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FIBROIDS IN UTERUS? FACTS THAT YOU NEED TO KNOW

About 30-50% females are detected to have fibroids in their uterus. This detection maybe incidental on an ultrasound exam without the patient having problems due to it; or this detection could be very much related to your medical problems. Here are some answers which might help you.

1. What are fibroids?

These are benign tumors which develop from the involuntary muscle of the uterus. These maybe within the wall (intramural) or arise from the wall but as they grow they project into the uterine cavity (submucosal), distorting it and often causing excessive menstrual bleeding. They may also project outside the wall (serosal); some may have a stalk (peduncle) which makes the fibroid vulnerable to twisting (torsion) as a complication. If a fibroid lies near the mouth of the uterus, it might cause difficult birth due to obstruction. One may have a variable number of fibroids which usually  grow slowly. Transformation to cancer is very rare (1:1000)

2. Who is more likely to have fibroids?

There is a mild increase in predisposition in Asian and African American women as compared to western women. But these can occur in any woman.

3. What are the symptoms of fibroids?

These maybe totally without any symptoms or may cause any of the following problems besides those  listed above.

  1. Longer, more frequent, or heavy menstrual periods.
  2. Menstrual pain (cramps)
  3. Vaginal bleeding at times other than menstruation.
  4. Anemia (from blood loss)
  5. Pain —In the abdomen or lower back (often dull, heavy and aching, but may be sharp); pain during  sex
  6. Pressure —Difficulty urinating or frequent urination; Constipation, rectal pain, or difficult bowel movements
  7. Abdominal cramps
  8.  Miscarriages
  9.  Infertility (need to rule out other causes of infertility first).
  10. What complications can occur with fibroids?

4. What causes fibroids?

The causes are to some extent genetic but most often these tumors have been found to be hormone dependent (estrogen/ progesterone). Therefore fibroids may regress after menopause.

5. How are fibroids detected?

These can be detected by ultrasonography, hysteroscopy (a slender device, the hysteroscope is used to see the inside of the uterus. It is inserted through the vagina and cervix, hysterosalpingography which is a special X-ray test which may be able to detect abnormal changes in the size and shape of the uterus and fallopian tubes. Sometimes a laparoscope (a slender device inserted through a small cut in abdomen might help the doctor see the inside of the abdomen. The doctor can see fibroids on the outside of the uterus with the laparoscope. Imaging tests, such as magnetic resonance imaging and computed tomography scans, may be used but are rarely needed. Some of these tests may be used to track the growth of fibroids over time.

6. When to see a doctor if detected with fibroid?

Small fibroids may cause no problem, its only when you have symptoms listed above that you need to get them treated.

7. Is there medical treatment for fibroids?

The decision on type of treatment, medical/surgical should be taken by you after you get an appropriate advice about the best option for you. The same will depend on your clinical condition, fertility status, types , number and location of fibroids. Medical treatment is available in the form of hormones (gonadotropin-releasing hormone; GnRH agonists). These are used best upto 6 months max. They help to shrink fibroids; however these may get back to their size after stopping. Hormonal intrauterine devices may also be inserted too into the uterus.

8. What are the surgery options?

These are individualised to each case depending upon whether you have completed your family and the types of fibroid. If pregnancy is desired then a myomectomy is the best choice; wherein only selective removal of the fibroid is done.  This procedure is usually done laparoscopically (through a small cut in the abdomen) and it preserves the uterus. Hysteroscopic removal with a resectoscope is another method used to remove fibroids that protrude into the cavity of the uterus. A resectoscope is inserted through the hysteroscope. The resectoscope destroys fibroids with electricity or a laser beam. Although it cannot remove fibroids deep in the walls of the uterus, it often can control the bleeding these fibroids cause. Hysteroscopy often can be performed as an outpatient procedure (you do not have to stay overnight in the hospital). Another procedure that your doctor may recommend depending on your case is `endometrial ablation` wherein inner lining of endometrium is destroyed. Thsi maybe a choice in v small fibroids (less than 3 cm). Blocking the blood supply selectively to the fibroid which helps to shrink it is another choice and is known as ùterine artery embolisation. Magnetic resonance imaging-guided ultrasound surgery is another non invasive procedure where ultrasound waves are used to destroy fibroids; its long term cure is still under research.
If the patient has completed her family the removal of uterus along with the fibroid in it maybe the best choice.

