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Friday, March 17, 2017

Uterine Fibroid Primer

What are Uterine Fibroids?

Uterine fibroids are the lay term for a condition of the uterus called uterine leiomyoma. The medical  definition of a fibroid is actually a uterine tumor. The word tumor, encompasses both benign and cancerous growths, and as frightening as uterine tumor sounds it is not likely that this is cancer it is usually a simple smooth muscle tumors. The uterine fibroid is  made up of the same cells that form our uterus to begin with, or cells that can comprise the wall of blood vessels..  The cells get disoriented, whirled around on each other, begin to seek blood supply and ultimately form growths.  They are neither dangerous nor cancerous cancerous growths are uterine sarcomas, and your gynecologist can often differentiate the two. Pain, pressure, heavy periods, or discomfort during intercourse can be signs of uterine fibroids.  In many cases they are noted on otherwise normal routine pelvic exam and  when first found, other than measuring them on ultrasound,  they may simply be observed.  Cat scans and MRI testing can show fibroids but ultrasound is probably the most effective. Many of us now have 3-D capabilities that enable the ultrasound to show the exact location of the fibroid relative to the uterine cavity. 30- 50% of all women have fibroids in their lifetime.  Only the minority of women require treatment.  Fibroids seem to be related to our reproductive cycling and circulating estrogens.  They do not seem to be related to the taking of birth control pills, in fact some studies have implicated they are less likely if you have taken birth control pills or shots.  They grow during our menstrual life and stop growing at menopause.  They can even shrink after menopause, but ones that have gotten to the size of pressure symptoms are unlikely to shrink enough to eliminate those symptoms.  The majority of fibroids do not cause any symptoms at all.  The diagnosis of fibroids on a check up where nothing else is bothering you should not necessitate any treatment whatsoever.That being said, we have yet to find medication that can resolve the fibroids effectively and permanently.

Location Location Location!

Symptoms from fibroids are usually related to where in the uterus the fibroid is located.  If there is a growth inside the uterine cavity (Submucosal fibroid) it can cause very heavy menstrual periods, in some cases dangerously heavy.  In fact this can lead to a serious anemia or low blood count if your diet or iron supplementation dose not keep up with the blood lost. For anyone having heavy menstrual periods a simple office blood test can determine the extent of the anemia. Blood loss, especially with anemia, results in fatigue and possibly even dizziness.  These same fibroids can interfere with fertility because the implantation site of the embryo may be compromised.  If the fibroid is in the uterine wall (Intramural fibroid) it can enlarge the uterus anywhere from a little bit to a great deal.  The largest fibroid I have ever removed was the size of a term pregnancy, almost a foot in diameter.  After this was removed, the uterus returned to normal size. These can also cause heavy bleeding by the way of passing clots. Passing clots can make your periods unusually painful and possibly prevent normal treatment like ibuprofen from being effective..  If the fibroid forms on the outside of the uterus (Subserosal or pedunculated fibroid) it rarely causes problems with bleeding and does not interfere with the uterine function much at all.  However, it can be confused with an ovarian mass, or can grow to be large enough to cause symptoms on this basis alone.  Of course it is possible for there to be several fibroids in several locations.

So when is it recommended to treat fibroids?
  1. If there is excessive bleeding
  2. If there is excessive size
  3. If there is pain
  4. If there is trouble getting pregnant (miscarriages)
  5. If there are pressure symptoms such as urinary incontinence
  6. If there is rapid growth
  7. If there is discomfort with sex
  8. If there are abdominal or gastrointestinal symptoms
  9. If it is associated with endometriosis
  10. If there is anemia due to the heavy menstrual periods

