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Avoiding Hysterectomy

A Compassionate Guide for Women


Suffering From Uterine Fibroids
John C. Lipman, MD, FSIR
Founder & Medical Director
Atlanta Interventional Institute

Avoiding Hysterectomy Copyright 2015 Atlanta


Interventional Institute

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Dedication
To the millions of women
who received an unnecessary
hysterectomy for fibroids
May their daughters and granddaughters realize that there are
options to hysterectomy for
fibroids, and may their physicians
explain those options completely,
and without bias.

Avoiding Hysterectomy Copyright 2015 Atlanta


Interventional Institute

Introduction
Many women suffering with uterine fibroids will be told that
they need a hysterectomy.
Hysterectomy is an option for women with symptomatic
fibroids, however it is completely unnecessary!
This guide is designed for those women who do not want to
lose their uterus, a precious organ of their bodies.

Avoiding Hysterectomy Copyright 2015 Atlanta


Interventional Institute

Understanding Fibroids
Fibroids are benign, non-cancerous tumors that involve the
uterus. They are the most common pelvic tumor in women.
One of every three adult women in the United States have
fibroids and up to 80% of adult African-American women have
these tumors.
Most women who have fibroids have no symptoms. These
women do not require any treatment, but it is our belief at
the Atlanta Interventional Institute that people need to be
more proactive with their own health. This often requires a
commitment to a healthier lifestyle. This approach is taking
immediate preventive measures rather than waiting for
something to break and try to fix it at that point.
This proactive, preventive approach is not only good for your
fibroid health, it is also beneficial for your overall health.
.

Avoiding Hysterectomy Copyright 2015 Atlanta


Interventional Institute

How Do Fibroids Cause Symptoms


Fibroids are round tumors made up of smooth muscle and fibrous tissue.
These balls of tissue are very hard and often can be felt by healthcare
providers during an examination or even the patient herself.
These tumors can cause symptoms depending on where they are located in
the uterus.
The 3 main locations in the uterus are:
1. Submucosal
2. Intramural
3. Subserosal

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Interventional Institute

Submucosal fibroids reside just underneath the lining of the uterus and are
responsible for the often heavy periods women with fibroids have.
Women will often report having to change pads (typically > 8/day) less than
every couple of hours and report episodes of blood gushing or flooding
out with the passage of clots (sometimes as big as her fist !).
Subserosal fibroids are located just beneath the outer surface of the uterus
and are responsible for the bulk-related symptoms that a fibroid sufferer
may experience. These fibroids grow away from the uterus and will press
on adjacent structures in the pelvis to cause these symptoms.
For example those fibroids located in the front of the uterus will compress
the bladder to cause increased urinary frequency and nocturia (waking up
at night to urinate; often multiple times each night). Those are located
more laterally will press on pelvic nerves to cause pelvic pain which can be
felt all across the pelvis, in to her lower back, hips, buttocks, and even
down her legs. Subserosal fibroids in other locations can cause dyspareunia
(painful intercourse), constipation, or hydronephrosis (blockage of the
kidney).
Intramural fibroids are found in the muscular wall of the uterus. These
tumors can grow in either direction (toward the lining or toward the outer
surface or both) and therefore have the potential to cause heavy bleeding
(like the submucosal fibroids) or bulk-related symptoms (like the subserosal
fibroids) or both.
Avoiding Hysterectomy Copyright 2015 Atlanta
Interventional Institute

How Do Fibroids Develop?


No one knows how fibroids develop. However, one very important fact that
is known about fibroids is that they grow with hormonal stimulation
(examples: estrogen & progesterone). This is why fibroids often grow
during pregnancy and why they tend not to be an issue for women once
they are in menopause. Therefore, a very important strategy in the
management of uterine fibroids centers around limiting outside exposure to
hormones, particularly estrogen.
Decreased consumption of estrogenic foods:
While it is impossible to completely avoid hormones which are pervasive
throughout our food supply, there are certain foods which are particularly
important to avoid or eat in moderation. These include red meat, chicken
(unless organic free-range), and dairy.
Increased consumption of anti-estrogenic foods:

Colored fruits and vegetables are rich in flavonoids. These compounds


block a very important enzyme in estrogen production.
Certain soy products contain plant-derived estrogens (phytoestrogens)
which can block estrogen from becoming activated by binding to sites
normally reserved for estrogen.

