Prof Saim Yılmaz, MD
"All patients who are recommended histerectomy should be evaluated for the possibility of embolization"
Treatment Options in fibroids
In patients with fibroids, treatment is not necessary if the fibroids do not grow, the patient's age is close to menopause and the fibroids do not cause any complaints. However, most of the patients have complaints such as pain, frequent urination, increased menstrual bleeding and anemia and thus, require treatment. In some patients, fibroid enlargement can be seen on intermittent ultrasounds or MRIs. In these patients, even if there is no complaint yet, treatment may be required since the growing myomas will eventually lead to some problems. The age of the patient is also important in the treatment decision. Young patients are more likely to have fibroids that grow and cause problems in the future, so younger patients are treated more often. On the other hand, in a patient close to menopause, if the fibroids do not grow and do not cause any complaints, the patient may prefer not to be treated. All of these factors should be considered when making a treatment decision for fibroids. The following options are currently available for patients whose treatment decision is made:
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In this treatment, the patient is given medications called GnRH agonists, which cause menopause and lower the estrogen level. Thus, shrinkage of the fibroids and thinning of the vessels feeding the fibroid can be observed, and patient complaints may decrease accordingly. However, this improvement is not permanent. When hormone therapy is discontinued, the fibroids grow rapidly and their vessels quickly come back. In addition, if these drugs are used for a long time, the patient may experience osteoporosis (bone loss) and severe menopause symptoms. Therefore, hormone drugs cannot be used for permanent treatment of fibroids. However, it can be used to provide short-term healing in patients who reject other treatment options and to make fibroids bleed less during myomectomy surgery.
Myomectomy is the surgical removal of uterine fibroids one by one under general anesthesia. In this way, fibroids can be treated without removing the uterus, and fertility potential can be preserved, especially in young women. Myomectomy is usually performed as open surgery on the abdomen, but can also be performed laparoscopically or hysteroscopically. Myomectomy may be an appropriate treatment method if one or several superficial fibroids are detected in the uterus on MRI examination. However, as the number of fibroids increases, the surgery becomes more difficult, the risks increase, and the results become less satisfactory.
In hysterectomy, the entire uterus is surgically removed under general anesthesia. If the patient is over 40 years old, it is generally preferred to have the ovaries also removed. Hysterectomy is generally applied in patients with multiple fibroids, menopause, or patients who no longer want to be pregnant at all. It is a radical treatment method, since the uterus is removed, all fibroids are treated, and the risk of uterine and ovarian cancer (if the ovaries are also removed) is eliminated. Hormones secreted from the ovaries are given to the patient as a medication after surgery (hormone replacement therapy). Although hysterectomy is not desired by most patients, it is the mostly applied treatment method for uterine fibroids today. In the United States, 650,000 hysterectomies are performed each year, of which about 90% are performed for "benign" diseases such as fibroids. However, the accuracy of this approach has recently been seriously questioned. In many studies, the risk of coronary heart disease, osteoporosis (bone loss), early dementia and depression were found to be higher in patients with hysterectomy. In addition, after hysterectomy, a number of problems that reduce the quality of life such as constipation, urinary incontinence, psychosexual problems and "severe menopause" may occur. For these reasons, hysterectomy is currently accepted as a method that should be considered last resort in patients with fibroids who that cannot be treated with other methods such as embolization and myomectomy.
HIFU (High Intensity Focused Ultrasound)
HIFU (High Intensity Focused Ultrasound) is the process of focusing high-intensity ultrasound waves on the desired tissue with a lens. The treatment is done under MRI or ultrasound guidance and the target tissue is heated with the high temperature generated. HIFU is a method that has been increasingly used in cancer treatment in the last 10 years. With this method, studies are mostly conducted on prostate, pancreatic cancer, bone and soft tissue tumors. However, it has not yet been clearly demonstrated to what extent the method is successful in which tumor types. Also, comparative studies with other proven treatment modalities are scarce. The method has also been used in uterine fibroids, with promising results. The most important advantage of the HIFU is that it provides treatment without any incision in the skin and the hospital stay is short. However, the method also has some disadvantages and limitations. For HIFU, ultrasound waves must be able to reach the tumor from the skin without any obstruction. However, bone tissue and organs filled with air (lung, stomach, intestine, etc.) block ultrasound waves. Therefore, if there are such tissues or organs between the skin and the tumor tissue, HIFU cannot be applied. In addition, while the tumor is burned during the procedure, heating occurs also in the tissues next to the tumor. This may cause leg pain, skin burns or hardening of the subcutaneous fat tissue as well as nerve damage in some patients.