Fibroids that cause bleeding

Fibroids located inside the uterine cavity, submucosal fibroids, interfere with the normal menstrual period and can cause very heavy bleeding with periods or between periods. The periods can be unusually long as well.  When this occurs, it is time to consider treatment.  First we must be certain it is the fibroids that are causing the bleeding.  An ultrasound of the pelvis can help distinguish between conditions such as fibroids, uterine lining polyps, or hormonal conditions leading to a thickened uterine lining. Uterine lining sampling, called an endometrial biopsy, can help identify any uterine lining conditions that also may be causing the heavy bleeding.  It is also important to be aware of other conditions that cause bleeding, such as a blood clotting abnormality like hemophilia, over use of blood thinning medicines such as aspirin, or Von Willebrand’s Diseases. These are rare conditions that are treatable medically, and usually come to attention when you are in your teens or early 20s.  Once the diagnosis is confirmed, treatment can be recommended. Rapid growth, unusual pelvic pain not during menstrual periods, or infertility may mean you have something other than a uterine fibroid.

Fibroid, Grow: But At What Pace or How Large is So Far Unpredictable

Fibroids can be microscopic or quite large; they can be single or too many to count within the uterus. Women probably are genetically predisposed to having one type or another, but that's not been determined either. They can develop rapidly, or more typically, slowly over many years, so it may not be unusual to have had a normal exam and then the next year have a fibroid found, but really most develop slowly.  If the fibroid is small and causing no symptoms, we can and should ignore it.  For women with large fibroids and no symptoms, it's thought you have merely gotten accustomed to your symptoms due to very slow growth. Since we don't technically have a preventative treatment, most physicians state no treatment is needed for small fibroids or asymptomatic fibroids. Heavy menstrual cycles or enlarging size or a fibroid that has grown into a tumor that presses on other vital organs like our rectum or our bladder we can experience serious symptoms that interfere with our quality of life. They can even cause problems with sex.  Fibroids can be located anywhere with in the uterus.  may be either intramural or subserosal fibroids.  Fibroids can grow to almost any size but when they reach the size of a large orange or a grapefruit they tend to have symptoms that require treatment.  We may experience an urge to urinate frequently if the fibroid presses on the bladder or difficulty with bowel movements if the fibroid may be pressing on our rectum.  This tends to get worse in time as the mass grows.  Even though it is a benign mass, (not cancer), it may need treatment.  There has been misinformation in the past that if a fibroid grows rapidly it might be cancer.  This is true less than a tenth of one percent of the time or very, very rarely. Rapidly growing fibroids most often can be treated the same as any similar size fibroid.

Fibroids that cause pain

There are times when usually non-painful fibroids can actually become very tender causing considerable pain.  If a fibroid outgrows its blood supply, this causes some of the muscle tissue to “die” or degenerate.  When smooth muscle dies, it can be painful, like when heart muscle dies causing a heart attack.  The difference is that while every part of our heart muscle is important to the overall function of our heart, and a heart attack is an emergency, the same is not so for the uterus.  When this process occurs in the uterus, it may be very painful, but since we really do not depend on the fibroid tissue for any function, there is no emergency, just pain.  This pain is usually self limited, will stop eventually on its own and can be treated conservatively with pain medicine until the process is over. This can take several weeks.  Other causes of pain are from the pressure of the fibroid pressing on other organs.  If the pain does not completely resolve, removal of the fibroid may be considered.

Treatment options

If treatment is needed for heavy bleeding the options include birth control pills, which reduce menstrual flow in most women, or the use of the long cycle pills where periods occur only every 3 months.  If this is not adequate, and it may not be, there is Lupron, which is a monthly or every three-month injection given at the doctor’s office. This causes temporary reversible menopause, stops the bleeding, and allows us to replenish our blood supply enough to withstand a surgical procedure that would be more definitive.  Low doses of hormones may be given to reduce any menopausal symptoms that might occur.  This is only a short-term solution for 3 – 6 months.  BUT it effectively stops the growth of fibroids and any accompanying bleeding.  This allows for safer surgery, emotional preparation and the possibility that if menopause is near, the avoidance of surgery entirely. At Women's Health Practice we also have many uterine fibroid research studies that we have participated in. There are many medications in development, or available already in other countries. We welcome patients to come and screen for these studies, and for this there is no charge. 

