Creating a Family: Talk about Adoption & Foster Care

Uterine Fibroids: Causes, Treatment, and Impact on Fertility

September 01, 2021 Creating a Family Season 15 Episode 36
Creating a Family: Talk about Adoption & Foster Care
Uterine Fibroids: Causes, Treatment, and Impact on Fertility
Show Notes Transcript

What do you need to know about uterine fibroids if you want to get pregnant? We talk with Dr. Desiree McCarthy-Keith, is the Medical Director of Shady Grove Fertility Atlanta and a Board Certified OB/GYN and Reproductive Endocrinologist. She also has a Master of Public Health in maternal and child health. She has been listed in Atlanta Magazine’s Top Doctors for Infertility from 2017-2021 and as one of Black Health Magazine’s Most Influential African American Doctors.

In this episode, we cover:

  • What are uterine fibroids?
  • What are the main symptoms of fibroids?
  • Who is most at risk for having fibroids?
  • Is there a genetic connection to uterine fibroids? Do fibroids pass through families?
  • Why do some fibroids grow very slowly and others rapidly? Is the speed the fibroid is growing something to worry about? How should women track this?
  • Are fibroids always a problem requiring treatment?
  • How to diagnoses fibroids.
  • Symptom distinction between endometriosis and fibroid?
  • What is the best way to medically treat uterine fibroids?
  • Are their alternative medicinal treatments that have been seen to be effective at treating uterine fibroids?
  • When is a hysterectomy the preferred treatment?
  • Skill of surgeon is important when using a surgical treatment. How can a patient determine the surgeon’s skill?
  • Can fibroids cause infertility?
  • Impact of fibroids on pregnancy?
  • What happens to fibroids during pregnancy? If a woman knows she has fibroids, what should she be aware of when she is pregnant?
  • Are their lifestyle factors that contribute to having fibroids or worsening fibroids once you have them?
  • Does diet affect fibroids?
  • Are women with fibroids at a higher risk for uterine cancer or reproductive tract cancers?
  • What other routine medical treatment should women with fibroids make sure they receive?
  • What can infertility nurses do to help patients with fibroid.
  • Other health issues associated with fibroids.
  • Are tampons safe to use? Do they cause or contribute to fibroids? Are the sponge and cup safe to use or better to use?
  • What happens to fibroids after menopause?

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Pardon the errors, this is an automatic transcription.

0:00  
Welcome everyone to creating a family talk about infertility. Today we're going to be talking about uterine fibroids and we will be talking with Dr. Deseret MacArthur Keith. She is the medical director of shady grove fertility Atlanta, and a Board Certified ob gyn and reproductive endocrinologist. She also has a Master's of Public Health in maternal and child health. And she has been listed in Atlanta magazine's top doctors for infertility from 2017 to 2021. And as one of black health Magazine's Most Influential African American doctors, welcome Dr. McCarthy keys to creating a family or we should say welcome back. We are so glad to have you. Thank you so much. Thank you for welcoming me back. I'm looking forward to our conversation today. Well, let's start by just identifying what uterine fibroids are, I think there can be misunderstanding are people think they know a thing or but they actually might not? Yes, so that's a perfect place to begin. So uterine fibroids are the most common benign pelvic tumor in women, benign, meaning they're not a cancer, they're not a bad tissue that are harmful in that way, but they can still impact a woman's quality of life, and how she feels and how she functions. fibroids originate from a particular muscle type in the uterus called a smooth muscle. And it starts with one cell. And that cell divides and divides and may form into these very firm, muscular masses or balls within the uterus. And they can be the size of a pea, they can be the size of a football, and it really depends on the size and the location for if they produce symptoms, and what types of symptoms they may produce. Well, let me ask a question before we do want to get into symptoms. But what determines the size? Is it just that the type of cell but they're all smooth, mirthless cells. So what is the what determines the growth rate? And and how large these fibroids get? You know, we are still learning so much about fibroids. And we don't know or understand why some women will maintain very small pea sized fibroids that never grow. And there are some women whose fibroids become very large or they grow at a faster rate. What we do know just from natural history studies, is that fibroids behave differently in women of different ethnicities. Specifically, women who are Black or African American descent, are more likely to have multiple fibroids. They're larger, they develop at a younger age, and they are more likely to be multiple that lead to symptoms in that ethnic group. Do we know why one ethnicity would have more fibroids and another? Again, we don't understand all of those. All of those factors at this point, we do know that they're extremely common for all women, first of all, so about 70% of all women will be diagnosed with fibroids by the time we're 50 Oh, wow, black women, it's about 80%. And again, for black women, we see the fibroids at a younger age, they grow faster, they're more likely to be multiple related to that. So we believe that it's multiple factors related to just genetics, exposure, tissue type and things that may predispose one group to the fibroids over another. And you answered one of my questions. Is there a genetic connection? And do fibroids pass through families? If your mom has one and your grandmother has one? are multiple? Are you more likely to have a fibroid? We definitely see familial connections with the fibroids. So women who have relatives of fibroids, many of them are more likely to have fibroids themselves.

