Dr. Rebecca Dekker – 00:00:00:
Hi everyone, on today’s podcast, we’re going to talk all about uterine fibroids and their impact on pregnancy and birth with Dr. Veronica Gillispie-Bell. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Decker, and I’m a nurse with my PhD and the founder of Evidence Based Birth®. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. Hi everyone, and welcome to today’s episode of the EBB podcast. Today, I’m so excited to talk with Dr. Veronica Gillispie-Bell, a board-certified OB/GYN and associate professor at Ochsner Health in New Orleans, Louisiana. Dr. Gillispie-Bell serves as the senior site lead and section head of women’s services at Ochsner Kenner, director of quality for women’s services for Ochsner Health System, and medical director of the Minimally Invasive Center for the Treatment of Uterine Fibroids. She earned her medical degree from Meharry Medical College, completed her residency at Ochsner Health System, and holds a Master of Applied Science from Johns Hopkins Bloomberg School of Public Health, along with a certification in diversity and inclusion from Cornell University. Dr. Gillispie-Bell is known nationally for her expertise in managing heavy menstrual bleeding associated with fibroids. And she performs advanced laparoscopic and robotic procedures. She is also the medical director of the Louisiana Perinatal Department of Health, leading initiatives to improve birth outcomes and eliminate racial disparities in maternal health. Dr. Gillespie-Bell has testified before the U.S. Congress, spoken at the White House Maternal Health Day of Action, and has been featured in numerous publications and media outlets including USA Today, The New York Times, Good Morning America, and the 1619 Project docuseries. Dr. Gillispie-Bell, welcome to the Evidence Based Birth® Podcast.
Dr. Veronica Gillispie-Bell – 00:02:08:
Thank you for having me.
Dr. Rebecca Dekker – 00:02:10:
We are so honored that you are here to share your wisdom and expertise with us today. And this is a subject that I was really excited for you to talk about because we’ve never covered it before on the EBB Podcast in our more than 300 episodes. But uterine fibroids is a subject that gets brought up a lot in terms of their impact on getting pregnant, on pregnancy, and whether or not you can have a vaginal birth or if you have to have a Cesarean. So I was wondering if you could start with the basics and educate us, what are uterine fibroids?
Dr. Veronica Gillispie-Bell – 00:02:45:
Sure. Uterine fibroids are benign growths of the uterus. There is a cancerous type called leiomyosarcoma, but it’s extremely rare. So for the most part, they are benign growths of the uterus. They are very common. 80% of Black women will have fibroids by the time they’re 50. 70% of white women will have fibroids by the time they’re 50. They are the most common reason for hysterectomy, although hysterectomy is not the only option for treatment. But they are the most common reason for hysterectomy. They plague women with heavy menstrual bleeding, pelvic pressure, pelvic fullness, and then some of the things that you mentioned as far as impact on pregnancy as well.
Dr. Rebecca Dekker – 00:03:27:
Like, can you start getting these younger in life too? So, you know, you say that you’re 50s, but like what age could somebody start seeing them?
Dr. Veronica Gillispie-Bell – 00:03:35:
Sure. So generally, very interesting. For most women, we see symptoms within their reproductive age. Now, for Black women in general, they present five years younger than their white counterparts, and they usually have a higher burden of disease and a higher burden of symptoms. But for the most part, most women do present with symptoms in their reproductive years. I have had patients as young as 14 where we’ve had to do surgical intervention because of symptoms, but they do start out as very, very small growths of the uterus. Fibroids have estrogen receptors on them. And so as women, we make estrogen every month when we ovulate, and that estrogen feeds the fibroids and they do grow over time. And so usually women are presenting again with their symptoms during their reproductive years.
Dr. Rebecca Dekker – 00:04:27:
Okay, and what are those symptoms exactly?
Dr. Veronica Gillispie-Bell – 00:04:31:
So they can range from heavy menstrual bleeding. And when I say heavy, it is so sad sometimes the amount of heavy bleeding that some patients face where patients tell me it looks like a murder scene or I just lay on a towel because it’s so heavy. So it can be heavy bleeding that is that heavy up to just heaviness where you’re soaking through a pad or a tampon in an hour, pelvic pressure, fullness. A lot of times, especially depending on the location of the fibroids, I have patients that tell me they’re having to urinate all the time. They feel like as soon as they drink something, they have to go to the bathroom to pee. And that’s because the fibroids are putting pressure on the bladder. Sometimes constipation, if the fibroids are on the back of the uterus, they can cause pain with intercourse as well. So it’s really a myriad, a large number of symptoms that we see.
Dr. Rebecca Dekker – 00:05:26:
And then I can imagine that has like downstream impacts on their health because if you’re bleeding that much each month, you’re probably anemic. Are there any other like health consequences of that?
Dr. Veronica Gillispie-Bell – 00:05:36:
Absolutely. I tell patients all the time, blood is life. So if you’re losing it every month and you don’t have it, then one, you yourself experience, like you said, fatigue, make it harder to do normal activities, shortness of breath. I think as women, we commonly have been taught to diminish our symptoms. And so we feel like if I can adjust, then it’s okay, but it’s not okay. If bleeding becomes very, very heavy and anemia is very severe, that can even result in heart attack and stroke. So anemia is more than just being tired, but that is one of the common side effects of having fibroids.
Dr. Rebecca Dekker – 00:06:19:
I’m just curious if you could tell us what got you interested in this subject, because I know you’re an OB/GYN. But if you’re spending all this time treating and talking about and educating people on uterine fibroids, was there a reason that you got involved in this field?
