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Uterine Fibroid Embolization Community Health Talk

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Presentation on uterine fibroid embolization, a minimally invasive nonsurgical treatment for fibroids.
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Uterine Fibroid Embolization Community Health Talk

  1. 1. Dr. Arun Jagannathan Dr. Jeffery Mendell Vascular and Interventional Radiology Central Illinois Radiological Associates, Ltd.
  2. 2. What is an Interventional Radiologist (IR)? <ul><li>Physician who specializes in minimally invasive image guided procedures </li></ul><ul><li>Training </li></ul><ul><ul><li>Undergraduate (4 yrs) </li></ul></ul><ul><ul><li>Medical School (4 yrs) </li></ul></ul><ul><ul><li>Radiology Residency (5 yrs) </li></ul></ul><ul><ul><li>Interventional Fellowship (1 yr) </li></ul></ul>
  3. 3. What else do we treat? <ul><li>Female Chronic Pelvic Pain (Pelvic Congestion Syndrome) </li></ul>
  4. 4. What are Uterine Fibroids? <ul><li>Benign tumors of uterine smooth muscle </li></ul><ul><li>Not considered pre-cancerous </li></ul><ul><li>Also known as myomas or leiomyomas </li></ul>
  5. 5. How Common are Fibroids? <ul><li>Estimated 50% or greater of all women eventually develop fibroids </li></ul><ul><li>Most common tumor of the pelvis in females </li></ul><ul><li>A minority, 20 to 30% of these women are symptomatic </li></ul><ul><li>Most frequently symptomatic ages 30s & 40s </li></ul>
  6. 6. What Causes Fibroids? <ul><li>Exact cause currently unknown </li></ul><ul><li>Fibroid growth hormonally linked (estrogen and progesterone) </li></ul><ul><li>Likely a genetic predisposition </li></ul><ul><li>More commonly symptomatic in African American women (up to 3 times) and can tend to occur at earlier ages, grow more quickly, and result in more symptoms </li></ul>
  7. 7. What Symptoms Occur with Uterine Fibroids? <ul><li>Bleeding Related </li></ul><ul><ul><li>Heavier prolonged menstrual bleeding, sometimes with passage of clots. Anemia can occur if blood loss is severe, resulting in fatigue. </li></ul></ul><ul><ul><li>Pain during or bleeding after intercourse </li></ul></ul>
  8. 8. What Symptoms Occur with Uterine Fibroids <ul><li>Mass related </li></ul><ul><ul><li>Pain, pressure, or fullness in the pelvis, abdomen, or lower back </li></ul></ul><ul><ul><li>Frequent urination or constipation </li></ul></ul><ul><ul><li>Infertility or miscarriage </li></ul></ul><ul><ul><li>Abnormally enlarged abdomen </li></ul></ul>
  9. 9. Types of Fibroids
  10. 11. How are they diagnosed? <ul><li>Usually initially detected during a gynecologic examination (if they are large enough) </li></ul>
  11. 12. How are they diagnosed? <ul><li>Presence most often confirmed and incidentally detected by pelvic ultrasound </li></ul><ul><ul><li>Ultrasound is not ideal in differentiating fibroids from other conditions such as adenomyosis, ovarian cysts or ovarian masses </li></ul></ul>
  12. 13. How are they diagnosed? <ul><li>Hysteroscopy can detect submucosal fibroids </li></ul>
  13. 14. MRI Evaluation – The Gold Standard <ul><li>Far superior to physical examination or even ultrasound </li></ul><ul><li>Demonstrates exact location and blood supply of the fibroids </li></ul><ul><li>Aids in differentiating from cancerous tumors (leiomyosarcoma) and other conditions such as ovarian tumors or cysts and adenomyosis </li></ul>
  14. 16. How are Fibroids Treated? <ul><li>Most fibroids do not cause symptoms and are not treated </li></ul><ul><li>When symptomatic, medical therapy is the first step </li></ul><ul><ul><li>Oral contraceptive pills or other hormonal therapy </li></ul></ul><ul><ul><li>Non-steroidal anti-inflammatory drugs such as ibuprofen or naproxen </li></ul></ul>
  15. 17. How are Fibroids Treated? <ul><li>In many patients, symptoms are controlled with medication and no other therapy is required </li></ul><ul><li>Some hormone therapies have side effects and other risks when used long-term so they are generally used temporarily </li></ul><ul><li>Fibroids often grow back after therapy is discontinued </li></ul>