9. How would I know if my fibroid is predisposed to cancer?

Most fibroids are benign. Certain features on imaging also reveal the same. It is important that after removal, the tissue removed is examined by a pathologist to ensure the same. There maybe certain miscroscopic features which suggest that you need a follow up. All human tissue removed at any surgery must be confirmed for its identity under a microscope by a histopathologist as per international health care standards.

10. After a myomectomy removal , how soon could a pregnancy be planned?

The best time is after 6 months although healing is complete by 3 months. 

Infections and Cancer

Certain infections if not cleared over a period of time lead to mutative changes in the cells in the organs that they infect and predispose to Cancer of these. Enlisted below are most of them. It is imperative that we get screened and remedies to clear these infections are sought in order to prevent these cancers. Most of these are viruses.

Infectious Causes of Cancer

Infectious-Causes

Prostate and Disease

Worldwide, Prostate cancer is the second most common cause of cancer and the sixth leading cause of cancer death among men. Cancer of the prostate has become a major health problem in industrialized world and the same is being reflected in India as its economy grows possibly due to changed lifestyles or increased migration of the rural section to the urban.
It is said if the current trend continues this cancer will become a far greater public health problem in the future. Delhi Cancer registry shows cancer of the prostate is the second most frequently diagnosed cancer among men in Delhi accounting for about 6.78% of all malignancies.

What and where is the prostate gland?

This is a funnel shaped gland weighing about 30 grams in an adult male. It surrounds the junction of urinary bladder to urethra. It has an outer and inner zone. Cancers mainly arise from the outer zone whereas enlargements occur mainly in the inner zone.

Role of prostate gland

Not known for sure but the prostatic secretions add to the sperm so appear to be nutritional to the same.

Diseases of prostate gland

  • Benign Prostate Hyperplasia

Commonest is an enlargement called prostatic hypertrophy. The gland steadily enlarges in men after 40 years and in most the problem gets problematic when this gland begins to obstruct the passage of urine! It is increases to the sizeof a walnut at 40yrs and to a lemon size by 60 years. Benign prostatic hyperplasia is the commonest urologic disorder in men.

Symptoms of BPH

  • Trouble starting a urine stream or making more than a dribble
  • Passing urine often, especially at night
  • Feeling that the bladder has not fully emptied
  • A strong or sudden urge to pass urine
  • Weak or slow urine stream
  • Stopping and starting again several times while passing urine
  • Pushing or straining to begin passing urine

Neglect of enlarged gland can eventually lead to obstruction of urine (may need cathetrization) and even renal failure as the obstruction increases.

TREATMENT

Treatment is medical (decreases size of gland and relaxes the urinary bladder sphincter to relieve obstruction) and surgical (removal of chips of prostate gland –TURP- in order to decrease obstruction, even lasers maybe used). These are provided by the urologist. The tissue removed at surgery MUST be examined by a pathologist to check if there is any cancer in the tissue removed although possibility of the same are usually remote.

Conservative with watchful waiting
Maybe resorted to if symptoms are not bothersome. Should carry out annual checks.

  • Prostatitis.

It is bacterial/ fungal/ tuberculous infection of the gland and is usually associated with urinary tract infection. This condition is treated medically by antibiotics by a urologist.

Symptoms of prostatitis

  • Trouble passing urine
  • A burning or stinging feeling or pain when passing urine
  • Strong, frequent urge to pass urine, even when there is only a small amount of urine
  • Chills and high fever
  • Low back pain or body aches
  • Pain low in the belly, groin, or behind the scrotum
  • Rectal pressure or pain
  • Urethral discharge with bowel movements
  • Genital and rectal throbbing
  • Sexual problems and loss of sex drive
  • Painful ejaculation (sexual climax)

Tests such as `digital rectal exam’(DRE) and a urine test, can be done to see if you have prostatitis. Correct diagnosis of your exact type of prostatitis is key to getting the best treatment.

