Don’t take uterine fibroids lightly

Gynecologists caution that inspite of fibroids being a common problem women should not take it lightly.

Past president Delhi  Gynae Endoscopy Society Padmashri Dr Malvika Sabharwal said fibroids arise from the musculature in the uterus, they are hormone-dependent and get stimulated to increase in size.

With over 50,000 surgeries under her belt, she even holds the world record for removing the largest fibroid from the uterus, and that too without harming the patient’s reproductive organ.

She said, fibroids “belong to the reproductive age of a lady, after menopause they will definitely  go down or they will  subside.”

 Dr Sabharwal said that it is a very common problem. These fibroids can grow large in size but they can also remain small in size. The problems a girl has will depend upon the position of the fibroids.

“Uterus has got three layers, if it is growing towards the outer wall that means it is subserosal, it may have no pressure effect in the inside. The inner lining is the one  which bleeds and so there being no pressure it may cause no problem inside while it keeps growing outside.”

Once it is becoming like say about three month baby size, four month baby size, and keeps growing it may start putting pressure effect on the bladder, the ureter, the kidney and the rectum, she said.

“We have had a patient who was unable to pass urine and on examination, we found a five month baby size fibroid”, she added.

In another scenario, she said, you can have a just a two centimeter fibroid on the inside wall, the area which bleeds every month and that will cause bleeding. “The patient will come and say I am having so much bleeding,just take it out.”

Pain generally doesn’t happen in fibroids, she said, though there may be other symptoms like bleeding, urinary special symptoms, urinary obstruction, pressure on the ureter, and pressure on the bowel.

If there is pain you have to find out why pain is there because there may be other reasons for the pain, she said.

There are three types of fibroids, one that grows in the inside causing bleeding, the second growing outside which causes pressure, and the third one is intramural or within the musculature which causes pelvic or low back pain.

Dr Sabharwal said, operations are routinely done for fibroids either we save the uterus and take out the fibroids laparoscopically or take out the uterus by hysterectomy. Fibroid mapping is done to know where the fibroids are located before it is removed, she said.

As fibroids tend to recur, she said, “I removes even fibroids and next year they come with nine fibroids. There is no permanent solution unless the uterus itself is removed.”

Today the incidence of fibroids is around 24 -28 percent, she added.

Fibroids, she pointed out are not conducive for pregnancy. Besides obstructing the tube, the chances of abortion are high, there may be premature delivery, it may lead to excessive bleeding and the uterus may not contract at the time of delivery. Women having fibroids should have an institutional delivery, she added.

Fibroid can cause pain in pregnancy. A lot of girls who get pregnant come for the removal of fibroids, she said.

Dr Sabharwal referred to the controversial case of Dr. Amy Reed, an anesthesiologist at Beth-Israel Hospital in Boston, about ten years ago who had a laparoscopic hysterectomy with morcellation technique. Morcellation is the process whereby the fibroid or uterus is shredded before being removed. Reed had undetected cancerous cells that were spread throughout her abdomen after the procedure.

This shocking incident led to the practice of the shredded tissues first being encased in a bag before being removed from the abdomen.

Dr Sabharwal said, “We were first to use this in-bag technique in north India. We use a technique to insert the  camera and the  morcellator to shred and remove the pieces and every bit stays inside the bag.”

Former President of Federation of Obstetricians and Gynecological Societies of India (FOGSI) and  Gynecological Endocrine Society of India (GESI), Delhi Gynaecological Endoscopic Society (DGES), Padmashri Dr Alka Kripalani said, “Surgery to remove fibroids requires lot of skill and patients should only go to  centres which have expertise in mymectomy.”

She said that fibroids “ distort the uterine anatomy” leading to several problems like heavy menstrual bleeding, irregular bleeding, pain, urinary problems, urinary pressure, difficulty in passing urine, infertility, abortion, pre-mature baby. Fibroid sucks up all the blood supply making the patient anemic.

Surgical removal of fibroids is the preferred mode, she pointed out, even though there were medicine to reduce the size the fibroids but they work only as long as you are taking the medicine and as soon as you stop the medicines the fibroids regrow.

Fibroids are very common about 30 -50 percent people coming to OPD have uterine fibroids, she said. But not every patient who has fibroid has any difficulty because of the fibroids. Those patients who have symptoms because of fibroids like excessive bleeding, irregular bleeding, infertility, pain , should seek treatment and should not take it casually, she added.

If the family is complete then usually the uterus is removed. What is abnormal should not be left inside particularly if it is big in size like more than 4 cm, she said.

It is a very safe procedure to remove it laparoscopically. There is a two day stay and the patient can eat and walk just the day after the operation. There is very early post operative recovery and within 3-5 days she can resume all normal activities, she added.

