Uterine Fibroid Symptoms, Diagnosis and Treatment
Highly Effective, Widely Available Interventional Radiology Treatment Often Replaces Need for Hysterectomy
Uterine fibroids are very common non-cancerous (benign)
growths that develop in the muscular wall of the uterus. They can
range in size from very tiny (a quarter of an inch) to larger
than a cantaloupe. Occasionally, they can cause the uterus to
grow to the size of a five-month pregnancy. In most cases, there
is more than one fibroid in 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.
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. They typically improve
after menopause when the level of estrogen, the female hormone
that circulates in the blood, decreases dramatically. However,
menopausal women who are taking supplemental estrogen (hormone
replacement therapy) may not experience relief of symptoms.
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. Fibroid tumors of
the uterus are very common, but for most women, they either do
not cause symptoms or cause only minor symptoms.
Subserosal Fibroids
These 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
These 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
These 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.
Prevalence of Uterine Fibroids
Twenty to 40 percent of women age 35 and older have uterine
fibroids of a significant size. African American women are at a
higher risk for fibroids: as many as 50 percent have fibroids of
a significant size. Uterine fibroids are the most frequent
indication for hysterectomy in premenopausal women and,
therefore, are a major public health issue. Of the 600,000
hysterectomies performed annually in the United States, one-third
are due to fibroids
Uterine Fibroid Symptoms
Most fibroids don’t cause symptoms—only 10 to
20 percent of women who have fibroids require treatment.
Depending on size, location and number of fibroids, they
may cause:
- Heavy, prolonged menstrual periods and unusual monthly
bleeding, sometimes with clots. This can lead to anemia.
- Pelvic pain and pressure
- Pain in the back and legs
- Pain during sexual intercourse
- Bladder pressure leading to a frequent urge to urinate
- Pressure on the bowel, leading to constipation and
bloating
- Abnormally enlarged abdomen
Imaging Expertise Enables Interventional Radiologists to
Provide Gynecologists and Their Patients Better Diagnosis and
Nonsurgical Treatment Options
Women typically undergo an ultrasound at their
gynecologist’s office as part of the evaluation process to
determine the presence of uterine fibroids. It is a rudimentary
imaging tool for fibroids that often does not show other
underlying diseases or all the existing fibroids. For this
reason, MRI is the standard imaging tool used by interventional
radiologists.
Magnetic resonance imaging (MRI) improves the patient
selection for who should receive nonsurgical uterine fibroid
embolization (UFE) to kill their tumors. Interventional
radiologists can use MRIs to determine if a tumor can be
embolized, detect alternate causes for the symptoms, identify
pathology that could prevent a women from having UFE and avoid
ineffective treatments. Using an MRI rather than ultrasound is
like listening to a digital CD rather than a record – the
quality is better in every way. By working with a patient’s
gynecologist, interventional radiologists can use MRIs to enhance
the level of patient care through better diagnosis, better
education, better treatment options and better outcomes.
Second Opinion Prior to Hysterectomy
For true informed consent before surgery, patients should be
aware of all of their treatment options. Patients considering
surgical treatment should also get a second opinion from an
interventional radiologist, who is most qualified to interpret
the MRI and determine if they are candidates for the
interventional procedure. You can ask for a referral from your
doctor, call the radiology department of any hospital and ask for
interventional radiology or visit the doctor finder link at the
top of this page to locate a doctor near you.
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Uterine Fibroid Treatments
Nonsurgical Uterine Fibroid Embolization – A Major
Advance in Women’s Health
Uterine fibroid embolization (UFE), also known as uterine
artery embolization, is performed by an interventional
radiologist, a physician who is trained to perform this and other
types of embolization and minimally invasive procedures. It is
performed while the patient is conscious, but sedated and feeling
no pain. It does not require general anesthesia.
The interventional radiologist makes a tiny nick in the skin in the
groin and inserts a catheter into the femoral artery. Using
real-time imaging, the physician guides the catheter through the
artery and then releases tiny particles, the size of grains of
sand, into the uterine arteries that supply blood to the fibroid
tumor. This blocks the blood flow to the fibroid tumor and causes
it to shrink and die.
UFE Recovery Time
Fibroid embolization usually requires a hospital stay of one
night. Pain-killing medications and drugs that control swelling
typically are prescribed following the procedure to treat
cramping and pain. Many women resume light activities in a few
days and the majority of women are able to return to normal
activities within seven to 10 days.
UFE Efficacy
- On average, 85-90 percent of women who have had the
procedure experience significant or total relief of heavy
bleeding, pain and/or bulk-related symptoms.
- The procedure is effective for multiple fibroids and
large fibroids.
