To diagnose fibroids, your doctor needs information about your symptoms and how they affect you.  He or she may ask for a blood test to check if you are anemic, may have you see a specialist who can do imaging, like ultrasound scan or MRI to visualize any fibroids you may have.

 

By Sarah Wassner Flyn
April, 2008

Chances are, you know someone who has battled uterine fibroids – abnormal, benign growths within the muscles of the uterus that can cause painful, heavy menstrual bleeding, constipation and lower back pain. After all, at least 25 percent of women in the U.S. between the ages of 25 and 50 suffer fibroids, with the percentage almost doubling among African American women, according to the National Institutes of Health.

Up until a few decades ago, women with fibroids faced with only one treatment option – a hysterectomy. But thanks to further research and advanced technology, less radical options are now available, including the noninvasive, uterus-saving uterine artery embolization. Here is a closer look at that procedure, as well as more info on fighting fibroids.

DO YOU HAVE FIBROIDS?

It is hard to miss some of the symptoms of fibroids — excessive pain in the pelvis, heavy bleeding, pressure on the bowel or bladder and infertility. But not everyone experiences these overt signs.

“Sometimes I see patients who have no other symptoms other than the fact that they can’t fit into their clothes even though they’ve been exercising like a fanatic,” says Dr. Bruce McLucas, a professor of obstetrics and gynecology at the University of California-Los Angeles and founder of the Fibroid Treatment Collective in Los Angeles. He adds, “Fibroids can cause the uterus to swell, but it’s easy to mistake that for a little weight gain.”

This reiterates the importance of regular check-ups with your gynecologist for routine pelvis exams that can detect fibroids, if you happen to have them.

A NON-SURGICAL APPROACH

If you find out you have fibroids, do not fear. You do not have to have a hysterectomy or undergo a similarly scary surgery.

“Forty percent of hysterectomies are due to fibroids, and most are unnecessary. So many women do not have to lose their uterus,” says McLucas. Rather, you can opt for uterine artery embolization, a relatively new procedure that injects microscopic plastic particles into the uterine arteries via a catheter, blocking the flow of blood to the fibroids.

As a result, the fibroid tissue shrinks, ultimately relieving symptoms and increasing fertility. Further, pregnancies following fibroid treatment do not appear to carry excess risk. Today more than several hundred thousand women worldwide have found relief with uterine artery embolization. “The entire procedure takes about 20 minutes, but the results can last a lifetime,” says McLucas.

RECOVERY TIME

A noninvasive procedure, recovery after a uterine artery embolization is minimal. “Sometimes we require patients to spend one night in the hospital for observation, but many go home the same day. You should be back up to speed within a week,” says McLucas. An added bonus is that there are no wounds or scars since the incision in your upper thigh is as small as a freckle.

SUCCESS RATE

The Fibroid Treatment Collective center boasts an extremely high success rate for uterine artery embolization. McLucas explains, “Over 99 percent of our patients have immediate relief from heavy bleeding, 94 percent experience up to 60 percent fibroid shrinkage, and 33 percent are able to successful conceive following the procedure.”

ANOTHER FIBROID TREATMENT OPTION: MYOMECTOMY

Myomectomy – the surgical removal of fibroids from the wall of the uterus via small incisions through the abdomen or the vagina – is another alternative to a hysterectomy. However, due to risky side effects and a higher reoccurrence rate, McLucas stresses looking into embolization first.

“With myomectomy you face complications like blood loss, uterine scarring, and a 30 percent chance of regrowth,” he says. “Go for an embolization first, and if that doesn’t work, you can always undergo a myomectomy. Embolization doesn’t burn any bridges.”

From Top Health Breakthroughs

11/21/07
By Dr. Isadore Rosenfeld

Nonsurgical treatments available are available for treatment of uterine fibroids, which can cause pelvic pain, frequent urination and vaginal bleeding.  Featured in this article on the Top Health Breakthroughs of 2007, uterine artery embolization treats fibroids by blocking their blood supply to shrink them.

 

Maybe I’m the wrong ex-patient to be telling you this: Experimental surgery erased Stage III colon cancer from my shell-shocked body six years ago. But even I’ve got to admit that all is not well in America’s operating rooms: At least 12,000 Americans die each year from unnecessary surgery, according to a Journal of the American Medical Association report. And tens of thousands more suffer complications.

