Question 1

Can you talk about the link between folic acid intake and uterine fibroids?

Dr. Suman Lal · Accepted Answer

A diet rich in folic acid can reduce fibroids, and folic acid can be given as a preventive measure in high-risk cases.

Question 2

What are some of the symptoms of a high-risk pregnancy if it can be detected only with the fibroid?

Dr. Suman Lal · Accepted Answer

Pelvic pain out of proportion to a normal pregnancy, urinary symptoms from an anterior fibroid pressing on the bladder, rectal or pelvic pressure from a posterior fibroid, and localised pain when the uterus is touched, which often signals degeneration within the fibroid. Any of these should prompt an ultrasound.

Question 3

How exactly do fibroids cause throbbing and burning pain during urination, and does it predispose patients to UTIs?

Dr. Suman Lal · Accepted Answer

Since the bladder sits anterior to the uterus, a fibroid growing on the front surface of the uterus can press into and separate the bladder, causing difficulty passing urine and the resulting pain sensation.

Question 4

Can tranexamic acid be used in treatment, like reducing the size of a myoma?

Dr. Suman Lal · Accepted Answer

No. Tranexamic acid doesn't reduce the size of a fibroid. It works by preventing clots from breaking down, so it reduces heavy bleeding caused by a fibroid, but has no effect on the fibroid's size.

Question 5

How far can progesterone hormone reduce the size of a fibroid?

Dr. Suman Lal · Accepted Answer

Progesterone is sometimes given, but it reduces the size by only about 20 percent. It is used for women with heavy bleeding who are waiting for surgery or cannot have surgery. It is not advisable for a woman who has a fibroid but no symptoms; it is given only for heavy bleeding, and surgery is the better answer than progesterone.

Question 6

What is the management of fibroids using medication without surgery, and what are the possibilities?

Dr. Suman Lal · Accepted Answer

If a woman has heavy bleeding and the fibroid is not inside the cavity, medical management is possible: painkillers, oral contraceptive pills and GnRH injections. GnRH injections reduce the size of the fibroid, but once they are stopped after six months to one year, the fibroid grows again. Medical management is therefore advised for perhaps one or two years to control symptoms, and is not advised in the long run. It has a clear role in three situations. A woman of around 50 with heavy bleeding and a fibroid, who will probably reach menopause within one or two years, can be managed with medicine to stop the bleeding, because fibroids usually shrink after menopause. A woman with a fibroid and bleeding who has recently miscarried, and who we do not want to operate on, can be given medicine to shrink the fibroid and then try for pregnancy with the reduced size; if she does not conceive, we operate. Finally, medicine can be tried preoperatively, where surgery is not possible, or where a very small fibroid is causing heavy bleeding.

Question 7

What is the role of the GnRH agonists used in India, leuprolide and goserelin?

Dr. Suman Lal · Accepted Answer

Either can be used. Both genuinely help to reduce the size of the fibroid; different centres use different ones.

Question 8

Do you suggest that a scan measuring a 5cm fibroid should be surgically removed?

Dr. Suman Lal · Accepted Answer

It depends. If a 5 cm fibroid is coming inside the uterus and causing heavy bleeding or obstruction, removal is needed. If the fibroid is outside the uterus and causing no problem, there is no need to operate. If it is in the muscle layer of the uterus and causing problems for a woman who wants a baby or needs IVF, it often has to be removed. The symptoms, the need, the location and the size must all be considered together before planning treatment.

Question 9

What is the relationship between fibroids and menstrual pain?

Dr. Suman Lal · Accepted Answer

A fibroid in the cavity acts like a foreign body. When menstruation starts, the uterine muscle contracts, and with every contraction the uterus tries to expel the fibroid, just as in labour it tries to expel the baby; this causes menstrual cramps. A fibroid within the muscle of the uterus enlarges the uterus and increases its surface area, which can cause much more pain and bleeding, both of which accompany menstrual cramps.

Question 10

What are the indications and limitations of uterine artery embolization for fibroids?

Dr. Suman Lal · Accepted Answer

Embolization is a very good technique that requires neither surgery nor medication, but it has limits. It cannot be done for a calcified fibroid, into which no blood vessel runs. It cannot be done for a woman who wants a pregnancy: the blood flow to the uterus falls, the baby would not get the nutrition and its growth would be hampered, so myomectomy is advised instead. Embolization is suitable for small, few, non-calcified fibroids, and best for a woman who has completed her family.

Question 11

What is the fate of myoma nuclei after embolization, and why is it contraindicated in women wishing to conceive in the future?

