Uterine Fibroid Tumors

Overview

Uterine artery supplying blood flow to fibroids Images coutesy of BIOSPHERE MEDICAL

Fibroid tumors of the uterus are benign growths that are found in 20-40% of all women over the age of 35. These benign tumors can cause symptoms, based on their size and location. The most common symptoms are heavy menstrual bleeding, severe menstrual cramping, frequent urination and constipation.

There are three types of uterine fibroids. Serosal fibroids grow outward from the outer portions of the uterus and can compress adjacent organs such as the bladder or colon. Intramural fibroids develop within the muscle layer of the uterus and can cause both pressure effects and heavy menstrual flows. Submucosal fibroids develop along the inner lining of the uterus. These are the least common type of fibroid but they produce the most symptoms, usually heavy and prolonged menstrual flow.

The traditional treatment for uterine fibroids has been hysterectomy. Approximately one-third of the 600,000 hysterectomies in the United States every year are performed because of fibroids. Surgical myomectomy, which involves removal of one or several fibroids, is another surgical treatment option. Approximately 25% of women treated with myomectomy, however, will need a second operation for recurrent fibroids. The second operation is usually a hysterectomy.

A relatively new option for the treatment of uterine fibroids is uterine artery embolization (UAE). This non-surgical technique can be performed with an overnight stay in the hospital, and recovery time is significantly shorter when compared to either myomectomy or hysterectomy. This procedure works by reducing the blood supply to the fibroids, thereby shrinking them. This uterine artery embolization procedure has been performed at Lenox Hill Hospital in New York City since 1997. The following discussion will further describe this procedure as well as its benefits.

Treatments

Uterine Artery Embolization (UAE) is a minimally invasive treatment for fibroid tumors of the uterus.

Eligible candidates for this treatment include:

1. Pre-menopausal women with symptomatic fibroids
2. Women who have been screened to rule out possible infection, malignancy, and pregnancy
3. Women who understand that long-term data with regard to fertility have not been fully evaluated

Ineligible candidates include:

1. Post-menopausal women
2. Women who desire to maintain their fertility and who are candidates for myomectomy

Evaluation

Women who fit the eligibility criteria will meet with an interventional radiologist to discuss uterine artery embolization in detail. The radiologist will answer the patient's questions and perform a brief physical exam to make sure that the patient is a good candidate for the procedure.

Reports of recent pelvic sonograms as well as those of recent Pap smears are required. An MRI of the pelvis may be ordered to better define the anatomy of the uterus and to exclude other possible causes for uterine bleeding.

The Procedure

Patients are admitted for uterine artery embolization on the day of the procedure. The embolization procedure is performed early in the morning and usually takes between 60 and 90 minutes.

The procedure begins with preparation of the patient's groin with a sterile soap and a local anesthetic. An intravenous antibiotic is given as well as an intravenous sedative, if needed. Then, a tiny incision is made in the groin and a thin hollow tube called a catheter is placed into an artery. The diameter of this catheter is similar to the diameter of a piece of spaghetti. The catheter is then placed into both the left and right uterine arteries, where small particles are injected to simply block the blood flow to the fibroids and deprive them of the oxygen they need. This causes the fibroids to shrink and prevents them from causing further symptoms. The particles do not contain any medication and do not move once they have been placed. They are injected under X-ray guidance, which enables the doctors to track their position at all times. Once the blood flow in both uterine arteries has been reduced, the catheter is removed and the incision site is compressed to prevent bleeding.

Patients are then transferred to a hospital bed where they receive strong pain medication to control any "crampy pain" they might have. While most patients stay overnight, a few patients go home the same afternoon on oral pain medications.

Post Procedure Management

After embolization, patients can expect to have "crampy" pelvic pain. This typically lasts a few days and rarely can last up to several weeks. Most patients resume their normal routine within one week. A low grade fever (less than 101ºF), light intermittent spotting of blood and passage of small amounts of tissue can be expected after the procedure.

Results

Studies both in Europe and in the United States reveal a success rate of approximately 85-90% with regard to control of heavy menstrual bleeding and excessive menstrual pain. All fibroids in the uterus are treated simultaneously during the procedure, resulting in this high success rate.

Shrinkage (volume reduction) of the fibroids can also be expected after UAE. The post-procedure volume reduction of the fibroids is variable; however, many studies reveal a reduction in size of approximately 40-60%. There is only a small chance that existing fibroids might re-grow or that new fibroids might appear after UAE.

Fertility

No long-term data is available with regard to fertility after uterine artery embolization. The initial results, however, are quite promising. In Europe, where UAE has been performed on women desiring fertility, the general perception is that women who were fertile prior to embolization maintained their fertility afterwards. Dozens of patients successfully carried pregnancies to term and one patient even had twins. In this country, one study concluded that women who underwent embolization with a substance similar to the particles that are now being used (a substance called gelfoam) did not experience negative effects on their fertility. Even though the early data suggests minimal negative impact on fertility, there is no long-term data for confirmation.

There is also a small incidence of early menopause following uterine artery embolization. The chance of early menopause, however, is thought to increase as the patient's age is closer to the age of natural menopause, i.e., 51 years of age. The current thinking is that the closer a woman is to the onset of menopause, the easier it is for this procedure to initiate these menopausal changes. Women who desire future pregnancies must weigh their desire to avoid surgery against the possible negative impact on their fertility from uterine artery embolization.

Summary

• Non-surgical alternative
• High rate of success with regard to reduction in heavy menstrual bleeding and excessive pelvic pain
• Fibroids typically reduced in size
• Low complication rate
• Short hospital stay with quick recovery period
• Treats all fibroids simultaneously
• Minimally invasive

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