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What are uterine fibroids?

Fibroids are common benign (non-cancerous) tumours in women. Up to 25% of women of reproductive age may harbour one or more fibroids. Not all women with fibroids suffer from symptoms. Between 10-40% women with fibroid develop symptoms and requires treatments.

Every one is different. A thin individual might find the fibroids more noticeable than a larger person. Someone who has a sensitive bladder may have bladder symptoms with quite average sized fibroids. Fibroids are benign tumours that require treatment only when symptoms are bothering you and affecting your quality of life. Of course if the heavy periods are causing anaemia you should consider treatment.


If you are not sure, make an appointment to see your doctor or Dr Liang to discuss further.

The choice of treatments depends on the type and severity of symptoms, as well as size and location of fibroids. Below is a general discussion of different treatment options. For detailed description of different treatments please see specific pages.


Your GP and gynecologist might have tried different medical therapies such as non-steroidal anti-inflammatory agents (eg. Naprosyn), birth control pills, or progesterone agents. If the above failed, the decision for further medical treatment depends on your age, the size of the fibroids, the desire for future pregnancy, and the severity of symptoms. In certain circumstances a Gonadotropin Releasing Hormone (GnRH) agonist may be used. However it may cause hot flashes and mood changes and osteoporosis. The use is usually limited to 6 months. Fibroids usually regrow after GnRH agonists are stopped.


Progestogen releasing intrauterine device (IUD) may be helpful for heavy period. However, it does not reduce the size of the fibroids.


Emdometrial ablation destroys the inner lining with heat energy and you may no longer have any more menstrual periods. The treatment however dose not shrink the fibroid and therefore will not relieve bulk related symptoms.


Small fibroids protruding into the cavity of the uterus can be removed by hysteroscopic resection (removal with the aid of using a camera through the vagina and cervix).


Traditionally when the above treatments failed or were unsuitable, hysterectomy (removal of the entire uterus) is offered to women. However, hysterectomy is a major surgery that requires 5-6 weeks of recovery. It carries the risks of a major surgery and is associated long-term adverse effects.


Myomectomy (removal of fibroid only) is offered to women who wish to retain the uterus and fertility. It is possible only for small number of fibroids in suitable locations. It is technically more demanding to the surgeon, takes longer time to perform and more likely that you will require a blood transfusion. Sometimes myomectomy is converted to hysterectomy if the surgeon is unable to control the bleeding or reconstruct the uterus. Like hysterectomy, abdominal myomectomy takes 5-6 weeks to recover. Laparoscopic (key-hole) myomectomy is quicker to recover then abdominal myomectomy, but is technically more challenging to the surgeons to perform.


Uterine fibroid Embolisation (UFE) is a non-surgical alternative to hysterectomy. It is minimally invasive, and highly effective in reducing heavy period, shrinking the fibroids and relieving period pain. Studies have shown that UFE is as effective as hysterectomy in improving the women’s quality of life.

Malignant (cancerous) fibroids are very rare. It is called leiomyosarcoma. It is found in 2-5 per thousand hysterectomies and 4 per thousand cases of uterine fibroid Embolisation. Fear of sarcoma should not be normally construed as a reason for hysterectomy. Hysterectomy itself has a mortality rate of 0.5-4 per thousand. Other adverse effects of hysterectomy significantly outweigh the very small risk of missing a sarcoma.(See also adverse effect of hysterectomy click here). Rate of growth, size of the fibroid, utrasound and MRI cannot reliably diagnose sarcoma. Failure to respond to Embolisation, especially continuing growth and pain, are warning signs. Therefore it is important to attend imaging follow-ups after UFE.

FIBROID TREATMENT OPTIONS

What are the treatment options for fibroids and which one is suitable for me?

The choice of treatment depends on the type and severity of symptoms, as well as the size and location of fibroids. Below is a general discussion of different treatment options. Please see specific pages for uterine fibroid embolisation and hysterectomy.

