In 70% of cases, the uterus is unexplained for fibroids. Why is nonsurgical treatment rarely used?

dr. Rares Nechifor

Dr. Rares Nechifor, primary intervention radiologist, talks about uterine fibroid, a condition that suffers half of women. The doctor explains why the noninvasive procedure that could save the uterus of women with fibroids is very little used and promoted.

– Doctor of the Day: What is uterine fibroid and why does it occur?

Dr. Rares Nechifor : Uterine fibroma is a benign tumor, is not cancer, and will never get malignant. But it's a frequent tumor. Half of the women have uterine fibroids. Not all of them are symptomatic, but about a quarter. They grow faster as a result of hormonal balance. If a hormonal imbalance occurs grow faster. And hormonal imbalances occur because of hormone foods like soy products. Soy contains a plant estrogen, a substance that goes into the body as a female hormone. There are also different wares, different substances in dishwashing detergents, which, in the body, behave like estrogens and stimulate the growth of fibroids. In addition, there is stress, fatigue, modern lifestyle that lead to hormonal imbalances.

– What are the signs that should worry us?

– First, it may be a fibroma or more. In general, there are several. Depending on their size and location, the symptoms and severity differ. In fibroids that grow to the uterine cavity, inside the uterus, the symptoms are abnormal bleeding on the cycle. There are patients who become anemic. The normal limit of hemoglobin is 12, and they reach 10, 9, 8 even 7. At 7, they are eternally tired, pale, they have no life. If bleeding is more important, life may be endangered, many end up in such situations, the cycle comes, it flows very abundantly, does not stop, goes to the hospital, needs to receive transfusions, and in some cases it can be in emergency surgery, the uterus can be removed altogether.

Another situation is caused by the excessive increase of fibroids that begin to press on the surrounding organs, on the bladder, and frequent urination occurs. Wake up the night many times, went to the toilet. When it presses on the intestines we have bloating, constipation, discomfort. Other symptoms: cycle pain, cold, sexual contact.

Another very important chapter is infertility. There are young women trying to get pregnant and they can not get or stay and lose their pregnancy, and the reason may be the uterine fibroid. If the uterus is deformed, if there is a fibroid that pumps into the cavity, these are reasons for infertility.

– At what age do you see, the fibroids?

– In the past few years younger women are getting bigger fibroids. There are, however, two periods of life in which fibroids occur more often: during pregnancy due to hormonal stimulation and premenopause. That is, a year, two, three inches of menopause, a series of hormonal changes that stimulate their growth.

In addition, the cycle comes faster now, it does not come at 12-14 years, it comes at 8, but this is not a random change but occurs because of the diet because of all the substances we swallow and which make the hormonal stimulus either stronger or earlier.

– What does a woman have to do if she observes she has symptoms, what kind of investigations are needed?

– If the woman has symptoms, the cycle if it is wrong if it is abundant or painful, if the stomach grows and first thinks that it has grown but then realizes that there is something strong there, in the belly that is bothering if there is infertility . The first step is to go to the gynecologist. It is mandatory, along with the gynecological consultation, an ultrasound. An ultrasound describing the uterus. If there are fibromatous nodules, what dimensions do they have, how many are, how they are located. Ultrasound is very, important. Often, ultrasounds are more brief. It is called fibromatous uterus, surgical indication. It's not okay because the uterus should only be removed if there is no other alternative. Unfortunately, it is the easiest solution for the doctor to solve the problem. The American Gynecology Society has developed a guide to hysterectomy (surgery to remove the uterus), and it has been observed that of the total number of patients who had hysterectomy in only one year, only 20% met the criteria. This means that the rest could have saved his uterus and benefited from less aggressive treatment. They made these criteria because hysterectomy is not a simple, easy operation, neither risk nor long-term effects.

– What are the effects of hysterectomy?

There are accessible sites and information where we can see what possible side effects exist after hysterectomy. From severe anesthesia, severe infections, surgical adhesions, 60-70% of women who have had hysterectomy then have depression or other emotional disorders, couple relationships, reintegration at work.

