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What are FIBROIDS?
FIBROIDS are benign (non-cancerous)
tumors of the uterus composed of smooth muscle found normally in the
uterus. They are also called myomas or leiomyomas. FIBROIDS are located
in different parts of the uterus.�
Why do I have them?
No one knows how FIBROIDS occur.
FIBROIDS affect 40% of women of childbearing age and an even higher
percentage of African-American women. There is a link between FIBROIDS
and estrogen. That is why FIBROIDS will often grow during pregnancy
and that is why they will often cease to be a problem after menopause.� �
Does everyone with FIBROIDS
need to be treated?
No. Patients who have FIBROIDS
with no symptoms do not need any treatment. They will be followed for
the development of symptoms.�
What are the symptoms caused
by FIBROIDS?
The most common symptoms from
FIBROIDS are heavy menstrual bleeding, pelvic pain, increased urinary
frequency, constipation, and painful intercourse. The symptoms result
from the FIBROIDS being hard and firm (i.e. like rocks). Depending on
their location, FIBROIDS will cause any or all of the above symptoms.
If the FIBROIDS are located centrally in the uterus near the lining,
they will stretch that lining not allowing it to heal. The result is
often heavy menstrual bleeding. Patients often report increasingly heavy
flow. They might have episodes of blood flooding or gushing
out when the stand up. They might pass large clots. Patients can become
anemic and tired. They might start craving/chewing ice or on rare occasions
laundry starch (from severe anemia). Sometimes patients who have been
bleeding for a long time do not realize that their bleeding is abnormal.
If you change more than 8 pads/day or if you need to change pads on
occasion every hour, that is too frequent.
If the FIBROIDS are near the
bladder they can act as a paperweight, not allowing the normal amount
of urine to enter the bladder before feeling the urge to urinate. The
bladder cannot fill normally and the result is the patient goes to bathroom
much more frequently and often wakes up in the middle of the night to
go to the bathroom. Often the women feels like her bladder is going
to burst if she doesn t go and is surprised by how little she actually
goes when she does empty her bladder. It is because her bladder is being
compressed by the rock-like fibroid on her bladder and she actually
has relatively little urine in it (it just feels really full).
FIBROIDS in the back of the
uterus can press on the colon and cause constipation. FIBROIDS near
the cervix can cause painful intercourse. �
Is UAE an experimental procedure?
Absolutely not. It has been
performed for over 10 years and in over 50,000 patients worldwide. Long-term
data has been published in peer-reviewed medical journals on the effectiveness
of UAE. �
Do gynecologists perform
the UAE procedure?
No. UAE is performed by Interventional
Radiologists. These physicians are specifically trained in image-guided
procedures. It is why an Interventional Radiologist (IR) does not have
to open the patient up to treat the FIBROIDS, like a Gynecologist (who
is trained like a traditional surgeon) would. A Gynecologist needs to
actually see the FIBROIDS that they treat, whether it is by surgically
opening the patient s abdomen, or inserting large scopes to peer inside
the belly. An IR uses x-ray imaging to see inside the patient
and their FIBROIDS without the need to open them up surgically. Therefore,
a tiny nick in the skin (less than width of one s pinky finger) is
all that is necessary to gain access to the patient s FIBROIDS using
image-guided catheters which are similar in size to a piece of spaghetti.�
How does the UAE procedure
work?
The rock-like FIBROIDS need
a blood supply to stay alive and grow. During the UAE procedure, this
blood supply is purposely blocked. This causes the FIBROIDS to die off.
They will first start to soften and liquefy, and eventually they will
shrink. While some FIBROIDS will disappear completely, it is not necessary
for them to do so. Often the FIBROIDS will still be present on imaging
(exs. MRI or ultrasound), but since they are now soft (like bags of
water rather than rocks) they can no longer cause the significant symptoms
anymore. For example, a woman had increased urinary frequency with waking
up multiple times to urinate because of a fibroid compressing the bladder.
After UAE, even if the fibroid does not shrink very much, it is now
a bag of water and the bladder can push it out of the way and fill normally.
The patient now sleeps through the night without waking up and she urinates
much less often. The average reduction in volume of the fibroid after
UAE is 40% by 3 months and 65% by 6 months. Therefore, we usually get
both significant symptom improvement (~90%) and significant size improvement,
but sometimes we only get significant symptom improvement. That s
what is most important. Remember that women who have no symptoms, do
not need any treatment. They might have FIBROIDS, but if they don t
have any symptoms, they don t need treatment of any kind.
How do you perform UAE?
