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Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And joining me today is Dr. Amira Quevedo. She's an Assistant Professor in the Division of Minimally Invasive Gynecologic Surgery at the University of Florida College of Medicine. And she's here to highlight evaluation and management of uterine fibroids.

Melanie Cole, MS: Dr. Quevedo, it's a pleasure to have you join us today. I'd like you to start by telling us a little bit about the prevalence of uterine fibroids, how or why they develop, and what you've seen in the trends.

Dr Amira Quevedo: Thank you again for having me, for the kind invitation. Fibroids are extremely common. They're found in up to 80% of women overall. Thirty to forty percent of fibroids are symptomatic, so a lot of women have fibroids and they don't really know it because depending on the location, the size, it can be pretty minimally symptomatic. But the patients that we see are essentially that 30-40% of the overall prevalence where, you know, they have the heavy bleeding, they have the painful periods, they're infertile because of them, they have bulk symptoms, they have a lot of compression of their intestines and bladder and they can have urinary frequency and constipation and so forth.

And we spend a lot of money in the US on fibroid care. Over 34 billion a year is spent on the management of fibroids, which speaks to the research that still needs to be done in the management of fibroids, because the pathogenesis is really not clear. We know that fibroids have a much higher number and burden in black women in the US. And the research shows that black and Latino women often get more open surgery for fibroids as well. So, we have some work on disparities there. And overall, one in three hysterectomies that are done in the US are due to fibroids. So, that's a little bit about the prevalence.

Melanie Cole, MS: Well, thank you so much for that. So, let's talk about assessment and evaluation of patients who present with symptoms suggestive of uterine myomas or uterine fibroids. What are those symptoms that a woman might notice? What complications might they cause? Tell us about some of the key clinical features of this condition.

Dr Amira Quevedo: Essentially, it could be a myriad of symptoms. Women can be, again, asymptomatic for the most part, or they can have increased heavy periods. They're soaking through their pads. Every one to two hours, they're having to change their sanitary napkins. They're essentially having to leave work because of this. They aren't able to go and enjoy quality of time with their families. A lot of times during their periods, they're missing work. And they can also have just infertility. So, women that can't get pregnant for several years and not sure why, everything else is normal. They can have urinary frequency, they can have like pressure bulk symptoms in their lower abdomen, constipation again. Oftentimes, they have painful sex just because of the location of the fibroids. And at this point, I would say that any of those symptoms would not be able to rule in fibroids, but I would certainly do further investigations with imaging studies. So, it's very easy to order a transvaginal ultrasound, which is the first line imaging study for fibroids. And then once you have that, then you can kind of tailor the approach a little bit more. In terms of physical exam findings, you may be able to feel fibroids on an abdominal exam. Oftentimes, it's difficult. You would have to do a bimanual exam and often refer those patients to a gynecologic specialist. And you could do a blood count. Ferritin is a good measure of the iron stores; thyroid testing if they have abnormal periods; and obviously, always start with ruling out pregnancy by doing a pregnancy test.

Melanie Cole, MS: So then, tell us how you tailor this diagnostic workup. You just gave us a bunch of different options and prognostic tools for this and approach. I'd like you to tell us how you approach for different patient populations with uterine fibroids, some of the influence of factors, Dr. Quevedo, such as age, fertility status, comorbidities on the clinical presentation and prognosis of this condition. Tell us about this patient-centered approach to managing these patients.

Dr Amira Quevedo: You definitely want to tailor it. This is not something that you're going to treat everybody the same. Obviously, it has a lot to do with the age of the patient. Ideally, start if they're having heavy periods, make sure that they're not anemic, because that also can complicate even management and obviously the quality of life of the patient. If they're anemic, they may need iron IV or just iron PO supplementation. If they can't tolerate the iron orally, then obviously there are IV formulations of iron that you can also treat them with. And essentially, the ultrasound is by far the first line imaging study. You want to know the shape of the fibroids, where they're located.

In essence, there are three major types of fibroids. There is the submucosal fibroid, there's the intramural fibroid, and then there's the pedunculated fibroid. We do have FIGO staging thanks to the group of Monroe. And we can further delineate exactly how far the fibroid is in the endometrial cavity, in the event that they have a submucosal myoma. And that will all sort of give us a picture, give us a map, give us a Google map of how those fibroids are situated in the uterus, and then what the therapeutic approaches can be and how we can tailor that to the patient. Ultrasound, if there are a lot of fibroids, if there's adenomyosis, can be a little bit limited. But that's by far the first line tool.

And then, you can order an MRI of the pelvis. And you want to do it with and without contrast. And you want to look again at the vascularity of the fibroids as well as the location. And you'll be able to do a much more highly sensitive and specific evaluation via MRI of the fibroids. And then, you can further tailor the treatment options of whether this patient would do better with medical management if her goal is not to get pregnant at the time versus if they no longer wish to have pregnancies or conceive, then you can talk to them about, again, medical management or even some of the interventional radiology therapeutic options such as embolization or you can talk to them about more surgical options that we can offer with either endometrial ablation or myomectomy, hysterectomy. All of those are options for women who don't want to have any more pregnancies.

Melanie Cole, MS: So, I'd like to expand a little bit more on the treatment options. Now, first of all, Dr. Quevedo, is treatment always necessary? How do you decide which of these many treatments based obviously on the childbearing status and age of the woman, and how that makes a difference in your decision? Tell us a little bit about how you come to this decision with shared discussions with the patient and based on their suitability to their needs and circumstances.

