Radiology

Uterine Fibroids - Treatment by embolisation

Dr. Krantikumar Rathod

(Patients are cautioned that this information is for general use only. In case you have queries or need further details, please contact us at the telephone numbers given at the end of this note)

Fibroids (also called as leiomyomas) are benign (noncancerous) swellings of the muscle wall of the womb (uterus). These are not uncommon in women in the reproductive age group. They occur as single or multiple masses & vary in size enormously - from that of grapes to that of pumpkins!. Though some fibroids (especially the small ones) may produce no symptoms, many can cause several problems depending on their size and position in the womb. Some women with fibroids have heavy, prolonged and painful bleeding during periods sometimes leading to anemia (deficiency of blood). This may also be associated with problems in the patient becoming pregnant or can lead to recurrent abortions. They can give rise to increase in the frequency or inability to pass urine, particularly before periods. Sometimes, they can cause constipation. Most women with fibroids also complain of heaviness in the lower abdomen.

The cause of fibroids is not known but their growth is dependant upon the estrogen hormone in the body. During pregnancy & with oral contraceptives, when there is excess of estrogen in the body, fibroids are known to grow rapidly; whereas, after menopause (termination of menstrual life), when there is much less estrogen in the body, fibroids are known to shrink, although larger fibroids may persist. New fibroids rarely appear after menopause.

Uterine fibroids, which are small and not causing problems do not require treatment. Many women go through their lives having fibroids without being aware of them and having no gynaecological problems .If symptomatic & treatment is required, it is important to be aware of the available treatment options.

Conventional treatments for fibroids

Organ sparing options:

Medicines:

They do not cure fibroids but may relieve symptoms associated with fibroids.

Pain killing medicines:

If fibroids cause pain, pain-killing tablets may be given. These are usually anti-inflammatory drugs such as NSAIDs ( e.g. Brufen).

Iron therapy:

For anemia due to excessive bleeding.

Progesterone hormones:

If periods are heavy, progesterones are given to reduce the amount of blood loss. However, as the underlying problem is not a hormone imbalance, this treatment is not usually effective.

GnRHa analogue:

These are synthetic drugs which act like hormones that are produced by body. They have the effect of reducing the level of estrogen. This in turn results in the reduction in blood flow to the uterus and the fibroid. This hormone drug can reduce the size of fibroids temporarily. However, as soon as drug is stopped, the fibroids grow back to their original size within few months. This drug can only be given for six months, as after this, it can cause thinning of bones. It is mainly used to reduce the size of fibroids, before surgery to make operation easier.

Uterus preserving surgery-Myomectomy:

This is a major operation usually done in infertile women or women desirous of childbearing and wishing to retain the uterus. This requires a stay in the hospital of five to six days and four to six weeks off work. This involves removing of the fibroids out of the uterus but leaving the uterus in place. However, as there are often several fibroids, it is rarely possible to remove all of them, as this would cause too much damage to the womb. The advantage of this procedure is that, as the uterus is left behind, it is possible to become pregnant. There are two possible disadvantages. Firstly, this surgery can leave behind adhesions (scarring) inside the pelvis, which, at worst can cause the fallopian tubes to become blocked. This would then prevent pregnancy from occurring. Secondly, on rare occasions, when myomectomy is being carried out, there may be bleeding to such an extent that it becomes necessary to remove uterus (hysterectomy) as an emergency measure to stop the bleeding.

Non-organ sparing options:

Hysterectomy: (Removal of the uterus)

This is the most effective treatment of fibroid as there is no possibility that the fibroids can regrow afterwards. This surgery also requires a stay in hospital of five to six days and four to six weeks off work, depending on nature of work. The major disadvantage of this operation is that women can no longer become pregnant & therefore is not suitable for people who have not completed their family.

Uterine Artery Embolisation (UAE) in the treatment of uterine fibroids

This is new organ sparing treatment for uterine fibroids that does not require an operation. UAE is a new way of treating fibroids by blocking off the arteries - uterine arteries - that carry blood to the fibroids, making the fibroid shrink. This procedure is performed by an interventional radiologist, a physician especially trained in to perform this procedure with specialized embolisation experience. This was first reported in 1995 by group in France. Since then, it has been widely practicised all over the world and proved to be a viable alternative treatment for uterine fibroids. This is an effective, minimally invasive procedure with relatively less pain, less complications and shorter duration of hospital stay and lay off from work.

Procedure

The procedure is done after consultation with the gynecologist. Pre-procedure imaging in the form of ultrasonography or MRI of pelvis is required to assess the response after the procedure with follow up imaging. This procedure is done in the radiology department in a special screening room called as DSA (digital subtraction angiography) suite. The patient needs to be admitted in the hospital a day prior to the procedure .As the procedure is done using an artery in the groin, the patient is asked to shave the skin around the groin. The patient needs to be fasting for four hours prior to procedure.

