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Fibroid uterus- a deep insight

Fibroid uterus- a deep insight

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Fibroid uterus- a deep insight

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  1. Fibroid uterus- a deep insight Presented by: Vishnu.r.nair, 4th year pharm.d, National college of pharmacy, Kerala university of health sciences(kuhs), kerala state

  2. INDEX/ CONTENTS OF THIS PPT : • GENERAL ACKNOWLEDGEMENT • GENERAL INTRODUCTION  • EPIDEMIOLOGICAL STATISTICS  • TYPES OF FIBROIDS  • ETIOLOGY/ CAUSES OF FIBROIDS  • PATHOPHYSIOLOGY  • CLINICAL MANIFESTATIONS  • RISK FACTORS FOR FIBROIDS  • COMPLICATIONS OF FIBROIDS  • DIAGNOSTIC PRINCIPLES FOR FIBROIDS  • MANAGEMENT STRATEGIES FOR FIBROIDS  • BIBLIOGRAPHY/ REFERENCE 

  3.  GENERAL ACKNOWLEDGEMENT  : HELLO READERS…………………. Its my 21st ppt…………………………… As far as making this ppt is concerned, I wish to thank the almighty, my ever-loving parents, dear teachers of 4th year, my friends, pharm.d group members and everyone, near and dear, for ur support, care & guidance in my initiatives n works…….. with a note of thanks, I surely hope that this ppt will prove worthy for anyone who go through it Do send me ur reviews n comments!!! @rxvichu-alwz4uh!   

  4.  General introduction  : • UTERINE FIBROIDS are defined as “NON-CANCEROUS GROWTHS of UTERUS, that usually appear during CHILDBEARING YEARS” • Also known as “ UTERINE LEIOMYOMAS”/ simply “MYOMAS” • Not associated (in most cases) , with UTERINE CANCER • FIBROID SIZE varies from SEEDLINGS(undetectable by human eye), to BULKY MASSES, that can DISTORT/ENLARGE the UTERUS • Fibroid may be SINGLE in OCCURRENCE/ MULTIPLE in number • Many women have UTERINE FIBROIDS at sometime in their lives • Most women do not know that they have fibroids, since they often are ASYMPTOMATIC……………………………

  5.  EPIDEMIOLOGICAL STATISTICS  : • According to NATIONAL INSTITUTE OF HEALTH, about 70-80% of women experience FIBROIDS by age 50 • About 77% specimens of HYSTERECTOMY(Conducted in US), were found to have FIBROIDS, in VARIABLE NUMBERS, SIZES & SITES • According to SONOGRAPHICSURVEY in 35-49 years aged AFRO-AMERICAN WOMEN  60% FIBROIDS were reported in them • WHITE WOMEN have LOWER PREVALENCE : 40% at age 35, and almost 70% by age 50……………………….

  6.  TYPES OF FIBROIDS  : FIBROIDS are classified as: • INTRAMURAL FIBROIDS: • MOST COMMON type of fibroid • Appears within UTERUS LINING(ENDOMETRIUM) • May grow larger & cause WOMB SWELLING 2. SUB-SEROSAL FIBROIDS: • Form on OUTSIDE of UTERUS(SEROSA) • May grow large enough to make WOMB appear BIGGER ON ONE SIDE

  7. 3. PEDUNCULATED FIBROIDS: • When SUBSEROSAL TUMORS develop a STEM(SLENDER BASE, that supports the TUMOR)  PEDUNCULATED TUMORS are formed 4. SUBMUCOSAL FIBROIDS : • Develop in INNER LINING (MYOMETRIUM) of UTERUS • Not as common as other types • Cause HEAVY MENSTRUAL BLEEDING & TROUBLE in CONCEIVING…………………….

  8.  ETIOLOGY/ CAUSES OF FIBROIDS  : CAUSES OF FIBROIDS INCLUDE: • GENETIC CAUSES: - Fibroidsare usually MONOCLONAL • 40% include CHROMOSOMAL ABNORMALITIES • 60% include UNDETECTED MUTATIONS • CHROMOSOMAL ABNORMALITIES include: • TRANSLOCATIONS between CHROMOSOMES 12 & 14 • DELETION of CHROMOSOME 7 • TRISOMY of CHROMOSOME 12 (in LARGE TUMORS)

