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Saving the Uterus: Alternatives to Hysterectomy for Women Suffering From Fibroids

Scott Chudnoff, MD (Guest): Fibroids grow in the uterus, and they're quite common. So common that 80% of women will develop fibroids by age 50. Fibroids are usually benign, but often they do need to be treated. So today we'll discuss the latest minimally invasive treatments with Dr. Scott Chudnoff. Dr. Chudnoff is Chair of Obstetrics and Gynecology at Maimonides Medical Center. This is MAIMO Med Talk. I'm Amanda Wilde. Dr. Chudnoff, thank you so much for being here today.

Thank you, Amanda. It's my pleasure to be able to be here.

Host: I read that you were born at Maimonides Medical Center in 1973, and now that baby that you were is heading up the baby department at Maimonides, right?

Guest: That's true. Yes. It actually was very exciting for me to be able to come back to the same place that I was born at and that took care of my mother and so many of my family members, so well.

Host: Well, I'm sure a lot has changed in the world of OBGYN since 1973. So I want to start with what we need to know about fibroids. What causes fibroids?

Guest: So we're not a hundred percent sure about why people get fibroids. We do know that there's some genetic predispositions that some people may have to the development of fibroids. However, we still do not know the exact reason why one woman will and another woman won't develop them. We do know, like I said, that there are genetics at play, but there are also some environmental factors that probably play into it as well.

The interesting thing about fibroids for me is that it is such a common condition, but despite that, there really has been a pausity of research until very recently regarding fibroids and various fibroid treatment options.

Host: Why do you think that is?

Guest: Well, I don't want to get overly political, but, I think that in a lot of areas of women's health, unfortunately, there hasn't been such a large focus. And additionally, I think historically when it came to fibroids in particular, there was this expectation that there is a treatment available, known as a hysterectomy, where you would remove the entire uterus and therefore the woman would no longer have fibroids.

And if I can give a little historical context on this, you know, the idea of a hysterectomy was something that in medicine was something that for a very long time people were trying to accomplish. Back in the times of Hippocrates when they first identified the uterus, he identified the uterus as an organ that traveled around the body causing trouble in various places and locations, and created a condition known as hysteria.

And the ideal treatment for that hysteria had been to do a hysterectomy to remove the hystero, which is the uterus from the woman. And for centuries, the goal was trying to figure out a way on how can we remove a uterus that causes all these problems for the woman, without endangering the woman in the process.

And it was only a couple of hundred years ago that the first successful hysterectomies were ever performed, where the woman at the time did not die as a result of the surgery.

Host: So there can still be a lot of side effects from removal of the uterus today.

Guest: There's tremendous amounts of side effects that can exist from it, not just from the surgery itself, where there are all the risks of the operation itself, but also post-surgical risks relating to scarring and pain, to prolapse where the vagina or the cervix, if it's left behind, could be falling down. There's a whole slew of complications that can happen as a result of a hysterectomy.

Host: So sometimes the solution causes other problems. So you are a specialist in the newest, minimally invasive techniques. I want to talk about those, but first of all, what are those fibroids? I've read their tumors. They're growths of some kind. How do they happen?

Guest: So fibroids are benign tumors that grow inside the uterus itself. The tumors will pop up in various places in the uterus. They could be located anywhere, whether it be on the inside of the uterus, the inside cavity of the uterus itself, in the walls of the uterus, or hanging off the outside of the uterus. And fibroids can come in all different types of shapes and sizes.

There really is no rhyme or reason as to why someone may get one or multiple or the size of those fibroids, but we do know that the fibroids that tend to be located towards the center of the uterus and in the cavity of the uterus tend to cause the most problems for women.

Host: So you can't take preventive measures against fibroids forming in the first place, are there symptoms that come with fibroids, especially the ones you were just talking about that are in the center of the uterus, or is it possible to have these fibroid growths without even knowing that?

