Uterine Fibroids

The most common health problem in women of reproductive age

Uterine fibroids are one of the most common health problems in women of reproductive age, with symptoms ranging from mild to moderate and severe. Uterine fibroids are noncancerous growths of the uterus that often appear during childbearing years.

Many women have uterine fibroids sometime during their lives. But you might not know you have uterine fibroids because they often cause no symptoms. Your doctor may discover fibroids incidentally during a pelvic exam or prenatal ultrasound.

When treatment is necessary, there are various treatment options including drug therapy, surgery or a minimally invasive procedure. In severe and advanced cases, a hysterectomy is performed. There are few known risk factors for uterine fibroids, other than being a woman of reproductive age. If your mother or sister had fibroids, you're at increased risk of developing them. Other factors include starting your period at an early age, obesity, a vitamin D deficiency; having a diet higher in red meat and lower in green vegetables, fruit and dairy; and drinking alcohol, including beer, appear to increase your risk of developing fibroids. Estrogen and progesterone, two hormones that stimulate development of the uterine lining during each menstrual cycle in preparation for pregnancy, appear to promote the growth of fibroids.

Fibroids contain more estrogen and progesterone receptors than typical uterine muscle cells do. Fibroids tend to shrink after menopause due to a decrease in hormone production.

In women who have symptoms, the most common signs and symptoms of uterine fibroids include:

• Heavy menstrual bleeding • Menstrual periods lasting more than a week • Pelvic pressure or pain • Frequent urination • Difficulty emptying the bladder • Constipation • Backache or leg pains Fibroids are generally classified by their location. There are fibroids located inside the uterine cavity and cause vaginal bleeding between periods as well as severe pain. This type of fibroid can be removed with hysteroscopy through the cervix without laparoscopy. In some other cases, part of the fibroids is inside the uterine cavity and the other part is in the uterine wall and cause thick blood loss during the period, and it is accompanied by vaginal bleeding between periods. This type of fibroid can be removed with hysteroscopy and there is no need for traditional surgery and making a large incision. Fibroids located inside the uterine wall range in size; they can be so small and not visible to the naked eye or large and accompanied by several symptoms. There are several ways to treat this type of fibroid, but most of them do not need any treatment. There are fibers that are present outside the uterine wall or are attached to the uterus; these do not need treatment if they become large, and may lead to pain if a twisting occurs, but it is one of the easiest types that can be removed through laparoscopy.

Treatment

Treatment methods vary according to the size of the tumor. If the fibroid is small, the patient can live with it or stop its growth with drug therapy. Surgical intervention may be required to remove the tumor or remove the uterus whenever it becomes large and depending on its location. Radiotherapy can also be adopted if the first two treatments were unsuccessful. If the size of the fibroid is less than 3 cm and there are no symptoms, it does not need treatment, and if the woman suffers from severe pain, painkillers, hormonal drugs or monthly injections can be used. When the tumor is large and causes discomfort and health problems, then surgical intervention is needed in order to remove it. Recent developments in the medical field have allowed doctors and surgeons to perform minimally invasive operations (laparoscopic or robotic) which contributed to a quicker recovery and less postoperative complications.

Fibroids located inside the uterine wall are difficult to remove through the cervix and require hysterectomy, which is a suitable option for women after menopause. But this option is the most difficult for women in reproductive age, therefore, the doctor resorts to other treatment options before making this decision as it affects a woman’s fertility and ability to get pregnant. If the fibroids are few in number, the doctor may opt for a laparoscopic or robotic procedure, which uses slender instruments inserted through three small incisions in the abdomen to remove the fibroids from the uterus. This type of surgery allows the patient to resume her daily activities in a matter of days, and does not require a hospital stay more than one day. It is also less painful than laparotomy.

Endometrioma and Infertility, When To Operate

By Dr Mazen Bishtawi FRCOG FACOG, Consultant in Obstetrics and Gynaecology, Subspecialist in Gynaecological Oncology and Advanced Laparoscopy at Al-Ahli Hospital - Doha / Qatar

Endometriosis has been estimated to affect up to 10% to 15% of reproductive-age women. Most women with endometriosis have a delay on average of 7 years from the onset of symptoms until the diagnosis is made, the symptoms could be irregular bleeding, menstrual dysfunction, pain and infertility.

