Kofinas Podcast Series

[00:00:05] Kristyn Hodgdon
Hi, I'm Kristyn Hodgdon, an IVF mom, proud women's health advocate, and co-founder of Rescripted. Welcome to
From First Period to Last Period, a science-backed health and wellness podcast dedicated to shining a light on all of
the women's health topics that have long been considered taboo. From UTIs to endometriosis, we're amplifying
women's needs and voices because we know there's so much more to the female experience than what happens at the
doctor's office. With From First Period to Last Period, we're doing the legwork on your whole body so you can be the
expert in you. Now, let's dive in.
[00:00:47] Kristyn Hodgdon
Hi everyone, and welcome to From First Period to Last Period, formerly called Dear Infertility. I'm so thrilled to be
officially introducing our new rebranded version of our podcast, all about women's health topics that have long been
considered taboo, from UTIs to infertility to today, we're going to be chatting about fibroids and racial inequities in
healthcare. I'm so thrilled to have Doctor Levica Narine with me. Hi, Dr. Narine.
[00:01:23] Levica Narine
Hi, Kristyn. So happy to be here. Thank you.
[00:01:26] Kristyn Hodgdon

Absolutely. So happy to have you here. For those of you who don't know her, Dr. Levica Narine is a board-certified ob-
gyn and fertility specialist at the Kofinas Fertility Group in New York City. Welcome! I'm so excited to chat with you

about fibroids today. It's something that we've actually never touched on this podcast, and I thought a perfect way to
open up to the broader spectrum of women's health conditions, considering I think I read a stat that up to 80% of
women will experience a fibroid by the time they're 50. Very common but often misunderstood and not highly discussed
topic.
[00:02:06] Levica Narine
Absolutely. Thank you for giving us the platform. There's so much to say about it, and there's so much education that
needs to be put out about it. I'm happy to be able to do that here. It's definitely a bread-and-butter part of our practice,
and there are a lot of misconceptions and myths. We're happy to set the record straight and educate, for sure.
[00:02:25] Kristyn Hodgdon
Absolutely. Tell us, what are fibroids exactly, and what causes them?
[00:02:29] Levica Narine
So fibroids are basically benign, meaning non-cancerous growths that can occur in the smooth muscle wall of the
uterus. They are generally classified in terms of like where they are in the uterus. So, you can have fibroids that are
within the cavity of the uterus called submucosal fibroids. You can have fibroids that are within the wall of the uterus
called intramural fibroids. And you can have fibroids that are within just on the top surface of the uterus called
subserosal fibroids. And then there are others. But just to give you an idea, and most commonly, they're called fibroids.
But in medical terminology, they're often referred to as leiomyomas or myomas.

[00:03:11] Kristyn Hodgdon
Okay, interesting. But most people know them as fibroids, right? Are there other type of fibroids? Because I've often
seen them referred to as just uterine fibroids. But are there other types out there?
[00:03:22] Levica Narine
They can often be mistaken with fibromas, I feel, so the terms are very similar. Fibroids, it's basically named according
to location. So, there could be ovarian fibroids. It could be like fibroids that are closer to other organs that are named as
such but, in general, are originating from the uterus.
[00:03:42] Kristyn Hodgdon
Okay, got it. And for someone who might be experiencing some mysterious symptoms, what are some of the common
symptoms of fibroids? How do you know if you have them?
[00:03:53] Levica Narine
Yeah. So basically, mostly women will present with symptoms of some change in period or some change bleeding
related to their period, whether that be heavier bleeding that can occur within the normal time of their periods.
