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An FAQ is
a collection of questions asked by our own patients, and by others
via E-Mail. We hope the answers will be helpful to everyone who
is trying to educate themselves about this procedure. However,
because everyone's situation is unique, it is best to discuss
it with your gynecologist. This is the person best qualified
to advise you as to whether or not it is the right treatment
in your case.
- Q: What fibroid size
responds best to UAE? (Uterine Artery Embolization)
A: Generally
speaking, the smaller the fibroid the better the response. However,
even in a uterine size up to a "20 week pregnancy"
or less, a 40-60% shrinkage is possible. In much larger fibroids
which are greater than a 20 week size uterus, the shrinkage
falls off to 0-20%. The fibroid size mentioned in this letter
is well below the navel, and in the neighborhood of a 12-14 weeks
sized pregnancy. Fibroids of this size tend to do very well.
(Click HERE to read the
interpretation of fibroid size as compared to the size of a pregnant
uterus.)
More recent data indicates that though the "shrinkage"
factor of a 20 wk size uterus is less (as stated) - it
appears that there is still a considerable decrease in pain and
pressure symptoms (perhaps because the venous distention of
vessels supplying the fibroids was decreased?), as well as
in bleeding abnormalities.
(11/99) It has generally been believed in UAE
circles, that 10 cm represents the upper size limit of which
fibroids will respond well to treatment. However, as experience
has grown, it appears that this may not be totally correct. For
instance, we have had 6 patients in our program, each of whom
had a uterine size equivalent to 26 weeks pregnancy. (In one
of these, the entire enlargment was caused by a single fibroid.)
In all cases, the fibroids decreased in size by approximately
91% after treatment.
See also two Animated Gifs
added to our Site (the 2nd on 12/31/99) which demonstrates by
actual MRIs an case which was unusually successful. But first
take our "Crash Course" in reading MRIs!
- Q: Is there a limit
to the number of fibroids in a uterus that will respond to this
therapy?
A: Our very first patient had 30 fibroids
and to date all have shrunk considerably.
- Q: Is there an age
limitation to UAE?
A: There does not appear
to be an age limitation. Both in our experience and in the literature,
patient ages have ranged from the 20's well into the 50's yrs.
There appears to be no age alone limitation.
- Q: Does UAE present
a problem for future pregnancies?
A: In France and in England,
the procedure has been done for over 8 years. In this longer
experience they have not noted a problem with future pregnancies.
We also have had one patient who became pregnant very soon after
UAE (a longer recovery time is always recommended), and
continued the pregnancy without a problem. Furthermore, tying
off a uterine artery via a full surgical procedure has also been
done because of a post delivery hemorrhage situation. Even in
this case, subsequent pregnancies appear to be successful.
(12/31/99) The issue of "Pregnancy
after UAE" has been raised by many patients during
1999. We would like to add a special page here that will give
more detailed information regarding this aspect of UAE.
- Q: If UAE is successful
for me and I am successful in becoming pregnant several months
after the procedure, will the "degenerated fibroids"
regrow or otherwise become enlarged during the pregnancy?
A: The effect of UAE
is to eliminate all live cells in the fibroid, and replace them
with scar tissue. Therefore it is virtually impossible to regrow,
and thus far there is a 9 year experience to support this. Whether
in an individual case a brand new fibroid could appear in the
uterine wall within the first year - could theoretically happen.
However fibroids do not seem to reoccur that rapidly, and thus
far in the cases reported it has not been observed.
- Q: In a young non-pregnant
patient (early 20's) who has a fibroid the size of a 12
weeks pregnancy - is there any point in treating it with embolization
before becoming pregnant?
A: If your gynecologist
believes that the location of the fibroid might be a problem
during pregnancy (i.e., might block the birth canal, or is
in the cavity of the uterus and might cause a miscarriage),
a case can be made for treating it ahead of time. As noted in
the previous question - there is no history to suggest that embolization
would interfere with a later pregnancy. At the same time - though
about 1% of patients may lose their periods after embolization
- a similar number could develop infertility from adhesions as
the result of a surgical myomectomy. The risk may well be equal,
and the two procedures a trade-off.
