TREATMENT OPTIONS FOR FIBROIDS

If the fibroids do not grow and cause any symptoms, and the age of the patient is close to the menapause, then no treatment may be necessary for the fibroids. However, this situation is not common; in some patients, treatment is required because they have severe complaints such as heavy menstural bleeding, anemia, pain and urinary frequency. In some others, fibroids may not cause any complaints but continue to grow in size on MRI or ultrasound. If this happens in a young patient, we may choose to treat the fibroids because growing fibroids will sooner or later cause some problems and it may be easier to treat them when they are not yet too big. However, if the patient's age is close to the menapause, we may choose not to make any treatment depending on the fibroid size and growth rate. Thus, when deciding whether or not to treat a patient with fibroids, a number of factors must be taken into consideration including size, number, symptoms and growth rate of fibroids as well as the age and complaints of the patient. In patients for whom treatment is necessary, there are currently the following options:

Hormonal Treatment

Some patients may be given hormonal drugs containing GnRH agonists. These drugs reduce estrogen levels and stop the vaginal bleeding by creating a temporary menapause. They can decrease the size and number of the feeding arteries of the fibroids. As a result, fibroids may become smaller and cause less problems to the patient. However, this effect is temporary; when the hormonal treatment is ceased, fibroids will grow rapidly and return to their original sizes. Besides, when they are used for a long time, these drugs may have side effects such as osteoporosis and serious menapausal symptoms. For this reason, hormonal drugs are not suitable for the permanent treatment of uterine fibroids. But they can be used before myomectomy to reduce the blood loss and facilitate the operation, or to provide a temporary relief in patients who refuse other treatments.

Myomectomy

Miyomektomi

In this operation, fibroids are surgically removed under general anesthesia through an incision. In this way, fibroids are taken out while the uterus are spared and thus, it is tried to preserve the ability to become pregnant. Myomectomy is generally performed through an incision made at the abdomen, but sometimes it can be done laparoscopically (through small abdominal incisions) or hysteroscopically (through the vagina). In patients with a single or a few subserosal fibroids, myomectomy is generally a suitable treatment. But in multiple or deeply located fibroids, the operation becomes longer, more difficult and risky. In such patients, it may be difficult to control the bleeding during the operation and sometimes emergency hysterectomy may be required to stop the bleeding. During myomectomy, it may be impossible to remove all the fibroids or to know which fibroid is the cause of the symptoms. For this reason, fibroids may recur in about 20-25% of the patients even after a successful operation. In these patients, a second operation (myomectomy or hysterectomy) is generally required.

Hysterectomy

Histerektomi

In this operation, the whole uterus is surgically removed. If the patient is over 40 years of age, generally, both ovaries are also removed. Hysterectomy is considered suitable in patients who have multiple fibroids and do not desire future pregnancy. It is a radical treatment; since uterus is totally removed, all the fibroids are treated in one operation. Besides, the risk of developing ovarian and uterine cancer in the future is eliminated since these organs are taken out. After the operation, the patient can take special pills for lifetime to substitute for ovarian hormones (hormone replacement therapy).

Although not so desired by the patients, hysterectomy is currently the most commonly performed treatment method for uterine fibroids. Each year, roughly 650.000 hysterectomies are performed in USA, and about 90% of them are done for “benign” conditions like fibroids. However, this approach is severely questioned today; in many studies, the risk of coronary heart disease, osteoporosis, dementia and depression have been found higher in patients who underwent hysterectomy. Besides, a number of problems such as constipation, urinary incontinance, psycosexual disorders and severe menapausal complaints may occur after hysterectomy and decrease the patients quality of life. For these reasons, it is generally accepted that hysterectomy should be performed for uterine fibroids only if the patient is not suitable for other treatment options such as embolization or myomectomy.

HIFU (High intensity focused ultrasound)

hıfu In HIFU, high intensity ultrasound beams are focused into a small (a few milimeters) spot in the target tissue. These focused beams produce heat, and the target tissue volume is destroyed by scanning the spot continuously. HIFU has been used in medicine, for about two decades, in certain types of cancer including prostate, bone and soft tissue, generally together with other therapies. Today, HIFU is still used in certain centers for such tumors. Although there are many studies on HIFU in the literature, very few of them compare HIFU with other well-established and proven treatments. For this reason, it is currently not known, in what tumor types and to what extent HIFU is successful.

