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

Myomectomy puts an incision into the uterus. Just as we advise a woman who has had a caesarean to leave a gap of about two years before the next pregnancy so the scar heals well, the same principle applies after myomectomy. If it was a laparoscopic myomectomy for a subserous pedunculated fibroid and the myometrium was not opened, she can try to conceive about six months after surgery. If the myometrium was opened to remove the fibroid, we advise her to wait at least one and a half to two years before trying to conceive.

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 is usually deep and comes with lower abdominal pain, tenderness on moving the cervix, abnormal or foul-smelling vaginal discharge, sometimes fever and sometimes urinary tract symptoms. With a fibroid, the dyspareunia is not accompanied by these features. A vaginal or cervical swab may show an infective organism in pelvic inflammatory disease, which is usually absent when a fibroid is the cause, although a negative swab does not rule pelvic inflammatory disease out.

Question 4

What are the benefits of GnRH analogues in treating fibroids?

Dr. Supriya Malhotra · Accepted Answer

The first indication is a large fibroid planned for myomectomy. A bigger fibroid means more bleeding during surgery, so we shrink it first with GnRH analogues for one to about three months, as a monthly or a three-monthly dose, which makes it easier to remove. The second indication is a perimenopausal woman. Once menopause sets in the fibroid will shrink anyway, and her hormones are already falling, so we give these hormones for a few months to make the fibroid shrink faster and control her symptoms until she reaches menopause.

Question 5

What delivery method should be chosen for a first-time mother who has had a myomectomy and is now pregnant?

Dr. Supriya Malhotra · Accepted Answer

If the cavity was opened, we would do an elective caesarean section. If only a subserous fibroid was removed, often by clamping a small stalk, the uterine musculature has not really been touched and she can have a normal delivery. But it must be an institutional delivery, never a home delivery, because complications can arise during labour, and then she can be taken for a caesarean immediately. So, an institutional delivery under proper surveillance.

Question 6

Could you explain the hormonal therapy in the medical management of fibroids?

Dr. Supriya Malhotra · Accepted Answer

We can give combined oral contraceptive pills, which reduce the body's own production of estrogen and progesterone. They do not remove fibroids, but they reduce the bleeding caused by the fibroid and make cycles painless. Sometimes we give progesterone alone. A newer option is Mirena, an intrauterine contraceptive device placed in the uterus that releases a very small amount of progesterone every day; it is suitable when the fibroid does not distort the uterine cavity. Both estrogen and progesterone drive fibroid growth, but the continuous local progesterone thins the lining of the uterus, so pain is controlled and bleeding becomes absent or very scanty. It controls the symptoms; it does not reliably decrease the size of the fibroid.

Question 7

Could you recap the indications for surgery?

Dr. Supriya Malhotra · Accepted Answer

There are two surgeries. Myomectomy removes only the fibroid and leaves the uterus intact. We do it when the patient wants to preserve the uterus: she is young and wants children, has had one child and wants more, or is 30 to 35 and does not want her uterus removed. It is a fertility-enhancing procedure, but the patient must understand that it removes only the fibroids that can be seen; seedling fibroids may grow and new ones may develop, because the hormonal milieu stays the same until menopause. The definitive treatment is hysterectomy, for a woman who has completed childbearing or does not want children, or has very big fibroids, is over 40 and does not want to keep suffering heavy bleeding and taking medication. The whole uterus is removed with the fibroids.

Question 8

At what stage should hysteroscopy be used instead of MRI?

Dr. Supriya Malhotra · Accepted Answer

They are two different modalities. MRI is a non-invasive radiological investigation with no radiation; it takes very thin slices of the soft tissues and gives a detailed view of the fibroid. Hysteroscopy is a minimally invasive endoscopic procedure: a scope is passed through the cervix without incisions, the cavity is viewed directly, and any fibroid or fibroid polyp seen can be removed. Fibroids are diagnosed clinically and confirmed on ultrasound; hysteroscopy is never used as an investigative tool. When a fibroid inside the cavity, a submucous fibroid, is seen on ultrasound, hysteroscopy is used to remove it. If there is doubt on ultrasound, such as a very small chance of cancerous change, we advise MRI, which gives a detailed image and can also show associated findings, such as lymph nodes or minimal fluid, that ultrasound sometimes misses. Hysteroscopy is a treatment modality: we see the lesion and treat it at the same time.

Question 9

What is your perspective on meat consumption versus a planetary health diet in managing uterine fibroids?

Dr. Supriya Malhotra · Accepted Answer

Nutrition is very important. Stay within your BMI: weight control matters especially because fibroids are more significant in obese patients. Exercise and diet control, with an anti-inflammatory diet, are recommended, generally the Mediterranean diet: plenty of green leafy vegetables and omega-3 sources such as walnuts, flax seeds, olive oil and olives, with no caffeine and no alcohol. Not smoking is important for general health. Eat less red meat, which is considered inflammatory; we recommend white meat such as fish, turkey and chicken.

Question 10

How effective is focused ultrasound in treating fibroids compared with the available modalities?

Dr. Supriya Malhotra · Accepted Answer

It is a hopeful non-invasive option. MRI-guided focused ultrasound and radiofrequency ablation are still undergoing clinical trials, and there is no definitive proof yet; more trials are needed before they come into routine clinical use. At present, the minimally invasive procedure in widest use is uterine artery embolisation.

Question 11

How should dysmenorrhoea be treated in an unmarried woman?

