Better Treatment for Fibroids?
Carla Dionne Takes Your Questions
New Treatment for Uterine
Fibroids Avoids Surgery
Introduction
Uterine fibroids are the most common pelvic tumors in women, occurring
in approximately 30% of women over the age of 35. Although fibroids are
benign (non-cancerous), they may produce a wide variety of symptoms including
excessive bleeding leading to iron deficiency anemia, pain and pressure
sensations, and even obstruction of the bowel or urinary tract.
Submitted by Edward L. Siegel, MD, Department of Radiology, University
of Kansas Medical Center, 10/99
http://www.mirs.org/fibroids.htm
(photos)
FIBROID EMBOLIZATION
http://www.fibroiduae.com/
The Fibroid Embolization Center at
the Northern Westchester Hospital
400 East Main Street, Mt. Kisco, NY 10549
Call 914-666-1200 (Ask for the Dept of Radiology and they will refer
you to Dr. Forcade.)
. . . a new treatment for uterine
fibroids
Uterine Fibroid Embolization
http://www.aafp.org/afp/20000615/3601.html
A patient information handout on uterine fibroid
embolization,
written by the author of this article, is
provided on page 3611.
STEVEN JANNEY SMITH, M.D
LaGrange Memorial Hospital, LaGrange, Illinois
Interventional radiologists have performed uterine artery embolization
to treat women with emergency uterine bleeding since the 1970s. In this
procedure, the physician guides a small angiographic catheter into the
uterine arteries and injects a stream of tiny particles that decreases
blood flow to the uterus. It is now considered a safe and highly effective
nonsurgical treatment of women with symptomatic uterine fibroid tumors.
Uterine fibroid embolization has several advantages over conventional hormonal
suppression and surgical procedures, including avoidance of the side effects
of drug therapy and the physical and psychologic trauma of surgery. In
addition, after uterine fibroid embolization, patients can normally resume
their usual activities several weeks earlier than they can after hysterectomy.
Along with hysteroscopic resection, myolysis and laparoscopic myomectomy,
uterine fibroid embolization widens treatment options for patients who
desire to avoid hysterectomy. (Am Fam Physician 2000;61:3601-7,3611-2.)
History
of Uterine Artery Embolization
http://www.indyrad.iupui.edu/public/interventionalradiology/uterine_fibroid_embo/ufe.html
Embolization is a type of procedure that is commonly performed by interventional
radiologists to occlude blood vessels. It has been successfully used
in arteries in virtually every part of the body to stop bleeding, block
abnormal blood vessels, and treat tumors. Embolization of the uterine arteries
has successfully been used for nearly 20 years to stop life-threatening
bleeding after childbirth.
Uterine Artery Embolization Procedure
Georgetown University.
Introduction
Uterine
artery embolization represents a fundamentally new approach to the treatment
of fibroids. Embolization is a minimally invasive means of blocking the
arteries that supply blood to the fibroids. It is a procedure that uses
angiographic techniques (similar to those used in heart catheterization)
to place a catheter into the uterine arteries. Small particles are injected
into the arteries, which results in their blockage. This technique is essentially
the same as that used to control bleeding that occurs after childbirth
or pelvic fracture, or bleeding caused by malignant tumors. The procedure
was first used in fibroid patients in France as a means of decreasing the
blood loss that occurs during myomectomy. It was discovered that after
the embolization, while awaiting surgery, many patient's symptoms went
away and surgery was no longer needed. The blockage of the blood supply
caused shrinkage of the fibroids resulting in resolution of their symptoms.
This has led to the use of this technique as a stand-alone treatment for
symptomatic fibroids.
The Procedure
The procedure is usually done in the hospital
with an overnight stay post-procedure. The patient is sedated and very
sleepy during the procedure. The uterine arteries are most easily accessed
from the femoral artery, which is at the crease at the top of the leg (figure
at right). Initially, a needle is used to enter the artery to provide
access for the catheter. Local anesthesia is used, so the needle puncture
is not painful. The catheter is advanced over the branch of the aorta and
into the uterine artery on the side opposite the puncture.
Before the embolization is started, an arteriogram
(an injection of contrast material while X-rays are performed) is performed
to provide a road map of the blood supply to the uterus and fibroids. After
the arteriogram, particles of polyvinyl alcohol (PVA) are injected slowly
with X-ray guidance (see figure at left). These particles are about
the size of grains of sand. Because fibroids are very vascular, the particles
flow to the fibroids first. The particles wedge in the vessels and cannot
travel to any other parts of the body. Over several minutes the arteries
are slowly blocked. The embolization is continued until there is complete
blockage of flow to the fibroids.
Both uterine arteries are embolized to ensure
the entire blood supply to the fibroids is blocked. After the embolization,
another arteriogram is performed to confirm the completion of the procedure.
Arterial flow will still be present to some extent to the normal portions
of the uterus, but flow to the fibroids is blocked. The procedure takes
approximately 1 to 1 1/2 hours.
