Scott Webb (Host): Fibroids are common for women and there are a variety of treatment options, including surgery. And my guest today is here to explain fibroids and the individualized approach at Salinas Valley Health. I'm joined today by Dr. Natalie Friedricks. She's the Medical Director of the Salinas Valley Health Obstetrics and Gynecology Clinic.

This is Ask the Experts, the podcast from Salinas Valley Health. I'm Scott Webb. Doctor, it's nice to have you here today. We're going to talk about fibroids and robotic surgery. And I get excited anytime I get a chance to talk about robots. So, it's good to have you on, good to have your expertise. And I know that fibroids are common, but many people may not know what they are, right? So, maybe you could explain what they are, and when do they become a concern?

Dr. Natalie Friedricks: I mean, you said it. So, fibroids are extremely common. By age 50, almost 80% of women will have them, but many of them don't even know they have it. Most of my patients have no idea until they get a CT scan or an ultrasound for a totally unrelated reason. Fibroids are generally benign, so that means they're not cancer, okay?

And they come from the wall of the uterus, so the muscle layer of the uterus. There are very rare instances when they become cancerous, but those are few and far between cases. The most important thing to know is that having fibroids doesn't automatically mean that you need treatment. It doesn't mean that you need medicine or surgery. And for women who have no symptoms at all, we just kind of monitor them and acknowledge that they exist and move on.

Now, fibroids become a concern when they affect a woman's life. So, the way that happens is maybe they have very heavy menstrual bleeding or pelvic pressure. Sometimes the fibroids can be so large that they push on other structures like the bowel or the bladder, causing, you know, frequent urination or constipation. Sometimes it can just be pain during intercourse or even difficulties becoming pregnant. But all of that, the symptoms kind of depends on the fibroid size and location. Usually, I tell patients, you know, we don't treat the ultrasound, we treat the person. So, we treat you and your symptoms. And if fibroids aren't bothering you, we may not even need to do anything. But if they're interfering with your daily life, then it's time to come in and talk about treatment options.

Host: Yeah, because I wanted to ask you about symptoms. As you say, a lot of times, they're diagnosed sort of accidentally, looking for something else, looking at other things. Say, "Oh, by the way, you have some fibroids." But it sounds like some women may have symptoms. So, what would be the concerning symptoms, I guess, and then maybe the possible treatment options?

Dr. Natalie Friedricks: Yeah. So, probably the most common symptom for fibroid-related issues is heavy menstrual bleeding. So if you're soaking through pads or tampons every hour, you're passing large clots, you know, you go to your primary care doctor and they tell you that you're anemic and the only thing you can think of is your heavy periods, or even you're planning your life around your periods, then that's not something you should accept as normal, and that might be something we need to address in the office.

Like I mentioned before, sometimes it's just that the fibroids are so large that they're pushing on other organs, so that can lead to symptoms where you feel like you're full, you have abdominal bloating, maybe frequent trips to the bathroom, pelvic pain, back pain, or discomfort during sex.

And sometimes the symptoms are a little bit more subtle. Patients tell me, "You know, I look three months pregnant. I can't button my pants anymore." But we look at the scale and their weight hasn't changed. You know, large fibroids can actually enlarge the uterus quite significantly. And for women who are trying to conceive or who have experienced recurrent pregnancy loss, fibroids definitely can play a role.

And so, that's something we need to evaluate. But it's important to know that not every fibroid affects your fertility. And, you know, the bottom line is this: if your symptoms are affecting your health or limiting your life, it's worth talking to an OB-GYN, as there's a lot of treatment options, and many more than most people realize.

Host: Yeah. And let's talk treatment options. Let's talk surgery and when that might be indicated. As you said before, sometimes it's just sort of surveillance of fibroids. Sometimes you have to do something about it depending on their size or how much they're affecting women. So, maybe what factors help determine, like, when a patient, when a woman is a good candidate for surgery?

Dr. Natalie Friedricks: So, you know, surgery, like you've mentioned, is just one of several treatment options, and it's not always the right answer for everybody. Usually, we treat symptoms with fibroids usually with medications first. And if the medications aren't helping, or if the fibroids are very large or growing rapidly, then, you know, we tend to move towards surgery. Or if in the case of fertility, if they're preventing pregnancy, that's a patient who may need surgery as opposed to medication.

The decision is very individualized. So, we look at the patient's age, we look at their symptoms, the number and size of fibroids, because many women have not just one, they come in clusters. We look at where they're located. So, is it hanging off the back of the uterus, right? So if you're trying to get pregnant, you know, a small fibroid hanging off the back may not disrupt anything. But a small fibroid poking into the inside of the uterus where the pregnancy is trying to attach, that might disrupt a pregnancy. So, it's important to look at where it is.

And then, just importantly, like evaluating the patient's goals, because a lot of times fibroids shrink in size, after menopause and stop becoming as much of an issue. So, you know, is your goal to get to menopause? Is your goal to fix the problem now? Is your goal to get pregnant? It really depends on where you are in your life stage and also where those fibroids are within your uterus.

Host: Right. Yeah. As you said, you're not treating the ultrasound, you're treating the patient, right?

Dr. Natalie Friedricks: Exactly.

Host: Yeah. So then, in the realm of surgery, and I teased a little bit that we might get a chance to talk about robots. Let's talk about the surgical options, how technology maybe has changed the way fibroids are treated, and specifically the minimally invasive robotic approach.

Dr. Natalie Friedricks: Yeah. So, minimally invasive surgery has been one of the most exciting developments in gynecologic surgery. So at Salinas Valley Health, our patients have some of the most up-to-date treatments available for fibroids. And if we're focusing on surgery, we have hysteroscopy, laparoscopy, and robotic surgery.

