Online Health Chat with Linda D. Bradley, MD, and Rosanne M. Kho, MD

Thursday, April 13, 2017


Description

It’s a fact: 50 percent to 80 percent of women will develop fibroids during their lifetime, depending on age, family history and ethnicity. Of those women, about half will have symptoms, which can be painful, frightening, and include excessive bleeding, pain during sex, pelvic pain and an enlarged abdomen. If you’ve been told you have fibroids, or think you might have them, this chat is for you. Get the facts and know your options. Learn what fibroids are and who is at higher risk for them. Find out how they are diagnosed and what medical treatments are available. If it looks like surgery is your best option, know that a total hysterectomy is not your ONLY option.


About the Speakers

Linda D. Bradley, MD, is an internationally recognized gynecologic surgeon known for her expertise in diagnostic and operative hysteroscopy, endometrial ablation, alternatives to hysterectomy, hysteroscopic sterilization and the evaluation of abnormal uterine bleeding. She is a gynecologist at Cleveland Clinic in Cleveland, Ohio and is vice chair of the Ob/Gyn & Women’s Health Institute, as well as the director of the Fibroid and Menstrual Disorders Center and director of Hysteroscopic Services. She was elected to the Board of Governors at Cleveland Clinic from 2006 through 2010. Dr. Bradley specializes in the evaluation, diagnostic testing and surgery for uterine fibroids and menstrual disorders. Her expertise in endometrial ablation technology makes her an innovative leader in the field of hysterectomy alternatives. She recently was involved in several multicenter clinical trials involving endometrial ablation, uterine fibroid embolization compared to abdominal hysterectomy.

Rosanne Kho, MD, joined Cleveland Clinic as director of Benign Gynecologic Surgery in 2016. Her clinical and academic work has focused on advancing vaginal and minimally invasive surgery. Dr. Kho was involved in the early adoption of robotics in gynecology during her fellowship training that has led to multiple publications evaluating the appropriate application of the technology in the field. She is a strong advocate of the vaginal approach for benign hysterectomy and is recognized for her passion to bring vaginal surgery back into the armamentarium of the gynecologic surgeon. In recognition of her expertise in vaginal surgery, Dr. Kho was the Donald Richardson Memorial Lecture Speaker for ACOG ACM in April 2014. Recently, she developed an online module on the essentials of vaginal hysterectomy in collaboration with AAGL, ACOG and SGS. In addition to speaking on these topics, she has participated in live surgeries nationally and internationally to demonstrate the applications of robotics and vaginal surgery in gynecology. Dr. Kho is published in the field of gynecologic surgery, having authored many peer-reviewed articles and book chapters. She serves as a senior editor for Journal of Minimally Invasive Gynecology.


Let’s Chat About Fibroids


Non-Surgical Solutions

Jani: Are blood clots common with embolization? I have waited 20 years for the right procedure (translation: I do not consider hysterectomy an option); therefore, the fibroids are enormous. They protrude past my ribcage.

Rosanne_M._Kho,_MD: Complications with blood clots are very low with embolization and are certainly lower than with surgery. However, you should be evaluated to determine if you would be a good candidate for this procedure. There are many factors to be considered, including the number, size and location of your fibroid(s). Also, whether you have any medical conditions that would preclude this as an option must be considered. For surgical options, hysterectomy is not the only option. Removing the fibroid(s) alone to preserve the uterus can also be considered.

pmpo68: I'm 52 and have fibroids, and I know that one of them is quite large. In 2014, I had a D&C. At that time, the doctor didn't want to surgically remove the fibroid, as he felt I might go into menopause within a year or so, and I agreed with that. Initially, the surgery seemed to relieve the heavy bleeding I was having, and I even went three or four months without a period. Then, I started having somewhat regular cycles with no cramping whatsoever. That went on for many months. In February of this year, I had horrible cramping (to the point of calling off work) and heavy bleeding. This happened again in late March; I had cramping, but not as severe. Why would the cramping return like this, and are there any treatment alternatives to help avoid surgery if I'm close to menopause?

