Uterine Fibroid


Uterine fibroids | Symptoms | CauseDiagnosis | Treatment


What is uterine / uterus fibroid ?

Uterine fibroids (myomas, leiomyomas, or fibromyomas) are the most frequent tumors of the female genital tract: 20 to 40% of women of childbearing age have a fibroid. Fibroids range in size from very tiny to the size of an orange or larger. In some cases, they can cause the uterus to grow to the size of a five-month pregnancy or more. Fibroid may be located in various parts of the uterus.

Fibroids affect at least 20% of all women at sometime during their life. Women aged between 30 and 50 are the most likely to develop fibroids. Overweight and obese women are at significantly higher risk of developing fibroids, compared to women of normal weight.

 

 


Types of uterine Fibroids

• Intramural fibroids are located within the wall of the uterus and are the most common type; unless large, they may be asymptomatic. It may cause heavy bleeding with clots. With time, intramural fibroids may expand inwards, causing distortion and elongation of the uterine cavity.
• Subserosal fibroids are located on surface of the uterus and can become very large. They can cause pressure over bladder and rectum producing urgent urination and constipation with back pain.
• Submucosal fibroids are located in the muscle beneath the endometrium of the uterus and distort the uterine cavity; even small lesion in this location may lead to bleeding and infertility.
• Cervical fibroids are located in the wall of the cervix (neck of the uterus).

Symptoms of fibroids depending on location, they may cause:

1. Heavy, prolonged menstrual periods and unusual bleeding, sometime with clots. This might lead to anemia.
2. Lower abdomen, back or leg pain
3. Lower abdomen pressure or heaviness
4. Bladder pressure leading to a constant urge to urinate
5. Pressure on bowel, leading to constipation and bloating
6. Abnormally enlarged abdomen


Diagnosis

Picture A. Ultrasound image shows sub mucosal fibroid Picture B. MRI image shows multiple intramural fibroids.

Fibroids are usually diagnosed during a gynecologic examination. The presence of fibroids is most often confirmed by a lower abdomen ultrasound. Fibroids can also be confirmed using MRI (magnetic resonance imaging). These imaging techniques serve as a baseline examination for follow-up after uterine fibroid embolization (UFE).

 

 

 

 


Causes

Doctors don’t know the cause of uterine fibroids, but research and clinical experience point to these factors:
Genetic alterations: – Many fibroids contain alterations in genes that are different from those in normal uterine muscle cells.
Hormones: – Estrogen and progesterone, two hormones that stimulate development of the uterine lining during each menstrual cycle in preparation for pregnancy, appear to promote the growth of fibroids. Fibroids contain more estrogen and progesterone receptors than do normal uterine muscle cells.
Other chemicals: – Substances that help the body maintain tissues, such as insulin-like growth factor, may affect fibroid growth.

Complications

Although uterine fibroids usually aren’t dangerous, they can cause discomfort and may lead to complications such as anemia from heavy blood loss.
Anemia: – if the bleeding is very heavy.
Urinary tract infections: – if pressure from the fibroid prevents the bladder from fully emptying
Pregnancy and fibroids: – Fibroids usually don’t interfere with conception and pregnancy. However, it’s possible that fibroids could distort or block your fallopian tubes, or interfere with the passage of sperm from your cervix to your fallopian tubes. In other cases, treatment for fibroids during pregnancy isn’t necessary. A common complication of fibroids during pregnancy is localized pain, typically between the first and second trimesters. This is usually easily treated with pain relievers. But if you have fibroids and you’ve experienced repeated pregnancy losses, if no other causes of miscarriage can be found and if your fibroids distort the shape of your uterine cavity.


Non – Surgical Treatment options for uterine fibroids

Uterine artery embolization / Uterine Fibroid embolization:

It is a minimally invasive interventional radiological procedure, which means it requires only a tiny nick in the skin. It is performed under sedation and local anesthesia – feeling no pain and usually requires a hospital stay of one night. Many women resume light activities in a few days and the majority of women are able to return to normal activities within one week.