Surgery is a trauma, regardless of the surgeon’s skills.

The fact is, no matter how talented the surgeon, the body doesn’t much care about the doc’s credentials. Surgery is a trauma, and the body responds as such — with major blood loss and swelling, and all manner of nerve and pain signals that can stick around sometimes for months.

Those are but a few reasons to try to minimize elective surgery. And I found even more after talking with more than 25 experts involved in various aspects of surgery and surgical care, and after reviewing a half-dozen governmental and medical think tank reports on surgery in the United States. Here’s what you need to know about five surgeries that are overused and alternative solutions that may be worth a look.

Hysterectomy

There’s long been a concern, at least among many women, about the high rates of hysterectomy (a procedure to remove the uterus) in the United States. American women undergo twice as many hysterectomies per capita as British women and four times as many as Swedish women.

The surgery is commonly used to treat persistent vaginal bleeding or to remove benign fibroids and painful endometriosis tissue. If both the uterus and ovaries are removed, it takes away sources of estrogen and testosterone. Without these hormones, the risk of heart disease and osteoporosis rises markedly. There are also potential side effects: pelvic problems, lower sexual desire and reduced pleasure. Hysterectomies got more negative press after a landmark 2005 University of California, Los Angeles study revealed that, unless a woman is at very high risk of ovarian cancer, removing her ovaries during hysterectomy actually raised her health risks.

So why are doctors still performing the double-whammy surgery? “Our profession is entrenched in terms of doing hysterectomies,” says Ernst Bartsich, M.D., a gynecological surgeon at Weill-Cornell Medical Center in New York. “I’m not proud of that. It may be an acceptable procedure, but it isn’t necessary in so many cases.” In fact, he adds, of the 617,000 hysterectomies performed annually, “from 76 to 85 percent” may be unnecessary.

Although hysterectomy should be considered for uterine cancer, some 90 percent of procedures in the United States today are performed for reasons other than treating cancer, according to William H. Parker, M.D., clinical professor of gynecology at UCLA and author of the ’05 study. The bottom line, he says: If a hysterectomy is recommended, get a second opinion and consider the alternatives.

What to do instead

Go knife-free. Endometrial ablation, a nonsurgical procedure that targets the uterine lining, is another fix for persistent vaginal bleeding.

Focus on fibroids. Fibroids are a problem for 20 to 25 percent of women, but there are several specific routes to relief that aren’t nearly as drastic as hysterectomy. For instance, myomectomy, which removes just the fibroids and not the uterus, is becoming increasingly popular. And there are other less-invasive treatments out there, too.

In France in the early 1990s, a doctor who was prepping women for fibroid surgery — by blocking, or embolizing, the arteries that supplied blood to the fibroids in the uterus — noticed a number of the benign tumors either soon shrank or disappeared, and, voila, Jacques Ravina, M.D,. had discovered uterine fibroid embolization.

Since then, interventional radiologists in the United States have expanded their use of UFE (typically a one- to three-hour procedure), using injectable pellets that shrink and “starve” fibroids into submission. Based on research from David Siegel, M.D., chief of vascular and interventional radiology at Long Island Jewish Medical Center, New Hyde Park, New York, 15,000 to 18,000 UFEs are performed here each year, and up to 80 percent of women with fibroids are candidates for it.

Another new fibroid treatment is high-intensity focused ultrasound, or HIFU. This even less invasive, more forgiving new procedure treats and shrinks fibroids. It’s what’s called a no-scalpel surgery that combines MRI (an imaging machine) mapping followed by powerful sound-wave “shaving” of tumor tissue.

Episiotomy

It can sound so simple and efficient when an OB-GYN lays out all the reasons why she performs episiotomy before delivery. After all, it’s logical that cutting or extending the vaginal opening along the perineum (between the vagina and anus) would reduce the risk of pelvic-tissue tears and ease childbirth. But studies show that severing muscles in and around the lower vaginal wall (it’s more than just skin) causes as many or more problems than it prevents. Pain, irritation, muscle tears, and incontinence are all common aftereffects of episiotomy.

