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Do’s And Don’ts For Talking To Your Doctor About Fibroids

 

Knowledge is power. When it comes to your health, your doctor has a lot of it – and a lot of empowering knowledge to share. At the same time, you know your body best. You know if things are “off”, and – in order for your doctor to effectively do his/her job – you need to share what you know about your state of health.

If you’ve been diagnosed with (or suspect) fibroids, you have a lot of options. Your visit with your gynecologist is an opportunity to learn about and discuss those options, as well as to gather information that will help you better understand your condition. To get maximum benefit from your appointment, observe these “do’s and don’ts”.

THE “DO” LIST

DO EXPLAIN YOUR SYMPTOMS – ALL YOUR SYMPTOMS

Being forthcoming about your symptoms will help both you and your doctor to better understand the nature of your condition. Among the estimated 25%-30% of women who have symptomatic fibroids, the nature and severity of symptoms can vary, depending on the size and location of fibroids. For example, urinary urgency often results when a large fibroid is growing next to – and pressing against – the bladder. In the initial phase of diagnosing your condition, gathering information about symptoms like this will give your gynecologist a clearer idea about the nature and location of your fibroids. In turn, he or she can help you understand how the symptoms you describe are impacted by your fibroids.

DO ASK YOUR BURNING QUESTIONS

If you’ve been newly diagnosed with fibroids, you probably have a number of pressing concerns and questions.  Bring them up! No matter how strange, gross, or personal you may consider a question to be, you’re probably not the first woman to ask it. In a 2012 survey of women aged 29–59 with symptomatic uterine fibroids that was conducted by Harris Interactive, concerns frequently cited by participants included:

  • Physical concerns, including: the potential for physical impairment, worsening of symptoms, future fibroid growth, health complications such as cancer, and impact on fertility
  • Employment-related concerns, including concerns about the ability to perform job-related duties and fear of missing work
  • Relationship concerns, including how fibroids will impact personal relationships, sex life, and home life

Your concerns are valid, and your doctor’s visit is the best time to get them addressed. Don’t be shy: whatever the question, chances are, you’re not the first fibroid patient to ask it!

 DO ARTICULATE YOUR PRIORITIES

Numerous treatment options are available to women with uterine fibroids, including pharmacological treatments, surgical and minimally-invasive options, and complementary and alternative therapies. In order for your doctor to recommend a course of treatment that fits your needs, he or she has to know what those needs are.

Perhaps the most important piece of information in this regard would be whether or not you want to get pregnant at some point in the future. Hysterectomy is notoriously overprescribed as a treatment for fibroids, yet it is obviously a poor option for women who desire to eventually get pregnant: a uterine-conserving procedure is usually a more suitable option in such cases.

DO EDUCATE YOURSELF

Too often, we hear women who have undergone hysterectomy saying they “wish they had known” about less invasive options for treating fibroids. While your gynecologist should – in theory – inform you about all of your treatment options, the best way to ensure the decision you make is an informed one is to inform yourself. Do some research in advance of your appointment, so you can use the visit as an opportunity to ask questions about the treatments you’ve investigated. There are numerous reputable websites that are loaded with information about uterine fibroids and new treatment options: a couple of good places to start are www.womenshealth.gov (published by the NIH) and www.reproductivefacts.org (published by the American Society for Reproductive Medicine. A hysterectomy is not for everyone, so get to know what other treatments are available to you; your subsequent discussion with your doctor will likely be more productive, as a result.

DO WRITE DOWN YOUR QUESTIONS IN ADVANCE

Most of us have, at some point, left a doctor’s office thinking “oh no, I forgot to ask about (insert pressing concern)”. It’s hard to remember everything you mean to ask when you’re in the midst of an exam or office discussion. Do yourself a favor and write those questions down. If you’re not sure what you want to ask, print out our handy list of “Questions To Ask Your Doctor” and bring it to your appointment.

 

THE “DON’T” LIST

DON’T SKIP THE GORY DETAILS

It’s not unusual to hear a woman with symptomatic fibroids share an anecdote about “sitting in the tub and just bleeding out” or describing how her bathroom regularly “looked like a warzone”. Sure, these are not dinner-table conversations, but the “colorful” details about symptoms like blood loss can actually be helpful to your doctor in diagnosing fibroids. Heavy menstrual bleeding is generally considered the definitive symptom of fibroids; but what constitutes “heavy” can be somewhat subjective for women experiencing the symptom. For this reason, describing gross realities like this can actually clarify the severity of your symptoms.

DON’T BE AFRAID TO SEEK A SECOND OPINION

If you don’t think that you have all the answers to your questions or you are not satisfied with the options that have been presented, you may want to get a second opinion.  It’s great to trust your physician; what’s more important, however, is that you feel comfortable with the decision you and he/she reach together. There’s no harm in seeking further information through a second opinion, even if you completely trust your doctor.

 

>> SEE ALSO:  Where Can I Learn More About Fibroid Treatment Options?

