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Understanding Abnormal Uterine Bleeding: Part 2

Posted Aug 24 2008 1:49pm
PAUL MONIZ: I'm Paul Moniz. Thank you for joining us on this webcast. Today we are discussing abnormal uterine bleeding and it's connection to fibroids. Fibroids are benign muscle tumors that usually grow in the uterus, but they can occur elsewhere, causing in some cases pain and infertility. As many as 20-50 percent of all women actually develop them. If you are suffering from abnormal bleeding, you may have what is known as a submucosal fibroid. Here to talk about that is a gynecologist and one of his patients.

To my left is Dr. Martin Goldstein. He is the Associate Clinical Professor of Obstetrics and Gynecology at Mt. Sinai Hospital. Next to him is Valerie. She is a 50-year-old mother of two who has agreed to join us. We are not showing her face because of the sensitive nature of this topic, but she is willing to share her story. Thank you very much for coming here Valerie. We appreciate it.

Dr. Goldstein, let's begin with you. You have to go through a number of steps to make this diagnosis and determine what, in fact, you're looking at. Take us through that. For instance, Valerie comes into you. What is the workup for a patient?

MARTIN GOLDSTEIN, MD: Valerie presented herself with severe anemia, which had been corrected by transfusion. My feeling was it was imperative to be certain there was not a bowel problem, such as a colon or rectal cancer, or an upper GI bleed from an ulcer, or another cause of blood loss. So, Valerie went through a colonoscopy, an upper GI series and a hematologic evaluation. Based on this, as Valerie had said, we knew that Valerie's blood production was correct, was adequate, and she did not have a cause for bleeding coming from the intestinal tract. Then after that, the most common cause of blood loss in a woman would be menstrual bleeding.

We performed a hysterogram, which is a test where we placed a radiopaque liquid, a liquid that doesn't allow X-rays to penetrate into the uterus.

PAUL MONIZ: We actually have a slide of that. We can show what that is and what that looks like. Walk us through how this tests work. How long is it? What does it show?

MARTIN GOLDSTEIN, MD: A hysterogram is an X-ray test. It is done by placing a small balloon catheter in the bottom of the uterus. The shadow on the bottom of this picture demonstrates the balloon catheter.

Through the balloon catheter, a radiopaque liquid, which shows up white, is injected into the uterus. In Valerie's uterus, which you see here, between the three dark marks there is a footprint shaped irregularity that represents a submucous fibroid. The submucous fibroid, in this case, is fairly large. It's approximately five by seven centimeters, which is about the size of a tennis ball.

PAUL MONIZ: So this is a large growth we're talking about.

MARTIN GOLDSTEIN, MD: Yes. This is a large growth. It was provoking significantly heavy bleeding. In addition to the submucous fibroid on the hysterogram, we also can see a small polyp, which doesn't show up as well. It's at about the 11 o'clock position in reference to the fibroid.

PAUL MONIZ: How long did it take you to find this after Valerie came to see you?

MARTIN GOLDSTEIN, MD: We had the hysterogram performed as soon as Valerie stopped bleeding, which was several days after she saw me. To provoke further cessation of bleeding, we used a medication called Lupron, which is a gonadotropin releasing hormone agonist. This is a medication that works by inhibiting estrogen production from the ovary. It temporarily will make a woman menopausal.The ovary then stops producing estrogen. Fibroids will shrink because fibroids are stimulated and will grow from estrogen.

Fibroids will frequently grow if somebody is on birth control pills. One of the first ways of treating heavy vaginal bleeding with menses by many doctors is to put the patient on birth control pills. I think it's very important to make a diagnosis before you start a treatment. In some cases, the management and treatment can aggravate the initial process that's happening.

PAUL MONIZ: Valerie, let's bring you into this again. While you're going through this workup, physically what are you feeling? Are these diagnostic tests painful or uncomfortable?

VALERIE: None of them were painful or uncomfortable. I was fine.