Dr. Veronica Gillispie-Bell – 00:06:35:
Yes. So I was a junior in college. I attended Xavier University here in New Orleans. I was a junior and I’d already decided I wanted to be an OB/GYN because I’d spent some time with my OB/GYN over the Christmas break and he opened my world to obstetrics and gynecology. And I was like, this is it. This is what I’m supposed to do. And so that going into the spring, into the summer, my mom told me she needed to have a hysterectomy because of fibroids. And I never heard of fibroids. I didn’t know what they were. So the nerd that I am, I started doing research. And so I started reading and I realized there were no options for treatment. There was a hysterectomy. At that time, there were some procedures to remove the fibroids. There was a medicine that you could take to decrease the size of the fibroids just to have surgery. And I said, that’s it. I’m going to find the cure for fibroids. And so that was my decision. Like I said, when I was in college and all through medical school, everybody that knew me knew I was like the fibroid person, like that was my thing. And then going into practice, I really have centered my practice around making sure women have options for treating their fibroids between making sure I’m counseling on the different options that are available, as well as I’ve been a principal investigator for clinical trials for medications that are now FDA approved for treating heavy menstrual bleeding associated with fibroids. But that was the initial thing that happened. I just felt like it was my calling to do something in this area.
Dr. Rebecca Dekker – 00:08:08:
Yeah. And we’ll get into treatments in a little bit, but that reminds me of something you said earlier about the racial disparities. So can you talk with us about like, why are there these racial disparities? Like, how does racism impact the growth of fibroids in your uterus?
Dr. Veronica Gillispie-Bell – 00:08:25:
Yes. So as I mentioned earlier, for Black women, they present five years younger than their white counterparts. They have a higher burden of disease, meaning they have more severe symptoms and they have more fibroids. That part, we don’t understand why. We’re not sure if there may be some sensitivity to estrogen or why the manifestation of symptoms is different. Now, when we look at treatment options, Black women are less likely to be offered minimally invasive options. So when we adjust for age, for body mass index, for size of the uterus, number of fibroids, anemia, all of those factors, when the only thing that is different is race, Black women are less likely to be offered minimally invasive options. And that is where we do see racism and implicit bias impacting healthcare providers and healthcare providers offering those options to Black women.
Dr. Rebecca Dekker – 00:09:22:
So. If a client came to you. And had fibroids, say they were a Black woman, and you wanted to offer them treatments that were minimally invasive. Can you describe what that is? What makes it minimally invasive?
Dr. Veronica Gillispie-Bell – 00:09:39:
Sure. So when I do counseling, I always tell patients, we’re going to start from the least invasive, meaning we’re going to start from medicine and we’re going to go all the way up to talk about what is available to you. So when we say minimally invasive, there’s no invasiveness. So doing medications. And then we have minimally invasive procedures, such as a uterine artery embolization, also known as a uterine fibroid embolization, that’s actually done by the interventional radiologist where it’s not surgery at all. And then we have laparoscopic and robotic assisted laparoscopic procedures that are considered minimally invasive.
Dr. Rebecca Dekker – 00:10:18:
Okay, so what’s the medicine then for uterine fibroids?
Dr. Veronica Gillispie-Bell – 00:10:22:
So there are two FDA approved medications, Myfembree and ORIAHNN. ORIAHNN was the first FDA approved medication. It was approved in February of 2020. So surprise, surprise, a lot of people didn’t hear about that because it was a big event that happened in March. So that was the first. And then Myfembree was approved later that year. Both of the medications work the same. They lower your estrogen and progesterone production. As I said earlier, fibroids respond to the estrogen that we make. And so the medications reduce the estrogen and progesterone so that we reduce what’s feeding the fibroids. In both of the clinical trials for both of the medications, greater than a 50% reduction in blood loss in the first month of treatment, down to 86% at three months, down to 89% at six, excuse me, three months and six months. So both were very, very effective for improving heavy menstrual bleeding associated with fibroids.
Dr. Rebecca Dekker – 00:11:24:
Okay. So if that’s like your main problem, it really helps with the menstrual bleeding most of the time.
Dr. Veronica Gillispie-Bell – 00:11:30:
It does. And those options, again, they’re medications that you can take by mouth. Right now they’re FDA approved for two years. And so I find that those to be very, very effective for patients that either cannot have surgery or don’t want to have surgery, or if they, and we’ll get into it when we talk about some of the surgical procedures, if they need to have surgery, but right now it’s just not the time either from a fertility standpoint or from just socially to be able to take that time off of work. Those medications work great to control that bleeding.
Dr. Rebecca Dekker – 00:12:04:
Okay. So those came out in 2020. And then you mentioned the radiology method. Can you describe a little bit more about what that means and when did that start to become available?
Dr. Veronica Gillispie-Bell – 00:12:13:
Yeah. So that was approved, FDA approved, I want to say in the late 2000s. It’s been around for a long time, but unfortunately we’re just now having these broad conversations around fibroids and fibroid treatment. So even though it’s been out, a lot of women don’t know about it or know that it’s an option. So basically what it is, it’s a procedure that’s done by an interventional radiologist. So it’s not done by the gynecologist. The interventional radiologist will either go through the artery in the arm called the radial artery, or they’ll go through an artery in the leg called the femoral artery. They put in a catheter, which is like a little tube. And through that, they can get to the blood vessels that feed the uterus. They use these little bitty beads. I can’t even make my fingers small enough. But they use these beads that block the blood vessels. And so that helps reduce the blood flow going to the uterus. And so for that procedure, it does help with the bulkiness of the uterus. The uterus does shrink. But the primary benefit of that procedure is also reducing heavy bleeding associated with fibroids. And so it’s a procedure that’s done under not general anesthesia. I call it twilight medicine. So there’s a benefit there, especially for those that have contraindications to general anesthesia. And it’s usually a one-day stay in the hospital just to make sure that pain is controlled as the fibroids are starting to shrink and degenerate or kind of die. And then it’s about a one to two-week recovery time.