- Q: What can happen
to a fibroid in pregnancy to make it painful? Can embolization
be used during pregnancy?
A: Embolization
is NEVER used in pregnancy, even if the fibroid becomes painful.
Any possibility of pregnancy is an absolute contra-indication
to the procedure. The treatment of a painful fibroid in pregnancy
is rest and pain-medication. It tends to quiet down quickly.
There is, however, an interesting comparison between embolization
and the "Painful Pregnancy Fibroid." A painful fibroid
in pregnancy is often due to something called "Red Degeneration"
- which occurs in about 10% of fibroids. It happens when -
because of the stimulation of pregnancy hormones - the fibroid
enlarges very quickly and outgrows its blood supply. The central
area of the fibroid degenerates - much the way a fibroid does
after embolization. The difference appears to be that the process
is much less complete in "Red Degeneration" than in
"Embolization". Later on, fibroids which have undergone
Red Degeneration - may re-grow. Embolized fibroids never grow
again.
- Q: I have heard that
there can be "fibroids" in the ovaries, or in the ligaments
on either side of the uterus. Can these be treated by embolization?
A: No. The blood vessels
to these ligaments and the ovaries are different from the ones
which supply the uterus. Hence uterine artery embolization will
not reach these tissues.
- Q: My gynecologist
says that the largest fibroid is in my cervix. Because this is
well below the largest part of the uterus, will the embolization
treatment work here?
A: Yes. Unlike fibroids
in the ovary, the blood supply of the entrance to the uterus
(i.e., the cervix) comes from the uterine arteries. Hence this
fibroid will be treated as well.
- Q: I have a fibroid
uterus approximately the size of a 16 wk pregnancy. This appears
to be caused by many small fibroids, the largest of which is
4 cm. I have no symptoms, but am concerned that if they grow
larger I may lose the opportunity to have them treated by Embolization.
What should I do?
A: This excellent question
is very complicated to answer. As we have tried to keep answers
in this FAQ as short as possible, I have opted to answer this
question on a separate page. If the reader is interested, please
click here to
go to the answer.
- Q: I had multiple myomectomies
done 9 years ago, but now numerous fibroids (both inside and
outside the uterus) have returned. I am in constant pain,
and my gynecologist has advised me that a repeat myomectomy (because
of the potential of adhesions) is not advisable. My uterus
is the size of a "5 Month Pregnancy," which your WebSite
indicates is much less responsive to treatment. It appears that
the only option available to me is hysterectomy. Yet, I am just
in my mid-thirties, and still hope to have a child. Is there
anything that Embolization could do to help in a situation such
as this?
A: This question was
partially addressed in the addendum to the preceding question,
i.e., "It is generally felt that a uterine size equivalent
to that of a 5 month pregnancy (top of uterus is at level
of the navel) responds less well to embolization than one
that is smaller. What is not known is whether this is
equally true if this size is caused by
(1)
One or two really large fibroids each greater than 10 cm in diameter,
or by
(2)
Multiple small fibroids, each less than 10 cm in diameter."
We believe that it is useful to evaluate the actual sizes of
the Fibroids which make up the uterine enlargement. In our experience,
multiple fibroids - if less than 10 cm in diameter - seem to
respond better than multiple fibroids over 10 cm. However, one
must remember that at this time there are no large studies to
confirm this impression. Thus even though measurement of these
fibroids show that most are less than 10 cm, the degree of success
in a case such as described above - cannot yet be guaranteed.
- Q: I understand that
the technique uses the injection of small microparticles called
PVA. If the uterine tissue degenerates and the body reabsorbs
it, what happens to all those PVA particles? Do they stay in
the body?
A: PVA particles remain
in the body for life. This could raise a question of whether
there might be late side-effects. The good news is that the material
has been used in surgical and radiological practice for over
20 years and there have been no reports of late side-effects.
(Read more about the use of these PVA particles in the page
entitled: "How Embolization
Works.")
- Q: I'm concerned about
the status of the plastic particles after the UAE. Your web site
states that the particles remain lodged in place. But because
the body has only one circulatory system, how could anything
remain forever lodged in your uterine arteries without destroying
all blood supply to the uterus?
A: There are three issues
here.
