Assisting Surgeons with Management: Initial Presentation of Abnormal Bleeding and Diagnosing of Fibroids

As an Advanced Practice Provider, when and why might a patient with uterine fibroids be scheduled to visit with you?

Ms. Haibach: Typically, with the flow of how our practice runs, a patient would schedule with me as an initial visit to explore their abnormal or heavy bleeding. Oftentimes, a patient is unsure with what they have going on medically and will view APPs as a safe place to start. Other times, I will see a patient for a general wellness exam who will mention heavier menses over the years or just a change in their bleeding pattern-- longer flow, things like that.

It may stem from something that seems out of the ordinary for them or a symptom impacting their life. For example, if a patient says, “I have to run home and change my clothes,” or “I'm bleeding through my bed sheets.” Those statements prompt further evaluation. At times, patients who have already been diagnosed with fibroids, will come to see me if they have chosen medical management over surgical management of their fibroids. They continue to follow up with me to reevaluate the success of their treatment plan periodically. So, whether I start them on a plan, or a physician does, they can follow up with me to revisit their medical plan and ensure it remains appropriate.

You touched on this a bit, but can you dive deeper into exactly what you are looking for as part of that visit? 

Ms. Haibach: Definitely. With an initial consult to me, the number one question that I would ask my patients first is, what is your most bothersome symptom? With this question, I'm looking to determine: is it pain that brought you to me? Is it heavy bleeding? Do you feel bulk and bloaty? Are you having issues getting pregnant? Do you have bowel or bladder issues?

The information I get from that one initial question, helps guide the remainder of my visit. If bleeding is the main concern, we would focus on getting that under control. So, we need to suppress the menses with medication options. If bulk and bloating is the main concern, for instance the patient feels like they have a pregnant-looking abdomen, typically surgical options are warranted. If the main complaint is infertility, we do have fertility specialists in our practice who remove fibroids to aid patients in achieving pregnancy.

The most important purpose of this visit is to really listen to the patient to find out how these symptoms are impacting their daily lives. From there, I can use that information to guide my treatment plan.

So, once it is determined that the patient is a good surgical candidate, what would be the next steps?

Ms. Haibach: If at the end of my visit, I determine that a patient is potentially a suitable surgical candidate, the first thing I would do is order appropriate imaging. For example, if the patient is interested in uterine preservation for future fertility, she is likely going to opt for a laparoscopic myomectomy, where fibroids would be removed, and her uterus would be left in place. In that case, she would require an MRI for fibroid mapping. If a woman has completed childbearing, then oftentimes a pelvic ultrasound would suffice, at least to start, since she'd likely elect hysterectomy if she has reached her fertility goals.

I would also perform an endometrial biopsy to rule out malignant process before going into surgery. To optimize a patient for our MIGS surgeons, I gather a thorough medical history to ensure their comorbidities are appropriately managed. For example, diabetes is under control, sleep apnea is being treated, no active infections. If there is anything else going on that needs to be addressed, I'd refer them to the appropriate provider first.

Once I have acceptable imaging, a negative endometrial biopsy and an adequate medical history, I would then assist the patient in scheduling with one of the surgeons on my team for a consult and physical exam to determine surgery planning. Once they see our physician, a surgery date is booked. The patient would come back to see me within 30 days of surgery, and we would do a preoperative education appointment. I see them again 2 weeks after surgery for a post-op visit. We’d perform the post-of visit virtually in our practice. We would see the patient sooner if there are any other concerns that arise post-operatively.

What if the patient is not a surgical candidate? How do you as an APP assist in ongoing medical management?

Ms. Haibach: The presence of fibroids alone, without symptoms, often does not require surgical intervention. There are occasions where a patient is, for example, seen in the emergency room for abdominal pain, whereas they’ll get a CT scan of the abdomen pelvis, and a fibroid is incidentally found. At that point, they are instructed to see gynecology for follow-up. If the patient was unaware of the fibroid, has no symptoms and there's no concerning imaging features, then management with ongoing surveillance (repeat imaging and office follow up) and instructions on when to return is usually appropriate.

