Dr Gauri: Uterine fibroids (also called as myomas) are non-cancerous (benign) growths that develop from the muscle layer of uterus.

HC: Are all fibroids the same?

Dr Gauri: Fibroids can differ with respect to their size, location, number and by the symptoms that they can produce.

Uterine fibroids are generally classified as:

• Subserous – growth is directed outwards
• Intramural – growth centred within the uterine walls
• Submucosal – growth towards the cavity of uterus

Rarely, fibroids can also form in cervix and broad ligament of uterus.

The size of the fibroids does not seem to be related to the severity of the symptoms. So even a small fibroid (especially submucosal type) can cause considerable symptoms and sometimes a woman with a large fibroid may be asymptomatic.

HC: Who is most likely to develop fibroids?

Dr Gauri: Approximately 60 to 80% of women will have fibroids. The following are some of the risks factors for uterine fibroids:

• Obesity (obese women produce more estrogen)
• Early age at first periods
• Family history of fibroids in mother or sister
• Metabolic syndrome( diabetes+hypertension+high cholesterol+obesity)
• Women with polycystic ovarian disease and irregular periods
• Age (older women are at higher risk than younger women )

HC: How are fibroids formed?

Dr Gauri: The exact cause of fibroids is not well understood but multiple factors play a role in their growth.

• Genetics
• Estrogen and progesterone hormones
• Environment and lifestyle

HC : What are symptoms in women having fibroids?

Dr Gauri: Most women with fibroids are asymptomatic.

However, some may have the following symptoms:

1. Changes in menses
2. Heavy menstrual bleeding
3. Painful menses ( cramps)
4. Irregular bleeding

These women are generally anemic (low hemoglobin) and complain of easy fatigue.

• Pressure of fibroids on surrounding organs can cause
• Difficulty in passing urine or frequent urination
• Difficult bowel movements
• Abdominal cramps
• Back pressure on kidneys causing swelling of kidneys(hydronephrosis)
• Feeling full in the belly

• Pain
• Dull ,aching pain in  abdomen and lower back
• Pain during sexual intercourse

• Difficulty getting pregnant

• Problems during pregnancy like miscarriage, preterm birth and pain in abdomen

• Feeling lump in abdomen or increase in girth of abdomen

HC: What tests are done to diagnose uterine fibroids?

Dr Gauri: Unless a woman has symptoms, it is unlikely that she knows she has fibroids. They can sometimes be detected during routine pelvic examination done by a gynecologist.

Some common types of investigations done are

• Ultrasound- mainstay of diagnosis.
• MRI indicated in large and multiple fibroids
• Hysteroscopy uses a small camera to visualize the inside of uterus.

HC: Is it true that pregnant woman with fibroids have complications in pregnancy?

Dr Gauri: Yes. The following problems may be encountered during pregnancy and childbirth

• Pain: especially in large fibroids more than 5 cm
• Recurrent miscarriage
• Preterm birth
• Premature separation of placenta (abruption)
• More chances of baby being in abnormal position (breech,oblique) thus requiring caesarean delivery.
• Excessive bleeding after delivery of baby .

Generally in pregnancy, fibroids can grow in 30% of patients, shrink in 30% and remain unchanged in 30%. The above mentioned complications are usually seen in patients with multiple fibroids and in whom the fibroids have grown during pregnancy. In the remaining, pregnancy may be uneventful.

Q: If I have fibroids, will it be difficult to get pregnant ?

A: Fibroids can impact fertility in the following cases

• Submucosal fibroids which grow and bulge in uterine cavity
• Multiple fibroids distorting the normal cavity and architecture of uterus
• Fibroids near the tubal opening or in cervical canal.

However it is prudent to also evaluate other causes of infertility before attributing the issue to fibroids.

HC: When is treatment necessary for fibroid uterus?

Dr Gauri: Several factors are considered before recommending treatment to a patient viz;

• Age
• Severity of symptoms
• Location, size and number of fibroids
• General health of the patient
• Whether patient is desiring pregnancy in future

Fibroids that are small and do not cause any symptoms may not need treatment. However surveillance will be important by regular check-up or ultrasound, to watch for increase in size or any obstructive symptoms. This is especially important in a woman nearing menopause where the hormone levels drop and the fibroid may shrink on its own.

Certain conditions which necessitate treatment are:

1. Heavy , painful, irregular menstrual bleeding
2. Uncertainty whether the growth is a fibroid or another type of tumor, such as an ovarian tumor.
3. Rapid increase in growth of fibroid
4. Infertility
5. Obstructive urinary and intestinal symptoms

HC: Can medicines be used to treat fibroids?

