Q. What is a normal period and how do I know if my periods are heavy?
What you loose every month varies between each woman. Normally, bleeding is between 3-5 days and the first 2 days tend to be heavy. On average, you can expect to change your sanitary towel or tampon every 4 hours.
Your periods are considered unusually heavy if:
You need to change your sanitary towel or tampon every two hours.
You need to use double sanitary protection (tampons plus towels).
You pass large blood clots larger than a 50 pence piece.
You bleed through your sanitary protection onto your clothes or bedding.
You bleed for more than 7 days.
Q. Does it mean hysterectomy, if I have fibroids?
Fibroids do NOT mean instant hysterectomy. There are several treatment options available.
Apart from hysterectomy, other available options include myomectomy, and non-surgical procedures (e.g. uterine embolisation, GnRHa medication), which are available to even women with very large fibroid uteri.
If you've just been diagnosed with fibroids and your gynaecologist has recommended a hysterectomy without discussing myomectomy or the non-surgical treatment options then it may be worthwhile discussing the reasons why the alternative options are not suitable for you.
If fertility preservation or uterus preservation is important, and treatment is indicated because of fibroid related symptoms, then myomectomy, uterine embolisation and GnRHa are options that could be considered. If there remains uncertainty about the reasons for hysterectomy treatment choice you are entitled to seek a second opinion.
It is important to note that both abdominal hysterectomy and abdominal myomectomy are major surgical procedures, with similar risks of complication (e.g. infection, bleeding, transfusion, DVT/PE) and similar rates of recovery (3-5 day hospital stay, 4-6w convalescence). Hysterectomy achieves a definitive cure but fertility and uterus are not preserved. However, repeat treatment due to recurrence of symptoms is possible following abdominal myomectomy.
The best treatment option is highly individualised and depends on your medical circumstances, future fertility wishes and preferences-it is not the same for everyone.
Q. I have fibroids and I am pregnant, what should I do?
Most women with fibroids do have a normal pregnancy and delivery.
Fibroids tend to swell during pregnancy due to high levels of oestrogen.
Problems can happen but they are rare which include: early labour, have a baby in breech position, pain when the fibroids shrink particularly later on in pregnancy and especially if your fibroids are large, problems passing urine if your fibroid presses on the tube that takes the urine of your body (urethra).
Doctors do not recommend removing fibroids during pregnancy, but you will be followed up by your GP after the baby is born if any symptoms persist.
Your obstetric care should be hospital obstetrician led. They may advise regular obstetric scans to monitor your baby’s growth and position as well as the position and growth of the fibroid(s).
You are at slightly increased risk of caesarean section, bleeding before labour, bleeding after labour, fetal growth restriction, pain during pregnancy, compared to women without fibroids-particularly if you have had previous fibroid removal surgery (abdominal myomectomy). However, most women have successful vaginal deliveries provided the head can enter the lower part of the uterus (called engagement). Women who have had previous abdominal myomectomy may be offered planned caesarean delivery due to a mainly theoretical risk of uterine rupture at the site of the fibroid removal during labour and vaginal delivery.
Q. Do fibroids ever go away?
In most women, fibroids stop growing or shrink when a woman passes menopause but this is not always true for all women with fibroids. They do not disappear.
Q. Do phytoestrogens in soya exacerbate fibroid growth?
Available scientific data would favour a conservative approach to avoid soya-rich product if you have fibroids. This is because:
Firstly, phytoestrogens behave like oestrogens (which affect fibroid’s growth)
Secondly, there is no large clinical trial to prove the definite association between phytoestrogens and fibroid growth.
Source: Atkinson et al. Am J Clin Nutr. 2006 Sep; 84(3):587-93.
Hedges L C et al. Ann N Y Acad Sci. 2001 Dec; 948:100-11
Q. How do fibroids affect my fertility?
The scientific evidence so far draws the following concluding remarks:
The exact impact of fibroids on fertility outcome is highly variable and is related to the size, position of fibroids, patient's age and many other factors. However, there is an overall tendency for fibroids to make women less fertile, but this is not absolute in all cases.
A woman with fibroids can conceive to have a normal pregnancy and birth.