Dr. Suman Lal · Accepted Answer

The contraindication follows from how embolization works. Material is placed to block the artery supplying the uterus and myoma; once the artery is blocked, blood no longer reaches the myoma, which dies off (infarcts) and gradually shrinks. Because blood flow to the uterus falls and a baby would not get enough nutrition, we should not do embolization for a woman who wishes to conceive after the procedure.

Question 12

In cases of infertility, is there any actual management in terms of medication?

Dr. Suman Lal · Accepted Answer

Infertility has several causes, and the cause must be established first. The tubes may be blocked, or the eggs may be too few; other causes include fibroids, adenomyosis and endometriosis. Each needs different medication and treatment. For a woman with fibroids who wants to conceive without surgery, GnRH agonists can shrink the fibroid. She cannot conceive while on the injections, but once they are stopped ovulation returns, and the shrinking effect lasts six to nine months before the fibroid regrows; within that window she can be given medication and can try to conceive.

Question 13

Can endometriosis be cured completely, and how can someone with endometriosis get pregnant easily?

Dr. Suman Lal · Accepted Answer

A complete cure of endometriosis is mostly not possible, but early detection and timely, adequate treatment are key. If an endometrioma needs surgery, it is better to perform a cystectomy, removing the endometriotic tissue while protecting the healthy ovarian tissue, and then help the woman conceive, so that if the disease recurs, the pregnancy is not affected. Many medications are available, but the first surgery matters most: if it is not done properly, recurrence is more likely.

Question 14

What is the best way to treat PCOS?

Dr. Suman Lal · Accepted Answer

PCOS is fundamentally a lifestyle disease, so lifestyle changes, decreased stress, better diet, exercise and meditation, are the most important treatment. Beyond that, treatment targets specific symptoms: hormonal pills for delayed periods, targeted medication for acne or hair loss, and ovulation induction with specialist support for women not conceiving.

Question 15

What is the conservative management of symptomatic uterine fibroids?

Dr. Suman Lal · Accepted Answer

Symptomatic fibroids most often cause heavy bleeding. Tranexamic acid can be given, a Mirena can be inserted, and if the cavity is normal, hormones can be given. If the woman does not respond, surgical treatment is needed. When the main symptoms are pain and pressure, GnRH agonists can be given: they reduce the fibroid by 40 to 50%, and the pressure symptoms are relieved.

Question 16

Is the presence of a single wart on the vulva significant?

Dr. Suman Lal · Accepted Answer

Vulval warts are generally caused by low-risk human papillomavirus. A woman with one vulval wart may develop more in future, and if more appear they should be treated. Her partner should be examined and, if he has warts, referred for treatment. The woman should be counselled that this is a low-risk virus, and she should stay up to date with routine cervical screening, which checks for the high-risk HPV types that can cause cervical cancer. The wart can also be removed and sent for biopsy to confirm that it is only a wart.

Question 17

What exactly is the role of dietary factors in the genesis of benign growths in the uterus?

Dr. Suman Lal · Accepted Answer

Stress reduction matters, as does reducing oxidative stress. Women who avoid excessive alcohol and take more folic acid and vitamins, especially vitamins A and C, which repair cells, have fewer of these hormone-related problems such as adenomyosis and fibroids. Diet does play a role, but genetics is also very important. Women should be advised to modify their diet, and those at high risk of developing fibroids should have ultrasound check-ups and see their doctor if they develop symptoms.

Question 18

What is the real cause of fibroids?

Dr. Suman Lal · Accepted Answer

Fibroids have long been the most common such problem, but it is still not known why they grow. What is understood is that the more unopposed oestrogen the uterus is exposed to, the more fibroids form: whenever there is more oestrogen in the body, fibroids can develop, and progesterone also drives their growth.

Question 19

After a myomectomy there is some adhesion trouble. Is physical therapy the only helpful therapy for reducing those adhesions?

Dr. Suman Lal · Accepted Answer

Adhesion formation is the rule after any surgery; some women form fewer adhesions and some more. Many anti-adhesive materials are on the market, but what matters is surgical technique: apposing the tissue accurately, not leaving blood inside and cleaning the surrounding tissue result in fewer adhesions. If there is more bleeding, a drain can be placed so that the blood drains out. When we operate this way and later perform a caesarean on these women, we find few adhesions. The omentum can sometimes be placed over the repair site so that the bowel does not adhere there; otherwise anti-adhesive products can be used. No drug, medicine or dietary advice can really reduce adhesions. Sterilisation of instruments is very important, because a woman who develops an infection after surgery forms more adhesions.

Live Discussion with Dr. Suman Lal