Dr Gauri: Medications can be used as a temporary option in some women to reduce pain and bleeding. Some newer medicines may also help to shrink fibroids. However they have to be taken only under strict medical supervision.

HC: What type of surgery is done for fibroids?

Dr Gauri: Myomectomy is the surgical removal of fibroids leaving the uterus in place.

It can be done endoscopically (laparoscopy or hysteroscopy) or open surgery.

Hysterectomy is the removal of uterus. Laparoscopic and open surgery options are available.

HC: Do fibroids turn Cancerous?

Dr Gauri: Fibroids are almost always benign (non cancerous)

Very rarely (less than 1 in 2000) a cancerous fibroid called leiomyosarcoma can occur.

HC: Can fibroids be prevented?

Dr Gauri: Though they can’t be totally prevented, certain lifestyle habits can reduce your chances of developing fibroids. Regular exercise can help. So also, include plenty of fruits and vegetables in diet. Avoid alcohol, red meat, processed foods and refined sugars. Remember, excess body fat is an important risk factor for fibroids.

I believe our Lifestyle is a major determinant of Health and well being.

Q:  Why is PCOS so commonly heard of lately?

A: Approximately 10 to 20 % of women in the age group of 15 to 45 years, have PCOS.

Its incidence is on a rise due to change in lifestyle, food habits, increasing obesity and environmental factors.

Q: what are symptoms of polycystic ovaries?

A: The symptoms include

• Menstrual irregularities:

No  menstrual  periods

 Frequently missed periods

Very heavy periods or prolonged periods

• Increase in body hair especially on face, chest, belly and upper thigh ( hirsutism )
• Loss of hair on scalp
• Being overweight, experiencing a rapid increase in weight or having difficulty losing weight
• Oily skin, pimples (acne)
• Difficulty becoming pregnant
• Patches of thickened ,dark skin over neck , axilla, groin ( acanthosis nigricans)
• Depression and psychological problems

Symptoms vary from woman to woman. Some women may have very few mild symptoms, while others are affected severely.

Q. What causes polycystic ovaries?

A: The cause is multifactorial

• Androgen excess seen in almost 60 to 80 % of women
• Insulin resistance or elevated insulin levels
• Family history in mother, sister, aunt
• Epigenetics : environmental factors like obesity, unhealthy lifestyle, low birth weight etc, can interact with genes to lead to PCOS

Q: How do I know if I have PCOS?

A:  There is no single test to definitely diagnose PCOS.

A diagnosis is made when you have any two of the following:

1. Irregular, infrequent periods, or no periods at all
2. An increase in facial or body hair and /or blood tests that show higher testosterone levels than normal.
3. An ultrasound scan that shows polycystic ovaries.

It is important to note that ONLY polycystic ovaries on ultrasound, in the absence of any of the above mentioned signs or symptoms,  is NOT PCOS.

Q: If I have PCOS, will I have difficulty getting pregnant?

A: PCOS is one of the most common but treatable causes of infertility. The hormonal imbalance interferes with the growth and release of eggs from ovaries, thus making it difficult to conceive.

Q: What are the treatment options to get pregnant if I have PCOS?

A:

1. Weight loss

If a patient is overweight, losing weight through healthy eating and regular physical activity can help to regularize periods in majority of women. Even 10% weight loss helps to restore ovulation.

• Medicines to induce ovulation like clomiphene citrate and letrozole
• Some women may need intra uterine insemination (IUI) or in vitro fertilization(IVF),  if the infertility is of long duration ,or if there are other factors of infertility associated.

Q: Can PCOS cause complications in pregnancy?

A: Yes.

Women with PCOS can have

• Miscarriage (especially in first trimester)
• Gestational diabetes
• Preeclampsia( high blood pressure)
• Macrosomia (large weight babies)
• Increased incidence of cesarean section.

Babies can also have increased risk of developing hypoglycemia (low blood glucose) and hypocalcemia (low calcium), in the immediate post natal period and can have long term risk of developing obesity and metabolic syndrome.

Q: Is there a cure for PCOS?

A: There is currently no cure for PCOS. Even after menopause, women with PCOS often have high levels of androgens as well as insulin resistance. Medical treatments aim to manage and reduce the symptoms or consequences of having PCOS. Medication alone has not been shown to be any better than healthy lifestyle changes.

Q: What are the various treatment options available?

A: PCOS treatment is tailored to each woman according to symptoms, existing health problems and whether she wants to become pregnant.

