GYNAECOLOGICAL DISORDERS

Although the majority of women with fibroids may experience no symptoms, fibroids can be associated with significant symptoms that impair the quality of life and interfere with fertility. The most common symptoms include;

• Heavy, prolonged menstrual periods with sometimes clots. This can lead to anaemia with dizziness and easy tiredness
• Bladder pressure leading to frequent urination and sense of urgency, sometimes
• Pelvic pain
• Pain in the back or legs as the fibroids press on nerves that supply the pelvis and legs
• Pain during sexual intercourse
• Pressure on the bowel, leading to constipation and bloating
• Abnormally enlarged abdomen

Women with the aforementioned symptoms should seek medical advice by seeing their GP or gynaecologist. Ultrasound examination and/or MRI confirms the diagnosis. The radiological examination identifies the type, number, size and location of fibroids. Also, US or MRI excludes other possible causes of patient’s symptoms such as ovarian cancer, endometrial carcinoma or endometriosis.

Hormonal treatment
This is usually in the form Gonadotropin realising hormone agonist. This causes blockage of hormone release by the ovary (Estrogen) resulting in controlling the fibroid symptoms and shrinkage of fibroid. This hormonal treatment results in hot flashes, water retention and decrease bone density (osteoporosis).Because of those symptoms, the hormonal treatment can not be given for longer than 6 months. Unfortunately, symptoms usually recur following stoppage of treatment and fibroid re-grows.

Surgical treatment
Myomectomy and hysterectomy have been the traditional methods of fibroid treatment with a long track record.

Myomectomy is a surgical option for patients who desire to preserve their fertility or uterus. The overall risk of symptoms recurrence range between 15-30% and risk of second procedure is 10% (Iverson 1996). Severe bleeding can occur following myomectomy and hysterectomy may be needed. Adhesions and subsequent fertility impairment, and uterine rupture during pregnancy are recognized complications. (Lumsden MA 2002)

Hysterectomy is the most common gynecological operation and fibroid is the most common benign cause for this operation (Vessey 1992). Approximately 72,362 hysterectomies are performed in England every year. The operation can be done trans-abdominally, or laproscopically. Although hysterectomy is the best treatment to achieve symptomatic relief from fibroids but it has significant morbidity and mortality. Gynecologists perform hysterectomy or myomectomy surgery. Hysterectomy is the removal of the uterus and is considered major abdominal surgery. It requires three to four days of hospitalization and the average recovery period is six weeks.

Depending on the size and placement of the fibroids, myomectomy can be an outpatient surgery or require two to three days in the hospital. However, myomectomy is usually major surgery that involves cutting out the biggest fibroid or collection of fibroids and then stitching the uterus back together. Most women have multiple fibroids and it is not physically possible to remove all of them because it would remove too much of the uterus. While myomectomy is frequently successful in controlling symptoms, the more fibroids the patient has, generally, the less successful the surgery. In addition, fibroids may grow back several years later. Myomectomy, like UFE, leaves the uterus in place and may, therefore, preserve the woman’s ability to have children.

Minimally Invasive Treatment - Uterine Fibroids Embolisation
Uterine fibroids embolisation (UFE) or uterine artery embolisation (UAE) is a minimally invasive treatment designed to preserve the uterus and fertility.

Following sterile preparation of the groin using aseptic solution, local anaesthesia is infiltrated in the skin. This is followed by introducing a tiny catheter(size of pin hole)into the artery and advancing it into the artery that supplies the uterus and fibroid (uterine artery).Images are taken to confirm accurate positioning of the catheter and small particles (700-900 micron) are injected to stop blood flow into the fibroid. At the end of the procedure there should be no blood flow into the fibroid while the uterus remains perfused. With time (6-9 months) the fibroid dies and shrinks and the woman gets relief of her symptoms.

1. Fibroid embolisation usually requires a short hospital stay of one night
2. Quick recovery. The majority of women resume light activities in a 3-5 days and almost all women are able to return to normal activities within seven to 10 days
3. On average, 90 percent of women who had the procedure experience significant or total relief of heavy bleeding
4. 85 percent of treated patients have significant pain relief. Similar percentage of patients experienced significant improvement in their urinary symptoms.
5. The embolisation is suitable for multiple fibroids as well as large fibroids.
6. 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. Long-term (10 year) data is ongoing and not yet available, but in one study in which patients were followed for six years, no fibroid that had been embolised re-grew.

Fibroid embolisation is considered to be very safe; however, there are some associated risks, as there are with almost any medical procedure. Most women experience moderate to severe pain and cramping in the first several hours following the procedure. Some experience nausea and fever. These symptoms can be controlled with appropriate medications. A small number of patients (1%) have experienced infection. This is usually manifested by fever, new abdominal pain and tenderness few to several weeks after embolisation. The infection should be confirmed by blood tests and US or MRI examination. Once infection is confirmed, antibiotics should be effective in most patients. Failure to control infection may lead to hysterectomy (less than 1%). These complication rates are probably lower than those of hysterectomy and myomectomy (surgical removal of fibroids).

A small number of patients (3-5%) have entered into menopause after embolisation. This is more likely to occur if the woman is in her mid-forties or older, and is already nearing menopause.

A small percentage of patients may experience vaginal discharge for few weeks. It is usually self-limiting. In a very small minority of patients, additional gynaecological procedure, hysteroscopy, may be needed to take out fibroid debris from the uterine cavity (6%).

Myomectomy (surgical removal of fibroids) and hysterectomy also carry risks, including infection and bleeding leading to transfusion. Patients who undergo myomectomy may develop adhesions causing tissue and organs in the abdomen to fuse together, which can lead to infertility. In addition, the recovery time is much longer for abdominal myomectomy, generally one to two months. It is , also, known that hysterectomy may accelerate menopause.

You should talk to your gynaecologist and interventional radiologist about possible risks of any procedure you may choose.