Posts

Fibroid: What to Do When Fertility Is Not on Your Mind

/in /by

If you have fibroids, you are probably saying a choice curse word every time you think of your little (and in some cases) big uterine friend(s). Like a bad house guest, they can be a big pain in the rear end. They can cause bleeding, pain, pressure, and infertility. Bottom line, they are not fun. And unfortunately, this un-fun party is very well attended; nearly a quarter of reproductive-age women have fibroids. Furthermore, fibroids are the cause for about 2% of infertility cases.

Simply stated, you are not the only person who RSVPed “yes” to the fibroid gala. While there are many ways to treat them, not everything works for everyone at every point in their life. Women at different stages of their lives (a.k.a. reproductive “stages”) and symptomology warrant different procedures. For those of you who are nowhere near ready for anything to do with the F word (FERTILITY) but want it in the future (be it near or distant), here’s what we recommend.

Fibroids can be treated medically and/or surgically. Medical treatments include oral contraceptive pills (a.k.a. OCPs or the pill), the intra-uterine device (a.k.a. the IUD), Lupron (a.k.a. “I feel like I am in menopause with these hot flashes and vaginal dryness”), progesterone receptor modulators (mifepristone or ulipristal acetate), SERMs (raloxifene), aromatase inhibitors (letrozole), and anti-fibrinolytics. While some of the medical options are better at improving some of the symptoms (for example, OCPs will improve heavy bleeding but not the pressure symptoms), they very rarely fix it all.

Just like when you’re selecting the OCP you want to marry, you may have to shop around for medical options before you land at your symptom-free spot. While Lupron (a GnRH agonist) will do it all, it will cost you in the side effect department. Hot flashes, sleep problems, vaginal dryness, muscle and bone pains, and even changes in mood/thinking often come along with the reduction in fibroid bleeding, pain, and pressure. It’s because of the side effect profile that we don’t go with Lupron as our first medical treatment.  

Surgically, the options are limited for women who have not yet had kids. It’s basically a myomectomy or bust. Fibroids have been nicknamed myomas; -ectomy means removal so myomectomy = fibroid removal. While a myomectomy is the only option for you ladies who are not yet ready to part with your uterus, what varies in the myomectomy part is how you “myomectomize.”

The procedure can be performed abdominally (through a bikini-cut incision), laparoscopically (through a camera), robotically (through a robot), or vaginally (no explanation needed!). The approach depends on the size of the fibroid(s), the location of the fibroid(s), and the number of fibroid (s). It also depends on your surgeon’s experience and preference. Make sure you are comfortable with all of the above before you commit to anything or anyone.

As with most things, there are pros and cons to both medical and surgical options. If you like lists (we love them!), here are the important points to note. For most young women who have not had kids but want them in the future, we like to go medical first. Most of the medical options are transient and provide birth control (killing two birds with one stone!). While they will not rid you of your “f”riends, they will decrease many of your symptoms:

Bleeding, check.

Pain, check.

Protecting your future fertility, check.

In many cases, with medical treatment, the fibroids will shrink. Fibroids feed off estrogen, so low estrogen equals famine for fibroids, and hopefully your symptoms will dissipate. If medical management doesn’t do much to alleviate your symptoms, you may have to amp up your treatment to surgery.

Surgery will almost definitely bring the bothersome bleeding, pain, and pressure to a halt. However, it can increase your chance for scar tissue (both within the uterus and the pelvis) and other surgical complications. Surgery, no matter who does it, is the real deal. For this reason, you want to avoid going under the knife unless it is absolutely necessary.

The only absolute cures for fibroids are menopause and/or a hysterectomy. For women who have baby making on their mind and in their future (be it near or distant), neither of the above is a good option: major con! It is for this reason that we need to find a way to temporize the symptoms until you get the pregnancy process started. We usually recommend starting low and going high, but only if you have to. Give the easy or simpler stuff a shot first before you shoot in out of the park.

