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Suggest Treatment For Multiple Fibroids, Irregular Periods, Variable FSH And LH Levels?
Question: Hello doctor, Im 52 yrs old. I have very large fibroids. In May 2013 I had FSH value 28.1. In Feb 2014 the FSH was 53 (two days ago). In between Ive been having somewhat irregular periods (in 2013: gaps of 40 days, 19 days, 37, 30, 32, 25, 22, 24, 35, 40, 28, 42 days), 5 times mid-cycle spotting between 2012 end and mid 2013. The last period was on 9th Feb almost no flow of blood.
One doctor says I have to have immediate hysteroscopy since the echogenic endometrial lining has changed from 1mm to 14 mm from May 2013 to Feb 2014. FSH value in May end 2013: 28.1 and LH value in end May 2013 is 32.1.
FSH value on 13th Feb 2014: 53.1 and LH value on 13th Feb 2014 : 30.9
They said hysterectomy can be delayed since no symptoms except negligible bladder misfunction from thin to normal flow of urine on and off.
Another doctor said everything is normal for the menopausal age and I need not do hysteroscopy and wait for no periods for 6 consecutive months before doing ET check and if then the ET is more than 4 mm it is cause for concern.
What do I make of this ? is it an emergency or not ? Please help. Thanks a lot
Brief Answer:
Do not worry, get hysteroscopy done
Detailed Answer:
Hi XXXXXXX
I understand your concern.
You have informed that you have multiple big fibroids. Unfortunately I am not able to view the ultrasound reports that are attached. The files do not open. It would help if you could just type it or send in another format. Or perhaps you can mail the file to YYYY@YYYY
However you have given sufficient details in your query for me to help you as much. First of all you must not worry about the variable FSH and LH levels. These hormones will have a daily variation as well as vary depending upon the day of the menstrual cycle. Levels more than 30 are considered to be menopausal. So these levels are normal at your age. Irregular cycles are also expected in this age.
The important issue is a thick endometrium and fibroids. For the menopausal women endometrium must begin to thin. So a 14 mm endometrium is slightly more considering your hormonal status. Both endometrium and fibroids depend upon estrogen hormone. This hormone decreases naturally after menopause so fibroids and endometrium both will regress but this takes time maybe a few years.
There is no hurry but it is better to get hysteroscopy done in view of the fibroids and endometrial thickness. Sometimes thick endometrium is a sign of developing cancer [ Endometrial cancer is also related to high estrogen levels and you already have fibroids indicating a higher estrogen environment in your body]. It is best visible on hysteroscopy and also allows a biopsy [remove a part of tissue ] for examination and confirm findings. This will help in deciding the future treatment.
Another option is an office endometrial biopsy. It may miss some cases of endometrial cancer as it is a blind procedure, but it is good as it can be done in the out patient department and is quick, does not need anesthesia. It also collects tissue pieces similar to hysteroscopy for examination under a microscope but it may sometimes miss sampling the affected part as it is a blind procedure.
Even though I was not able to see the Ultrasound report, I can say that fibroids need treatment if they produce symptoms or are very big. So a decision for hysterectomy will depend upon the findings of hysteroscopy and size of fibroids. If hysteroscopy is normal, you will not need any treatment if fibroids are asymptomatic. They will just need a yearly follow up to see if their size is decreasing. Hysterectomy will be advisable only is they are not shrinking or growing.
So do not think so much. Hysteroscopy is a routine procedure nowadays. Also the report is more likely to be normal as cancer of the endometrium is very rare. You may discuss all these issues with your doctor once more to clear any more doubts. I am always there to help.Do not worry. You will be fine.
Hope I was able to help you. Thanks for using Health Care Magic.
I would be happy to answer any further queries.
Have a nice day and take care.
Dr. Madhuri Bagde
Consultant Obstetrician and Gynecologist
Above answer was peer-reviewed by :
Dr. Prasad
Dear Doctor,
Thank you for your kind reply and analysis. I paste the word document below containing reports pelvic scan done in end May 2013, Dec 7 2013 and a CT scan in Dec 9 2013 and the different FSH values I was talking about.
I have another question:
In the light of the fibroid sizes that you will see now and asymptomatic state, do you still recommend postponing hysterectomy ? Im taking a homeopathy medicine for fibroids sepia, 220K 30 dilution once a month since feb 2014 for 6 months and ayurvedha treatment since 7 feb 2014 for 1 month for the same.
As for the endometric thickening, how grave is the emergency for hysteroscopy ? With the fibriod description that you will see, do you still recommend hysteroscopy ? Will there be any damage of the uterine wall in my condition ?
How is D and C different from hysteroscopy ?
What should I do ? In how many days I must act for hystereoscpy ?
Here are the reports. I thank you very much doctor for your kind help.
