New Treatment Options for Uterine Fibroids

J. Kevin McGraw, M.D.

Fibroid tumors of the uterus are very common, but for most women, they either do not cause symptoms or cause only minor symptoms. Fibroids can cause very heavy menstrual bleeding, clotting and pelvic pain, leading many women to seek treatment. Fibroids often fail to respond to medical therapy and then surgical procedures are often recommended. Now there is a new, minimally invasive procedure known as Uterine Fibroid Embolization that is effective at relieving the symptoms associated with most fibroid tumors.

This procedure is performed by Interventional radiologists, specially trained doctors who use X-rays and other imaging techniques to "see" inside the body. They guide narrow tubes (catheters) and other very small instruments through the blood vessels and other pathways of the body to the site of a problem, treating a variety of medical disorders without surgery. Procedures performed by interventional radiologists (IRs) are generally less costly and less traumatic to the patient, involving smaller incisions, less pain, and shorter hospital stays.

Q. What are uterine fibroids?
Uterine fibroids are the most common tumors of the female genital tract. You might hear them referred to as "fibroids" or by several other names, including leiomyoma, leiomyomata, myoma and fibromyoma. Fibroids are noncancerous (benign) growths that develop in the muscular wall of the uterus. While fibroids do not always cause symptoms, their size and location can lead to problems for some women, including pain and heavy bleeding.

The exact causes for fibroid development are unclear, but researchers have linked them to both a genetic predisposition and a subsequent development of susceptibility to hormone stimulation. Women may have a genetic predisposition to fibroid development and then subsequently develop factors that allow fibroids to grow under the influence of a number of hormones. This would explain why certain ethnic groups or racial groups are more likely to develop fibroids and also why there tends to be genetic predisposition in some families.

Fibroids range greatly in size from very tiny (a quarter of an inch) to larger than a cantaloupe (10 inches or more). In some cases they can cause the uterus to grow to the size of a five-month pregnancy and the woman looks as though she is pregnant. In most cases, there is more than one fibroid in the uterus.

Fibroids can be located in various parts of the uterus. There are three primary types:

Subserosal fibroids, which develop under the outside covering of the uterus and expand outward through the wall, giving the uterus a knobby appearance. They typically do not affect a woman's menstrual flow, but can cause pelvic pain, back pain and generalized pressure. The subserosal fibroid can develop a stalk or stem-like base, making it difficult to distinguish from an ovarian mass. These are called pedunculated. The correct diagnosis can be made with either an ultrasound or magnetic resonance (MR) exam.

Intramural fibroids, which develop within the lining of the uterus and expand inward, increasing the size of the uterus, and making it feel larger than normal in a gynecologic internal exam. These are the most common fibroids. Intramural fibroids can result in heavier menstrual bleeding and pelvic pain, back pain or the generalized pressure that many women experience.

Submucosal fibroids, which are just under the lining of the uterus. These are the least common fibroids, but they tend to cause the most problems. Even a very small submucosal fibroid can cause heavy bleeding - gushing, very heavy and prolonged periods.

Q. What are typical symptoms?
Most fibroids don't cause symptoms - only 10 percent to 20 percent of women who have fibroids ever require treatment. Depending on location, size and number of fibroids, a woman might experience the following:

Heavy, prolonged menstrual periods and unusual monthly bleeding, sometimes with clots, which can lead to anemia (a low blood count). This is the most common symptom associated with fibroids.
An increase in menstrual cramps
Pelvic pain or, more accurately, pressure or discomfort in the pelvis that is caused by the bulk or weight of the fibroids pressing on nearby structures
Pain in the back, flank or legs as the fibroids press on nerves that supply the pelvis and legs
Pain during sexual intercourse
Pressure on the urinary system, which typically results in increased frequency of urination, including the need to get up at night. (Occasionally, an enlarged uterus may press on the ureter connecting the bladder to the kidney, resulting in partial blockage of urine flow from the kidneys.)
Pressure on the bowel, leading to constipation and bloating
Abnormally enlarged (distended) abdomen, which can be misinterpreted as a progressive weight gain

If you are experiencing these types of symptoms, consult with your personal physician.

Q. Who is most likely to have uterine fibroids?
Uterine fibroids are very common. The number of women who have fibroids increases with age until menopause: about 20 percent of women in their 20s have fibroids, 30 percent in their 30s and 40 percent in their 40s. From 20 percent to 40 percent of women age 35 and older have uterine fibroids of a significant size.

African-American women are at a higher risk: as many as 50 percent have fibroids of a significant size. It is not known why, although genetic variability is thought to be a factor.

Fibroid tumors may start in women when they are in their 20s, however, most women do not begin to have symptoms until they are in their late 30s or 40s. Physicians are not able to predict if a fibroid will grow or cause symptoms.

Fibroids can dramatically increase in size during pregnancy. This is thought to occur because of the increase in estrogen levels during pregnancy. After pregnancy, the fibroids usually shrink back to their pre-pregnancy size.

Fibroids typically improve after menopause when the level of estrogen decreases dramatically. Fibroids can grow while a menopausal woman is taking estrogen supplements (hormone replacement therapy) or they may not be affected at all.