Last year the American College of Obstetricians and Gynecologists released new guidelines that said that episiotomy should no longer be performed routinely — and the numbers have dropped. Many doctors now reserve episiotomy for cases when the baby is in distress. But the rates (about 25 percent in the United States) are still much too high, experts say, and some worry that it’s because women aren’t aware that they can decline the surgery.

“We asked women who’d delivered vaginally with episiotomy in 2005 whether they had a choice,” says Eugene Declercq, Ph.D., main author of the leading national survey of childbirth in America, “Listening to Mothers II,” and professor of maternal and child health at the Boston University School of Public Health. “We found that only 18 percent said they had a choice, while 73 percent said they didn’t.” In other words, about three of four women in childbirth were not asked about the surgery they would soon face in an urgent situation. “Women often were told, ‘I can get the baby out quicker,'” Declercq says, as opposed to doctors actually asking them, ‘Would you like an episiotomy?'”

What to do instead

Communicate. The time to prevent an unnecessary episiotomy is well before labor, experts agree. When choosing an OB-GYN practice, ask for its rate of episiotomy. And when you get pregnant, have your preference to avoid the surgery written on your chart.

Get ready with Kegels. Working with a nurse or midwife may reduce the chance of such surgery, experts say; she can teach Kegel exercises for stronger vaginal muscles, or perform perineal and pelvic-floor massage before and during labor.

Angioplasty

Every year in the United States, surgeons perform 1.2 million angioplasties, during which a cardiologist uses tiny balloons and implanted wire cages known as stents to unclog arteries. This Roto-Rooter-type approach is less invasive and has a shorter recovery period than bypass, which is open-heart surgery.

The problem: A groundbreaking study of more than 2,000 heart patients indicated that a completely nonsurgical method — heart medication — was just as beneficial as angioplasty and stents in keeping arteries open in many patients.

The bottom line: Angioplasty did not appear to prevent heart attacks or save lives among nonemergency heart subjects in the study.

What to do instead

Take the right meds. If the study is right, medications may be as strong as steel. “If you have chest pain and are stable, you can take medicines that do the job of angioplasty,” says William Boden, M.D., of the University of Buffalo School of Medicine, Buffalo, New York, and an author of the study. Medicines used in the study included aspirin, and blood pressure and cholesterol drugs — and they were taken along with exercise and diet changes.

“If those don’t work, then you can have angioplasty,” Boden says. “Now we can unequivocally say that.”

Of course, what’s right for you depends on the severity of your atherosclerosis risks (blood pressure, cholesterol, triglycerides) along with any heart-related pain. The onus is also on the patient to treat a doc’s lifestyle recommendations — diet and exercise guidelines — just as seriously as if they were prescription medicines.

Heartburn surgery

A whopping 60 million Americans experience heartburn at least once a month; 16 million deal with it daily. So it’s no wonder that after suffering nasty symptoms (intense stomach-acid backup or near-instant burning in the throat and chest after just a few bites), patients badly want to believe surgery can provide a quick fix. And, for some, it does.

A procedure called nissen fundoplication can help control acid reflux and its painful symptoms by restoring the open-and-close valve function of the esophagus. But Jose Remes-Troche, M.D., of the Institute of Science, Medicine, and Nutrition in Mexico, reported in The American Journal of Surgery that symptoms don’t always go away after the popular procedure, which involves wrapping a part of the stomach around the weak part of the esophagus.

“That may be because surgery doesn’t directly affect healing capacity or dietary or lifestyle choices, which in turn can lead to recurrence in a hurry,” he says.

The surgery can come undone, and side effects may include bloating and trouble swallowing. Remes-Troche believes it’s best for very serious cases of long-standing gastroesophageal reflux disease, or GERD, or for those at risk of Barrett’s esophagus, a disease of the upper gastrointestinal tract that follows years of heartburn affliction and can be a precursor to esophageal cancer.

What to do instead

Make lifestyle changes. A combination of diet, exercise, and acid-reducing medication may help sufferers beat the burn without going under the knife. But it’s a treatment that requires perseverance.

“It took me four years of appointments, diets, drugs, sleeping on slant beds — and even yoga — to keep my heartburn manageable,” says Debbie Bunten, 44, a Silicon Valley business-development manager for a software firm, who was eager to avoid surgery. “But I did it, and am glad I did.”

