Melanie Cole: Welcome to Better Edge, a Northwestern Medicine podcast for physicians. This episode is part three of our better Edge parts and Labor miniseries

Dr Angela Chaudhari (Host): Welcome to Parts and Labor, A Roundtable Discussion with the OB gyn experts here at Northwestern Medicine. My name is Angela Chaudhari and I'm a minimally invasive gynecologic surgeon and serve as the chief of Gynecology here at Northwestern Medicine. I will be your host today discussing treatments for Uterine Fibroids. We have a really amazing panel with me today when my colleagues from the Center of Complex Gynecology here at Northwestern Medicine. First up, Dr. Magdy Milad, the Albert P B Kurby, Professor of Obstetrics and Gynecology, and the division Chief of minimally Invasive Gynecologic Surgery. Here at Northwestern Medicine.

Dr. Milad is board certified in reproductive endocrinology and infertility with a focus practice designation in minimally invasive gynecologic surgery. Next up, Dr. Susan Tsai, a board certified and fellowship trained gynecologic surgeon, associate professor, and the associate program director of the fellowship in minimally invasive gynecologic. And next, Dr. Linda Yang, also a fellowship trained, minimally invasive surgeon, associate professor and assistant program director of our fellowship program here at Northwestern.

And last, but certainly not least, Dr. Bob Vogelzang, the Albert Nemec Education professor of radiology. Here at Northwestern Medicine with a focus on vascular and interventional radiology. He's also the past president of the Society of Interventional Radiology and the previous recipient of the Society of International Radiology Gold Medal Award. Now today we brought this panel together to start to begin to discuss some treatment options that are available for Uterine Fibroids. Now, before we get started, because there are a lot of treatment options we'll be talking about today, I'd love to hear from some of our gynecologists, what are the common symptoms of Uterine fibroids? Dr. Yang, do you wanna take that?

Dr Linda Yang: I would love to. So just starting very broadly, I think patients may come to the office with a variety of fibroid related symptoms. I would say that most commonly many of our patients will report atypical menstrual periods. Often they will report that their menstrual periods are much heavier than normal. Also, they may report prolonged episodes of menstrual bleeding and occasionally irregular bleeding patterns even beyond that. The other types of very common fibroid symptoms I would say that patients will complain of or report to me include symptoms related to pelvic pain or discomfort.

And then another category specific to fibroids are the category of bulk symptoms. Meaning that because of the substantial space in size that fibroids can take up within the uterus and in the pelvic area, then patients may report sensation of increased sense of bladder urgency or frequency or potentially impact on bowel movements. And then another category that can also be reported or described by patients is impact on fertility or pregnancy related complications.

Dr Angela Chaudhari (Host): So let's break that down. Dr. Yang. We have bleeding, we have pain, we have bulk, and we have it how it impacts fertility. And I think when we think about how our patients come to us, and we all see these patients every day, right? We think about how do we go about. Counseling patients about some of our treatment options. Dr. Tsai, can you share how you start, begin beginning the discussion about medical versus procedural versus surgical treatments?

Dr Susan Tsai: I would love to, so it really depends on the patient and what their goals are. So if we have a patient who is younger and is interested in fertility, we might talk more. depending on where they are in their fertility status and whether or not to they're ready to start a family is if it's mainly bleeding, we might give her some more medical treatments with some hormonal birth control or some hormones that would potentially turn off their hormones to decrease some of that bleeding. If they're getting ready for pregnancy and they've tried and it's impacted them a little bit, we might consider something surgical, which could be removal of the fibroids.

For people who potentially don't have a lot of symptoms or are not ready to proceed with something potentially as invasive as surgery, we might direct them to our colleagues in interventional radiology for the uterine fibroid embolization procedure.

Dr Angela Chaudhari (Host): That is so helpful to hear, and I know so many of our colleagues out in the community. When patients come in complaining about bleeding with uterine fibroids, they're often stuck in the scenario of what do we give them, what do we start with? And sometimes because they don't know the patient's bleeding kind of gets thrown under the rug with, there are many other medical problems. So it's nice to hear, starting with something simple. Medical therapies like estrogens, progesterones can be really beneficial.

I'm sitting here today with a group of proceduralists ins surgeons, so let's try to focus in a little bit so our colleagues out in the community can really hear what we are offering our patients from a procedural and surgical standpoint in our office. Dr. Vogelzang saying, can you share with us what the uterine fibroid embolization procedure is?