3. Cancer of the Prostate

Although cancer of prostate is rising, this cancer has an excellent 5 yr survival rates if on treatment.
Prostate cancer means that the glands begin to proliferate and infiterate the stroma of the gland; eventually could lead to spread beyond the gland especially the lower spine.

Of note is that Prostate cancer tends to grow slowly as compared to other cancers. Cell changes may begin 10, 20, or even 30 years before a tumor gets big enough to cause symptoms. By the time symptoms appear, the cancer may already be advanced.

By age 50, very few men have symptoms of prostate cancer, yet some precancerous or cancer cells may be present. More than 50 % of men in some countries especially America have cancer in their prostate by 80 years. We do not have the figures for India. In India most men suffer from other diseases and succumb to them before the prostate lesion is identified!

Symptoms of Prostate Cancer

  • Trouble passing urine
  • Frequent urge to pass urine, especially at night
  • Weak or interrupted urine stream
  • Pain or burning when passing urine
  • Blood in the urine or semen
  • Painful ejaculation
  • Nagging pain in the back, hips, or pelvis

Spread
Prostate cancer spreads most commonly to bones especially lower spine. Therefore back pain inolder men needs to be taken seriously.

Risk Factors For Prostate Cancer

  • Age. Men older than 50 yrs.
  • Family history. Men whose fathers or brothers have had prostate cancer have a 2 to 3 times higher risk of prostate cancer than men who do not have a family history of the disease. Prostate cancer risk also appears to be slightly higher for men from families with a history of breast cancer.
  • Diet. The risk of prostate cancer may be higher for men who eat high-fat diets.

Screening for Prostate Cancer

Screening means testing for cancer before you have any symptoms. A screening test may help find cancer at an early stage, when it is less likely to have spread and may be easier to treat. By the time symptoms appear, the cancer may have started to spread.
The most useful screening tests are those that have been proven to lower a person’s risk of dying from cancer. Doctors do not yet know whether prostate cancer screening lowers the risk of dying from prostate cancer. Therefore, large research studies, with thousands of men, are now going on to study prostate cancer screening. The National Cancer Institute is studying the combination of PSA testing and DRE as a way to get more accurate results.
Talk with your doctor about your risk of prostate cancer and your need for screening tests.

PLEASE REMEMBER…..

Most prostate cancers grow slowly and don’t cause any health problems in men who have them. If you decide not to get screened, you can always change your mind later. If you decide to get screened, it does not mean you have to go to the next step. You should discuss each step with your doctor. Most prostate cancers found by screening are small and slow growing and may not be fatal. Some men may have a faster growing prostate cancer and will benefit from early treatment. Older men, African-American men, and men who have a family history of prostate cancer have a greater risk for developing prostate cancer. If you are concerned that you may have a greater risk for prostate cancer, talk to your doctor about screening.

Tests Used to Check the Prostate

Screening for Prostate Cancer
One screening test for prostate cancer is a blood test, which can be abnormal (not normal) for several reasons besides prostate cancer. It is looking for levels of Prostate Specific antigen (PSA). The only way to know if an abnormal test is due to cancer is to do a biopsy. A biopsy is a minor surgery to get small pieces of the prostate to look at under a microscope. If the biopsy shows there are cancer cells, then your doctor will discuss treatment options.

Treatment of prostate cancer may include:

  • Close monitoring and follow-up visits.
  • Radiation
  • Surgery to remove the prostate.

Side effects from radiation or surgery could happen and these are
– Impotence
– Loss of bladder control
– Problems with your rectum.

The first step is to talk to your doc about your prostate concerns. Symptoms like pain, fever, or trouble passing urine need to be looked for. Your own personal medical history including medications should be provided to the doc. You may be asked to give a urine sample for testing.