3:48  
Other than race, is there any other factor that indicates a propensity towards developing fibroids? Will age is an important factor. So fibroids, because they are stimulated by reproductive hormones are much more likely to develop or progress and women of reproductive age. So by the time we're in menopause, our ovaries are no longer producing hormones, particularly estrogen. fibroids usually start to shrink or they do not continue to develop or grow. Once we're in menopause, like we mentioned, family history can definitely be another risk factor for that. Okay, so now let's get to the symptoms. What are the main symptoms of fibroids and obviously, it somewhat depends on their location and their size. Exactly. It's always about size and location. So many women do not even realize that they have fibroids until they're incidentally found on ultrasound or they have a pelvic exam and their provider tells them that the uterus feels enlarged, but the symptoms most commonly related to fibroids are related to the menstrual cycle. So a fiber the very large are there within the cavity of the uterus, where the uterine lining builds up and sheds every month of the menstrual cycle. Those fibroids have more

5:00  
likely to cause heavy menstrual cycles, irregular bleeding between menstrual cycles, more painful menstrual cycles, they can cause pressure in the pelvis pressure on the bladder leading to more frequent urination or just need to go more often, they can press on the rectum and cause constipation or some bowel related symptoms. Some women may have pain with intercourse related to the size or location of their fibroids. Also, my area of specialty is infertility. And we know that fibroids that are particularly inside the uterine cavity where an embryo needs to implant and develop those fibers can impact fertility, they can make it sometimes harder to get pregnant, or they can increase the risk of a miscarriage once a pregnancy is established. With the very heavy bleeding some women experienced they might even become anemic and need blood transfusions or iron infusions and things like that related to their fibroids. Alright, so so it can affect fertility, but that somewhat depends on the location. It absolutely does. And so the fibroids that we focus, predominantly on from a fertility standpoint are what we call sub mucosal. So again, there are many locations for fibroids, they can be within the muscle wall of the uterus, they can be inside the cavity where an embryo needs to implant so baby can develop and grow. They can be what's called pindot circulated, meaning that there's just a stock on the totally on the outside of the uterus and the fiber just kind of hanging off on the outside. On the fibroids that are submucosal are the ones that are in the cavity are the ones that we really focus on when we're looking at fertility because again, the embryo needs to have a healthy place to attach an implant in the uterine cavity in order for the pregnancy to progress. So as fertility specialists, if we see submucosal fibroids, we will often recommend that those be removed before a woman goes through fertility treatment or tries to get pregnant so that she has less risk of miscarriage and better chance for an embryo to implant. So it's it's not just the fact that that it may result in the failure of implantation where the the embryo doesn't have a healthy spot or a

7:12  
nurturing spot within the uterus to implant, but it can also impact the ability of the woman to carry a baby to term is that am I hearing you correctly? Absolutely. So there's many studies showing that when fibroids involve the cavity or even if they're not directly in the cavity if they're large enough that women with those type of fibroids have an increased risk of miscarriage. We know that fibroids can be stimulated to grow from hormones, and pregnancy is the high hormone state. So for many women who get pregnant with fibroids, their fibroids may grow as the pregnancy progresses and the uterus enlarges with the pregnancy. And as the fibroids get larger, they can stimulate the uterus. So women may have preterm labor, they might even have early contractions or an early delivery related to their fibroids. fibroids are very large, they can even distort the uterus so that the baby may be in a different position. It might be breech or it might be transverse or kind of sideways, trying to fit around the fibroids and based on the position of the fetus in the uterus that might require a C section delivery if the baby is not in the proper position for a natural delivery also. Alright, yeah, that makes sense that within that, then we're so in addition to preterm birth, our miscarriage, it could also increase your chance of having to have a C section. Absolutely. And also the risk of higher blood loss and delivery is associated with larger fibroids in pregnancy. Why is high? Why is increased blood loss risk? Well, that's how fibroids are stimulated and that's how they grow. And what we will probably talk about later in the show is one of the treatments for fibroids is taking the blood flow away from fibroid. So fibroids are viable, smooth muscle tissue within the uterus, more blood supply to them. And so if you have more that blood flow going to the fibroids in the uterus, you might have more bleeding related to that when you're going into labor or if you're having a C section delivery. Okay, gotcha. That makes sense. All right. So are fibroids always a problem that require treatment assuming that they're not interfering with your ability to get pregnant or any of the other main symptoms that you described? They are not and and you know, especially because they are extremely common, we we would be working 24 hours a day if we intervened for every single fiber that we see so many women will become alarmed if they're told they have a fibroid ma automatically feel like they will need to have some type of intervention for it. But it's really only fibroids that are causing significant symptoms, whether it's physical symptoms related to their daily function, if their quality of life is impacted, if their fertility is effective, those are the five ways that we

