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Uterine Fibroids
What are uterine fibroids?
Uterine fibroids are benign tumors formed from muscle and other tissue of the wall of a woman's uterus. But while uterine fibroids can cause pain, heavy or abnormal bleeding and other problems, it should be emphasized that — as the term benign indicates — they are not cancerous and are not life-threatening.
Uterine fibroids are very common. It's estimated that as many as 75 percent of all women develop them, but that approximately half of the women who do develop them don't experience any symptoms or problems whatever from them.
However, this means that more than 25 percent of women in the United States can exhibit problematical symptoms related to uterine fibroids, including menstrual bleeding that is heavier than normal or more prolonged, pressure or pain in the area of the pelvis, frequent or difficult urination, fertility problems or one or more miscarriages.
Although there are medical therapies that cause fibroids to shrink, their effectiveness is temporary and the traditional permanent solution has been surgery, whether to remove the fibroids only or to remove the entire uterus. It's estimated that more than 200,000 hysterectomies — a procedure to remove the entire uterus — are performed each year in the United States due to fibroids.
A minimally invasive alternative to surgery developed in recent years is uterine fibroid embolization, an interventional radiology technique to cut off the flow of blood to the fibroid tumors, starving them and causing them to shrink or even disappear.
The interventional radiologists of Connecticut Surgical Group have extensive experience in the uterine fibroid embolization, and have been pioneers in development of techniques for its use. They work closely with CSG's surgical staff to ensure that each patient receives the treatment approach most appropriate for her case.
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What are interventional radiologists?
Traditional radiology is the medical specialty concerned with diagnosing and defining disease through the use of x-rays, ultrasound and magnetic resonance that provide visual images of internal organs.
Interventional radiologists are specially trained practitioners of a relatively new subspecialty who use those images to help them thread long, thin, hollow tubes called catheters through the body's arteries and other passages to provide treatment without conventional surgery.
Making only a tiny incision that can be covered with a bandaid, interventional radiologists can work with catheters to open up blocked arteries, to inject medical cement to stabilize collapsed vertebrae or to patch weaknesses in the wall of the aorta.
And, they can cut off the flow of blood to cancerous tumors and noncancerous fibroids by blocking key blood vessels with tiny plastic beads or gel — the technique called embolization.
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What causes uterine fibroids?
The actual cause of uterine fibroids is not known, although some researchers suspect that a genetic predisposition for the problem in some people may be activated by uncertain hormonal and perhaps environmental factors.
It is known that a prevalence for uterine fibroids runs in families, and it also varies among ethnic groups. African American women are twice as likely to develop them as Caucasian and Asian women.
The course of uterine fibroids is such that their development is clearly related to the hormone estrogen. Uterine fibroids very rarely develop before the onset of puberty, when menstrual cycles begin and estrogen becomes an important factor in a woman's life, and they tend to shrink after menopause, when levels of estrogen decrease. They can increase in size during pregnancy, when estrogen is elevated, and they can grow in response to estrogen replacement therapy.
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What are the risk factors for uterine fibroids?
There are no clear risk factors for developing uterine fibroids other than being a woman of reproductive age, especially an African American woman, and perhaps having a family history of the problem. Uterine fibroids are most frequently found in women between the ages of 35 and 49.
Some researchers believe that obesity slightly increases the risk of uterine fibroid development.
Often, it should be noted, uterine fibroids can be present and remain basically stable in size, number and absence of symptoms, and then begin to grow rather rapidly. This suggests that once detected, asymptomatic fibroids should be monitored periodically by your doctor.
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What are the symptoms of uterine fibroids?
Since most women who have developed uterine fibroids don't have any symptoms — or problems related to them — the presence of fibroids is often identified in the course of an examination for some other problem, perhaps a regular pelvic exam.
