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I am trying to conceive for the past 2 years. My doctor told me that the mucus secretion of my cervix during ovulation was scanty and thick and this could be hostile to the sperm. What are the reasons for scanty mucus? Any treatment? In normal menstrual cycle, a copious amount of transparent clear mucus is produced by the cervix during ovulation. The mucus guides and helps the sperm swim through the vagina into the cervix and beyond and provides nutrients which the sperm needs for the long journey ahead. But in some cases, it may turn hostile to the sperm by immobilising and/or killing the sperm before it has a chance to meet the awaiting egg. This condition is called cervical hostility. Causes of scanty mucus include: • Vaginal infection, usually from sexually transmitted diseases: The vaginal fluid becomes tainted, killing or damaging sperm as they enter the vagina. • Cervical infection, also from sexually transmitted infection: This will damage the glands that produce the cervical mucus. • Acidic cervical mucus: The inflammatory cells resulting from bacterial or yeast infections will make the cervical secretions too acidic and hostile to the sperm. • Anti-sperm antibodies: In this uncommon condition, cervical mucus contains anti-sperm antibodies which will immobilise or attack the sperm. • Trauma to the cervix: Electro-cautery, cryosurgery or biopsy of the cervix may damage the cervical glands that produce the mucus. • Medications: Fertility drugs such as clomiphene, may cause scanty mucus by affecting the production by cervical glands. Treatment includes: Eating a diet high in vegetables Cutting down the consumption of processed foods, soda, meat, dairy products and sugar Drinking an adequate amount of water to hydrate the body Cessation of drugs that may be causing scanty mucus Treating the infection using antibiotics and/or antifungal agents Patients with anti-sperm antibodies may be treated with a course of steroids Employing advanced reproductive technology (Intrauterine insemination and in-vitro fertilisation) to bypass the cervix

My close friend, who is single, had an abortion recently. She was very upset soon after the abortion. She got angry with herself easily, and at times felt depressed over the situation. How can I help? Your friend probably has what we called ‘post abortion syndrome’. This term was coined by the psychotherapist, Dr. Vincent Rue in the 80s, to describe broad range of diverse emotional reactions attributable to abortion. Women after abortion may suffer from repressed feelings and denial of reality. They may avoid people, situations or events associated with abortion. Some may suffer from depression, as with your friend. Loss of self-esteem, sleep disorders, anxiety, sexual dysfunction, chronic relationship problems, guilt and remorse are not that rare. The most severe reactions are self-hatred, drug and alcohol abuse, and suicidal tendencies. You can help her go through the grieving process and in so doing, helping her accept the situation and moving on with life. There are various stages of grief which differ from person to person. The duration of healing from grief also varies. You could also ask her to write a journal about her experiences and emotions. She could also talk to a counsellor or join a support group. Your support is crucial during the times of grief. With time, and healthy grieving processes, acceptance of the loss would become easier. If you find that her grieving experience is difficult and she remains depressed, you should advise her to seek professional help from the psychiatrist.

I am 48 years old. During the recent annual check up , the doctor told me that I have a fibroid about the size of a groundnut .He told me not to do anything about it as I have no symptom. What is fibroid? Can it turn cancerous? A. To understand fibroid, you must know about the anatomy of the womb. It has mainly 2 layers ; the inner lining(endometrium) which breaks down and discharges every month as menstruation; and the muscle layer (myometrium) which contracts during labour and delivery of a child. Fibroid is a solid growth in the muscle layer. It is fairly common and is present in 20 % of women of childbearing age. The cause of fibroid is not well understood although it is known to grow quickly during pregnancy or when the woman is taking hormone tablets. It usually stops growing and starts to shrink during menopause. Fibroid very rarely becomes cancerous. Since you do not have any symptom and you are near the menopausal age, it can be left alone.