  9. 2. HORMONES: • ESTROGEN & PROGESTERONE (Hormones, that stimulate DEVELOPMENT of UTERINE LINING, during each MENSTRUAL CYCLE , in preparation for PREGNANCY) Promotes fibroid growth • Fibroids contain more ESTROGEN & PROGESTERONE RECEPTORS than NORMAL UTERINE MUSCLE CELLS do • ESTROGEN  induces INCREASED EXPRESSION of PROGESTERONE RECEPTORS  Promotes ONCOGENIC EFFECTS of PROGESTERONE • This explains why: • Fibroids tend to SHRINK after MENOPAUSE • Fibroids tend to occur during HRT(ERT)

  10. 3. GROWTH FACTORS: • GROWTH FACTORS  PROTEIN POLYPEPTIDES , produced LOCALLY by SMOOTH MUSCLE CELLS & FIBROBLASTS • GROWTH FACTORS  increase EXTRACELLULAR MATRIX  promote FIBROID GROWTH • GROWTH FACTORS include: • TUMOR-GROWTH FACTOR(BETA) • BASIC FIBROBLAST GROWTH FACTOR • EPIDERMAL GROWTH FACTOR(EGF) • PLATELET DERIVED GROWTH FACTOR (PDGF) • VASCULAR ENDOTHELIAL FACTOR (VEF) • INSULIN- LIKE GROWTH FACTOR

  11. 4. MISCELLANEOUS CAUSES: INCLUDE: • OBESITY • ERT • ENDOMETRIOSIS • ENDOMETRIAL CANCER • OVULATORY INFERTILITY • EARLY MENARCHE • PREGNANCY………………………………………………….

  12.  PATHOPHYSIOLOGY OF FIBROIDS  : - There are 2 types of FACTORS, that cause FIBROID UTERUS: • PRE-DISPOSING FACTORS: INCLUDE: • Age g. Use of ORAL CONTRACEPTIVES • Gender h. High fat diet • Race i. Obesity • Lifestyle j. Family history • Early menarche k. Anxiety • Nulliparity

  13. 2. PRECIPITATING FACTORS: INCLUDE: • Hormone replacement therapy (hrt) • Luteal insufficiency • Anovulation • Both PRE-DISPOSING & PRECIPITATING FACTORS  Cause ESTROGEN DOMINANCE  If ESTROGEN DOMINANCE is not treated  PROLIFERATION of CELLS in UTERUS occurs  OVERGROWTH of ENDOMETRIAL LINING occurs  UTERINE FIBROID develops  FIBROIDS interferes with VASCULAR SUPPLY  Causes DEGENERATION in INTERIOR PART of FIBROID  causes HYPERMENORRHOEA, and OTHER SYMPTOMS………………………

  14. - ESTROGEN DOMINANCE is associated with: • SWELLING OF BREASTS • DEPRESSION • LOSS OF SEXUAL DRIVE • DYSMENORRHOEA………………………………

  15.  CLINICAL MANIFESTATIONS  : • HEAVY MENSTRUAL BLEEDING • MENSTRUAL PERIODS, LASTING MORE THAN 1 WEEK • PELVIC PRESSURE/ PAIN • DIFFICULTY IN EMPTYING THE BLADDER • CONSTIPATION • BACKACHE • LEG PAINS • ACUTE ABDOMINAL PAIN • FREQUENT URINATION

  16. 10. DYSPAREUNIA 11. ANOREXIA 12. SWELLING/ ENLARGEMENT OF ABDOMEN…………………………..

  17.  RISK FACTORS FOR FIBROIDS  : INCLUDE: • AGE: • Incidence increases with AGE, till ONSET of MENOPAUSE 2. ENDOGENOUS HORMONAL FACTORS: INCLUDE: • EARLY MENARCHE • LATE MENOPAUSE • HYPER-ESTROGENIC STATES • INCREASED RESPONSIVENESS & EXPRESSION OF PROGESTERONE RECEPTORS ‘A’ & ‘B’

  18. 3. FAMILY HISTORY : • FIRST DEGREE RELATIVES  have 3.5 TIMES more risk of DEVELOPING FIBROIDS 4. ETHNICITY : • BLACK WOMEN  develop FIBROIDS 2.9 TIMES more than WHITE WOMEN 5. BODY WEIGHT: • Risk of FIBROIDS increases by 21% , with each 10 KG increase in BODY WEIGHT 6. DIET : • Diet , rich in RED MEAT, HAM, BEEF  Increases FIBROID RISK 7. EXERCISE: - Women doing REGULAR EXERCISE (at least 7 hrs./ week)  have LOW RISK , than those who DON’T EXERCISE

  19. 8. ESTROGEN REPLACEMENT THERAPY: • Increased INCIDENCE observed when PROGESTERONE is added 9. PREGNANCY: • PREGNANCY increases production of ESTROGEN & PROGESTERONE  Encourages RAPID DEVELOPMENT of FIBROIDS 10. TISSUE INJURY: - Increases LOCAL PRODUCTION of TISSUE GROWTH FACTORS…………………………

  20.  Complications of fibroids  : INCLUDE: • ANEMIA (DUE TO HEAVY BLOOD LOSS) • INFERTILITY • PLACENTAL ABRUPTION • FETAL GROWTH RESTRICTION • PRE-TERM DELIVERY • CHF………………………………….

