Prof Saim Yılmaz, MD
"Giant fibroids can be treated with embolization in selected patients"
Are Fibroids Hereditary?
Fibroids occur in about a third of women. It is controversial whether fibroids are hereditary. However, the incidence of the disease in those with a family history of fibroids is approximately 2 times higher than in those without fibroids.
Which Risk Factors Are Effective in Fibroid Formation?
Age: Fibroids are most common between the ages of 30-40, they decrease after menopause.
Family history: The risk is 2 times higher in those with a family history of fibroids.
Race: Fibroids are more common in blacks than in whites.
Obesity: The risk of fibroids increases 2-3 times in obese people.
Eating habits: Red meat eaters are at higher risk than vegetarians.
Is Drug Treatment Effective in Fibroids?
The effectiveness of drug therapy in fibroids is limited and usually temporary. Painkillers, iron preparations and low-dose birth control pills can be used in those with mild complaints. Apart from these, there are also drugs called GnRH agonists that cause menopause and shrink fibroids. They are mostly given to provide short-term reduction in complaints and to shrink fibroids before myomectomy. However, these drugs must be used under the control of a gynecologist.
Are herbal cures useful in fibroids?
For fibroids, a number of plant extracts originating from China are used in the world. In some countries, there are those who use some plant extracts or mixtures, especially onion cure. However, there is no reliable scientific evidence that these herbal products shrink or treat fibroids.
Do Fibroids become Cancer?
No. Less than 1/1,000 of those with fibroids may develop a cancer called leiomyosarcoma, but this cancer is thought to originate from normal muscle cells in the uterine tissue, not from fibroids. Therefore, a patient with fibroids has the same risk of developing leiomyosarcoma or other types of cancer in the uterus as those without fibroids.
Which fibroids need treatment?
Some of the fibroids do not grow and do not cause complaints. Such fibroids do not require treatment, periodic follow-up is sufficient. However, if the fibroids are large, show significant growth, are numerous, and cause complaints, treatment is necessary.
Is it useful to remove the uterus after menopause?
Some physicians argue that the uterus and ovaries lose their functions after menopause, but there is a risk of uterine and ovarian cancer, and therefore, the uterus should be removed together with the ovaries in patients with fibroids. But this is not a scientific approach, because:
1. If the uterus and ovaries are removed, the patient will experience a more severe menopause period called "surgical menopause" than normal menopause.
2. After menopause, hormones secreted in small amounts from the ovaries protect women from cardiovascular diseases and osteoporosis. The tendency to these diseases increases in women whose uterus and ovaries are removed.
3. Patients who have their uterus and ovaries removed may be affected psychologically. The tendency to depression increases in these patients.
4. The most common cancers in women are breast cancer and lung cancer. Uterine cancer and ovarian cancer are seen 7-8 times less than breast cancer. It is not a beneficial approach for the patient to have a surgical operation to prevent these uncommon cancers and to increase the risk of heart diseases, osteoporosis and depression, which are more common.
4. Every surgical operation has a risk. Side effects such as pulmonary embolism and infection may also occur in patients who have undergone hysterectomy, and there may be loss of life, although rarely.
What are the negative effects of hysterectomy?
As explained above, the development of a severe surgical menopause, cardiovascular diseases, osteoporosis and increased tendency to depression, and risks of surgical operation can be listed as. Click here for more detailed information on this
In which patients is myomectomy suitable?
Myomectomy can be performed by cutting the abdominal skin (classic) or by hysteroscopy through the vagina (hysteroscopic). The most suitable fibroids for classical myomectomy are those that grow outward from the uterus and are preferably attached to the uterus by a thin stalk. In hysteroscopic myomectomy, fibroids located on the inner surface of the uterus, smaller than 2-3 cm and preferably attached to the uterus with a thin stalk, are more suitable for treatment. Apart from this, myomectomy is not suitable for fibroids, especially intramural, large and numerous fibroids, in these cases embolization should be preferred.
What is HIFU, in which patients is it suitable?