10:00  
recommend for intervention, if again, they're found incidentally at an ultrasound, or they're identified on a pelvic exam with an annual exam and the woman is having those symptoms, then she can just follow those with annual checks with her ob gyn just to make sure that they're stable. Of course, if she starts to develop symptoms at any point, then she would need to talk to her provider and talk about if there's an intervention that needs to be made at that point, is the speed that the fibroid is growing something to be worried about? And how would a woman track this? So there is a subset of fibroids that are actually a cancerous transformation of a fibroid is called a Lyle Mio sarcoma. And those are very different from the very common fibroids that we see. And one of the hallmarks of a sarcoma or allow mouse or coma is fibres that rapidly increase in size. Most fibroids when they're benign, just kind of gradually increase over time. But if you're seeing rapid growth where, you know, you're palpating the abdomen and you can feel a mass there that wasn't there, you know, a couple months ago, then the last year of those types of symptoms are very heavy bleeding, those always warrant and evaluation with a provider to see if this is a fibroid that's giving symptoms or if this is something that is more significant than that regular Natural History of a fibroid is they start off pretty small and they may just increase in size over time. Okay, but it kind of slow gradual rate data.

11:30  
What are the symptom distinctions between endometriosis and fibroids? Because so much of which the symptoms you described are also some of the symptoms of endometriosis? Yes, so endometriosis is where the endometrial tissue or the endometrium is the tissue that lines the uterine cavity. And that is the tissue that builds and thickens every month and then is shed with a menstrual cycle with endometriosis that endometrial tissue gets transplanted to other parts of the body. Most common site for endometriosis is in the pelvis. And the theory behind endometriosis is that for some women, when they have a missional seipel, instead of that endometrial tissue, leaving the uterus through the cervix and being shed as menstrual blood, that the blood goes backwards through the uterus into the fallopian tubes and gets kind of scattered in the pelvis. And so when you see endometriosis that surgery there are characteristic, what we call endometrial implants, they might look like cigarette burns a little dark spots in the pelvis, they can cause a lot of inflammation and scar tissue and things like that. Because of the inflammatory nature of endometriosis, the symptoms are mostly related to pain. Not so much bleeding like you would see with a fibroid but common features with endometriosis are very painful menstrual cycles, pelvic pain at other times even when she's not having a menstrual cycle, or pain with intercourse can be hints that there may be endometriosis present. Alright, so a seeing a ob gyn, would it be able to make a distinction between the two? Yes, and I'll have to say that the definitive way to diagnose endometriosis is with surgery. And we definitely do not recommend that every woman have a surgery just to confirm that we have suspicion based on her symptoms. And a lot of times we can try medications like birth control pills, or other hormonal therapies that can bring the estrogen levels down to see if that can treat the endometriosis. But yes, if a woman is ever having those kind of symptoms, and evaluation with an OB GYN is the first step to kind of determining Is there a uterine enlargement with fibroids? Are there other features of endometriosis Cyst On the ovary or things like that that should be evaluated further? Okay?

13:48  
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14:18  
Now let's talk about the how do we diagnose a fibroid How is that diagnosed? You mentioned ultrasound is one way is ultrasound an effective way of diagnosing fibroid? Yes, ultrasound can be very effective for evaluating fibroids. It's outpatient, it's very easy to perform in most ob gyn offices and fertility office we have ultrasonographer is and we perform ultrasounds frequently throughout the day. So that is an easy way women can also go to a hospital radiology center to have an ultrasound performed. Some another way to diagnose fibroids again is with just a physical exam. So women should have an annual physical exam.

15:00  
And part of that exam is just a palpation of the uterus or using a hand on the abdomen and handed called a bimanual exam. So, hand in the vagina, hand on the abdomen and you kind of are having the uterus between your two hands, where you can assess the size of the uterus, any irregular shape, or potentially any fibroids there. So bimanual exam and a pelvic exam is always very helpful. For women who have very large fibroids. We will often also order a pelvic MRI, which will give much more discreet and clear pictures of the size and location of the fibroids in relation to the uterus, the uterine cavity and other structures within the pelvis. So you said that a lot of times people won't know that they have a fibroid. So if they were trying to get pregnant naturally, and they were not already seeing a specialist. Would if they have a family history of fibroids, would it be recommended that they have an ultrasound before they try to get pregnant? I wouldn't say necessarily before they even try but the first step would definitely be you know, just a physical exam with their ob gyn bimanual exam. If there's anything that stands out from the exam, then yes, and ultrasound be the next step to say uterus feels a little bit enlarged. Let's do an ultrasound to see if there is a fibroid present. When women come to my office for fertility evaluation. ultrasound is a standard part of what we do because we're looking for any factors that may have led to infertility, including anatomic factors. So again, an ultrasound is a less invasive, less expensive way to assess the uterus compared to a hospital MRI or more invasive type of procedures. Okay, that makes sense. So what now Now let's move to talking about treatment of fibroids. So what is the best way to treat to medically treat a uterine fibroid? So there are several options. We many times still fall back on surgery as the definitive way to treat the fibroids that are present. But there are non surgical and less invasive treatments for fibroids and it really depends on the size of the fibroids location if they're symptomatic or not, and also Most importantly, what a woman's reproductive future plans are. So for the less invasive treatments, they may be effective for women who are not candidates for surgery, or who may not plan to have children in the future. But many times from a fertility perspective, women are having surgery to remove the fibroid completely rather than have procedures that may shrink the fibroids or still leave them in place. And what type of surgery is that? Is it? Is it interventional or is it open abdominal? How does that mean? How how invasive is this surgery.

