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An Introduction to Uterine Fibroids: What Is A Fibroid? What Are The Fibroid Treatment Options?

Dr Eisen Liang - Monday, February 20, 2017


You've probably heard of uterine fibroids but don't know much about them. Or even if you've read about them, it may be difficult to understand all the medical jargon.

Dr. Eisen Liang is an interventional radiologist and fibroid embolization specialist. Together with obstetrician and gynaecologist Dr. Bevan Brown, they seek to spread knowledge on uterine fibroids and the different treatment options for women in our modern era of advanced medicine. 

Their 5000 words article How to Treat Fibroids was published in the GP Magazine Australian Doctor. Here's a section that's been reworded to help you better understand the nature of fibroids.
 


Uterine fibroids are benign tumours that are commonly present in women. In fact, it's so common that it affects one in four women of reproductive age. While they are non-cancerous, 10-40% women may experience accompanying symptoms that significantly affect their quality of life and may need treatment. Most would find these symptoms bothersome, inconvenient, and painful.

Before, when simple medical measures proved to be ineffective, the only treatment option given was a hysterectomy, the removal of the entire uterus. Now with advancements in procedures in the past two decades, there have been less-invasive options offered. 



(Image via: mirena-us)

One is Mirena, an intrauterine device used for birth control. It releases a steady dose of progesterone hormone. It might help to reduce heavy menstrual flow but does not shrink fibroids.

Another is endometrial ablation, a procedure that destroys a thin layer of the lining of the uterus with heat energy. It stops menstrual flow altogether. 

A very effective non-surgical procedure is uterine fibroid embolization (UFE). It works by blocking blood supply to the uterus, starving the fibroids, and shrinking them without having to remove them. According to many studies, UFE has been proven to be as effective as hysterectomy in relieving symptoms of heavy menstrual bleeding, period pain, and bladder symptoms.



Because of the development of these less invasive treatment options as well as advances in techniques in hysteroscopic, laparoscopic, and robotic surgery, hysterectomies for uterine fibroids are no longer necessary in many cases. In fact, they should only be considered as a last resort when other less invasive treatments have trialed and failed.

Women who are experiencing symptoms related to uterine fibroids should speak with their GP or gynaecologist to discuss the many treatment options and find the one best suited for them. You GP or gynaecologist might not be familiar with UFE. To download a Fact Sheet to take it to your doctors, click this link:
Factsheet For Doctors

To find the full set of articles for you and your doctor on uterine fibroids, its symptoms, and the various treatment options, click on this link below:

Doctor's Resources


6 Alternative Fibroid Treatment Options For Women Considering Hysterectomy

Dr Eisen Liang - Thursday, February 09, 2017

Just diagnosed with Fibroids? What are the fibroid treatment options?

Before consenting for hysterectomy, be fully informed about other less invasive treatment options.

There are various treatment options for uterine fibroids. However, some women may not be aware of these and are quite often advised that the only solution is a hysterectomy, which is the removal of the uterus from the body. Unless it’s cancerous, hysterectomy may not be necessary. Hysterectomy is, of course, a major surgery and carries with it all the risks of major surgery. Also, some women understandably mourn the loss of their womb.

That's why more women need to be aware of the alternatives to hysterectomy. Below is a brief discussion of various treatment options. Suitability will depends on the type and severity of one's symptoms as well as the location and size of the fibroids, and more importantly, the woman’s personal preference.  Hysterectomy should be considered as a last resort, when all other less invasive treatments have failed or deemed unsuitable.

Fibroids are common benign tumours. Many women with fibroids do not experience symptoms.  However if one is suffering fibroid symptoms, treatment may be needed.

 

Medical therapy

To control heavy bleeding during periods, a doctor may prescribe non-steroidal anti-inflammatory drugs, birth control pills, or progesterone agents. Keep in mind though that these do not reduce the size of fibroids.

