Overview
Uterine fibroids are benign tumors that develop within the muscular wall of the uterus. They are extremely common. Twenty to 40 percent of women over the age of 35 have uterine fibroids. Over 50 percent of African American women have fibroids. They are the most frequent indication for hysterectomy in premenopausal women. Of the 600,000 hysterectomies performed annually within the United States, one third are due to symptomatic fibroids. Now there is a proven, non-surgical alternative to hysterectomy for the treatment of symptomatic uterine fibroids, uterine fibroid embolization (UFE).
Uterine Fibroid Symptoms
Most fibroids don’t cause symptoms. Only 10 to 20 percent of women with fibroids have symptoms that require treatment. Symptoms may include:
- Heavy menstrual bleeding that tends to be prolonged
- Intermittent, unusual monthly bleeding
- Anemia (low blood count)
- Pelvic pain and pressure
- Painful menstrual cramping
- Frequency in urination secondary to bladder pressure
- Constipation
- Bloating
- Pain during sexual intercourse
- Increase in waist size
Fibroid Types
Uterine fibroids are categorized by their location within the muscular wall of the uterus.
Subserosal fibroids develop under the outside lining of the uterus. They typically don’t cause changes of menstrual flow, however may cause symptoms of pelvic or back pain, pressure, and/or bloating. Subserosal fibroids can have stalk or stem. These are called pedunculated subserosal fibroids.
Intramural fibroids are the most common type of uterine fibroids. These develop within the muscular wall of the uterus and ten to grow inward. They cause enlargement of the uterus. Intramural fibroids can cause heavy menstrual bleeding, generalized pelvic pressure, increased waist size, frequency in urination, and or constipation.
Submucosal fibroids develop under the uterine cavity lining. Although they are the least common type, they cause the greatest symptoms. Even small subserosal fibroids can cause heavy menstrual bleeding with clots and gushing as well as prolonged cycles.
Diagnosis
Typically an ultrasound can determine the presence of uterine fibroids. However, it is limited. An MRI (magnetic resonance imaging) is far superior in determining the presence, location, and type of fibroids. It is also a better test to diagnose other uterine and pelvic pathology that may be the cause of a patient’s symptoms. It is necessary prior to uterine fibroid embolization (UFE).
Nonsurgical Uterine Fibroid Embolization – A Major Advance in Women’s Health
Uterine fibroid embolization (UFE), also known as uterine artery embolization, is performed by an interventional radiologist, a physician who is trained to perform this and other types of embolization and minimally invasive procedures. It is performed while the patient is conscious, but sedated and feeling no pain. It does not require general anesthesia.
The interventional radiologist makes a tiny nick in the skin in the groin and inserts a catheter into the femoral artery. Using real-time imaging, the physician guides the catheter through the artery and then releases tiny particles, the size of grains of sand, into the uterine arteries that supply blood to the fibroid tumor. This blocks the blood flow to the fibroid tumor and causes it to shrink and die.
UFE Recovery
UFE can be performed safely in an outpatient setting. Non steroidal medication (Motrin) and pain killers are prescribed for several days following the procedure. This helps to control pain and cramping. In addition, medication for nausea may be prescribed as needed. Most women resume light activities in a few days and are able to return to normal activities within ten days. In comparison, recovery time after a hysterectomy is approximately six weeks.
UFE Facts
- 85-90 percent of women have significant relief of their symptoms
- UFE is effective on most size and types of fibroids
- Recurrance of treated fibroids is rare
- Approximately 14,000 UFE procedures are performed annually in the U.S.
- Embolization of the uterine arteries has been performed by Interventional Radiologists for over 20 years. It was and still is used to treat life-threatening bleeding after childbirth.
- The embolic particles are FDA approved and have been in use in people for over 20 years.
- UFE is covered by most major insurance companies.
- It is an organ sparing procedure
- UFE preserves fertility with numerous reports of successful pregnancy after UFE
Risks
UFE is a very safe method and, like other minimally invasive procedures, has significant advantages over conventional open surgery. However, there are some associated risks, as there are with any medical procedure. A small number of patients have experienced infection, which usually can be controlled by antibiotics. There also is a less than one percent chance of injury to the uterus, potentially leading to a hysterectomy. These complication rates are lower than those of hysterectomy and myomectomy.
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Ovarian Vein Embolization
Pelvic congestion syndrome, also known as chronic pelvic pain syndrome, is caused by
Pelvic Congestion Syndrome - Chronic Pelvic Pain in Women
It is estimated that one-third of all women will experience chronic pelvic pain in their lifetime. Many of these women are told the problem is "all in their head" but recent advancements now show the pain may be due to hard to detect varicose veins in the pelvis, known as pelvic congestion syndrome.