Just a side note: while fibroids are pretty pesky for most of us, some women are completely unaware of their presence. They find out totally by accident during an ultrasound, a pelvic exam, or during pregnancy. And just like if it isn’t broken don’t fix it, fibroids that are causing no symptoms are really no big deal. They can hang with you for as long as you both shall live. No divorce in sight.

If they don’t bother you, don’t do anything with them until you have to. Prophylactic or preventative therapy to avoid future problems is not recommended—no pre-nup here! Fibroids need to be fixed only if you can’t take them anymore. Otherwise, do your best to forget they even exist!

Putting Out the Fire: Endometriosis Treatment

/in /by

Living in New York City, we don’t usually see those forest fires some of you ladies see out West. While we watch it on TV and read about it on the Internet, those days and days of blazes are something of a foreign concept to us. However, what we have taken away from those images are the hoses upon hoses and the buckets upon buckets that those firefighters must use to quell those flames.

Endometriosis (a.k.a. endo) is to your pelvis as a big forest fire is to California. If it is not put out quickly, it can be devastating. The good news is that, just as the firefighters have many tools in their truck, we too have several potential treatment options.

For women who do not have babies on the brain, there are many “hoses” that can help put out your fire. You have both medical and surgical options. When fertility is not in the near future, shutting your own system off medically with hormonal therapy is no big deal. Most GYNs will recommend that you start basic (non-steroidal anti-inflammatory agents/NSAIDs plus hormonal contraceptives).

Go big only when the fire continues to rage. NSAIDs combined with continuous hormonal contraceptives (continuous birth control pills) are usually pretty good at putting out “smaller fires” (mild/moderate endometriosis). It doesn’t matter if you prefer the oral, vaginal, or skin (a.k.a. patch) route for hormonal treatment. They all work the same, and here, it is more a matter of preference than potency. If estrogen is out because of a medical contraindication (clots, smoking etc.), then progesterone can be given in isolation with NSAIDs.

If this concoction is not keeping your symptoms quiet, we start climbing the treatment ladder. Our next step is usually a GnRH agonist (cue Lupron) combo’d with add-back hormonal therapy (estrogen and progesterone). If this doesn’t bring things to a halt, we usually give aromatase inhibitors (think Femara) a try. The aromatase inhibitors work by decreasing circulating estrogens in the body.  Estrogen is like gasoline to the endo fire. It doesn’t take a firefighter to tell you that it’s probably not a good idea to throw gasoline on a fire!

One treatment is not necessarily better than another. Some just work better in certain people. What is different is how they are administered (oral, injection), how frequently they must be taken (daily, weekly, monthly), and how much they cost (a little vs. a lot!). You have to see what works best for you and your symptoms.

When medical treatment isn’t cutting it, surgery is an option—no pun intended. We try to reserve the bigger guns for the bigger flames; starting with surgery is usually not a good idea. In general, the basic tenant of endo is to max out on medical treatment and avoid repeat surgeries—repeat trips to the operating room do not earn you frequent flier miles. It just earns you a lot of scar tissue, a lot of risk, and a lot of anesthesia. It’s not something you want to do.

If you do find yourself needing to make that trip down the runway, make sure your pilot has been around the block several times—no first-timers here. Endo surgery is no walk in the park; you want your surgeon to be experienced.

Gynecology has gained a couple of new subdivisions in the past few years. There are now GYNs who spend years after their residency learning how to do endo surgery. Their second home is in the operating room. Let’s just say that, when you need a tour, they should be the ones to do it! There are a variety of surgical procedures that can relieve your symptoms. The specifics are above the scope of our conversation, but what you do need to know is the following. Know your surgeon, know why they are doing what they are doing, and know how many times they have done what they are suggesting you do. Trust us; it’s super important.

No two fires are exactly alike. Similarly, no two cases of endo are exactly alike. While for some, pain is the biggest problem, for others, it is GI symptoms. Because of the variability in symptoms, in severity, and in life plans (fertility vs. no fertility), the treatment plan that “puts out your fire” will likely vary. What gets you going or stops your endo from growing may be different than what helped your sister or what helps your BFF.

