Gynecologic surgeon at the Mercy Medical Center, Dr. Latasha Murphy talks about an old drug being used to treat endometriosis.
Interview conducted by Ivanhoe Broadcast News in 2023.
Can you describe this process?
MURPHY: So, with minimally invasive surgery, this is a whole new approach to doing very complex surgeries. Previously, we thought, if you had to do a complex surgery, you had to do the largest incision possible for the greatest amount of visibility. As it turns out, that’s not really true. So when you do a laparoscopic or robotic surgery, not only can you get a 3D approach to it, but you also have the ability to see 360 degrees around, and not looking in a two-dimensional view in one incision. You have the opportunity to see around the entire abdomen and pelvis at once. It’s quite incredible.
Are you doing those combined the laparoscopic?
MURPHY: Yes, in order to do a robotic surgery, you first have to go in laparoscopically, and then you hook up the robot after that. So yes, there is a combination of those things. But in terms of whether a procedure is a laparoscopic versus robotics, simply depends on how you actually do the core of the surgery. So with the robotics, you’re doing the actual procedure using the assistance of a robot. And when you’re doing a laparoscopic surgery, you are at the patient’s bedside street sick during the entire surgery that way.
Are you going in through the navel?
MURPHY: Typically, it’s through the umbilicus, yes.
So, let’s take Caitlin for example because she’s got both fibroids. What did you see?
MURPHY: So, for Caitlin, we got to see both. As soon as we got into the abdomen, we’re able to see an enlarged uterus with multiple fibroids all over the uterus, which actually ended up being a lot more than her imaging initially thought. So the imaging thought that there were about four fibroids in there, we ended up taking out 10. And then for her endometriosis, we were able to remove endometriosis from about four different locations in the pelvis.
Had that spread like to the exterior of the organs?
MURPHY: So, we found it overlying the bladder, and underneath both fallopian tubes and ovaries on both sides, and her posterior cul-de-sac, which is the area between the rectum and the cervix.
And what does this do to women of childbearing age, or any age?
MURPHY: That depends on where we find it. So we do know that with endometriosis, there’s about a 10 percent of patients with infertility is caused by endometriosis. So there is a possibility that it can cause infertility. One of the most common reasons for that is what we call tubal factor. So endometriosis is inflammatory, so if it causes inflammation in the fallopian tube, it can block off that fallopian tube, and it doesn’t allow for the egg from the ovary to get to the uterus. So that can cause infertility.
Describe to the viewer what it looks like. Is it like mossy green grass, or how does it stop the eggs from getting where they need to go?
MURPHY: Primarily, just by closing off the tube. So if you look at a fallopian tube that’s been affected enough by endometriosis to be occluded is usually very thickened, like you can think of it almost like a sausage, like it looks very swollen, and that swelling can cut off the guess the canal or the opening inside the fallopian tube. So it is a physical blockage. And sometimes you can also get what we call a hematosalpinx. So with endometriosis, you can get blood filling up the fallopian tube, and that blood is what causes the physical blockage.
So, the thickening of the fallopian tube, is that scar tissue?
MURPHY: Oftentimes, that’s scar tissue.
From the actual endometriosis, right?
MURPHY: Yes.
How did the fibroids mix in both?
MURPHY: So, with fibroids, fibroids account for about three percent of infertility in patients with infertility. And that is oftentimes related to where it’s located. So if a fibroid is very close to the fallopian tube, of course, it can, again, occlude it, or if it is in the endometrial cavity, so within the uterine lining, then it can cause a physical barrier to a growing pregnancy or place for the pregnancy to attach to within the uterus.
I’ve always thought of endometriosis as being a separate entity almost, but it’s really just scar tissue.
MURPHY: What it actually is is uterine lining. So there is a- there are three layers to the uterus. The innermost layer is called the endometrium, and that’s what sloughs off when a person has a cycle. That uterine lining we have found out goes through what we call retrograde menstruation. So some of that tissue flows out of the fallopian tubes into the pelvis. That happens with just about every person who has a cycle. But with patients with endometriosis, the body doesn’t do a very good job of breaking that tissue down, and so it sticks onto the pelvic lining, and since it’s not supposed to be there, it creates a lot of inflammation, inflammation that ultimately leads to pain and the scar tissue.
