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PubMed2004

[Uterine fibroid embolization with spheric micro-particles using flow guiding: safety, technical success and clinical results].

PURPOSE: To evaluate safety and mid term efficacy (> or = 1 year follow-up) of uterine fibroid embolization (UFE) using spherical particles (Embosphere) in a study applying criteria identical to those submitted to the FDA for initial material approval. MATERIALS AND METHODS: Twenty of the first 26 consecutive patients referred for potential UFE were enrolled in the study. Pre-interventional MRI was used to assess morphologic contraindication to UFE. The embolization procedures were performed from a unilateral femoral approach using 4F selective catheters in straight vessels, > 2 mm in diameter, and micro-catheters in smaller and tortuous arteries. The endpoint of the "flow guided" embolization was defined by reaching the angiographic "pruned tree" appearance and sluggish flow in the main stem of the uterine artery. Assessment of morphologic mid term success was done by MRI 10 days, 3 months, 6 months, 9 months and 1 year after UFE. The clinical mid term success was assessed by having questionnaires completed for menstrual bleeding, retention of clinical (symptomatic) benefit and quality of life. RESULTS: Technical success was 100 %, with 8 minor (2 post-interventional collapses, 2 hematomas, 4 relevant post-embolizations syndromes, 1 spontaneous expulsion of a submucous myoma) and 3 major complications (1 hysterectomy because of vaginal bleeding for 5 weeks, 1 transient amenorrhea and 1 spontaneous expulsion of myoma with transient bleeding requiring admission). In 17 of 19 patients, MRI showed total fibroid devascularization throughout the entire follow-up. The average shrinkage of the dominant fibroid was 71.3 % at one year. The menstrual bleeding record in the cohort group fell from an average of 501.6 before treatment to 76.2 points at one year. At the same time, the clinical symptoms significantly improved. The patient satisfaction with the applied therapy was > 95 % at 1 year. One patient with residual fibroid perfusion underwent a second procedure, which achieved complete devascularization and adequate clinical success at one year. The second patient with incomplete devascularization had a persistent clinical benefit. CONCLUSION: Under controlled study conditions, flow guided UFE with spherical particles achieves high overall success and patient satisfaction. MRI provides exact morphologic description of the fibroid for the initial evaluation and for post-procedural follow-up.

Adult↗
PubMed2001

Uterine artery embolization for the treatment of uterine fibroids: an outpatient procedure.

OBJECTIVE: Our objectives were to establish an outpatient program for uterine artery embolization of fibroids and to monitor the following: percentage of patients who required immediate hospitalization or admission within 2 weeks, outcomes in terms of the degree of ultrasound regression of the fibroids, patient satisfaction, reduction of pressure symptoms, and reduction of bleeding. STUDY DESIGN: Patients were screened by a gynecologist with the use of a designed care algorithm; they then underwent uterine embolization, performed by an interventional radiologist. Patients were evaluated at 6 weeks and 6 months after the procedure, and ultrasound studies were performed both before and at 2 to 6 months after the procedure. RESULTS: Of 35 patients, 29 (83%) went home on the day of the procedure, whereas 6 were observed overnight. Three (9%) patients required admission within 1 week. Of 26 patients, 24 (92%) were satisfied with the reduction of bleeding, and 14 of 18 (78%) were satisfied with the reduction in pressure symptoms. The mean decrease in uterine volume was 36%, and the mean decrease in the size of the dominant fibroid was 49%. CONCLUSIONS: Uterine artery embolization for the treatment of uterine fibroids might be done on an outpatient basis with a low rate of same-day admissions and delayed admissions. Patient satisfaction was high, and uterine artery embolization might become an accepted option for the treatment of uterine fibroids.

Adult↗
PubMed2002

Interventional magnetic resonance imaging cryotherapy of uterine fibroid tumors: preliminary observation.