Although we probably won’t ever treat you, we can recommend that you treat yourself with the utmost respect. Be aware of your symptoms and what makes them better or worse. Have your GYN on speed dial—don’t tell them we told you that!—and tell them when things are not going so well. And while we don’t recommend you ringing them on weekends and in the nighttime unless urgent, you should feel comfortable calling them. If their answers are not cutting it, don’t be afraid to remove them from your contacts and find a different doctor.

Unfortunately, endo is a chronic condition. Once the treatment hoses are turned off, the fire will likely return. After your baby days are done, you may elect to undergo definitive surgical treatment (a.k.a. a hysterectomy and bilateral salpingo-oophrectomy: simply stated, ovaries, tubes, and uterus out) to ensure that you never face another forest fire. Until then, let us help you temporize the flames so that you can fight whatever fires, be it professionally or personally, that you choose to extinguish. There is nothing you can’t put out if you put your mind to it!

Variety, Variability, and a Very Good Surgeon: The Many Flavors of Removing the Uterus

/in /by

As if reaching a decision about if and when you want to get your uterus out is not enough, you now must also decide how much and in which way your uterus will come out. Unbeknownst to many, the uterus can come out from above (a.k.a. abdominal), below (a.k.a. vaginal), or a little of both (laparoscopic assisted or robotic). But it’s not so cut and dry (no pun intended). Imagine you are standing on line at your favorite ice cream shop. In those minutes before you give your order, you run through the options and the pros and cons of the various choices—chocolate with sprinkles, vanilla with chocolate chips, or maybe toffee crunch with nuts. Although whatever gets you to go with chocolate over vanilla is not so memorable and fairly insignificant, what makes you choose a vaginal hysterectomy versus an abdominal hysterectomy or doctor A versus doctor B should be unforgettable. So, as your favorite ice cream scoopers, here’s what’s on the menu—step by step.

Flavor (Is my uterus coming out?)

The first decision that must be made (whether on the ice cream line or in the hysterectomy process) is the most basic one: are you going to remove your uterus? This decision is a big one, and when making it, you must be comfortable and clear on why you are doing what you are doing. Is it because of pain, pressure, bleeding, or cancer? And have you tried medical or non-surgical treatments before moving on to surgery? Whatever the reason there must be a reason and a reason that does not have any other solution. And while we are not knocking vanilla ice cream, your reason for taking out your uterus should not be “vanilla!”

Cone or cup: Are you going to take out all of it (a complete hysterectomy) or a part of the uterus (a.k.a. a supracervical hysterectomy?)

After you decide what flavor you are choosing, you must decide how to eat it. Translate that into your uterus. After you decide if you are going to take your uterus out, you must decide if you want to remove your uterus and cervix (total hysterectomy) or just your uterus (supracervical hysterectomy). There has long been a suggestion that women who take out their cervix will suffer sexual consequences, dysfunction, and urinary incontinence. However, more recent data have debunked these theories, and most women opt to take the cervix out with the uterus to reduce the risk of cervical cancer. And while you have a lot of say in what you are going to leave and what you are going to remove, your doctor will also be a big part of this decision.

Toppings (Is my uterus coming out abdominally, vaginally, laparoscopically, or robotically?)

Even for us GYNs, it’s sometimes hard to believe how many different ways there are to remove the uterus. Long gone are the days of it’s abdominal or bust. Depending on things like the size of the uterus, the pathology (problems) affecting the uterus, the shape of the vagina, the presence of other medical conditions (think things like heart and lung disease), past surgical history (previous abdominal/vaginal surgeries), and the need for concurrent procedures (removing your ovaries as well as your uterus), one way may be recommended over another.

While there are pros and cons to each approach, research shows that, in most cases, the safest way to remove the uterus is vaginally. And while you may not be a candidate for a vaginal hysterectomy (the uterus is too big or you have had 3 C-sections in the past), it’s important to ask your MD why she is recommending a certain route and why you are not a candidate for another. It’s your uterus, and you deserve answers. And remember, the answer should never be because that is what the surgeon is most comfortable with…it should always be what you are most comfortable with.

