Question 1

How best can we differentiate a fibroid from a molar pregnancy?

Dr. Supriya Malhotra · Accepted Answer

Fibroids have a typical whorled appearance on ultrasound, round and well encapsulated. A molar pregnancy shows an erratic collection of cells rather than a defined mass, and hormonal testing helps too: hCG levels rise well beyond what is normal in pregnancy. An ultrasound or MRI clearly distinguishes the two, since fibroids have a characteristic encapsulated, whorled appearance that a molar pregnancy does not.

Question 2

How long after a myomectomy should a woman expect to be able to conceive?

Dr. Supriya Malhotra · Accepted Answer

It depends on whether the myometrium was opened. If it was a laparoscopic myomectomy for a subserous, pedunculated fibroid where the myometrium was not opened, pregnancy can usually be attempted after about six months. If the myometrium was opened to remove the fibroid, the advice is to wait one and a half to two years, similar to the healing time given after a previous caesarean section.

Question 3

How do we differentiate dyspareunia caused by a uterine fibroid from dyspareunia caused by pelvic inflammatory disease?

Dr. Supriya Malhotra · Accepted Answer

Dyspareunia from pelvic inflammatory disease usually comes with vaginismus, foul-smelling vaginal discharge and sometimes urinary tract symptoms. With a fibroid, the dyspareunia is not accompanied by these features. A vaginal swab sent for examination will show an infective organism in pelvic inflammatory disease, which is usually absent when a fibroid is the cause.

Question 4

What are the benefits of GnRH analogues in treating fibroids?

Dr. Supriya Malhotra · Accepted Answer

GnRH analogues are used to shrink a fibroid before a planned myomectomy, since a smaller fibroid means less bleeding during surgery; a monthly or three-monthly dose is given for this. The second use is in a perimenopausal woman, where these hormones hasten the natural shrinkage that would occur anyway as menopause approaches, since fibroids are otherwise known to delay menopause.

Question 5

At what stage should hysteroscopy be used instead of MRI?

Dr. Supriya Malhotra · Accepted Answer

The two are not alternatives for diagnosis. MRI is a radiological procedure with no radiation that gives a detailed, thin-sliced view of a fibroid, and it is used when there is diagnostic doubt on ultrasound, for instance the rare possibility of a cancerous change. Hysteroscopy is a minimally invasive endoscopic procedure passed through the cervix, and it is never used as an investigative tool for diagnosing a fibroid. It is a treatment modality: it is used once a fibroid or polyp inside the cavity has already been identified, so it can be removed under direct vision.

Question 6

What is your perspective on meat consumption versus a plant-based diet in managing uterine fibroids?

Dr. Supriya Malhotra · Accepted Answer

Weight control through exercise and diet is important, since fibroids are more common in obese patients. An anti-inflammatory, broadly Mediterranean diet is recommended: plenty of green leafy vegetables, omega-3 sources like walnuts, flax seeds and olive oil, and less caffeine, alcohol and smoking. Red meat is considered inflammatory, so white meat such as fish, turkey and chicken is the better choice.

Question 7

How does uterine artery embolization compare with myomectomy?

Dr. Supriya Malhotra · Accepted Answer

Myomectomy is a surgical procedure requiring hospitalization, done by a gynaecologist through open surgery, laparoscopy or robotically. Uterine artery embolization is an outpatient procedure done by an interventional radiologist together with a gynaecologist, who passes a catheter through the groin artery into the vessel feeding the fibroid and injects small particles to cut off its blood supply, so the fibroid shrinks over time. It is less invasive and generally preferable to myomectomy, but it has limitations: it is not suitable for very large fibroids, for fibroids with any suspicion of malignancy, or where there is an active uterine infection.

Question 8

Is hysterectomy the best option for a woman who has completed her family, and are there side effects afterward?

Dr. Supriya Malhotra · Accepted Answer

Yes, hysterectomy is a good option for a woman over 40 who has completed childbearing and wants to be free of ongoing fibroid symptoms and medication. If she is under 50 and the ovaries are healthy, they are usually left in place; if she is over 50, the ovaries are usually removed as well. If healthy ovaries are removed before the natural age of menopause, hormone replacement therapy is given until the patient reaches the normal menopausal age, to avoid the more severe mood swings, hot flushes, breast pain and anxiety that a sudden surgical menopause can cause compared with a natural one.

Question 9

Is there any possibility of targeted gene therapy for fibroids, and how do you see the future of blocking the hormones that drive their growth?

Dr. Supriya Malhotra · Accepted Answer

There is a genetic predisposition, but no definitive targeted gene therapy exists yet, largely because the exact cause is still not fully known beyond the working assumption that estrogen and progesterone drive growth, based on the fact that fibroids shrink after menopause. On blocking hormones, this is already happening in a milder form: oral contraceptive pills, which many women take from their late teens into their mid-thirties, work by suppressing internal hormone production, and are safe as long as the patient does not smoke and has no family history of stroke or hypertension.

Question 10

Does the Mirena IUCD treat fibroids?

Dr. Supriya Malhotra · Accepted Answer

No, Mirena is an intrauterine contraceptive device that releases a small daily dose of progesterone, and it does not treat the fibroid itself. It helps control the symptoms, mainly heavy bleeding, but the only definitive treatments remain removal by myomectomy or hysterectomy, or one of the minimally invasive procedures.

Question 11

When do we use Primolut-N in uterine fibroids?

Dr. Supriya Malhotra · Accepted Answer

Primolut-N is a progesterone, similar in principle to Mirena, and can be given when a patient cannot tolerate a combined estrogen-progesterone pill. It can be taken twice daily from day five to day 25 of the cycle if the patient wants a withdrawal bleed, which will be much lighter and pain-free than a normal period, or continuously if she prefers not to have periods at all.

Question 12

Is there any way to prevent a fibroid from recurring in a woman who has had a myomectomy and has not been able to conceive for a long time afterward?

Dr. Supriya Malhotra · Accepted Answer

Recurrence cannot be prevented while a woman is still in her childbearing years, because myomectomy only removes the fibroids that can be seen; the same hormonal environment remains, and small seedling fibroids too tiny to detect at surgery can go on to grow. If a woman has not conceived for a long time after myomectomy, there is no reason to keep waiting: IVF is a reasonable next step rather than continuing to hope for natural conception.

Prevalence, Symptoms, Diagnosis and Treatment of Uterine Fibroids

Questions Doctors Asked Dr. Supriya Malhotra