What are the different types of fibroids and how are they removed?
Fibroids may be described as subserous, intramural or submucous depending on where they are situated in the uterus. The site of the fibroid is an important consideration when deciding how it will be removed.
Subserous fibroids protrude from the outer surface of the uterus, intramural fibroids are buried in the wall of the uterus, and submucous fibroids protrude from the endometrial lining into the interior of the uterus. A further term used to describe fibroids is pedunculated. Pedunculated fibroids, usually of the subserous or submucous variety, grow at the end of a stalk.
When myomectomy is chosen as the treatment method for fibroids, the abdominal approach to entering the uterus is chosen if the fibroid is subserous or intramural. (The abdominal approach may be open cut or by laparoscopy.) If the fibroid is submucous or pedunculated submucous and the surgeon is sufficiently skilled, a hysteroscopic myomectomy maybe carried out.
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Smoking
A study published in the British Journal of Cancer showed that men, who smoke, while their partner doesn’t, run the risk of fathering children who develop cancers such as leukemia and brain tumours. The theory is that chemicals in tobacco smoke can damage the DNA in the sperm. Taking this one step further, it’s easy to see that any changes in DNA in the sperm could lead to a possible increase in miscarriage rate. DNA damage cannot be picked up in a normal semen analysis so this problem would not be seen during routine fertility investigations.
Quite apart from the possible increase in abnormalities in babies of women who smoke during pregnancy, there is also an increased risk of miscarriages.
Another study, by Professor Jane Golding of the Royal Hospital for Children in Bristol, highlighted how our own actions can affect the next generation. Jane Golding looked at daughters who didn’t smoke but whose mothers had smoked. The daughters subsequently suffered a significantly increased risk of miscarriages.
It is universally acknowledged that alcohol can alter a man’s sperm count and cause an increase in abnormal sperm. Therefore, it follows that if an abnormal sperm fertilises an egg, nature will try to ‘get rid’ of that embryo because it is working on ’survival of the fittest’.
Alcohol is a substance that is known to cause mutations. For example, studies have shown that alcohol given to female mice immediately after mating caused severe damage to the chromosomes of one-fifth to one-sixth of the embryos. This resulted in a higher percentage of miscarriages or death shortly after birth. Chromosomal damage is a recognized cause of miscarriage.
Research has also shown a strong relationship between alcohol and miscarriages. A 1977 study found that women who have a drink every day have a risk of miscarriage 2.5 times higher than non-drinkers. In this same study they found that if the woman was a drinker and a smoker her risk of having a miscarriage increased by up to four times.
The conclusion, from a number of the studies on women, is that even moderate alcohol consumption works as a reproductive toxin and as such increases the risk of a miscarriage.
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Every woman should be aware that a second opinion is her right and she should never be made to feel guilty about wanting one. A second opinion will give you peace of mind so it is essential that you get this from a specialist well-versed in the treatment of endometriosis and one who is well up on the latest research and technology. It is important that the doctor giving the second opinion is not in the same practice as the first doctor.
If you are unable to communicate with your doctor or you are uneasy about your doctor’s attitude, approach and explanations then you should seek a second opinion.
You should also obtain a second opinion if you are unsure about the type of treatment recommended, or if your doctor says there is nothing wrong with you.
If you do not feel that adequate tests and evaluations have been carried out or you wish to consult a doctor who has expertise in one particular aspect of the treatment of endometriosis – such as laser therapy or infertility – then seek a second opinion.
A second opinion is important for women who:
• Have been recommended a hysterectomy.
• Are told by their doctor that nothing further can be done to treat their disease.
• Need reassurance that the treatment suggested by their first doctor is appropriate.
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Many women find that losing their hair from chemotherapy is the most disturbing thing that happens. (Talk with your oncologist about what to expect from your chemotherapy. Not all the drugs used cause the same degree of hair loss.) You should go to see someone who sells wigs while you still have your own hair so that there will be the best chance for a good match of color, texture, and style. Of course you may decide that you want to deal with hair loss by using hats, scarves, turbans, or a combination of all of these. Even when you are told that hair loss may or is likely to happen to you, it is still traumatic. Since this may begin to happen within the first three weeks of treatment, you will want to think about this as soon as you can. If you have a close friend or family member who can go with you to look at wigs, plan to go with her. As you decide on the type of wig to purchase, bear in mind that a synthetic or mixed fiber wig is not only less expensive but is also lighter, cooler, and more comfortable to wear.
Your doctor or nurse can give you an accurate guess as to when you might lose your hair. It is very predictable and depends on what chemotherapy drugs you are receiving. Some women find that their scalp becomes quite sore or tender a few days before the hair loss begins. This may not happen to you, but if it does, consider it a forty-eight-hour warning.
There is no way to make the actual experience of losing your hair anything less than a crisis. As hard as this is to imagine, it will be easier to bear once the hair is gone. The anticipation of the loss and the actual process of losing it are the worst. One strategy for when your hair begins to go is often very helpful for many people. You will know with certainty when this is happening; if you are wondering whether your hair is coming out, it is not. If you can muster the courage and determination to do so, consider having your hair buzzed and/or your head shaved. Many women find that their hairdresser is more than willing to meet them before or after hours at the salon or even to come to their home to do this. Your husband/friend/partner could also provide this service to you. Taking it off, all of it, puts you in control and gets you through it as quickly as possible. Once the hair is gone, you will start to adjust to your new bald head.
