Carla Dionne

Welcome everyone.

The information provided during this chat is to be used for informational purposes only. In no event shall the host moderator or chat guests be liable to you or anyone else for any decision made or action taken by you because of this information nor does your use of this information constitute the offering of medical advice by the chat guests. Please seek the advice and supervision of a health care provider when considering the medical information provided here tonight.

That said I would like to welcome Dr. Michael Broder, gynecologist, and Dr. Scott Goodwin, Interventional Radiologist to the uterinefibroids chat room and open the floor to questions. Please feel free to ask away!

barb450

I had a UAE on March 29^th of 1999. My 5 month checkup showed that my largest fibroid went from 9.7 cm to 7.8 cm. Would you call that a significant reduction so far?

uffdakab

I've been told a myomectomy is not an option in my case because of location of fibroid – 4-month, both inside and outside the uterus, 49 yrs old. Have appt. with my gyn tomorrow to consult. Appreciate suggestions for questions to ask.

Carla Dionne

Dr. Goodwin, perhaps you could address barb450's question first.

barb450

Since it's measured by volume what would the percentage of reduction be?

Dr. Goodwin

The amount of shrinkage for barb450 is not that much so far, but sometimes fibroids will continue to shrink for up to 1 year after embolization.

barb450

Well I do feel less bulk and no pressure. Do you think I might be able to avoid hyst? I'm 46.

Dr. Goodwin

Also, sometimes the character of the fibroid changes after embolization so that it is much softer.

barb450

Thank you Dr. Goodwin.

Carla Dionne

Thank you Dr. Goodwin. Dr. Broder, could you please address the issue of when a myomectomy is not possible in the case of uterine fibroids?

Dr. Broder

Sure. First I'd like to tell barb450 that she should base her decisions more on her symptoms than on measurements or other "objective" criteria. Those are fine for studies, but if you feel better, you are better.

barb450

Thank you.

Dr. Broder

As far as myomectomy not being possible, there really isn't a particular location or number of fibroids that makes myomectomy "impossible." It depends on the comfort level of the surgeon. Some gynecologists say "it's too risky" to do myomectomies if there are more than X number, or if they're in a particular location. It's true that blood loss and operating time is longer with more fibroids, but if that's what you want, you should be able to find someone qualified to do it.

uffdakab

My gyn had indicated that it would rip up my uterus, that's why she said it was not a good choice. Does that make sense?

kim.ransdell

Hi Everyone. At the risk of sounding redundant, I had UAE on 9-25-98 with Dr. Goodwin. Unfortunately, my dominant fibroid is still causing "bulk" symptoms. I'm scheduled for a myomectomy and curious about the location of the fibroid issue…what would preclude a gyn from doing a myo? My Dr. sounds like he's undaunted by ANY fibroids. Mine is large, pedunculated subserosal fibroid.

Dr. Broder

Well, myomectomy IS "ripping up the uterus," you just have to put it back together at the end. And taking many fibroids out means lots more "rips," that's why she thinks it's not worth doing. Studies comparing myomectomy and hysterectomy don't support the idea that hysterectomy is safer—but as I said, it can be easier, especially if there are many of them.

uffdakab

I have the one main large one. Not sure of the "type," just know it is partly in and partly outside.

kim.ransdell

AGGGHH! I've never heard myo portrayed in this light. If I hadn't already survived one, I may be having 2^nd thoughts. :)

Dr. Broder

Fibroids are named by whether they are inside the cavity of the uterus, inside the wall of the uterus, or on the outside of the uterus. The ones inside the uterus can be hardest to remove, but that's not a hard and fast rule.

uffdakab

What about progesterone as an alternative treatment to try?

Carla Dionne

Dr. Broder – with a case like uffdakab describes, would you present the option of UFE?

chattcat

What sort of fibroids are not candidates for embolization? I had a myomectomy 5 yrs ago for a large fibroid…grapefruit size or larger is how it was described to me…a pedunculated sort…I now suspect it is back…all the same old symptoms…is UAE a possibility for me?

Dr. Broder

Yes, I would present UFE as an option, though one with a shorter track record than myomectomy.

Dr. Goodwin

Pedunculated fibroids on a narrow stalk can frequently be removed fairly easily with a myomectomy.

rumarr

Do fibroids always shrink at menopause. I'm 51 just starting with menopause symptoms. I've already had a myo 16 years ago.

Dr. Broder

I'd also say that almost no one should have an invasive procedure for fibroids (UFE or surgery) unless they had significant symptoms and didn't get relief from (or didn't want to take) some hormonal treatment.

Dr. Goodwin

Subserosal pedunculated fibroids can fall off inside the abdomen after embolization and cause problems for several months.

uffdakab

When planning on a hyst for a large fibroid (4-month), how necessary is it to use Lupron for a couple of months to try to shrink it prior to surgery? Lupron scares me!

kim.ransdell

Gulp…can ANY subserosal fibroids "fall off" or just the type on thin stalks?