  21.  DIAGNOSTIC PRINCIPLES FOR FIBROIDS  INCLUDE: • ULTRASOUND: • ULTRASOUND  uses SOUND WAVES  obtains PICTURE of UTERUS  confirms diagnosis , and also helps to MEASURE FIBROIDS • DOCTOR/ TECHNICIAN  Moves the ULTRASOUND DEVICE (TRANSDUCER) over ABDOMEN (TRANS-ABDOMINAL) / places it inside VAGINA (TRANS-VAGINAL) , to get images of UTERUS 2. BLOOD TESTS: - If ABNORMAL MENSTRUATION is observed  doctor may order other tests to investigate POTENTIAL CAUSES

  22. - TESTSinclude: • CBC (COMPLETE BLOOD COUNT) : To see if ANEMIA has occurred , due to CHRONIC BLOOD LOSS • OTHER TESTS : To rule out OTHER BLEEDING DISORDERS/ THYROID PROBLEMS 3. MRI-SCAN : - Usedfor the following purposes: • To show SIZE & LOCATION of FIBROIDS • To identify DIFFERENT TUMOR TYPES • To determine APPROPRIATE TREATMENT OPTIONS

  23. 4. HYSTEROSONOGRAPHY: • Also known as “SALINE INFUSION SONOGRAM” • Here  STERILE SALINE is used  EXPANDS UTERINE CAVITY  Makes easier to get images of SUBMUCOSAL FIBROIDS & ENDOMETRIUM 5. HYSTEROSALPINGOGRAPHY: • Here  DYE is used  HIGHLIGHTS UTERINE CAVITY & FALLOPIAN TUBES on X-RAY IMAGES • Helps in: • Revealing fibroids • To determine if FALLOPIAN TUBES are OPEN

  24. 6. HYSTEROSCOPY: - In this procedure  doctor inserts a HYSTEROSCOPE (Small, lighted TELESCOPE) through CERVIX into UTERUS  then SALINE is injected into UTERUS  expands UTERINE CAVITY  Allows doctor to examine walls of UTERUS & OPENINGS of FALLOPIAN TUBES……………………………..

  25.  MANAGEMENT STRATEGIES FOR FIBROIDS  : INCLUDES: • GOALS OF THERAPY • PHARMACOTHERAPY • NON-PHARMACOTHERAPY

  26. A. GOALS OF THERAPY : • To relieve pain & discomfort • To avoid progression into complications • To assess need of therapy & its proper planning • To improve hrqol (health-related quality of life) • To ensure patient convalescence as much as possible…………………….

  27. B. PHARMACOTHERAPY : • Gnrh (gonadotropin-releasing hormone) agonists: • Temporary treatment for PRE-MENOPAUSAL WOMEN, with HEAVY MENORRHAGIA • Actions include: • DRUG BLOCKS PRODUCTION of ESTROGEN & PROGESTERONE  Puts patient in a TEMPORARY MENOPAUSAL STATE  MENSTRUATION STOPS  FIBROIDS SHRINK  ANEMIA IMPROVES • DRUG  REDUCES UTERINE VOLUME by 35% • DRUG  REDUCES FIBROID VOLUME by 30% • DRUG  REDUCES BLEEDING

  28. SYMPTOMS RETURN , when MEDICATION IS STOPPED • Usually given for 3-6 MONTHS • DRUGS used include: • TRIPTORELIN (TRELSTAR): • MOA : DRUG  REDUCES ‘FSH’ LEVELS  SUPPRESSES STEROIDOGENESIS  REDUCES ESTROGEN levels • ADRs: • HOT FLUSHES (82%) • BONE PAIN (17%) • IMPOTENCE (10%) - INTERACTION : DRUG + AMIODARONE  Increases TOXICITY OF LATTER  High risk of TDP(TORSADES DE POINTES)

  29. DOSE : 3.75 mg DEPOT (i.m) MONTHLY…………… II. LEUPROLIDE ACETATE(LUPRON) : • MOA : DRUG  INHIBITS GONADOTROPIN SECRETION  SUPPRESSES OVARIAN STEROIDOGENESIS  REDUCES FSH LEVELS • AGONIST ANALOGUE of luteinizing hormone-releasing hormone(lhrh) • ADRs: • HOT FLUSHES (57%) • ISCHEMIA (19%) • FATIGUE (18%) • INTERACTION : DRUG + AMIODARONE  increased risk of TDP • DOSE : 3.75 mg DEPOT (i.m) MONTHLY……………………………….

