Endometriosis and Fibroids Don't Stop at Menopause with Dr. Karen Tang

20:39So C-sections and other procedures like DNCs, like for miscarriage, increase the risk of adenomyosis. We think maybe because it's breaking the normal separation between those parts.

20:51Dr. Mary Claire Haver:I did not know this. Really? No. No. What? My God, I can't believe I talked to you something. That's amazing. I did not know that having a surgical procedure in your uterus would increase the risk of adenomyosis. Yeah, absolutely. C-sections is the big one. DNCs, like I said, a scraping, like if you had a miscarriage and then you need to kind of like, you know, take the tissue out from the cavity. And surgeries for fibroids where you cut the fibroids out of the uterus. We think because maybe it breaks that border. There's supposed to be a border between the cavity and the muscle. And if you break that border, maybe the tissue kind of starts to grow into the muscle.

21:22Dr. Mary Claire Haver:Okay. It makes sense. But it's very classic. It makes total sense. Classic, classic. So anyone out there, if you're like, I had some C-sections, I was doing okay, and then I was miserable afterwards, very, very likely adenomyosis. What is the bleeding profile for adenomyosis in general? So it's both the heaviness of the flow. So meaning you're still having your predictable cycles, but the actual amount is much more. Okay. It can be more painful. And you can have more irregular bleeding too. So meaning unpredictable bleeding. And we were talking a little bit before about the influence of hormone replacement therapy, the menopause hormone therapy that people are given, sometimes can cause some of the worsening bleeding profile when you have these problems like adenomyosis and endometriosis because you're giving estrogen, which sometimes can flare these problems.

22:08And then again, people are like, I was okay. And then suddenly, you know, I'm bleeding all over the place. I'm bleeding between my periods. I'm bleeding, you know, for a longer time during my period. So any or all of those are game.

22:20Dr. Mary Claire Haver:What about imaging? Can we see adenomyosis on ultrasound or any other imaging? Yeah, so that is much easier to see on ultrasound and MRI than endometriosis is. So you can see on ultrasound or MRI, like the muscle looks blotchy. the fancy medical terms, heterogeneous myometrium that the muscle looks like, not just one uniform smooth look, but that there's like little blotches inside or even little kind of pockets of blood. Like it can bleed into the muscle, like almost like a mini period is happening in the walls. And you can also see that the normal tissue border is gone. So there's sort of this border that usually looks very sharp.

22:56Now is a little bit more blurry. They're indistinct. And the uterus can get bigger. Like we sometimes will see the uterus is like more swollen looking. It's rounder. It's, you know, enlarged for no reason. There's things like fibroids, which are benign tumors that grow in the wall, also very common. But you don't see anything like that, but you have a big uterus.

23:14Dr. Mary Claire Haver:I just remember being a big, boggy uterus. Big, boggy, yeah. We say like soft and boggy, like it feels kind of squishy. So let's go back to endometriosis for a minute. And we'll, you know, how does that intersect with perimenopause and menopause? Would a patient expect her symptoms to get better? Would she expect it to get worse? You know, in this zone of hormonal chaos, and we've lost our predictability and the trailing progesterone, what typically in endometriosis does a patient experience? Any or all, like I said, all comers. Basically, there are some people who, as the estrogen is, you know, quietly decreasing, like they can start to feel better.

23:56But as you've talked about on the podcast before, it's almost never just like a quiet decrease to nothing. It's a roller coaster. If you picture like the ups and downs, the estrogen is really high and it's really low. And, you know, progesterone is sometimes there and sometimes not if you're ovulating or you're not. So the problem is it's totally unpredictable. Like some months you could be like absolutely miserable. You're having the heaviest bleed of your life or you're having the most painful period of your life. And then the next month you may be like there's barely anything and you feel great.

24:23So very unpredictable. And then the important thing to know is that whatever it is, if you are starting to feel like this is bothering you, like you mentioned before, that's where it's time to maybe talk to your gynecologist. You know, the slowly petering away, periods are getting better. Like, that's great. We're, like, very happy. But if you're like, wow, suddenly the amount of bleeding, the painfulness, like the associated stuff, like the bowel stuff is all over the place. like that's where you should go and see your gynecologist and maybe ask for an ultrasound, see if there's something else like adenomyosis or fibroids that are popping up.

24:58Dr. Mary Claire Haver:So now you go to your clinician and you get the diagnosis. This looks like without surgery yet. Okay. For endometriosis, what are our treatment options? So anything with a progestin and progestin sort of like that category of medicine like progesterone, which are made by your ovaries when you ovulate. So like I said, there are things like birth controls. That's what oftentimes gets suggested. And so people in perimenopause obviously can still get pregnant. So if they need birth control, then that's great. It kind of kills the multiple birds with one stone. But there's a lot of people who don't need birth control.

25:29They're not sexually active. They've had a tubal ligation or their partner had a vasectomy. And they're like, you know, I just really don't want to do birth control. We have lots of other things that we can give as well. So there are separate progestin medicines that are not birth controls, but are given, I say in a bottle rather than a pill pack like a birth control is. There's something called Northendrone. The brand name is called Agustin. And then there's Medroxyprogesterone or Provera. And the nice thing about those is you can take more than one. So sometimes if people are having a particularly heavy period, you can take more than one tablet to suppress it.

