Uterine Fibroids, what are they?
Fibroids are benign growths that affect the body and lining of the uterus. They can appear on the surface of the uterus (Subserosal), in the uterine body (Intramural), under the lining of the uterine cavity (Submucosal) or hang into the uterine cavity ( Intracavitary). They are very common and can range in size from microscopic to very large filling the entire abdominal cavity. The majority of patients have multiple fibroids. In 1 in 1000 cases they can transform into cancer. Other names for fibroids are: Leiomyoma, leiomyomata and myoma.
What causes fibroids?
No one knows why fibroids develop. It is believed that there is a genetic component. Fibroids will eventually stem from random uterine muscle cells. Their growth is generally be spurred by hormones such as estrogen.
Who is at risk for fibroids?
Overall about 40 % (20% to 80%) of women will develop fibroids by age 50. The average age range when symptoms start is 35-50. African American women appear to be more prone to developing fibroid tumors. Asian women have the lowest incidence. Obesity has been described as a risk factor. The levels of reproductive estrogen and progesterone hormones in the body do play an important role. In fact, fibroids may grow rapidly during pregnancy and the growth will slow after menopause.
What are some symptoms of uterine fibroids?
The most common symptoms are:
- Heavy bleeding either during or between periods.
- Pelvic pain and pressure.
- Rectal pain and constipation.
- Urinary frequency and leakage.
- Painful sex and strained relationships.
- Abdominal bloating and feeling of weight gain.
- Chronic stress from all the above.
How are fibroids diagnosed?
Most of the time, a patient with bothersome symptoms such as heavy bleeding or pain will be prescribed an ultrasound of the abdomen/pelvis. The ultrasound may show the cause to be fibroids.
While ultrasound may be the starting point for diagnostic work up in a patient with fibroids, MRI is generally more accurate in determining the number, size and location of the fibroids as well as the overall volume of the uterus at the time.
For patients who can’t have an MRI, a CT scan may be ordered.
How do I proceed when I find out I have fibroids?
First and foremost, educate yourself on fibroids and, if you have symptoms, on the treatment options available to you. It is crucial to understand the difference between non-surgical fibroid embolization and other traditional surgical techniques. A well informed patient always makes a good decision! You might for example want to visit a website like the National Uterine Fibroids Foundation (www.nuff.org).
Armed with all the info now, your next step is to give us a call and we will arrange for a detailed consult with one of our experts. Once we determine that embolization is the best treatment for you, we will coordinate your care with your primary and Gyn doctors. We will go through a care plan for you that entails all steps including before, during and after your procedure. You will be provided with a literature detailing all the steps.
What if I decide not to treat my fibroids, are there any complications?
Most women who develop fibroids may not even notice them. Its only when they become symptomatic that they need evaluation with possible treatment. There are however issues that can arise when you have fibroids. These can greatly alter the quality of life. Heavy bleeding: Is the most serious symptoms. Excessive bleeding during and/or between periods can cause anemia. Anemia in turn can cause lack of oxygen delivery to the entire body. This in turn pushes the heart into overdrive which on the long run can weaken the heart and cause palpitations. Significant anemia in this context is also responsible for a constant state of feeling tired, weak and winded. Some patients we see in our practice do require iron infusions and/or blood transfusions. Pelvic pain: Can be cyclical or constant. It is quite debilitating. Bulk symptoms: When fibroids reach a certain size, they will start putting pressure on surrounding organs, notably the bladder where it causes urinary frequency /frequent trips to the bathroom, the intestines where it can cause constipation, the lower back where it can cause back and leg pain. Bulk symptoms may also cause bloating and increased belly size (Abdominal girth). Infertility: When symptoms reach a certain size or number or are in parts of the uterus needed for conception, they may compromise the anatomy of the uterus and thus be responsible for the inability to conceive and the possibility of miscarriage. Note that fibroids do grow at a faster rate during pregnancy which makes for increased risk of complications. Other symptoms: Pain during intercourse can cause relationship issues. All the symptoms above can create a great deal of stress and have a negative impact on quality of life.
What are my treatment options?