 

SOURCES:

Stewart, E. et al. “The Burden of Uterine Fibroids for African-American Women: Results of a National Survey”, Journal of Women’s Health. 2013; 22(10):807-16

 

 

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New Directions in Fibroid Treatment: The Acessa Guidance System

 

Fibroids have just become easier to treat. Why? Because a new application for an old technology has given practitioners of radiofrequency ablation the ability to target them with unprecedented precision.

Earlier this year, Acessa Health (the company behind Acessa Procedure), introduced the Acessa Guidance System¹. Developed as a supplement to the existing Acessa System, Guidance leverages electromagnetic tracking technology to provide precise fibroid targeting capabilities. In simple terms, it’s like a GPS system for the uterus.

How The Acessa Guidance System Works

Acessa Procedure, a minimally invasive method of treating fibroids that’s also known as radiofrequency ablation, treats symptomatic uterine fibroids laparoscopically, without harming the healthy uterine tissue that surrounds them. The procedure involves an instrument known as the Acessa handpiece, which applies focused radiofrequency energy directly to the fibroid, destroying the fibroid with heat (a process known as “ablation”). The Guidance component adds an electromagnetic tracking function to the handpiece, which, when coupled with ultrasound, provides a real-time view on the device’s trajectory to the targeted fibroid.

A Novel Use For Tried-and-True Technology

Electromagnetic tracking technology is not new. However, until the release of Acessa Guidance, the technology had never been applied in the field of gynecology. This application helps overcome a longstanding challenge in treating fibroids: efficiently accessing small and hard-to reach fibroids.

Historically, gynecologic surgeons have identified fibroids through pre-operative imaging. A variety of imaging techniques – including transvaginal ultrasound, sonohysterography, MRI, and diagnostic hysteroscopy – can be used to provide surgeons with a snapshot of the existing fibroid tumors. While they vary in cost and convenience, the fibroid imaging techniques have one thing in common: the images they generate are static.

Typically, surgeons use reference images to determine how to best reach the fibroid during surgery. In real time, however, movement can occur that makes a certain fibroid inaccessible by a path that appeared clear in the reference image. In the context of the previous analogy that likened Acessa Guidance to GPS, a reference image is the functional equivalent of a printed map.

In a recently published feasibility study, gynecologic surgeon Dr. Don Galen explains, “reference images…do not provide real-time, intraoperative findings. Lack of real-time imaging is especially problematic for the surgeon if the patient has symptomatic intramural fibroids or intramural fibroids abutting—but not distorting—the endometrium.”

Before its introduction to gynecology, electromagnetic tracking technology had already proven its value in other medical applications. Image guidance systems have been widely adopted for use in neurosurgical, hepatobiliary, and endoscopic procedures, among others, with positive results. Referring to a study of the technology’s application in hepatobiliary surgery, the Galen study noted: “These surgeons tested their ability, time, and mental workload when targeting the analog tumor under different controlled conditions. The guidance system significantly reduced the number of required needle withdrawals and repositionings, and…their mental workload.”

Guidance For Treating Fibroids

Galen has seen similarly positive results since the technology has been incorporated into the Acessa System to help with the targeting of fibroid tumors. He found the dynamic animation to be helpful in the process of targeting each fibroid, reaching the fibroid quickly, and visualizing the positions of the transducer and handpiece within the pelvic cavity during surgery. The feasibility study concludes:

Its significant application is in the targeting of those fibroids not readily visualized on laparoscopy (such as intramural fibroids) prior to ablation… Consequently, any technology that facilitates the targeting and treating of otherwise hard-to-reach fibroids is of benefit to the gynecologic surgeon as well as to the patient’s wellbeing.

With powerful image guidance technology enhancing an advanced, minimally invasive fibroid treatment procedure, treatment for fibroids is clearly moving in the right direction.

 

¹Patented AIM™ guidance software provided by InnerOptic Technology, Inc.

SOURCES:

Galen, D. “Electromagnetic image guidance in gynecology: prospective study of a new laparoscopic imaging and targeting technique for the treatment of symptomatic uterine fibroids”, BioMedical Engineering Online. Oct. 2015; 14:90.

“Halt Medical, Inc. Announces The First Acquisition Of Acessa Guidance System”, PR Newswire. June 27, 2016.

Metson, R. “The Role Of Image Guidance Systems for Head and Neck Surgery”, JAMA Otolaryngology. Oct. 1999; 125(10): 1100-1104

 

 

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Fibroid Treatments Demystified, Part V: Pharmacological Hormone Therapies

 

Uterine fibroids are almost always benign, but the debilitating symptoms experienced by an estimated 30% of women with fibroids can feel far from it. The nature and severity of fibroid symptoms depends on the size, and/or classification (submucosal, subserosal, intramural, or pedunculated) of the fibroids: common symptoms include abnormally heavy uterine bleeding, pelvic pain and bloating, abdominal pressure, urinary frequency, and constipation. A variety of surgical options are available to eliminate the tumors; for many women, however, the first step in addressing their condition is to seek relief of the symptoms through pharmacological treatments.