Dr. Rebecca Dekker – 00:13:43:
And then you mentioned laparoscopic. Is that like the next step up?
Dr. Veronica Gillispie-Bell – 00:13:48:
That would be the next step up. Laparoscopic or robotic-assisted laparoscopic, pretty much the same in terms of the treatment for patients and recovery and those things. And so for patients, for me, there’s no… national standard, but I would say for those of us that do robotic myomectomies, this is kind of commonly our decision process. For patients that have less than 10 fibroids and a fibroid that’s less than 10 centimeters, they may be a candidate for a laparoscopic or robotic approach. With that procedure, it’s minimally invasive in that there’s no big cut on the belly. They’re little small incisions. We see decreased blood loss. We have less pain after surgery, shorter recovery time. For those patients that undergo that procedure, they are able to go home the same day, and it’s a two to four-week recovery time.
Dr. Rebecca Dekker – 00:14:42:
And then what is the next option for maybe somebody whose fibroids are too large for that?
Dr. Veronica Gillispie-Bell – 00:14:48:
So for someone who’s fibroid, if their fibroids are too large and they are wanting to either maintain their fertility or they just want to keep their uterus, which this I think is a definitely I met a lot of what’s the word? I had met a lot of hesitation from other providers. There are women that want to keep their uterus because they don’t want to have a hysterectomy. And that’s OK. They don’t have to want to have children to keep their uterus. And so if their fibroids are too big to remove laparoscopic or robotically, then we can do what we call an abdominal myomectomy. With that, it’s making a small incision on the abdomen, depending on the size of the fibroids. Usually we can do a bikini cut similar to a C-section. Sometimes the incision is smaller than the one that we would use for a C-section. If fibroids are very big, meaning that they’re extended above the belly button, sometimes we do have to do an up and down incision. But with that procedure, again, we’re able to remove those fibroids. Those patients do have to stay overnight in the hospital, usually one day, sometimes two, depending on blood loss and how they’re recovering. And it’s a four to six week recovery time.
Dr. Rebecca Dekker – 00:16:00:
With a laparoscopic, is that general anesthesia or is that like sedation?
Dr. Veronica Gillispie-Bell – 00:16:05:
That’s general anesthesia.
Dr. Rebecca Dekker – 00:16:06:
Okay, so the laparoscopic surgery and the… myomectomy are under general anesthetics in an operating room. And then is there a step up from that as well?
Dr. Veronica Gillispie-Bell – 00:16:16:
Well, there’s a step in between. So there are some other newer procedures on the market, radiofrequency ablation. There are two techniques and two ways of doing that. One is coming in through the cervix, going into the uterus and basically putting a needle into the fibroids, burning the fibroids, 70% reduction in the size of the fibroids over a year’s time. That is called Sonata. The other way is called Acessa and it’s doing the same thing, but laparoscopically. With the Acessa, there’s a small incision in the belly button. That’s where a camera goes. Small incision down by the pubic bone. That’s where an ultrasound goes. Ultrasound goes on top of the uterus, identify those fibroids, and then we stick the needle into the fibroids and do radiofrequency ablation or burning the fibroids. And again, about a 77% reduction in the size of the fibroids over a year’s time. With that procedure, it is done under general anesthesia, whether it’s laparoscopic or if it’s done vaginally. But both of the procedures is a go home the same day, one to two-week recovery time. Although in the clinical trials, most patients did go back to work after 24 hours. I usually tell patients to expect though one to two weeks for recovery time.
Dr. Rebecca Dekker – 00:17:35:
Wow. That’s an option I hadn’t heard of. I’ve heard of it in other areas of healthcare. So is that relatively new as well?
Dr. Veronica Gillispie-Bell – 00:17:42:
It is. It is relatively new.
Dr. Rebecca Dekker – 00:17:45:
Okay. Relatively new or gaining a popularity perhaps.
Dr. Veronica Gillispie-Bell – 00:17:49:
Well… it’s relatively new, starting to gain more popularity, but the rate limiting factor is starting to be covered by insurance.
Dr. Rebecca Dekker – 00:17:58:
Oh, it’s just starting to be covered in the United States.
Dr. Veronica Gillispie-Bell – 00:18:02:
When I started doing Acessa about two years ago, I think it was about two years ago, maybe three years ago now, there was only one insurance provider in the state that was covering the procedure. And so that has progressed for both the procedures, Sonata and Acessa. So that’s making the procedures more accessible to patients.
Dr. Rebecca Dekker – 00:18:25:
Okay, so the radiofrequency ablation, laparoscopic, the myomectomy, anything else?
Dr. Veronica Gillispie-Bell – 00:18:31:
And so hysterectomy, always an option. Again, fibroids, that’s the number one cause of hysterectomy is fibroids. And with doing the hysterectomy, that can be done vaginally, depending on the size of the fibroids. If fibroids are large, that’s probably not the best approach. But vaginally, laparoscopically, robotically, or abdominally. Vaginal, laparoscopic, and robotic would be considered minimally invasive. So with those procedures, small incisions. Vaginally, there’s no incision. But laparoscopic, robotic, very small incisions. Again, with that procedure, patients can go home the same day. Four to six-week recovery time. Abdominal is a little bit more of a recovery because we are cutting the abdomen and going through all of the layers. And that usually is at least a one-day stay in the hospital just to make sure things are moving the way they should. And then a four to six-week recovery time.