 

Treating Troubling Fibroids Without Surgery
By: Linda Villarosa
November 23, 2004

Condoleezza Rice, the national security adviser, shares at least one thing with millions of other American women: she had fibroids, benign tumors in the uterus that required treatment.

Ms. Rice, the nominee for secretary of state, entered the hospital for an overnight stay last week to undergo a procedure – uterine artery embolization – that is rapidly becoming an alternative to major surgery for troublesome fibroids.

For most women, fibroids, consisting of muscle and fibrous tissue, are no bother. But for millions of others, fibroids can be so large (in some cases, the size of a melon) or so numerous that they cause discomfort, severe bleeding, anemia, urinary frequency and other symptoms.

What causes fibroids is unknown, although estrogen is known to promote their growth. More than one woman in five age 40 and older has the tumors, with higher rates among black women.

For decades, major surgery – a hysterectomy to remove the uterus or a myomectomy to remove selected fibroids while leaving the uterus in place – was the main therapy for women whose symptoms were not controlled by oral contraceptives or other hormonal therapies. About 30 percent of the 600,000 hysterectomies performed in the United States each year are for fibroids.

With the introduction of technologies like ultrasound, C.T. scans, magnetic resonance imaging and new drugs, however, doctors have in recent years developed a number of alternative therapies.

This year in the United States, about 13,000 women are expected, like Ms. Rice, to choose the embolization technique, which is less invasive than surgery. French doctors first reported the embolization procedure in 1995. Since then, the number of the procedures has grown, in part because of direct-to-consumer advertising by interventional radiologists, who perform them.

Embolization involves injecting pellets the size of grains of sand, made from plastic or gels, into uterine arteries to stop blood flow and shrink the tumors by starvation. The procedure is so named because the pellets are emboli, objects that lodge and stop blood flow. M.R.I. scans are often used to screen out fibroid patients who are not candidates for the embolization procedure.

In performing the procedure, interventional radiologists insert a thin tube into an artery in the groin and thread it up to the main uterine artery in the pelvis. A dye is injected that outlines the smaller arterial branches on an X-ray, producing a map that guides injection of pellets through the tube into the arteries that nourish the fibroids.

“Of the patients we see, at least a third have fibroids the size of an orange or larger,” and the size does not influence the outcome of the procedure, said Dr. John H. Rundback, an interventional radiologist at Columbia University.

The procedure, which may be painful, usually lasts 60 to 90 minutes. Most patients also experience intense pain for several hours afterward and stay overnight in the hospital. For some patients, the pain persists for several days, or even two weeks. Surgery for fibroids requires a longer hospital stay.

Additional complications from the embolization procedure can include abscesses and other infections; heavy uterine bleeding; early menopause from the pellets damaging the ovaries; or destruction of the uterus, requiring emergency surgery.

Although the procedure is safe, “there are still significant uncertainties about the procedure, especially in terms of future fertility and long-term outcomes,” said Dr. Evan R. Myers, chief of the division of clinical and epidemiologic research in Duke University’s department of obstetrics and gynecology.

Judging the safety and effectiveness of embolization compared with to other therapies is hard because randomized controlled studies are lacking and because earlier studies did not report how different symptoms responded to different treatments, Dr. Myers said.

“It is amazing that for a condition as common as fibroids, that has such significant impact on reproductive-age women, there is not a lot of high-quality scientific evidence for many of the things that are done for fibroids,” Dr. Myers said.

“There still is no gold standard randomized trial comparing embolization to the other interventions,” he added. This is largely because patients and physicians have such strong preferences for one method or another that it is hard to recruit enough patients for clinical trials comparing the embolization procedure to hysterectomy, myomectomy, hormonal and other therapies.

Dr. Myers directs a registry that the Society of Interventional Radiology has created to monitor the outcome of 3,000 women who have undergone the embolization procedure. He said that the effectiveness and complication rates for embolization seem comparable to surgery. But there is insufficient information to draw conclusions about the procedure’s safety for women who desire to become pregnant, according to Dr. Myers, the interventional society and the American College of Obstetricians and Gynecologists.

In very rare cases – less than 1 percent – fibroids are cancerous. The cancers usually develop among postmenopausal women and the embolization procedure is not recommended for that group. Biopsies are not routinely performed on fibroid patients before embolization, and even if they were done, biopsies would not be able to detect cancerous fibroids deep in the uterine muscle. So statistically, as more women undergo embolization procedures, the cancers are unlikely to be detected in the very few patients who have them.