The Digital Rectal Exam (DRE)

DRE is a standard way to check the prostate. With a gloved and lubricated finger, your doctor feels the prostate from the rectum. The test lasts about 10-15 seconds.
This exam checks for:

  • The size, firmness, and texture of the prostate
  • Any hard areas, lumps, or growth spreading beyond the prostate, and
  • Any pain caused by touching or pressing the prostate

The DRE allows the doctor to feel only one side of the prostate. A PSA test is another way to help your doctor check the health of your prostate.

PSA (Prostate-Specific Antigen) Test

The U.S. Food and Drug Administration (FDA) has approved the use of the PSA test along with a DRE to help detect prostate cancer in men age 50 and older. PSA is a protein made by prostate cells. It is normally secreted into ducts in the prostate, where it helps make semen, but sometimes it leaks into the blood. In prostate cancer, more PSA gets into the blood than is normal. Please remember, a high PSA blood level is not proof of cancer, and many other things can cause a false-positive test result. Blood PSA levels are often increased in men with prostatitis or BPH. Even things that disturb the prostate gland–such as riding a bicycle or motorcycle, or having a DRE, an orgasm within the past 24 hours, a prostate biopsy, or prostate surgery–may increase PSA levels.
PSA tests are often used to follow men after prostate cancer treatment to check for signs of cancer recurrence.
man has a high PSA level. For now, men and their doctors use PSA readings over time as a guide to see if more follow-up is needed.

PSA test results

PSA levels are measured in terms of the amount of PSA per volume of fluid tested. Doctors often use a value of 4 nanograms (ng) or higher per milliliter of blood as a sign that further tests, such as a prostate biopsy, are needed. Your doctor may monitor your PSA velocity, which means the rate of change in your PSA level over time. Rapid increases in PSA readings may suggest cancer. If you have a mildly elevated PSA level, you and your doctor may choose to do PSA tests on a scheduled basis and watch for any change in the PSA velocity.

Free PSA test

This test is used for men who have higher PSA levels. The standard PSA test measures total PSA, which includes both PSA that is attached, or bound, to other proteins and PSA that is free, or not bound. The free PSA test measures free PSA only. Free PSA is linked to benign prostate conditions, such as BPH, whereas bound PSA is linked to cancer. The percentage of free PSA can help tell what kind of prostate problem you have.

  • If both total PSA and free PSA are higher than normal (high percentage of free PSA), this suggests BPH rather than cancer.
  • If total PSA is high but free PSA is not (low percentage of free PSA), cancer is more likely. More testing, such as a biopsy, should be done.

You and your doctor should talk about your personal risk and free PSA results. Then you can decide together whether to have follow-up biopsies and, if so, how often.

Prostate Biopsy

If your symptoms or test results suggest prostate cancer, your doctor will refer you to a specialist (a urologist) for a prostate biopsy. For a biopsy, small tissue samples are taken directly from the prostate. Your doctor will take samples from several areas of the prostate gland. This can help lower the chance of missing any areas of the gland that may have cancer cells. Like other cancers, prostate cancer can be diagnosed only by looking at tissue under a microscope.
A positive test result after a biopsy means prostate cancer is present. A pathologist will check your biopsy sample for cancer cells and will give it a Gleason score. The Gleason score ranges from 2 to 10 and describes how likely it is that a tumor will spread. The lower the number, the less aggressive the tumor is and the less likely it will spread. Treatment options depend on the stage (or extent) of the cancer (stages range from 1 to 4), Gleason score, PSA level, and your age and general health. This information will be available from your doctor and is listed on your pathology report.
Ref: https://www.cdc.gov/cancer/prostate