OBJECTIVE: The purpose of this study was to identify alternatives to hysterectomy. We have developed a transabdominal interventional magnetic resonance imaging-guided cryoablation procedure and report this novel approach. STUDY DESIGN: This represents the preliminary and first report of a prospective Institutional Review Board-approved protocol to study interventional magnetic resonance imaging-guided cryoablation of uterine fibroid tumors. Women were selected on the basis of symptoms that were related to uterine fibroid tumors (bleeding, uterine pain, pelvic congestion, compression symptoms) and the absence of any desire for child bearing. A physical examination confirmed the presence of fibroid tumors, and magnetic resonance imaging was performed before the procedure to measure the size and number of fibroid tumors. Patients returned to the interventional magnetic resonance imaging and underwent placement of 3 to 5 probes (2-3 mm) under magnetic resonance imaging-directed guidance. Follow-up magnetic resonance imaging determined the size reduction of the lesion, and a clinical evaluation determined the change in symptoms. RESULTS: Nine patients were treated and had substantial reduction in the uterine size (average, 66% volume reduction), and their primary symptoms have either improved or resolved. CONCLUSION: This is the first reported review of interventional magnetic resonance imaging-directed cryotherapy of uterine fibroid tumors. This minimally invasive therapy produced shrinkage of the tumor in 8 of our first 9 patients.

Adult↗
PubMed2005

Uterine artery occlusion for the treatment of symptomatic fibroids: endoscopic, radiological and vaginal approach.

Uterine fibroids are the most common solid pelvic tumors in women. Although many fibroids seem to cause no symptoms, for some women they can have serious adverse effects and impact on quality of life. Common symptoms associated with fibroids include abnormal uterine bleeding, pelvic pressure and reproductive dysfunction. The past decade has witnessed highly sophisticated diagnostic and therapeutic technology for fibroids. The tools currently at our disposal permit greater management flexibility, which must be tailored to the individual clinical situation. Nonsurgical treatments include medical therapy and treatments interfering with the blood supply to the uterus or the fibroid; among the latest introduced are uterine artery embolization performed by the interventional radiologist and laparoscopic uterine occlusion performed by the gynaecologist. Even simpler is the non-incision temporary uterine clamp directed with Doppler and placed in the side fornices in the vagina.

Journal Article↗
PubMed2001

Risk factors for uterine fibroids among women undergoing tubal sterilization.

Uterine leiomyomas are reported to be the most common benign gynecologic tumors affecting premenopausal women, and they are often associated with considerable morbidity. The purpose of this study was to identify risk factors for uterine fibroids among women undergoing tubal sterilization. Cases comprised women aged 17-44 years whose uterine fibroids were first visualized at the time of tubal sterilization (1978-1979 or 1985-1987) or who reported a history of uterine fibroids (n = 317). Controls were randomly selected from women with no laparoscopic evidence of or history of fibroids (n = 1,268). Adjusted odds ratios were estimated using unconditional logistic regression separately for White (n = 1,235) and African-American (n = 350) women. Risk factors for White women included: age 40-44 years (odds ratio (OR) = 6.3; 95% confidence interval (CI): 3.5, 11.6), > or =5 years since last delivery (OR = 1.9; 95% CI: 1.1, 3.1), lifetime cigarette smoking of > or =1 pack/day (OR = 1.6; 95% CI: 1.1, 2.3), menstrual cycle length of >30 days (OR = 1.6; 95% CI: 1.1, 3.3), and menstrual bleeding for > or =6 days (OR = 1.4; 95% CI: 1.0, 2.0). Parous women were at reduced risk compared with nulliparous women (OR = 0.2; 95% CI: 0.1, 0.3). Advancing age was the only significant risk factor for African-American women (ages 40-44 years, OR = 27.5; 95% CI: 5.6, 83.6). Current oral contraceptive use and elective abortion were not associated with fibroids.

Adolescent↗
PubMed1998

Treatment of uterine fibroids with a slow-release formulation of the gonadotrophin releasing hormone antagonist Cetrorelix.

