Treatment of uterine fibroids: embolization of uterine arteries

Uterine fibroids, also known as leiomyomas or fibromyomas, are non-cancerous (benign) tumors that develop in the muscular wall of the uterus and can occur in up to 40% of women of childbearing age. Although fibroids do not always cause symptoms, depending on their size and location they can cause pain and significant bleeding. With menopause they improve as the level of circulating estrogens in the blood decreases. Symptoms may not improve in women who have taken hormones (estrogens) as a treatment during menopause.

The size of a myoma varies from a few millimeters (olive) to 15-20 centimeters, and they can be single or multiple. They develop in one of the three layers of the wall of the uterus. Subserosal fibroids (more external) grow outside the uterus and do not produce hemorrhagic symptoms but do produce abdominal discomfort. Intramural fibroids (in the middle), which are the most frequent and grow in the thickness of the uterine wall, can produce alterations in menstrual flow, pain and pelvic weight. Finally, the submucosal (more internal), which grow in a thin layer lining the uterine cavity and develop towards it.

What are the most frequent symptoms?

The symptoms depend on the size of the myoma and its location (subserosal, intramural or submucosal). Fibroids are very common among women over 30 years of age and the vast majority do not cause problems. The most frequent and important symptoms are:

  • Swelling of the abdomen
  • Pain and heaviness in the lower abdomen.
  • Back and leg pain
  • Pain during sexual intercourse
  • Alterations in menstruation with prolonged and copious hemorrhages, even with blood clots. This hemorrhage may even cause anemia.
  • Compression on the urinary bladder producing constant and/or frequent urination.
  • Compression on the bowel leading to constipation.
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How is a uterine fibroid diagnosed?

Uterine fibroids are usually suspected in routine gynecological examination and are confirmed by imaging techniques: transvaginal ultrasound, computed tomography and magnetic resonance imaging. For the control and follow-up of small and asymptomatic fibroids, ultrasound and medical control are sufficient. Large myomas with many symptoms may require other imaging techniques. MRI and ultrasound are innocuous and painless.

What is the surgical treatment of uterine fibroids?

The vast majority of fibroids do not cause problems and do not require treatment. Symptomatic, small myomas can be controlled with various drugs: contraceptives, non-steroidal anti-inflammatory drugs (Ibuprofen, etc.) and hormone therapy. These treatments generally improve symptoms and control myoma growth while they are taken. However, the symptoms reappear and the tumor grows again as soon as they are stopped.

When symptoms persist, despite medical treatment, when they are very important or when the size exceeds a certain limit, they must be treated with more invasive techniques.

Surgery has been the traditional treatment for uterine fibroids. Large, intramural tumors almost always required removal of the uterus, while small tumors can be resected and the uterus preserved.

Currently surgical techniques have evolved and certain fibroids can be resected without the need for conventional surgery (opening the abdomen). Removal of the tumor alone is called myomectomy. In general, myomectomy improves symptoms but does not guarantee the possibility of new myomas after a few years.

Conventional surgical technique: consists of opening the abdomen with conventional surgical techniques, accessing the uterus, opening it and removing the tumor. It requires general anesthesia and several days of hospitalization. With this procedure all types of fibroids can be removed (submucosal, subserosal and intra mural).

When the tumor is large or multiple, it is located in a menopausal woman and/or she accepts that after this technique she will not be able to become pregnant, the entire uterus can be removed. This procedure is called hysterectomy and consists of opening the abdomen by conventional surgery and removing the uterus. It is performed under general anesthesia and requires several days of hospitalization and long convalescence. Fibroids are the cause of approximately one third of hysterectomies performed annually.

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Minimally invasive treatment of fibroids: What does embolization of the uterine arteries consist of?

In the last 20 years, a new technique has been added to the therapeutic arsenal for fibroids. Uterine artery embolization consists of total and permanent occlusion of the uterine arteries. Embolization produces a lack of blood flow in the tumor and a significant reduction in tumor size. It is necessary a powerful and continuous analgesia that can be performed by epidural or IV sedation. This technique is used to treat all types of uterine myoma.

It is performed by Interventional Radiology techniques that require minimal invasion. By means of catheterization the femoral artery in the groin and navigating through the arteries, with X-ray control (fluoroscopic) will lead us to the vessels that irrigate the tumor. By means of small mats of very small size, the arteries that feed the tumor will be plugged, producing their death and consequent atrophy. Pain and abdominal swelling are two common effects of this technique. To combat the pain, strong analgesics are used by epidural or venous route. After the acute phase of the first 24 hours, painkillers are administered orally for a week.

Who performs embolization and what are its advantages?

The procedure is performed by the Interventional Radiologist. However, other medical professionals (gynecologists, anesthesiologists, general radiologists, etc.) are involved in the diagnostic and therapeutic process. Interventional Radiologists are physicians who have special training to diagnose and treat processes using tiny, sophisticated tools guided by X-rays or other imaging techniques.

Interventional techniques, in general, are less invasive and safer, although their main advantage lies in a shorter hospitalization and convalescence time.

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The Interventional Radiology room is a hospital room with special aseptic conditions. It has sophisticated imaging equipment (X-rays and ultrasound) as well as human personnel and technical means of vital control and resuscitation adequate to ensure patient safety.

The Interventional Radiologist works closely with the gynecologist to give the patient the best possible care and attention.

What types of fibroids can be treated with embolization?

In general, any type of symptomatic myoma can be treated with this technique, although larger and multiple myomas have the greatest advantages over surgical techniques.

What are the medical results of embolization?

Medical studies show that between 85 and 95% of patients have improved their symptoms. Up to 80% of patients had a significant reduction in the volume of their fibroids. The recurrence of myomas is comparable to conservative surgery, although with fewer complications and a faster recovery to normal activity.

Are there any risks in myoma embolization?

Uterine artery embolization is a safe technique, but it is not completely risk-free. Pain, as already mentioned, can be significant although it is controlled with intravenous analgesia.

In less than 1% of patients with uterine alteration, hysterectomy was considered as a potential treatment.

Finally, post embolization induced menopause has been described in 2-5% of cases.

Is it possible to have children after embolization?

There are no conclusive studies in this regard. It is advisable to avoid pregnancy during the first months after embolization. Subsequently, some women have had full-term pregnancies without complications. However, due to the possibility of ovarian involvement in 2-5% of women with a desire to procreate, it should not be the technique of choice in their treatment.