I am in my early 40s and this is my first pregnancy. It is done by IVF. After successful implantation, I notice there is slight urine leaking, ie it happens during first trimester. I have tested my urine and that there is urinary tract infection. May I know if this is normal? Can I do anything to make the condition better? Answer: It is not normal to have a urinary tract infection in pregnancy. If you have an infection, you should have it treated appropriately with the right antibiotics. If left untreated, it may lead to kidney infection which can be serious and may cause premature birth.

Q. I am 54 years old and have been menopausal for the past 2 years. My husband is 2 years younger. We had painful sex for the past one year. I don’t like using the lubricant as it is messy and sticky. I also don’t take hormone pills or apply hormone cream as I am afraid of the side effects. Is there any alternative treatment for my condition? Recently, my friend told me that she had the vaginal laser treatment with good results. Can you please tell me more about this treatment? A. The vagina becomes dry and thin after menopause due to the low levels of female hormone, oestrogen. Sexual intimacy often causes discomfort and pain. Laser is a new way to treat painful sex for these women. It is delivered by a slender probe inserted in the vagina and will stimulate both the cells on the surface and the deeper layers of the vagina to grow. The vaginal skin will get thicker and the underlying connective tissues will produce more collagen which helps make the vagina firm and supple. The end result is the repair of the vagina back to its normal state of lubrication and elasticity. The procedure is done as an outpatient. It is completely painless and no anesthesia is needed. The patient may feel some warmth during treatment but there are no unpleasant side effects .There are no complications such as bleeding and infection. Complete treatment entails four sessions at an interval of four to six weeks. Each session takes about 15 minutes. Women in a recent clinical trial reported good results after treatment. They had less vaginal dryness, pain, and irritation with much improvement in sexual pleasure.

I am married for 2 years, trying actively to conceive for the past 6 months without success. I went for a check-up recently and was told that I had uterine polyps. What are they and what are the causes? Must I have them removed? A. Uterine polyps also known as endometrial polyps are overgrowth of the cells in the inner lining of the womb (endometrium). They are attached to the wall of the womb by a stalk, the base of which can be thin or broad. They can be single or in a cluster and vary in size from a few millimetres to several centimetres. They usually extend into the cavity of the womb, but may slip down occasionally through the neck of the womb (cervix). They are usually noncancerous (benign), but may be pre-cancerous occasionally. They rarely turn cancerous. Hormonal imbalance resulting in an over-dominance of circulating female hormone, oestrogen appears to play a role in the formation of uterine polyps, the cells of which grow in response to oestrogen. Obesity and infertility are also associated with uterine polyps. Uterine polyps can occur in any age group but more commonly in older women around or completed menopause. They do not give rise to symptom usually but may cause the following occasionally · Bleeding in between menstrual periods · Excessively heavy menstrual flow · Irregular vaginal bleeding · Vaginal bleeding after menopause · Infertility Uterine polyps may be detected by ultrasound examination, hysterosalpingogram (an X-ray examination for the uterine cavity) or by hysteroscopy using a thin telescope inserting into the cavity of the womb. Small polyps without symptoms might resolve on their own. No treatment is required unless other risk factors for uterine cancer are present. Since you have fertility issues, surgical removal using hysteroscope may be necessary. After the polyps have been examined under microscope, you may require medications such as progestogens to balance the oestrogen or GnRH agonist injection.