A depot preparation of the third-generation gonadotrophin-releasing hormone (GnRH) antagonist Cetrorelix (SB-75) was used for preoperative treatment in twenty premenopausal patients with symptomatic uterine fibroids who were to undergo surgery. In a prospective, open, randomized setting 60 mg of Cetrorelix pamoate salt was administered i.m. on cycle day 2. Patients were randomized for a second dose of 30 or 60 mg of Cetrorelix depot, which was administered according to the degree of oestradiol suppression (<50 pg/ml) on treatment day 21 or 28. Surgery was done after 6 or 8 weeks of treatment, depending on second dosage administration. Weekly transvaginal sonography (TVS) and magnetic resonance imaging (MRI) before and after treatment was performed, for fibroid volume assessment. Sixteen patients showed satisfactory suppression of gonadotrophins and sex steroid secretion, avoiding any initial flare-up effect. In these patients a mean shrinkage rate of largest fibroid volume of 33.5% at the end of treatment could be observed according to TVS, while the mean shrinkage rate obtained after 14 days of treatment was 31.3%. In good responders (shrinkage >20%) largest fibroid volume at day 14 was approximately 56.7% of basic assessment. Although MRI showed minor mean shrinkage rates of only 25.4% of the initial volume, these differences in comparison to TVS assessment were not statistically significant. The avoidance of any initial flare-up in gonadotrophin secretion may explain this extremely fast reduction in fibroid size. The advantages of GnRH antagonist treatment in this indication consist in the short treatment time with a fast restoration of the ovarian function. The rate of poor responders may be reduced by using an improved slow release preparation.

Adult↗
PubMed2006

The normal human myometrium has a vascular spatial gradient absent in small fibroids.

BACKGROUND: The human uterine vasculature is highly structured, exhibiting circumferential and radial branching. Previously published angiograms of the arterial network describe a system of regular coils. Uterine fibroids lack this structured vasculature. In this study, we make a comparison between the vasculature in normal myometrium and in fibroids using robust stereological methods thus far lacking in the literature. METHODS: Stereological and morphometric analysis of the vascular system was carried out on 15 normal and 27 small fibroid (5-40 mm) uteri taken from women suffering menorrhagia. Projected images of published angiograms were also re-examined, measuring tortuosity. RESULTS: A decreasing gradient of vascular smooth muscle from outer to inner myometrium was found in normal uteri, with no corresponding gradient in capillary tissue fraction. An association between vascular luminal size, amplitude and frequency of vessel bending was also established. Conversely, fibroids were found to lack structured or muscularized vasculature. CONCLUSIONS: A quantitative gradient within the myometrial vascular system, which is absent in fibroids, has been demonstrated. These structural differences between diseased and healthy tissues are probably because of differing expression of angiogenic growth factors and may explain the distribution of particles seen after uterine artery embolization.

Biopsy↗
PubMed1988

Epidemiologic characteristics of women with uterine fibroids: a case-control study.

Risk factors for uterine fibroids were analyzed in a hospital-based case-control study conducted in the greater Milan area, based on 275 women with histologically confirmed fibroids and 722 controls with acute nongynecologic or hormone-related conditions. Questions were asked about menstrual and reproductive characteristics, education, history of various diseases, and lifetime use of oral contraceptives and other hormonal treatments. The risk of uterine fibroids was reduced in parous women relative to nulliparous ones (relative risk 0.6) and in those who were postmenopausal (relative risk 0.1 compared with premenopausal women of the same age). Women with fibroids tended to have an earlier age at menarche and at the last birth, to be more educated, and to use intrauterine devices and oral contraceptives more frequently, although these findings were not statistically significant. Current smoking (but not past smoking) lowered the fibroid risk by about 40%. No associations were found with body mass index, history of spontaneous or induced abortions, and age at first birth.

Adult↗
PubMed1992

Oral contraceptive use and risk of uterine fibroids.

