Posted on February 18th, 2021by RMANY

Ep: 50 The “Scary” Topic of Fibroids Debunked with Dr. Tia Jackson-Bey

Fertility Forward Epsiode 50:

Many patients who discover they have fibroids often have a lot of fear associated with the diagnosis. The aim of all of these episodes is, as always, to put out reputable information. Today’s episode should help you feel a little bit less fearful and more understanding about what fibroids are, how they can be treated, and how it affects your fertility. Tuning in, you’ll hear from Dr. Tia Jackson-Bey of RMA of New York. Dr. Jackson-Bey is a reproductive endocrinologist and infertility specialist and board-certified obstetrician-gynecologist who cares for patients at RMA of New York’s Brooklyn office. Her professional interests include physician-patient education, IVF outcome improvement, global public health, and mentoring underrepresented college and medical students on careers in medicine. Dr. Jackson-Bey is passionate about reproductive justice and increasing access to fertility care for all. She was recently appointed a member of the newly formed ASRM Diversity, Equity, and Inclusion Taskforce, which will enhance opportunities in reproductive medicine for underrepresented minority populations and reduce health disparities and access to care. She is a talented surgeon and dedicated fertility expert, who is focused on fertility preservation, IVF success, and great outcomes for her patients. As she dives into the topic of fibroids, she shares some knowledge around what they are, where they are located, factors associated with increased and decreased risk of uterine fibroids, possible treatments, and much more. Tune in today!

Transcript of Episode 50

Rena: Hi everyone. We are Rena and Dara, and welcome to Fertility Forward. We are part of the wellness team at RMA of New York, a fertility clinic affiliated with Mount Sinai Hospital in New York City. Our Fertility Forward podcast brings together advice for medical professionals, mental health specialists, wellness experts, and patients, because knowledge is power and you are your own best advocate.
Rena: All right, well, we are so excited to welcome to Fertility Forward today another recurring guest, Dr. Tia Jackson-Bey of RMA of New York. Thank you so much for coming back we are really, really excited to have you.
Dr. Jackson-Bey: Yes, I'm excited to be here, always love talking to you guys.
Rena: So I'm really excited today to do this episode about fibroids, because fibroids are something that I know not so much about. And my patients always ask me about fibroids. So then I have to go to you and ask you, so I'm really excited to present this information to people because I think fibroids can sound really scary. I know a lot of my patients hear that they have fibroids and they get very, very scared. So I was left to first start by telling everyone what is a fibroid.
Dr. Jackson-Bey: Yeah. And thank you so much for, you know, kind of even considering this topic. I agree. It can be very scary, especially as they're often described as fibroid tumors. You know, the important thing to realize is fibroids are actually benign tumors. So yes, tumors are a collection of cells, but these are not cancerous. They're actually an overgrowth of cells of smooth muscle. The uterus is made up of muscular tissue. Ever so often one cell can kind of reproduce and reproduce, and it is what we call monoclonal. It's all kind of arising from the same tissue and form these tumors, which are fibroids. They can have a very characteristic appearance on ultrasound and that's typically how we diagnose it.
Rena: Okay. And so where do fibroids live? I mean, where are they located?
Dr. Jackson-Bey: Yeah, so they can be located throughout the uterus. We tend to think of the uterus in terms of about three layers. The endometrium is the innermost layer kind of like where that apple core is, where the seeds would be. That is the tissue that comes out monthly with menstruation. There can be fibroids in that cavity, like where the pregnancy grows. And that is typically categorized as what we call submucosal fibroids. Those are the ones that tend to give the issues of heavy menses or bleeding throughout the cycle and things like that. The muscle layer of the uterus can also have fibroids. And if you think of the apple analogy, that tends to be more of like the flesh of the apple. So we see lots of fibroids in this area and that's called intramural. Very common to have fibroids in that layer. And then right beneath the outermost layer or the serosa of the uterus can also be fibroids on the outside. These may be ones that are more symptomatic, you know, and if they grow very large, you can actually feel them by putting your hand on your abdomen. And so that would be kind of under the, the apple’s skin or peel. Those also can be problematic more so with like making the uterus bulky can make you have a lot of, you know, pressure or pain, or even kind of push your bladder or your bowels to the side. We approach each of those a little bit differently. It's not uncommon to have, you know, submucosal, intramural and subserosal fibroids or some combination of that. The location can actually maybe predict or explain some of the symptoms that women with fibroids have.
Rena: Okay. So what are some of the symptoms you might have if you have fibroids?
