Melanie Cole, MS (Host): Today, we're learning how minimally invasive gynecologic surgery may help treat pelvic pain, fibroids, cysts, endometriosis, and so many other conditions that women suffer from. Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System. I'm Melanie Cole.

And today, we're highlighting minimally invasive surgery for women's health conditions. Joining me is Dr. Farinaz Seifi. She's an Associate Professor specializing in Minimally Invasive Gynecologic Surgery, and she's the Vice Chair of Gynecology and Gynecology subspecialties at the University of Maryland School of Medicine.

Dr. Seifi, welcome. Thank you so much for being with us today. So when we think of the problems that we women have, from pelvic pain to fibroids to ovarian cysts, there are so many of them, how common are these? What are some of the most common that you see every day?

Farinaz Seifi, MD, FACOG: Thank you so much for having me, and hello everybody. The most common that I see is a fibroid, especially in Maryland and Baltimore area that we work; the endometriosis, the cyst, ovarian cyst that is related to endometriosis; and chronic pelvic pain is the most common that my daily patient presents with to our clinic.

Melanie Cole, MS: Are these a normal part of aging? Because I know, myself, I'm post-menopausal, and I have many of these things. You know, things start to grow, cysts and, you know, fibroids and stuff. Is this a normal part of aging, and are they dangerous?

Farinaz Seifi, MD, FACOG: Actually, they can come as early as you start your menarche, and that's the part that we are definitely ignoring it in our adolescence when they get their menstrual cycle and they complain of a pain and cramping, and everybody was told that it's normal. It's not normal. It needs to be evaluated. And the cyst can come as soon as, like, you're 14, 15. The endometriosis can be diagnosed at age 17 easily, and the fibroid can grow in a patient as young as 20 or even younger. And they have a tendency to run in the family. So if your mom or your sister is diagnosed with a fibroid or endometriosis, take it seriously. Do regular checkups, do ultrasound, and followup.

And once you are actually aging, the fibroid grows, they can multiply, they recur after the surgery. And the cysts, they can get larger. Also, there's different kinds of the ovarian cyst with different aging. In younger patient, we have more cyst type of dermoid. In older patient, we have more cystadenoma and other kinds of ovarian cysts.

Melanie Cole, MS: So, many of these things can happen and they can be really scary and especially something like abnormal bleeding, which can happen really throughout our lifetime. I think it's probably the most scary if it happens postmenopausally. But how do you diagnose what's going on, what's causing our pain or bloating or any of these reasons before we get into the treatments? How do we know what's going on?

Farinaz Seifi, MD, FACOG: I'm so glad that you asked this question because one of the very important factor is that our community doesn't know what is heavy menstrual bleeding or abnormal uterine bleeding is. Everybody thinks that bleeding is a part of the menstrual cycle. But how much bleeding is normal? Nobody really, really educated us.

Normal period is 80 cc of blood. What does that mean, 80cc of blood? It means that if you are bleeding for five days, it should not be more than 80cc. Eighty cc means eight maxi pads or eight super tampons in five days. If you're using more than that, that I'm pretty sure 90% of my patients are using more than that, and they're calling it regular bleeding, it's not regular bleeding. That is heavy menstrual bleeding, and that's a part of abnormal uterine bleeding. And that can cause eventually anemia silently. You feel fatigue, you feel that you cannot do your daily work, you are very anxious, and that's all coming from anemia, and you think that you have your normal bleeding. You don't.

Any bleeding after menopause needs immediate attention. Immediate attention. You can have pre-cancer. You can have simple polyp. Most of the time, it's benign. But we cannot assume things until, otherwise we specify and biopsy and have a tissue sampling to make sure that it's not cancer. Any bleeding over age 45, which is abnormal. You're having your menstrual cycle twice a month or you're spotting for a long time. That needs to be biopsied. That needs to be worked up. So, please don't ignore heavy menstrual bleeding, and do not oversee the irregular bleeding after age 45 or any bleeding after post-menopause.

Melanie Cole, MS: That was great information. Really important because we need to hear that from someone like you, that these things are not normal and abnormal bleeding is scary, but we can't just let these things go. And we women, Dr. Seifi, we tend to care for everybody else, and we put off taking care of ourselves. But if we don't do that, if we don't put our own masks on, we cannot take care of those that we love. So, that was really important information.

Now, first line of defense, if we notice this stuff, if you've diagnosed what we've got going on, we've come to see you, what then happens and when do these problems start to have that discussion about surgical interventions?

Farinaz Seifi, MD, FACOG: So if you have a fibroid and the fibroid is growing fast or is causing a problem, what does problem mean? You feel heavy in your pelvis. You have back pain. You feel pressure in your bladder. You constantly have to go to bathroom. You cannot hold your urine. You have heavy menstrual bleeding as we defined it. And you are ending up in anemia, had to use iron or blood transfusion. And we started you on any medical treatment, and it's not responding, that's the time that we have to do the surgery.

The old traditional thought was that, "Okay, if you have a five-centimeter fibroid and it's not bothering you, let it be." No, don't let it be. That fibroid is not going to go away by itself. Even if you go to menopause, it's not going to go away. It's just going to become calcified, and it's still going to hurt. I have so many patients that come at age 60, 65. And one of them actually was diagnosed in an X-ray that they saw a big calcified ball thing in the pelvis and turned out to be a fibroid. And once she had surgery, all her hip pain, back pain, everything is gone. So, don't ignore it. Don't let it sit there because that fibroid, if you don't treat it, if you don't suppress it, if you don't do surgery eventually, it's going to get bigger. It's going to get more, and more and more fibroids are going to grow.

