Arteriovenous malformations (AVMs) inc. Uterine Fibroids
Uterine fibroids (leiomyomas, leiomyomatas) are benign hypervascularised tumours of the uterine muscle, which form when cells depart from their normal alignment and begin to grow as circular masses. It is estimated that fibroids affect up to 30-40% of all women of childbearing age and may account for 60% of all hysterectomies performed. Small fibroids do not generally cause symptoms unless they are numerous. Larger fibroids, however, can cause heavy menstrual bleeding, pelvic pain, pain during sexual intercourse, frequent urination and even obstruction of the kidneys. In addition, fibroids may also be associated with infertility. African American woman are at a higher risk for fibroids with as many as 50% having fibroids of a significant size.
Drug therapy is usually the first line of treatment and might include NSAIDs, the contraceptive pill or hormone therapy. Surgical approaches include myomectomy and hysterectomy. In the UK alone, approximately 30,000 hysterectomies are carried out due to fibroids and in the US the figure is as high as 150,0001.
Types of Fibroids
Fibroids are classified by location (Figure 1), which affects the symptoms caused, and treatment options.
Current Fibroid Treatments
|Fibroid that is centered in the wall of the uterus with or without mild to moderate distortion of the endometrial or serosal surface
|A broad based fibroid that substantially distorts the endometrial lining of the uterus
|A fibroid centered in the outer myometrium with substantial distortion of the serosal surface of the uterus
Pedunculated (either Submucous or Subserous)
|Fibroid connected to the uterus by a stalk narrower than 50% of the diameter of the fibroid
NSAIDs or conventional hormone therapy (drug therapy) are usually used as the first line treatment for symptoms related to fibroids. More recently a new group of drugs known as gonadotropin-releasing hormone (GnRH) agonists are being used. These are synthetic hormones given by injection that reduce the level of oestrogen in the body thereby reducing blood flow to the uterus and fibroids decreasing the size of both. Once the drug treatment is stopped the fibroids and uterus will continue to grow again1. GnRH analogues usually cause some side effects that mimic the menopause such as hot flushes, vaginal dryness, mood swings and osteoporosis that some women find difficult to endure. Drug therapy, is sufficient to control the symptoms related to fibroids in some patients and no other treatment is required, however additional treatments are required in other cases.
Abdominal Myomectomy involves open surgery to remove fibroids and leave the uterus intact to enable the possibility of future pregnancy. The procedure is usually performed under general anaesthesia. There are risks associated with this treatment including infection and bleeding, in addition adhesion formation may make future surgery difficult2. Although myomectomy is successful in controlling symptoms in about 80% of cases2, this success rate will be reduced if a patient has numerous fibroids.
Laparoscopic Myomectomy also requires general anaesthesia but has a much shorter recovery period than abdominal myomectomy. It is best suited for pedunculated and subserosal fibroids or smaller intramural fibroids. Large, deep or multiple fibroids are more difficult to treat and adhesion formation is often a problem for future surgery3. The port incisions for the laparoscopic equipment may need to be extended to allow removal of large fibroids reducing the benefit of the laparoscopic approach.
Hysteroscopic Myomectomy usually requires general or paracervical block anaesthesia and has a very short recovery period of seven to ten days. Only small submucous and intracavity (particularly pedunculated) fibroids can be removed with this method4.
Hysterectomy involves removal of the uterus either through the vagina or in an open surgical procedure, or as required. The operation is a major surgery and requires general anaesthesia, as well as
requires three to four days of hospitalisation and a four to six week recovery period, during which the patient may not be able to return to full work capacity. It carries a serious postoperative complication rate of 4-6% and a mortality rate of 1:1000-15005,6
. Serious complications of hysterectomy include bladder, bowel and ureteric damage, infection and haemorrhage7
This treatment uses a laser probe to heat coagulate uterine fibroids. Treated fibroids may shrink as much as 40% by 6 month follow-up, however adhesion formation can be a serious complication after the treatment3.