During the procedure, the patient lies down on the DSA table. A needle is put in arm vein to give sedative or pain killer. General anesthesia is not required. Monitoring devices are attached to chest or fingers to monitor vital parameters. The skin over the groin is prepared with antiseptics & rest of the body is covered with sterile towels.

There is no need for general anesthesia and the patient is fully awake during the procedure. The skin & deeper tissues over the artery in the groin area are anesthetized with local anesthetic, (once this given patient do not feel pain) and then needle is inserted into artery. Once this is correctly placed, a guide wire is passed into artery over which a device called sheath is inserted. Through the sheath, a fine plastic tube called catheter is passed into arteries feeding fibroids, which are called right and left uterine arteries under x-ray control. All this is painless. A radiological dye called contrast medium is injected into these arteries, which may cause a warm feeling in pelvis. Once the fibroid's blood supply has been identified, the catheter is navigated into the uterine arteries ( one on each side ) & fluids containing small particles are injected into these arteries,which blocks these arteries so that fibroids are starved of their blood supply. Both the right and left uterine arteries are blocked in this way .At the end of the procedure, the catheter and sheath are withdrawn and interventional radiologist compresses the puncture site for about ten minutes to prevent any bleeding. Six-hour immobilisation of leg in which the puncture is made is required. The times taken for complete procedure vary depending how complex and straightforward the arterial anatomy in a particular patient is procedure is, but generally it is between 1-2 hours. The patient is kept for monitoring & antibiotic medication in the ward for two days. The patient can join her regular work three to four days following UAE.

Fibroid embolisation is normally a safe procedure but there are some risks and complications that can arise as with any medical treatment. Occasionally, a small bruise called hematoma around the site where the needle has been inserted can occur, which is quite normal. Most patients feel pain, fever , particularly in first twelve hours but can be controlled by painkillers. A few patients may get vaginal discharge persisting for approximately two weeks.. Infection is the most serious complication of fibroid embolisation .The signs of this include pain, pelvic tenderness and high fever. Post procedure antibiotic prophylaxis is given to prevent the same.

Uterine artery embolisation is well-tolerated, safe and effective procedure in the treatment of fibroids, and has opened a new door to success for patients in whom other treatments are ineffective or contraindicated.

If you require further information regarding UAE,
please contact
Dr.Hemant Deshmukh /Dr.Krantikumar Rathod on Tel. 24136051 ext 2543 or 24103906 or email us on websitecontact@kem.edu .

The following two patients who have undergone UAE and have agreed to talk to any patient who wants to know a patient's perspective can be contacted at the following addresses.

Mrs.Anusaya Shamrao Desai,
Room No.6,
Tata Mills Chawl No. 6/C,
J.B.Road,
Parel,
Mumbai-400012

"I was suffering from pain in the lower abdomen and heavy periods since three years I consulted the gynecology OPD at K.E.M. Hospital. My sonography done at K.E.M.Hospital showed a large fibroid in the uterus which was causing heavy periods & pain in the lower abdomen. The doctor advised me to undergo immediate operation to remove the uterus. On hearing the word operation, I was frightened & worried. Since I am diabetic & hypertensive, I was high risk for surgery. Then the doctor suggested me the option of uterine artery embolization for which I was referred to the vascular & interventional radiology section. There doctor explained me the procedure which gave me confidence. Accordingly, I underwent this procedure in this department which was tolerable with uneventful recovery. After one month, I got my sonography done which showed decrease in the size of the fibroid. I never had heavy periods following this procedure. Thanks to doctors and Hospital authorities".

Mrs.Madhuwanti Suhas Bhagwat
Granthalaya Services E -2/3:1,
Sector 1, Vashi
Navi Mumbai-400703
E-mail: bmadhuwanti@rediffmail.com
Phone: 27823719 / 27826546

It was vicious circle.

Due to heavy loss of blood, the hemoglobin level was always low. Iron deficiency anemia was persistent and this would again lead to heavy periods causing heavy loss of blood for more than five days.

The hematologist had confirmed that it was iron deficiency anemia and need for immediate treatment of mennorhagia. Pelvic sonography revealed multiple intramural uterine fibroids. The gynecologist had recommended hystrectomy .I had my reservation about hystrectomy as it would lead to blood loss during surgery, post operative care, might lead to harmone replacement therapy and so on...

My friend who herself had undergone this procedure and benefited immensely suggested the option of uterine artery embolisation. I met Dr.Hemant Deshmukh and Dr. Krantikumar Rathod in last week of September 2002 .The doctors were positive about results and benefits I would get after the UAE procedure.

I underwent this procedure on 4th October 2002. I could interact with doctors during the procedure & there was no pain at all. I started my routine work within one week.