James Robinson, MD

Are you familiar with uterine fibroids?   If you’re a woman, chances are you may gain firsthand experience with fibroids at some point in your lifetime. In fact, the National Institutes of Health estimates that 80 percent of all women will develop one or more uterine fibroids by age 50.   Fibroids develop when a muscle cell in the uterus clones itself and expands. The good news is, these growths are not cancerous or even pre-cancerous, never spread beyond the womb, and are not life-threatening.   Many remain small and cause no symptoms or issues; however, others may enlarge and affect a woman’s quality of life by causing excess bleeding or by placing pressure on abdominal organs. Here are four things to know about uterine fibroids:  Because fibroids are so prevalent in adult females, every woman is considered potentially at risk. That risk increases if your mother or sister has experienced fibroids. African American women are more likely to develop fibroids and tend to experience them earlier as well, often by age 30.   What causes uterine fibroids? The female hormones estrogen and progesterone stimulate their growth, so fibroids may occur at any time during the reproductive years, from onset of menses through menopause. They rarely disappear on their own, although they do tend to shrink post-menopause.  It’s suspected that exposure to certain elements in the environment—for example, certain plastics, hair care products, cosmetics, and even repeated handling of printed cash register receipts—may affect hormone levels and increase a woman’s risk.  Diet may play a role, too. Foods containing plant-based estrogen, such as tofu and other soy products, could increase risk; likewise, diets high in red meat and low in fruit and vegetables are suspect, as is alcohol consumption.  To date, there are no known ways to prevent fibroids. But choosing a diet high in whole grains, vegetables, fruit, and lean meats; maintaining a healthy weight; and limiting alcohol are recommended to help protect against these growths and a host of other diseases.  Fibroids can develop anywhere in or on the womb and can range in size from undetectable by the human eye to much larger. Smaller fibroids with no symptoms may eventually be detected during a woman’s routine gynecologic visit or prenatal exam.   Other signs of uterine fibroids may be more problematic:  If or when a larger uterine fibroid outgrows its blood supply and begins to die, it can cause sharp pain in the process.  Heavy and prolonged bleeding during menstrual cycles is a common symptom of fibroids. As the uterus contracts in an attempt to slow the bleeding, pain from cramping can also occur.  Depending on their size or location, one or more fibroids can create undue pressure on nearby organs. For example, if a fibroid presses on the bladder, it can cause urinary frequency or urgency. If the rectum is compressed, the patient may experience bloating and constipation. When a fibroid is low in the pelvic region, the patient may have discomfort sitting or during intercourse. And if a fibroid is high on the uterus, the patient may notice or feel an abnormal bulge in her belly.  Fibroids within the womb may interfere with an embryo’s ability to attach to the uterine lining, resulting in infertility, miscarriage, or preterm labor.  When a woman with one or more uterine fibroids does become pregnant, the developing fetus is rarely affected; however, the fibroids can make the pregnancy more uncomfortable. Increased hormone levels during pregnancy can also accelerate fibroid growth.  And if a fibroid mass begins to die, the expectant mother may require pain management until it shrinks. If we suspect the presence of uterine fibroids, we first conduct a physical exam and a review of the patient’s personal and family history. If fibroids appear likely, we will typically perform some form of imaging to better characterize the fibroids. This might be an ultrasound or MRI.  In selected cases, we perform hysteroscopy in the office, using a thin tube with lights and a camera to examine the interior of the uterus.   Even when fibroids are found, not all growths call for treatment. Some women will choose to delay treatment until and unless they experience problematic symptoms.   In cases where uterine fibroid treatment is indicated, a main consideration is whether or not the patient plans to become pregnant. If she does:   We can remove fibroids via a procedure called myomectomy, leaving the uterus intact and preserving potential fertility. In patients with fibroids in the endometrial cavity or womb, the same hysteroscope camera used during diagnosis can be fitted with instruments to aid fibroid removal. Patients typically recover quickly from this hysteroscopic same-day surgery, with all symptoms resolved.   When a fibroid growth is too large to be removed via hysteroscope, we perform minimally invasive laparoscopic surgery using keyhole-sized incisions. Even large growths can be eliminated this way, with faster recovery time and fewer complications.   Although oral contraceptives may be used to reduce bleeding, they may actually spur further growth of the fibroid. Oriahnn® is the only oral medication approved by the FDA to control heavy bleeding due to fibroids; it’s been well tolerated so far, and long-term studies are underway. Non-steroidal anti-inflammatory drugs like ibuprofen and naproxen can also help reduce a patient’s discomfort and bleeding.  