1. Exercise

• At least 150 min/week of moderate intensity exercises like brisk walking, playing light sports etc. OR
• At least 75 min/week of vigorous intensity activities like running, field sports, swimming, jumping rope,etc. OR
• Weight training  helps to strengthen the muscle and increase bone density
• Medications
• Combination birth control pills
• Progestins
• Metformin
• Myoinositols
• Healthy food
• Balance carbohydrates with protein and healthy fats
• Choose nutritious or high fibre carbohydrates instead of sugary or refined carbohydrates
• Eat small frequent meals instead of large meals
• Do not skip breakfast

Q:  Why have I been prescribed Metformin although my blood sugar is normal?

A: Hyper insulinemia or insulin resistance is seen in almost 80% patients of PCOS. In hyper insulinemia , the cells can’t utilize insulin properly,  thus the pancreas makes more insulin to compensate.

High levels of insulin trigger the production of androgens by the ovaries and causes the arrest of normal follicle development.

Metformin is an insulin sensitizer, which helps to increase uptake of insulin. Moreover it helps to lose weight in obese patients.

Q: What could PCOS mean for my long term health?

A: Women with PCOS  are at greater risk of developing long term health problems, as:

1.  Diabetes

In view of insulin resistance, majority of patients with PCOS develop diabetes , especially if obese and over age of 40 years.

• Metabolic syndrome ( obesity+ hypertension+ diabetes+ high cholesterol)
• Sleep apnea (snoring) and day time drowsiness
• Depression and mood swings
• Endometrial cancer

Since women with PCOS do not ovulate, the lining of the womb (endometrium) may thicken, leading to increased risk of developing cancer of endometrium in few women.

Q: How common is it?

A: India accounts for nearly one fourth of the world’s cervical cancer deaths. It is the second most common cancer in Indian women (breast cancer being the first). Unlike women in developed world who have regular screening programmes to detect cervical cancer early , women in India are often diagnosed too late because of the lack of self screening, and the stigma and shame associated with a pelvic examination. Therefore, many women are diagnosed only in advanced stages, thus making treatment and recovery difficult.

Q: What are the symptoms of cervical cancer?

A: Cervical cancer in very early stages usually does not have any symptoms. The longer a woman has cervical cancer without diagnoses, the more likely she will have symptoms.

1. Abnormal vaginal bleeding

Bleeding /spotting between cycles; after intercourse; after menopause

• Unusual vaginal discharge

While vaginal discharge is considered normal, the type of discharge you experience could be an indicator of vaginal/cervical health. With cervical cancer you may notice discharge that is foul smelling and pink, brown or bloody in color. Sometimes there can be foul smell associated.

• Weight loss, painful bowel movement, painful intercourse and obstruction to urine flow may be seen in advanced stages.

Q: What  are the risk factors for cervical cancer?

A: 1) HPV infection.

 The most important risk factor for cervical cancer is infection with Human Papilloma Virus (HPV) .More than 90% of cervical cancers are linked to the virus. There are many types of HPV. The high risk types can cause cancer of cervix, anus, vulva, vagina and penis.

It is important to note that most healthy women infected with HPV do not develop cervical cancer, and most HPV infections will eventually go away on its own. When exposed to HPV, the body’s immune system typically prevents the virus from doing harm. However, in a small percentage of people, the virus survives for years, contributing to the process that causes some cervical cells to become cancer cells.

The following risk factors increase your risk of becoming infected with HPV

• Early age at first intercourse (especially younger than 18)
• Multiple sexual partners
• Smoking: women who smoke are about two times more likely to get cervical cancer , compared to non smokers
• History of sexually transmitted infections especially gonorrhea, Chlamydia and syphilis
• Poor hygiene and sanitation and low economic status
• Weakened immune system as in HIV infection or in patients on immunosuppressant medications and steroids

2) Not getting screened

    Cervical cancer is most often found in women who have not been screened with the Pap test in more than five years or who have never been screened at all.

3) History of cervical dysplasia (abnormal cell growth) which has not been adequately followed up or treated.

Q :How can cervical cancer be prevented?

A: There’s no single way to completely prevent cervical cancer, but there are certain measures that can reduce your risk.

• Screening tests

Cervical cancer is preventable by screening women for precancerous cervical lesions. Cervical cancer has a long pre cancerous period, generally 10 to 15 years. This provides a considerable window of opportunity to detect pre malignant lesions. Early detection of the pre malignant conditions allows the disease to be cured completely. If regular screening is made part of the routine check-up of all women who are susceptible, the onset of cancer can be detected and combated effectively.