1) Remember that the blood supply to the uterus, after UAE, remains
intact. The PVA particles selectively enter only
the large vessels of the fibroids, and bypass the smaller vessels
which are the major blood supply to the normal part of the uterus.
2) It is important to understand what happens at the point where
the particles lodge in the vessels.
When the
blood supply to the fibroid is cut off by the particles, the
surrounding tissue (the fibroid) degenerates because of
the lack of oxygen and nutriments. The body then sends in specialized
cells to remove the dead tissue and in turn the area decreases
in size.
Ultimately other cells called "Fibroblasts"
enter the area to form scar tissue - but only in the area of
the former fibroid. This is how the body heals many injuries
- for example, the scar which forms in the area of an appendectomy
incision is an example of what scar tissue is like. The area
of the former fibroid as well as
the plastic particles become enclosed in this scar tissue permanently.
This is the reason why these particles no longer have the ability
to "travel further." They are locked forever in the
same spot. One additional property of a scar is to become smaller
and more dense. (Appendectomy scars which start as relatively
wide red areas, in most people end up several months down the
road as thin and white.) This shrinking is the reason the
fibroids seen in our MRI pictures became smaller.
3) Though it is true that the body has only one blood system,
it turns out that the body has the ability to recreate a NEW blood supply in many situations! Blood supply
is not as static as you would imagine. As the "fibroblast"
cells enter the former fibroid to heal the area, they bring with
them this new blood supply - though considerably less extensive
than before. It is this blood supply that supplies the area that
remains - now no longer fibroid tissue - with oxygen and nutriments.
Thus, the resulting scar tissue remains healthy, and slowly contracts.
- Q: What about rejection
and allergy issues? These plastic particles are foreign bodies
after all, and typically anything foreign induces an immune system
response.
A: It is true that PVA
particles are "foreign bodies." However, many substances
- not native to the body - are used in surgery every day. "Good
Materials" share one common property - the body has a minimal
reaction to their presence. This is a characteristic of the metals
used in hip replacement, the mesh for arterial grafts, PVA particles
and others. Though the studies that are conducted over short
periods of time give a clue as to how "non-reactive"
these substances are - it is the long term experience that gives
us more assurance they will not be harmful. The long term experience
with Titanium Metal (as in hip replacement) has been good.
The long term experience with silicon (which I believe is
why you asked the question) has a major liability in inducing
immune problems - and hence is no longer used. Fortunately, there
is a "long term experience" with PVA (since 1970),
and in that time no such adverse allergic or immune reactions
have been reported.
- Q: Is Ultra-sound used
to find the uterine artery during the procedure? Have there been
any cases where the PVA particles went to the wrong place?
A: We do NOT use Ultra-sound
during the procedure. The first step in embolization is to perform
a "diagnostic angiogram." During the angiogram, contrast
media is injected and watched with the aid of fluoroscopy - a
"real time" X-Ray technique. This creates a "road
map" of all the pelvic vessels used in the procedure. By
following this "map" the catheter can be manipulated
directly into the uterine artery on each side.
Another use of this "map" is to detect any unexpected
blood vessel abnormalities (such as arterial venous malformations
or unusual vessel anatomy) and avoid them. It is because
of this "road map" that PVA particles are kept from
going to the wrong place. Thus far we are unaware of particles
escaping into the bloodstream and creating embolisms elsewhere.
Careful attention during the angiogram appears to avoid the theoretical
problem of distant embolisms.
- Q: I have read that
the size of the PVA particles used in France and in the U.S.A.
are different. Is this important?
A: French physicians
use PVA with a 300 micron size particle, while in this country
a larger - 500 particle size - is used. Thus far the results
have been the same.
As of 11/98 there are ongoing studies using even smaller particles
(50 microns and smaller) - the intent of which is to get
the particles still further out into the smallest capillary vessels.
Though this doesn't seem to represent an improvement in the Fibroid
embolization procedure, it may have usefullness in the treatment
of certain cancers such as a Liver tumor called a "Hepatoma."
- Q: I understand that
the "adhesions" that form after any surgery (myomectomy,
for example) can be a concern in having another pregnancy.
Is this a problem with embolization as well?
