Fibroid Embolisation

Fibroids are benign swelling of the muscle wall of the uterus which can cause several problems related to their size and position.  Some women with fibroids have heavy and/or painful periods or bleed between two periods.  In other women, fibroids may be associated with problems in becoming pregnant.  Sometimes, by pressing on the surrounding structures, the fibroids can cause difficulty in passing water, or give a feeling of fullness.  Fibroids sometimes occur as single swellings, but frequently women have several fibroids within the uterus. 

They can vary in size enormously from being the size of a cherry stone to the size of a watermelon.  Although we do not understand what causes fibroids to develop, we know that they are dependent on the oestrogen hormone in the body.  After menopause, when there is no oestrogen in the body, fibroids may shrink away, although larger fibroids tend to persist.  Hormone replacement therapy (HRT) will tend to potentiate the fibroids after the menopause.

Fibroids only need treatment if they are causing problems.  Many women go through their lives having fibroids without being aware of it and have no gynaecological symptoms.  However, if treatment is necessary, there is unfortunately no easy option.

 CONVENTIONAL TREATMENT FOR FIBROIDS:

 1. Drugs

Drugs will not cure fibroids, but may relieve some of the symptoms.  If periods are heavy, progesterone hormones are sometimes tried to reduce the amount of blood loss, but as the underlying problem is not a hormone imbalance, this treatment is often not effective, If fibroids are causing pain, pain-relieving tablets can be given.

There is one type of hormone drug available that can reduce the size of fibroids temporarily, which is called gonadotrophin-releasing hormone analogue (GnRH).  This drug fools the body into thinking it is going through the menopause so the fibroids shrink.  However, as soon as it is stopped the fibroids grow back again to their original size within a few months.

The drug can only be given for 6 months, as after that it can cause osteoporosis.  It is mainly used to reduce the size of the fibroids, just before surgery to make the operation easier.

2. Surgery- There are two main types of surgery which are performed to cure fibroids.

• Hysterectomy

Hysterectomy means removal of the uterus.  When the operation is performed for fibroids, the ovaries are usually not removed.  This is the most effective treatment for fibroids as there is no possibility that the fibroids can re-grow afterwards.  Hysterectomy is a major operation and usually women need to stay in hospital for approximately 5 days after surgery.  They need to take between 6 weeks and 3 months off work afterwards, depending upon the nature of their job.  The major disadvantage of hysterectomy is that women can no longer become pregnant.  It is not suitable for people who have not completed their family and particularly for women who are seeking fertility treatment.

•   Myomectomy

Myomectomy is the alternative surgical treatment for fibroids.  It is also a major operation requiring a stay in hospital of 5 - 6 days and up to 6 weeks off work.  Myomectomy involves cutting the fibroids out of the uterus, but leaving the uterus in place.  However, as there are often several fibroids, it is not always possible to remove all of them, as this would cause too much damage to the remaining uterus.  The advantage of this procedure is that, as the uterus is left behind, it is possible to become pregnant.  The disadvantages are that there is often a lot of scarring inside the pelvis as a result of this surgery which can, at worst cause the Fallopian tubes to become blocked, this would then prevent pregnancy from occurring. 

Also rarely, when myomectomy is being carried out there may be bleeding to such an extent that it is necessary to perform a hysterectomy, as an emergency to stop the bleeding.  All women should be warned about this before a myomectomy is performed. Most often myomectomy is performed with an abdominal incision (Abdominal Myomectomy) but in some cases when a fibroid is growing on the inside of the uterus it is then possible to remove it via the vagina (Hysteroscopic Myomectomy)

As can be seen from the above descriptions, the treatment of fibroids is in many ways unsatisfactory, particularly for women who do not wish to lose their uterus. 

Fibroid Embolisation:

In recent years a new treatment has emerged that does not require an operation and experience has shown that it will significantly reduce the size of fibroids and therefore improve their symptoms.  This treatment is called FIBROID EMBOLISATION OR UTERINE ARTERY EMBOLISATION, first reported by a group in Paris in 1996. We pioneered this procedure in the UK doing our first case in 1996 and have now a very large experience approaching 1000 cases.

Fibroids develop from the wall of the uterus and receive blood from the same arteries that supply the uterus.  Usually new blood vessels also arise to supply nutrients and oxygen to the fibroids.  The treatment blocks the blood vessels supplying the fibroids and causes them to shrink.

What is involved in fibroid embolisation?