Depending on the symptoms, medical management typically includes hormonal suppression of menses in the form of a birth control pill or an IUD. If bleeding is the main concern, it is my goal to at least slow her bleeding, if not try to stop it. Not all women are good candidates for hormone therapy, so there is a medication option that is non-hormonal. In my role, I would start a medication plan for a patient and initiate a new medication such as hormonal suppression in the form of birth control, IUD, non-hormonal medications etc.

Typically, when I do that, I'll have the patient follow up with me in about two to three months to reassess the medication’s effectiveness. The goal of the reassessment is to determine if it is working for her life, to be sure there are no major side-effects, and just to make sure she is amenable to the plan. As part of the medical management, sometimes it is necessary to monitor blood counts for anemia to be certain that medical management is still appropriate for her.

From your experience in practicing, are you more likely to be visited by one age bracket or ethnicity over another? 

Ms. Haibach: Actually, data tells us that most fibroids occur in women of reproductive age. They are also diagnosed in African American women two to three times more frequently than in white women. Fibroids are infrequently seen in premenstrual women. A relief of symptoms of the fibroids often occurs at the time of menopause, when the menstrual cyclicity seizes and steroid hormone levels decrease. My demographic is consistent with the above statistics. I tend to see women within the ages of  20’s-50’s and more often African Americans.

Was there anything else that you'd like to mention?

Ms. Haibach: Abnormal bleeding can be very stressful for women. APPs are a great place to start an abnormal bleeding or fibroid work-up. Patients should rest assure that although we cannot perform surgery, APPs can help get them in the right direction for the best care possible.

As an Advanced Practice Provider, when and why might a patient with uterine fibroids be scheduled to visit with you?

Ms. Haibach: Typically, with the flow of how our practice runs, a patient would schedule with me as an initial visit to explore their abnormal or heavy bleeding. Oftentimes, a patient is unsure with what they have going on medically and will view APPs as a safe place to start. Other times, I will see a patient for a general wellness exam who will mention heavier menses over the years or just a change in their bleeding pattern-- longer flow, things like that.

It may stem from something that seems out of the ordinary for them or a symptom impacting their life. For example, if a patient says, “I have to run home and change my clothes,” or “I'm bleeding through my bed sheets.” Those statements prompt further evaluation. At times, patients who have already been diagnosed with fibroids, will come to see me if they have chosen medical management over surgical management of their fibroids. They continue to follow up with me to reevaluate the success of their treatment plan periodically. So, whether I start them on a plan, or a physician does, they can follow up with me to revisit their medical plan and ensure it remains appropriate.

You touched on this a bit, but can you dive deeper into exactly what you are looking for as part of that visit? 

Ms. Haibach: Definitely. With an initial consult to me, the number one question that I would ask my patients first is, what is your most bothersome symptom? With this question, I'm looking to determine: is it pain that brought you to me? Is it heavy bleeding? Do you feel bulk and bloaty? Are you having issues getting pregnant? Do you have bowel or bladder issues?

The information I get from that one initial question, helps guide the remainder of my visit. If bleeding is the main concern, we would focus on getting that under control. So, we need to suppress the menses with medication options. If bulk and bloating is the main concern, for instance the patient feels like they have a pregnant-looking abdomen, typically surgical options are warranted. If the main complaint is infertility, we do have fertility specialists in our practice who remove fibroids to aid patients in achieving pregnancy.

The most important purpose of this visit is to really listen to the patient to find out how these symptoms are impacting their daily lives. From there, I can use that information to guide my treatment plan.

So, once it is determined that the patient is a good surgical candidate, what would be the next steps?

Ms. Haibach: If at the end of my visit, I determine that a patient is potentially a suitable surgical candidate, the first thing I would do is order appropriate imaging. For example, if the patient is interested in uterine preservation for future fertility, she is likely going to opt for a laparoscopic myomectomy, where fibroids would be removed, and her uterus would be left in place. In that case, she would require an MRI for fibroid mapping. If a woman has completed childbearing, then oftentimes a pelvic ultrasound would suffice, at least to start, since she'd likely elect hysterectomy if she has reached her fertility goals.