Uterine Fibroid Embolisation
Uterine fibroid embolisation (UFE; also known as uterine artery embolisation, UAE) is a minimally invasive procedure performed whilst the patient is sedated but conscious. A catheter is inserted in the femoral artery and guided through to the uterine artery angiographically (Figure 2). Once in position in the blood vessels feeding the fibroid, an embolic agent is injected through the catheter into the blood vessel. The embolic agent (typically particles or spheres) wedges in the vessel and blocks the flow of blood to the fibroid causing the lesion to begin to shrink due to the restricted blood flow.
Fever and cramping are common in the post-procedural period and are usually controlled with drugs. Patients can usually return home within 24 hours after the procedure, and back to work after a few days.
Transarterial embolisation for the successful treatment of obstetric and gynaecological haemorrhage has been practised for over 30 years, the first report appearing in 19798. Embolisation of the uterus has been performed subsequently in situations including:
- Postpartum and post-caesarean haemorrhage
- Haemorrhage following gynaecological surgery
- Haemorrhage following ectopic pregnancy
- Arteriovenous malformations
- Haemorrhage complicating gynaecological cancer11
Clinical success rates have varied between 86 and 100%.
Uterine fibroid embolisation was first reported in clinical use by Ravina et al in 1995 and more than 40,000 UFE procedures have been performed since that date9.
Subsequent prospective patient series utilising a range of embolic agents have been published which demonstrate in the short term that UFE is associated with low risk of complications and high procedural success rates10. More recent reports have contained specially developed quality of life questionnaires, which demonstrate patient satisfaction with the outcome of the procedure11, 12.
Using such measures, long term outcomes have been reported13, 14.
These authors report that, in patients with 5 years or longer follow up; approximately 73-80% of women had continued symptom control. Further, between 76 and 88% of patients were satisfied with the outcome. There have been no randomised trials with long term follow-up reported to date resulting in continuing questions regarding long term benefits to patients compared with other accepted treatment modalities.
Several clinical studies recruiting a large number of patients15, 16 have shown improvements in menorrhagia (81-93%) pain (64-93%) and mean fibroid volume reduction (20-100%). Nonetheless, one of the most challenging aspects of the UAE procedure is effective post-procedural pain management.
Up to 95% of patients will experience several hours of moderate to severe pain after the procedure11, 15-19. The pain intensity will peak within the first 24 hours post-embolisation20, 21, and is followed in some patients by a period of mild to moderate pain that can last up to several days19, 21, 22.
Pain is most likely related to fibroid necrosis and post-embolisation uterine ischemia23. Inflammation plays a significant role in the post-operative pain experienced after UAE because the ischemic fibroid tissue and the transiently ischemic uterine tissue trigger a rapid inflammatory response that produces target organ swelling and pain24.
Pain management regimens vary from hospital to hospital. In some cases pre-procedure analgesics, including anti-inflammatory drugs are given19,22. The pain is controlled with intravenous medications post-procedure, usually with a patient controlled analgesia pump, backed up with strong anti-inflammatories and oral analgesics23-28, such as NSAIDs.
More information about uterine fibroids and treatment options are available at:
National Women's Health Information Centre
Uterine Fibroid Symptoms and Diagnosis
- Wallach EE. Myoemctomy. In: Thompson JD, Rock JA editors. Te Linds Opererative Gynaecology, 7th edition. Philadelphia:JB Lippencptt;1992.p. 47-62
- Hutchins FL. Abdominal myomectomy as a treatment for symptomatic uterine fibroids. Obstet Gynaecol Clin North Am 1995;22:781-9
- Donnez J et al. Laparascopic myomectomy today. Fibroids: management and treatment: the state of the art. Human Rerpod 1996;11:1837-40
- Indman, PD. Hysteroscopic treatment of menorrhagia associated with uterine leiomyomas. Obstetrics and Gynaecology. 1993 May;81(5):716-720
- Wingo PA et al. The mortality risk associated with hysterectomy. American Journal of Obstetrics and Gynaecology 1986;152:803-8
- Takamizawa S et al. Risk of complications and uterine malignancies in women undergoing hysterectomy for presumed benign leiomyomas. Gynaecol Obstet Invest 1999;48:193-6
- Hill DJ, Complications of hysterectomy. Balliere’s Clinical Obstetric and Gynaecology 1997;11:181-195
- Heaston DK et al. Trans-catheter arterial embolisation for control of persistant massive puerperal haemorrhage after bilateral surgical hypogastric artery ligation. AJR AM J Roentgenol 1979;133:152-4
- Ravina JH et al. Arterial embolisation to treat uterine myomata. Lancet 1995;346:671-2
- Katsumori T et al. Uterine artery embolisation using gelatin sponge particles alone for symptomatic uterine fibroids: midterm results. AJR Am J Roentgenol 2002;Jan 178:135-9
- Worthington-Kirsch RL et al. Uterine arterial embolisation for the management of leiomyomas: Quality of life assessment and clinical response. Radiology 1998;208:25-9
- Spies JB et al. Uterine fibroid embolisation: Measurement of health-related quality of life before and after therapy. J Vasc Interv Radiol 1999;10:1293-303
- Spies JB, Bruno J, Czeyda-Pommersheim F, et al. Long-term outcome of uterine artery embolozation of leimyomata. Obstetrics and Gynaecology 2005;106:933-939.
