From the 35th Annual Meeting - Las Vegas, Nevada- November 2006
Dr. Goldfarb: Good afternoon, I’m Dr. Herbert Goldfarb from New York City and here we are with Dr. Benjamin Gocial from Philadelphia. Dr. Gocial is a reproductive specialist who also specializes in minimally invasive surgery. Dr Gocial, tell us a little bit about your practice. You mentioned to me about normalizing the uterine cavity.
Dr. Gocial: Yes, thank you. It is a pleasure to be here. I primarily deal with fertility and reproductive endocrine issues. I try to help women conceive and oftentimes fibroids are in the way, one of the obstacles, especially when they involve the cavity. Doing hysteroscopy and hysteroscopic techniques for evaluating the uterine cavity and getting rid of uterine fibroids, so that they can conceive normally, is my goal. Oftentimes also the fibroids can cause abnormal uterine bleeding and trying to correct that situation so that they have normal periods is also my goal.
Dr. Goldfarb: I have had patients who say to me, “I have a fibroid, and I want to have a child. Do I need to have the fibroid removed before I have the child?” How do you approach these patients and what do you tell them, and how do you make a decision as to which fibroids need to be removed?
Dr. Gocial: That’s a great question because many women have fibroids and most of them do not need treatment. Trying to make that distinction is important, it’s critical. The main way is by hysteroscopy to look inside the uterine cavity to see if the fibroid is impacting the cavity or not. Another very important way is ultrasound to see how large the fibroids are, how many there are, and where they are.
Dr. Goldfarb: An MRI, as we spoke about, is critical?
Dr. Gocial: I use an MRI often if I feel that I am uncertain about the ultrasound imaging, or if I feel that surgery is needed. It gives me the best possible information on categorizing and identifying the size and depth of that fibroid, and how involved it is in the uterus.
Dr. Goldfarb: Now, some of the groups that claim to be advocates for women feel that a fibroid never needs to be removed in a woman who is going to be pregnant. My concern is that these fibroids can grow, and they can impact on the placental development. What is your feeling about that?
Dr. Gocial: Well, I think it is hard in that area to argue with the literature and the statistics. Clearly the presence of a uterine fibroid does increase the risk of a miscarriage, a premature delivery, sometimes so premature that the child is lost, and the incidence of pain or bleeding during the pregnancy. Lastly, perhaps not as important, it may be responsible for malpresentations so that the woman is more likely to need a cesarian.
Dr. Goldfarb: You know today we have many alternatives to hysterectomy. We have endometrial ablations, we have myolysis, but for women who want to be pregnant none of these techniques has really proven to be safe. We have to treat them very conservatively. We have to make a decision as to which patients need treatment. I think one of the greatest decision making problems is to help the woman make a decision. Not long ago I got a call from the daughter of a friend who had a 12 – 14 week sized fibroid, in other words, the size of a 14 week pregnancy. It so impacted in the back of the uterus that she couldn’t void. The physicians wanted to operate on her, and she was 14 weeks pregnant as well. They wanted to operate on her and I said to her that even if she had to self-catheterize every day, don’t let them operate on you. Indeed, what happened was she just did this and eventually the fibroid popped out of the bottom of the pelvis. Just tell us in closing, how you approach the patient who comes in with problems like bleeding and pain, and who want to be pregnant?
Dr. Gocial: I think the most important thing is one of the things you implied, individualizing the care. Every woman is different, every uterus with fibroids is different, and trying to determine which of the problems are most severe and which need treatment and which don’t, is the key. Having a good overall idea of what is likely, in other words, having experience with what fibroids will do, and therefore what you can expect from them is key to deciding on which treatment regimen is best. For instance, in pregnancy, it is well known that the fibroids can grow during pregnancy, but most of the growth occurs during the first trimester. So, if you can do as you suggested for your patient, bide their time through the first trimester, you are usually going to be okay.
Dr. Goldfarb: One of the things we really worry about of course is prematurity intervention and certainly we have to treat the patient very, very tenderly. Bed rest sometimes helps significantly. In any case, both Dr. Gocial and I are on the fibroid panel. We welcome your questions and will try to help you as much as we can. I’m in New York City at the Downtown Hospital. Dr. Gocial is in Philadelphia, and we can be reached through OBGYN.net. It was a pleasure talking to you this afternoon.
Dr. Gocial: My pleasure, thank you very much.