FFPLP_1.Fibroids: Audio automatically transcribed by Sonix

FFPLP_1.Fibroids: this mp3 audio file was automatically transcribed by Sonix with the best speech-to-text algorithms. This transcript may contain errors.

Kristyn Hodgdon:
Hi, I'm Kristyn Hodgdon, an IVF mom, proud women's health advocate, and co-founder of Rescripted. Welcome to From First Period to Last Period, a science-backed health and wellness podcast dedicated to shining a light on all of the women's health topics that have long been considered taboo. From UTIs to endometriosis, we're amplifying women's needs and voices because we know there's so much more to the female experience than what happens at the doctor's office. With From First Period to Last Period, we're doing the legwork on your whole body so you can be the expert in you. Now, let's dive in.

Kristyn Hodgdon:
Hi everyone, and welcome to From First Period to Last Period, formerly called Dear Infertility. I'm so thrilled to be officially introducing our new rebranded version of our podcast, all about women's health topics that have long been considered taboo, from UTIs to infertility to today, we're going to be chatting about fibroids and racial inequities in healthcare. I'm so thrilled to have Doctor Levica Narine with me. Hi, Dr. Narine.

Levica Narine:
Hi, Kristyn. So happy to be here. Thank you.

Kristyn Hodgdon:
Absolutely. So happy to have you here. For those of you who don't know her, Dr. Levica Narine is a board-certified ob-gyn and fertility specialist at the Kofinas Fertility Group in New York City. Welcome! I'm so excited to chat with you about fibroids today. It's something that we've actually never touched on this podcast, and I thought a perfect way to open up to the broader spectrum of women's health conditions, considering I think I read a stat that up to 80% of women will experience a fibroid by the time they're 50. Very common but often misunderstood and not highly discussed topic.

Levica Narine:
Absolutely. Thank you for giving us the platform. There's so much to say about it, and there's so much education that needs to be put out about it. I'm happy to be able to do that here. It's definitely a bread-and-butter part of our practice, and there are a lot of misconceptions and myths. We're happy to set the record straight and educate, for sure.

Kristyn Hodgdon:
Absolutely. Tell us, what are fibroids exactly, and what causes them?

Levica Narine:
So fibroids are basically benign, meaning non-cancerous growths that can occur in the smooth muscle wall of the uterus. They are generally classified in terms of like where they are in the uterus. So, you can have fibroids that are within the cavity of the uterus called submucosal fibroids. You can have fibroids that are within the wall of the uterus called intramural fibroids. And you can have fibroids that are within just on the top surface of the uterus called subserosal fibroids. And then there are others. But just to give you an idea, and most commonly, they're called fibroids. But in medical terminology, they're often referred to as leiomyomas or myomas.

Kristyn Hodgdon:
Okay, interesting. But most people know them as fibroids, right? Are there other type of fibroids? Because I've often seen them referred to as just uterine fibroids. But are there other types out there?

Levica Narine:
They can often be mistaken with fibromas, I feel, so the terms are very similar. Fibroids, it's basically named according to location. So, there could be ovarian fibroids. It could be like fibroids that are closer to other organs that are named as such but, in general, are originating from the uterus.

Kristyn Hodgdon:
Okay, got it. And for someone who might be experiencing some mysterious symptoms, what are some of the common symptoms of fibroids? How do you know if you have them?

Levica Narine:
Yeah. So basically, mostly women will present with symptoms of some change in period or some change bleeding related to their period, whether that be heavier bleeding that can occur within the normal time of their periods. Sometimes, that bleeding can occur outside of their period. So they're saying they're bleeding for 12 days instead of seven days. Blood clots. Sometimes, they present just with anemia. So we have to work that up where they thought they have normal periods and the heavy bleeding is normal, but other symptoms include a lot of pelvic pressure because fibroids enlarge the uterus, and that generally causes a lot of like, it causes a mass effect or a bulk effect. So it creates like pressure on the other organs and structures and the pelvis. So, some women may present with gastrointestinal effects such as constipation if the fibroids are pressing on her bowels, or this urgency and frequency for urination if it's pressing on the bladder. Sometimes, it can be pretty severe enough that, not that someone will notice it, but they'll notice a different quality of their urinary symptoms because it can put pressure on the ureter itself. So those are the most common.

Kristyn Hodgdon:
And does a fibroid have to be pretty large in order to have some of those more severe symptoms?

