In this episode of PodMD, experienced Obstetrician & Gynaecologist Dr Tanushree Rao will be discussing the topic of fibroids, including what fibroids are, the risks of fibroids, the current treatment options, any warning signs to look out for, when to refer and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMd studio Dr Tanushree Rao.
Dr Tanushree Rao is an experienced Obstetrician & Gynaecologist providing care in Sydney’s Southwest. Tanushree is skilled in advanced laparoscopic surgery and experienced in all areas of Obstetrics and Gynaecology.
Dr Rao studied Medicine at the Rajiv Gandhi University of Health Sciences in India and went on to be granted the prestigious MRCOG at the Royal College of Obstetricians and Gynaecologists in London. Following this she completed her Fellowship of Royal Australian and New Zealand College of Obstetricians and Gynaecologists in Sydney. She then underwent an additional two years of advanced laparoscopy training after receiving a fellowship, which was recognized by the esteemed AGES committee in Australia.
Today, we’ll be discussing the topic of Fibroids.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Tanushree, thanks for talking with us on Pod MD today.
Tanushree: Thank you for having me.
The topic of today’s discussion is Fibroids. Tanushree, Can you give us a brief overview about fibroids?
Tanushree: Yeah, for sure. And so fibroids are benign tumour of the muscular tissue of the uterus. It typically develops in the wall of the uterus. Now, fibroids are noncancerous growths of the uterus that often appear during the childbearing years. There are researchers who believe that it actually arises from a single cell and divides repeatedly, creating a firm rubbery mass that’s distinct from the nearby tissue.
And then you know the growth patterns of these fibroids, wary as well. They may just remain the same size throughout the lifetime. Alternatively, some of them may go through growth spurts, and others may shrink. So if you take women you know like just like me, about 100 of them, and so you will have at least 20 to 30 of us being diagnosed with fibroids in the reproductive age group. Which is OK, essentially between 35 to 45 years, they do cause ymptoms, but they probably exist in microscopic form before the age of 30 as well.
They’re more common in what we say nulliparous, or relatively infertile women, and there is an old adage that says that the uterus you know consoles itself because it didn’t have a baby with a fibroid. I don’t know how true that is, and then we have racial and genetic factors, you know notably Africans are especially prone to develop uterine leiomyoma and sometimes irrespective of the race, they can also have familial incidents. There’s always a good point of practise to ask for family history of fibroids.
How would a patient with Fibroids typically present?
Tanushree: eah look, I usually try to remember this in in in this format usually either bleeding symptoms or abnormal uterine bleeding, and that could be in the sense they could have heavy menstrual bleeding or menstrual periods that lasts for more than a week, or intermenstrual bleeding even.
The other set of symptoms are pressure symptoms and that manifests in terms of just pelvic pressure, or pain, frequent urination, difficulty in emptying the bladder and all of this usually happens in the fibroids that are on the anterior wall. Now, if the fibroids on the posterior wall you can have pressure symptoms such as Constipation, pain etc.
The last set is infertility and symptoms, so sometimes you can have inability to fall pregnant and that can give an inkling to the GPSsthat something is amiss and you know, probably can prompt a pelvic ultrasound. There can be wake symptoms as well, like back ache or leg pains and just feeling a bit of bloating. So all of this also could point where it’s a fibroid.
Apart from this whole set, if you move towards pregnant women and they can have few symptoms like a miscarriage or preterm labour, intrauterine growth restriction and all of this is attributed to the fact that the placenta has a defective implantation, so you know.Fully developed endometrium reduce space for the growing foetus and placenta. All of this could contribute, but more commonly as a point of, you know, practise what I see is red degeneration of the fibroid, and that is usually managed conservatively in pregnancy.
What are the risks of Fibroids?
Tanushree: Yeah, sure there are a few risks that I associated with fibroids andone of the changes are atrophy, and I’m not sure if that’s a risk, because it could be a good thing. And usually women after menopause due to the loss of support from oestrogen kind of undergo shrinkage of fibroids, which probably is good, now sometimes you can have necrosis and this is mainly because of the circulatory inadequacy that may result in central necrosis of the tumour, and this is present in submucous polyps or pedunculated subserosal fibroids, and with infection it can happen sometimes and this usually gains access to the tumour core through the thinned out and sloughed surface of the epithelium of submucosal fibroid.
There can be vascular changes such as dilatation of these vessels, which we call till Telangiectasia or dilation of the lymphatic channels as well. But more importantly, even though the risk is small, but we’re what we’re worried about, is the sarcomatous changes, and I usually follow the RCOG guidelines on this.
To this so if you just Google RCOG and patient information leaflet and put fibroids as your keywords and there will be a document that comes up and it would state that you know the fibroids that are growing quickly and especially on your ultrasound or MRI. If there are certain suspicious features based on your age, it usually is higher towards the end of menopause and increases after that.
Your ethnicity, like we mentioned before, there’s an increased risk in black women. And if you’ve tried some medical management and your fibroid is still growing despite. That, and if you’ve ever used drugs like tamoxifen or you’ve been exposed to radiotherapy and these are all your risk factors for it being cancerous. So I think it’s important to note the age group, the ethnicity and what medications they take, and you know if they want to read about this and you can give them access to these articles as well.
What are the treatment options?
Tanushree: Sure, now usually my mantra is if it’s not troubling, you know, don’t intervene. So if it’s asymptomatic and small, just leave it as it is and like I said, you know the incidents is quite high in a reproductive age group. So I guess if you do find some you can probably offer them some monitoring of sorts with ultrasound.
