All about FIBROIDS

Dr. Sueldo: -Dr. Cheruba Prabakar, how are you? Thank you so much for joining me and for kicking off this series. I mean the response was just incredible.

Dr. Prabakar: -Yes, yes. I am so excited. This is such a fabulous idea and right in line with a lot of the things that I've been doing as well.

Dr. S: -So I'm just so excited too, you know, we are going to be discussing all things about Fibroids today. Dr. Prabakar is a specialist in that world and I'll be doing a formal intro here in just a second. But how long have you been in practice now?

Dr. P: -Gosh I graduated fellowship about seven years ago.

Dr. S: -Oh okay, right on par. So I finished my fellowship in June of 2015.

Dr. P: -Oh me too.

Dr. S: -Perfect. Perfect. So you did your fellowship, where?

Dr. P: -In Brooklyn. New York and Maimonides Medical Center in NY.

Dr. S: -I did my fellowship in Connecticut. I always tell the story that when I interviewed, they said ‘You know I just want you to know that we have a stable faculty, we're not going to look to hire at the end of your training’ and I was like ‘Guys, you are my number 1 pick and I love University of Connecticut. I have no intention of staying in the East Coast, like the Northeast is not for me.’ So yeah, I definitely hear you, but let's go ahead and get started. I know people are kind of coming in and out, so we'll move forward. But I did want to do a proper introduction. So for those of you who are watching live please, you know, put in the comments, any questions as you go along. For those who are watching the replay, make sure you hit hashtag replay in the comments and then any questions you have. Dr. Prabakar and myself will be happy to answer after this session.

So first of all. Dr. Cheruba Prabakar. She is a board-certified OBGYN. She is fellowship-trained in minimally invasive surgery and so she has a passion for treating patients with fibroids and offers them the latest medical-surgical treatment options. She's well-versed in vaginal, laparoscopic, robotic and open surgical techniques and outside of medicine she enjoys hanging out with her family, swimming and playing tennis which I love. So your family, who is included in that?

Dr. P: -So I live here in the Bay Area with my husband, my three kids, and my two cats.

Dr. S: -I know I count my puppy as my fur child, but people think a little odd…so talk to me a little bit. First of all what are fibroids? I know it's super commonly talked about myomas, leiomyomas, fibroids. What are these things?

Dr. P: -Yeah so fibroids are smooth muscle tumors, so if you think about the uterus, the uterus is made up of smooth muscle and fibroids are just like a bundle of smooth muscle tissue that grows on the uterus and it can be located in different parts, it can be inside the uterus, it can be in the wall of the uterus or it could be outside the uterus kind of on the surface of the uterus and they can be different sizes and can cause different symptoms based on their location and their size.

Dr. S: -How do you get them?

Dr. P: -You know that that is a million-dollar question. There's so much research that's still being done on how someone gets fibroids. So often we know it is genetic. A lot of patients will say like ‘Oh my mom had fibroids, my grandma had fibroids, they needed surgery for it’. There are more and more studies that are coming out linking diet and fibroids and high estrogen diets, high inflammatory diets. Fibroids also affect African-American women disproportionately and women of color. And there was one theory that like hair straighteners or relaxers that black women used were implicated in this. So there's some different theories that are going on. But there are more studies that are coming out with diet. Unfortunately, genetics does play a role as well.

Dr. S: -So interesting, okay and talk to me about symptoms. So if you have a fibroid, how would you know that you had a fibroid?

Dr. P: -Yeah so that's a good question. Actually a lot of people don't know they have a fibroid, so they were doing a scan for something else and the doctor said ‘Hey, by the way you have a fibroid’ and patients are like ‘What? Nothing is wrong with me.’ So oftentimes the most important thing to remember is fibroids can be completely asymptomatic, so you may have no symptoms. But for those who actually are experiencing symptoms, they can be pain, pressure, bloating, bladder pressure, abnormal bleeding is a huge one. So very heavy periods, irregular bleeding and then infertility. A lot of patients will have miscarriages. They're not sure why, then they you know get a more detailed workup and boom, they have a fibroid or they're not able to get pregnant. And then they realize they have a fibroid so they can be some of these more silent symptoms. And then some of the more overt symptoms like the bleeding and the pain and the cramping.