A: Adhesions are bands
of fibrous tissues that occur in varying degrees in different
patients as a response to surgery, endometriosis and infection.
If they form in a location to block the tubes and keep ovulated
eggs from entering a woman's tubes - yes, they can interfere
with becoming pregnant. One of the good things about embolization
is that it does not appear to cause adhesions.
- Q:
Does a previous myomectomy alter performance of a UAE or change
the success rate?
A: The statistics reported
do not change regardless of a previous surgical myomectomy.
- Q: Does a prior endometrial
ablation interfere with the effectiveness of Embolization?
A: No. Endometrial ablation
is a method of cauterizing the lining of the uterus. It
is intended to induce scarring, and often fusion of the front
and back walls of the uterine cavity. As such, it is really a
local surface treatment. It has been estimated that 58% of treated
patients lose their periods; 34% will improve; and 8% will experience
no improvement. (Baggish MS, Am J Obstet Gynecol, 174(3):908-13
1996 Mar ) Successful or not, ablation - because it is a
"surface treatment" - affects only the endometrial
vessels, and does not alter the blood flow in the uterine arteries
which are the critical pathways for embolization.
- Q: Does a history of
previous pregnancy terminations increase the likelihood of Fibroids?
A: No. The development
of significantly large fibroids is not a known complication of
either spontaneous or elective pregnancy loss. Fibroids appear
more common in certain ethnic groups such as Afro-Americans,
but the cause for this difference in incidence is unknown.
- Q: What happens to
fibroids when they are embolized? Do they merely shrink, or do
they "fall off" in some way?
A: After losing their
blood supply, fibroids lose their fluid content, their cells
liquify and are removed by the body. In time they undergo a process
of fibrosis, and lose their ability to grow again. The overall
effect is that the fibroid "shrinks" but does not become
detached and "fall off.
(Read more about this process on the page entitled "How Embolization works"
This page shows several MRI pictures which help visualize
the actual changes that occur.)
- Q: I am confused as
to the way the size of a uterus is compared to the size of a
pregnant uterus at different months. Could you give me some way
to understand this?
A: According to Obstetricians/Gynecologists,
the estimation of fibroid size (based on the model of the
size of a uterus in pregnancy) goes like this:
(1) 12 weeks - just up to the level of the pubic bone
(2) 16 weeks - 4 fingerbreadths above the pubic bone
(3) 18 weeks - 2 fingerbreadths below the navel
(4) 20 weeks - at the navel
(5) 24 weeks - 1 fingerbreadth above the navel
(6) 28 weeks - 3 fingerbreadths above the navel
There is one problem with this model, i.e., the top of a Fibroid
Uterus can be very irregular, whereas the top of a Pregnant Uterus
is usually smooth and uniform. Although it complicates this method
of "sizing" fibroids, it is still useful and the most
comon way Gynecologists record uterine size.
There are a number of other ways that Gynecologists use to describe
fibroid size - often using a comparison to commonly used items.
The following "Bestiary" of items might help visualization
by translation into actual measurement!
Average Sizes of Items
|
Item |
Cm |
Inches |
Item |
Cm |
Inches |
|
Pea |
1 cm |
3/8" |
Apple/Pear |
7.5 cm |
3" |
|
Walnut |
3 cm |
1 3/16" |
Orange |
9 cm |
3 1/2" |
|
Lemon (diameter) |
5.5 cm |
2 3/16" |
Grapefruit |
11.5 cm |
4 1/2" |
- Q: What is the . .
. size of a normal uterus? Mine is enlarged and 8-10 centimeters.
How much larger than normal is that?
A: Gynecologists use
the following reference for uterine sizes:
(Note: having had a previous pregnancy slightly increases
uterine size during the menstrual years. Well into the menopause,
most uteri are the size of the Never Pregnant uterus.)
|
|
Front to Back |
Side to Side |
Length |
|
Never Pregnant |
2 cm |
3/4" |
4 cm |
1 1/2" |
6 cm |
2 1/3" |
|
Prior Pregnancy |
4 cm |
1 1/2" |
6 cm |
2 1/3" |
9 cm |
3 1/2" |
As you can see, the normal uterus
is slightly flattened. A fibroid uterus, on the other hand, tends
to be spherical, and the stated size is generally the diameter
of the sphere. Hence your uterus (assuming 10 cm, and that
you have been pregnant before) is probably 4 cm (1 1/2")
larger in the Side to Side measurement, and 6 cm (2
1/3") larger in the Front to Back measurement.
