Transcription:
Parts and Labor: Symptoms and Management of Uterine Fibroids

Melanie Cole: This is Better Edge, a Northwestern Medicine Podcast for Physicians. This episode is part of a Better Edge mini series

Dr. Angela Chaudhari: Welcome to Parts and Labor, a round table discussion with the OB GYN experts here at Northwestern Medicine. My name is Angela Chaudhari and I'm a minimally invasive gynecologic surgeon here at Northwestern Medicine. I have the opportunity to serve as the chief of gynecology and gynecologic surgery, but today I will be your host discussing a very common disease, uterine fibroids, that impact so many people's lives.

Our panel today are my very own and very esteemed gynecologic surgical colleagues. First off Dr. Magdy Milad, the Albert B Derby professor of obstetrics and gynecology and the division chief of minimally invasive gynecologic surgery here at Northwestern Medicine. He also serves as the medical director of the center for complex gynecology. He's board certified in reproductive endocrinology, and infertility with a focus practice designation in minimally invasive gynecologic surgery or makes.

Next up Dr. Susan Tsai, a board certified and fellowship trained gynecologic surgeon, associate professor, and the associate program director of our fellowship in MIGS here at Northwestern. And last, but certainly not least Dr. Linda Yang, a fellowship trained minimally invasive surgeon. Associate professor and assistant program director of our fellowship in MIGS here at Northwestern. Now this topic is very dear to my heart, and I know to all of my panelists as well, because we have the opportunity to discuss a disease that afflicts so many of our patients every day. So I'd love to start with Dr. Yang. How common are uterine fibroids?

Dr. Linda Yang: Well, I'll first start by saying that uterine fibroids are extremely common. And I think that often the patients that we see are very scared and nervous. Because they feel like they're the only patients who are affected by such a common condition. So I feel like it's important to share with them facts about uterine fibroids, including how common they actually are. The numbers vary. However, we think that certainly over 50% of women over their lifetime may have uterine fibroid.

Dr. Angela Chaudhari: So 50%. of women. And my understanding is it's even greater for our African American population. Is that true? How common are fibroids in the African American population?

Dr. Linda Yang: So we think that due to various factors, but certainly in terms of race and ethnicity, that certain populations are affected more greatly. So upwards. Up to 80%, I believe are affected.

Dr. Angela Chaudhari: The next question. I I'm certain, our listeners wanna know is really why are fibroids so common? What causes fibroids, Dr. Milad as our reproductive endocrinologist. Can you share some of the background of uterine fibroids?

Dr. Magdy Milad: Well, fibroids are, as you've mentioned, extremely common and in reproductive age women. So we know that reproductive hormones must play a role in it, whether it's estrogen or progesterone. You almost never see fibroids in girls under menarchy. And it's unheard of almost unheard of to see fibroids after menopause. And we don't see them in men, but there's obviously other factors that may play a role in it.

Maybe environmental factors and growth factors oxidative stress may be associated with it. Hypoxia may be associated with it. So it's not absolutely clear that although there does seem to be a common denominator associated with DNA methylation profile and how that may precipitate smooth muscle proliferation into this monoclonal tumor.

Dr. Angela Chaudhari: So it sounds like an excess of tissue growth overall is what we're talking about. That's really very hormonally, mediated, estrogen, and progesterone. And we're not gonna get in too much into the treatment, but what does that mean for women who are trying to get pregnant? Will their fibroids grow? Will they cause problems?

Dr. Magdy Milad: Well, I think that's a very complex question to ask actually, because you'd think, right. You'd think that if estrogen progesterone are the central mediators of alone of fibroid growth, you'd see significant growth during pregnancy. And yet that hasn't really been well documented. You'd think that if estrogen progesterone were the sole factor of causing fibroids to grow that women that were on birth control pills would be at higher risk. They don't seem to be. Similarly for IUDs.

There's actually a modest reduction in fibroids in some papers associated with a progesterone IUD. So I don't know if there's really like a obvious answer to that question. All we know is that not only is estrogen and progesterone related, but there are many other factors that are related to fibroids.

