Dr. Jessica Opoku-Anane is a gynecologist who specializes in the minimally invasive treatment of fibroids, abnormal uterine bleeding, chronic pelvic pain, endometriosis, intrauterine scarring (Asherman's syndrome), pelvic organ prolapse and ovarian pathology.
Opoku-Anane's research interests include making gynecologic surgery safer and improving treatments for endometriosis and fibroids.
What we Discuss
Difference between uterine fibroids vs. endometriosis vs. adenomyosis, including the symptoms for each
Uterine fibroid symptoms, diagnosis, and treatment
Quality of life and fertility impact for those with uterine fibroids
Questions to ask your doctor to ensure your uterine fibroids and diagnosed early and proactively treated
Transcript
Jessica Opoku-Anane 03:12
Uterine fibroids are benign, meaning not cancerous growth of the muscle tissue inside the uterus. So you could do this is just a really big muscle that contracts and causes cramping that it causes with periods, if like one little muscle fibroids starts to grow, or one little muscle cell starts to grow really fast and replicate itself over and over again, it can make a little ball of tissue and that's what we call a fibroid. It's a tumor, but it is not a cancer tumor.
Why are these problematic? So they used to contain the uterus and a lot of times they're often not problematic. So if we look at all women 70 to 80% of all women will have uterine fibroids, but not all the time where they are problematic. They only cause problems if they grow into the wrong place or if they get really large as they're pushing on things in terms of the wrong place.
If they start to grow into your uterine cavity or your womb, they disrupt the normal fibroids that are there that allow you to menstruate once a month. And so if you can't if the uterus can't work in a coordinated manner to cramp and stop you from bleeding a whole lot, but you can end up with really heavy periods or hemorrhaging with your periods. If it's into the cavity can affect fertility because it's just not enough space for a pregnancy to implant or to grow. But if they grow on the outside of the uterus, or even in the muscle wall, the uterus and get really big, they start to push on things like your bowel or your bladder and cause pain and discomfort.
Georgie Kovacs 04:38
Now some of the things that you're talking about seem to be fairly similar to endometriosis as well. Maybe you can tell us a little bit about how endometriosis and uterine fibroids and even adenomyosis differ.
Jessica Opoku-Anane 04:52
Endometriosis. This is when the endometrial tissue, the cells that line the inside of the uterus, comes out once a month with the gooey stuff that comes with the blood. It goes back through the fallopian tubes and spills into the pelvis outside of the uterus. We call this endometriosis.
Fibroids are part of the uterus and endometriosis is when the lining cells, endometrial tissue go outside of the uterus, and they're very different disorders. So for fibroids, the mass is like the actual pressure or location of it that's causing problems. With endometriosis, it is the inflammation that causes pain and discomfort and scar tissue. So you don't tend to have as much inflammation with uterine fibroids.
Adenomyosis is something closer to endometriosis in most situations. So instead of the endometrial tissue with those periods, cells going back with fallopian tubes and spilling outside of the uterus, they go into the muscle wall of the uterus similar to a fibroid, but again, it causes inflammation. And so the inflammation causes pain. It's much more significant pain with endometriosis compared to fibroids. And it can still cause the same issues as fibroids disrupting the normal muscle fibroids can cause bleeding.
Georgie Kovacs 06:06
What are the symptoms for these conditions and how do they differ?
Jessica Opoku-Anane 06:51
For fibroids, the best way for me to describe it is our bulk symptoms and bleeding. Think of a pregnant woman, the uterus is designed and meant to grow up to the size of a full-term baby. And so the symptoms that happen with fibroids is the uterus is just growing. So you're going to feel the same symptoms as a pregnant woman - bulk symptoms, pressure is pushing against your bladder. You're gonna have to urinate more. If it's pushed against your bowels, you may have more constipation or difficulty with your bowel movements, but bloating, pressure discomfort, those are usually the bulk symptoms of uterine fibroids. And they're rare other symptoms, but they're so rare. I don't think that most women should think about those.
Then there are the bleeding symptoms. So the heavy periods that's the other really significant portion for uterine fibroids. Just because we brought this up for like adenomyosis or endometriosis is very different - those disorders tend to cause pain. It's not a pressure, it's not a bulk. It's literally severe pain with your periods.