I would also perform an endometrial biopsy to rule out malignant process before going into surgery. To optimize a patient for our MIGS surgeons, I gather a thorough medical history to ensure their comorbidities are appropriately managed. For example, diabetes is under control, sleep apnea is being treated, no active infections. If there is anything else going on that needs to be addressed, I'd refer them to the appropriate provider first.

Once I have acceptable imaging, a negative endometrial biopsy and an adequate medical history, I would then assist the patient in scheduling with one of the surgeons on my team for a consult and physical exam to determine surgery planning. Once they see our physician, a surgery date is booked. The patient would come back to see me within 30 days of surgery, and we would do a preoperative education appointment. I see them again 2 weeks after surgery for a post-op visit. We’d perform the post-of visit virtually in our practice. We would see the patient sooner if there are any other concerns that arise post-operatively.

What if the patient is not a surgical candidate? How do you as an APP assist in ongoing medical management?

Ms. Haibach: The presence of fibroids alone, without symptoms, often does not require surgical intervention. There are occasions where a patient is, for example, seen in the emergency room for abdominal pain, whereas they’ll get a CT scan of the abdomen pelvis, and a fibroid is incidentally found. At that point, they are instructed to see gynecology for follow-up. If the patient was unaware of the fibroid, has no symptoms and there's no concerning imaging features, then management with ongoing surveillance (repeat imaging and office follow up) and instructions on when to return is usually appropriate.

Depending on the symptoms, medical management typically includes hormonal suppression of menses in the form of a birth control pill or an IUD. If bleeding is the main concern, it is my goal to at least slow her bleeding, if not try to stop it. Not all women are good candidates for hormone therapy, so there is a medication option that is non-hormonal. In my role, I would start a medication plan for a patient and initiate a new medication such as hormonal suppression in the form of birth control, IUD, non-hormonal medications etc.

Typically, when I do that, I'll have the patient follow up with me in about two to three months to reassess the medication’s effectiveness. The goal of the reassessment is to determine if it is working for her life, to be sure there are no major side-effects, and just to make sure she is amenable to the plan. As part of the medical management, sometimes it is necessary to monitor blood counts for anemia to be certain that medical management is still appropriate for her.

From your experience in practicing, are you more likely to be visited by one age bracket or ethnicity over another? 

Ms. Haibach: Actually, data tells us that most fibroids occur in women of reproductive age. They are also diagnosed in African American women two to three times more frequently than in white women. Fibroids are infrequently seen in premenstrual women. A relief of symptoms of the fibroids often occurs at the time of menopause, when the menstrual cyclicity seizes and steroid hormone levels decrease. My demographic is consistent with the above statistics. I tend to see women within the ages of  20’s-50’s and more often African Americans.

Was there anything else that you'd like to mention?

Ms. Haibach: Abnormal bleeding can be very stressful for women. APPs are a great place to start an abnormal bleeding or fibroid work-up. Patients should rest assure that although we cannot perform surgery, APPs can help get them in the right direction for the best care possible.

As an Advanced Practice Provider, when and why might a patient with uterine fibroids be scheduled to visit with you?

Ms. Haibach: Typically, with the flow of how our practice runs, a patient would schedule with me as an initial visit to explore their abnormal or heavy bleeding. Oftentimes, a patient is unsure with what they have going on medically and will view APPs as a safe place to start. Other times, I will see a patient for a general wellness exam who will mention heavier menses over the years or just a change in their bleeding pattern-- longer flow, things like that.

It may stem from something that seems out of the ordinary for them or a symptom impacting their life. For example, if a patient says, “I have to run home and change my clothes,” or “I'm bleeding through my bed sheets.” Those statements prompt further evaluation. At times, patients who have already been diagnosed with fibroids, will come to see me if they have chosen medical management over surgical management of their fibroids. They continue to follow up with me to reevaluate the success of their treatment plan periodically. So, whether I start them on a plan, or a physician does, they can follow up with me to revisit their medical plan and ensure it remains appropriate.

You touched on this a bit, but can you dive deeper into exactly what you are looking for as part of that visit? 

Ms. Haibach: Definitely. With an initial consult to me, the number one question that I would ask my patients first is, what is your most bothersome symptom? With this question, I'm looking to determine: is it pain that brought you to me? Is it heavy bleeding? Do you feel bulk and bloaty? Are you having issues getting pregnant? Do you have bowel or bladder issues?