17:57  
So there are minimally invasive and more invasive procedures. And the first distinction to make is that many patients often will come to me and they'll be confused when they hear the term myomectomy. And they often assume that myomectomy means the invasive, most invasive abdominal procedure. And actuality myomectomy just means removing a fibroid. So fibroids are called myomas. And ectomy means removing it the same way that you have an appendectomy or think like that, okay, it's the approach that is more definitive. So you can have an abdominal myomectomy, which means going through the abdominal wall to remove the fibroids that way, there are two approaches for even an abdominal myomectomy. That traditional abdominal myomectomy sometimes we call an open myomectomy. And this is where we make a long incision across the lower abdomen. Similar to like a scar for a C section, kind of a bikini cut is what some people call it, cut the abdomen that way, go into the pelvis and you can directly visualize and touch the uterus. You cut over the outside of the uterus where the fibroid is present. And again, because fibroids are just discrete, very firm muscle balls, they come out in one mass, and they just kind of shell out and pop out when you do that. And so an abdominal myomectomy is going to cut over the surface of the uterus and just exercise or remove each of the fibers that are present. And then you have to sew up the uterus where the fibroid has been removed to repair that defect that you have made in the muscle of the uterus. Another abdominal approach though, is to do this what's called laparoscopically or even laparoscopic with the assistance of a robot. The work inside the pelvis is the same still have to cut over the fibroids and remove them and sew up the defects on the uterus. But because it's done through a laparoscope or a robot, the incisions on the abdomen are much smaller. So compared to a lower abdomen incision across the bottom

20:00  
With a robot or laparoscopy, there are usually three or maybe four one inch incisions, one in the belly button, one in the lower quadrants on both sides and maybe one in the middle. And there are long instruments that are passed through those small incisions so that the work on the uterus this performed through laparoscopic or robotic instruments, instead of manually with your hands and a suture inside the pelvis. The risks of the surgery are the same. The recovery is going to be faster with a robotic laparoscopic because you have smaller incisions to recover from pain after the procedure. And you're back to your normal activities more quickly with that type. Is there a distinction and as far as success is probably not the correct word but efficacy of the of removing the fibroids removing you said they pretty much pop out so it's not it's not so much an issue of removing all of them. But the efficacy of the surgery is there any difference between the two?

21:05  
You know what's most important about the success of the surgery is really the skill of the surgeon so all ob gyn are not trained in robotic surgery or laparoscopic surgery. And so it really depends on you know, the surgeons expertise and what they recommend. So, there are surgeons who perform both types of procedure and they will make their recommendation for which approach based on the size and location of the fibroids and if they feel like they are accessible through laparoscopic incisions or if they really need to be removed through an open incision is is it possible to do an interventional surgery so that there are no abdominal incisions?

21:46  
Yes, and that procedure also myomectomy is called hysteroscopic. So he is does uterus and scope means camera. So a hysteroscopic myomectomy is where a woman still goes under anesthesia, we place a speculum in her vagina and we pass a camera through the cervix and look just on the inside of the cavity. There are instruments that we can pass through the history of scope. And under direct visualization through that camera, we can watch an instrument just shave away or reset those fibroids while we're watching the fibroids that can be removed hysteroscopic least have to be in the cavity though. And so if you have very large fibroids that are on the outside of the uterus, or they're not in the cavity, that hysteroscopy is not the approach that is appropriate for that. It's really fibroid that are completely or predominantly in the cavity that we can see fully and can resect completely through the history scope.

22:42  
procedure. There's no and there's no incisions on the abdomen. So that is an outpatient procedure where a woman goes home the same day. All right, you mentioned that there were non surgical methods of treating fibroids. What are those and when are they call for? So there are medical treatments. We can use medicine to temporize symptoms related to fibroids or to reduce the size of fibroids. For many women if they are not trying to get pregnant and their main symptom related to their fibroids is heavy menstrual cycles. birth control pills can be very effective in producing lighter menstrual cycles more predictable. And that can be some all that some women need to manage their fibroids if they're not trying to get pregnant. There is an injection called leuprolide, which is a it's called a G in Rh antagonist basically suppresses the estrogen production of the ovaries. And so fibroids will shrink if you remove that estrogen stimulation. You cannot take a gnrh agonist indefinitely because it drops the estrogen. So if you take it for prolonged periods of time, it can induce a kind of medical menopause, which is tolerable in the short term, but for long term it will have the same effects of menopause have effects on the bones risk of osteoporosis and symptoms for the woman with her estrogen is low, like hot flashes and things like that. The women who receive the gnrh agonist are usually receiving that in a short term of just a few months, most often to reduce the fibroids so that they're easier to remove that surgery, so they're smaller. But that's not something that women can just take for years and years to just manage their fibroids. There are newer investigations of other types of hormone modulating medications that focus on progesterone, not just estrogen, which may also be helpful in reducing fibroids and those investigations are ongoing. Is the hysterectomy ever a treatment option for fibroids?