The device is inserted in the rooms of your GP or gynaecologists. It is only helpful for heavy period. It does not reduce the size of the fibroids. When fibroids are large and distorting the cavity, it may be difficult to insert and remove the device. Sometimes device may not stay in. In some women, heavy bleeding could be converted to prolonged spotting which could be quite annoying as well.

The procedure is performed under general anaesthetic in an operating theatre. It uses heat energy to destroy the inner lining of the uterus. You may no longer have menstrual period. However, the treatment dose not shrink the fibroid and therefore will not relieve symptoms related to the bulk of the fibroids, such as urinary symptoms.


If your uterine cavity is distorted by fibroid, the procedure may not be successful due to lack of effective contact between the heating device and the lining of the uterus.

This is usually a general anaesthetic procedure performed in operating theatre. The procedure is much less invasive than hysterectomy. The procedure is only suitable for small fibroids protruding into the cavity of the uterus. They are removed with the aid of a camera through the vagina and cervix.

This is a surgical operation to remove one or a few fibroids. This is offered to women who wish to retain the uterus and fertility. It is possible only for a small number of fibroids in suitable locations. 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 myomectomy is converted to hysterectomy if the surgeon is unable to control the bleeding or reconstruct the uterus.


Myomectomy improves heavy menses in 70-80% of patients. Development of adhesion (internal scarring of the abdomen) is a potential side effect. Recurrence of fibroids occurs in 40-50% of women*.


The recovery is quicker with laparoscopic myomectomy, but the surgical risks are not lower. Laparoscopic surgery is technically more demanding and there is a steep learning curve for the surgeons. Due to limited access and visualization, and it can be more risky in terms of injuries to blood vessels, bowel, bladder and ureter. Whether laparoscopic surgery is the right choice for you depend on the reason for your hysterectomy, your desire for quick recovery, as well as skill and the experience of the surgeon.


* Reference: Chapter 9, Williams Gynaecology 2008.

Uterine fibroid embolization(UFE) is a non-surgical alternative to hysterectomy. It is minimally invasive, but highly effective in reducing heavy period, shrinking fibroids and relieving period pain. Studies have shown that UFE is as effective as hysterectomy in improving the women's quality of life. Please see separate sections on "Uterine Fibroid Embolisation", "Hysterectomy vs UFE" and "Patient Testimonials".

Advantage:


Painless. Non-invasive. Outpatient.


Disadvantage:


Long treatment time on the MRI machine.


High equipment cost and staff cost ( radiographer, nurse, supervising radiologist).


Viable fibroid tissue left behind becomes nidus for regrowth.


Only small fraction of suitable patients


No Medicare nor health fund rebate, and therefore there will be no rebatable doctors' fee, theatre banding charges and in-hospital bed fee.


Currently only available in Melbourne.


Exclusion criteria:


Obesity >120 kg or 250lbs


Pedunculated fibroid


Abdominal scar


Desire future pregnancy


Fibroid volume >900mL or more than 7 fibroid


Submucosal fibroid > 3cm


Adenomyosis


Bright T2 and/or vascular fibroids


Calcified fibroid


Longer then 3 hours of treatment time


Safety concerns:


Abdominal scar distort ultrasound beam and can cause skin injury and ineffective heating of fibroids.


Fibroids too close to skin can cause skin burns.


Fibroids too close to bone cause overheating and nerve damage.


Fibroids too close to bowel cause thermal injury.


Subserosal fibroid < 3cm in size may cause thermal injury to adjacent tissue, because focal ablation zone is 2.5cm along its beam.


Submucosal fibroid > 3cm may slough off and cause cervical obstruction.


Efficacy concerns:


8cm fibroid takes 3 hours to treat.


T2 bright/vascular fibroids difficult to heat, may not respond.


Heterogenous/sepatated/non-perfused fibroids do not respond well


Calcified fibroid difficult to heat up. It may refocus ultrasound and cause thermal injury to non-target organs.