One woman whose hair came out in the early spring was enormously helped by her husband’s tender suggestion of putting clumps of hair in and near the bushes and trees in their yard. He said that birds would use the hair to build their nests, and this turned out to be true. In the fall, when the leaves were gone and the nests visible, she found several empty nests warmly and softly lined with her hair.
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Radiation therapy, following lumpectomy, is given five days a week for approximately six and a half weeks. The specific schedule of your treatment will be discussed with your radiation oncologist and nurse. If you are also getting chemotherapy, radiation may be administered at various points:
* Prior to chemotherapy
* Following chemotherapy
* “Sandwiched” in the middle of chemotherapy
* Concurrently with chemotherapy
* Recent studies have indicated the value of radiation for some women who have had mastectomies. If this is suggested to you, it will probably be at the end of your other treatments. You may have more trouble with skin burning when the radiation is directed at your chest wall rather than at a breast.
Most women find their radiation treatments to be relatively uneventful. It can be tiring to make a daily trip to the hospital, and it certainly is a daily reminder of what has happened to you. It may also require a major psychological shift to think of radiation as life-giving, instead of as an encounter to be avoided whenever possible.
In Hester’s clinical practice, she has encountered some women who have a very difficult time psychologically during radiation therapy. Again, for most women, these treatments are quite manageable and sometimes more of an inconvenience than anything else. However, Hester believes that two groups of women may have real trouble during these weeks:
* Women who have a childhood history of sexual abuse
* Women whose primary coping mechanism is avoidance
Women in the first group may have a strong reaction to having to lie prone and still while a large and powerful object is suspended over them. These feelings may be intense but confusing, as they come from semiconscious or unconscious memory. If you know that you have a history of sexual abuse, it would be wise to talk over these feelings and your planned treatment with an experienced oncology social worker or other mental heath clinician. Unless you choose to do so, you do not need to tell your medical team of your history. You can simply say that this treatment is difficult for you and that, therefore, you will require a little extra time and attention.
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We have heard college age and adult sons and daughters of mothers with breast cancer describe the fear of being excluded from the real situation at home and their anger when they discover that certain details have indeed been kept from them during their absence in order to spare them unnecessary worry. We have also known many who opt to maintain some distance and separation from what is happening at home. As is the case with their younger siblings, most college age and young adult children will do fine as long as they are given honest information and the chance to participate or not, as they choose.
Some adult children may try a combination of different coping mechanisms, sometimes fully engaging in social situations, sometimes retreating and withdrawing from peers, except those who also have a parent struggling with a life-threatening disease. At other times, these young adults might find solace in rituals that provide comfort; some are based in conventional religious practices and others are less traditional in origin. Still other adult children might display different forms of rebellion, such as a predilection for unusual risk-taking activities.
Having a mother (or father) who goes through cancer is likely to impact significantly how a young person thinks about, and shapes, major life decisions. The extent to which this medical crisis affects the maturing children depends on whether or not the cancer treatment succeeds in vaulting the patient into remission. In most cases when the treatment is, or appears to be, successful, the children go on about their business. Obviously, when a family is not so fortunate, and the patient’s condition worsens, the effect is profoundly different.
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Some husbands have told us they were surprised that from the very beginning they felt they were unimportant to the doctors and other caregivers trying to help their wives. Some of them had a difficult time getting used to the fact that for the duration of their wives’ treatment, the doctors attending their wives, as well as the entire hospital staff, were focused completely on their wives’ well-being and did not ever acknowledge the husbands’ needs. This is, of course, uncomfortable and unfortunate. Full attention and support is often focused on the patient, and to some extent, this is completely appropriate. Husbands/partners may need to look elsewhere to find support for themselves. It is not really reasonable at this time to lean on your wife. She needs to lean on you. Husbands/partners need to talk with their own family (perhaps siblings or parents) and friends.
Husbands/partners often experience a total sense of loss of control from the first minute of the diagnosis. Events unfurl extremely fast. Appointments are often made for tests and for surgeries without any attempt to consult with them in any meaningful way. This, too, is less than ideal, but the realities of busy hospitals are that appointments are made without much consideration of anyone’s schedule. The emphasis is on getting the patient what he/she needs as quickly as possible. In most cases, the husbands had confidence in the doctors helping their wives, and they trusted the doctors’ judgment and were content to stay in the shadows. However, some husbands want to emphasize the point that if you or your partner feel that something is wrong with the way the diagnosis is being made or the treatment is being planned, you must reassert some measure of control and press the doctors for further explanations. In the rare case that you feel something is very wrong, you must discuss your feelings with your husband and get a second opinion. You both must feel comfortable with the physicians you ultimately choose. Remember, however, that you are the patient. If you don’t have confidence in the doctor, find another one that you trust. Don’t allow yourselves to be stampeded by the medical establishment.