Dr. Broder

Rumarr, most symptoms of fibroids decrease with menopause, though it doesn't happen overnight. The closer you are to menopause, the more "watchful waiting", or perhaps treatment with progesterone or Lupron, is a good idea.

uffdakab

Can you please speak more about the progesterone and Lupron?

Carla Dionne

Dr. Goodwin - when subserosal pedunculated fibroids fall off after UFE, what kind of problems are presented and how are they usually resolved?

Dr. Goodwin

Usually pedunculated fibroids, i.e. those on a stalk, are those that can fall off.

Dr. Broder

Lupron is best suited for treating someone if their fibroids make it necessary to do an abdominal rather than vaginal hysterectomy. It is also useful if you're anemic from bleeding, and want to increase your blood count before surgery.

Dr. Goodwin

When subserosal fibroids fall off patients can have abdominal pain, which can last several months.

rumarr

Is Lupron safe? I've heard negative things about it.

Carla Dionne

Dr. Goodwin – has this occurred with any patients that you are aware of?

chattcat

And what happens to relieve the symptoms, Dr. Goodwin? Or do they eventually just go away on their own?

uffdakab

Ditto on the Lupron safety question. I've heard horrible things about it.

Dr. Goodwin

The number of patients who have experienced sloughing of subserosal pedunculated fibroids is very small measuring less than 1% as far as I know.

chattcat

I took Lupron for several months prior to both surgeries, horrible experience and in both cases did not shrink fibroids.

hanapa1

I had a myomectomy 16 months ago and a c-section 5 months ago. Should I wait more time before having UFE for another tumor?

Dr. Goodwin

Patients are managed with pain medications. Symptoms will eventually resolve on their own.

barb450

When you have a chance, I think a key question would be how long is an embo effective for? Do you have any data on that?

Dr. Broder

Dr. Goodwin, is there any danger besides pain with a myoma that falls off after embolization?

kim.ransdell

Would it be intermittent or constant pain? I've had a lot of pain post-UAE, but no one checked into whether the "giant" had fallen off.

Dr. Goodwin

UFE is not contraindicated in a patient with your surgical history.

Dr. Broder

To respond to the Lupron question: Lupron does have significant side effects, but there really isn't any indication that those last more than several months, and not everyone experiences them. So using it is a question of what the expected benefit is versus the possible risks.

Dr. Goodwin

Most UFE failures have occurred at the outset. Delayed failures have been unusual. Post procedural MRI on Kim showed no sign of sloughing of the fibroids.

Dr. Broder

I'd like to know why hannapa1 is having UFE – it sound like she's still having children, and UFE is generally not advised for those women.

Dr. Goodwin

USA data on UFE is only 3 years old.

barb450

I see. Thank you.

uffdakab

Is there much data available on use of progesterone as an alternative to any of the procedures discussed?

Dr. Goodwin

I agree that UFE is indicated in patients desiring fertility only under special circumstances.

Dr. Broder

Responding to barb450, about 10-15% of women who have myomectomies end up back for more surgery for fibroids by the time they reach menopause. As Dr. Goodwin pointed out, UFE data is really too new to make a good comparison, but in the short run, recurrences don't seem to be any more of a problem than with a myomectomy.

Carla Dionne

Dr. Broder – I think hannapa1 was merely asking if UFE was a viable choice for her at this time.

barb450

Have you ever heard of that polyvinyl substance moving? Sorry, didn't mean to interrupt.

Dr. Goodwin

PVA cannot migrate after embolization.

barb450

whewwwwww

kim.ransdell

Thanks, I'm a nervous patient, as you know. It was still "hangin' on" in December, so probably still is. I have had no studies done since then, besides an ultrasound in March. I'm just paranoid. :)

hanapa1

After 6 months bedrest during my last pregnancy due to fibroid and preterm labor, I am not going to have any more children.

Carla Dionne

Dr. Goodwin – what's the difference between polyvinyl alcohol particles and silicone particles?

Dr. Broder

Progesterone can be used to treat bleeding from fibroids when it's given cyclically (typically 5-10 days per month). It can also sometimes help symptoms of pain, but it works much less well for "bulk" related symptoms, like pressure.

Dr. Goodwin

PVA is a completely different plastic material than silicone.

barb450

Doesn't progesterone cause tumor growth?

uffdakab

Dr. Broder, does that mean it doesn't help much for shrinking, but can maybe help get a woman to menopause, when it will hopefully shrink? Just saw barb450's question – never heard that one. Please address.

Carla Dionne

Thought so. :) Saw some "scare" stuff on a "medical" site (put out by a doctor) that indicated IRs were really using silicone for UFE and that women undergoing UFE would end up just like women with silicone breast implants – with all sorts of random immune disorders.

barb450

I thought hormones did. Sorry if I'm wrong.

uffdakab

Thought estrogen was the culprit in the growth.

barb450

But my mom who had a total hysterectomy 20 years ago was put on some sort of hormone and had to stop because she was growing tumors.