How Hormone Therapies Work

The majority of pharmacological products used to treat uterine fibroids do so by acting on the body’s hormonal balance. Research has shown that fibroid growth is fueled by hormones, specifically the hormones estrogen and progesterone. By directly or indirectly altering the levels of these hormones in the body, hormonal therapies can reduce the severity of fibroid symptoms like heavy bleeding and potentially shrink or inhibit the growth of fibroids. Approved hormonal therapies include GnRH agonists, oral contraceptives, progestins, aromatase inhibitors (AI), and other hormone-suppressing drugs like mifepristone.

Gonadotripin-releasing hormone agonists (GnRH-a) suppresses the body’s production of estrogen, creating a post-menopausal degree of estrogen deficiency. GnRH-a therapy has proven effective in both shrinking fibroids and managing symptoms like heavy bleeding. However, these effects are not sustained after discontinuing treatment. Use of GnRH agonists carries certain serious long-term health risks, including bone loss. Furthermore, because GnRH-a therapy essentially pushes the body into a menopausal state, women undergoing the treatment experience menopausal symptoms like hot flushes, vaginal dryness, weakness and fatigue, mood swings, and lowered libido. The negative effects of GnRH-a therapy can be countered by supplemental hormone treatments, but its associated health risks make GnRH agonists appropriate only for short term use, typically no longer than 6 months. Perhaps its most useful clinical application is rapidly shrinking large fibroids in preparation for surgical removal.

Oral contraceptives and progestins can be used for symptom relief, but their ability to reduce fibroid size is still uncertain. Studies have shown improvement in abnormal uterine bleeding with oral contraceptives. Drugs in this category, including lynestrenol, dienogest, and norethisterone, are considered relatively safe, and their low cost combined with potential benefit make them a promising choice for some women. However, women with pressure symptoms may not experience relief with oral contraceptives and progestins since they do little to shrink the fibroids or provide relief of bulk symptoms.

Aromatase inhibitors (AIs), part of a class of drugs known as anti-oestrogens, suppress the activity of the enzyme aromatase, which is responsible for the conversion of androgens into estrogens. Studies have suggested that use of AIs could inhibit fibroid growth and eliminate the need for surgery; however, further research has failed to provide sufficient evidence of this effect. Research surrounding the usefulness of AI’s in treating uterine fibroids continues, but in the meantime, the treatment is still considered experimental.

Mifepristone, a drug formerly known as RU486, belongs to a class of drugs known as progesterone receptor antagonists. As the category name implies, the drug acts on progesterone receptors. Mifepristone has proven effective in reducing uterine volume, thereby reducing blood loss and relieving related “bulk symptoms” like pelvic and lower back pain, abdominal pressure, and urinary frequency. The side effects of mifepristone are similar to GnRH-a therapy’s menopausal symptoms: hot flushes, mood swings, fatigue, and decreased libido are common, as well as headache, nausea, and diarrhea. In clinical trials, endometrial hyperplasia, a thickening of the uterine lining that creates a potential cancer risk, frequently resulted from mifepristone use. Due to a lack of data related to the safety outcomes of mifepristone use, the drug is not indicated for long-term use.

Comparing Pharmacological Treatment Options

How do these various hormonal therapies compare in terms of effectiveness? Comparative study data is still somewhat limited. One study compared the oral progestin lynestrenol with leuprolide, a GnRH agonist, and found no significant difference in their effectiveness for relieving pelvic pain and heavy bleeding. A separate, randomized clinical trial compared the GnRH agonist triptorelin with an aromatase inhibitor called letrozole, and revealed similarly significant decreases in fibroid volume (33% and 45%, respectively) with both therapies. In the latter study, however, none of the women treated with the aromatase inhibitor reported experiencing hot flushes, whereas 96% of the women taking a GnRH-a did. All of the approved hormonal therapies have shown some degree of effectiveness in treating fibroid-related symptoms; what determines their relative usefulness is predominantly the patient’s unique health history, as well as the nature and severity of each drug’s known side effects.

Limitations

While the available treatments vary in their mechanism for altering hormone levels, the hormonal therapies have a common limitation: they are not meant for long-term use. Clinical studies have consistently associated safety concerns with continued use of hormonal therapies in the treatment of fibroids. For many women, however, pharmacological treatments are an appropriate first step in addressing symptomatic fibroids. When symptoms persist and fibroids continue to impact a woman’s quality of life after trying a pharmacological treatment, a surgical approach would be an appropriate next step. For women concerned about the invasiveness of surgery, or the potential harm to the uterus that a procedure like hysterectomy entails, less invasive surgical options are worth consideration. Minimally invasive, uterine-sparing fibroid treatments like the Acessa Procedure offer a quicker recovery then major surgeries like hysterectomy, while providing the longstanding results that pharmacological therapies cannot.