26:03A lot of your listeners probably know literal progesterone, micronized progesterone. Prometrium. Yeah, Prometrium, exactly. That's actually very weak progestin. It's great for perimenopause symptoms and sleep. and calming. It's wonderful. It's actually not usually enough for endometriosis, adenomyosis suppression. It's sort of like a drop in the bucket. It's great for the perimenopause stuff, it's probably not enough for these really bad period things. So what happens a lot is very well-meaning, very excellent and skilled menopause specialists may just give progesterone, give estrogen too, which then sometimes makes the endo and the adeno worse.

26:39It's like throwing fuel on the fire. And then they're like, wow, why is my patient suddenly just bleeding all over the place? It's oftentimes there's these hidden things like the adeno, the endometriosis, polyps too, like little fleshy balls of tissue inside the cavity that are being stimulated. And you actually have to counteract that by doing a stronger progestin or a Mirena IUD. Progesterone IUDs are very good. Put them in the uterus if somebody doesn't want to take as much stuff, you know, by mouth. Yeah, it helps to control bleeding and inflammation and pain a little bit more locally to the pelvis.

27:09Dr. Mary Claire Haver:Does the type of formulation matter? You talked about the pharmacology of progesterone. What people don't understand are these progestins were developed really to suppress pregnancy. So they bind super tight to the receptors, way higher affinity typically than our natural hormones. Exactly. The bioidentical ones, quote unquote. So it may not be your best option if symptom control is for you. Exactly. Yeah. So we always have to see like what are people's concerns? So if some I have some people on two types. I was going to ask, do you ever stack your progesterone? I do. I do have people on micronized progesterone or Prometrium for the sleep and the calming.

27:47And it helps with things like the hot flashes and night sweats as well. And I have them on a stronger kind of synthetic one for the bleeding control. So I'll pop an IUD in for the bleeding control, or I'll have them take an oral, like a Justin, for endometriosis suppression. And we always have to talk through, there's not one size fits all for everybody, but we can do different. I call it the Chinese menu. Like you can kind of pick and choose of the different things that you need based on the person's symptoms and what they're looking for.

28:14Dr. Mary Claire Haver:I love having options. I know, right? Awesome. All right. So let's take a woman like she's who's listening and she had endometriosis in her 30s. She maybe had had the laparoscopy, gotten a biopsy, got the diagnosis, and then she was on hormonal suppression and she did great. Now she's 47 and she's starting to have hot flashes during her breakthrough week, you know, during her placebo pills. What should she expect? So some people do great. I always tell people I don't want to scare them and think like, oh, if you take HRT, there's going to be problems. I always just want to make people aware because I don't want them to be surprised if they're the ones who, as soon as they start that, you know, wonderful transdermal estrodol patch, which is definitely necessary in so many cases, that I don't want them to be like shocked.

28:55Oh, my God. Afterwards, oh, my gosh, why am I bleeding more? What's going on? So we just want to make people aware. And I always tell people it's about having a game plan, like to know what could happen, to make people aware. if you are having any more issues, come back so we can talk about different things. And then sometimes too, if people have been through the ringer with endometriosis, like they're pros, like they know like what they need to do and if they need to come back. There are some times that, you know, and we didn't get into this before with the management, but you know, some people do need another surgery.

29:23When is surgery an option? Yeah, exactly. So laparoscopic surgery to excise or remove the endometriosis if someone is not having good enough symptom control with just medications. So they tried the medication, is not working, or say some people have side effects from the stronger progestins, like they get mood symptoms, they feel like they can't tolerate it. So either if it's not doing the job, or if the medications are causing more problems than they're helping with, then we move to the surgery. When people are younger, kind of in reproductive age, the surgery question gets pushed a little bit more for fertility purposes.

29:57Like obviously, like, you know, if you are wanting to get pregnant, you can't be on birth control or these hormones or have an IUD. So like I said, that sort of like kind of funnels people into the surgery path a little bit more often when you're a perimenopausal menopausal and you obviously don't care about like getting pregnant, then it's not as much of a kind of a pressing issue, but it's more of a quality of life. So if we can't get your quality of life where it needs to be with just medications, then the surgery is there.

30:22Dr. Mary Claire Haver:How long do people suffer in general with endometriosis or adeno before they are diagnosed formally? It's on average seven years and it's actually eight years in the UK because also So their system, there's a longer wait period just to see a gynecologist. Like, take a step back. So imagine something, I would say, imagine something affected at least 10 % of men. It's actually much higher, but it caused excruciating pain. It hurt when you had sex, like debilitating pain when you have sex. It made you bleed through your penis and it gave you diarrhea and you were having like incredible bloating. We would, you know, like have a little bit more like awareness and research and all these things.

30:59But for women, we were just like, oh, you know, like it's it's just you just kind of deal with it. So the fact that we let people suffer like that for seven years, like you can't even conceive of forcing men on average to wait seven years in that much pain before they get a diagnosis. It's insanity. Like it would never stand. Nobody would would be OK with that. They'd be like, this is like an international like crisis.

31:22Dr. Mary Claire Haver:if you're complaining of fertility that will speed up your diagnosis like this country worships the ability to get pregnant and the ability to be a mother which is very important to me very important to you and i don't want to make light of this but you'll get a quicker diagnosis if you layer infertility yeah on rather than just pain i was about to say the quality of life angle is so underappreciated uh like i said obviously fertility is extremely important and you know it's important for me. It's important for so many listeners. But the fact that it is that much more important than just your ability to function or work or like live your day-to-day life is insane.