Sometimes, that bleeding can occur outside of their period. So they're saying they're bleeding for 12 days instead of
seven days. Blood clots. Sometimes, they present just with anemia. So we have to work that up where they thought
they have normal periods and the heavy bleeding is normal, but other symptoms include a lot of pelvic pressure
because fibroids enlarge the uterus, and that generally causes a lot of like, it causes a mass effect or a bulk effect. So it
creates like pressure on the other organs and structures and the pelvis. So, some women may present with
gastrointestinal effects such as constipation if the fibroids are pressing on her bowels, or this urgency and frequency for
urination if it's pressing on the bladder. Sometimes, it can be pretty severe enough that, not that someone will notice it,
but they'll notice a different quality of their urinary symptoms because it can put pressure on the ureter itself. So those
are the most common.
[00:05:06] Kristyn Hodgdon
And does a fibroid have to be pretty large in order to have some of those more severe symptoms?
[00:05:13] Levica Narine
Yes. They usually have to be pretty large for the bulk effect. For the bleeding effects, actually, even small fibroids within
the cavity of the uterus called the endometrial cavity or the uterine cavity. They can be pretty small or relatively pretty
small, but they exist within that cavity where that lining is shed every month. So, that increases bleeding.
[00:05:36] Kristyn Hodgdon
Okay, got it. And so, how do you ultimately get diagnosed with fibroids?
[00:05:41] Levica Narine
We started off very basic. Any woman who comes in, we do a thorough history and physical. We want to know like what
her history is, what her medical issues are, what her symptoms are. The physical exam is very important, and that
often includes an abdominal exam and also a pelvic exam. And then it can go into a very simple ultrasound or
sonogram that's in office that allows us to actually visualize the pelvic organs, and we can see fibroids on the
ultrasound.
[00:06:10] Kristyn Hodgdon
Okay. So like a transvaginal ultrasound that you would get at your ob-gyn or fertility clinic?
[00:06:16] Levica Narine
Exactly. So like on this day and age, like most GYNs are very proficient with their sonogram. So mostly, like the annual
visits, most annual visits will include a pelvic ultrasound. So, it's something that can be easily done in the office. For
more severe fibroids, if there's more information that's needed. If we want to, if we feel the fibroid is very large or maybe
causing effects on other organs, an MRI may come up for advanced imaging if needed.
[00:06:43] Kristyn Hodgdon
Okay. And are they ever misdiagnosed?

[00:06:47] Levica Narine
They can be because there are certain things, there are certain other conditions that can mimic the symptoms, ... have
to be very careful about that. The most common condition that often mimics similar symptoms of bleeding and pressure
is something called adenoma. And basically, it also enlarges the uterus and can cause issues with bleeding and can
cause issues with fertility. But it's not fibroids, it's basically, some people commonly call it endometriosis of the uterus;
when they go for the lining of the uterus, it kind of seeps into the muscle wall, and it makes it very tough and fibrotic,
and they continuously get very bulky. That causes very similar symptoms. So that's one issue. And then there's a rare
cancer called leiomyosarcoma, which is very rare, but it's something we always have to be on the lookout for, which
can also mimic those symptoms.
[00:07:41] Kristyn Hodgdon
Okay, really good to know, because so much of what we do at Rescripted is giving women the information they need to
be their own advocates. And yeah, knowing that other conditions are out there that kind of mimic the same symptoms
can help them get to the bottom of, I think, whatever's plaguing them a little bit easier.
[00:07:57] Levica Narine
Well, yeah, for sure. It's good to have that idea that simply just bleeding can cause anemia. A lot of women just don't
even realize that. So they even present with symptoms of fatigue and feeling tired and not being able to get through
their day. And then we don't even sometimes even mention those symptoms when I talk to them. And then I may be
bleeding for like how many pads or tampons do you use? And then that kind of brings it to light.
[00:08:20] Kristyn Hodgdon
Yeah, fatigue. I was having a conversation with someone recently that, about my, I got diagnosed with the thyroid
autoimmune condition a couple of years ago, and my main symptom was like crushing fatigue, and, but I was
gaslighting myself. I was like, oh, I'm just a tired mom. I just got over COVID, like all of the different things that I could
have possibly been the reason behind my fatigue, except for the fact that I had an autoimmune disease. It's your body
better than anyone else. If you are feeling out of anything out of the ordinary, it's important to chat with your doctor.