HIFU is based on the fact that sound waves from outside the body focus on a single point on the body and create a temperature of 60-80 degrees at that point. By moving this focus within the fibroid, it is aimed to destroy a large part of the fibroid with heat. Hayfu is a method that can treat some fibroids without surgery or embolization. However, it is technically applicable in only 25% of fibroid patients. It is not suitable for large, multiple fibroids located at the back of the uterus. In addition, it is not recommended for patients who are very close to the skin, behind the intestine, and who have surgical scars on their skin. Hayfu is a long and impractical treatment method. In addition, it is quite expensive and is not available in Turkey.
Why is MRI absolutely necessary in fibroids?
All patients with fibroids requiring treatment should have a good MRI. Because:
1. MRI shows the number, size and location of fibroids much better than ultrasound.
2. MRI can also show diseases such as adenomyosis, which is often confused with fibroids, better than ultrasound.
3. MRI can give additional warning information to the doctor that the mass is actually cancer in some cases that are thought to be fibroids.
4. MRI is the only imaging modality that can show whether fibroids are alive or dead (ultrasound cannot differentiate). For this reason, control MRI should be taken 6 months after the procedure to show that the fibroids have died and shrunk as a result of the treatment in myoma patients.
Who discovered the embolization and how?
Living in Paris, France, Dr. A gynecologist named Jacques-HenriRavina saw that the embolization method successfully stopped tumor bleeding in the uterus in 1989 and decided to use this method before the operation in patients who were going to have myoma surgery. Dr. Ravina aimed to first occlude the vessels of fibroids with embolization and then to perform myomectomy in a bloodless and comfortable way. Surprisingly, however, he noticed that some of the patients did not come to the operation after their complaints disappeared after embolization, and that the fibroids shrank in the majority of those who came to the operation and tissue death (necrosis) occurred. Based on these observations, Dr. Ravina reported for the first time that embolization method can be used as a stand-alone treatment method in the treatment of uterine fibroids. Later, embolization was applied more and more frequently and in the last 30 years it has become a known treatment method all over the world.
How is embolization done?
Myoma embolization is a procedure performed under local anesthesia and sedation on the angiography (DSA) device. After the patient is given painkillers and relievers, an injection is made in the groin and that area is anesthetized. Next, the inguinal artery is entered and a very thin tube (catheter) is advanced into the arteries that feed the uterus. After the necessary angio shots are taken, small particles that block the uterus and myoma vessels are given from this tube. After this procedure, which takes about an hour, control shots are taken and the catheter in the groin is taken out. To prevent bleeding, the inguinal artery is manually pressed for 15 minutes and a bandage is applied.
Which particles are used in embolization?
Several types of occlusive particles are used today for fibroid embolization. The most commonly used are polyvinyl alcohol (PVA) particles. These particles are cleared by the body within 1-2 months and the blocked vessels are reopened. Apart from this, some particles with slippery surface (Embosphere, Embozen etc.) are also used in embolization. All of the particles used are materials that have been used in interventional radiology for decades, are harmless to the body and approved by the "Food and Drug Administration" (FDA) in the USA. These particles have no proven superiority to each other. All are safe and effective in fibroid embolization.
What happens to fibroids that die after embolization?
After embolization, fibroids with occluded vessels become bloodless and die completely in a short time. At this time, the body's natural defense system is activated and cells that clean the dead tissues become active. These cells shrink the fibroids by clearing the dead fibroids. This shrinkage is rapid in the first months, then slows down, but continues for up to 5 years. After all, dead fibroids turn into a small remnant, and their harmful effects completely disappear.
How does uterine tissue stay alive while fibroids die in embolization?
Fibroids contain much more vessels than normal uterine tissue. Therefore, most of the arterial blood coming to the uterus is drawn by fibroids, and a small part of it goes to the normal uterine tissue. This situation, which disrupts the nutrition of the normal uterine tissue, provides some benefits in terms of embolization:
The normal uterine tissue, whose nutrition has decreased, begins to produce vessels for itself over time from neighboring organs such as the vagina, tubes and ovaries. These formed vessels are called “collaterals”. The collateral veins are normally quite thin, but when the uterine veins are occluded by embolization, these veins immediately thicken and begin to feed the normal uterine tissue, so that the uterine tissue is not bloodless.