32:00But it is true. Like it will kind of fast track you a little bit rather than saying, oh, I just am having a really hard time pain-wise. If you're like, well, I need to try and get pregnant. I'm trying to conceive and nothing's happening and I'm worried about my fertility being affected. It does sort of kind of speed you through to kind of the laparoscopy and things like that.

32:17Dr. Mary Claire Haver:Yes or no. I'm seeing this on the internet. I'm getting so many questions about this. A woman with endometriosis or adenomyosis are being told they cannot take HRT because it will make their disease worse. Yeah. And it's funny because one, I feel like so few people are talking about endo and menopause, but of the people I'm seeing talk about it, a lot of times it's phrased that negative way because of the concern about estrogen. Like so much of endometriosis medical management is based on dropping estrogen and keeping it low. We luckily don't do this as much, but back when I first started training, and this is probably the case with you too, we did so many surgical menopause ovary removals for endometriosis.

33:01We were taking out everyone's ovaries to plunge them into surgical menopause to treat endometriosis because, again, if your estrogen is low, it helps with the disease, but then you get completely miserable. The thought process is, well, we work so hard to get your estrogen low, like why would you then give estrogen back and make it flare again? So the good news is, is that those of us who do know endo and perimenopause know that you can take HRT. Of course you would. I give it all the time for my patients.

33:28Dr. Mary Claire Haver:What are the nuances here a patient needs to understand? Yeah. So the nuances are you have to kind of go into it planning that you might need to go stronger on progestins than you normally would. So as I'm sure you've gone over a million times on your podcast, normally the progesterone is there to protect your uterus. It's sort of like forgotten. It's a non-negotiable. I was about to say, you got to take progesterone, micronized progesterone usually to protect your uterus from the estrogen causing problems with cancer. But we sometimes need to, again, think stronger if you have endometriosis because we want to counteract potential stimulation.

34:02So this is where I'll tell patients in advance, like, okay, right off the bat, do you want me to give you a stronger progestin like a norethindrone just so we don't take the chance that it will flare your endo? Or do you want to see how things go? Like, we'll try with just marginalized progesterone. If you feel like your endo is flaring, we can pretty quickly jump in with like an Agestin or Provera to suppress it or add an IUD for bleeding control, et cetera, if you've had no meiosis. So as long as you kind of have that plan in place and you talk it through, people do great. Like people do very, very well and they have all of the quality of life stuff handled.

34:37They aren't having the pain anymore. They are having all their menopause, perimenopause symptoms taken care of. So there's definitely ways to do it. It's just you have to go into it with that, you know, that foresight. I always tell people it's like playing chess. Like if you like, if I move this, it could cause this move next, but then I'll do this. You think multiple chess steps ahead and it'll all be fine. Okay.

35:07Dr. Mary Claire Haver:what about the patient who had surgical menopause so we were also quite often removing ovaries in my training program and this is before migs was really minimally invasive gynecologic surgery fellowships where you were doing a lot of that kind of surgery were robust they were just starting so that's an age thing between the two of us and there was zero discussion maybe maybe there was a whisper a hint of, oh, we got to watch your bones, but not like get an early bone scan or anything like that. No discussion of cardiovascular disease risk. You know, in modern endometriosis practice, how often are we recommending ovary removal?

35:43Dr. Mary Claire Haver:And then if we are, which I'm sure is still needed on a case-by-case basis, are we being aggressive enough about the downstream effects of early menopause? Yeah. And so this is one of the good things that has changed since I trained. So I did my fellowship 2009 to 10. And it was sort of the early years of this formal field. So again, for listeners, it's not like endometriosis as a specialty or this specialized surgery has been around for a really long time. No, I was one of the first kind of fellows. When I applied, I think there was like 10 programs or maybe like 15 programs in the whole country training women in these women, training GYN surgeons in these like advanced surgeries and also management of pain.

36:24So back then, again, we were so much more aggressive. We're like, okay, you have really bad endo, ovaries are coming out. You're done with fertility, they're gone. Now, because we know about the dangers of surgical menopause, both in terms of the longevity aspect, the cardiovascular disease, bone thinning, increased diabetes risk, quality of life issues, we don't want to trade one quality of life problem with pain for another, potentially much worse one. So we really try and avoid taking out the ovaries unless there's some other pressing issues. So say if there's like a really strong family history of ovarian cancer, or if someone's had just surgery after surgery with really good surgeons who know what they're doing, it's not like endos being left behind so that it's like not like an optimal surgery.

37:07So if somebody really is getting good surgery and removal and it's still recurring, and there are some of these cases, it's almost like a cancer. I would say it's not cancer and that's going to, you know, like potentially like end your life, But it is sometimes so tenacious. It can grow into other organs. And there are versions that are very aggressive and they come back no matter what you do. There are some situations that we do remove the ovaries because we're like, look, you've had like four surgeries and it may continue to come back unless we do this. But we always now, at least most people I know, will have that conversation.

37:38We'll be like, we may do this, but we're going to want to talk about HRT if you're young to avoid the quality of life issues and the bone thinning, etc. As long as, again, we're careful with the progestin part. And this happens to, I think you probably have gone over the whole, you know, you've had a hysterectomy, you don't need progesterone. That gets told all the time, which is so wild because, again, there's so many good things about progesterone. It's not that you have to have a uterus to benefit from it, but especially in endometriosis. There's times that people will get the whole shebang surgery.