The approach for UAE is like
a heart catheterization. Patients are asleep during the procedure which
takes about an hour to perform. They receive conscious (intravenous)
sedation like you would get during a colonoscopy. Local anesthetic is
placed in the right groin/top of the thigh area. A catheter is positioned
under x-ray guidance into the blood supply of the uterus. This blood
supply can be thought of as a tree with leaves. The trunk is the main
uterine artery and the leaves are the branches that supply the FIBROIDS.
Tiny particles are injected which are specifically sized for the fibroid
vessels. These vessels become blocked, resulting in pruning of the
tree . The trunk stays open and supplies the normal uterine tissue,
but the FIBROIDS will start to wither away, soften, and eventually shrink
in size.�
 
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How do I know if I am a
candidate for UAE?
To know for sure, you would
need a consultation with Dr. Lipman in his office. We would obtain a
pelvic MRI prior to your consultation, which our office will arrange
for you. The consult takes about 45 minutes and Dr. Lipman will discuss
your symptoms, treatment options, and go over your MRI pictures with
you. In general, patients that have been told that they are candidates
for other fibroid treatments (exs. Hysterectomy, myomectomy, endometrial
ablation, etc.) are usually candidates for UAE. Rarely, a fibroid may
not be suitable for UAE and it is one of the reasons for obtaining the
MRI. �
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What are the benefits of
UAE over other fibroid therapies?
1. Minimally invasive:
There is no general anesthesia, no inpatient hospitalization, and no
surgical incision. A tiny nick in the skin (which is covered by the
pad of a bandaid) is the only footprint that any procedure was performed.
This is usually completely invisible by the one week follow-up visit.
2. Highly successful:
In our experience, over 90% of patients have found significant improvements
in all of their symptoms, or the symptoms are completely gone. The remaining
10% of patients are usually only slightly better or unchanged (i.e.
not worse). These patients typically have adenomyosis which is harder
to treat than FIBROIDS (see Adenomyosis) or have ovarian branches that
are also feeding the FIBROIDS in addition to the uterine branches. These
ovarian branches keep the fibroid alive and therefore the symptoms remain
after the initial UAE. If a woman is not interested in fertility and
has these ovarian branches feeding the fibroid, she can undergo a 2nd
embolization to treat this rather than undergoing hysterectomy. UAE
is a global therapy (like hysterectomy) in the fact that it treats all
of the FIBROIDS. Myomectomy only treat some of the FIBROIDS, and Endometrial
Ablation does not treat any of the FIBROIDS (tries to treat the bleeding
symptom but does nothing to the actual fibroid(s) causing this symptom).
3. Outpatient procedure:
98% of patients discharged home the day of the procedure, and the rest
discharged within 23 hours (ie. overnight stay).
4. Shorter recovery time:
Average recovery 4 days and one week away from work versus 6 to 8 weeks
for hysterectomy or myomectomy.
5. Less risk: No general
anesthesia or surgical incisions. For the risks of UAE see separate
discussion in this section.�
I had a pelvic ultrasound
in my gynecologist s office. Is this satisfactory imaging, or do I
still need a MRI ?
While we will look at the ultrasound
reports that you have had, it is still necessary to obtain a pelvic
MRI. There are conditions that mimic FIBROIDS and are hard to diagnose
just on ultrasound (see Adenomyosis). �
Does the size and number
of FIBROIDS matter?
No. Patients that are told
that they are not candidates for UAE because they have too many FIBROIDS
or that they are too big are being given false information. �
�
I have had a myomectomy,
can I still be considered for UAE?
Yes. Myomectomy is the removal
of the largest fibroid or collection of FIBROIDS and attempts to sew
the uterus back together. FIBROIDS are often multiple and reside in
multiple areas of the uterus. It is often not possible to remove all
of the FIBROIDS and still be able to have a uterus left intact (2-3%
of patients that undergo myomectomy wake up with a hysterectomy). Therefore,
after myomectomy, there is still a significant fibroid burden which
will continue to grow after surgery and the symptoms will recur. It
recurs at a rate of 10% per year (i.e. over half of the patients will
recur within 5 years, over 1/3 within 3 years). UAE treats all
of the FIBROIDS that are in the uterus and therefore the recurrence
rate after UAE is much lower than that seen with myomectomy.�
I have had an Endometrial
Ablation, can I still be considered for UAE?
Yes. Endometrial Ablation burns
the lining of the uterus through different forms of heat (exs. Scalding
hot water in a balloon, microwave energy, etc.). This can only try to
treat the bleeding associated with FIBROIDS, but does nothing to the
fibroid itself or the bulk symptoms associated with FIBROIDS (exs. Pelvic
pain, increased urinary frequency, constipation, etc.). �
How long will I spend in
the hospital?