--------------------------------------------------------------------
Patient name: XXXXXXX XXXXXXX
AGE/SEX: 51 YEARS / FEMALE
VIST DATE: 01/06/2013
KUB AND PELVIS SCAN REPORT
INDICATIONS
C/O INTERMENSTRUAL SPOTTING
K C/O FIBROID UTERUS
SCAN TO RULE OUR PELVIC PATHOLOGY
REAL TIME B- MODE ULTRASONOGRAPHY OF KUB AND PELVIC DONE
LMP: 13/5/2013 / MC REGULAR / UNMARRIED
KUB
Right kidney measured 10.6 X 4.5 X 1.6 cms
Cortex and collecting system of right kidney appeared normal. No calculi seen
Left kidney measured 0.1 x 4.5 x 1.4 cms
Cortex and collecting system of left kidney appeared normal. No calculi seen
Pelvis
Transabdominal and transvaginal sonography of the pelvis done
Anteverted bulky uterus
Uterus with fibroid measured 16.9 x 9.9 x 10.4 cms (Vol 904.8 c)
Uterus itself measured about 13.8 x 6.5 cms
Multiple fibroids noted:
F1) Posterior wall upper corpus left sided submucous fibroid measuring 7.3 x 6.2 x 6.9 cms (vol 165 cc) Flow seen around this with RI of 0.59 Peak systolic was 39.4
F2) Anterior wall right sided mid and lower corpus submucous fibroid extending from the midrorpus to beyond the cervix measuring 10.6 x 7.4 x 12.3 cms (vol 507 cc). Flow seen in this with RI of 0.47. Peak systolic was 15.2
F3) Right sided subserous fibroid which appears to be arising from right lateral wall of the uterus at the upper corpus had a short pedicle of about 2.0 cms in thickness. Flow was seen in this fibroid with RI of 0.56. Peak systolic was 22.
F4) Anterior wall upper corpus intramural midline fibroid above F2 measuring 1.9 x 1.1 x 1.6 cms
None of the fibroids were found atypical. There is a possibility of the other small fibroids, however this is difficult to delineate due to shadowing by the larger fibroid.
Endometrical cavity appeared echogenic.
Two layer thickness measured 1.0 cm
Nabothian follicles noted in the cervix
Right ovary measured 3.0 x 1.5 x 3.2 cms (volume 7.5 cc)
Right ovary appeared normal.
Left ovary measured 2.8 x 1.4 x 2.4 cms (volume 4.9 cc)
Left ovary appeared normal.
IMPRESSION
Anteverted bulky uterus with multiple fibroids noted (ref text)
Echogenic endometrium of 1.0 cm
Both ovaries appeared normal. These were not visualized on TVS as they were placed high up and laterally.
---------------------------------------------------------------------
Patient name: XXXXXXX XXXXXXX
AGE/SEX: 51 YEARS / FEMALE
VIST DATE: 07/12/2013
KUB AND PELVIS SCAN REPORT
INDICATIONS
K C/O FIBROID UTERUS
FSH ON 31/5/2013 – 28.2 AND LHS WAS 32.1
Real time B-mode Ultrasonography of KUB and Pelvis done
LMP: 30/11/2013 / MC IRREGULAR / UNMARRIED
KUB
Right kidney measured 10.6 X 4.1 X 1.4 cms
Cortex and collecting system of right kidney appeared normal. No calculi seen
Left kidney measured 10.8 X 5.0 X 1.7 cms
Cortex and collecting system of left kidney appeared normal. No calculi seen
Pelvis
Transabdominal and transvaginal sonography of the pelvis done
Uterus measured 13.4 x 8.2 x 12.8 cms (Vol 904.8 c)
Midposition uterus
Multiple fibroids noted:
F1) Posterior wall upper corpus left sided submucous bollilated fibroid, in some views they appeared to be 2 fibroids besides each other. It measured 7.7 x 6.3 x 7.3 cms (vol 187 cc)
F2) Anterior wall right sided mid and lower corpus submucous fibroid extending from the midcorpus to beyond the cervix measuring 10.5 x 7.7 x 11.9 cms (vol 507 cc). Flow seen in this fibroid with PS 34.7 and RI of 0.6
F3) Right sided subserous pendunculated fibroid which was not seen on TVS, probably due to bowel shadowing. It measured 6.1 x 4.5 x 6.3 cms (Vol 64 cc)
F4) Anterior wall upper corpus intramural midline fibroid above F2 measuring 1.8 x 1.3 x 1.8 cms
Endometrial cavity appeared echogenic
Two layer thickness measured 9.7 mm
Endometrium was visualized with difficulty.
Right ovary measured 2.3 x 0.8 x 3.3 cms (vol 3.2 cc)
Right ovary was placed high up and there not seen on TVS and to the extent seen appeared atrophic.
Left ovary measured 2.8 x 2.1 x 3.0 cms (vol 9.2 cc)
Left ovary appeared normal
There was a dominant follicle in the left ovary measuring 2.5 x 1.9 x 2.5 cms
IMPRESSION
Midposition uterus with an echogenic endometrium of 9.7 mm
Multiple fibroids noted (ref text). One of fibroid (F4) has increased in size marginally, while others are almost of the same size as in the previous scan in XXXXXXX 2013.
Right ovary was placed high up and there not seen on TVS and to the extent seen appeared atrophic.
Left ovary appeared normal with a dominant follicle within.
Note: Visualization of uterus, fibroids and ovaries were suboptimal despite repeat scan following bowel preparation.