Dr Robert Vogelzang: Certainly fibroid embolization has been around for about 25, 30 years. I think we've done seven or 8,000 here at Northwestern and it's a minimally invasive way to treat fibroids. Cutting off the blood supply in a simple one hour procedure, which then proceeds over the next few days, weeks, and months, to have the fibroid shrink. And as they shrink, the patient's symptoms improve. It's an outpatient procedure and it's been very effective in a variety of situations, including bleeding and bulk.

Dr Angela Chaudhari (Host): That is really helpful to hear. For a lot of our colleagues on the community, I think they think, Okay, this is a less invasive procedure. The patients can keep their uteruses, which is obviously of utmost important to so many of our patients. What do you think the best symptoms are that UAE really treats?

Dr Robert Vogelzang: I think bleeding and bulk both respond well, bleeding better than bulk, especially for the very large uterus. In other words, we know that uterine fibroid embolization reduces the uterine volume by about 50%, and obviously for you start with something very large, it's still large when it shrinks by 50%. Now everybody's a little different, but thankfully we have other options and we often use fibroid embolization in conjunction with. For example, myomectomy, laparoscopic myomectomy. And so we do not have a one size fits all in this program.

Dr Angela Chaudhari (Host): That's one of the wonderful things about coming to a center, like we have the Center for Complex Gynecology, where really you get doctors who are working together to find the best treatment options for individual patients. Dr. Milad, I'd love to ask your thoughts about Uterine Artery embolization. I know you, as I refer a lot of patients for that procedure, I would love to hear how you counsel patients about the efficacy of that procedure, especially how it may impact their fertility moving forward.

Dr Magdy Milad: As Dr. Vogelzang Outlined it's been around for a long time. It's a very well established procedure, and there have been hundreds, maybe thousands of pregnancies that have been reported after uterine fibroid embolization. So a common myth is that it shouldn't be used in the patient that's interested in fertility, and that's obviously established not to be the case. I would just reinforce what Dr. Tsai Indicated, which is understanding the patient's priorities is critical, and I think educating the patients so that they can have a shared decision making about what procedure they think is the best. Because they're the ones that I obviously have to live with it.

Embolization, as I said has been very reliable and as was suggested earlier is commonly used with other procedures whether it's an IUD or whether it's a hysteroscopic myomectomy or a laparoscopic maybe it's maybe the fibroid is peculated and preoperative embolization will reduce the bleeding at the time of surgery. It's been very versatile in managing patients with symptoms.

Dr Angela Chaudhari (Host): I think that is a really good overview of how we think about embolization and how we refer patients on. I'd love though to pick your brain, Dr. Milad, about a newer procedure that's out to treat uterine fibroids, specifically radiofrequency ablation. When do you use that as a therapy for patients and how do you counsel patients about that?

Dr Magdy Milad: There's, yeah, there's two devices that are currently FDA approved, they both use RA radiofrequency ablation, which is simply electricity. There's a common misunderstanding that radio frequency ablation is some kind of magical, unique modality and it's just simply electricity, similar to what we use in the operating room every single day, every or in the world. The frequency is a high frequency electrical current to avoid depolarization, it's bipolar. So they typically will have pads on their thighs. There's twos. One is the excessive procedure, which is done on our general anesthetic. There's two incisions, one at the belly button and one below for the ultrasound device.

And under the general anesthetic with incisions a probe is placed through the skin and placed into the fibroid or fibroids. It's known as myolysis. It's an coagulative necrosis. Myolysis has been around for like decades. But this device has been around since 2013. And then more recently is the Sonata procedure. Sonata is done under Mac anesthetics. So it's not, there's no incisions at all. It's done trans uterine. Ultrasound probe is placed through the cervix into the uterus. And similarly needles placed into the fibroids and deployed.

Typical improvement is approximately 50%, 45, 50% reduction in overall size. And there have been reports of improved bleeding as well as bulk symptoms with the use of it. Neither are necessarily recommended for patients that are interested in pregnancy, although there have been pregnancies reported afterwards.