“That small risk has to go into the counseling before the embolization procedure,” said Dr. Howard T. Sharp, chief of the general division of obstetrics and gynecology at the University of Utah.

Dr. Sharp said he believed that there were probably more cases of cancer than the single report in the medical literature, because doctors often “don’t report the bad outcomes.”

While some researchers are trying to study the embolization procedure further, others, like Dr. Elizabeth Stewart of the Brigham and Women’s Hospital in Boston, are testing another fibroid treatment, the ExAblate 2000 System, that won approval from the Food and Drug Administration last month.

The system, made by InSightec Ltd. of Israel, uses ultrasound to destroy the fibroids with heat and M.R.I. to map the uterine anatomy and monitor the degree of fibroid destruction from a repeated application of multiple ultrasound waves on the tumor. The device centers the ultrasound waves similarly to the way a magnifying glass focuses light.

The patient remains in an M.R.I. machine for about three hours and then can go home. Initial studies found that serious side effects occurred in 2 percent of cases, compared with 13 percent among women who underwent a hysterectomy, Dr. Stewart said. Additional studies are being conducted at a small number of hospitals. The procedure is intended for women who have completed childbearing or who do not intend to become pregnant.

For the original version of this article: Treating Troubling Fibroids Without Surgery

As an educational service, members of the FTC provide
questions and answers regarding fibroids. Please note that the questions and answers are not medical advice and there is no substitute for diagnosis and, where appropriate, treatment by a qualified and licensed physician of your own choosing.

 

By: Lee Peterson

When doctors told Victoria Overton she needed a hysterectomy, she balked. She wanted to know the alternatives. But her first- and second-opinion gynecologists gave her no options. To them, a large uterine fibroid on her uterus meant that the entire organ would have to be removed.

The benign tumor was causing problems: heavy bleeding, a frequent need to urinate and pain during sex. Overton knew she had to do something. The surgery was scheduled. She was even about to bank some blood in preparation for the operation. Then the Playa del Rey woman after badgering another gynecologist, heard about an alternative, a treatment for fibroids called uterine artery embolization.

In the procedure, a doctor clogs the blood vessels leading to the tumors with tiny plastic pellets. Starved of a blood supply, the fibroids shrivel, but the uterus stays alive. The minimally invasive treatment usually is done with local anesthetic and a conscious sedation, requiring only a one-night hospital stay. It might sound like an easy choice, but the medical community is sharply divided over the new technique. The group of physicians who perform it struggle for acceptance in the eyes of gynecologists, who as a group say it is not a proven substitute for hysterectomy.

Proponents say women, at least, should be offered the choice. The only other uterus-saving operation in which a surgeon removes the fibroids but leaves the uterus was not an option for the 47-year-old software executive. Her tumor was too large. “I did not want to have surgery. I did not want to be put under anesthesia. I did not want to miss that much work,” Overton said.

Overton found Dr. Richard Reed, an interventional radiologist who performs embolization at Daniel Freeman Memorial Hospital in Inglewood, one of a handful of places where it is available in the Los Angeles area.

The American College of Obstetricians and Gynecologists said 165,000 to 175,000 hysterectomies for fibroids were performed in the United States in 1994, the most recent year reflected in the statistics. Reed said the number today is 200,000 to 250,000, with another 50,000 myomectomies in which just the fibroids are removed. While Reed and the Society of Cardiovascular & Interventional Radiology support embolization as an alternative to hysterectomy in many cases, gynecologists say there is a reason that they don’t recommend it to patients: No one has proved in a controlled, randomized study that it is safe and effective.

Radiologists argue that gynecologists, who perform hysterectomies, worry about losing part of their turf. The OB-GYNs dismiss that and say they want only what’s best for the patient.

Doctors at UCLA Medical Center performed the first uterine fibroid embolization in this country in 1995. So far, about 6,000 have been done in the United States, while a total of about 10,000 have been performed worldwide. Reed said he spends a great deal of time making the case for the procedure to health insurers, trying to show why uterine artery embolization should be covered.

