Gynaecology Thrissur

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O varian cysts 

 Normal pregnancy Abnormal uterine bleeding


What are fibroids? Fibroids are tumours found in the uterus.  They are NOT cancerous by nature.  Routine ultrasonography done for various symptoms show that fibroids are commonly seen in almost 40% of all women.  These tumours are made of fibrous and muscle tissue and are usually seen in women who have excess of the hormone called “Estrogen” in circulation. They are usually found in the reproductive age group and may regress after the woman attains menopause.  However, in the odd woman, symptomatic fibroids may be found even after menopause. There is one variety called fibrosarcoma which is cancerous by nature.  But it is usually symptomatic and grows very fast.  It is very, very rare and by nature cannot remain asymptomatic for long.

 What are the symptoms caused by fibroids? In many women, fibroids may remain symptom free.  However, in some women, it may cause symptoms like excessive bleeding during periods, excessive pain during periods, etc. Some patients get symptoms like increased urinary frequency, or excessive backache or pressure sensation in the pelvis.

Which are the fibroids which need medical attention? Today, ultrasonography is being done routinely for many indications like indigestion, mild abdominal discomfort, etc.  If fibroids are seen on ultrasonography incidentally at such times, they could be ignored.  On the other hand, a  woman may go to a doctor with specific gynaecological complaints like excessive periods, excessive pain during periods,or severe pressure sensation in the back or pelvis. If fibroids are found, either on ultrasonography or even on clinical examination, in such a situation, the symptoms are likely to have been caused by the fibroids.  They require treatment.  Is it possible to cure fibroids with medicines? No, there are as of now, no medicines which could permanently cure fibroids.  There are certain injections (GnRh analogues) which can reduce the size of the fibroids,temporairily for a period of a few months.  But these injections are costly . Each injection costs around Rs.5000/-  They are to be administered every 28 days for a minimum of 3 injections.  The tumour regresses temporarily and recurs after about 6 months.  This sort of treatment is useful when one wants to postpone surgery for some reason or other. It cannot be construed as a permanent treatment.   What is the treatment for fibroids? The 3 modalities of treatment for fibroids are: 1.Surgery to remove the fibroids only (Myomectomy) 2.Surgery to remove the uterus along with the fibroids 3.Nonsurgical embolization therapy which will necrotize the fibroids.   
What are the indications for active intervention in a case of fibroids? Active intervention in case of fibroids is necessary only in severely symptomatic patients.  In infertile patients, surgery for fibroids need be done only if fibroids are thought to be the cause of infertility.   

What are the indications for hysterectomy (removal of uterus) in a case of fibroids? Hysterectomy as a treatment for fibroids is usually done only in patients who have completed their family.  However, hysterectomy being a major surgery, it should be performed on a patient only if she is severely symptomatic. Certain guidelines for the performance of hysterectomy are: A.Documented growth is > 6 cm per year (any age patient) B.Postmenopausal patient with uterus > 12 week size or fibroid with documented growth      rate > 2 cm/year C.Patients age 30 years to menopause who do not wish further children    1.Documented fibroid > 20 week size with or without symptoms   2.Documented fibroid 12-20 week size and one of the following:         a.Documented submucous fibroid with persistent bleeding, unresponsive to medical therapy, or         b.Urinary retention, frequency or incontinence or difficulty evacuating stool       c.Uterine bleeding for more than 8-10 days in the last 2 cycles or last 40 days, and Hgb < 10 (or transfusion within the          last 6 months), or        d.At least 6 months of moderate to severe pelvic pain, interfering with daily activity . 3.Fibroid < 12 week size and one of the following:        a.Documented submucous fibroid  with persistent bleeding, unresponsive to medical therapy, or      b.Uterine bleeding for more than 8-10 days in the last 2 cycles or last 40  days, and Hgb < 10 (or transfusion within the         last 6 months). In patients in the reproductive age group, who have completed their family, there may be a debate on the wisdom of removing the uterus. It is generally felt that removal of the uterus may jeopardize the blood supply to the ovaries and stop its function prematurely. This may lead to the patient getting perimenopausal symptoms like hot flashes, sweating, etc much before the actual time of biological menopause.  Hysterectomy is also known to predispose to urinary symptoms later on.  In view of all these factors, some doctors prefer not to remove the uterus even if the patient has completed child bearing.Instead of removing the uterus, myomectomy, a surgery which removes only the fibroids is done.  Surgery for removing only the fibroids is technically associated with more blood loss. Besides that, the tendency for formation of fibroids being inherent, the patient is also liable to have a recurrence of symptoms.  Thus, weighing the pros and cons of hysterectomy vs myomectomy, a mature decision has to be taken.  In my practice, in the very young patient, I would prefer not to remove only the fibroid, and uterus is not removed..  In the older patient, above 35 years of age, I would prefer to do a hysterectomy.

