Jamie Lewis (Host): Many of us have heard about fibroids, but we don't know much or anything about them. And many more of us actually have fibroids, but have no idea what they mean for our reproductive health. We set out to learn what fibroids are, which symptoms to look for and available treatment options with Dr. Imad Mufarrij, Director of OB-GYN Education at Holy Cross Hospital.

Host: This is your Best Life Podcast, women's health from Holy Cross Hospital. I'm Jamie Lewis. Dr. Mufarrij, thank you for being here today.

Imad Mufarrij, MD: Thank you for having me. Nice meeting you.

Host: So, your expertise is in advanced and minimally invasive surgery like laparoscopy and hysteroscopy, so I'd imagine you can tell us quite a bit about fibroids. So, what are fibroids and what are their main causes?

Imad Mufarrij, MD: Well, fibroids are essentially smooth muscle tumors in the body of the uterus, and they arise in different locations. And by definition, if they're true fibroids, they're not cancerous. They're just like muscular tumors. Most of them will look spherical like a ball, and they vary in size from a small pellet to literally the size of a small or even a large melon. They can appear in different locations. And the locations can vary from hanging out of the uterus like a fruit on a stalk to hanging inside the uterus, again, like a fruit on a stalk or bulging through the wall of the uterus outside externally, but still incorporated as part of the main body of the uterus or bulging inward into the cavity of the uterus, what we call the endometrial cavity, but still mostly as part of the uterine muscles. And finally, the last location could be inside, totally engulfed inside the muscle of the uterus. These are the majority of fibroid locations and types. And once in a while, there's an exception for fibroids appearing in the lower portion of the uterus, like in the cervix. And that would be called a cervical fibroid. So, these are the different locations of fibroids. And of course, locations are significant because they can affect symptoms, they can affect complications caused by fibroids. And we'll get to that, you know, in a little.

Host: Yes. So, what about their main causes? What causes these to form?

Imad Mufarrij, MD: We don't understand the exact cause, except we do know that there is a genetic factor and that they do tend to have also a racial factor. For instance, fibroids are more common among black women, African-American women than among white women. There's a considerable difference, and they seem to appear again in the premenopausal age before the menopause for the vast majority of fibroids.

Host: Okay. Let's talk about treatment options then. Which treatments are available for fibroids?

Imad Mufarrij, MD: Well, there are many treatments and the choices are a little complicated because they depend on what we are trying to accomplish. For instance, if a woman has fibroids causing major problems, she's through having children, then the treatments could be something as drastic as removing the uterus or still as occluding the blood flow to the uterus, therefore shrinking the fibroids and getting rid of their symptoms. These would be the options around the time of menopause or shortly before in a patient who's decided that she desires no more children.

It gets more complicated when it's in the earlier phase of life, when the patient still has childbearing plans and where these fibroids are causing problems. And the treatments here would include certain medications that could shrink the fibroids or certain medications that would lower the impact of fibroids on the lining of the womb, the endometrium; therefore, reducing blood loss, saving her recurrent transfusions and other potential complications, at the same time saving the uterus.

And in between is, again, the final option for this, which is surgical, i.e., removing the fibroids. And of course, removing the fibroids has many options within that category. So, removing fibroids would depend on the location of the fibroid among other things. So if the fibroid is mostly inside the endometrial cavity, i.e., inside the cavity of the womb, then the most likely option for the vast majority of them would be to insert a telescope inside the uterus and locate the fibroid and then remove it with surgical excision, typically using some energy form, either electrical or sound energy. If the fibroid is hanging outside the uterus into the abdominal cavity, then it's approached abdominally. And the minimally invasive options include laparoscopy as one option or robotic surgery as another option. And that would allow for the removal of the fibroids. Of course, there are other variables such as the size of the fibroids. If they're tremendous, that may cause certain surgical implications and may require even a traditional open surgery where the abdominal cavity is entered via a large open incision, and the fibroid or fibroids are then removed one by one.

Now, the more difficult ones are the ones that are in locations that could pose certain potential complication, risks. One of them is if the fibroid is sitting near the tubes, the fallopian tubes, where the egg enters the uterus to get fertilized by the sperm and to allow for the patient to get pregnant. The other location would be inside the cervix, where if it is inside the cervix, it could be impinging on the urinary flow into the kidney, i.e., affecting the ureters. Therefore, the surgery there could lead to damage of the ureters and, therefore, could harm the kidneys. Of course, this also would be a potential risk to the bladder as well as the vaginal vault if the fibroid is large. Removing it there could affect bladder function as well as vaginal function. So, all these are potential considerations when we're talking about removing fibroids.

The approach has to be first looked at from a general point of view of the patient's general health; two, the problems the fibroids are causing; three, the patient's future plans, i.e., does she plan childbirth or not. Because again, if she's still planning to have children, we would like to offer every conservative option possible, rather than going to the more drastic options of removing the uterus. So in between these, there are options, medications that would help shrink the fibroids. And there are some surgical techniques that could target the fibroids and shrink them. But again, those will depend on the size and location. Enormous fibroids cannot be handled by energy shrinking. And by the way, some of these procedures are not approved yet in the United States, but they are available in parts of Europe, and one I believe is available in China. I think we will have them in the near future and they'll become available.