Dr. Rebecca Dekker – 00:19:23:
I feel like, has there been a shift then in the last 20 to 25 years? Because when I graduated from nursing school in 2002, I worked on a general medical surgical floor. And I took care of a lot of people who were having abdominal hysterectomies. Eventually, we started seeing more vaginal hysterectomies, the removal of the uterus. And they clearly had an easier recovery when it was done vaginally as opposed to abdominally. But it just seemed like there was a lot of young people having their uteruses removed. And has that rate changed or is that still often offered to people early on?
Dr. Veronica Gillispie-Bell – 00:19:59:
It has changed. I will say, too, we see regional changes. So it’s more likely in the South to have a hysterectomy compared to the Northeast, the West, and other areas of the country. So that’s part of it. But definitely, as I think women are aware of their options, I think that they are advocating for their options. I think as providers, that’s really important that we know the options and that we are counseling patients on all the options and not choosing for them. I cannot tell you the number of patients that have come in to see me because they’ve seen another provider that has told them a hysterectomy is the only option. And the patient is saying, I know that there are other things. I know that a hysterectomy is not it, but that’s all they were offered. And so they come in to see me after, you know, for a second and a second opinion. And many of those women is after many years of suffering. There’s data that shows it takes three years and three providers just to be diagnosed with fibroids. And then if you walk in and you’re told that that’s the only option and that’s not the option you want, it then takes courage to go and seek and care from someone else and to find someone else that’s going to give you another option.
Dr. Rebecca Dekker – 00:21:13:
With a lot of our listeners, you know, being pregnant or hoping to have babies in the future or again in the future, how do these treatment options impact them? Like, for example, are the medications safe? Do you need to go off of them if you’re trying to conceive? And then similarly, like if you’re talking with someone who has years left in their childbearing journey, what do you tell them?
Dr. Veronica Gillispie-Bell – 00:21:36:
Yeah, so that’s a great question. And so I think the best way to tackle it is let’s just go talk through each of those options.
Dr. Rebecca Dekker – 00:21:42:
Okay.
Dr. Veronica Gillispie-Bell – 00:21:42:
With the medications, you cannot conceive while you’re on the medications because for the most part, they decrease your ability to ovulate. So that’s not the best option for someone that’s interested in conceiving within that two-year timeframe. Depending on the location of fibroids, fibroids need to be removed in order to conceive. The bad part is that we don’t know what causes fibroids. And so that means we can’t stop them from coming back. We do now have information, though, for Black women, we have lower levels of vitamin D. And so there’s studies that show that when we do vitamin D3 as a replacement, that does decrease the time for fibroids coming back. So we do have that now in our toolbox. And so that’s helpful. But in general, and from my experience, there’s a high recurrence of fibroids. And so for my patients that are coming in, for example, let’s say that they are 28 years old and they’re having symptoms and we need to treat those symptoms, but they know they’re not planning on having children for another four or five years. Removing the fibroids at that age may not be the best option because now if we remove them, we know they’re going to come back and they have to have them removed again before they could conceive. So that’s a patient that’s a great candidate for the medication to control those symptoms until they get to the point six months to a year out of being ready to conceive when surgery may be a better option.
Dr. Rebecca Dekker – 00:23:08:
Okay.
Dr. Veronica Gillispie-Bell – 00:23:09:
So that’s the medication for the surgeries again with removing the fibroids that does help in terms of if you have fibroids in the lining of the uterus, for example, then we know that causes an increased rate of miscarriage because there’s something in the cavity where the baby needs to be. And so we do recommend removing fibroids in that situation, depending on the location and size, we know that having fibroids in pregnancy can also increase the risk for preterm birth, fetal growth restriction, preterm labor, increase the rate of C-section, you know, all of those things. And so a lot of times we want to remove fibroids before pregnancy. And so for some of the other options that we talked about, this gets a little tricky. So with the uterine fibroid embolization, that’s the procedure that we talked about that the interventional radiologist does.
Dr. Rebecca Dekker – 00:23:59:
Basically blocking the flow of blood to the uterus, decreasing the flow of blood.
Dr. Veronica Gillispie-Bell – 00:24:03:
Yes, correct. Sometimes those polyvinyl beads, the little beads we talked about that we put in to block the blood vessels going to the uterus can affect the blood vessels going to the ovary, and that can make it harder to ovulate. So we usually do not recommend that procedure for women that are interested in childbearing, in future childbearing, not because the uterus is damaged, but it can impact the ovaries and can stop ovulation. So that would not be an option for those listeners that are interested in conceiving in the future. With the Sonata and the Acessa, that’s the radio frequency ablation that we talked about. There have not been clinical trials that show that it’s safe to have a pregnancy after either one of those procedures. However, with the Acessa, they have followed patients that have had the procedure and have gotten pregnant after. They’ve reported on about 168 cases. And there were no maternal complications. There were no baby complications. But I’m always very transparent with my patients that we’ve not done the clinical trials to say that it’s safe.
Dr. Rebecca Dekker – 00:25:11:
And we don’t necessarily know the impact on fertility either for that one.
Dr. Veronica Gillispie-Bell – 00:25:17:
Correct. Just because to me, those numbers are still small.
Dr. Rebecca Dekker – 00:25:21:
Right.