Are there different ways of doing a hysterectomy in a patient with fibroids?  What are they? Hysterectomy can be performed by various methods, viz,abdominal, vaginal,Laparoscopic,&Laparoscopically Assisted vaginal hysterectomy. Abdominal hysterectomy: Hysterectomy in the traditional way was performed by making an incision in the abdomen. This is called abdominal hysterectomy.  The patient is kept in the hospital for 5-7 days depending on the time taken for removing the stitches and wound healing. The patient has to convalesce at home for a month and she has to avoid lifting heavy objects for 6 months, the time taken for internal defects to heal.  In the first few days after surgery, generally there is some amount of pain and assistance may be needed for getting up from bed, moving towards the toilet, etc, as abdominal incisions tend to be painful.  The degree of mobility achieved by a patient after surgery varies from patient to patient depending on each patient’s pain threshold ,length of incision, etc.  

Vaginal hysterectomy: In vaginal hysterectomy, the uterus and fibroids are removed by making an incision in the vagina.  The uterus being very large in the presence of fibroids, it is usually removed after morcellation and is taken out piecemeal. The patient is kept in the hospital for 2-3 days.  She can join her duties after a week or so and it is not mandatory to avoid heavy labour for a long period. Advantages: There being no wound on the abdomen, the patient has very minimal pain post-operatively. The patient does not need assistance for doing routine chores like walking, going to the toilet,etc from the very next day of the operation.     This procedure is associated with fewer complications.  Chances of injury to the ureter are less with this procedure.  Moreover, there being no incision on the abdomen, there are no chances of incisional hernia.  Wound infections are minimal. Disadvantage: Technically vaginal hysterectomy is more difficult to perform for the average gynaecologist and thus the facility is available only in selected centers.  The cost of therapy is the same for both the procedures.     