24:48  
Yes. And so hysterectomy is definitive and that's going to be removing the uterus with the fibroids intact. Obviously if a woman still desires to be pregnant, and we are not going to

25:00  
recommend the hysterectomies for her. If there's a woman who is has completed her childbearing, she does not desire to maintain her uterus in the future, then hysterectomy may also be an option to remove the fibroids so that she doesn't have any risk of fibroids coming back or any symptoms related to that. Okay, so what happens to the fibroid during pregnancy? it you know there it's a growth in the in the uterus but potentially in the uterine cavity. I guess it doesn't have to be. But it what happens during pregnancy? How does that coexist with the fetus?

25:37  
Well, it can be a challenge. So if fibroids are very small, they may grow but not significantly and a pregnancy can progress normally. If the fibroids really enlarge significantly during pregnancy, again, they can increase the risk for preterm labor and early delivery and those types of things. Also, like I mentioned, fibroids have blood supply

25:58  
keeps the fibroid tissue viable. If a fibroid continues to grow, blood flow may not reach the center of the fibroid. And over time, those fibroids can become what we call necrotic, which means that the center of the fibroid starts to die, because blood is not penetrating all the way to the center of the fibroid. And if you have a necrotic fibroid, it can start to degenerate during the pregnancy, or just if it outgrows its blood supply. And that can cause a lot of pain if you have a degenerating fibroid, and that sometimes can occur with pregnancy. Also, if fibroids become very large, they are taking blood flow from the uterus, and that may affect how much blood is flowing to the pregnancy or the fetus.

26:43  
And that may also be an issue.

26:46  
It's the presence of flu. We know that fibroids are more common in women of color. We also know that the maternal outcomes with birth are worse for women of color. Is there a correlation there?

27:00  
There are many disparities. I'm related to fibroids and the outcomes for women of color. More likely to have definitive surgery and hysterectomy less likely to be offered myomectomy or uterine sparing type of procedures, which are not, you know, permanently sterilizing them if they manage their fibroids. And yes, our outcomes are are related to the fibroids not just with pregnancy, but also with fertility. And so when we look at studies of women of all ethnicities who go through fertility treatment, black women seeking fertility treatment, even IVF are more likely to have fibroids more likely to have uterine factor as their cause for infertility. And we know that pregnancy outcomes pregnancy rates with fertility treatment are lower. miscarriage risk is higher when fibroids are present. And we see that when we look at different ethnicities going through fertility treatment, and specifically that experience for black women.

27:57  
Interesting, okay. Are there lifestyle factors that contribute to either having fibroids or worsening fibroids once you have them? You know, there are some women who, you know, look for dietary factors that may relate to fibroids, it's hard to say if those are a significant factor. Again, we know that fibroids are hormone they stimulated so they're you know, soy has a very weak estrogen effect. We do not have evidence that eating soy products and things like that will cause fibers to grow. You know, significantly. There are certain vegetables that have chemicals in them that may reduce estrogen. So there are certain diets that some women try to follow, um, to manage their fibroids, but there's nothing definitive that we can say if you follow this, then your fibroids will shrink or go away unfortunately, are they do we have any correlation between things such as smoking, or amount of sleep? are anything like that exercises? Have we been able to find any correlation between, again either getting fibroids or the growth of the fibroids when you have

29:15  
nothing that has been substantiated at this point regarding those type of lifestyle factors? Okay. And from a diet standpoint? No, I mean, low estrogen might have some but it's not going to have a significant impact. This is what I'm hearing. We will not the estrogen and soy is very weak and not really considered to be significant in stimulating these types of conditions.

29:37  
So are women with fibroids at a higher risk for uterine cancer or reproductive tract cancers? You mentioned I think it was a sarcoma that you mentioned, that is a specific type of fibroid, so that clearly Yes, they would be but it is there just in general if a woman does not have that type of fibroid, but just has the

30:00  
Well playing run of the mill type of fibroids. Is that woman at a higher risk for uterine cancer or any type of reproductive tract cancer?

30:09  
No, we don't see that association either. And you know, lie Omarosa coma is similar to a fibroid. But it is a distinct category and want to be very clear that when women have fibroids, we don't monitor them or expect that they might change into a sarcoma or anything like that. It's a different type of tissue that develops in a very different way than a benign, kind of very common fibroid that we see. So there's no type of additional type of screening. And if a woman has a fibroid, she should be getting screened more often for uterine or cervical cancer.

