FREQUENTLY ASKED QUESTIONS

CAN FIBROIDS TURN INTO CANCER?

No. In about 1/1000 of patients with fibroids, a cancer called “leiomyosarcoma” may be seen. It is demonstrated however, that this cancer develops not from the fibroids, but from the normal muscle tissue of the uterus. Therefore, in a patient with fibroids, the risk of developing malignant uterine tumor is exactly the same as the one in a patient who has no fibroids.

CAN FIBROIDS BE TREATED WITH DRUGS?

In fibroids, drug treatment has a limited and temporary effect. In symptomatic fibroids, pain killers, iron preperations or low-dose oral contraceptives are frequently used to fight with the symptoms. Besides, there are also other drugs called “GnRH agonists” which may decrease or stop mensturation temporarily. They are generally used to reduce the size of the fibroids before myomectomy operation or provide a symptomatic relief for a short time. All these drugs must be used under the supervision of a gynecologist.

ARE FIBROIDS HEREDITARY?

Fibroids are seen in about one third of women of reproductive age. It is controversial whether fibroids are hereditary or not. However, if there is one fibroid patient in the family, the other family members are two times more likely to develop fibroids.

WHAT ARE THE RISK FACTORS FOR FIBROIDS?

Age: Fibroids are most commonly seen in 40-50 years, they are uncommon after menapause.

Family history: The risk is two times higher if one family member has fibroids.

Race: Fibroids are more common in black women.

Obesity: In obese patients, fibroids are 2-3 times more common.

Dietary habits: The risk of fibroid is higher in women who consume red meat compared with vegetarians

DO SIZE AND LOCATION OF FIBROIDS AFFECT THE RESULTS OF UFE?

UFE is effective regardless of the size, number and location of uterine fibroids, and this is one of its most important advantages over myomectomy. Besides, after a successful UFE, fibroids are unlikely to recur while after myomectomy, remaining unnoticed fibroids can grow later and cause problems. UFE is effective in any fibroid size. However, it is generally accepted that fibroids smaller than 10cm in diameter will shrink more rapidly after UFE than larger fibroids. And finally, UFE is effective in fibroids of any location in the uterus. However, pedinculated (attached to the uterus with a thin neck) subserosal and submucosal fibroids may detach from the uterus after UFE and cause problems.

IS UFE EFFECTIVE IN FIBROID PATIENTS

Yes. In such patients, previous myomectomy may cause a number of problems including adhesions (stiff bands that attach abdominal organs), which make another operation more difficult. In contrast, such problems do not affect UFE. Therefore, UFE should be the first line treatment in fibroid patients who previously underwent myomectomy.

IN WHAT SITUATIONS UFE MUST NOT BE PERFORMED?

These situations are extremely rare; patients who have a history of contrast allergy or renal insufficiency, or those who are taking blood thinners like coumadin can still undergo UFE, but certain measures have to be taken. In patients with infection of the uterus, ovaries or genital organs, UFE can be done after the infection is completely treated. In patients with an intrauterine contraceptive device, it is preferable to get it removed before UFE. In patients who have been taking GnRH agonists, these drugs must be stopped at least three months before UFE since they may reduce the size of the feeding arteries and prevent the embolic particles to go deep into the fibroids.

WHAT ARE THE TREATMENT OPTIONS FOR ADENOMYOSIS?

In adenomyosis, drug treatment is not very successful. HIFU and percutaneous ablation may be an option only if the adenomyosis is focal and clearly visible on ultrasound and MRI, which is not common. Because of the limitations of these treatments, most patients with adenomyosis are recommended hysterectomy. Embolization has been introduced as an alternative to hysterectomy and successfully used in many patients with adenomyosis in the last decade. It is effective in all types of adenomyosis and may eliminate or substantially reduce adenomyosis symptoms in about 75% of the patients.

WHAT ARE THE ADVANTAGES OF EMBOLIZATION IN ADENOMYOSIS?

Embolization has many advantages over other treatment options in adenomyosis:

  • It is effective. It has been demonstrated in recent studies that embolization successfully reduces or eliminates adenomyosis complaints in about three fourth of the patients.
  • Its success is durable. Studies have shown that the effect of embolization is not temporary. In the vast majority of the patients, the symptoms have not recurred after successful embolization.
  • Its success does not depend on the type, extention, size or visibility of adenomyosis. It has been shown that embolization can be effective in all types of adenomyosis.
  • It is minimally invasive. Embolization for adenomyosis is exactly the same procedure as embolization for fibroids (UFE); it is done through a 1-2mm puncture hole under local anesthesia using the angiography device.

WHY IS MRI NECESSARY IN ALL FIBROID PATIENTS?

Fibroids are generally diagnosed with ultrasound. However, ultrasound may not show all the fibroids, and is not reliable in the determination of their location (e.g. submucosal, subserosal or intramural). MRI not only shows fibroids and their location much more accurately, but also demonstrate coexisting pathologies such as adenomyosis etc. better than ultrasound.

WHICH PATIENTS ARE IDEAL CANDIDATES FOR UFE?

  • Patients who were recommended hysterectomy for their fibroids.
  • Patients with nonpedinculated fibroids for whom pregnancy is not absolutely important.
  • Patients who wants pregnancy absolutely, but not very suitable for myomectomy (e.g. multiple fibroids, previous myomectomy etc).