Sleep and health are closely linked. The quality and quantity of sleep are important for our bodily functions including reproduction. Poor sleep and sleep deprivation have been known to cause irregular menses and infertility in females. T, a 29-year-old lady, is the case in point. She had been suffering from insomnia for the past few years. She attributed it to erratic sleeping habits when she was studying in junior college and university. She was rather lax in her time management, always chatting with her friends or rushing to complete her assignments in the wee hours of the night. She would drink cups of coffee to keep herself sober. The insomnia was made worse after she started working as a forex dealer when she had to call people at different time zones. Her menses started at the age of 12. The cycles were regular at monthly intervals. She began to have longer cycles occurring every 35 to 40 days during those years in the university. The menstruation became erratic after she started working. She could miss her periods for two to three months at times. She was slightly overweight with a BMI of 26 (normal for Asians is between 18.5 to 23). Clinical and ultrasound examination of her reproductive system were normal. The blood level of oestrogen, the female hormone, was low. Physiology of sleep We spend about one third of our life in sleep. It is a physiological process in which our brain is in a relative state of rest and is reactive primarily to internal stimulus. Why we need to have such a long duration of rest is not well understood. Sleep is organized in a relatively predictable cyclical pattern between 2 major phases: Non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep. It is controlled by two systems located within the brain: the homeostatic processes, which are functionally the body’s “need for sleep” center, and the circadian rhythm which is an internal clock for the sleep-wake cycle. Association between sleep and ovarian function Studies assessing the impact of sleep quality and/ or sleep duration on ovarian function have revealed an increased risk of menstrual cycle irregularities if the mean sleep duration was less than 5 hours among adolescents and women of reproductive age. Poor sleep quality was also associated with an increased incidence of menstrual cycle problems such as longer menstrual flow length or premenstrual syndrome. Insomnia was found to have a twofold increased risk in menstrual cycle irregularity in a study of 287 nurses. Shift work can impact ovarian function negatively. In a study of over 70,000 nurses, it was found that women who had experienced more than 20 months of rotating shift work were more likely to have irregular menses. T was getting married in about a year’s time. She understood the negative effects of sleep deprivation on her fertility (please refer to the article Fertility and Sleep in this website). She decided to take a year of sabbatical leave from work. With counselling and medications, her sleeplessness gradually improved and her menses were becoming more regular on recent follow-ups.

A Rare Case of Bleeding From A Cancerous Uterine Polyp M, 68, was taken aback one morning when she discovered slight staining on her underwear after passing urine. Three days later, she noticed some spotting again after peeing. She alerted her husband who brought her to see a urologist. A thorough urological investigation was carried out and included urine culture, ultrasound examination of the kidneys and cystoscopy (examination of the bladder using a telescope). The tests were found to be normal. She was then referred to me to exclude the source of bleeding from the genital organs. M was obese with a medical history of high blood pressure and diabetes. She had menopause 15 years ago. She denied any recent trauma to the vagina and did not have sexual intercourse for years. Vaginal examination using a speculum did not reveal any bleeding from the cervix and vaginal wall. Pelvic ultrasound examination showed that the uterus and ovaries were small and atrophic. There was no pelvic mass. She was advised to have a hysteroscopy, a minor procedure in which a slender telescope was inserted into the uterine cavity to check for abnormality in the uterine lining. This was carried out and a uterine polyp about 1.5cm in size was removed. Microscopic examination of the polyp revealed that it was a cancerous growth. Cancerous uterine polyp Uterine polyps or endometrial polyps, are small, soft growths that are attached to the inner wall of the uterus. They come from the tissue that lines the uterus, called the endometrium. (refer “Endometrial Polyp” in this website). It is rare for uterine polyps to be cancerous. According to various research studies, of those polyps that present with symptoms such as irregular bleeding, 10% to 25% may contain cells that are overactive (hyperplasia) and about 1 to 10 % may undergo malignant changes. Risks factors of cancerous uterine polyp There is no consensus among researchers on the exact risk factors that are associated with malignant transformation of polyps. But most workers agree that the risk of malignancy is increased with: Age: The older the patient, the higher the risk. Menopausal status: Cancerous uterine polyp is about 1-2 % in pre-menopausal women. The risk increases 3-4 folds after menopause. Symptoms: Women with symptoms run a higher risk of malignancy than those without symptoms. Size of the polyp: The larger the size of the polyp, the higher the risk. Some researchers have identified that polyps measuring more than 1.0 cm are associated with malignancy. Other factors such as obesity, diabetes, hypertension, and use of tamoxifen(anti-breast cancer drug) are found to be less predictive. Management of cancerous uterine polyp Removing the polyp by hysteroscopy is the mainstay of evaluation and management of endometrial polyps as the procedure is relatively simple with very minimal risk. It allows visualization of the entire uterine cavity and complete removal of the polyp. If malignancy is found within the polyp, further assessment and surgery should be done. Fortunately, M’s cancerous growth was localized in the polyp with no further spread to the uterine lining. She was advised to have the uterus, tubes and ovaries removed. This was done via keyhole surgery. Post-operative recovery was well and she was discharged from the hospital after 2 days.