Historically, fibroids are the most common reason patients undergo a hysterectomy. But with evolving technology and medical knowledge, new, a lot less invasive procedures are available. In our opinion, it would be substandard of care to present the patient with hysterectomy as the sole option for fibroid treatment. We will list here the most common treatments but keep reading further to find out which one is appropriate for your case.
- Medications: Lupron is a medication that interferes with the production of estrogen by the ovaries. It is given by injection. Since fibroids are sensitive to estrogens, Lupron helps keep the fibroids in check. This however comes with two major drawbacks: Lupron if used long term can cause brittle bones (Osteoporosis) and whenever it is stopped, the fibroids will regrow. Birth control pills and IUDs have also been used to control bleeding.
- Hysterectomy: Refers to removal of the uterus through either an abdominal incision, vaginal approach or laparoscopically. The ovaries are often also removed during the procedure.
- Myomectomy: Refers to removal of the most bothersome fibroids only. It is done through either an abdominal incision, laparoscopically or via hysteroscopy.
- Other options such as MRI guided focused ultrasound, laser, radiofrequency, robotics are being done in few centers but have yet to get wide acceptance.
- Uterine artery/fibroid embolization (UFE): Embolization refers to injecting tiny beads into the blood supply to the fibroids. This causes all the tumors present at the time of treatment to shrink, regardless of their size, number or location. Embolization is a pinpoint and proven technique in treating fibroids. It is virtually completely non-invasive, without any serious complications and very favorable outcomes.
WE SPECIALIZE IN NON-SURGICAL UTERINE ARTERY/FIBROID EMBOLIZATION
Which treatment is right for me?
It is important to understand that only patient who do have symptoms need to be treated The right treatment is one that is best for you! It is very important to carefully choose a practitioner who is well versed in treating fibroids. The ideal treatment would be one that provides a one stop shop where all your symptoms are addressed, all the fibroids are treated, minimal complications, excellent outcome and cost effective among others. Each case is unique and each patient deserves personalized attention. We will work in concert with your primary care and Gyn doctors to optimize your care.
We encourage you to come see us. We listen to our patients, We work together to come up with the most comprehensive plan tailored to your case. We accompany you through all the steps before, during and aftercare. If you need a different treatment than we provide, we will point you in the right direction.
What treatments do you provide?
We are experts in the most state of the art, minimally invasive uterine fibroid embolization techniques. Our physicians are formally fellowship trained in some of the most prestigious institutions. Uterine fibroid embolization is very safe and very effective. No cuts or wounds. It is truly a non-surgical alternative to more invasive operations like hysterectomy and myomectomy. No hospital stay is required as it is an outpatient procedure. No major complications either and you can go back to work much quicker than with any other common surgical procedures. When done with skills, the procedure does indeed alter the quality of life in a very positive way.
What specialists are trained qualified to perform Embolization?
Fibroid embolization is performed by Interventional Radiologists. It can be performed in a hospital setting or at an outpatient clinic such as our clinic. It is a same day procedure with on average a recovery of one week. Hysterectomies and myomectomies can be performed by your Surgical ObGyn. They are usually performed in a hospital setting and require hospital stay and an average of 6 weeks of recovery. Please note that Interventional Radiologists are the only fibroid specialists that undergo formal training in non-surgical minimally invasive treatment of fibroids, through recognized fellowship programs at university hospitals.
Is embolization totally covered by my insurance?
Yes. The procedure is medically necessary if you are a candidate. Our practice is credentialed with all insurance companies in our area. The only out of pocket costs you may incur are copays, coinsurance and deductibles. We will work with you on the out of pocket costs Our goal is for you to get the best treatment for your case.
You won’t have to deal with your insurance. We take care of that for you. We make sure we get all required pre-authorizations before you are scheduled for the procedure.
Please don’t forget to visit the insurance glossary link on our website.
Is fibroid embolization safe? Any complications I should worry about?