 

SOURCES:
Levy, B. S. “Modern Management of Uterine Fibroids”, ACTA Obstetricia et Gynecologica, 2008, pp. 812-823

Song, H. et al. “Aromatase inhibitors for uterine fibroids”, Cochrane Database for Systematic Reviews/Cochrane Library, Oct 23, 2013. Web: http://onlinelibrary.wiley.com/enhanced/doi/10.1002/14651858.CD009505.pub2. Retr: Aug 1,2015

 

 

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Fibroid Treatments Demystified, Part IV: Myomectomy

 

Myomectomy, a widely practiced method of removing subserosal or intramural uterine fibroids, is an alternative to hysterectomy for fibroid patients seeking uterine preservation.

How Myomectomy Works

In myomectomy, a surgeon removes one or more fibroids by cutting them out of the uterine wall. While incisions are made in its tissue, the uterus itself ultimately stays in place. Depending on the type and location of the fibroids, myomectomy may be performed laparoscopically (accessing the uterine cavity through abdominal incisions) or hysteroscopically (accessing the uterine cavity by way of the vagina).
The method used for performing myomectomy dictates the recovery and hospitalization time. Post-operative hospital stays currently range from 0-2 days, and recovery time ranges from 4-6 weeks.

Treatment Outcomes

Myomectomy patients typically see an enduring reduction in symptoms: in a recently published study, the research team of Pitter et al. reported that 62.9% of the myomectomy patients in their study population were free of symptoms at three years post-procedure.

Once a fibroid is completely removed, it will not grow back. That is not to say, however, that new fibroids won’t develop, potentially triggering the return of symptoms. A study by Yoo et. al assessed the probability of fibroid recurrence in laparoscopic myomectomy patients over an 8-year follow-up period. The researchers observed that the cumulative probability increased steadily from 11.7% at 1 year post-procedure to 84.4% at the 8 year mark. Factors influencing fibroid recurrence were found to be patient age, number of fibroids, pre-operative uterine size, and childbirth following the procedure. Another team of researchers, Obed et al., added family history of fibroids and multiple symptoms as to that list of factors, and concluded from their own study that “there is a high recurrence of uterine fibroids following myomectomy”.

Risks associated with myomectomy include post-surgical adhesions and both intra- and post-operative bleeding. Dubuisson et al. observed adhesions, or scars produced as incisions in the uterine tissue heal, in 35.6% of patients during “second-look” laparoscopy; this result that has been corroborated by additional studies. Cases of uterine rupture during pregnancy following a laparoscopic myomectomy have also been reported.

Since a myomectomy does not involve removal of the uterus, it is possible to preserve the patient’s fertility. Research largely suggests that myomectomy is an appropriate procedure for fibroid patients who desire pregnancy. That said, certain complications associated with myomectomy, such as adhesions, can, themselves, impair fertility – a fact that should be taken into account when considering the fertility-sparing aspects of the procedure.

One technique for removing larger fibroids through small ports in laparoscopic myomectomy, called power morcellation, has recently been the subject of major controversy. In power morcellation, a tool called a morcellator is used to dissect large fibroids, so that the dead tissue may be more easily extracted without expanding the abdominal incisions. In April 2014, the Federal Drug Administration (FDA) released a safety communication notice discouraging use of power morcellation, citing concerns that the technique could spread cancerous cells within the abdominal cavity if it came in contact with cancerous tissue. While uterine fibroids (also called leiomyomas) are almost always benign, the rare fibroid (about 1 in 1,000) that is malignant may not be detected as such in advance of surgery. Several manufacturers of the power morcellator have since pulled the device from the market, and power morcellation is now rarely used in laparoscopic myomectomies.

 

 

SOURCES:

Pitter, M.C. et al. “Fertility and Symptom Relief following Robot-Assisted Laparoscopic Myomectomy”, Obstetrics & Gynecology, Apr 19, 2015. ePub. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4417601/. Retrieved July 2, 2015

Yoo, E. et al. “Predictors of leiomyoma recurrence after laparoscopic myomectomy.” Journal of Minimally Invasive Gynecology, Nov-Dec 2007; Vol. 14(6):690-7

Obed et al. “Uterine fibroids: risk of recurrence after myomectomy in a Nigerian population.” Archives of Gynecology and Obstetrics, Feb 2011; Vol. 283(2):311-5

Dubuisson J.B., et al. “Second look after laparascopic myomectomy”, Human Reproduction. 1998; Vol. 13:2102–6

“FDA discourages use of laparoscopic power morcellation for removal of uterus or uterine fibroids”, FDA News Release, Apr 17,2014. Web: http://www.fda.gov/newsEvents/Newsroom/PressAnnouncements/ucm393689.htm. Retrieved July 2, 2015.

 

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Fibroid Treatments Demystified, Part III: Focused Ultrasound

 

Among the hysterectomy alternatives available to women with fibroids is the high intensity focused ultrasound approach (HIFU), more specifically identified as Magnetic Resonance Guided Focused Ultrasound (MRgFUS). MRgFUS is a thermoablative technique that destroys fibroids by focusing a high-intensity beam of ultrasound energy on specific tissue.