- Walker WJ & Barton-Smith P. Long-term follow up of uterine artery embolisation – an effective alternative in the treatment of fibroids. British Journal of Obstetrics and Gynaecology 2006;113:464-468.
- Walker WJ, Pelage JP. Uterine artery embolisation for symptomatic fibroids: clinical results in 400 women with imaging follow up. Br. J Obstet Gynecol. 2002; 109:1262-1272.
- Pron G, Bennett J, Common A, Wall J, Asch M, SInderman K et al. The Ontario Uterine Fibroid Embolization Trial. Part 2. Uterine fibroid reduction and symptom relief after uterine fibroid embolization for fibroids. Fertil Steril 2003; 79:120-127.
- Goodwin SC, McLucas B, Lee M, et al., Uterine artery embolisation for the treatment of uterine leiomyomata midterm results. J Vasc Interv Radiol.1999, 10:1159-1165.
- Bradley EA, Reidy JF, Forman RG, et al. Transcatheter uterine artery embolisation to treat larger uterine fibroids. Br J Obstet. Gynacol. 1998, 105:235-240.
- Pron G, Mocaraski E, Bennet J, et al., Tolerance, hospital stay, and recovery after uterine artery embolisation for fibroids: the Ontario uterine fibroid embolisation trial. J Vasc Interv Radiol, 2003, 14:1243-50.
- Bruno J, Sterbis K, Flick P, et al. Recovery of uterine artery embolisation for leiomyomas: a detailed analysis of its duration and severity. J Vasc Interv Radiol. 2004, 15:801-807.
- Baakdah H, Tulandi T. Uterine Fibroid embolisation. Clinical Obstet Gynecol. 2005, 48:361-368.
- Joffre F, Tubiana J-M, Pelage J-P. FEMIC (Fibromes Embolises aux MICrospheres calibres): Uterine Fibroid Embolisation using tris-acryl microspheres. A French multicenter study. Cardiovasc. Intervent. Radiol. 2004, 27:600-606.
- Ryu RK, Omary RA, Sichlau M et al., Comparison of pain after uterine artery embolisation using tris-acryl gelatine microspheres versus polyvinyl alcohol particles. Cardiovasc Intervent Radiol. 2003, 26:375-378
- Siskin GP, Bonn J, Worthington-Kirsch RL, et al. III. Uterine Fibroid embolisation: Pain management. Tech. Vasc Intervent Radiol. 2002, 5:35-43.
- Pelage J-P, Le Dref O, Soyer P, et al., Fibroid-related menorrhagia: Treatment with superselective embolisation of the uterine arteries and midterm follow-up. Radiol. 2000, 215:428-431.
- Worthington-Kirsch RL, Andrews RT, Siskin GP, et al. II: Uterine fibroid embolisation: Technical aspects. Tech. Vasc Intervent Radiol. 2002, 5:17-34.
- Pinto I, Chimeno P, Romo A, et al., Uterine fibroids: Uterine Artery embolisation versus abdominal hysterectomy for treatment – A prospective, randomized, and controlled clinical trial. Radiol. 2003, 226:425-31
- Andrews RT, Spies JB, Sacks D, et al., Patient care and uterine artery embolisation for leiomyomata. J Vasc Interv Radiol 2004, 15:115-120.