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Introduction: Einstein Health Care Network in Philadelphia, Pennsylvania presents Doc Talk with Dr. Donee Patterson, a board certified family physician and our Director of Medical Community Outreach. In these podcasts, Dr. Donee sits down with our medical experts to discuss health topics important to you. In this podcast, Dr. Donee talks about fibroids. Dr. Donee, take it away.
Patterson: Hello, so we are here today with Dr. Jay Goldberg and as the host introduction, he is our new Vice Chair of the OB/GYN Department and we are so happy to have you.
Goldberg: Thank you Dr. Patterson; thanks for having me today.
Patterson: I want to tell people exactly what is a fibroid? I know myself but I want us to explain it for our listening audience. Can you help explain that for us?
Goldberg: Absolutely. Fibroids are the most common benign tumors in the female reproductive tract. They are benign tumors of the uterus. The tumor affect women primarily in their 30s and 40s and early 50s and the fibroids cause three main areas of symptoms:abnormal bleeding, bulk symptoms which could be pelvic pain, pain with sexual relations and increase urinary frequency and additionally they can cause infertility.
Patterson: So you said the word tumor, can you go back and just highlight that again because people hear the word tumor and they get afraid. So can you explain to them what you mean by tumor in this case?
Goldberg: Absolutely. Fibroid tumors are growths of the uterus, so their normal uterine smooth muscle cells that then start rapidly dividing to form enlargements. So fibroids can range in size from a pea to I have taken fibroids out that are as big as a watermelon.
Patterson: Wow. So for our listening audience, fibroids have different names, so they may hear their doctor use different names interchangeably. Can you say some of those names that they may hear?
Goldberg: Yes. Fibroids are also known as myomas, as leiomyomas. There is a type of cancerous tumor that is sometimes confused with fibroids that is called a sarcoma or a leiomyosarcoma.
Patterson: So those are all fancy names for people, but we don't want you to be overwhelmed. We often called them fibroids. I want you to listen on so you can learn more. How does a person even know they have a fibroid?
Goldberg: That's a really good question. Probably half the women don't even know they have them. When they come in for a check-up the uterus may be felt by the doctor to be a little bit enlarged or irregular or additionally, they may undergo an imaging study such as an ultrasound or a CT scan which visualizes them. The other half of women who are symptomatic may have bleeding irregularities such as very heavy periods that can even lead to anemia or low blood count or may bleed between their periods. The bulk symptoms that women get, some women may have pelvic pain,especially during their menstrual cycle or they may have pain with sexual relations and sometimes women may have increased urinary frequency which means they feel they need to go to the bathroom very frequently or several times at night they need to go to the bathroom or the women may have difficulties getting pregnant.
Patterson: I hear people talk often and they say well I have heavy periods and I have always had heavy periods and they never think to get it checked out. Why would you emphasize to someone who is having really heavy periods to just get it checked out?
Goldberg: Well the good thing about fibroids is that there are many treatment options available to women today. In the past, many women purposely neglected getting treatment for fibroids because the only option they were given was a hysterectomy or removal of the uterus and to many women a hysterectomy is a four letter word, something they really don't want to do. However, today there are many other options that allow uterine preservation.
Patterson: Some of the statistics say that obese women are more likely to get fibroids. Is there a reason why? Do we know why?
Goldberg: That is a true observation; we don't know exactly why. One reason may be that women who are overweight may have increased levels of estrogens they are circulating in their blood stream and we know that estrogens and progesterones stimulate the fibroids, stimulate growth. Most women know that when a woman goes through menopause, when her estrogen levels go down, the fibroids will usually shrink down by about half and any abnormal bleeding will cease and their other symptoms usually improve.
Patterson: Have you heard of reasons between the correlations of people eating differently, like high red meat diets? Does that have a correlation?
Goldberg: I get asked that a lot. Most studies have shown that diet really does not impact fibroid growth and diet modifications do not help fibroids. There have been some small studies looking at things like Vitamin D that show a very weak association. The thing is, many women feel they have done something to cause their fibroids and unfortunately there is a big genetic component that women really can't help.
Patterson: Speaking of that genetic component, there is statistics that say African American women more often get fibroids. Is that just all genetic or is there something else going on?
Goldberg: It probably is all genetics and African American women really do, of the patients I see, have the highest rate of fibroids. However, my wife, who is Italian, she developed some very large fibroids when she was in her late 20s and actually she needed to have treated so we could have children. So it does affect African American women more than other populations, but it does affect women across the board.
Patterson: I know the answer to this but I want people to hear you say it. I hear people tell me often can a fibroid turn into cancer, like a malignant cancer? I want our audience to know the answer to that.
Goldberg: That's a great question and I get many women who come to see me because they are told that their doctor found that they had fibroids and they need to undergo a hysterectomy because they likely have cancer. The truth of the matter is cancerous fibroid are extremely rare and I probably see more fibroids than anybody in the region certainly and in my whole career I have only seen three cases of cancerous fibroids. The best study I know looked at women who have had a hysterectomy for rapidly enlarging fibroids where they were very suspicious of a cancerous fibroid or a leiomyosarcoma and of the 400 women in the study, only one of them actually had a cancerous tumor, so it is very rare.
