Episode Transcript
Dr. Jennifer Enman:
Women, in general, downplay their symptoms. Everybody thinks that it’s normal, but quite frankly a lot of us aren’t ever taught what is normal and what isn’t normal.
Courtney Collen (host):
Hello and welcome to “Her Kind of Healthy,” an informative and unfiltered podcast series brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. I’m so glad you’re here. We’re starting new and honest conversations about age-old topics from fertility to postpartum and so much more with our Sanford Health experts.
In this episode, we are talking about uterine fibroids, something that affects so many women, probably more than you think. If you’ve ever had painful periods, heavy periods, pelvic pressure or felt like something just isn’t quite right, this conversation’s for you.
Uterine fibroids are very common, but there’s a lot of gray area. So to help us break it down in a way that makes sense, and answer those common questions from symptoms to diagnosis to treatment and also how they affect fertility, I have Dr. Jennifer Enman joining me.
She is a board-certified OB/GYN at the Sanford Aberdeen Clinic in Aberdeen, South Dakota. And the perfect person to join me for this conversation. Dr. Enman, thank you so much for your time. Welcome.
Dr. Jennifer Enman (guest):
Thank you for having me.
Courtney Collen:
I have so many questions. So let’s start simple with this: What exactly are uterine fibroids and how common are they?
Dr. Jennifer Enman:
That’s a great question. So I think we should start with first, what is your uterus? Your uterus is the muscle where a baby would grow when you’re pregnant. It’s also the muscle that contracts to help push menstrual products out. So it’s a muscle, and fibroids are usually benign or non-cancerous muscle growths on or in your uterus.
Courtney Collen:
Who are they affecting? Are some women more prone to these than others?
Dr. Jennifer Enman:
So the literature suggests about 70% of women will be affected by fibroids by the time they go through menopause. However, we don’t know the accuracy because many women can have fibroids and not have any symptoms at all.
Courtney Collen:
Is it hormones, genetics, lifestyle?
Dr. Jennifer Enman:
We don’t think that it’s lifestyle. There’s definitely a genetic component. We see women between 30 and 40 (years old) and sometimes after 40 most affected by fibroids. There is some data to suggest that Black women may be at increased risk for fibroids.
But again, it’s difficult to know because some women have fibroids and aren’t aware of it. Or on the contrary, some women have had fibroids for so long and their periods have been so painful and so heavy they don’t know that it’s abnormal. So we don’t ultimately find out that they have fibroids.
Courtney Collen:
I feel like a lot of women will normalize the symptoms. So tell us what are the signs or symptoms that it could be fibroids versus just a normally painful period?
Dr. Jennifer Enman:
Unfortunately you can have a variety of symptoms, but the most common ones will be a change in your period. They can be a little bit longer, they can be more heavy or they can actually happen more frequently than previous.
So on average, we say every 28 days is considered normal, but I will say there’s variants from female to female in that. But when you have fibroids, they tend to have more frequent periods and the periods are a lot heavier.
You can also have more pain with your periods, and sometimes, depending on the size and the location of a fibroid, you can actually have pain with intercourse. Some women who have very, very large fibroids will actually have constant pelvic pressure, urinary frequency and actually in severe cases cannot fit into their clothing anymore.
Courtney Collen:
What determines how severe the symptoms are?
Dr. Jennifer Enman:
So usually it’s based on the size of the fibroid and the location in general. Fibroids that are very large are going to cause more severe symptoms, bleeding, pain, while very small fibroids – and we’re talking one to two centimeters – most women aren’t going to know that they have those. Now that’s not true for everybody, but in general that’s a good, good way to think about it.
Courtney Collen:
Are there different types of fibroids, and do they affect women differently?
Photo by Sanford Health
Dr. Jennifer Enman:
We differentiate fibroids based on their location. So some can be within that uterine wall. Some can be within the outside layer of the uterine wall. Sometimes they can be inside the uterine layer, so that’s when we see them affecting pregnancy. Or people with fertility issues. And sometimes they can completely be on the outside and actually attach by a little stem.
And again, depending on the size and the location, that’s when we see the biggest variance in the symptoms that somebody might have. In general, lifestyle doesn’t necessarily affect the fibroids, but someone who has a really big fibroid and is experiencing really heavy bleeding and pain might not be able to participate in the things that they love to do, exercise, et cetera.
Courtney Collen:
Let’s move on to diagnosis. Dr. Enman, how do you diagnose uterine fibroids and why is it difficult in some cases to diagnose these in women?
Dr. Jennifer Enman:
The best way to diagnose uterine fibroids is usually based on imaging. Now when a patient comes in and they’re complaining of different symptoms that they’re having around their menstrual cycle, I want to preface that it can be a variety of things.
Sometimes it definitely can be fibroids, but there’s a lot of other things. So if you came into the office and said, I’m having really heavy periods, they’re super long I’m having a lot of pain, then the first thing we would do would be a physical exam.