The causes of chronic pelvic pain are varied, but are often associated with the presence of ovarian and pelvic varicose veins. Pelvic congestion syndrome is similar to varicose veins in the legs. In both cases, the valves in the veins that help return blood to the heart against gravity become weakened and don't close properly, this allows blood to flow backwards and pool in the vein causing pressure and bulging veins. In the pelvis, varicose veins can cause pain and affect the uterus, ovaries and vulva. Up to 15 percent of women, generally between the ages of 20 and 50, have varicose veins in the pelvis, although not all experience symptoms.
The diagnosis if often missed because women lie down for a pelvic exam, relieving pressure from the ovarian veins, so that the veins no longer bulge with blood as they do while a woman is standing.
Many women with pelvic congestion syndrome, spend many years trying to get an answer to why they have this chronic pelvic pain. Living with chronic pelvic pain is difficult and affects not only the woman directly, but also her interactions with her family, friends, and her general outlook on life. Because the cause of the pelvic pain is not diagnosed, no therapy is provided even though there is therapy available.
If you have pelvic pain that worsens throughout the day when standing, or any of the other symptoms mentioned below, you may want to seek a second opinion with Dr. Makris. He will work with your gynecologists to determine the best treatment option for your pain.
Prevalence
- Women with pelvic congestion syndrome are typically less than 45 years old and in their child bearing years.
- Ovarian veins increase in size related to previous pregnancies. Pelvic congestion syndrome is unusual in women who have not been pregnant.
- Chronic pelvic pain accounts for 15% of outpatient gynecologic visits.
- Studies show 30% of patients with chronic pelvic pain have pelvic congestion syndrome (PCS) as a sole cause of their pain and an additional 15% have PCS along with another pelvic pathology.
Risk Factors
- Two or more pregnancies and hormonal increases
- Fullness of leg veins
- Polycystic ovaries
- Hormonal dysfunction
Symptoms
The chronic pain that is associated with this disease is usually dull and aching. The pain is usually felt in the lower abdomen and lower back. The pain often increases during the following times:
- Following intercourse
- Menstrual periods
- When tired or when standing (worse at end of day)
- Pregnancy
Other symptoms include:
- Irritable bladder
- Abnormal menstrual bleeding
- Vaginal discharge
- Varicose veins on vulva, buttocks or thigh.
Diagnosis and Assessment
Once other abnormalities or inflammation has been ruled out by a thorough pelvic exam, pelvic congestion syndrome can be diagnosed through several minimally invasive methods. An interventional radiologist, a doctor specially trained in performing minimally invasive treatments using imaging for guidance, will use the following imaging techniques to confirm pelvic varicose veins that could be causing chronic pain.
Pelvic venography: Thought to be the most accurate method for diagnosis, a venogram is performed by injecting contract dye in the veins of the pelvic organs to make them visible during an X-ray. To help accuracy of diagnosis, interventional radiologists examine patients on an incline, because the veins decrease in size when a woman is lying flat.
MRI: May be the best non-invasive way of diagnosing pelvic congestion syndrome. The exam needs to be done in a way that is specifically adapted for looking at the pelvic blood vessels. A standard MRI may not show the abnormality.
Pelvic ultrasound: Usually not very helpful in diagnosing pelvic congestion syndrome unless done is a very specific manner with the patient standing while the study is being done. Ultrasound may be used to exclude other problems that might be causing pelvic pain.
Transvaginal ultrasound: This technique is used to see better inside the pelvic cavity. As with a pelvic ultrasound it is not very good at visualizing the pelvic veins unless the woman is standing. However it may be used to exclude other problems.
Treatment Options
Once a diagnosis is made, if the patient is symptomatic, an embolization should be done. Embolization is a minimally invasive procedure performed by interventional radiologists using imaging for guidance. During the outpatient procedure, the interventional radiologist inserts a thin catheter, about the size of a strand of spaghetti, into the femoral vein in the groin and guides it to the affected vein using X-ray guidance. To seal the faulty, enlarged vein and relieve painful pressure, an interventional radiologist inserts tiny coils often with a sclerosing agent (the same type of material used to treat varicose veins) to close the vein. After treatment, patients can return to normal activities immediately.
Additional treatments are available depending on the severity of the woman's symptoms. Analgesics may be prescribed to reduce the pain. Hormones such birth control pills decrease a woman's hormone level causing menstruation to stop may be helpful in controlling her symptoms. Surgical options include a hysterectomy with removal of ovaries, and tying off or removing the veins.
Efficacy
In addition to being less expensive to surgery and much less invasive, embolization offers a safe, effective, minimally invasive treatment option that restores patients to normal. The procedure is very commonly successful in blocking the abnormal blood flow. It is successfully performed in 95-100 percent of cases. A large percentage of women have improvement in their symptoms, between 85-95 percent of women are improved after the procedure. Although women are usually improved, the veins are never normal and in some cases other pelvic veins are also affected which may require further treatment.