Dr Angela Chaudhari (Host): So when we think about these procedural options, it sounds like from both what you said, Dr. Milad as well as you, Dr. Vogelzang was saying that really we have so many different procedural options available to patients, sometimes in conjunction with surgery, sometimes on their own. I wanna talk a little bit more about myomectomy because we keep referring to that procedure as an alternative for women who wanna keep their uteruses maybe in conjunction with some of the procedures we just talked about. Maybe just having those fibroids out on their own. And I know my colleagues at the Center for Complex Gynecology certainly do a lot of these procedures. Dr. Vogelzang, what types of patients with fibroids do you recommend Myomectomy for?

Dr Linda Yang: After discussing all of the treatment options with our patients, I think the reason that myomectomy may come to the forefront in terms of the better choice for a particular patient. I think as you had mentioned, there are patients who number one, desire future fertility or who prioritize retention of the uterus for for either personal reasons or because they truly desire our uterine sparing type of procedure. I think, patients that benefit from a myectomy are patients who have significant bothersome symptoms related to the fibroids including bleeding, bulk symptoms.

And also, thinking that the goal of a myomectomy is to restore normal anatomy. So potentially for those patients that are experiencing fertility related issues from a myoma those are all patients that would benefit from a myomectomy.

Dr Angela Chaudhari (Host): Now, historically myectomy used to be these big up and down incisions.

I like to call them the myomectomies of our mother's generation, right? How are we performing these, myomectomies now how are we getting these large fibroids out through now, these minimally invasive techniques? Can you describe how that goes?

Dr Linda Yang: Sure. So I would say that a lot has changed in the way that we perform myomectomy, namely our ability to perform essentially the same procedure, but through very small incisions or a very small incision. Notably laparoscopic myomectomy or robotic assisted myomectomies are one method of removing significant fibroid burden without making a large incision or a laparotomy incision. Mini laparotomy is also a very reliable method or approach of performing myomectomy. Also as a minimally invasive option for our patients. And then, Hysteroscopic myomectomy for resection of intra cavitary or sub mucosal myomas.

Dr Angela Chaudhari (Host): So there's so many options out there now for myomectomy, and I think it has to be individualized, patient to patient, right? I think that is really what it comes down to, is sending patients in to really get a good idea. So many times, patients will come to my office and say, I was sent here for a laparoscopic myomectomy and they have 22 fibroids, and I say, Wait a second. You gotta go see Dr. Vogelzang you need an embolization before we can do anything, because we need to find every way to save your uterus. And so I think so much depends on what an individual patient's needs are, what their anatomy is.

We mentioned uterine sparing procedures. For patients who really just wanna keep their uterus, but so many of our patients have delayed childbearing or considering about considering fertility in the future. Dr. Milad, can you share, I know you've done lots of research over the years on myomectomy and fertility outcomes. Can you share how you counsel patients about what their fertility outcomes are after myomectomy?

Dr Magdy Milad: Sure I would probably take a step back and just su suggest that as you'd alluded to fibroids all about location location and location. And what's been demonstrated like over and over again is that the fibroids that are intra cavitary are the most likely those that are going to impact fertility and those that are intramural, in the wall of the uterus or on the outside of the uterus, really have not been demonstrated to interfere with fertility. So it's not uncommon for patients to be referred in for a myomectomy or for some treatment for fibroids that have for, from a fertility perspective and yet intramural fibroids, even four centimeters are greater, really have not been demonstrated to be consistently interfering with fertility.

Now is if it's a diagnosis of exclusion, there's nothing else. They've failed IVF a number of times. Maybe in that specific setting, there's nothing else to do. It's worth trying, but just wanna reinforce like how important location is and be able to counsel around which fibroids should be removed and which one's not. And of course, the larger the fibroid it is, the more likely it's gonna interfere with fertility. With regards to pregnancy outcome, we still don't really have a great data on this topic with regards to the need for C-section. But We still follow the old adages of fibroid entering myomectomy.

I'm sorry, myomectomy entering cavity, entering fibroid surgery. Potentially is gonna recommend a C-section, but it's very dependent on their obstetrician and also where they're located. If a patient is. In rural Montana, any type of myomectomy may be enough to prompt a C-section versus one that's in a more urban area. So I try not to advise extensively about whether they're gonna need a C-section or not after myomectomy.