Patterson: So why are these fibroids so painful?
Goldberg: Well they are painful because they enlarge the uterus so a normal uterus is about the size of a plum and some women will develop fibroids that can be the size of an apple, the size of a volleyball, the size of beach ball even. That can cause a lot of pain to women and the key is, the fibroids affect on their quality of life,that's the key because if a women's uterus is enlarged but it is not causing them any problems with reassurance they may not need to do anything as long as there is not a desire to get pregnant. Whereas some women may have very small fibroids but it is really affecting their quality of life through bleeding or pain or infertility issues and those fibroids may need to be treated.
Patterson: So for those women who are having significant pain and significant bleeding, just tell us, what is the worse thing that could happen?
Goldberg: The worse thing that could happen would be the patient may become extremely anemic potentially needing to have a blood transfusion. In terms of the pain and other symptoms, many women come to me because it is disrupting their life so much that they are missing work; it is affecting their relationship with their partner and some women get very depressed from these symptoms they developed and other women who want to get pregnant really cannot get pregnant due to their fibroids. Of everything I do, the thing I like the most is to have a patient who comes to me who has infertility due to fibroids and be able to treat them and they get pregnant and they come back to me; I do obstetrical care too so just two days ago I had a patient who was in that situation and we took out her fibroids and she got pregnant and delivered her baby just two days ago. That really makes it all worth while.
Patterson: That is awesome. So what happens to the woman that finds herself pregnant and then they find a fibroid afterward; they didn't know ahead of time; what do we do in those cases?
Goldberg: Well you really are not going to treat the fibroids when the patient is pregnant. The key to the fibroids is where they are located. If the fibroid is located within the cavity of the uterus where the baby is going to grow, that would decrease her change of getting pregnant and once she gets pregnant it is certainly going to increase her risk of miscarrying. If the fibroid grows more towards the outside of the uterus it probably shouldn't affect her fertility. Once the patient does get pregnant, if she can get out of the early part of pregnancy, what we call the first trimester, most women will actually do very well in the pregnancy.
Patterson: So the reason why women are having miscarriages is because the fibroid is growing along with the baby? Can you explain that a little bit more?
Goldberg: Early on in the pregnancy, fibroids do tend to increase in size and about half way though the pregnancy the growth usually stops. Probably one of the reasons why women have increased miscarriages with fibroids may involve where the placenta is implanting on the lining of the uterus. For example, if it is implanting over a fibroid, that might affect blood supply to the placenta which can lead to a miscarriage.
Patterson: Walk us through this. For a woman who knows she has fibroids,what are some of the work-ups? How does the work-up happen?
Goldberg: I think the most important thing is to sit down and talk with the woman and really find out how it is affecting her quality of life and what her goals are. Again, I want to find out if she has bleeding issues, does she have what we call the pain bulk issues,does she have infertility type issues. Once we determine those, for many women, all they need is reassurance and probably the second opinions I give patients, probably half of them I reassure the patient and I say you probably don't need the hysterectomy that you were told and we really don't need to do anything because you might be going into menopause in a few years and it will take care of itself or we will just wait and see if your symptoms don't get worse. For the other women, we will look and see what their goals are and there are a whole host of treatments; we may discuss medical treatment for the patient, we may discuss different surgical options for them, such as removal of the fibroids which is a surgery called a myomectomy. There is also a procedure called UFE, or uterine fibroid embolization, we are going through the blood vessels, little particles are injected which block up the blood supply and will shrink the fibroids down by half in the patients. In some patients, a hysterectomy is actually a very good procedure and that is a procedure where the uterus is removed. Most of the times we don't take out the ovaries so it is not putting the women into menopause and that would be a procedure certainly for a woman who doesn't want to have future fertility and a woman who is not very invested in keeping her uterus.
Patterson: I have patients that often say I just want my uterus out; I don't want to think about it but I really want them to know all the options. Can you explain to our listening audience about some of the risks of hysterectomy and why they should possibly consider some alternatives?
Goldberg: Most of the time a hysterectomy will go well and I certainly perform many hysterectomies. Any time you undergo a surgery, no matter how experienced the physician, there are always risks and the risks we always talk to the patient about are the risk of infection, certainly we give antibiotics at that time, but that is always a risk. The risk of bleeding and again, that risk would certainly increase if the person had adhesions or scar tissue from prior surgeries or if their uterus or fibroids are very large. If the patient has had many surgeries before with adhesions, there is always the risk that there could be injuries to organs such as the intestines or the bladder. Those are the main risks I would say.
Patterson: Then after the uterus is out, sometimes women get their ovaries out as well and then they have some vasomotor symptoms like the hot flashes and that could lead to bone loss. There are certain complications so it is not just something they can get done and not have to think about it anymore. There is still some risk associated with it.
Goldberg: Right, and in terms of the ovaries, a lot of people, and there is confusion about terms, when patients come in and some people think the term a total hysterectomy, in some peoples' mind that means taking out the uterus and the tubes, fallopian tubes and the ovaries; however, a total hysterectomy is really just removing the entire uterus. Sometimes it is very confusing what people are saying.