MRGFUUFE
Size and number fibroid
Limited
Any size and numbers
Desire pregnancy
Maybe suitable
Maybe suitable
Adenomyosis
Not suitable
Effective
T2 bright Heterougenous Hypervscular
Less effective
Effective
Calcification
Nontarget energy reflection
Not affected
Abdominal scarring
Skin injury
Not affected
Obesity, thick uneven abdominal fat
Less effective
Not affected
Target deeper than 12 cm
Not effective
Not affected
Too close to bone 
Nerve damage
Not affected
Too close to skinSkin injuryNot affected

UFE and MRgFU are not competitive, but complementary.

There are cases not suitable for UFE but suitable for MRgFU, and vice versa.

WHAT IS UTERINE FIBROID EMBOLISATION (UFE)?

UFE is also known as UAE (uterine artery embolisation). It is a minimally invasive procedure performed by interventional radiologist to embolise (block) the blood supply to the uterus. By limiting blood supply to the uterus, the fibroids will shrink and the associated symptoms subside. It is a non-surgical alternative to hysterectomy..

The procedure is performed in an angiography suite. The patient is conscious but sedated with IV medications. Local anaesthetic is given at the groin where a tiny nick in the skin is made. Catheter (a small tube 1-2 mm in diameter) is inserted into the femoral artery at the groin and guided under X-ray to reach the uterine arteries. Tiny plastic particles (0.3-0. 5mm) are mixed with X-ray dye, and injected under X-ray control to block the uterine arteries.

Studies suggest UAE is as effective as hysterectomy in controlling primary symptoms of heavy period, bulk related symptoms and period pain. UFE and surgery are equivalent in improvement of quality of life. On average, 85-90 % of women who have had the procedure experience significant or total relief of heavy bleeding, pain and/or bulk-related symptoms. Our own success rate at Sydney Adventist Hospital is higher than 90%. The procedure is effective for multiple fibroids and large fibroids. Recurrence of treated fibroids is very rare. Short and mid-term data show UFE to be very effective with a very low rate of recurrence. In one study in which patients were followed for six years, no fibroid regrew after embolisation.

UFE is a minimally invasive procedure. It is very safe compare with major surgery. Spillage of particle away from uterine artery, vessel injury at the groin are all very rare complications, each occuring in less than 1 %. We did not have any significant procedural related complications at the Sydney Adventist Hospital.


Infection of the uterus (endometritis) is rare (3 %). Pain, fever and vaginal discharge are the symptoms. This is usually managed with prompt administration of IV antibiotics.


Fibroid expulsion through the cervix occurs in < 3%. In majority of cases, the fibroid fragments can be passed successfully. Some may require a minor procedure to remove the fibroid fragments.

Transient amenorrhea occurs in 5-10 % of patient after UFE. Younger patient tends to regain periods within 6 months. Permanent amenorrhea (menopause) occurs in less than 3% of women younger than age 45, but more frequent (7-14%) in age > 45. This may reflect the fact that women in mid 40s or older is already nearing menopause.

This is a complex issue. Presence of fibroids can make you difficult to get pregnant, potentially cause miscarriage and difficulties in normal vaginal delivery. Traditionally myomectomy is recommended if fibroids are thought to be interfering with fertility and pregnancy. Myomectomy however is still a major surgery, usually more technically challenging than hysterectomy. The risk of blood transfusion is higher than hysterectomy. There is also risk of hysterectomy if the surgeon is not able to preserve the uterus.


Studies have shown that UFE does not appear to affect ovarian function in younger women. Menopause after UFE tends to occur in older women close to natural menopause. There are theoretical concerns about negative impact on ovarian and uterine function after UFE. However, there are numerous reports of pregnancies following UFE. Dr Walker from UK has a large series of 105 pregnancies following UFE. His result has influenced the way in which patients with fibroids wanting to become pregnant should be counselled. For fibroids interfering with fertility, especially those not suitable for myomectomy or hysteroscopic resection, UFE should be considered as an option for treatment with advice that a successful pregnancy outcome is possible after UFE.


It should be emphasised that the aim of UFE is to treat fibroid symptoms with a minimally invasive technique to avoid hysterectomy. UFE is not intended to maintain uterine viability for pregnancy, although pregnancy is possible after UFE.