Dr Angela Chaudhari (Host): I think that's is such a personal discussion between the patient and their obstetrician. Obviously getting as much information from us doing the surgeries as they can, but I completely agree. Dr. Mead, now, you know it's funny, we talked about procedures and we talked about myomectomy, all these uterine sparing procedures, but certainly there are many patients who are finished and completed their childbearing who are at their wits end, whether it's bleeding, bulk, Pain, they're there and they're ready to have something that is completely finishing their bleeding. And so many of our patients have had these procedures, or they've had multiple myo ectomies, and now they're ready for hysterectomy. Dr. Tsai, how do you counsel patients about the option for hysterectomy?

Dr Susan Tsai: As we discussed and alluded to before, it's really all about patient preference, right? So if it's a bleeding issue and you've counseled them about medical management or potentially fibro embolization, but ultimately they just wanna be done hysterectomy is the ultimately the only one way that we can stop their bleeding. So whether or not we approach it through the different routes that we have, so laparoscopically, robotically, vaginally, are all routes that we can discuss depending on their prior histories.

And then we have to go into talking about do you want to keep the cervix or remove the cervix? And so we talk about what we call super cervical or subtotal hysterectomy, where we keep the cervix. So in those patients we would continue to do pap smears. We may counsel them that they may still have some bleeding because if we don't cut low enough on the cervix, they might still have some cyclical monthly bleeding.

Total hysterectomy really just refers to the uterus. In this case, removing the area where the fibroids are as well as a cervix. In this case, then there would be no more need for pap smears unless someone had a history of abnormal ones that required Further surveillance. I always tell people the uterus is like a hot air balloon, so we're gonna move the balloon, the strings, and the bottom of the basket. That's what a total hysterectomy is.

Dr Angela Chaudhari (Host): I love it. Now I would love for someone to comment, because how many patients do we get in saying I want a partial hysterectomy? You just heard Dr. Tsai Mention total hysterectomy, super cervical hysterectomy. What in the world? Dr. Yang is a partial hysterectomy?

Dr Linda Yang: I think that there is a tendency when using vague terms like that, that it may not be clear as to the type of surgery that you're performing and what you're actually removing. So in patients who use those terms, I actually like to be very specific, sometimes even like drawing a picture of what the uterus and cervix are, the fallopian tubes and the ovaries so that I can explain that a total hysterectomy. Actually relates specifically to the uterus in cervix and really doesn't include the removal of the ovaries.

I think patients, when they come in, fearful sometimes of a total hysterectomy, what they're truly fearful of potentially is removing the uterus in cervix as well as the ovaries. Whereas when they express a preference for a partial hysterectomy to be very clear about what their preferences are in terms of retention of the cervix versus retention of the ovaries. Where partial hysterectomy could actually mean different things. So I think to be very specific.

Dr Angela Chaudhari (Host): Yeah, I feel like we constantly are nailing down those those rumors out there that happen in patients' families or from their friends. And are you having a, are you having a total or a partial? You should get a partial, so you don't go into menopause. But what we know is that right, the ovaries have separate blood supplies. They're not gonna go into menopause with the total hysterectomy. It is just the hot air balloon, as Dr. Tsai called it, the basket the strings and the balloons.

As we wrap up our discussion today about treatment options, I think one of the things that really sets the Center for Complex Gynecology and Northwestern Medicine apart is our approach to this combined multi-modal therapy for uterine fibroids. It's really an. Excellent collaboration between gynecologic surgeons and our interventional radiology physicians. And I'd just love to hear Dr. Milad and Dr. Vogelzang have been at the forefront of this for so many years, working together to really get the patients the options that they need. Dr. Vogelzang, I'd love to hear when you think multimodal is at its best and what types of procedures or patients do you really think, do well with this type of technique?

Dr Robert Vogelzang: It's a great question. Multimodal therapy or therapy that includes one or more, usually two types, means that for us, myomectomy and embolization are not competitive. They're complimentary. So I'll give you a few examples of that. It's very often that Dr. Milad will refer me a patient in whom they have large fibroids, which we know will probably be bulk problematically from a bulk perspective, but also may have a numerable smaller fibroids. Because embolization is a global treatment, we're gonna treat all the smaller ones, of course, and then the larger ones can be resected. Usually at some interval.

We had a patient the other day who was emblematic of that. She works in the department of Radiology, wanted to avoid a hysterectomy, and we did an embolization. She got some reduction, but Dr. Milad then did a laparoscopic myomectomy. And that's the other thing that's really beautiful about this collaboration is that you downsize and reduce the size of the uterus. So sometimes or very often, laparoscopic procedures are available when previously they were too large and could only be done open.