Dr. S: -How common are they?

Dr. P: -So by the time you are 50, almost 80% of women will have a fibroid, so very common.

Dr. S: -I had no idea. I always quoted about 50% of reproductive age. But that makes sense by the time you get to menopause because it is so common. Wow.

Dr. P: -Exactly yes, and 90% of African-American and Black women. So it's pretty common. Yeah.

Dr. S: -So basically in your circle of friends, at least one person has fibroids.

Dr. P: -Exactly exactly. Yeah.

Dr. S: -Wow, okay. So if you are thinking about fibroids, you think you might have symptoms. Or you know, you think, as part of your fertility workup, you want to assess for fibroids. How are fibroids diagnosed? What's the best way to look for them?

Dr. P: -So the most common way fibroids are diagnosed is via an ultrasound, so a simple pelvic ultrasound, no radiation. It is a probe that goes in the vagina to really kind of see well the uterus and the ovaries and the nearby structures. That's the most common way. If they are diagnosed that way and then you actually want to do something about it like surgery, then oftentimes your gynecologist may say, you know what, let's get an MRI to look at it a little bit more in detail for surgical planning.

Dr. S: -And can you explain a little bit about the difference of why the ultrasound vs. the MRI? What's the pros and the cons of that?

Dr. P: -Yeah so the good thing is both of them have no radiation, ultrasound and an MRI, but an MRI often is more expensive so we want to start out with just the most common, the basic, the easiest modality which is an ultrasound. And if you can clearly see ‘Oh, yeah, it's four centimeters, this is exactly where it is. It's not really invading into the tissue nearby,’ then you're done. You don't always need an MRI but sometimes it's a little hard to tell. Sometimes it may be kind of growing into the nearby tissue which would make surgery a little more difficult and your surgeon would want to know that prior to you going under anesthesia and going to the OR so if you want a little more detail as to exactly the location and the nearby like features of the fibroids itself, then an MRI is often recommended.

Dr. S: -Got it and then talk to me about Saline Sonogram or HSG or for submucous fibroids.

Dr. P: -Yeah. So it's often called a water ultrasound and this can be done in a lot of gynecologists office or definitely reproductive endocrinologist like yourself where it's an ultrasound but right before they look at the images they put a little catheter into the cervix and they using a syringe just inject a little water or saline, salt water, to help get the cavity a little bit bigger so they can really pinpoint is there a little polyp? Is there a little fibroid in there? It just helps your doctor see a little bit better and it can be done quickly in the office.

Dr. S: -It can help to see if it's in the cavity or not.

Dr. P: -Exactly. How much is it jutting into the cavity and then does it need to be taken out? Especially if there's somebody trying to conceive.

Dr. S: -Perfect. So then kind of shifting gears to what everyone is curious about. When we talk about treatment, I typically break it down, kind of into an umbrella, and I talk about lifestyle changes, I talk about supplements, I talk about medical therapy, and then I talk about surgical therapy. So as our fibroid expert for the afternoon, can you walk us through those four and what you would recommend to somebody with fibroids and specifically for my patients, somebody who's trying to get pregnant.

Dr. P: -Yeah, that's great overview there. So for the sort of lifestyle modifications trying to have a very clean diet, so reducing the inflammation reducing a lot of sweets. For some people that means reducing gluten, flour. And then also eating cruciferous vegetables. So if you look at the data, two studies have come out, one from China actually recently that does show that cruciferous vegetables can shrink fibroids can reduce a recurrence. So a lot of broccoli, cauliflower in your diet is really great. I would generally suggest a plant-based diet to my patients. I think we're going to find more that comes out in this area, but a plant-based diet, exercise, kind of holistically taking care of your body, lowering stress, moving. And you know, just really, really taking care of your body. I think is number one. And that's just not for fibroids. As you know, it translates to many other benefits in life and in medicine, but definitely for fibroids. That's what I suggest first.