With medical management, we do have GNRH agonists, and that’s something I do use as a prior preparation for my patients as well. Usually I use [inaudible] 3.6 MG subcut and the only thing is they can be used for a short term and so say six months but after which they will need an add back therapy and I usually don’t tend to use them more than six months now.
Mirena can also be tried for heavy menstrual bleeding, but as a practical point of note, I have noticed that at times, depending on the size and location of fibroids, sometimes it can actually get displaced or pushed out even. Earlier that we did study about mifepristone and [inaudible] , but they’re no longer used and we all know about Ulipristal which has been banned because of its effects on liver functions.
And so I guess the next management mainly is surgical management, which I usually offer patients depending on what they want. You know, out of their future fertility wishes. So if they do want to conserve the uterus, I go ahead and offer them in a myomectomy which can be done either hysteroscopy or through a laparoscopy.
Or if they’re done with childbearing, then I offer them a total laparoscopic hysterectomy. Now I do have a YouTube channel FYI, and so if you just Google Tanushree Rao and YouTube, my channel will come up and I have a dedicated playlist just for fibroids where we have all the procedures that I just described earlier mentioned.
The last option is also uterine artery embolization and I can see that a few people are using it recently. It’s just that we don’t know what effect it has with fertility. And also it does not make the mass go away completely and has certain risks, like embolization syndrome. Etc. However, if you know the patient has, it’s just not accepting the risks of surgery, this this would be a good alternative as well.
Have there been any developments in treatment in the last years or are there any in trials or development now?
Tanushree: Yeah, for sure there have been few you, you know recent developments with GNRH antagonist and so the first one that comes to my mind is elagolix and this sometimes is used in combination with oestrogen and progesterone. This was approved by the US FDA in May 2020 and they said that you can use it for a maximum of 24 months for heavy menstrual bleeding related with fibroids and the other one is relugolix. And you know, it’s similar action it’s an antagonist, and it was recently approved in 2021, again for a period of two years.
There is a new modality called focused ultrasound surgery. It’s also called a haifu, so essentially you use high intensity focused ultrasound and try to use this energy to induce coagulative necrosis of fibroids, and this is usually guided by ultrasound. But MRI can be used as well, and I’ve seen most of my colleagues in China and Hong Kong use this. I haven’t seen this taken up much in Australia yet, but you know watch this space
Are there any warning signs a GP or their patient can look out for?
Tanushree: I would say increasing symptoms and you know growing size of fibroids even if they are asymptomatic, would be a red flag. These would need an immediate referral I would think, yeah.
What is the likelihood of recurrence of the condition?
Tanushree: Yeah look, I always mentioned this when I offer surgery, especially with uterine conserving procedures. Myomectomy does not ensure you know no recurrence. They will always sealing fibroids that may or may not be visible to the naked eye, which then may develop a growth potential later on. There has been a study by Radosa et al. in 2014 conducted where he studied around 331 patients that underwent laparoscopic myomectomy to treat uterine leiomyoma. So he found the cumulative risk of recurrence was 4.9% at 24 months and 21.4% at 60 months post operatively.
When should a GP refer?
Tanushree: Yeah, and so GPS are often the first point of contact, so if there are any symptoms if there’s a fibroid size more than 3-4cm, if they are asymptomatic but suffering from infertility, I would say just reference to a specialist, but you know if they are asymptomatic and it’s less than three centimetres, I would say that they can still monitor the patient. How often is still debatable. There are still no clear guidelines. I would say start off with annual and then based on you know the growth rate and you can probably increase the frequency or duration of monitoring as well.
What role does the GP play in the treatment of the condition?
Tanushree: Yeah, look, I think GPs are really, really important in the sense that apart from being first point of contact, they often meet the patients even after they’ve seen the specialists. And now I can see that some GPs are quite proficient in inserting in Mirena so if they’re comfortable to do so, they can offer it themselves for heavy menstrual bleeding, which can be quite useful for the patient.
They can also offer preoperative counselling which is really important if the woman is leaning towards surgery so that the patient is always out really aware and you can have a more meaningful consult with the specialists. Like I said, you can offer the patient information leaflets from the RCOG website and I do that to my patients as well, just, you know, ask them to take their phone out and you know Google it out in front of me and then a PDF appears where they can read it at home.
You can also direct them to my YouTube channel for better understanding of the surgery if they want and if the patient says, you know I’m not interested or I have no concerns regarding surgical management. They can also make a referral for uterine artery embolization to the radiologist even.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on Fibroids?
Tanushree: I think the three main take home messages would be do not ignore the symptoms, especially if wake ones like you know pressure symptoms, “I’m just having a bit of frequency”, “I’m just feeling a bit of bloating “and sometimes they can just have vague symptoms. I’ve often seen women are able to put up with the pain or just disregard what they go through saying, “oh, you know I have more important things to do and I have a family to take care of”, so they do tend to put their health and you know on second or third place in their priority list.
I would say off offer patient options like we discussed before and counsel them so that they have a range of options to choose from. And do monitor the fibroids, if you’re choosing conservative management. At times in my clinic I see patients when they’ve already you know the fibroid reached around 28 weeks size of 32 weeks size, which I do offer laparoscopy but it can be quite challenging.
So if you can pick these cases on a bit earlier on and it would benefit you, know the woman immensely is what I feel, so yes. That’s that’s about it.
Thanks for your time and the insights you’ve provided.
Tanushree: This has been great and thank you so much for having me. I hope this has been useful and if there are any questions please don’t hesitate to get in touch with me. And you can just Google my name and my e-mail address would be over there. So please get in touch with me.