Dr. Bradley's Interview
Dr. Moon's Interview Contact Dr. Moon
Dr. Newman's Interview
Linda Bradley M.D. is an internationally recognized gynecologic surgeon known for her expertise in diagnostic and operative hysteroscopy, endometrial ablation, alternatives to hysterectomy, hysteroscopic sterilization and the evaluation of abnormal uterine bleeding. She is an obstetrician gynecologist at the Cleveland Clinic Foundation in Cleveland, Ohio and is the director of Hysteroscopic Services.
Fibroids1: From your bio it appears that you are the woman behind the camera. Can you talk about how technology has enhanced your diagnostic and operative work in gynecology?
Dr. Bradley: I think that the last decade has brought about major improvements in imaging the female anatomy. Traditional transvaginal ultrasound has been usurped by saline infusion sonography (SIS), which provides greater details of the endometrial cavity, and the relationship of the depth of fibroid penetration into the myometrium. Additionally, office hysteroscopy, now employs small 3 - 4 mm instruments that can comfortably be inserted into the endometrial canal and provide a detailed panoramic view of the endometrium and tubal ostia, as never before seen. Lastly, MRI imaging is particularly useful in detection of adenomyosis and assisting in the evaluation of complex adnexal masses. Each of these techniques are comfortable, quickly performed and really paint a great portrait of female anatomy that allows physicians to interpret the results and then individually tailor medical therapy, surgical therapy or other alternative options. An excellent pre operative evaluation enables the physician to offer the most minimally-invasive procedure to patients.
Certainly, a detailed history, physical exam, and pertinent laboratory testing is still imperative. But gone are the days of only evaluating the uterus with a bimanual examination and D&C (dilation and curettage) alone. Technology is of paramount importance evaluating abnormal bleeding and fibroids.
Fibroids1: Why are alternatives to hysterectomies preferable?
Dr. Bradley: Consumers have demanded alternatives. All fibroids do not cause the same symptom for all patients. Between 25 - 50 percent of women with fibroids may have no symptoms. Interestingly, size, number and location of fibroids may cause heavy bleeding in some patients - pressure, pain, and bulk symptoms in others, and infertility and recurrent miscarriages in others. Draconian measures such as hysterectomy are not necessary for all patients. Particularly, women with menorrhagia and submucosal fibroids, experience a very favorable outcome and resolution of menorrhagia. Additionally, low reoccurrence rates are consistently demonstrated with outpatient hysteroscopic myomectomy, a 30 - 60 minute procedure.
Fibroid embolization has become increasingly sought as an alternative to hysterectomy for women who do not want major incisional surgery. Increasingly patients learn of the excellent success in treating heavy bleeding, dysmenorrhea, and bulk symptoms with UFE. Additionally, myomectomy whether performed laparoscopically, via minilaparotomy, or traditional abdominal myomectomy alleviate symptoms without total extirpative surgery. In the past, we thought that uterine conservation was only for patients who desired future pregnancy. We now realize that many women have a personal desire for preservation of uterine function. With all of the newer alternatives available, we can often comply with their wishes.
Don't forget that minimally-invasive options might also include nonsteroidal medication, progesterone IUD's, and low dose oral contraceptives. It's remarkable, how many symptoms ranging from dysmenorrhea and irregular menstruation are effectively treated by one of these modalities.
Alternatives allow women quicker return to work, family, sexual function, hobbies and sports. Women are often the glue of family life - they are caretakers, nurturers, and provide infinite support to others. Alternative procedures permit a seamless return to all important activities.
The word of mouth passes quickly among friends - one satisfied and enthusiastic patient, tells five other friends. The momentum builds for minimally invasive surgical options.
Fibroids1: What are the questions patients typically ask you?
Dr. Bradley: Women often want to know if they are normal. Often they need reassurance about issue ranging from mood, memory, sexual frequency, libido, aging, parenting, relationships and concerns about menstruation. Most of my counseling in the office revolves around normalization of common medical conditions.
