What are Fibroids?
Fibroids are benign, hormone sensitive tumors of the uterine muscle that can occur at varying areas of the uterine wall, and cause pain, excessive vaginal bleeding, dysfunctional menstrual cycles, and pressure on other organs. When there is pressure from a fibroid on the bladder or rectum, it can cause symptoms such as excessive urgency to urinate or problems urinating. When they push on the rectum, or other areas of the intestine, they can result in the sensation of bloating, distention, and fullness, or other symptoms. They can also cause problems with fertility, and interfere with normal implantation of a fertilized egg in the uterine lining.
How are fibroids diagnosed?
Fibroids may be diagnosed non-invasively, using ultrasound, CT scan, or MRI. In general, pelvic ultrasound is very accurate about diagnosing fibroids is non-invasive, and does not involve radiation. At times, depending on anatomy, you may need more than one test to obtain all information on the fibroid, but this is determined after ultrasound is performed in most cases. Transvaginal ultrasound allows the best view of fibroids so that they may be seen clearly without the other organs being in the way, mostly the intestines.
Sometimes fibroids are detected are performed after performing imaging for other reasons, and sometimes they are found after symptoms produced by them prompts other imaging, such as back pain from pressure on a nerve.
When should fibroids be treated?
Fibroids should be treated any time they are causing symptoms that the patient would like to alleviate. Pain, bloating, cramping, bleeding, urinary problems, infertility, and back or pelvic pain are all reasons to treat fibroids.
What are my options for removing fibroids?
Fibroids may be removed by several methods today. There are options including removal of the fibroid by traditional surgery, treating it with a heat probe that destroys it (called radiofrequency ablation), or embolization. In rare cases, a hysterectomy (removal of the uterus) may be required but is almost never performed for this reason in our practice. In more complex cases, several combinations can be used as well, depending on the patient. We are familiar with all modalities at NYC Surgical Associates, and tailor the approach to suit the patient.
It is important to understand that fibroids can occur at any part of the uterus, and the location of the fibroid is a critical factor in deciding which method is ideal for treatment. This is best discussed with your surgeon. At NYC Surgical Associates, we are experienced and skilled at all methods of fibroid removal, and will tailor a plan specific for your particular issue as needed.
What is fibroid embolization?
Fibroid embolization is a procedure in which a IV type catheter is placed into an artery that supplies the fibroid that is symptomatic. The artery is then blocked off with a material that is injected specifically into that artery. When the artery is blocked off, the fibroid shrinks, and eventually dies and falls off the uterus in the following weeks due to being starved of its blood supply, much like the umbilical cord on a newborn. In general, this procedure works very well for fibroids that are in the wall of the uterus, on the inside of the uterus, or smaller fibroids on the outside of the uterus, where they are difficult to visualize externally, and are best visualized by the artery feeding them.
How do you perform fibroid embolization and why is the experience different at NYC Surgical Associates?
Most fibroid embolization in our practice is performed using a small, largely unimportant artery at the wrist called the radial artery as the site of access for the procedure. Radial artery access procedures do require a very specific skill set, and are not yet practiced widely, but at NYC Surgical Associates, are used consistently for arterial embolization procedures, with excellent results. Because the radial artery is very close to the skin at the wrist, a small compression bandage is all that is needed after the procedure, and the patient typically has minimal risk of bleeding, blood vessel damage, and other complications associated with the traditional procedure using the femoral artery in the leg, and can walk and be discharged immediately after their procedure, eliminating the need for a hospital stay. This is the main reason we are available to do fibroid embolization safely as an outpatient at our sites, unlike most centers performing this procedure in the hospital.
Patients who undergo embolization therapy for treatment of fibroids typically undergo hospital admission for 2 major reasons, prevention of bleeding risk, which is far greater with femoral access (the main artery supplying the leg), and post-operative pain, which can be significant, as treatment of fibroids universally causes often significant spasms and cramping of the uterus. Most often, they are given IV narcotics for this reason over 1-2 days and discharged afterwards, when the pain becomes manageable.
At NYC Surgical Associates, we are able to perform a very specific nerve block, numbing the nerve that supplies sensation to the uterus, called the hypogastric nerve, typically this pain is very manageable immediately after surgery. By using radial artery access for treatment, and hypogastric nerve blocks, both of which are not widely taught or practiced other than in specialized centers such as ours, we are able to cut cost, effectively eliminate hospital stay, minimize the need for narcotics, and maximize comfort and convenience for our patients.
What is fibroid ablation?
Fibroid ablation is a procedure in which a minimally invasive instrument is placed, usually with video guidance, into the fibroid and heat is delivered through the instrument to essentially burn the inside of the fibroid and cause it to die. This method is very effective treatment for fibroids on the outer wall of the uterus, where they can be seen and treated under direct vision, especially those that are attached by a very small stalk which could make them difficult to treat via embolization. We use this in a minimal number of patients largely due to the fact that most fibroids that present to medical attention are located in an area.
What other fibroid treatment options are there?
Medical management of fibroids using hormonal manipulation is an option for fibroid treatment, and is not performed at our centers. This should be discussed with your primary women’s health specialist. Fibroids may also be removed via surgical excision called “myomectomy” or via a hysterectomy (removal of the uterus). In general, we tend to avoid both of these approaches unless we absolutely need to, because we at NYC Surgical Associates feel that a less invasive option is always more appropriate. In some cases, hysterectomy is the best option, because there are several problems with the uterus, especially in women over 45, or with other uterine abnormalities that complicate their clinical scenario.