Linda_D._Bradley,_MD_: This is a great question. The pattern you have now with skipping menses is consistent with the perimenopause. When you skip menses, it is an age-related phenomenon related to a decline in progesterone. This can be easily managed with medication. Pain from fibroids is often related to degeneration of fibroids. It would be great to be re-evaluated by your physician. I would recommend a special type of ultrasound called a saline infusion sonogram to evaluate all areas of the uterus and to allow for the evaluation of your ovaries. Most menstrual cycles stop between ages 51 through 58. Have a talk with your gynecologist for re-evaluation. We would also be happy to see you for a second opinion if desired. We offer virtual visits.

Note: You may need to call 216.444.6601, toll-free at 800.223.2273 (extension 46601) to confirm the schedule of the virtual visit.

GuestVisitor: If I have fibroids and heavy bleeding at age 52, what is the risk of doing nothing and waiting it out until menopause?

Rosanne_M._Kho,_MD: Thank you for joining us. To determine if you need to do anything at this time depends on a thorough evaluation, including imaging and an endometrial biopsy. These are done to make sure as much as possible that a pre-cancer or outright cancer is excluded, symptoms such as debilitating bleeding (causing anemia) and pain, as well as to determine the size, location and number of your fibroid(s). It is important to know that fibroids do not "disappear" during menopause, but may decrease in size/volume. If the location of the fibroid is determined not to be a cause of your bleeding, you certainly can continue to observe only at this time. However, if the fibroid is within the cavity or impinging upon the cavity, then removal should be considered. We would be happy to see you in clinic or with a virtual visit to help you with this decision.


Signs and Symptoms

GuestVisitor: I have had fibroids for more than 10 years, and my periods have increased to eight to nine days over the past year or so with very heavy bleeding. I have had a biopsy, and there were no issues. I am slightly anemic and don't have any other medical issues. In May, I will be 52. When it comes to intervention, I'm a minimalist and would rather not take pills to reduce bleeding nor have a procedure to minimize or stop the bleeding. What are the risks of not doing anything and waiting out the heavy bleeding until menopause? Are there any holistic medicine options?

Linda_D._Bradley,_MD_: It's important to know the location of your fibroids. If they are located in the uterine cavity (also called submucosal fibroids), they can be easily treated with a brief outpatient procedure called operative hysteroscopy. We feel that localization is best with a specialized transvaginal ultrasound called saline infusion sonography. Additionally, a non-hormonal, FDA approved medication called Lysteda is very useful in treating heavy menses. A blood count should be done to exclude anemia, and I would recommend a thyroid-stimulating hormone (TSH), to exclude a thyroid condition that also can be associated with heavy bleeding. Anemia can be associated with a decrease in quality of life symptoms including fatigue, shortness of breath, craving ice, loss of hair and lethargy. Please see your physician for re-evaluation.

MineOrYours2: Hello, doctors. I have seen three different gynecologists in the past two years, and no one seems to be able to tell me what my problem is. They say there is none. I don't get my period every month, and when I do it's extremely heavy. I do have pain during sex when a certain area is contacted. I have pain in the area below my bellybutton but above my pelvic bone. At times, this pain lasts for no longer than a minute. I've had an ultrasound of my cervix, and nothing was a problem. They tested my blood levels, still nothing. Do you have any ideas what this could be?

Linda_D._Bradley,_MD_: I would recommend you have an MRI of the pelvis with and without contrast to rule out adenomyosis, which is a condition that can cause severe pelvic pain, pain with intercourse or heavy bleeding. There are many causes for missing a period, including medications, thyroid disease, stress, weight, exercise, age, polycystic ovarian disease and many other conditions. This concern really requires a physician visit. Feel free to request a second opinion appointment at Cleveland Clinic.


Finding Fibroids

fran49: I am a post-menopausal woman in my 60s who needs another surgery to have fibroids removed again, one year later. Since I have had the office procedure during which the fibroids were found inside my uterus, how do I know if they are not on the outside also? Is there another procedure or ultrasound for that, and shouldn't it be checked out ahead of time so there is a whole picture of what is going on to get the best and, hopefully, final surgery?

