William Parker, MD
February 28, 2002

In February 2002, we resumed monthly online chats and had as our first guest Dr. William Parker.

Dr. Parker is a member of the Board of Directors for the National Uterine Fibroids Foundation and is clinical professor of obstetrics and gynecology at the UCLA School of Medicine. He is the former Chairman of Obstetrics and Gynecology at Santa Monica-UCLA Medical Center and past president of the American Association of Gynecologic Laparoscopists. He is a board-certified Fellow of the American College of Obstetricians and Gynecology and maintains an active private practice in Santa Monica, California.

Dr. Parker has been a researcher for over a decade in the areas of ovarian cyst surgery, fibroid treatment and laparoscopic surgery and is the author of numerous publications in professional journals including Uterine Sarcoma in Patients Operated on for Presumed Leiomyoma and Rapidly Growing Leiomyoma (1).

In 1996, Dr. Parker co-authored the book A Gynecologist's Second Opinion: The Questions and Answers You Need to Take Charge of Your Health. In addition, Dr. Parker served as a Consultant on the Women's Health and Hysterectomy Project for the RAND Corporation in 1997 and is currently an Editor for the Journal of American Association of Gynecologic Laparoscopists. Dr. Parker has been chosen for Best Doctors in America and Top Doctors since the late 90's. He has received numerous awards for his medical/surgical expertise and compassionate care of patients.