38:07They're going to get the hysterectomy for adenomyosis. They're going to get the ovaries removed. And then they will just get an estrogen patch because they're like, well, we want to give you estrogen. you quote unquote don't need progesterone, that's like the worst thing you could do because now you've done all this big, huge surgery.

38:23Dr. Mary Claire Haver:Because there is usually microscopic disease left behind that you couldn't see. You can only remove what you can see with your eyeballs. There could definitely be, I always say this to my patients, you could always have microscopic disease and you give just estrogen, no progesterone, like you're just going to flare it again and you've done all this work for nothing. So that's another mistake that people do. You know, if they give HRT, they sometimes only give estrogen without a progesterone because there's no uterus. and then they're like, wow, patient's still having pain. What's going on? And then sometimes the patient gets blamed.

38:50You're like, well, I guess it's just in your head. Like, no, we flared your endometriosis.

38:54Dr. Mary Claire Haver:There's some emerging data that women, when I was doing the research for this, women with endometriosis may experience accelerated ovarian aging. You want to talk about that a little bit? Yeah. So again, most of this is known in the context of fertility because again, that's what a lot of the research has been on. Endometriosis, because it's inflammatory, can inflame everything. And that includes your ovaries. So this is where people with endometriosis we know have a higher likelihood of problems with like egg quality and like, you know, kind of premature, like you said, ovarian kind of dysfunction stuff just because it just doesn't function as well as it normally does.

39:29And again, we think of it mostly in terms of the getting pregnant. But yeah, it can, you know, we're learning more and more that it could just, you know, in terms of hormone production may be affecting things.

39:38Dr. Mary Claire Haver:So let's talk about something that's rare, but is there, the malignant transformation of endometriotic foci. So I've seen it a couple times in residency, but it is something worth talking about. Yeah, there's a very slight increased risk of ovarian cancer with endometriosis. I will say in my whole career, so, you know, 15 plus years of practice, I've only seen it three times. And every time was in a big endometriosis cyst of the ovary. So it was never just sort of microscopic in what we found it. There was a huge cystic thing on the ovary that when we did the surgery, it ended up being an ovarian cancer.

40:12So I get a lot of patients who are worried about that because they've heard this. And so I want to put people's minds at ease that, one, it's quite rare. It is a tiny increased risk, but it's not common. And so me, as somebody who sees endometriosis all the time, I've seen very few cases of the cancer. And it's usually in the context of a pretty large ovarian cyst. So it is something that we do take seriously. We always make sure we're getting imaging studies. We're checking those ovaries. You know, when we do a surgery to do a cyst removal, we send the specimen to a pathologist so they can make sure that it's just a benign cyst.

40:44It's not something else. So we have it kind of in the back of our minds, but it's not something I tell people that they need to like live in fear about.

40:50Dr. Mary Claire Haver:Okay. You were ready to talk about fibroids? Let's do it. Yeah. What is a fibroid? Yay. So fibroids are benign tumors. And again, I always kind of, because people hear the word tumor and they get kind of scared. It's not a cancerous tumor. It's basically a mass that grows out of the muscles in the wall of the uterus. And here's a fun fact. They are clones of each other. So all of the cells in a fibroid are identical cells. They kind of all are cell clones of each other. It's kind of a neat little fact. And we don't know, again, where it comes from. Shocking. Shockingly, we don't know because it's a women's thing.

41:24And say those stats again because I think people don't realize this. Isn't it crazy? So it's 70 % of white women, 80 % of black women have fibroids. And the fact that we just don't know where they come from is just ridiculous. It's just like this mystery of life. They show up. We don't know. And so they do tend to run in families. So this is actually both endo and fibroids run in families. So this becomes important because all the women in the family have bad periods. So I have a lot of patients, especially black women who say, my mom, my grandmother, my sisters, everybody's periods was miserable.

41:56Like they were bleeding super crazily. They're always in pain. They're always bloated. But every woman had that. So they didn't have a frame of reference that was different. So sometimes it takes where they're like literally hemorrhaging with their fibroids, like in the ER getting a blood transfusion before someone's like, wow, you have fibroids. Have you heard of this? And they're like, no, I don't know what that is. I didn't know I had anything. So the main symptoms, like we kind of mentioned, number one is really bad bleeding. So both heaviness of the bleeding, irregular bleeding, pain, especially with your periods.

42:26And then we would call bulk symptoms, which is almost like pregnancy symptoms because fibers can be enormous. They can be tiny, like one centimeter, or they can take up your entire abdomen as if you were full-term pregnant, like the size of a watermelon. So they can cause things like bloating or they push on your bladder, make you need to urinate a lot. Disprenia. Yeah, disprenia, pain with sex because you feel like you're hitting something. Or it can push on your rectum, make you feel like you can't poop, like you have constipation. And it can also cause infertility. If it's blocking the cavity of your uterus, it can cause miscarriages if there's no room for a fetus to grow or to implant on a fibroid.

