Wednesday, March 7, 2012

Health Sense: Various ways of identifying and treating fibroids and cysts

Health Sense: Various ways of identifying and treating fibroids and
Lee Keen Whye, Contributor, Singapore | Wed, 03/07/2012 10:59 AM
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Gynecology is the study of female diseases, as opposed to obstetrics, which is the study of pregnancy and its related disorders. The three most common gynecological problems which may need surgery are uterine fibroids, ovarian cysts and heavy menstrual bleeding.

The most common difficulty when a female is diagnosed with a pelvic growth or tumor is to differentiate a fibroid (myoma) from an ovarian cyst and vice versa.

Fibroid and ovarian cysts are the two most common female pelvic growths that cause confusion for patients. Even the term ‘tumor’, which just means a growth and does not indicate whether it is benign (non-cancerous) or a cancer, can be confusing.

A fibroid is commonly referred to as a “meat” or “muscle” tumor. This is because the growth arises from the smooth muscles of the uterus.

Indonesians call it “myom”. Fibroids are common non-cancerous growths found in about 10 to 20 percent of women of reproductive age.

The exact cause is unknown, but is believed to be due to a localized hormonal imbalance of the uterus. Female hormones and drugs or herbs containing traces of estrogen can stimulate the growth of fibroids. Fortunately, the risk of fibroids becoming cancerous is less than 0.5 percent.

Most fibroids are asymptomatic and are often discovered during routine health screenings. Often women regard a bulge at the belly as a “fat” collection associated with overeating, lack of exercise or simply middle age paunch.

The bulge can turn out to be a silently growing fibroid.

When fibroids multiply or enlarge, they can cause pressure on surrounding organs like the bladder, rectum, backbone and pelvis. Patients may complain of urinary symptoms, rectal symptoms, backaches and bloatedness.

In severe cases, it may cause obstruction to the urinary flow leading to kidney damage. Fibroids are known to cause heavy menstrual bleeding and, in some instances, infertility, miscarriage and pre-term labor.

Small fibroids can be observed and in menopause they shrink in size. However, big fibroids that do not shrink after menopause need to be monitored carefully for fear of them turning cancerous.

A symptomatic fibroid needs medical attention. Drugs associated with male hormones and menopause hormones may provide temporary relief but can cause side effects like masculinizing changes (deeper voice, hair growth, acne, etc.) or menopause changes (dry skin, hot flushes, osteoporosis, etc.).

There are newer techniques like uterine artery embolization or ultrasound ablation, but these are for selective cases in specialized centers.

Most symptomatic fibroids are removed surgically via laparoscopic surgery, either in a keyhole or open operation. The choice of laparoscopic or laparotomy surgery depends on the surgeon’s skill, equipment level, size, number and location of the fibroids.

Whether it would be a myomectomy (removal of fibroid) or hysterectomy (removal of womb) will depend on the age, fertility status, and other associated medical factors of a patient. The best option is often arrived at after consultation with a gynecologist.

Ovarian Cyst

Ovarian cysts are fluid-filled tumors that arise from one or both ovaries. The cyst wall, or capsule, is soft and may appear round, oval or irregular in shape.

The cyst’s contents is liquid, mostly fluid, filled with water (clear cyst), filled with blood (hemorrhagic or “chocolate” cyst) or mixed with other human tissues like hair, fat, tooth, cartilage and bone. There are many types of ovarian cysts but I will simplify them into four main types for easy understanding.

Functional cysts are by far the most common reported daily in ultrasound reports causing the most unwarranted anxiety to the patient.

These functional cysts are mostly physiological in nature and best known as ovarian follicles (preovulation) and corpus luteum (post ovulation). These are natural occurrences in normal, menstruating females. Benign cysts can also be found in females on fertility drug treatments, having hormonal imbalances or on progestogenic intra-uterine devices like Mirena. Almost all functional cysts disappear with time and rarely require surgery.

The endometriosis cyst is commonly known as ‘chocolate cyst’ and colloquially called a “blood” cyst. The “chocolate” or “blood”’ inside is actually menstrual blood produced by the endometrium (menstrual lining) of the uterus that has escaped into the pelvis, eroding or invading into pelvic organs and giving rise to a condition called endometriosis.

The invading menstrual lining engulfs itself to form a capsule and hence an endometriosis cyst is formed with a collection of menstrual blood and secretion within. When an endometriosis cyst ruptures, spillage of blood is poured onto surfaces of the pelvis, rectum, uterus, ovary, intestine and bladder, giving rise to discomfort and pain.

The resulting aftermath is inflammation, scarring and destruction of normal pelvic anatomy. Hence dysmenorrheal, pelvic pain and infertility are often encountered. Fortunately, endometriosis cysts are mostly benign but their appearance can be threatening and suspicious looking.

The three most common types are the serous cyst adenoma (30% cancer risk), the mucinous cyst adenoma (5 to 10% cancer risk) and the dermoid cyst (teratoma) that can contain hair, tooth, fat, cartilage and bone. The cause of these cysts is unknown.

Ovarian cancer can be considered the deadliest of all female cancers because it is often discovered late.

The cyst content is liquid, mostly fluid, filled with water, blood or mixed with other human tissues. It occurs in roughly five percent of all ovarian cysts. In its early stage, it is asymptomatic and hard to detect. In its later stages, it causes abdominal bloatedness, pain, loss of appetite and weight and spread to other parts of the body.

What are the common symptoms of ovarian cyst?

An ovarian cyst is generally asymptomatic when it is small. When it enlarges, it can cause abdominal swelling, discomfort and pain. Severe pain can result when the cyst ruptures or twists (torsion). It may also put pressure on bladder causing urinary symptoms, or on the rectum causing bowel symptoms.

Do I need an operation?

The need to operate depends on the severity, size of cysts, number of cysts and complexity of cysts and prevention of complications like rupture, torsion, enlargement and suspicion of cancer. The common operations for ovarian cysts are cystectomy, oophorectomy and total hysterectomy with bilateral oophorectomy.

The approach to the operation, whether via laparoscopy or laparotomy, and the surgical procedures are best discussed with the attending gynecologist.

It is advised that all sexually active females should see a doctor as early as possible for pap smear, cervical cancer vaccination advice, breast examination, pelvic examination (with or without ultrasound) and contraceptive or fertility advice. Routine examinations like an annual check-up and pre-employment screening have picked up a large number of asymptomatic growths.

Any female, regardless of age or sexual activity, should consult a doctor if she has gynecological-related complaints like heavy menses, abnormal vaginal bleeding, painful menses, pelvic discomfort, bloatedness or palpable pelvic lump.

A combined vaginal and abdominal examination is often able to detect a pelvic tumor, and a fibroid feels harder than a cyst to the doctor. With the help of an ultrasound, the differentiation of a cyst from a fibroid is made easier. Occasionally, an MRI scan is requested to gauge the likelihood of encountering cancer in the pre-operative counseling of the patient. But the definitive diagnosis still rests with the histology of the respected tumor.

A benign fibroid or cyst can lead to pain, distortion of pelvic anatomy, menstrual problems, side effects on pelvic organs and infertility.

A cancerous growth can bring about morbidity, poor quality of life and death. Hence, early detection of pelvic tumors, be it ovarian cyst or fibroid, can prevent further harm to the health of the individual and keep healthcare costs low.

Dr. Lee Keen Whye Consultant Obstetrician and Gynecologist at the Gleneagles Medical Centre, Singapore.

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