Diagnosing and Treating Uterine Fibroids

In this podcast, Regina Gouder, FNP-C, APN, speaks about how uterine fibroids are detected, the gold standard treatment options, and what primary care physicians need to know about screening for uterine fibroids. 

Regina Goulder, FNP-C, APN, is a family nurse practitioner at Methodist Medical Group in Atoka, Tennessee. 

For more uterine fibroids content, visit our Resource Center. 

TRANSCRIPTION:

Jessica Bard: Hello, everyone. Welcome to another installment of "Podcast360," your go‑to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant360 Specialty Network.

Uterine fibroids are the most common benign pelvic tumors in women. The prevalence is still underestimated because many women are asymptomatic.

Regina Goulder is here to speak with us about diagnosing and treating uterine fibroids. She's a family nurse practitioner at Methodist Medical Group in Atoka, Tennessee. Thank you for joining us today. How are uterine fibroids detected?

Regina Goulder: Through a bimanual exam, you may notice a large or more firm uterus, and this would remind you to do more imaging such as an ultrasound. If a patient presents with symptoms and confirmation is needed, like I said, the gold standard for diagnosis is an ultrasound. You would want to do transvaginal and transabdominal ultrasounds because you can't see all types of fibroids from a transvaginal ultrasound. I'll always order a transvaginal and a transabdominal, so we can make sure that we get the full picture of what we're treating.

Jessica: After uterine fibroids are diagnosed, what's the next step in the pre‑treatment assessment?

Regina: This is the big thing with primary care providers. We have to have the conversation, because, obviously, in primary care, we may not do a lot of treating of the actual uterine fibroids. It is our job to have family planning conversations.

Prior to treatment, we have to discuss with our patients what your future fertility plans, and what is your uterine preservation plans? Although not everybody has future fertility plans, some women are pretty headstrong about uterine preservation. We have to know and be able to talk them through this in order to decide on a treatment plan for their fibroids.

Jessica: We talked about gold standard, and you mentioned some treatment options. If you could sum it up, what is the gold standard for treatment options, would you say?

Regina: There's a lot of treatment options out there for fibroids. Some are heavily studied and researched, and some are not. If uterine preservation and no future fertility is wanted by the woman, the gold standard and the only proven permanent solution for uterine fibroids is hysterectomy. It is the only one.

Anytime that the uterus remains, there is a risk for redeveloping the uterine fibroids. That's not always possible. There's always sometimes younger women that want fertility in the future or the uterine preservation, then we can go back to medication management.

Medications, let's go into that first. You'll see the gonadotropin‑releasing hormone agonist use. Here's what they do, they block your estrogen and progesterone and pretty much throw you into a menopausal state. This in return does cause menopausal‑type symptoms, like hot flashes, and bone loss. Those things are important.

We can't stay on these medicines long term. I will tell you these are great medications to use for short term in order to correct anemias before surgery. I'll get into myomectomies and things in a minute. You can correct that anemia and shrink that fibroid before surgery. That's when these are good to use.

Honestly, as soon as you stop these type medicines, typically, the uterine fibroids will return in 10 to 12 weeks. It's only a matter of time they come back. It's not something you can stay on long‑term, but they are great in pre‑surgery treatments.

I talked about this term earlier, the tranexamic acid. This is a non‑hormonal medication. It does help reduce bleeding during cycles. You take it as needed. It doesn't really shrink the fibroid, but it's good for management.

If they're not having a lot of pain and more of their symptoms is long or heavy cycles, they can use this medication to help slow the flow during their cycle time. Like I said, you only take it on your heavy bleeding days.

We do use oral contraceptives at times. Once again, this reduces bleeding during their cycle time, but it does not reduce the fibroid status. They're not having a lot of pain. It's just about the amount of bleeding that they're having. The oral contraceptives may be a thing to us. We use NSAIDs a lot, but that's more to control pain.

There are some research studies that suggest that they decrease the blood flow, but they do not decrease the size of the fibroids.