So, getting to the root thing that’s not doing a good job of breaking it down, what is it lacking? The motivation break it down or some chemical?
MURPHY: I wish we knew that. We’re still working on that research, while I to figure out what the problem is in that process.
How much does it complicate it that she’s got both of them working?
MURPHY: It is quite complicated because not only are we dealing with an inflammatory and pain component of endometriosis, but then she’s going to have to deal with the physical and structural problem of fibroids. So that it’s a little bit more than, Hey, take this medication to help with the pain, and also what can we do to prevent, one, the fibroids from recurring or the endometriosis for that matter, from recurring.
Where exactly are the fibroids growing?
MURPHY: So again, she had fibroids all over the uterus, but they were growing. So if you think of a uterus, it’s like a triangle. She had fibroids on the top, which is called the fundus, on the front of the uterus, which is the anterior portion, the back of the uterus, and she also had one coming from the left posterior side, so the left aspect of the uterus, but on the backside of it. And that one was pedunculated, probably about this big. Pedunculated means it was on a stock, attached to the uterus, but not actually in the wall of the uterus. And then there were some others which were- we would call subserosal. So like I said before, there are three layers to the uterus: The innermost layer, the endometrium, the thick portion of the uterus is the muscle or the myometrium, then there’s a serosa, very thin protective layer or skin on the outside of the uterus. With the subserosal fibroid, you find that the layer, that serosa, gets pushed up away from the uterus and the fibroid is right underneath that layer. So again, not in the muscle, but attached to the uterus. So her larger ones where subserosal, and probably the largest was about that big.
How much will this increase her fertility? I know she had a laparoscopy recently, right?
MURPHY: Yes. Now, I’m not sure that we have a good number for that, but I will say in my experience, probably 80 percent of my patients that I’ve done a myomectomy for removal of the fibroids end up getting pregnant if that was their plan.
How long was her surgery?
MURPHY: So, her surgery ended up being about three hours, and the majority of that was removing the fibroids.
How do people get this?
MURPHY: So, fibroids in particular, they arise from uterine muscle cells. So what happens is these uterine muscle cells grow at a more rapid pace than the remainder of the uterus. And that’s primarily because we found uterine muscle cells that create or that turn into fibroids have more hormone receptors, in particular estrogen receptors, then the remainder of the uterus. So with a normal amount of hormone that a reproductive age woman has, those fibroids cells are being stimulated at a much more rapid pace. And so they end up over growing and becoming a fibroid.
Why?
MURPHY: I wish I knew.
So, there’s nothing anybody can do about it, in terms of patients, right?
MURPHY: No, there’s no way that anyone can prevent them from occurring, and they’re extremely common. So we believe that about 70 percent of women have fibroids, but only 25 percent end up being symptomatic. It’s a very common occurrence.
How do they tell the difference between fibroid pain and endometrial pain?
MURPHY: With fibroid pain, usually that’s more of a bulk thing, meaning people feel very heavy and like a pressure associated with it. With endometriosis pain, typically that’s described as a burning or a sharp stabbing type of sensation, which is not typically what you would feel, with the fibroid.
So in Caitlin’s case, she can’t just leave the room when she feels bad. So, how does this interfere with daily life?
MURPHY: Oftentimes, patients are really having to decrease their activities. So I have patients who often say, “I really shouldn’t call out of work, but I physically cannot get out of bed, so I cannot go into work.” They are in a fetal position because the paint is so unbearable. It really does affect people. I’ve had one patient recently who told me that she even had to stay at a vacation longer than she was supposed to because she couldn’t get out of bed to get to the airport.
Percentage wise, cycle pain times what equals endometriosis?
