Caitlin Whyte (Host): Today, we're diving into the critical topic of uterine fibroids and when it's time to seek treatment. Joining us is Dr. Scott Bovelsky, a Board Certified Gynecologist from Health First.

This is Putting Your Health First. I'm your host, Caitlin Whyte. Doctor, thank you so much for joining us today. To start off our conversation, can you tell us what are uterine fibroids and how do they affect a woman's health?

Scott Bovelsky, M.D.: Yes, but thank you very much for having me. Fibroids are a non cancer tumor of the muscle of the uterus. Very common, but doesn't necessarily mean that they cause problems in everybody. But they respond to estrogen, and so as you secrete estrogen, they're going to grow and get bigger and bigger. And they can certainly, over time, cause problems with pelvic pain, heavy bleeding, and sometimes they get quite large, 8 to 10 centimeters, and cause lots of issues. If they're in certain locations, they can also have problems with fertility and ability to get pregnant.

Host: All right. So what are some treatment options and when is surgery then necessary?

Scott Bovelsky, M.D.: So, there are lots of treatment options. The first thing to realize is if they're not bothering you, you don't have to do anything at all. So, one treatment option is do nothing and just watch. If women are having heavy bleeding and pain, it really depends on what their future childbearing desires are. If fibroids are in the muscle of the uterus and not in the cavity, then you really don't have to do anything in terms of pregnancy. It's not going to impact pregnancy at all. If they are poking into the cavity where the egg implants, then sometimes we have to take them out and there's different ways to do that.

If they're entirely in the cavity, we can actually do that with the telescope that goes through the vagina and the uterus and you can shave out the fibroid. And that's a very minimally invasive way to take it out. If women want to preserve their fertility, but their fibroids are quite big, you can have what's called a myomectomy, which just means removal of the fibroid.

And that's a little bit more of an invasive surgical procedure that has recovery and you really have to wait six months to get pregnant after that.

Host: Gotcha. Well, let's dive into that a bit more. How does that myomectomy differ from a hysterectomy? And how do you help patients decide which option is best for them?

Scott Bovelsky, M.D.: So the myomectomy is removing the fibroid by itself. We're leaving the uterus and you go in, I do these robotically, so you go in, have these done, go home the same day, and we literally shell the fibroid out of the muscle of the uterus and then you have to sew the muscle up. So that is a way to preserve fertility and preserve the uterus.

The key thing to remember after having a myomectomy is you have to wait six months before you do get pregnant and you have to have a C-section. And the reason for that is we're cutting into the muscle of the uterus and that's a weak spot, so we don't want your uterus contracting and going into labor.

Now, alternatively, a hysterectomy is removal of the uterus. You will hear this term partial hysterectomy and there's really no such thing. It's more of a layman's term. What people mean is leave your ovaries. So a hysterectomy by itself does not put a woman in menopause. It's only if you take the ovaries out. Now a hysterectomy is a 100 percent fix. So that takes out the fibroids and the uterus. You're never going to have bleeding. You're never going to have more fibroids, but obviously you can't have children. The goal of the physician is to guide the patient into what they want to do. If they want to preserve their fertility, leave the uterus, take the fibroids.

If they're 45 and they have heavy bleeding and pelvic pain and they're done having children, then I recommend hysterectomy because she's never going to have a problem with fibroids in the future. Once you make one fibroid, you'll make another one. So even if I go in when somebody's 25 or 30 and take out a bunch of fibroids, 10 years later they're going to have more fibroids. So once they're done with childbearing, I recommend just taking the uterus out.

Host: Alright, well, for patients struggling with infertility, how can a myomectomy potentially improve their chances of conceiving?

Scott Bovelsky, M.D.: Sure, so there's lots of reasons why women can have infertility, multiple factors. And one of them could be a fibroid, but as I mentioned before, it's really the location. So we call that what's called a submucosal fibroid, and that is a fibroid that is distorting the cavity of the uterus where the egg implants.

So if you have a fibroid that's in the cavity or distorting the cavity, that can prevent the fertilized egg from implanting. And then we would need to remove those fibroids to help with infertility. At the same time, there are a lot of other reasons that women can have infertility. We want to make sure we're not dealing with more than one problem.

If the fibroid is not distorting the cavity or in the cavity, you really do not have to have them removed from a fertility standpoint.

Host: Well, would you tell us more about what a robotic myomectomy is and how does it differ from traditional surgical techniques?

Scott Bovelsky, M.D.: So when I was in training, 20, 25 years ago, a lot of these surgeries were done open, meaning you had a C-section type incision or even an up and down incision through your belly button. And you actually had to pull the uterus out and shell out the fibroids, sew the uterus back, put it back in.