Recently, there have been more questions about the safety of medications including hormone replacement therapy, contraception, nonsteroidals and antidepressive medications. Patients want us to put into context the relative risk versus absolute risk of complications and side effects of frequently prescribed medications.
Lastly, women ask about safety, effectiveness, availability, durability, costs and outcome of newer alternatives to hysterectomy including uterine fibroid embolization and endometrial ablation. Patients are reading, surfing the web, asking friends about alternative procedures - but they need a knowledgeable physician's perspective of what options exist for them. They are looking for an unbiased, evidence based answer, and hopefully one that is based on the expertise of their doctors. They want to know numbers: How many patients have you referred for embolization? What has been your own experience and that of your patients? How many hysteroscopic, laparoscopic or abdominal myomectomies have you done? Do you believe in alternatives or are you biased against newer options? Who are the referral sources in your community? If you cannot truthfully say that you have had any experience in other technologies or direct them to resources and have never recommend any other procedure besides hysterectomy - the patient will be very skeptical about your knowledge and honesty.
Fibroids1: What are your answers to those questions?
Dr. Bradley: Sometimes my answers are: I don't know and we'll have to learn together. But generally, I try to approach everything with patients on their same level. For patients that don't like medicine I work on holistic approaches that can range from diet to medication to yoga to talk therapy. So it all depends on where they're coming from.
For patients that want to be very proactive and look at high-tech ways to solve problems, we look things that are conventional or new and up and coming. If there are clinic trials at our university I see if they are candidates for those.
A variety of approaches are available today.
Fibroids1: If you had a chance to speak from your heart about your career, what would you say?
Dr. Bradley: I think my career, which has spanned almost two decades, now, has been been an important part of my life. I have become a much better doctor since becoming a mother and patient too. My patients have taught me a lot about humanity and I've taught my patients a lot. I have mentored many young physicians and nurses.
During my career, I have seen the miniaturization of technology, portability of technology and the implementation of more safety check points to promote safer surgical outcomes. Gynecologic surgeons can now perform all of our basic procedures laparoscopically. Hysteroscopic sterilization was recently FDA approved, and presented the last gynecologic frontier to conquer. The next frontier will be understanding the genetics of cancer, fibroid biology and development of medical therapies for the treatment of many gynecologic ailments. I believe that in the next two decades, we will decrease the number of gynecologic surgical procedures by half!!
We now explain surgical procedures more succinctly to patients, encourage decision making as a team effort, and provide more printed and web-based resources that enhance patient education. We encourage and support second opinion appointments. We encourage conversations with patients. I am a better listener.
Both obstetrical and gynecologic surgery is safer and faster. I think it's been a fabulous time to practice medicine and be on the cutting edge of new things in my specialty. I finished training in 1985 and probably almost 90 percent of what I do employs new techniques and medications that were not available in the 80s.
I've been a life long learner and love working in an academic institution with young physicians. I enjoy new ways of thinking about problems. We need to challenge the status quo. I really enjoy the number of women that have entered medicine. They bring a whole different class of service to our specialty and it's changing the face of medicine. So I love that aspect too. I enjoy the camaraderie between male and female physicians.
My career has been fulfilling. It's been an honor to be a part of so many lives. Being a physician is truly a privilege and honor. In quiet confidence many secrets have been shared. Many fears allayed and many questions answered. Not too many careers can claim that. The ability to mentor and shape the philosophy of developing young medical students, residents and fellows is rewarding. I am honored to have helped provide the highest level of sensitive, compassionate care to my patients.
Dr. Eunice K. Moon, M.D. has been a full time Interventional Radiologist at the Cleveland Clinic Foundation since 2000. Her areas of expertise include fibroid
embolization and fallopian tube recannallization. She is also the mother of two young boys, ages 2.5 and 6.
Contact Dr. Moon
Fibroids1: Do you think being a female physician helps your patients to be more comfortable?
