I have uterine fibroids, what do I do now?

What should we do before, during and after fibroid treatment? #SaberEsPoder and in this master class Dr. Claudia Cortés and Dr. Arturo Valdés explain to us the importance of prior studies, pre-anesthetic assessment, treatment options, logistics in case of surgery and care to follow after the procedure.

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Hello, good afternoon, we are here to talk about the same topic of myomatosis but now from a more comprehensive point of view with Dr. Claudia Cortés Pineda, who is our anesthesiologist and these are very important topics, because we have more and more consultations and obviously we need that the patient is aware. Why is preanesthetic assessment important? What should be done in pre-surgical evaluations? both the laboratories and studies that must be carried out and why it is necessary to arrive with the knowledge of which patient is going to be operated on, both due to the age of the patient, the morphological characteristics of the patient, if she has diseases, since they are already systemic and There obviously they come in with a more planned surgery. Because we had a case of a patient weighing 6 kilos 800 who fortunately everything went well, but she did have a transoperative hemorrhage and it is very important to know what to do beforehand and how we approach it at the time of the complication.

Symptoms, diagnosis and studies prior to surgery

Remember, there can be three cases of patients: The young patient who does not yet have the reproductive desire and who obviously does not yet have pregnancies, the patient who already comes for consultation for infertility or fibroids and who wants to get pregnant and the patient who has already had children, but who has fibroids, then in these three types of patients the approach, management and therapy can be completely different because it can be one that is only observational, conservative, another that is surgical or that is with medications and another that is surgery or medications in the final stage of reproduction. So, it is very important that when they write to us we always tell them to give us a little more information. First, how old are you, when was the date of your initial menstrual cycles, whether or not you are pregnant and what are your symptoms because we must remember that there are many symptoms that can lead us to a diagnosis.

The main symptoms of fibroids are sometimes the bulging that we feel, or the heaviness, or sometimes we feel that if we do some activity something moves inside us, pain during sexual relations, metrorrhagias that are intermenstrual bleeding, that is, they end the menstrual cycle. and maybe after 7 or 10 days they have 2, 3 days of spotting, uterine hemorrhages, that is, instead of having a regular menstrual cycle, they are very abundant hemorrhages and this often leads to anemia, fatigue. They tire easily with activity, so it is very important to review the symptoms and diagnoses. How are we going to make a diagnosis of fibroids? Well, mainly the ultrasound is like the “Gold standard” for women, that is, it can be an abdominal ultrasound or a vaginal ultrasound if they have already had a sexual life, but there are complementary studies for this diagnosis such as tomography and then the preoperative ones that The doctor will say that they are important. Why? Because the most important preoperatives are reviewed by the doctor and we know how we are going to enter.

So, doctor, tell us a little about what are some important studies for the pre-anesthetic evaluation and really the pre-operative ones for surgery. Among these important factors that we have to do are: First, the age of the patient is essential and the laboratories are closely related, especially to blood biometry, which interests us greatly in hemoglobin and hematocrit, platelets, which are the cells that help us. to coagulate the blood, glucose, urea, creatinine well to see how the kidney and liver are functioning, especially with regard to glucose and clotting times, which are generally the tests that help us see how feasible or how difficult it is for a patient to have major or minor bleeding in a surgery, nothing more… The electro Dra. We also request an electrocardiogram, generally in patients over 40 years of age, because that is what The regulations tell us, but the other one too… To the doctor, it helps a little to see if there are some alterations there in the electrocardiographic record because the medications she administers during surgery can obviously harm or improve your condition. of the electrocardiogram. Yes, of course it is important to know that generally the advantage of these patients is that the majority are young. We have hardly had patients over 60 years old, however, we have had young patients who are diabetic, who have thyroid problems and well, if it can help us to have an electrocardiogram to know how the patient’s physical function is in general. , hence the importance of preanesthetic assessment. Being able to talk to them and they can tell us any symptoms that they may have that are different or strange, or that they may think is normal and it really is not and that from there and our function is to detect it in order to follow up and have an adequate management plan so that the transanesthetic and post-surgery are the best possible for them.

