Fibroids are benign tumours of the uterus (womb). They are not cancerous and so are very unlikely to be a threat to life. Fibroids are however very common affecting about half of all women at some stage in their lives. Though most women with fibroids have no symptoms and may not even know they have them, a minority suffer very distressing symptoms.
Fibroids are made up of muscle and are very vascular i.e. have a large supply of blood to them. No-one knows for sure what causes fibroids but they are certainly influenced by hormones and most likely to grow faster when oestrogen is highest in a woman’s middle life.They are rare in teenagers, most common in 30-50 year olds and shrink naturally after the menopause.
Fibroids are much more common in black women than white women. Your chance of developing them is also increased if you are heavy, if other members of your family have been diagnosed with them, or if you have no children. Fibroids vary considerably in size and number; some may be the size of a marble others are like a large pumpkin.
Fibroids can affect a woman’s life very profoundly. Their affect and the effect of their treatment vary considerably from one patient to another. Although fibroids are a common problem, however many women have been affected by fibroids before you, your reaction physically and emotionally to the disease and its treatment is unique to you. Take time to assess all the options, talk to your doctors and make sure that you get the treatment that is right for you.
Most fibroids do not affect your ability to become pregnant or the pregnancy itself. Some may cause pregnancy to be more uncomfortable than normal. In a minority of women, the fibroids can make conception difficult and can cause miscarriage. This is logical as an abnormal lump in the uterus can easily be imagined to block the fallopian tube preventing the egg travelling from the ovary to the uterus. A fibroid within the lining of the womb is also likely to interfere with the growing embryo and increase the chance that the pregnancy will be lost. Occasionally, a fibroid may lost its blood supply during pregnancy and die. If this happens, it can cause severe pain and can induce a miscarriage or bring on a premature delivery.
At the time of birth, large fibroids can give difficulty by obstructing the passage of the baby. If this occurs, a caesarean section may be necessary. After birth, the fibroids increase the risk of bleeding which can be heavy and may require some form of medical intervention to stop it.
You may experience pain, pressure or abnormal menstrual bleeding, which may increase in volume, duration or frequency. You may also find that the fibroid causes pressure on your bladder or rectum.
If you have large fibroids, your doctor may suspect this after physically examining you, but most fibroids are diagnosed by ultrasound. In some cases, when planning treatment, the doctor will use MRI to characterise the fibroids and assess their response to therapy
Once the diagnosis is accurately established with the magnetic resonance scan, a range of different treatment options is available for patients whose fibroids are causing problems. Remember before considering treatment to always weigh up the risks of treatment against the potential benefits. No medical treatment is totally risk free, and if your fibroids are causing no problems, it would be silly to take any risk however small. Also consider what the likely progression of your problem is. If for example you are nearing the menopause then it is likely that the fibroids will naturally get smaller and your symptoms naturally improve. The options for active treatment nowadays are many and varied including drugs, surgery, UAE, magnetic resonance and HIFU (high intensity focused ultrasound).
Drugs are available which reduce oestrogen levels and cause fibroids to shrink. A six month course can reduce the fibroid by up to 50% and reduce many of the symptoms. The drugs stop your normal periods. They can, however, only be taken for about six months. After this time, the fibroids often start growing again and causing more symptoms. The drugs themselves can cause side effect including hot flushes and vaginal dryness. Drugs may be very helpful in patients nearing the menopause, but are unlikely to be a good solution for younger women with large symptomatic fibroids. They may be helpful in making surgery easier and safer.
This has traditionally been the most common form of treatment for fibroids, and huge numbers of women used to undergo hysterectomy (removal of the womb) for this reason. Hysterectomy is not however the only surgical option. The fibroids themselves can be removed leaving the uterus intact (myomectomy). This can be performed through normal surgery or with keyhole techniques.
UAE (uterine artery embolisation)
UAE is an established minimally invasive treatment which avoids the need for surgery and anaesthesia and which is very popular with many patients.