  16. 18. How are Fibroids Treated? <ul><li>LUPRON </li></ul><ul><ul><li>GnRH agonist, blocks ovarian estrogen production </li></ul></ul><ul><ul><li>Advantages: noninvasive, shrinks fibroids, often improves symptoms </li></ul></ul><ul><ul><li>Disadvantages: may induce premature menopause, fibroids usually return to original size after therapy is stopped, sometimes side effects may limit duration of therapy </li></ul></ul>
  17. 19. How are Fibroids Treated? <ul><li>Invasive therapies are the next step </li></ul><ul><ul><li>Endometrial ablation </li></ul></ul><ul><ul><li>Myomectomy </li></ul></ul><ul><ul><li>High Frequency U/S </li></ul></ul><ul><ul><li>UFE </li></ul></ul><ul><ul><li>Hysterectomy </li></ul></ul>
  18. 20. Endometrial Ablation <ul><li>The lining of the uterus is removed or destroyed to control heavy bleeding, can be done with laser, wire loops, boiling water, electric current, microwave, freezing, and other methods </li></ul><ul><li>Can be done outpatient, complications are uncommon </li></ul><ul><li>Recovery is mild, fairly effective in controlling bleeding </li></ul>
  19. 21. Endometrial Ablation <ul><li>Advantages </li></ul><ul><ul><li>Can effectively control bleeding </li></ul></ul><ul><ul><li>Preserves uterus </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Does not treat fibroids, just bleeding symptoms </li></ul></ul><ul><ul><li>Will not treat symptoms from fibroid size </li></ul></ul><ul><ul><li>Bleeding may recur requiring more procedures </li></ul></ul>
  20. 22. Myomectomy <ul><li>Individual fibroids are removed through an abdominal incision or sometimes with a laparoscope or hysteroscope </li></ul>
  21. 23. Myomectomy <ul><li>Advantages: Can preserve fertility, well established, less invasive if done by laparoscopy or hysteroscopy </li></ul><ul><li>Disadvantages: Same potential surgical complications as hysterectomy, not all fibroids treated at one time, 15-25% require additional procedure (usually hysterectomy), adhesions can lead to infertility or bowel obstructions </li></ul>
  22. 24. High Intensity Focused Ultrasound <ul><li>Precise MRI guided procedure using ultrasound to heat and destroy fibroids </li></ul>
  23. 25. High Intensity Focused Ultrasound <ul><li>Advantages: No incision, one to two day recovery with minimal discomfort, preserves uterus </li></ul><ul><li>Disadvantages: Procedure can take several hours. Usually only appropriate for small fibroids near surface. Insurance may not cover. Fibroids may recur. </li></ul>
  24. 26. Hysterectomy <ul><li>Surgical removal of uterus and fibroids, performed through abdominal incision or vaginally, sometimes with a laparoscope </li></ul><ul><li>Advantages: 100% curative, well established procedure. </li></ul>
  25. 27. Hysterectomy <ul><li>Disadvantages </li></ul><ul><ul><li>Major surgery with potential complications </li></ul></ul><ul><ul><li>General anesthesia </li></ul></ul><ul><ul><li>2 days to 6 weeks recovery </li></ul></ul><ul><ul><li>Hormonal changes if ovaries removed </li></ul></ul><ul><ul><li>Emotional </li></ul></ul><ul><ul><li>Sexual </li></ul></ul>
  26. 28. Hysterectomy <ul><li>Over 600,000 performed a year compared to 40,000 myomectomies and 25,000 UFEs </li></ul><ul><li>2 nd most frequent surgical procedure </li></ul><ul><li>90% for benign reasons </li></ul><ul><li>35% for fibroids </li></ul><ul><li>20% of all women by age 40 </li></ul><ul><li>33% of all women by age 65 </li></ul>
  27. 29. Why not have a hysterectomy? <ul><li>Patient Reasons </li></ul><ul><ul><li>Avoid surgical adverse events </li></ul></ul><ul><ul><li>Pelvic support issues </li></ul></ul><ul><ul><li>Bladder dysfunction </li></ul></ul><ul><ul><li>Menopause and HRT </li></ul></ul><ul><ul><li>Hospitalization, recover time </li></ul></ul><ul><ul><li>Sexual dysfunction </li></ul></ul><ul><ul><li>Loss of source of femininity, fertility, self and sexual image </li></ul></ul>