Number two supplements so I don't really specifically champion any one supplement over the other. I think there's a lot out there and it's very difficult to see, like ‘Okay, which one is legit?’ I mean, you know, every day I feel like there's another ad about some other powder that you should be taking to detoxify yourself from fibroids. But really like, is there a lot of, you know, information about this? I'm not really that sure. So when patients ask me for supplements, I mean, it seems great, like a quick fix. But honestly, in good conscience. I can't recommend a supplement. Now some integrative functional medicine doctors have told me ‘Yes. I have helped shrink fibroids.’ But if you really look at what they're doing, it is going back to that number one thing which is lifestyle. You're looking at your diet. You're making sure your cholesterol, your thyroid, all of those things are tuned up right. So it's going back to the basics. So that's what I would say there about that.

And then medical treatments. I mean, we've got a whole host of them and that really depends on what your symptoms are. So, for example, if you're somebody with bleeding, then you can definitely use birth control pills. So we can use the Mirena IUD, which I love for fibroids because it goes right in the cavity. You can use the nexplanon, which is the little arm rod.

Dr. S: -I’m going to stop right there. Can we actually rewind a little bit on all of those hormone methods that you talked about? So the birth control, the implant and the patch? What is the purpose or why are we using those in the diagnosis of fibroids?

Dr. P: -So you're not really using so much in the diagnosis but more in the treatment. So if somebody says ‘Yeah, I've got a little fibroid’, you find out through the ultrasound that they have a little fibroid right in the cavity. They don't really want to do any surgery. What can I do medically to help because I'm bleeding all the time? So when we introduce hormonal medications, be it estrogen and progesterone like found in a common birth control pill or just progesterone like found in an IUD, then we are trying to regulate your cycle to prevent these abnormal bursts of heavy bleeding that these fibroids cause. So we're trying to kind of supersede what the fibroid is doing by causing these random spotting and random bleeding episodes. So that is the purpose of the birth control. The birth control is to regulate your cycle. It's not necessary to shrink it, you know. For some people it does shrink fibroids. For other people, they grow because of the estrogen stimulation. So the sole purpose is for the bleeding.

Dr. S: -Gotcha with that fibroids feed off of estrogen. So if you eliminate that estrogen production by giving these hormones, so eliminating that estrogen production, you eliminate sort of that feed or that stimulus for the fibroid, is that correct to say?

Dr. P:-Yes. I think that's yeah, that's good.

Dr. S: -And then do you have a preferred method of all of the ones that you mentioned?

Dr. P: -Yes so it depends on the fibroid. If it's right in the cavity, I often suggest the Mirena IUD for patients. It's quick to put in and it often takes care of the problem. If they have a larger fibroid that is in the wall and its causing bleeding, you know birth control pill is also good, so any of those that will stop the bleeding and it may not work for everybody. For some people the fibroid is just too big and you know these these medications are not going to work, but for somebody who figures this out then they're so close to menopause and they really don't want to do anything else. They just need a couple more years to go by and this may be something that works. So it's not a one-size-fits-all but you know.

Dr. S: -So I back in my obgyn training, now we're talking like a decade ago, we were taught that if you have a submucous fibroid, so basically a fibroid that's inside the cavity that an IUD would not really be indicated. But we're saying that in fact, yes, that's definitely an option.

Dr. P: -Yes, it really depends on the size. So now if your submucosal fibroid is 6 centimeters and it's filling your whole cavity, well we can't even put in an IUD or it's going to get expelled and I've seen that before. But if you have a small 1 centimeter or 1.5 centimeter fibroid then you know a lot of times it works well for those patients, so it really depends on the size.

Dr. S: -So it's on a case by case, perfect. Of course, my area is infertility, so patients who are coming to me do not want to talk about any sort of contraception because they're trying to get pregnant. So what would be some treatment options either medical or surgical that you would recommend for them?