There is variability in the technique used at
different centers that are performing UAE. At Georgetown, a second arterial
catheter is placed from the opposite femoral artery to the other uterine
artery and the embolizaton of the fibroids is done from both sides simultaneously.
At other centers, a single catheter technique is used with one side treated
then the other. In any case, all physicians who are performing UAE treat
both uterine arteries.
There are other variations in technique, including
the use of different types and sizes of particles to block the arteries.
Many patients have questions about the particles and their fate. For a
more detailed discussion of the various substances used to block the arteries,
please review the page on embolic
agents.
Complications
Serious complications are rare after UAE,
occurring in less than 4% of patients. These include injuries to the arteries
through which the catheters are passed, infection or injury to the uterus,
blood clot formation, and injury to the ovary.
The most severe complications to date have been
4 deaths reported after UAE, 3 in Europe and 1 in the United States. In
England, a patient developed a very serious infection in the uterus 10
days after the procedure. Despite a hysterectomy, the patient developed
septicemia (blood stream infection) and died 2 weeks later. Another patient
recently died in the Netherlands from a similarly severe infection. There
have been 2 deaths from pulmonary embolus, which is the passage of a blood
clot from the veins in the legs or the pelvis to the lungs. Pulmonary embolus
may occur after any of a number of different surgical procedures, including
most gynecologic surgeries. It does not appear that a patient treated with
UAE is at any greater (or lesser) risk for pulmonary embolus than surgery
patients. While pulmonary embolus usually does not result in permanent
injury, it can cause death in rare instances. These very serious complications
are the only deaths that have occurred in the 20,000 to 25,000 patients
treated worldwide thus far.
About 1% of the time, a patient might have an
injury to the uterus or infection in the uterus that might necessitate
a hysterectomy. Injuries to other pelvic organs is possible but has not
yet
been reported. There have been a few patients that have had a nerve injury,
either in the pelvis or at the puncture site, although happens in less
than 1 in 200 patients. An injury to the puncture site, such as clot formation
or bleeding, is also similarly rare.
The most likely problem to develop in the first
several months after the procedure is the passage of fibroid tissue. This
is only likely to happen with submucosal or intramural fibroids that touch
the lining of the uterus. In our experience, this occurs in about 2 or
3 % of cases. While the fibroids may pass on their own, a D and C may be
needed to remove the tissue. While the passage of tissue may be beneficial
in the long run, it may be associated with infection or bleeding and this
may be severe enough to require hospitaliation. For this reason, it is
important to monitor this process carefully to avoid more serious problems.
X-rays are used to guide the procedure and this
raises a concern about potential long-term effects. There have now been
several studies of X-ray exposure during uterine embolization, and in most
of these, exposure was found to be below the level that would be anticipated
to have any health effect to the patient herself or to future children.
It is always possible that very prolonged exposure could cause an injury,
and there has been one patient reported (not at Georgetown) that developed
a skin burn after uterine embolization. Most interventionalists limit the
duration of X ray exposure in any procedure and will stop the procedure
if it cannot be completed within a safe interval.
Another unresolved question is the effect, if
any, of this procedure on the menstrual cycle. The overwhelming majority
of women who have had embolization of fibroids have had decreased bleeding
with normal menstrual cycles. There have been a few women (most of whom
are near the age when menopause would be expected) who have lost their
menstrual periods after uterine embolization. The most likely cause is
decrease in blood supply to the ovaries as a result of the embolization.
Most researchers have noted a 2 to 6% chance of losing menstrual periods
and the onset of menopause as a result of UAE. There has been one study
that noted a higher rate of menopause after the procedure (15% of patients
treated) but the reason for this higher rate is not clear. We have completed
a study on ovarian function after uterine embolization. In women under
the age of 45, there was no permanent change in FSH, a hormone often used
to estimate ovarian reserve. That report is discussed in the section on
Research
at Georgetown University
About 1% of the time, a patient might have an
injury to or infection in the uterus that might necessitate a hysterectomy.
Injuries to other pelvic organs is possible but has not yet been reported
and the chance of other significant complications is less than 4%. We have
recently reviewed our experience in the first 230 patients treated at Georgetown
and we have summarized our complications. You may review that experience
on the page describing our experience
at Georgetown
Expected result
As of this time, 20.000 to 25,000 patients have
had this procedure world-wide. Our initial results, along with those that
have been published or presented at scientific meetings, suggest that symptoms
will be improve in 85-90% of patients with the large majority of patients
markedly improved. The improvement rate is similar for heavy menstrual
bleeding and for pressure and pain symptoms. Most patients have rated this
procedure as very tolerable and in almost all cases hospitalization is
necessary for only one night. In some centers, the patients are treated
and discharged the same day.
The quality of life of patients also improves
significantly. Again in research completed here at Georgetown, with either
a quality of life questionnaire specific for fibroids or a more general
questionnaire, statistically significant improvement is evident in all
areas.