And it can be difficult to distinguish between the two but more just thinking of bulk discomfort, bloating, that's more fibroids. Actual pain that's once a month, the same time every month - that's the most classic symptoms for endometriosis, although it can look like a lot of different things.
Georgie Kovacs 08:12
Yes, that is definitely true. Now, you mentioned heavy periods. So I must ask because, you know, we women aren't taught necessarily what a normal period is. Heavy to one woman may not actually be heavy, but then heavy to another woman actually is heavy. So what is considered a heavy period?
Jessica Opoku-Anane 08:34
Yeah, the technical term is more than 30 milliliters of blood. But I think that that's hard to quantify. The way that we will ask patients is, “Are you filling a tampon or a pad front to back the whole thing, within an hour to two hours?” That's heavy.
If you're saturating through your clothes and having accidents, that's too heavy.
If you're anemic, feeling lightheaded and dizzy with your periods, that's too much as well.
Georgie Kovacs 09:04
I know that sometimes when women start their period may be heavier on the first day or two and then it gets lighter and lighter. And when the flow first comes out, it could be heavier. So is this like, throughout a certain period of time? Because what if you know when that period first comes out, it may be heavier than throughout? So when you're saying that tampon in an hour is that over a certain time period, or even if it's that first tampon?
Jessica Opoku-Anane 09:31
Even if it's that first tampon, if this consistently even through that first tampon then it can be, but yes, for most women, it's heavier in the beginning, but some of it's a little bit subjective. It's what's heavy to you. But that's just a general way to gauge - Is this normal or not normal?
Georgie Kovacs 09:49
I wonder if the menstrual cups are starting to help with understanding the milliliters a little bit better? I've tried the menstrual cup and I don't even know if I know how many milliliters it fills,
You were also talking about not necessarily the pain but just the feeling that one may get if they do have uterine fibroids - that pressure feeling. Do you find that patients tend to wait too long?
In talking to so many women and experts, I hear women tend to grin and bear it because again, we aren't taught this is normal. So whatever we live with, and whatever our mothers and aunties and grandmothers and friends or the school nurse tell us is what we define as normal. It's not like we get this textbook handed to us when we're 14 years old that said, “This is how a woman's body should work.”
I'd love to hear if you have any perspective to add around that feeling of pressure, because I also understand, with uterine fibroids if you wait too long, that's when it's harder to actually help women.
Jessica Opoku-Anane 11:14
I think this is really important for all women's health, I think we suffer too much. You should not be suffering with your periods in any fashion, whether your periods are too heavy, and you're having embarrassing episodes, that's not necessary. That's not normal. We have lots of treatment options.
When it comes to discomfort and pain, most women don't present early enough. Once we actually treat the fibroids, women always expressed, “I wish I would have done this earlier.” So if you're thinking that maybe this is normal, it is not normal. That's the time to go in to see a doctor.
Georgie Kovacs 11:54
What are the impacts when you have uterine fibroids, long term and short term?
Jessica Opoku-Anane 11:59
In terms of long term consequences, I know a lot of people worry about the risk of cancer, but that risk is relatively low.
In symptomatic women, the risk is somewhere between 1 and 350 women. 1 in 1000 women have it being the worst one that people worry about something called leiomyosarcoma cancer.
For most women, there's not an emergent consequence of uterine fibroids unless you're just bleeding way too much and starting to hemorrhage with your periods, but there are a lot of cost consequences in your quality of life.
The second biggest thing that I think is concerning is fertility. That has obviously huge impacts for most women. Uterine fibroids can affect your ability to get pregnant and also affect the chance of you delivering too early or miscarrying.
There are significant consequences to fibroids depending on where they're located.
Outside of those two more urgent issues, the remaining symptoms are about quality of life. You don't have to do anything about your fibroids. After menopause, they will tend to shrink or at least stay the same size because they grow in response to your reproductive hormones, estrogen and progesterone. Those tend to go down after menopause, in particular, estrogen.
It's mostly a disease of reproductive age women - teenagers closer to the 20s up to the 40s. And then later on, the closer you are to menopause, the more likely you are to have symptoms from your fibroids.