Carla Dionne	Welcome everyone. We'll go ahead and get started now even though more people may enter and leave the room throughout the chat.The information provided during this chat is to be used for informational purposes only.In no event shall the host moderator or chat guests or the National Uterine Fibroids Foundation 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 today.That said, let's get started. I'd like to throw out the first question. Dr. Parker, why do you have a special interest in uterine fibroids?
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Dr. Parker	This is one of the most common problems women have and one of the most common problems I deal with patients about.
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Carla Dionne	Isn't that true for all gynecologists though?
Dr. Parker	Yes, but many only know one way to treat fibroids -- hysterectomy. I have been interested in the alternative treatments for many years. Always looking for the best way to take care of problems.
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Carla Dionne	I would like to welcome everyone again and certainly let you know that you may jump in any time with questions of your own.
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Dr. Parker	I know I am supposed to be answering the questions, but why do you all feel that doctors are not providing alternatives?
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Subserosy	In my case, when I was diagnosed with a large fibroids, the first thing my OB suggested was surgery.
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Dr. Parker	I evaluate every woman and usually offer a number of alternatives. I really try not to influence the decision because it is not my body and I don't have the symptoms.
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Terrigeri	Do you offer myomectomy to women who are over 40 or who don't want children?
Dr. Parker	Absolutely.
Carla Dionne	Dr. Parker, you know from my story…no gyn offered alternatives. Not when I was 30 or 35 or 40. They just didn't.
Dr. Parker	I am doing a myomectomy laparoscopically next week on a 58 year old woman. I was her 5th opinion.
Terrigeri	Some doctors feel that myomectomy is not a good surgery, for some reason.
Dr. Parker	There are old studies that said that the risks were higher. All the newer studies show that, in the right hands, the risks are no higher.
Subserosy	Are there steps being taken to educate Obs about alternatives…it seems that most of them offer hysterectomy?
Dr. Parker	I am giving a lecture tomorrow on embolization to a group of about 200 gyns. Some will listen and some will not want to know about something that takes business away.
Weavfl	Will the former (take business away) still refer for UAE?
Dr. Parker	Not in my area. They tell the patient that it is still experimental and has unknown risks.
Terrigeri	I just had a myomectomy last week and am doing well. I lost only 50 ccs of blood.
Carla Dionne	In your experience, is the bleeding issues surrounding myomectomy significantly worse than with hysterectomy?
Dr. Parker	There is a good study that shows no significant difference between blood loss as a result of myomectomy versus hysterectomy.
Carla Dionne	Then why is bleeding always thrown out to the patient asking about myomectomy as though it could never occur with a hysterectomy?
Dr. Parker	Most gyns have performed more hysterectomies and are comfortable with that operation. Myomectomy takes more time and skill.
Terrigeri	Do they have to learn these skills in training beyond medical school?
Dr. Parker	A surgeon's skills increase with experience. Most of us take additional courses after residency to keep those skills up. This weekend I was teaching a course where we operated on donated cadavers with the laparoscope to improve gynecologists' skills.
Carla Dionne	I know that myomectomies are performed only about 40,000 times a year in this nation…and yet there are around that many practicing gyns in this nation. So, it seems like there aren't enough procedures to even go around for training. Is that a problem in residency programs?
Terrigeri	I think so few procedures are done because they are not offered to women.
Dr. Parker	Most residency programs are performing less surgery today than when I trained. So the new doctors have less experience and are less comfortable with myomectomy.
Subserosy	Women are being scared to go right away into hysterectomy.
Carla Dionne	So how ARE doctors picking up that live surgery skill with myomectomy procedures?
Dr. Parker	The way most doctors learn these skills is to start with easier cases -- smaller fibroids in this case -- and get more experience over the years.
Carla Dionne	That's if they choose to do so….beyond the hysterectomy?
Dr. Parker	Yes, Carla, but we can't force them to learn, unfortunately. You also don't want to encourage doctors to perform procedures they are uncomfortable with.
Weavfl	Will HRT studies impact hysterectomy rates within the decade?
Dr. Parker	Weavfl -- I didn't understand your question.
Weavfl	Studies are beginning to question efficacy of HRT for cardiovascular disease, osteoporosis, etc.
Dr. Parker	Yes, the HRT issue gets more confusing every day. I just gave a lecture on this and still feel there are advantages for some women. Like everything, the risks may be too great for other women.
Weavfl	Patients are, I agree for those women hysterectomized before 50?
Dr. Parker	Also, we are all waiting for the Women's Health Initiative to be published in 2004 which studies 60,000 American women -- half on hormones and half on placebos.
Weavfl	I'm waiting too, thanks Dr. Parker.
Subserosy	Are there extensive studies being made regarding UAE? It seems like it's a famous choice among women nowadays.
Dr. Parker	There are two studies I know about on UAE. Unfortunately, the interventional radiologists started performing this procedure without truly comparing it to other procedures, so the studies will be less than perfect, but still very helpful.
Subserosy	In summary, did these studies produce good results at all?
	The studies for UAE to date have been very encouraging.
Subserosy	Thanks Dr. Parker, that's good news I think.
Carla Dionne	I wanted to ask a question about cervical fibroids.
Dr. Parker	OK.