Comparison to normal uterine size becomes more difficult when
the uterus is irregularly distorted by multiple fibroids.
- Q: Does the procedure
produce any pain?
A: Yes it can. However,
unique to our treatment protocol (which uses epidural anesthesia
and an additional medication
(morphine) which extends the pain free area another 12-18 hours). The patient experiences no pain during
this time, and that which remains afterwards is generally no
more than cramping. The latter appears quite controlled by oral
pain medications.
- Q: Suppose there is
some reason why I do not want an Epidural. Or an epidural was
not effective when I was in labor. Will you still do the procedure?
A: Yes, of course. There
are a number of reasons why we may need to use other methods
of pain relief. For example: Some patients may have an allergy
to the local anesthesia used in epidurals. Others may have a
back disorder that contraindicates use of an epidural. And still
others may just have personal reasons for preferring another
method. (As an aside,
my Obstetrical colleagues tell me that they have seen an epidural
failure in one delivery, but a successful epidural in the same
patient next pregnancy.)
In these cases, our anesthesiologists
use a technique called "Intravenous Sedation." (Another
name for this method is "Conscious Sedation.")
This uses a combination of several drugs such as Fentanyl (a
narcotic similar to Demerol), and Versed (a tranquilizer
similar to Valium). A full general anesthesia can also be
used, but this degree of anesthesia is generally not required.
The major reason why we recommend
(but do not insist on) Epidural Anesthesia is that (along
with a small dose of Morphine in the cathether) it provides
the best pain relief of all. The patient is virtually pain free
without the need for post-operative "shots". It allows
her to be wide awake, undrugged and able to visit with family
or friends comfortably in the immediate post-embolization hours.
An Epidural usually carries the patient to the point where oral
pain pills alone can control discomfort.
(Review
our section on pain as a side effect.)
- Q: I have heard that
with an epidural I may need to remain in the hospital for 2-3
days after the procedure. Is this what you have found to be necessary?
(from
a patient in Australia)
A:
In our experience, 98-99% of our patients can be discharged after
Uterine Artery Embolization under Epidural Anesthesia within
23 hours*, and are quite comfortable by the time they leave.
(* = an overnight stay but without the need for a full admission
under our hospital's admission guidelines)
- Q: How much must I
limit activity after the procedure? Suppose my job is very physically
demanding - such as a riding instructor?
A: We believe that normal
activity - though perhaps not strenuous activity - will be very
comfortable after a few days. However, very athletic things or
activities which cause much jolting body motion (such as horseback
riding) are probably best put on hold for 1-2 weeks. After
this, the major limiting factor is a tender uterus - and though
activity will not be harmful - it may not be comfortable. Because
everyone's ability to rebound after any procedure varies widely,
it is hard to give sharp guidelines. Simple observation after
the 2nd week as to what you can or cannot do comfortably - is
probably the best indicator of when full activity can be resumed.
- Q: How do I know who
is qualified to perform a procedure of this kind?
A: The physician who
has the special skills to perform this procedure is called an
"Interventional Radiologist." This is a specialty branch
of physicians who receive fellowship training beyond board certification
in diagnostic radiology (a Field which includes diagnosis
of disease through X-Ray, MRI, Ultrasound, and CatScan) to
treat certain conditions non-operatively. Using catheters, balloons,
and other small instruments, the interventional radiologist uses
X-Ray imaging to guide them through the body's vascular and other
systems, performing procedures that are often excellent alternatives
to surgery.
UAE procedures are one of the techniques
this type of radiologist can perform. However, since the procedure
is new, it would be expected that this physician would have (1)
a particular interest in the technique, (2) spent time learning
from others, and (3) studied the details of performance, management,
and outcome extensively.
- Q: Do Gynecologists
perform UAE?
A: Not generally, unless
the Gynecologist has had radiologic training, and is experienced
in the more focused area of Interventional Radiology. Gynecologists,
however, are an important part of our team as their expertise
in the evaluation/treatment of pelvic masses, hormonal effects
and surgical management of complications - is invaluable.