Dr. P: -So for patients who want to get pregnant, the best treatment options are actually surgical. So there's a couple of scenarios that I see and I see a lot of referrals from reproductive endocrinologists. So patients are trying to get pregnant, the first one (scenario) is they're about to do a transfer. They do a sonogram and boom, there's a polyp or there's a fibroid right in the cavity and now this is going to stop their transfer, so this is not the time to be trying lifestyle modifications for the next year and stuff right, time is of the essence for a lot of these patients, so the best treatment there is to come into the operating room quickly take that out, you know, go home the same day, move on and get your transfer 3 or 4 weeks later. So that's one of the scenarios I see. The second is the fibroid is actually larger, it's 4, 5, 6 centimeters and it's not in the cavity, but it's pushing into the cavity. And so a lot of times the specialists like yourself get concerned like ‘Well, is it going to push out that embryo? We’ve spent so much money and time creating these embryos. We really want to put it in a cavity where there's a chance that that could happen?’ And so we want everything to be as perfect as possible obviously before we do transfer, so a lot of times those patients come to me and then we say ‘Okay, yeah, if you're having a fibroid that's clearly pushing in the cavity, let's get this out’ and I'll often do those robotically and I remove those fibroids and then you know you heal 5, 6 weeks and then you get your transfer. Depending on where the fibroid was, you may have to wait up to 6 months to get that transfer. For example, if you to really cut into the wall of the uterus and really do a lot of work to get that fibroid out, we want to really give some time for that uterine muscle to heal.

Dr. S: -Interesting, okay. So the first procedure you talked about was a vaginal procedure that same day. Surgery, go home the same day. What about the robotic procedure? Because it sounds a little bit more involved.

Dr. P: -Yeah so a lot of the beauty about robotic surgery is I do send a lot of patients home the same day, so the robotic surgery is done via very small incisions, about 3-4 tiny incisions in your belly and it's know it's a little more involved, of course. But if everything goes well and the patients do well and we don't have any complications or anything, most patients go home the same day. The total recovery when you go home is a little bit longer because you had gas in your abdomen and it's a little bit slower versus the vaginal procedure. You know you just get up and the next day you're back to work. But in terms of hospitals stay we've gotten things to the point where everybody can go home.

Dr. S: -Awesome, that is incredible. So are there cases where doing the robotic procedure would not be appropriate or where it would not be possible?

Dr. P: -Yes, if your fibroid is very large, so I usually have a cut off of more than like 12 centimeters, so really big. Or if you have many fibroids like, you know, more than 10, I've taken out 30 fibroids. You know there's a lot of fibroids, then the quickest way and the safest way really to do it is an open procedure. So the incision is like a c-section incision. And then we just quickly take out as many as possible. Try to minimize your blood loss. And for this procedure oftentimes patients will stay over in the hospital, maybe 2-3 days.

Dr. S: -Gotcha okay, and then recovery, in terms of the time delay that would be similar? Would you agree?

Dr. P: -Yeah. I think about six weeks to kind of recover from surgery and then waiting again six months prior to transfer an embryo.

Dr. S: -And then what are some of the risks of surgery? You know, we've all heard about risk of bleeding, infection, pain, damage to organs, okay, fine, but specific to, you know, surgical risk, what can happen in the operating room and then for my people, reproductive risks. So what are the risks after surgery for potential pregnancy?

Dr. P: -So the first thing as you touched upon is for any surgery. We always say that once you going around a seizure, risk of infection, bleeding, injury to nerves / organs, your bowel, the bladder, blood vessels, all that stuff, very rare, very rare. But they can happen. And that is really for any open abdominal procedure. And then for the fertility aspect, scar tissue is one so I really look carefully how many times someone has had surgery like how many times have they been instrumented in their cavity, and so we want to make sure that we are trying to do everything the most minimally invasive way possible to prevent scar tissue. I think that's a big one for those who are trying to get pregnant.