[00:08:56] Levica Narine
For sure, and think about it. If your child presents those symptoms, you're like, okay, we're making a doctor's
appointment. And for like us, busy ... just that, okay, I'm not getting enough sleep, or this is happening, and we put our
back burner. I get that, exactly.
[00:09:11] Kristyn Hodgdon
So fibroids, for someone who's not trying to conceive, they're not dangerous. Correct.
[00:09:18] Levica Narine
Yeah.
[00:09:19] Kristyn Hodgdon
They don't have to be treated or?
[00:09:21] Levica Narine
Exactly. So how one presents is the most important thing. So fibroids can be very large. So we look at the symptoms.
We look at the signs. Some women have fibroids, but they are completely asymptomatic. And if they are asymptomatic,
their health status is fine. They're not anemic. They're not trying to get pregnant. No, we don't have to let, we don't have
to do anything about it. If they're close to menopause, nature will take its course. And oftentimes, when you're no longer
having periods, the food or the fibroid, which is estrogen, decreases. So that's nature's way of naturally helping the
fibroids to shrink or regress.
[00:10:00] Kristyn Hodgdon
Okay.
[00:10:00] Levica Narine
So, correct, if it's asymptomatic and a woman has no goals of pregnancy or no concerns of that, they can just be
monitored.
[00:10:11] Kristyn Hodgdon
Okay. And then, obviously, million-dollar question. You're a fertility specialist. What about when you are trying to
conceive? How does that come into play? Does someone typically, when you have a patient with fibroids, have they
been trying to conceive for a while and obviously not, like how does it affect fertility? Does it always cause infertility, or
only sometimes?

[00:10:33] Levica Narine
I would say it causes fertility in several ways, and some can be very direct, and some can be very subtle. When I was
first being trained, we were always taught that fibroids will never affect you getting pregnant. It's actually holding on to
the pregnancy and what happens after you get pregnant. But that's not true. We have a huge patient population that
has fibroids, and like everything in New York, location is very important of where the fibroid exists. So, for example, the
endometrial cavity or the uterine cavity, which is the inner cavity of the uterus, where pregnancy, rather an embryo has
to implant and a pregnancy has to develop. If a fibroid is within that small cavity that takes up space, it can also go to
the embryo competes with space with that fibroid. Fibroids feed off of estrogen. So, in pregnancy, which is a high
estrogen state, fibroids can also grow. So there is a successful implantation. The growing fibroid can cause issues with
bleeding which can lead to early pregnancy losses or miscarriages. Outside of that, fibroids that are within the wall of
the uterus and then extend out of the uterus can also cause that, like mass effect or pressure on the other reproductive
structures, and one of the most important is that it can cause tubal blockage. The tubes are literally the cool bars of our
system. That's the only place where the sperm and the egg are going to meet. So if there's any sort of obstruction or
blockage there, a woman may be ovulating beautifully, her partner's semen analysis is completely fine, but there's no
meeting place, so there's no fertilization, so that causes issues with fertility as well. And interestingly enough, one of the
forefronts and one of the newest and exciting parts of fertility, and I think for a lot of things, is immunology. So
immunology and there's an autoimmune effect that happens with fibroids, regardless of where they are. Our bodies are
very brilliant. It's what the heck is this thing doing here? Let me try to get rid of it. So, it produces antibodies against
those fibroids. So, your pelvis and your uterus is constantly under this low level of inflammation or attack. So that
causes the, not to be in a hospitable place for implantation and growth.
[00:12:53] Kristyn Hodgdon
Do you think that's the case? I'm just so curious because I have an autoimmune disease, and I've had five failed
embryo transfers, including a six-and-a-half-week loss and a chemical pregnancy in the past two years. And with,
because I have twins that are five and I didn't have Hashimoto's then, so I can't help but think that the autoimmune
component has something to do with it. But like research hasn't caught up yet to say there's definitely a correlation
there. So that's such an interesting thing that you brought up.
