Uterine Fibroids - Women's Health Talk

What are Uterine Fibroids?
Benign (Noncancerous) tumors that develop in the wall of the uterus
Can cause problems because of their size and location
Typically improve after menopause
Can grow in different places in the uterus
Typically improve after menopause
MR09-001 Rev. B

Benign tumor of uterine smooth muscle
Fibroids are not considered to be pre-cancerous
Also referred to as myomas or leiomyomas
Types: submucosal, intramural, and subserosal

What Causes Uterine Fibroids?
Exact cause currently unknown
Fibroids linked to estrogen
Evidence that progesterone may stimulate fibroid growth
Genetic Predisposition ?

How Common are Uterine Fibroids?
Estimated that 25 to 50% or greater of all women eventually develop fibroids
Fibroids most frequently diagnosed in 30s & 40s
Most common tumor of the pelvis in females
About 10% to 30% of these women are symptomatic

Who Gets Fibroids?
Incidence increases with age
20% of women in their 20’s
40% of women in their 40’s
Genetic predisposition
African-American women at higher risk
Familial tendencies
Exact cause currently unknown

What Symptoms Occur With Uterine Fibroids?
Heavier prolonged menstrual bleeding, sometimes with passage of blood clots. Anemia can occur if bleeding is severe
Pain, pressure, or feeling of fullness in the pelvis, abdomen, or lower back
Frequent urination or constipation
Pain during or bleeding after intercourse
Infertility or miscarriage
Abnormally enlarged abdomen
Bladder pressure leading to a constant urge to urinate

What Symptoms Occur With Uterine Fibroids?
Image courtesy of Mark Cockerill, MD, www.ufecenter.com

How are Uterine Fibroids Diagnosed?
Fibroids are usually diagnosed during a gynecologic internal examination
Your doctor will conduct a pelvic exam to feel if your uterus is enlarged

The presence of fibroids is most often confirmed by an abdominal ultrasound
Fibroids also can be confirmed using magnetic resonance (MR) and computed tomography (CT) imaging techniques
Other conditions such as adenomyosis or ovarian cysts may be mistaken for fibroids

MRI
Ultrasound

Hysteroscopy

How are Uterine Fibroids Treated?
Most fibroids do not cause symptoms and are not treated
When they do cause symptoms, drug therapy often is the first step in the treatment
This might include a prescription for birth-control pills or other hormonal therapy, or the use of non-steroidal anti-inflammatory drugs, such as ibuprofen or naproxen sodium

In many patients, symptoms are controlled with these treatments and no other therapy is required
Some hormone therapies do have side effects and other risks when used long-term so they are generally used temporarily
Fibroids often grow back after therapy is discontinued

LUPRON
GNRH agonist blocks ovarian estrogen production
Advantages:
Not Invasive, shrinks fibroids, often improves symptoms
Disadvantages:
Induces premature menopause and associated symptoms
Fibroids usually return to original size after cessation of therapy. Only used for short periods of time because of side effects

The next step is to move to more invasive therapy. The most common treatment options include:
Myomectomy
Hysterectomy
Endometrial Ablation
MR-guided Ultrasound
UFE

Myomectomy
Individual fibroids are resected through an abdominal incision or sometimes with a laparoscope or hysteroscope.
Advantages:
Fertility can be preserved
Well established procedure, less invasive if laparoscopic or hysteroscopic
Disadvantages:
Potential surgical complications
Only part of uterus is treated and recurrence can occur; 15 to 25 % need repeat procedure
Not all fibroids are treated via myomectomy

Myomectomy
Laparoscopic

Myomectomy
Hysteroscopic
Submucosal
Fibroid

Myomectomy - Abdominal

The lining of the uterus is removed or destroyed to control very heavy bleeding. Endometrial ablation usually just treats bleeding symptoms and not the fibroids themselves.
Advantages:
Can effectively control bleeding. Preserves uterus.
It can be done on an outpatient basis or even in a doctor's office.
Most people recover quickly. About half of women who have this procedure have no more menstrual bleeding. About three in 10 women have much lighter bleeding.

