Jessica Shepherd, MD, Gynecologist at Baylor Scott & White Health talks about treating uterine fibroids with radio-frequency ablation.
Interview conducted by Ivanhoe Broadcast News in February 2019.
What is your specialty?
JESSICA SHEPHERD: Gynecology minimally invasive surgery which means that we do complex, benign, gynecologic cases to anything through laparoscopy or robotics.
Do you do it here in the office or is it something that is done in the hospital?
JESSICA SHEPHERD: Minimally invasive gynecology is technically the operations that we do in the operating room which allows women to get any complex procedures or any major surgery such as hysterectomies, myomectomies, and any pelvic reconstruction. The procedures are done through a minimally-invasive fashion where we use very small incisions to accomplish the same thing.
What will we be talking about today?
JESSICA SHEPHERD: We’ll be talking about fibroids today. It is the most common benign tumor of the female pelvis and up to 50 percent of women have fibroids by the time that they’re 50. However African-American women in particular have fibroids up to 70 to 75 percent by the time that they’re age 50.
Why?
JESSICA SHEPHERD: That’s the million dollar question. Why do African-Americans or women in general have fibroids? We know that it’s a benign smooth muscle tumor but, what we don’t know is the reason why females get it and more specifically why African-American females get it and why they seem to have even bigger fibroids or fibroids that cause more severe symptoms such as bleeding.
Do you know what causes the fibroids?
JESSICA SHEPHERD: We don’t know what causes the fibroids. We know the architecture of it; what cell line it’s from. But when you look at different reasons why someone might be more predisposed to having a condition such as fibroids, it could be genetic. We know that it’s very strongly-linked to genetic factors and you’ll see that family history has a lot to do with fibroids. However it could be linked to diet and specific weight factors, but we don’t know that one specific reason why women have fibroids.
Shanelle told us that her mother had them, I’m sure you’re aware of that. When you’re asking her questions or when you did ask her questions initially you must have gone into that. And what did you tell her about that family connection?
JESSICA SHEPHERD: Anytime we have women that come in with pelvic pain or heavy bleeding issue with their cycles, we try to hone into their family history. When we ask them about genetics, we ask them whether or not their mother, aunts, or grandmothers ever had any issues with heavy bleeding or if they themselves had been diagnosed with fibroid tumors.
Do they manifest themselves in terms of pain and bleeding during menstruation?
JESSICA SHEPHERD: Yes. Typically when you have fibroids of the uterus usually you’ll see the most common symptom which is heavy bleeding. Heavy bleeding is what you’ll see through the menstrual cycle. Women will usually come in complaining about their menstrual cycle and say they have heavier bleeding than they have had in the past, or typically some women just have heavy bleeding from the time that they start menses.
What about the pain?
JESSICA SHEPHERD: The pain can come with fibroids generally when they grow very big in size. When they grow to a certain size in the pelvis, the pelvis can be somewhat limiting when you think in terms of space. This means fibroids are going to be space-occupying so the larger they get, the more space that they’ll take in the pelvis. This can manifest in many ways when you have pelvic pressure. You can have pain during intercourse, you can also have fibroids that rest on the bowel which would cause issues with bowel movements, and if they rest on the bladder they would cause some urinary issues as well.
So Fibroids are not confined to the uterus?
JESSICA SHEPHERD: They are confined to the actual uterus tissue but when they grow with size they can grow further into the abdomen just because there is nowhere for them to grow. They can grow upwards and outwards but they’re still confined to the actual uterine tissue.
How big can they get?
JESSICA SHEPHERD: They can get pretty big. I’ve seen some as small as grape size but some as large as a small watermelon size. Fibroids can get really, really large and that’s why women come in with symptoms such as pain or heavy bleeding; because these fibroids can get magnificent in size.
What kinds of complications happen besides the pain and the bleeding? Do fibroids lead to any other problems?
JESSICA SHEPHERD: Fibroids can cause issues with fertility. Depending on their size and location, they can either obstruct conception or they can have women who do happen to get pregnant, increased risk for miscarriage or even preterm labor or delivery.
You said they’re benign but are there any cancer risks or anything like that?
JESSICA SHEPHERD: There’s no cancer risk for fibroid tumors but there are certain growths of the uterus that are cancerous. Those are what we would consider more of the malignant growths of the uterus. Fibroids in general, when they are fibroid tumors, are benign.
So are those cancers or some other type of growth?