With a cherry on top (Whom are you selecting as your surgeon?)

Deciding who is going to do the “scooping” (a.k.a. your surgeon) is a big decision. Not all “scoopers” were created equal. Some of us scoop daily, while others scoop no more than once a year. And as you can imagine, the more you do it (otherwise known as operate), the better you are at it. Make sure to ask about the surgeon’s experience, surgical outcome data, and training. It can make a huge difference in how your procedure goes.

While this is no ice-cream parlor and you may not be lining up to get your uterus out, if done in the right way, for the right reasons, and with the right surgeon, you will be enjoying an ice cream cone in no time. A hysterectomy may not be the treat you were dreaming of, but it will likely take care of many of your problems—at least when it comes to your female organs. So start building your perfect “hysterectomy sundae.” It can bring you sweetness and satisfaction for years to come!

Are the Tubes More Than a Tunnel? Their “Connection” to Ovarian Cancer

/in /by

For decades, we thought of the fallopian tubes as no more than a plus one. Whether they were the sidekick to the ovaries or to the uterus, they were sort of like the accomplice that everyone overlooked. We did make some noise about damaged or blocked tubes in women who were trying to get pregnant because damaged tubes meant the sperm and egg would need to find another way to meet up. But for women who had let the fertility ship set sail, the tubes seemed like no more than an afterthought. However, times have changed: the tubes have taken center stage. Here’s why.

In order to understand the tube story, you must first hear the ovary story, specifically the part that addresses ovarian cancer and ovarian cancer screening. Unfortunately, when it comes to ovarian cancer screening tests, the ending is not a happy one. The tests either fail to detect ovarian cancers until they are advanced, or they over call benign processes (think simple cysts, dermoids, and endometriosis) as cancers. And while you certainly don’t want to miss an ovarian cancer, you also don’t want to put women through additional testing and surgery that they may not need. Hence, every GYN faces a conundrum when trying to screen for ovarian cancer. How do you avoid missing an ovarian cancer without miscalling something as ovarian cancer? Cue the tubes…

When the news broke that the tubes might play a big role in ovarian cancer (basically, that ovarian cancers might start in the tubes and the endometrium and then spread to the ovary) and that tubal removals (medically termed salpingectomies) could be the answer to early screening and detection, the OB/GYN community erupted in cheers. Could we have found a clue to cracking the ovarian cancer code? For decades, the theory had been that cancer spread from the ovary to the tube. Could it really be the opposite? Evidence suggested that for select types of ovarian cancer this could very well be the case. A breakthrough that could have big-time benefits: if you took out the tube, then you could take out or at least take down the chance of ovarian cancer later.

While the excitement in the OB/GYN community is palpable, neither the American Congress of Obstetricians and Gynecologists nor we are recommending salpingectomies for everyone. Rather, we are suggesting that you view the tubes as more than just an afterthought, that you treat them as more than a plus one. If you are planning to extract your uterus or you are planning a tubal sterilization procedure (a.k.a. tie your tubes), you should have a serious conversation about simply removing the tubes at the same time. Think of it this way: if you aren’t planning future fertility, those tubes will not be missed. And their departure might help you duck out of the way of ovarian cancer.

Ovarian cancer is like the enemy that lurks in the dark. You often can’t see it until it’s too late. And while many have attempted to find some good night-vision goggles (a.k.a. good screening tests), they have repeatedly come up short. Tubal awareness/removal may be the first light in the dark. And although there is still a lot of black and grey in the area of ovarian cancer prevention and early detection, the data on salpingectomies have certainly brightened the situation.

Maybe soon, we will be able to see it all.

Fibroid: Is This Causing Your Infertility?