Disadvantages:
May not be possible due to location and size of fibroids
Will not reduce symptoms related to fibroid bulk
Addresses only bleeding symptoms, does not treat the fibroids
Abnormal uterine bleeding may recur, requiring additional procedures
Women cannot have children after this procedure

High Intensity Focused Ultrasound
HIFU (high intensity focused ultrasound) is a highly precise procedure using high intensity, focused ultrasound to heat and destroy diseased tissue.
Advantages:
No incision
One to two day recovery with minimal discomfort
Preserves uterus

High Intensity Focused Ultrasound
Disadvantages:
Procedure can take several hours
Treats only one fibroid at a time
Usually only appropriate for small fibroids near the surface of the uterus
Insurance may not cover this procedure
Fibroids may recur, requiring additional procedures

Hysterectomy
Surgical removal of uterus and fibroids, performed through an abdominal incision, vaginally, or laparoscopically
Advantages:
100% Curative
No risk of future fibroids
Well established procedure

Hysterectomy
Disadvantages:
Major surgery with potential surgical complications: infection, hemorrhage, injury to adjacent organs, adhesions
Loss of child bearing potential
General anesthesia
2 days to 6 weeks recovery time
Hormonal changes (if ovaries are removed)
Long term side effects have been reported
Emotional
Sexual

Hysterectomy
Over 600,000 hysterectomies per year
40,000 myomectomies, 25,000 UFE
2nd most frequent surgical procedure in women of reproductive ages (after C-section)
90% for benign reasons
35% for fibroids
20% of women by age 40
33% of women by the age of 65
A very common procedure, often offered to women promptly following a diagnosis

Why Not Have a Hysterectomy?
Patient Reasons
Avoid surgical adverse events
Pelvic support issues
Bladder dysfunction
Menopause & HRT
Hospitalization, recovery
Sexual Dysfunction
Save uterus because
Source of femininity
Fertility
Self image
Sexual image

Uterine Fibroid Embolization performed by an Interventional Radiologist
What is an Interventional Radiologist?
Interventional radiologists are physicians who are specially trained to diagnose and treat conditions using tiny, miniaturized tools, while watching their progress on X-ray or other imaging equipment
Typically, the interventional radiologist performs procedures through a very small nick in the skin, about the size of a pencil tip
Interventional radiology treatments are generally better tolerated by the patient than surgery because they involve no surgical incisions, less pain, shorter hospital stays, and a faster recovery

Uterine Fibroid Embolization (UFE)
The interventional radiologist makes a small nick in the skin (less than 1⁄4 of an inch) in the groin and inserts a catheter into an artery.
The catheter is guided through the artery to the uterus while the interventional radiologist watches the progress of the procedure using a moving X-ray (fluoroscopy).
The interventional radiologist injects tiny plastic particles the size of grains of sand into the artery that is supplying blood to the fibroid tumor.
This cuts off the blood flow and causes the tumor (or tumors) to shrink.

Uterine Fibroid Embolization
Angiography Suite, like an OR with a modern X-ray machine, sterile conditions
Epidural anesthesia or conscious sedation
Procedure typically takes one hour to complete
Fibroid embolization usually requires a hospital stay of one night

Post Procedure Expectations
Pain-management medications and drugs that control swelling typically are administered intravenously immediately post-procedure to treat cramping and pain, which are common side effects
Fever is an occasional side effect, and is usually treated with acetaminophen - Starts a few hours after the procedure and may last 3 to 5 days
Many women resume light activities in a few days and the majority of women are able to return to normal activities within one week

Post Procedure Expectations
Studies show that 78-94% of women who have the procedure experience significant or total relief of heavy bleeding, pain and other symptoms
The procedure is effective for multiple fibroids
Recurrence of treated fibroids is very rare

Mechanism of Action

Mechanism of Action
Embospheres

Advantages:
Treats all fibroids simultaneously
Minimally invasive, complications infrequent
Recurrence of treated fibroids rare
Shorter recovery period than open surgery
No adhesion (scar) formation
Minimal blood loss. No need for transfusion
Epidural or conscious sedation vs. general anesthesia
Emotionally, physically, and sexually - UAE can have advantages over surgery

Disadvantages
10-15% do not respond despite technical success
Up to 2% of procedures technically unsuccessful
Pelvic pain or cramping after procedure can remain moderate to severe for several days
1% to 2% chance of serious complication i.e. hysterectomy
Patients over 45 have potential for ovarian failure

FAQ
Q. Will my fertility be affected?
Conclusive studies with large numbers lacking
Dozens of reported healthy pregnancies, with no reports of any adverse outcome due to UAE
If infertility due to fibroids, fertility may improve in select patients after UAE. Research ongoing.
Women with symptomatic fibroids desiring fertility probably should consider myomectomy first, especially if relatively uncomplicated.
Q. Will my insurance pay for the Uterine Fibroid Embolization procedure?
Most insurance companies cover UFE. You will want to speak with your interventional radiologist about this before your procedure

Results
Friday, November 19, 2004 Posted: 4:07 PM EST (2107 GMT)
WASHINGTON (CNN) -- National security adviser Condoleezza Rice, President Bush's nominee to be the next secretary of state, is doing well after successful surgery, Jim Wilkinson, deputy national security advisor, told CNN Friday
Rice 'resting comfortably' after surgery
Expected to return to work on Monday

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Uterine Fibroids - Women's Health Talk

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