Dr. Moon: I like to think so. I know what a cramp feels like. I know what it means to have to use a super tampon and a super pad every hour. I understand what it feels like to be pregnant and have children. I've been through the whole gamut and I think I can be more sympathetic when talking with my patients about how to relieve their pain and trying to give them advice. I have not personally had the procedure done but so many of my patients tell me about what they are doing. We can discuss certain things openly, birth control, about sexual practices and very rare complications like sexual dysfunction after embolization. Something like that might be hard for my patients to discuss with a man.
Fibroids1: When you are being consulted, what is the most frequently asked question coming from patients?
Dr. Moon: Well most of the time the patients have done a lot of their homework by the time they come to see me. Most of my patients are very educated and have done quite a bit of research. The question that baffles me but is asked so many times is "What happens to the particles?" or "Can they go somewhere else?" I suspect that some patients do not understand that blood flows one way and when the particle are released into the uterine artery, they are carried down stream by the blood flow to the target (which is basically the little branches of the fibroid). If you use the analogy of a ship without a sail or motor not being able to move upstream, you can see that there is no way the particle can back-up and go somewhere else.
Fibroids1: Why do most patients elect for embolization?
Dr. Moon: Most of the women that I see are not interested in having surgery. They have been plagued by the symptoms of their fibroids for so long they know they have to have something done. But they don't want surgery or they really can't afford to recovery for 4 - 6 weeks after a surgical hysterectomy. Most busy women in their late 30s and 40s are in the peak of their careers and family; if I had to take six weeks off from my job and my family - well, that's just not possible. A lot of women end up delaying their thinking it will get better if they wait. Basically, by the time they come to see me they are so fed up with what has been happening to them that they just want the problem taken care of. Some of our patients have ended up having to get a blood transfusion before they come to see me. It can take a couple of trips to the emergency room for the patient to finally acknowledge that this is something that requires their attention.
Fibroids1: Are there any other major concerns?
Dr. Moon: There are some patients who want to know when they are going to be able to go back to work. This is an important and valid question. We have had patients go back to work within one week but most of our patients end up going back to work within two weeks. The big concerns include how they are going to feel, how long will it take to recover, when can they drive - all of which are really pertinent to their lifestyles. They want to get back to their former lives. These are the most common questions asked.
Fibroids1: How do you answer their concerns and questions?
Dr. Moon: When I do a consultation with my patients it takes 45 minutes to one hour. We sit down and go over their medical history and concerns. The patient may have other symptoms that she is not overly concerned about, but there is one large issue caused by the fibroids that is really bothering her. I like to address these things beforehand. After that, I basically walk her through the procedure, step by step. Most of my patients will get an MRI before the procedure so we go through that process. We discuss what is involved the night before the procedure (including how they can't have anything to eat or drink). Then, I describe how the patient comes in and gets an I.V. and I describe the medications that will be used. It's step by step, describing exactly what will happen before/after the procedure, during the recovery period in the hospital and what happens two weeks, four weeks, six weeks, three months, and up to one year following the procedure. We discuss all of the risks and benefits. The consent process has to be pretty thorough.
Fibroids1: How do you explain the different fibroids?
Dr. Moon: I think of the uterus as a melon. Fibroids can happen anywhere. Those just below the inside lining are submucosal fibroids. They don't have to be very big to cause large problems - one to two centimeter lesions in that area that gives you profound symptoms. Myometrial fibroids are the most common and they occur deep inside and cause enlargement of the uterus, bleeding and cramping. Sometimes, when the uterus is enlarged because of fibroids, the patient ends up having her bladder "pressed." It makes her feel the first trimester of pregnancy when the woman has to urinate all the time. Subserosal fibroids are fibroids under the skin on the outside part of the uterus. They don't cause a lot of direct bleeding but they give rectal pressure and certainly contribute to urinary frequency. I've had patients complaining of pelvic pain and shooting pain down the legs because there is a fibroid rubbing up against a nerve. All three are different and all three are painful in different ways.
Fibroids1: Who would be an ideal candidate for embolization?
