Addressing Disparities in Care in Women’s Reproductive Health - Episode 10
Drs Lopes and Al-Hendy describe the unmet needs they see when treating patients with UF.
Maria Lopes, MD: The unmet need in uterine fibroids is to have more effective and safe options that can be alternatives to surgery and be used over the long haul as needed. Some of the challenges we’ve had include surgical and nonsurgical options. Among the surgical options, it’s interesting to look at data, and if we’re looking at regional variations in care, how many women are going straight to hysterectomy, sometimes without any conservative treatment? It would be fascinating to look at that among racial and ethnic backgrounds as well. We need more options that are safe, effective, and fit into patient wishes, because the treatment of fibroids is usually as individualized as the patients themselves. One of the challenges we’ve had with some of the pharmacotherapies in the past has been, they’re not suitable for chronic long-term use, especially when you get into the oral contraceptives, which have their own issues with cardiac, DVT [deep vein thrombosis] concerns, or cancer. More options and getting into the GnRH [gonadotropin-releasing hormone] agonists, you can only use them typically for 6 months because of concern for hypo estrogen. Also, you tend to then add back estrogen to protect the bones if you’re going to continue.
The newer agents offer exciting options to be able to continue with the GnRH antagonists. These are oral agents that you can continue with bone protection or that don’t have as much of an impact on BMD [bone mineral density]; they also address pain, anemia, and uterine volume. For some women, it’s a bridge to menopause, where hopefully the fibroids shrink and they can avoid surgical intervention. The unmet need is around treatment options that are safe, effective, and meet the needs of women.
Ayman Al-Hendy, MD, PhD, FRCSC, FACOG, CCRP: That’s an excellent point; there are several unmet needs, even with these new developments and new medical treatment options for patients with fibroids. One of the top in that group is the fertility issue. When I listed the different medical treatment options, most of them are hormonal. What happens when you use them, you don’t ovulate, regardless of the mechanism of action. Most of them work by inhibiting ovulation, then the patient cannot pursue fertility. This is challenging because we tend to use medical treatment options in younger patients because they don’t want to consider hysterectomy, and appropriately, they should not consider it if they want to pursue future fertility. The younger patients with fibroids are excellent candidates for medical treatment options, but at the same time, while they are being treated, they cannot pursue pregnancy. I have dealt with many patients in this situation, who want to get pregnant but they have significant fibroid issues. We then do a lot of medical aerobics. We tell them, for the next 6 months we’re going to treat your fibroid and try to shrink it as much as we can and relieve your symptoms, but during that time, you cannot get pregnant and you cannot try to get pregnant, because you won’t be able to. Then after that, we’ll stop the treatment options for fibroids, and you will have a window of probably 3 to 6 months before the fibroids regrow to try to get pregnant, either spontaneously or using things like assisted fertility treatment. As you can imagine, this can be very stressful for some patients who feel they don’t have much time.
One of the major unmet needs in the field is fertility friendly medical treatment options, something the patient can take, let’s say by mouth, to treat her fibroids while she can continue to pursue pregnancy. Something that’s obviously ovulation friendly and safe during pregnancy. Another unmet need is, because of the mechanism of action of many of these treatment options I mentioned, bone health becomes an issue. Estrogen is a very pleotropic molecule, it’s bad on the fibroid, it makes it grow. It also has negative effects on some other reproductive disorders, such as endometriosis and adenomyosis, but it also has some good effects, on the bones and heart. It’s important for bone growth and bone health, so when we decrease the production of estrogen aiming to make fibroids struggle, we also might have a negative effect on bone.
This transcript has been edited for clarity.