Ideal Patient for uterine artery embolization

  1. They have single / multiple fibroids
  2. The fibroids are symptomatic
  3. There is no cancer

UFE treats all uterine fibroids at the same time and is, therefore, an extremely effective.
The interventional Radiologist makes a small nick in the skin (less the ¼ of an inch) at groin, inserts a catheter, identifies uterine artery by using angiography with contrast media injection and then inject embolization particles (polyvinyl alcohol) that block the tiny vessels supplying all the fibroids. This blockade of blood supply to fibroids causes infarction (loss of blood supply to the fibroids) and subsequent degeneration of the fibroids and it starts reducing in size reaching half the size in few weeks. Symptoms due to the fibroids (like bleeding and pain) resolve in 85% to 95% of patients.

 

A. Embolization preparation. A tiny angiographic catheter is inserted through a nick in the skin in to an artery and advanced into fibroids.
B. Injection. Tiny polyvinyl alcohol particles of 500 um in diameter are wedge in the small arteries, blocking the blood flow to the fibroids.
While embolization to treat uterine fibroids has been performed since 1995, embolization of the uterus is not new. It has been used successfully by interventional radiologist for over 20 years to treat heavy bleeding after childbirth. The procedure is now available at hospitals.


Uterine Artery Embolization has many Indications:-

  • Single / multiple Uterine Fibroids.
  • Adenomyosis.
  • Failed myomectomy / recurrence of fibroids after myomectomy
  • High risk patient for surgery like obesity, anemia, Chronic renal failure etc.
  • Post-partum Hemorrhage
  • Bleeding from Cancer of Cervix & Uterus
  • Pre-operative embolization to reduce bleeding during uterine surgery.

Advantages of Uterine artery embolization

  • It is performed under Local anesthesia. Not General anesthesia.
  • Requires only a tiny nick in the skin (No surgical incision of abdomen).
  • Recovery is shorter than from hysterectomy or open myomectomy.
  • Virtually no adhesion formation has been found. But in surgery adhesions are common.
  • All fibroids are treated at once, which is not the case with myomectomy.
  • Recurrent growth of treated fibroids is uncommon.
  • Uterine fibroid embolization involves virtually no blood loss or risk of blood transfusion.
  • If the presenting complaint was excess vaginal bleeding, 87-90% of cases experiences resolution within 24 hours.
  • Emotionally, financially and physically – embolization can have an overall advantage over other procedures for the patient as the uterus is not removed.

Focused ultrasound surgery: –

MRI-guided focused ultrasound surgery (FUS) is a noninvasive treatment option for uterine fibroids that preserves your uterus. This procedure is performed while you’re inside of a specially crafted MRI scanner that allows doctors to visualize your anatomy, and then locate and destroy (ablate) fibroids inside your uterus without making an incision. Focused high-frequency, high-energy sound waves are used to target and destroy the fibroids. One or two treatment sessions are done in an on- and off-again fashion, sometimes spanning several hours.

Because it’s a newer technology, researchers are learning more about the long-term safety and effectiveness of FUS. Research continues, but so far data collected show that FUS for uterine fibroids is safe and very effective.


Treatment Options for Fibroids

There’s no single best approach to uterine fibroid treatment. Many treatment options exist. Watchful waiting Many women with uterine fibroids experience no signs or symptoms. If that’s the case for you, watchful waiting (expectant management) could be the best option. Fibroids aren’t cancerous.
Surgical: – A. Hysterectomy B. Myomectomy
Non-surgical: – A. Uterine artery embolization B. HIFU

A. Hysterectomy (removal of uterus)

What it is It is surgical removal of the uterus, usually performed by a gynecologist. Hysterectomy may be total (removing the body, fundus and cervix of the uterus; often called “complete”) or partial (removal of the uterine body while leaving the cervix intact; also called “supracervical”) But partial or complete, hysterectomy is major surgery.

How it is done it needs general anesthesia and requires surgical cut in lower abdomen, the size of scar depends on how big the uterus is.  It can be abdominal, vaginal or laparoscopic.