Host: That's so interesting. You've touched on fertility and I was going to ask you anyway, for those of us who are looking to conceive, do fibroids affect fertility?

Imad Mufarrij, MD: Yes. They can affect fertility in several ways. Number one, they can interfere with the implantation of the embryo, i.e., if the fibroid is sitting inside the cavity of the womb, of the uterus. And again, given it's of a certain size, it can prevent the embryo from attaching itself to the wall of the endometrial cavity. And therefore, it would lead to either lack of pregnancy or recurrent pregnancy failure. So, that's one.

The other one could be that they could interfere with the function of the tubes if the fibroids are sitting in the upper part of the uterus and causing enough narrowing or even closure of the tubal openings; therefore, preventing, as we said earlier, the egg from moving inward to get fertilized, and that would be a cause for infertility.

Host: So, I know that there are a lot of variables in considering this, but what happens if fibroids go untreated?

Imad Mufarrij, MD: It depends. Typically, fibroids will grow before the end of a woman's hormonal cycle, i.e., before the menopause. The growth rate is not predictable. It is variable. So if they go untreated, they will grow, they will continue to cause symptoms, be it bleeding, pain, pressure or all of the above. And again, depending on the size, there are fibroids that fill the whole abdo abdominal cavity. Fortunately, that's not a very common event in a woman who gets, you know, routine evaluation, because it is intercepted in an earlier phase. But if they get to be that big, then certainly even bowel dysfunction becomes an issue as these fibroids sit on the intestines and interfere with mobility of the intestines. And it'll give a feeling of abdominal pressure and discomfort and eventually pain. So, that's one.

Now, the other problems they may cause would include pain from the fibroid itself, especially if it grows fast and then overgrows its blood supply. There could be some element of infarction and, therefore, the fibroids may somewhat degenerate by their own action, therefore causing pain. And then of course, the main problem we encounter with fibroids is bleeding. And bleeding is a function of location, of size and general other health situations that the patient has. For instance, if the fibroid is sitting inside the cavity, inside the womb, bulging into the cavity, a small fibroid can cause considerably more bleeding than one that's sitting out outside the womb, like hanging from a stalk like what we call a pedunculated fibroid or one that's part of the wall of the uterus, but it's mostly bulging outward into the abdominal cavity. So again, the variables that enter this formula would be size and location and, of course, rate of growth because some of them will remain for years and either not grow much or grow very slowly and others will grow faster.

And of course, one little note here, rapidly growing fibroids should alert the patient and, of course, the caregiver to the fact that, number one, there could be a pregnancy that causes a rapid expansion of the womb and the fibroids. And the other thing is an entity that presents itself sort of like a fibroid, but is a completely malicious entity, and that would be a cancer that we call leiomyosarcoma. And that is one that one should be aware of if there is rapid growth and pain. Having said that, most of these occur in the menopause. So again, you don't have to distinguish between pregnancy and a tumor when this is occurring in a 55-year-old, let's say.

Host: Now, if a patient is able to have fibroids removed, what is the chance that they would return?

Imad Mufarrij, MD: Well, the fibroid itself will not return because it's removed. Unless it was partially removed, then the leftover portion may grow, but the uterus may produce more fibroids. And of course, it is a function, again, mostly of age because most of these fibroids are removed in women in the mid to later years of reproductive life, after which menopause kicks in and, therefore, becomes much less likely for new fibroids to form.

Host: Okay. So if a woman does need surgery for fibroids, what does her recovery look like?

Imad Mufarrij, MD: Great question. And the recovery will depend on the fibroid's location and size. For instance, if we are removing a relatively small fibroid inside the cavity of the womb that is causing a lot of bleeding. Then, there's virtually no recovery. This can be removed hysteroscopically with the telescope inserted through the vagina into the cervix and the cavity of the uterus and can be removed, again, in a very non-invasive way. Patient goes home the same day and there's really no recovery time except for a day or two of rest. Of course, we always advise that pregnancy should not be attempted in the near future after these surgeries.

Now, if the fibroids are approached abdominally with a laparoscope or with a robot technique, then it will require longer recovery. But again, recovery will depend on the overall, of course, patient's health, but also on the amount of surgery, the duration of the surgery, the scarring that results from this surgery, as well as the blood loss. So if the fibroids removed were substantial, then the recovery could be a matter of a few weeks. If the fibroids could not be removed with the minimally invasive methods, that is if we ended up having to do an open procedure, then the recovery would be considerably long, and we're talking about one to two months, depending on the size of the incision and the location of the incision.

Host: Well, thank you, Dr. Mufarrij, for pulling back the veil on fibroids and how we can educate ourselves and get treated for them. It's been really helpful.

Imad Mufarrij, MD: Thank you.

Host: We've been speaking with Dr. Imad Mufarrij, who serves as the OB-GYN Clerkship and Education Director at Holy Cross Hospital. To learn more about fibroid treatment, visit holycrosshospital.org/maternity. This has been Your Best Life Podcast, women's health from Holy Cross Hospital. I'm Jamie Lewis.