Levica Narine:
Yes. They usually have to be pretty large for the bulk effect. For the bleeding effects, actually, even small fibroids within the cavity of the uterus called the endometrial cavity or the uterine cavity. They can be pretty small or relatively pretty small, but they exist within that cavity where that lining is shed every month. So, that increases bleeding.

Kristyn Hodgdon:
Okay, got it. And so, how do you ultimately get diagnosed with fibroids?

Levica Narine:
We started off very basic. Any woman who comes in, we do a thorough history and physical. We want to know like what her history is, what her medical issues are, what her symptoms are. The physical exam is very important, and that often includes an abdominal exam and also a pelvic exam. And then it can go into a very simple ultrasound or sonogram that's in office that allows us to actually visualize the pelvic organs, and we can see fibroids on the ultrasound.

Kristyn Hodgdon:
Okay. So like a transvaginal ultrasound that you would get at your ob-gyn or fertility clinic?

Levica Narine:
Exactly. So like on this day and age, like most GYNs are very proficient with their sonogram. So mostly, like the annual visits, most annual visits will include a pelvic ultrasound. So, it's something that can be easily done in the office. For more severe fibroids, if there's more information that's needed. If we want to, if we feel the fibroid is very large or maybe causing effects on other organs, an MRI may come up for advanced imaging if needed.

Kristyn Hodgdon:
Okay. And are they ever misdiagnosed?

Levica Narine:
They can be because there are certain things, there are certain other conditions that can mimic the symptoms, ... have to be very careful about that. The most common condition that often mimics similar symptoms of bleeding and pressure is something called adenoma. And basically, it also enlarges the uterus and can cause issues with bleeding and can cause issues with fertility. But it's not fibroids, it's basically, some people commonly call it endometriosis of the uterus; when they go for the lining of the uterus, it kind of seeps into the muscle wall, and it makes it very tough and fibrotic, and they continuously get very bulky. That causes very similar symptoms. So that's one issue. And then there's a rare cancer called leiomyosarcoma, which is very rare, but it's something we always have to be on the lookout for, which can also mimic those symptoms.

Kristyn Hodgdon:
Okay, really good to know, because so much of what we do at Rescripted is giving women the information they need to be their own advocates. And yeah, knowing that other conditions are out there that kind of mimic the same symptoms can help them get to the bottom of, I think, whatever's plaguing them a little bit easier.

Levica Narine:
Well, yeah, for sure. It's good to have that idea that simply just bleeding can cause anemia. A lot of women just don't even realize that. So they even present with symptoms of fatigue and feeling tired and not being able to get through their day. And then we don't even sometimes even mention those symptoms when I talk to them. And then I may be bleeding for like how many pads or tampons do you use? And then that kind of brings it to light.

Kristyn Hodgdon:
Yeah, fatigue. I was having a conversation with someone recently that, about my, I got diagnosed with the thyroid autoimmune condition a couple of years ago, and my main symptom was like crushing fatigue, and, but I was gaslighting myself. I was like, oh, I'm just a tired mom. I just got over COVID, like all of the different things that I could have possibly been the reason behind my fatigue, except for the fact that I had an autoimmune disease. It's your body better than anyone else. If you are feeling out of anything out of the ordinary, it's important to chat with your doctor.

Levica Narine:
For sure, and think about it. If your child presents those symptoms, you're like, okay, we're making a doctor's appointment. And for like us, busy ... just that, okay, I'm not getting enough sleep, or this is happening, and we put our back burner. I get that, exactly.

Kristyn Hodgdon:
So fibroids, for someone who's not trying to conceive, they're not dangerous. Correct.

Levica Narine:
Yeah.

Kristyn Hodgdon:
They don't have to be treated or?

Levica Narine:
Exactly. So how one presents is the most important thing. So fibroids can be very large. So we look at the symptoms. We look at the signs. Some women have fibroids, but they are completely asymptomatic. And if they are asymptomatic, their health status is fine. They're not anemic. They're not trying to get pregnant. No, we don't have to let, we don't have to do anything about it. If they're close to menopause, nature will take its course. And oftentimes, when you're no longer having periods, the food or the fibroid, which is estrogen, decreases. So that's nature's way of naturally helping the fibroids to shrink or regress.

Kristyn Hodgdon:
Okay.

Levica Narine:
So, correct, if it's asymptomatic and a woman has no goals of pregnancy or no concerns of that, they can just be monitored.