  30. III. GOSERELIN(ZOLADEX): • LHRH ANALOGUE • Same MOA as that of LEUPROLIDE • ADRs: • FLUSHING (46-96%) • VAGINITIS (5-75%) • BREAST ATROPHY (33%) • DEPRESSION IN WOMEN (54%) • REDUCED LIBIDO (47-61%) • INTERACTION : DRUG + AMIODARONE  Increased risk of TDP • DOSE : 3.6 mg DEPOT (s.c) MONTHLY………………………………

  31. 4. Nafarelin (synarel): • Synthetic decapeptide • Moa : drug  desensitizes response to ENDOGENOUS GnRH  REDUCES FSH SECRETION  REDUCES OVARIAN PRODUCTION • ADRs: • ACNE (10%) • BREAST ENLARGEMENT (8%) • VAGINAL BLEEDING (8%) • DOSE : 200 mg , taken TWICE DAILY, INTRANASALLY ( ONE SPRAY into 1 NOSTRIL in MORNING, & 1 SPRAY into OTHER NOSTRIL at EVENING)

  32. 2. PROGESTIN-RELEASING INTRAUTERINE DEVICE: • REASONABLE TREATMENT for selected women of CHILD-BEARING AGE , with FIBROIDASSOCIATED MENORRHAGIA, andinterested to have CONCEPTION • Reduces HEAVY BLEEDING caused by FIBROIDS • Provides only SYMPTOMATIC RELIEF • Doesn’t SHRINK FIBROIDS/ make them DISAPPEAR • PREVENTS PREGNANCY • 85% of such women returned to their normal bleeding in 3 months • 40% developed REVERSIBLE AMENORRHEA at the end of 1.5-2 YEARS • Example : MIRENA-LEVONORGESTREL RELEASING IUCD……………………………….

  33. 3. TRANSEXAMIC ACID (LYSTEDA): • NON-HORMONAL MEDICATION • EASES HEAVY MENSTRUAL PERIODS • Taken only on HEAVY BLEEDING DAYS • DOSE : 10mg/kg i.v (over 30 mins)………………………. 4. ORAL CONTRACEPTIVES/ PROGESTINS: • CONTROL MENSTRUAL BLEEDING • Don’t reduce fibroid size

  34. 5. NSAIDs: - Relieve pain associated with FIBROIDS • Don’t reduce BLEEDING caused by FIBROIDS 6. VITAMIN & IRON SUPPLEMENTS: - Used to control HEAVY MENORRHAGIA & ANEMIA…………………………………..

  35. B. NON-PHARMACOTHERAPY : INCLUDES: • NON-INVASIVE PROCEDURES • MINIMALLY INVASIVE PROCEDURES • TRADITIONAL SURGICAL PROCEDURES • HOME REMEDIES FOR FIBROID UTERUS • PATIENT COUNSELLING TIPS(DO’S FOR FIBROIDS) • PATIENT COUNSELLING TIPS(DON’T’S FOR FIBROIDS)

  36. 1. NON – INVASIVE PROCEDURES : INCLUDES: • FOCUSED ULTRASOUND SURGERY (FUS): • Helps in UTERUS PREPARATION • Requires NO INCISION • Done on OUT-PATIENT BASIS • Performed in presence of MRI-SCANNER, that is equipped with a HIGH-ENERGY ULTRASOUND TRANSDUCER • IMAGE PROVIDED by TRANSDUCER Provides PRECISE LOCATION of UTERINE FIBROIDS  When LOCATION of the FIBROID is TARGETED  ULTRASOUND TRANSDUCER FOCUSSES SOUND WAVES(SONICATIONS) into FIBROID  HEATS & DESTROYS small areas of FIBROID TISSUE…………..