However, there can be symptoms that warrant seeking medical attention. You should see a physician if you experience:
- Abnormally heavy menstrual bleeding, one of the most common symptoms of fibroid problems
- Menstrual bleeding that continues for a prolonged period, also among the most common symptoms of fibroid problems
- Anemia, related to the abnormal bleeding
- An increase in menstrual cramps
- Pain in the lower back or legs, related to pressure of the fibroids on nerve tissue
- Pain or pressure in the abdomen, related to fibroids pressing up against other structures
- Pain during sexual intercourse
- A need for frequent urination, related to pressure on the bladder
- Difficulty in urinating, related to pressure on the bladder
- Constipation, related to pressure on the colon
- Fertility problems, related to inability of eggs to implant on the lining of the uterus
- Miscarriage, related to interference with development of fetuses on the lining of the uterus
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What are the kinds of uterine fibroids?
Fibroids may develop as a lone tumor or in clusters, and a single fibroid can range in size from as small as a pinto bean to as large as a cantaloupe.
Clinically, uterine fibroids are classed into three primary types, depending on where they're found within the uterus.
- Intramural fibroids, which are the most common type, develop within the uterine wall and extend inward. They can increase the size of the uterus and can cause abdominal distension, pressure on the bladder to urinate frequently, back pain, pain in the pelvic area and heavier than normal menstrual bleeding.
- Subserosal fibroids, the second most common form, develop in the outer segment of the uterus' wall, and tend to grow outward, possibly into the abdomen or the uterus' own ligaments. If they develop a stem-like base, they are called pedunculated. While they most commonly don't affect menstrual flow, they can press on the bladder, cause abdominal distension or back pain and pain in the pelvic area.
- Submucosal fibroids, the least common type, develop just under the uterus' lining and near the endometrial cavity. Because of their location, even very small submucosal fibroids generally cause very heavy or prolonged bleeding and can cause problems with miscarriages. They can become pedunculated and can extend into the cervix.
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How are uterine fibroids diagnosed?
Your doctor is most likely to be able to diagnose problematical uterine fibroids through a history of your symptoms — and perhaps a family history — and a complete pelvic examination, in which he or she may be able to feel the fibroids and tell whether the uterus is enlarged.
Your doctor may also order an abdominal ultrasound test, a painless noninvasive procedure using high speed radio waves generated by a transducer placed against your abdomen to develop a visual image of the size, shape and structure of your uterus. A variation that may be ordered is transvaginal ultrasound, in which an ultrasound probe is placed within the vagina to obtain clearer images of the uterus.
Magnetic resonance imaging (MRI) may be ordered to obtain the clearest images possible of individual fibroids and their characteristics. And, your doctor may want to perform a hysteroscopic examination, using a flexible, fiber-optic "telescope" to visually examine the lining of your uterus and possibly capture tissue samples, as well.
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What are the treatment options for uterine fibroids and what are the success rates?
If your doctor has determined that you have uterine fibroids but you don't have symptoms, the best course of action may be doing nothing but monitoring them over time. Often called "watchful waiting," this means that at each pelvic examination your doctor will check to see whether and how much they have grown since the last exam.
Traditionally, the standard treatment for uterine fibroids has been surgery, primarily a hysterectomy, or the complete removal of the uterus. A hysterectomy is also the only permanent solution for fibroids.
Although less radical surgical and nonsurgical options have been developed, each has a small rate of fibroids recurrence over time. These include drug therapy, a surgical procedure called myomectomy in which the fibroids are removed but the uterus remains intact, and uterine fibroid embolization, in which the blood supply to the fibroids is cut off.
While hysterectomy offers the only permanent solution, it has several drawbacks, both psychological for some women and physical for women who still anticipate having children. Since hysterectomy eliminates the possibility of pregnancy, the alternatives may be worth considering.
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What are the drug treatment options for problems caused by uterine fibroids?
Uterine fibroid symptoms like mild pain and inflammation might be controlled simply by use of a nonsteroidal anti-inflammatory medication such as ibuprofen. Birth control pills can be used to reduce bleeding and severity of cramping, but don't have any effect in terms of reducing the size of fibroids.
Drugs mimicking the hormone known as gonadotropin-releasing hormone (Gn-RH) may be used to cause the fibroids to shrink. Administered by injection, they reduce the level of estrogen in your body, thereby reducing blood flow to the uterus — and the size of the fibroids.
