I’m joined by Dr. Brooke Winner, a board-certified OB/GYN and fellowship-trained minimally invasive gynecologic surgeon. We’re diving into two of the most common. and often misunderstood conditions that affect fertility: fibroids and endometriosis.
Dr. Winner explains how these conditions can impact your reproductive health, including how they affect the uterus, ovaries, implantation, and even IVF success rates. We discuss when surgery is appropriate, the latest minimally invasive techniques, and what recovery looks like. Dr. Winner also shares advice for patients navigating painful symptoms and fertility challenges, and how to advocate for the right treatment options.
Whether you’ve been diagnosed with fibroids or endometriosis, or you’re wondering if they could be part of your fertility picture, this episode offers expert insight and encouragement to help you move forward.
In this episode, we cover:
- How fibroids and endometriosis impact fertility
- The signs, symptoms, and diagnostic process for both conditions
- When surgery is helpful, and the benefits of minimally invasive techniques
- What to expect during recovery and how to prepare
- The importance of patient advocacy and personalized care
Resources:
Dr. Brooke Winner’s website at Full Spectrum Fibroid & Endometriosis
Dr. Brooke Winner and Full Spectrum Fibroid & Endometriosis on Instagram
Find Dr. Aimee’s Fertility Essentials & Supplements
Full Transcript:
Dr. Aimee: Did you know that minimally invasive surgery can transform the way we treat fibroids and endometriosis? And today’s guest is going to tell us all about it, and I’ve been so lucky to get to work with her. The title of today’s show is Minimally Invasive, Maximum Impact with Dr. Brooke Winner on Fibroids and Endometriosis. I’m very jealous of your last name, Brooke.
Dr. Brooke Winner is a fellowship trained, board certified, minimally invasive gynecologic surgeon and founder of Full Spectrum Fibroid and Endometriosis in Seattle. She earned her medical degree from the University of Washington and completed her OB GYN Residency and Fellowship at Washington University. Specializing in fibroids and endometriosis,
she leads a multidisciplinary team focused on holistic patient centered care. Welcome, Brooke. Thank you for being here.
Dr. Brooke Winner: Thank you so much for having me.
Dr. Aimee: So tell us what led you to specialize in minimally invasive gynecologic surgery?
Dr. Brooke Winner: I think I went into OB GYN with the same personal statement everybody does, which is it’s amazing to be able to get to deliver babies, but then also take care of women long term and do some surgery, but not all surgery and the variety is amazing. And that is true, but as I went through my training, I just realized that surgery is really complicated.
And as I got closer to the end of training. I just didn’t feel like I was ready to be operating independently. And if I was going to do surgery, I wanted to do it really, really well. And I like delivering babies just fine, but, you know, I also like sleeping in the middle of the night, and that’s when babies like to be born.
But mostly it was that I felt I needed some additional skills, so Fellowship was the way to do that. And then just focusing on surgery, I just came to realize that volume is so important, and so if you want to be good at something, you really should be doing it all the time, especially something as complicated as surgery.
Dr. Aimee: Yeah, and you’re really good at it. I would love it if you could explain the basics of fibroids and endometriosis and how they commonly affect women’s health.
Dr. Brooke Winner: So fibroids are benign growths in the muscular wall of the uterus, and they’re very common. About 80% of women develop fibroids at some point in their life. And whether or not women have to do anything about them depends on if they’re bothering you or not. When fibroids are near the lining of the uterus, where the periods come from, those are the ones that are more likely to cause heavy or irregular menstrual bleeding, and they can also cause trouble getting pregnant.
And then when fibroids are more on the outside and they get bigger, they can press on things that are nearby and cause pelvic pain and pressure. And so that’s sort of the basics of fibroids.
Endometriosis is different. Endometriosis is when cells that are similar to the cells in the lining of the uterus are growing outside the uterus. And we don’t know how they get there.
There’s lots of different theories, but my favorite new theory is that maybe people are just born with the cells in the wrong place. And the problem is that every month when the lining of the uterus sloughs off and women bleed out the vagina and have a period, the endometriosis cells bleed too.
But they’re in the wrong space to come out the vagina. They’re trapped in your belly. And blood in your belly can cause pain and inflammation. It can cause fibrosis, which is like a thickening or hardening of the tissue. And then over time it can cause adhesions, which means organs are stuck together when they should be sliding freely.
And that can all cause significant pain, full periods, pain with intercourse, pain with bowel movements, pelvic pain, bloating, and also infertility.
Dr. Aimee: So let’s talk specifically about how they impact a woman’s fertility, fibroids, and especially endometriosis.
Dr. Brooke Winner: Yeah, so fibroids are a little bit more straightforward, fibroids that are impacting the lining of the uterus. And I guess we don’t completely understand the mechanism, but the theory I think is that the endometrium, overlying the fibroid that’s sort of within the cavity, is somehow not as conducive to implantation as normal endometrium.