Gonadotropin Releasing Hormone (GnRH) agonist also controls bleeding and may reduce the size of the fibroid and the uterus. However patients are usually advised to limit their use of this drug to 6 months due to its common side effects such as hot flashes, mood swings, and osteoporosis. After stopping GnRH agonists, fibroids usually start to regrow.

Cyclokapron reduces heavy bleeding by enhancing clotting ability. In rare cases for high risk patients, it can cause serious side effects such as deep venous thrombosis (DVT) and pulmonary embolism (clots in the lung).

 

Mirena IUD

(Source: Image via mirena-us.com) 

A Mirena IUD is an intra-uterine device, which is a device that is inserted into the uterus and stays in for a period of time where it slowly releases the progesterone hormone. While an IUD may be helpful for reducing the heavy periods associated with fibroids, it does not reduce the size of fibroids. Also, if one has large fibroids that are distorting the cavity, the IUD may be difficult to insert or remove and sometimes it may not stay in. Some women may experience prolonged / irregular periods, or continuous spotting with the Mirena IUD.

 

Endometrial Ablation

This procedure involves the use of heat energy to get rid of the inner lining of the uterus. The patient is put under general anaesthesia and the surgery is done in an operating theatre. After the procedure, the patient may no longer have a menstrual period. If the uterine cavity is distorted by fibroids, the procedure may not be successful due to lack of effective contact between the heating device and the lining of the uterus.

The procedure does not shrink fibroids and therefore does not relieve bulk symptoms such as urinary frequency.

 

Uterine Fibroid Embolization (UFE)

UFE is local anaesthesia non-surgical procedure performed by an interventional radiologist. The procedure embolizes or blocks the blood supply to the uterus. The lack of blood supply to the uterus makes the fibroids shrink and as a result alleviates bulk symptoms such as urinary frequency. UFE is also highly-effective in reducing heavy menstrual bleeding and relieving period pain. This non-surgical alternative to hysterectomy is essentially as effective as hysterectomy. UFE has shorter hospital stay and quicker time to return normal life and activities

 

Hysteroscopic Resection

This procedure is much less invasive than a hysterectomy but still need to be performed under general anaesthesia and in an operating theatre. It is only suitable for small fibroids protruding into the cavity of the uterus which are removed with the aid of a camera inserted through the vagina and the cervix.

 

Myomectomy

This procedure is done to surgically remove one or a few fibroids and is offered to women who wish to retain the uterus and fertility. Only when there is a small number of fibroids in suitable locations can this procedure be possible. It is technically more demanding to the surgeon, takes longer time to perform, more likely to require blood transfusion, and requires 5-6 weeks for recovery. Sometimes a myomectomy is converted to a hysterectomy if the surgeon is unable to control the bleeding or reconstruct the uterus.

Myomectomies improve heavy bleeding in 70-80% of patients. Development of internal scarring of the abdomen is a potential side effect. Recurrence of fibroids occurs in 40-50% of women.

Another procedure is laparoscopic myomectomy- a key hole surgery. The recovery time is quicker, although the surgical risks are not lower. Laparoscopic surgery is technically more demanding of surgeons due to limited access and visualization. It also poses the risk of injuries to blood vessels, bowel, bladder, and ureter. Whether laparoscopic surgery is the right choice for a patient depends on the reason for it, the desire for a quick recovery, as well as the skill and the experience of the surgeon.

 

Hysterectomy

When all other conservative treatments failed or deemed unsuitable, a hysterectomy may be needed. This operation removes the uterus from the woman's body. It is a major operation and  carries the risks of a major operation.

There are also potential long-term adverse effects to be aware of, such as vaginal prolapse.  Vaginal prolapse is where the top of the vagina gradually slips out of place, and may fall toward the vaginal opening because the uterus is removed. The uterus serves as important structural support for the top of the vagina. As the top of the vagina falls as a result of missing structural support, this may put additional stress on other ligaments supporting the pelvis.

Another potential side effect of hysterectomy involves the small intestines herniating downwards near the top of the vagina because the structural support provided by the uterus is gone. This condition is known as enterocele.