Rosanne_M._Kho,_MD: Hello. It sounds like you had a hysteroscopy or ultrasound done in the office during which the fibroid inside the cavity was diagnosed. It also appears that you were noted to have another one diagnosed after a previous surgery. Indeed, an imaging test such as one with a thorough pelvic ultrasound or MRI can be done to evaluate for other fibroids. This imaging can be obtained depending on your symptoms (abnormal bleeding or pain) and physical exam (such as enlarged uterus).

MK: In a recent CT scan, I was found to have an enlarged uterus with multiple rounded heterogeneous masses internally measuring up to 7.0 x 1.8 cm. Are these the same as uterine fibroids? I had Novasure ablation in 2006 for heavy periods and was diagnosed with MS in 2008. Can or should I have anything done now to get rid of the fibroids?

Rosanne_M._Kho,_MD: Hello. Not having seen the images or the report of your recent CT scan, it sounds indeed like the uterine masses are fibroids. The measurements, however, do not sound quite right. Fibroids are very common. Up to 70 percent to 80 percent of women have them. Just because they are seen on imaging does not mean any intervention needs to be done. It would be important to know if you have any symptoms, such as abnormal bleeding, pelvic pressure, pain, etc. If not, I would not pursue any intervention. If you are having any of the symptoms mentioned, you should inform your gynecologist and be seen in clinic.


Medical Management

fran49: Because my post-menopausal fibroids keep reoccurring, for my next procedure, I will have a Mirena IUD implanted. This concerns me because of the hormones and possible side effects of the device. I have been Xanax-dependent for more than seven years and always will be. My dosage is 1 mg four times a day every day. The side effects of Mirena worry me since I was first treated for PTSD and am still being treated for anxiety and panic attacks. Also, the chance of weight gain would not make my cardiologist happy, with my CHF and DCM causing shortness of breath. My ability to exercise is limited. Is this the correct procedure for me? Do you have any thoughts?

Rosanne_M._Kho,_MD: Hello. I am assuming from your note that you presented with abnormal bleeding during menopause and was noted to have fibroids. It would be important that pelvic imaging and an endometrial biopsy have been obtained to exclude pre-cancer or cancer of the pelvic organs. If pre-cancer or cancer has been excluded, with your existing medical conditions of CHF and DCM, I would agree that medical (as opposed to surgical) therapy would be the next best option. The Mirena IUD (which contains progesterone) is a good choice. It requires only an office procedure for insertion. It lasts five years and can protect your endometrium (or uterine lining) from pre-cancer or cancer. The Mirena should not interact with your Xanax. The side effect of weight gain is also a very small risk (and certainly much less than taking progesterone by mouth).

fran49: When a women is over 65 and has other serious health issues (heart disease), is there a point at which it might be better to do a complete hysterectomy instead of inserting an IUD? In five years, she will be in her 70s and possibly in a weaker health state for surgery.

Rosanne_M._Kho,_MD: Hello. You pose a good question. It would be important to determine the indication for a hysterectomy. With other, "serious" medical condition such as heart disease, the risks of anesthesia and surgery need to be weighed against the risks of medical therapy (such as with a Mirena IUD). When pre-cancer or outright cancer has been excluded, the Mirena IUD is a good option to protect the endometrial lining. I would discourage pursuing a surgical procedure now because of fear that you might be in a worse medical condition in the future and especially if the Mirena IUD is working. You should know soon after insertion of the IUD if the bleeding associated with menopause resolves.

fran49: Dr. Kho, I do not have bleeding right now but do have fibroids that have reoccurred with slight pelvic pain. The best guess is that being on Eliquis is part of the problem. Since I will always be on a blood thinner, my fear is getting ovarian cancer at a later date, so why not remove the organs that are no longer needed before I get too old or too frail because of age or a heart condition to do surgery at all.