Dr. S: -Gotcha and then can the tubes be impacted because obviously the tubes connect with the uterus?

Dr. P: -Yeah so sometimes fibroids right are on the tube, but the time when I see tubes being more impacted is actually endometriosis. So I do see when endometriosis causes scar tissue and the tubes are kind of mingled in there with that. But just for pure fibroids it's rare that the tubes are going to be affected.

Dr. S: -Perfect and then how do you decide? So it sounds like someone who's trying to get pregnant. If there's a fibroid in the cavity for sure it has to go. But for somebody who doesn't have it in the cavity, how do you decide? ‘Okay, we should probably remove it, or we should probably leave it in’ and avoid kind of those risks of scar tissue.

Dr. P: -Yeah, so this is a conversation I have with all my patients. It really depends on the size and location. So if it's kind of hanging out on the surface of the uterus and it's about 3 or 4 centimeters I often will just say’ just leave it alone’. But if it's more really in the wall of the uterus close to the cavity, I encourage patients to remove it. If it's above about 4 to 5 centimeters, because as you see they get pregnant and as the baby grows, there can be other complications like preterm labor, or the fibroids can start to die off and cause a lot of pain. So there's a lot of pregnancy complications as well. Or they can start to really grow and start to push into the cavity and cause a miscarriage. So I use that 4 or 5 centimeter number as kind of a benchmark to decide.

Dr. S: -Yes, that's consensus in my world as well. Generally there's no black-and-white guideline from our society, but I will say the consensus generally is the rule of 4. So if you have more than four fibroids, or if the fibroid is more than 4 centimeters, you're probably starting to talk about removal. So it sounds like a similar guideline. So awesome we've actually been here for almost half an hour. I do have if anyone who's watching has questions, please let us know, but I do have a couple more questions for Dr. Prabakar. So there's a couple new kids on the block and specifically one that patients you know kind of come to me and talk about is Oriahnn. And I believe now there's another one that's sort of similar but a different company. And then there's a new surgical technique called Accessa and I wanted to go through some of these with you and so that'll be kind of one piece. And then some of the alternatives like interventional radiology and those types of embolization, if you can just touch upon those as well.

Dr. P: -Yeah. So Oriahnn and MyFembree are the two new medications on the block. To help reduce bleeding from fibroids. So these are not medications that are going to take them away for a fertility patient. They're not going to really help you in that case. But for patients with fibroids, and they don't really want surgery or they're a poor surgical candidate, they are like five previous surgeries, they have a ton of scar tissue, they don't really want to have another surgery, but they're bleeding, these two medications block your estrogen, progesterone receptors reduce the bleeding and can kind of be used as a temporizing measure. Maybe six months to two years. So this is best for patients who are closer to menopause and you know, just want to get through that hump, so those are two medications there and then Accessa, it's interesting we actually sort of trialed that procedure when I was in residency in New York and it's done through a laparoscope, so three small incisions and the probe goes right into the fibroid and using radioactive ablation heat it sort of kills the center of the fibroid and helps it shrink. So it's ideally used for fibroids that are not huge, so kind of medium 4-5 centimeters, and it can help really shrink it. You know in my experiences, some of these fibroids have grown back. So then I see patients now, you know who have had this procedure before then now they want it removed totally, and I think it can help for patients again to at least shrink it and it's not going to cause that pain or that, you know every time I roll over like I can feel that fibroid. So for those patients who kind of feel the bulk symptoms and the pain symptoms, that procedure would work better for them.

Dr. S: -Oh, very interesting and then a little just one minute on IR embolization.

Dr. P: -Yeah, so that is an underutilized procedure. So I think that's a great procedure where an interventional radiologist does it. They shoot these little pellets through your groin or actually through your radial artery as well, and then it goes right into your uterine artery and blocks of blood supply to those fibroids and to portions of the uterus and help these fibroids just die off. And for a couple of weeks, you may have some discharge as these fibroids kind of expel out of your body. It's a great procedure for those again who want to reduce the size of these fibroids, reduce the bleeding. The literature with fertility, I still tell patients, ‘okay if you're really trying to get pregnant, this is not the way to go’ because you could inadvertently, you know, burn off some good parts of the uterus that you would need to be pregnant. So it's not ideal for those who are considering pregnancy, but for other reasons, it's still, it's still a good procedure.