What it accomplishes –effective in curing gynecological problems like urinary incontinence due to uterine prolapse, very large fibroids of more than 18 cm and uterine, cervical, endometrial cancer.

Side effects Risk of bleeding is very common, requires blood transfusion. Short term death rate (within 40 days of surgery) is usually reported in the range of 1-6 cases per 1000 when performed for benign causes. The mortality rate is several times higher when performed in patients having cancer or other complications.

Long term effect on mortality is relatively more under the age of 45 years believed to be caused by the hormonal side effects of hysterectomy and prophylactic oophorectomy.
Approximately 35% of women after hysterectomy undergo another related surgery within 2 years.
Ureteral injury is not uncommon and can range from 2.2% to 3%.

Pros & Cons of surgery – Hospital stay is 3 to 5 days or more for the abdominal procedure and between 2 to 3 days for vaginal or laparoscopically assisted vaginal procedures.
Time for full recovery is very long and largely independent on the procedure that was used. Depending on the definition of “full recovery” 3 to 12 months have been reported. Serious limitations in everyday activities are expected for a minimum of 4 months.

It ends your ability to bear children, and if you also elect to have your ovaries removed, it brings on menopause and the question of whether you’ll take hormone replacement therapy.

B.Myomectomy (removal of fibroid)

What it is It is surgical removal of the fibroids, usually performed by a gynecologist. Myomectomy may be open or laparoscopic approach. Some time it done by hysteroscope. But it is also a major surgery.

How it is done.it needs general anesthesia and requires surgical cut in lower abdomen, the size of scar depends on how big the fibroid is.  It can be abdominal or laparoscopic.

What it accomplishes It is done for uterine fibroids.

Side effects Excessive blood loss. The uterus has a rich network of blood vessels and fibroids stimulate growth of new vessels to obtain their own blood supply. So during myomectomy, surgeons must take extra steps to avoid excessive bleeding.

Scar tissue.Incisions into the uterus to remove fibroids can lead to adhesions — bands of scar tissue that may develop after surgery. Within the uterus, adhesions may block implantation of a fertilized egg in the uterine lining and adhesions could entangle neighboring structures and lead to a blocked fallopian tube or a trapped loop of intestine.

Development of new fibroids. Myomectomy doesn’t eliminate your risk of developing more fibroids later. If fibroids return, future treatment — a repeat myomectomy, hysterectomy or other procedure — may be necessary.

Childbirth complications. Having had myomectomy surgery can pose some risk factors for delivery if you become pregnant. If your surgeon had to make a deep incision in your uterine wall, the doctor who manages your subsequent pregnancy may recommend cesarean delivery to avoid rupture of the uterus during labor.

Inability to restore the structure of the uterus. To remove embedded fibroids, the surgeon might cut into the muscular wall (myometrium), leaving a gap.
Pros & Cons of surgery – Hospital stay is 3 to 5 days or more for the abdominal procedure and between 2 to 3 days for  laparoscopically. Time for full recovery is very long and largely independent on the procedure that was used.

 


Non-Surgical – Uterine Artery Embolization

It is a non- surgical treatment called Uterine Artery Embolization it is done without any scar in abdomen and it need just mild sedation. No risk of blood loss or blood transfusion. It can be done in women who:

  • Experiencing symptoms of uterine fibroids.
  • A desire to retain her uterus and pursue hysterectomy alternatives.
  • Does not desire surgery.
  • Poor surgical candidate (e.g., because of obesity, bleeding disorders, anemia).
  • If she is not pregnant.

How it is done – Uterine fibroid embolization is a non-invasive, non-surgical outpatient procedure. This procedure blocks the blood supply of the arteries that supply fibroids causing them to shrink. Embolization uses angiographic techniques to place a catheter into the uterine arteries so that particles the size of grains of sand can be injected through catheter and into the blood supply of the fibroids.

What it accomplishes

  • Single / multiple Uterine Fibroids.
  • Adenomyosis
  • Failed myomectomy / recurrence of fibroids after myomectomy
  • High risk patient for surgery like obesity, anemia, chronic renal failure etc.
  • Post-partum Hemorrhage
  • Bleeding from Cancer of Cervix & Uterus
  • Pre-operative embolization to reduce bleeding during uterine surgery.