There is limited evidence to support the notion that removal of intracavity fibroids (submucous type) is likely to improve fertility outcome.
There is insufficient evidence to support the notion that removal of intramural fibroids by open myomectomy or laparoscopic surgery has a beneficial improvement in fertility outcomes.
There is moderate level evidence to support the notion that subserosal fibroids have no detrimental effect on fertility outcome. Hence, in most cases of non-tubal obstructing subserosal fibroids, their removal is not mandatory in women who seek improved fertility outcome.
Q. What is the preferred/recommnended treatment for fibroids, if a woman has not had any children and still wants children. It seems that opinions differ on some treatments e.g U.A.E, but ongoing research by Dr Walker at Royal Surrey County Hospital seems to indicate that successful pregnancies have occurred after UAE?
We are fully aware that some women achieved successful pregnancies after UAE BUT there are insufficient data to say for definite. Many women have either unfortunately misinterpreted the results of pregnancies post UAE themselves or have been misinformed.
In addition, there is a small inherent risk of ovarian failure associated with UAE technique and for this reason, no one is able to give you an absolute guaranteed fertility preservation post UAE treatment.
At a recent public consultation meeting on NICE Guidance for UAE/UFE (May 2010), the advice from the expert committee for a woman who has an absolute desire to get pregnant afterwards is that UAE is NOT recommended and she is asked to opt for myomectomy where there has already established supporting evidence.
Q. Can fibroids turn cancerous?
Fibroids are not associated with cancer. Fibroids rarely develop into cancer and the risk is less than 0.1% of cases. A cancerous muscle tumour in the womb is rare and called leiomyosarcoma.
Q. Is GnRHa pre-treatment (for either 2-3 months or six months) necessary BEFORE myomectomy or hysterectomy?
The arguments FOR the pre-operative use of GnRHa are:
There is strong research evidence to show that, for myomectomy or hysterectomy procedure, pre-operative GnRHa (such as Decapeptyl, Zoladex, Prostap) therapy reduces the size of fibroids and the total blood loss during the operation (i.e. less risk of need for blood transfusion). The reduced size of fibroids is particularly important for procedures like hysteroscopic myomectomy (removing the fibroids that are inside the uterus with a camera inserted via the vagina) and abdominal hysterectomy.
Indeed, for abdominal myomectomy or abdominal hysterectomy, the pre-operative use of GnRHa could allow the surgeon to perform a bikini line cut instead of a midline vertical cut from the belly button. Obviously, a bikini line cut has a greater cosmetic appeal to a woman.
The arguments AGAINST the pre-operative use of GnRHa are:
There is concern that pre-operative GnRHa therapy may fibrose (stiffen) the skin capsule surrounding the fibroid making enucleation (‘shelling out’) of the fibroid surgically difficult.
GnRHa may shrink fibroids to such an extent that they are ‘missed’ by the surgeon at the time of abdominal myomectomy, only to re-grow later post operatively and lead to a possibly increased risk of fibroid recurrence post operation.
In summary, to balance the advantages and disadvantages of the pre-operative GnRHa therapy, many myomectomy specialists recommend for:
Planned hysteroscopic myomectomy or hysterectomy: 4 to 6 months of GnRHa pre-operative treatment prior to surgery.
Abdominal myomectomy: none or no more than 2 months of GnRHa treatment prior to surgery.
The exact duration of pre-operative treatment would depend on the size of the target fibroids, approach of the planned surgery, the need to minimise a blood transfusion risk (e.g. Jehovah’s witness), patient preferences and patient tolerability of the side-effects.
The side effects (essentially menopausal symptoms like hot flushes, night sweats, loss of energy) of GnRHa occur in around 30% of women, but can be minimised by limiting the duration of treatment and/or using add-back HRT (e.g. oral Tibilone 2.5 mg once daily) in combination with the GnRHa treatment.
Q. How long does it take for the menopausal symptoms caused by GnRHa to go away after stopping it?
Your hormone production should return to normal 4 to 6 weeks after stopping monthly GnRHa injection (e.g. Zoladex). The induced menopausal symptoms should disappear then.