42:59Dr. Mary Claire Haver:Conventional wisdom is that they shrink after menopause. Is that true? They do shrink a little bit. I always tell people if you have pretty big fibroids, they may not necessarily go away. So maybe like, you know, a three centimeter fibroid may shrink enough that you can't find it anymore. But if you have like a 10 centimeter fibroid, it's probably still going to be there in some way. So it also tends to prolong periods. I've had women with fibroids who are still having regular periods when they're 59. So it does kind of just keep things going longer in terms of periods. And also you can have bleeding after menopause too because the fibroids can just bleed.

43:34Dr. Mary Claire Haver:So fun fact, I had a C-section 22 years ago with my daughter and no one told me I had fibroids. And I never got imaged again, okay? I really didn't have any gynecologic issues other than my polycystic ovarian syndrome. you know, which was managed. And then I went into menopause. I was imaged for another reason. I have a big family history of cancer. So I got an image and the radiologist called me because I'm a doctor and was like, hey, you've got a seven centimeter fibroid. And I'm like 55 years old going, seven centimeters. Yeah. What kind of gynecologist am I that I did not know I had a significant size It's fibroids sitting in the back of my uterus and it never caused me a problem.

44:18Dr. Mary Claire Haver:I knew my mother had them. It's supposed to be her hysterectomy after eight children. So in South Louisiana, there were a lot of hysterectomies done for birth control in the Catholic hospitals. So I always kind of assumed mama's was, but now I know maybe she did have fibroids because I certainly had one. But it never really caused me a problem. But I thought, you're like, I'm a whole gynecologist. How did this happen? No, but it's never really caused me a problem. I feel like I probably should get imaged at some point to see what it's doing. Yeah, keep watching it. The running in the family thing, again, people may not necessarily be talking about this.

44:48Sometimes women's health stuff and periods especially, people don't feel comfortable sharing with even their family members. So a lot of times people say, well, I actually don't even know what was going on with my mother, my grandmother, but everyone had mystery hysterectomies. So a lot of the listeners are probably thinking, oh, yeah, every woman in my family has had a hysterectomy. No one knows why. There's sometimes a history of miscarriage or infertility. all the time almost certainly there's probably either endometriosis or fibroids and it's just that's the clue is every woman quote-unquote had a hysterectomy in my family yes we don't know why they all needed them they all had trouble we used to call it family history of hysterectomy

45:26Dr. Mary Claire Haver:absolutely yes so i would say today in 2026 when i'm taking a medical and surgical history 20 of my patients cannot tell me why they had the surgery yeah i used to practice in miami You said it was time. Exactly. Yes. I think I didn't need it anymore. Yep. I practiced in Miami. It was only going to cause me problems. Literally every woman who was postmenopausal had had a hysterectomy. They're just like, doctor told me I needed one. I don't know what it was for. But yeah, just if you're not having pregnancies anymore, if there's like a whisper of a problem with your periods, they're like, it's gone.

45:57Take it out. But then they don't tell them what it was for. And then no one knows. So the children, the daughters, granddaughters have no idea. And then everyone goes through the same cycle again. I always point out to people, I get these sometimes and the patient is miserable. They're like literally pouring blood out. There's something wrong with that uterus, even if pathologists can't see it under the microscope. So I've definitely had patients where I'm like, you've got to have adenomyosis. There is no way you don't. And it comes back with a quote unquote normal uterus. I'm like, lies.

46:25Dr. Mary Claire Haver:Go back and look again. Go back and look again. Not that I don't believe the pathologist, but just to say that there's definitely times that a uterus will act up, we say. and it may not necessarily show up on the slides that they're looking at under the microscope, but there's something going on with it. So let's talk about fibroid types and location mostly. A fibroid's a fibroid, but location matters. Absolutely. And this is where we say, if somebody is coming in, they're like, I have fibroids. We always have to look at the images because fibroid size and where they are in your uterus makes all the difference in what symptoms they cause you, in the options you have for removing them or treating them.

47:00So for instance, if you have a fibroid that's in the cavity, so there's pushing into the cavity, that's where the tissue is coming out like period blood. It could be teeny tiny. It could be one centimeter and you could be like just literally pouring out blood. I had a patient once who was literally, I had never seen a blood count this low. Like her hemoglobin was like two. Like it was, you should be dead. Like you should not be alive right now. We've all seen that in the ER. Absolutely. And she had, I think like a two centimeter fibroid, but it was just right smack in the middle of her cavity and just bled like crazy, like a gunshot wound.

47:30And you can have like a huge fibroid that is outside of the uterus, like almost like a mushroom, and you could have no bleeding at all because it's not touching the cavity. But that can cause a lot of pain and can cause lots of pressure almost as if you're pregnant. So the treatment options also vary because the ones that are in the cavity, we can actually reach through the vagina. We can put a camera called a hysteroscope through the vagina into the uterus and shave away fibroids that are inside. If it's obviously on the outside surface, then you have to go through your abdomen. There's different treatments where you can destroy the fibroids.

48:02You can cut them out. You can take the whole uterus out. That's the hysterectomy where you remove the entire uterus. So we always kind of have to look at the exact number, location, how big they are in order to give someone their options.

48:15Dr. Mary Claire Haver:Does it matter where it is and how it's going to respond or flare to hormones at all? Not necessarily. Like I said, the ones that are in the cavity probably more likely to have the bleeding problem. So those, if we know that someone has a fibroid right in the middle, that might be something you want to have removed before starting like an estrogen just so that it doesn't end up with like lots of bleeding. Not that you have to do it, but just again to be aware that it could cause some bleeding problems. Does HRT make a fibroid grow? We're seeing, I'm seeing some of that on social media. You know, we just don't have enough data.