Dr. Broder

There is no evidence that progesterone (taken orally) causes fibroids to grow, although progesterone in the body may be one of the things that causes them to grow. That may not make sense, but there are many differences between "physiologic hormones" (ones the body make) and pharmacologic hormones (ones you buy in the drugstore). Estrogen has also been implicated as a cause of fibroid growth, but again, taking estrogen doesn't cause them to grow.

uffdakab

Dr. Broder, so do you agree that natural progesterone is the way to go if taking progesterone? Can you address oral vs. cream?

Dr. Broder

All menstruating women have high levels of both progesterone and estrogen, yet many don't get fibroids. You can't tell who will have them, or how big they'll be by measuring hormone levels either. There may be individual cases where hormones seem to cause fibroids to grow, but millions of women have taken birth control pills for decades, and their rate of having fibroids isn't any higher than women who never took the pill.

uffdakab

I've heard of estrogen dominance being a major problem, and natural progesterone can help counteract that. Is that viable?

barb450

But we already have fibroids so in that case would it make a difference?

Dr. Broder

"Natural" progesterone has theoretical advantages, but in practice you just need to do what works. It's true that as women approach menopause, they ovulate less regularly, and ovulation provides the natural level of progesterone. So, no ovulation, no progesterone. As a result, many women in their forties have symptoms that can be resolved with progesterone treatment.

uffdakab

Thank you Dr. Broder. Can that be measured somehow – to determine ovulation and progesterone levels? (hope I'm not hogging the floor here)

Dr. Broder

As I mentioned, if your symptoms are bleeding or pain, then a trial of hormones (progesterone) may be worth it. After all, we're talking about taking medication maybe 2 weeks per month for 3-6 months. There is no really useful way to choose who to treat based on hormone levels. You may have normal progesterone values one month, but not another. And what's normal for you might not be normal for others.

uffdakab

…and do you recommend oral or cream? Is natural available as an oral?

Dr. Broder

It's easier to judge the dose with oral progesterone. I haven't used progesterone cream much, but I do have several patients who find it useful. "Natural" progesterone is available in oral form.

uffdakab

Thank you very much, Dr. Broder. This info will help with my consultation tomorrow.

Carla Dionne

To both doctors – I get asked a lot about the difference between a vaginal doppler ultrasound and a MRI when checking on fibroids pre-procedure. Both are used – which is better and why?

Dr. Goodwin

UTZ provides better flow information. MRI provides better anatomical information.

Dr. Broder

I would say that both have their uses – mainly in studying the response of fibroids to the procedure. I don't think it makes any difference to the patient, though. If the procedure works, she will feel better.

barb450

Thank you also to both Doctors.

Dr. Goodwin

MRI is better at diagnosing comorbid diseases such as adenomyosis.

uffdakab

What is adenomyosis? (or is it too late to ask that question?)

Carla Dionne

Can you explain what the significance of finding adenomyosis would be when considering UFE?

Dr. Goodwin

Adenomyosis is deposits of endometrial tissue in the uterine wall which can cause bleeding and can be difficult to diagnose.

Dr. Broder

Adenomyosis is when tissue normally found only in the lining of the uterus is found within the wall of the uterus. Significant adenomyosis reduces the chances that a myomectomy will work. I don't know if it affects UFE.

Dr. Goodwin

UFE is probably not generally effective for the treatment of adenomyosis.

Carla Dionne

So, if one has adenomyosis then perhaps UFE is not the best course of treatment for their fibroids? But if myomectomy also is unable to resolve this issue, what choices does a woman have left?

Dr. Goodwin

UFE has worked in some women with both fibroids and adenomyosis, but there is reason to believe that their symptoms were principally due to the fibroids.

Dr. Broder

Adenomyosis is a tough thing to be sure about – often it's not clear that it's the cause of symptoms until after a myomectomy doesn't work. I didn't say myomectomy never works if there is adenomyosis, only if the adenomyosis is really the cause of the symptoms, not the myomas.

Carla Dionne

So adenomyosis can be silent and not cause any symptoms?

Dr. Broder

Yes, often it causes no symptoms at all. Like fibroids, adenomyosis is common and so are problems like bleeding and pain. So it's hard to know if adenomyosis is the cause or an innocent bystander.

barb450

alert

Dr. Broder

I'm afraid I have to sign off, I have a patient in labor…

Carla Dionne

Well, it's 7 p.m. and time for the chat to come to an end. I want to thank both Dr. Broder and Dr. Goodwin for joining us tonight. Transcripts will be made available and placed in the archives.

uffdakab

Thank you so much doctors – and all you wonderful ladies.

Carla Dionne

Dr. Broder – go deliver that baby!

Dr. Goodwin

Thank you for the opportunity to communicate with all of you. I will be signing off now.

Carla Dionne

If anyone wants to hang around and chat awhile, you're welcome to do so. Goodnight.