UFE is a non surgical way of treating fibroids by blocking off the arteries that feed the fibroids, the uterine arteries, and making the fibroids shrink. It is performed by an interventional radiologist, rather than a surgeon, and is an alternative to an operation. UFE was first performed in 1995, and since then over 200,000 women have had the procedure performed, world-wide. As with all relatively new procedures, a careful data collection and audit will be performed.
Other tests that you have had done will have shown that you are suffering from fibroids, and that these are causing you considerable symptoms. Your gynaecologist and your GP should have told you all about the problems with fibroids, and discussed with you ways of dealing with them. Previously, most fibroids have been treated by an operation, generally a hysterectomy, where the womb is removed altogether. In your case, it has been decided that embolisation is the best treatment.
The doctors in charge of your case, and the inreventional radiologist doing the fibroid embolisation, will have discussed the situation, and feel that this may be the most suitable treatment. However, it is very important that you have had the opportunity for your opinion to be taken into account, and that you feel quite certain that you want the procedure to go ahead. If, after full discussion with your doctors, you do not want the UFE carried out, then you must decide against it.
A specially trained doctor called an interventional rRadiologist. Interventional radiologists have special expertise in using X-ray equipment, and also in interpreting the images produced. They need to look at these images while carrying out the procedure. Consequently, interventional radiologists are the best trained people to insert needles and fine catheters into blood vessels, through the skin, and place them correctly.
Generally in the X-ray department, in a special “screening” room, which is adapted for specialised interventional procedures.
You need to be an in-patient in the hospital. You will probably be asked not to eat for four hours beforehand, though you may be told that it is alright to drink some water. You may receive a sedative to relieve anxiety. You will be asked to put on a hospital gown. As the procedure is generally carried out using the big artery in the groin, you may be asked to shave the skin around this area.
If you have any allergies, you must let your doctor know. If you have previously reacted to intravenous contrast medium, the dye used for kidney x-rays and CT scanning, then you must also tell your doctor about this.
You will lie on the X-ray table, generally flat on your back. You need to have a needle put into a vein in your arm, so that the radiologist can give you a sedative and painkillers. Once in place, this will not cause any pain. You may also have a monitoring device attached to your chest and finger, and may be given oxygen through small tubes in your nose. The interventional radiologist will keep everything as sterile as possible, and will wear a theatre gown and operating gloves. The skin near the point of insertion, probably the groin, will be swabbed with antiseptic, and then most of the rest of your body covered with a theatre towel.
The skin and deeper tissues over the artery in the groin will be anaesthetised with local anaesthetic, and then a needle will be inserted into this artery. Once the interventional radiologist is satisfied that this is correctly positioned, a guide wire is placed through the needle, and into this artery. Then the needle is withdrawn allowing a fine, plastic tube, called a catheter, to be placed over the wire and into this artery.
The interventional radiologist will use the X-ray equipment to make sure that the catheter and the wire are then moved into the correct position, into the other arteries which are feeding the fibroid. These arteries are called the right and left uterine arteries. A special X-ray dye, called contrast medium, is injected down the catheter into these uterine arteries, and this may give you a hot feeling in the pelvis. Once the fibroid blood supply has been identified, fluid containing thousands of tiny particles is injected through the catheter into these small arteries which nourish the fibroid. This silts up these small blood vessels and blocks them so that the fibroid is starved of its blood supply
Both the right and the left uterine arteries need to be blocked in this way. It can often all be done from the right groin, but sometimes it may be difficult to block the branches of the right uterine artery from the right groin, and so a needle and catheter needs to be inserted into the left groin as well. At the end of the procedure, the catheter is withdrawn and the Interventional Radiologist then presses firmly on the skin entry point for several minutes, to prevent any bleeding.
When the local anaesthetic is injected, it will sting to start with, but this soon passes, and the skin and deeper tissues should then feel numb. The procedure itself may become painful. However, there will be a nurse, or another member of staff, standing next to you and looking after you. If the procedure does become too painful for you, then they will be able to arrange for you to have some painkillers through the needle in your arm.
As the dye, or contrast medium, passes around your body, you may get a warm feeling, which some people can find a little unpleasant. However, this soon passes and should not concern you.