Most of the occlusive particles given during embolization go into the fibroids, and a very small part goes to the normal uterine tissue. Because the dense vascular tissue and increased blood flow in fibroids absorb these particles into the fibroids. In fibroids whose blood vessels are completely occluded, tissue death (necrosis) occurs rapidly since there is no other vessel feeding them. On the other hand, normal uterine tissue is not affected by embolization since its vessels are less occluded and the collateral vessels that feed it are activated.
What are the side effects of fibroid embolization?
Symptoms such as pain, fever, vomiting, and nausea may occur after fibroid embolization. This picture, which usually lasts 3-5 days, is called postembolization syndrome and resolves spontaneously.
After embolization, some patients may temporarily cease menses, which usually resolves after a few months. This condition may be permanent in approximately 5% of patients. In this so-called pseudo-menopause, the patient has not actually entered the menopause because the ovarian hormones are found to be normal. Therefore, typical menopausal complaints such as hot flashes, vaginal dryness, sexual reluctance, and osteoporosis do not occur. The patient cannot menstruate only because the uterine cells that make menstruation are affected. Menstrual bleeding can usually be restarted by using some hormonal drugs in patients who want it.
Fibroids located on the inner surface of the uterus (submucous) can sometimes be spontaneously expelled from the vagina after embolization. This condition, which allows the inner surface of the uterus to heal more quickly, can sometimes cause pain. In a very small part of the patients, a gynecological intervention such as abortion may be required to remove the fibroids.
In less than 1% of patients after embolization, uterine infection may occur and antibiotic treatment may be required under hospital conditions. Large fibroids located adjacent to the inner surface of the uterus may completely die and liquefy after embolization, opening to the inner surface of the uterus and causing a long-term vaginal discharge.
Will I receive radiation in embolization?
The dose of radiation received during the embolization procedure may vary depending on the experience of the physician and is, on average, the dose taken in a large intestine x-ray film or computed tomography examination. However, physicians with sufficient experience can also complete the embolization process with much less radiation dose. Since most of the embolized women are young-middle-aged women of reproductive age and the treated area is the uterus-ovary region, it is very important to keep the amount of radiation received during embolization to a minimum.
Can the particles used in embolization escape into the heart and brain vessels?
During embolization, as the uterine arteries are seen on the angio screen, the occlusive particles are sent to the fibroids in a controlled manner. However, if care is not taken or given with too much pressure, there is a possibility that these particles may escape into the vagina, ovary and leg arteries. However, if the procedure is performed by an experienced physician, this probability is close to zero.
Can the particles used in embolization escape to other vessels?
No. Embolization is a procedure performed below the navel, and it is not physically possible for the occlusive particles to move upward in the opposite direction to the blood flow and reach the heart or brain vessels. This is an ill-intentioned statement to discourage patients from embolization therapy, if not out of ignorance.
In which fibroids is embolization more appropriate?
Embolization is effective on all uterine fibroids, regardless of their number, and this is its most important advantage over myomectomy surgery. In addition, fibroids that are successfully embolized are less likely to recur, whereas small fibroids that remain in the uterus after myomectomy may enlarge and cause re-complaints.
Embolization therapy is effective for fibroids of all sizes. However, fibroids less than 10 cm in diameter have been shown to shrink more after embolization than larger fibroids.
Embolization therapy is effective for fibroids in every layer of the uterus. However, myomectomy should be preferred rather than embolization in subserous or submucous fibroids that are attached to the uterus with a thin neck (with stem).
In which patients is embolization not suitable?
Conditions that prevent embolization are very rare. However, it may be necessary to take some additional precautions in those who are allergic to the contrast material used in angiography, who take blood thinners such as coumadin, and who have kidney failure. In patients with infections of the uterus, ovaries or genital organs, embolization should be performed after the infection has been completely treated. In those using a contraceptive intrauterine device (RIA), removal of the IUD prior to embolization is preferred, but is not an absolute requirement. In patients using drugs that temporarily shrink fibroids by causing menopause, these drugs should be discontinued at least 3 months before embolization. Because these drugs can also shrink the fibroid vessels and prevent the occlusive particles from entering the fibroids sufficiently in embolization.
In terms of the type of fibroids, the overwhelming majority of fibroid patients are actually amenable to embolization therapy. However, myomectomy surgery is very easy and safe, especially in fibroids that grow outward (subserous) and are connected to the uterus with a small stalk, so it should be preferred. In all other fibroid types, patients should be evaluated for embolization by an experienced interventional radiologist.