Georgie Kovacs 13:30
I have a friend, around the same age as I am. She texted me that she had uterine fibroids and had to have a hysterectomy. I know that once someone is through with their fertility journey, having their uterus is maybe not as important but as a woman, having a body part removed that you were born with could be psychologically so traumatic even if it helps ease some of the consequences and symptoms that one is facing.
My understanding is the earlier you treat the uterine fibroids, the easier it is to minimize what those symptoms could be because I've heard women talking about just how awful the symptoms can be.
They could if I'm not mistaken, still come back. So it's not as easy as, “Oh, I'll just go to the doctor when I'm really sick at the surgery and I'm fine.”
Jessica Opoku-Anane 14:24
Most people start to develop it in fibroids in their 20s, rarely in teenage years. They tend to grow over your lifespan, generally in the 30s and 40s. When people start to feel more symptomatic about it, it's a little bit tricky to say to treat them as early as possible. We do wait until you have symptoms because of the fact that they're going to come back... so let's say a woman is going to develop 10 fibroids over the course of their reproductive life. If at 20, you have one fibroid but no symptoms and we take care of that one fibroid, that doesn't mean that you're not going to have the nine other fibroids develop. We don't want to do multiple procedures on a woman over her reproductive lifespan.
We do generally say wait until you have some symptoms before you address them, because they can come back so often. The chances of them coming back are dependent on how many fibroids you have. So the more fibroids you have, the more likely, if we remove all of them or treat them, the more likely they're going to come back again. If you just have one single dominant fibroid, it's much less likely that they will come back again.
The rate of growth is not the same, and, some women will have very little growth over many, many years, some will grow rapidly. It's important that, if you do have symptoms, to see a gynecologist to get some imaging to record the size and location of the fibroids, and then if you're not that symptomatic, sometimes they'll just repeat the imaging in a year to see how fast your fibroids are growing, and then make plans dependent on that.
Fertility is often something to consider. If you're not that symptomatic, we might say wait until you're closer to when you want to conceive and then take care of the fibroids because if you take care of them too early, then you risk the chance that you might need a second surgery again, right before you deliver. So it is a little bit tricky. The timing of when you do treat the fibroids, but in general, we try to wait until you have symptoms.
Georgie Kovacs 16:16
With respect to the diagnosis of uterine fibroids. You mentioned imaging. What else needs to be done to have the proper diagnosis?
Jessica Opoku-Anane 16:20
Imaging is most common. Most people will start off with the ultrasound before proceeding with any interventions like uterine artery embolization.
One of the procedures to shrink the fibroids is surgery.
Most people require an MRI to determine whether you're a candidate for a more minimally invasive procedure, or for some of the other interventions to shrink the fibroids. Sometimes it depends. If your periods are irregular or there's concern for other causes of irregular bleeding, meaning that you're skipping periods all the time or your periods are coming more than once in a month, sometimes we'll do an endometrial biopsy, which is taking a sample the inside lining of the uterus sending it off for biopsy to make sure there's nothing worse like cancer.
Georgie Kovacs 17:10
Are there issues that you found with women being diagnosed? So much of what I'm seeing through these interviews, research, and the women I talk to is that for a lot of conditions, it takes them a really long time to get diagnosed. For endometriosis, I think it's 7 or 10 years. It's crazy!
Jessica Opoku-Anane 17:41
The diagnosis for uterine fibroids is much more straightforward. All right. How long it takes for women to present with their symptoms is still a little bit delayed. But it's one of the easiest of the other things that you mentioned. It's one of the easier ones to diagnose.
Georgie Kovacs 17:53
Well, thank goodness!
Jessica Opoku-Anane 17:54
There are always caveats, like diagnosing a fibroid versus adenomyoma can sometimes be tricky, but because it does make a big enough mass, it is much easier to diagnose with ultrasound or MRI.
Georgie Kovacs 18:11
Now, what about getting treatment for the uterine fibroids? Are there things that women should be cautious of? Is it that anyone can do this, everyone's properly trained? Do they need to go to a sub specialist?
