Occupational Health Clinic
November 2, 2018

Shaina Farfel of Occupational Health speaks with Dr. Amanda Yunker, Associate Professor of Obstetrics and Gynecology at VUMC, about fibroids, a common women's health diagnosis. They discuss fibroid symptoms, affects on health, and treatment strategies.

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Shaina Farfel: Welcome to this edition of the Vanderbilt Health and Wellness wellcast. I'm Shaina Farfel with Occupational Health. Today, we are speaking with Dr. Amanda Yunker, Associate Professor of Obstetrics and Gynecology and Director of the Minimally Invasive Gynecologic Surgery Fellowship. Hi, Dr. Yunker. Thanks so much for being with us today. Fibroids are a common diagnosis in women and can affect many aspects of their life and their health. They may also be associated with shame and stigma for some women and the hope is that today's conversation will help shed some light on the diagnosis and answer, at least, some initial questions that women may have. Let's start with the definition of fibroids. What are they?

Dr. Amanda Yunker: Fibroids are smooth muscle tumors that grow in the uterus. They are benign 99.9% of the time and they are prevalent in anywhere between 30 and 50% of patients, depending on which literature you read.

Shaina Farfel: Do we know what causes them? Like, are there certain risk factors?

Dr. Amanda Yunker: The most prominent risk factor seems to be ethnicity. So, they are definitely more common in African-American women than any other race or ethnicity. Why they happen, we are not exactly sure. We know that the cells that start a fibroid have a mutation that is different than their adjacent uterine muscle cells that are normal. So, there is some sort of predisposition, genetically, for a fibroid to grow, but we are not exactly sure why that happens.

Shaina Farfel: What are some typical symptoms of fibroids?

Dr. Amanda Yunker: The most common symptoms are usually heavy periods, sometimes bleeding outside the period, and increased pain with periods compared to someone without fibroids. Other patients can get what we call "mass symptoms," meaning the presence of the fibroid is large enough that it is pushing on adjacent organs. So, the most common things would be like the bladder or the bowels or maybe some nerves that are in the pelvis. So, patients can get a lot of pressure or feel the need to go to the bathroom more than they would like to.

Shaina Farfel: Do fibroids have any other effects on health? For example, can they affect fertility or increase cancer risk?

Dr. Amanda Yunker: They, themselves, don't increase the patient's risk for cancer, but we do think there is a small percentage of fibroids that are actually a cancer, a leiomyosarcoma. So, actually, that wouldn't be a fibroid, and we don't think it starts as a fibroid and genetically turns into a cancer. We think it was probably always predestined to be a cancer. So, that is important to note. As far as infertility, yes, they can impact fertility, really, depending on location and size. So, typically we say, starting at around 4 to 5 cm in diameter is when they are going to start to impact fertility, and of course, fibroids that are closer to the tubes might have more of an impact than one that is maybe toward the outside of the uterus.

Shaina Farfel: How do we treat fibroids? What are the traditional options and are there any complementary and alternative medicine options for treatment?

Dr. Amanda Yunker: We usually start by treating the symptoms because there are only a few things we can do to remove or shrink the fibroids and most patients aren't going to jump to surgery to begin with. So, we try to start with something medical and that is often aimed at controlling how much someone is bleeding during their period or how much pain they are having during their period. So, commonly, birth control pills or some other type of hormonal medication or an IUD is often what patients will start with and that will help, usually, control and regulate their cycle. But when they get to a certain size, then we are no longer thinking about just controlling bleeding. Now, we are thinking about those "mass effects." So, at that point, we either want to shrink the fibroid or we want to get rid of it altogether. The only options currently for shrinking a fibroid are, one, medication, which there are a couple on the market right now that are in the same realm, but one that we have used traditionally is called Depo-Lupron or leuprolide, and that is the medication that chemically induces a temporary menopause. So, you can see, most women aren't jumping at that. So, by shutting down the ovarian production of hormones, then we decrease the stimulation of the fibroid and then the fibroid shrinks. It is only as good as while you are using it and we limit the amount of time we can use it because it induces that menopause, and over time, that can be negative on other health systems, specifically bone. So, it is only really a good short-term fix, but other things that reduce the size are procedural-based. One is done by a radiologist, called a uterine artery embolization. You will also see that it is called, at times, uterine fibroid embolization, so "UAE" or "UFE." The goal is to decrease the blood supply specifically to the fibroid or to the uterus in general, thereby decreasing the blood supply to the fibroid, thereby causing the fibroid to shrink. So, essentially, you are kind of strangulating the fibroid. The problem with that treatment is, because it could decrease the blood supply to the uterus in general, we don't recommend someone try to get pregnant after that procedure, because it can have a negative effect on a pregnancy or fetal growth. There is a procedure where you direct ultrasound-guided waves, or MRI-guided ultrasound waves, to the fibroid, essentially necrosing it, or heating it up, with ultrasound waves, thereby causing sort of the same thing, sort of a tissue necrosis and death. Again, we are not exactly sure what the overall effect on the uterus is, so, in this country, we don't recommend that someone attempt a pregnancy after that. That is called HIFU treatment, or high-intensity-focused ultrasound. There is another product on the market, which is a lot like the HIFU, but it is done under laparoscopy, where you actually inject probes into the fibroid laparoscopically and heat it up that way. So, you are really actually looking at what you are heating up as opposed to just watching on MRI. So, those are some techniques to keep the uterus in place but shrink the fibroid - again, not a great option if someone is going to try to get pregnant in the future. So, really, the only option we have for patients who want to get pregnant in the future and get their fibroid removed is a myomectomy. So, that is a surgical removal of the fibroid, and depending on the location and size, there are different routes for how we do a myomectomy.

Shaina Farfel: If a patient was concerned that they may be having symptoms of a fibroid, would their first stop be to see their OB/GYN?

Dr. Amanda Yunker: So, they could start with their primary care doctor, who will usually order some sort of imaging to see what's going on, or they may just refer to a gynecologist, but then we would follow that up with, usually, an ultrasound to see if the uterus has a fibroid or not.

Shaina Farfel: Thanks so much for sharing your expertise with us today. I think our listeners will find this information very valuable on their journey to health and wellness.

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