Q&A with Millie Behera, MD

Location is everything, says Duke gynecologist Millie Behera, MD, about fibroids, the non-cancerous growths of tissue in the walls of the uterus that affect up to 50 percent of women by the time they are 50. Fibroids can be as tiny as a marble or as large as a melon, but where they grow is often what makes the difference in whether they cause no problems, mild annoyances, or extremely disruptive symptoms from excessive bleeding during periods to painful periods to feelings of pressure in the abdomen and difficulty with voiding.

Fibroids are a hot research focus -- not only because they are so common, but also because they’re still a mystery. “We haven’t figured out what causes them,” says Behera. “It may be something that’s related to our hormones, the menstrual cycle, our environment, or genetics.” It’s known that fibroids are exacerbated by obesity and hypertension, and that they are more common among African American women than other races. “We’ve got a lot of pieces that we’re just starting to put together,” says Behera, “but to explain them fully we’ve still got a long way to go.”

A new focus for therapy

Dealing with fibroids, however, is getting steadily easier. While research into medical therapies continues, surgeries to remove fibroids are now conducted laparoscopically, sometimes with robotic assistance. That means the incisions are getting smaller -- and in one new treatment, they’ve gone away altogether. Duke’s Fertility Center (part of the Duke Department of Obstetrics and Gynocology) is the only facility in North Carolina that offers the newest option for removal of fibroids: focused ultrasound ablation, which uses pulses of ultrasound energy to destroy fibroid tissue while leaving the surrounding tissue unharmed.

“Some patients who have the procedure hop off the table and go back to work the same day,” says Behera, “and the chances of complications are low. We like to say that it’s beyond minimally invasive -- it’s basically noninvasive.
“It’s really exciting to give this option to women who don’t want surgery but who are struggling with their symptoms,” she says. “Women with fibroids have a lot of different options available to them now.” Behera answered a few of HealthLine’s questions about the therapy:

Could fibroids keep me from having a baby?

We find that fibroids may be present in many cases of otherwise unexplained infertility. However, fibroids’ effects on fertility are still controversial -- the only times when it’s clearly a factor are when a fibroid is altering the shape of the uterine cavity. In those cases, fibroids can cause problems with both conception and carrying a baby to full term.

What happens during focused ultrasound ablation?

The woman lies down with her belly on a special panel called ultrasound transducer. She’s inside an MRI machine, having a real-time MRI scan to map out the fibroids that we want to remove. Ultrasound beams are focused through the transducer into her belly. Where the beams meet, they destroy the fibroid without affecting the surrounding tissue, and there is essentially no pain. We do give the woman medication to sedate her for the procedure, but that’s because she has to lie still for 2 to 3 hours. She’s awake during the procedure.

Is this procedure a cure?

This procedure is not a cure. As with any conservative treatment, there is a small chance that the ablated fibroids will grow back, or that new fibroids will develop. Recurrence is a possibility with any surgical, procedural, or drug treatment, except for hysterectomy (which is surgical removal of the uterus). A hysterectomy is the only definitive cure for fibroids.

Are there other treatments?

If you have a fibroid, I always discuss all the options. One option is to do nothing, particularly if the fibroid is small or there are no symptoms. There are also medications that may help, but there’s a lot of work still to be done in that arena. Fibroids respond to the hormones in your cycle, so drugs that suppress these hormones can reduce fibroid size and symptoms. But hormone suppression has side effects, so it’s not recommended for long-term use. Other medical treatment options are being studied.

How do I know if I’m a good candidate for focused ultrasound?

Your doctor can refer you for screening. Focused ultrasound is a new procedure, approved by the FDA in 2004. The initial trials were limited to perimenopausal women, so for now only women who have completed childbearing years are eligible. Although pregnancies after this procedure have been reported, further study is needed in this area. That’s next on the horizon.