IS UFE PAINFUL?

There is no pain during UFE. The procedure is done under local anesthesia and sedation in the angio suite through a 1-2mm puncture hole at the groin. After UFE, there may be pain particularly during the first day, which is treated with intravenous pain killers. In some centers including ours, a special nerve block is also done during the UFE, which eliminates most of the pain on the first day. After UFE, besides the pain, nausea, fatigue and lack of apetite may also be seen for a couple of days. The patients typically stay at the hospital for 1-2 days and then, they can be discharged with oral medications.

IS UFE SAFE?

UFE is considered to be a very safe procedure. However, like any other medical intervention, it has also some risks, although they are less common and milder compared with those of myomectomy and hysterectomy. After UFE, in less than 1% of the patients, an infection may develop in the uterus which may require hospitalization and antibiotic treatment. In some patients, mensturation may stop after UFE. In most patients, this is temporary and menstural bleeding will start normally in a couple of months. In others, it may be permanent. Permanent stop of mensturation is rare but more likely to occur in premenapausal (45-55 years of age) women.

WHAT IS THE RISK OF RADIATION IN UFE?

The radiation dose to the patient during UFE is generally minimal, and similar to the dose of an abdominal computed tomography or barium enema examination of large bowel.

WHAT PARTICLES ARE USED DURING UFE?

During UFE, the most commonly used materials are polivinyl alcohol (PVA) particles. Gel foam particles are also used when a temporary occlusion is desired. There are also more recently introduced materials such as embosphere, embozene etc. All these particles have been extensively used in human body for years, and no specific side effects have been observed.

WHAT HAPPENS TO FIBROIDS AFTER UFE?

After UFE, fibroids become dead and start to shrink. Their internal structure also changes from a firm mass to a relatively soft and spongy tissue. The shrinkage of fibroids continues for months after UFE. At six months, an avarage of 50% volume reduction of fibroids is generally seen on follow-up MRIs.

HOW cAN UFE KILL FIBROIDS WITHOUT HARMING NORMAL UTERUS?

This is a very interesting phenomenon, and can be explained by several mechanisms.

  • Fibroids have much more vessels and blood supply than normal uterine tissue. Thus, when particles are injected into the main uterine artery, most of them are “sucked” by the fibroids. As a result, the majority of the particles go into the fibroid vessels while only a small part of them go into the normal uterine vessels.
  • Since fibroid tissue is used to a lot of blood supply, it is very sensitive to changes in blood circulation. As a result, when its vessels are occluded it rapidly becomes dead. In contrast, normal uterine tissue is used to a low blood supply, and is not very sensitive to changes in circulation. Therefore, it will survive after UFE.
  • Fibroids have blood vessels that originate only from the main uterine arteries. Thus, when these vessels are occluded, they die in a short time. By contrast, normal uterine tissue have other blood vessels, besides their own arteries, from the surrounding organs such as ovaries, tubes and vagina. Thus, when the main uterine arteries are occluded, the normal uterine tissue continue to have blood from other vessels and survive after UFE.
  • Following UFE, the main uterine arteries generally reopen after some time. This has been demonstrated in some studies using MR angiography. The reopened arteries start to feed the normal live uterine tissue again, but they can not feed the fibroids because they are already dead.

In conclusion, owing to the combined effects of these factors, fibroids in the uterus become dead after UFE, while the normal uterine tissue survives and keeps its normal function.

HOW LONG WILL IT TAKE FOR FIBROID SYMPTOMS TO DISAPPEAR?

Following UFE, pain will decrease on the second day and most patients will become well enough to go home. However, return to normal active life may take 5-7 days. Because, after UFE, some patients may have typical complaints of “postembolization syndrome”, such as nausea, pain, fatigue and lack of apetite, and this may last for about one week.After this period, fibroid symptoms begin to decrease; heavy menstural bleeding will generally return to normal shortly after UFE, but at times, this may take weeks or months. Sometimes, the patient may not have mensturation for a couple of months and then starts to have menses normally. After UFE, it will take at least several months for the patient to notice a decrease in the compression symptoms such as urinary constipation, bloating and constipation. The rate of symptom improvement following UFE depends on the size, number and location of the fibroids. The symptomatic improvement may continue for upto two years, but in most patients, it reaches its maximum level in one year.

IF UFE IS SO GOOD WHY IS IT NOT PERFORMED MORE OFTEN?

There are a couple of reasons for this. First, interventional radiologic treatments are not widely known not only to to patients but also to many doctors. Likewise, UFE is not sufficiently and correctly known to doctors including gynecologists. For this reason, most fibroid patients are not informed on UFE by gynecologists, and not referred to interventional radiologists. Second, the number of interventional radiologists in the world is not enough for the big potential of these treatments and only a small part of these doctors have sufficient knowledge and experience in UFE. And third, the equipment such as a digital angiography device and staff are not everywhere available.

However, despite these negative factors, UFE is increasingly known to doctors and patients. The number of IRs who can perform UFE is also rapidly increasing. As a result, UFE is more and more frequently used in the treatment of uterine fibroids.