If a patient does not plan to become pregnant, we can offer additional options such as laparoscopic hysterectomy, a measure that can resolve bleeding or fear of recurrence.   Be assured, today’s hysterectomy procedure is minimally invasive and very well tolerated by most women. Over 98 percent of hysterectomies are completed same day, laparoscopically, via keyhole incisions. Ovaries and the hormones they produce are left intact. The vagina is unaltered, so sexual function is preserved. Supportive pelvic structures are untouched, for less risk of prolapse or incontinence.   Recovery typically takes about two weeks, and many of our patients say they wish they’d had the procedure years earlier.  In occasional cases where surgery is not viable, our interventional radiology team may be able to shrink the growth by inserting a small catheter into a blood vessel in the groin or wrist and threading it to the artery supplying oxygen to the fibroid. The procedure blocks the growth’s blood and oxygen supply, forcing it to shrink and die. Most patients who feel pressure from fibroid growths notice improvement following this treatment; 85 percent see a significant decrease in bleeding.  In addition, a new approach called The Sonata® Treatment can deliver radio-wave energy directly to a fibroid. This procedure can be performed in an outpatient setting with light anesthesia or sedation, similar to what is administered during a colonoscopy. This promising technology enables significant decreases in bleeding with very low complication rates.  Another approach to treatment is use of a drug such as Lupron to block production of the estrogen and progesterone feeding the fibroid; however, these drugs tend to be used for a short time because of potential side effects. We may use them, for example, to reduce bleeding while a woman recovers from anemia, or in cases when blood transfusion is not an option.   If you endure routinely heavy menstrual bleeding, feel persistent pelvic pain or pressure, or have had recurring miscarriages, reach out to the team at MedStar Washington Hospital Center. Our multidisciplinary team includes gynecologists, interventional radiologists, and some of the best-trained surgeons performing minimally invasive surgery in the country, many of them at the forefront of research activities spurring advances in the field.   Team members collaborate to offer a full range of treatment options that meet the individual needs of every patient. Surgeons and specialists will often meet with the patient together.   Remember: it isn’t necessary to tolerate pain, bleeding, or discomfort from fibroids. The earlier we can work with you to address the issue, the more quickly we can have you comfortable and pain-free!

For centuries, women who experience severe menstrual pain have been told that the discomfort is just part of being a woman. It’s not. This level of pain could be endometriosis, and a woman who experiences it should not hesitate to seek help from a well-trained specialist. The disease occurs when endometrial tissue—tissue from the lining of the uterine cavity—is found outside the uterus. In a normal cycle, it grows under the influence of estrogen as the ovaries are making an egg. It then stabilizes under the influence of progesterone. If a pregnancy does not occur, progesterone production eventually stops and the menstrual shedding of the tissue occurs. Endometrium that exists outside the uterus—regardless of whether it’s in the pelvis, or on the ovaries, colon, rectum, or bladder—goes through these same hormonal changes. And this process tends to cause pain, inflammation, scarring, and in many cases, infertility. The disease is complicated because the extent of the condition does not correlate well with the symptoms. There are women who have the disease and don’t suffer from symptoms, yet many women have minimal disease and horrendous, life-changing pain. Typically, though, there are common symptoms associated with this disease: Debilitating menstrual cycle. In women with this disease, painful periods often present in their teen years. Periods that cause vomiting or send a girl or woman to bed in the fetal position are not normal. It is not normal for a girl to miss school because of the amount of pain she is having, or if her pain can’t be managed with an average dose of an over-the-counter pain reliever. Girls with these symptoms should seek help from a physician as soon as they can, to pinpoint underlying issues. Progressive symptoms. These symptoms become more problematic over time as endometrium continues to grow outside the uterine cavity. The symptoms tend to extend beyond the menstrual cycle; rather than just being a cyclic pain, it begins to take over more and more of the patient’s life. We start to see secondary causes of pain, where the pelvic floor muscles become tight and the surrounding pelvic nerves become hyper-sensitized. Urinary or bowel symptoms. Endometrial tissue can grow on major organs. We see it frequently on the colon, rectum, or bladder. When the disease manifests on those organs, people can have painful urinary or bowel symptoms. Many women also complain of painful bloating, which is worse cyclically. Worsening pain with sex. Although not a classic symptom, the other thing we often see is that women have worsening pain with sex—both with deep penetration and with entry. And for many women, it starts to impact their mood and ability to live the life that they want. It’s hard to nail down just what causes the