Dr. S: -Awesome. So Dr. Prabakar, How did you end up in fibroids? I guess I should have asked this when we started. Like within the world of obgyn, it's sort of within the niche of obgyn’s and then it's sort of further niched down. So I'm just curious how you ended up here.

Dr. P: -Yeah, that's it. I was thinking about that the other day. You know, after my residency in New York, I did a fellowship in Brooklyn, and there during my two years this was kind of our bread and butter. We saw a lot of patients with fibroids, a lot of patients with bleeding, and that's just kind of what I see. And you know, depending on where you do your fellowship, everybody has a little bit of a different flavor. You know some do more endometriosis, some do more infertility, oncology, whatever. So for us in Brooklyn, it was really a lot of fibroids. And then when I started my first job, I came to Oakland and Oakland, California, and my patient population here is very similar to that of Brooklyn. You know, very diverse and a lot of fibroids as well. So it kind of further solidified my interest in fibroids and then I think just seeing the daily struggle that women have with fibroids and just not getting adequate treatment and information. So I really started to become like a champion for you know, women with fibroids. And that's kind of how my story came about.

Dr. S: -It's so crazy because 80% frequency by the time we get to menopause and the fact that there's not as much education about it, so I guess a couple takeaways before we wrap up here. So one is what would be your tip for my patients or #1 this is what you should do if you're concerned or if you think you have fibroids? Or if you know you have fibroids?

Dr. P: -Yeah, so I think for those who know that they have a family history of fibroids or somebody’s told you personally when you were 22 and you went to the ER for ruptured ovarian cyst, someone said ‘Hey, you have a fibroid and now you're 30 trying to think of pregnancy.’ I would be proactive. Go see your GYN and get a pelvic ultrasound. See what's going on in there. Because if you do have a fibroid now and it needs to be removed prior you're trying to get pregnant. You have time. So I would say just being proactive about your health and not just waiting till the last minute. You know when you're 35/38 and then trying to figure this out because time runs by really fast, then. So I would just say really being proactive and talk to your family members. A lot of people after I tell them they have a fibroid. Then they go talk to their mom and they're like ‘Oh my gosh, you know everybody. All the women in my family had fibroids.’ And if you knew that then you could just kind of get a scan early on and just say ‘Hey, I'm trying to get pregnant in the next couple years, want to make sure everything is cool, everything is good’, and so I would just speak to your obgyn and find somebody who's going to really have an honest conversation with you about it.

Dr. S: -Because my whole message is all about empowerment through education and this whole informing yourself and educating yourself. It just aligns perfectly with what I'm trying to convey as well. So Dr. Prabakar, this has been amazing. I've learned a lot. I hope my audience has as well. As we wrap up, tell me where can people find you? I know you're in California. You mentioned you're in the Bay Area, but give me more. I want all of the details.

Dr. P: - Thank you. Yes, so I am in Oakland, California. So if anybody has a fibroid they want to be removed or you want to talk about it, please come and find me. You can follow me on Instagram @thefibroiddoc. I also have a YouTube channel called the Fibroid Doc where I upload a video every week about a common question about fibroids and my website is www.thefibroiddoc.com. And so you can find me in all of those places. You know, send me a DM with questions. I'll make a quick video of it, and I look forward to answering them.

Dr. S: -Awesome awesome. Thank you so much for your time. This has been amazing.

Dr. P: -Yes, you are welcome. Thank you so much for having me on.

Dr. S: -This was so much fun. Thank you, talk to you soon. Bye-bye now.

*This content is intended solely for educational purposes and is not to be construed as medical advice. For personalized recommendations concerning your specific healthcare needs, kindly consult with your healthcare provider.