MURPHY: Pain is very subjective. It’s hard to say, but I would say cycle pain times 100. I mean, it is extremely unbearable that type of pain that patients with endometriosis endure.
So between the taboo and the invisibility, how would you suggest that people let others know they’re hurting?
MURPHY: Honestly, it’s all about being an advocate for yourself. And while it seems like it’s something that you shouldn’t or wouldn’t want to talk about, you also want to make sure that you have a good quality of life. So it comes down to taking care of yourself and making sure that you’re living the best life that you can. So I would simply say if you feel like your cycles are keeping you from doing your normal activity, that is the time that you should go ahead and open up about it and see what’s available to be done.
Can you tell us how Myfembree works?
MURPHY: So with Myfembree, it is a medication that has three different medicines in it. It has, which is a gonadotropin releasing hormone antagonist, meaning it drops that hormone. And then you also have estrogen in it and you have norethindrone at it. So the way it works is it decreases the brain’s message to the ovary secrete estrogen. And the way it does that is by blocking the gonadotropin releasing hormones effect on the brain. And that ultimately has a downstream effect to the ovary to say, don’t produce estrogen anymore.
And that goes back to what you said initially, that they’re overproducing hormones.
MURPHY: So estrogen stimulates endometrialisis and fibers to grow. And so if you can reduce the estrogen, then essentially those tissues become inactive. So that’s the way the medication works. The reason for the estradiol and the norethindrone is the patients who tend to be affected by these issues are reproductive age women. So they have significant amount of estrogen that is circulating and when you then decrease it significantly there are side effects from that. Hot flashes and night sweats and potentially mood changes into the estrogen that is placed in it and the norethindrone this place it is to mitigate some of those side effects so that you’re not fixing one problem and then creating a whole host of another set of problems.
Which is what happen on her on birth control?
MURPHY: Exactly.
Previously, that was it, right?
MURPHY: Correct. So, this way or trying to find a happy medium and a good balance between treatment and its effect.
How long does it take to work and how often do you recommend it to your patients?
MURPHY: Honestly, for every patient who comes into my office who doesn’t have a contra indication to taking the medication, who I believe has endometriosis I will offer it. Because well, previously we would say that either you have to do surgery or be on birth control or do something like Lupron. This is a good option for patients who don’t want to get to those major surgery. Things are lupron completely shutting down the reproductive system. So I offered to everyone who is a candidate for it.
Is it a lifelong medication or do you take it until you get pregnant?
MURPHY: It’s actually only FDA-approved to be used for two years consecutively. And again, that’s because of the potential side effects of decreasing the estrogen and a reproductive age person. And that particular side effect that they’re concerned about is the decrease in bone mineral density. So we have seen that if you drop the estrogen level for too long of a period of time then the bone mineral density can decrease. But it is a reversible change, which is why after two years can come off of it and that reverses itself.
So how do you manage all of that?
MURPHY: There are a couple of ways to do it, but one, you have to know what you’re giving the patients and know what the potential side effects are to know how to manage it. So again, one of the big things it’s about having decreased bone mineral density. So one of the things you can do is a DEXA scan. So you do imaging to look specifically at what the bone mineral density is and you monitor that and treat the patient accordingly. So if prior to those two years that bone mineral density loss is more than you’d expect, then you’re going to pull that patient off a little bit sooner than the two years. Or if the bone mineral density is not decreasing to the point that you’d expect, then honestly you can potentially even on there for longer if it is working the way it should be with them.
Does it lead to cancer or is there any connection between that?
MURPHY: We have not seen any connection with that. But I’m going to also put out there that it has estrogen and progesterone in it. So in theory, it can increase the chances of the hormone induced cancers, like breast cancer, endometrial cancer in theory. But if you think about it. So we have seen what the actual estrogen level is on a patient who is taking this medication. And that’s about 20 picograms per deciliter, which is in the menopausal range. So if you are expecting that giving exogenous estrogen is going to cause someone to have increase risk of cancer, likelihood is not going to happen at that menopausal or it.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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Latasha Murphy
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