Dr. Angela Chaudhari: Yeah. I think what our listeners probably wanna hear is what are the symptoms of uterine fibroids? How can they go about diagnosing them? Dr. Tsai, can you share with us, cuz I know you take care of so many fibroid patients. What are the most common symptoms that we see?

Dr. Susan Tsai: A lot of the symptoms related to fibroids can be bleeding. So abnormal bleeding, bleeding between he cycles bleeding after intercourse, but they can have bulk symptoms which are like pressure symptoms, pressure, heaviness, discomfort, difficulty with urination and complete emptying and potentially painful intercourse symptoms really vary depending on the location of fibroids. Fibroids that are close and impacting the endometrium might cause more bleeding issues. Fibers are closer to the surface might cause more of those pressure, heaviness, discomfort symptoms.

Additionally fibers also can impact fertility depending also on location. The ones that impact fertility the most seem to be the ones that are part of the endometrium, where the period is coming from. And that might result in difficulty with implantation or implantation in the wrong spot that might result in miscarriage.

Dr. Angela Chaudhari: Fertility is such an important question for patients and, you know, I feel like historically when we were training and in medical school, we thought about fibroids as a disease of women in their mid to late forties. It was something where it caused abnormal bleeding. As we got closer to menopause, Dr. Milad as a fertility expert, can you talk about what you really think the impact of fibroids are on women's fertility?

Dr. Magdy Milad: Certainly the location of the fibroids has a significant impact on whether there's gonna be a fertility factor or not. And it's estimated that up to 10% of women that are presenting to an infertility practice may have a uterine factor specifically, typically a fibroids. The larger the fibroid, the more likely the infertility. So a fibroid that's half a centimeter that's in the cavity of the uterus may have less of an impact than a fibroid that's larger than two centimeters. Although even polyps have been thought to cause infertility.

Separate from the whole question of mechanical disruption of implantation. There's been a lot of theories about whether the presence of fibroids may change endometrial environment and its receptivity. There's a lot of research that's sort of looking into that. Fibers that are in the wall of the uterus don't seem to have an impact despite, decades of research looking at this question. So certainly fibers that are less than four centimeters that are in the wall, less likely to cause infertility or be related to infertility. And certainly operating on those types of patients probably does not have improve their outcome.

Dr. Angela Chaudhari: So do any of you have a patient that you can talk about that really sort of stuck with you, a patient with uterine fibroids who came to you and had some of the worst symptoms you've ever seen? I'd love to hear some of those stories, because I think our listeners out in the community who are caring for patients every day probably hear about, for example, abnormal, uterine bleeding, or I'm having some pelvic pressure. And so often we just blame that on age, or we blame that on the fact that maybe there's changes after pregnancy and sometimes people don't really recognize what all those symptoms can be. Dr. Yang, do you have a patient in mind?

Dr. Linda Yang: I actually do. So one of my recent patients reported that she had been over probably a couple of years having, you know, worsening symptoms. Heavier menstrual periods. Also, worsening discomfort in her pelvic regions. And although she had reported these symptoms to her physicians, the sort of treatment plan had consisted of monitoring her symptoms and initial imaging. She did have some fibroids that were diagnosed on ultrasound. And I think that she subsequently developed, you know, worsening symptoms that ultimately led to more acute pain episodes and that's how we kind of met.

And so, for this particular patient, I think explaining to her that her symptoms were likely due to the fibroids, was reassuring to her because she finally had an explanation in terms of why she was having these symptoms that were quite debilitating in nature. Once we discussed the findings of her imaging, we sat together, talked through a comprehensive treatment plan and ultimately she elected to have a fertility sparing surgery. Consisting of a myectomy to remove the fibroids and postoperatively. She did wonderfully and had excellent symptom resolution.

Dr. Angela Chaudhari: So it sounds like when she was being seen by her primary care physician, she had a lot of complaints for a long time. Would you say that ultrasound would be the first step that you would recommend for our primary care docs looking to diagnose fibroids?

Dr. Linda Yang: Pelvic ultrasound is definitely the first line imaging modality that is recommended for evaluation of patients of reproductive age, who present with abnormal menstrual symptoms or pelvic pain symptoms.