- Q: I do not have a
hospital in my area where embolization is done. Is it possible
to fly to your area, have the embolization done and return home
soon afterwards? Have you performed the procedure on patients
from out of your area?
A: Yes we have treated
patients from out of our area, and most have returned home 24
hours after the procedure.
Arrival Sequence for Treatment:
(All dates and times
will be provided prior to arrival at the hospital on Day#1.)
Day#1: Appointments scheduled for (a) GYN evaluation,
(b) Evaluation by Dr. Forcade and discussion of procedure, anesthesia
and answers to any remaining questions, (c) MRI with Dr. Forcade (if already done, this is when he will review the MRI films
brought by the patient.)
Day #2: (a) Arrival at Northern Westchester Hospital,
Ambulatory Care Unit approximately 9-10AM, (b) Procedure done
in afternoon, (c) Stay in Hospital until the following morning
(a 23 hr stay - not an admission)
Day #3: Return to hotel in AM. (Some patients prefer
to rest locally for another day, while others have flown home
later the same day.)
Followup Care:
(a) We will give you
detailed instructions for the post-procedure care
(b) We will provide you with a full copy of the procedure with
our recommendations to your own gynecologist for followup.
(c) We have recommended a followup
MRI in 3 months, but now find that 6 months is a better time
to evaluate ultimate size change. And there can even be slight
further shrinkage in even the next 6 months, though this is much
less and hence 6 months appears to be a good compromise. (Though
we can arrange this at United, it can be done easily by your
gynecologist using your own community's medical facilities.)
Air Transportation to our area:
The nearest airport to
Northern Westchester Hospital is the Westchester County Airport in White
Plains, NY. This is the closest and most convenient. However, LaGuardia
and John F. Kennedy Airports in New York City are also within
3/4 to 1 hour by limousine. One limousine company actually transports
to a nearby hotel where many of our patients stay. We will arrange
transportation to and from the hotel to United if you wish.
Call our Nursing Staff at (914)
666-1529, or (888)
666-2002
(Our Toll Free number) M-F, from 9 - 5 EST, for further details and assistance.
After hours this number will give you an option to leave a voice
message.
- Q: I have heard that
many institutions do not accept Health Insurance, or Managed
Care Coverage for a Fibroid Embolization Procedure. Is this true
at Northern Westchester Hospital?
A: Our Department and
Northern Westchester Hospital accept many different Managed
Care and Insurance Plans. Please contact us to see if your particular insurer
is
one of the many we do accept. Remember that even if you are covered,
in most cases you will need to arrange pre-certification for
the procedure. Our office is willing to assist you in this process
on request.
- Q: On checking with
my insurance carrier I was told that they will not cover UAE
because it is an experimental procedure. What information can
I give them to support my belief that this is not true?
A: Arterial Embolization
is a technique that has been used for almost 20 years; uterine
artery embolization for 8 years. Considerable investigation has
been done on all aspects of this technology by excellent researchers
throughout the world. The technique is being used in many centers
as a treatment option, not as ongoing research.This being
so, it is hard to support the idea that it is still "experimental."
However, Insurance Companies often have their own internal criteria
- that do not appear to be in line with medical practice. Why
is this so? The reasoning is difficult to understand, and hence
there may be some purpose in asking your carrier to put its detailed
criteria in writing.
- Q: I really have no
idea what the cost of such a procedure might be. Could you provide
an estimate?
A: This is a difficult
question because what is really being asked is: "What will be my
"Out of Pocket" expense?"
(Click HERE for a fuller discussion
of this subject)
- Q: Why do you prefer
MRI to evaluate the fibroids both before and after the procedure?
A: There are three reasons:
(1) We believe that the accuracy
of MRI in measuring fibroids - as well as seeing how well they
have responded to treatment - is far superior to Ultra-sound.
(2) Also - once your gynecologist
has ruled out uterine malignancy (assuming bleeding was one
of the problems) - MRI tends to make Hysteroscopy and Laparoscopy
(as a prerequisite for the procedure) unnecessary. MRI
very accurately evaluates associated ovarian and tubal disease
which might alter or contraindicate the procedure.
