Fibroids – Interview With Dr. Linda Bradley

	Dr. Linda Bradley Cleveland Clinic Dept of Obstetrics and Gynecology Vice Chair of Obstetrics, Gynecology and Women’s Health Institute Expert in minimally invasive gynecological surgery Dr. Linda Bradley talks with NWHRC Executive Director Elizabeth Battaglino Cahill, RN about medical options for treating fibroids using minimally invasive techniques.

Video Transcript

Dr. Bradley, what exactly are fibroids?
Fibroids are the most common, benign, non-cancerous growth within the uterus in women. Mostly occurring during the reproductive years.

How does a woman know if she is at risk for fibroids?
Well actually all women are at risk for fibroids. Approximately 75 to 80% of women have fibroids. It’s more common the older the patient becomes. More common if it runs in your family and more common if the woman is of African descent.

How does a woman know if she has fibroids?
Well the good news is that only 50% of women actually have symptoms. So the other 50% may have symptoms that lead her to see a physician and those symptoms might be things like abnormal bleeding, abdominal pressure, severe menstrual cramping, pain with intercourse, maybe a cosmetic effect where a fibroid, which is the muscle of the uterus gets thicker such as the woman has a protuberance of her abdomen or even difficulty becoming pregnant. And then lastly, sometimes pressure symptoms where she is urinating frequently or even having symptoms like constipation. So it’s a constellation of these symptoms that often drive a patient to see a physician. But as I mentioned, the best news is that most women who have them have no symptoms.

Can you develop fibroids at any age and do they change with age?
Actually most women develop fibroids in their twenties, thirties and forties. Very rarely in the teen years and virtually no evidence of growth once a woman enters menopause. So, again, it tends to be during the reproductive years. If I had to choose an age, I’d say between 25 and 45 are the most common times women will present with symptoms.

Do they ever get smaller on their own and/or do fibroids just go away?
That’s the best news about getting older is that they do get smaller. I always tell my patients we diagnose it by, most often by ultrasound, so even if someone gets to be 105, we’ll see the imprint or the footprint of fibroids but the symptoms won’t be there. So generally after age 50, while they may have the fibroids, they shrink in size and then the symptoms go away.

What are the options available for treating fibroids?
I think it’s important for women to know that there are many options. But fibroids are unique and one of a kind. And so the treatment options depend upon the patient’s age, her desire for fertility but most importantly remember the size and the location of fibroids. I like to usually explain to my patients that the uterus has three components. The most inside is where baby lives. And if a fibroid is located only in that region the approach might be hysteroscopic where there’s no incisions made in the abdomen. If it is in the muscle of the uterus, then it may be approached laparoscopically, also with something called mini-laparotomy or tradition open surgery. Once in a while fibroids can just be also removed vaginally, depending on if they’re in that location. So size, number, location would dictate how a physician approaches the treatment. There are some fibroids that are as small as a walnut. There are others that are as large as a watermelon. So, again, we have to look at so many different things in terms of techniques. When possible, however, if the patient meets the inclusion criteria for a minimally invasive procedure, we strongly urge women to look for those options.

Can these treatments be done on an outpatient basis?
There are some procedures like a hysteroscopy that can be done as an outpatient procedure where the procedure takes about an hour and the patient is usually home about three hours after surgery and able to get back to work within a day. Then there’s laparoscopic procedures that also allow patients to either go home that day or the next day. And then the traditional myomectomy, which is done abdominally, would keep a patient in the hospital on the average in the U.S. about two days and a recovery of about four weeks. So, again, it’s hard to give one answer because there’s such a variety and ways that fibroids look and so we have to look at the whole patient before we can say. But you’re right, there are times we can do things where they go home the same day.

How do different treatments for fibroids affect a woman’s fertility? What should a woman who wants to have children do?
Well if the patient wants to have kids and is having no symptoms from the fibroids, in general we do not recommend any treatment whatsoever. If she’s trying to get pregnant, we try to determine whether the fibroids are impinging or blocking the fallopian tubes or if they’re in the compartment, the space where baby would live. So no symptoms, no treatment. And if they are having symptoms, then again we have to really individualize the type of surgery that a patient might have.

If a woman thinks she has fibroids, who should she talk to?
I think if a patient is having symptoms she should speak with her gynecologist. That’s going to be the first best step. Of if she is seeing a healthcare provider like a nurse practitioner or a midwife. So basically a healthcare provider and then once she is seen we often like to confirm the concern about fibroids, with usually doing an ultrasound.

Lots of women have seen the same gynecologist for many years but their doctor might not offer all of the latest treatments for fibroids. How does a woman know if she should seek a second opinion?
A second opinion should be sought I think certainly if a patient wants to have children and her only option being given is a hysterectomy. So I think you want kids and your doctor says hysterectomy the odds of your needing that are very, very low and I would say in those situations most certainly look for a second opinion. When you’re looking for a second opinion so that tests are not repeated, take a copy of your Pap smear with you, take a copy of your ultrasound report and maybe the last two or three-year office visit notes to see if that fibroid has grown. Or if a patient is told that they need open surgery, traditional surgery, I think it’s a good idea to get a second opinion to see whether that is actually what’s necessary. There are times that minimally invasive surgery can’t be done but more times than not again a hysteroscopy or a laparoscopic approach would be something that a patient might be able to have.

If a woman with fibroids does need a hysterectomy, is a laparoscopic hysterectomy ever an option?
Yes. laparoscopic hysterectomy is an option. We look at the surgeon’s skills. But again, getting back to the size of the uterus, the number of fibroids and the location. But I think working with a physician that has all skill sets, traditional surgical skills, laparoscopic, vaginal, hysteroscopic and an additional skill, sometimes even to prevent surgery at all would be the use of something called uterine fibroid emobolization or uterine artery embolization, which is a totally non-surgical procedure that in women who do not want children can also be offered. So it’s a totally non-invasive surgically invasive procedure that can be done.

What does it mean to women’s healthcare that the number of hysterectomies performed each year has pretty much remained the same for the last 25 years and that the dominant type of hysterectomy used is the oldest procedure, the open abdominal hysterectomy?
Well I think it speaks volumes of a need for change. So I think that physicians need more training. Our training programs such our residencies and internships need to begin to teach physicians about new alternatives. Patients also should look at maybe sometimes medical therapies or other non-surgical approaches. For some women they’ve come in demanding that they have hysterectomy. And some women are not willing to wait for alternatives. I tell my patients that medicine is not like McDonald’s, meaning that sometimes we need to try things, we need to give it time to look at medical therapy, to take notes to journal, those kinds of things. And then not make a rapid decision for a surgical approach.

Thank you very much, Dr. Bradley.
Thank you.