JESSICA SHEPHERD: They’re another growth and another cell line and another tissue of the pelvis and of the uterus, but the fibroid tumors are benign tumors.
We’ve known about fibroid tumors for a long time. Can you tell me how long and how they’ve been treated?
JESSICA SHEPHERD: Fibroid tumors have been known to be around for a long time but we don’t know the actual timeframe in which we’ve known about them. Historically when you look at the literature they’ve been known for decades if not centuries, but when we talk about fibroids again we don’t know exactly what causes them to grow or why they grow to such significant size. What we do focus on is the actual treatment and recommendations for management when women come in with complaints of fibroids. Fibroids in general do not necessarily mean that we have to do anything about them. Now, if they don’t grow to a significant size or they’re not causing any severe symptoms of the ones that we mentioned before with bleeding, then we can observe them and watch them because they’re not causing any harm or any complications to the woman who has them at that time. When we do try to intervene with fibroids it’s usually because women start to have some type of symptom whether that’s a bleeding symptom, a pressure symptom, anything with fertility. In this case, we have to intervene and talk about the treatment and the management with patients and that management can range anywhere in medical management. If it’s a bleeding issue we can manage the fibroids by giving the woman some form of oral contraceptives to decrease the bleeding. We can always use an intrauterine device and place it inside the uterus which is typically a contraceptive but it minimizes bleeding. In other words, if the woman’s complaint is only bleeding then we can use things such as an IUD but there are some procedures that we can do which are small procedures. We can treat the lining of the uterus if it’s a bleeding issue as well. But when we do run into the fibroid that’s causing a bulk symptom such as the size causing an issue, that’s when we usually discuss more of the surgical intervention with fibroids, and that can range anywhere from having myomectomy which is where we remove the fibroid tissue from the uterus but keeping the uterus intact. However, there are some very minimally-invasive techniques which I love discussing because the woman does not have to have a lot of downtime when she has these procedures so the recovery is much quicker. They are done in the operating room and are done on a same day. Some of the procedures include a hysteroscopy myomectomy which is when we retrieve fibroids from the endometrial cavity of the uterus. We also have a novel technique which is newer and that’s a laparoscopic radio-frequency ablation of the fibroids, what this does is we approach the fibroids in the laparoscopic fashion and we take the device and insert it into the fibroids under ultrasound guidance. This is done at the time of the procedure and the operation, and what that energy does is it allows it to denature the actual fibroid and makeup of the tumor allowing it to shrink in size, and that can help a woman when we decrease the size of the fibroid.
Can you tell me more about hysterectomies?
JESSICA SHEPHERD: A hysterectomy is the removal of the uterus along with the fibroids that’s composed within the uterus. When a woman comes in and she has symptoms from fibroids whether it’s bleeding or just the bulk symptoms of a fibroid, they can get this procedure if they don’t want to keep their uterus. Hysterectomies are definitive, meaning that that’s the gold standard of decreasing the issue with the bleeding and the mass because we take the actual organ out and therefore the woman wouldn’t have any issues.
But she wouldn’t have any babies?
JESSICA SHEPHERD: She wouldn’t have any uterus left and therefore she wouldn’t have the capability or the ability to conceive in the future.
How often does that happen?
JESSICA SHEPHERD: Hysterectomies are probably the second-most common gynecologic surgery after caesarean sections. Up to 600,000 hysterectomies are done a year and most of those are done due to a bleeding issue or a fibroid issue.
Are pain relief and bleeding problems really the main reason it’s done?
JESSICA SHEPHERD: Historically when you look at hysterectomy it is a procedure that used to be the only option for women who had these issues, but as we progress throughout technology and medicine we know there are other options. However, hysterectomy still remains done very often and most commonly done for those reasons.
Are women who have already had kids more likely to go for the hysterectomy?
JESSICA SHEPHERD: Yes. Women who have conceived and who are finished with childbearing are most likely to get the procedure done. Sometimes in their journey they know they’re done with the other options that are offered because they are not definitive. Those other options are not taking out the organ, so by getting a hysterectomy they’re eliminating any possibility of having a bleeding issue and any recurrence of fibroids in the future.
Tell me exactly what this new procedure is and what it does.
JESSICA SHEPHERD: It affects the fibroid tissue without affecting the uterine tissue outside of the fibroid. In terms of the radio-frequency ablation technique it delivers that radio frequency energy to the fibroid tissue, therefore allowing the fibroid tissue to decrease in size and shrink by 40 percent in volume.
When you say the energy, what are we talking about?