Myomectomy

There are three ways to approach a myomectomy, the removal of the fibroids and reconstruction of the uterus.
 

Hysteroscopy Resection Myomectomy

The simplest is in the case of the isolated submucosal fibroid in the uterine cavity. This can be removed with a resectoscope myomectomy, which is very much like a sophisticated D & C.  This procedure is performed with an anesthesia in a hospital or surgicenter.  The cervix is opened and a telescope, called a hysteroscope, is inserted into the uterus with a cutting wire attached. The fibroid in the cavity is removed piece by piece with the heated wire loop through a procedure called cautery. This removes the fibroid entirely if it is completely in the cavity.  If it is partially in the wall of the uterus as well, the portion in the wall will be left behind, as it is not safe to dig into the wall to remove more than that which is visible in the telescope.  Usually this is all that is necessary to stop the bleeding. Normal activity is resumed the very next day. There may be light bleeding for up to a couple of weeks. The only limitations are that nothing should be in the vagina, no intercourse, tampons, swimming, or baths for 2 weeks while healing occurs (showers are fine).  Otherwise you may resume normal exercise and activity.

Abdominal Myomectomy

If the fibroid is in the wall of the uterus or protruding into the abdomen it may be removed through a “bikini” type incision, much like that done for a c-section, but often these can be much smaller in total length than that. This is about an inch above the pubic bone and can be as long 6 inches in length.  Medicine is used to help control bleeding so that the fibroids can safely be removed from the uterus, depending on the location the goal is to not enter the cavity of the uterus, and to reconstruct the uterus as normally as possible with several rows of stitches.  Most patients will go home the day of surgery. There are ways we can help you manage the discomfort. For most women low doses of short term use of pain medication is all they actually require. Many women have been told by their physician that their fibroids are too large for a myomectomy, that only a hysterectomy will be possible, that the risks of bleeding or the surgical difficulty is too great.  This has not been shown in the scientific literature.  There are many techniques to manage the blood loss of surgery.  Of interest is the cell saver. This is technology where any blood loss is recaptured and returned to the patient in the form of an auto-transfusion.  It is a very effective way to avoid hysterectomy or blood transfusions.  Even the largest fibroids have been successfully removed, as I mentioned before, the largest I have removed was about 25 cm or almost a foot in diameter. If there are several fibroids, this method will succeed as well.  I have removed as many as 25 fibroids from one woman.  Even with these seemingly extreme circumstances, three months after surgery, the pelvic exam was normal and the symptoms were gone! In other cases I have seen return of the fibroids, to even larger than the original size, and in less than a year. This fortunately is not typical.

Laparoscopic Myomectomy

Whenever possible it is best to avoid the abdominal “bikini” incision with a minimally invasive procedure.  Laparoscopic myomectomy involves the placement of a small telescope, the laparoscope, through a half-inch incision in the umbilicus and 2 – 3 other quarter to half-inch incisions in the lower part of the abdomen.  The fibroid is cut away from the uterus and in a fashion similar to the abdominal myomectomy, stitches are placed in multiple layers to close the uterine incision.  The fibroid tissue is most effectively removed in pieces, but the tools to make this available have not been widely available due to some safety concerns on the part of the manufacturer.  This technology cuts fibroid tissue into long strips that can be removed through a half-inch incision.  A laparoscopic myomectomy may require more evaluation including an ultrasound and possibly an MRI. e use of robots just allow the laparoscopic instruments to bend, but the DaVinci procedure is just a laparsocpic procedure with larger instruments.

Fibroid Embolization

Uterine artery embolization is performed by a radiologist in an outpatient setting with sedation.  General anesthesia is not required.  A small tube (a catheter) is threaded through the arteries to the uterine artery.  Through this catheter, pellets are injected to temporarily block the artery and stop the blood flow to the fibroid.  This halts the growth of the fibroid and the associated bleeding.  It encourages shrinkage of the fibroid to approximately half its original size.  This is a reasonable option for women with heavy bleeding and a dominant fibroid who want to avoid surgery.  The vessels reopen after a while and new fibroids may form or untreated fibroids may grow.  Pedunculated fibroids are not treatable by embolization.