30:44  
Well, yes, but not necessarily related to the fibroid. So for women in general, screening for cervical cancer is always very important for reproductive age women. And the guidelines for that have changed in the last couple of years. So we always refer women to their ob gyn to be up to date with their pap smear, whether it's annually or if they can space them out over a longer period of time based on their history of abnormal or normal pap smears in the past. So monitoring for cervical cancer is important for women, whether they have fibroids or not, if a woman knows that she has fibroids, then yes, she should have routine evaluations with her ob gyn every six to 12 months or so just to monitor the fibroids make sure that they're stable, that there have been no changes. And of course, if a woman has fibroids, and she's been doing well, and all of a sudden she starts to have more menstrual related symptoms or pelvic symptoms, then she should see her ob gyn sooner. What if for no other reason, if she is wanting to get pregnant, making certain that she is her ob gyn is aware and can be giving her advice on that. As far as that whether the physician needs to worry about them, it would be important, I would think,

31:58  
absolutely. And one thing we didn't mention is that, you know, with the myomectomy, depending on the approach, a woman would need to wait a certain period of time before it would be safe for her to even get pregnant. So the hysteroscopic, again, is an outpatient procedure kind of shaves a fibroid off from the inside of the cavity, no incisions with that type of procedure, women can try to get pregnant a month or two after that surgery. If a woman has an abdominal myomectomy, whether it's through the open incision, or laparoscopic or robotic, once you cut deep into the muscle or the wall of the uterus, that way, you have to wait for that incision or that scar in the uterus to heal before it's safe to get pregnant. So after an abdominal myomectomy of any approach, we usually recommend that women wait at least three to six months after that procedure before they try to get pregnant, and that is to give the incisions on the uterus time to heal. If you cut fibroids out of the uterus and get pregnant too soon, you can rupture those scars or rupture the uterus where it's been cut if you have not allowed adequate time to heal. And even if it's years after an abdominal myomectomy, women would need to have a C section for any delivery, we would never want them to go into natural labor or have very strong contractions of the uterus, where it's been cut in that way. So having an abdominal myomectomy that goes deep into the muscle of the uterus, commit to women to having a C section for any pregnancies or deliveries in the future is once you cut the uterus, is it always going to be a weak spot or the potential for rupture?

33:33  
Yes, and that's why we wrecked why we would schedule a C section. And so again, if even if it's been, you know, 10 years since the mile maximum of myomectomy was performed. When that woman is pregnant, her ob gyn is going to schedule a C section about a week before her due date before she even goes into labor so that she can have a controlled and scheduled delivery and is not at risk of going into labor and having strong contractions where that uterus has been cut at some point in the past. If in the procedure that's interventional where you are shaving off the the fibroid that's inside the tissue inside the uterine cavity. Is there a danger of causing scar tissue? Because I don't think that that scar tissue or I would ask I would imagine that scar tissue is not as as nurturing of a implantation spot, as would be regular endometrial lining. So is there a risk there?

34:31  
Yes, there absolutely is. And there's a risk of scar tissue. With an abdominal procedure as well. The scar tissue could be inside the cavity or also in the pelvis when you have an abdominal procedure, but for a history of scopic approach as you go into the uterine cavity and are removing tissue there that can cause some inflammation or possible scar tissue of the uterine cavity. If there's a significant fiber that is removed, to prevent scar tissue, sometimes we will prescribe estrogen after the person

35:00  
To let that area heal over and let the endometrium develop and grow where the fiber has been removed. Sometimes we will even place a balloon inside the uterus and just inflate that right after we remove a fibroid and keep the walls of the uterine cavity separated until they heal so that there's less likely to be scar tissue to form immediately after that procedure. And we leave the balloon in the uterus for about a week, and then remove it after the uterus is at some time to recover from that type of resection. With the abdominal approach, scar tissue is possible in the uterine cavity but also in the pelvis. So for women who've had an abdominal myomectomy, we often want to evaluate her fallopian tubes after the procedure. So even if she's had normal abdominal cavity, normal open fallopian tubes prior to mom ectomy. scar tissue is just a form of healing of the body. And some women may have very minimal scar tissue from having an abdominal procedure, and some women may have significant and if scar tissue forms around the fallopian tubes, after the mole megami that may potentially damage or close off the fallopian tube, so that uterus is repaired. But now if there's a tubal blockage, that is another infertility factor that we would need to address and how and how do we Is there a way a woman will know ahead of time, whether she is going to be more likely to produce scar tissue. I mean, there are definitely and I think there may be ethnic differences on the production of scar tissue. But I certainly know that certain people know that at least externally, they scar quickly, or produce a lot of scar tissue in it with that type with that woman also need to worry that that would be internal as well, so that she needs to be thinking at a doctor who is is very aware of the potential for scar tissue. There is potential for more scar tissue if a woman is predisposed to that other inflammatory conditions in the abdomen and pelvis can lead to scar tissue like endometriosis that we mentioned can cause scarring as well. The surgical technique is very important. There are no products that can be applied over the surface of the uterus where it's recently been cut or suture to reduce scar tissue in that way. And so there are techniques and equipment that can be used to reduce the risk of scar tissue. But again, scar tissue is just a form of healing. And there's no way to absolutely guarantee or prevent all scar tissue from occurring. As soon as you have an abdominal procedure and touch tissue in the pelvis and tissue is exposed to the atmosphere. You know, you can have scar tissue to form as part of that procedure. It is worth it from a patient standpoint to talk about this possibility with their doctor though. Absolutely, yes. And so whenever we counsel patients about especially abdominal myomectomy, there are risks to it being a major surgery, and the risks are bleeding anytime you have an abdominal procedure. If bleeding is significant, or a woman is anemic, she might need a blood transfusion during or after the surgery. Not very often, but that can occur. scar tissue can occur like we mentioned, there are other structures in the pelvis. So the blood vessels, nerves, intestines, bladder, the fallopian tubes, and the ovaries are all in the same vicinity as the uterus. So there's a risk of injury to pelvic structures. If you have an abdominal procedure. That's why the skill of your surgeon is very important. Have to have general anesthesia to have that procedure. So there's a risk of reacting to any anesthetic that you have. So it's important for women to be healthy and appropriate for surgery to expose them to those risks. There's also a risk of fibroids growing back. So even if every fibroid that is visible is removed. That does not guarantee that a woman won't have fibroids in the future. And we have all seen women who've had more than one myomectomy where all the fibers are removed. And at some time in the future, they've had fibroids to develop again and require the repeat procedure. We offer what