[00:13:23] Levica Narine
It's one of the most exciting parts of our industry right now, Kristyn, because it's made such a huge difference. So it's
absolutely necessary to have labs that we can look into. We can also look and see what that immune profile inside your
uterus is. Sometimes, it's at odds with what's going out, going on outside of the uterus. So we have to kind of balance
that out. Any autoimmune issue in women, especially young reproductive-age women, are most prone to autoimmune
issues, even simple things: eczema, psoriasis, all the way to lupus, thyroid issues. It's really like our body's attacking
ourselves. So, it does play a big role in us accepting this foreign being, which is a baby. So it plays a huge role.
[00:14:07] Kristyn Hodgdon
That's really refreshing and validating to hear. As much as it's not the answer I want to hear, it's validating.
[00:14:13] Levica Narine
And there's a lot that we can do about it, too. So once we have those answers, there's a lot we can do about it.
[00:14:18] Kristyn Hodgdon
Amazing. So, you talked about how fibroids can potentially influence pregnancy outcomes. What if you do have a
successful pregnancy? Is there are there any risks associated there?

[00:14:30] Levica Narine
Yes. If you do have a successful implantation and the pregnancy is well established. Usually, I would say except for the
early first 6 to 8 weeks, if you've gone through that and you've been successful, there hasn't been any bleeding or
anything like that when you get through the first trimester. As I said before, pregnancy is a high estrogen state. So we
also run the risk of the fibroids growing because just the fibroids are a problem for reproductive-age women because
reproductive-age women are producing a lot of estrogen. So if we're in a state that's also increasing that, like
pregnancy, it's going to take that food. So, depending on where it is, and usually if we have a successful implantation
and development of the baby at that point, maybe it's not in the cavity. It's probably not, but it could be within the wall or
just hanging off of the wall. So it's within that wall and grow and can cause a little compression and can cause issues
with how well the baby is able to grow and how that cavity is able to expand. Then there's another type of fibroid, which
has a stalk, which is called a pedunculated fibroid, which just hangs off. It's usually like it's the one that we worry about
the least in terms of getting pregnant. But if it grows, it can twist, and that causes pain. So when it causes pain that can
cause contractions, it can cause like early and preterm labor and hence, potentially bedrest. You have a woman has to
stop her life and be on bed rest for her pregnancy. It can also cause degeneration. Sometimes, those fibroids grow too
large, and it just outgrows its vasculature. And that can cause infections and pain as well, so that may lead to early
deliveries. And much of that time, it's like surgical deliveries, meaning C-sections and, of course, a preterm baby, which
we never ultimately want to have.
[00:16:21] Kristyn Hodgdon
Yeah. Wow, I didn't realize it had such an impact. So let's talk about, I know this is your specialty. Let's talk about how
fibroids are treated because it's not all bad news. They are very treatable, and can you talk a little bit about how they're
treated. Does like the size factor in, or the location sort of factor into that at all?
[00:16:42] Levica Narine
Yeah. There are several treatment modalities that are available. Again, it depends on where a woman is in her life, and
what's happened, and what she wants to happen. A woman is done with her childbearing and maybe having symptoms
of bleeding and was maybe several years away from menopause. The most definitive treatment is the hysterectomy,
where she no longer needs. But for a woman who wants to have a child, we here at the Kofinas Fertility Group, we
usually recommend doing a procedure called a myomectomy, which is essentially removing the fibroid but leaving the
uterus intact and go on to become pregnant on her own or, if needed, with fertility therapy. Outside of that, there are
less invasive treatments, some which may or may not be, some which may cause issues with fertility at times. There's
one particular treatment called uterine artery embolization that's not done by a GYN surgeon or a gynecological
surgeon. It's done by an interventional radiologist, and it's very non-invasive, and it's very attractive for that, for those
means, because basically, it's a small incision that's made in the groin. And through very minimally invasive techniques,
certain substances are placed in the uterine artery that blocks the blood flow to the uterus and the fibroids, and that
allows shrinkage to happen. But it could be a relative contraindication for a woman who may want to get pregnant. And
that is also very dependent on size because it often will not work on a uterus that has large fibroids. You may have a lot
of complications related to that.