The association between oral contraceptive (OC) use and the risk of uterine fibroids was analyzed in a case-control study conducted between 1986-1990. The subjects were 390 patients under 55 years of age with histologically confirmed fibroids and 1136 controls in hospitals for a spectrum of acute conditions (other than gynecologic, hormonal, or neoplastic) apparently unrelated to OC use. A total of 78 cases (20%) and 200 controls (18%) reported OC use. Compared with never-users, the multivariate relative risk for ever-users was 1.1 (95% confidence interval [CI] 0.8-1.5). No direct relationship emerged with duration of use, the estimated relative risk being 1.3 (95% CI 0.9-2.0) in users of OCs for less than 3 years and 0.8 (95% CI 0.5-1.3) in users for 3 years or more. The risk of fibroids was apparently (though not significantly) greater with longer recency of use: The estimated relative risks were 0.9 and 1.5, respectively, in women reporting last OC use less than 10 years before and 10 or more years before diagnosis of the disease. No relationship emerged with latency of use. There was no noteworthy interaction regarding risk of fibroids between OC use and potential covariates. These findings suggest that fibroids are unrelated to the use of OCs.

Abortion, Induced↗
PubMed2005

The role of uterine artery embolization in the management of uterine fibroids.

PURPOSE OF REVIEW: Uterine artery embolization is increasingly being offered as an alternative to hysterectomy and myomectomy for the treatment of symptomatic uterine fibroids. This review is intended to evaluate the role of this technique in the management of uterine fibroids using information provided from recently published literature. RECENT FINDINGS: A growing body of literature supports the efficacy of uterine artery embolization in relieving fibroid-related menorrhagia, pelvic pain and pressure symptoms and in substantially reducing the fibroid size in most patients. Recent publications also show significant improvements in health-related quality of life and high long-term satisfaction rates. The procedure is associated with shorter hospitalization and recovery times and lower morbidity rates compared with conventional surgical treatments. However, serious complications, such as uterine infarction or infection leading to emergency hysterectomy, have been reported in a few cases, and considerable work is currently underway to determine how the safety of the procedure can be enhanced. Although no long-term data on subsequent fertility are yet available, early reports on ovarian function and pregnancy outcomes after uterine artery embolization are encouraging. SUMMARY: Based on current evidence, uterine artery embolization can be considered a valuable alternative to surgical therapy in the management of well-selected women with symptomatic uterine fibroids. Additional research is needed to help define the place of this technique for women who desire future pregnancy.

Embolization, Therapeutic↗
PubMed1989

The binding of steroids to myometrium and leiomyomata (fibroids) in women treated with the gonadotrophin-releasing hormone agonist Zoladex (ICI 118630).

Since uterine leiomyomata (fibroids) are not found in conditions where oestradiol is either absent or present only in low concentrations, oestradiol is considered to be an important factor in the control of fibroid growth. To investigate whether this is due to a direct effect on the tissue, oestradiol and progestogen receptors were measured in tissue removed at hysterectomy from 12 normally cycling women and 13 women who had received the gonadotrophin-releasing hormone (GnRH) agonist Zoladex (ICI 118630) as a subcutaneous depot given at monthly intervals for 3 months preoperatively and a third group of three women who had received the antioestrogen tamoxifen (20 mg daily) for 3 months before surgery. Both unoccupied oestradiol receptors (measured by separating bound from free hormone with dextran-coated charcoal; DCC) and 'total' receptor populations (as measured by an enzyme immunoassay) were measured in each fibroid and adjoining myometrium. There was significantly more binding of both oestradiol and progestogen to fibroid than to myometrium in both the control (P less than 0.01) and agonist-treated groups (P less than 0.05). Oestradiol binding to fibroids in women treated with Zoladex exceeded that in the normally cycling women (P less than 0.05) which in turn exceeded that in the tamoxifen-treated group (P less than 0.05). However, the binding of progestogen, measured by DCC showed the reverse trend. These results may be explained by the low circulating oestradiol concentration in the GnRH agonist-treated women leading to low receptor occupancy.

Buserelin↗
PubMed1996

Risk factors for self-reported uterine fibroids: a case-control study.