39:10  
this show would not be possible without the support of our partners and our partners are organizations that believe in our mission of providing unbiased medically accurate information to the patient community. One such partner is Christ's international sperm and egg bank. They are dedicated to providing a wide selection of high quality, extensively screened frozen donor sperm and eggs from all races, ethnicities and phenotypes. And they do this for both home insemination and fertility treatment. prayas International is the world's largest sperm bank and the first freestanding independent egg bank in the United States helping to provide the gift of family and we thank them for their support.

39:54  
So you've mentioned the skill of the surgeon is being important which makes good sense that would be the case. Anytime you're having

40:00  
Surgery I'm sure how can a patient determine this skill of their surgeon and with their surgeon be their regular ob gyn? Is there a specialized surgeon that they should be seeking? What questions should they ask to make a decision on whether this is the person that they want to be performing their surgery? Sure. So myomectomy is a very standard routine, General gynecologic procedure. That is a part of your standard training in becoming an OB GYN. So a woman's ob gyn may be the appropriate person to perform her surgery. There are gynecologists who have done additional specialized training, specifically in robotic surgery or laparoscopic surgery, they may have done a fellowship focusing just on on pelvic surgery, you can look at a surgeon's certification, their affiliation with laparoscopy groups or robotic associations and things like that. In meeting with a surgeon, it's important to ask them how many of that type of procedure have they performed? How often, you know, patient reviews, all those things are very important when you're choosing your surgeon. Okay. Are there alternative medicine treatments or alternative medical treatments that have been shown to be effective at treating uterine fibroids outside of surgery?

41:26  
Yes, so another that we haven't touched on yet is the uterine artery embolization, which is a non invasive outpatient procedure to treat the fibroids. Sometimes it's called a uterine fibroid embolization but it's truly the uterine arteries which are immobilized or blocked off or closed. So this is a procedure, which is performed by an interventional radiologist. For that procedure. There are large blood vessels in the groin, and the femoral arteries are in the groin. And a radiologist can pass a catheter through the femoral arteries up to the blood flow to the uterus, which are the uterine arteries. The uterine arteries provide the majority of the blood flow to the uterus. There are collateral blood vessels that also provide blood flow to the uterus, but the majority comes from the uterine arteries. And so the embolization procedure, radiologist can pass a catheter through the femoral arteries up to the uterine arteries, and then inject permanent pellet into the uterine arteries and it will occlude or block off those blood vessels. Again, we've talked about fibroids are stimulated, are fed by blood flow. So if you block off major blood flow to the fibroids, fibroids will shrink. If you remove that blood flow 3d the uterine artery, again, there's enough collateral circulation from other blood vessels so that the whole uterus does not become compromised and die off, I was just going to say that can't be a good idea to block the uterine artery. I mean, yes, that's like throwing the baby out with the bathwater.

43:04  
Well, again, thankfully, the collaterals are going to spare the uterus. And so what you usually see is that the fibroids will shrink, when you take away a good amount of blood flow to the uterus. The reason that this can be complicated for some women is because there is some reduction in blood flow to the body of the uterus when you do that. And so from a fertility perspective, we do not encourage women to have and uterine artery embolization if they plan to carry pregnancy in the future, because for some women, after a UAE, UAE, they may become pregnant and have a successful delivery. For other women that removing blood flow through the uterine arteries can affect the overall function of the uterus and can affect how the endometrium develops, it might lead to problems with how the placenta develops and attaches and grows into the uterine wall. And it can complicate a pregnancy after you at the main issue is that if you have a embolization procedure, and you don't have any symptoms, you're fine. But if you have a poor outcome from that procedure, it is permanent and irreversible. And so if the uterus is compromised, there is no way to go back and remove those pellets or restore that blood flow. Once the uterine arteries have been occluded, it is intended to be permanent and irreversible.