Carla Dionne	I know of two women currently plagued with cervical fibroids and trying to figure out what to do. One underwent UAE but did not have the entire uterine artery embolized because she was afraid of losing uterine orgasms. Now these fibroids are back with a vengeance. The other woman is just now looking at her options and trying to make a decision. But every doc simply says hysterectomy to these women. Are cervical fibroids that difficult to remove by themselves? If so, why?
Dr. Parker	I think some cervical fibroids can be removed by myomectomy. The other option might be myolysis -- coagulating the fibroid with a laparoscopic instrument to shrink it.
Carla Dionne	That would work with cervical fibroids? Wouldn't it cause adhesions possibly in the vagina?
Dr. Parker	Adhesions have been found after myolysis, but low down near the cervix that should be less of a problem because the large intestines is there and should cover up the raw tissue.
Weavfl	Any cervical fibroids in Heleen LeRoux's group?
Carla Dionne	You mean for mifepristone trials?
Weavfl	Yes.
Dr. Parker	I don't know much about their protocol.
Carla Dionne	What if the cervical fibroid is growing on the exterior of the cervix and even making pap smears difficult?
Dr. Parker	That is harder to get to, but still might be able to be removed, either vaginally or abdominally if it extends upward.
Carla Dionne	Depending on how deeply attached the fibroid was growing, would the woman possibly lose part of her cervix during a myomectomy to remove this?
Dr. Parker	Usually with any myomectomy, the goal is to leave all of the normal tissue. Scar tissue would form though and might cause discomfort with intercourse.
Terrigeri	Can adhesions be expected in almost all myomectomies or other surgeries?
Dr. Parker	Adhesions seem to form after myomectomy more than other surgery for reasons that are not clear. However, we use adhesion barriers to help keep adhesions to a minimum.
Terrigeri	Yes, my doctor used interceed.
Weavfl	Advice for younger women and fibroids?
Dr. Parker	Young women with fibroids have many options. The first is to do nothing if you feel well. Otherwise, myomectomy, either laparoscopic or abdominal for pain or pressure, hysteroscopic myomectomy for bleeding with fibroids bulging into the uterine cavity.
Subserosy	Would you recommend UAE for a 29 year old woman with a 9 cm fibroid located in the posterior of the uterus?
Dr. Parker	I am not comfortable yet recommending UAE to women who want to get pregnant because we do not know enough about this yet. Also, there is a very small risk that the ovary might stop function after UAE and cause early menopause.
Marciael	Is a myomectomy possible for a woman with large fibroids -- the size of 5+ months?
Dr. Parker	Yes, myomectomy is possible for large fibroids. Carla has introduced me to Dr. Stanley West who some of you have seen. I am going to visit him in New York in the next few months and watch him remove very large fibroids and see what his technique is.
Weavfl	Fantastic!
Subserosy	Does anybody here heard of Female Alternative Surgery, I find it odd that only one doctor here in the U.S. performs that…
Terrigeri	Isn't that just a myomectomy?
Dr. Parker	Yes, that is a fancy term for myomectomy.
Marciael	Would the myomectomy for large fibroids have a very high risk of turning into a hysterectomy? Would you know the odds of that happening?
Dr. Parker	Again, that depends on the skill of the surgeon. I have never performed a hysterectomy when the woman wanted just a myomectomy. I think Dr. West feels the same way.
Carla Dionne	Is there a point in the middle of surgery where some doctors get frustrated and just basically throw in the towel and do a hysterectomy?
Dr. Parker	From what I read online, sounds like that happens. I also wonder how hard they try.
Weavfl	Nothing like seeing the vascularity of fibroids on angiography. Do you feel comfortable, Dr. Parker, with the idea of gynes adapting UAE as an office procedure, i.e., F. Hutchins' interview on OBGYN.net?
Dr. Parker	I do not think gyns should be doing this procedure at all -- they are not trained to do angiography. I observed Dr. Goodwin doing a procedure and it is not easy. There are a few companies trying to develop devices to tie off the uterine artery surgically, avoiding the catheterization. I still can't see that being performed in an office.
Weavfl	Thanks Dr. Parker.
Carla Dionne	But if the artery is permanently tied off, won't that create ovarian failure in some women? It was my understanding that UAE does not permanently occlude the uterine artery. But, even with UAE we're seeing roughly 5% experience ovarian failure anyway. If it's permanently occluded, couldn't that ovarian failure number end up being even higher with ligation?
Dr. Parker	My understanding is that the loss of ovarian function may be the result of misembolization to the ovarian vessels. If you tie off the uterine artery and the ovarian artery is left alone, that might work better.
Carla Dionne	What about the 11% anastomoses ratio between the uterine artery and ovarian artery that Pelage (2) documented in retrospective review in 1999 of 197 embolizations?
Dr. Parker	Please explain the anastomoses ratio.
Carla Dionne	Uterine artery directly supplying the ovarian artery.
Dr. Parker	Without any supply from the ovarian artery?
Carla Dionne	No or limited supply was my understanding. Uterine artery directly responsible for primary blood source to ovaries.
Dr. Parker	I have operated on thousands of women and never once seen a missing ovarian artery, so I don't know.
Carla Dionne	I've wondered, since reading this paper, whether or not this could be the reason that some women who undergo hysterectomy but keep their ovaries experience subsequent ovarian failure. Any thoughts on this?
Dr. Parker	It also may be that the doctor gets too close to the ovary and stops some of the blood flow. You may also be right though. It is possible that the remaining vessels are too small to fully supply the ovaries.
Carla Dionne	It seems like there's just a lot we don't know still. For me this makes it even harder to make that decision "for" hysterectomy. For me, anyway.
Dr. Parker	I know that is frustrating when you are the patient. But, medicine is moving fairly quickly.
Terrigeri	Dr. Parker, what statistics have you seen regarding regrowth after myomectomy?
Dr. Parker	I just reviewed this literature for a lecture I am giving next month at the Pacific Coast Fertility Conference. I think it is about 15% of women who require another surgery after myomectomy. More women have some new fibroids grow, but they are not bothersome and really should not be counted in the data.