Kristyn Hodgdon:
Okay. And then, obviously, million-dollar question. You're a fertility specialist. What about when you are trying to conceive? How does that come into play? Does someone typically, when you have a patient with fibroids, have they been trying to conceive for a while and obviously not, like how does it affect fertility? Does it always cause infertility, or only sometimes?

Levica Narine:
I would say it causes fertility in several ways, and some can be very direct, and some can be very subtle. When I was first being trained, we were always taught that fibroids will never affect you getting pregnant. It's actually holding on to the pregnancy and what happens after you get pregnant. But that's not true. We have a huge patient population that has fibroids, and like everything in New York, location is very important of where the fibroid exists. So, for example, the endometrial cavity or the uterine cavity, which is the inner cavity of the uterus, where pregnancy, rather an embryo has to implant and a pregnancy has to develop. If a fibroid is within that small cavity that takes up space, it can also go to the embryo competes with space with that fibroid. Fibroids feed off of estrogen. So, in pregnancy, which is a high estrogen state, fibroids can also grow. So there is a successful implantation. The growing fibroid can cause issues with bleeding which can lead to early pregnancy losses or miscarriages. Outside of that, fibroids that are within the wall of the uterus and then extend out of the uterus can also cause that, like mass effect or pressure on the other reproductive structures, and one of the most important is that it can cause tubal blockage. The tubes are literally the cool bars of our system. That's the only place where the sperm and the egg are going to meet. So if there's any sort of obstruction or blockage there, a woman may be ovulating beautifully, her partner's semen analysis is completely fine, but there's no meeting place, so there's no fertilization, so that causes issues with fertility as well. And interestingly enough, one of the forefronts and one of the newest and exciting parts of fertility, and I think for a lot of things, is immunology. So immunology and there's an autoimmune effect that happens with fibroids, regardless of where they are. Our bodies are very brilliant. It's what the heck is this thing doing here? Let me try to get rid of it. So, it produces antibodies against those fibroids. So, your pelvis and your uterus is constantly under this low level of inflammation or attack. So that causes the, not to be in a hospitable place for implantation and growth.

Kristyn Hodgdon:
Do you think that's the case? I'm just so curious because I have an autoimmune disease, and I've had five failed embryo transfers, including a six-and-a-half-week loss and a chemical pregnancy in the past two years. And with, because I have twins that are five and I didn't have Hashimoto's then, so I can't help but think that the autoimmune component has something to do with it. But like research hasn't caught up yet to say there's definitely a correlation there. So that's such an interesting thing that you brought up.

Levica Narine:
It's one of the most exciting parts of our industry right now, Kristyn, because it's made such a huge difference. So it's absolutely necessary to have labs that we can look into. We can also look and see what that immune profile inside your uterus is. Sometimes, it's at odds with what's going out, going on outside of the uterus. So we have to kind of balance that out. Any autoimmune issue in women, especially young reproductive-age women, are most prone to autoimmune issues, even simple things: eczema, psoriasis, all the way to lupus, thyroid issues. It's really like our body's attacking ourselves. So, it does play a big role in us accepting this foreign being, which is a baby. So it plays a huge role.

Kristyn Hodgdon:
That's really refreshing and validating to hear. As much as it's not the answer I want to hear, it's validating.

Levica Narine:
And there's a lot that we can do about it, too. So once we have those answers, there's a lot we can do about it.

Kristyn Hodgdon:
Amazing. So, you talked about how fibroids can potentially influence pregnancy outcomes. What if you do have a successful pregnancy? Is there are there any risks associated there?

Levica Narine:
Yes. If you do have a successful implantation and the pregnancy is well established. Usually, I would say except for the early first 6 to 8 weeks, if you've gone through that and you've been successful, there hasn't been any bleeding or anything like that when you get through the first trimester. As I said before, pregnancy is a high estrogen state. So we also run the risk of the fibroids growing because just the fibroids are a problem for reproductive-age women because reproductive-age women are producing a lot of estrogen. So if we're in a state that's also increasing that, like pregnancy, it's going to take that food. So, depending on where it is, and usually if we have a successful implantation and development of the baby at that point, maybe it's not in the cavity. It's probably not, but it could be within the wall or just hanging off of the wall. So it's within that wall and grow and can cause a little compression and can cause issues with how well the baby is able to grow and how that cavity is able to expand. Then there's another type of fibroid, which has a stalk, which is called a pedunculated fibroid, which just hangs off. It's usually like it's the one that we worry about the least in terms of getting pregnant. But if it grows, it can twist, and that causes pain. So when it causes pain that can cause contractions, it can cause like early and preterm labor and hence, potentially bedrest. You have a woman has to stop her life and be on bed rest for her pregnancy. It can also cause degeneration. Sometimes, those fibroids grow too large, and it just outgrows its vasculature. And that can cause infections and pain as well, so that may lead to early deliveries. And much of that time, it's like surgical deliveries, meaning C-sections and, of course, a preterm baby, which we never ultimately want to have.