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Interventional Institute

Exercise and weight loss to decrease body fat:


Fat cells produce estrogen which leads to production of more body fat.
Losing excess body fat interrupts this vicious cycle.
Decreased use of hair relaxers:
There appears to be an association between frequency of use of hair
relaxers (which contain phthalates which has a similar chemical
composition and effects as estrogen) and fibroid risk for women that used
these products more than 10 years in the past.

Avoiding Hysterectomy Copyright 2015 Atlanta


Interventional Institute

How Do I Know If I Have Fibroids?


Fibroids may be felt on a routine physical examination by a healthcare
provider or by the patient herself. Some care providers describe a womans
uterus based on the size of a pregnant woman (ex. if the fibroids enlarge a
womans uterus up to her belly button that corresponds to a 16week or 4
month size uterus).
A common imaging tool to diagnose fibroids is the pelvic ultrasound exam.
There are 2 common probes used for this exam:
Transabdominal: A small amount of gel is placed on the end of this probe
and scanning occurs across the skin of her lower abdomen and pelvic
regions.

Transvaginal: A gel containing condom is placed over the thin probe. Gel is
placed on the end of the condom and scanning is performed inside the
patients vagina.
Pelvic MRI scanning is another imaging tool that is used to evaluate
fibroids. This exam is performed by the patient laying flat on the MRI table.
A picture of the womans pelvic area is created by the use of magnetic and
radiofrequency waves.

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Interventional Institute

Unlike a CT scanner (which looks similar to a MRI machine), the MRI images
are created without the use of x-rays. The MRI pictures are much higher in
resolution than ultrasound and are often used to better evaluate the
complete extent of the fibroids in the uterus and for the presence of other
conditions that have similar symptoms to fibroids (example: adenomyosis).

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What Medicines Can I Take for Fibroids?


Patients with symptomatic fibroids are often placed on medicine in an
attempt to alleviate their symptoms.

Non-steroidal anti-inflammatory medications like ibuprofen and oral


contraceptive pills are common first-line therapies tried to help with the
symptoms from fibroids. A hormone containing IUD can also be tried
although this may be difficult to place or keep from expelling due to the
presence of the fibroids.
A newer medicine tranexamic acid (Lysteda) can be used to treat the heavy
bleeding commonly seen in fibroid patients. It can be given for up to 5
days each month to lighten the womans flow.

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Understanding the Consequences of Hysterectomy


Once medical management fails and the womans symptoms are significant,
patients will often return to their Gynecologist to seek other treatment
options.
Unfortunately, it has been shown in a number of medical studies, that most
women only hear about the surgical options (exs. myomectomy, surgically
removing some of the fibroids or hysterectomy, surgically removing the
uterus) from their Gynecologist.
While hysterectomy is an option for some women suffering with fibroids and
it does result in an elimination of the womans symptoms, it is at a very
significant and steep price (i.e. the loss of her uterus and perhaps her ovaries
as well).
Hysterectomy has a profoundly negative effect on many women. It can affect
them psychologically (like male castration), sexually (loss of libido, loss of
orgasm), increases their risk for significant bone loss (osteoporosis), and there
is even data to suggest an increased cardiovascular risk.

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A study in the Journal of Womens Health in 2013 looked at approximately


1,000 pre-menopausal adult women suffering with fibroids. Their findings
included:

Average time waited to seek treatment 3.6 years with 25% over 5
years.

When asked why they waited so long, over 50% did not want
hysterectomy and 75% wanted a treatment option that avoided
surgery altogether (but werent given one).

Hysterectomy is unnecessary to effectively treat fibroid-related symptoms.