The association between endometriosis and infertility is well supported throughout the literature, but a definite cause-effect relationship is still controversial. The prevalence of endometriosis increases dramatically to as high as 25% to 50% in women with infertility, and 30% to 50% of women with endometriosis have infertility. The fecundity rate in normal reproductive-age couples without infertility is estimated to be around 15% to 20%, whereas the fecundity rate in women with untreated endometriosis is estimated to range from 2% to 10%. Women with mild endometriosis have been shown to have a significantly lower probability of pregnancy during a period of 3 years than do women with unexplained fertility.

Ovarian endometriomas have always been subject for controversy, controversy on pathogenesis and controversy on treatment. We see many patients coming with endometriomas and infertility, these patients usually get conflicting advice whether to go for surgery and remove endometrioma or proceed for IVF. Ovarian endometrioma affects 17-44% of woman with endometriosis, endometriomas also known as chocolate cysts containing thick old hemorrhage that appears as brown fluid. In 50% of cases, the endometriomas are bilateral, they are more frequently located in the left ovary. Pathogenes is still controversial and many theories are trying to explain the nature and the cause of this disease. The most acceptable theory is invagination of ovarian cortex secondary to implant of metaplastic cells in the coelomic epithelium. Pelvic ultrasound is usually enough to make the diagnosis of endometrioma, however MRI is the gold standard.

The causes of infertility in women with endometrioma can be attributed to many factors such as adhesions and blockage of the fallopian tube,

inflammatory response that may participate in degradation of oocyte and sperms. Endometrioma might lead to poor embryo quality, poor ovarian reserve and inflammation affecting endometrial receptivity.

Management of ovarian endometrioma can be complex and should be individualized. The optimal treatment will depend on the patient age, severity of pain, characteristics of the cyst, unilateral or bilateral, the presence of coexisting deep infiltrating lesion and clinical history of previous surgery.

Laparoscopic surgeons believe that surgery should be the first step in management of endometriomas as these lesions are less likely to disappear on their own. Surgery will improve pain, improve fertility, reduce risk of ovarian cancer, reduce risk of pelvic infection at the time of oocyte retrieval, reduce risk of contamination by the chocolate material which affects the quality of oocytes, and surgery is less costly compared to IVF treatment.

While IVF specialists believe that surgery might increase the damage to the ovary and further reduce the ovarian reserve, the Royal College of obstetricians and gynaecologists (RCOG) guideline advised for surgery before IVF in highly symptomatic women and those with good ovarian reserve, patients with unilateral large cysts, and cysts with suspicious features.

If surgery is to be contemplated, laparoscopy is the surgery of choice, as it offers quicker recovery and resumption of everyday activities. Surgeon's expertise and technique is of paramount importance to minimize damage to the ovary. The best technique is to strip the endometrioma wall, but it is not always possible to do in all cases.

Laparoscopic cystectomy for ovarian endometriomas greater than 4 cm improves fertility compared to cyst drainage and coagulation, which is associated with a high risk of cyst recurrence. Proper assessment before surgery is extremely important as a significant number of women with endometrioma had reduced ovarian reserve due to pathology itself. Transvaginal aspiration before IVF cycle is useless, dangerous and should not be contemplated.

Postoperative medical therapy has been advocated as a means of eradicating residual endometriotic implants in patients with extensive disease in whom resection of all implants is impossible or inadvisable. Postoperative hormonal therapy also may treat microscopic disease; however, none of these treatments has been proven to enhance fertility. But these therapies are sometimes to reduce pain.

Ultrasound Laparoscopy

PATHOGENESIS IS STILL CONTROVERSIAL AND MANY THEORIES ARE TRYING TO EXPLAIN THE NATURE AND THE CAUSE OF THIS DISEASE. THE MOST ACCEPTABLE THEORY IS INVAGINATION OF OVARIAN CORTEX SECONDARY TO IMPLANT OF METAPLASTIC CELLS IN THE COELOMIC EPITHELIUM. =