The radiology society reports that about half of all health plans cover the procedure. The turf conflict is similar to how cardio-thoracic surgeons at first viewed angioplasty in which a catheter is used to reopen clogged coronary arteries of the heart, before it earned widespread acceptance. “It’s a shame,” Reed said, “that women are not at least being offered the choice between embolization and hysterectomy. There are women who suffer in silence who don’t want a hysterectomy. They bleed so much they have to stay in bed,” Reed said.

“Embolization has been used for two decades to control bleeding for other obstetrical and gynecological problems, such as postpartum hemorrhage,” Reed said. “Through those procedures, it was found that it could be used to cut off the flow of blood to fibroid tumors.”

The procedure requires a great deal of skill as the radiologist guides the catheter through a single opening in the femoral artery, through the groin’s winding arterial system, using a fluoroscope. The doctor must enter both the left and right uterine arteries, one at a time. The sterile plastic balls are sent through the tube into the uterine arteries. Care must be taken so that they do not spread to arteries supplying blood to the legs or other places where they could cause serious problems. Doctors generally use a particle of 500 microns in diameter, the size of a typical grain of sand. That’s the right size, Reed said, to block the arteries to the fibroids, but not clog vessels that will still supply the uterus with its blood.

Women who ask for embolization (non-surgical treatment for uterine fibroids) are informed that it’s going to hurt. In the first hours afterward, the pain can be very sharp as the fibroids lose their blood supply. Overton, the patient, said she had a lot of pain that first day. But it was worth it, she said, as the symptoms that had sent her to the doctor in the first place quickly faded. She spent one night in the hospital and was back to work in about a week.

Fibroid tumors are benign masses on or in the walls of the uterus, a problem common in women age 35 to 55. Even if there are no symptoms of bleeding or pain, they can cause infertility.

For fertility patients with fibroids, embolization is not offered. Instead, the woman would likely undergo myomectomy, which preserves the uterus. While embolization is not offered as a fertility treatment, Reed said there have been a number of successful, if unplanned, pregnancies after embolization.

Reed argues that unless there is a fertility issue, myomectomy is not a good alternative to hysterectomy. Doctors agree that it can leave tiny seedling fibroids that grow and require the procedure all over again. Although some gynecologists will refer patients to doctors like Reed, the OB-GYN community at large is not sold on uterin artery embolization.

It is common in Europe, doctors said, for women with fibroids to request procedures that preserve their uteri, but it is not the norm in this country. Some are trying to change cultural attitudes, however, and promote keeping the uterus the womb intact whenever possible. Gynecologists note that surgery for fibroids, whether hysterectomy or myomectomy, can be performed often in ways that make it less invasive, either laparoscopically or also in cases of hysterectomy, vaginally. This means a woman is not staying in the hospital as long and is not having to wait six weeks to drive again as with an open procedure through the abdomen.

Embolization does not have the track record nor a large, randomized study to persuade gynecologists to offer it, said Dr. Buell Miller, a clinical professor at the University of Vermont’s Maine Medical Center in Portland, Maine. As a past member of the board of directors of the American College of OB-GYNs, and as current chairman of the board of the Maine Medical Assessment Foundation, he has not been impressed with the data on embolization so far. It’s not been well-studied, Miller said. Reed said about 1,500 uterine artery embolization have been part of published medical reports, showing a complication rate of about 3 percent.

As for a large, randomized study, Reed said it would be difficult to recruit patients, because candidates would have to agree to have either hysterectomy or embolization, whichever was randomly chosen for them. And then the study’s results would take about six to 10 years to report.The jury is still out on embolization, said Dr. Jordan Phillips, chairman of the board of the American Association of Gynecologic Laparoscopists, a Sant
a Fe Springs-based organization. But Phillips expects that enough procedures will have been performed soon for the medical community to judge if it is safe and beneficial.

I’m sure that by next year, we’ll have a very clear picture of the relative benefits of this procedure, Phillips said.

If you are showing signs of fibroid symptoms and think you have fibroids, schedule an appointment for a professional diagnosis. One of our fibroid surgeons will talk to you about your symptoms and perform a pelvic exam. We may order further testing including an imaging procedure such as an ultrasound. If fibroids are diagnosed we will discuss the best fibroid treatment for you. Here at the Fibroid Treatment Collective, we offer free consultations in-office or over the phone. Feel free to contact us for more information. To learn more about fibroids, visit our homepage.