Q. What is the effect of pre-operative obesity on the outcome of my operation?
Recent investigation shows that pre-operative obesity as measured by BMI is not a risk factor for poor surgical outcome in patients undergoing robotic myomectomy [George et al. J Minim Invasive Gynecol. 2009 Nov-Dec;16(6):730-3].
Q. I suffer terrible constipation since coming home from a myomectomy operation, what can I do?
Constipation is a frequent problem after pelvic surgery such as myomectomy or hysterectomy. About 3 days after your operation, the hospital usually ensures that you can open your bowel and may assist by showing you the correct way of emptying your bowel without straining to pass stools and supply some suppositories. Continued constipation problem at home could be helped by:
Cut down on the amount of pain killers containing codeine or morphine because one of the side-effect of these products is constipation;
Drink plenty of orange juice and eat high fibre food;
Speak to your pharmacists to obtain some mild laxatives (lactulose or senokot) or suppositories (glycerine or Dulcolax).
Failing all of that, see your GP.
Q. How soon can I start having sex after myomectomy?
After 6 weeks, you can start sexual intercourse if you have no pain or vaginal bleeding. If you experience pain or bleeding after sex, contact your GP for advice.
Q. Do I need HRT after hysterectomy?
If your ovaries were not removed during hysterectomy operation then you do NOT require HRT.
Removal of the ovaries puts you straight into premature menopause. You may choose to have HRT to relieve menopausal symptoms as well as to prevent osteoporosis. You may have concerns about the increased risks of breast cancer and heart disease associated with HRT that is understandable. The decision to have HRT or not depends on your medical history and how you would cope without it. It is advisable that you discuss with your doctor the pros and cons of HRT applicable to your own individual case.
Q. Does hysterectomy affect my sexual activity/performance?
It is difficult to predict how hysterectomy affects your sexual perfomance. Some women feel no difference. Others find that their sexual performance is renewed because after hysterectomy they no longer suffer problems that caused painful sex previously. Some of the common changes that you may experience include:
Loss of femininity – some women may feel this as a result of the removal of their wombs. Talking it through with your partner may help you to adapt.
Fear of pain by sexual intercourse – after the operation, it is natural that you feel tense because of “trauma” done to your private part. Talking it through will help to get over the fears, relax and enjoy your sex as before.
Difficulty in reaching orgasm - the operation can alter certain part of your reproductive system which can affect your ability to reach orgasm. Discuss alternative and more inventive ways of gaining orgasm with your partner, which may bring more sexual satisfaction.
Vagina dryness and loss or reduction of sexual desire (libido) – can be caused by the loss of your ovaries. K-Y jelly helps lubrication and you may consider HRT to compensate for your loss of sex hormones.
On the whole, there is scientific evidence to show that hysterectomy does not alter the sexual function of your reproductive system.
Q. How soon do my stitches come off?
This depends on the type of stitches being used by the surgeon.
If dissolving stitches were used, there is no need to remove them and they will dissolve completely when the cut (incision) is healed.
When non-dissolvable stitches or clips were used, they are removed between 4-6 days after the operation. This should not be a painful procedure.
Q. How soon does the scar disappear?
At first, the scar may appear as a red line and lumpy. You may experience some pulling sensation as it heals. The red line will gradually fade away after one year it appears as a thin white line.
There are products you can buy to reduce scar such as Dermatix and silicone plaster “Cica Care” or Mepitel but they are expensive. Ask your pharmacists for further information.
Q. How soon can I start driving again and what is the correct way of getting in and out of the car?
Usually, it is safe enough to drive about 3 weeks after any operation depending on how confident you feel and your ability to do an emergency stop.
To get into the car:
Stand with the back of your legs close to the car seat;
Bend forwards from the hips;
Bend your knees;
Sit backwards into the car seat using your hands on the car door frame to steady yourself.
Pull in your tummy muscles and lift one leg into the car then slowly lift the second leg.
Get out of the car in the same way and make sure you stand up straight before walking away.
Written by:Dr Nicki On, PhD, MRPharmS. Dr Rajesh Varma, MA, PhD, MRCOG. Dept of Obstetrics and Gynaecology, Guy's and St. Thomas' NHS Foundation Trust, London SE1 7EH, UK.
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This page was last modified on Saturday 5 June 2010 12:04 am.