Guest: So many women never realized that they had fibroids growing and as a matter of fact, the majority of women probably who have grown fibroids never had any symptoms that rose to the level of investigation for people to see whether they did or didn't have fibroids. But for many women who have fibroids, they suffer from a variety of conditions. It could be anything from abnormal uterine bleeding, heavy menstrual cycles, irregular menstrual cycles, pelvic pain, urinary symptoms, sexual dysfunction, infertility are all many of the conditions that can be the result of a woman having fibroids.

Host: So that's when fibroids really become an issue. Under what circumstances do those fibroids then need to be removed?

Guest: Well, a lot of it will depend on the symptoms that the patient has. And I also want to caution the use of the word removal because we have so many treatment options today that are available that don't necessarily require removal, but can actually directly treat the fibroids themselves.

Host: Dr. Chudnoff, can you describe some of these newer treatment options?

Guest: So when I think about different treatment options, I like to break it up into the medical options and the surgical slash procedural options that exist, for treatment of fibroids. And historically, most of the treatments that were medical were focused primarily on treating the symptoms related to fibroids, the most common one being abnormal bleeding.

And so most of what we used to use, for treatment of fibroids, and we still use it in some minor cases, are things like birth control pills, or other types of contraceptive hormones to help control the bleeding symptoms. However, there are other options which have come out even just for treatment of symptoms alone. One of those is called tranexamic acid, which also can help to reduce the amount of bleeding that somebody has. However, none of these treatments directly treat the underlying cause, which is the fibroids themselves. Recently there's been the development of new medical options for the treatment of fibroids.

Previous treatment that was medical, specifically geared for the treatment of fibroids was something called a GnRH agonist. And what that medicine did was it allowed the entire body to go into a quasi menopausal state. The reason why that's important is because fibroids will only grow when a woman is before menopause.

Once a woman is in menopause, fibroids will stop growing and will actually shrink down in size. And so what we used to do sometimes, especially when a woman was close to menopause, is we would give one of these types of medicines, the GnRH agonist. And what that would do is it would allow to bridge to get a woman from before menopause, till after menopause, and to help to treat her symptoms and to allow the fibroids to shrink in size. Recently there's a new class of medicine known as the GnRH antagonist, which compared to the other medicines, allow to be taken orally. Previously the GnRH agonist required an injection, so it's a much more tolerable medicine.

Additionally, it includes hormones attached to it. So what it does is it reduces the amount of side effects that women would have as a result of those hormones. But again, the problem with all of the medical options as they exist, are that they're only effective during the time of treatment and when you stop the medicine, if a woman is not in menopause, those fibroids will regrow and come back again. So there have been other options now which have been created, directing specifically at the fibroids themselves. As I mentioned before, hysterectomy, where we cut out the entire uterus is something which obviously, if there's no uterus, there'll be no more fibroids, but is an incredibly invasive type of procedure. But on the less invasive options of what we have, there are three new types of treatments.

One is known as radiofrequency ablation of fibroids, and what this does is it allows us to take a needle. We insert the needle into the fibroid, and that needle could be inserted, either laparoscopically through the belly itself, or now we have another method where we can do it through the vagina. So it requires absolutely no cuts at all, and that needle is inserted into the fibroid. And that allows us to be able to destroy the fibroid, to allow the fibroids to shrink in size and to improve the symptoms.

Another option which exists is known as uterine artery embolization, and this is typically done by interventional radiologists where they thread a catheter into the artery which feeds the uterus and they block the artery that feeds the uterus in the fibroids. If you could imagine a heart attack, it's like a uterus attack. By reducing the blood going to the fibroids, it will cause them to shrink down in size as well.

And the third new option that's out there is something called an MRI guided, high frequency focused ultrasound ablation. That's a mouthful and it's abbreviated as HIFU. And what this does is a woman sits inside an MRI machine and they zap ultrasound waves into the fibroid similarly, to try to destroy the fibroid. The advantage to that procedure is that there are no incisions made whatsoever.

Aside from those new treatment options, if a fibroid is located in the center of the uterus, in the cavity of the uterus, a treatment which has been around for some time but has been advanced recently is something known as hysteroscopic fibroid resection, where we can use a special camera that goes into the uterus through the vagina without any incisions. And we can shave the fibroid out from the inside out. But that only works for fibroids, which are located in the cavity itself in some fashion.