-------------------------------------------------------------------------
NAME: MS. XXXXXXX XXXXXXX DATE: 10.12.2013
AGE: 52 YRS / FEMALE
CT – SCAN LOWER ABDOMEN PLAIN AND CONTRAST STUDY
Helical scan of the lower abdomen done from iliac crests to sub-public arch level and before and after giving IV contrast. Coronal and sagittal 2D reconstructions are also studied.
The study shows enlarged uterus with multiple anterior, posterior, myometrial, intramural, submucosal, subserosal and pedunculated subserosal fibroids distorting the endometrium, causing mass effect on the bladder, sigmoid colon, iliac vessels both distal ureters and ovaries.
The uterus measures 16.5 x 14.8 x 13. 5 cm
The largest fibroid measures 9.5 x 8.9 x 7.6 com in the body of the uterus
No ascites / no lymphadenopathy
Few atheromatous calcifications of aorta and iliac arteries
Dorsolumbar spondylosis. Bilateral sacroilitis.
URINARY BLADDER:
The urinary bladder is well distended with normal. The bladder wall thickness appears normal with no focal thickening. No abnormal intra luminal contents noted. The peri-vascular fat planes are normal.
OVARIES / ADNEXA:
Both ovaries appeared normal.
Both adnexal appeared normal.
BOWEL LOOPS:
The visualized bowel loops reveal no gross abnormality.
IMPRESSIONS
• ENLARGED UTERUS WITH MULTIPLE ANTERIOR, POSTERIOR MYOMETRIAL, INTRAMURAL, SUBMUCOSAL, SUBSEROSAL AND PENDUNCULATED SUBSEROSAL FIBROIDS DISTORTING THE ENDOMETRUIM, CAUSING MASS EFFECT ON THE BLADDER, SIGMOID COLON, ILIAC VESSELS BOTH DISTAL URETERS AND OVARIES.
• THE UTERUS MEASURES 16.5 X 14.8 X 13.5 CM
• THE LARGEST FIBROID MEASURES 9.5 X 8.9 X 7.6 CM IN THE BODY OF THEUTERUS
• NO ASCITES / NO LYMPHADENOPATHY
• FEW ATHEROMATOUS CALSIFICATIONS OF AORTA AND ILIAC ARTERIES
• DORSOLUMBAR SPONDYLOSIS. BILATERAL SACROILITIS
----------------------------------------------------------------------
NAME: MS. XXXXXXX XXXXXXX DATE: 16.02.2014
AGE: 52 YRS / FEMALE
PREABDOMEN AND TRANSVAGINAL PELVIC SONOLOGY
UTERUS: Anteverted, bulky and lobular. It measures 14.2 cms in length, 10.3 mm AP and 13.9 com across. Multiple fibroids noted, measuring (1) intramural 7.3 x 5.2 x 6.84 cm of volume 136 ml in the anterior myometrium (2) subserosal 6.32 x 4.12 x 4.92 cm of volume 6.7 ml at the dome (Minimal vascular on Doppler ) and (3) largest fibroid 9.88 x 9.57 x 9.8 cm of volume 488.8 ml at the uterocervical region. (minimal vascular on Doppler)
Cervix normal
Endometrium is thickened and measures : 14 mm (TVS)
Both the ovaries are normal in size and echopattern. The ovaries measure:
Right ovary: 3.09 x1.8 cm
Left ovary: 2.93 x 2.18 cm
Pouch of XXXXXXX is clear. No other adnexal pathology noted.
IMPRESSION:
1) UETRUS – BULKY, LOBULAR WITH MULTIPLE FIBROIDS AND THICKENED ENDOMETRIUM
2) OLD SCAN REPORT DATED 06/12/2013 –DONE OUTSIDE ) IS REVIEWED.
-----------------------------------------------------------------------------
NAME: XXXXXXX XXXXXXX
AGE: 51 YRS / FEMALE
DATE: 31/05/2013
SERUM FSH – FOLLICLE STIMULATING HORMONE
RESULT: 28.2
UNITS: mIU/ml
REFERENCE: * Female: Follicular phase: 2 – 11
Ovulatory phase: 7 -25
Luteal phase: 2-10
Postmenopausal: 20 – 120
SERUM LH – LUTENIZING HORMONE
RESULT: 32.1
UNITS: mIU/ml
REFERENCE: * Female: Follicular phase: 1-20
Ovulatory phase: 26-75
Luteal phase: 1-21
Postmenopausal: 26-95
NAME: XXXXXXX XXXXXXX
AGE: 52 YRS / FEMALE
DATE: 13/02/2014
SERUM FSH – FOLLICLE STIMULATING HORMONE
RESULT: 53.1
UNITS: mIU/ml
REFERENCE: * Female: Follicular phase: 2 – 11
Ovulatory phase: 7 -25
Luteal phase: 2-10
Postmenopausal: 20 – 120
SERUM LH – LUTENIZING HORMONE
RESULT: 30.9
UNITS: mIU/ml
REFERENCE: * Female: Follicular phase: 1-20
Ovulatory phase: 26-75
Luteal phase: 1-21
Postmenopausal: 26-95
Brief Answer:
Reports are very useful
Detailed Answer:
Hi XXXXXXX
These reports are immensely helpful in making a decision.
All the reports suggest that you have big fibroids. The CT scan says that they are causing an effect on adjacent organs most likely compressing them.