And about the cyst or pelvic pain, if you have a chronic pelvic pain, which by definition is, like, you have pain more than six months, and it's not alleviated by ibuprofen, Motrin or Tylenol or hormonal therapy, then we really need to think about the surgery that what is causing this pain. Do you have endometriosis? There is a way that we then try all of the medical treatments for endometriosis and see if it's responding or not. If it's not responding, don't wait. Don't suffer from pain. Don't let the pain in your body. That's the time that we can start doing a surgery.

Melanie Cole, MS: Isn't that so interesting? We don't typically think of those hip pains, back pains as being something that would be caused by pelvic pain. We think of it as our back or our hip or something. So, that's really, really important to know. So, tell us a little bit about minimally invasive gynecologic surgery. What does that mean and how is it different from what our mothers had 20 years ago, 30 years ago with traditional open surgeries?

Farinaz Seifi, MD, FACOG: So, minimally invasive surgery is between three to five small incisions. Small incision, each of them five millimeters, which is half a centimeter, which is one-fifth of an inch. So, imagine how small the incision could be. there is a camera that magnifies everything. The robotic camera can magnify up to 70 times. So, it will give us a very good visualization and special instruments that help us to do the surgery, help us to basically do a very detailed surgery, even much better than open surgery.

Then, you don't have to suffer from a big incision, and the post-op pain is way less than traditional surgery. You go home. Most of our patients, 99% of our patients that is benign condition, they go home the same day. They can eat and drink at the same day. They go up and down the stairs, and they go back to their normal activities in a few days.

Even the hysterectomies for a very large uterus can be done minimally invasive. So, you have a very quick return to work, return to your activities, and less pain and faster recovery.

Melanie Cole, MS: Isn't it amazing the technology? And so, we understand the benefits for the patient as far as recovery. What about benefits to you doctors, to you surgeons? In this age of minimally invasive surgery, and we hear about robotics and all these things, how does that make your job easier, more efficient so that we reap those benefits that you just mentioned?

Farinaz Seifi, MD, FACOG: So, robotic surgery makes our life way easier because, first of all, you sit on a console and you operate on a patient. It saves my back and shoulder, honestly. I can do up to three to five surgeries a day and finish by 5:00, 6:00. And honestly, sitting and doing the surgery all the time, which is great.

And faster surgery means that I can take the patient out of anesthesia faster, because with the magnifying 3D camera that robots give to us, it's way easier than doing the surgery in an open traditional way. And of course, if you see the patient going home the same day with less pain, that's rewarding for every physician.

Melanie Cole, MS: It certainly is. It must be very rewarding. Now, what about candidacy, patient selection? Who is a candidate to be having minimally invasive surgery as compared to someone who may need it in the traditional way?

Farinaz Seifi, MD, FACOG: So, that changed a lot in the last maybe five years with new techniques, new equipments, and better visualization, better instruments. Before, like 20 years ago, when we started, doing a laparoscopy, it was really a very limited number of patients were candidates. But right now, we don't have that much limitation anymore.

We can operate on a wide range of patients from BMI of 20 to BMI of 60. We had a patient which was 300 kilograms, and we were able to do a robotic procedure with no big incisions, and she was discharged home in a very good condition that actually prevents her to have more complication like a blood clot and all other post-operative complications.

So at this point, the size of the uterus and the weight of patient and the body mass index is not a limit. The only limit that can be a little bit questionable is when we are concerned about some sort of cancer, especially an ovarian cyst. If they're complex and you're concerned, we don't want to have any leakage of the fluid of the cyst content into the, pelvic cavity.

So, we have to have a good discussion with patient about the possibility that this cyst may leak, may not leak, or what process we're going to do during the surgery to prevent the leakage, and what is the consideration. Maybe a going on consult, oncology consult, or MRI, or other test to make sure the cyst is a benign cyst before proceeding with the laparoscopy procedure.

Melanie Cole, MS: Dr. Seifi, when we're looking for a surgeon to do these kinds of procedures, what questions would you like us to ask you? How do we find someone like yourself who specializes in these things, who understands all this advanced technology, which is really moving so quickly and is so amazing? What questions should we be asking?

Farinaz Seifi, MD, FACOG: What is my options? What route of surgery should I have? Is there any way that I can have this surgery without a big incision? And do you know anybody that are specialized in minimally invasive that can help me to do this procedure? Can you refer me? And also, I wanted to mention that we, in University of Maryland, we have an option for laparoscopy, which is an incision-less laparoscopy, with no abdominal incision, we can do the vaginal laparoscopy and use the natural orifice to do the hysterectomy or even removing of the fallopian tubes for sterilization with no incision.

Melanie Cole, MS: give us your best advice here. Final takeaways. What would you like us to know about minimally invasive gynecologic surgery and the amazing work that you're doing at the University of Maryland Medical System?

Farinaz Seifi, MD, FACOG: First, don't ignore your symptoms. Don't think everything is normal. Don't ignore your pain, your pelvic pressure, hip pain, back pain. Come to us and we are here. We can offer you a wide range of minimally invasive laparoscopy, robotic, vaginal laparoscopy procedures. You can go back to your work as soon as possible, and you can really improve the quality of your life.

Melanie Cole, MS: Thank you so much, Dr. Seifi, for joining us today and sharing your incredible expertise. It's so important that we women hear what you said here today. So, share this with your friends and family on your social channels, because we are learning from the experts at the University of Maryland Medical System together.

Thank you again so much. And to listen to more podcasts, please visit umms.org/podcast. You can also visit us on YouTube or your favorite podcast platform. Thank you so much for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again. And again, please share this always on your social media. I'm Melanie Cole.