Hysterectomy for Fibroids

Hysterectomy should be undertaken if the other alternatives fail or if you have contraindications to the medications or other alternatives. It may actually be logistically simpler to remove the uterus than to perform a laparoscopic myomectomy if there are several fibroids, or if the location of the fibroids is difficult to approach laparoscopically.  If myomectomy has been performed before, it would be reasonable to discuss hysterectomy although sometimes a second myomectomy is possible. Prior surgeries can produce scar tissue that may make repeat surgeries harder, and it's important to have your physician consider techniques or medications that will reduce the risk of future scaring so that repeat surgery is not as dangerous. I have performed as many as 3 separate myomectomies on some patients.  Since fibroids can continue to form, there comes a time that a woman might prefer the certainty of a hysterectomy.  If a woman knows she wants to take estrogen replacement at some point in the future, it is simpler to take without a uterus and will never cause bleeding. We usually recommend ovarian conservation for young women, and there is no need to take ovaries just to treat fibroids.  As long as there is not an issue of future fertility hysterectomy is reasonable.  If future pregnancy is desired, all efforts should be made to save the uterus.

Uterine Fibroid Research

  A large body of research is being done into medications that can shrink fibroids and control uterine bleeding. At www.Clinicaltrial.org or at www.womenshealthpractice.com you can find some of these research trials to follow the progress or to enroll in a study near your home.

Let Us Help You Make Your Own Decision

It is most important to collaborate with your physician.  Get a second opinion, ask questions until you educate yourself about your options and feel comfortable with your decision.  Ask about your doctor’s philosophy about myomectomy and hysterectomy. Bring questions to your appointment. If uterine preservation is important to you, make sure the surgeon is on board and has the same philosophy.  Do not be afraid to ask specific questions about options and the procedures themselves.  Ask about recovery details as well as pain management. 

Remember, if your fibroids are not too large, and not symptomatic simple observation may be all that is required.  Most fibroids do not require treatment, but in those cases when treatment is needed, be an educated consumer.  As a physician, I always appreciate it when the patient participates in the treatment plan.  A collaboration is much more satisfying for both the patient, her loved ones, and the physician and leads to better outcomes.


Hormone Therapy Facts never Changed, But Rhetoric Around the Research Definitely Colored the Discussion

Were you ever on hormone therapy? Were you ever taken off hormone therapy? Were you ever too scared for hormone therapy? All of this is understandable in light of new findings that politics, and 'alternative interpretations' hampered the interpretation of the Women's Health Initiative study findings. To read about this perspective here are some editorial comments. The good news is that there has been aggressive study of the following menopausal helpful strategies because of this 'misinterpretation' of the risks of hormone therapy:
1. A search for effective bust even safer dosages
2. A search for alternative therapy
3. A better understanding of long term bone health and the risks of alternative therapies
4. Nutritional and fitness management of menopause
5. Non-medication laser therapy for sexual pain with menopause
6. Non-hormonal management of irregular bleeding in perimenopause


All of these have significantly helped women, and thus we have to argue that this was a benefit of the WHI information. For more information, search some of the other posts on this topic in this blog.

Thursday, March 16, 2017

HPV Vaccination: Schedule Simplified: 2 Doses, and Physicians Urging it to Become Routine Practice.