Uterine fibroid embolization is one of the safest and most successful procedures to undergo in the treatment of fibroids. It is definitely safer than invasive surgery such as hysterectomy and myomectomy. Bleeding and infections are very rare in a controlled environment such as our practice. Uterine injury is unlikely with proper skills and technique. Blood clots risk is reduced with the use of compressive stockings. You will be able to ambulate much quicker than with any other procedure. The overwhelming majority of patients do not experience any major side effects. Some patients do experience flu like symptoms immediately after the procedure. This is called post embolization syndrome and is transient in nature.
In reviewing the literature, few side eeffcets are reported such as thromboembolism, endometritis and transient or permanent amenorrhea.
Can you explain what happens during the procedure? Is it painful?
Uterine fibroid embolization is done under sedation by using an IV and gentle pain and sleep medications. As opposed to more invasive hysterectomy and myomectomy, we do not use general anesthesia or a tube down the throat. You will be sleepy throughout the procedure and won’t remember anything but will be able to wake up as soon as the procedure is completed. The procedure by itself is painless. A tiny catheter is inserted into the femoral artery at the hip level. Another thin catheter is then threaded into the uterine arteries. Through this catheter, small beads are delivered into the fibroid vascular supply under imaging guidance. This shuts down the blood flow to the fibroids and the healing process starts immediately. At completion, a tiny plug is placed on the artery puncture followed by a Band-Aid and you are done.
Patients do experience abdominal cramps for a couple hours as the fibroids start undergoing blood depletion. If left untreated, the cramps will subside eventually. At our practice, however, we appropriately and aggressively address these issues ahead of time using a combination of medications to significantly reduce painful episodes. Very few patients may continue to have some discomfort for few days which can be managed with pain and anti-inflammatory medicines. Keep in mind that at all times, You will be able to reach our doctors. They will address any issues you might have 24/7, 7 days a week.
Will the procedure harm my normal uterus that doesn’t contain fibroids?
Another amazing fact about embolization is that it will treat all the existing fibroids at the time of procedure regardless of their number, size or location. The beads used are usually released into the uterine arteries which feed both the fibroids (Abnormal tissue) and the unaffected uterine tissue. But because the fibroids are tumors, their vessels do not obey the anatomic and physiologic rules a normal organ tissue would go by. They grow fast and their vessels are random and behave like tubes diverting blood flow towards them. This flow differential makes the particles go more towards the fibroids than the normal tissue. Some of the particles are still going to end up in territories of normal tissue, may still cause some injury to the normal uterus but keep in mind that the normal tissue can form new blood channels and heal irritated areas, something fibroids can’t do unless embolization is not complete.
This is why it is important you choose a specialist who understands this disease process and its treatments well and has the necessary skills and experience. Remember, under-embolization will cause procedure failure and recurrence of symptoms while over-embolization may cause post-operative symptoms such as pain to linger more than it should making for a not so great experience.
What happens to my fibroids after treatment? Are they going to disappear?
The beauty of embolization is that it starts working right away. Once the blood supply to the fibroids has been interrupted, they start going through an inflammatory process called ischemia. Eventually, the nutrient depletion from cessation of blood flow will cause a gradual dissolution process called necrosis. Following that, the body’s immune system will take over the gradual elimination of the no longer viable fibroid tissue. The process overall will take few months. You will see a reduction of up to 60% in volume within just the first 3-5 months.
Is there a possibility my fibroids might come back?
When done by a skilled operator, uterine artery embolization will treat all existing fibroids regardless of their number, size and location. In that regard, it is a much better choice than myomectomy where only the major fibroid is treated, leaving behind other smaller fibroids which will potentially cause issues in the future and need reintervention. The rate of recurrence with myomectomy is reported to be 30%.
With embolization, the adequately treated fibroids will not recur. Hence, choosing the right doctor with the right skills and experience is very important. In general, if you are prone to developing fibroids because of genetic predisposition, theoretically there is a slight chance that years down the road, you may form new ones but you are less likely to have a recurrence of the already treated fibroids.
Is there any follow up after the procedure?
After your procedure is complete, you will be discharged home with instructions and some prescriptions. You will receive a phone call the following day from our doctor to check on you. After that, we will see you at one week and at 3 months. We will request a follow up MRI at the time to evaluate your progress.
Would uterine fibroid embolization affect my fertility?