48:46Like, I don't know if you've seen, again, I hate to always be coming back to like, we don't know.

48:50Dr. Mary Claire Haver:I've been on HRT since day one with a seven centimeter fibroid at 57 and I'm like. It's okay. You know what? She can stay there. She's not bothering me. She's doing fine. We already didn't know enough about fibroids as is. And now we're adding in this layer of there are so many more women going on HRT, which is fantastic. We love it. Just like the problems with people not being able to get patches because suddenly we're like, oh, a lot of people are using this. We definitely are playing catch up with the research. What's the additional layer of HRT and fibroids? Hormones in general can stimulate fibroids.

49:23obviously that's why they...

49:24Dr. Mary Claire Haver:I mean, a lot of women are scared off from seeing a report or doctors telling them, someone well-meaning but not educated, like, you can't have HRT because you have fibroids. It will make them grow. And they're having hot flashes and osteoporosis and all the things. They're miserable, yeah. It's not a myth because when someone's, say, pregnant and they are getting lots of hormones, fibroids can grow really big under the influence of hormones. So again, everyone who has taken care of pregnant patients with fibroids knows that they can get larger. What's interesting is because the HRT is not like those gangbusters, huge, huge levels of hormone like you get in pregnancy.

49:59Like I actually, like you said, I haven't personally seen people coming back with like significant enlargement of the fibroids with HRT. Like postmenopausal. Postmenopausal, right. You've already gone through menopause. So it is something, again, we kind of make people aware. We're like, let us know if you're having any pain, you feel like something's getting bigger, you're bleeding at all in a strange way so that we can kind of jump in, get an ultrasound early or keep an eye on it. What we don't want to do is just sort of like, you know, fling hormones and then be like, never come back again.

50:27We don't want that. But again, it's definitely not something I'm withholding at all. Like I think that women with fibroids need hormones just like any other woman does. But just as long as they're aware, and it's just like the endometriosis, we just have to have that plan. Because like if say something were to happen, you know, talk through what your treatments are for the fibroids. I've had a lot of women who end up being like, I need my hormones. Maybe I am having more pain and we're bleeding, endometriosis, fibroids, whatever. And they end up needing a surgical procedure so that they can then enjoy their hormones without the problems that it's causing with say like the fibroids and stuff.

51:00But the good news is in my experience, I'm not having people come back with major problems. Like you said, you yourself have a pretty big fibroid and you're on hormones and it's almost -

51:10Dr. Mary Claire Haver:It was an incidental finding. Yeah. I mean, I was like, show me that, please. Yeah, we, in our minds, think of it, we're just trying to get you back to where you were when you were like, you know, like kind of right in your main reproductive years we're not like going super high like when you're pregnant. Let's talk about perimenopause and fibroids because we do have most of us will have periods where we have these loop ovulation cycles and we'll have very high estrogen levels. So I try to warn patients with who are going to cycle try to go through perimenopause without the aid of hormone therapy.

51:38Dr. Mary Claire Haver:You know, your fibroids might grow, they might get worse, you may have bleeding, like you need to be prepared for this. And then we'll talk about treatment options or I'll get you over to gynecology because I'm not doing surgery anymore. Are you in your clinical practice seeing kind of like a little bit of a jump, a surge in fibroid symptomatology through perimenopause? I actually diagnose new fibroids a lot in perimenopause. Yes, all the time. And this actually happens a lot after someone starts HRT because they were like doing okay, like, or they kind of just gotten used to a certain level of periods.

52:08And then again, we start the hormones and the estrogen kind of flares something and then they're like, oh, it kind of hurts. Like, I'm feeling a little bit more bloated or like my period was really heavy this time. I'm not sure what happens. I have a very low threshold to get an ultrasound because I've diagnosed so many fibroids and polyps. And I've actually started telling my patients this because it comes up so often. Or I inherit patients from other doctors who have started them on HRT and the patient's like, whoa, what's going on? And then just want a second opinion. I'm like, let's get an ultrasound.

52:37And we find the fibroids. We find the polyps. We find the adenomyosis that someone may have gone their whole life, didn't know that they had. Like you said, it's not often if you're doing well, like we aren't getting ultrasounds all the time. We would never know. You would never know. So a lot of people just quietly had their fibroids and polyps and just didn't realize it. And only kind of, I quote, you know, we wake up the fibroids with the estrogen that we're giving them, which is, again, not a problem. Now we know and now we can address them.

53:03Dr. Mary Claire Haver:Is a progestin containing IUD like Mirena or Skyla ever a good option for a patient with fibroids? It can be. Yeah. It depends on the fibroid. So there are some times that the fibroid is so big that it actually pushes on your cavity and makes it either impossible to get an IUD in or if someone's already bleeding like crazy. I've had a few patients where they bleed the IUD out. So before it's had a chance to kind of kick in and lighten everything, they actually pour out blood or a huge clot comes out and the IUD just washes out right with the clot. So it is something that we do have to be aware of, but it can be a good option.