In HIFU, the tumor is displayed real time on the ultrasound or MRI screen, and the focal point of the ultrasound waves is constantly shifted within the tumor, trying to burn every part of the tumor. This is a time consuming process. Especially if it is done under the guidance of MRI, the cost increases as the normally very busy MRI devices have to be reserved for this process for a long time. The larger the number and diameter of the tumor, the longer and more costly the HIFU is. For this reason, HIFU may be a good option in patients with a single or several fibroids that are not very large in diameter in the uterus, especially if the fibroids are located close to the skin. HIFU application is not practical in other patient groups. In addition, for HIFU, the fibroid must be visible on ultrasound or MRI. It will not have any benefit on small fibroids that cannot be seen with these methods. Studies have shown that HIFU can be applied in only about 25% of myoma patients, and that it is not a suitable option for the remaining patients.
HIFU is a method with few side effects and complications. However, there are some question marks about its long-term effectiveness in fibroids. This is because it is difficult to burn all of the fibroids at once with this method. Therefore, HIFU may need to be done several times in order to completely kill the fibroid. Fibroids that are not completely treated can grow back and cause problems. In a study comparing HIFU with percutaneous radiofrequency ablation, it was found that the rate of complete ablation of fibroids was lower with HIFU (Meng X et al, CVIR 2010). In another study, it has been shown that secondary treatments are more frequently needed in patients who underwent HIFU (Froeling et al, CVIR 2013) compared to embolization and ablation.
Percutaneous ablation is the process of destroying tumors in the body with a special needle placed into the tumor under ultrasound or CT guidance. For this, methods that heat the tumor such as radiofrequency and microwave or freeze the tumor such as cryoablation can be used. In the literature, there are studies on the use of all three methods in the treatment of uterine fibroids. Percutaneous ablation is a proven method that has been used in cancer treatment for years. However, during ablation, the needle must be inserted through the skin or through the vagina and placed in the middle of the fibroid. For this, just like in HIFU, the fibroid should be easily visible on ultrasound, be superficially located, and be few in number. In addition, it is thought that percutaneous ablation is not effective enough in tumors larger than 5 cm, and it may be risky in tumors close to the inner surface of the uterus (endometrium).
Embolization (UFE) is the most commonly applied nonsurgical treatment for uterine fibroids. In embolization, a thin catheter is inserted through the groin into the arteries feeding the fibroids and these feeders are occluded by injecting very small particles. Fibroids with occluded vessels cannot survive because they deprive of blood. The dead fibroids become smaller by time as a result of tissue death and their complaints such as pain and bleeding disappear or decrease significantly. In contrast, normal uterine tissue is not affected by the embolization process as it continues to be supplied from other vessels in the abdomen. Therefore, with a single procedure, all the fibroids may be dead while the normal uterine tissue is preserved. This is one of the biggest advantages of embolization over other treatment options and may explain why the risk of recurrence is so low after embolization.
Embolization is a method used more and more frequently in the treatment of uterine fibroids, especially in the 2000s. The most important advantages are that it is performed with an "angio" procedure with local anesthesia, there is no surgical incision and most patients can leave the hospital the next day. The superiority of this method over hysterectomy is the preservation of the uterus, and over myomectomy is its ability to treat all the uterine fibroids with one session without any surgical incision and suturing. However, like any treatment, embolization therapy is successful only when applied to "correctly selected" patients, and an experienced interventional radiologist should always be consulted for the feasibility of treatment.
Video: How is uterine fibroid embolization is performed