Unlike many other centers performing
UAE, patients are not routinely admitted overnight. Patients typically
spend the day at the Center and are discharged the same afternoon. Roughly
2% of patients will need to spend the night, and no one will need to
stay beyond overnight. Therefore, it is helpful to have an overnight
bag just in case, but most likely you will not need it. Patients will
need someone to drop them off and pick them up at the end of the day.
We also do not routinely place a catheter in the patient s bladder
which can be very uncomfortable and may cause a urinary tract infection.
Patients have their own spacious room in the Center and are not transported
to a separate area of the hospital or admitted to a hospital floor with
inpatients. Each nurse is responsible for only one patient, which gives
the patient the personal nursing attention that is not present in a
traditional hospital setting. Family members can be with the patient
throughout their stay at the Center. �
 
Dr. Lipman displays a catheter that will be Dr. Lipman performing the UAE procedure in the
inserted over a guidwire and steered under x-ray interventional suite.
guidance under x-ray guidance into the
patient's uterine artery. From
there,
the embolic particles will be injected
into the fibroid's blood supply. Without
a blood supply, the fibroids will die off,
and as they do the patient's symptoms
resolve.
What is the recovery period
at home and how long will I be out of work?
The average recovery period
is 4 days. Patients are typically out of work for 1 week. Occasionally,
patients will need a second week away from work. �
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What are the risks of UAE?
From a risk profile, UAE is
safer than the surgical options. The main risks of the procedure are
as follows:
1. Menopause: Roughly 2% of
women will go into menopause after UAE. The large majority of these
women are over 45 years of age. A much smaller percentage of women enter
menopause after UAE that are between 40 and 45 years of age. No one
in our experience under 40 years of age has experienced this.
2. Fibroid slough: Roughly
5% of women will slough fibroid tissue with menses after UAE. The material
is from a fibroid that is near the lining and falls into the cavity
and passed in pieces after the UAE. This is not concerning, except that
it is important to tell patients about this so that they are not alarmed
if they see this after UAE. On very rare occasions (~1 in a 1,000 patients),
the material is in the cavity, but a woman cannot pass it. Symptoms
of sudden, sharp pain, fever, and a foul malodorous discharge alert
the women of this occurrence and the Interventional Radiologist is immediately
notified. The patient is placed on antibiotic therapy and watched closely
for ~24 hours. If she passes the material, no further steps are taken.
If she cannot pass the material, an elective outpatient D&C with
her gynecologist may be necessary.�
3. Allergy to the contrast:
Rarely, patients will be allergic to the x-ray contrast. In the very
rare event that a reaction occurs, patients are given medicine to reverse
and stop it.
4. Fertility: Myomectomy adversely
affects fertility such that after one myomectomy the fertility rate
drops to ~50% and after 2 myomectomies to ~10%. We don t know yet
what the drop is with UAE. That is because while the UAE procedure has
been performed since 1995, it is only more recently that patients who
desired fertility have been treated. A number of patients have delivered
full-term babies after UAE (we have even had a set of twins) without
difficulty. Small recent papers show higher fertility rates after UAE
compared to myomectomy, but the numbers are still too small. Patients
need to weigh all the risks before deciding on UAE if they desire fertility.
In general, patients with single FIBROIDS (simple myomectomy) may be
better served with myomectomy until the fertility risks are known, whereas
patients with multiple FIBROIDS and a complex myomectomy favors UAE. �
What should a patient expect
after UAE?
While the UAE procedure is
entirely pain free, after the procedure the patient can be uncomfortable.
Most patients describe the feeling after UAE as a heavy, crampy discomfort
that they often experience with their menses. The first afternoon and
evening of the procedure are the most uncomfortable, with patients feeling
significantly better the day after the procedure. Each day over the
next several days, the patient will feel better than the previous day. ��
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What is the follow-up after
UAE?
Patients are discharged home
the day of the procedure. They receive a telephone call from the nurses
the day after the procedure. A one week follow-up visit with Dr. Lipman
is available but voluntary. Any questions or concerns after the UAE
are directly handled by Dr. Lipman and not the gynecologist. Dr. Lipman
will communicate with the gynecologist by letter on every patient seen
and will call them directly if there is any issue that he feels is important
to notify them about. All patients are seen at three months after UAE
and at one year after UAE. Rarely, additional follow-up is necessary. �
Can a woman have a child
after UAE?
Yes. A patient should not attempt
to get pregnant for at least 6 months following UAE. Since the gynecologic
experience of pregnant UAE patients is not large, these patients will
usually be monitored more closely than a routine pregnant patient. �
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