In all likelihood, some member of your family will have an especially hard time coming to grips with your illness. It may be one of your children or it may be your mother or father. A partner can provide immeasurable help by spending time with this child or with whoever most needs extra attention.
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You need a sympathetic ear and advice about how to deal with several issues simultaneously: your own feelings and those of other family members, including perhaps your parents, siblings, children, and friends. You may not feel up to the emotional requirements of dealing with so many people all at once. Both you and your partner may need advice about how best to inform family and friends; your clergy member should be able to help you sort this out and may also connect you to leaders within your community who stand willing to organize other members to help you in the weeks and months ahead.
You and your partner will most likely want to have your intense, almost overwhelming feelings validated by your religious leader. She should respond to your concerns by saying either “I know how you feel” (only if she truly does from personal experience) or “I can imagine how you must be feeling.” Most people we know resent the presumption of another person assuming s/he knows how you feel—even a professional clergy or physician—unless s/he has actually lived through a similar crisis. Even professional training does not entitle other people to assume that they really know how you are feeling; the truth is that, unless they have had the same experience themselves (either personally or through an immediate family member or close relative), they really do not know what you are going through.
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List of some more commonly prescribed drugs, and the main potential side-effects.
The combined oral contraceptive pill – Given continuously, without a break for periods, for nine months, the pill has been used to treat endometriosis by preventing menstruation. It seems to be used less commonly now, as other treatments have become available.
Progesterone tablets—Examples of these are norethisterone (trade name Primolut N) and dydrogesterone (trade name Duphaston). These are generally well tolerated, although reported side-effects of Duphaston include dizziness and breast pain. Other potential but less common problems with these drugs include menstrual irregularities, abdominal discomfort, headache, fluid retention, pain in the legs, chest or groin, depression, rashes, nausea, hair growth on the face or body and acne.
Other progesterone treatments—Medroxyprogesterone can be given orally (trade name Provera) or injected (trade name Depo-Provera). Provera is like Primolut N, and the side-effect profile is similar.
Danocrine (trade name Danazoic)—This is related to the male sex hormone, testosterone. This is the most effective drug, and commonly prescribed. The fact that it is related to male hormone should not cause alarm; it does not generally have permanent effects. For the time it is taken it reverses the endometriotic process. Women are warned of the possible side-effects, including fluid retention, weight gain, increased hair growth, especially on the face, acne and oily skin, rashes, nausea, increased sweating or flushing, change in breast size, increase in the size of the clitoris, vaginal irritation, and a change (usually deepening or huskiness) of the voice. The voice change, although uncommon, is the only side-effect that may not revert when the drug is ceased. All these things sound pretty horrible, but in fact most women tolerate the treatment fairly well, and significant problems seem rare. Although it should be unlikely that a women would become pregnant while taking danocrine, because of its hormonal effect, it is advisable to take precautions against conceiving while taking it, as it is not recommended during pregnancy. Therefore, it would be advisable to use condoms or a diaphragm during the time of treatment. Setter treatments—Some of the newer treatments being tried use the hormonal pathways with the aim of altering the messages sent to the brain and the ovaries. These are synthetic forms of naturally occurring stimulating hormones which affect release of the sex hormones which in turn stimulate the endometriotic tissue.
Non-Western medicine treatments—Other practitioners, such as Chinese medicine practitioners, natural therapists, acupuncture therapists, and others have specific treatments for endometriosis. The mechanisms of action and rates of success vary, but anecdotal evidence suggests that ‘alternative’ or ‘complementary’ methods of treatment may be very helpful to some women. Specific information should be available from practitioners.
Pregnancy—This is also a treatment for endometriosis. It acts in the same way as the drug treatments in that it changes the hormonal signals to the endometrium for nine months, and the extra scattered bits remain unstimulated and, with luck, disappear. There is, however, a significant recurrence rate after pregnancy.
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Weight gain. We are told that the average weight gain during a pregnancy is 10 to 14 kilograms (1-2 kilograms in the first three months, and 1-2 kilograms a month for the next six months). That is fine, if you are average. Some women will possibly gain less over die nine months. Some will gain more. Still, it is reasonable to presume most women will add about this amount, and usually will lose it in the months after the end of the pregnancy. Extra weight put on during the pregnancy will be just as difficult to lose as at any other time.
Pregnancy is not an ideal time to try to lose weight, because restricting your diet, or drastically increasing your exercise, could make your passenger suffer, as well as you.
Fortunately, foetuses are fairly assertive when it comes to taking what they need. If there is only a certain amount of iron, for instance, the foetus will usually get it, and the woman will miss out. This means that unless you look after yourself you may not be in terrific shape (nutritionally) by the end of the pregnancy, and be unwell as a result. The end of a pregnancy, and start of motherhood is not a great time to be anaemic and poorly nourished.
Pre-pregnancy diet. Your general health and well-being is important during pregnancy, and it is probably important to enter the pregnant state in as good condition as you can. Eating sensibly prior to pregnancy will mean that your body’s stores of nutrients will be better stocked for when you need them. Beginning your pregnancy significantly overweight or underweight can increase your chances of having problems through the pregnancy.
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