  37. 2. MINIMALLY INVASIVE PROCEDURES: INCLUDE: • UTERINE ARTERY EMBOLIZATION: • In this process  SMALL PARTICLES (EMBOLIC AGENTS)  INJECTED into ARTERIES supplying the UTERUS  CUTS OFF BLOOD SUPPLY to FIBROIDS  Cause them to SHRINK & DIE • Complications may occur if the BLOOD SUPPLY to the OVARIES/ other ORGANS is COMPROMISED…………………….. II. MYOLYSIS: - LAPAROSCOPIC PROCEDURE

  38. Here  RADIOFREQUENCY ENERGY, ELECTRIC CURRENT / LASER is used  DESTROYS FIBROIDS  SHRINKS BLOOD VESSELS that feed them • CRYOMYOLYSIS : Involves FREEZING of FIBROIDS III. LAPAROSCOPIC/ ROBOTIC MYOMECTOMY: • During MYOMECTOMY  SURGEON removes FIBROIDS, keeping UTERUS in its place • LAPAROSCOPIC method is used if FIBROIDS are FEW & SMALL in NUMBER • Here  SLENDER INSTRUMENTS are INSERTED through SMALL INCISIONS in the ABDOMEN  FIBROIDS are broken into SMALLER PIECES (A process, known as MORCELLATION) • ROBOTIC MYOMECTOMY gives surgeon a MAGNIFIED, 3-D IMAGE OF UTERUS Provides MORE PRECISION,DEXTERITY & FLEXIBILITY…………………….

  39. IV. HYSTEROSCOPIC MYOMECTOMY: • Applicable for SUB-MUCOSAL FIBROIDS • Here  SURGEON removes FIBROIDS, using INSTRUMENTS, inserted through VAGINA & CERVIX into the UTERUS V. ENDOMETRIAL ABLATION: - Here  a SPECIALIZED INSTRUMENT is inserted into UTERUS  Uses HEAT, MICROWAVE ENERGY, HOT WATER/ ELECTRIC CURRENT  Destroys UTERINE LINING  Ends MENSTRUATION/ REDUCES MENSTRUAL FLOW…………………………

  40. 3. TRADITIONAL SURGICAL PROCEDURES: INCLUDES: • ABDOMINAL MYOMECTOMY: • Applicable for MULTIPLE FIBROIDS, VERY LARGE/ DEEP FIBROIDS • OPEN ABDOMINAL SURGICAL PROCEDURE • DEMERIT : SCARRING after surgery  can affect future FERTILITY II. HYSTERECTOMY: • Only proven PERMANENT SOLUTION for UTERINE FIBROIDS • Ends ABILITY TO HAVE CHILDREN, since the procedure involves REMOVAL OF UTERUS as such……….

  41. 4. Home remedies for fibroid uterus : INCLUDE: • CASTOR OIL PACK: • CASTOR OIL PACK  Appliedon ABDOMEN  Stimulates LYMPHATIC & CIRCULATORY SYSTEM  Increases LYMPHOCYTES (Disease- fighting cells)  Eliminates TOXINS from body • CASTOR OIL  Contains RICINOLEIC ACID  has ANTI-INFLAMMATORY ACTION  SHRINKS FIBROIDS  Relives PAIN • SATURATE a piece of WOOL FLANNEL in CASTOR OIL  Place it on your ABDOMEN  Cover it with a PLASTIC WRAP  Place HEATING PAD/ HOT WATER BOTTLE on it  cover it with an OLD TOWEL  Leave it on for about 1 HOUR  REMOVE IT  REPEAT 3-4 times a week, (for 1 month), unless SYMPTOMS RESOLVE • NEVER USE THIS REMEDY during MENSTRUATION/ if you are trying to CONCEIVE…………

  42. II. CHASTEBERRY: • Also known as “VITEX AGNUS-CASTUS” • Found in SOUTHERN EUROPE & MEDITERRANEAN AREAS • Good HERBAL SOLUTION to maintain HORMONAL BALANCE, REDUCE ESTROGEN LEVELS, & REDUCE INFLAMMATION • Take 25-30 drops of CHASTEBERRY TINCTURE TWICE/ FOUR TIMES DAILY • CHASTEBERRY may REDUCE EFFECTIVENESS of BIRTH CONTROL PILLS………………….. III. MILK THISTLE: • METABOLIZES & gets RID of EXCESS ESTROGEN • Take 15-20 drops of its TINCTURE (THRICE DAILY) for 3-4 months……………………