On 30th of June 2021, the Royal College of Obstetricians and Gynaecologists (RCOG) published a publication on Covid-19 vaccination in pregnancy for healthcare professionals. I have extracted some interesting information on Pfizer and Moderna Vaccines which are used for pregnant mums locally. Vaccine safety The side effects of the two vaccines were similar in their clinical phase 3 trials. Pregnant women were not included in the large randomized controlled trials testing the safety and adverse effect profiles of the COVID-19 vaccines. However, as of 7 June 2021, over 120 000 pregnant women from diverse ethnic backgrounds in the USA have had both vaccines with no evidence of harm being identified. Common minor adverse effects A report on the first 35 000 pregnant women who received either vaccine in the USA revealed that most had a minor local reaction (pain, redness or swelling at the injection site). Mild side effects like fatigue, headache or muscle aches (myalgia) were common; these usually lasted less than a few days. About 10–20% of participants had a fever after vaccination but this was less common in pregnant mums. The incidence of nausea and vomiting was more frequent in pregnant women after the second dose of the vaccine. In general, adverse reactions are more common after the second dose than the first dose. Other maternal effects About 104 out of 827 or 12.6 % of pregnant women had miscarriages, with 92.3% of these miscarriages occurring in the first trimester. The incidence are similar to those in the general population. There have also been very rare reports of inflammation of the heart muscle (myocarditis), and inflammation of the outer lining of the heart (pericarditis) following vaccination Fetal effects Pregnancy outcomes following the 2 vaccines appear similar. According to one study (Shimabukuro T et al 2021), the most common adverse outcomes among 724 live births were preterm birth (9.4%), small-for-gestational-age (3.2%) and major congenital anomalies (2.2%). These figures are similar to those of the general population. None of the mothers whose babies were born with congenital anomalies had received the COVID-19 vaccine in the first trimester or the periconceptional period. Antibody transfer In the United States, there were two studies of over 100 women that showed the presence of antibodies in the infant cord blood and breast milk after vaccination. There is some suggestion that timing of vaccination in pregnancy or during lactation may have an effect on the level of passive immunity conferred to the new born. Studies have also found that production of antibodies and their subsequent transfer were improved following a second dose of either vaccine. Similar to natural infection, levels of antibodies appear to remain stable for several weeks following vaccination suggesting continual transfer of antibodies during lactation. However, how much protection these antibodies confer to the baby is not yet known. Timing of vaccination in pregnancy There is no robust evidence to guide the timing of vaccination in pregnancy. The vaccines should be effective at any stage of pregnancy. Some women may choose to delay their vaccine until after the first 12 weeks of gestation, which is the period during which the embryo or fetus is most vulnerable to substances that may produce physical or functional defects in the baby. Pregnant women are more likely to become seriously unwell when compared to non-pregnant women and have a higher risk of their baby being born prematurely if they develop COVID-19 in their third trimester. It is therefore reasonable to aim to have the vaccine before the third trimester, bearing in mind that it takes time for immunity to develop and protection is higher after the second dose of the vaccine. Women who had a first dose of vaccine before becoming pregnant should complete the course with the same vaccine. Benefits of vaccination Reduction in severe disease for a pregnant woman. Potential reduction in the risk of preterm birth associated with COVID-19. Potential reduction in transmission of COVID-19 to vulnerable household members. Potential reduction in the risk of stillbirth associated with COVID-19. Potential protection of the newborn from COVID-19 by passive antibody transfer. Risks of vaccination Minor local reaction (pain, redness or swelling at the injection site). Mild systemic adverse effects like fatigue, headache or myalgia, typically short-lived (less than a few days). There has been no evidence to suggest fetal harm following vaccination and fetal harm is considered to be extremely unlikely based on evidence from other non-live vaccines. Risk of fetal harm cannot be completely excluded until large scale studies of vaccination in pregnancy have been completed. Risks from COVID-19 in pregnancy Maternal risks: Most women with COVID-19 in pregnancy will have no symptoms. However, some women will develop critical illness from COVID-19. The risk of severe illness from COVID-19 is higher for pregnant women than for non-pregnant women, particularly in the third trimester. There is consistent evidence that pregnant women are more likely to be admitted to an intensive care unit than non-pregnant women with COVID-19. Fetal risks Symptomatic maternal COVID-19 is associated with a two to three times greater risk of preterm birth. Although the overall risk of stillbirth is small, the risk is approximately doubled with Covid-19 infection

G, 29, a first-time mum, requested to have a Cesarean Section (CS) done at her 38 weeks of gestation. Her reason: So that she could celebrate her birthday together with her baby on the same day in future. G was not alone with her request. Social indication for planned CS is on the rise and has contributed to the increase in the overall CS rate in Singapore which has risen from 10-15% of total births in the early 1990s to about 40 % of all births now. This is probably because CS has become a very safe procedure in Singapore with very few maternal and fetal complications. Some mothers are frightened of the pain during birth while others may want to schedule the birth to suit the convenience of the families. CS also allows mothers to choose the auspicious time and date of birth to ensure a bright future for their babies. For some mothers, CS prevents trauma to the pelvic floor muscles. This will ensure a better sexual life and prevent urinary incontinence later on in life. While CS is deemed necessary for medical reasons such as for fetal distress, maternal request on its own is not an indication. Many mothers may not be aware that babies delivered by CS may have a delay in the development of their immune system which is important in protecting them against diseases in later life. Microbes When babies are in their mother’s womb, they are free of germs or microbes. But as soon as they are delivered normally and exposed to the outside world, they begin taking in good microbes, which rapidly colonize organs in the body, particularly in the large intestines. This early colonization helps initiate and develop the infant’s immune system. Vaginal Seeding Studies have shown that babies born by CS do not get a good blend of microbes that come from a vaginal birth. They lack the strains of gut bacteria found in healthy children and adults. Instead, their guts harbour more harmful microbes which will delay the development of the immune system. Immaturity of the body's defenses make these infants more vulnerable to infection. The incidence of metabolic and allergic disorders such as asthma and obesity also increases in later life. This observation has led some parents to swab infants born by CS with vaginal fluids in an attempt to restore the missing microbes. But the practice, known as vaginal seeding, has been found to be unsafe and with unproven effectiveness. Fecal Microbiota Transplants (FMT) Studies have revealed that the ecosystem of microbes in the gut of the newborns delivered vaginally derives from maternal fecal matters and not from the vaginal fluid. The babies presumably pick up mum’s poop at the moment of birth. To find ways to improve the immune system of CS babies, a group of researchers from Helsinki recently performed FMT on these babies. FMT refers to the procedure in which a small amount of well-screened mother’s poop is given orally to the baby after birth. They found that this early-life bacteria could “normalize” their gut microbes and give the infant’s immune system a healthier start. However, these experts warned that the babies were monitored cautiously in a hospital and the procedure should not be tried by anyone at home. Long term studies of FMT are ongoing. G was counselled on the disadvantages of CS on social grounds. With the support and persuasion of her husband, she finally abandoned the idea of having the same birthdate as her baby and delivered a healthy boy vaginally at full term.