Dr. Angela Chaudhari: What about pelvic exams? I mean, that's what we all learned in medical school. Right? You start with a pelvic exam. Does that work? What do you think Dr. Tsai?

Dr. Susan Tsai: I still think it does. And I think there's some merit to doing a pelvic exam. Oftentimes people do get diagnosed, not necessarily per se a hundred percent for fibroids, but they go to see their gynecologist for the routine annual exam. And lo and behold, oh, something feels different, right? Something feels larger. And so that can be our first line to say, we need to take a better look at this. And that's where ultrasound can help us. Whether or not that's gonna be a fibroids or some other pathology. That's what we now need to figure out. So pelvic exam, I think is a great start and then imaging after that.

Dr. Angela Chaudhari: And so pelvic exam, if patients are having pressure symptoms or bleeding symptoms, any other tests that you guys really recommend that our primary care doctors do, Dr. Milad?

Dr. Magdy Milad: Certainly. In patients that have fibroids that are larger than let's say 12 week size or for 14 week size, ultrasound oftentimes can be inaccurate because it just doesn't have the focal depth to be able to identify and locate and measure fibroids. So commonly in our practice at the center for complex gynecology, MRI is of central importance because not only do MRI tell you the number of fibroids, the location of the fibroids, the size of the fibroids, but also it tells you some information about whether they're degenerating or not. And it also can give you information about the presence of adenomyosis or adenomas, which ultrasound isn't quite as sensitive to. And also the presence of endometriosis, which has symptoms that are very similar to patients that have fibroids with regards to pelvic pain.

Dr. Angela Chaudhari: MRI sounds like a great modality. Would you recommend that our primary care doctors, our gynecologists jump straight to MRI?

Dr. Magdy Milad: No. I think patients, if they have symptoms associated with fibroids and are suspected to have fibroids would undergo an ultrasound first and maybe use MRI as a role in better understanding fibroids in a specialty setting.

Dr. Angela Chaudhari: Yeah. I love that idea of let's start with blood counts and an ultrasound imaging, but also letting patients know that sometimes there is a need for more imaging that we need more information to really treat the problem as a whole. As we start thinking more about this. We think about this patient that Dr. Yang brought up, a patient who really suffered from bleeding for a long time. I'd love to hear everyone's thoughts about how you really think this is impacting our individual patients, and women in society as a whole? Dr. Tsai?

Dr. Susan Tsai: Many women undergo pain and suffering from their fibroids and as a result, their quality of life, not only at home orally at work are completely affected. It's not something that they often wanna talk about. And so we as physicians really need to ask these questions to determine whether or not they're pain or their bleeding is really affecting their lives. And from there delve into what potentially is causing those issues. It's just not something that's commonly discussed. And we really need to pull that information out from the patients.

Dr. Angela Chaudhari: Dr. Yang?

Dr. Linda Yang: I would like to also echo those same thoughts as Dr. Tsai, I think that the impact from a wellbeing point of view, but also physical and certainly financial point of view, in terms of the financial burden, that results from women who suffer from fibroid symptoms is immense. Related to inability to work or to provide care for their family. So when patients come to us, I. Um, our duty and responsibility to really address all the, not only the fibroid symptoms, but how it may impact their lives.

When I ask patients about their symptoms, I often ask them how much they bleed, how often they bleed. I hear so much from patients. And it's amazing to me that women have to go to work and experience this, how they would have a heavy cycle and have an accident at work, and they're in their place of work and need to rush to the bathroom and how embarrassing that is. And I think that probably plays into this whole idea that women just don't speak about what's going on.

They hide it. And so, part of the discussion today that I really wanted to get out there was, this is so impactful to our patients. And so many times they're too embarrassed to share with us what all those symptoms are. And we, as surgeons can obviously help them from a treatment standpoint, but it's really our colleagues out in the community that can really help address this and begin to start treating them prior to them ever reaching us.