(3) Finally MRI is not only superior
to CatScan in fibroid evaluation, but unlike CatScan, does not
use radiation.
- Q: I understand that
after the menopause fibroids may decrease in
size dramatically on their own. How long does the process of
shrinking take?
A: The answer to this
question is not as simple as it may seem. The details are as
follows:
Fibroids do tend to decrease in
size after the menopause - the loss of Estrogen is the reason.
But if Estrogen Replacement is required for (a) relief
of symptoms, (b) to protect bones from Osteoporosis, or (c) to
decrease the incidence of cardiac problems - it can nullify this
expected decrease in fibroid size. In this case, the woman may
find herself in an unenviable "between a rock and a hard
place" situation.
Yet experience has shown that adding
estrogen in the menopause may not always be a negative for a
patient with fibroids. Some authorities believe that the dosage
of estrogen used for replacement is less than what a menstruating
woman normally produces. For this reason, the stimulating effects
of Estrogen Replacement on fibroid size in the menopause may
be less than expected. If the problem with the fibroids is "bleeding
problems" rather than "size problems" - then hormone
replacement - regardless of amount - may be more of a problem.
Always talk to your gynecologist about the outcome of hormone
replacement in your situation. It is not always easy to predict
what will happen.
You may also be aware that the
drug LUPRON causes a "temporary
menopause", with a rapid decrease in fibroid size over 3-6
months. Logically, a natural menopause with its shutdown of the
ovaries should result in the same rate of change. In practice,
the decrease in fibroid size after the menopause is much less
dramatic. A natural menopause - in contrast to the use of LUPRON
- results in a more gradual loss of estrogen. Thus the decrease
in size takes place over a number of years, rather than a few
months. Do not expect a sudden decrease in fibroid size when
menopause arrives.
Finally remember that growing fibroids
can become significantly larger in the years while waiting for
the menopause. Again, your gynecologist is always the best person
to advise you on whether or not a potential size increase may
demand treatment before menopause arrives.
- Q: My Gynecologist
gave me LUPRON to shrink my fibroids, but now I think I would
prefer to consider embolization instead. Can I have it done right
away?
A: No. The purpose of
LUPRON is to shut off your natural estrogen supply and induce
a temporary menopause. According to a study reported in OB/GYN
9/95, it also causes the arteries in the fibroid to narrow by
24%. Because successful embolization requires the natural dilation
of fibroid vessels, the treatment is likely to fail.
If LUPRON has already been given,
a waiting time of 3-6 months is recommended by most authorities
so the large fibroid blood vessels can reappear.
In the unusual case when (a) the
LUPRON does not shrink the fibroids, and (b) a severe bleeding
condition continues - this may be the exception to the rule.
For this situation we recommend an "Doppler Blood Flow
Study" on the fibroid. (Color Doppler - an ultra-sound
procedure - has the ability to determine how much blood flow
is present.) If we judge the vessels to be sufficiently large
despite recent LUPRON treatment - we will perform embolization
without delay.
- Q: I have heard that
fibroids can contain very strange tissues such as hair or teeth.
Is this true?
A: No, it is not. A Fibroid
is actually made up of smooth muscle and fibrous tissue and has
a smooth appearance. (Read our section on "Fibroid
Facts"
for a description of Fibroids, their origin and growth patterns.)
What
you have described is a special type of Ovarian Tumor called
a "Dermoid" . These tumors are completely unrelated
to fibroids, and are not treated by embolization techniques.
- Q:Is it possible to
have a "fibroid" in the breast?
A: In the breast there
can be a benign growth called a "fibroadenoma." Under
the microscope, it too has a fibrous component like a uterine
fibroid. But the comparison stops there. Whereas a uterine fibroid
is believed to arise from the smooth muscle tissue of blood vessels,
the growth in the breast arises from glandular tissue. The two
conditions are unrelated, and having one does not predispose
to having the other.
- Q: Do you have any
information on the Treatment for Fibroids using Shark Cartilage?