  28. 30. Uterine Fibroid Embolization <ul><li>Minimally invasive image guided procedure </li></ul><ul><li>The IR physician makes a small nick in the groin and inserts a catheter into the femoral artery and directs it using real-time x-ray guidance into the uterine arteries on both sides </li></ul>
  29. 32. <ul><li>Tiny plastic particles the size of grains of sand are then injected into the artery supplying the uterus and the fibroids, cutting off their blood supply </li></ul>
  30. 33. Where is it performed? <ul><li>RMC Angiography Suite, a multimillion dollar operating room containing advanced imaging technologies </li></ul>
  31. 34. Sedation Options <ul><li>Conscious IV sedation provided by radiology RN </li></ul><ul><li>Epidural or Spinal Anesthesia provided by Anesthesiologist </li></ul><ul><li>Continuous monitoring of EKG, blood pressure, heart rate, respirations, and oxygenation </li></ul>
  32. 35. How long does it take? <ul><li>Procedure lasts about one hour </li></ul><ul><li>Overnight stay with >95% of patients discharged next day </li></ul>
  33. 36. What to expect afterwards? <ul><li>Cramping, pelvic pain, and nausea are common and related to cutting off the fibroid blood supply – generally well controlled with medications </li></ul><ul><li>Vaginal discharge </li></ul><ul><li>Low grade fever, fatigue, and muscle aches for a few days (similar to a mild flu) </li></ul><ul><li>Most women resume light activities in a few days and return to work in one week </li></ul>
  34. 37. How well does it work? <ul><li>Bleeding related symptoms resolve or are significantly improved in >85% of patients </li></ul><ul><li>Mass related symptoms resolve or are significantly improved in >70% of patients </li></ul><ul><li>Procedure is effective for multiple fibroids </li></ul><ul><li>Recurrence requiring repeat UFE is rare (less than 5%) </li></ul>
  35. 38. Follow-up Care <ul><li>Clinic visit 1-2 weeks after procedure, then again at 4 weeks, 3 months, 6 months, and 1 year </li></ul><ul><li>MRI at 6 months and 1 year to assess effect of procedure and measure the fibroids </li></ul>
  36. 39. Common Questions <ul><li>Will I retain my fertility? </li></ul><ul><ul><li>Prospective studies are lacking, retrospective studies have shown no significant impact on younger women, but in older women (late 30s, early 40s) there is a greater chance of premature menopause </li></ul></ul><ul><ul><li>Given current research, if a woman desires more children, we do not recommend or perform UFE </li></ul></ul>
  37. 40. Common Questions <ul><li>Are the particles safe? Are they inside me permanently? </li></ul><ul><ul><li>Yes, and yes. They preferentially lodge in the small blood vessels supplying the fibroid, therefore the normal uterine tissue does not die. </li></ul></ul><ul><ul><li>They have been FDA approved for over 20 years and no complications have resulted from their use. </li></ul></ul>
  38. 41. What are potential complications? <ul><li>Bleeding and infection, both occur infrequently (less than 3% of the time) and are less common than with myomectomy or hysterectomy </li></ul>
  39. 42. UFE <ul><li>Advantages </li></ul><ul><ul><li>Treats all fibroids at once </li></ul></ul><ul><ul><li>Minimally invasive, infrequent complications </li></ul></ul><ul><ul><li>Recurrence of symptoms rare </li></ul></ul><ul><ul><li>Shorter recovery than surgery </li></ul></ul><ul><ul><li>No adhesion (scar) formation </li></ul></ul><ul><ul><li>Minimal blood loss, no need for transfusion </li></ul></ul><ul><ul><li>Epidural or conscious sedation vs. general anesthesia for surgery </li></ul></ul><ul><ul><li>Emotional/physical/sexual advantages of retaining the uterus </li></ul></ul>
  40. 43. UFE <ul><li>Disadvantages </li></ul><ul><ul><li>10-15% do not respond despite technical success </li></ul></ul><ul><ul><li>Up to 2% of procedures technically unsuccessful (usually due to difficult vessel anatomy) </li></ul></ul><ul><ul><li>Pelvic pain or cramping after procedure can remain moderate to severe for several days </li></ul></ul><ul><ul><li>1% chance of serious complication requiring hysterectomy </li></ul></ul>