Dr. Angela Chaudhari: As we talk about these patients, I can think of so many patients in my head who really we offer obviously treatment options, but who come to me and talk about sort of how they've suffered with these fibroids for so long. Dr. Milad do you, do you have a patient like that?

Dr. Magdy Milad: Well, certainly, over the past decades, being at Northwestern, I've had just many patients that have come in suffering, whether it's suffering from bulk symptoms, whether it's suffering from bleeding to the point where they're anemic and requiring transfusion every month, on their menses or whether it's infertility. I think a really good example of patients that suffer is a patient who actually is coming in, in the next few weeks. This patient was noted to have fibroids.

It was being monitored and the fibroid rapidly grew, and she was told by her doctor that this is likely to be cancer. And it's just important to remember that rapid growth is not a risk factor for leioma sarcoma. And I told her that, and we'll be operating on her next week, but she's been just completely consumed by this idea that you may have cancer, despite the fact that fibroids virtually always are non-cancer except for those sort of rare cases.

Dr. Linda Yang: I think that is such a great point. I think when people hear tumor, right, fibroids are called benign tumors, but when patients hear tumors, they automatically. Their head goes straight to cancer. And certainly when we think about fibroids that grow over time, you know, it's imperative that we evaluate those monitor those as Dr. Tsai mentioned, but also remind our patients that really fibroids are almost always benign. These don't tend to be cancerous conditions.

And so when women come to us, they're often so scared, they're gonna need a hysterectomy. They're gonna need major surgery. And I think that one of the things to really remind them about is that we're here to be their partners. We're here to be their partners and find the best treatment options we can such that we can really improve their quality of life, that we can get them back to work, that we can get them not missing things every single day.

Dr. Magdy Milad: I mean, one interesting caveat to this topic of rapid growth is that there was an interesting study looking at rapid growth as a preoperative diagnosis, and actually, patients that had the diagnosis of rapid growth were less likely to have leioma sarcoma than those patients that didn't have rapid growth. Such an interesting study that is very reassuring.

Dr. Angela Chaudhari: As we wrap up this discussion. I wonder if Dr. Milada, if you'd share sort of the one thing you want, our referring physicians, our primary care physicians in general, OB GYNs in the community to really take from our discussion today?

Dr. Magdy Milad: I think it was well said earlier, fibroids are extraordinarily common. Symptoms of fibroids include, bulk symptoms, bleeding and infertility. If a Patient seems to have those symptoms based on history, I think having a low threshold to do an exam, get an ultrasound, is really important and get that patient referred into somebody that can manage that patient. Not just individually, but potentially in a collaborative fashion with other providers.

Dr. Angela Chaudhari: Dr. Tsai, dr. Yang, anything to add?

Dr. Linda Yang: I think that also just acknowledging that their symptoms are impactful, is a great starting point. And then if the. Provider has the ability to connect them easily with a local gynecologist or a specialty gynecologist. And then even in that interim, if there might be a delay in care, potentially even just to schedule a close follow up visit, to make sure that their symptoms are addressed, that there they're not lost to follow up because the delays in scheduling, I think that means a lot to the patient who is actively experiencing those symptom.

Dr. Susan Tsai: I think it's important for patients to know that they have fibroids. Like Dr. Yang said, oftentimes this information isn't conveyed. But for a woman who's of reproductive age, just to be aware of that. So potentially their gynecologist can monitor them as they're aging and potentially approaching fertility ages to see is this growing big enough that potentially in the future might cause issues. Many fibroids don't cause symptoms for anybody. And so just because you have one doesn't necessarily mean you need to be operated on.

Dr. Angela Chaudhari: Yeah. Well, thank you all for being here today. I think we've really sort of touched on all the different impacts that fibroids have, whether it's bleeding or some of the pressure and discomfort that our patients experience. And I really hope to our listeners that you guys have found this really useful to really begin to think about fibroids in the primary diagnosis of your patients who come to you with these issues. Thank you so much.

Melanie Cole: To refer your patient or for more information, please visit our website at BreakThroughsforPhysicians.NM.org/OBGYN. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for Physicians. Please always remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts and for updates on the latest medical advancements and breakthroughs, please follow us on your social channels.