PAUL MONIZ: What about psychologically? Obviously, you were concerned?

VALERIE: Psychologically, I was concerned, but I was relieved that I was getting help and was going to become healthy. So, my outlook and my sense of well being were beginning to be more reassured.

PAUL MONIZ: You came to the conclusion that hysteroscopy was indicated?

MARTIN GOLDSTEIN, MD: I felt it was necessary to remove the myoma. We knew that Valerie did not have a malignancy. We did a biopsy of the endometrial lining. We found that there was no malignancy present. We did a hysterogram, which demonstrated a large submucous fibroid. This being the cause of the bleeding, it was necessary to do something to remove the fibroid. The options were either to remove the fibroid with the uterus and perform the hysterectomy, which Valerie did not want as an option, or to do some procedure to remove the fibroid.

The options were either doing a hysteroscopy, which is a minimally invasive technique where no incisions are required, or doing an abdominal myomectomy where you would require an abdominal incision, which would require major surgery. You make an incision into the uterus, remove the fibroid, reconstruct the uterus and then close the abdominal incision. This would require a probable three to four day hospitalization and a two to four week recovery time. If we would be able to remove the fibroid hysteroscopically without making an incision, then the patient would be able to go home the day of the procedure.

PAUL MONIZ: Which is, in fact, what happened with Valerie.

MARTIN GOLDSTEIN, MD: Fortunately, we were able to do this procedure hysteroscopically. Valerie was very pleased with the way the procedure went, and she was able to return to work, as she'll tell you.

PAUL MONIZ: Valerie, let me get this straight. You had this on Friday and you were returning to work on Monday?

VALERIE: I returned to work on Monday. I could have returned to work the next day, if it was a day I was working. There was no pain. I walked out of the hospital, and I didn't need any pain medication at home. Although I was advised by Martin to relax and stay home and take it easy, I didn't need bed rest. I had really no bleeding. And I was healthy, and am healthy. And I didn't have a hysterectomy, which is really important for people to know.

PAUL MONIZ: You did not obviously want to have a hysterectomy for, I would imagine, the same reasons that most women do not want to have them.

VALERIE: Right. There was no reason for me to go through that type of surgery.

PAUL MONIZ: When isn't this procedure not indicated?

MARTIN GOLDSTEIN, MD: The procedure is not doable hysteroscopically if the fibroid is not in the endometrial cavity. If we don't have a submucous fibroid, then we can't get the fibroid out hysteroscopically. If the fibroid would be within the muscle, and only a small portion of it penetrating into the cavity, we might not be able to remove the fibroid with the resectoscope.

PAUL MONIZ: So, it's important to know what you're dealing with here. What about the risks? I mean, any time you have any kind of surgery there are risks. What are the chief ones for this?

MARTIN GOLDSTEIN, MD: In most surgery, the first risk is anesthesia. In hysteroscopic surgery, many times we can do with this moderate anesthesia care, which is a localized anesthetic plus intravenous sedation. At times, if a fibroid is large, we will have to use a general anesthetic. The general anesthetic is usually rapid onset and rapid recovery. The risks of the procedure itself are the risk of damaging or perforating the uterus, or making a whole in the uterus as you place the resectoscope. To prevent this from happening, I use a laminaria, which is a way of dilating the cervix slowly over a 24-hour period, so that when the patient is in the operating room we don't have to use a steel instrument to stretch the cervix. The cervix is already open and will accommodate the hysteroscope.

PAUL MONIZ: Overall though, we're talking about a procedure that is fairly safe.

MARTIN GOLDSTEIN, MD: Hysteroscopy, if done by people who are experienced in doing it, who know the complications and risk and take steps to avoid these complications and risks, is a safe procedure.

PAUL MONIZ: Dr. Martin Goldstein thank you very much for joining us and that important information. Valerie, thank you for sharing your story, as well.

I'm Paul Moniz. We are talking about hysteroscopy today. If you have any questions, you should ask your doctor. Thanks for joining us.

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