  41. 44. Take Home Points <ul><li>Fibroids are a common problem and often cause significant pain and suffering in many women </li></ul><ul><li>Variety of treatment options, from over the counter medication all the way up to hysterectomy </li></ul><ul><li>Know ALL your options before you make a decision about your health </li></ul>
  42. 45. Take Home Points <ul><li>Every physician that treats you, regardless of disease process, should inform you of all viable treatment options, regardless of whether they perform them or not (if they don’t know they should refer you to another specialist who does) </li></ul>
  43. 46. Take Home Points <ul><li>UFE is a safe and effective alternative to more invasive surgeries for treatment of fibroid related symptoms </li></ul><ul><li>The American College of Obstetrics and Gynecology  Practice Bulletin of August 2008 states that there is &quot;Level A&quot; evidence [scientifically solid proof] that &quot;based on long and short-term outcomes,  uterine artery embolization [UFE] is a safe and effective option  for appropriately selected women who wish to retain their uteri. </li></ul>
  44. 48. What else do we treat? <ul><li>Female Chronic Pelvic Pain (Pelvic Congestion Syndrome or PCS) </li></ul><ul><ul><li>Also known as pelvic varicose veins </li></ul></ul><ul><ul><li>Up to 15% of women between 20 and 50 have this disease, though not all have symptoms </li></ul></ul><ul><ul><li>Diagnosis often missed as the veins are often deep in the pelvis </li></ul></ul>
  45. 49. PCS <ul><li>Pelvic Congestion Syndrome (PCS) </li></ul><ul><ul><li>Ovarian veins increase in size w/ pregnancies </li></ul></ul><ul><ul><li>30% women with chronic pelvic pain have PCS alone and another 15% have PCS and another pelvic problem (such as fibroids) </li></ul></ul><ul><ul><li>Symptoms </li></ul></ul><ul><ul><ul><li>Dull aching lower abdomen and lower back pain which is worse… </li></ul></ul></ul><ul><ul><ul><ul><li>Following intercourse </li></ul></ul></ul></ul><ul><ul><ul><ul><li>During periods </li></ul></ul></ul></ul><ul><ul><ul><ul><li>When tired or standing for long periods </li></ul></ul></ul></ul><ul><ul><ul><ul><li>During pregnancy </li></ul></ul></ul></ul>
  46. 50. PCS <ul><ul><li>Other Symptoms </li></ul></ul><ul><ul><ul><li>Irritable bladder </li></ul></ul></ul><ul><ul><ul><li>Abnormal menstrual bleeding </li></ul></ul></ul><ul><ul><ul><li>Vaginal discharge </li></ul></ul></ul><ul><ul><ul><li>Varicose veins on vulva, buttocks or thigh </li></ul></ul></ul>
  47. 51. PCS <ul><li>Diagnosis </li></ul><ul><ul><li>Pelvic venogram – gold standard </li></ul></ul><ul><ul><li>MRI/MRV – best noninvasive </li></ul></ul><ul><ul><li>Ultrasound – Usually not helpful unless done standing, but performed to exclude other problems </li></ul></ul>
  48. 52. PCS MRV
  49. 53. PCS Treatment <ul><li>Hysterectomy </li></ul><ul><li>Surgical vein ligation </li></ul><ul><li>Minimally invasive ovarian vein embolization </li></ul>
  50. 54. What else do we treat? <ul><li>Peripheral Venous Disease </li></ul><ul><ul><li>Treatment of Deep Vein Thrombosis (DVT) </li></ul></ul><ul><ul><li>Treatment of Varicose Veins </li></ul></ul>
  51. 55. What else do we treat? <ul><li>Peripheral Arterial Disease </li></ul><ul><ul><li>Angioplasty/Stenting </li></ul></ul><ul><ul><li>Abdominal Aortic Aneurysm </li></ul></ul>
  52. 56. What else do we treat? <ul><li>Pulmonary Embolism </li></ul>
  53. 57. What else do we treat? <ul><li>Acute Stroke </li></ul><ul><ul><li>Catheter directed clot removal or dissolution </li></ul></ul>
  54. 58. What else do we treat? <ul><li>Cancer </li></ul><ul><ul><li>CT Guided Ablation (destruction) of kidney, liver, and bone tumors </li></ul></ul><ul><ul><li>Catheter directed embolization of liver tumors with chemotherapy </li></ul></ul>
  55. 59. What else do we treat? <ul><li>Osteoporotic Spinal and Pelvic Fractures </li></ul><ul><ul><li>Kyphoplasty/Sacroplasty </li></ul></ul>