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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