Understanding Irregular Menstrual Cycles
Understanding Uterine Fibroids
Fibroids may be so small that they are not detected by the naked eye but can also reach the size that they cover the entire abdomen. They are almost never malignant.
Symptoms of Uterine Fibroids
When fibroids become large and bulky, they often, but not always, create symptoms such as:
- Heavy menstrual bleeding
- Menstrual periods that last longer than 7 days
- Pelvic pressure or pain
- Frequent urination
- Difficulty emptying the bladder
- Back ache and/or leg pain
Causes of Uterine Fibroids
Vitamin D inhibits the growth of fibroids, and it is important to examine vitamin D levels in patients with fibroids. Achieving normal vitamin D levels can help prevent further growth. The pharmacologic industry is working with vitamin D analogs to inhibit the growth of fibroids and even prevent them from development.
Uterine Fibroids and Pregnancy
If the fibroid is located next to the placenta, it may interfere with the placental function, and special supervision of the pregnancy is needed. Fibroids interfere with the normal uterine contraction and frequently lead to irregular, prolonged and heavy bleeding that can result in anemia and the need for iron therapy. Blood transfusions are rarely needed.
Treatment for Uterine Fibroids
Estrogen deficiency caused by the treatment and negative effects on bone development were prominent disadvantages in the early LH inhibiting medical treatment. Now, however, effective add-back estrogen and progesterone treatments have been developed.
In addition, two new orally active LH antagonists have come on the market — Elagolix (Orilissa®), which needs dosing morning and night, and relugolix (Myfembree®) that is only dosed once a day.
Uterine Fibroids and Fertility
Now, smaller fibroids, 1 – 2 cm up to 4 cm, and fibroids just under the endometrial surface are suspected to interfere with the implantation of the embryo. Controversy exists, but removal is suggested. However, the risk of damage to the tissue next to the uterine cavity could create an even more pronounced problem.
• Weight loss
• Proper diet
• Smoking cessation
• A regular exercise program
A 5-10% weight loss can restore normal menses and ovulation with improved fertility. If a woman’s body mass index (BMI) is over 35 kg, bariatric surgery may be recommended, especially if prolonged weight loss with other methods have failed.
Additional PCOS treatments include the following:
- Clomid has become a first-line drug treatment for PCOS. It is an anti-estrogen that blocks the effects of estrogen on the pituitary and through negative feedback, leads to development of follicles. Cervical mucus tends to be thick under Clomid treatment, particularly if higher doses are needed. Careful attention should be paid to the cervical mucus quality during treatment.
- Letrozole is an aromatase inhibitor that results in decreased estrogen secretion to induce development of follicles. It is less effective than Clomid in the estrogen inhibition but has the advantage of creating a lower risk of multiple pregnancies. Clomid and Letrozole are sometimes used together.
- Gonadotropin therapy also has a place in the treatment of PCOS patients. However, ovarian hyperstimulation syndrome (OHSS) and multiple pregnancies are risks with gonadotropin treatment of PCOS patients.
If you are seeking to improve your fertility and the treatments above fail, in vitro fertilization (IVF) or even IVM (in vitro maturation of immature eggs) can be used.
Surgical procedures, including laparoscopic or transvaginal ovarian drilling as well as transvaginal hydrolaparoscopy, also improve the pregnancy rate in PCOS patients. However, the frequent development of pelvic adhesions after these procedures is a strong factor for caution.
Metformin, because of its role in PCOS-induced insulin resistance, has been a frequent add on in the treatment of PCOS patients. However, several randomized trials have failed to show an increased live birth rate with metformin, and it is no longer favored.
Instead, inositol has been recommended for PCOS treatment. Inositol is involved in intracellular insulin signaling and is a second messenger to regulate hormones like TSH, FSH, LH, and insulin. Inositol reduces insulin resistance and improves the metabolic profile in PCOS patients. When using a dose of 2 g of inositol and 200 mcg of folic acid twice daily, better fertilization rate and embryo quality has been seen in IVF treatments.