1. All patients will be required to have a pre-procedure consultation by the interventional radiologist. This allows us to obtain a gynaecologic and general medical history, to review the imaging findings and to discuss the procedure with the patient.


2. A MRI of the uterus is preferred. We prefer this be done at facilities familiar with fibroid imaging and reporting. The MRI helps the interventional radiologist to rule out fibroids unsuitable for embolisation. The MRI is also used as a baseline for follow-up evaluation at 6 month.

We believe in multidisciplinary approach to deliver the best care for your fibroid related problems, therefore we share the care with your GP and gynaecologist.


You need to see your own gynaecologist or we can recommend a gynaecologist who is familiar with UFE.


You GP and gynaecologist may perform some of the following assessment:


1. A pelvic examination within six months of the procedure.


2. A Pap smear within the last year and should be normal.


3. If you have abnormal uterine bleeding (such as bleeding in between periods, periods lasting longer than 10 days or more frequently than every 21 days), an endometrial (inner lining of the uterus) biopsy is needed, preferably within the preceding 3 to 6 months. This is to be certain that the bleeding is not due to abnormal growth.


4. If you have a history of pelvic infection, cultures for Gonorrhoea and Chlamydia need to be obtained.


Your gynaecologist and GP will also take part in your follow-up, as well as your on-going well women care.

On the day of your procedure, you need to avoid solid food from midnight. Clear fluid and medications are allowed up to the time of procedure. We will start an intravenous line to give you fluid, sedatives and pain relief medications. You must not be pregnant. A pregnancy test is needed if there is possibility of pregnancy and the procedure is done more than 10 days since the beginning of your last menstrual cycle.


We also need to place a catheter in your bladder, so that the bladder will remain empty during the procedure. Since the bladder is in front of the uterus, X-ray dye collected in the bladder will obscure our view.

You will need to see the interventional radiologist to check your recovery at about 1 week after discharge from hospital. Since we have not removed your uterus, it is important to follow you up for up to two years. The follow-up schedule with the interventional radiologist consists of clinic visits at 3, 6, 12 and 24 months. All patients are required to have a 6-month MRI. For patients with large fibroids, ultrasound at 3, 12 and 24 months maybe required to monitor changes.


You will need to liaise with your GP and gynaecologist to tailor your follow-up schedule depending on your situation.

Resurgence of pelvic pain and fever, or development of foul smelling vaginal discharge might indicate sloughing of fibroid and infection. You may require urgent medical assessment. If any of these symptoms occur, please try to contact us immediately, or present to your GP or gynaecologist. If the symptoms are serious and urgent (e.g. after hours), you should present to emergency department for assessment and ask the emergency doctors to contact interventional radiologist or your gynaecologist for advice. Blood tests are usually required to check for serious infection. IV antibiotics need to be given promptly. Very rarely a minor procedure (D&C) is required to clear the fibroid slough. Hysterectomy is highly unlikely to be necessary.

UFE and Pregnancy: Dr Walker's Pregnancy Data on more than 105 pregnancies following UFE. Dr Walker's paper on the topic can also be found on the website.


http://www.fibroids.co.uk/fibroid_embolisation/walkers_series.html

WHAT IS HYSTERECTOMY?

Hysterectomy is the surgical operation to remove all or part of the uterus due to a number of reasons, including relieving the symptoms presented by benign tumours such as uterine fibroids

There are several types of hysterectomy depending on the reason for the hysterectomy.


Total hysterectomy and bilateral oophorectomy: the entire uterus including the cervix and both ovaries are removed.


Total hysterectomy without oophorectomy: the entire uterus and cervix are removed, but ovaries are left behind.


Subtotal hysterectomy: only the body of the uterus is removed, leaving behind the cervix.

There are many ways of removing the uterus depending on the surgeons' skill, experience and preference, and of course the reason for the hysterectomy.


Abdominal hysterectomy: through a 15 cm incision in the lower abdomen.


Vaginal hysterectomy: through a speculum in the vagina; cervix will have to be removed.