– What other treatment solutions are there?

There is also a myomectomy, a surgical solution that removes the fibroid and the uterus, but it is only possible in about 20% of the cases, depends on the size of the fiobrom, if it occupies more than half the wall of the uterus or if we have more fibroids , then nothing remains.

There are certain criteria when it can be done and about 20% of the patients meet the criteria.

Drug treatment is two-fold: naturally and hormonally, but unfortunately, they are symptomatic treatments that reduce bleeding, pain, discomfort, but lack the power to treat fibromas, they can only keep them under control. Do not grow so fast, grow slower. In addition, hormonal treatment can not take more than three months due to side effects, one of which is the increased risk of endometrial cancer. In the three months of treatment, fibroma may decrease in size, but after stopping treatment, it starts again to increase. That is why the first phrase in the medicine leaflet is that it is symptomatic preoperative treatment. It is a given treatment to prepare the uterus for surgery.

Some women take medication, believing that this is how the problem is resolved, but it is not. It's a solution that makes his work easier.

Embolization is a therapeutic method, which I have been doing for 14 years. It is a procedure that involves interventional radiology, not gynecology. Therefore, the procedure is not well known or promoted in gynecology offices. It can be perceived as a concurrent solution that steals the patients.

There is a study done in England that revealed that after complete patient information on solutions, 90% did not even want to hear about surgery and chose embolization. So the potential of the procedure is very high. However, there are not enough physicians prepared to do the intervention, no special equipment, or enough places where such an intervention can be made, so even real competition for surgery. Only 3% of fibroid patients are currently embolising.

– What are the benefits of embolization?

– It's the least invasive procedure, it lasts for half an hour, the patient is awake, has no pain, there is no general anesthesia, there is no incision, just a small prick to the hand to catch the artery.

By the procedure, all fibromas are treated simultaneously, it does not matter that they are one, that they are 10. We recently had a patient with 19 fibroids that we treated simultaneously. This makes us able to give patients a guarantee that there will not be a relapse and give a lifetime guarantee, which myomectomy can not do.

The relapse rate after surgery is 25% -30% in the first 2 years and over 60% after 5 years. There are good chances if you did the surgery in 2-3-4 years to relapse.

– Contraindications to embolization?

– Allergy to iodine, to contrast. Fortunately, modern contrast substances do not really give allergies. And it's a simple two-minute test that tests allergy.

There are a number of contraindications: if the patient is pregnant, if the fibroma diagnosis is not certain, if it does not look like a fibromy, it does not behave like a fibromus, then we do not embolize, if it has an infection we must first treat it then we do the embolization . If the fibroids are located completely outside the uterus, because they are easy to operate because the uterus is not affected. We can also treat them by embolization only that their resorption is slower.

If a fibroid has gone through hormonal treatments, the speed at which it is absorbed is not as good. Because such treatment makes the fibrous composition change and have more inert fibers, more collagen and fewer cells. And after embolization it does not resolve as quickly and well as the hormone that did not intervene.

If you do embolization, there is a risk of infection, but this risk is at least five times lower than the risk of infection if you are taking the surgery. The risk of losing your uterus to embolism is 100 times smaller than surgery. The risk of other organs being affected is 500 times smaller than surgery. There are study figures that help us understand the risks of each procedure. In terms of fertility, there is a study that showed that patients who have embolized and who have done myomectomy have had the same success rate related to pregnancy and the same rate of complications. But the embolization patients were, in fact, patients who were refused myochemistry because it was too complicated.

– Why is embolization not used more often?