And it kind of makes sense, because if there’s another sort of foreign body within the uterus, like an IUD, that works as contraception. So if you have a fibroid within the uterine cavity where the baby is supposed to be, it’s just physically in the way. Fibroids are generally classified as submucosal, which means impacting the lining, intramural, which is just in the wall, and then subserosal, which is more on the outside, but there’s a more detailed grading system that really dials down on like how much of the fibroid is impacting the lining.
So that’s the zero through seven fibroid fibro grade system. Fibroids that are completely in the lining, more than half in the lining, less than half in the lining, and then not in the lining at all, but just touching it: all of those zero through three negatively impact fertility and when we take out the type zero through twos in fertility improves. Type three, we haven’t really been able to show that, but it’s probably ’cause there’s a smaller effect and you just need a really large sample size.
So fibroids, it’s really all about their location in terms of their impact on fertility. Fibroids that are in the muscular wall of the uterus and more on the outside, can also impact fertility, but that tends to have more negative impacts during the pregnancy and less trouble getting pregnant in the first place.
But, you know, women with fibroids in all locations can have an increased risk of miscarriage, preterm labor, abnormal presentation, baby being in the wrong position, big fibroids, obstructing labor, and needing a c-section. C-sections are more complicated because there’s a big, vascular fibroid in there.
So they can affect fertility in a lot of different ways. And then some people have fibroids that don’t affect their pregnancy and they’re totally fine. So it’s really important to dial down on the specifics of how many fibroids you have, exactly where they are, and then you need to talk to a specialist who can kind of parse out whether or not they might be a problem. So that’s fibroids.
Endometriosis is a little bit more complicated. So the most obvious way that endometriosis negatively impacts fertility is when it’s causing significant adhesions, which are blocking the fallopian tubes, impeding the eggs, you know, traveling through the tubes and meeting up the sperm.
And often when tubes become blocked, they can become filled with fluid. That’s called a hydrosalpinx. And then not only are they sort of not functional, but then they have this inflammatory fluid in them that can backwash into the uterus and negatively impact the success rate of IVF. So that’s sort of the most obvious structural way endometriosis can impact fertility.
Some women with endometriosis will have an endometrioma cyst on their ovary, also called a chocolate cyst, which is an ovarian cyst lined with endometriosis, and then it fills up with old blood over time. We know that just having an endometrium cyst in your ovary decreases your ovarian reserve, so that can impact fertility.
And then even in people who don’t have an endometrium cyst on their ovary, their fallopian tubes are fine, they’re open. They just have like, you know, stage one, stage two, a few small spots of endometriosis. There just seems to be something about the inflammation from endometriosis that maybe affects sperm motility, like, we just honestly don’t know.
So lots of different ways endometriosis can negatively impact fertility. And then again, some people with endometriosis get pregnant fine.
Dr. Aimee: And I’m so glad you brought up the issue with the fallopian tubes because oftentimes patients, when they go online, they read about STDs and they think somehow they’ve acquired some sort of sexually transmitted infection. And the first thing I think about is endometriosis. And I don’t think that’s talked about enough, so thank you for bringing that up.
What is minimally invasive gynecologic surgery or MIGS, and what are its advantages over traditional surgical methods and treating conditions like fibroids and endometriosis?
Because obviously you have this expertise that OB GYN doesn’t have, and that’s where patients go to first.
Dr. Brooke Winner: MIG stands for Minimally Invasive Gynecologic Surgery and all OBGYNs do some minimally invasive surgery, right? So minimally invasive surgery includes hysteroscopy, vaginal surgery, laparoscopy, robotic surgery, basically anything that’s not done the old fashioned way through a big incision.
When people say MIGS and minimally invasive gynecologic surgery, they’re usually talking about the Fellowships. So that’s two years of additional surgical training after the regular OB GYN training, which is what I did. And then a lot of MIG surgeons, once they go into practice, they don’t deliver babies.They don’t do routine care.
All they do essentially is minimally invasive surgery for fibroids, endometriosis, and other things that are not cancer. And so the benefits of minimally invasive surgery overall are less pain, faster recovery, lower blood loss, fewer infections, shorter hospital stay, quicker recovery, and then also long-term less adhesive disease.
And adhesions can both cause pain, they can make subsequent surgeries more difficult, and then they can also impair fertility by blocking fallopian tubes, et cetera.
Dr. Aimee: Who are the best candidates for seeing someone like you and why would they go to you when they can see their OB GYN?
Dr. Brooke Winner: Some patients have seen their OB GYN and their OB GYN says, “you know what? This surgery is gonna be too complicated for me,” and they refer to a specialist. Some patients are told by their regular OB GYN, that their surgery has to be done open through a big incision, and so they see me as a second opinion.