That's quite an invasive procedure. You'd be in the hospital two to three days, much longer recovery with significant pain. We now can do them laparoscopically. And that is, making small little incisions in your belly, approximately eight millimeters, blowing your belly up with gas, it makes a pocket and we can use the laparoscopic instruments to take the fibroids out.

Traditional non robotic laparoscopy is much harder to do for myomectomies. When you add robotic surgery, it's almost like having many little hands inside a person's abdomen. It makes taking a fibroid out minimally invasive much easier. And the benefit is women can go in and have this done, go home the same day and their pain control, return to work, overall recovery is much quicker with a robotic myomectomy than with an open myomectomy.

Host: And to continue that thought, what are the main advantages of robotic assisted myomectomy for patients compared to again, those traditional approaches?

Scott Bovelsky, M.D.: So the main benefit is recovery, pain control. Typically people who have an open myomectomy or an open hysterectomy end up on a pain pump overnight. They have a catheter in their bladder until the next morning. It's become an outpatient procedure. And you can sew easily with the robot, so it's much easier to sew the uterus closed.

It's just the overall recovery is the main benefit. Anytime you can convert an open procedure to a minimally invasive procedure, patients do well. It's less blood loss, less complications in terms of readmission or infection rates. So it's just overall better for everybody.

Host: And how has the use of that robotic technology transformed your ability to handle more complex or challenging cases?

Scott Bovelsky, M.D.: It's completely transformed it. You know, I've been doing robotic surgery for the past 15 years and it now allows me to do these much more complicated cases, including myomectomies and endometriosis resection, minimally invasive. These were cases you just could not do well laparoscopically. You couldn't get into the right plane to see things, the camera shakes and it was the visualization was horrible. This has improved and in my mind has completely transformed minimally invasive surgery.

It really allows me to do much more complex cases through the laparoscopes with better recovery. Whereas people that are not robotically trained, and this is my opinion; a lot of times have to open these cases. The other thing to remember is when somebody starts a case minimally invasive, there is a what's called a conversion rate.

So the idea you start with a laparoscopic surgery and you get in there and you just can't do it and you have to convert to an open. Robotic surgery conversion rates are very low. My conversion rate is less than one percent. So it's 99 percent chance if we think we're going to go in and do robotic minimally invasive surgery, that that's what you're going to get.

Host: Well, what can patients expect during the recovery process after a robotic myomectomy? And how does the recovery timeline compare to traditional surgery?

Scott Bovelsky, M.D.: Again, the main thing is going home the same day. That's huge. Pain control is usually not a problem, with minimally invasive surgery. You go home on medicines by mouth. I actually have some women that don't even take narcotics and they just take ibuprofens. They're up walking around that day, they're doing their normal daily things.

You know, they're not going to be able to do any super heavy lifting or strenuous for at least a couple weeks; but in terms of getting up, moving around, I tell them they should just be a professional couch potato for a few days. Hang out on the couch, get up, move around, do their things, but not do heavy lifting.

With an open surgery, you're really out for four weeks and total recovery is really six weeks, so it can be very impactful. People are in the hospital for two, three days. Even when they get home, they kind of struggle with pain control, can't move around too much. So the minimally invasive surgery really allows them to go home the same day, recover quicker, and have to use less pain medicine.

Host: And just to wrap up our conversation here today, Doctor, we touched on it a bit already, but how do you decide if a patient is a good candidate for a myomectomy versus other treatment options?

Scott Bovelsky, M.D.: So there are other treatment options for fibroids. So there are medical treatments, so there are some medicines we can put people on that help shrink the fibroids. The problem with that is you can only use them for two years, so it really depends on the patient's age. If they're close to menopause, we might be able to use that to kind of buy them time until they get through menopause, and then the fibroids are not an issue because you're not bleeding and they shrink.

There are ways we can control bleeding non surgically, but that doesn't impact the fibroids. So I always recommend people go from a minimally invasive to a more invasive procedure. So depending on each woman's symptoms depends on the approach. If the fibroids are small, then maybe we can get away with medical treatment.

If they're really large and she's having heavy bleeding and her blood counts and she's anemic so her blood counts are low; then sometimes surgical option is really what you need to do. And in my opinion, if you're going to have a myomectomy surgery, it should be minimally invasive. Very rarely does a myomectomy surgery have to be done open.

I've had a few occasions where they're so large that you cannot even get the camera in and see anything. Those have to still be open. But I would say in this day and age, 90 percent of myomectomies should be done minimally invasive.

Host: Thank you, Dr. Bovelsky for sharing your insights and helping us understand the treatment options available. Remember, understanding your health is the first step to taking control of it. If you have any concerns or suspect that you might have uterine fibroids, it's crucial to consult with a gynecologist to explore the best treatment path for you. For more information, visit hf.org/women'shealth. Don't forget to follow us on Facebook and Twitter to stay informed about upcoming health topics.