This is a crucial point to discuss with your provider if you desire to have children in the future. While the ideal patient for this procedure is near menopause with complete family, studies have shown that embolization is effective in all age group patients with symptoms. Here patient selection is of utmost importance.
Studies show that pregnancy is possible after embolization. In fact, some patients who couldn’t get pregnant because of fibroids have found success after embolization. Because of that reason alone, we actually advise our patients who are not planning on becoming pregnant after embolization to use a reliable form of birth control to prevent pregnancy. In addition, if fibroids are left untreated, they will grow rapidly during pregnancy and pose a serious risk of bleeding and miscarriage.
The overwhelming majority of women who undergo embolization for fibroids return to normal menstrual cycle. In rare cases reported, few women nearing menopause have lost their periods.
If you need fibroid treatment and desire to have children in the future, come see us for a complete evaluation. The chance of pregnancy in the presence of fibroids depends on few variables. Few examples for the sake of discussion, if a patient has multiple bulky fibroids causing uterus deformity, the likelihood of carrying a pregnancy to term are not the best. If a patient has a large fibroid in the uterine cavity causing bleeding and mass effects, the odds are likely not better.
Based on the above, we prefer to do a full evaluation including reviewing imaging findings (Our expert doctors are also trained to read all imaging modalities) then we will advise you on the best approach.
What if I desire to have children in the future but I don’t want to have surgery?
If this is your case, i.e. you are of childbearing age, desire to have children in the future but do not want to have invasive surgery, then fibroid embolization is the way to go. While fibroid embolization is not a procedure to increase fertility, patients have been able to get pregnant after the procedure when they were unable to do so before.
What are the risks of conventional myomectomy or hysterectomy surgery?
Whether these surgeries are done through a big incision on the abdomen or several smaller incisions through laparoscopy or through the vagina, they are not truly minimally invasive. They still breach the abdominal wall and instruments do come in contact with the internal organs. This in turn causes tissue reaction and scarring which carries future risk of bowel obstruction and need of further surgery. The use of general anesthesia: Requires placement of a tube down the throat to secure breathing. The surgery often takes hours to complete. Myomectomy: When you have fibroids, you most likely have many of them at a microscopic stage since you are prone to having fibroids. While these tiny fibroids may not be picked up on imaging studies, they may at some point in time grow to become symptomatic. Myomectomy is invasive, removes only one or few fibroids. We see many patients who have had many myomectomies only to see their symptoms come back. They are subsequently offered hysterectomy either partial or total. Hysterectomy: Is a MAJOR operation. Suffice it to say that the Lancet, a respected medical journal reported recently that 600,000 hysterectomies were performed last year in the US, most often for fibroids and a whopping 75% of these procedures were unnecessary. Some of the complications of hysterectomy: Post-operative infection and abscess formation, blood clots in legs and /or lungs, vaginal prolapse, bowel obstruction in later years, hot flushes, sexual problems, dry vagina, depression, osteoporosis or brittle bones, emotional distress Injury to adjacent structures: In case this happens, patients may face a long recovery and further surgeries may be needed to correct the problem such as fixing an injured bladder, urine conduit blocking the kidneys or bowel causing overwhelming infection (Sepsis). Long downtime: Recovery may take weeks to months assuming there are no complications. A long recovery time makes for a negative experience and quality of life. Long-Term complications: Open surgery inherently causes adhesions to form inside the abdomen / pelvis. This could make future interventions very difficult. Other effects reported are constipation and weight gain.
Can fibroids be treated with certain foods herbs or vitamin/supplements?
Obesity has been described as a risk factor for fibroids. Losing weight, exercising and eating healthy will have positive impact on your overall health. A diet high in saturated fats may promote estrogen which may promote fibroids. Lack of B vitamins used to convert estrogen in the liver to a weaker form called estriol may promote fibroids. Vitamin D and Omeg-3 fatty acids may ease dysmenorrhea. Foods rich in phytoestrogens such as flax seeds may reduce the risk of endometrial cancer.
So, for your overall health benefit, it helps when you make the right choices. More research is needed however to determine if any specific foods, vitamins or supplement would have any long lasting effects in terms of managing fibroids.