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Fibroids

Fibroids are benign (non-cancerous) tumours that grow in or around the womb. They are made up of muscle and fibrous tissue and can vary in size. Fibroids usually develop during a woman’s reproductive years (from approximately 16 to 50 years of age). They are linked to the production of oestrogen, which is the female reproductive hormone. Fibroids are common, with at least one in four women developing them at some stage in their life. They most often occur in women who are from 30 to 50 years old. Fibroids tend to develop more frequently in women who are of Afro-Caribbean origin. After the menopause, fibroids often shrink, and it is likely your symptoms will either ease slightly or disappear completely.

Fibroids can grow anywhere in the womb with the five main types being:

  • Intramural fibroids develop in the muscle wall of the womb and they are the most common type of fibroids found in women.
  • Subserosal fibroids grow outside the wall of the womb into the pelvis and can become very large.
  • Submucosal fibroids develop in the muscle beneath the inner lining of the womb wall and they grow into the middle of the womb.
  • Pedunculated fibroids grow from the outside wall of the womb and are attached to the womb wall by a narrow stalk.
  • Cervical fibroids develop in the wall of the cervix (the neck of the womb).
In many cases, fibroids do not cause symptoms and treatment is not required. However, sometimes fibroids can cause symptoms, such as pain or heavy bleeding. In such cases, medication may be prescribed. If this proves ineffective, surgical or non-surgical techniques may be recommended. If your fibroids do cause symptoms, you may experience one or more of the following:

Heavy or painful periods

Benign fibroids do not cause irregular bleeding but they can cause heavy or painful bleeding. Heavy bleeding can some-times cause anaemia. If you have fibroids, particularly if you have large ones, you may experience discomfort or bloating (swelling) in your stomach. If your fibroids press on your bladder, you may need to urinate frequently. Fibroids can also press on your rectum (large intestine), which can cause constipation. You may also experience pain in your back and legs. They do not cause severe pain unless they twist. This latter only happens in pedunculated fibroids.

If you have fibroids growing near to your vagina, or cervix (neck of the womb), you may experience pain or discomfort during sexual intercourse.

Diagnosing fibroids

As fibroids do not often cause symptoms, they are sometimes discovered during a routine gynaecological (vaginal) examination or during a diagnostic test or scan. A diagnostic test is any test that is carried out to help confirm or rule out a health condition that may be causing your symptoms.

Ultrasound scan

An ultrasound scan of the womb is often used to confirm a diagnosis of fibroids. It can also be used to rule out any other possible causes of your symptoms.

Trans-vaginal scan: A trans-vaginal scan is sometimes used to diagnose fibroids. It involves inserting a small scanner into your vagina to take a close-up image of your womb.

Hysteroscope: It may be possible to see fibroids that are near your inner lining (intramural fibroids), and those within the cavity of your womb (submucosal fibroids) using a hysteroscope. A hysteroscope is a small telescope used to examine the inside of your womb.

Laparoscope: A laparoscope is a thin, flexible microscope with a light on the end that is used to look inside the stomach. It can also be used to examine the size and shape of the outside of your womb.

Treatment options

Treatment for fibroids may not be necessary in cases where they do not cause symptoms, or where symptoms are minor.

Medication

Gonadotropin releasing hormone agonist (GnRH): GnRH is a hormone that is often recommended to treat fibroids. GnRH is given by injection and works by making your body release a small amount of oestrogen, which causes your fibroids to shrink. It stops your menstrual cycle (period) but it is not a form of contraception. It does not affect your chances of becoming pregnant after you stop using it. The drug is not a long-term treatment but may be used prior to more definitive measures such as shrinking fibroids prior to having surgery to remove them. Sometimes, a combination of GnRH and low doses of hormone replacement therapy (HRT) may be recommended to preventing the side effects of the menopause.
The drug can cause a number of menopause-like side effects including:
  • hot flushes,
  • increased sweating,
  • muscle stiffness, and
  • vaginal dryness.

Other medicines

There are other medicines available that can be used to treat heavy periods, but they can to be less effective the larger your fibroids are.

Tranexamic acid: Tranexamic acid tablets are taken three to four times a day throughout your period. The tablets work by helping the blood in your womb to clot, which reduces the amount of bleeding These tablets are not a form of contraception and will not affect your chances of becoming pregnant once you stop taking them. Treatment should be stopped if your symptoms have not improved within three months.

Anti-inflammatory medicines
: Anti-inflammatory medicines, such as ibuprofen and mefanamic acid, are taken for a few days during your period and will help ease your heavy bleeding.  Anti-inflammatory medicines are also painkillers, but they are not a form of contraception.