J was woken up one morning by the tingling sensation and soreness over her right leg. She was shocked to see that the leg was swollen from the hip down to the ankle. The calf was also tender to touch. Her left leg looked normal. With the help of her husband, she got up from her bed limping. Realizing that something was amiss, they rushed to hospital immediately. J, a 32-year-old teacher had delivered her first baby normally two weeks ago. There were no complications during her antenatal period and labour. She was discharged well on the 3rd day after delivery. On examination, her right leg was swollen from the hip downwards with pitting ankle oedema. The skin on the affected leg appeared bluish red and felt slightly warmer compared to that of her left leg. An urgent ultrasound doppler examination revealed a large blood clot in the deep veins of her leg. J was suffering from a potentially life-threatening condition called deep vein thrombosis (DVT). What is DVT? DVT is a condition where blood clots are formed in veins located deep inside the body. A blood clot is a clump of blood that has turned into a solid state. The blood clots typically form in the thigh or lower leg, but they can also develop in other parts of the body. These blood clots can break loose, travel through the bloodstream and get stuck in the lungs, blocking the blood flow. The condition is called pulmonary embolism and requires emergency care as it can be fatal. What are the symptoms of DVT? DVT can occur without noticeable symptoms. According to the Centers for Disease Control and Prevention (CDC) of the USA, symptoms only occur in about 50% of patients. Common symptoms include: Swelling in the affected leg. Rarely, there are swelling in both legs. Cramping pain in the affected leg that usually begins in the calf A feeling of warmth in the affected leg Skin over the affected area turns pale or has reddish or bluish coloration Severe, unexplained pain in the foot and ankle What are the causes and risk factors of DVT? Any condition that slows down the blood flow or promotes blood clotting can cause DVT. This may occur when there is: Damage to a blood vessel’s wall from surgery or trauma Reduced mobility or inactivity which will slow down the blood flow in the lower extremities. Inflammation of blood vessels due to infection Drugs that increase the tendency of blood to clot Risk factors include: Pregnancy: Pregnant women are 5 to 10 times more likely to develop DVT than women who are not pregnant. This is because during pregnancy, the levels of blood-clotting proteins increase. Blood flowing back from the lower extremities to the heart also slows down due to compression of the pelvic veins by the expanding uterus. This risk of DVT continues for up to six weeks after delivery as in J’s case. Prolonged sitting or bed rest Injuries or surgery Obesity Smoking Oral contraceptive pills Family history of DVT How is DVT diagnosed? Besides the signs and symptoms, DVT is usually diagnosed by ultrasound examination of the blood flow of the veins. Blood level of a product of the blood clot (D-dimer) is also raised in almost all patients with severe DVT. Treatment J was referred straightaway to the hematologist who put her on blood thinners (anticoagulant) to prevent the clot from getting bigger and reduce the risk of developing more clots. She also had to wear compression stockings. These stockings reduce the chances of blood pooling and clot forming. With timely intervention, the fatal complication of pulmonary embolism did not occur. The leg swelling gradually subsided after 4 months. She was advised to wear the stockings for 2 years. She is currently being monitored by the hematologist at regular intervals.