And then the other treatment, which has been around for some time, is known as a myomectomy. A myomectomy is where we just cut the fibroids out from the uterus. And then sew the uterus back together. The major advancements that have been made to myomectomies, particularly with robotic surgery is the ability to do it in a much more minimally invasive surgical approach.

Host: These treatments you're describing sound much more precise and light years beyond hysterectomy. Are they permanent and how effective are they?

Guest: So the only permanent treatment for fibroids is a hysterectomy because as long as the uterus is in place, fibroids can always regrow. In the procedures where we do destruction of the fibroids, there is a chance that those fibroids may recur. But even when we cut the fibroids physically out with a myomectomy, there's up to a 50% chance that those fibroids will grow again in the future, depending on the age of the woman and how close she is to menopause,

Host: So far, since these are newer treatments, what is their effectiveness that you've seen?

Guest: So what I've seen is significant improvements for most women in regards to their overall symptoms. We see a reduction in the size of the fibroids, usually about a 50% reduction in the volume size of a fibroid. And usually within the first three months of those less invasive treatments, whether it be the radiofrequency ablation, the HIFU or the uterine artery embolization, usually fairly rapidly, we start to see that improvement within the first few months.

Host: So when should women see a doctor about fibroids?

Guest: Well, anytime somebody is suffering from any types of discomfort in the pelvic area, if they're having abnormalities to their menstrual cycles, if they're experiencing infertility or if they're having urinary symptoms, all of those things could be related to fibroids and warrant being seen by a doctor just to evaluate and to see whether or not fibroids are present.

Host: So any discomfort, you really should see a doctor and get that diagnosed, see where that discomfort's really coming from?

Guest: Yeah. I will say that the number one treatment right now for fibroids is to do nothing. And that's because most women either ignore the symptoms that they have, or if they're even aware of the fact that they have fibroids, are unfamiliar with these other treatment options, and decide to choose to be what we call the silent sufferers.

Host: And what would be the outcome of not getting those fibroids treated?

Guest: Well, in general, there could always be a progression of the size of the fibroids and an increase in the level of symptoms. I've had women who have had fibroids that were so large, it looked like that they were pregnant with triplets, it's horrible. I have one patient of mine, who again, protecting her own rights, but is a CEO of a corporation. And when she came in to see me, she was in tears because at her last board meeting, she had completely soaked through her clothing because of the heavy bleeding she was having and had to wait for the room to clear before she felt comfortable even getting out of her seat.

Host: So it can really interfere with your life.

Guest: Many women with fibroids really have serious impacts in terms of their normal daily function. I have women who say that when they are on their period, basically they stay home.

Host: So we don't want to have to undergo treatment, but the main thing is to find out what's going on if you have pain, and then if fibroids do need to be treated you have described some really, great treatment options that don't include invading and just pulling out the uterus so it sounds much more specific now and much more individualized as far as the treatment goes.

Guest: Yes. And that's really the key. If someone is seeing a physician and they feel that they are not hearing what they want in regards to the types of options, they should definitely go and seek out a second opinion as well, because there are constantly new advances that are happening right now.

We here at Maimonides are actually in the process of studying a whole nother new treatment option for fibroids that's never been done before. And we've been leading quite a few clinical trials, specifically at trying to find alternative options. The treatments are not a one size fits all and I think the key is what you said, Amanda, it's about individualizing it specifically to what the patient's needs are.

Host: Well, Dr. Chudnoff, thank you for sharing your expertise today and the advancements that you're making and continue to make in treating uterine fibroids.

Guest: Well, thank you. I appreciate the opportunity to be here with you.

Host: That was Dr. Scott Chudnoff, OBGYN Chair of Obstetrics and Gynecology at Maimonides Medical Center. To make an appointment, call 718-283-9044 or visit maimo.org. This has been Maimo Med Talk. I'm Amanda Wilde. Be well.