Performed as an outpatient procedure, the focused ultrasound method is entirely non-invasive: no insertion of a catheter or needle is necessary, and no cutting is involved. The MRgFUS procedure is approved by the FDA for use in premenopausal women with symptomatic fibroids who have completed childbearing. While certain limitations prevent the technique from being widely used or universally appropriate, its effectiveness in reducing symptom severity and improving patients’ quality of life has been demonstrated in a variety of cases.

How Focused Ultrasound Works

MRgFUS is performed without anesthesia, under conscious or no sedation, by a physician, with the patient in an MRI unit. Using magnetic resonance imaging (MRI) allows the practitioner to achieve clear visualization of the reproductive organs and provides real-time thermal monitoring, enabling the practitioner to optimize the ultrasound treatment’s ablative effects. The physician then directs high intensity ultrasound waves to a small area of fibroid tissue, destroying the targeted tissue with thermal energy. The ultrasound beam has a frequency range of approximately 1–1.5 MHz, which is on the low end of the spectrum for diagnostic ultrasonography. Immediately following the treatment, the patient is injected with an MRI contrast agent called gadolinium, which allows the practitioner to view the treatment’s impact on the fibroid’s vascular structure.

Treatment Outcomes

Patients who undergo a focused ultrasound procedure typically experience rapid recovery. Symptom improvement is usually seen within the first three months post-procedure, and research has shown this improvement to be sustained through 24 to 36 months in most cases.

While generally effective, focused ultrasound therapy is limited in its usefulness. For example, MRgFUS cannot be performed effectively if certain kinds of structures—such as the bowel, the pelvic bone, a skin fold, or an implanted device — are obstructing the path to the fibroid. Furthermore, characteristics of the fibroids themselves—including size, vascularity, and placement—can sometimes make them difficult to treat. The maximum size treatable is uncertain; however, most practitioners surveyed indicated that fibroids larger than 10cm are generally more difficult to treat with focused ultrasound.

Since focused ultrasound is limited in its ability to target all fibroids, repeated treatments are often required: Stewart et. al found that, “With minimal [initial] treatment the probability of additional treatment exceeds 50% at 24 months, but this is substantially reduced with increasing ablation”.

The MRgFUS procedure is not widely available, mostly due to cost: few clinics are equipped with the high-priced system, and insurers are not typically inclined to cover costly procedures. On the positive side, short-term morbidity is low and the recovery time is short. No specific pattern of complications with pregnancy has been identified; however, the procedure is not indicated for women who plan to get pregnant. For others who are seeking a uterine-sparing, non-invasive treatment to relieve symptomatic fibroids, the focused ultrasound approach may be a viable option.

 

SOURCES:
Stewart, E. et al. “Clinical Benefit of Focused Ultrasonography”, Obstetrics & Gynecology. Aug. 2007; Vol.110(2):279-287
InSightec, “MR Guided Focused Ultrasound for Uterine Fibroids”, Information for Prescribers: ExAblate Version 2.46. Revised Nov. 2004
“HIFU Treatment (High Intensity Focused Ultrasound).” Uterine Fibroids. Retrieved June 26, 2015. http://www.uterine-fibroids.org/hifu.html.

 

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What Is A GnRH Agonist?

If you’ve done a little homework on fibroid treatments or discussed treatment options with your gynecologist, you may have encountered the term “GnRH agonist”. Here’s what it is: GnRH stands for Gonadotrophin Releasing Hormone; it is a hormone that the body naturally produces and in women, it serves the function of stimulating egg production in the ovaries. The term “agonist” refers to a synthetic drug that simulates the body’s own, naturally produced material (or in this case, hormone).  Supplementing the body’s natural supply of GnRH with a GnRH agonist effectively inhibits the ovaries’ production of estrogen and testosterone, pushing the body into a menopausal state.

GnRH agonists have multiple uses in reproductive medicine, including treating pain associated with endometriosis and temporarily relieving symptoms of uterine fibroids. GnRH agonists can be used to treat heavy bleeding, one of the most common symptoms experienced by fibroid sufferers and women with endometriosis. In fact, for women taking GnRH agonists, bleeding tends to cease altogether, a condition known as amenorrhea. In this way, the treatment (also referred to as “GnRH analogue therapy”) helps to resolve anemia and a low blood cell count. When taken in advance of surgery, GnRH agonists can reduce the likelihood of a blood transfusion being required.

Furthermore, the drug’s significant effect on the growth of fibroids has been observed in many clinical studies. It’s not surprising: fibroids, benign uterine tumors, are estrogen-dependent. When estrogen levels in the body drop, fibroids shrink. By decreasing the body’s estrogen production, GnRH agonists—commercially available in such drugs as Lupron, Zoladex, Synarel, Buserelin, and Prostap—cause fibroids to shrink. Research indicates that continuous use of a GnRH agonist reduces fibroid size by approximately 50% after 3 months. Due to its fibroid-shrinking properties, GnRH agonists are commonly prescribed to women who are scheduled to undergo myomectomy; shrinking the fibroids in advance of the procedure minimizes the invasiveness of their extraction through laparoscopic surgery.