• HPV vaccine

The link between the development of cervical cancer and some types of HPV is clear. Although the vaccine may protect against only four subtypes of the virus( 16, 18, 51, 55), these account for majority of cervical cancer cases.

HPV vaccines work best if administered prior to exposure to HPV. Therefore, the World Health Organization recommends vaccination for girls aged between 9 and 14 years, when the sexual activity has not started

An important point to be noted is that vaccine does not replace cervical cancer screening.

• Avoiding multiple sexual partners

 The more sexual partners a woman has, higher is the risk of transmitting HPV virus

• Delaying first sexual intercourse

The younger the woman is when she has sexual intercourse for the first time, the higher the risk of HPV infection becomes. The longer she delays it, the lower her risk

• Stopping smoking

Q: How long does it take for pre cancerous lesions to become cancerous?

A: It takes many years for cervical cancer to develop and spread.

In the early stages cell changes that occur before cancer is detected are called dysplasia. Many women are diagnosed with precancerous cell changes in their 20s and 30s but the average age of diagnosis of cervical cancer is age 49, which indicates the slow progression of the disease.

Q: what are the different screening tests available?

A: 1) Pap smear is the most commonly used cervical cancer screening test.

    2) HPV DNA test for high risk HPV types

3)  Visual inspection with acetic acid (VIA) inspects the cervix using acetic acid to identify abnormal changes on the cervix

Q: What is a pap smear/test?

A: Pap smear is a screening test to find conditions that may lead to pre cancer or cancer of cervix.

Regular Pap smear screening is the best way to identify abnormal changes in the cells of the cervix at an early/ pre cancerous stage.

Pap smear can be done during routine gynecology check up. It is procedure done without anesthesia and it involves collecting of cells from cervix and vagina by a gentle applicator or brush.

 Pap smear screening recommendation (American cancer society 2020)

<25 years: no screening

25 to 30 yr: Pap smear every 3 years

30 to 65 years: Pap smear every 3 years or Pap + HPV testing every 5 years

>65 years: No screening if consistent negative screening in last 15 years. However women with no prior screening should undergo tests once at 65 years, and if negative, exit screening. Women who have had a  total hysterectomy with removal of the cervix also do not need to ne screened al

Q: What is HPV test

This test looks for cervical infection by high risk types of HPV. The HPV test and the Pap test are done the same way and both can be done together (co test). However the HPV test is costlier as compared to a conventional pap test.

The take home message is that cervical cancer is one of the most preventable cancers today.

Knowledge and awareness about regular screening can help in early detection and significantly reduce the associated complications and disease burden.

A: Endometriosis is a condition where tissue similar to the lining of the uterus (endometrium), is also found elsewhere in the body, mainly in the pelvis and abdominal cavity.

Every month a woman’s body goes through hormonal changes. Hormones cause the lining of the womb to increase in preparation for a fertilized egg. If pregnancy does not occur, this lining breaks down and bleeds. This is released from body as periods.

Endometriotic cells react in a similar way- except that they are located outside the womb. During the monthly cycle, hormones stimulate the endometriotic tissue, causing it to grow, then break down and bleed. Unlike the cells in the womb that leave as periods, this blood has no way to escape. This causes a chain of inflammatory reaction causing scar tissue and adhesions (abnormal bands of fibrous tissue) that cause the pelvic organs to stick to each other.

Q: How common is Endometriosis?

A: 10% of all women in their reproductive years are affected by endometriosis. These are typically the years between onset of menses until menopause.

Q: Does endometriosis affect only the ovaries and fallopian tubes? A: No.

Although ovaries and the fallopian tubes are most commonly affected, endometriotic lesions can be found in the following sites:

• On the pelvic side walls
• The surface of the uterus, especially posterior surface
• Ligaments of the uterus
• In the body of the uterus (adenomyosis)
• Urinary bladder
• Bowel (especially rectum)
• Ureter
• Laparoscopy / laparotomy scars
• Vagina
• Skin
• Rarely in lungs, brain and spine

Q: Is endometriosis hereditary?

A: It is known that first degree relatives of women with this disease are more prone to develop endometriosis. And when there is a hereditary link, the disease tends to be worse in the next generation.