Jessica Opoku-Anane 18:47
Well, I think this is where training and going to centers are really important. What a physician is allowed to offer is dependent on what resources their institution provides. For example, artery embolization is very common, but there are other procedures like MRI-guided shrinkage or radiofrequency ablation that are not available in most hospitals and clinics. When going to a larger center for fibroids, you're more likely to be offered many non-surgical procedures that you wouldn't be offered at other places.
When we do regular OB GYN training, most people are not trained to do a minimally invasive laparoscopic or robotic myomectomy currently, so there are some surgeons and we have some really good ones in our institution, who, after residency, took their own initiative to work with some of the industry representatives for the robotic company to learn it.
I did a fellowship so we did two extra years to learn how to do laparoscopic or robotic removal of the fibroids through tiny incisions. So we're very committed to doing that, but if you go to a provider who has not had other training in that, they're less likely to offer you those more minimally basic procedures.
Georgie Kovacs 20:09
And how would a woman know, the training specifically? Do they have to ask?
Jessica Opoku-Anane 20:19
I do think for all surgery, you should always ask, “How many of these procedures have you done?” If you know that there are options, which can be hard, but knowing that there are options for laparoscopic or robotic myomectomy for surgery, you could ask them, “Do you do these procedures? How many of these procedures and what's your training?” - in a nice, polite way.
There's a really great website - MIS For Women that's actually a good way to look up more minimally invasive surgeons in your community.
There's been a lot of push to try to standardize Centers of Excellence for things like fibroids and endometriosis. There's a little bit of pushback, obviously, because that does take away certain procedures from certain OB GYNs, but it is important.
The only problem is a lot of times people don't know baselines. Sometimes doing a procedure five times a year is a lot. You have to ask the question, “Compared to your colleagues or compared to other people, how many of these procedures are you doing?” I think in general volume matters. Most high volume surgeons are doing anywhere between 100 and 300 cases a year.
Then you can ask your surgeon how many of these cases there are. I bring it up because there are certain procedures like a cerclage, where you're trying to help prevent people from losing babies. People ask me, “How many have you done per year?” I've done 10 per year, but that's actually more than 99.9% of the gynecologists in the country.
Georgie Kovacs 23:49
That's a really important nuance.
I'd love to talk a little bit more about the hysterectomy. I've become a bit passionate about this, because when I was at the Endometriosis Foundation of America conference in 2019, I had been hearing stories about 20 year olds having to get hysterectomy. I have so much empathy for women who have to make that decision regardless of their age, because even if you're done having kids or choose not to have kids, I cannot even fathom what that must be like. So for women who are potentially having to make that decision, what would you say to them, because I'd hate for a woman to make the decision coming from the wrong place.
Jessica Opoku-Anane 25:01
For fibroids, if somebody asks you to have a hysterectomy before the age of 30, get another opinion. It's rare that we would ever need to do that at that age. In general, if you feel uncomfortable with a hysterectomy getting a second opinion is always a great idea. Because there's a lot of variation in what physicians offer for uterine fibroids based on our training and what we have available in our systems. You just want to make sure that you're actually being offered everything that could possibly be done.
Procedures can include:
Shrinking fibroids
Removing fibroids, like a myomectomy procedure, both laparoscopic robotic or the traditional bigger incisions
Burn the lining of the uterus, if you're having bleeding
If your doctor is not offering all of those procedures, then maybe you need to get a second opinion.
There are situations where hysterectomy is the obvious choice. Those situations are when you have a whole lot of fibroids, especially big fibroids. The reason is because, more importantly, a whole lot of fibroids is when you have so many, you are taking more risks to do a myomectomy, in particular, the risk of hemorrhaging and bleeding and needing a blood transfusion, having to convert from a minimally invasive procedure to a bigger incision surgery. It puts associated increased risk of infection and pain, so there are certain situations where a hysterectomy seems to be the more obvious answer.
Even with my patients, even though I know that that's the obvious answer, if they still want to keep their uterus, I will still comply up to the point where I believe that this is just unsafe. When that does happen, I'm much more likely to say, “Some of what the research shows is if a woman has greater than about 8 to 10 fibroids, or fibroids that are bigger than about 8 to 10 cm, then you're starting to have much higher risk from doing the myomectomy procedure to remove the fibroid than to just take out the uterus.”