This leads me into not medications, but now we go into more of our surgical treatments. As far as minimally invasive treatments, the uterine artery embolization is used. This is not used in somebody that is desiring future fertility. Long‑term studies of these are lacking. They are good. They go in, and it cuts off the blood supply to the fibroids. They work.

We do know that fibroids do reoccur after this, but it could be 3 to 5 years down the road. If your patient is wanting more of a minimally invasive procedure, it is something that can be used.

They also do endometrial ablations. This is one that you cannot have any fertility after, either. We have to put you on oral contraceptives afterwards, because ectopic pregnancies are common after this. We have to watch for that. That is another minimally invasive procedure that can be used.

Your most common procedure that you're going to see the most is a myomectomy. We do different ways. You can have open abdominal myomectomy, which is a more major surgery, more of a C section type swap a scar.

They also do the laparoscopic and the robotic options for myomectomy. This is where they go in and they remove the uterine fibroid from the uterine cavity. This will preserve their fertility.

When you use the open abdominal option, you do have more scarring which could lead to some fertility issues later on. If they're wanting future fertility, typically, we'll do the laparoscopic or robotic type myomectomies.

Like I said before, the only one proven solution for fibroids is the hysterectomy. There are different ways to do those too. They can do a transvaginal. They can do an open abdomen. We've come a long way with hysterectomy. I will say that. [laughs]

Jessica: What happens if uterine fibroids go untreated? What are the long‑term effects?

Regina: They can grow larger. They may produce symptoms. They may be asymptomatic at first, and then, of course, we leave them untreated. Then they start producing symptoms, or they may remain asymptomatic, and we don't ever have any problems out of them. It's really a watch‑and‑wait type game.

We do annual pelvic examinations to document the stability and the size. That's your biggest thing. If you're going to do a watch‑and‑wait game, you have to do annual pelvic examinations to make sure the size of the fibroid is remaining about the same.

It doesn't recommend ultrasounds, transvaginal or transabdominal ultrasounds every year, the annual pelvic exams. In that way, you can get a feel for the patients' symptoms, pelvic pressure meralgia, all of that. Less than 1 in 1000 uterine fibroids turn cancerous with their watch‑and‑wait game.

The ones that are there don't turn cancerous. It's the new growth. The rapid growth fibroids move towards that menopausal age group that we're going to be more concerned about for them being cancerous.

Jessica: Can a primary care provider screen for uterine fibroids, or does the patient need to be referred to a specialist?

Regina: Absolutely, we can screen. If you're doing routine paps in your clinic, you do a bimanual exam of the uterus, if you feel any abnormalities. The only thing that would prevent you from doing a good bimanual examination in the clinic is BMI.

Like I said, BMI over 40, it's a little hard to do a bimanual exam and get a good feel for the uterus. If you're doing paps in your clinic, you do the bimanual exam, if you feel a large or firm uterus, then it's time to get an ultrasound.

Also, in primary care, we get a lot of women that present with the clinical symptoms of uterine fibroids, the meralgia or anemia, fatigue, pain with intercourse. That would lead you to go ahead and do a pelvic examination in office and do a manual exam of the uterus.

Then, if you need a transvaginal, transabdominal ultrasound at that point in time for confirmation, then that's what we do.

Management of fibroids is referred out to specialty.

Jessica: In your opinion, are the current guidelines sufficient, or do you think that they need to be updated?

Regina: I feel they are sufficient. We're doing lots of research on new treatments. Of course, this is going to be forever changing with the newer technology that we have.

The literature of the efficacy of most interventions that we have, it's good literature out there. We have good treatments. We have multiple treatment options. I feel like this is very beneficial for the patients.

Jessica: Thank you again for joining us. Is there anything else that you'd like to add regarding diagnosing and treating uterine fibroids today?

Regina: I don't think so. Thank you for having me. I enjoyed it.

Jessica: Thank you. I did too. I appreciate it.