Kristyn Hodgdon:
Yeah. Wow, I didn't realize it had such an impact. So let's talk about, I know this is your specialty. Let's talk about how fibroids are treated because it's not all bad news. They are very treatable, and can you talk a little bit about how they're treated. Does like the size factor in, or the location sort of factor into that at all?

Levica Narine:
Yeah. There are several treatment modalities that are available. Again, it depends on where a woman is in her life, and what's happened, and what she wants to happen. A woman is done with her childbearing and maybe having symptoms of bleeding and was maybe several years away from menopause. The most definitive treatment is the hysterectomy, where she no longer needs. But for a woman who wants to have a child, we here at the Kofinas Fertility Group, we usually recommend doing a procedure called a myomectomy, which is essentially removing the fibroid but leaving the uterus intact and go on to become pregnant on her own or, if needed, with fertility therapy. Outside of that, there are less invasive treatments, some which may or may not be, some which may cause issues with fertility at times. There's one particular treatment called uterine artery embolization that's not done by a GYN surgeon or a gynecological surgeon. It's done by an interventional radiologist, and it's very non-invasive, and it's very attractive for that, for those means, because basically, it's a small incision that's made in the groin. And through very minimally invasive techniques, certain substances are placed in the uterine artery that blocks the blood flow to the uterus and the fibroids, and that allows shrinkage to happen. But it could be a relative contraindication for a woman who may want to get pregnant. And that is also very dependent on size because it often will not work on a uterus that has large fibroids. You may have a lot of complications related to that.

Kristyn Hodgdon:
And how successful is the is it the myectomy?

Levica Narine:
Close, close. It's the myomectomy, very successful. We have our own surgical center here. We're a reproductive surgical center. Most of our surgeries are done at our center. They're done laparoscopically. So it's minimally invasive cameras. We're really able to like pinpoint where the fibroids are, and we remove the fibroids completely. Within that procedure, there's a technique to remove fibroids within that cavity that I was talking about, called a hysteroscopy requires no incisions. It's a purely transvaginal procedure, but the fibroids that are within the wall, through small incisions, we can remove that, and we remove the fibroids, and they're gone. For again, a lot is dependent on where how old the woman is. Like how many reproductive how many more reproductive years she may have. At that time, they're gone. And then we can they a certain woman can pursue conceiving on her own or pursue, like, fertility treatments at that point.

Kristyn Hodgdon:
If a woman is typically, unless there are other underlying issues after surgery, she can go on to get pregnant and stay pregnant.

Levica Narine:
Yeah, absolutely. Sometimes, that's all she needs, and she may not. If all we look at certain parameters for fertility and if she's otherwise healthy and she has a great reserve and her eggs are healthy, removing that fibroid just releases a lot of potential pressure or that immune effect, so that inflammatory effect decreases. So we have our patients who go on to conceive on their own.

Kristyn Hodgdon:
Love it. So discussing fibroids, I couldn't help but notice that they disproportionately affect women of color. Black women are three times more likely to experience fibroids than white women. Can you speak to that a little bit? Do you see that often in your practice? And why is that?

Levica Narine:
Yeah, the racial disparities really do exist. There are some stats where, like you said, by age 50, nearly two-thirds of women have experienced some sort of fibroids. And according to some national estimates, nearly a quarter of black women between 18 and 30 have fibroids, compared to only about 6% of white women. And by age 35, that number increases to 60%. Black women also tend to usually have larger fibroids and may have more symptomatology and also complications related to that. No one could, no one knows for sure why that reason is. Genetics plays a huge role, but there are associated risks that can happen to anybody but may exist in certain ethnicities and races more than others. Some think of starting your period at a younger age. Obesity measures, lack of access to healthy diet, an organic diet, or plant-based diets not having the access to like having those nutritious and organic foods. Those things do play a big role.

Kristyn Hodgdon:
That's so interesting. So are there lifestyle changes like diet and nutrition or exercise that can contribute to the management of fibroids?