  43. IV. DANDELION: • According to HERBALISTS POOR LIVER FUNCTION  Causes POOR ELIMINATION of EXCESS HORMONES  results in FIBROIDS • DANDELION has 2 actions: • Aids in LIVER DETOXIFICATION • Clears EXCESS ESTROGEN from the body • BOIL 3 tbsp. of DANDELION ROOT in 3.5 cup water  let it SIMMER for 15 minutes  turn off heat  allow to steep for 15 minutes  STRAIN it  Drink this tea thrice daily for 3 months………

  44. V. GREEN TEA: • According to STUDIES  GREEN TEA contains a compound called “EPIGALLOCATECHIN GALLATE(EGCG)”  INHIBITS GROWTH of FIBROID CELLS  Increases its DEATH RATE • EGCG  Has ANTI-INFLAMMATORY, ANTI-PROLIFERATIVE & ANTI-OXIDANT effects • According to RESEARCHERS  Along with reducing FIBROID SIZE  GREEN TEA also reduces SEVERITY of FIBROID SYMPTOMS • Drink 2-3 cups of GREEN TEA daily for several months……………………… VI. MILK: - According to a study published in AMERICAN JOURNAL OF EPIDEMIOLOGY in 2009 RESEARCHERS at BOSTON UNIVERSITY SCHOOL OF MEDICINE found that BLACK WOMEN, who consumed 4/ more DAIRY SERVINGS a day, had 30% REDUCED RISK of UTERINE FIBROIDS, compared to those with <1 serving/day

  45. CALCIUMfound in milk  reduces CELL PROLIFERATION • Combine MILK with BLACKSTRAP MOLASSES(rich in IRON)  Helps to FIGHT ANEMIA , resulting from HEAVY BLEEDING due to FIBROIDS • Mix 1-2 tbsp. BLACKSTRAP MOLASSES in a cup of WARM MILK  Drink it OD/ BID, for few months…………………………….. VII. BURDOCK ROOT TEA: • Improves LIVER’S ABILITY to METABOLIZE ESTROGEN  Reduces FIBROIDS • BURDOCK ROOT  Contains LIGNAN “ARCTIGENIN”  Reduces FIBROID SIZE  Prevents NEW TUMOR GROWTH • Add 1 tsp. of DRIED BURDOCK ROOT to a cup of HOT WATER  STEEP for 10-15 minutes  STRAIN it  Drink it TID, for 3-4 months…………………………………….

  46. VIII. APPLE CIDER VINEGAR: - APPLE CIDER VINEGAR  REMOVES TOXINS & PROMOTES FAT LOSS  helps to REDUCEFIBROID SYMPTOMS • Add 1 tsp of APPLE CIDER VINEGAR to a glass of water  add NATURAL SWEETENER to taste  drink it daily on a regular basis ……….. IX. GARLIC: • NATURAL ANTI-OXIDANT & ANTI-INFLAMMATORY AGENT • Reduces GROWTH of TUMORS & UTERINE FIBROIDS • Eat 3-4 GARLIC CLOVES a day, along with a glass of milk………..

  47. x. Indian gooseberry(amla): - Amla potent anti-oxidant & immunomodulator  Reduces fibroids & their SYMPTOMS - Mix 1 tsp of AMLA POWDER & HONEY  CONSUME it in MORNING, for few months…………………………

  48. 5. PATIENT COUNSELLING TIPS (DO’S FOR FIBROIDS) : • EXERCISE REGULARLY • DRINK PLENTY OF WATER A DAY • CONSUME WHOLE GRAINS, LIKE OATS, BROWN RICE, ETC • EAT BEANS, NUTS, SEEDS • EAT PLENTY OF GREEN VEGETABLES • EAT PLENTY OF FIBER RICH FOODS • COMBAT OBESITY, BY PROPER MEDITATION & FOCUSSING ON JUSTIFIABLE FOOD CHOICES………………………………….

  49. 6. PATIENT COUNSELLING TIPS(DON’T’S FOR FIBROIDS): • AVOID JUNK FOODS • AVOID FRIED FOODS AS MUCH AS POSSIBLE • AVOID RED MEAT & HAM • AVOID STRESS AS FAR AS POSSIBLE • AVOID ALCOHOL CONSUMPTION • AVOID HIGHLY SUGARY PRODUCTS………………………………..

  50.  BIBLIOGRAPHY/ REFERENCE  : • www.sciencedaily.com/releases/2009/12/091204.html • www.top10homeremedies.com/home-remedies-fibroids.html/3 • www.mayoclinic.org • www.healthline.com • Thomason.P; Lin.C.Eugene; “UTERINE LEIOMYOMA(FIBROID) IMAGING”; emedicine.medscape.com………………………