[00:18:20] Kristyn Hodgdon
And how successful is the is it the myectomy?
[00:18:26] Levica Narine
Close, close. It's the myomectomy, very successful. We have our own surgical center here. We're a reproductive
surgical center. Most of our surgeries are done at our center. They're done laparoscopically. So it's minimally invasive
cameras. We're really able to like pinpoint where the fibroids are, and we remove the fibroids completely. Within that
procedure, there's a technique to remove fibroids within that cavity that I was talking about, called a hysteroscopy
requires no incisions. It's a purely transvaginal procedure, but the fibroids that are within the wall, through small
incisions, we can remove that, and we remove the fibroids, and they're gone. For again, a lot is dependent on where
how old the woman is. Like how many reproductive how many more reproductive years she may have. At that time,
they're gone. And then we can they a certain woman can pursue conceiving on her own or pursue, like, fertility
treatments at that point.
[00:19:21] Kristyn Hodgdon
If a woman is typically, unless there are other underlying issues after surgery, she can go on to get pregnant and stay
pregnant.

[00:19:29] Levica Narine
Yeah, absolutely. Sometimes, that's all she needs, and she may not. If all we look at certain parameters for fertility and
if she's otherwise healthy and she has a great reserve and her eggs are healthy, removing that fibroid just releases a
lot of potential pressure or that immune effect, so that inflammatory effect decreases. So we have our patients who go
on to conceive on their own.
[00:19:52] Kristyn Hodgdon
Love it. So discussing fibroids, I couldn't help but notice that they disproportionately affect women of color. Black
women are three times more likely to experience fibroids than white women. Can you speak to that a little bit? Do you
see that often in your practice? And why is that?
[00:20:12] Levica Narine
Yeah, the racial disparities really do exist. There are some stats where, like you said, by age 50, nearly two-thirds of
women have experienced some sort of fibroids. And according to some national estimates, nearly a quarter of black
women between 18 and 30 have fibroids, compared to only about 6% of white women. And by age 35, that number
increases to 60%. Black women also tend to usually have larger fibroids and may have more symptomatology and also
complications related to that. No one could, no one knows for sure why that reason is. Genetics plays a huge role, but
there are associated risks that can happen to anybody but may exist in certain ethnicities and races more than others.
Some think of starting your period at a younger age. Obesity measures, lack of access to healthy diet, an organic diet,
or plant-based diets not having the access to like having those nutritious and organic foods. Those things do play a big
role.
[00:21:16] Kristyn Hodgdon
That's so interesting. So are there lifestyle changes like diet and nutrition or exercise that can contribute to the
management of fibroids?
[00:21:26] Levica Narine
Absolutely. Obesity plays a huge role because, interestingly enough, in our fat cells or our adipose cells, if we want to
be formal, there are cells, those cells produce a type of estrogen called estrone. So if a woman is overweight or obese,
or they have extra estrogen that contributes to allowing the fibroid to grow larger and even greater rate. So, definitely
maintaining a healthy body composition, exercise, eating well. Anecdotally, there have been found to be good results
with a mostly plant-based diet, which tends to be like more anti-inflammatory, higher antioxidants, and exercise is good
for everything. We hate to say it, but yeah.
[00:22:15] Kristyn Hodgdon
It's, I'm actually starting an egg retrieval cycle tomorrow, and I can't exercise for a few weeks, and it's going to be the
death of me.
[00:22:22] Levica Narine
It also decreases stress, and stress plays a huge role.