The drawback to these drugs is that they cause most of the symptoms of menopause — mood swings, vaginal dryness, hot flashes and loss of bone mass — and can be used only temporarily. Once they are stopped, the fibroids regrow to their original size in six months or less. For this reason, they are primarily employed to shrink fibroid tissue in preparation for surgery, or for women approaching menopause.
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What is the surgical treatment myomectomy?
Myomectomy is a surgical procedure in which the fibroids are removed and the uterus left otherwise intact. Usually performed by a gynecologist, the procedure is about 80 percent effective in controlling symptoms. The advantage of myomectomy is that it retains your ability to have children, so it is an important option if pregnancy is a goal for you. Studies indicate pregnancy rates of 40 to 60 percent for women who have undergone myomectomy.
The major disadvantages are that the more fibroids present, the less successful it is, and that over the course of several years fibroids grow back in 10 to 30 percent of cases.
A variation on conventional myomectomy is hysteroscopic myomectomy, in which the procedure is performed endoscopically through a hysteroscope inserted through the vagina into the uterus. This eliminates the need for an incision, reduces scarring on the uterine wall, and dramatically reduces hospitalization and recovery time. However, only 10 to 20 percent of fibroids are in a location in which it can be performed, and the fibroids must be relatively small. The procedure can also be performed laparoscopically, in which an endoscope is inserted through a small incision in the abdomen to reach the uterus from a different direction.
These procedures usually are performed under general anesthetic and require a two-to-three-day hospital stay and a recovery period of several weeks.
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What is a hysterectomy?
A hysterectomy is a surgical procedure to remove the entire uterus, thereby eliminating problematic fibroids, their symptoms and any possibility of their recurrence. The uterus' removal can be done through the vagina, laparoscopically or with a conventional open abdominal incision.
The advantages of a hysterectomy are that it has a low complication rate and that it provides a permanent solution to fibroid problems. The obvious disadvantages are that it precludes any possibility of childbearing — and for this reason is most often performed on women past, at or approaching menopause — and it can also affect a women's sense of self-concept.
Problematic fibroid symptoms are estimated to be responsible for some 200,000 hysterectomies performed in the United States each year. It is a procedure usually performed under general anesthetic and requiring a three-to-four-day hospital stay and a four-to-six-week recovery period.
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What is uterine fibroid embolization?
Uterine fibroid embolization is a minimally invasive, interventional radiology procedure to deal with uterine fibroids without any need for surgery. By threading a catheter through your vascular system to the specific arteries supplying blood to the fibroids in your uterus, the interventional radiologist can deliver a substance right at the site to cut off the blood supply and shrink the fibroids by starving them.
The clear advantages are that you remain sedated but awake throughout the procedure, it usually requires only a one-night hospital stay, the only incision needed is a very tiny nick that can be covered with a bandaid and recovery time is much shorter.
As of 2003, uterine fibroid embolization procedures have been performed on approximately 10,000 patients in the United States, but it is a relatively new procedure and long-term results are not available. Some studies indicate that the procedure significantly or completely relieves pain and other symptoms in as many as 94 percent of patients who have undergone it.
According to the Society of Interventional Radiology, the expected average reduction in the size of the fibroids is 50 percent after three months, with an overall reduction in the size of the uterus of about 40 percent. Data as to whether or what percentage of fibroids grow back is not yet conclusive, although the Society notes that in women followed over a six-year period, none have grown back.
The procedure is still too new (and more frequently done on women for whom childbearing is not a goal), so outcomes related to fertility and pregnancy are not available, other than to say that the Society notes that a number of pregnancies have been reported.
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What should I do to prepare for uterine fibroids embolization?
Prior to your procedure you probably will have a number of tests ordered, such as chest x-ray, EKG and blood analysis. You should stop taking any medications that may thin your blood, and you should be sure to tell your caregivers if you are pregnant, have asthma, have a bleeding problem or are allergic to iodine (the substance used in the dye), to medications or to any other substance, even shellfish.
You should not eat or drink for four to eight hours before your procedure.