Many of the times, in addition to asking us via Skype or via YouTube or on our website, is whether this fibroid is an indication for surgery or for removing the uterus or not for surgery, that is what I always tell patients, is that everything is relative. We must remember first or mainly: The volume or size of that fibroid, if it is a single language, if there are multiple languages, the age of the patient, whether she wants reproduction or not, where those fibroids are located and obviously, if we have a symptoms of anemia or bleeding. Because? When a patient has fibroids, even if it is a single one with large elements, but it causes a lot of bleeding and there is anemia, even if she is young, in many cases it is better to operate to precisely eliminate the anemic state and to ensure that there are no longer those menstrual hemorrhages. Second, when we have a lot of fibroids, but they do not invade the cavity, they are not large, but they also cause hemorrhages, these are sometimes the most complicated and especially at an early age.

For the advantage of the woman or so that they are calmer, fibroids normally begin or begin at the stage of puberty, however, when fibroids with large elements or medium elements are already considered, they can already cause some symptoms, because at It is best to start between the age of 28 or 30 years. So, we young women normally do it in an expectant manner, seeing if it improves with some medications, with contraceptives for bleeding mainly, but for almost all fibroids that exceed between 5 or 7 centimeters, we generally prefer to do simple myomectomies, obviously always preserving the uterus, we must remember… Like the patients who sometimes arrive, perhaps the diagnosis is made early at 28 years old but they wait eight years, ten years, 1 because they are afraid of surgery, 2 because they do not They liked the doctor’s explanation, 3 because they are afraid that their uterus will be removed and that delays the surgical event and also causes the fibroids to continue increasing and therefore surgery for a 15 or 15-inch fibroid will be riskier. 20 centimeters than an early surgery of 7-8 centimeters in diameter.

So, I always tell patients, come quickly, don’t be afraid, generally the vast majority of fibroids are surgical but without the need to remove the fibroids and the other is, well, there are fibroids that are only inside the cavity that are called submucosal, those do not even need open surgery, but we have to go below, which is called a hysteroscopy, so it is very important to first have a good diagnosis, to have the necessary ultrasound images, whether abdominal or vaginal. I have had patients who have never had intercourse and I go through the abdomen and then the image is not as good or as clear and then, in this type of patient, I always requested an MRI or a tomography to have a better definition of whether it is one or two or various tumors, what size they are and decide the approach, because remember that the approach can be a midline transverse incision or a longitudinal incision. In the 6 kilo 800 patient it was a 12 centimeter incision in a midline because it allows us to have a wider surgical field and even so, that patient was complicated by the size of the tumor and obviously the bleeding, what we do not want is to have patients that are very complicated, that is, the longer we wait, the more risk there is of hemorrhages, of bleeding and that it is a fibroid where it is more difficult to remove them without having to remove the uterus.

Logistics and preparation for the day of surgery

Once we know that the patient is scheduled for myomectomy, then the pre-anesthetic assessment is carried out. The purpose of the pre-anesthetic assessment is so that we can get to know the patient in a comprehensive way and know their physical condition. Knowing your physical condition means that you first meet the anesthesiologist and that I explained to him, that he let me know his medical history and talk especially about aspects that sometimes we do not take much into account, such as cigarettes, if the patients smoke, If the patients have alcohol intake, the previous surgeries they have had, the previous anesthetic complications they have had and all that gives us a guideline to know what the best anesthetic technique is and explain to the patient what the plan is. What are we going to have with her?

For patients who are going to undergo surgery, it is important for those patients who smoke, that if they have at least three weeks before surgery, ideally they should reduce and if possible they will give up cigarettes, however, those patients who They are going to undergo surgery in one or two days, really there we as anesthesiologists do not tell them to stop smoking and we do not tell them to continue smoking, simply if they can reduce the number of cigarettes, if they smoke five then they should smoke two or Just three a day, so that the airway does not become inflamed. Generally, when a patient who smokes stops smoking, there is inflammation in the respiratory tract and it produces more mucus, so arriving at the operating room two or three days after quitting smoking, who has more secretions, can cause more cough, so the having a cough after surgery, it is not going to be very pleasant, it can become more painful and more problematic, you can even get hernias.