Dr. Veronica Gillispie-Bell – 00:25:21:
Even though we’ve not seen complications, that’s still a very small number of patients. So for me, for patients that are very interested in childbearing, I don’t usually recommend those procedures just for that reason. Now, I do have some patients that tell me that I want something minimally invasive. You know, if I get pregnant, that’s okay. If I don’t get pregnant, that’s okay too. Then I think they are still good candidates for the embolization as well as the radiofrequency ablation that we talked about. The primary surgical procedure for those women that are wanting to conceive is the myomectomy, removing the fibroids, because it does remove the fibroids and preserves the uterus. But again, with that, when the fibroids are removed, we don’t know what causes them so they can come back. And then we usually tell patients to wait about four months before they get ready to conceive because we need time for the uterus to heal. Also, when we’re removing those fibroids, if we have to go all the way into the lining, so from the outside of the uterus having to go through all the layers to the inside, that has made the uterus weaker. And so we don’t want to contract on the uterus because it can rupture in labor. And so for those patients, we recommend a C-section for delivery.
Dr. Rebecca Dekker – 00:26:39:
Yeah, that was one of the questions I had. With the procedures and if someone gets pregnant afterwards, which of those tend to lead in a better chance of being able to have a vaginal birth?
Dr. Veronica Gillispie-Bell – 00:26:50:
So if we are, I guess, if we’re able to remove the fibroids laparoscopically, robotically, abdominal, the route doesn’t matter. It’s really the layers. So if we’re just on the outside uterus of the uterus and we call those fibroids subserosal, or if we’re in the muscle wall a little bit, that’s called intramural, then those patients are okay to have a vaginal delivery. But if we have to go all the way into the cavity and those fibroids are called submucosal, then we don’t recommend doing a C-section. I’m doing, excuse me, doing a vaginal delivery. Now, one procedure that we did not talk about, and I’ll say not many patients are candidates for this procedure, is removing the fibroids through what we call a hysteroscope. So putting a camera into the cervix, looking into the lining of the uterus, and removing the fibroids that way. To be a candidate, the fibroid has to be pretty much completely inside the cavity. And that’s not very common to have a single fibroid that’s just in the cavity. But if we remove fibroids that way, then those patients are also candidates for vaginal delivery.
Dr. Rebecca Dekker – 00:27:59:
Because you’re not cutting through all the layers of the uterus. Yeah. We do get that question a lot about, you know, a myomectomy, which… My understanding that means like an incision through the uterus, that kind of surgery. With people who still want to have a vaginal birth, even though their OB/GYN says they will only attend a Cesarean. So can you talk a little bit about that dilemma from the OB/GYN’s perspective?
Dr. Veronica Gillispie-Bell – 00:28:27:
Yeah, it’s a hard conversation. I do try to have that conversation before my patient makes their decision about the surgery itself. And the way I explain it is that the uterus, when it hasn’t been operated on, is like a rubber band. So when you’re in labor, it’s going to contract and it’s going to stretch like a rubber band and go back into place. If you operate on the uterus and you cut through all those layers, it heals like Velcro. So there’s only so much stretching it’s going to do until it will pull apart. And so that means an increased risk of death to the mom and death to the baby. And so, you know, we just, we discussed that and we discussed how they feel about that. It is very upsetting to a lot of women because I think a lot of women anticipate that they’re going to decide to have a baby at some point. They’re going to get pregnant without any complications or any issues or having any trouble getting pregnant. And then they’re going to have a vaginal birth. It is the natural way that we expect to have a baby. And so it is very upsetting if that is your plan to hear that that’s not an option for you. And so we definitely discuss it, talk about that, deal with the emotions. I believe in patient autonomy. So I always leave it up to the patient in terms of the surgical treatment as well as route of delivery. After going through the risk and benefits, I haven’t in my 15 years, 16 years of practice, had patients to say or 15 years of practice say that they are concerned about still wanting to have a vaginal delivery because of the risk and benefits. But I think it’s important for me as a physician and a woman and a mother and a mother who had a myomectomy and then had to have a C-section. It’s important for me to sit with them and sit in that moment and sit with that understanding of that emotional response and grieving that loss of whatever dream they had about how they were going to deliver.
Dr. Rebecca Dekker – 00:30:34:
I know in the past I’ve gone on PubMed, you know, because I get this question about once a year, at least, and I go look and see if there’s any new research. And it seems to be that the research that we do have has very small numbers of patient samples. So we don’t have a lot of data on outcomes of the vaginal delivery after a myomectomy. So it’s just, it’s a hard situation because you don’t have a lot of data to go off of. But, you know, you do have opinions and preferences and knowledge of like anatomy and physiology. So what you’re saying makes sense. And then I can also put myself in the shoes of someone who doesn’t want to have a required Cesarean. And I have heard of a few OB/GYNs who will support a vaginal birth after a myomectomy, but they seem to be pretty few and far in between.
Dr. Veronica Gillispie-Bell – 00:31:22:
Yeah, I mean, you hit the nail on the head. We don’t have good data. The guidance to perform a C-section, that guidance coming from ACOG, the American College of Obstetricians and Gynecology, is really based on data extrapolated from classical C-sections. It’s not from this number of patients had a myomectomy and they attempted a vaginal delivery and then they had a rupture. So it’s not good data. It’s a bit of a, it’s a quandary though. It puts physicians and patients between a rock and a hard place because if anything happens and there is a uterine rupture and God forbid, there is a bad outcome for mom or for baby, then as a physician, you really don’t have a leg to stand on because you went against what is the professional society’s recommendation. So we really do need the research to know that’s going to be a hard study to ask women to sign up for in addition to getting approval to do the study to say, would you like to try to have a vaginal delivery and we’ll see what happens because we don’t really, we’re not really sure because we’ve never tried this out. It’s an area that needs to have more research.
