A great number of women consider heavy menstrual bleeding to be normal. But this symptom—frequently caused by uterine fibroids—can harm women’s health.
As a college student, Veronica Gillispie-Bell, MD, MS, decided she would become an ob-gyn and find a cure for fibroids. She was motivated to do so by a hysterectomy her mother underwent to treat these usually noncancerous tumors that can develop during a woman’s childbearing years. Was there no other treatment for uterine fibroids? she wondered.
Today, Gillispie-Bell focuses more on treating the condition, which affects about 80% of Black women by age 50. She educates her patients about all available options for uterine fibroids and— based on their health status, individual circumstances, preferences and reproductive goals—helps them to choose the best therapy for their situation.
Here, she shares her medical knowledge and perspective on uterine fibroids with Real Health readers.
Under what circumstances can heavy menstrual bleeding be life-threatening to a woman?
During my career, I’ve had a couple of patients who came in to see me because they were anemic and their blood count got so low that they had experienced a stroke. If a woman experiences heavy menstrual bleeding to the point that she is severely anemic, it can result in stroke, heart attack or loss of consciousness, and depending on how severe the loss of consciousness is, there’s a host of related events that can happen.
As a health provider, what is your approach to treating women with uterine fibroids?
When I start talking to women about treatment options, I start with what is the least invasive to what is the most invasive and who is the right person for each of those choices. The least invasive approach is always going to be to start with a medication.
Quite commonly, women are started on birth control pills, which, to some degree make cycles lighter. But they don’t make fibroids smaller. Also, women who are on birth control pills may have lighter cycles, but their cycles are usually still considered heavy, and they are more likely to have irregular cycles. This is why birth control pills are an option, but they’re not always the best option. Depending on the location of the fibroids, a hormonal IUD (an intrauterine device that releases levonorgestrel) is also an option as it is FDA [Food and Drug Adminstration] approved for heavy menstrual bleeding. But if a woman has distortion of the endometrial cavity because of fibroids, then she’s likely to expel the IUD.
Now, there’s also an FDA-approved oral medication for treating heavy menstrual bleeding from fibroids. The drug is very effective at reducing the menstrual blood flow due to fibroids and is well tolerated, so it’s nice that there’s an oral medication.
There’s also an antifibrinolytic medication that you can take three times a day for five days. It controls heavy menstrual bleeding and makes cycles lighter. I don’t like to use this drug as a long-term treatment option because, basically, the way that it works is, it stops your body from breaking down clots. I use it when I’m trying to control bleeding because women are anemic and we’re going to surgery, but it is an option.
Then we have a GnRH agonist drug that’s an injection. Once again, it’s a good option for women who are trying to improve their anemia as a presurgical treatment or trying to reduce the size of the fibroids before doing surgery.
Next are surgical treatments, such as uterine artery embolization, a procedure that’s done by interventional radiologists, not by gynecologists. It is a nice minimally invasive surgery if you’re a good candidate. But this treatment option for heavy menstrual bleeding is more for women who have completed childbearing.
For women with smaller fibroids, or fibroids that are not really impacting the [uterine] cavity, sometimes an endometrial ablation is an option. This procedure entails burning the inside lining of the uterus. I find that it’s a good option for women with a normal uterus who are bleeding for reasons other than fibroids. After the procedure, patients can go home the same day with a one- or two-week recovery period. I actually perform this procedure in the office, but I don’t find it to be a good option for women with fibroids.
Then there’s myomectomy, where we can surgically remove the fibroids. But there’s always the risk of them coming back. Finally, women can undergo a hysterectomy, where the uterus, cervix, and fallopian tubes are removed. But, of course, then there’s no chance for fertility.
What are your thoughts about the complaint that health care professionals suggest hysterectomy too quickly as the most effective cure for uterine fibroids?
I agree with that 100%. I do think that this tendency to recommend hysterectomy is regional. I practice in the South, and I think historically we have performed more hysterectomies compared to other parts of the country. I have patients who come in saying, ‘I was planning on getting a hysterectomy because my mother had one and my grandmother had one.’ Sometimes patients really don’t know that there are other options to consider.
I have invested a lot of time into learning about the different treatment options for uterine fibroids and building my practice around that. But I think that some providers don’t really understand or know all the options, and so hysterectomy does become the option that they probably were trained on in residency and offer. In addition, I think because of implicit bias there is a disparity in the number of hysterectomies performed on Black women.
What advice do you give women who want to advocate for themselves and not accept this treatment recommendation from a physician?
We’re at a point in time when we have so much access to information. You can just click a button on the computer or on your phone. The first thing I say is, “Equip yourself with information so that you are knowledgeable, so that you can ask the right questions and so that you can ask about other options if the option you’re given is not the one that you want.”
Then the second thing that I say is, “Find a provider who is going to listen to you.” If your provider is only pushing one option, and that’s not the option that you want, you need to find another provider. Gynecology to me is a very intimate relationship, so you need to be able to have a conversation with your provider. You need to be able to have a provider that exercises a shared decision-making model.
As I tell my patients who say, ‘Well, you just tell me what’s best.’ There is no just what’s best! There is a what is best for you! Emotionally, I have to live with whatever decision we make. But you have to physically live with it, so we need to make sure that we’re on the same page about what you want. That means that if patients are feeling like they’re being painted into a corner, then they need to find another provider.
What role do you think stigma plays in African-American women’s experiences with uterine fibroids?
I think that there is a failure in our society to recognize heavy menstrual bleeding. Also, just in general, as women, we tend to put off our medical needs to take care of the needs of our family. For example, if fibroids are causing us pressure and pain, we just try to work through it.
Then, again, there is bias in terms of the options that are offered to women. I think that, in general, in our community, we don’t talk about periods and surgery. You’re taught that those are taboo subjects, so I think that culturally—meaning the community—we have to get comfortable discussing this with our daughters and among ourselves. These are conversations that we need to feel comfortable having.
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