Levica Narine:
Absolutely. Obesity plays a huge role because, interestingly enough, in our fat cells or our adipose cells, if we want to be formal, there are cells, those cells produce a type of estrogen called estrone. So if a woman is overweight or obese, or they have extra estrogen that contributes to allowing the fibroid to grow larger and even greater rate. So, definitely maintaining a healthy body composition, exercise, eating well. Anecdotally, there have been found to be good results with a mostly plant-based diet, which tends to be like more anti-inflammatory, higher antioxidants, and exercise is good for everything. We hate to say it, but yeah.

Kristyn Hodgdon:
It's, I'm actually starting an egg retrieval cycle tomorrow, and I can't exercise for a few weeks, and it's going to be the death of me.

Levica Narine:
It also decreases stress, and stress plays a huge role.

Kristyn Hodgdon:
That's what I use it for, like it's such a stress reliever for me. So it's going to be tough, but just gotta get outside and walk on those nice days. So is there anything else that you think women should know about fibroids? What would you, we always like to ask, what would you rescript about the conversation surrounding fibroids and just some of the misconceptions that there may be?

Levica Narine:
I think that I always find in my practice that everyone comes with this idea that everything is okay, like pain with your periods is okay. That's just part of being a woman. But so, when it's associated with certain things that it's not okay, but it's not okay, that you have very painful periods, it's not okay that you have very heavy periods where you feel like fatigued, and you're like laid out for a week every month. Those things are not okay. So really, our patients and really exploring those things are very important. So we find that a lot because, obviously, our ultimate goal here is to get a woman pregnant. So it's very important for us to investigate what are the things that can be contributing to that, whether they are hormone related, age-related or physically related and oftentimes physically related things like fibroids, inflammation, scar tissue, endometriosis, those are things that we can control. So it's very thing that we're able to do that, and sometimes that's all it, that's all it takes.

Kristyn Hodgdon:
You bring up a good point. I didn't ask this question, but if you do, you typically need to do fertility treatments then, or sometimes it's just the surgery is the magic piece of the puzzle? Do you typically tell people to try on their own after surgery to see what happens, or do you ever just jump right into fertility treatments, like how do you make that decision as a physician?

Levica Narine:
It's really a conversation with our patient, with each particular woman, because it depends on what her goals are, where she is in life. You know what her family planning goals are as well.

Kristyn Hodgdon:
Yeah.

Levica Narine:
It could there could be a small fibroid that's within the cavity that's been causing issues. And just removing that will allow her to go on to get pregnant on her own, or there's a small fibroid that's causing like a small obstruction on the tubes. However, if they're the uterus is incredibly enlarged and it's been there for a long time, usually, unfortunately, the damage has been long-lasting, and those tend to need fertility treatments. Age plays a huge role. Age plays a huge role. So sometimes, by the time you get to seeing and managing the fibroid, we also have to manage the biological components of what's going on with the woman's like egg reserve and quality of eggs. I would, being in the fertility world, we see a lot of women who are at that stage where it's usually recommended that this is the time that where we know fertility treatments are going to work, you'll get healthy embryos and not take the time to potentially get pregnant on your own for six months.

Kristyn Hodgdon:
And with the estrogen kind of fueling the fibroid growth, does IVF play into that at all? Just like knowing that your estrogen levels rise when you do a retrieval, and then also like being on estrogen for a frozen embryo transfer.

Levica Narine:
Great question, and the answer is yes. The answer is yes. And we have to decide when we'll do that removal of the fibroid. So we have to be careful with that because as you've experienced and as those medications are going to increase estrogen, and that can fuel the regrowth of fibroids, Don't see much of that because you want to take steps to move forward pretty quickly. The general, once the surgery is done, especially done in the way that we often do this, which is laparoscopically or minimally invasive, that lessens the time of healing for the uterus, for when the woman will be able to get pregnant. So I start that process of egg retrieval fairly soon. We don't often see that, but it can certainly happen.

Kristyn Hodgdon:
Interesting. Such a great episode. So much helpful information for anyone who suspects they may have fibroids, or does have fibroids, or fears that they have a fibroid. Really appreciate you diving deep into this topic, Dr. Narine.

Levica Narine:
Thank you so much. Pleasure to be here with you.

Kristyn Hodgdon:
If this podcast means something to you, be sure to hit follow or subscribe. This helps you because you'll never miss an episode, and it helps us because you'll never miss an episode. For science-backed women's health content that meets you exactly where you are, head to Rescripted.com or follow us on social @HelloRescripted.

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