These fibroids are less likely to regress after treatment with medicines. They suggest an excess estrogen. The endometrium is between 1 cm to 0.9 cm. So it is not alarming. It is expected with excess estrogen.
The D and C is a procedure where tissue is collected from the uterus just like an endometrial biopsy. D and C is a blind procedure meaning that the surgeon cannot see the inside of the uterus. He just sample tissues from all sites based on his judgement.
The difference between this and hysteroscopy is that the hysteroscope has a camera, so we can actually see the tissue inside and take biopsy from areas that we feel are suspicious or have an abnormal morphology. Also it is possible to do some operative procedure like remove polyps and destroy endometrium by hysteroscopy [both most likely not needed in your case].
The only indication for this procedure for patients like you is to rule out any underlying cancer before planning surgery. We practice a D and C or hysteroscopy for every patient posted for hysterectomy as it safeguards the patients interest. The risk of cancer as such is very low. But if a patient has an underlying cancer and we perform simple surgery, only to discover later that a more extensive procedure was needed, it is injustice to the patient.
So please do not worry about the hystero or D and C. They are very routine investigations done for such conditions. The chances of damage to the uterus are minimal if the surgeon is skilled.
Having said all this, it seems that you will eventually need a hysterectomy considering the sizes of fibroids.
Regarding how urgent it is, I suggest you get the D and C done earlier say within a month or so. The further procedure may be done based upon the reports but within 6 months as the D and c report is not valid after 6 months and you may need to repeat the whole procedure again. Do not waste any more money on FSH and LH. They will not help you in guiding treatment in any way as fluctuating levels are expected at your age.
Please do not worry so much. Discuss all these with your doctor. I am always here to help you.
Please feel free to ask any more queries that you may have.
Thanks once more.
Have a good day.
Above answer was peer-reviewed by :
Dr. Prasad
Thanks doctor for your quick reply.
So do I do D and C or hysteroscopy ? There are so many multiple fibroids that I am scared of damage when they negotiate the hysteroscopy instrument.
Another suggestion was that I wait for 2 months of no bleeding and then do the ET test. What is your opinion on this ?
You have written the endometrium is between 1.0 and 0.9 cm. Thats the case only from may 13 to Dec 13. But two months later I took one more reading on 15th Feb, it has risen to 1.4 mm. (after 6 days of the last very scanty period, almost like spotting on 9th Feb)
Could you pl comment on the ET value of 1.4 cm on 16th Feb 2014 ? I would like to understand the analysis for it.
Thank you doctor for your attention.
XXXX
Brief Answer:
Do not worry about procedure so much
Detailed Answer:
Dear XXXXXXX
I understand your concern completely. Please do not be scared that they will damage the tissues. You may discuss this with your gynecologist who will perform the endoscopy. Some time when we attempt endoscopy or even D and C, it is not possible to gain entry into the uterine cavity. In that case, the decision to continue with risk or abandon is usually decided in the Operation theater itself. We also inform the patients relatives about the case and degree of difficulty and risk and take a collective decision. So please do not be scared and talk about all these with your treating gynecologist before making a decision.
Waiting for one or two months does not make much of a difference as the surgical difficulty remains the same as the fibroids will not shrink in a month or two. If you need time to decide and think a little bit more, you may wait.
The endometrial thickness has a variation between observers who perform the ultrasound as well as between two ultrasounds also. So a few millimeters here and there do not make much difference. But the increasing trend is a cause of concern.
Another thing is that fibroids, fibroadenomas in breast and thick endometrium [increasing thickness in the perimenopausal group] all are leading towards one direction that is estrogen excess which is not desirable.
I suggest that you do not delay the D and C and get it done at the earliest to rule out cancer. Then you may relax if the report is negative and decide about future management.
Hope this satisfied your query.
Please feel free to ask any more queries. I am always there to help you.
Take care and be safe and happy.
Dr Madhuri.
Above answer was peer-reviewed by :
Dr. Prasad
Thanks doctor. You are very clear. Shouldnt D and C be completely ruled out as it is blind and my estrogen is high ? SInce hysteroscopy is hard because of fibroid, is hysterectormy the only solution ? What are the bad effects of uterus removal. Apparently ovaries are OK. Please help me decide between the 3 options.
By the way I took the CA 125 blood test for cancer yesterday, it was 11.3 for a range of 0 to 35. SO its OK.
Are these tests useful ?
Thanks and regards
XXXX
Brief Answer:
Ca 125 is normal, so no worry.
Detailed Answer:
Hi XXXXXXX
Thanks for the query.
D and C and hysteroscopy would both involve difficulty but having said that, this is not the case every time. Some cases with big fibroids may be easy while some with small fibroids may be difficult. That was the reason I mentioned that decisions regarding continuing the procedure or abandoning it, may be needed to be taken on time while the doctor tries to conduct the procedure. The main purpose is to obtain a small bit of tissue [its less than 1 cm sometimes] for examination, so that we are having some information that a cancer has not built up inside. All hysterectomies are not similar. The type of hysterectomy needed after cancer is very extensive. Once a simple hysterectomy is done and cancer is detected in the hysterectomy specimen, it is almost impossible to reoperate and do an extensive procedure. The risks also increase. You may ask for an office endometrial biopsy where a small instrument is introduced in the uterus on day 1 of the menses and tissue collected. It needs some cooperation from the patient as gives a bit of pain. It must be done by a skilled person only for women with big fibroids like yours.