You and your doctor should make certain you have not been on the Gn-RH hormone or any of its substitutes for at least 12 weeks, since these medications cause constriction of the arteries involved and can make the embolization procedure more difficult.
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How is uterine fibroid embolization performed?
A uterine fibroid embolization procedure usually is performed by an interventional radiologist assisted by a nurse and a technician. Your uterine fibroid embolization procedure begins with a small incision at a point in the femoral artery in your thigh near your groin (you'll receive local anesthetic to mask any pain) and the insertion of the catheter into your vascular system. Then, guided by fluoroscopy (real-time x-rays) the interventional radiologist will thread the catheter up the femoral into the uterine artery. Using a medical dye introduced through the catheter, he or she will be able to visualize on the fluoroscope which arterial branches are supplying blood to the fibroids.
Then your doctor will begin to slowly deliver sand-grain-size plastic beads through the catheter and into the fibroid-serving arterial branch. These tiny beads may be composed of polyvinyl alcohol or a gelatin substance. As they adhere to the arterial wall, they lead to a build-up that eventually will block the supply of blood into the fibroid.
Once the blockage is in place, the medical dye will be used again to image the resulting pattern of blood flow. Your interventional radiologist may see a need to embolize fibroids on both sides of your uterus, and may either use the same entry-point in the same femoral artery, or may make a new insertion in the other femoral.
Usually, the procedure takes between one and three hours. Once the catheter is withdrawn, your nurse will apply pressure for 10 to 20 minutes to the spot where the catheter was inserted to prevent bleeding and give blood time to clot at the site.
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What happens following the procedure?
You will be kept in the recovery area for six to eight hours and possibly in the hospital overnight. It will be important during your time in recovery for you to keep your leg straight to prevent the incision site from bleeding. You should let your nurse know if you experience any bleeding, swelling or pain.
You are likely to experience abdominal pain for at least a few hours and possibly a day or more following the procedure. You'll be given pain killers to offset it.
You should make certain you have a family member or friend available to drive you home from the hospital, as you cannot drive yourself. Once home, you should plan on taking it easy for a period of time. Complete recovery can take a week or more.
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What complications could result from a uterine fibroid embolization procedure?
Uterine fibroid embolization is a very safe procedure, but like any medical procedure it is accompanied by a very small risk of complications such as reaction to anesthetic or the iodine used in the medical dye, bleeding problems and infection.
With uterine fibroid embolization specifically, there is a slight risk of such problems as premature onset of menopause, loss of menstrual periods and injury to the uterus.
It may be useful to note that although it is new to the treatment of fibroids, embolization has been used safely for more than 20 years to treat heavy bleeding following childbirth.
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What should I think about in considering my treatment options?
Among other factors, major considerations might be the severity of your symptoms, your age and any future goals you might have regarding childbearing.
If childbearing is not an issue, a hysterectomy offers the safest, most permanent route. It also requires that you address psychological issues involving your feelings of self-concept as a woman. If childbearing is an issue, myoectomy may offer a proven surgical solution, with a realization that 10 to 30 percent of fibroids return over time.
Uterine fibroid embolization offers significant advantages in that it eliminates a need for general anesthesia or for a surgical incision, it can treat all fibroids in one procedure, it doesn't cause loss of bone mass, and it has been shown to significantly or completely resolve pain and other symptoms in as many as 94 percent of patients.
Its effect on fertility and pregnancy has not been conclusively demonstrated statistically, but it is demonstrated that a number of women who have undergone it have successfully borne children.
In terms of uterine fibroid embolization performed by the interventional radiologists of Connecticut Surgical Group, their experience is extensive and their outcomes are strong.
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For additional information:
You can find additional information about uterine fibroids and uterine fibroid embolization at web sites sponsored by government agencies, societies and healthcare institutions. It should perhaps be noted that the World Wide Web is open to many sources posting questionable information and promises, and you are encouraged to seek information from established, reputable organizations.
Likely sources include:
The Society of Interventional Radiology
www.sirweb.org
Emedicine
www.emedicine.com
National Institute of Child Health and Human Development
www.nichd.nih.gov
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