Patterson: Yes, I find that as well. Maybe we will have to bring you back so we can do a whole talk on pap smears and hysterectomies so that we can clarify that for people.
Patterson: Some people ask me, if they remove the fibroid does that take away my pain? What do you say to that?
Goldberg: Again, it is very important, Dr. Patterson, to sit down and talk to the patient because some patients may have pelvic pain or abdomen pain and fibroids, but it is not being caused by the fibroids. So first you really have to sit down and try to figure out why they are having the symptoms. Sometimes the patients' symptoms that they blame on the fibroids might be symptoms to irritable bowel disease or other conditions, but many times the symptoms will be due to the fibroids and removing the fibroids really can significantly improve a patient's quality of life.
Patterson: So are there people that are a particular good candidate for the uterine fibroid embolization?
Goldberg: Absolutely. So uterine fibroid embolization or as many people call it, UFE, uterine fibroid embolization is a procedure that really has only been around since the late 1990s for treatment of fibroids. It is a procedure where little particles are injected and it will shrink down the fibroids by about half and in terms of patients getting relief, probably 75% of patients will have significant improvement where they don't need to have any other treatments. The best patients for that are certainly women who have fibroids, women who do not wish to have future fertility or don't want to have future pregnancies. I think a patient who is a high surgical risk such as somebody who has a lot of scar tissue from prior surgeries or patients who have a lot of medical problems such as diabetes or patients who are very overweight. That certainly may be a better procedure for them than undergoing a major surgery.
Patterson: I understand that a lot of people come to you for second opinions where they may have gotten advice from other doctors and they are not quite sure. How does that actually work?
Goldberg: In my career, as well as being a busy clinician, I have done a lot of research on fibroids in the areas of uterine fibroid embolization and in myomectomy, the surgical removal of fibroids and I give a lot of talks on fibroids and a lot of patients have found me out by reading the articles or through our fibroid website. Probably the patients I see with fibroids, the typical patient is somebody who is getting her second or third opinion because they haven't been happy with the options that were given to them. When a patient comes in like that we really go over her symptoms; we look at the imaging studies, such as ultrasounds that the patients had and we try to figure out what her goals are. I try to be as objective as possible and give her all the different options and the pros and cons because ultimately the woman needs to choose what is best for her. What I say to patients, I say many times there are several options and I say I could have you and your twin sister sitting in my office and choice A might be the best for you and choice B might be the best for your sister.
Patterson: For those patients that are going to different outside OB/GYNs that may not have experience in doing fibroid surgery, what do you say to that because I really have strong opinions about that but I would like to hear yours.
Goldberg: I think for something as important as this, especially if the patient wants to have children, it's a huge decision and I think it is something that many patients come to me because they want to be evaluated and possibly treated by somebody who has a lot of experience and I would tell patients before undergoing a major treatment it is always good to get a second opinion.
Patterson: Awesome, I think that's great. Lastly, I think the biggest question that people ask me about fibroids, if I get them removed or if I get the fibroid embolization, will it come back? Do the fibroids come back?
Goldberg: That's a really good question and it is important. I am an evidenced base medicine type of doctor where I think it is important to look and see what the research studies have shown. The research studies, looking at fibroid embolization in terms of we think about failure rate and I guess the failure rate would be patients who had the treatment and need to have another type of treatment. So the failure rate with embolizations is probably about 25%. Probably three out of four women get good success with that. With a procedure like a myomectomy which is the surgical removal of fibroids, the best studies out there show the failure rate is about 10%. Probably with a myomectomy, probably 90% of people will get great results from that. Certainly if you are doing a hysterectomy on a patient, removing the uterus, there is no chance that fibroids could grow back because they don't have a uterus, so certainly by default will be 100%. In general, I tell people most of the time the fibroids aren't growing back but more often than not it is development of new fibroids.
Patterson: I understand, that's awesome. Do you have the information for your fibroid website if people are interested in knowing more?
Goldberg: Currently, the Fibroid Center, what we call the Philadelphia Fibroid Center at Einstein is seeing patients at two locations. In the Kline Building at Einstein Medical Center in Philadelphia, which is on Old York Road in the Olney section of Philadelphia. We also see patients at our Jenkintown office which is on Old York road in Jenkintown. The phone number to call is 267-763-1030. Additionally, if patients go to the website for the Philadelphia Fibroid Center at Einstein there is a lot of education content on there. There is links to fibroid articles, there are many imagines that will actually show your viewers what fibroids look like; the different treatments arediscussed there. We also have something there called the fibroid treatment algorhythm which lets a woman look through this and try to figure out which treatment options might be the best for her.
Patterson: So there you have it. To schedule your initial consultation with Dr. Jay Goldberg, who is the Director of the Philadelphia Fibroid Center at Einstein or for a second opinion with this expert, you can call 267-763-1030. We appreciate you listening and if you would like to follow us Einstein has a Facebook page, that's Einstein Health or you can follow us on Twitter @EinsteinHealth. We wish you the best ad you can always do better so make sure you follow up with your primary care doctor.