Rosanne_M._Kho,_MD: Hi Fran. It would be helpful to have a thorough discussion with your gynecologist or one of us via a virtual visit, if appropriate, to review your entire condition. Surgery while on anticoagulation can entail complications such as bleeding. Again, we would be happy to go through your entire condition.


Double Trouble

LexiKY: What treatment options are to be considered if you have fibroids (in the muscle wall) as well as endometrial hyperplasia? Is a D&C, as well as an ablation, a solution rather than a hysterectomy?

Linda_D._Bradley,_MD_: Endometrial ablation is totally contraindicated when a patient has endometrial hyperplasia. There are several types of endometrial hyperplasia that can be associated with future development of endometrial cancer. Patients with complex atypical endometrial hyperplasia should be treated with a minimally invasive hysterectomy. Lesser types of endometrial hyperplasia can be treated with progesterone hormone therapy for three months. This requires repeat endometrial sampling (biopsy) to make sure that it goes away. It also may be treated with a Mirena intrauterine device. A D&C must also include the use of a hysteroscope at the time of surgery, as the doctor must visually see all the tissue that is being removed. Depending on the type of endometrial hyperplasia that exists, there may be other methods to treat it. Don't get lost to follow up.


Closing

That is all the time we have for questions today. Thank you, Dr. Bradley and Dr. Kho, for taking time to educate us about Fibroids.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at http://my.clevelandclinic.org.

Linda_D._Bradley,_MD_: Thanks for participating in this chat. Most gynecologic conditions are benign and not malignant or cancerous. However, it is very important to see your physician if there are changes in your menstrual bleeding that affect the quality of your life, interfere with sexual function, cause ongoing pain or are associated with persistent abdominal bloating. There are many treatments for menopausal symptoms, vaginal dryness, hot flashes/night sweats, infertility, cancer and urinary or bowel incontinence. Tremendous advances in minimally invasive gynecologic surgical procedures are available for most gynecologic conditions.

Take time for yourself to keep up-to-date with screening recommendations for Pap smears, mammograms, colonoscopy and vaccinations. Don't ignore symptoms, and don't forget to follow up for additional testing if that is needed. Use your annual exam to talk with your provider about any health issues or concerns you have.

Take care of all of you: Sleep well, eat healthy, exercise, forgive and have gratitude for the life you have. I encourage you to seek a second opinion with the Ob/Gyn & Women's Health Institute. We are proud to be the number 1 department of gynecology in Ohio and number three in the country. At Cleveland Clinic, our board-certified gynecologic specialists are dedicated to individualizing and personalizing your treatment pathway for all gynecologic conditions.


For Appointments

To make an appointment with a physician in the Center for Menstrual Disorders, Fibroids and Hysteroscopic Services or with any of the specialists in Cleveland Clinic’s Ob/Gyn & Women’s Health Institute, please call 216.444.6601, toll-free at 800.223.2273 (extension 46601) or visit us at clevelandclinic.org/obgyn for more information.

  • Virtual Visit Information
    Note: You may need to call 216.444.6601, toll-free at 800.223.2273 (extension 46601) to confirm the schedule of the virtual visit.

For More Information

Center for Menstrual Disorders Fibroids & Hysteroscopic Services

In our Center, we put patients first. We individualize the evaluation and treatment of each woman we see, taking into account her preferences about preserving her fertility and other matters. This patient-centered philosophy reaffirms our commitment to offer alternatives to hysterectomy, including the latest hysteroscopic, laparoscopic, robotic and radiologic techniques.

We are similarly committed to interdisciplinary, collaborative research aimed at advancing treatment and improving outcomes for women with fibroids and menstrual disorders. For this reason, our patients can sometimes participate in clinical trials.

Event Information


Cleveland Clinic Health Information

Learn more about symptoms, causes, diagnostic tests and treatments for uterine fibroids.

Additional Cleveland Clinic Health Information

Clinical Trials

For additional information about clinical trials, visit ClinicalTrials.gov.


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This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician’s independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians. ©Copyright 1995-2017. The Cleveland Clinic Foundation. All rights reserved.