The most common symptoms experienced by patients undergoing the hormone-suppressing treatment are the symptoms typically associated with menopause: these can include hot flashes, vaginal dryness, moodiness or depression, headaches, and loss of bone density. “Add-back” hormone therapies (i.e. taking estrogen drugs) can usually provide some relief from these symptoms, without undermining the effectiveness of the primary therapy. No permanent side effects have been noted in human studies, though GnRH agonists are not indicated for long-term use. Studies have demonstrated the continuous use of a GnRH agonist, in conjunction with hormone add-back therapy to counteract bone density loss and other symptoms of estrogen deficiency, to be safe and effective for up to 2 years.

While the effects of taking a GnRH agonist may be profound, they are not permanent. Once the GnRH agonist is discontinued, estrogen levels start to return to the pretreatment state, reversing menopausal symptoms triggered by the treatment. In a study conducted by the research team of Rein et al., fibroid patients who were treated with a GnRH agonist became amenorrheic shortly after starting treatment. Four to ten weeks after discontinuing the treatment, the patients’ menses returned. The researchers also observed a rapid regrowth of fibroids once patients discontinued the GnRH agonist therapy. However, since fibroid patients GnRH agonists are most commonly prescribed in preparation for myomectomy, regrowth of fibroids following cessation of the drug is not a matter of concern.

 

SOURCES:

  1. Rein M. S. et al. “Fibroid and myometrial steroid receptors in women treated with gonadotropin-releasing hormone agonist leuprolide acetate” Fertility & Sterility. 1990; Vol. 53: pp.1018-1023
  2. American Society for Reproductive Medicine, “GnRH Agonist Therapy”, ReproductiveFacts.org: 2011. Retrieved July 10, 2015, from https://www.asrm.org/detail.aspx?id=1884
  3. Burbank, F. Fibroids, Menstruation, Childbirth, and Evolution, pp. 93-98. Wheatmark, 2009. Tucson, AZ.
  4. Friedman, A.J. et al. “Long-term medical therapy for leiomyomata uteri: a prospective, randomized study of leuprolide acetate depot plus either oestrogen-progestin or progestin add-back for 2 years”, Human Reproduction. 1994; Vol. 9: pp.1618-1625

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Where can I learn more about fibroid treatment options?

If you have been newly diagnosed with fibroid tumors or fear that you might have developed one or more fibroids, it is valuable to educate yourself on the condition and all of the treatment options available. These days, Internet research is, the preferred and most convenient method of obtaining information. With the vast amounts of medical information and fibroid-related websites that are floating around in cyberspace, however, you may not know where to start, or which online sources are reliable. For those fibroid sufferers who prefer to do research offline, certain sources are also more reliable than others. To ensure that the information you’re getting is trustworthy, follow these tips:

Government and Academic Websites

Not all websites are created equal, and bogus information can often be packaged in very fancy or official-looking websites. (Didn’t your mother warn you to not trust everything you read on the Internet?) Generally speaking, websites with URLs ending in “.gov” or “.edu” are going to be some of the most trustworthy sources of medical information, because their contents are produced and verified by government or educational institutions, respectively.

PubMed.gov [link: http://www.ncbi.nlm.nih.gov/pubmed/] is operated by the National Institute of Health and is an extension of the US National Library of Medicine; it contains a massive database of research studies, clinical data, and medical journal articles. The U.S. Department of Health and Human Services operates WomensHealth.gov [http://www.womenshealth.gov/index.html], where fibroid patients can find a wealth of information on fibroids and their treatment.

Additionally, reputable medical schools with affiliated women’s health clinics typically provide general information on gynecological conditions, as well as information on fibroid treatments that their clinics perform and any clinical trials in which their institution is participating. The Women’s Health Center at the University of California, San Francisco (UCSF) operates a dedicated Comprehensive Fibroid Center [http://coe.ucsf.edu/coe/fibroid/index.html], where cutting-edge treatments and fibroid research are continually being performed.

Websites of National Health Organizations

In addition to government and academic websites, websites published by nationally-recognized associations, such as the American Society for Reproductive Medicine’s ReproductiveFacts.org [http://www.reproductivefacts.org/] can be good resources for information on gynecological conditions like Uterine Fibroids.

Websites of FDA-Regulated Products

Websites belonging to companies that develop and/or manufacture fibroid treatments (such as acessaprocedure.com), are also excellent resources for learning about your treatment options, since the accuracy of the information they contain must follow FDA requirements and are sometimes included in FDA audits. Companies manufacturing fibroid treatments typically offer ample information about the procedure, device, or drug or their website, and any product claims made on sites by these FDA-regulated products must be substantiated by clinical data. Be advised that such quality assurance does not necessarily exist, however, with the websites of companies that sell or endorse homeopathic or “alternative” fibroid treatments, however, because the claims of products or procedures of this nature may not have been approved or cleared by the FDA; thus, you may want to double-check any information obtained about your condition from those sites.