Terrigeri	Thank you.
Weavfl	Do you believe we will see a cure for the prevention of fibroids by 2025?
Dr. Parker	Yes, I think it will be gene therapy related. Carla and I have shared some new information about locating specific genes responsible for fibroids. In the future you may just get a shot of new genes and the fibroids will go away.
Subserosy	Wow…I hope that happens sooner that we expect.
Weavfl	I hope my daughter can use that therapy, Dr. Parker.
Dr. Parker	Won't be too much for doctors to do then.
Weavfl	We appreciate ALL that you have done for us and the National Uterine Fibroids Foundation.
Subserosy	Less money for them….
Carla Dionne	! Talk about loss of revenue…what will gyns do? !
Dr. Parker	I may have to learn how to play golf!
Weavfl	Following a distinguished career…your book helped me immensely.
Dr. Parker	Thank you. We are revising it now to include all the new advances including UAE. Should be published next year.
Weavfl	Excellent.
Subserosy	Thanks!
Carla Dionne	Do women come into your practice with printouts from the internet?
Dr. Parker	All the time. And articles from magazines, newspapers, etc.
Carla Dionne	How do you handle that? I saw one recommendation on another site that told patients to mail or fax those to their doctors BEFORE the visit so as to not take up office time?
Dr. Parker	I like to see what everyone is reading. If I don't know about it, it is a good source of information for me too. If it sounds bogus, then I look into it.
Weavfl	Please mention that technique at your talk to the 200 gynes.
Subserosy	There are only a handful of doctors who are willing to talk to their patients. How can we change this attitude?
Dr. Parker	Carla has heard this talk before and she knows I make a plea for them to open up to these new treatments.
Marciael	Are there clinical trials that look promising?
Dr. Parker	There is a clinical trial looking at UAE and myomectomy that should give us some information about how effective each procedure is over a few years' time.
Terrigeri	Yes, I am in that study.
Dr. Parker	Excellent -- we need women to help us figure all this out.
Carla Dionne	I heard there is still a need for myomectomy patients for that study but that the UAE arm was filled. What has been the problem in getting patients for myomectomy?
Terrigeri	I don't know. Maybe more UAEs are performed at this point.
Subserosy	Many women choose UAE.
Reneehale	I had my myomectomy in December and wasn't aware of the clinical trial. Maybe the word is not getting out about the trial.
Terrigeri	It's at only certain hospitals.
Reneehale	I had my myomectomy at UCLA and they have the trial going on there…
Terrigeri	Yes, you are right.
Dr. Parker	We are in the UCLA arm of the myomectomy study.* They said they would publicize the trial, but have not as yet.
Carla Dionne	So they haven't publicized this clinical trial at UCLA at all? What can we do to change that?
Dr. Parker	Call Boston Scientific and ask them.
Reneehale	I would have gladly participated if I had known. Perhaps that's the case for others.
Marciael	How about the trials with drugs that suppress progesterone? How does that look to you?
Dr. Parker	I don't know much about RU-486. I don't know anyone out here involved in those studies. I have been getting my information from you guys!
Carla Dionne	Heleen LeRoux, the study coordinator, was offline from the uterinefibroids list group for awhile but is now back on the list. I think they are prepping for patients into the next phase of the clinical trials. You might post that question to the uterinefibroids list group to see if she replies. The first phase was only at Rochester…however, it's my understanding that there may be enrollment in a mifepristone study at UC San Diego on the horizon.
Dr. Parker	Interesting, because the first studies on other medications were done at UCSD.
Carla Dionne	Yes, Samuel Yen and UCSD own the trademark and patent to use of mifepristone for endometriosis and fibroids, I believe.(3)
Dr. Parker	Sam Yen was the head of the program when I trained at UCSD.
Terrigeri	How long before that can be approved by the FDA?
Dr. Parker	Usually takes a few years.
Weavfl	Will it be an off-label use?
Dr. Parker	Probably at first.
Carla Dionne	The trials on mifepristone out of Rochester are seeking specific use in treatment of fibroids.
Dr. Parker	Yes, but regular doctors will start using it before FDA approval if it works.
Carla Dionne	Mifepristone is currently approved to abort a fetus and pharmaceutically available at a much, much higher dose than one would ever want to take routinely for fibroids.
Marciael	Have you heard of any instances where these progesterone creams helped shrink fibroids?
Subserosy	I heard that progesterone creams don't really work. I even read that somewhere it was a scam.
Dr. Parker	Most progesterone creams do not contain enough progesterone to work. Others that say they are natural include synthetic progesterone to make them stronger.
Marciael	Is there any evidence that progesterone could help shrink fibroids?
Dr. Parker	There is some theoretical evidence that progesterone may increase fibroid growth. I do not use progesterone as treatment for fibroids.
Subserosy	Has anyone heard of High Intensity Focused Ultrasound? I think this is also promising…they're doing extensive research on this at the University of Washington.
Dr. Parker	I don't know much about this either. I wonder how they protect the intestines from injury?
Carla Dionne	Dr. Parker, our time is just about up and I do want to take the opportunity to thank you for taking time out of your busy schedule to chat with us today.
Dr. Parker	Thank you for inviting me.

(1) Parker WH, Fu YS, Berek JS. Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstet Gynecol. 1994 Mar;83(3):414-8. [Abstract]

(2) Pelage JP, Le Dref O, Soyer P, Jacob D, Kardache M, Dahan H, Lassau JP, Rymer R. Arterial anatomy of the female genital tract: variations and relevance to transcatheter embolization of the uterus.
AJR Am J Roentgenol. 1999 Apr;172(4):989-94. [Abstract]

(3) United States Patent 5,468,741
Inventors: Yen; Samuel S. C. (La Jolla, CA)
Assignee: The Regents of the University of California (Oakland, CA)
Appl. No.: 068554
Filed: May 28, 1993.
Granted: November 21, 1995. [Patent Details]

* The UAE and myomectomy clinical trial discussed in this chat is now closed and no longer accepting patients.