Immunity, because of vaccination, is the best way we have of protecting ourselves and out children from the HPV virus and the cancers it causes. The newest version of the vaccine Gardasil has now more protection than ever and one less shot to make it even easier.  The vaccine has both gotten stronger and easier to administer. Getting us closer to the dream of eliminating cervical cancer.
 Gardasil 9 is easier to administer as  now we are requiring only 2 doses instead of 3 to be protected.  We have known for many years, since the earliest vaccine research, that the vaccine protects boys as well from both warts and genital cancers, and that protecting both boys and girls helps protect their partners in the future. Now the Pediatric society has come out with strong recommendations regarding vaccination of boys as well. Making this part of routine vaccine schedules helps practices and families comply with the recommendation. 

Our US Food and Drug Administration (FDA) in December of 2015 approved this version of the HPV vaccine Gardasil 9, a human papillomavirus (HPV) vaccine from Merck that prevents cancers and other lesions, such as genital warts, caused by one of nine HPV types, five more than the original Gardasil protected against. There is virtually 100% protection of the HPV type you get in this vaccine if you have not yet been exposed to that virus already. The first vaccine protected against HPV types 6, 11, 16, and 18. Gardasil 9 covers these as well as types 31, 33, 45, 52, and 58. These latter five are currently responsible for roughly one in five cases of cervical cancer. In the earlier vaccine there was some cross protection of other viruses, and since there are 14 HR types of HPV we can project some cross protection there as well. Gardasil is indicated  for girls and boys ages 9-26. Gardasil 9 is given on the same schedule. There is no indication to repeat Gardasil if you have had the earliest version of the shot. And the risks are both low, and unchanged from the first Gardasil vaccination.
As per Medscape web site Gardasil 9 is indicated in females aged nine through 26 years for the prevention of:
  • Cervical, vulvar, vaginal, and anal cancer caused by HPV types 16, 18, 31, 33, 45, 52, and 58
  • Genital warts caused by types 6 and 11
  • Various precancerous or dysplastic lesions of the cervix, vulva, vagina, and anus caused by types 6, 11, 16, 18, 31, 33, 45, 52, and 58
It is also indicated in males aged nine through 15 years for:
  • Anal cancer caused by types 16, 18, 31, 33, 45, 52, and 58
  • Genital warts caused by types 6 and 11
  • Anal intraepithelial neoplasia grades 1, 2, and 3 caused by types 6, 11, 16, 18, 31, 33, 45, 52, and 58.

More information on today's decision is available on the CDC or the  FDA's website .

Tuesday, March 14, 2017

Defeminization, It's Actually A Medical Condition and Breasts Shrinking May be a Sign of This Condition

Although 'Defiminization' sounds like a political cause or picket-able offense, it's actually a medical condition. The physical examples of defiminization usually are shrinking of the breast and uterus, changes in the fat distribution, followed by loss of the menstrual period. It's most commonly due to rising testosterone levels that can rise very high due to testosterone producing tumors. Typically defeminizaiton occurs first, and then the physical signs of male hormone excess. the signs of male hormone excess could included excess hair growth (chin, chest, lower abdomen, etc), lowering of voice due to the hypertrophy of the vocal cords, and, or clitoral enlargement. Most of these conditions are due to cancerous tumors of the ovary, it may be due to a simple cyst. Being in tune to changes of your hormones is an important way to identify these disorders quickly and prevent any lasting complications. So report any suspected defeminisation, we want to stamp it out in what ever form it takesz

Monday, March 13, 2017

Recovering Faster After Bladder Surgery

Women have alternatives when it comes to fixing incontinence, but the use of a FDA approved sling is still considered on of the best and most successful surgeries. The use of a targeted and very successful new surgery that is for incontinence is enabling women to get back to exercise, work, and sexual activity, very quickly.
Immediately after surgery, the shock to the bladder nerves and the swelling in the area cause the temporary inability of the bladder to function normally. But this literally can last hours to only a few days, and few women will have to wear a catheter home after that sort of surgery. In the past the types of surgeries done, accompanied by very extensive dissection used to require a long dwelling catheter.Then  a catheter was placed through the abdominal wall to allow emptying of the bladder during healing. This is rarely necessary, in fact most women will not use a bladder catheter when they finish the surgery. Most women are able to recover quickly and it is a same day surgery to get bladder incontinence fixed.The best way to recover is to eat well, drink adequate amounts of water, get rest, and take any medications or supplements your physician recommends. The newer operations allow for both intercourse and heavy exercise rapidly, some physicians even say a week. Report any suspected bladder infections to your gyno. Untreated infections can lead to chronic problems, thus rapid reporting of any symptoms is important!