Laparoscopic hysterectomy: this is so-called key-hole surgery. Through three small cuts in the abdomen, the surgeon inserts a camera and other surgical instruments.


Laparoscopy assisted vaginal hysterectomy: combining laparoscopic technique with vaginal hysterectomy.

The recovery is quicker with laparoscopic surgery, but the surgical risk is NOT lower. Laparoscopic surgery is technically more demanding and there is a steep learning curve for the surgeons. Due to limited access and visualisation, it can be more risky in terms of injuries to blood vessels, bowel, bladder and ureter. Whether laparoscopic surgery is the right choice for you depend on the reason for your hysterectomy, your desire for quick recovery, as well as skill and the experience of the surgeon.

For more detailed information regarding hysterectomy please see the following links:


Hysterectomy: From Wikipedia, the free encyclopedia. A detailed discussion with citations.


http://en.wikipedia.org/wiki/Hysterectomy


Hysterectomy: Better Health Channel. Easy to read patient information produced by State Government of Victoria.


http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Hysterectomy?open


How abdominal hysterectomy is carried out: An animation produced by BUPA health to show how abdominal hysterectomy is carried out.


http://www.youtube.com/watch?v=hLJrsJjhQgc&feature=youtube_gdata_player

HYSTERECTOMY SIDE EFFECTS

Why should you consider alternatives to hysterectomy?

Hysterectomy is a major surgery that carries a risk of death of 5-38 per 100,000. Non-surgical means to treat fibroid symptoms are much safer. For example, UFE mortality is 1/100,000, which is 5-40 times safer than hysterectomy.
Besides risks of surgery, there are many other potential adverse effects of hysterectomy on your health.
Unless you have cancer of the uterus, hysterectomy is rarely needed to deal with your fibroid related symptoms.
There are many less invasive treatment options to deal with your fibroid related symptoms without resorting to hysterectomy.

It has been known for a long time that hysterectomy patients took longer to recover compare with patients who had other major surgeries. Symptoms include urinary problems, tiredness and depression. Doctors were puzzled and labelled this Post Hysterectomy Syndrome. It was thought to be due to hormone imbalance after hysterectomy.


Hysterectomy is shown to be associated with earlier onset of menopause. Women who had hysterectomy enter menopause almost 4 years earlier compared to similar women who did not have hysterectomy. Blood supply to the ovary maybe in interrupted during surgery by ligation, spasms or thrombosis.


Early menopause is known to be associated with increased cardiovascular risk such as heart attacks and strokes, as well as osteoporosis.


Premature menopause can also increase risk of dementia.


Unfortunately hormone replacement therapy (HRT) is not a simple answer to premature menopause caused by hysterectomy. Instead of protective against cardiovascular disease, recent studies have shown that HRT may actually increase the risk of heart attacks. In addition, HRT increases the risk of breast cancer.

Urologists are familiar with women who complain bitterly of urinary symptoms related to a previous hysterectomy. "Everything was alright until I had my hysterectomy".


Hysterectomy weakens the pelvic floor and can cause stress urinary incontinence. Gynaecologists specialised in advanced pelvic floor surgery may advise against hysterectomy. We have had gynaecologists specialised in pelvic floor surgery referring patients for UFE to shrink the fibroid before pelvic floor surgery.


Patients who developed severe constipation after hysterectomy may have had their nerves damaged during surgery.

Studies regarding the effect on sex life after hysterectomy can be confusing. Essentially it depends on whether the fibroids were affecting sex life in the first place.


For those women whose sex life was ruined by fibroid related symptoms, they might find hysterectomy actually improves sex life.


For those women whose sex life were not affected by fibroids, they need to be aware that studies have demonstrated decreased libido and orgasm after hysterectomy, especially total hysterectomy.


Nerve damage during surgery may be a cause. Surgery may change the anatomy of the top of the vagina, resulting in altered sensation for women and her partner. For some women, uterine contraction is essential for orgasm. This could be lost after hysterectomy.