Dr. Jackson-Bey: Yeah. So the vast majority of women with fibroids are actually asymptomatic which means they would not even know they had them until we see it on, you know, pelvic ultrasound done for any number of reasons. The most common symptoms tend to be heavy bleeding with your period when sometimes that bleeding can be so much that your red blood cell counts get low after your period or even persist through, persist to be low throughout the month. Other times, you know, if the fibroids are large or if there are many of them, you can have pain, sometimes pain with menses from when the uterus cramps or pain throughout the cycle as the fibroid is kind of growing and expanding. That can also be of what we call bulk symptoms, which is, you know, pelvic pressure or feeling like some women say there's like a knot in their stomach, having even GI upset, you know, constipation issues, just because the fibroid may make it difficult for the bowels to move, feeling like you need to urinate more frequently because the fibroid is putting some pressure on the bladder. Those are, you know, the wide spectrum of symptoms that can occur. Some women may also have different pregnancy outcomes such as miscarriage or even preterm delivery, but those are a bit more uncommon. Again, most women with uterine fibroids don't have any symptoms. And, and actually a lot of women have fibroids. It’s said that up to 70 to 80% of women, by the time they're 50 will have fibroids.
Rena: So it sounds like they're the only way you would really know if you had them would be, if it was big enough that you could see, or if you had any of these symptoms but there aren't so many. And I know a lot of my patients, they get frustrated because they feel like, well, I'm living a healthy lifestyle. I didn't feel anything. And I only found this out, you know, when I was trying to get pregnant. So is there anything you can do to prevent fibroids?
Dr. Jackson-Bey: Yeah. There are some factors that are associated with decreased risk for uterine fibroids. Some of the things would be like plant-based diet, maintaining a normal weight, actually exercise as well. There are some links or some proposed links between vitamin D and uterine fibroids. Whereas a vitamin D deficiency could predispose you to fibroids and that's led by one theory of women of African descent around the world tend to have higher risk of uterine fibroids. And we also have, you know, kind of natural sun protection from the melanin in our skin. And so there's this idea of, is that one of the reasons why women of African descent tend to have more uterine fibroids? On the other side, there are things that increase your risk: having higher body weight, having a diet that contains meat products and dairy. There are some of the other things that we would typically discuss is family history. You know, I always ask my patients, do the other women in your family ever, you know, complain of fibroids? Have you heard that discussed? Did your aunts or your mother or older sisters have to have a hysterectomy due to bleeding? Because that can be a very strong predictor of fibroids as well is family history.
Rena: And what's the difference between a fibroid and a cyst?
Dr. Jackson-Bey: Yeah. So good question. So fibroids are again these smooth muscle tumors within the uterus. Cysts are typically described as something that's in the ovary. So they can be, typically cysts are like fluid-filled sometimes follicles where an egg is growing and the ovary can be described as a cyst, but in, in general, I would say fibroids are like a uterine issue and then cysts tend to describe issues going on in the ovary.
Rena: Okay. And so if you are, if you do find out that you have fibroids, what is the treatment plan? If any?
Dr. Jackson-Bey: Yeah. So it all depends again on how it fits in the scope of why you're presenting. There are frequently times where treatment is not necessary either because the fibroids are small in size or few in number or not causing any particular issues, no issues with bleeding or pain or pressure, and may just be an incidental finding. So sometimes in those cases, we just note it, we can watch them over time and make sure that they're not growing quickly. Sometimes we may do additional imaging just to make sure that we can characterize it as well as possible and just go from there. Other things that can be used if you're not attempting pregnancy would be to use different hormonal medications to help with fibroids because part of fibroids are kind of hormonally responsive, which means that, you know, higher levels of estrogen can accelerate growth. It's also now proposed that progesterone plays a role in fibroid growth as well. And these are two of the dominant hormones in any woman's daily life. So throughout the menstrual cycle, you'll have elevations in estrogen and progesterone. And so it's hard to get around it, but hormonal treatments such as different forms of hormonal contraception are actually commonly used to treat uterine fibroids. Even being on birth control pills, because that shuts down your ovaries production of estrogen can help to kind of keep them at a steady state. Some women who may have a lot heavy bleeding from uterine fibroids may benefit from something like a Mirena IUD which is locally acting progesterone to the uterus. But sometimes if your fibroids are in the uterine cavity and causing a lot of bleeding, having that locally active progesterone can decrease it. There are also some research into anti progestins, things that we would frequently use to treat other medical conditions. Medications like mifepristone, or ulipristal, I believe it's called? But these anti progestins are now being used to decrease bleeding and size of uterine fibroids. And it's something I think our community may be more familiar with because sometimes we include in treatment plans is Lupron. And so Lupron is actually works at the level of the brain to decrease some of the hormonal signals that would activate ovarian hormone production. And so by decreasing those signals and we decrease ovarian estrogen and progesterone production, they actually have been shown that Lupron over a short course of time can shrink uterine fibroids. It's not typically a long-term treatment. It's typically something that we may use before a fibroid surgery to help them shrink, to help decrease the amount of blood loss at surgery and to help patients not have so much blood loss so that they can build up their blood counts prior to surgery. There are some oral formations of that medication now, and we're looking into using those to treat fibroids as well.
