IN MEMORY OF MINDEL BAT R' CHAIM - לזכר מינדל בת ר' חיים


Abstract: Fibroids can cause abnormal bleeding [1]. This is of particular concern to the halacha observant woman, as it may lead to prolonged intervals of niddah during which all physical contact with her husband is prohibited. It is important to first assure that there are no halachic interventions that can ameliorate the effect of the bleeding on the couple. The patient will want to know about the details of any diagnostic or treatment procedures so she can consult with a rabbi about their effects on her halachic status. If a treatment will lead to prolonged or permanent infertility [2], halachic consultation may be needed.

Discussion: Fibroids (uterine leiomyomas) are a common benign tumor in women with significant direct and indirect health costs [3]. In general, treatment is indicated if they grow large enough to cause pressure on other organs, such as the bladder, grow rapidly, interfere with fertility, or cause abnormal bleeding [2]. Vaginal bleeding raises special concerns in the halacha observant population.

Issues in diagnosis

Commonly used tests are vaginal ultrasound and hysteroscopy. The first does not render a woman niddah. The implications of the latter are subject to halachic debate. Please refer to the article on specific gynecological procedures for more information.

Issues in treatment

If treatment is being considered only because the woman is niddah too long or too often, the first step is to consult with a halachic authority to confirm that there are no halachic interventions that can ameliorate the effect of the bleeding.

At times, contraceptive methods such as combined hormonal contraceptives or hormone-impregnated intra-uterine devices are attempted for management of the heavy bleeding associated with fibroids. At other times, shrinkage is attempted by GnRH agonists (such as leupride) or progesterone receptor modulators such as ulipristal acetate [4]. Rabbinic consultation is advised if the use will be prolonged as these medications affect fertility. If the couple already has a boy and a girl, this will be easier to permit.

There are a number of new modalities being used to decrease the size of fibroids and thus reduce their symptoms. These include uterine artery embolization [5], high frequency ultrasound [6] and microwave ablation [7].

Procedures to destroy the blood supply such uterine artery embolization or laparoscopic uterine artery ligation as do not enter the uterus and thus would not render a woman niddah. Procedures that are done via laparoscope, such myolysis [4], also do not render a woman niddah as the laparoscope is inserted via the abdomen and not the cervix.

When surgical resection is decided upon, rabbinic consultation should be considered to determine optimal timing. There are different opinions as to whether specific gynecological procedures will render a woman niddah. The woman should be provided with information about the procedure so that she can discuss it with her rabbi.

Women will definitely have vaginal bleeding after these procedures. Some authorities rule that bleeding from a uterine cause can render a woman niddah even if it is due to injury. The effects of a hysteroscope (mentioned above) and a resectoscope (a hysteroscope with built in wire loop that can cut through tissue) are similar. A laparoscopy for extramural fibroids does not render a woman niddah, as it does not enter the uterus.

Hysterectomy is a form of sterilization. While it will be permitted to alleviate a woman’s medical suffering, it is particularly important to assure that other methods are considered prior to suggesting this as a cure for fibroids, especially if the main complaint is abnormal bleeding.

Implications for Patient Care: The abnormal bleeding that can result from fibroids is of particular concern to the halacha observant woman. This may lead her to seek treatment earlier than other women.

Halachic consultation should be considered prior to recommending treatment to assure that intervention is in fact needed and to optimize the timing.

Halachic consultation should also be considered prior to procedures that have prolonged or permanent effects on fertility.

Medical References

[1] Van den Bosch T et al .Intra-cavitary uterine pathology in women with abnormal uterine bleeding: a prospective study of 1220 women. Facts Views Vis Obgyn 2015;7:17-24.

[2] Vilos GA et al. The management of uterine leiomyomas. J Obstet Gynaecol Can. 2015 Feb;37(2):157-81.

[3] Soliman AM et al. The direct and indirect costs of uterine fibroid tumors: a systematic review of the literature between 2000 and 2013. ] Am J Obstet Gynecol. 2015 Mar 11. [Epub ahead of print]

[4] Marret H et al.Therapeutic management of uterine fibroid tumors: updated French guidelines. Eur J Obstet Gynecol Reprod Biol. 2012 Dec;165(2):156-64.

[5] Gupta JK, Sinha A, Lumsden MA, Hickey M.
Uterine artery embolization for symptomatic uterine fibroids.
Cochrane Database Syst Rev. 2014 Dec 26;12:CD005073.

[6] Wang W et al. Safety and efficacy of US-guided high-intensity focused ultrasound for treatment of submucosal fibroids. Eur J Radiol. 2014 Dec 15. [Epub ahead of print]

[7] Yang Y et al. Ultrasound-guided percutaneous microwave ablation for submucosal uterine fibroids. J Minim Invasive Gynecol. 2014 May-Jun;21(3):436-41.

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