Some patients, even though their regular OB GYN is offering them minimally invasive surgery, they just decide on their own that they’d like to be seen by a specialist. You don’t need a referral to see a minimally invasive gynecologic surgeon, and some patients don’t already have an OB GYN, and so they’re just going to go to somebody fresh, right?
So in that case, you know, why not start with a minimally invasive GYN surgeon?Sometimes specialists are booked out longer, sometimes we don’t take insurance, et cetera. So there are other reasons, but I think the take home point is really anyone is a candidate to see a specialist, if they want to.
Dr. Aimee: And then when you see a specialist, you’re sometimes treated in a way that’s considered the gold standard. And I wanna talk to you a little bit more about that. What I’m referring to is how we treat endometriosis surgically, ablation versus excision. I think that’s an important topic. Can you talk a little bit about that for us?
Dr. Brooke Winner: When we are working laparoscopically and we see endometriosis, there’s sort of two main ways surgeons can treat that. One is ablating it, which is just burning it. And that’s usually done sort of like a hot instrument with energy. Or you can excise it, which is actually removing it.
And, when we do really big studies looking at ablation versus excision, it appears in very large studies done with sort of all sort of comer level of surgeons that, for earlier stage one to two endometriosis, excision and ablation may be equivalent. And then for stage three to four, with more deeply infiltrating endometriosis, excision is clearly superior.
However, we do have one randomized control trial that shows that excision is superior for pain with intercourse. And surgeons who do a high volume of endometriosis surgery always prefer excision.We think that the studies that show that in earlier stages that ablation excision are equivalent, are probably flawed.
But the reason that we think excision is always better is that, number one, sometimes the endometriosis nodule is going deeper than you think it might be. And so if you excise it, you can make sure you get the whole thing, versus if you’re just ablating it, you might be just burning the surface.
Number two, if there’s any surrounding fibrosis, which is that thickening or hardening of the tissue around the endometriosis, that can be removed as well, which we think provides additional pain relief versus if you’re just burning it, that obviously doesn’t get removed and might even get worse. And then finally when you excise it, you actually generate a little piece of tissue to then send off to the lab so they can look underneath the microscope to confirm the diagnosis.
So for all of those reasons, high volume endometriosis surgeons always prefer excision.
And then the other thing I see happen commonly when people are having surgery with lower volume, less skilled surgeons, is that they often find endometriosis in a tricky location like near the bladder or the rectum, and then they’ll be scared to touch it at all. So they won’t even ablate it.
They just won’t do anything, which is obviously not ideal. And then sometimes endometriosis is obvious, like a dark brown or a black spot, but sometimes it’s really subtle, like a little clear droplet, a little red droplet, or even just a subtle dimple or puckering in the tissue.
And you know, I don’t know any regular OB GYNs who are trained to recognize all that subtle stuff can be endometriosis. But when we take all that out, a lot of it does come back positive. So just a couple other reasons why we know that surgical experience and volume matters, and that’s why we think seeing a specialist is important, especially for endometriosis surgeries, which can be complicated.
Dr. Aimee: I wish more of our patients knew about MIG surgeons because even today, I have patients that see their OB GYN, they do endometriosis surgery and they say, “yes, you have endometriosis,” and that’s it. And they didn’t actually treat the patient. The patient needs another surgery after I kind of explained what happened during their surgery.
And they were basically just diagnosed with endometriosis at the time of surgery and they weren’t treated.
Dr. Brooke Winner: I had a patient the other day that was like, “sS you’re gonna diagnose it and treat it in the same surgery? I thought that was two surgeries.” And I was like, “Well, that happens a lot, but ideally it’s one surgery.”
So OB GYN is so broad. I mean, you know, delivering babies, doing routine care in the office, also operating, and most OB GYNs are spending most of their time delivering babies. So that’s important for people to understand.
Dr. Aimee: And your practice is really special because it also emphasizes a multidisciplinary team. How do specialists like pelvic floor physical therapists, acupuncturists, and nutritionists contribute to your patient’s care?
Dr. Brooke Winner: So I’m really excited to have put this team together. It’s pretty new. We just opened in December, and so we’re kind of learning how to fit all the pieces together.
Pelvic floor physical therapy, I think, was the first sort of multidisciplinary piece that I was utilizing even before I opened this clinic. So the pelvic floor muscles are like a bowl of muscles that hold everything up. And there’s only three things that pass through the pelvic floor, the urethra where you pee from, the vagina and the rectum. And somewhere when those muscles become very tight and spasmed, that’s another common cause of pelvic pain.
And a lot of times what’s happening is people have Endo. Endo hurts.
What does your body do in reaction to pain? It tenses up. So if I go in there and fix what’s wrong, sometimes the pain gets better and the muscles relax and everything’s great. Sometimes even though I go in there and fix what’s wrong, those muscles have just been spasming for so long that they don’t let go.