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Interventional Institute

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Getting a Second Opinion from


an Experienced Interventional Radiologist
Interventional Radiologists (IR) are physicians who specialize in minimally
invasive targeted procedures from inside of the body which replaces the need
for open or laparoscopic surgery.
IR physicians are the ones who developed Uterine Artery Embolization (UAE)
also known as Uterine Fibroid Embolization (UFE).
While there are on occasion some other physicians that will try to perform
embolization, IRs are uniquely trained in this procedure. The other physicians
also will typically not have either the experience in managing fibroid patients
or the volume of embolization procedures necessary.
It is incumbent on the patient to ask detailed questions about the experience
of the doctor who is performing UFE (or surgery).
Women who have been offered surgery for fibroids should seek out an
experienced IR for a 2nd opinion regarding UFE as a potential treatment
option.

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The patient should come to the consultation prepared with information:

Make a list of the most troubling symptoms


List all of the medications, including vitamins and supplements
List any allergies

Questions the patient should consider asking during the consult include:

Are my fibroids causing the symptoms that Im experiencing?


Do my fibroids need to be treated?
What are all my treatment options?
What are the pros and cons of each of these treatment options?
Which of these do you recommend and why?
How many UFE procedures have you personally performed? How
long have you been performing UFE? Do you perform these
procedures every day? Every week? Every month?
Who will manage any issues that might arise after the procedure?
Who will see me in follow-up? When?

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Interventional Institute

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If Uterine Fibroid Embolization Is Chosen


If you choose UFE you will want to have the most experienced Interventional
Radiologist to perform your procedure. Some examples of experience include:

Number of UFE procedures performed


Peer recognition of excellence (ex. FSIR after the IRs name. This title
is bestowed by the Society of Interventional Radiology on only ~10%
of IRs in their career)
Published papers or invited lectures on UFE

UFE is typically performed in an outpatient setting, although less experienced


hospitals may routinely keep the patients overnight. More experienced
Centers also do not require placement of a catheter in to the womans
bladder.
The procedure should take less than one hour to perform. Intravenous
medications (exs. Fentanyl and Versed) are given to allow the woman to sleep
during the procedure and will help in the management of post-procedural
pain.
The recovery at the hospital or Center is typically 4-6 hours.
90% of patients treated with UFE will experience significant or complete relief
of their symptoms.

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Follow-up is with the IR in his/her office typically 3 months after the


procedure. A contrast-enhanced MRI exam is performed and should show
enhancement of the uterus with no enhancement in the fibroids (because the
fibroids should all be dead). If this is present along with noticeable or
complete resolution of the patients symptoms, the patient does not need to
see the IR again unless a clinical issue arises in the future.
For the majority of women treated with UFE successfully, they will not need
any other procedure. This is particularly true the older a woman is at the time
of the procedure (i.e. closer to menopause).
Risks of hysterectomy surgery include:

Intraoperative/postoperative bleeding requiring transfusion


(myomectomy patients may revert to hysterectomy due to this)
Pelvic Infection/abscess
Incisional infection/dehiscence (loss of wound closure)
Deep vein thrombosis/pulmonary embolus (Blood clots)
Adverse reaction to anesthesia
Damage to urinary tract, bladder, rectum or other pelvic structures
during surgery, which may require more surgery
Earlier onset of menopause even if the ovaries aren't removed
Rarely, death

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Risks of UFE procedures, significantly lower than hysterectomy include:

Temporarily pass vaginally some fibroid material (~5%, usually


ceases without treatment, rare to need a D&C or hysteroscopic
removal of fibroid material)
Permanent amenorrhea (no more menstrual) Extremely rare in
any patient <40 years of age. Rare (<5%) <45 years and small
(<10%) incidence <50yrs.
Deep vein thrombosis (much lower incidence than surgery due
to very short procedure times and early mobility after
procedure, often 2 hours after UFE)
Infection
Rarely, missed malignancy (treating a cancerous tumor as a
fibroid)

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For More Information


Society of Interventional Radiology

http://www.sirweb.org/patients/uterine-fibroids/
National Uterine Fibroid Foundation
http://nuff.org/

For specific questions on fibroids or UFE, please e-mail Dr. Lipman


directly john@atlii.com.
To make an appointment with Dr. Lipman, please call:
(770) 953-2600
Atlanta Interventional Institute
3670 Highlands Parkway, SE
Smyrna, GA 30082
http://atlii.com

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