A: No, although we are
aware that Shark Cartilage has been suggested by a few individuals,
primarily in the area of Cancer Therapy. The theory is that Shark
Cartilage contains chemicals which suppress new blood vessel
formation. By restricting new blood vessel formation in a cancer
- it might (its proponents suggest) supress growth of
the tumor. And because of the blood vessel formation in fibroid
development, there has been talk that limiting blood vessel response
would decrease fibroid development.
As we are not involved in cancer research, let us refer you to
a page at the Oncology
Link at the University of Pennsylvania which does offer some
conclusions. Their overall opinion is that there is currently
no solid research to support the claim that Shark Cartilage prevents
either Cancer
or Fibroid development.
- Q: Is it possible for
someone to shrink the size of or eliminate fibroid uterine tumors
through ANY means, such as diet, weight loss, acupuncture, etc.?
(Remember,
in reading the answer - this question is about changing physical
size of fibroids, not the relief of symptoms.)
A: Unfortunately
at this time, there is no diet, herbal or acupuncture treatment
proven to decrease the size of uterine fibroids. But there are
a few things that a patient might do for herself, and it seems
primarily to involve weight control. What remains unclear, however,
is how much of an effect all this has in the long run.
(Click HERE to
read an answer to a patient who asked this question.)
- Q: Have there been
any deaths attributed to the procedure?
A: As of 10/99, it has
been estimated that over 4000 cases of uterine artery embolization
has been done in the United States alone. To our knowledge, no
deaths have been reported in the United States. One death was
reported from England secondary to a severe urinary tract infection
and overwhelming sepsis; one has been reported in Italy from
a Pulmonary Embolization (not thought secondary to the injection
of particles). But remember that in any X-Ray procedure using
intravenous iodinated dyes, there is always a very low risk of
an allergic reaction to the dye.
(Please refer to Complications
of the Procedure section for other data.)
- Q: When the fibroid's
blood supply is cut-off, what happens to the blood supply to
the muscular uterine wall which surrounds the fibroid?
A: Before embolization,
a fibroid's blood supply is enormous. It diverts so much blood
from the uterine wall, that the normal muscle wall is already
in a state of starvation. But something useful takes place because
of this starvation. The uterine wall (well before the procedure)
has already begun to develop a blood supply from other arteries.
These vessels - which normally supply other pelvic tissues, i.e.,
the vagina, cervix, tubes and ovaries - are called a "collateral
blood supply." When the blood supply to the fibroids is
shut off by embolization, the remaining uterine artery calls
on this collateral supply for help. These vessels expand rapidly,
and - working with the uterine arteries - adequately protect
the normal muscular wall of the uterus from harm.
(For additional explanation, please refer to our discussion
on "How Embolization
works" .)
- Q: Can a woman
ever completely lose her periods after this procedure?
A: It has been reported
in about 1% of cases. However, the majority have occurred in
women just before the menopause.
- Q: Is it possible for
uterine artery embolization to affect blood flow to the ovaries
causing postoperative ovarian failure?
A: The uterine artery
has connections to the ovarian artery, and hence there is a small
possibility it could happen. However, the objection is theoretical
at this time, as in 1200 cases done world-wide by 9/98 ovarian
injury has not been definitely demonstrated. There is still the
possibility that the 1% loss of periods noted in the previoius
question might be related to changes in ovarian blood supply.
But the frequent correlation of this with the pre-menopausal
time suggests a different explanation.
- Q: What is the significance
of blood clots during the menstrual cycle for those who have
large fibroids? Do large clots mean that the fibroid is breaking
down?
A: The significance of
"large clots" is that the amount of period blood has
overwhelmed the "Anti-Clotting" chemical the lining
of the uterus produces. Thus it is an indication of excessive
blood loss - not a fibroid that is degenerating.
Fibroids cause excessive blood loss by two mechanisms.
(1) By bulging into the cavity of the uterus (submucous
fibroid) the lining of the cavity is stretched. This
can set up an irritation effect (chronic endometritis) causing
increased bleeding.
(2) As fibroids expand within the uterine wall the surface area
of the cavity increases. (Picture a stack of balls, each one
of which is growing larger. Ultimately the height of the stack
increases.) As bleeding is a function of the amount of surface
area to bleed from, increase the surface area and blood loss
increases as well.
Embolization attempts to improve bleeding by shrinking fibroid
size.
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