- Recurrence of treated fibroids is very rare. Short and
mid-term data show UFE to be very effective with a very
low rate of recurrence. Long-term (10-year) data are not
yet available, but in one study in which patients were
followed for six years, no fibroid that had been
embolized regrew
Additional UFE Facts
- In 2007, the first gorilla was treated with UFE for her fibroids. View TV coverage from CBS in Chicago.
- An estimated 13,000-14,000 UFE procedures are performed
annually in the U.S. (as of 2004)
- Embolization of the uterine arteries is not new. It has
been used successfully by interventional radiologists for
more than 20 years to treat heavy bleeding after
childbirth.
- Embolization has been used to treat tumors since 1966.
Embolization to treat uterine fibroids has been performed
since 1995 and the embolic particles are approved by the
FDA specifically to treat uterine fibroid tumors, based
on comparative trials showing similar efficacy with less
serious complications compared to hysterectomy and
myomectomy (the surgical removal of fibroids).
- Embolization of fibroids was first used as an adjunct to
help decrease blood loss during myomectomy. To the
surprise of the initial users of this method, many
patients had spontaneous resolution of their symptoms
after only the embolization and no longer needed the
surgery.
- UFE is covered by most major insurance companies and is
widely available across the country.
- Most women with symptomatic fibroids are candidates for
UFE and should obtain a consult with an interventional
radiologist to determine whether UFE is a treatment
option for them. An ultrasound or MRI diagnostic test
will help the interventional radiologist to determine if
the woman is a candidate for this treatment.
- Many women wonder about the safety of leaving particles
in the body. The embolic particles most commonly used in
UFE have been available with FDA approval for use in
people for more than 20 years. During that time, they
have been used in thousands of patients without long-term
complications.
Effect on Fertility
There have been numerous reports of pregnancies following
uterine fibroid embolization, however prospective studies are
needed to determine the effects of UFE on the ability of a woman
to have children. One study comparing the fertility of women who
had UFE with those who had myomectomy showed similar numbers of
successful pregnancies. However, this study has not yet been
confirmed by other investigators.
Less than two percent of patients have entered menopause as a
result of UFE. This is more likely to occur if the woman is in
her mid-forties or older and is already nearing menopause.
Risks
UFE is a very safe method and, like other minimally invasive
procedures, has significant advantages over conventional open
surgery. However, there are some associated risks, as there are
with any medical procedure. A small number of patients have
experienced infection, which usually can be controlled by
antibiotics. There also is a less than one percent chance of
injury to the uterus, potentially leading to a hysterectomy.
These complication rates are lower than those of hysterectomy and
myomectomy.
Magnetic Resonance Guided Focused Ultrasound
Magnetic resonance guided focused ultrasound (MRGFU) is a
non-invasive outpatient, procedure that uses high intensity
focused ultrasound waves to ablate (destroy) the fibroid tissue.
During the procedure, an interventional radiologist uses magnetic
resonance imaging (MRI) to see inside the body to deliver the
treatment directly to the fibroid. The procedure is FDA approved
for treating uterine fibroids, but is under investigation for the
treatment of breast, prostate, brain and bone cancer.
MRI scans identify the tissue in the body to treat and are
used to plan each patient's procedure. MRI's provide a
three-dimensional view of the targeted tissue, allowing for
precise focusing and delivery of the ultrasound energy. MRI also
enables the physician to monitor tissue temperature in real-time
to ensure adequate but safe heating of the target. Immediate
imaging of the treated area following MRGFU helps the physician
determine if the treatment was successful.
The ultrasound energy used in MRGFU can pass through skin,
muscle, fat and other soft tissues. High-intensity ultrasound
energy that is directed to the fibroid heats up the tissue and
destroys it. This method of tissue destruction is called thermal
ablation.
This procedure is new and not widely available. Information on
research findings can found in our MRGFU
bibliography.
Surgical Treatments for Fibroids
Gynecologists perform hysterectomy and myomectomy surgery.
Hysterectomy is the removal of the uterus and is considered major
abdominal surgery. It requires three to four days of
hospitalization and the average recovery period is six weeks.
Depending on the size and placement of the fibroids,
myomectomy can be an outpatient surgery or require two to three
days in the hospital. However, myomectomy is usually major
surgery that involves cutting out the biggest fibroid or
collection of fibroids and then stitching the uterus back
together. Most women have multiple fibroids and it is not
physically possible to remove all of them because it would remove
too much of the uterus. While myomectomy is frequently successful
in controlling symptoms, the more fibroids the patient has,
generally, the less successful the surgery. In addition, fibroids
may grow back several years later.
Myomectomy, like UFE, leaves the uterus in place and may,
therefore, preserve the woman’s ability to have children.
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