Q. How are uterine fibroids diagnosed?
Typically, fibroids are first diagnosed during a gynecologic internal exam, which enables the doctor to feel if the uterus is enlarged. The presence of fibroids is most often confirmed by an abdominal ultrasound. This is a painless procedure in which a radiologist or technician moves an instrument (transducer/receiver) about the size and shape of a computer mouse across the outside surface of the abdomen. Sound waves are transmitted through the skin and allow the technician to "see" the size, shape and texture of the uterus. A picture is displayed on a computer screen as the radiologist or technician takes the ultrasound. In some cases, a transvaginal ultrasound may be necessary. The radiologist inserts an ultrasound probe into the vagina so the inside of the uterus can be seen even more clearly than with the abdominal procedure. There is generally little if any discomfort associated with this procedure

Fibroids also can be confirmed using magnetic resonance (MR) imaging or computed tomography (CT). MR and CT also are painless diagnostic tests that can give accurate and clear information on the presence of fibroids.

Diagnostic hysteroscopy also is an option, particularly to evaluate the presence of submucosal fibroids. A long, thin probe-like instrument is passed through the vagina and cervix into the uterus, where the physician can check for growths and take samples of tissue. The lighted hysteroscope illuminates the uterus. This procedure, which can cause some discomfort, is generally performed by a gynecologist, and can be done without anesthesia or with a local anesthetic in an office.

Appropriate treatment depends on the size and location of the fibroids, as well as the severity of symptoms. If a woman is not experiencing symptoms, her doctor will most likely suggest "watchful waiting" - checking the fibroid at annual gynecologic examinations and monitoring for symptoms.

If symptoms develop, there are a number of treatment options:

Drug therapy, including non-steroidal anti-inflammatory drugs (NSAIDs), birth-control pills and hormone therapy; Surgical treatments, including myomectomy (surgical removal of the fibroids) and hysterectomy (surgical removal of the uterus) ; and

Uterine fibroid embolization, a new non-surgical treatment that causes the fibroid to shrink.

Treatment Option: Drug Therapy
Drug therapy is usually tried first. This might include:

the use of non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin) or naproxen sodium (Naprosyn),
birth-control pills, or
hormone therapy.

In some patients, symptoms are controlled with these treatments and no other therapy is required. However, some hormone therapies can have risks and side effects (menopausal symptoms, erratic or no menstruation, bloating, moodiness) when used long-term, and generally are used temporarily.

Surgical Treatments: Myomectomy
Myomectomy is a surgical procedure that removes just the fibroids, not the entire uterus. This is most commonly used in younger women who wish to maintain their ability to have a child. Myomectomies are typically performed by a gynecologist. As with any surgery, it is important to choose a doctor who is specially trained and experienced in the specific procedure.

While myomectomy is successful in controlling symptoms about 80 percent of the time, the more fibroids there are in a patient's uterus, the less successful the surgery generally is. In addition, fibroids grow back several years after myomectomy in 10 percent to 30 percent of cases.

Hysteroscopic Myomectomy:
Hysteroscopic myomectomy is used only for fibroids that are inside the uterus, just below the lining and projecting into the uterine cavity. There is no need for a surgical incision. The doctor inserts a flexible fiber-optic scope (hysteroscope) into the uterus through the vagina and cervix and removes the fibroids using special surgical tools fitted to the scope.

Laparoscopic Myomectomy:
Laparoscopic myomectomy may be used if the fibroid is on the outside of the uterus. Small incisions are made so the doctor can insert a probe with a tiny camera attached and another probe fitted with surgical instruments inside the abdominal cavity. The doctor can view the fibroids though the laparoscope camera as the instruments are guided to the site to remove the tumors. It is performed when the patient is under general anesthesia and not conscious.

Abdominal Myomectomy:
This is a surgical procedure, in which an incision is made in the abdomen to access the uterus, and another incision is made in the uterus to remove the tumor. Once the fibroids are removed, the uterus is stitched closed. The patient is given general anesthesia and is not conscious for this procedure, which requires a several-day hospital stay. Typical recovery is four to six weeks.

Surgical Treatments: Hysterectomy
Approximately one-third of the more than half-million hysterectomies performed in the United States each year are due to fibroids. In a hysterectomy, the uterus is removed either through the vagina, or in a laparoscopic surgery, or in an open surgical procedure. A procedure is selected based on the size of uterus, previous surgery, other problems the woman might be having at the same time, and the preference of the woman. In all cases, the operation is performed while the patient is under general anesthesia. It requires three to four days of hospitalization and a four- to six-week recovery period. Hysterectomy has a 2 percent risk of post-operative bleeding and a 15 percent to 38 percent risk of postoperative fever.

Hysterectomy is the most common current therapy for women who have fibroids and is effective in essentially all cases in which bleeding is a problem. It usually resolves the pain or urinary symptoms that women may have. It is typically performed in women who do not wish to have more children.

