Fibroids

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Introduction
A fibroid is a benign tumor of the uterus. Various terms are used to refer to the tumor, such as fibromyoma, myofibroma, leiomyofibroma, fibroleiomyoma, myoma, fibroma, and fibroid. Of these, fibroid is the most common term, although myoma is more accurate.

Incidence
The incidence of fibroids is uncertain, but they are the most common tumors of the uterus and female pelvis. It has been estimated that one out of every four to five women older than 35 years of age has a uterine fibroid. It is also well documented that patients of African descent have a higher incidence of fibroids than Caucasian women, although the reason for this is not known. Leiomyomas are responsible for about one-third of all hospital admissions for gynecological services.

Causes
The exact cause of uterine fibroids is not known, but it has been suggested that they arise from persistent small embryonic germ cells. Most studies have shown that the hormones estrogen and progesterone(Drug information on progesterone) are involved in myoma growth. Most of the tumors occur during the reproductive years and usually become smaller after menopause. Oral contraceptives may cause myomas to enlarge. Older women who have never had children may have an increased risk of developing myomas. Women who have given birth have a decreasing risk of developing these tumors. A woman who has had five term pregnancies has only one-fifth the risk of developing a fibroid when compared to a woman with no children. Interestingly, the risk is reduced in women who smoke but increased in obese women.

Symptoms
Most fibroids, even large ones, do not cause any symptoms. Indeed, most are discovered incidentally during a routine gynecological exam. Distortion of the normal abdominal wall contour due to a large tumor may also be discovered during self-exam. Patients with symptomatic fibroids typically have excessive or prolonged menses. This may sometimes cause anemia due to the large amount of bleeding. After bleeding, pressure is the second most common symptom of myomas. Pressure on the bladder can produce urinary frequency and urgency and, occasionally, inability to urinate. Pressure on the rectum may cause constipation. In cases of extremely large fibroids, pressure on the pelvic vessels may cause edema or varicose veins in the legs. Kidney symptoms are also possible if the fibroid extends upwards.

Abdominal and pelvic pain, a feeling of heaviness in the pelvis, or pain upon intercourse are also common symptoms. The pain may be dull or sharp, but is usually intermittent. Occasionally, fibroids cause dysmenorrhea (pain during menses). Myomas may also be related with infertility, especially if the myoma distorts the cervix enough that it becomes occluded. Pregnancy causes growth in size of any preexisting myomas, potentially causing an otherwise asymptomatic myoma to become symptomatic.

Treatment
In many cases, treatment is not necessary, particularly if there are no associated symptoms, if the tumors are small, or if the patient is postmenopausal. However, any patient with a diagnosed myoma should be carefully examined every three to six months to check for any unusual growth. If the patient is symptomatic, the myoma should be treated. Medical treatment, such as GnRH analogues, are available. They are effective, causing most myomas to shrink after a few months. Unfortunately, the myomas regain their original size several months after treatment is discontinued. Thus, surgery is still the best treatment option Common surgeries consist of either
myomectomy (removal of the myoma alone) or hysterectomy (removal of the uterus and any associated myomas).

Traditionally, the surgeries were done by laparotomy (making a large abdominal incision) and excising the appropriate tissue. However, recent advances in surgical technology now allow most patients to be treated with new minimally invasive techniques, consisting of laparoscopic myomectomy or laparoscopic hysterectomy. Laparoscopic surgery is performed via three or four small incisions in the abdomen. The myomas are then removed through these incisions by first cutting them into small pieces inside the abdomen, then removing each small piece. This has many advantages, because it leads to shorter hospital stay (about 24 hours, compared to three days after laparotomy) and less postoperative pain (due to a smaller incision, which leads to less scar tissue). It is also a good choice for any women desiring children in the future, because it causes less pelvic adhesions.

For further information regarding laparoscopic removal of myomas, e-mail info@nezhat.com.