The information I get from that one initial question, helps guide the remainder of my visit. If bleeding is the main concern, we would focus on getting that under control. So, we need to suppress the menses with medication options. If bulk and bloating is the main concern, for instance the patient feels like they have a pregnant-looking abdomen, typically surgical options are warranted. If the main complaint is infertility, we do have fertility specialists in our practice who remove fibroids to aid patients in achieving pregnancy.

The most important purpose of this visit is to really listen to the patient to find out how these symptoms are impacting their daily lives. From there, I can use that information to guide my treatment plan.

So, once it is determined that the patient is a good surgical candidate, what would be the next steps?

Ms. Haibach: If at the end of my visit, I determine that a patient is potentially a suitable surgical candidate, the first thing I would do is order appropriate imaging. For example, if the patient is interested in uterine preservation for future fertility, she is likely going to opt for a laparoscopic myomectomy, where fibroids would be removed, and her uterus would be left in place. In that case, she would require an MRI for fibroid mapping. If a woman has completed childbearing, then oftentimes a pelvic ultrasound would suffice, at least to start, since she'd likely elect hysterectomy if she has reached her fertility goals.

I would also perform an endometrial biopsy to rule out malignant process before going into surgery. To optimize a patient for our MIGS surgeons, I gather a thorough medical history to ensure their comorbidities are appropriately managed. For example, diabetes is under control, sleep apnea is being treated, no active infections. If there is anything else going on that needs to be addressed, I'd refer them to the appropriate provider first.

Once I have acceptable imaging, a negative endometrial biopsy and an adequate medical history, I would then assist the patient in scheduling with one of the surgeons on my team for a consult and physical exam to determine surgery planning. Once they see our physician, a surgery date is booked. The patient would come back to see me within 30 days of surgery, and we would do a preoperative education appointment. I see them again 2 weeks after surgery for a post-op visit. We’d perform the post-of visit virtually in our practice. We would see the patient sooner if there are any other concerns that arise post-operatively.

What if the patient is not a surgical candidate? How do you as an APP assist in ongoing medical management?

Ms. Haibach: The presence of fibroids alone, without symptoms, often does not require surgical intervention. There are occasions where a patient is, for example, seen in the emergency room for abdominal pain, whereas they’ll get a CT scan of the abdomen pelvis, and a fibroid is incidentally found. At that point, they are instructed to see gynecology for follow-up. If the patient was unaware of the fibroid, has no symptoms and there's no concerning imaging features, then management with ongoing surveillance (repeat imaging and office follow up) and instructions on when to return is usually appropriate.

Depending on the symptoms, medical management typically includes hormonal suppression of menses in the form of a birth control pill or an IUD. If bleeding is the main concern, it is my goal to at least slow her bleeding, if not try to stop it. Not all women are good candidates for hormone therapy, so there is a medication option that is non-hormonal. In my role, I would start a medication plan for a patient and initiate a new medication such as hormonal suppression in the form of birth control, IUD, non-hormonal medications etc.

Typically, when I do that, I'll have the patient follow up with me in about two to three months to reassess the medication’s effectiveness. The goal of the reassessment is to determine if it is working for her life, to be sure there are no major side-effects, and just to make sure she is amenable to the plan. As part of the medical management, sometimes it is necessary to monitor blood counts for anemia to be certain that medical management is still appropriate for her.

From your experience in practicing, are you more likely to be visited by one age bracket or ethnicity over another? 

Ms. Haibach: Actually, data tells us that most fibroids occur in women of reproductive age. They are also diagnosed in African American women two to three times more frequently than in white women. Fibroids are infrequently seen in premenstrual women. A relief of symptoms of the fibroids often occurs at the time of menopause, when the menstrual cyclicity seizes and steroid hormone levels decrease. My demographic is consistent with the above statistics. I tend to see women within the ages of  20’s-50’s and more often African Americans.

Was there anything else that you'd like to mention?

Ms. Haibach: Abnormal bleeding can be very stressful for women. APPs are a great place to start an abnormal bleeding or fibroid work-up. Patients should rest assure that although we cannot perform surgery, APPs can help get them in the right direction for the best care possible.