Dr. Moon: The majority of patients are good candidates for this procedure, but a few may not be. A patient with a single polypoid or submucosal fibroid may not be the best candidate. A patient who has a large pedunculated fibroid (growing on a large mushroom-like stalk) may have problems after the procedure. Often, the stalk may fall off and the ball of fibroid tissue may try to pass through the cervix. It can get stuck in the cervix with a potential risk for infection and prolonged discharge. That can be scary for the patient. Sometimes we still do the embolization but there is complete understanding between the patient and myself that should the fibroid fall off the stalk, they may have to have a D and C (dilation and curettage) to remove the residual tissue. We like to cover all of these things ahead of time.
Fibroids1: What other treatment do you offer your patients?
Dr. Moon: If we have determined through an MRI that the patient has a condition called adenomyosis, treatment options may be different. If the patient wants to have children, myomectomy maybe a better option. Myomectomy is a surgical procedure where the doctor opens the uterus, takes out the fibroids and basically sews the uterus back up (myomectomy may not be feasible depending on the size and number of the fibroids). The fibroid recurrence rate after a myomectomy is something like 20 to 40 percent, depending on who you ask. These patients may return with fibroid problems in the future but hopefully they have been able to successfully have children. I have some older patients who are interested in having children but those are the more difficult cases. If they are over 40 years old, their fertility rate drops, which is natural. If they are not sure if they want children, I send them to a fertility specialist. I usually say, "Why don't you give yourself a year or so to see if you can become pregnant and if that doesn't work and you have given up at that point, come and see me." I don't believe that anything I can do to the uterus is going to improve their fertility.
Fibroids1: What kinds of recommendations do you give to your patients suffering from fibroids?
Dr. Moon: A lot of people have fibroids but not everyone needs to be treated. I tell my patients that if they feel like getting treatment solely because they know it's available, then that's not a good enough reason; I can't make patients any better than asymptomatic. I tell them to give me a call back when it's at the point where it is really bothering them. I also have patients who have a high level of anxiety about the procedure. If their symptoms are present but not significant, I tell them we will do a follow-up in six months to see if the fibroids are getting bigger. If they are having more problems at that point then I will treat them. I also try to work with my patients' timelines. Some patients come to see me in March but they don't want any treatment until June because they are teachers and school is let out. We treat a lot of patients in December because their insurance is going to be defunct at the end of the year or they want it done at the holiday season when they have time off work. All those things make sense so we try to be as accommodating as possible. Treatment depends on the patient's level of symptoms and anxiety; she may need the symptoms to get to the point that they overcome her anxiety.
Fibroids1: Do you think fibroids are genetic?
Dr. Moon: There seems to be a predilection in certain families. A patient that I saw recently claims to be the oldest female in her family with an intact uterus. Her sister, her mother and grandmother all had hysterectomies and so she is holding onto her uterus. It does seem to run in families and with certain races it is certainly more common. African American women are much more likely to have fibroids, but not all African American women with fibroids have symptoms.
Fibroids1: What has been your biggest challenge?
Dr. Moon: I think the biggest challenge I have is talking to people and basically bringing the skeptical gynecologist on board. That's has been a real challenge. In the past, many of my patients had to find out about the procedure by doing their own research and then asking their gynecologists for a referral. There were only a few gynecologists openly talking about uterine embolization. Dr. Linda Bradley, who I worked with very closely on the main campus, has been very open-minded and incredibly supportive of this procedure with her patients; however, it hasn't gotten that kind of reception from everyone. In the past three years, a lot of gynecologists have been more open to uterine embolization. The media has also caught on as we have had some great news pieces come out on shows like "20-20" and "Nightline." The Wall Street Journal had a very provocative article out a few weeks ago talking about how uterine embolization is revolutionizing how we treat uterine fibroids in the future. There are about 10,000 women predicted to have the embolization done - the same number as last year - compared to 100,000 women who have will have hysterectomies. We have a long way to go.
