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1.Tranexamic acid- oral antifibrinolytic, given only when there is heavy bleeding

2.Combined oral contraceptives - prevent proliferation of the endometrium, reduces blood flow. Side effects are fluid retention, nausea, headache,deep vein thrombosis, mood changes, breast tenderness

3.oral progesterone - also prevent proliferation of the endometrium-usually less side effects bloating, headache, mood changes, breast tenderness

4. Injected progesterone -also prevent proliferation of the endometrium -similar side effects as oral progesterone. One additional side effect is the possibility of bone density loss. Evaluation of bone density should be done.

5. Levonorgestrel-releasing intrauterine system(LNG-IUS)
-also prevent proliferation of the endometrium
-side effects includes irregular bleeding up to 6 month, amenorrhea(no menses),
breast tenderness, and headache.

Surgery
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1.Endometrial ablation
may be done only
a.if medications has failed
b.if no desire to coceive
c.if the uterus is normal

Usually involve the removal of the endometrium through the cervical opening.
There are forms of endometrial ablation:
a.First generation:
hysteroscopy with general anaesthesia
-Rollerball ablation
-Transcervical resection of the endometrium

b.Second Generation:
non-hysteroscopy, no general anaethesia, day surgery,fast recovery
-Impedance-controlled bipolar radiofrequency ablation
-balloon thermal ablation
-microwave ablation
-free fluid thermal ablation

2. Hysterectomy
used only as a last resort in treatment of menorrhagia
if other treatment are contraindicated
there is a desire for amenorrhea
there is no desire to retain uterus and fertility

Treatment of Underlying causes:
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hypothyroidism with thyroxine tablets

intrauterine device removal

reduce anticoagulant treatment if possible

treat any bleeding disease with platelets or blood factor deficient infusion

treatment of endometriosis,

antibiotic treatment of pelvic inflammatory idsease

treatment of uterine carcinoma

surgical removal of fibroids and polyps

A Simple Guide to Menorrhagia

A Simple Guide to Menorrhagia
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What is Menorrhagia?
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Menorrhagia is defined as excessively heavy or prolonged bleeding through the vagina either during menstrual period or any time between menses or after menopause in women.
It is a symptom not an illness.

What is the cause of Menorrhagia?
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The cause of Menorrhagia is abnormal uterine bleeding.
The most common causes are

1.hormonal imbalances.
During a normal menstrual cycle, there is a balance between estrogen and progesterone, two female hormones in the body. These regulate the buildup of the endometrium which is the lining of blood and tissuein the wall of the uterus and which is shed each month during menstruation.
Menorrhagia can occur because of an imbalance between estrogen and progesterone.
As a result of this imbalance, the endometrium keeps building up. When it is eventually shed, there is heavy bleeding.
Hormone imbalances are often present in adolescents and in women approaching menopause. This type of menorrhagia also known as Dysfunctional Uterine Bleeding is fairly common in these groups.

2.fibroids and benign tumour of the uterus
Another frequent cause of menorrhagia is uterine fibroids (benign tumours of the lining of the womb).
Together, hormone imbalances and fibroids account for about 80% of menorrhagia cases.

Other causes include

3.cancer of the uterus(endometrial cancer) or cervix

4.inflammation or infection of the vagina, cervix, or pelvic organs

5.polyps which are small growths on the cervical or uterine wall

6.thyroid diseases

7.liver, kidney diseases

8.blood bleeding diseases,

9.the use of blood-thinning drugs

10.stress affects the hormonal imbalance

11.injury or disease of the vaginal opening as a result of intercourse, infection, polyp, genital warts, ulcer, or varicose veins.

12.vaginal injury from insertion of foreign objects, from malignancy, or from infection

13.dry vaginal walls from lack of estrogen after menopause

14.abortion spontaneous or induced

15.stopping and starting birth control pills or estrogens

16.low thyroid function

17.IUD or intrauterine device use for contraception can cause occasional spotting

18.abnormal pregnancy eg.ectopic pregnancy

19.drugs such as oral contraceptives and anticoagulants

20.cervical conization or cauterization procedures

Bleeding may be more serious in women over 50 (post-menopausal) or younger than 12 (prepubertal).

The risk of cancer increases with
1.age.

2.obesity,

3.taking estrogen (without progestin),

4.young women who have not established a regular ovulation cycle,

5.approaching menopause.

What are the Signs of Menorrhagia?
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The most common sign is excessive bleeding per vagina.
Make sure that bleeding is coming from the vagina and not from the rectum or in the urine.

Some women may experience paleness and fatigue (anaemia)due to loss of blood.

Women with menses which consistently last more than seven days or whose periods are less than 21 days apart (unless that's normal for the woman) may be required to have a medical examination.

For a married woman or non-virgins,
1.a pelvic exam (examination of the internal reproductive organs),

2.a Pap smear test.

3.blood tests for hormonal changes and bleeding tendencies

4. urine and stool tests for conditions of the gastrointestinal and urinary systems.

5.investigations to determine ovulation

6.pregnancy test may be done if you are sexually active.

7.tests for any sexually transmitted diseases.

8.colposcopy- examination of the inside ot the uterus with a small amount of tissue taken from the endometrium may be taken for testing for canceror hormonal disorders.

Cancer should be ruled out in older women (aged 35-40) or in younger women with longer duration of exposure to unopposed estrogen.

For a non-married woman or virgin, the same examination may be done except care is taken to avoid damaging the hymen.

What is the Treatment of Menorrhagia?
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Any underlying medical condition (eg infection,bleeding disease)causing menorrhagia should be treated first.

If a hormone imbalance is responsible for Menorrhagia, hormonal treatment or replacement may be started.

Polyps are generally removed.

Anti-bleeding drugs such as daflon, dicyclone, etc can be given but may not necessarily work.

If the bleeding do not stop in spite all these measures, hysterectomy sometimes may be your only option.
Recently there is a procedure makes use of lasers or microwave technology to remove the lining of the womb (which is the part that bleeds) while leaving the rest of the womb intact.

Fibroids may require myomectomy or hysterectomy.

Hysterectomy and radiation are the usual treatment for endometrial cancer.

Bed rest may be recommended if bleeding is heavy.
The number of pads or tampons used should be recorded (so that the doctor can determine the amount of bleeding). Change tampons regularly, at least twice a day.

To help in relieving menstrual cramps, nonsteroidal anti-inflammatory drugs e.g. mefenemic acid and ibuprofen are prescribed.

The menstrual cycle is not the same for every woman. Menstrual flow occurs about every 28 days, lasts about 5 days, and produces an average of 30 - 40 mls (six to eight teaspoons) total blood loss. The menses may be regular, irregular, light, heavy, painful, pain-free, long, or short, and still be normal. Any variation in the menstrual cycle is medically less important than bleeding, pain, or discharge between menses.

The best prevention of Menorrhagia is having annual pelvic examinations with a cervical smear test (Pap smear).