JESSICA SHEPHERD: Radio frequency energy is not anything radioactive. It’s an energy delivered to the fibroid which allows it to decrease in size through heat, and denatures the tissue in the fibroid. Therefore not allowing it to grow any further, that’s why you’ll see that shrinkage.
Was this just recently approved?
JESSICA SHEPHERD: It was approved by the FDA in 2012.
How commonly is it being used?
JESSICA SHEPHERD: It’s being used in various states. One of the reasons that we see that radio frequency ablation is because it is not being used as much as a hysterectomy is due to widespread knowledge of the technology as well as insurance. When you look at insurance carriers they decide what procedures are approved and what aren’t, so you’ll find that there are some women who live in certain states where their insurance carriers do not cover that procedure versus women who are in states where their insurance will cover it.
What do you think about the future of this? Is this something that should go nationwide and be covered by everybody?
JESSICA SHEPHERD: From someone who does minimally-invasive surgery I think absolutely. When you look at the procedure, it’s done in one day and women get to leave the same day. Their recovery is as short as a week. When women think about the ability to conceive in the future, they want to maintain having their uterus. Recovery inputs how much they’re able to devote to going back to their careers, and taking care of their family and children after surgery. With this type of procedure women can address their fibroid situation, decrease their bleeding, decrease the size of the fibroid, resume their daily activities, and improve their quality of life within the course of a week.
In what way does the term Medical Breakthrough apply to this new procedure? Why?
JESSICA SHEPHERD: Fibroid tumors have been here for decades and possibly even centuries, so when we look at what has been offered for fibroid treatment there have not been many options. Some women are not ready to have a hysterectomy when it’s recommended to them. When you look at science and technology this is something that should be offered nationally because we’re able to offer women a minimally-invasive fashion procedure and allow them to resume their normal daily activities in a short amount of time. I think all women should be given all the options of fibroid treatment and not just some variation of a list depending on where they live or what type of insurance they have.
This is a procedure that can be applicable to all women, to all different varieties of fibroids and allow them to decide if a minimally-invasive approach is the way that they want to go.
Is it a breakthrough?
JESSICA SHEPHERD: Absolutely a breakthrough when we think of fibroid treatment and management. Many times there are women who do medical management and when they fail that management they’re only offered the most definitive way which would be the hysterectomy. When you look at alternatives and women who don’t necessarily want a hysterectomy, I think that this is a major breakthrough for fibroid treatment and a surgical approach that allows women to resume their daily activity and quality of life.
What are the drawbacks to the procedure if any?
JESSICA SHEPHERD: If we were to think about things that might be limitations to the procedure, the main one is it’s an actual surgery. It has to be done in the operating room but some women do not want to take that approach and would prefer to do a medical management. When you talk about the journey of fibroids and what women are offered, some women are not necessarily ready to do a surgical approach whether it’s minimally invasive or not. I think another limiting factor could be the insurance, women who do want the procedure but are not able to do it that can be something that is not optimal.
Is it possible to do it here? Is it possible to get the insurance in Texas?
JESSICA SHEPHERD: It is approved all over the country but in terms of insurance, it depends what state you’re in. Texas is one of the states where it is approved by certain insurance carriers, you’ll find that Texas probably has more women being approved for the procedure and getting it done compared to other parts of the country.
To what degree is this increasing in your practice?
JESSICA SHEPHERD: I think because I have focused on this technology and the fact that I have done it in this state and other states as well, this is an option that I offer to patients all the time because I’m able to provide it and I know about the technology. I think that there is a portion of education awareness both to providers and to women to know about this technology that would improve and increase the knowledge of this actual procedure.
What kind of feedback are you getting from your patients in terms of their satisfaction with it?
JESSICA SHEPHERD: I think that women are very satisfied with the procedure because of the fact that the downtime is very minimal. They’re seeing a decrease in their bleeding and, for women who do have a bulk symptom or a pressure symptom with their fibers, they’re seeing reduction in that fibroid size and therefore they’re having great outcomes.
Overall this is a new alternative, right? This is a really positive breakthrough for someone?
JESSICA SHEPHERD: Yes. I think this is groundbreaking. I feel that the trajectory of how we look at fibroids and how we’re able to treat them could be possibly changed by this procedure and technology itself because it will allow us to go even further in fibroid treatment. We’re able to do something that is so novel and different to what we’ve done in the past, we’re only going to be able to get better with our treatment and management of fibroids.
END OF INTERVIEW
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