To identify risk factors for uterine fibroids, a case-control design used to analyze data from control subjects enrolled in the Cancer and Steroid Hormone Study. Case patients were 201 women who reported a history of uterine fibroids, and control subjects were 1503 women without fibroids, individually matched by age to case patients. Reporting of fibroids was more frequent among premenopausal women, women who had frequent Papanicolaou (Pap) smears, women who used oral contraceptives and had infrequent Pap smears, and women with higher education. Reporting of fibroids was less frequent among women with a lower body mass index who were current or long-time smokers.

Adult↗
PubMed2002

Uterine artery embolization using gelatin sponge particles alone for symptomatic uterine fibroids: midterm results.

OBJECTIVE: The purpose of this study was to assess the safety and effectiveness of uterine artery embolization using gelatin sponge particles alone for women with symptomatic uterine fibroids. SUBJECTS AND METHODS: During 38 months, 60 patients (age range, 32-52 years; mean age, 42.5 years) with symptomatic uterine fibroids underwent uterine artery embolization. Only gelatin sponge particles, approximately 500-1000 microm in diameter, were used in all patients. The improvement of clinical symptoms was assessed by questionnaire. Reduction of the largest tumor and uterine volume reductions were assessed using MR imaging. The follow-up period ranged from 1 to 38 months (mean, 10.6 months). RESULTS: Menorrhagia improved markedly or moderately in 41 (98%) of 42 of patients 4 months after embolization and in 20 (100%) of 20 patients 1 year after embolization. Bulk-related symptoms improved markedly or moderately in 31 (97%) of 32 of patients 4 months after embolization and in 19 (100%) of 19 of patients 1 year after embolization. MR imaging revealed that the mean largest tumor volume reduction rates were 55% at 4 months and 70% at 1 year after embolization, and the mean uterine volume reduction rates were 40% at 4 months and 56% at 1 year after embolization. Follow-up MR imaging showed no new fibroids and no regrowth of existing fibroids. No major complications were observed in any women. CONCLUSION: We suggest that uterine artery embolization with gelatin sponge particles alone is a safe and effective treatment for symptomatic fibroids. The outcomes bear comparison with those of uterine artery embolization using polyvinyl alcohol particles, which have been reported in the literature.

Adult↗
PubMed1993

An open study of luteinizing hormone releasing hormone agonists in infertile women with uterine fibroids.

Twenty infertile women with fibroids were treated with luteinizing hormone releasing hormone agonists (LHRHa) to investigate if the use of these drugs, both with and without myomectomy, was effective in contributing to pregnancy in these women. All women had fibroids as their sole cause for infertility. Seven women conceived within 1 year of myomectomy or LHRHa treatment alone without myomectomy. The overall pregnancy rate was 36% and the postmyomectomy pregnancy rate was 50%. Initial fibroid size and extent of fibroid shrinkage on LHRHa therapy made no difference to the subsequent pregnancy rate. We also found no significant interaction between the number of fibroids present and the effect of myomectomy on the proportion of pregnancies. We conclude that the fertility enhancing value of myomectomy in otherwise idiopathic infertility is confirmed, and that the use of LHRHa premyomectomy in infertile women needs to be investigated in randomized controlled trials to assess its value as a preoperative therapy.

Adult↗
PubMed2002

Three-dimensional color Doppler sonography and uterine artery arteriography of fibroids: assessment of changes in vascularity before and after embolization.