Side effects about 1% chances for infection is typically characterized by fever and smell from vagina. It needed typically antibiotics and it subsided in 99% of women, remaining may need another surgical procedure. Mild pelvic pain will remain for 1-2 days it is controlled very well by simple pain medication.

Mild fever also aspected, it is well control by paracetalmole oral tablets. About a half percentage of the woman land-up in short term menopause letter they may resume normal periods.

+ Pros & Cons of surgery it shows overall successes rate is about 96-98% which is unlikely in other method of treating fibroids.

  • It is the only method that can treat the multiple fibroid in one sitting.
  • The uterine artery embolization treats the fibroid and adenomyosis together.
  • No surgical scar or blood loss during the procedure.
  • It needed just day care or 24 hrs hospitalization.
  • Short recovery time it may be one day.

Best solution – Non surgical treatment Uterine artery embolization

What it is Uterine artery embolization (UAE) is a procedure where an interventional radiologist uses a catheter to deliver small particles that block the blood supply to the fibroids. If the procedure is done for the treatment of uterine fibroids it is also called uterine fibroid embolization (UFE). The procedure is not a surgical intervention and allows the uterus to be kept in place.

 


Benefits of non surgical treatment

  1. It is performed under Local anesthesia. Not General anesthesia.
  2. Requires only a tiny nick in the skin (No surgical incision of abdomen).
  3. Recovery is shorter than from hysterectomy or open myomectomy.
  4. Virtually no adhesion formation has been found. But in surgery adhesions are common.
  5. All fibroids are treated at once, which is not the case with myomectomy.
  6. Recurrent growth of treated fibroids is uncommon.
  7. Uterine fibroid embolization involves virtually no blood loss or risk of blood transfusion.
  8. If the presenting complaint was excess vaginal bleeding, 87-90% of cases experiences resolution within 24 hours.
  9. Emotionally, financially and physically – embolization can have an overall advantage over other procedures for the patient as the uterus is not removed.

Watch Video:

 


Procedure – It is under local anesthesia, an interventional radiologist introduces a catheter into the femoral artery at the groin and uses radiographic guidance to advance the catheter into the uterine artery. Microparticles (spheres or beads) are then released, which will block blood flow through the vessel. Even if both uterine arteries are occluded, abdundant collateral circulation prevents the uterus from necrosing. The procedure is not a surgical intervention, and allows the uterus to be kept in place.

UAE is frequently used to relieve symptoms caused by uterine fibroids. It has satisfaction rates similar to hysterectomy and much shorter recovery times

After treatment – Studies have shown that uterine artery embolization reduces symptoms such as heavy bleeding, pain, urinary incontinence and abdominal enlargement.  Five years after treatment with uterine artery embolization, more than 85-97 percent of women maintain symptom control. These results are comparable to that of myomectomy, in which the fibroids are surgically removed and the uterus repaired.

Menstruation and menopause Your menstrual period will probably resume as normal as before within a month. A small number of women, however, enter menopause after the procedure. The risk appears highest among women age 45 and older.

Women those have fibroids always have risk of fertility. Despite these risks, many women have had successful pregnancies following uterine artery embolization.


Medications

Medications for uterine fibroids target hormones that regulate your menstrual cycle, treating symptoms such as heavy menstrual bleeding and pelvic pressure. They don’t eliminate fibroids. Medications include:

Gonadotropin-releasing hormone (GnRH) agonists. Medications called GnRH agonists treat fibroids by causing your natural estrogen and progesterone levels to decrease, putting you into a temporary postmenopausal state. Many women have significant hot flashes while using this medication.

Androgens. This drug similar to male hormone testosterone, may effectively stop menstruation, correct anemia. However, this drug is rarely used to treat fibroids. Unpleasant side effects, such as weight gain, feeling depressed, anxious or uneasy, acne, headaches, unwanted hair growth and a deeper voice, make many women reluctant to take this drug.


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