The contraceptive pill
: As well as making bleeding lighter, some contraceptive pills can help to reduce period pain. Your GP will be able to provide you with further advice about contraception and the contraceptive pill.

Levonorgestrel intrauterine system – Mirena Coil: Mirena is a small, plastic device that is placed in your womb and slowly releases the progestogen hormone called levonorgestrel. It stops the lining of your womb from growing so that it is thinner and your bleeding becomes lighter.
Side effects include:
  • irregular bleeding that may last for more than six months,
  • acne (inflamed skin on the face),
  • headaches, and
  • breast tenderness.

Surgery

Surgery may be considered if your fibroid symptoms are particularly severe and all forms of medication have proved ineffective. There are a number of different surgical procedures used to treat fibroids. Some of these surgical procedures are explained below.

Uterine artery embolisation (UAE): UAE is an alternative procedure to a hysterectomy and myomectomy for treating fibroids. It may be recommended for women with large fibroids. UAE is performed by a radiologist (a doctor who has been trained to interpret X-rays and scans). It works by blocking the blood vessels that supply blood to the fibroids, causing them to shrink. During the procedure, a chemical is injected through a small tube (catheter), which is guided by X-ray through a blood vessel in your leg. It is carried out under local anaesthetic, which means you will be awake but the area being treated will be numbed. (see further details)

Endometrial ablation: endometrial ablation is an alternative to having a hysterectomy and involves removing the lining of the womb. It is usually only recommended for fibroids that are near to the inner surface of the womb, are small and do not significantly change the size and shape of the womb.(see endometrial ablation)

Myomectomy
: A myomectomy is a surgical procedure to remove the fibroids from the wall of your womb. It may be considered as an alternative to a hysterectomy, particularly for women who still wish to have children. A myomectomy may not always be possible as it depends on your individual circumstances, such as the size, number and position of your fibroids. It is a complex operation and recovery is slower than a hysterectomy. 1% of women who have a myomectomy need an emergency hysterectomy because of excessive bleeding. You are usually given GNRH injections to shrink the fibroids and decrease their blood supply prior to a myomectomy.

Hysterectomy
: This is a surgical procedure to remove the womb. It may be recommended if you have large fibroids or severe bleeding. A hysterectomy is the best way of preventing fibroids re-occurring. You may want to consider it if you have fibroids that are particularly troublesome and you do not wish to have any more children.

Uterine Fibroid Embolisation

Uterine fibroid embolisation (UFE),

Also known as uterine artery embolisation (UAE) and is a more recent treatment first used clinically in Paris in the early 1990s. Not every case is suitable for this treatment but if unsuitable there is still the option of conventional surgery to fall back on.

What is embolisation?

Embolisation is the process of causing an organ or tumour to reduce in size by blocking its blood supply. This can be achieved using a number of different materials such as small foam particles, metal coils or, as in the case of fibroid embolisation, polyvinyl alcohol (PVA) particles specially designed for the purpose. The interventional radiologists performing the procedure already have years of experience of embolisation in other parts of the body for problems such as cancerous growths or to stop bleeding following trauma. Uterine fibroid embolisation simply applies these skills and techniques in a new setting.

What is involved before the procedure?

Your gynaecologist who will have performed an examination and possibly arrange imaging tests such as an ultrasound or MRI scan will have referred you to the interventional radiologist. It is necessary to exclude any possibility of infection before proceeding to embolisation. A MRI scan is routinely performed before proceeding to embolisation. MRI very accurately defines the size and location of fibroids and, more importantly excludes other conditions that can mimic fibroids. For follow up post embolisation we rely on ultrasound at one month (and possibly at three months depending on progress) with a repeat MRI scan at 6-12 months.

The radiologist and sister will discuss the procedure with you.

Any pregnancy test is routinely performed prior to the procedure.
Before coming to the x-ray department you will be seen by the pain control nurse. As embolisation can be painful and we routinely set up a PCA (patient controlled analgesia) pump which runs through a small drip in the back of your hand and allows you to give yourself small doses of morphine as required. This can be used during the procedure and for 24 hours or so afterwards. The amount of discomfort felt by patients varies enormously and the advantage of a PCA pump is that you are in complete control of the painkillers and can use as much or as little as you need so there is no need to feel any pain.

The nursing staff will insert a small catheter in your bladder before coming to the Radiology department. This is primarily for your own comfort as the contrast agent injected during the angiogram will fill your bladder and you will need to lie flat during the procedure and for several hours afterwards.