Can Embolization Be Applied in Those Who Have Had Myomectomy Before?
Yes. Some problems, especially intra-abdominal adhesions (adhesion), may occur in patients who have undergone myomectomy operation for their fibroids before, in subsequent operations. These problems are not relevant for embolization. Therefore, embolization should be the first-line treatment for patients whose fibroids recur despite previous myomectomy.
Can embolization be performed in patients with multiple uterine fibroids?
Yes. Embolization is a method that can treat all uterine fibroids with a single operation. So much so that even fibroids that are not noticed on ultrasound and MRI can die after embolization and become visible on the control MRI. On the other hand, myomectomy is a method based on cutting out the fibroids one by one, and often recurring is seen because not all of the fibroids can be removed. Therefore, the ideal treatment for patients with multiple fibroids is embolization, not myomectomy.
Can embolization be done in giant fibroids?
Fibroids larger than 10 cm are considered unsuitable for embolization. However, in some patients, larger fibroids can also be embolized using special techniques. Our team has many years of extensive experience in the treatment of giant fibroids. Based on our experience, we can say that we can successfully treat fibroids up to 20 cm in some patients using some techniques.
Can I get pregnant after embolization?
Yes. In the early years of embolization, there was a widespread assumption that it was unsuitable for those seeking pregnancy. However, over the years, it has been observed that thousands of women can become pregnant and give birth healthy after embolization. Our team has also witnessed that many of our patients gave healthy births after myoma embolization, which we have been performing since 2003. Studies conducted in recent years have shown that more than half of women who want to get pregnant after embolization can become pregnant by normal means. However, it should be kept in mind that pregnancy is also dependent on many other factors, and conception can never be guaranteed, whether embolization or myomectomy.
Can myoma recur after embolization?
Yes, it can recur, but the probability of recurrence is much lower than in myomectomy surgery. In one study, it was shown that approximately 60% of fibroids recur after myomectomy, while this rate is approximately 8% after embolization. The reason for this is that the particles given in embolization are effective on fibroids all over the uterus and can generally kill all fibroids, whereas in myomectomy, each fibroid must be removed with a separate incision, and as a result, some of the fibroids cannot be treated.
Is Myoma Embolization painful?
The embolization process itself is not painful. Before the procedure, a numbing needle is made in the groin (like dentists do for the tooth) and the whole procedure is performed through a 2 mm hole in the groin. No general anesthesia or waist numbing is required. After the procedure, pain may begin as the uterus tries to expel the deceased fibroids like a foreign body. The pain may be more for the first two days, then it gradually disappears. After embolization, the patient stays in the hospital for an average of 2 days. During this period, painkillers are administered. Apart from pain, nausea, vomiting, fatigue, mild fever, and a pinkish vaginal discharge may also occur after embolization. However, all patients are able to walk, eat and bathe the next day and can be discharged from the hospital 2-3 days later.
With a simple injection called "superior hypogastric nerve blockade" during fibroid embolization, the pain that occurs especially on the first day after the procedure can be eliminated to a great extent. Our team has been using this method in every patient for about 6 years. This method, which relieves pain only on the first day, has been further developed by our team and modified to reduce the patient's pain in the following days. In this way, it is possible to say that our patients feel much less pain after embolization.
If embolization is such a good treatment, why don't other doctors recommend it?
There are several reasons for this situation. Interventional radiology is a new and rapidly developing field, and the therapeutic procedures in interventional radiology are not sufficiently recognized not only by patients but also by most of the doctors. Fibroid embolization is a treatment method that is not known enough or known incorrectly by a significant part of physicians other than interventional radiology. For this reason, most of myoma patients cannot reach interventional radiologists for this treatment method. Another important reason is the low number of interventional radiologists all over the world, but especially in our country. While the number of interventional radiologists in the USA is over 5,000, this number is around 300 in our country, and very few of them deal with myoma embolization. A very small part of those who are interested have sufficient experience.
However, these problems are improving over time. Fibroid embolization is being recognized and adopted more and more by physicians and patients. With the increase in the number of experienced interventional radiologists who are interested in and apply this treatment method, more patients will be able to benefit from embolization treatment in our country over time.