So if people continue to have pain after surgery, which I’d hope that they didn’t, but if they did, the next step is teaching those muscles to relax. And that’s done with pelvic floor physical therapy. It’s intravaginal work. You need to make sure you have a physical therapist who does a lot of pelvic floor because it is a sub-specialized area.
And then sometimes people will try pelvic floor physical therapy first, but in my experience, if you’re trying to teach those muscles to relax, but they’re continuously being irritated by what’s wrong on the inside, that’s just not as effective as trying to teach the muscles to let relax once everything’s all cleaned up.
But seeing a pelvic floor physical therapist can be helpful in just sort of prepping for surgery in general. So that’s pelvic floor physical therapy. So we have a physical therapist who sees patients in our clinic on Thursdays.
Acupuncture is a little newer to me, so I kind of started keying into acupuncture when I realized that my fertility colleagues had acupuncturists, like in their clinic. I have a friend who’s REI going through IVF herself, and she was seeing an acupuncturist. I just didn’t really realize that this was sort of, so part of the mainstream part of fertility care. I started asking around, talking to acupuncturists and there’s actually pretty good data for endometriosis pain, and acupuncture, which I was not aware of.The problem is you have to keep going, which can be inconvenient schedule-wise, but it can be a great adjunct, especially when patients have both endometriosis and infertility.
So we’ve got an acupuncturist who sees patients here on Thursday and she’s been doing women’s health and fertility focused acupuncture for 30 years, so that’s awesome.
And nutrition is tricky because a lot of patients are really hoping I can give them a diet that will cure their endometriosis. And I wish I had that, but I don’t think it exists. But what nutrition can do is optimize your gut health in other ways, right? So endometriosis can certainly cause bloating and pain with bowel movements, but you just wanna make sure you don’t have additional causes of bloating, you know, so optimize everything else.
I’ve not seen people be able to tweak their diet enough that they don’t eventually need surgery if, if what they’re having is pain. But I think it can be a helpful adjunct. So the dietician is great. She specializes in endometriosis patients.
And we also have a mental health provider because a lot of endometriosis patients in particular, but some fibroid patients have just been in pain for so long and people didn’t believe them and they didn’t have a diagnosis.
And they may have been going to all these other GI specialists and getting all these wrong diagnoses. This takes a toll on people’s health. I mean, they’re missing work, their relationships are suffering, and so that really takes a toll on mental health. So having a mental health support person around is also super important.
So we’re excited about our team, and most recently we had some primary care doctors that are actually interested in starting to see patients here. So it’s just like more and more people were adding, we’re thinking maybe chiropractic, maybe massage. So eventually we can have a really, really big team. It’s really exciting.
Dr. Aimee: That is really exciting because you’re helping so many people in a lot of different ways and they can use what they learn even beyond, let’s say, being a fertility patient. They can continue to get support from your team. So when is a good time for someone to see a specialist for these conditions? Someone like you?
Dr. Brooke Winner: For endometriosis, most of the time it doesn’t show up on imaging, so that’s really based on symptoms. Extremely painful periods that are bad enough that you’re missing school, work, daily life: time to see a specialist.
And then some patients with endometriosis don’t really have any symptoms besides infertility um, and so we’re often getting referrals from our infertility colleagues. So that’s another great time if your fertility doctor thinks you should see a surgeon.
And for fibroids, again, it’s really all about symptoms, and usually people try to treat both fibroids and endometriosis medically first, and if medical management fails, then they might consider a surgery.
But most of the medical management options are birth control or medicines that work by putting you into menopause. And you can’t get pregnant when you’re on those medications. So, you don’t have to fail birth control if you’re actively trying to get pregnant. If you have the symptoms or the evidence of fibroids on imaging, you can see a specialist and you can either go straight to the specialist or start with your OB GYN.
Dr. Aimee: And for people who are listening who want to see you, how do they do that?
Dr. Brooke Winner: We’re located in Seattle, Washington, the clinic is in Ballard, and I operate at Swedish Hospital downtown. We are at www.fullspectrumgyn.com and our fax and email is all on the website.
You can also follow me on social media. I’m on Instagram at Dr. Dot Brooke Winner, Dr. Brooke Winner, um, and also on Facebook at Dr. Brooke Winner, MD.
Then our clinic, Full Spectrum Fibroid and Endometriosis is also on Instagram, also on Facebook.
Dr. Aimee: Thank you again, Brooke, for coming on today and sharing all your wisdom. I have miracle babies from my practice because of the work that you’ve done to help my patients succeed.
So just thank you for everything that you’ve done for them. I really appreciate your time today. Thank you for joining us.
Dr. Brooke Winner: Thank you for having me. I really appreciate it.