53:37And so especially for the women who have, you know, side effects, like they don't love the stronger progestin because of side effect potential or they just want to have to remember something. A lot of people, you know, like the IUD for both uterus control and then also for the HRT if they don't want to take the progesterone orally. So it's kind of a nice option to kind of kill two birds with one stone, too. Okay.

53:59Dr. Mary Claire Haver:When is a surgery an option for these women? I always tell people, you know, if the medications aren't doing what they need to do. So we always, I'm somebody who likes to go through all the options right off the bat so someone can choose for themselves. Because there's a lot of people who end up just being like, I've heard all this. Like, I know medications are not for me, which is great. Like, you know, we just jump right over medications. In general, we always kind of in medicine in general, go from less aggressive, less risk to more aggressive, more risk. And obviously surgery is kind of on the upper end of those things.

54:29But if somebody is like, look, you know, I tried X, Y, and Z, didn't work. It's not for me. I had side effects. I don't want to take something every day, then we can pretty quickly jump to surgeries. And there are quite a few surgeries for fibroids now. For somebody who's not trying to get pregnant, we skip over the like just cut, you know, like a big kind of... Myomectomy. Yeah, exactly. Let's talk about surgical options.

54:48Dr. Mary Claire Haver:I think our audience is really interested. And there's probably new ones since I've stopped doing... Yeah, there's one new one. Yeah. Let's go from the most mentally invasive, like all the way up. Yeah. So starting like less invasive. Like we said, if there are fibroids that are not that big and they are in the cavity, we can do what's called a hysteroscopy, which is, I say, it's our version of a colonoscopy. It's a thin camera that you can operate through, and we put it through the vagina into your uterus, and we can use like a spinning blade or a little wire loop with electricity to basically shave away the fibroids.

55:19And then there are, as you kind of go up the ladder, this is the new one, which there's very few breakthroughs in women's health, which is very sad, but this is one of them, which is what we call radiofrequency ablation of fibroids. So there's two different ways. One is done through the hysteroscope, like through the vagina, and one is done through a laparoscopy through the abdomen. So the one through the vagina is called Sonata, through the abdomen is called Assessa. And basically you do an ultrasound or you look with a camera at the same time and you put these little needles into the fibroid that pass electricity into the fibroid and heat it to destroy it.

55:53So it decreases bleeding, it shrinks the fibroid. It doesn't make it completely disappear, but it makes it smaller, softer, less painful, less bloody. And so it's a great way to treat the fibroids without being as invasive as like cutting the whole thing out or taking the whole uterus out. So it's a really nice, I actually have been following this technology for like 15 years before it was a little bit more widely available. So now we have it at least, you know, in not everywhere, like only certain pockets of the country, but we're starting to kind of have that a little bit more available for people.

56:24And then for people who are wanting to get pregnant, like they want to keep the uterus for pregnancy. There is myomectomy, which is a way of saying just cutting the fibroids out of the wall of the uterus and basically like stitching it back up, putting the uterus back together. It is actually the most invasive and takes the longest and the most risk because you basically have more bleeding. You're basically cutting into something that's already very vascular, has a lot of blood flow to it. That's why people bleed so much normally. And it takes longer because you're getting all these things out.

56:54You're repairing and putting the uterus back together. So if someone's like, look, I don't want to have kids anymore. I'm like 49. Like I'm over it. This is not what I need to do. We would skip right over that to hysterectomy, which is take the whole uterus out. And that is for somebody who's like over it, over it. Like there, we are done. I want no more periods. I want these fibroids gone forever. I don't want them to come back. Anything else where we're leaving a uterus behind, the fibroids can return. So you can grow new ones, the ones that you're shaving down, like maybe leave a piece a bit, it could grow again.

57:23So the downside of all those other options is you might be coming back another day. So we always say there's always a chance you're going to need something else, including maybe a hysterectomy. Hysterectomy is obviously the biggest thing. You're taking out the whole organ, but it's definitive, meaning that you're not going to have any more fibroids or periods. And a lot of people are like, I'm all for that. It's a whole big discussion because even if you leave your ovaries, when we say hysterectomy, by the way, this is a big myth. People think that there's like, you're somehow talking about the ovaries and hormones, it's only referring to your uterus, which is just holds a pregnancy.

57:55The ovaries removal is something called ophrectomy. And so when we say the word hysterectomy, like you'll see, you'll hear people say the word partial hysterectomy. And total. And it means different things to surgeons. Exactly. We gynecologists don't use that term. When people say partial hysterectomy, they usually mean I want to leave my ovaries behind. We just assume that. Like we're not even talking about the ovaries. So we're leaving the ovaries unless we specifically say, yes, let's take the ovaries out. But even if you leave the ovaries, the hysterectomies are associated with a little bit of an earlier age of full-blown menopause.

58:25And then people can even temporarily feel more menopausal symptoms like hot flashes or mood fluctuations because you're breaking a connection between the ovaries and the uterus, which can temporarily affect ovarian function. So not uncommon people after hysterectomy be like, oh God, I kind of feel like really hot flashier. I'm really sweaty or my mood's all over the place. A lot of times that gets better after a few weeks. But there are some people who are already perimenopausal and it sort of just like launches them into full bone menopause, even if you keep your ovaries.