Hypertensive patients should not stop taking their medications, that is where we give them the initial measurements and instructions to be able to enter surgery, not stopping taking their blood pressure medications is important, not stopping taking their medications for some other disease, especially thyroid, hypothyroidism which is also very common, that is also important. For patients who are diabetic, the ideal is that they have adequate glycemic control prior to surgery and all hypoglycemic medications will be stopped one night, or six hours before surgery. As for dietary habits, it really is necessary to modify a little, perhaps it is to reduce the intake of fats, carbohydrates, very spicy or very irritating food, very seasoned, but otherwise the majority can continue eating normally. Also sometimes patients have doubts about what the procedure is going to be like, how we are going to schedule it.

Generally, the scheduling of surgeries depends mainly on having all the preoperative studies that we had mentioned. Preferably, if they are over 40 years of age, the pre-anesthetic evaluation can also be done via Zoom or via Skype with us to give the patient’s information to the doctor so that the doctor knows the patient and explains to them what some prior indications are. to surgery and anesthesia, however, well, the surgical time or programming depends on the doctors’ schedules, the size of the fibroids, because on average a surgery can last an hour and a half, two, but sometimes we can extend more than two hours. If they are foreigners, then they should know that we generally treat them for two nights unless it is a very simple fibroid, because they only stay one night.

They also ask us a little about “Hey, I’m very overweight. Do I have to lose weight before having surgery or is there no problem?” Well, that depends a lot on the symptoms and the tumor, that is, if the patient is obese and also It’s been 8 years since she wanted to have the operation and she already has a giant fibroid with hemorrhages and anemia, because obviously we can’t wait for her to lose weight. Would it be ideal to go in with a patient who is not overweight? Yes, unfortunately like her age Of the patients with surgical fibroids are between 38 and 45 years old, many of them are overweight and it is more complicated 1 to stick to an eating routine, 2 to exercise and 3 to lose weight. So, only in very extreme obesity if we postpone surgery, it is better to plan the surgery, see that he has not been anemic and obviously the anesthesiologist doctor is also in charge of management, but we always explain to the patient that yes, being overweight carries a certain greater risk both intraoperatively and postoperatively. and obviously hemorrhages or infections. We generally fast 6 to 8 hours before surgery, with six hours of solids sufficient, that is, the patient can drink liquids up to four hours before surgery. For patients taking medication drugs for diabetes should not take them beforehand, because they can cause hypoglycemia. Pre-feeding or… Pre-feeding for surgery should be something light, nothing spicy, nothing very greasy, nothing very spicy, something light like fruit or your.

Follow-up and aftercare

Ok, right now we are going to talk a little about postoperative care, mainly in fibroid surgeries, which is the topic that concerns us. The patient stays one day, that is, we operate on her one day and the next day she is discharged, that is the vast majority of patients, however, when they are foreigners we generally leave them for two nights, especially to keep a little surveillance. their nutritional status, their intestines begin to work, they urinate properly and pain management mainly. So…

When do they register? The next day, 24 hours or 48 hours at most. In very specific and special cases where red cell packets need to be transfused because there was intraoperative bleeding, we sometimes leave it for one more day. Why? Well, because you have to watch her hemodynamic status, make sure the patient stands up, doesn’t get dizzy, doesn’t have lipothymia, doesn’t faint, and then see how she’s tolerating her wandering a little bit.

Should you have a diet or special care? Yes, generally the diet is soft or normal, without condiments, irritants, or greasy at least during the first week, because we must remember that when the approach is abdominal we always enter the uterus, or the cavity and there are intestines, so, although not Let’s manipulate the intestines, the intestines, due to a normal reaction, are momentarily paralyzed and little by little they begin to have their regular movement or peristalsis. So there are patients who distend a little more and we have to eat a softer diet and also start feeding depending on how long the surgery lasts, between 6 hours after surgery or we can go up to 12 hours after.

Will there be pain or bleeding? For how long? That is very difficult to answer because bleeding depends mainly on the patient, yes it is true, just two months ago I operated on a patient and after 15 days she told me “I am bleeding a lot and it hurts.” Well, it was her cycle, she got together with her cycle. Obviously, these surgeries, when they are due to bleeding or menstrual pain, can generally take two or three months until there is no longer such significant bleeding or pain. Because this is not corrected the month after the surgery, it takes a little longer to recover from both the uterus and the bleeding and the pain, and also the pain, whether surgical or post-surgical, is normally very mild or very tolerable because the The doctor makes a very important block with specific and specific medications that last between 24-36 hours of analgesia. In addition, there is also an administration of analgesics in the line, in the vein and when they are discharged they leave with a double dose of analgesics with the intention that they do not have any discomfort or suffering.

