Uterine Fibroids & Pelvic Congestion Syndrome

Additional Info

• Audio File:uab/ua047.mp3
• Doctors:Oser, Rachel
• Featured Speaker:Rachel Oser, MD
• CME Series:Clinical Skill
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4382
• Guest Bio:Rachel Oser, MD is an Associate Professor, Department of Radiology with UAB Medicine.
  
  Learn more about Rachel Oser, MD 
  
  Release Date: November 17, 2017
  Reissue Date: November 18, 2020
  Expiration Date: November 18, 2023
  
  Disclosure Information:
  
  Planners:
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no commercial affiliations to disclose.
  
  Faculty:
  Rachel F. Oser, MD
  Associate Professor in Radiology, UAB
  
  Dr. Oser has no financial relationships related to the content of this activity to disclose.
  
  There is no commercial support for this activity.
• Transcription:Melanie Cole (Host): Uterine fibroids are the most common benign tumors in women of childbearing age. Many women with uterine fibroids have no symptoms. However, fibroids can cause a number of symptoms depending on their size, location within the uterus and how close there are to adjacent pelvic organs. My guest today is Dr. Rachel Oser. She's an associate professor in the department of radiology at UAB Medicine. Welcome to the show. What are fibroids and is it inevitable that most women will get them?
  
  Dr. Rachel Oser, MD (Guest): As you said in your introduction, which was very nicely said, they're a benign tumor. They are an abnormal growth that occurs in women uteruses, but they are benign, which means that they are not cancer and they typically do not turn into cancer. The most common tumor in women uteruses in about 50% of African American women, maybe 30% of other women, tend to develop fibroids during the course of their lifetime. It's an extremely common problem. It can run in families but often it does not, and they are in fact the number one cause for hysterectomy in the country right now. It's extremely common, they're found in all different groups of women, not cancer but can cause symptoms, which need to be treated because they could bother people and limit their lifestyles.
  
  Melanie: Do we know how or why uterine fibroids develop? You mentioned just a bit about genetic contributions, so speak a little bit about the etiology.
  
  Dr. Oser: Right now, we don't really know why women develop fibroids. There's a lot of research on that right now. There's a lot of research going into medications and other treatments, but currently, there aren't any good long-term treatments for women with fibroids that are not either surgical or interventional radiology based. What happens is that as the tumors grow, they can cause several different problems. In women who are of childbearing years, if they're adjacent especially to the cavity of the uterus, they can distort that cavity and they can cause problems with pregnancy that could include difficulty getting pregnant and can include difficulty carrying the pregnancy to term, so repeated early miscarriages, and also they can cause problems with delivery. If you have large fibroids, sometimes it can make deliveries more complicated and cause a required C section.  
  
  They also can cause problems with heavy periods. Sometimes women will have almost continuous periods, passing blood clots, extremely heavy cycles, things like that. They can also be associated if they're very large with mass symptoms. If you think about it, when you're uterus gets big, if you're pregnant for example, you have to pee all the time. You have to urinate frequently. You can have issues with constipation, you can have abdominal pain, you can have nausea on a full stomach, and all of these symptoms can be associated with fibroids if they become extremely large. They can range in size from small enough that you would never really feel them unless you're doing a pelvic exam to big enough that women can look like their eight or nine months pregnant. The symptoms can be related to where they are and to where the size of the fibroids are. Because they're benign, they don’t need to be treated unless they are in fact causing you symptoms, and that’s when women will typically come to either their gynecologist or to the interventional radiologist for their treatment options for the fibroid tumors.
  
  Melanie: Let’s speak about some of those treatment options. What's available to women if these fibroids are causing symptoms? As you said, they don’t necessarily need treatment, but if these symptoms are affecting the quality of a woman’s life or her ability to get pregnant or very heavy periods, what are some treatment options you might recommend?
  
  Dr. Oser: One of the main treatment options, and the one that has been around the longest, is going to be a surgical option. Typically, there are two different ways that this can go. One of them is called a myomectomy and that is where you just remove the myoma, or the fibroid, so they actually do an open surgical procedure or sometimes laparoscopic or robotic assistance, and they can go in and try to remove the fibroid itself and leave the remainder of the uterus intact. That is also very effective if it's a solitary fibroid or if they're smaller fibroids, in women who are in childbearing years who really want to preserve fertility; that's often what gynecologists will suggest first. That has been fairly well studied and can be effective. The problem with it is that these fibroids tend to occur over the life of the woman, so even if you've had a myomectomy at a younger age, you could expect that later on in your life you will develop subsequent fibroids that might need treatment.
  
  The ultimate treatment for fibroids is to do a hysterectomy where the uterus is entirely removed. The advantage to that is that once your uterus is gone, you are never going to have problems with your fibroids again. But for many women, that’s a very invasive option. There are many complications that can be associated with hysterectomy that women want to avoid, and obviously, if you're at all interested in preserving fertility, having a hysterectomy means that’s no longer an option for you, even with assistance. The newer option for treating uterine fibroids is uterine artery embolization and that's the procedure that I do. What this is, is a catheter-based procedure. We put a catheter in your artery just like when they do a heart cath to treat blockages in the heart, except instead of looking at the arteries that go into the heart, we're looking at the arteries going to the uterus. We actually get a little catheter all the way out to the uterus in these arteries. It’s a very small diagnostic catheter about the size of a piece of angel hair pasta that we can get way out there, and we put in small particles that block off the blood supply to the fibroid tumors in the uterus. Once they lose their blood supply, the tumors start to die and they shrink and scar down. They're not being removed entirely, but because we cut off their blood supply and they shrink and scar down, you can get extremely good resolution in the symptoms.
  