Rena: Well, I'm glad you mentioned surgery because I know that is often a treatment method for fibroids. So maybe you can touch on that a little bit, you know, when that would be recommended and what that entails?
Dr. Jackson-Bey: Yeah, absolutely. So for some women, for a long time, a mainstay of fibroid treatment with actually surgical removal of the uterus, which is a hysterectomy. Some women who are past childbearing age are no longer interested in childbearing may still opt for a hysterectomy to deal with uterine fibroids. Fortunately, we do have lots of steps before that. And we do have for women who want to either preserve their uterus or are interested to become pregnant in the future, we have different ways to treat fibroids surgically. So one of those would be, you know, surgical removal of fibroids, which is called a myomectomy. It can be approached in various different ways. Again, if the fibroid is on the inside and the endometrial cavity, we may take a vaginal approach to use a hysteroscope, a small camera that looks inside the uterus, to identify exactly where the fibroid is. And then we can use a resection tool that has a vacuum attached to actually resect the fibroid. And so in those cases, typically with submucosal fibroids, it's the same day surgery. There are no cuts on the abdomen, and that would be a way to eliminate submucosal fibroids. Other fibroids may need abdominal approaches. So either with laparoscopic approach, which is very small incisions on the abdomen or in a larger incision, similar to a C-section to, you know, access the uterus and make sure that we can remove all of the fibroids safely. So sometimes if fibroids are larger in number or in size, we may have to do the C-section route, but more and more gynecologic surgeons are approaching these what we call a minimally invasive technique with just the small laparoscopic incisions and sometimes even using a robot to help them with that surgery.
Rena: So it sounds like there's a lot of different options. And I guess, so if you're, if fibroids don't really cause symptoms, it sounds like, you know, if you didn't ever really go to conceive, you might not even ever know that you have fibroids?
Dr. Jackson-Bey: Absolutely. And that's, that's exactly true. Even maybe a few decades ago before our ultrasound technology was as good as it was today. You know, the way that we actually have derived how common fibroids are at a population level is from pathology results. As I've mentioned, a lot of women, maybe a few generations ago, the way to deal with heavy bleeding was hysterectomy. And so anytime you remove the uterus, the pathologist has to kind of look and make sure there's no cancer and just kind of describe what was happening. And that's actually how we discovered how frequent fibroids usually are, was from examining them after surgical removal.
Rena: So do you think that reproductive endocrinologists actually discover or diagnose fibroids more than any other doctor?
Dr. Jackson-Bey: I wouldn't be surprised to say, I think between us and maybe obstetricians who will also do a lot of ultrasounds, we’re going to see it more frequently. It doesn't mean that the fibroids have a negative impact on reproduction. Very rarely are they the sole cause of anything like fertility or recurrent pregnancy loss, but yes, we do a lot more ultrasounds, very detailed ultrasounds and so we see them more commonly in our patient population.
Rena: So that's what I was going to ask, because I know, you know, I've had many patients with fibroids and they've all been treated in various ways from kind of this monitoring, so no treatment to a minimally invasive surgery to the C-section route. And I've seen patients who had a history of miscarriage get the fibroid removed and then go on to carry a pregnancy to term have a healthy baby. And I think, you know, so many patients, they get very scared about fibroids and they feel like, you know, that that can really impact their fertility journey or really set them back and the journey. So, you know, maybe can we talk a little bit about sort of timelines for fibroid treatment and what that might entail for each present treatment?