For hysterectomy, recovery can take up to 5-6 weeks. Hysterectomy should only be considered as a last resort when all other treatments for uterine fibroids have been tried and proven to be ineffective.

For women diagnosed with uterine fibroids who are experiencing severe symptoms, speaking with their  GP or gynaecologist about these options is the best route in finding the right treatment for them.

11 Questions Women Want to Ask When Considering UFE as Their Non-Surgical Fibroid Treatment Option

Dr Eisen Liang - Saturday, February 04, 2017

Did you know that one in four women will develop uterine fibroids during their reproductive age? It is the most common tumour in women and while it is not malignant, it can still cause some symptoms that 10-40% of women need medical treatment or even surgery for. Sometimes, they will even get a hysterectomy which, most of the time, is too invasive just for removing uterine fibroids and relieving its associated symptoms.

Uterine fibroid embolization (UFE) is the non-surgical alternative to a hysterectomy for treating uterine fibroids. It's been proven to be highly effective in shrinking fibroids and relieving symptoms such as heavy bleeding, bladder symptoms and period pain, while being less invasive with a shorter hospital stay, faster recovery, and fewer adverse events compared to hysterectomies.

Compared to hysterectomy, uterine fibroid embolization is minimally invasive. Only a tiny nick in the skin is required to insert  a small catheter into the uterine arteries, blood flow is cut off from the fibroids, ‘starving’ them and causes fibroids to shrink. All of this is done under local anesthetic with x-ray guidance by a skilled interventional radiologist.

Uterine fibroid embolization (UFE) has been around much longer than most people realize. UFE is no longer an experimental procedure and has been around for 20 years. In fact, then Secretary of State of the US Condoleeza Rice had Uterine Fibroid embolization (UFE) back in 2004.

For women who have been diagnosed with uterine fibroids and are thinking of getting treatment for fibroids, here are some questions to ask about UFE, or find answers to, in order to make an informed decision.

                                                  

What is uterine fibroid embolization (UFE)?

Uterine fibroid embolization (UFE) is an interventional radiology procedure done under local anaesthetic and performed in an angiographic suite. Embolization means the blocking of blood vessels, in this case the left and right uterine arteries. They are catheterised and injected with embolic particles so blood flow to the fibroids is stopped, resulting in fibroid shrinkage. This alleviates the symptoms of heavy bleeding, period paid, and bladder problems. UFE is also known as uterine artery embolization (UAE).

Is UFE still experimental?

Uterine fibroid embolization (UFE) has been around for around 20 years. It was first described in 1995. Since then, more than 200,000 UFEs have been performed worldwide. It got approved for medicare funding in 2006 and it's been endorsed as a fibroid treatment option by the American College of Obstetricians and Gynecologists and the Royal Australian and New Zealand College of Obstetricians and Gynecologists in 2008. There are currently six randomized control trials comparing uterine fibroid embolization (UFE) with surgical alternatives like hysterectomy and myomectomy.

How does UFE compare with hysterectomy or myomectomy?

With UFE, there is no surgical cuts, no blood loss, no risk of blood transfusion or wound complications, and no risk of bladder, bowel or ureteric injuries. Hospital stays and time to resume routine activities are also shorter.

UFE and hysterectomy are essentially the same in terms of patient outcomes. A Cochrane review concluded that there is no difference in quality of life improvement at 1 year or patient satisfaction rate at 2 and 5 years.

Not all fibroids can be removed by myomectomy and the remaining fibroids can continue to grow. UFE simultaneously treats all fibroids present in the uterus and was shown to have higher success rate in controlling heavy periods compared to myomectomy.

 

Can fibroids be malignant?

Malignant fibroids are called leiomyosarcoma and their occurrence is very rare. Malignant fibroids are found in merely 2-5 per thousand hysterectomy specimens. Fibroids vary in size and growth rate but these do no indicate malignancy. Fear of one's uterine fibroids turning malignant should not be used to justify getting a hysterectomy when the surgery itself has a mortality rate of 1-6 per thousand.