The treatment is performed in a special X-ray room by a specialised interventional radiologist. A general anaesthetic is not necessary, but some sedation is given.  Local anaesthesia is put into the skin crease of the right groin and a flexible plastic tube (catheter) is inserted into the artery under the skin.  Apart from the injection of local anaesthetic, the procedure itself is not painful.  The catheter is then advanced upwards through the artery while watching its progress on an x-ray television monitor.  It is usually possible to pass a catheter into the 2 main arteries (1 right and 1 left uterine artery) which supply the uterus. With the catheter positioned in the uterine artery X-ray dye or contrast is injected through it and it is then possible to see the blood vessels supplying the different parts of the uterus and the fibroids.  Once the fibroid blood supply has been identified, fluid containing thousands of tiny particles is injected through the catheter into the small arteries which nourish the fibroid.  This silts up these small blood vessels and blocks them so the fibroid is deprived of its blood supply.  The particles consist of an inert plastic-like material (Polyvinyl alcohol or PVA) which has been in regular use for over 25 years and there have never been any problems associated with its use.

There is one uterine artery on each side and both need to be treated. Usually this can be done through a single entry point in the groin.  The whole of the procedure usually lasts about 45 minutes.  No stitches are necessary, though you may have a little bruising in the groin region afterwards.  This is not an operation nor is it key-hole surgery, but rather a pin-hole interventional procedure.

 What can I expect after fibroid embolisation treatment?

London Bridge Hospital, along with Guys Hospital  has been performing fibroid embolisations for twelve years now and have now treated close to 1000 women.  The side effects of the treatment appear to be fairly clear and all patients are advised to expect fairly severe pain in the first 12-18 hours following the procedure.  For this reason, all patients are hospitalised for 24 hours following the embolisation to allow them to receive strong painkillers.  Patients are then fit for discharge from hospital.  They can anticipate having lower abdominal pain for the next week or so and occasionally even longer which is similar to a strong period pain.  This is usually controlled with painkilling tablets.

 Many women experience a vaginal discharge which starts a few days after the procedure.  This can be a bloody discharge or may be brown, yellow or mucoid.  It is not due to infection, but probably represents breakdown products of the fibroids.  Usually the discharge persists for approximately two weeks from when it starts, although occasionally it can persist intermittently for several months.  This is not in itself a medical problem, although patients may need to wear sanitary protection.  If the discharge becomes offensive and if it is associated with other symptoms such as a temperature and feeling unwell, there is the possibility that infection may have occurred. If there is any suggestion of this the radiologist or the referring gynaecologist should be urgently consulted so that effective treatment can be started if necessary.

Several patients say they felt very tired up to two weeks following the procedure.  This is not universal and some women have been able to return to work three days later.  However, patients are advised that it would be best to plan to take two weeks off work following their embolisation treatment.  Approximately 5-10% of women have spontaneously expelled a fibroid, usually six weeks - three months after the embolisation.  This is more likely to occur if the fibroids are in the uterine cavity or close to the cavity.  When this happens, the patient may experience some bleeding associated with period-type abdominal cramps.  The fibroid is then spontaneously expelled.  Although this is not the anticipated outcome for the procedure, in the long run, it appears to be beneficial because these patients have had a myomectomy without surgery.

 Results of Fibroid Embolisation Treatment

There is an increasing worldwide experience of this procedure and as long-term results are becoming available the procedure is becoming more established. Fibroid embolisation appears to be a successful treatment with around 85-90% patients who have undergone the procedure  having experienced relief of their presenting symptoms and needing no further treatment.  Followup assessments with MRI scans have shown that the average shrinkage in the size of the fibroid uterus is around 50%. but it may be several months before this occurs.  However, the relief of symptoms is constant and seems to be irrespective of the percentage shrinkage of their fibroid.

 What are the risks of Fibroid Embolization

Of the women we have treated, five needed a hysterectomy some while after the procedure for infection of the fibroids. This was mainly in our early experience and was in women with larger and more complex fibroid disease.  We are now advising women that there is a less than 1% chance of this complication occurring.  Also one woman who was not close to the menopause has experienced menopausal changes following the procedure. In women who are close to the menopause periods may not resume afterwards.  In the follow-up of our patients so far, there does not appear to be re-growth of the fibroids once they have shrunk and interestingly new fibroids do not appear to develop.

Fibroid Embolization and Fertility

There is some concern about the effect of the embolisation on fertility in women who might want to become pregnant some time in the future.  Limited data are available but there are better data for fertility and pregnancy following myomectomy which has been available for longer. We and other groups have had a number of pregnancies following embolisation for fibroids and other conditions and the outcome of these pregnancies has been normal. In one  study 33% of women under the age of 40 wanting to get pregnant following embolization became pregnant 6 months later. These pregnancies were otherwise uneventful. Other groups have reported similar results. In women under 40 where future pregnancy is an important issue, the alternative treatment of myomectomy should be considered. If Myomectomy is considered to be a reasonable option then it is to be preferred rather than embolization. In some cases the size and location of the fibroids may make myomectomy difficult and embolization is then the better option. If a woman has already had a myomectomy this makes a second operation more difficult and risky and then embolization is a better alternative.
Fibroids are commonly associated with infertility and may result in miscarriages.  We do not currently believe there is a place for embolisation in such women, unless they also have significant symptoms due to the fibroids.