Physicians and Patients Should Know and Question the Following

Ref: American Society for Clinical Pathology

  1. Don’t perform population based screening for 25-OH-Vitamin D deficiency. Vitamin D deficiency is common in many populations, particularly in patients at higher latitudes, during winter months and in those with limited sun exposure. Over the counter Vitamin D supplements and increased summer sun exposure are sufficient for most otherwise healthy patients. Laboratory testing is appropriate in higher risk patients when results will be used to institute more aggressive therapy (e.g., osteoporosis, chronic kidney disease, malabsorption, some infections, obese individuals).
  2. Don’t perform low risk HPV testing. National guidelines provide for HPV testing in patients with certain abnormal Pap smears and in other select clinical indications. The presence of high risk HPV leads to more frequent examination or more aggressive investigation (e.g., colposcopy and biopsy). There is no medical indication for low risk HPV testing (HPV types that cause genital warts or very minor cell changes on the cervix) because the infection is not associated with disease progression and there is no treatment or therapy change indicated when low risk HPV is identified.
  3. Only order Methylated Septin 9 (SEPT9) to screen for colon cancer on patients for whom conventional diagnostics are not possible. Methylated Septin 9 (SEPT9) is a plasma test to screen patients for colorectal cancer. Its sensitivity and specificity are similar to commonly ordered stool guaiac or fecal immune tests. It offers an advantage over no testing in patients that refuse these tests or who, despite aggressive counseling, decline to have recommended colonoscopy. The test should not be considered as an alternative to standard diagnostic procedures when those procedures are possible.
  4. Don’t use bleeding time test to guide patient care. The bleeding time test is an older assay that has been replaced by alternative coagulation tests. The relationship between the bleeding time test and the risk of a patient’s actually bleeding has not been established. Further, the test leaves a scar on the forearm. There are other reliable tests of coagulation available to evaluate the risks of bleeding in appropriate patient populations.
  5. Don’t order an erythrocyte sedimentation rate (ESR) to look for inflammation in patients with undiagnosed conditions. Order a C-reactive protein (CRP) to detect acute phase inflammation. CRP is a more sensitive and specific reflection of the acute phase of inflammation than is the ESR. In the first 24 hours of a disease process, the CRP will be elevated, while the ESR may be normal. If the source of inflammation is removed, the CRP will return to normal within a day or so, while the ESR will remain elevated for several days until excess fibrinogen is removed from the serum.
  6. Don’t test vitamin K levels unless the patient has an abnormal international normalized ratio (INR) and does not respond to vitamin K therapy. Measurements of the level of vitamin K in the blood are rarely used to determine if a deficiency exists. Vitamin K deficiency is very rare, but when it does occur, a prolonged prothrombin time (PT) and elevated INR will result. A diagnosis is typically made by observing the PT correction following administration of vitamin K, plus the presence of clinical risk factors for vitamin K deficiency.
  7. Don’t prescribe testosterone therapy unless there is laboratory evidence of testosterone deficiency. With the increased incidence of obesity and diabetes, there may be increasing numbers of older men with lower testosterone levels that do not fully meet diagnostic or symptomatic criteria for hypogonadism. Current clinical guidelines recommend making a diagnosis of androgen deficiency only in men with consistent symptoms and signs coupled with unequivocally low serum testosterone levels. Serum testosterone should only be ordered on patients exhibiting signs and symptoms of androgen deficiency.
  8. Don’t test for myoglobin or CK-MB in the diagnosis of acute myocardial infarction (AMI). Instead, use troponin I or T. Unlike CK-MB and myoglobin, the release of troponin I or T is specific to cardiac injury. Troponin is released before CK-MB and appears in the blood as early as, if not earlier than, myoglobin after AMI. Approximately 30% of patients experiencing chest discomfort at rest with a normal CK-MB will be diagnosed with AMI when evaluated using troponins. Single-point troponin measurements equate to infarct size for the determination of the AMI severity. Accordingly, there is much support for relying solely on troponin and discontinuing the use of CK-MB and other markers.
  9. Don’t order multiple tests in the initial evaluation of a patient with suspected non-neoplastic thyroid disease. Order thyroid-stimulating hormone (TSH), and if abnormal, follow up with additional evaluation or treatment depending on the findings. The TSH test can detect subclinical thyroid disease in patients without symptoms of thyroid dysfunction. A TSH value within the reference interval excludes the majority of cases of primary overt thyroid disease. If the TSH is abnormal, confirm the diagnosis with free thyroxine (T4).

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

Ref: American Society for Clinical Pathology
Released February 21, 2014 and February 4, 2015