Dr. Jackson-Bey: It's not frequent that we would recommend surgery. Certainly for submucosal fibroids or any fibroid that's kind of impinging on the inside of the uterus where pregnancy would grow, particularly if you're having pregnancy issues, you're coming to us for infertility or for recurrent miscarriage, then we want to eliminate those. And so those are probably the most commonly treated with surgical route. Other fibroids that are kind of on the outside of the uterus or within the muscle layer. it may just depend on the symptoms and the clinical situation as to whether or not we recommend surgery. I would say, you know, if it's recommended that it's typically a pretty strong reason why, because, you know, we don't want to intentionally make any incisions on the uterus knowing that you want to use it. So typically if there's a surgical kind of recommendation, there's a pretty strong reason why. And I would encourage patients to really ask their doctors, what is the reason for, you know, surgery? What are the different surgical approaches? What can I expect? How quickly after surgery can I try to conceive? What do I expect from the recovery? Things like that. And so, you know, I would, I would just encourage patients that feel okay to have that conversation, just discuss it with their doctor.
Rena: Absolutely. Well, you know, I’m big on patient advocacy and patients asking questions. I think it's so important, but it's amazing how a two minute conversation with your doctor can really change your life.
Dr. Jackson-Bey: And similarly, if you, you know, are not getting the answers that you need from your physician. Sometimes you need a second opinion or a third. You know, I think that's something that, you know, unfortunately, some patients may not feel as comfortable with the advice that they're being given and in those cases, it is okay to seek the advice of maybe different sub-specialists to understand, you know, here at RMA we work very closely with a minimally invasive gynecologic surgeon, Dr. Rosen. And so she's great, like I send lots of patients to her to say, you know, tell me your thoughts. Maybe you need to hear it from someone else. Maybe you need to go to someone who specifically deals with these minimally invasive techniques and other reproductive issues so that you can kind of see it from a different viewpoint. She's a great resource on fibroids as well.
Rena: Absolutely. I think, you know, something, patients get very frustrated within the process with medicine that it oftentimes is it's referring and it's collecting data and it takes time. You know with health if you don't have an answer for something you want it. And so it's the waiting, that's very, very hard. But, you know, I always say, trust the process and go with your gut. And I think as you said, it's really important to seek multiple opinions and…
Dr. Jackson-Bey: It absolutely can be.
Rena: Yeah. Yeah. It's really important.
Dr. Jackson-Bey: And just back to your other point about, you know, surgery being kind of scary again, you know, I may be biased, I'm a physician. So I really do take it to heart that if it's, we're making the recommendation for surgery, that it's with good reason. And after surgery for fibroids, you know, the doctor will discuss the timeline for trying to conceive. Sometimes it can be as short as one to two months with, you know, a submucosal fibroid removal. If there's a larger incision on the uterus, we really do want the uterus to heal as much as possible before a pregnancy because that's the ultimate kind of stress test of the uterus. So it may be up to three months. But overall, you know, if it's recommended, the benefit to be achieved from maybe reducing the fibroid burden of the uterus would be a healthy, successful pregnancy. And so it could be necessary. So it does seem like more time and more waiting and certainly, you know, a huge sacrifice in terms of having to undergo a surgery. But I just try to encourage patients to focus on the outcome, focus on what you have to gain. In some cases we may need to even do a myomectomy or a fibroid reducing surgery before IVF just because, you know, if the fibroids are too large, maybe we can't even access the ovaries. So again, just to focus on what we have to gain from it as opposed to maybe what's being taken from you sometimes that can help to refocus.
Rena: Well I love that way of thinking and reframing - what do you have to gain from something instead of what are you losing? I think that’s always in life important to frame your thoughts that way, and look on, you know, try and find the positives. That was actually going to be my other question in terms of IVF. So say your a patient who maybe you have diminished ovarian reserve or your post 35 so age is a factor and you need to do an egg retrieval, but you have fibroids and you need treatment. What would the order be? Would you do a retrieval first and then a fibroid surgery or you would do a fibroid surgery first and then an egg retrieval?
Dr. Jackson-Bey: To be honest, it depends. It depends on the clinical situation. I would always try to do the egg retrieval and, you know, either we’re freezing eggs for fertility preservation or try to create embryos prior to the surgery. The only reason why I would say that the surgery would be first is if we literally cannot access the ovaries. That would be the one limitation. But you know, a lot of times if it's feasible, we have two different competing issues - what's going on with your reproductive timeline and, you know, the reason for your IVF, which may be infertility or other reasons versus what's going on with the uterus. And we can kind of deal with them individually. And so I tend to kind of prioritize what's going on with the ovary because I know that’s a little bit more finite. Dr. Sekhon always has this, this saying that, you know, the uterus can have a much longer timeline and life course than the ovary and so I try to prioritize the ovary if it's safe and if it's possible. So sometimes the IVF, at least the first part of it comes first then we can do the fibroid surgery, let the uterus heal, and then we can circle back and maybe do the transfer afterwards.