This is the main purpose of the D and C and hysteroscopy. Also it allows examination under anesthesia when muscles are relaxed. The surgeon is able to understand better the type and level of difficulty that may be anticipated during the major surgery. The CA 125 levels are low so the chances of cancer are very less [ this is useful in predicting cancer to some extent ] So if you do not want to undergo the D and C you may go for surgery directly. Another option is to do a frozen section intraoperatively. In this the specimen removed during surgery is sent for examination during surgery and a provisional report is provided regarding the status of endometrium.
Regarding hysterectomy being the only solution: There are many other options like myomectomy. This is done in women who want to have children or want to keep the uterus. In this only the fibroids are removed. It involves considerable amount of bleeding and it may not be always possible to remove all the fibroids.
Drugs like Danazol and Gn Rh analogues: They are used to shrink fibroids. Since they decrease estrogen. they produce menopausal symptoms like hot flashes. Danazol also may cause facial hair growth.
Uterine aretery embolization: The blood vessel supplying blood to the uterus is blocked under ultrasound guidance. So the fibroid shrinks in size.
All these therapies are useful for short term in small fibroids. In my experience they mostly fail with big and multiple fibroids. Also after 50 years of age, we advocate hysterectomy rather than conservative management as the benefits are more.
Only removing the uterus does not cause any harm. removing the ovaries with the uterus produces menopausal symptoms. I prefer to keep the ovaries in patients that have normal ovaries and no family history of cancer.
Please discuss all these issues with your gynecologist before surgery and then decide about the course of treatment for the best results as the gynecologist will have done the actual examination of the fibroids and will be able to tell you how much difficulty is anticipated in your case or it may be simple even.
Hope this helped XXXXXXX
Thanks for choosing HCM.
Take care and I am always happy to help you.
Above answer was peer-reviewed by :
Dr. Prasad
Hello Doctor, Im back ! Following your kind advice, I consulted another Gynocologist. She said it is very urgent, 14 mm endometric thickness could be cancer and a hysterectomy has to be done with freeze biopsy for any cancer presence. What do you think of the emergency aspect ?
To recapitulate:
FSH 28.1 endometrical thickness 1mm, in May 2013,
FSH is 53 ET is 14 mm in Feb 2014,
52 years old.
CA-125 test negative last week (around 17 th Feb 2014)
No symptoms
Between May 2013 with FSH 28.1, Ive had periods every month irregularly (pl check previous XXXXXXX for no of days) till Feb 2014. Are these periods abnormal in the light of 28 FSH. One docter made it seem like after 28 FSH, the whole set of periods for the one year were abnormal, its not menopasal periods tapering down, but bleeding caused by abnormal ET. One year of it, imagine to what extent cancer has sent it !
SO emergency and alarm declared.
Another thing is they say hysteroscopy is difficult given the fibroid positions. Im sending you a picture. Please advise if hysteroscopy is possible.
Im of the opinion that with XXXXXXX doctors, they want to make it a commercial case. But you lack the first hand infn. So Im sending you the picture in attachment. You have now all that they have at this stage.
Pl tell me once again. For my case, another doctor said I can wait 6 months, all this is normal for tapering menopause, wait for 2 months successive no peiods and take ET.
Pl let me know the periods I had the last year is end of menopause or ET problem ? All depends on how one interprets FSH 28 in May 2013, periods followed afeter that for 9 months and then FSH 53 in Feb 2014 and ET 14mm
Where do I stand now ?
Thanks and regards, pl gibe me quick response as Im anxious.
Once again thanks a million,
XXXX
Attached jpg file of fibroid
Brief Answer:
Do not worry so much.
Detailed Answer:
Hello XXXXXXX and welcome back.
I completely understand your state.
The pictures show that the fibroids are big and would eventually need a hysterectomy. It is but a question of time.
Please do not worry about the FSH levels. Variable and rising FSH levels indicate menopause. Levels up to 30 are normal. The menopausal levels are usually above 100.
Hysteroscopy seems difficult considering that one fibroid is just near the cervix from where the instrument is introduced. But a D and C and endometrial biopsy may be attempted.
I suggest that you consult a XXXXXXX gynecologist preferably in a Medical college as they are more experienced in handling such cases. A hysterectomy with a frozen section is a very good option as it does away the need for a D and C or a hysteroscopy.
The advantage of D and C is that you may have more time to get mentally prepared for the surgery if the report is negative for cancer.
Dear XXXXXXX considering the size of fibroids, a hysterectomy will be needed at some point of time. So you will have to be prepared for it. A skilled surgeon will ensure that you will not have any harm. Also if there is a cancer, future treatment can be started early and it will be good for you as an endometrial carcinoma is usually very slow growing.
The chance of cancer as such are low in the general population and they increase if there is post menopausal bleeding. You have never attained menopause [it is complete absence of periods continuously for one year]. So chances are low. But it is advisable to get the surgery done.