Dr Amira Quevedo: So, I think you pointed out a very good point, which is, one, is you want to know the patient's goals. So if they have no symptoms, they happen to have a fibroid, it's less than five centimeters, you can say, "Okay, well, we'll see you in a year, but I do want to follow your fibroids for any interval change." So, you may want to order another ultrasound for that patient and not necessarily just say we don't have to necessarily worry about it because there can be some interval growth, and you want to not necessarily take away the option of having some of the more minimally invasive approaches, conservative approaches in the future, if you can monitor those fibroids for interval changes.

And if you then have this very symptomatic patient, so she's coming in with quality of life issues, she's missing work, you know, these are questions that you do kind of have to, gather during the history. It's not something that the patient may always tell you. But if you really get into the story of their bleeding and of their pain, you can start to see patterns of, "Oh, I'm missing work. A lot of my college years were affected by fibroid symptoms." All of these things, usually they point to something that you are really going to have to either offer them medical management or surgical management. And for women essentially, it really depends on what their goals are at the time that they present essentially. Are they actively trying to get pregnant? Because if they're actively trying to get pregnant at the time, then you can say, "Well, these are the options." And usually, we would get more into the discussion of a myomectomy, so just removing the fibroids.

Now with the myomectomy, you would have to wait three months at least for the uterus to heal for the remodeling of the uterus to occur after surgery, because myomectomy does need some healing time. And If the patient is not trying to get pregnant at the moment they don't have a partner or they're not interested in pregnancy at the time, then you can talk to them about just starting an anti-inflammatory medication like ibuprofen. You can talk to them about tranexamic acid, which is an antifibrinolytic that they can take just during their periods. You can talk to them about progestin pills or progestin intrauterine device. There's also the option of other sort of second, third and fourth line medications like GnRH analogs, which work at the level of the pituitary gland to block FSH and LH and therefore cause a hypoestrogenic state since fibroids are receptive to estrogen and progesterone for their growth. So, these are all options that you can give patients that aren't trying to actively get pregnant in terms of medications. And then, you can talk to those patients that no longer wish to have pregnancies. You can talk to them about uterine artery embolization. That can shrink the fibroids. It can help with bleeding. They actually can see between 40% and 50% volume reduction of the fibroids. And then, there's some other surgical approaches that can preserve the uterus, like radiofrequency ablation that can be done either laparoscopically or transcervically. And then, you know, in women that have tried other options or no longer wish to preserve their uterus, obviously, hysterectomy is also an option.

Melanie Cole, MS: Tell us a little bit about how your patients react to all of these different options, and you discuss with them potential complications and these outcomes of each intervention. Tell us a little bit about how you work with the patient based on all of these options.

Dr Amira Quevedo: I think that's a great point because a lot of women, they've either been going through something like symptomatic fibroids for 10 years sometimes, and they've tried everything. I mean, they've tried the progesterone IUD. They've tried the progestin pills. They've tried GnRH analogs. And at some point, women are just like, "Okay, I don't want this to ever happen again. I'm tired of the bleeding. I don't want a recurrence of any of the fibroids." So then, that becomes more of a clear cut diagnostic recommendation of more definitive surgical management, like a hysterectomy.

But a lot of women also want options. So, we talk to them about uterine artery embolization that there is shrinkage of the fibroids. It's not great if women are having a lot of painful periods, if they have severe dysmenorrhea, but it's really a good option if they have mainly bulk symptoms or if they essentially just have a lot of heavy periods that can shrink the fibroids and cause a reduction of the surface area of the endometrial cavity. And then, they have good results with that. They'll still have periods, but their periods will be much lighter.

There's also the option of having some of these other like a myomectomy. But both embolization, myomectomy, radiofrequency ablation, they do come with recurrence rates, although the volume of the fibroids are reduced anywhere between 40% up to 70%. They can get new fibroids. The fibroids that initially shrunk, they can have recurrence of those symptoms and it's usually if they're younger patient, if they have multiple fibroids and so forth. So, it is a delicate discussion about the pros and cons. Like you said, uterine artery embolization comes with about a 5% complication rate of sort of this post-ablation embolization syndrome that they can get, where they can get fever, and they can have a lot of pain in the initial stages after the procedure where they can get a lot of fibroid necrosis.

And then, you have myomectomy, which also has some complications of extra blood loss during the procedure because you're not ligating the blood supply to the uterus completely during that procedure. So, there is blood transfusion risk. There's risk of just having a surgery and a seizure risk. And then, we talk to them about Sort of the other radiofrequency ablation options like laparoscopic radiofrequency ablation and transcervical radiofrequency ablation, which do have great outcomes, but also can have bowel injury or bladder injury in rare occurrences.

So, those are all things that we talk to patients and they have to know the risk of having recurrence of fibroids and then future repeat procedures. So, they may end up ultimately having a hysterectomy because they failed some of the other more conservative procedures like embolization or radiofrequency ablation or a myomectomy.

Melanie Cole, MS: Wow, what a comprehensive and informative podcast this was. Thank you so much, Dr. Quevedo. You've really given us a lot to think about and explained all of the treatment options for uterine fibroids so very well. Thank you again. And to learn more, please visit innovation.ufhealth.org. And to listen to more podcasts from our experts, you can always go to ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. Thanks so much for joining us today.