HIFU has also been used for benign tumors such as uterine fibroids for more than 10 years. Its most important advantage is that there is no surgery or needle insertion, and hospital stay is very short. But it has also a number of limitations and disadvantages:

  • Ultrasound beam used in HIFU can not pass through the bones and air-containing organs such as lungs, stomach and bowels. For this reason, HIFU can not be done from the back because there are the vertebral column and large bowel between the skin and the uterus. In some patients, there may be also bowel in front of the uterus, and in such cases HIFU may not be performed.
  • During HIFU, the spot where the ultrasound beams are focused is heated most, but nearby tissues are also heated to some extent. As a result, skin burns, sciatic nerve damage and hardening of the fat tissue under the skin may occur.
  • For HIFU, the fibroids must be visible with ultrasound or MRI. For fibroids that can not be seen with these methods, HIFU will have no effect.
  • In HIFU, the focal spot is a cigar-shaped area with several milimeters in length. During the HIFU, this focal spot is scanned through the fibroid and the whole fibroid volume is tried to be destroyed. However, since the volume of a spheric fibroid is proportional to the cube (third power) of its radius, a small increase in fibroid diameter means a very large increase in its volume. Thus, if the fibroid is large or there are multiple fibroids, then it will be difficult and take a lot of time to treat all of them. If the fibroids are many, it is usually impossible to treat them with HIFU.

Because of the above-mentioned limitations, it is generally accepted that HIFU can be an option in only 25% of patients with fibroids.

HIFU has few side effects and complications. But its long term efficacy in uterine fibroids are not known. The reason for this is the difficulty to treat the fibroids in one session with HIFU. Due to reasons stated above, multiple sesssions are generally required to burn all the fibroid tissue. Despite that, it may not be possible to kill all the cells in the fibroids and if the fibroids are not completely treated they may regrow and cause problems. In a study that compares HIFU with percutaneous ablation, HIFU was found to be less successful (Meng X et al, CVIR 2010). In another study that compares HIFU with embolization, HIFU was found less effective in symptom relief and required more treatment sessions (Froeling et al, CVIR 2013).

In summary, HIFU has a number of advantages and disadvantages, but certainly a place in the treatment of uterine fibroids. The best candidates for HIFU are the patients with superficially located single or a few small fibroids. Since such patients are also best for myomectomy, it may be considered that HIFU may be an alternative to myomectomy in this group of patients.

Percutaneous Ablatıon

PERCUTANEOUS In percutaneous ablation, a special needle is inserted through the skin, placed into the center of the fibroid under ultrasound guidance and the fibriod is destroyed by using heat (radiofrequency, microwave) or freezing (cryoablation). Percutaneous ablation is a well-established technique in the treatment of certain types of cancer with proven efficacy. However, there is less data in the literature regarding its use in uterine fibroids.

For the treatment of fibroids, the ablation needle must be advanced through the skin or vagina into the center of the fibroid. To do this, the fibroid must be visible on ultrasound and preferably superficially located. The more the fibroids are, the more needle punctures will be necessary. Thus, percutaneous ablation will be difficult and impractical if there are too many fibroids. Besides, ablation is not effective in fibroids more than 5 cm in diameter and not recommended for those close to the endometrial surface because of the risk of endometrial damage.

UFE Embolization

In embolization, a tiny catheter is inserted through the groin and placed into the uterine arteries. Then, these arteries are occluded by injecting very small particles through the catheter. The fibroids located in the uterus have a lot of feeding vessels and are very sensitive to changes in blood circulation. Thus, they will die shortly after the embolization (necrosis) when their blood supply is blocked. In contrast, the healthy uterine tissue is not so sensitive to changes in blood circulation. Besides, it has also alternative blood supply from the vessels of the surrounding organs. Thus, even if the arterial blood supply is totally stopped, the normal uterine tissue will stay alive while all the fibroids will become dead. This very interesting phenomenon can be easily seen on the follow-up MRI images, and constitutes the most important difference of UFE from the other treatment options.

UFE is currently one of the most commonly employed treatments for uterine fibroids. Its most important advantages include use of local anesthesia, absence of any incisions or stitches and short hospitalization times. In UFE, unlike hysterectomy, the uterus is preserved, and unlike myomectomy, all the fibroids can be treated in contrast to only the fibroid that is surgically removed. However, as in any other treatment in medicine, selecting the right patient is extremely important also for embolization, and for this selection, an interventional radiologist experienced in fibroid management must always be consulted.

Video: How do we perform pain free UFE?