58:54Dr. Mary Claire Haver:So I read in it, and the earlier you have a hysterectomy, the more years you'll lose. But on average, a woman with a hysterectomy and has her ovaries left behind will lose four years off of her shelf life of her ovaries. So she'll go through menopause four years sooner than she would have had she not. And I was never taught to counsel that when we were, you know, and so I think it's really important for our listeners to understand, like, we need hysterectomies. It's an important surgery, but we really have to pay attention to your symptoms and blood work because we're not going to have a period to guide us anymore as to when your menopause starts so we can counsel you appropriately.

59:29Dr. Mary Claire Haver:Exactly. So it's all about awareness. Like you said, we never, like, and I went to a very good residency. I feel like we were very well taught. I can deliver a baby like nobody's business. And I always kind of just like to pause and say, I know a lot of the discussions here are like, well, here are like the things that we're doing wrong as a field of medicine. The people who go into OBGYN are so dedicated. Like they are just truly devoting their whole life to this. The fact that we do this wrong is not because someone just like doesn't care enough. It's just because like we just as a field, we don't have enough resources.

1:00:00Like we don't have research. We don't have data. So a lot of stuff is sort of based on we were told this by our attendings and that was taken as fact. And so we get perpetuating all these sort of myths. So just to kind of take a step back and say, like, you know, when we when we say we were never taught to do this, it's not that we went to a bad program. We went to great programs. We were, you know, really well-meaning attendings. But we never were taught to tell people with hysterectomies.

1:00:25Dr. Mary Claire Haver:That's lower and for lack of data. Yeah, exactly. And so I always kind of also say with the whole earlier age of menopause, we don't actually know if the hysterectomy is necessarily causing that. It could be a correlation causation thing. That whatever inflammatory process caused her to have her uterus removed could also affect the ovaries. Exactly. So that's exactly right. We think maybe the inflammation of the chronic fibroids or the endometriosis may also have affected the ovaries, leading to more tendency to, you know, have an earlier menopause. But just the fact is, the phenomenon still exists.

1:00:59So we do need to tell people when they're making these decisions, like, hey, just, you know, like, these are things to keep in mind. You know, that may make the difference between someone choosing hysterectomy and not.

1:01:10Dr. Mary Claire Haver:What do you think about, there's a push right now, and it's getting popular in social media, in the doctor world, that we should not have OBGYN as a residency. It should be obstetrics or gynecologic surgery. And I'm like, whoa, whoa, whoa, we need three. So we need the health of women outside of delivering babies and doing surgery. Absolutely, yeah. We need gynecologic surgery as its own standalone, you know, and then we need OB. Yeah. So what do you feel about that? There's a lot of people who trained traditionally who were like, uh-uh, I can do it all. And I'm like, can you though? Yeah. In an ideal world, yeah, of course they would be separate.

1:01:49There's no way to cram this much information into a four-year residency. Like either you'd have to make it much longer to do it really well, or you split it up so that everyone can have their lane that they really focus. They know all the data. They do it every single day. You know, they're not sort of like occasionally doing surgery or occasionally talking about menopause, occasionally delivering a baby. We serve people best by having like really concentrated training practice. And that's just the way it should be. Now, the reality is that OBGYN as a field is in trouble. Like we are, I think a third of the counties in America have no OBGYN at all, zero, like no labor and delivery unit.

1:02:30So where a lot of the, and I understand this because obviously logistically it makes sense. A lot of the people who work in rural areas are like, look, we can barely get someone to come here anyway. Like we are, even under the best of current circumstances, have no one willing to come here because of liability, because of abortion laws, because of poor reimbursement. They just can't keep the doors open. So they're like, well, that would be great if we could have like these ultra kind of specialized things. But right now, we're just like, we can't even get a single OBGYN of any sort of any training to come to our county.

1:03:02So like I said, in an ideal world, I think a lot of us, especially in the GYN laparoscopic surgery world have always sort of thought it would make sense because there are no other surgical specialties that try to do as much as we do. Like urology or neurosurgery are not trying to do, well, I guess urology a little bit, but like they're not trying to do preventative care. They're not trying to do some other specialty like OB is like its own thing. Like this is like critical care. I mean, it's everything. It's a lot of stuff. So it's very hard to kind of be the master of all those things. So I think for those of the surgical people, we've always sort of said it makes sense for people to be high volume surgeons to do the best that they can for people.

1:03:42But I understand the realities of it, especially in rural areas. They're just like, we just want anyone who is trained, who is qualified of any sort. Just to be here. She has a uterus next. Yeah. They're saying like, we're not going to get like ultra specialized person who wants to live in the city to come to, you know, the middle of nowhere. It's going to be hard to attract somebody.

1:04:02Dr. Mary Claire Haver:You can follow Dr. Tang on Instagram and YouTube at KarenTangMD, and you can find her through her website, KarenTangMD.com. Her book, It's Not Hysteria, Everything You Need to Know About Your Reproductive Health But We're Never Told, is available wherever you buy your books. I'd love to hear from you about this topic and anything else that's on your mind. You can find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at thepawselife.com. My new book, The New Perimenopause, is available now everywhere and anywhere you buy books and through our website.

1:04:41Dr. Mary Claire Haver:If you're loving this podcast, be sure to click follow on your favorite podcast app so you never miss an episode. While you're there, leave us a review and be sure to share the show with the women you love. We would be so grateful. You can also find full episodes on YouTube at Dr. Mary Claire. Unpaused is presented by Odyssey in conjunction with Pod People. I'm your host, Dr. Mary Claire Haver.