44:24  
Yeah, has there been any research on any form of complimentary medicines, acupuncture, anything along those lines that has been shown to be effective, not for a significant reduction, possibly for symptom relief and those type of effects but again, you know, we we go back to the surgery or these five, you know, procedures that can really target fibroids and reduce the blood flow or shrink them that are most effective. There's another a newer procedure that uses directed radio frequency

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energy or heat, where you can apply a probe directly into a fibroid and use heat to just coagulate or heat up that tissue, and then the tissue of the fiber will die that way. And when the when the tissue dies, what happens? It's dying, your body just absorbs it. Yes, it does. So and it can be a little painful initially as that necrosis is occurring. But yes, as the tissue kind of coagulates and dies, it just kind of shrinks down and gets smaller. For those type of procedures, or for the fibroid, embolization. A lot of times the fibroids will get smaller, but they may not completely disappear. And so we often are, we sometimes may see a woman who's had, you know, a uterine sparing procedure, and fibroids are still enlarged or still symptomatic. And she may end up having an abdominal procedure or surgery to remove the fibroids that we're not, you know, completely resolved with the less invasive treatment. But if she is knowing she wants to have children, then it does this in certain cases, would it make sense to the less invasive to prevent the risk of scar tissue or damage to any of the ancillary reproductive tract organs for that surgery might cause? Is that an option as well? It may be but again, with the less invasive you know, it's very attractive for women to hear, you know, go home, same data procedure, leave with a bandaid instead of an incision across your abdomen, get back to your daily life more quickly. But if you take the blood flow away from the uterus, and the remainder, the uterus does not function well. Right in that reverse. That seems a little Yeah, but what about the one that's ablation?

46:46  
And that is a newer procedure. So we don't we have a lot more experience with the embolization. And we've seen outcomes from that the radio frequency and those procedures are newer, just last couple of years. And so we you know, we're still kind of evaluating those for fertility. Yeah, too early to know. Okay.

47:06  
What can infertility nurses do to help patients with fibroids? They're obviously if they're if the patient is coming in, they at this point, they at least one of the symptoms is likely involving fertility, or they wouldn't be at an infertility clinic. So what's the role of nurses at that point? I think that the the first thing for nurses is to just be educated about the fibroids and what they are with their origin, what type of symptoms they may they may produce and if they are informed about that, then they can counsel patients or you know, relate to the experiences that they're having. From the fibroids. Again, they're extremely common. And so if they're familiar with the treatment options, or what we may recommend, then they can be there to support patients, as we make those kind of plans for how to take care of the fibroids.

47:56  
Knowing about it would be extremely helpful, and understanding what the experience and what the symptoms and what the issues potentially would be, because that's where patients really need the help. Exactly, and what not just from a fertility standpoint, but what we don't we need to recognize is that fibroids can significantly impact a woman's quality of life. If she cannot go to work for several days every month, because she's bleeding so heavy, she's having accidents, she's bleeding unscheduled, she has to take a change of clothes with her everywhere she goes, she cannot engage in intercourse with our partner because of pelvic pain or irregular bleeding. These are very significant impact on her daily function. And so we have to recognize the impact that fibroids can have just on the quality of life as well as you know, physical effects or fertility effects. So what are some of the other health issues associated with fibroids? You mentioned one, which would be anemia associated with heavy menstrual flow. Are there other health issues that we've talked about needing to be assessed for the growth the how quickly they're growing? So regular appointments or other things that need to be addressed other health issues, if you've got fibroids you need to be aware of, you know, it's really just related to the size and the location of the fibroids. Again, we keep coming back to these kind of common themes. For some women. If the uterus is so enlarged with the fibroids, it may even press on her ureters which are the tubes that drain the kidneys into the bladder. And if you have pressure on your ureter, you can start to have dilation of the ureter and it can affect kidney function and things like that. And so we really don't want women to let their fibroids go undiagnosed or unrecognized. And they progress to a point where they're extremely large, they're causing more symptoms mostly related to pelvic pressure and just relation to other structures in the pelvis, anemia, blood transfusions and things like that can be very significant. Yeah, for sure. And also if the fibroids are too

50:00  
Large, it can complicate the surgery. So it would be much easier and lower risk to remove smaller fibroids and, you know, higher risk procedure of removing fibroids that are up to the rib cage or something like that which we have all seen. Wow. And if that case is a hysterectomy, and if they're just so large and assuming the woman is finished with childbearing, or does not want to have children, is that when you would just say, all right, at this point, it makes sense just to take the fibroids intact in the uterus.

50:33  
Possibly so I mean, that would definitely be you know, if a hysterectomy compared to a myomectomy usually has lower blood loss. The surgery time is faster to just remove the whole uterus versus carving out fibroid and having to sew up each place on the uterus and things like that. But if there are women who for you know, fertility reasons are just because they don't want to have their uterus removed. Say I do not want to have a hysterectomy. They may still undergo a myomectomy with a skilled surgeon even if the uterus is very enlarged, and I've seen positive outcomes from that as well.

51:08  
A question that we get not infrequently is about the safety of tampons and whether or not they cause or contribute to fibroids. So let me ask that question.

51:21  
I do not know of any association with tampons and fibroids more often you're thinking about toxic shock syndrome and things like that. But nothing that would cause a fibroid to enlarge or change the Natural History of the fibroid, I would say. Okay, excellent. Well, thank you so much Dr. Deseret McCarthy Keith for talking with us today about uterine fibroids. I truly appreciate it. And to our audience. Thank you for being with us. And I will see you next week.

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