/in /by

If you have fibroids, you are probably saying a choice curse word every time you think of your little (and in some cases) big uterine friend(s). Like a bad house guest, they can be a big pain in the rear end. They can cause bleeding, pain, pressure, and infertility. Bottom line, they are not fun. And unfortunately, this un-fun party is very well attended; nearly a quarter of reproductive-age women have fibroids. Furthermore, fibroids are the cause for about 2% of infertility cases. Simply stated, you are not the only person who RSVPed yes to the fibroid gala. They work their magic (or rather interfere with the magic) usually by interfering with implantation, distorting the uterus, or blocking off one or both of the tubes. They can take up prime real estate, and this can lead to miscarriage and pre-term delivery.

Depending on the block they chose to call their home (a.k.a. their location in the uterus), their impact on fertility and pregnancy may be more pronounced. Fibroids that are located within or partly within the uterine cavity (medically termed submucosal) almost always need to be evicted before pregnancy. Additionally, these are the ones that are most likely to cause true infertility. Intramural fibroids (those located in the muscle) can go both ways; how they are going to lean is really anyone’s guess. As a general rule, the bigger, the bigger pain for you and everything fertility related. They can press on important things (like tubes or the cavity) and cause problems that need to be dealt with. Last, those hanging out outside the uterus (subserosal) have almost no effect on fertility or pregnancy. Don’t even give them a second thought.

While fibroids can be treated medically or surgically, when it comes to fertility, medical options are no bueno. Most, if not all, medical options will prevent ovulation and implantation, which will prevent pregnancy, so that’s not going to work. Surgical options are really the only ones on the table, and even these “dishes” are limited.

So here is what is on the menu—myomectomy (myoma means fibroid and ectomy means removal). Myomectomies can be performed through an open bikini-cut incision, a camera (laparoscope), a robot, or vaginally. The approach depends on the size of the fibroid(s), the location of the fibroid(s), and the number of fibroid(s). It also depends on your surgeon’s experience and preference. Make sure you are comfortable with all of the above before you commit to anything or anyone.

Surgery will almost definitely bring the bothersome bleeding, pain, and pressure to a halt. However, it can increase your chance for scar tissue (both within the uterus and the pelvis) and other surgical complications. Surgery, no matter who does it, is the real deal. For this reason, you want to avoid going under the knife unless it is absolutely necessary. It will also in many cases, particularly when there are many fibroids, require that you to have a C-Section. The uterus is a muscle, and after surgery, it will be forever changed, scarred, and sometimes weakened. You want to make sure that you treat your muscle with tons of TLC—labor, contractions, and hours of pushing is not anyone’s definition of TLC.

And while we are talking about surgery, we recommend that you always ask your surgeon for their notes from the surgery (a.k.a. the operative report). This is super helpful to anyone else—your OB/GYN or your fertility doctor—who decides to date your uterus in the future. Knowing who has been there and what they have done will help us guide your treatment.

Two big questions come to patients’ minds and ours when considering fibroids and fertility. Are they causing my infertility, and should I treat them before I do fertility treatment? First things first, fibroids are very rarely the sole cause of infertility. If you think of a pizza pie, they are even smaller than the smallest slice (think more of like a baby bite). Usually, fibroids plus something else are keeping you on the fertility sidelines. So even if your fertility doctor diagnoses you with fibroids, they are usually not alone in making this baby thing difficult. For this reason, we always recommend completing the entire fertility work-up before pointing the finger at the fibroid.

The second question is way more complicated. When do you treat a fibroid? This question about fibroids is more controversial than religion and politics at a family dinner! However, while getting us all to agree on when to treat is nearly impossible, we can almost all agree that fibroids, which are on the outermost layer of the uterus, are outside the realm of what we need to treat. They are not causing infertility and don’t need to be treated before a fertility treatment. Exceptions to this are if they are very large causing pain and pressure of the bladder.

On the flip side, fibroids that are in the uterus (submucosal) of women who are experiencing infertility or recurrent miscarriages need to come out before any fertility treatment is started. The fibroid is like a roadblock, blocking any and all traffic. They need to come out before any cars try to pass. The trickiest ones are the ones in the muscle (intramural). It’s like our Congress—no one can really agree on what is right. For most there is a split down the aisle for which to treat and when. The line in the sand usually comes down to how big it is, where it is, and if you had previous fibroid surgery. Fibroid surgery is not something you want to double down on!