How safe is UFE?

The rate of complications from UFE is very low and most complications are temporary. One potential  complication from UFE is passage of fibroid debris that occurs in approximately 2.5% of patients. This is likely to occur if the fibroid is protruding into the uterine cavity.

The most serious UFE complication is endometritis, with a reported incidence of 2%. This can be managed with prompt administration of antibiotics and removal of the sloughed fibroid if it is present.

The rate of hysterectomy subsequent to UFE ranges between 0.25% and 1.6% and is generally due to infection, pain, and bleeding.

Is UFE painful?

The procedure itself is not painful. Pain can be at its worst in the first few hours after the procedure. This is managed with paracetamol, NSAID and patient controlled narcotic analgesia. Common symptoms after UFE include low-grade fever, nausea and vomiting, lethargy, and minor vaginal discharge. Patients should expect to return to normal activities in one week.

Is there local Australian data?

Yes, in 2012 we published in ANZJOG the first Australian series of 75 UFEs, achieving a 96% success rate for alleviating heavy periods, 93% overall patient satisfaction, and reported improvement in painful period in 89% of patients.

Can a woman lose her period after UFE?

Yes, but this is more likely to be due to natural menopause. If the patient is a younger woman, UFE does not appear to affect their ovarian function whereas permanent loss of period tends to occur in older women who are about to enter into their menopausal stage.

Is pregnancy possible after UFE?

Yes, pregnancy is possible after UFE. The birth weight were shown to be not affected by previous UFE. However, because women who require UFE already have an abnormal uteruses to start with, they generally have a higher rate of miscarriage, caesarean section, and postpartum haemorrhage compared to the normal obstetric population. Currently a randomised control trial is being conducted in UK to compare fertility outcomes between UFE and myomectomy. In the meantime we recommend MRI to study fibroid anatomy. We would consider UFE if myomectomy is technically challenging and its outcome is likely to be unfavourable for pregnancy, or if the woman prefers a non-surgical approach. 

Can adenomyosis and adenomyoma be treated by UFE?

Yes, we have 90% clinical success in alleviating symptoms of heavy bleeding and period pain. These conditions are usually missed or misdiagnosed on ultrasound. MRI is the most reliable imaging test. Smaller embolic particles are used to treat adenomyosis and adenomyoma.

Who are the ideal candidates for UFE?

Women who are significantly troubled by fibroid or adenomyosis related symptoms such as heavy periods, severe period pain, and bulk symptoms, but want to avoid major surgery and have faster recovery time.


What Are Fibroids: The 3 Most Common Uterine Fibroid Symptoms Every Woman Should Know

Dr Eisen Liang - Friday, January 27, 2017



Uterine fibroids are benign tumours found in the uterus and are the most common tumours in women. It affects one in four women who are at the reproductive age. In fact, 800,000 Australian women have the potential to have the disease at any time.

 

While the tumours are non-cancerous, 10-40% of women who have uterine fibroids require some form of treatment due to the tumours' accompanying symptoms. The most common of these are heavy bleeding during menstruation, period pain different from the usual cramps, and frequent and urgent urination. Most would find these symptoms bothersome, inconvenient, and painful.  




These symptoms fall into two major categories—heavy menstrual bleeding, and what are known as “bulk symptoms”. Symptoms are attributed to types of fibroids, either submucosal, intramural, or subserosal. Submucosal means these fibroids develop on the inner side of the uterus, protruding into its cavity. Intramural means they are between the muscles of the uterus. Subserosal means they are found on the outer surface of the uterus.

 

Heavy bleeding during menstruation is the most common symptom experienced by women with fibroids Studies have linked both intramural and submucosal fibroids to heavy bleeding.