Dr. Rebecca Dekker – 00:32:35:
Yeah. And perhaps it’ll be observational research and maybe not in the US where we have so much liability around birth with the scheduled Cesarean then like, what is the timing? Are you trying to avoid contractions? So you do the Cesarean early.
Dr. Veronica Gillispie-Bell – 00:32:52:
So that’s another area of controversy, I have to say. So the recommendation has really been to do that C-section. Well, I will say this when I was in training, the recommendation was to do the C-section around 35 to 36 weeks. We would do amniocentesis to see if the lungs were mature in the baby. If the lungs were mature, we would go with the C-section at that time. And if not, we would wait. Okay. So that’s been a little bit controversial. The recommendation now is to do that C-section around 37 weeks because that is considered term. Now, let me also say that 37 weeks, even though that’s considered term, there is still a 10% risk of admission to the NICU for respiratory distress syndrome because know that the lungs are developed at 39 weeks. There’s still a percent of infants that between 37 and 39, their lungs have not completely developed in the way that they would not have respiratory distress syndrome. For me, for my patients in my practice, I usually do their C-section between 38 and 39 weeks. And that is we’re taking a bunch of things into consideration. And I’ve discussed all of this with the patients, taking into consideration that I’ve done their myomectomy. So I know how extensive the myomectomy was. I know how big the fibroids were. I know what happened. So that’s one part of it. The other part is, again, understanding that we’re balancing out trying to do the C-section before mom goes into labor, but also not wanting to have a baby go to the NICU because we did that C-section too early. And then the third part is then thinking about most moms will deliver, especially first-time moms, they’re going to deliver around their due date or a little bit after. So even if we’re doing that C-section at 39 weeks, then we’re usually capturing those patients before they’re going into labor. I have pulled my data. I’m working with my medical students. We’re pulling my data for the last 15 years. And we hope to have a publication out soon. I’ve talked to other providers who have asked for that because they feel the same.
Dr. Rebecca Dekker – 00:35:04:
Like that it would be probably safe to move that Cesarean to 38 to 39 weeks and it wouldn’t increase the risk of uterine rupture. But there’s not data been published on it yet. So you’re hoping to do that.
Dr. Veronica Gillispie-Bell – 00:35:17:
That’s correct. Exactly.
Dr. Rebecca Dekker – 00:35:19:
That’s awesome. Kind of going full circle back to the racial disparities and the discrimination and implicit bias, what advice do you have for listeners or birth workers or healthcare workers, you know, who they themselves or someone they know is not being given, they think, the care they deserve with maybe undiagnosed fibroids? Maybe they’ve reached that point where they’re suffering, but nobody’s identifying what the problem is, or they’re not being offered the full range of treatments. How do we advocate for ourselves? How does somebody help them advocate?
Dr. Veronica Gillispie-Bell – 00:35:53:
Yes, I think a few things. There are really, really great patient advocacy resources through the White Dress Project, who I work with, and the Fibroid Foundation, who I also work with. And they have information just to help validate your symptoms. I think, again, as women, we are taught societal wise to diminish our symptoms. And so sometimes you just need somebody to confirm what you’re thinking, that something’s not right. So they have some great resources to help give you that confidence. And then as, again, patients, as community workers, whatever your position is, understand that this is your health and you have choice in your health. So if you’re seeing a provider that is not listening to you, is not responding in the way that you need to be responded to, is offering you only one choice for treatment, you need to seek another provider. And there are other providers out there. The White Dress Project, the Fibroid Foundation, they also have lists of providers that if you’re trying to find someone in your area. Most of my patients, quite honestly, have found me. They told me that they found me either from word of mouth from other friends or they Googled fibroid treatment New Orleans. And that’s how they found me. And so Google can be your friend as well. And so seeking out those providers who have spent their time dedicating research and time to treating fibroids. And making sure that you’re finding someone that will hear you.
Dr. Rebecca Dekker – 00:37:26:
Yeah, it makes sense. Not every OB/GYN is going to be a specialist in fibroids, right?
Dr. Veronica Gillispie-Bell – 00:37:32:
Correct. Yeah. And I tell patients that because I also want to give grace to physicians. I tell them, I give them an example. I say, look, if you came in here and you had prolapse and your uterus was falling out, I can understand that. I can recognize that. I have not treated that in 20 years. I’m going to send you to somebody else because that’s not my thing. That’s not what I do every day. That’s not where my passion is. And so just understand that sometimes OB/GYNs are meant to be jack of all trades when it comes to women’s health. And we’re not. And so don’t necessarily think that you have a bad doctor because they weren’t able to offer you X, Y, and Z option. They just may not know because that’s not their area.
Dr. Rebecca Dekker – 00:38:15:
And they may refer out if they don’t feel comfortable. Anyway, so I liked your idea, but we’ll make sure to link in the show notes to those two organizations.They have lots of educational resources and provider directories, like you said. And then I also was wondering if you could share with us a little bit about your work in Louisiana fighting the maternal mortality crisis. Like what’s going on in the state of Louisiana and what are you working on right now?