OBJECTIVE: To assess the accuracy of three-dimensional color Doppler sonography and uterine artery arteriography in depicting changes in fibroid vascularity before and after embolization. METHODS: Preembolization and postembolization three-dimensional color Doppler sonography and selective uterine artery arteriography were retrospectively compared in 15 patients who underwent uterine artery embolization for treatment of symptomatic fibroids. Three-dimensional color Doppler sonography was performed by using a scanner with color power angiographic imaging capability. Vascularity was quantified by using an estimation of power-weighted pixel density as described by our group in previously published studies. Uterine artery arteriography was performed by using a standard selective microcatheter embolization technique. For purposes of comparison, fibroids were classified as either hypervascular or hypovascular relative to myometrial vascularity before and minutes to several hours after uterine artery embolization. Changes in fibroid vascularity (i.e., from hypervascular to hypovascular) as depicted by three-dimensional color Doppler sonography were compared with those shown on uterine artery arteriography and classified as being in agreement or disagreement. RESULTS: In 13 (87%) of 15 patients there was agreement; in 2 (13%) of 15 there was disagreement. In both cases of disagreement, three-dimensional color Doppler sonography showed collateral flow not depicted by uterine artery arteriography The mean reduction in quantitated vascularity after uterine artery embolization was 44% (range, 19%-78%). CONCLUSIONS: Three-dimensional color Doppler sonography accurately depicts fibroid vascularity and in some cases can reveal collateral flow not depicted by uterine artery arteriography.

Adult↗
PubMed1998

Treatment of uterine fibroid with triptorelin before hysterectomy.

OBJECTIVE: To study the effects of pretreatment with triptorelin on uterine fibroid before abdominal hysterectomy. METHODS: Fifteen premenopausal Chinese women with symptomatic uterine fibroids requiring hysterectomy were recruited in the study. All patients received monthly intramuscular injections of 3.75 mg triptorelin for three months prior to abdominal hysterectomy. RESULTS: There was significant reduction in the serum levels of oestradiol (68.6%), progesterone (95.6%) and luteinizing hormone (73.9%) and in uterine (45.0%) and fibroid (68.0%) volumes. The serum level of follicle-stimulating hormone and haemoglobin concentration were not significantly different. CONCLUSIONS: Shrinkage of uterine fibroids can be achieved in women who are rendered hypoestrogenic with monthly injections of triptorelin for three months. This treatment modality may be of value prior to hysterectomy or myomectomy especially when the fibroid is large.

Adult↗
PubMed1999

[Medical treatment of uterine fibroids with the LHRH antagonist: Cetrorelix].

A depot preparation of the LHRH-antagonist Cetrorelix was used for the preoperative treatment of 20 premenopausal women with symptomatic uterine fibroids to undergo surgery. In an open, prospective and randomised study, 60 mg of this depot preparation were administered i.m. at the second day of cycle. Patients were randomised for a second dosage of 60 mg or 30 mg to be injected on day 21 or day 28 of treatment according to the degree of estradiols' suppression (< 50 pg/mL). The operation was carried out after six or eight weeks of treatment according to the timing of second dosages administration. Weekly transvaginal sonography as well as MRI before and after Cetrorelix treatment were performed for fibroids volume assessment; 16 patients showed satisfactory suppression of gonadotrophins and sexual steroids. No flare up effect was to be observed. In this group of patients the maximum reduction in fibroids size was of 33.5% at the end of treatment. After 14 days of treatment the reduction was of 31.3%. Within the group of good responders (reduction of fibroids size > 20%) the volume of the biggest fibroid after 14 days of treatment was of 56.7% of the initial assessment. Although MRI showed minor mean shrinkage rates of only 25.4% of the initial volume, these differences in comparison to transvaginal sonography were not statistically significant. The avoidance of any flare up phenomenon by the LHRH-antagonist may explain this fast reduction in size. The basic advantages of this treatment modality are the reduction of treatment time with a fast restoration of the ovarian function. The rate of poor responders may be reduced by improving the galenic preparation.

Adult↗
PubMed2000

[Fibroids and fertility].

Fibroids are the most common benign uterine tumours. A relation between fibroids and infertility is suggested. Successful implantation depends on a normal, receptive endometrium. Fibroids can change the normal appearance of the uterine cavity and can adversely affect the endometrium. It seems that treatment of fibroids in infertility patients is useful but this is not yet proven scientifically. It is advised to refrain from extirpation of fibroids in patients with fertility problems.

Contraindications↗