Uterine Fibroid Embolization
Known medically as uterine artery embolization, this is a fundamentally new approach to the treatment of fibroids that blocks the arteries that supply blood to the fibroids. It is a minimally invasive procedure, which means it requires only a tiny nick in the skin, and is performed while the patient is conscious but sedated - drowsy and feeling no pain.

Fibroid embolization is usually done in a hospital by an interventional radiologist, a physician who is specially trained to perform this and other minimally invasive procedures. The interventional radiologist makes a small nick in the skin (less than one-quarter of an inch) at the crease at the top of the leg to access the femoral artery, and inserts a tiny tube (catheter) into the artery. Local anesthesia is used so the needle puncture is not painful. The interventional radiologist steers the catheter through the artery to the uterus using X-ray imaging (fluoroscopy) to guide the catheter's progress. The catheter is moved into the uterine artery at a point where it divides into the multiple vessels supplying blood to the fibroids.

An arteriogram (a series of images taken while radiographic dye is injected) is performed to provide a road map of the blood supply to the uterus and fibroids.

The interventional radiologist slowly injects tiny plastic (polyvinyl alcohol or PVA) or gelatin sponge particles the size of grains of sand into the vessels. The particles flow to the fibroids first, wedge in the vessels and cannot travel to other parts of the body. Over several minutes, the arteries are slowly blocked. The embolization is continued until there is nearly complete blockage of the blood flow in the vessel.

The procedure is then repeated on the other side so the blood supply is blocked in both the right and left uterine arteries. Some physicians block both uterine arteries from a single puncture site, while others puncture the femoral artery at the top of both legs. After the embolization, another arteriogram is performed to confirm the results. The skin puncture where the catheter was inserted is cleaned and covered with a bandage.

As a result of the restricted blood flow, the tumor (or tumors) begin to shrink.

Fibroid embolization usually requires a hospital stay of one night, although some women do go home the same day. About six to eight hours of bed rest is typical after the procedure. Pain-killing medications and drugs that control swelling typically are prescribed following the procedure to combat cramping, which is a common side effect. Fever also is an occasional side effect, and is usually treated with acetaminophen. Total recovery generally takes one to two weeks, but can take longer.

While embolization to treat uterine fibroids has been performed for more than six years, embolization of arteries in the uterus is not new. The procedure has been used successfully by interventional radiologists in uterine arteries for more than 20 years to treat heavy bleeding after childbirth. Today, fibroid embolization is being performed at hospitals and medical centers across the country, in Canada and around the world. As of the end of 1998, about 1,500 to 2,000 fibroid embolization procedures had been done worldwide.

Expected Results
Fibroid embolization was first studied in the United States by Scott Goodwin, M.D., of the University of California Los Angeles, who reported his results in 1997. Since that time, a number of interventional radiologists have studied the procedure and have reported similar success with the technique reported by Dr. Goodwin.

The results of studies that have been published or presented at scientific meetings report that 78 percent to 94 percent of women who have the procedure experience significant or total relief of pain and other symptoms, with the large majority of patients considerably improved. The procedure has been successful even when multiple fibroids are involved. Most patients have rated the procedure as "very tolerable." The expected average reduction in the volume (size) of the fibroids is 50 percent after three months, with a reduction in the overall size of the uterus of about 40 percent.

The long-term outcome is not known as only short-term follow-up is available. It is not yet known if the fibroids can re-grow, however no recurrences have occurred in women who have been followed for up to six years.

Fertility
The majority of patients who have fibroid embolization are finished with childbearing and few women have tried to subsequently become pregnant, making fertility difficult to study. More than a dozen pregnancies have been reported, however, and patients who have had uterine arteries embolized for other reasons, such as bleeding after childbirth, have successfully become pregnant. Research is underway to study this issue.

There have been a few women whose menstrual periods have stopped after the procedure, which would result in infertility. See side effects/complications for a further discussion of this topic.

Side Effects/Complications
Fibroid embolization is considered to be very safe, however, there are some associated risks, as there are with almost any medical procedure. Most patients experience moderate to severe pain and cramping in the first several hours following the procedure; some experience nausea and, possibly, fever. These symptoms can be controlled with appropriate medications. Most symptoms are substantially improved by the next morning, however, there may be some pain and cramping for several days or more. Many women report returning to work within a week of having the procedure.

Complications occur in fewer than 3 percent of patients. Serious possible complications include injury to the uterus from decreased blood supply or infection. This is uncommon and hysterectomy to treat either of these complications occurs in less than 1 percent of patients. Injury to other pelvic organs is possible but has not yet been reported and the chance of other significant complications is less than 1 percent.

Long-term complications are not expected, although questions about potential side effects remain.

It is not known what effect, if any, fibroid embolization has on the menstrual cycle. The overwhelming majority of women who have had embolization have had decreased bleeding with normal menstrual cycles. There have been a few women, most of whom are near the age of menopause, whose menstrual periods have stopped after the procedure. It is uncertain whether these cases are a result of decreased ovarian function resulting from the procedure. Based on this limited information, it appears that the procedure may cause a loss of menstrual cycles (premature menopause) in a very small number of patients.

Insurance
A number of insurance companies are paying for fibroid embolization procedures. You will want to talk with your interventional radiologist about this before your procedure