Uterine polyps, also commonly known as endometrial polyps are soft fleshy growths attached to the endometrium that is the inner wall of the uterus (or womb) and extend into the uterine cavity. Although uterine polyps have a low incidence rate compared to other reproductive ailments with every one in 10,000 females being affected. However, they can be absolutely worrisome when they straightforwardly affect fertility, pregnancy outcomes, and reoccur after polyp removal. These are somewhat similar to skin tags, which are normal tissues in essence but grow in an abnormal fashion and often flatten out to fit the cavity of the uterus. Endometrial polyps range from a few millimeters in diameter – such as a sesame seed – to several centimeters, like a golf ball or larger. They are attached to the uterine wall by either a large base or a thin stalk (or pedicle). Uterine polyps are commonly observed in 10-25% of women worldwide that are usually in their fifties. These are rare to find in women under 20 years of age or those who have surpassed menopause.
Polyps can occur anywhere in the body ranging from stomach, ear, and nose to different locations in the female reproductive system such as ovarian polyps. It is to be noted that there can be more than one polyp in the uterine cavity. Usually, polyps are contained within the uterus, however, occasionally, they slip down through the cervix (opening of the uterus) and into your vagina, blocking the opening. In such cases, they are referred to as cervical polyps and vaginal polyps, respectively. The vast majority of these polyps are usually noncancerous (benign), although in some cases they can be cancerous or eventually turn into cancer at the end.
Often times people misunderstand the difference between uterine polyps and uterine fibroids since both polyps and fibroids are similar in the essence that they grow on the uterine wall. Statistics show that about 80% of women experience at least one of the conditions in their lifetime. Uterine polyps are oval tissue growths that form in the lining of the uterus; whereas fibroids are benign growths that are found either outside or in the endometrial wall or within the uterine cavity (womb). Fibroids are likely to be developed in younger females, in contrast to polyps that are usually observed in middle-aged women.
Why Do Uterine Polyps Occur?
To date, the exact cause of endometrial polyps in women is not known. However, there are some theories that can best explain why they occur in the first place. These include:
Hormonal Imbalance: It’s been observed that polyps tend to grow when there is more of the hormone estrogen produced in the body.
Endometrial hyperplasia: It is the abnormal growth of the uterine lining. Since uterine polyps arise from the endometrial cells which grow during the menstrual cycle in preparation for embryo implantation. In case of absence of pregnancy, this lining sheds; however, due to numerous reasons, if the endometrial lining grows too much, it results in the formation of tissue outgrowth.
Genetic Factors: Various genetic factors have been found to be linked with the growth of uterine polyps, such as over expression of an enzyme found in the lining of the uterus called aromatase has been found to be one of its causative factors.
Risk Factors for Developing Uterine Polyps
The possible risk factors that increase the chances of developing uterine polyps are jotted down as follows:
Perimenopause or postmenopausal period
Hypertension
Obesity
Hormone replacement therapy or drug therapy
Uterine Polyps Symptoms
Uterine polyps are rarely symptomatic. However, in case of being symptomatic for these polyps, women show various signs and symptoms such as,
Irregular menstrual bleeding
Menorrhagia (heavy menstrual bleeding)
Bleeding after intercourse
Cramping in the lower abdomen (dysmenorrhea)
Infertility or miscarriage
Uterine Polyps Diagnosis and Treatment
After your normal check-up and history, your medical specialist will likely recommend some tests to ensure if the condition correlates to uterine polyps or not. These tests may include vaginal ultrasound, hysteroscopy, endometrial biopsy, and curettage for confirmation.
If you are not symptomatic, then you shouldn’t worry too much about its treatment. However, polyps’ removal becomes a necessity if they are causing any aforementioned symptoms or if they are suspected to be precancerous or cancerous.
Medications: Certain hormonal medications such as drugs that help regulate the hormonal balance, like progestins or gonadotropin-releasing hormone agonists, could be used as a temporary treatment to relieve the symptoms. However, the symptoms will likely return after the medications are stopped.
Surgical removal: Polypectomy is a procedure to remove polyps. The most effective way to perform a polypectomy is through hysteroscopy, in which a small camera is placed inside the uterus using a thin, flexible, lighted telescope (hysteroscope) through your vagina and cervix for visualization of the uterine cavity. The procedure is performed under anesthesia to overcome any discomfort. During the procedure, it is possible to remove polyps from the uterus using a hysteroscope. Curettage is another surgical way to scrape uterine lining and removal of small polyps other than hysteroscopy. Other than that, hysterectomy is performed in cases uterine polyps are found to be cancerous, and thus the whole uterus is removed surgically.