– Unfortunately, the procedure is not so well known. Surgery has been done for 100 years, has entered into popular culture and especially doctors. And the family doctor knows that if he has such a patient, he sends it to the gynecologist and tells him he will do surgery. It is a very old and rooted procedure. Alterntiva does not come from the gynecologist. There is no new, modern, gynecologist's procedure to tell the patient: I have a new, better solution. He has to say, "I can not offer you the best solution, I can offer you the classic solution, but you can go elsewhere where to do it." There comes the pride, the finchancial aspect, the ignorance, because it is a procedure that it has not learned and does not practice, it does not know it. He may know her to the extent that he is interested in alternatives and to sit back and read. For example, I went to a surgery course for gynecologists who wanted to learn to operate laparoscopically. I was invited to talk about embolization. Obviously the world expected to be eaten because they were learning something and I was coming to explain them about something else that said there was no need for the procedure they were learning. Or, in most cases, there is no need. And I figured out how to get them to catch their attention. So I started to show them cases. One of the examples was a woman with three large fibroids who wanted a baby and I asked her what solutions she would have to treat her and save her uterus. They said the fibroids are very large and can not do myomectomy and it is not possible to save their uterus. At that moment I showed them a picture of the baby. She was a patient of mine to whom I had embolished and who then got pregnant and gave birth to a healthy baby. I showed them that I can. And after I showed them some other cases, they could see that there were real, effective alternatives to what they were learning and practicing.

And then I wonder how to know the patients about embolization if they are not told. Most patients who are embolized are patients who have entered at least one gynecology clinic and who have been offered radical or risk of losing their uterus, and have always lamented with shock, searching for solutions on the Internet , forums. And who has the luck to read, to find out and open to understand, to come to consult and discuss alternatives. But when the doctor gives you an opinion and you compare it to something you read on the internet, it's harder to trust what you read than what the doctor said. But when what your doctor gives you is far from what you want, if you want a baby and tells you to cut your uterus and you will not have children, you will obviously refuse even if you seems the last solution and you are looking for alternatives. There's a reason why many women come with big fibroids, but not because they've been through the years and they did not know it, but because they did not find a reasonable solution that they could accept. That's how they stay for a year, when the fibroma grows, and they went to a doctor, and they refused, and so until they got to know about embolization.

This has not happened to us yet, but in the USA it happened that the fibroma patient was pulled out of the uterus and then found out that there was an alternative and coming back to a doctor to ask for it, to sue it and to win, but money can not put you back on your uterus or a child you may want.

The British Health Society has made a guideline that says that every patient has the right to be informed about all existing treatment alternatives, linked to the affection he has, has the right to know what doctors practice each of these alternatives, where they do and what experience each doctor has. Because the same procedure by an experienced doctor or a beginner does not have the same results. More than 70% of physicians do not know how to do myomectomy, they are not trained, they only do hysterectomy.

– What happens if the fibroid patient is pregnant?

– If the patient is pregnant and learns to have fibromas, it should be monitored and in most cases it increases. She probably will have a Caesarean section if she gets to the deadline. If it grows a lot it can lead to sacrifice loss. That's why it's a good thing for a woman, before she gets pregnant when she makes her plan, to make a check and an ultrasound and to know she has a good "cottage" for the baby because during pregnancy we can not intervene in any way. But if you want to make a baby, you have control, and if there are small fibroids under 3 cm, it should not bother the task. If they are older or their position climbs to the uterine cavity they should be treated first.

– What happens after embolization and how long can the patient try to get pregnant?

– After 6 months of treatment, the woman may try to become pregnant.

We also have a smartphone application that monitors patients. The patient goes home, teleclone, every day, tells him what medication he has to take and asks if he has pain, nausea, if he gets angry, something. He has only to answer the questions and all the information comes to us. So we know all the time if our sins are good. Any possible problem, if it does not take the treatment, if it fever, we immediately call and talk and solve it. Patients feel so protected and cared after they left the hospital.

I had a patient with a 13 cm fibroid, a big fibrom and who was very fond of a baby. Obviously, with such a large fibroid he could not. He went to a lot of doctors and they all told him there was a big fibroma, there was nothing left of the uterus after surgery, that he had no chance. In addition, her husband had varicocele (a condition that gives fertility disorders). I treated both of them. Lady I embolized him, sclerotherapy. Now she has another month and has to give birth. Though no one had given her a chance.

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