Sunday, March 12, 2017

When A Fibroid Leaves the Uterus....Where Would It Go?

Uterine fibroids are essentially nodules of uterine tissue that normally reside within or as part of the wall of the uterus. They arize from the type of cells that a normal uterine muscle cell or a blood vessel cell arises but they are probably what was called 'undifferentiated'. In other words, the thAlthough I haven't checked many sites, most describe the largest uterine

Friday, March 3, 2017

Your Brain is Talking To Your Fat, and The Other Way Around: The Brain-Fat Axis

We have talked, in women's health, a lot about the HPO: the endocrine system that communicates between the H: the hypothalamus, the P: the pituitary gland, and the O: the ovary. Generally speaking when we talk about 'hormone imbalance' the gynecologic endocrinologist means there is something off with this cycle of how the ovary talks to the brain. Now it has been realized that other endocrine systems have just such a channel of communication and how that works between the brain and the adipose tissue has  now been called the "brain-fat axis" and this is an important control of how your body uses energy, or decides to amass fat stores. It is now well-known that appetite-regulating peptides that were studied as neurotransmitters in the central nervous system can act both on the hypothalamus to regulate feeding behavior and also on the adipose tissue to modulate the storage of energy. Energy balance is thus partly controlled by factors that can alter both energy intake and storage/expenditure.  Exercise and  the types of food you consume in your daily diet work in mysterious ways to control what you weigh.. Ultimately this is the simplistic way we understand that bariatric surgery or extremely low calorie diets work. It is also how the medications we use for weight control work: but they work first on the forces that control both intake and the metabolism of the intake, then in turn making those food and exercise choices translate into body sculpting . A greater
understanding of the brain-fat axis and regulation of fat deposition bythe biologically active molecules produced in our body,  to help gain strategies to prevent or treat being overweight or obese..

Tuesday, February 28, 2017

Genetic Screening is Now Recommended to Be Expanded, This May Include All Patients Planning a Pregnancy

In an internal membership communication the Committee on Genetics from American College of Obstetricians and Gynecologists’  physicians have been guided to consider expanding genetic services. We have entered the age of genomic medicine and your care can be prioritized based on what your genetics are. Genetic testing is widely available, and the laboratories which offer this testing as well as the insurance companies which care for patients have begun to work together to make these tests widely available. It is still possible, based on your particular genetic background to test for conditions known to be passed through certain ethnicity or families. It is also now thought that expanded testing can be very beneficial for those who appear to have the risk of a typical American woman. The ACOG information is specifically looking at couples who are pregnancy planning, but it can be important for others as well. Specifically it is thought that young individuals should be tested, and that makes sense as there is, then, more time to medically intervene and make a difference in your health. There are a lot of choices when it comes to genetic tests, literally hundreds of tests are available. Your personal health care provider needs to help you sort which tests to get, and what to do with the information. No test is perfect, and individuals should know there are cases that test negative for a genetic condition that they do contract, as genetic mutations are possible as we age. So there are limitations to every test! As a rule ACOG is encouraging women to get tested for the more 'common' disorders, even though those disorders might be considered 'uncommon' to the average patients. If you have a 1/100 chance of finding a particular gene that causes a genetic disorder, that means there is only a 1/40,000 chance of the disease! The numbers can be quite confusing when sorting what test to have, consult your gyno if you have questions. .

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If you are a female between the ages of 18 and 35 you may be eligible for a contraceptive ring investigational contraceptive medication study. Qualified participants will receive study-related medical evaluations and care at no cost. If interested, please call 217-356-3736.

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