And depending on what you had tried – hormones, NSAIDs – then the next step would usually be an ultrasound. In general, that ultrasound can be transabdominal or on the top of your belly. But sometimes we do have to do what’s called transvaginal, which is where you have a probe inside the vagina, which allows us to better measure the size and determine the location of the fibroids.
Some additional ways that we can diagnose fibroids include hysteroscopy, which is a device that has a camera and we insert it through the vagina, through the cervix up into the uterus. This helps us to see fibroids that might be within that uterine cavity.
We can also do a test called a hysterosalpingogram, which is an X-ray that allows us to see abnormalities within and around the uterus. Finally, you can do a sonohysterogram, which is when we actually put fluid into the uterus through the cervix and then we use an ultrasound to show the inside of the uterus to see if there’s any intracavitary fibroids.
And then there’s surgical diagnosis, which usually occurs through laparoscopy, which is when you have small incisions on your belly and we go in with a camera and take a peek at your uterus. If we think you need advanced imaging, sometimes we will do an MRI, which just allows us to better see where the fibroids are and how big they are. But usually we use that for surgical planning purposes.
Courtney Collen:
When we talk about treatment, how would a uterine fibroid be treated? And let’s just walk through some of the options that patients have at Sanford.
Dr. Jennifer Enman:
Sure. It really depends on the severity of symptoms. So if we have someone who has painful periods, also known as dysmenorrhea, and heavy bleeding, but that bleeding isn’t heavy enough where it’s causing anemia – which is when you bleed so much you have low blood count – it’s just kind of annoying, then we might start with some form of hormonal treatment, whether that’s birth control pills or a Mirena IUD.
And again, it really depends where those fibroids are, what treatment we’re going to best utilize. But if we have small fibroids, a little bit of pain and a little bit of annoying heavy bleeding, we might start with hormonal options.
NSAIDs like Motrin is going to be helpful with the cramping. If we have somebody that has more severe symptoms, then we can utilize something called gonadotropin-releasing hormones. And these medications are kind of big-game medications that stop the menstrual cycle and can shrink fibroids. Usually we use these when we’re trying to shrink fibroids prior to surgery to just better prepare for surgery.
As I said, an IUD is a good option. There’s another medication called tranexamic acid, and that just reduces heavy bleeding and blood loss during periods. And then there’s surgical management. So depending on what we’re trying to treat – and right now we’ll just say it’s heavy bleeding and pain – if we’ve gone through all of the noninvasive options without success, then we can move on to a hysterectomy, which is when we remove the uterus. And in doing so, remove those fibroids.
Now in someone who plans to have babies in the future, this would not be a viable option. So there’s another surgical option called myomectomy, and that’s when we actually go in and remove the fibroid itself while leaving the uterus in place. And this gets pretty complex depending on location and size but if you want to preserve fertility, that would be an option.
Courtney Collen:
Can you tell us about any new or emerging therapies that we should know about?
Dr. Jennifer Enman:
So some newer options are radiofrequency ablation, and what this does is it uses energy and heat to shrink the size of fibroids. And usually this is done by a laparoscopy, which is the small incisions on your belly again, or there’s another option called uterine artery embolization. And in this procedure we block the major blood vessels to the uterus, and this helps to prevent blood from getting to that fibroid and feeding it and allowing it to grow. So oftentimes we see that this can reduce the size of the fibroid.
Courtney Collen:
A lot of options it sounds like. So that’s good news.
Dr. Jennifer Enman:
Yep.
Courtney Collen:
A big concern for a lot of women, especially those of childbearing years in our 30s, how might fibroids and treatment affect the ability for a woman to get pregnant and stay pregnant to carry full-term?
Dr. Jennifer Enman:
Yeah, that’s a good question. So again, it goes back to the location of the fibroids. Sometimes if you have a fibroid that’s within the uterine cavity. If a pregnancy embeds over where that fibroid is, there can actually be decreased blood supply to that pregnancy, which can increase the risk of miscarriage. Now this is not for all, but it is a risk.
People who have really big fibroids are also at increased risk of preterm delivery. So usually we will monitor pregnant women with fibroids a little closer. Those kiddos are actually at risk of something called IUGR. If the fibroid is within the uterine cavity, IUGR is intrauterine growth restriction, which is just a really big word for baby is growing smaller than we would expect for that gestational age.
And in some cases a baby can be breech because of the location of the fibroid and we are unable to turn the baby to allow for a vaginal delivery because that fibroid is so big.
Courtney Collen:
OK, thank you. Are there any lifestyle changes that can help manage symptoms or anything we can do to prevent uterine fibroids?
Dr. Jennifer Enman:
So exercise is known to decrease a patient’s pain symptoms with periods. So having a regular exercise routine can help decrease pain.
Yeah, unfortunately there’s nothing we can do to prevent getting fibroids. You know, there’s no medication we can take or no lifestyle changes that we can make. It’s just something that happens. So the biggest thing is raising awareness about what fibroids are, the symptoms they can cause, and encouraging women to see their OB/GYNs or primary care docs if they have concerns.