Q: Are there any risk factors for endometriosis? A: The following factors may increase the risk:

• Early start of periods and late age of menopause
• Conditions which prevent the passage of menstrual flow out of body (imperforate hymen, vaginal septum, reproductive tract anomalies)
• Mother, aunt or sister with endometriosis
• Low body mass index
• Never giving birth or delayed childbearing
• Short menstrual cycle
• Long duration of menstrual flow
• Higher levels of estrogen in body or a greater lifetime exposure to estrogen

Q: What are the symptoms of endometriosis? A: 1.PAIN

The most common symptom of endometriosis is pelvic pain. The pain is usually cyclical and associated with periods, however some may have acyclical and atypical pain. Sometimes, the pain is so severe and debilitating that it affects a woman’s day to day activities

Pain may be felt:

• Before/during/after menses (dysmenorrhoea)
• During ovulation
• Pain during passing motions(dyschezia)
• When passing urine
• During or after sexual intercourse
• In the lower back and abdomen

Endometriosis must be suspected in any patient with progressively increasing dysmenorrhoea and in any new onset cyclical pain.

• Infertility

Around 30 to 40% of endometriosis have difficulty conceiving. Women with moderate to severe endometriosis may require help of surgery, assisted reproductive techniques or both. Some of the possible causes of infertility are:

• Distorted anatomy of ovaries and tube
  • Poor quality and quantity of eggs

• Chemicals produced by endometriotic tissues are toxic to sperm, egg and embryo
  • Pelvic adhesions
  • Altered immune function 3. Other symptoms may include
  • Diarrhoea or constipation (especially during menses)
  • Abdominal bloating
  • Fatigue
  • Heavy or irregular bleeding

Q: Do all patients with painful periods (dysmenorrhoea) have endometriosis?

A: No.

Dysmennorhoea can be primary or secondary.

Primary is defined as painful periods in the absence of pelvic pathology. This can be considered as normal phenomenon and usually subsides with simple painkillers taken under doctor’s supervision.

Secondary dysmenorrhoea refers to painful periods due to pelvic pathology. Endometriosis is the most common cause of this. Other causes may include fibroid uterus, infections of genital tract, ovarian cyst etc.

Endometriosis is suspected when patient has progressively worsening pain with every period, severe pain right from the start of first menses, heavy and irregular menstrual bleeding, associated symptoms of diarrhoea, constipation or vomiting.

Q: What is a chocolate cyst?

A: A chocolate cyst (ovarian endometrioma) is seen in endometriosis, wherein there is collection of altered blood in the ovary. They get their name from their brown and tar like consistency that is similar to melted chocolate. This cyst is benign (noncancerous). A chocolate cyst can affect one or both ovaries and can be single or multiple. It affects ovarian function and can cause pain.

Q: Can endometriosis be prevented?

A: Currently there is no way of preventing endometriosis.

Q : How is endometriosis diagnosed?

A: The gold standard method to diagnose endometriosis is laparoscopy, which enables a direct visualisation of the disease. However, this is an expensive, invasive procedure requiring hospitalisation.

Ultrasound may show ovarian cyst (chocolate cyst) or adenomyosis

MRI is helpful to diagnose the extent and depth of the disease, especially involving rectum, urinary bladder and ureter.

A thorough clinical history and gynaecological examination can also help. Q: What are the treatment options in endometriosis?

The goal of treatment is aimed at relieving pain, controlling the progression of disease and preserving fertility for future childbearing. The treatment decided is dependent on several factors, viz; age, severity of symptoms and disease, desire to have children.

• Hormonal treatment

Although hormonal treatment is not a permanent fix, it may help to slow endometrial tissue growth and prevent new implants. The various medicines used are, progestins (tablets or injection), oral contraceptive pills, GnRH agonist injections, etc.

• Surgery

Surgery aims to remove or destroy the deposits of endometriosis and is usually done via laparoscopy.

• Pain medication

Non steroidal anti inflammatory drugs like ibuprofen, mefenamic acid, naproxen sodium etc can help to ease menstrual cramps. These may also be used along with hormonal treatment.

Q: Do dietary and lifestyle measures help to control endometriosis? A: Yes.

Exercise releases endorphins (feel good hormones) which help to relieve pain. Moreover, regular exercise lowers the amount of estrogen in the body.

A healthy balanced diet with plenty of fruits, vegetables and omega 3 fatty acid (found in mackerel, sardines, walnuts, flaxseeds, pumpkin seeds) is advocated. Certain immunity boosting Indian foods like turmeric, fenugreek seeds, ginger and amla also help.

Avoiding or limiting use of plastic in kitchen, home, or workplace would help to limit the exposure to bisphenols and dioxin (endocrine disrupting chemicals). Plasticisers and phthalates found in cosmetics can also lead to abnormal hormonal milieu.

Alternative therapies with acupressure and yoga are helpful in certain patients.