[00:22:26] Kristyn Hodgdon
That's what I use it for, like it's such a stress reliever for me. So it's going to be tough, but just gotta get outside and
walk on those nice days. So is there anything else that you think women should know about fibroids? What would you,
we always like to ask, what would you rescript about the conversation surrounding fibroids and just some of the
misconceptions that there may be?
[00:22:52] Levica Narine
I think that I always find in my practice that everyone comes with this idea that everything is okay, like pain with your
periods is okay. That's just part of being a woman. But so, when it's associated with certain things that it's not okay, but
it's not okay, that you have very painful periods, it's not okay that you have very heavy periods where you feel like
fatigued, and you're like laid out for a week every month. Those things are not okay. So really, our patients and really
exploring those things are very important. So we find that a lot because, obviously, our ultimate goal here is to get a
woman pregnant. So it's very important for us to investigate what are the things that can be contributing to that,
whether they are hormone related, age-related or physically related and oftentimes physically related things like
fibroids, inflammation, scar tissue, endometriosis, those are things that we can control. So it's very thing that we're able
to do that, and sometimes that's all it, that's all it takes.

[00:23:52] Kristyn Hodgdon
You bring up a good point. I didn't ask this question, but if you do, you typically need to do fertility treatments then, or
sometimes it's just the surgery is the magic piece of the puzzle? Do you typically tell people to try on their own after
surgery to see what happens, or do you ever just jump right into fertility treatments, like how do you make that decision
as a physician?
[00:24:15] Levica Narine
It's really a conversation with our patient, with each particular woman, because it depends on what her goals are, where
she is in life. You know what her family planning goals are as well.
[00:24:25] Kristyn Hodgdon
Yeah.
[00:24:25] Levica Narine
It could there could be a small fibroid that's within the cavity that's been causing issues. And just removing that will
allow her to go on to get pregnant on her own, or there's a small fibroid that's causing like a small obstruction on the
tubes. However, if they're the uterus is incredibly enlarged and it's been there for a long time, usually, unfortunately, the
damage has been long-lasting, and those tend to need fertility treatments. Age plays a huge role. Age plays a huge
role. So sometimes, by the time you get to seeing and managing the fibroid, we also have to manage the biological
components of what's going on with the woman's like egg reserve and quality of eggs. I would, being in the fertility
world, we see a lot of women who are at that stage where it's usually recommended that this is the time that where we
know fertility treatments are going to work, you'll get healthy embryos and not take the time to potentially get pregnant
on your own for six months.
[00:25:21] Kristyn Hodgdon
And with the estrogen kind of fueling the fibroid growth, does IVF play into that at all? Just like knowing that your
estrogen levels rise when you do a retrieval, and then also like being on estrogen for a frozen embryo transfer.
[00:25:38] Levica Narine
Great question, and the answer is yes. The answer is yes. And we have to decide when we'll do that removal of the
fibroid. So we have to be careful with that because as you've experienced and as those medications are going to
increase estrogen, and that can fuel the regrowth of fibroids, Don't see much of that because you want to take steps to
move forward pretty quickly. The general, once the surgery is done, especially done in the way that we often do this,
which is laparoscopically or minimally invasive, that lessens the time of healing for the uterus, for when the woman will
be able to get pregnant. So I start that process of egg retrieval fairly soon. We don't often see that, but it can certainly
happen.
[00:26:20] Kristyn Hodgdon
Interesting. Such a great episode. So much helpful information for anyone who suspects they may have fibroids, or
does have fibroids, or fears that they have a fibroid. Really appreciate you diving deep into this topic, Dr. Narine.
[00:26:35] Levica Narine
Thank you so much. Pleasure to be here with you.
[00:26:40] Kristyn Hodgdon
If this podcast means something to you, be sure to hit follow or subscribe. This helps you because you'll never miss an
episode, and it helps us because you'll never miss an episode. For science-backed women's health content that meets
you exactly where you are, head to Rescripted.com or follow us on social @HelloRescripted.