So, hysteroscopy allows us to target fibroids that are located on the inside of the uterus. So, these are maybe your smaller fibroids poking out on the inside that may be affecting fertility or could be leading to heavy bleeding. And for those patients, we're able to introduce a camera through the cervix into the uterus, fill the uterus with saline, which allows us to visualize the fibroids and actually use a small tool that I compare to a Pac-Man tool to remove the fibroid. It's fun because I played a lot of Pac-Man when I was a kid.

Host: Of course.

Dr. Natalie Friedricks: And so, it makes me good at this surgery. So, that's one option. And for those patients, it's a really great option because downtime is minimal. Usually, I just have the patient take the day of the surgery off, as well as maybe the day after. But after that, there's no activity restrictions. Patients are up and moving and, for the most part, feeling better and healthier for it.

The other two options, laparoscopy and robotic-assisted surgery, are maybe a little bit more invasive, but those are for kind of our larger fibroids or our fibroids that are located in the muscle wall of the uterus or hanging off the back of the uterus.

And so I do a lot of robotic-assisted surgery, which is where the surgeon remains in complete control of the instruments, but the robotic platform allows more precision, improved visualization with high-D 3D imaging and greater dexterity. And we make just a couple small incisions in the abdomen, and we're able to sort of take apart the uterus, take out the fibroids, and reconstruct them within the body, taking out those fibroids through very small incisions.

And compared with traditional open surgery, these kind of minimally invasive techniques mean smaller incisions for patients, which leads to less pain, less blood loss, lower risk of infection, shorter hospital stays, and a much faster return to normal activities. Many people are really surprised by how quickly they're back on their feet and they're feeling fine.

Most patients, you know, the recovery period is anywhere from two to four weeks, depending on their individual healing, but that's much better than the six weeks it used to take with open abdominal surgery.

Host: Right. Yeah. And in the realm of video games, so you talked about Pac-Man, and now what you're describing there sounds more like Operation. So, it sounds like a fairly fun day for you.

Dr. Natalie Friedricks: There you go.

Host: Yeah. Not so bad. Yeah. So, I know, doctor, a lot of patients worry about recovery, maybe future fertility. What do they need to know? What needs to be on the table as they might consider fibroid surgery?

Dr. Natalie Friedricks: So, recovery really depends on the type of surgery, like I alluded to. After minimally invasive surgery, many patients are back to light activity within a couple weeks and feeling kind of much more like themselves within two to four weeks. Most of my patients are only on really strong pain medications for even just a few days after surgery. And within hours of the surgery, they're on their feet.

Open surgery, so open abdominal surgery where we make a large incision like a C-section incision, generally requires like a much longer recovery, like six to eight weeks. And then, for fertility, preserving fertility is definitely one of our primary goals. If a woman hopes to become pregnant in the future, we really focus on carefully removing the fibroids while protecting the uterus.

For fibroid-specific surgery, the main thing is knowing whether your surgeon had to go all the way through the wall of the uterus or just into the wall. And the reason that's important is because if your doctor doesn't go all the way through the wall of the uterus, you may still be even able to have a vaginal delivery in the future. But if you go all the way through the wall, then you have to have C-sections moving forward. So if you do get a surgery like this, it's really important to clarify that piece with your doctor before and after the surgery so that you know if you become pregnant, what your options are for delivery.

And then, you know, it's also important to have realistic expectations. So, you know, if you come in with a 12-centimeter fibroid, we're probably going to have to go through the wall of the uterus. Whereas if you maybe have a two-centimeter fibroid, we can preserve the inside of the uterus and hopefully allow you to have a vaginal delivery in the future. And removing fibroids can improve fertility in certain situations, but it doesn't guarantee pregnancy because fertility, you know, depends on many factors beyond fibroids alone.

And I encourage patients to discuss their family-building goals early in the decision-making process because it really does help us choose the best treatment strategy for them.

Host: A lot of great information today. I just want to leave listeners, women especially here just, you know, your best advice when/if they've been diagnosed with fibroids and they're trying to figure out their course of action. Is it to start conservatively, go right to surgery, you know, fertility mixed in there as well. What's your best advice?

Dr. Natalie Friedricks: So first off, just don't panic. So many patients come to my office and are really concerned because they were told they have a tumor or a mass or something growing in their uterus, and they're freaked out that it's cancer, and they don't know what fibroids are. And if you walk away from this podcast with nothing else, you should just walk away with the information that fibroids are really common and most are not dangerous. Even if they're large, they're not necessarily dangerous.

And secondly, I just want people to know that surgery isn't the only option. Obviously, I love doing surgery. I love minimally invasive surgery. That's my passion. But surgery may not be the right option for you, and you should be able to discuss all of these medical and surgical options with your provider.

And then, depending on your symptoms, we may recommend observation, like I said, medication, procedures, sometimes even with interventional radiology or surgery, but it really depends on your situation. And just don't hesitate to ask questions. I encourage patients to understand the benefits, the risks, and recovery, and how each option aligns with their future plans and lifestyle.

Again, my goal is shared decision-making. So, I will give my expertise, but the patient knows their own life and what their goals are, and together we can come up with the best plan for them.

Host: Right. Yeah, real team approach. I love that, and just lots of options for women, tools in the toolbox, whatever metaphor we want to use. So, appreciate your time and your expertise today. Thanks so much.

Dr. Natalie Friedricks: Thank you, Scott. I appreciate being here.

Host: And to listen to more of our podcasts, please visit salinasvalleyhealth.com/podcasts. And if you found this podcast to be helpful, please be sure to tell a friend, neighbor, or family member. And subscribe, rate and review this podcast, and check out the entire podcast library for additional topics of interest. This is Ask the Experts from Salinas Valley Health. I'm Scott Webb. Stay well, and we'll talk again next time.