  

1. Heavy Periods


Fibroids cause heavy periods, also known as menorrhagia, when they distort the inner lining of the uterus. Menorrhagia causes a lot of inconveniences for women. They have to change tampons and pads more frequently, they worry about blood staining their clothes during long travels, exercise, or when they're out with other people. Prolonged menorrhagia may lead to anaemia, a deficiency in red blood cells or hemoglobin that leads to weariness and fatigue. Severe anaemia can cause shortness of breath, palpitations, and even heart failure. If hemoglobin in the blood is too low, blood transfusions are needed.

 

2. Bulk Symptoms


Other common symptoms of uterine fibroids are connected to the third type of fibroid, the subserosal type. Subserosal fibroids are largely responsible for bulk symptoms as they grow outward from the uterus and may press against neighboring organs in the abdominal cavity. This can cause a protrusion in the lower abdomen making it seem like weight has been gained. Intramural fibroids that grow large or are abundant can also contribute to bulk symptoms. 


A normal size uterus lies below the pubic bone, well down in the pelvis. It is just above the bladder, in front of  the rectum, and surrounded by the intestines. Since it is so near to these other organs, growth of the uterus from fibroids may cause pressure or, rarely, pain in the pelvis. The uterus is normally about the size of a small pear and weighs about 100-200 grams. But with fibroids, the uterus will enlarge and can cause an awareness of fullness or pressure.


If the uterus gets to be as large as a rockmelon, it may be seen as a noticeable swelling in the lower abdomen, perhaps even making a woman appear pregnant. While not dangerous, the enlarged uterus may cause enough discomfort or enough visible change for women to want to seek treatment.


3. Urinary Symptoms

The uterus normally sits on top of the bladder. Enlarged uterus with fibroids can push against the bladder and can cause urinary symptoms. One can experience frequent urination and feel the urge to rush to the washrooms. Exercise and even just coughing or sneezing can cause the bladder to lose control.

While the above symptoms are very common amongst women with fibroids, the symptoms does not necessarily indicate the presence of uterine fibroids. Women should see their doctors to discuss about their symptoms and have an ultrasound if needed.


Latest update for GPs on Fibroid Treatment Options and Uterine Fibroid Embolisation by Sydney Fibroid Clinic Dr Bevan Brown and Dr Eisen Liang

Dr Eisen Liang - Friday, June 27, 2014
Norwest Private Hospital published two articles for GPs in the Norwest Sydney on fibroid treatment by Dr Bevan Brown and Dr Eisen Liang. The articles written in question and answer formate summarised the latest knowledge on fibroid management.
Please click the link below to see the articles.

Steve Price of Health Matters on Sydney radio station 2GB interviewed Interventional Radiologist Dr Eisen Liang on non-surgical fibroid treatment as an alternative to hysterectomy

Dr Eisen Liang - Friday, June 27, 2014

Health Matters will feature a health professional from Sydney Adventist Hospital each week. This week, Interventional Radiologist Dr Eisen Liang speaks to Steve Price about non-surgical fibroid treatment on 2GB.

How to treat Fibroids: Australian Doctor October 2015

Dr Eisen Liang - Sunday, March 31, 2013

Dr Eisen Liang and Dr Bevan Brown's article on How to Treat Fibroids were published  in the October issue of Australian Doctor, a GP megazine that has a circulation of 20,000. In the article, Dr Liang and Dr Brown has comprehensively reviewed all fibroid treatment options with emphaisis on less invasive options. Follow the link to view the article. 

 

Dr Bevan Brown MBBS (Syd), FRANZCOG Dr Eisen Liang MBBS (NSW), FRANZCR

Dr Bevan Brown is a Gynaecologist Obstetrician with special interest in Pelvic Pain, Endometriosis, Prolapse, Fibroids and Adenomyosis.

Dr Eisen Liang is an Interventional Radiologist with special interest in uterine artery embolisation for fibroids and adenomyosis, Pelvic Congestion Syndrome, Oncology and Vascular Interventions.

Norwest Hospital Gynae GP Seminar

Dr Eisen Liang - Sunday, March 31, 2013

Norwest Hospital Gynae GP Seminar

Please find below the Norwest Hospital Gynae GP Seminar programme.

