Wednesday, May 4, 2016

FIBRIODS IN TEENAGERS

Teresa aged 16 of Italian decent came to see me in my consulting rooms with her dad, they were both very irate. Her dad was told by her GP that she may be pregnant; however she denied it with great anger.  She was well developed, very understanding and knew what he was talking about. I advised them to sit down and calm down. The only problem she had was a sizeable lump on her belly, and she had to go to the toilet frequently, which was a nuisance particularly during school. I examined her in my office. It did not take me more than a few seconds to know what it was. Besides that she had an intact hymen. So the question of pregnancy did not arise. I told them it was a uterine fibroid, which was about the size of a football. I also explained to them that although the fibroids are the commonest tumours in women between the   ages of 35 T0 50, the percentage quoted in the literature varied between 35 to 50%. I had seen one case of fibroid tumour about 5 years earlier in a girl aged 15. These tumours are very rare in teenagers; however I think Teresa had a fibroid.  Teresa’s pregnancy test was negative which reassured him. There was no ultrasound in those days. Her dad was happy that she was not pregnant and requested that I treat her. So far in the last 50 years only 19 cases of teenage girls with fibroids (they are also called myomas) are reported in English literature. I am sure there will be a few more. I did not report this case, as I did not have the facility to do so. However I never saw another case in my 55 years of practicing as a gynaecologist.
The most common treatment in those days and even now is a simple operation called myomectomy. This means removal of the fibroid or fibroids, depending on if there is more than one. This does not disturb the young girl’s reproductive function. In some cases the fibroids are reported to have reoccurred, than another myomectomy is performed. The risk of myomas being cancerous is very rare. It has been estimated to be one in 1000.No malignancy was reported in the 19 cases described in literature. I performed a myomectomy on Teresa. From then on I saw Teresa every 6 months. Later on when ultrasound became available, then I used this for Teresa on her subsequent visits. I was very lucky during my active practice years that she had two pregnancies, and I delivered two lovely boys for her by caesarean section without any trouble. It is mandatory to deliver babies by caesarean section after myomectomy. Labour can damage the uterus. 30 years down the track I still see her some times.
These days the treatment of fibroids has improved. There are many drugs we can use to decrease the size of fibroids so that myomectomy and hysterectomy become easier, there is less blood loss, recovery is easier.  The other technique is uterine artery embolization,( UAE )this means the blood to the uterus is impeded, then less blood goes to the fibroid and it dies. Both these types of treatment are not offered to teenagers although recently a 12 year old girl with fibroid and severe bleeding as well as a Bleeding Disorder had an UAE.
The latest is a new machine which uses a very high intensity focussed ultra sound in conjunction with an MRI. After detailed assessment of the women and detailed preparation it kills the fibroid. If the fibroid is a very large one it requires more than one focussed area. This has not been used in teenage woman with fibroids so far.  The Royal Women’s Hospital in Melbourne, Australia has the one and only machine for this method of treatment.
In conclusion never exclude fibroids if a young girl presents with a pelvic mass
Teresa never had any other gynaecological problems

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