Unfortunately, of all the partners you will have, your fibroid is the least likely to leave you. Only menopause and a hysterectomy will break you two up. However, there are ways to temporize them and to temporarily remove them so that you can “attempt to see other people.” Take our advice. Tell them, “It’s not you. It’s me. I just really want to have a baby and don’t want you hanging around.” While they may reappear one day, hopefully, they will leave you alone long enough for a pregnancy to take place.

A Is for Adenomyosis

/in /by

Of all the words, terms, and phrases you have heard us utter, adenomyosis may sound the most foreign—and if you think it’s hard to say, try spelling it! It’s likely that, unless you have it or know someone who has it, you will close the chapter (or computer) on this piece pretty quickly. But Bear with us for a minute; push past the A to C of what this Diagnosis is really all about and why it’s something worth learning about.

In many ways, adenomyosis is sort of an Enigma. If you don’t look for it, you won’t Find it. And Getting the diagnosis right can be Hard. Unless you have surgery or an Individual who is really skilled at his or her Job looking at your ultrasound or MRI, you may not Know that you are suffering from adenomyosis. It can often masquerade itself as a Leiomyoma (medical term for fibroids). Although adenomyosis also forms Masses in the uterus, they are no fibroids.

In many ways, adenomyosis is like the first cousin of endometriosis. Both pathologies arise from endometrial tissue that has gotten lost (a.k.a. made its way out of the uterus) and is Not sure how to get back—uh Oh. While in endometriosis this lost uterine tissue can go pretty far (think lungs and even skin), in the case of adenomyosis, the endometrial tissue Prefers to stay much closer to home. In adeno (the medical nickname for adenomyosis), the tissue inside the uterus has taken up residence within the muscle of the uterus. So although that trip may be small in distance, the impact of this unwanted visitor can be big.

And unlike those distant cousins that you never knew you had, adenomyosis is not so unknown or removed. In fact, nearly 10% of all women suffer from adenomyosis. The number is much higher in women with infertility. And while many might not know they have it, they will be aware of the heavy bleeding, the dysmenorrhea, the abdominal pressure/bloating, and the infertility that often accompanies adenomyosis. The symptoms can be pretty severe and often send women (usually in their 30s and 40s) to the GYN in a Quandary (a.k.a. not the best of physical and mental states…we needed a Q!).

Historically, the only way to diagnose adeno was in the operating Room with a piece of tissue that was sent off to our pathology friends. Oftentimes, women were incorrectly diagnosed with fibroids (for years), and until the uterus came out Surgically, they didn’t really know what was causing their unpleasant symptoms. Nowadays, due to huge improvements in our imaging Techniques (cue Ultrasound and MRI), we can see adeno before women walk into the operating room.

Although there is much crossover between the treatments for fibroids and adeno, surgery for the latter can be much less successful and much riskier. The division between normal healthy uterine muscle tissue and adenomyotic tissue can be harder to find. With fibroids, the distinction between the two is pretty clear. Thus, there can be a loss of healthy tissue and, in some cases, loss of the uterus.

The treatment for adenomyosis, like its cousins the fibroid and endometriosis, Varies based on the severity of a woman’s symptoms as well as where a woman is in her fertility plans. For Women who have said sayonara to their baby-making days, a hysterectomy is usually their best bet. Goodbye, uterus, means goodbye, symptoms. For women who are not ready to make their uterus their eX, hormonal treatments (oral contraceptive pills, IUDs, aromatase inhibitors, and Lupron are also pretty good at getting you back to a Zen state. Whatever path You choose, it’s super important to go hand in hand with a physician who can recite the ABCs of adeno as he or she catches some Zzzzs (that is, in his or her sleep). Trust us. This is a song that you don’t want to “sing” alone.