Uterine
Fibroids & Uterine Artery Embolization for Fibroids
Treatment Options
Uterine fibroids that are not causing symptoms do not require
any therapy, other than periodic examinations by a family doctor
or gynecologist. Usually the diagnosis is made by physical examination
and confirmed by ultrasound examination. Once diagnosed, the
growth of fibroids may be monitored by physical examination or
ultrasound .
Medical Management
Once symptoms develop, medical management is usually the first
therapy. This might include treatment with non-steroidal anti-inflammatory
agents (such as Motrin or Naprosyn), birth control pills, or
progesterone agents. If these fail to control the symptoms, the
decision for further medical management depends on the patient's
age, the size of the fibroids, the desire for future pregnancy,
and the severity of symptoms.
Another medication that may be used in certain circumstances
is a Gonadotropin Releasing Hormone (GnRH) agonist. This group
of medications block the production of hormones, particularly
estrogen, by the ovary. The most commonly used GnRH agonist in
this country is Lupron, which is given by injection either once
a month or every three months depending on the dose. Because
these medications decrease estrogen levels and because fibroid
growth depends on estrogen, fibroids usually shrink when treated
with Lupron or other GnRH agonists. These drugs may cause hot
flashes and mood changes in some patients, similar to those experienced
with menopause. These symptoms may be controlled with small doses
of supplemental estrogen. A potentially more serious side effect
of these medications is a decrease in the density of bones, which
can lead to osteoporosis if used long term. For this reason,
the use of these medications is usually limited to 6 months.
Unfortunately, fibroids usually regrow after GnRH agonists are
stopped.
Hysteroscopy
If the fibroids are submucous (inside the uterus, just below
the lining) and projecting into the uterine cavity, a hysteroscopic
resection may be possible. Hysteroscopy is a procedure in which
a fiber-optic scope is advanced into the uterus through the vagina
and cervix. It is commonly used in conjunction with a dilatation
and currettage (D and C) to diagnose abnormal bleeding.
A hysteroscope may also be used to remove polyps or submucosal
fibroids. Larger submucosal fibroids can sometimes be removed
or partially removed with a hysteroscopic device that shaves
off pieces of tissue. These methods may be combined with techniques
to ablate or remove the lining of the uterus to control bleeding.
Endometrial ablation is the intentional destruction of the uterine
lining and is intended to permanently stop menstrual bleeding.
If successful, it will prevent future pregnancy.
In the hands of a skilled operator, hysteroscopic procedures
are safe and effective. They are usually performed in the operating
room under general anesthesia, but a patient is typically discharged
on the same day as surgery and may return to normal activities
within a few days.
Hysteroscopic removal of fibroids is usually only done after
a GnRH agonist is given for three to six months. This causes
the fibroid to shrink and decreases its blood supply, which reduces
bleeding at the time of the surgery and improves the chance for
success.
Surgical procedures
The two conventional surgical choices are myomectomy and hysterectomy.
Myomectomy is an operation in which the fibroid
or fibroids are removed leaving the rest of the uterus in place.
This is most commonly used in younger women who wish to maintain
their ability to have a child. While bleeding and other complications
are somewhat higher than with hysterectomy, myomectomy appears
to be successful in controlling symptoms in about 80% of women.
Fibroids may regrow after myomectomy, with recurrence rates of
between 10% and 30% by 3 to 5 years after treatment. The procedure
may cause extensive pelvic scarring which may make future surgery
very difficult and may contribute to future fertility problems.
Long-term studies of myomectomy patients attempting to become
pregnant have shown pregnancy rates between 40 and 60%. In recent
years, there has been the development of less-invasive techniques,
such as laparoscopy, for performing myomectomy and these may
represent alternatives to conventional surgery in some patients.
Hysterectomy is effective in essentially all
cases in which bleeding is the primary symptom and usually it
resolves the pain or urinary symptoms which women may have as
well. It is a safe procedure, with a very low complication rate
in experienced hands. It is the standard therapy for fibroids
that fail to respond medical therapy in women who do not wish
to have further children. While it is a major surgical procedure,
with a four to six week recovery, studies have shown that the
patient's quality of life after hysterectomy is normal for most
patients within 2 months of the surgery. Recent large studies
have confirmed that hysterectomy is effective and safe, with
a very low complication rate.
There are patients who will have depression and other psychological
effects from hysterectomy and others whose sex lives will be
worse after the surgery. Since it is major surgery, there can
be complications and it takes several weeks to recover. For these
and many other reasons patients have long sought an alternative
to surgery for control of symptoms caused by fibroids.
Uterine Artery Embolization (UAE)
Uterine artery embolization is a treatment for fibroids that
has developed over the past decade. It was originally performed
in France and first reported in the medical literature in 1995.
Since that time, numerous centers in North America have begun
uterine embolization programs.
Embolization is a medical term for a procedure in which a physician
injects small particles through a catheter placed in the uterine
artery. The particles block the blood supply to the fibroids,
resulting in the death of the fibroid tissue. This leads to shrinkage
of the fibroids and relief of symptoms for most patients, without
the need for surgery or removal of the uterus. For additional
information on this procedure, please review the page on UAE.
Uterine Artery Embolization for Fibroids Case Study
Sanjoy Kundu BSc., M.D., F.R.C.P.(C), D.A B.R., FASA, Division
of Interventional Radiology
Scarborough Hospital – General Division, Scarborough, Ontario,
Canada
Case History:
47 year old female presented with a one year history of very
heavy periods lasting for four days during each menstrual
cycle. Her past medical and surgical history was otherwise
unremarkable. A MRI demonstrated a dominant intramural
fibroid in the uterine fundus (Figure 1). After assessing the
different therapeutic options, the patient chose to go ahead
with a
Interventional Procedure (Case performed at Scarborough General
Hospital – General Campus):
Uterine Artery Embolization Procedure for her fibroids. The
patient’s right common femoral artery was accessed. Using
a C2 catheter, the patient’s left uterine artery was cannulated
(Figure 2). One and a half vials of Contour SE PVA measuring
500-700um was injected, until there was complete stasis in
the main left uterine artery (Figure 3). Cannulation of the
right uterine artery was also performed followed by injection
of one and half vials of Contour SE PVA.
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Figure 1 |
Figure 2 |
Outcome:
A nine month follow up MRI demonstrated greater than 50 percent
reduction in size of the index fibroid. The patient’s menstrual
cycles also normalized with no episodes of heavy bleeding
during her periods (Figure 4).
Comments:
Uterine artery embolization for fibroids is a attractive,
less invasive treatment for women with symptomatic fibroids.
Uterine artery embolization is a viable and effective alternative
to surgical myomectomy or hysterectomy, without the postoperative
risks of bleeding, ureteric injury or pulmonary thromboembolism.
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Figure 3 |
Figure 4 |
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