I suggest that you look for a surgeon who operates cases with cancer and knows how to do a Wertheims hysterectomy [the one needed for cancer] in case it is needed.
Fibroids also cause increased ET as they are all dependent on one hormone that is estrogen. Repeating ET will not help as your menopausal state is not confirmed yet. So to compare that it must not be more than 4mm [criteria used for post menopausal women] cannot be applied to you are you are perimenopausal.
Your options as of now are:
1. Get a D and C or hysteroscopy done to rule out cancer. If report is negative, hysterectomy may be done at any time within the next 6 months. Meanwhile you can take progesterone preparations to control endometrial growth.
2. Get a hysterectomy with frozen section biopsy done now. This will cure the symptoms and problem forever and also if no cancer is found, it will do away with the risk of ever developing endometrial cancer in future.
Remember that the surgeries are for your own benefit. I understand that you do not want to undergo a surgery and it is but natural. No one wants to do that. I myself never want to get admitted in any hospital as it is one of the most boring places to be in. But sometimes we have few choices. If it is good for our health we have to do it. You will not only be getting rid of the fibroids but also getting rid of the dilemma that you face now. It is difficult to keep thinking that one may have a possible cancer inside ones body and live with it. So I suggest that you get atleast some procedure, may be D and C done to say that there is no cancer. Then the surgery can be done anytime when you feel you are ready for it.
Please consult one or two more good XXXXXXX gynecologists and choose the one where you feel complete trust. As this is very important for a good outcome.
I am sure that you will be very well and get over all this.
I am always here to help you through everything.
Take care and do not worry.
Dr Madhuri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dear Doctor,
Im back !! Thanks for your extensive time. I dont get that time with XXXXXXX doctors.
I went to another XXXXXXX gynocologist today.
She says latest FSH values and ET values (53 and 14 mm) are incompatible and abnormal and we have to rule out cancer.
She says we dont know if the bleeding the last 8 months after FSH 28 is due to menstrual or ET bleeding or any other polyp.
So hysteroscopy. She says with the picture it may be possible.
But in her report she has wriiten: Hysteroscopy or Laporotomy !
That according to Internet is 4 weeks recovery and incision across.
I dont mind doing hysterectomy, if required, she knows that.
But why did she suggest hysteroscopy, if not possible laporotomy instead of hysterectomoy with frozen section ?
I cant ask her, they suspect we ask many doctors and get angry and speak only if we are coming for operation.
Please help me.
In hysterectomy with frozen section if cancer is detected, what will they do apart from removing the uterus.
My CA 125 test was negative. One doctor said it means ET is not cancerous and today's doctor said it is only for ovarian cancer and not for anything else.
What synthesis you can make of it ?
Thanks a lot. Please reply me fast as Im anxious. I didnt see your last answer as the the heading in the email are all the same and I overlooked it. Sorry!
Brief Answer:
sorry for the headings.
Detailed Answer:
Hi XXXXXXX
Please understand one thing, feel free to ask as many questions as you feel to your doctors. After all they will be subjecting you to a surgery and it is your right to clear all your doubts. So do not hesitate at all and even if they try to avoid it, ask and clear your doubts.
Having said this,
I think that what the XXXXXXX gynecologist has written is absolutely fine. She has written hysteroscopy or laparotomy as if there are any problems during hysteroscopy, a laparotomy may be needed. Laparotomy means opening the abdomen and the ultimate procedure that will be done is removing the uterus or hysterectomy.
When we write a laparotomy we mean that sometimes hysterectomy may not be possible [ It happens in cases with ovarian cancers when we want to do a hysterectomy but it is not possible as the cancers are very fast growing and inoperable when we open it]. But still it is a protocol to open and see how much we can remove as it affects treatment outcome. So this may be the reason she writes laparotomy instead of hysterectomy. So laparotomy also means that it may just be a open and close procedure if hysterectomy is not possible. As she has seen you she is better able to judge the case. Discuss this with her before you go for a surgery. Ask her if she feels that the fibroids may be inoperable specifically and if she feels that hysterectomy may not be possible. I feel that you must know this before you go for surgery as some women do not want to subject themselves to the procedure if they feel it may be open and close while some are willing to take the chance.
The reason for suggesting a hysteroscopy is to rule out cancer by doing biopsy. I have already said that this can be avoided if you do a frozen section during hysterectomy itself. Please check if these facilities are available with the hospital. You can always consult her junior colleagues for such information or the hospital pathology lab will help you about this.
Regarding a transverse incision on the abdomen, it is a surgeons preference. I usually prefer to give vertical incisions if I do a wertheims hysterectomy [the one required in malignancy] as the surgery is extensive and it is easier for me to do it with a transverse incision.
Regarding recovery: It is variable. Usually simple hysterectomy patients are fit for discharge by day 5. Those with more extensive surgeries like a radical hysterectomy [wertheims] may be kept longer. Uncomplicated cases usually recover in a week and are able to look after themselves with minor help from others and complete recovery may take up to 3 months [minor aches and pains etc].