Fibroids1: How have you handled this challenge?
Dr. Moon: I communicate very closely with the referring gynecologist. In most of radiology, a dictated report gets sent out; however, when I see a patient for a consult I dictate a consultation note and then send out a letter to her gynecologist letting him/her know what we talked about, the patient's position, and, if we have decided on treatment, what the schedule will be. The patient may need additional studies, and I send them back to the gynecologist to have the work-up prior to procedure. After the patient has the uterine fibroid embolization, I send out another letter to her referred gynecologist for the follow-up, including what kind of problems to look for, what the patient is going to need and a dictated report of the procedure itself. They know exactly what happened and they have that for their records. I think this has been very effective and I am seeing gynecologists sending additional referrals. Hopefully that will continue to grow. In interventional radiology, we have had to learn how to become better communicators. I have gone around to other hospitals to give lectures and explain the procedure. I have also done community talks to try and explain to patients what this is all about. So, I have taken on more than one front trying to spread the word.
Fibroids1: What improvements would you like to see with the procedure?
Dr. Moon: At this point, I would like to see long-term follow-up. We have a five to 10 year follow-up at this point but I don't have numbers for 20 to 25 year follow-ups. I believe continued research is really important and tracking the patients is really important to see recurrence or failures. I think interventional radiology is learning how to do these things better because we want to take responsibility for these patients and make sure they do well.
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James S. Newman, M.D., Ph.D., graduated from Dartmouth College and Case Western Reserve University School of Medicine, earning the M.D. and Ph.D. in Biomedical Engineering. Dr. Newman pursued residency programs at Cleveland Metropolitan General Hospital and the Mallinckrodt Institute of Radiology in St. Louis, then fellowship training in Interventional Radiology at the Johns Hopkins Hospital in Baltimore, serving on the faculty at Johns Hopkins until 1991. He returned to Cleveland MetroHealth Medical Center, serving as Chief of Interventional Radiology there for eight years, before joining the Cleveland Clinic in 1999.
Dr. Newman's clinical and research interests include TIPS, portal hypertension procedures, uterine artery embolization for fibroids, and new approaches to improving patient comfort during and after procedures.
Contact Dr. Newman
Fibroids1: What are the most frequent questions you hear from your patients?
Dr. Newman: How long does this procedure take? How much does it hurt? Can you help us manage the discomfort? They've all heard about the discomfort after the procedure. Does it work?
Fibroids1: And how do you answer those questions?
Dr. Newman: Well we have quite a lot of details about how we manage the pain and the cramping. Statistics are very favorable for most people getting a good result, and we quote them approximately 90 percent of people with heavy bleeding will have significant improvement within one or two cycles. For people who are having pelvic pain it will take a little longer, typically three to six months before we know how things are going.
In terms of the pain management, we go into a lot of detail and we want patients to realize that they're not being ignored if they have discomfort afterwards. I tell them, "We're not going home until we know that you're comfortable for the night." The patient is provided with what's known as a PCA pump, which is an intravenous line where the patient pushes a button, so they're not the patient at the end of the hall waiting for the nurse to give them a pain shot. They can self administer. The great majority of patients get very good relief this way and about 100 percent, I'd say 99 percent, are doing much better by morning, and almost everybody is able to go home the next morning after breakfast.
Fibroids1: How did you come to specialize in uterine fibroid embolization?
Dr. Newman: Technically, it's a very interesting procedure and as I've done more of this I've found that I really like meeting the people. We're meeting people in a very accomplished age group, generally in their 40s, late 30s. They're very well informed; they've done a lot of research on their own before they come around to seeing us.
And the fact that the procedure achieves its goals in the great majority of patients is very gratifying. Doing this procedure, learning it, and working with these patients has been very rewarding. People are really happy to have an alternative that works a great majority of the time.
As a radiologist, there's a stereotype that we're not involved with our patients and this is a great way to throw some ice water on that. It's a lot of fun and it doesn't stand still. There's been a lot of evolution in the procedure since I started doing it five years ago and I'm looking forward to learning more.