Every patient’s situation is different, and it is not always easy to predict how complex or how straightforward the procedure will be. Some uterine fibroid embolisations do not take very long, perhaps half an hour. Other embolisations may be more involved, and take rather longer, perhaps an hour. As a guide, expect to be in the X-ray department for about two hours.
You will be taken back to the recovery area on a trolley. Nurses in the recovery area will carry out routine observations, such as taking your pulse and blood pressure, to make sure that there are no untoward effects. They will also look at the skin entry point to make sure there is no bleeding from it. Once any pain is controlled you will be transferred to the ward. You will generally stay in bed for a few hours, until you have recovered. You will generally be kept in hospital over night or for a day or two. Once you are home, you should rest for three or four days. You will be prescribed painkillers and other drugs and an explanation of their usage will be given prior to your discharge.
Uterine fibroid embolisation is a safe procedure, but there are some risks and complications that can arise, as with any medical treatment.
There may occasionally be a small bruise, called a haematoma, around the site where the needle has been inserted, and this is quite normal. If this becomes a large bruise, then there is the risk of it getting infected, and this would then require treatment with antibiotics.
Most patients feel some pain afterwards. This ranges from very mild pain to severe cramp, period-like pain. It is generally worst in the first 12 hours, but will probably still be present when you go home. While you are in hospital this can be controlled by powerful pain killers. You will be given further tablets to take home with you.
Most patients get a slight fever after the procedure. This is a good sign as it means that the fibroid is breaking down. The pain killers you will be given will help control this fever.
A few patients get a vaginal discharge afterwards, which may be bloody. This is usually due to the fibroid breaking down. Usually, the discharge persists for approximately two weeks from when it starts, although occasionally it can persist intermittently for several months. This not in itself a medical problem, although you may need to wear sanitary protection. If the discharge becomes offensive and if it is associated with a high fever and feeling unwell, there is the possibility of infection and you should contact your interventional radiologist and GP and ask to see your gynaecologist urgently.
The most serious complication of uterine fibroid embolisation is infection. This happens to perhaps two in every hundred women having the procedure. The signs that the uterus is infected after embolisation include great pain, pelvic tenderness and a high temperature. Lesser degrees of infection can be treated with antibiotics, and perhaps a small operation on the womb, a “D and C” (dilatation and curettage) or hysteroscopy (looking into the womb with a small flexible endoscope and removing any abnormal tissue stuck in the womb). If severe infection has developed, it is generally necessary to have an operation to remove the womb, a hysterectomy. One patient in the UK has died after UFE because of severe infection. If you feel that you would not want a hysterectomy under any circumstances, then it is probably best not to have UFE performed.
Some patients may feel very tired for up to two weeks following the procedure, though some people feel fit enough to return to work three days later. However, patients are advised to take at least two weeks off work following UFE. Approximately 8% of women have spontaneously expelled a fibroid, or part of one, usually between six weeks to twelve months afterwards. If this happens, you are likely to feel period like pain and have some bleeding.
A very few women have undergone an early menopause, the change of life, after this procedure. This has probably happened because they were at this time of life to start with.
There are now many good, long term studies of the results of uterine fiberoidembolisation. Over 90% of women will be relieved of their symptoms after UFE and reduction in uterine and fibroid volumes of over 60% are expected. Incomplete death of the fibroids can lead to failure of the treatment in 5-10% of cases and reoccurance of fibroid symptoms can occur in up to 25%. Improvements in equipment and techniques have been made to try to reduce these early failures and late recurrences.
Some women, who could not become pregnant before the procedure because of their fibroids, have become pregnant afterwards. However, if having a baby in the future is very important to you, you need to discuss this with your doctor as it may be that an operation is still the better choice.
Some of your questions should have been answered by this information, but remember that this is only a starting point for discussion about your treatment with the doctors looking after you. Do satisfy yourself that you have received enough information about the procedure, before you sign the consent form.
UFE is considered a safe procedure, designed to improve your medical condition and save you having a larger operation. There are some risks and complications involved, and because there is the possibility of a hysterectomy being necessary, you do need to make certain that you have discussed all the options available with your doctors.