Dr Angela Chaudhari (Host): So how does this work? Do these procedures happen the same day? Is there a timeframe between those two procedures?

Dr Robert Vogelzang: No, they usually happen at an interval, although they can happen the same day as you. But they are complimentary and that I think we're working at a very high level that's unique perhaps in the United States. Many examples of that are use of MR for example, to identify fibroids and we could go on and on, but we are trying to give the patients the best options and produce the best results I think as a consequence.

Dr Angela Chaudhari (Host): Yeah. Dr. Milad, when patients come in and do multimodal therapy with you, how do you counsel them on outcomes and recovery from going through more than one procedure for their fibroids?

Dr Magdy Milad: Generally counseling around multimodal therapy is unique because we have the. Risk and complications of each of the procedures individually. But the hope is that by` combining the two, we can reduce the overall risks. Because we have so much experience with it, it's pretty easy to counsel around outcomes and we have rarely seen a problem with it. It was, there were some initial learning curves with it with regards to consenting patients for surgery. If they have an embolization under a Mac anesthetic, You can't really consent them for a procedure the same day. And so we've had to strategize around how to resolve that.

And obviously we did that many years ago. Patients can be quite drowsy after two procedures. And it really isn't necessary do it all in the same day. In fact, there's some advantage to waiting, doing an embolization a day before, a week before, a month before, even three months before. Oftentimes we'll do an embolization preoperatively and patients have such improved symptoms that they end up canceling their surgery or putting it off until they feel like they need it. I would just add one more specific indication for multimodal therapy, and that's the patient that has these really vascular fibroids.

Even if we can approach it hysteroscopically, we see on ultrasound doppler flow really a unique amount of blood supply to it, and preoperative embolization has been enormously helpful in reducing bleeding and also being able to be able to finish the procedure on the one setting.

Dr Angela Chaudhari (Host): It seems like there's so many benefits to this multimodal therapy. Blocking blood flow, potentially decreased surgical time, potentially even improved outcomes in the long term because we're shrinking these smaller fibroids and immediately taking out these larger. Bulky fibroids. It's so exciting to hear and to share, some of the work that we're doing here that really is very cutting edge. As Dr. Vogelzang mentioned, this is, one of the first centers in the country that's really using this complimentary therapy for our patients.

Just really wanna thank all of our panelists today for being here and talking to our colleagues out there about what treatment options are available for Uterine Fibroids. Before we finish up today, I'd love to hear any final takeaways for our colleagues who are referring patients to us. Dr. Vogelzang, you wanna start?

Dr Robert Vogelzang: You bet. I think your patient's gonna be well-managed here. We are gonna take care of them in the best possible way, often in a single visit, for example, at the Center for Complex Gynecology, and we will find the best solution for them.

Dr Angela Chaudhari (Host): That is, that says it all. I feel like Dr. Milad, do you wanna edit anything there?

Dr Magdy Milad: Yeah, I think the mission of the center is really to. Take care of complex conditions that either outside the, a generalist practice or something that they just don't wanna deal with. And our intention is not to steal the patient or keep the patient, but really to just manage their complex issue and send them back to the referring doctors. And and everything about the center is directed around that mission.

Dr Angela Chaudhari (Host): Dr. Yang. Dr. Tsai.

Dr Linda Yang: I would just add that, in terms of from a patient perspective that when they come to see myself or any one of my wonderful colleagues that really were trying to educate the patient potentially about options that they've never heard about before. So they may not leave the office with necessarily a decision about what to do, but they will walk away with a better understanding of the options that they have.

Dr Susan Tsai: I wanna echo Dr. Yang. I think it is all about education. We sometimes with working with our residents and our fellows, have that time to really educate them and they leave, I think as she said, with a better understanding. Not necessarily different information, but just a better understanding of it.

Dr Angela Chaudhari (Host): Yeah, I think we really hit on all sort of the topics about treatment for uterine fibroids that I think many of our colleagues that are listening in wanna learn about, wanna hear more about because they wanna go back and offer this to their patients that are coming in and really suffering from the bleeding, the bulk, the pain. I just really wanna thank our amazing panel today. Thank you for everyone out there listening and here at the Center for Complex Gynecology. We're more than happy to see patients get second opinions and really be here as a source of education for your patients to make the best individualized and personalized decision for them. 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,