Fibroids1: Can you explain in layman's terms what interventional radiology is?
Dr. Newman: It is what now people call minimally-invasive treatment, using the tools of radiology for guidance.
Fibroids1: Can you describe how that works?
Dr. Newman: Well the tools of radiology guidance involve ultrasound, CT scanning and probably most heavily fluorscopy. So we can see where we're putting the tools but we're making very small incisions.
Fibroids1: How does fibroid embolization work?
Dr. Newman: The procedure is done generally through one very small incision at the groin to gain access to the femoral artery. From that one site we can place catheters that will treat both arteries, both the right and left uterine arteries that lead to the uterus and the fibroids. Once we've placed the catheter we can steer the catheter internally and that part is painless. We can see where the catheter is going and we can direct the catheter to a place where it will be actually in the blood supply of the fibroids. Once the catheter is in place we can inject different kinds of particles, special embolization particles, which will block the blood supply to the fibroids.
The reason this procedure is practical is that the fibroids demand a very large blood supply in order to stay alive. If we can cut down the blood supply of the fibroids the cells of the fibroids will actually die in place and the body will reabsorb them. The result is that the fibroid is much smaller after several months and in many cases, if they are causing bleeding, the bleeding is reduced significantly.
Fibroids1: Does the type of fibroid you have determine the course of treatment?
Dr. Newman: Certain fibroids are considered not the best and some are considered very favorable. The ideal situation would be the smaller the better because we'll probably make them almost invisible. But we can treat fibroids up to a size of 15 centimeters or so.
Fibroids1: How often do you see fibroids that big?
Dr. Newman: Pretty frequently. At least a third to a half of our patients. Many times patients have waited a long time before they are motivated to take action. The average age of our patients is about 44. Many times they have been struggling with heavy bleeding or pelvic discomfort for many years and they've been told by their gynecologists that if they can just make it to menopause their fibroids will shrink on their own. However, that's a long time to wait for people who are often very limited by the symptoms. They're having heavy bleeding, sometimes embarrassing incidents of bleeding, things that just inhibit them tremendously from doing the things they want to do.
Fibroids1: What changes and discoveries would you most like to see in this field?
Dr. Newman: I'd like to see the procedure become totally painless and I'd like to see it become more reliable so we don't see 5 to 10 percent not getting quite the results they were hoping for.
Fibroids1: What are some advances that might do that?
Dr. Newman: I can't disclose all of it. We're working on different approaches to delivering medications, using a variety of medications, that have in some cases been tried previously and in other cases not.
In terms of the effectiveness of the treatment and we have some idea which nuances of the technique lead to greater effectiveness or may be disappointing. So you look carefully, you watch your competitors and your colleagues to see how they are doing things, and try to pick up some tips from them.
Fibroids1: What are some other options besides fibroid embolization for treating fibroids?
Dr. Newman: Well the classic one that most patients are hoping to avoid when they come see us is hysterectomy. That is very reliable in relieving the symptoms and the fibroid problem. Removing the uterus essentially eliminates the problem. However a hysterectomy is not something that most people say, "Wonderful, I'm getting a hysterectomy." It's a big decision. It's a tremendously well documented procedure - 200,000 hysterectomies every year in the United States, approximately.
However, our patients come to us because they're looking for an alternative. Other surgical options include myomectomy in selected patients. Myomectomy is removal of individual fibroids while preserving the uterus. In many cases this is possible but there are a large number of patients for whom it's not. Patients who have a dozen fibroids or more it's simply not practical. Generally if there are three or four or more it's going to really require an expert. Also there are certain locations on the uterus that require a more complex myomectomy. Many myoectomies can be done laparoscopically but there are some that are technically very difficult. Also, with any myomectomy the patient has to be aware that in certain situations if there is heavy bleeding the procedure may be converted to a hysterectomy.
We've had quite a number of patients come to us a few years after a myomectomy and about 20 percent of patients after