Former President of the Federation of Obstetric and Gynecological Societies of India Jaideep Malhotra said that fibroids were basically benign growths and not malignant or “cancerous”.

Nearly 30 percent of women have fibroids, she said, which could be from very small pea-sized to large-sized like a nine month old baby.

Generally, they do not cause any problem but inside the cavity of the uterus they may result in infertility, excessive bleeding or pressure. There can be a single fibroid or multiple fibroids, she added.

The treatment of fibroids depends on the age, problem and symptoms. If the woman is of 40-45 years of age and there are small fibroids we just leave it alone.

If the fibroid is big 4.5 cm or more and the woman wants to have a baby or the woman has symptoms like excessive bleeding and pain then we remove the fibroids, she said.

As far as non invasive method is concerned, she said,  there is High-Intensity Focused Ultrasound where sound waves are targeted on the fibroid to destroy it, another minimally invasive method is to block the supply of blood to the fibroid by stenting.

She said even though the non-invasive and minimally invasive methods are very popular, Indian women if they are old and do not want children prefer to go in for hysterectomy or removal of the uterus altogether as a permanent solution to the problem which can recur. Prof. Dr. Abha Majumdar, Director and Head of the Centre of IVF and Human Reproduction at Sir Ganga Ram Hospital, Delhi, said, “ Removal of fibroid should be done judiciously with caution and only if necessary.”

Judgment of the gynecologist is very crucial, she said, as it can lead to scarring of the uterus with stitches which can weaken the uterus for pregnancy. Multiple removal of fibroids can lead to multiple scarring of the uterus, she added.

“When fibroids are removed specially in open surgery they tend to bleed more and while stitching intestines or tubes can stick, then a fully healthy fertile woman who can conceive is unable to conceive,”she said.

Dr Abha Majumdar said, “Fibroids are fibro muscular tissue overgrowth, round ball like structures which grow into the musculature of the uterus. They are  generally absolutely benign (99.99 percent)and can be left untouched.”

Depending on the different placements of these fibroids women have symptoms.

“If the uterus has to be removed it must be done for specific reasons like fibroid is growing very fast and the uterus is likely to become becomes very huge very early for the patient. If at every sequential ultrasound it observed that there is an increment increase in size even if the fibroid is growing just two centimeters every year then in 5-6 years it will become huge,” she added.

In a large percentage of women it has been found that women above 40 years of age have fibroids in the uterus, maybe one small one or maybe more and large ones also.

In early ages like adolescence and young girls, it is seen less, like 12 – 15 percent would have fibroids, but after 45 years of age nearly 40-50 percent of women have fibroids or adenomyomas, she said. The only treatment is to remove surgically, she added.

There are semi-invasive methods like High-Frequency Ultra Sound and blood being stopped to the fibroids but these are suitable  only for patients with very high risk of surgery, aged women  or those with any other medical condition.

These treatments do not remove fibroids, they infact degenerate the fibroid in its own place and slowly the body absorbs it. It does not evaporate the fibroid, just shrinks the fibroid which takes a very long time, she said.

If removed surgically the same fibroid does not come back again. But as the uterus has the tendency to develop fibroids new fibroids can always occur.

Dr Majumdar said,“ I had a young 21-year-old patient who had huge fibroids and we surgically removed  14-20 fibroids, she came back after 8 years again with huge fibroids covering the entire uterus which we again removed. But when she came a third time, she was not interested in removing her fibroids but told us to remover her uterus itself.” 

“Conception does not take place if the placement of the fibroid is inside the cavity. However, in all other fibroids which are on the surface or partly into the musculature pregnancy happens without any problem even with large fibroids which may be four times the size of the uterus,” said Dr Abha Majumdar.

“I have had patients who have come pregnant with fibroids reaching right upto the chest, as large as that”, she said.

The fibroids are removed laparoscopically these days, we don’t open the abdomen. We morcellate and take out even large fibroids, she added.

“I perform at least 6-8 fibroid removal every month that too in infertile women who feel that fibroid is the main culprit due to which they are not being able to have a successful pregnancy,” she said.

Dr Majumdar said,“ I will say that if you are diagnosed with a fibroid don’t try to get it removed always because it may cause no harm in either becoming pregnant or to your pregnancy. These are benign masses of fibro muscular tissue they don’t interfere in any function of the uterus.”

“Seventy to eighty percent of fibroids don’t affect the women’s pregnancy or her getting pregnant. If we collect 100 patients who have fibroids, 80 patients will get pregnant naturally and deliver also. Twenty might have difficulty,” she added.