 Laparoscopic hysterectomy: The whole procedure is done laparoscopically.  Laparoscope is an instrument through which the contents of the abdomen are visualized through a telescope introduced through a small 1cm incision below or in the umbilicus.  The intraabdominal organs are visualized n a TV screen via a CCD camera fitted on to the telescope.  The connections of the uterus are severed through instruments inserted through small 5mm incisions on the abdomen and the final removal achieved through the vagina. Sometimes, part of the connections is released laparoscopically and the rest released vaginally.  This is called laparoscopic assisted vaginal hysterectomy (LAVH). The after effects of hysterectomy are the same as if the procedure is done vaginally. There is minimal pain and hospital stay is reduced.  The choice of performing the surgery either vaginally or with the use of the laparoscope depends on the surgeon’s preference and the type of illness.  In cases where the pelvic organs are expected to be adherent to each other, the help of a laparoscope may be absolutely essential. In cases without adhesions, it is the surgeon’s preference.  In our center, I do 90% of surgeries  with laparoscopic assistance.   In patients who have not completed childbearing, it is absolutely necessary that the uterus be kept intact as it is necessary for childbearing. In these patients fibroids are managed by myomectomy by all gynecologists.  In the patient who has completed childbearing, the treating physician has to weigh the pros and cons of removing the uterus against removing only the fibroids, keeping back the uterus.  Technically, the operation for removing the fibroids is associated with more blood loss and in multiple fibroids; it may be difficult to perform.  There is, although very small, a chance for recurrence of fibroids, as the exact cause which causes fibroids remains untreated.  However, hysterectomy has its own complications like injury to bladder, bowel,etc and after effects like bladder and bowel dysfunction in many patients.  Even if the ovaries are preserved, it may lose its bloodsupply and undergo atrophy long before natural.menopause.  As a general consensus, Indian doctors by and large prefer hysterectomy over myomectomy  for patients with fibroids in the perimenopausal period.  For others, (younger patients in the reproductive age group) management varies from center to center. If a patient who is infertile has fibroids, is it necessary to do a myomectomy? Superficial, small fibroids will not interfere with conception and may be left alone.  But some fibroids are situated in particular areas which may be harmful to conception.  These may need removal.  Again, if after prolonged treatment for infertility the patient does not conceive and there is no abnormality seen except for the fibroid, then, it may be worthwhile to remove the fibroid. What are the ways in which myomectomy may be performed? Myomectomy, or the surgery for removing the fibroids may be performed by laparotomy, laparoscopy or through the hysteroscope. Laparotomy:  This is the traditional route by which fibroids are removed.  The abdomen is opened, usually through a low transverse incision to remove the fibroids. It involves a longer hospital stay and convalescence period, like any other laparotomy. Laparoscopy: The procedure is done through 3 or 4 tiny holes in the abdomen, with the help of the laparoscope. This can be


Laparoscopic myomectomy. The white tumour in

the center is the fibroid. The edges of the wound have to be sutured endoscopically.

 done only in specialized centers as it involves suturing the uterus using needle and thread looking at a TV-monitor.  Even in specialized centers, if there are multiple fibroids, there are chances that deep fibroids may be missed and left alone.  There are many studies in medical literature which have shown scientifically that even in multiple fibroids, laparoscopy is better than laparotomy. However, in the author’s opinion, Laparoscopic myomectomy is best reserved for single or at the most 2 or three superficially located fibroids.  Hysteroscopy: In patients with fibroids that protrude into the lumen of the uterus, it is best to remove them hysteroscopically. This is called hysteroscopic myomectomy. Hysteroscope is an instrument shaped like the laparoscope. It is a tubular scope with a camera attached at one end.  It is introduced into the uterus via the vagina.  The fibroids protruding into the uterus like in the picture below are removed using cautery.  There are no incisions anywhere on the body and the patient can start working almost immediately.  This procedure is reserved for only small fibroids protruding into the uterine cavity. hysteroscopic myomectomy  What is the nonsurgical and permanent solution to fibroids? Of late fibroids are being treated by “Embolization therapy.” Through a small prick in the groin area, the main vessel supplying the lower limb, viz, the femoral artery is cannulated.  The cannula is then guided into the uterine artery, the main blood vessel supplying blood to the uterus.  Some particles are injected into this main vessel to block it and thus the uterus is deprived of it’s main supply of  blood.  This causes the fibroids to degenerate and undergo necrosis.  The uterus does not atrophy as alternate channels of blood supply take over and supply enough blood to the uterus to keep it functioning, but not enough to allow fibroids to grow.  The procedure can be done in any center with an angiography machine. It requires specialized skills in radiology. The patient may get abdominal cramps after the procedure and can be discharged from the hospital in a day or two.  At present, the procedure is not recommended for women who have not completed childbearing.  What are the complications of a pregnant woman getting fibroids? Fibroids may grow in size along with the uterus. It may cause abdominal pain in some patients. Rest and painkillers that are safe in pregnancy may help tide over this period.   Generally fibroids are not interfered with in the pregnant state.  Some fibroids may cause obstruction to labour necessitating a caesarian section for delivery.  In the past, it was thought it was best not to remove the fibroids at the time of caesarian section.  However, currently many surgeons, including the author have successfully removed many fibroids at the time of caesarian section, so that the patient does not need a second surgery to get rid of them.   







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