Rena: Okay. And I know that you are, you have a plethora of really great resources for reputable fibroid research and organizations. Can you maybe share some of the top ones you recommend?
Dr. Jackson-Bey: So we have quite a few, I mean, there are all sorts of things online and I always tell patients to be careful with where they get their information because if it's like a personal blog or something that can just give more of a, give more of someone's opinion than actual facts. And so that's really important. There are actually quite a few pages. I think the fibroid foundation is a really good one for patients in our fertility space. ASRM, American Society for Reproductive Medicine has a lot of good material about fibroids and the impact on reproduction, which can kind of help patients understand a little bit in terms of, yes, you have fibroids, you may have infertility or other issues, are they necessarily related? And how do we have to kind of approach and address that?
Rena: We can also link in our show notes anything.
Dr. Jackson-Bey: Yeah, we can do that. I'll pull a few good ones for you, but then we have some blog posts on the RMA website, which I found, you know, just they're short, to the point and could be a good resource. We had one that Dr. Rosen did just about fibroids versus polyps and the surgical approaches for that. I wrote one on fibroids not too long ago, which may have some of the same information, but it, you know, it's also nice to just have it as a reference.
Rena: Awesome. I think, and I think too, the takeaway really is that each person is very individual be it with their body and the fibroids and their own path to conceive so really it comes down to, I think it's really important to trust your doctor, trust your team. Don't be afraid to ask questions because the internet doesn't know you, they don't know your body, they don't know your case. So really, I mean, this team around you, have great supports and I, a healthcare team that you trust is really the most important. You know, I know it's so easy for people to go down the rabbit hole of the internet. So I just encourage people to stay off of that. You know, it's definitely well within your rights to schedule a call with your doctor, if you have questions about it. Make sure you ask, you know, what they recommend for a treatment plan, it's timeline, it's really common after you hang up the phone from your doctor, you’ll probably have more questions that you wish you had asked. That’s OK. Schedule another call. So I think this is super helpful. And I think really, I certainly learned a lot about fibroids and I think this episode hopefully will provide a lot of really great, you know, reputable information. Again, I know that my patients that get diagnosed with fibroids, there's often a lot of fear there. So I hope that this helps people feel a little bit less fearful, a little bit more understanding of what they are, how they can be treated, that it doesn't mean that you won't be able to go on to have a healthy pregnancy. It doesn't mean that you did anything wrong. Even if you live the healthiest lifestyle, you might still get fibroids.
Dr. Jackson-Bey: Absolutely. One of my biggest takeaways is don't delay. If you have been told that you had uterine fibroids, that you have symptoms, maybe a doctor told you something that you didn't like to hear that you needed surgery, you know, is not to kind of avoid the situation. Maybe seek out another doctor, maybe talk to friends and family. I think even in, by kind of open up conversations in that way, you may find that other people that you know have had to deal with fibroids and you can talk a little bit about their experiences. There's lots of different pop culture advice on how to treat fibroids and in different ways. And some of them may be just overall health adjuncts, but some of them could even be kind of dangerous. And so I would way rather you come, you know, come in and see one of us or see one of my colleagues or another trusted professional just to kind of get as much evidence-based information as you can. And then of course the choices, you know, it's up to the patient as to how they want to proceed. My biggest thing is just don't delay. Don't bury your head in the sand about it. Be willing to confront it, to talk about it. We're always here for our patients to give them the best support and information, the education that they need.
Rena: Well, I think that's great advice. I could not agree more with that. So thank you so much for coming on today and sharing this information. The way we like to end our podcasts is with a note of gratitude. So something that we are grateful for, something positive. So is there anything you want to share today?
Dr. Jackson-Bey: Yes. I am just grateful for my family including my sister, Maya and just in everything that we've done for each other and that she's done for me. She's on my brain today so I'm super grateful for her.
Rena: I love that. And I think I'm just going to say I'm grateful for today. Grateful for being here today, January 28th. We had this on our calendar. We're both here and on being present. This has definitely been sort of a tough week. I've heard a lot of various things as we're going on with patients and people I love so more than ever just grateful for today. So thank you so much for coming on and you know we'll have you back again soon.
Dr. Jackson-Bey: My pleasure. Thank you.
Dara: Thank you so much for listening today and always remember: practice gratitude, give a little love to someone else and yourself. And remember you are not alone. Find us on Instagram @fertility_forward. And if you're looking for more support, visit us and tune in next week for more Fertility Forward.

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