endometrium to grow in abnormal places in the body of any one individual. Reasons may include: Genetic predisposition. The disease can often occur in women whose mothers also have it. Fetal development. As we evolve as embryos, the reproductive organs descend through the developing body. All the tissue designed to be endometrium is supposed to end up in the uterus. In many women with the disease, some of that tissue becomes deposited in other parts of the body. It can then grow outside the uterus as soon as young women begin to menstruate. Immune issues. In these cases, the bodies of people with the disease don’t clean up or eliminate the endometrium that ends up in their pelvis as effectively as the bodies of those people who don’t have the disease. Although this is a disease that goes from menarche (the first menstruation) to menopause, women in their 20s, 30s, and 40s make up the vast majority of our patients. The pain and symptoms of this disease are often multimodal, impacting several organ systems. Therefore, the best treatment is generally multifaceted and may require multiple coordinated approaches. Wellness is a holistic approach, and diet alone has never been shown to eliminate this disease. However, women with symptoms of the disease plus irritable bowel syndrome (IBS) symptoms often respond beautifully to a low-FODMAP diet (fermentable oligo-, di, mono-saccharides and polyols). Keeping stress levels down, exercising regularly to keep endorphins up, meditating, and eating in a way that doesn’t exacerbate bowel or bladder symptoms will help the patient better manage their pain. If we catch the disease early, we can slow its progression and improve a patient’s quality of life. For instance, we may suggest that a girl begin birth control pills—even as young as the age of 14—if she suffers from debilitating periods. This can hugely benefit that young woman, giving her many more pain-free years than she may have otherwise experienced. A lot of parents are hesitant to start their daughters on hormonal therapy, partly because we tend to think of this treatment as simply birth control. But the fact remains that hormonal therapy or birth control pills are outstanding preventive treatments for women with the condition. This is especially important in our youngest patients to try and delay or avoid surgery. In women with chronic pelvic pain, the pelvic muscles often respond by getting tight and tender. This leads to worsening low back, hip, and nerve pain. It also leads to worsening sexual dysfunction and pain. Even after adequate medical or surgical treatment of endometriosis, this pain can persist and often requires help from a specialized pelvic floor physical therapist. Hormonal suppression should be a first-line approach in most cases. On the other hand, if we already know that someone has an eight-centimeter endometrioma in one of their ovaries, no medicine we can give them will make that go away. As a result, they may go straight to the operating room without us initiating a trial of medical therapy. Surgery, when it’s appropriate, can be life-changing for many women. It rids them of the disease and allows them to start fresh. In fact, when surgery is appropriate, nearly 100% of this disease can be managed through minimally invasive procedures. Surgically, we are able to do a much better job removing invasive endometrial tissue when it’s done laparoscopically or robotically, rather than through large incisions. Because this disease is so complicated—in part, due to its potential to impact so many organs—and the surgery can be so complex, it is very important that women seek the services of a specialist. In most cases, the average Ob/Gyn should not be performing surgery to remove endometrial tissue growing outside the uterus. It should be left in the hands of specialists who regularly perform the procedure because it is among the most complex of surgeries we do. I would like to encourage more patients to advocate for themselves. If their Ob/Gyn suggests they need surgery to remove abnormal tissue growth, here are some questions to ask: How often do you perform this type of surgery? Every month? Every week? Every day? Are you comfortable performing a complete excisional surgery? If it’s on my bowel, can you remove it and repair the bowel? If it’s on my bladder or ureter, can you remove it and repair the bladder or ureter? If not, can you refer me to a specialist who can perform that type of surgery? A wide range of resources exists for women with endometriosis. For example, a Facebook group called “Nancy’s Nook” identifies expert excisional surgeons all over the country, and provides a forum for patients to listen to each other and exchange information. Patients can also check to see if a doctor has completed a fellowship in minimally invasive gynecologic surgery. These doctors complete two to three years of surgical fellowship above and beyond their Ob/Gyn residency. They manage 500 to 800 cases in those years and become experts. Most importantly, we can support our friends, family, and colleagues by not minimizing their period pain, and by encouraging them to seek an expert opinion. If you are experiencing this type of pain, find a specialist you are comfortable with; one who will spend time getting a thorough medical history from you and who will help you understand possible treatments for your condition. You want a doctor who is willing to work with you for the long term to help improve your quality of life.