Gynae February 2013

Dr Bevan Brown and Dr Eisen Liang will join force to speak in the upcoming Women’s Health Public Forum scheduled for Wednesday 17th April 2013

Dr Eisen Liang - Sunday, March 31, 2013

The Forum will be held at Fox Valley Community Centre, located on the Sydney Adventist Hospital Campus. The Forum will open at 6:15pm for a 7:00pm start and conclude at 9:00pm.


TITLE: Uterine Fibroids – Embolisation & Other Minimally Invasive Treatments

 

Description: Update on minimally invasive treatments for fibroids and embolisation as alternative to hysterectomy.

 

Dr Bevan Brown MBBS (Syd), FRANZCOG Dr Eisen Liang MBBS (NSW), FRANZCR

Dr Bevan Brown is a Gynaecologist Obstetrician with special interest in Pelvic Pain, Endometriosis, Prolapse, Fibroids and Adenomyosis.

Dr Eisen Liang is an Interventional Radiologist with special interest in uterine artery embolisation for fibroids and adenomyosis, Pelvic Congestion Syndrome, Oncology and Vascular Interventions.

Dr Liang and Dr Brown were invited to speak in the forthcoming Women’s Heath GP Conference scheduled for Wednesday evening, 22nd May 2013

Dr Eisen Liang - Sunday, March 31, 2013

The conference will take place in the L2 Conference Room at Sydney Adventist Hospital, commencing at 6.15pm with dinner, for a 7.00pm start.

Topics:             Update on Minimally invasive treatments for fibroids

Uterine Fibroid Embolisation: an alternative to Hysterectomy

 

Presenter(s) Details (include title):

Dr Bevan Brown, Obstetrician and Gynaecologist

Dr Eisen Liang, Interventional Radiologist

 

Contact: 9680 3738, Lawton House, Suite 8, 60 Cecil Ave, Castle Hill

 

Women with fibroids usually don’t need a major surgery to deal with their symptoms. Yet each year more than 6000 hysterectomies are performed in NSW alone. There is a lack of awareness amongst GPs and public regarding UFE and other minimally invasive options. Australian women should be adequately informed and empowered to choose the best treatment for themselves. GPs have an important role to play in advocating for less invasive options.

 

Medical Therapy
Mirena IUD
Endometrial ablation
Hysteroscopic resection

Uterine Fibroid Embolisation
Myomectomy
Hysterectomy: disadvantages and adverse effects.

 

Fact Sheet on Uterine Fibroid Embolisation (UFE)

Uterine Fibroid Embolisation (UFE) is also know as Uterine Artery Embolisation (UAE)

UFE is a safe and effective non-surgical alternative to hysterectomy. This has been proven by numerous studies.

UFE is no longer new or experimental. It has been around for more than 18 years.

UFE is a fibroid treatment option endorsed by Colleges of Gynaecologists in Australian and New Zealand, UK and USA

From our local experience in Sydney, we have 93% overall success rate, with 73% patients very happy and 20% happy with the UFE outcome.

For menorrhagia 96% of patients have resolution or significant improvement of their symptoms.

For dysmenorrhea, 89% has at least some improvement, 75% has at least significant improvement, 56% has complete resolution

For urinary symptoms, 50% has significant improvement or resolution of symptoms, 97% has at least some improvement.

Adenomyosis has been successful treated by UAE as well.
Uterine volume reduction of 50% is expected @ 6 months; dominant fibroid volume reduction of 60% is expected @ 6 months.

There were no procedural complications in our series published. There were 3 delayed endometritis (5%), two managed with antibiotics, one semi-elective hysterectomy.

Condoleezza Rice had her UFE in 2004 on a Friday afternoon and went back to work in the White House on Monday morning.

 

Further information on www.fibroid.com.au

 

Two ANZJOG reference papers can be downloaded from http://www.fibroid.com.au/resource.html