What are Fibroids?
Fibroids are benign, hormone sensitive tumors of the uterine muscle that can occur at varying areas of the uterine wall. Also known as leiomyomas or myomas, fibroids are often identified in women during childbearing years. Studies suggest 70-80% of women will develop fibroids in their lifetime, yet most women do not know they have uterine fibroids because they often show no symptoms.
Symptoms of Fibroids
Many women who have fibroids do not experience symptoms. Those that do will notice pain, excessive vaginal bleeding, dysfunctional menstrual cycles, and pressure on other organs.
When fibroids put pressure on the bladder or rectum, they can cause symptoms such as urination urgency or problems urinating.
When they push on the rectum, or other areas of the intestine, the sensation of bloating, distention, and fullness may be experienced.
Fibroids can also cause problems with fertility, and interfere with normal implantation of a fertilized egg in the uterine lining.
Non-invasive fibroids diagnosis methods include ultrasound, CT scan, and MRI.
In general, pelvic ultrasound is a very accurate method of diagnosis and does not involve radiation. In some cases, we perform multiple tests to obtain all information on the fibroid. The need for additional tests is usually determined by your anatomy, and after an initial ultrasound.
Transvaginal ultrasound captures the best view of fibroids. This method produces images of the fibroids without obstructions such as other organs.
Fibroids are also sometimes detected after symptoms prompt imaging tests, such as back pain from pressure on a nerve.
Fibroid Treatment Options
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.
There are several options for treating fibroids. The location of the fibroids is a critical factor in determining how they should be removed. These removal methods include:
- Removing the fibroid by traditional surgery
- Destroying it with heat probe treatment (radio-frequency ablation)
In very rare cases, a hysterectomy (removal of the uterus) may be required.
In addition, combinations of treatments are sometimes necessary in complex cases. We are familiar with all modalities at NYC Surgical Associates, and tailor the approach to suit the patient.
NYC Surgical Associates has the experience and skills required for all methods of fibroid removal. Our doctors will explain your options and tailor a plan specific to your needs.
Types of Fibroid Treatment
In fibroid embolization, a surgeon places an IV-type catheter into an artery that supplies the fibroid that is symptomatic. Next, a material superficially injected into the artery blocks it off from the fibroid. Once blocked off from the artery, the fibroid shrinks, and eventually dies. Within weeks the fibroid falls off the uterus due to a lack of blood supply. This is not unlike the umbilical cord on a newborn.
Embolization typically very effective fibroids in the wall or inside of the uterus. Embolization is also effective for smaller fibroids on the outside of the uterus (where they are difficult to visualize externally, and are best visualized by the artery feeding them).
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.
Fibroid Embolization at NYC Surgical Associates
We perform most fibroid embolizations using a method with the radial artery as our access site. The radial artery is a small and largely unimportant artery at the wrist. The radial artery method requires very specific skills and is not yet practiced widely. Our team prefers this method for arterial embolization procedures due to the excellent results we can achieve.
Because the radial artery is very close to the skin at the wrist, benefits of this approach include:
- Needing only a small compression bandage after the procedure.
- Minimal risk of bleeding, blood vessel damage, and other complications associated with traditional procedures using the femoral artery in the leg.
- No hospital stay. Patients can walk and complete discharged immediately after their procedure.
Access via the radial artery is also a reasons why we can perform fibroid embolization safely as an outpatient, unlike most centers performing this procedure in the hospital.
Patients who receive fibroid embolization therapy 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).
- 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 specialize in a very specific nerve block. This approach numbs the nerve that supplies sensation to the uterus, called the hypogastric nerve. Post-surgery pain is very manageable when a nerve block is used.
Radial artery access and hypogastric nerve blocks are unique aspects of NYC Surgical Associates’s fibroid treatment. These methods are not widely taught or practiced outside of specialized centers such as ours. They enable us to cut treatment costs, effectively eliminate hospital stay, minimize the need for narcotics, and maximize comfort and convenience for our patients.
In fibroid ablation, a surgeon places a minimally invasive instrument into the fibroid (usually with video guidance). The instrument delivers heat to essentially burn the inside of the fibroid and cause it to die.
Ablation is a very effective treatment for fibroids on the outer wall of the uterus, where they can be seen under direct vision. The benefit of direct vision is especially true when fibroids are by a small stalk (which complicates embolization).
Alternative Fibroid Treatment Options
Medical management of fibroids using hormonal manipulation is an option for fibroid treatment, but not performed at our centers. Discuss this option discussed with your primary women’s health specialist.
Fibroid removal via surgical excision called “myomectomy” or a hysterectomy (removal of the uterus) are also option for treatment.
In general, we tend to avoid taking either of these approaches unless we absolutely need to. In some cases, hysterectomy is necessary due to problems with the uterus, especially in women over 45, or with other uterine abnormalities that complicate their clinical scenario. However, we feel that a less invasive option is almost always more appropriate.
Why Patients Usually Need Multiple Procedures
Fibroids tend to compress surrounding structures and veins in their vicinity and this backs up the blood in and around the pelvis. As such, prior to fibroid embolization, we typically proceed with a venogram procedure to study the pelvic veins.
We evaluate pelvic veins first because:
- They are a common source of pain and other symptoms
- Findings lead to a more complete resolution to symptoms after embolization
- If left untreated, pelvic veins cause persistent symptoms in many cases if left untreated
- Pelvic veins are simple to address with minimal risk and significant benefit
In most cases we also stage fibroid embolization into two procedures (unless the anatomy is very simple). We do this because the blood vessel supplying the fibroid often also supplies areas of normal uterine tissue. As such, blocking these vessels too aggressively can lead to the death of normal uterine tissue, an 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. This is not always necessary.
Every step of the way, we choose the safest approach to get you the most optimal results with minimal problems.
Comparing Fibroid Procedures
In rare cases, other than the reasons already specified above, ablation or surgical removal is a superior option. In certain rare cases, traditional surgery may be best, depending on the patient, especially in older patients. Every patient is unique so we must take all aspects of their condition and lifestyle into consideration when determining treatment. 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 better for fibroids located in the middle or inner lining of the uterus. as these are typically more difficult to address surgically or with radio frequency ablation. Your surgeon will discuss your anatomy with you in detail, as it is specific to each patient. Be sure to discuss the specifics of your condition with your doctor to determine the right path forward.
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.
Fibroid Treatment Risks & Recovery
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.
The primary risk specific to embolization is damage to blood vessels. There is also a very low risk of “non-target” embolization. This occurs when blood flow is inadvertently blocked to an area not meant for embolization. These situations are unlikely, and we perform 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 significantly lower than traditional surgery, with results that are equal or superior in most cases.
Embolization often leads to moderate pain in the hours following a procedure. This is the result of the fibroid being starved of its blood supply. Pain typically passes within the first 24 hours, and with specialized nerve blocks, is typically minimal at our centers. Our anesthesiologists have a strong understanding of how in minimizing pain in these procedures.
After the procedure, most patients (more than half) experience a flu-like feeling known as “post embolization syndrome”. This includes cramping, fever, and nausea which usually last 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. At this time, we discuss any issues and questions that may arise, as well as 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. Additional tissue can discharge at 2-3 months in some cases, as well.
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.