Non-Invasive Solution to Uterine Polyps
Even though surgical removal is one of the available options for the affected females, however, it is not the common and most preferred choice since it involves either cutting you open or putting instruments into your uterus through the vagina. Moreover, the literature suggests that there are about 2.5% – 43.6% chances of recurrence after polypectomy. Additionally, in Asian societies and cultures, like that of Pakistan, fears regarding woman’s loss of ‘virginity’ are insurmountable. Therefore, preserving the virginity of an unmarried female is taken as the utmost priority so that it doesn’t affect their eligibility to get married or their future marital status and life. For this reason, many women remain either undiagnosed or untreated which ends up substantially affecting their quality of life or becomes a threat to their life, in general.
Here is the good news: there is a low-risk and non-invasive alternative procedure to surgical intervention known as 3-D Precision guided uterine artery embolization (UAE), which is now routinely available as an option. This is an outpatient procedure in which the uterine arteries that supply blood to the vascular polyps are located using real-time 3D fluoroscopic equipment. Blood supply to these polyps is blocked by injecting biocompatible particles into the bloodstream through a catheter at the wrist or groin, in which it leads to their ischemic infarction. As a result, they may be dislodged and excrete out from the uterus. This procedure has high success and minimal recurrence rate which eventually restores the quality of life of the affected individuals, taking them back to life.
The facility of 3-D Precision guided uterine artery embolization (UAE), is now available in Pakistan in its two major cities; Karachi and Lahore, by Prof. Dr. Imtiaz Ahmad and his team, who is a renowned interventional radiologist and endovascular surgical specialist with surgical training and extensive experience in Most Advanced Endovascular and Interventional Procedures.
The beginning of reproductive age or puberty in females is marked by the onset of menstruation. The inner uterine lining, also known as endometrium, builds up every month to prepare for fertilization or pregnancy, under the regulation of hormones known as estrogen and progesterone. However, when fertilization is not achieved, the endometrium lining is shed and is removed from the body through the cervix and vagina. Therefore, menstruation or periods can be described as the monthly vaginal bleeding that women experience because of the shedding of the uterine lining. On average, the menstrual cycle lasts for about 25 to 35 days, out of which, menstruation occurs over a period of 3 to 7 days. The menstrual waste comprises not only blood but also tissue and vaginal secretions. As opposed to the nature of normal blood loss, period blood does not clot as it is mixed with vaginal secretions and mucus. Clotting in the endometrium actually ensures that too much blood is not lost. Period blood clots usually occur during heavy bleeding because they have a greater quantity of proteins that are disposed to coagulate blood. Period blood clots may also just maybe clumps of cells of the endometrium.
It is important to realize that period blood clots are not always alarming. These can occur occasionally, and if they are not big and frequent, there is nothing to worry about. These normal clots appear dark or bright red in colour and shouldn’t be more than a quarter in size. Adding to that, if these clots are frequent, large in size, accompanied by painful periods and heavy bleeding, it is time to take a trip to the doctor.
Causes of period blood clots
Women’s issues related to period bleeding are not uncommon. From experiencing emotional, physical, and mental exhaustion as part of the premenstrual syndrome and during menstruation, an unhealthy diet and lifestyle may become a reason for other period problems. While non-frequent menstrual clots may not be alarming, sometimes these clots are an indication of something more serious. Heavy bleeding is one of the reasons for larger blood clots. These larger blood clots need a bigger opening to pass out, which is why larger blood clots are usually accompanied by intense pain and cramps. A woman can conclude that she is, in fact, experiencing menorrhagia (heavy menstrual bleeding) when she has to change the sanitary pad every two hours or lesser and the clots are bigger than a quarter. Normally, 15 to 80 ml of blood is lost during menstruation, so anything beyond 80ml of blood is also counted towards menorrhagia. Some of the most common causes of menorrhagia and period blood clots include uterine fibroid, endometriosis, adenomyosis and hormonal imbalance (including polycystic ovary syndrome, hyperthyroidism, and menopause), amongst others.
Uterine Fibroid and its types
Uterine fibroids are also known as leiomyomas and are one of the most common tumors of the genital tract, reported in women of all age groups. These are muscular, non-cancerous growth of the uterus which may go unnoticed for a long time. The risk of developing fibroid increases with age and genetic predisposition. Although the exact cause of developing fibroid is not known, a strong link has been found with varying hormone levels. Uterine fibroids may be symptomatic or asymptomatic. The latter requires no medical intervention, and only regular monitoring may be sufficient. However, women with symptomatic uterine fibroids may experience lower back pain, frequent need to urinate, constipation and several period problems. In general, there are four different types of fibroids, which is best understood once you know that the uterus has three layers. The outer, middle, and inner layers. Fibroids are classified based on their locations amongst these 3 layers and can occur in combination, as well.