Your Physician

While you can probably find out everything you ever wanted to know about the condition and treatment of Uterine Fibroids on the Internet, a knowledgeable, licensed gynecologist is still the best source of advice on treating your individual case. As with any medical condition, no single treatment is appropriate for every patient. A physician has the ability to consider your unique medical history, state of health, and the nature/severity of your fibroids when recommending a course of treatment.
***
If you have not yet been diagnosed with fibroids and are experiencing abnormal symptoms like heavy menstrual bleeding, abdominal or lower back pain, and severe bloating, protect your health by seeing a doctor as soon as possible. Once you have seen a doctor and know exactly what you’re dealing with, you can start exploring your options for relieving those burdensome symptoms, treating their underlying cause, and moving on with your life.

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Endometrial Ablation vs. Radiofrequency Ablation: What’s The Difference?

 

The term “ablation” refers to a process by which tissue is destroyed, typically using either heat (thermal ablation) or cold (cryoablation). Ablative technologies are used to treat numerous medical conditions, including gynecological issues. We often hear of two procedures in particular, endometrial ablation, and radiofrequency ablation, and many people confuse the two treatments. Don’t let the similar names deceive you though: while both procedures leverage ablative technology, they are very different in their applications. To clear up the confusion, here’s a rundown on the defining characteristics of the two ablation therapies.

Endometrial Ablation (EA)

How EA Works
Endometrial ablation is typically used to treat prolonged, abnormal uterine bleeding. It does so by ablating the lining of the uterus, known as the endometrium, permanently destroying the tissue. There are several different methods of endometrial ablation: these include freezing (cryoablation techniques), directly applying heat from fixed-frequency microwaves or radiofrequency energy; and using hot fluid through techniques like balloon endometrial ablation.

In EA, treatment is limited to the endometrial layer, the surface tissue that lines the uterine cavity, and the basalis layer, where the endometrial tissue originates. Destroying the basalis layer prevents new tissue from growing, thereby reducing or eliminating menstrual bleeding.

EA procedures are performed in an office or hospital setting, usually with the patient under conscious sedation. Patients typically go home the same day, and full recovery takes about 1-2 weeks, depending on the specific procedure.

Outcomes
Endometrial ablation is used to control prolonged, abnormal vaginal bleeding. EA is most appropriate for patients that have completed childbearing, who have not seen results from other treatment approaches, and who are seeking an alternative to hysterectomy.

In most cases, EA meets its objective: an estimated 9 out of 10 women have lighter periods or no periods after undergoing the procedure. However, it’s difficult to predict whether a woman’s bleeding will stop completely. Estimates regarding the incidence of amenorrhea (the absence of menstrual bleeding) after EA vary widely from one study to the next, but it’s typically estimated to fall between 20% and 50%. A study by El-Nashar et al. asserted that the likelihood of amenorrhea occurring after EA depends on the type of ablative technology used, as well as patient characteristics like age and uterus size. Regardless, amenorrhea is not a guaranteed outcome. “If… a woman’s goal is amenorrhea, hysterectomy is the only reliable op¬tion,” reports Dr. Joseph Sanfilippo in an update to the medical community on EA-related developments.

It is important to note that endometrial ablation is not indicated for the treatment of uterine fibroids; any destruction of fibroids in the process of ablating the endometrium is incidental. Fibroids that grow partially or entirely within the walls of the uterus (known as intramural fibroids), as well as those growing outside the uterus (subserosal fibroids), are not reached during ablation. Those that protrude into the uterine cavity (submucosal) are sometimes shaved down hysteroscopically before ablation; however, if the fibroid originates below the basalis layer of tissue, it cannot be completely eradicated during ablation and may grow back, following the procedure.

Radiofrequency Ablation (Acessa Procedure)

How RFVTA Works
Radiofrequency ablation (short for “radiofrequency volumetric thermal ablation”, or RFVTA) is a specific ablation technique that is used to treat uterine fibroids in a procedure known as Acessa. In the Acessa procedure, a controlled volume of heat is applied directly to the fibroid, killing the tissue of the fibroid while leaving healthy surrounding tissue unharmed. Once the fibroid is destroyed, the dead tissue is simply reabsorbed by the body.
In performing RFVTA, a scope and a laparoscopic ultrasound probe are inserted through the abdominal incisions. Using the scope in conjunction with the ultrasound probe allows the operating physician to precisely pinpoint the fibroids’ location. Once the fibroids have been located, the surgeon uses a special tool with a retractable electrode array (the Acessa handpiece) to ablate the fibroid with radiofrequency energy.
RFVTA is performed in an outpatient setting. The surgery is minimally invasive: with the exception of two tiny incisions (no wider than 1/4 inch) on the abdomen, there is no cutting or suturing of uterine tissue. Patients go home the same day and return to normal activities within 2-3 days.