Sometimes a surgeon might say a hysterectomy is a better option for your safety, but it's important for women to make sure that that's the reason why they're saying that. Maybe it's just asking him that question, “Are you saying to do the hysterectomy because you're worried about my safety, or are you saying to do the hysterectomy because (in a nice way) that's the procedure that you're more comfortable with?”
I do think that if you're going to choose that surgery, and lots of women like to have surgery with the person who they’ve known the longest, who delivered all their babies. If a surgeon says to you, “I feel more comfortable with this type of procedure. You should go with that.” - don't force a surgeon to do a procedure they're not comfortable with. You just have to get an understanding of why they are pushing you towards a hysterectomy or not.
Georgie Kovacs 28:17
What about prevention?
Jessica Opoku-Anane 28:41
There's not that great of evidence behind this. Probably one of the areas of evidence is for Vitamin D deficiency. Otherwise, theoretically, it's trying to decrease estrogen or progesterone, because we know that those are the hormones that drive fibroid growth and production. Sometimes, people will try to decrease things high in estrogen progesterone such as soy, added foods, fried foods, red meats. We don't know if those are very helpful, but it seems likely that they might be helpful in preventing them either from developing or growing.
Georgie Kovacs 29:27
How does birth control play a role with uterine fibroids?
Jessica Opoku-Anane 29:31
Very controversial. Estrogen and progesterone stimulate fibroid growth and production. Most of our birth control methods are estrogen and progesterone. However, the data is not clear about whether it should be contraindicated in women who have fibroids, but we often use them anyways because they're very good treatments for bleeding.
For fibroid growth, if you wanted to avoid or do choose a method that has the least amount of hormones like an IUD and Mirena IUD that has progesterone only. So it's probably the best option for someone who has bleeding and fibroids.
This is an area where we go back and forth about - whether it's a good idea or not to do to use birth control. If you're hemorrhaging, it's a great idea. If there's very, very few things that work for heavy bleeding, you can try tranexamic acid or lysteda, which has no hormones in it, to help, which sometimes people are not offered.
Georgie Kovacs 30:45
What is this? I've never heard of this.
Jessica Opoku-Anane 30:46
It's a pill that you take only with your periods. It has no hormones in it and works on your coagulation cascade, so more working for you to clot in the correct way to stop bleeding. And that's very much an option I give to patients when they want to avoid our hormones who have hybrids. So that's an option.
If you're hemorrhaging all the time, birth control actually does work, so I wouldn't say don't don't take it, but there are a few other options, though. The only other non-hormonal option that we have available in the US is for birth control pills. There are some other options, but they're just not available currently in the United States.
Georgie Kovacs 31:39
What are those? I'm curious.
Jessica Opoku-Anane 31:41
Ulipristal acetate has some early evidence. It doesn't increase estrogen or stop the fibroids, but it possibly can shrink the fibroids. They use it a lot in Europe, but there are some concerns about it causing some side effects, so it's not available in the United States right now. There are some people that still go to try to get it from other countries to still use it.
Georgie Kovacs 32:08
I believe when we just did our introductory call to get to know each other, we talked about holistic medicine and the role that it plays. I'd love for you to talk about any concerns that you have that women should be aware of, whether you work with these types of practitioners.
Jessica Opoku-Anane 32:32
I do so we're really looking at UCSF, we have a Center for Integrative Medicine or Osher Center. We refer a lot of women there to help them talk about dietary changes and about other interventions for discomfort or pain, like acupuncture or pelvic yoga. I promote all of them.
I've never seen those methods shrink or vibrate, but I've definitely seen that those methods helped delay needing a surgery or the timing for the surgery.
Georgie Kovacs 33:26
Is there anything else that you would want women to know that maybe I haven't asked during this podcast, or when it comes to uterine fibroids or even just generally about their health?
Jessica Opoku-Anane 33:40
I think that it's important to develop a good relationship with their gynecologist to ask these questions early, to not be afraid to get tested and to do your research. I agree with you on doing your research to know as you're being offered all of the options. And then more importantly, just knowing that you know, it's not normal to really have significant discomfort and bleeding with your periods. There are options.
Resources
Learn more about your Hormones and Menstrual Cycle.
Learn more about Endometriosis.
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