Intramural: In the wall of the uterus
Subserosal: On the outside of the uterus
Submucosal: Beneath the uterine lining
Pedunculated: may grow on the inside or outside the uterus, but have a stalk or stem for attachment.
The most common out of these are the intramural and sub serosal fibroids. Heavy bleeding is often observed in women who develop fibroids in the submucosal or the intramural layer of the uterus. Heavy bleeding can then lead to anemia and period blood clots, as discussed before. Uterine fibroids are often diagnosed on an ultrasound imaging of the pelvis, after which the size and quantity decides the approach towards treatment.
Treatment for fibroids
Uterine fibroids that are symptomatic and larger than 10 mm in size, may be treated surgically. In traditional gynecology, uterine fibroids causing complications are treated by hysterectomy, which is the removal of the uterus. On the other hand, myomectomy may also be performed, wherein surgical intervention removes only the fibroids in the uterus. While uterus removal may be a nightmare for women, especially those willing to conceive, myomectomy also adds to the misery with its high recurrence. The best treatment for fibroids with a high success rate is the non-surgical uterine artery embolization method, which may also be better known as 3-D precision-guided treatment. Dr Imtiaz Ahmad, an Endovascular Surgical Specialist and Interventional Radiologist, is the pioneer of this treatment/technique and has introduced this procedure for the first time in Pakistan in November 2017.
The 3-D precision-guided treatment is an umbrella term that encompasses a handful of procedures, out of which uterine artery embolization, alone, constitutes 60-70%. The entire procedure uses real-time 3-Dimensional Fluoroscopy, which is a type of X-ray that shows live imaging in 3- Dimensions. Live imaging helps in precisely locating the fibroids. The procedure begins with administering local anesthesia in the form of a “Cold Spray” applied to the skin of the groin area to numb it, after which local anesthesia is also injected into the skin and soft tissues overlying the right groin. Conscious sedation is achieved via IV, in which the patient remains awake and relaxed. Avoiding any skin incisions or cuts, a microcatheter is introduced through the femoral artery in the leg. The catheter is guided towards the uterine artery, through which the blood to the uterus is supplied. Serial 3-Dimensional images are obtained followed by placement of specialized/engineered micro-catheters if needed to complete the embolization. In this way, the embolization procedure causes the blockage of blood flow to the fibroids or adenomyosis. Additionally, Embolic agents are small micron-sized particles that are passed through these catheters, these particles are engineered /programmed to block the blood supply to fibroids or adenomyosis only while sparing the normal uterine walls. Another major component of the procedure comprises intra-arterial pain management done by intra-arterial infusion of carefully titrated medications directly into the fibroids/adenomyosis with super-selective catheters selectively placed within the uterine fibroids or adenomyosis.
The patient is ensured more comfort via fluoroscopic guided nerve block, which is effective for at least 18-20 hours post-procedure. Post embolization syndrome which is an expected sequela after an embolization procedure is dealt with there and then by infusion of specific medications directly into the fibroids/adenomyosis. All in all, the procedure takes around 45-60 minutes and has a high success rate amongst patients of all age groups. It is often difficult to relocate the access site, since no incisions are made during the procedure. The patients are usually discharged only a few hours after the treatment in outpatient settings or are kept overnight under observation as a 23-hour admission.
Information about Gamma block bariatric arterial embolization treatment strategies. Treatment of obesity and saying goodbye to the extra inches shaking your confidence. Bariatrics is a field which studies therapies pertaining to weight loss and management. This includes surgical procedures and behavioral therapies. Gamma block bariatric arterial embolization treatment strategies (Dr Imtiaz Ahmad is the pioneer of this technique and named it as Gamma block bariatric arterial embolization in Nov 2017 after performing the first ever Gamma block bariatric arterial embolization procedure in Karachi Pakistan)also fall under the umbrella of this field and is a modern approach towards treatment of obesity. Approximately, 39% of the world’s adult population is suffering from either obesity or being overweight.
A person is regarded as obese if his/her body mass index (BMI) is greater than 30kg/m2 in which case, they can make good use of Gamma block bariatric arterial embolization treatment strategies. Obesity may occur due to metabolic dysregulation which could be genetic, lack of physical inactivity, diseases such as PCOS in women or simply because of overeating. Making balanced lifestyle choices is the way forward towards losing all that extra weight.