What are the risks?
In general, there is always a risk of bleeding, damage to other structures, such as blood vessels, nerves or other organs with any procedure, but in experienced hands, less invasive options in general carry with them a lower risk profile.
Risks specific to embolization include damage to blood vessels, a very low risk of “non-target” embolization (inadvertently blocking off blood flow to an area that was not meant to be embolized). These situations are unlikely, and we go through a series of checks to minimize the occurrence of them, but are possible.
Extremely rare risks include uterine infection, ovarian dysfunction or hormonal disturbances, which almost always occurs in women over age 45.
Risks specific to ablation include damage to normal tissue or adjacent structures by the heat device, as well as possible damage to other structures while obtaining entry into the abdomen or pelvis for the purpose of doing the procedure. While these are also very low risks, you should discuss them with your surgeon.
Overall, the risk of minimally invasive procedures is in general significantly lower than traditional surgery, with results that are equal or superior in most cases.
What are the benefits of fibroid embolization over other procedures?
The major risk is the minimally invasive nature, without an incision and minimal downtime, but several others exist. Some fibroids are very deep into the uterine tissue, making surgical removal or ablation technically very difficult, and are much more easily treated with embolization. In patients who have had multiple abdominal or pelvic surgery in the past, often very significant scar tissue exists in the pelvis, which greatly increases the risk of complications from surgery and ablation. With embolization, since we are treating from a blood vessel, scar tissue is largely unimportant and does not increase the risk of treatment.
Why do patients usually need more than one procedure?
We typically proceed with a study of the pelvic veins prior to fibroid embolization, called a venogram. Very often, fibroids compress surrounding structures, and often veins are compressed in the same vicinity causing the backup of blood in and around the pelvis. Typically, we evaluate the pelvic veins first, as it is a very common cause of pain and other symptoms, leads to a more complete resolution to symptoms after embolization, and is a cause of persistent symptoms in many cases if left untreated, as well as simple to address with minimal risk and significant benefits.
Also typically, in most cases we stage fibroid embolization into two procedures unless the anatomy is very simple, which is most often not the case. This is because most often, the blood vessel supplying the fibroid also supplies areas of normal uterine tissue, and blocking these vessels too aggressively can lead to the death of normal uterine tissue, and unwanted and dangerous problem. Most often, we block off some of the supply, to allow the uterus to recover and reconfigure its blood supply, and a week or two later, block off the vessel more aggressively. In some cases this is not needed.
Every step of the way, we choose the safest approach to get you the most optimal results with minimal problems.
What can I expect after my procedure?
With embolization, very often a moderate amount of pain occurs in the hours following the procedure. This is because the fibroid is starved of its blood supply. This often passes within the first 24 hours, and with specialized nerve blocks, is typically minimal at our centers. Our team of anesthesia staff is well versed in these procedures.
Most patients (more than half) have a generalized flu like feeling that is called “post embolization syndrome” after the procedure that typically includes cramping, fever, and nausea. Typically, this resolves in less than 48 hours. If it persists, you should contact us immediately. In general, we see all of our patients 24 hours post procedure for a check-up to discuss any issues and questions that may arise, as well as to perform a post-operative examination.
Often, a week or more after the procedures, if the fibroids were inside the uterus, they may fall off and produce a discharge similar to a heavy period. This is normal, and it is the way your body rids itself of the dead tissue. In some cases, at 2-3 months, additional tissue is discharged. In rare cases, a gynecologic curettage, or scraping of the inside of the uterus is needed after embolization due to the inability of the fibroid to detach itself from the lining of the uterus. You should always contact a member of our physician team immediately if worried by any post-operative issues for ANY reason.
In general, most patients tolerate the procedure very well, with minimal complications afterwards, and are very happy.
Is one procedure better than the other?
In some instances, other than the reasons already specified above, ablation or surgical removal is a superior option, but in the minority of cases. In certain rare cases, traditional surgery may be best, depending on the patient, especially in older patients. Every single patient must be considered as a unique situation, taking all aspects of their condition and lifestyle into the decision. There is a small, but real difference in obtaining fertility with traditional myomectomy vs embolization for fertility reasons specifically, and if this is the specific reason for undergoing fibroid treatment, you may be better off with myomectomy.
For uterine bleeding, because embolization disrupts the blood supply to the fibroid, embolization typically results in a better solution. Embolization is also a better option for fibroids located in the middle of the uterus, as well as the inner lining, as these are typically more difficult to address surgically or with radiofrequency ablation. Your surgeon will discuss your anatomy with you in detail, as it is specific to each patient. Like all medical conditions that have several options available, this should be discussed with each patient in details specific to their particular condition.
We hope this informational has helped explain the most common questions about the various options available for the most modern, cutting edge treatment of symptomatic fibroids. If more questions arise, please feel free to contact our team, and we can help alleviate your concerns, and develop a plan based on your specific problem, lifestyle, and goals.
At NYC Surgical Associates, we believe our role is to gather information, present it in a format you can understand, and help you make the right decision for yourself, as we would do for our own family.