Dr. Veronica Gillispie-Bell – 00:38:41:
Yes. So I serve for the Louisiana Department of Health as a medical director of our Maternal Mortality Review Committee, as well as our Quality Collaborative. And so the way that works is the Maternal Mortality Review Committee reviews all the maternal deaths in Louisiana, or of Louisiana residents, I should say, because we do review them if the death occurs outside of the state. And a death is defined as the death of an individual at the time of pregnancy up to one year of the end of pregnancy, regardless of the cause. And so as a committee, we sit down and we look at whatever information we can gather around that individual. So that’s medical records, obituaries, coroner’s reports, police reports. We now do informant interviews where we have a trauma-informed trained social worker that goes to the family to do interviews. We take all of that information to try to understand what could have been prevented, what could we have done differently for this one person’s life to prevent deaths. The committee is multidisciplinary. So what it is not is a bunch of physicians sitting in a room looking at medical records. We do have physicians. We have midwives. We have doulas. We also have a patient. We have domestic violence specialists. We have addiction specialists. So really trying to do a 360 evaluation.Â
From there, we take that information, make recommendations about where we can make changes at the level of health providers, healthcare systems, community workers, public health experts. And then in my other role with the Quality Collaborative, we take those recommendations and we work with our birthing facilities to implement the recommendations. So through the Louisiana Perinatal Quality Collaborative, we launched in 2017 and launched our first initiative in 2018. We have worked on obstetric hemorrhage, obstetric hypertension, sepsis, lowering the C-section rate, substance use disorder. We’re now working on caregiver, perinatal depression screening and pediatric practices. We work on breastfeeding. Next year we’re gonna be working on transitions to postpartum care. We’re working with emergency departments next year. So, a lot of work. Has seen improvement. Seen severe maternal morbidity from hemorrhage decrease, severe maternal morbidity for hypertension decrease for Black patents and white patients. Still have a disparity gap around severe maternal morbidity from hypertension, but getting better. We’ve seen the C-section rate decrease. So really moving things in the right direction. It’s going to take a very, very long time to improve our maternal outcomes because, again, we’re working with the birthing facilities. But there’s a whole other landscape around the social factors that are impacting outcomes. And so there are things that we’re doing outside of the Collaborative within the Louisiana Department of Health to try to address those social factors that we know that are impacting those outcomes.
Dr. Rebecca Dekker – 00:41:41:
It doesn’t just happen in a like microcosm. It’s…maternal deaths happen in a bigger context.
Dr. Veronica Gillispie-Bell – 00:41:47:
Correct. I mean, two things, 80% of clinical outcomes are due to social factors. So that’s one thing to think about. Like I can come up with the best with my patients sitting with me, we can come up with the best treatment plan for let’s use example, hypertension about we’re going to do this and exercise and all of these things. But if when they leave my office, they are choosing between paying for their medications and feeding their family. Then their health is what’s going to lose out because that’s what we do as women. We take care of our families. And so we have to address those social factors. The other thing, when we look at our maternal mortality data, the majority of deaths happen after discharge from the hospital up to one year postpartum, with the majority happening in the first six weeks. For our data in Louisiana, 93% of the deaths occur from discharge to one year postpartum, when we talk about pregnancy-related deaths. 53% occur in the first six weeks.
Dr. Rebecca Dekker – 00:42:48:
So what if, you know, I know there’s so many different varying causes of maternal death, but what are, would you say are three like takeaways that anybody can implement for those first six weeks to improve safety?
Dr. Veronica Gillispie-Bell – 00:43:01:
Sure. So if we look at the Maternal Mortality Review Committees’s 38 maternal mortality review committees have a report through the CDC. Where they’ve compiled all of our data together, the leading cause is mental health conditions. And that includes mental health conditions and substance use disorder. The other things that we see, hemorrhage, cardiovascular conditions, hypertension. So it’s really important if you’re pregnant or if you are supporting someone that’s pregnant to know the early urgent maternal warning signs. We can find, I’m going to go through them, but you can find them at the CDC Hear Her campaign. You can find them through the Alliance for Innovation on Maternal Health and Maternal Urgent Warning Signs as well. But those are things like headache that’s not cured by Tylenol, blurry vision, pain in the right upper side, bleeding through more than a pad an hour, dizziness, lightheadedness, chest pain, passing out, shortness of breath. Also, again, mentally, just emotionally not feeling well, feeling like you’re going to hurt yourself or harm your baby. Those are all what we call those urgent warning signs when you should get back into the emergency room. And again, it’s important not just for pregnant people to know those signs and symptoms, but their support system is the one that really needs to know what those are, because those are quite often the first ones to recognize the symptoms.
Dr. Rebecca Dekker – 00:44:26:
Right. I think you’re spot on. We’ll link to the CDC Hear Her campaign because I know they have handouts and infographics with the urgent warning signs. And I love how you’re encouraging us to educate support partners, especially about those warning signs. Is there anything else that… birth workers or community workers can do to better support families in those first six weeks?
Dr. Veronica Gillispie-Bell – 00:44:52:
Sure. I think, one, I think that community birth workers are so, so, so important to helping us solve the issues around maternal morbidity and maternal mortality because those community workers are in the patient’s community. So they understand those barriers. What they can do is, one, encourage patients to come back into the healthcare system. Again, we as women diminish our symptoms all the time, but having someone that can say, no, you need to go to the hospital is so, so, so important. I can just tell you the number of stories and the number of misses because women did not, they didn’t come back in. And so being able to tell someone, no, you need to go back in. Also, if you can be with that person, it’s important. It’s important to have someone that can advocate on your behalf. We know from the number of stories and the data that we don’t always do the best job of listening to women when they come into the healthcare system. And we really do not do a good job if you are a woman of color. And so having that person to advocate on your behalf is also super important. So if you’re a community health worker. And you have the ability to accompany that woman to the hospital so that you can help advocate and can help communicate for her on her behalf.