If a cancer is detected on frozen section:
The uterus is removed along with both the tubes and ovaries, certain arteries feeding the uterus are removed very close to their origin, the structures are removed as much as possible [whereas in simple we remove only the uterus but in radical surgery we remove the surrounding tissue as well], the ureters are dissected, all possible lymph nodes are sampled for presence of cancer. It takes around 3-4 hours for the complete procedure depending upon the case as a lot of tissue is to be delicately sampled. The reason for such extensive tissue removal is to know the extent of spread of cancer if any and if it is found to have spread, further treatment like chemotherapy or radiotherapy is given.
Regarding CA 125: I had informed you that it is positive in some cancers, in some non cancerous conditions and also negative even if there is cancer. So the report has meaning only if histopathology report is available. A negative report does indicate that chances of cancer are low but a positive also does not always mean cancer. Also it is used as a marker more in ovarian cancer but also in endometrial cancer but to a lesser extent. meaning that false positive or false negative rates are higher in endometrial cancer.
Dear XXXXXXX these are all complicated issues. for us they are routine but as a patient I understand that you want more concrete information which is not always possible in medical science. Things are unfortunately not very accurate and we have to rely on chances. It is just like a detective who has a few clues, some are good and some bad. So we put them together, weigh them and then give our final call. It may be wrong at times as reports themselves are not 100% accurate and subject to some inherent error. This is because we have a lot more to learn still and medicine is still evolving.
So ultimately I would like to say that for any patient whom we post for a surgery, there is always a small, very small possibility that surgery may not be possible due to unexpected findings after actually opening the abdomen. This happens in very small number of cases and this is a risk that every patient takes before going for a surgery.
If we expect difficulty beforehand, we usually inform them before hand that it may be open and shut and also about how much is the need to open and see. I suggest that you discuss this with your family members and also involve them in helping you come to a decision. Weigh all the benefits of the procedure in mind and also the risks and then decide about your course of action.
Hope I was able to answer all your queries. [sorry if they are too long]
Take care. Remember it may just be simple fibroids!! And I wish that they would be simple fibroids.
Dr Madhuri Bagde
Above answer was peer-reviewed by :
Dr. Shanthi.E
Dear Doctor,
I understand much better, thank you very much.
One more question: why 4 doctors said hyterecotmy and only the last one said laporotomy ?
You know as much about me as them, except with physical examination they all said fibroids are big, have to be removed.
3 of them said hyterectomy with frozen section. Sorry for being dumb, but wouldn't this be better than laporotomy ? What is the difference in my case ? I think you have answered it, but I dont understand completely.
So the whole action is very urgent ? For how long I can put off hyteroscopy or hysterectomy ?
What do you mean by inoperable case of hysterectomy ? Everyone advocates that and never spoke of inoperability, why is that ?
3 out of 4 doctors said ET values (including you I think) are normal for the premenopausal, age. So who's diagnosis is correct ?
What is your gut feeling for the type of surgery I have to do in my case ? Dont worry, Im only asking you the gut feeling.
From the picture of my uterus I had sent in the previous mail, you think hysteroscopy is not possible ?
I was born after 3 abortions for my mother, she was given progesterone to keep the foetus and then I was born. You think this has affected my body ? My mother then had 4 children after me, I was the first. I remember she also had D and C before menopause, but no cancer.
Sorry Im asking you some questions again, but you are very good, thanks a lot !
God bless you !
XXXX
Brief Answer:
Thanks for the good wishes.
Detailed Answer:
Hi,
As I have said earlier that laparotomy is a technical term for us doctors. We use this term in cases where we anticipate that it may be a open and close procedure. By this I mean that in some cases it is not possible to do surgery as there are dense adhesions between the intestine or urinary bladder or other abdominal organs making surgery XXXXXXX as there may be an accidental injury to important structures. These are rare cases, and in most of them we know before hand that it may be possible that we may not be able to remove the tumor. This happens more in cases of cancer with advanced stages or patients with other abdominal infections like abdominal tuberculosis or any other, or patients in whom already multiple surgeries have been done. So we use the term laparotomy. Every hysterectomy is a Laparotomy as Laparotomy means to open the abdomen. We have to do that in every abdominal surgery including a hysterectomy. I cannot comment upon operability as it can be determined only after examination so you will have to trust your doctors for that. Even the XXXXXXX gynecologist did not say it was inoperable. The fact is that if doctors feel it is inoperable or difficult to operate they will tell this to you before hand as they too do not want to face you after posting you for a surgery and then come out and tell you that we could not operate. So the chances that it is inoperable are very low.
The ET values are just a guide. Fluctuating values are expected in perimenopausal age. These values do not mean that a thick endometrium is always cancerous. That is the reason I advised a D and C or hysteroscopy or endometrial biopsy to get a confirmation that the endometrium is cancerous or not. It does not matter whose diagnosis is correct because ultimately it needs a biopsy to say what it actually is.
Regarding my feeling:
The picture you sent was hand drawn so it gives a rough idea. But my experience is that many times big fibroids are easy to remove and sometimes a small uterus may lead to difficulties. So as a surgeon I am always ready for anything. The only thing of importance to me at that moment of surgery is the commitment to my patient. It never stands before my ego. If I feel that surgery will do more harm, I abandon it leaving my ego aside because it is done for the best of the patient. It happens very rarely but it does happen when we open cancer ovary. We always attempt to do a hysterectomy but in advanced stages it is not possible so we do remove as much as we can and inform the patients relatives of the situation. Mostly it is done before hand as these cases are difficult so patients already know that removal of uterus may not be possible. Most of the doctors who have been my mentors work in a similar fashion so I believe that most of the other professionals work that way. In your case, big fibroids do not mean not removable, they are very very common and we do operate them.