For the past 2 years, G, 31, had been enduring menstrual pain and heavy bleeding with clots. She had become accustomed to the “stormy time of the month”. “I did not seek medical help as I thought it was normal to have some discomfort or clots during menses after childbirth, ” she recalled. After the birth of her son 4 years ago, her periods had become increasingly heavier and longer. There were clots on the first 3 to 4 days. About 2 year ago, she began to experience abdominal cramps on the first few days of menses as well. The pain was relieved by applying a hot pack to the lower abdomen and by taking painkillers. She also felt weak and exhausted during menstruation. One morning, she was brought to the emergency department in the hospital when she collapsed and passed out in her office. It was the second day of her menstruation. She looked pale with a fast pulse rate of 110 beats per minute. Her blood pressure was low at 90/60mm Hg. Her uterus was enlarged and palpable in the lower abdomen, corresponding to about 14 weeks of pregnancy. A large amount of blood clot was noted in her vagina. Ultrasound examination revealed a large uterine mass about 8 cm in diameter, protruding into the uterine cavity. Her hemoglobin was low at 9.2 gm/dl. She was transfused with blood. Her bleeding was stopped with medication. G was having heavy bleeding and severe anemia due to a huge uterine fibroid. What are uterine fibroids? Uterine fibroids are common muscle growths of the womb. About 20 to 70 percent of women will have fibroids during their childbearing years. They are usually non-cancerous. Fibroids can range in size from tiny seedlings to huge masses that can distort and enlarge the uterus. They can present either as a single lump or multiple ones. They are generally classified by their location. Intramural fibroids grow within the muscular uterine wall. Submucosal fibroids bulge into the uterine cavity. Subserosal fibroids protrude outside the uterus. What are the symptoms? Majority of the fibroids do not present with any symptoms. If symptoms are present, they are dependent on the location, size and number of fibroids. Common symptoms include: Heavy menstrual bleeding Prolonged or painful periods Spotting or bleeding between periods Pelvic pressure or pain Frequent urination Difficulty emptying the bladder Constipation What are the causes? It is not clear why fibroids develop; but research and clinical experience suggest the following factors: Hormones: Fibroids are stimulated by ovarian hormones. They may develop and grow rapidly during pregnancy and tend to shrink after menopause. Genes: Fibroids may run in the family. If a woman's mother had fibroids, her risk of having fibroids is about three times higher than average. Obesity: The risk of obese women having fibroids is two to three times higher than normal. Other factors: Ethnic origin; menstruation at an early age; vitamin D deficiency; drinking alcohol and a diet higher in red meat and lower in vegetables, fruit and dairy appear to increase the risk of developing fibroids. What are the complications? Anemia: Heavy periods may lead to iron-deficiency anemia resulting in fatigue, dizziness and shortness of breath. Pregnancy problems: Preterm birth, intrauterine growth restriction, abnormal fetal position and pregnancy loss may occur. Infertility: Fibroids usually do not cause infertility. However, submucosal fibroids may be a factor as they may block the fallopian tubes or cause repeated miscarriages. Cancer: Cancerous fibroids, known as leiomyosarcomas, are rare. They occur in less than 1 in 1,000 cases. How are fibroids diagnosed? Uterine fibroids are frequently found incidentally during a routine pelvic examination or ultrasound scan. Other imaging tests may include: Pelvic Magnetic resonance imaging (MRI). This test can show in more details the size and location of fibroids, identify different types of tumors and help determine appropriate treatment options. Hysterosalpingography (HSG) and hysterosonography or saline infusion sonogram using sterile saline to expand the uterine cavity may help in the diagnosis of submucosal fibroids. How are fibroids treated? Fibroids can be treated in various ways. They include: Watchful monitoring: Many women with uterine fibroids have no symptoms. Watchful monitoring could be the best option. Medications; Nonsteroidal anti-inflammatory drugs (NSAIDs), tranexamic acid, hormones and GnRH agonists have been used to reduce the menstrual bleeding. They do not reduce the size of the fibroids. Non-invasive procedure using ultrasound (Hifu) has been used to destroy fibroids. (see the article “Surgery without knife” in the website) Minimally invasive procedure: Embolic agents are injected into the uterine artery to block the blood supply of the fibroids (uterine artery embolization). This can destroy fibroids without actually removing them through surgery. Surgery: Removal of the fibroids (myomectomy) or the entire uterus (hysterectomy) can be done either by open surgery (laparotomy) or by minimally invasive surgery (laparoscopic surgery). Submucosal fibroids can be removed via hysteroscopy. After G had recovered from her anemic state, we had a full discussion of the pros and cons of the various treatment modalities. She opted for the laparoscopic key-hole surgery to remove the fibroid as she was young and would like to start a family in future. Myomectomy was successfully performed. She was amazed of her quick recovery. Her menstruation had returned to normal and she has remained pain free since.