The expected average reduction in the volume of
the fibroids is 40-50% in three months, with reduction in the overall uterine
volume of about 30-40%. Over time, the fibroids continue to shrink. With
several years follow-up now available, it does not appear that fibroids
successfully treated regrow. It is not known whether patients may develop
new fibroids.
This section was written to provide patients with
an overview of uterine artery embolization. If you are interested in a
more detailed discussion of the reported scientific results, we encourage
you to read our Literature
Review.
If you would like to consider this procedure or
would like more information about uterine artery embolization at Georgetown
University, please review our Patient's
Guide. Also our patient's guide gives a detailed discussion of what
the patient can expect before, during, and after UAE.
Pregnancy after UAE
While UAE has not been used as a fertility
procedure, there have been many pregnancies after uterine artery embolization.
For a detailed review, please consult the section on Pregnancy
after UAE
For more information
You may call James B. Spies M.D. of Georgetown
Interventional Radiology at (202) 784-5478 to make an appointment.
You may also contact us via email at spiesj@gunet.georgetown.edu.
If your gynecologist is interested in information
on this procedure or if you are interested in more technical detail about
UAE, additional information is available at our Physician's
Resource page. They may also call us; we would be happy to discuss
this procedure with them.
What is Uterine
Artery Embolization
What are fibroid tumors?
Uterine Fibroid tumors are the most common benign tumor of the female
genital tract. They occur in at least 20% of Caucasian women over the age
of 40 years. Fibroid tumors occur even more frequently, and often at an
earlier age in black women. Fibroids can result in an increase in uterine
size. The presence of uterine fibroids is sometimes associated with heavy
menstrual bleeding, pain, fullness, and pressure. Uterine fibroids most
often cause few or no symptoms.
What are the symptoms most frequently associated with
fibroid tumors?
The symptoms that can be associated with fibroids are: an increase
in menstrual flow (heavy menstrual bleeding and the passing of clots);
pain; and pressure, heaviness and discomfort. Other symptoms associated
with fibroid tumors may include urinary urgency and frequency, constipation
and discomfort during sexual intercourse.
What are the options available for treating fibroids?
Your gynecologist probably has discussed many of the treatment options
with you. Five of the options are described below:
1. A myomectomy is the surgical removal
of the fibroids but not the uterus. The procedure id often done for women
who still want to have children. A hysterectomy may still be required following
a myomectomy. Regrowth of the fibroids occurs in approximately 50% at five
years.
2. A hysterectomy is the complete surgical
removal of the uterus. The woman becomes unable to have children after
a hysterectomy.
3. There are several hormonal therapies
available. The hormonal therapy can decrease the symptoms and the tumor
size. However, rapid regrowth of the fibroids usually occurs when the hormone
therapy is stopped.
4. Uterine fibroid embolization is the selective
blocking of arteries supplying blood to the fibroids. This procedure has
only been done for fibroids since 1991. At least 14 normal term pregnancies
and births have occurred following uterine artery embolization. However,
the affects of the procedure on the ability to become pregnant and have
a normal pregnancy are not known. Therefore, most physicians recommend
against future pregnancies after the embolization procedure. Having made
this statement, a few women who have been told that they could not become
pregnant because of the fibroids have become pregnant after the embolization
procedure. Therefore, we recommend that you have "protected" sex following
the procedure.
5. Do Nothing. You and your doctor decide
that your symptoms are not related to the fibroids or that you can tolerate
your symptoms.
What is Uterine Artery Embolization?
Uterine artery embolization is a procedure that has been used for approximately
20 years to stop severe bleeding after a child birth, thereby eliminating
the need for a hysterectomy. Since 1991, physicians in Paris, France have
used the uterine artery embolization procedure to decrease the symptoms
associated with uterine fibroid tumors. The uterine artery embolization
involves the selection of arteries feeding the fibroid with a small tube
(catheter) and then blocking the arteries with tiny particles the size
of grains of sand. Symptoms such as heavy bleeding, pain and discomfort
usually improve following the procedure. About 90% of women who undergo
uterine artery embolization have resolution or enough improvement in their
symptoms that they do not have to undergo a hysterectomy. About 5-10% of
patients have persistent symptoms. Less than 1% of patients have a complication
requiring a hysterectomy. After the embolization procedure, the fibroids
decrease in size by an average of 50-60% and the uterus an average of 40%
by 6 months.
Who are candidates for the procedure?
Patients with fibroids and associated symptoms are potential candidates
for the embolization procedure.
Who are not candidates for the procedure?
Patients with chronic salpingitis or other chronic pelvic infections
are not good candidates for the procedure. Patients who desire to become
pregnant should not currently undergo the procedure. Patients wishing to
preserve their child bearing potential should consider myomectomy. Patients
with a suspected cancerous tumor of the uterus, cervix, or ovaries should
not undergo the procedure until the concern for cancer has been resolved.