Courtney Collen:
Could eating less sugar or perhaps taking supplements help at all?
Dr. Jennifer Enman:
No, I am not aware of any studies that suggest that to be the case.
Courtney Collen:
- Well thanks for making it clear and easy to understand (laugh).
What questions, Dr. Enman, should patients be asking their doctors if they might suspect uterine fibroids in their body? And how would you encourage them to advocate for themselves when they are seeking care?
Dr. Jennifer Enman:
Sure. I think the biggest thing is to bring your symptoms with you. I really encourage patients to have a menstrual diary to say, you know, I started my period on the 11th and I kept bleeding until the 22nd. That’s not normal.
When you have evidence of the length of bleeding time and also the severity. So if you come to me and say, well, I used one tampon during the day and a pad at night, that sounds like very normal bleeding to me. However, if you say, well, I soak through my super tampon and I have to wear a super pad, and that happens two or three times a day, that is too much bleeding and not enough.
So more so than questions, it’s bring those symptoms to me and more than likely your provider will say, “hey, maybe we should look into this.” And if not, just say, do you think I could have fibroids? It’s also always great to know if you had family members, moms, sisters, aunts who may have also suffered from heavy bleeding and pain and if they had fibroids or not.
Courtney Collen:
Good to know, especially on that risk or family history piece, too. We talk about periods a lot and that being such an indicator of potential fibroids if periods are painful or if they’re heavier than normal. Is there a decreased risk for uterine fibroids after, say, menopause and postmenopause? Like are women beyond, you know, mid-40, mid-50s?
Dr. Jennifer Enman:
Yeah, I would say that’s a correct assumption. Fibroids are increased in size usually because of estrogen. Once we reach premenopause or perimenopause, excuse me, and menopause, we don’t have as much estrogen. And once we’re through menopause, we have a lot less estrogen. So therefore the growth of those fibroids should slow. And in most cases, in postmenopausal women fibroids actually decrease in size.
Courtney Collen:
Sure. OK. Thanks for clarifying, Dr. Enman. If someone listening right now is thinking, this sounds like me, what is their first step?
Dr. Jennifer Enman:
I think the first step is to write down your symptoms and the very next step is to get in to see your primary care doc or your OB/GYN and discuss your symptoms and your concerns.
Courtney Collen:
Yeah. How important is it to avoid normalizing the suffering? We like to normalize a lot of conversations, especially when it comes to women’s health, and talk about them. But when it comes to like having that painful period or bleeding longer during your period, you know, how important is it to raise those concerns and not just live with them?
Dr. Jennifer Enman:
I would say incredibly important. You know, women in general downplay their symptoms. Everybody thinks that it’s normal, but quite frankly, a lot of us aren’t ever taught what is normal and what isn’t normal. So first educating yourself on what’s normal, and we can include some things at the end of the podcast for people to refer to. And also questioning when you go in to see your provider, “Hey, is this normal? What should I do about it?”
One thing that fibroids can cause is pain with intercourse, and as the fibroid grows, you can have more pain within intercourse. So if you have gradual increase in pain with intercourse, it’s not improved by position, that would be something I think you should go in and talk to your provider about. And hopefully we’d get an ultrasound or by physical exam could determine if something was going on.
Now there are other things that can cause pain with intercourse like ovarian cysts, but when sex becomes painful, there could be something additional going on. So you should always seek evaluation for that. Especially if it’s something persistent. It wasn’t just a one-off.
There is one type of fibroid that usually we see in older women, oftentimes postmenopausal. It’s very fast growing and it is a cancerous fibroid, but again, it’s in older women. It’s very, very, very rare. So if you’re listening to this and you know someone or personally have severe pelvic pain, feel like your abdominal girth has increased, have a heaviness that’s constant, it would be worth going in to get checked out. But just wanting to say, it’s very, very rare for this to occur, but it can happen.
Courtney Collen:
Yeah. Well, thank you for bringing that up. Again, it’s all about, you know, normalizing the conversation. We don’t want to normalize the suffering. We want women to recognize these symptoms, to note these symptoms and then bring them to their provider. Because the only way that things can get better is if they, you know, seek care and explore options, which there are options.
Dr. Enman, this has been so insightful. As a woman myself, it’s incredibly helpful to dive a little deeper into this topic in a way that feels empowering instead of scary. So thank you for that. Thank you so much for your time and for all that you do to care for women in our communities.
Dr. Jennifer Enman:
Thanks so much for having me.
Courtney Collen:
You are listening to “Her Kind of Healthy,” a podcast series brought to you by Sanford Health. A reminder you can find any of our Sanford Health podcast series wherever you listen and anytime at news.sanfordhealth.org. I’m Courtney Collen. Thanks so much for being here.
Get more episodes in this series
…
Posted In Aberdeen, Gynecology, Health Information, Pregnancy, Specialty Care, Symptom Management, Women's
