By Dr. Donald Denny
University Medical Center at Princeton
Sunday, Aug. 20, 2000

Uterine fibroid embolization is considered a miracle by many women who in the past have suffered with fibroid tumors. These women were resigned to living with the symptoms because they did not want to undergo a hysterectomy, which was the standard treatment.

It is only within the last two years that uterine fibroid embolization has become widely available. The procedure, which involves blocking the flow of blood to a women's fibroids, is the highly successful, minimally invasive alternative to having a hysterectomy.

A uterine fibroid is a benign growth on the smooth muscular wall of the uterus. Quite common, it is estimated that at least 25 to 50 percent of all women over the age of 35 will eventually develop fibroids, although they are often so small that they cause no problems and can be left alone.

Because they range in size from quite small to the size of a cantaloupe or larger and can grow in different locations within the uterus, their size and location determines how bothersome they will be.

There are three main types of uterine fibroids: subserosal, intramural and submucosal. Subserosal fibroids develop in the outer portion of the uterus and continue to grow outward, sometimes causing pressure due to their size.
Intramural fibroids are the most common and they develop within the uterine wall where they expand and cause the uterus to feel larger than normal. Women suffering from these fibroids may experience a heavier menstrual flow and pain or pressure in the pelvis.

The least common type of fibroids is the submucosal which are located deep within the uterus, just under the lining of the uterine cavity. Submucosal fibroids often result in very heavy and prolonged menstrual periods.

The exact cause of fibroids is currently unknown, although they are clearly linked to estrogen and there is evidence that progesterone may stimulate fibroid growth. Fibroids usually stop growing by menopause, and will often progressively shrink beyond that time.

Because fibroids respond to estrogen stimulation and a growing number of women use estrogen replacement to alleviate the symptoms of menopause, we may start to see fibroids continuing to grow and cause symptoms beyond menopause. Symptoms include heavier menstrual bleeding, sometimes with passage of blood clots. If the bleeding is severe, anemia can occur.

Pain and pressure, sometimes described as a feeling of fullness in the pelvis, abdomen or lower back, are common, as are frequent urination or constipation. Sometimes women will experience pain during or bleeding after intercourse.
Fibroids are diagnosed during a gynecologic internal examination. Should your doctor feel that your uterus is enlarged, a pelvic ultrasound, MRI or CT can confirm the presence of fibroids. Once fibroids are detected, treatment will depend on the size and location of the growths as well as the severity of the symptoms.

If the fibroids are small and there are no symptoms, there is no treatment required. If the symptoms are mild to moderate, drug therapy is most often prescribed. This may include over-the-counter pain medications or a prescription for birth-control pills. For women suffering more intense symptoms, the most recent innovation is uterine artery or fibroid embolization.

This is a non-surgical procedure performed by a doctor known as an interventional radiologist. Interventional radiologists are highly trained subspecialists skilled at diagnosing and treating conditions using miniaturized tools while watching their progress on some form of imaging equipment such as X-ray, ultrasound or CT. These kinds of treatments are easier for patients because they result in no surgical incisions, shorter hospital stays and less pain.

Uterine fibroid embolization is performed in a specially-equipped X-ray procedure room, using local anesthesia. Intravenous sedation is given to keep the patient comfortable. The radiologist makes a tiny incision in the groin, punctures the femoral artery with a small needle, and inserts a thin catheter into the artery.
Using X-ray guidance on a television monitor, the radiologist steers the catheter through the circulation to the uterine arteries, the vessels which supply blood to the uterus and fibroids. Tiny polyvinyl particles (PVA) are inserted into the catheter and used to embollize (block) the arteries that supply the flow of blood to the fibroids.
There are no known reports of any adverse side effects due to this embolization material. Once the blood no longer flows to the fibroids, the fibroid tissue will die, causing the fibroids to scar down and shrink.

The procedure typically lasts about one and a half hours. The principle side effect is pelvic pain and cramping, which is treated with pain medication. Depending on how severe the pain is, about 50 percent of patients stay overnight in the hospital and the other half opt to go home the day of the procedure.

Patients can expect mild to moderate cramping for several days to a week after the procedure. About 20 percent of women develop a temporary fever known as Post-Embolization Syndrome which can last three to seven days. After two weeks, most women report a full recovery and have a follow-up appointment. Within two to three months, patients will have a repeat ultrasound to re-measure the size of the fibroids and the uterus.

The statistics are encouraging. According to the Society of Cardiovascular and Interventional Radiology, 90 percent of women reported satisfaction with the procedure. Between 85-90 percent of women have reported improvement or complete resolution of symptoms, particularly decreased bleeding. In the three to 12-month follow-up period, 85-90 percent of women demonstrate an average of 40-70 percent shrinkage in uterine and fibroid volume.

Although this process is just now coming into its own as a treatment for uterine fibroids, the history of uterine fibroid embolization is an interesting one. The embolization of uterine arteries for severe post-partum or post-traumatic hemorrhage has been performed for over 20 years. Then, in 1990, a French gynecologist named Jacques Ravina started to use embolization prior to performing hysterectomies to decrease blood loss during surgery. When his patients started noticing that their bleeding and pain improved, they started canceling their surgeries. This discovery lead to uterine fibroid embolization as it is currently practiced.

Potential candidates for this treatment include women who want to preserve their uterus, wish to avoid surgery or have symptomatic fibroids for whom hysterectomy has been recommended.

As with many procedures, though, it is not for everyone. This includes women with asymptomatic fibroids, instances where there is a suspicion of malignancy, and women who have an infection or pelvic inflammatory disease. Women who still wish to have children should consider myomectomy, as the effects of uterine fibroid embolization on fertility are not yet known.

But for those to whom this treatment provides much-needed relief, uterine fibroid embolization is something of a miracle cure.

Copyright © 1996-99 The Princeton Packet, Inc.