1. Chlebowski RT, Kuller LH, Prentice RL, et al. Breast cancer after use of estrogen plus progestin in postmenopausal women. New England Journal of Medicine. 2009;360(6):573–587.


2. Farquhar CM, Sadler L, Harvey SA, Stewart AW. The association of hysterectomy and menopause: a prospective cohort study. BJOG: An International Journal of Obstetrics & Gynaecology. 2005;112(7):956–962.


3. Kilkku P, Grönroos M, Hirvonen T, Rauramo L. Supra Vaginal Uterine Amputation VS. Hysterectomy: Effects on libido and orgasm. Acta obstetricia et gynecologica scandinavica. 1983;62(2):147–152.


4. Manson JAE, Hsia J, Johnson KC, et al. Estrogen plus progestin and the risk of coronary heart disease. New England Journal of Medicine. 2003;349(6):523–534.


5. Richards D. A post-hysterectomy syndrome. The Lancet. 1974;304(7887):983–985.


6. Rocco W, Bower J, Maraganore D, others. Increased risk of cognitive impairment or dementia in women who underwent oophorectomy before menopause. Neurology. 2007;69(11):1074–1083.


7. Smith A, Varma J, Binnie N, Papachrysostomou M. Disordered colorectal motility in intractable constipation following hysterectomy. British journal of surgery. 1990;77(12):1361–1365.

For more detailed information regarding alternatives to hysterectomy please see the following links:


Hysterectomy Alternatives and After-effects by Hers Foundation: Hysterectomy Educational Resources and Services. HERS is the independent, international organization dedicated to the issue of hysterectomy. HERS advocates for fully informed medical decisions by women.


http://www.hersfoundation.com/facts.html

HYSTERECTOMY VS UFE

WOMEN'S STORIES

My wife had your procedure to reduce her fibroids, which were sapping her of a lot of red blood cells. She was very ill for a long while until she was referred to you by way of Dr Jeremy Tham to Dr Beven Brown.My first impression was how easy it all unfolded, from her first consultation to post surgery.


My wife is a very active person who will see everything there is to see and be involved in a host of different activities. She was hamstrung by her Fibroid problem that needed her constant attention to work her very day life.


Her embolisation has maintained her new found high red blood count to a very healthy and safe level, which has made her much happier and healthier. The main difference is that she can go about her normal life with out the worry of Fibroids sapping her of all her energy and avoiding places and events because she was feeling flat or exhausted.


She is back to full strength and loving life, I highly recommend your work and feel that more or all women suffering with Fibroids must take this action before going down the road to removal of their Uterus.


The procedure was easy on her body and the results are astronomical, so thank you for your work and care and I hope you will help a lot more women with their health.

Please let me know if there is anything else I can do as I have quite often thought of ways to help other women who are in the same situation.I am so happy to help raise awareness in order to help someone else out there!


You are the reason for my sweet little boy and I can never thank you enough!!!


About 10 years ago I started seeing several doctors, as I knew there was something wrong with my body, just not sure what it was. My symptoms were severe iron deficiency, unexplainable weight gain, mood swings and in general very lethargic.


As the years passed all would tell me I simply needed to change my diet and one even gave me a course of 6 iron injections to fix the problem.It wasn't until I was so tired of having the same problems that I went to see a few specialists and years later one finally diagnosed me with having an unusually large fibroid in my uterus.


I was referred to one of the best gynecologists to see what my options were and after a long journey to this point, I was told my only option was a hysterectomy and that I would never have any children.


My husband and I were devastated and very emotional that day in the doctor's office at the thought of never having the option of having a child and the doctor was quick to get me to sign the hospital paperwork to have the procedure done as soon as possible.


I decided to check one last doctor whom my sister and friend had to deliver their children and was told I did have another option of Fibroid Embolisation.


Basically after more consultations I elected to have the Embolisation done and keep my uterus in tact.


Now 4 years later have better health and a very healthy and happy 10-month-old little boy who is the best thing that has happened to my husband and I.


I am so grateful for a second chance and the option to be a mother.