I will share my professional instinct with you:
For a similar patient in my clinic:
I will say that with your history and investigations, there is a small chance that it may be cancer. The risk is low as you do not have any history suggesting cancer and low Ca 125, but I have not examined you and this makes a big difference. But in any case, a biopsy or a confirmation of the reason for thick endometrium is needed by examination under microscope using any procedure of those that are available and it is best done as early as possible. This will help in knowing the exact state and the urgency of hysterectomy. If it is non cancerous, it can be delayed but not forever. If cancer is detected, do it in the same week or next if possible because the earlier the better.
Regarding possibility of hysteroscopy: Since our prime importance is to determine cancer or not, and hysteroscopy is the procedure of choice, as a surgeon I would always attempt it. If I find that I cannot introduce the scope, I would try to do a D and C or a endometrial biopsy atleast. These are modifications that may be needed depending upon surgical difficulty. An attempt is always made to get tissue for biopsy by any means that are safest for the patient at that point of time. It will not make any difference to you as anesthesia required for all is the same and these will be the things that we decide on spot. This is routine procedure, we always improvise as it is absolutely impossible to say what will be there when we begin surgery and we are trained for it. These are technical issues that you should not worry about.
Regarding progesterone use in mother:
As of now, most of the literature links estrogen use in mother to endometrial cancer. Progesterone is used very commonly and it has not been implicated in endometrial cancer. So do not think about it.
I hope that this has answered your queries.
Do not think so much. Have faith and thanks a lot for your blessings. They are the priceless treasures that I have and will never leave me. Thank you once again.
Dr Madhuri.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Thanks doctor. I'm coming back with another opinion:
My Neighbour whose our general physician and advices us when to see which specialist said the following:
ET values not at all alarming, they are normal. Periods after after Fsh value 28 in may 13 are normal and not a problem
Fibroids are shrinking and not posing a problem..no abnormal or excessive bleeding. Don't do anything. No hysteroscopy, no laparotomy. Only scan test after a few months.
So everything boils down to how to interpret the ET values... And the source of blood flow in the last 8 months. He says I have not attained menopause, so no clash with ET values. Put away all these files for another 6 months
What is your comment ?
Sorry for the trouble I'm giving you !
Thank you very much for your continued support, very useful !XXXX
Brief Answer:
There is no trouble
Detailed Answer:
Hi XXXXXXX
Considering everything, you may delay hysterectomy if you want but an endometrial evaluation is needed before waiting.
I had already said this in my first reply, get an endometrial biopsy done, if it is negative, you may wait.
Regarding the ET:
I will give you a small example to show you how things are interpreted.
It is a child's birthday and he gets a gift box. He asks all the guests to guess what is in the box without opening it. Everyone tries and makes a guess. Later the box is opened, some were correct and the others wrong. But the point is no one was sure until actually the box was opened and the contents actually seen.
It is the same way with ET. We can see that it is thick. But no one knows the reason for thickness. We can keep on guessing and balancing the probabilities as to what it may be, but we will know only when it is actually seen under the microscope. That is the reason I advice a biopsy so that cancer is ruled out. Then you may wait if you want.
I went through all your reports again. The fibroids are just showing a minor variation in size which is expected for us between two reports and even if the same person does it twice on the same patient. If you read the report on 7/12, it says that one fibroid was not seen on transvaginal scan and was visible after the abdominal scan. So these things are common and we understand all this. I have already said that medical science is not absolutely accurate. So a few millimeters here and there do not matter much. If they had shown a substantial decrease in size, I would have been happier and suggested you to wait. They are unlikely to shrink unless you attain menopause. And as you are still menstruating, such results are expected. The only good thing that I find is that they are not growing very fast. They are maintaining their size as of now.
The source of blood flow is not a cause of concern as it needs a doppler to test the blood flow. It is not a routine to test it. Some of the doctors are more enthusiastic and want to know everything perfectly and they would go at length to do an extra test. Others may also have tested it but not mentioned as they did not think it was important or may not even have tested. We do not know about it now. But such blood flow patterns are expected in fibroids as they are very vascular tumors.
If you want to wait for six months, you may do so, but it would be better if you had an endometrial biopsy and a report and then waited. In that case there would be less risk of having a cancer inside and waiting.
With a skilled surgeon there is usually no problem with a D and C or an endometrial biopsy. So please do not think so much about them.
You may wait without doing the biopsy for six months if you want to but this small risk would be there. So keep these things in mind before you decide.
And also please do not think that this is a trouble. It is my duty to share whatever small knowledge I may have with everyone who may benefit from it. So it is a pleasure and not trouble.
Thanks and take care.
Dr. Madhuri
Note: Revert back with your gynae reports to get a clear medical analysis by our expert Gynecologic Oncologist. Click here.
Above answer was peer-reviewed by :
Dr. Shanthi.E
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