However, many men and women try to fight obesity by incorporating these lifestyle changes but are often demotivated by the weighing balance’s consistent reading. This may be due to a disease, medication, or psychological stress. Bariatric surgery for weight loss is often advised to people that are suffering from diseases that have either occurred due to obesity or are getting much worse because of it. These patients may have a BMI of 35–40 kg/m2 which is alarming and must be addressed in due time. Bariatric surgery has been around since a while and has proved beneficial. Average weight loss with bariatric surgery has been about 5 to 15 pounds in only the first 30 days. However, bariatric surgery is invasive and therefore, variations to the procedure have been introduced under interventional radiology.
What are the health risks following Obesity?
Obesity imposes several health risks and becomes the starting point of multiple chronic diseases. Ranging from metabolic dysfunctionality to cardiovascular and respiratory diseases, obesity is a defining factor in their progression. It is easy to understand why excess fat in the body would be so detrimental to health. Greater body mass affects almost every part of the body, from bones to muscles and from heart to brain, every organ faces the consequence. Risk of getting diabetes mellitus type 2, hypertension, osteoarthritis, coronary heart disease, respiratory problems, and some cancers, increase manifolds because of obesity. Moreover, in the recent age of social media, selfies, and fashion, being overweight or obese also contributes towards lower self-confidence, eventually leading a person into depression. Health risks following obesity and increasing mortalities have shifted attention towards studying ways in which weight could be reduced or the process of weight reduction could be hastened.
Treatment Of Obesity
The most obvious treatment plan for losing weight is to strike a balance between physical activity and healthy eating. It is no secret that losing weight is less about what you do to shed it and more about how consistently you are doing it. It is a lifestyle shift and being aware of the choices you make in your day-to-day routine. Special diets include intermittent fasting, calorie restricted diet and keto diet, to name a few. Most people require external help for their weight management where specialists plan a personalized routine for a person and conduct sessions to check up on the progress. Weight management programs under a specialist have proven more beneficial than being on your own and trying to lose weight since there is little accountability in the latter case.
Unfortunately, in some cases, a good diet and greater physical activity is also ineffective. Weight loss medicines and devices are advised to people who do not respond to management therapies, but it comes as no surprise that anti-obesity medications come with their fair share of side effects. Additionally, bariatric arterial embolization for weight loss has gained attention as being a minimally invasive procedure for obese people with comorbidities.
Gamma Block Bariatric Arterial Embolization
While the main cause of obesity remains ambiguous, hormones have been linked with controlling hunger, appetite, and weight gain by signaling the brain. Some of the hormones involved in the appetite regulation include oxyntomodulin, cholecystokinin, adiponectin, and ghrelin. Ghrelin is a hormone made from peptides and is released from the PD1 cells of the fundus, which is an important part of the stomach. Release of ghrelin is directly proportional to the food intake. Studies show that hunger increases on administration of ghrelin in subjects and during fasting or weight loss diets, levels of ghrelin rise, while once the hunger is quenched, ghrelin levels decrease. This variation points towards its role in hunger management.
The decrease in ghrelin level has been reported after bariatric surgery and believed to be associated with the weight loss process. Understanding the role of ghrelin is important to rationalize the bariatric embolization procedure which is an improved version of bariatric surgery. Fundus contributes to producing 90% of the ghrelin in the body. Blood supply to the fundus of the stomach is through the left gastric artery. right gastroepiploic artery and Short gastric arteries.
Dr Imtiaz Ahmad is the pioneer of Gamma block bariatric arterial embolization
procedure. This is a highly improved and precision guided procedure in which three blood vessels supplying the gastric funds are targeted as compared to rest of the world where only 1-2 blood vessels are targeted. The first ever “Gamma-Block” was performed in Pakistan in the month of Nov 2017. Patient was a 55 year male who lost approximately 67 pounds over a period of 3 months.
The procedure is a non-surgical alternative to bariatric surgery and does not involve the removal of any part of the digestive system. This aspect makes it minimally invasive yet achieves a similar goal to that of bariatric surgery. Gamma-block procedure is performed under image guidance. Catheter is introduced through the radial or the femoral artery to reach the left gastric artery,right gastro-epiploic artery followed by short gastric arteries supplying the Gastric fundus . Once image guidance confirms the correct position, embolization of the arteries is performed to disrupt the blood supply to the fundus. where “Hunger Center” The 90% ghrelin released from the” Hunger Center” located in gastric fundus causing hunger and overeating in already obese people is now “significantly”inhibited. Weight loss and management now yields much more promising results.
It is crucial to understand that while bariatric arterial embolization alone can prove quite effective, for an enhanced outlook, lifestyle changes and pharmacotherapy may become adjuvant to the treatment. It is helpful to remember that sometimes a loss is also a gain.