The procedure itself

The interventional radiologist injects some local anaesthetic in the groin. This may just sting a little for a few minutes but will then go numb. A small nick of only a few millimetres is made at the crease at the top of the leg to access the femoral artery, and a tiny tube (catheter) is inserted in to the artery. The interventional radiologist steers the catheter through the arteries to the uterus using x-ray imaging to guide the catheter’s progress. The catheter is moved into the uterine artery at a point where it divides into the multiple vessels supplying blood to the fibroids. An angiogram (a series of images taken while radiographic dye is injected) is performed to provide a road map of the blood supply to the uterus and fibroids. The interventional radiologist slowly injects tiny plastic (polyvinyl alcohol-PVA) or gelatin sponges particles the size of grains of sand in to the vessels. The particles flow to the fibroids first, wedge in the vessels and cannot travel to the other parts of the body. Over several minutes, the arteries are slowly blocked. The embolisation is continued until there is nearly a complete blockage of flow in the vessels.

It is necessary to embolise the arteries feeding both sides of the uterus even if the fibroids are confined to one side. It has been shown that if we just block one side the artery on the opposite side will grow to take over and feed the fibroid. This usually means having to make small punctures in both groins. The x-ray dose is small but as the ovaries are very sensitive to radiation we take all possible measures to minimise the dose. This is a particular concern in women who wish to become pregnant following embolisation.

The whole procedure normally takes about an hour. You will be awake during the procedure. Some patients who are anxious can have some light sedation if required but this is very rarely necessary.

What to expect after fibroid embolisation

The results of studies that have been published or presented at scientific meetings report that 78% to 94% of women who have the procedure experience significant or total relief of pain and other symptoms, with a large majority of patients considerably improved. The procedure has been successful even when multiple fibroids are involved. Most patients have rated the procedure as “very tolerable”. The expected average reduction volume (size) of the fibroids is 50% after 3 months with a reduction in the overall size of the uterus of about 40%.

The long-term outcome is unknown, as only short-term follow-up is available. It is not yet known if the fibroids can re-grow, however no recurrences have occurred in women who have been followed up to six years.

Fibroid embolisation is considered to be very safe, however, there are some associated risks, as there are with almost any medical procedure. Most patients can experience moderate pain and cramping in the first several hours following the procedure. We anticipate this and aim to prevent it using the pain control pump that you yourself control. Some experience nausea and, possibly, fever. These symptoms can be controlled with appropriate medications. Most symptoms are substantially improved by the next morning. However, there may be some pain and cramping for several days or more. Many women have reported returning to work within a week of having procedure.

Complications occur in no fewer than 3% of patients. Serious possible complications include injury to the uterus from decreased blood supply or infection. This is uncommon and a hysterectomy to treat either of these complications occurs in less than 1% of patients. Injury to other pelvic organs is possible but has not yet been reported and the chance of other significant complications is less than 1%.
Long term complications are not expected, although questions about potential side effects remain.

Periods

It is not uncommon for your first period to be missed after the procedure. Following that your periods should return normally. Some have reported episodes of vaginal bleeding after the procedure, but these settle quickly. If they continue, or if your periods do not resume, seek advice.

Pregnancy

The effects of this procedure on fertility are not known. Some patients have become pregnant unexpectedly, even within one month of the procedure, so continue with contraception. Official guidelines here in the UK currently do not recommend fibroid embolisation in women wishing to become pregnant, as there are concerns about effects on development of the foetus. There are, however, many reports from around the world of successful pregnancies following embolisation.

Infection

This is a rare but serious complication that occurs in about 1-2% of patients treated. It may occur within a week or two, but may appear up to 20 weeks (five months) later. If you develop increasing pain, tiredness, discharge or an unexplained fever at any time after the procedure, you should contact your GP, gynaecologist or radiologist immediately for further advice, as you will need to have a swab taken to check for infection. You may need to be admitted for antibiotics, a delay in starting this treatment may be hazardous to your health.

Vaginal discharge

Some patients have complained of a persistent discharge, which has lasted some weeks after the procedure. If you feel otherwise well, this is not cause for alarm; it represents dead fibroid tissue being expelled from the womb and it should eventually clear up. A few patients have even passed solid lumps of fibroid tissue, sometimes many weeks after the procedure.

Follow up

We would normally expect you to be seen by your gynaecologist at about one month post embolisation. You will see the radiologist for a follow up ultrasound scan at one month. In some cases, particularly large fibroids, a further ultrasound scan may be arranged at 3 months and we would usually arrange a follow up MRI scan at 6-12 months post embolisation to asses shrinkage of the fibroid.

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