Dr. Supriya Malhotra · Accepted Answer

First rule out a fibroid, adenomyosis, endometriosis or pelvic inflammatory disease as the cause; if we know the cause, we can treat it much better. Medical treatment for dysmenorrhoea is NSAIDs and over-the-counter painkillers such as Tylenol, ibuprofen and naproxen. If it is very severe, a trial of oral contraceptive pills can be given, as they reduce period pain and flow, making periods regular, scanty and pain-free.

Question 12

How does uterine artery embolization compare with myomectomy?

Dr. Supriya Malhotra · Accepted Answer

Myomectomy is a more invasive surgical procedure needing hospitalisation, done by a gynaecologist by laparotomy, laparoscopy or robotically. Uterine artery embolisation is an OPD procedure done by an interventional radiologist with the gynaecologist: a catheter is passed through the groin artery into the uterine artery, and small particles, mostly polyvinyl alcohol, are injected into the vessel feeding the fibroid, cutting off its blood supply so that the fibroid shrinks over time. It is less invasive than a myomectomy, and for a woman who is suitable for it I consider it better than undergoing a myomectomy, but it has limitations and cannot be done for every fibroid. It is contraindicated in pregnancy, where the fibroid may harbour cancer, where there is a uterine or pelvic infection, and for very large or pedunculated fibroids.

Question 13

How do you identify the exact location of a fibroid on the uterus?

Dr. Supriya Malhotra · Accepted Answer

On bimanual examination we can feel irregular enlargement of the uterus, anteriorly, posteriorly or at the sides. To confirm the diagnosis we ask for an ultrasound, which gives the exact location.

Question 14

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. For a woman over 40 who has completed childbearing, hysterectomy is a very good option so she no longer suffers the effects of the fibroids. If she is under 50, we normally leave the ovaries if they are healthy; over 50, we normally remove them as well. If the ovaries are left, there is no surgical menopause. If in a younger woman the ovaries look unhealthy, we remove them rather than risk a second operation a year or two later for an ovarian cyst or tumour. If they are removed before the normal age of menopause, we give hormone replacement therapy until about the age of natural menopause, 52 or 53, because a surgical menopause is much more severe than a natural one: bad mood swings, hot flushes, breast pain, depression, anxiety and palpitations. We no longer recommend HRT for very long, only until that age.

Question 15

Is there any possibility of targeted gene therapy for fibroids?

Dr. Supriya Malhotra · Accepted Answer

There is a genetic predisposition, but there are no definitive targeted gene therapies yet, because we do not really know the definitive cause. We assume it is estrogen and progesterone, because fibroids shrink after menopause. Targeted gene therapy will come, perhaps in the coming years, but not right now.

Question 16

How do you view the future of blocking the hormones that stimulate fibroid growth?

Dr. Supriya Malhotra · Accepted Answer

We are already blocking the internal hormones, even with the pill. Girls now take oral contraceptive pills from about 17 to 35, and as long as there are no contraindications, there is no problem: for example, she should not smoke if she is over 35, and she should not have high blood pressure, migraine with aura, or a history of blood clots or stroke. It is quite safe.

Question 17

Does the Mirena IUCD treat fibroids?

Dr. Supriya Malhotra · Accepted Answer

No. Mirena is an intrauterine contraceptive device that releases very small amounts of hormone. It does not treat fibroids, but it helps control their symptoms. Definitive treatment is removal by myomectomy or hysterectomy, or the minimally invasive procedures.

Question 18

When do we use Primolut-N in uterine fibroids?

Dr. Supriya Malhotra · Accepted Answer

Primolut-N is one of the progesterones and can be given, like Mirena. A combined pill is better, but when a patient cannot tolerate the estrogen-progesterone combination, we can give Primolut-N twice daily from day five to day 25 of the cycle, or continuously. If she does not want periods, give it continuously. If she wants a withdrawal bleed, give it from day five to day 25 and stop; the bleed will be much lighter than a normal period and painless.

Question 19

Is there a chance of relapse after myomectomy?

Dr. Supriya Malhotra · Accepted Answer

Yes. We remove only the fibroids we can see. Small seedling fibroids may grow and new fibroids can develop, because the body's hormonal milieu is unchanged: the patient is still producing estrogen and has not reached menopause, so fibroids can recur.

Question 20

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

If a woman has had a myomectomy and is not getting pregnant, there is no reason to keep waiting; we can go for IVF. Recurrence cannot be prevented while she is still in her childbearing years, because the hormonal milieu remains the same. Surgery removes only what the fibroids have caused and what we can see. Some seedling fibroids are too small to see at surgery, and they will grow.

Question 21

How safe is a pregnancy in the presence of fibroids?

Dr. Supriya Malhotra · Accepted Answer

Fibroids, especially very large ones or submucous fibroids bulging into the cavity, can prevent pregnancy and cause infertility, and if the patient does conceive they can cause early miscarriage. If the pregnancy continues, it may progress uneventfully, completely without symptoms. But fibroids can cause pain, enlarge, undergo degeneration, cause malpresentation and premature labour, and cause incoordinate uterine action that raises the caesarean rate, as well as postpartum haemorrhage. It is a high-risk pregnancy and should be monitored closely.

Question 22

Does pregnancy affect fibroid growth?

Dr. Supriya Malhotra · Accepted Answer

In the first trimester fibroids can grow, because more blood goes to the uterus and so to the fibroids. Once they have grown, they do not increase much more in the second and third trimesters, and after pregnancy they shrink back to their original size.

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