How long do I have to wait or when can I try to get pregnant? The same as the previous time, as he mentioned, it is: If it is a submucosal fibroid, for example, to give you an idea of how it changes: A three-centimeter submucosal fibroid that we enter hysteroscopically, you operate on it and the following month it has its cycle we can now start a treatment because there is no longer healing or recovery, it is like a mushroom, where you remove the base. mushroom and the cavity will be intact and you will be able to get pregnant. But if they are intramural fibroids, which are the most common, or multiple fibroids, the wait is normally 4 to 6 months, because it depends a lot on the size of the fibroid. Generally, above 6 centimeters intramural we have to wait more than four months, that is, 6 months, but if they are less than 6 centimeters, 4 months is more than enough and more so in single fibroids.

Will fertility treatment be mandatory? No, notice no. Curiously, there are patients who we can remove large intramural tumors of 8 to 10 centimeters, you operate on them, they wait 3, 4 months and on many occasions, when I tell them to wait six months, they are already pregnant in the fifth or sixth month, that is, Yes it depends a lot on the location. If the patient is fertile and is a young patient between 28 and 30 years old, then generally the vast majority of them can get pregnant spontaneously because fibroids are not always related to the fallopian tubes not working well or that later there will be infertility secondary to the surgery.

Will pregnancy have risks? Yeah. Generally remember, there are some qualifications or some points that we take into consideration in obstetrics to say if a patient is high or low risk, mainly if she is primigravida, if she is over 35 years old, if she has had previous surgeries, if she has had previous cesarean sections. , if you already had hemorrhages. Fibroid surgery also gives a check if the patient is hypertensive, diabetic, overweight, that is, there are several characteristics to say if the patient is low or high risk, however, with fibroid surgery, pure surgery of fibroids it’s not that the pregnancy is going to be complicated. Be careful! Simply, we must have closer surveillance because in many cases it may be that placentation is not adequate and then it gives us a restriction in intrauterine growth for example, or that placenta is placed in an area that can cause hemorrhages or bleeding from the first trimester or the delivery route will not be possible due to the size of the surgery that was performed, then it is very important that once you have the operation you do not lose the follow-up and evaluation with both the doctor who operated on you, or with your obstetrician the moment they want to get pregnant.

For those patients who become pregnant after a myomectomy, regarding the risks of anesthesia, there really are none. Many people say “I’ve already had two or three blocks, is there a problem with having another one put on me or how risky is it to have another block put on me?” Generally there is no problem. The lumbar area, which is where we enter or make the approach to administer the anesthetics, is an area that only has ligaments and that would not have to generate greater damage or cause a later problem or for them to later say “They already put two blocks on me, now.” “They can’t give me another one.” That generally does not apply, patients can have an infinite number of blockages. There are patients who have had 4, 5 or 6 blockages due to different types of surgeries, so there is no problem there and as for whether it is a birth or a cesarean section, the indication is basically how the evolution of your pregnancy goes.

There are patients who can be delivered without any problem and yet there are patients who cannot be delivered and that would be the doctors’ indication.

Just lastly, thank you for the response we have had about fibroids. The truth is that many people are consulting us, which gives us great pleasure. Being like a reference for whether the patient should have surgery or not, that fills us with satisfaction because it says that we are doing things well, that we have a very important work group, but let them know that: The main thing, #KnowledgeIsSuccess that the patient to really make a decision about whether I need to have surgery or not and most importantly, be sure if that surgery is going to be a hysterectomy or not, the hysterectomy must be remembered, I always tell patients, like this patient of the 6 kilos 800. There are times when we also cannot do that type of surgery and it is complicated. Don’t let time pass, because the more time passes, these fibroids may become larger and also carry a greater risk of surgery. So call us, we are on our page, there you have the contacts, via Zoom, via Skype we can make a first consultation, now, without them coming to the clinic and from there the time to actually plan a surgery does not exceed a month, a month and a half depending on the cases.

“Both the first consultation and the pre-anesthetic assessment can be carried out by video call, it is just a matter of having the appropriate studies”

Dra. Claudia Cortés
Dra. Claudia Cortés
Anesthesiology and ambulatory surgery

Certified by the Mexican Council of Anesthesiology.

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