Endometriosis

Endometriosis is a disorder in which abnormal growths of tissue, histologically resembling the endometrium, are present in locations other than the uterine cavity. Although endometriosis was described in detail more than 100 years ago, it continues to be one of the unsolved, enigmatic diseases affecting women. It is often called "the career woman's disease," because it occurs almost exclusively in women of reproductive age. Endometriosis is usually confined to the pelvis in the region of the ovaries, uterosacral ligaments, cul-de-sac, and uterovesical peritoneum.

The development and extension of endometrial tissue in the uterine muscles is termed adenomyosis. It can also affect the bowel, especially the rectum, colon and appendix. Endometriosis is one of the most common reasons for pelvic pain and infertility.

Causes
There are three main theories as to the cause of this elusive disease, but the exact etiology remains a mystery. The most common and scientifically valid theory is a combination of immunological alteration and retrograde menstruation- direct transportation of viable endometrial cells through the fallopian tube into the pelvis which then implants in ectopic sites. Other suggestions are coelomic metaplasia, which proposes that peritoneal epithelial cells change to endometrial cells. The last theory is lymphatic spread/mechanical transport, where the cells are picked up by the lymphatic or circulatory system and ferried about the body.

Incidence
Endometriosis is a common and important health problem. Its exact prevalence is unknown because surgery is required for its diagnosis, but it is estimated to be present in 10% of all reproductive age women. It is seen in 1-2% of women undergoing sterilization, in 10% of hysterectomy surgeries, and in 16-31% of laparoscopies. Endometriosis has a higher incidence among Caucasians than among people of African descent. Some genetic influences in the development of endometriosis have been described. Studies have found that 7-9% of endometriosis patients' first-degree female relatives are diagnosed with the disease, significantly greater than the control rate of 1-2%.

Symptoms and Diagnosis
Unfortunately, there is no current noninvasive test for diagnosing endometriosis. However, the typical symptoms include infertility, ovarian cysts, or chronic pelvic pain such as generalized vague and sometimes sharp pain; painful periods (dysmenorrhea); painful intercourse (dyspareunia); back pain; and painful ovulation. Pain with bowel movement and bladder pain can also exist. The symptoms are often related to the menstrual cycle, generally resulting from functioning endometrial tissue or scarring in the affected site. Pelvic examination may confirm suspicion. However, in mild to moderate stages of endometriosis, physical and pelvic examinations may be completely normal. Pain or bleeding from any site coinciding with menses should raise suspicions of endometriosis and lead to careful evaluation of specific anatomic areas involved such as lungs, umbilicus, previous incisions, bowel, bladder, ureters and diaphragm.

Treatment
Different hormonal therapies, such as birth control pills, progesterone, danazol(Drug information on danazol), GnRH analogs, and recently RU486 have been used with some success to decrease the size of endometriotic lesions. This treatment can be used alone or in conjunction with surgery. Preoperative hormonal therapy has been shown to create a pelvic environment with much less blood flow and reduce inflammatory reaction, making surgical identification and removal of endometriotic lesions easier.

In the past, surgical treatment of endometriosis included laparotomy and hysterectomy. This was mainly due to the fact that surgeons were unfamiliar with endometriosis and how to treat it. A fairly recent improvement in technology, called operative videolaseroscopy, has revolutionized the way patients are treated for endometriosis. The advantages over laparotomy include a smaller incisional site (1/4-1/2 inch vs. 4-6 inches), shorter hospital stay (one day vs. 3-5 days) and a shorter recovery period (1 or 2 weeks vs. 4-6 weeks).

Through operative videolaseroscopy, endometrial implants can be coagulated, excised or ablated using a carbon dioxide laser or electrosurgery. Laparoscopic scissors and a laser can be used to cut lesions close to vital structures. Laparoscopic restoration of pelvic anatomy, especially at the area of the posterior cul-de-sac, is not simple and should only be undertaken by a surgeon who is familiar with performing surgery on genital, gastrointestinal, and urinary tract.

For further information on laparoscopic surgery for treatment of endometriosis, e-mail info@nezhat.com.