  The advantage of this procedure is that it is minimally invasive. We do it through a little nick in your groin, probably a quarter-inch incision in your groin, just like a heart cath that you might have heard about, you end up with a Band-Aid when we're done instead of a big incision, and people can return to work within one to two weeks as opposed to an open surgery where you may be out for four to six weeks. It's much less debilitating and the results are extremely good. When we talk about treating the main symptoms that we see with fibroids like heavy bleeding, over 95% of women in large studies have a resolution of their symptoms after fibroid embolization.
  
  Melanie: Have you been able to evaluate the long-term outcome of the uterine artery embolization as opposed to a surgical treatment?
  
  Dr. Oser: The uterine artery embolization is a newer therapy. It has been around in live use since the early 2000s. There are tens of thousands of women in this country who have had uterine artery embolization and long-term people seem to do very well. They have good resolution of their symptoms, there is a lower recurrence rate than there is after a myomectomy, although it is not zero. Most people who present with symptomatic fibroids tend to be by the time they become really symptomatic in their 40s and 50s anyhow. At that point, you're looking at maybe 10 to 15 years until menopause at which point those symptoms are going to resolve. Many of these women who have this procedure can have a minimally invasive procedure, resolution of their symptoms and then they don’t really see a recurrence because by the time you might be starting to see some recurrence, they're already heading into menopause.
  
  In younger women, we've also seen good results. It is possible to have a successful pregnancy after a fibroid embolization, although there isn't good data on what the percentage is. There's better data for a myomectomy on that. However, I know in my practice, I've had several women who've had successful pregnancies post uterine artery embolization. Those women tend to get good symptom relief and there is a small recurrence rate of fibroids as they age, but once again, overall it's lower than it is with a myomectomy.
  
  Melanie: Are there any contraindications for the institution of it?
  
  Dr. Oser: Typically for fibroid embolization, we prefer to not do it when individual fibroids are larger than about 12 centimeters or when your uterus is bigger than about a six-month pregnancy. The reason for that is that we are not removing the fibroids entirely as they do with surgery and it takes a while for that shrinkage to occur, and they never totally go away like they do if you scoop them out surgically. If you have an extremely large fibroid or a very large uterus because of multiple fibroids, although we will probably get good relief of some of your symptoms and the uterus will shrink, it’s not going to go back to normal. If your symptoms are mainly related to the size of the fibroids or the size of your uterus, it may be that in that case surgery is a better option. We have, however, women who really don’t want to have a surgical procedure, and as long as we all understand what the results are going to be or likely to be, I'm fine. We have embolized those women and they’ve had good results with it.
  
  Melanie: What about medicational management? As you mentioned, some women don’t want to have a procedure. Is there some medicational management that can be used in this case?
  
  Dr. Oser: Some of the symptoms can sometimes be managed by things like oral contraceptives with good results. Sometimes women can be treated with hormone suppression therapy to try to shrink the fibroids themselves. The problem with that is that the hormonal therapies have side effects and they tend to be temporary, so once you stop the medications, they fibroids are still there and your symptoms are going to return. They're not a therapy that you can take for six weeks and you're better; it’s something that is going to be more of a lifelong issue.
  
  Melanie: Are there any current studies you'd like to discuss for other physicians that might make them more aware of the situation?
  
  Dr. Oser: Uterine artery embolization at this point is really an accepted practice. In fact, the American College of Obstetricians and Gynecology considers it a level one evidence-based treatment for uterine fibroids. The studies that are going on right now are things looking more like long-term outcomes, pregnancy after uterine artery embolization things like that. Overall, the therapy has become fairly well accepted in practice of literature. It still is not as widely available in the community as we would like to see. Certainly, I don’t think it’s a replacement entirely for surgical options depending on the patient, but I really do think that something that I wish people would think of it and talk to their patients about as a potential option going forward. I think it really is nice to provide our patients with all the possible options.
  
  Melanie: In summary, tell other physicians what you'd like them to know about uterine fibroids and when to refer to a specialist.
  
  Dr. Oser: I think what I would say about uterine fibroids for other physicians is to know that there are nonsurgical options that are available. They're available in your community. I know that at UAB, we have an interventional radiology clinic that you can refer symptomatic patients to, and what we do when that happens is we sit down with them, we get an MRI to image their uterus and that gives us a really good idea of how many and the size of the fibroids they have, what kind of blood supply they have, and if they're a good candidate for the procedure. We then sit down with the patient and go over their potential treatment options, we show them their images, and we just give them the information. Many of the women I talk to go on to have a uterine artery embolization, some of them prefer a more definitive therapy and some of them are not good candidates for our procedure, but we’d really like to have that chance to inform the patient and let them be a partner in their medical care. Any symptomatic fibroid patient is a candidate to at least find out about what her options are.
  
  Melanie: Tell us about your team. Why is UAB so great to work with?
  
  Dr. Oser: We have a fantastic team here. All of our physicians who perform this procedure have trained in interventional radiology. Most of us have added certification in it and the ones who don’t have been doing it for over 30 years and have specialty training as well. We have a team of physicians, dedicated nurses, technologists, a physician assistant who all work with us to streamline our patient care. The clinic setting is great for talking to patients, letting them know what their options are, and then we do their procedure in the hospital. We work really hard to get good pain control after the procedure and most of the patients have been extremely happy with their care. I think we bring a lot of expertise of a diverse team of professionals to taking care of our patients in a really high tech environment that is unique in central Alabama.
  
  Melanie: Thank you so much for being with us today. A community physician can refer a patient to UAB medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You're listening to UAB Medcast. For more information on resources available at UAB Medicine, you can go to uabmedicine.org/physician. That’s uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.
  
  
  
• Hosts:Melanie Cole, MS