Dr. Rebecca Dekker – 00:46:11:
That’s a great example of something tangible we can do. Like you said, if you have a friend, family member, client who has to go to the ER because they’re having an urgent warning sign postpartum, go with them if you can or send somebody else. And I don’t know if I know we teach family to advocate. And I would say that should be the spouse or the partner’s role. But they’re not always in a situation where they can speak up either. Right?
Dr. Veronica Gillispie-Bell – 00:46:40:
Correct. And. For several reasons. When I testified before Congress, it was with Charles Johnson. His wife, Kira, passed away from a massive hemorrhage during a C-section. And he started the organization Kira for Moms. And he talked about his experience in the hospital where he brought it to the health care team’s attention and they didn’t listen. And he felt like he couldn’t be any more loud, I guess, if you want to say, because he didn’t want to be any more vocal because he didn’t want to be seen as the angry Black man. And then be separated…
Dr. Rebecca Dekker – 00:47:17:
Separated from his wife. Yeah.
Dr. Veronica Gillispie-Bell – 00:47:18:
Exactly. And then it brings security in. So there are times that fathers, like you said, are not able to advocate. And sometimes fathers are not able to advocate because they’re not there. They’re with the other children, just for a number of situations. And so. I always say there’s an adage that it takes a village to raise a child. No, it takes a village to get a child here. And so every birthing woman that’s giving birth needs to have a village of support. And so whether that be a spouse and a family member and a friend and a community health worker and a doula and a midwife, whoever it is. But you need to have a community, a tribe that is helping you through that pregnancy and through that postpartum period. So you have a multitude of individuals that are able to advocate on your behalf.
Dr. Rebecca Dekker – 00:48:09:
And I think also calling out hospital staff that they need to listen when women and birthing people say that there’s something wrong. You know, I think we wouldn’t have to all do all this advocacy if we were just being listened to. So I don’t want to expect people to be the bandaid on a broken system. We need to fix the system.
Dr. Veronica Gillispie-Bell – 00:48:30:
You’re 100% correct. And I love things like the CDC Hear Her campaign because it does give providers those tools and resources for helping them to advocate and to help them listen. Because I’ve done quality improvement work for so long, I always feel like when you’re trying to improve a process, you need to carrot and you need to stick. And so we really have not created accountability in our systems for making sure that we’re not using bias and discrimination in how we’re providing care. And so we need when we’re thinking about quality and we’re thinking about a C-section rate as one of our quality metrics, that’s great. But what quality metric and what accountability do we have around health equity, around listening to our patients, around implicit bias? And so I think we need to think about that accountability fact and that accountability piece.
Dr. Rebecca Dekker – 00:49:25:
Yeah. And then one last thing, I think it’s part of the Hear Her campaign as well, but not just telling them your symptoms, but saying, I was recently pregnant and I gave birth X amount of weeks ago.
Dr. Veronica Gillispie-Bell – 00:49:37:
Yes, yes. That is one of the first, as I mentioned for the Perinatal Quality Collaborative in 2025, we’re going to be working directly with emergency departments. And that is one of the first things that we’re going to work on is how EDs can add to their triage. Identifying patients that are pregnant, recently postpartum, and lactating, because we don’t do a good job of that either. And so I think for those listeners, you may not understand or may not know that just because you go into the hospital, that the providers are going to know that you were recently pregnant. And it’s crazy to think that. I would think if I just gave birth, and I’m going back to the hospital that I gave birth in,
Dr. Rebecca Dekker – 00:50:24:
Yeah.
Dr. Veronica Gillispie-Bell – 00:50:24:
And I’m in the emergency department, surely they know I just gave birth, but that’s not always the case.
Dr. Rebecca Dekker – 00:50:29:
So you can’t assume that they know that?
Dr. Veronica Gillispie-Bell – 00:50:31:
No, especially because what we find happens is before you even get back to the back, where the doctors and nurses are, where they have your medical record, you have to get past the triage nurse, and the triage nurse doesn’t have all of that information. And the triage nurse is going to decide where you go and the things that they are triaging. And so if you come in and you say, yeah, I have a headache and I have blurry vision, that could be a migraine, that could be anything. And if you have someone over here that’s had a heart attack, now you’re going to get triaged lower on that totem pole. However, if you have a headache, a blurry vision, and you just delivered a baby a week ago, that is as urgent as a heart attack, because you may be getting ready to seize or have a stroke. And so it’s important that you do voice to the healthcare team, I just had a baby, so that they can triage, you appropriately.
Dr. Rebecca Dekker – 00:51:27:
Mm, yeah. Well, thank you, Dr. Gillispie-Bell. I feel like I could listen to you all day. I learned so much today about uterine fibroids, and I loved hearing from you about what you’re doing in Louisiana and nationally. And we’re just honored to have you and so grateful for the work that you’re doing.
Dr. Veronica Gillispie-Bell – 00:51:43:
Thank you so much for having me. I could talk to you all day as well.
Dr. Rebecca Dekker – 00:51:48:
Well, thanks everyone for listening. And I hope you learned a lot and take something from our amazing conversation with Dr. Gillispie-Bell and put it into practice this week. Thanks, everyone. Bye.
Outro – 00:52:00:
Today’s podcast was brought to you by the Evidence Based Birth® Professional Membership. The free articles and podcasts we provide to the public are supported by our professional membership program at Evidence Based Birth®. Our members are professionals in the childbirth field who are committed to being change agents in their community. Professional members at EBB get access to continuing education courses with up to 23 contact hours, live monthly training sessions, an exclusive library of printer-friendly PDFs to share with your clients, and a supportive community for asking questions and sharing challenges, struggles, and success stories. We offer monthly and annual plans, as well as scholarships for students and for people of color. To learn more, visit ebbirth.com/membership.