Outcomes
Clinical research has shown radiofrequency ablation to be very effective in shrinking or completely eliminating fibroids. The use of laparoscopic ultrasound reduces the risk of symptom recurrence by allowing the physician to find and treat all fibroids present in the uterus, not just the ones that were identified through previous diagnostic imaging. At 36 months post-treatment, 90% of patients needed no additional fibroid treatment. Though objectively measured bleeding at 12 months of follow up decreased in 82% of the women treated with RFVTA, the goal of treatment was not to destroy the endometrium or induce amenorrhea but merely to treat the fibroids.
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In the field of gynecology, ablation techniques can be used in addressing multiple conditions but it’s important to understand the difference between the technologies. Radiofrequency ablation with Acessa is an effective method for treating only the uterine fibroids without harming the rest of the uterus, whereas endometrial ablation effectively controls abnormal vaginal bleeding by directly ablating the lining of the uterus. Their usefulness is entirely related to their objective, and despite the commonality of a name, these procedures are very different in the objectives they serve.

SOURCES:

  1. American Society for Reproductive Medicine, “Endometrial Ablation”, ReproductiveFacts.org: 2011. Retrieved May 28, 2015, from http://www.reproductivefacts.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/endoablation.pdf
  2. El-Nashar, S.A. et al. ” Prediction of Treatment Outcomes After Global Endometrial Ablation”, Obstetrics & Gynecology, Jan. 2009; 113(1): 97–106. doi:10.1097/AOG.0b013e31818f5a8d.
  3. Sanfilippo, J. “Update: Options in Endometrial Ablation”, Supplement to OBG Management, Dec. 2009
  4. Berman, J.M. et al. “Three Years’ Outcome from the Halt Trial: A Prospective Analysis of Radiofrequency Volumetric Thermal Ablation of Myomas”, The Journal of Minimally Invasive Gynecology, 2014.

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Fibroid Treatments Demystified, Part II: Radiofrequency Ablation (Acessa Procedure)

How Radiofrequency Ablation (RFVTA) Works

Acessa’s RFVTA is performed laparoscopically in an outpatient setting, with the patient under general anesthesia. The surgeon makes two tiny abdominal incisions (no wider than 1/4 inch), and inserts a scope, which allows for visualization of the uterus, followed by a laparoscopic ultrasound probe which is used to detect fibroids not seen through the scope. Once fibroids have been located, the surgeon uses a special probe (the Acessa handpiece) with a retractable electrode array to directly apply a controlled volume of heat to the fibroid. Once treated with heat, the destroyed fibroid tissue shrinks and is typically reabsorbed by the body. The treatment targets only the fibroid tissue, so healthy tissue in surrounding organs is unharmed.

Treatment Outcomes

Clinical research has shown radiofrequency ablation to be very effective in shrinking or completely eliminating fibroids. The use of laparoscopic ultrasound reduces the risk of symptom recurrence by allowing the physician to find and treat all fibroids present in the uterus, not just the ones that were identified through previous diagnostic imaging. Study data from the team of Chudnoff et. al indicate that, at 12-months post-treatment, 94% of RFVTA patients had seen lasting reduction in symptoms and improved quality-of-life, and device-related complications were low (3.6%). A study by Guido et al. affirmed the findings of Chudnoff’s team and reported that 6 of 124 patients (4.8%) required surgical reintervention for fibroid-related bleeding between 12 and 24 months post-treatment. After three years of follow-up in the same group of patients, Berman et al. reported that symptom reduction and quality of life were sustained.

Limited data exists regarding fertility and pregnancy outcomes related to RFVTA, so RFVTA cannot yet be indicated for women seeking pregnancy. Commenting on the results of an early feasability study, Lee et. al reports, “future pregnancy and potential vaginal delivery post RFVTA are being explored in three trials, respectively, in Canada, California, and Germany.”

Radiofrequency ablation is a uterine-sparing procedure, and it is a less invasive surgical option for women who are looking to avoid hysterectomy. Since it is one of the newer fibroid treatments available, women may be challenged to find doctors who are trained in the procedure. However, as awareness and demand for the procedure grows, additional doctors will seek training in the technique of radiofrequency ablation for the treatment of uterine fibroids. In a 2013 article profiling Acessa’s RFVTA, Dr. James Macer commented, “patients are increasingly aware of uterine sparing treatments for symptomatic fibroids. Women seek conservative procedures to avoid the risks and extended recovery times commonly associated with major surgery.”

 

SOURCES:

  1. American Society for Reproductive Medicine, “Treatment of Uterine Fibroids”, ReproductiveFacts.org: 2011. Retrieved May 25, 2015, from http://www.reproductivefacts.org/FACTSHEET_Treatment_of_Uterine_Fibroids/
  2. Berman, J.M. et al. “Three years’ outcome from the Halt trial: a prospective analysis of radiofrequency volumetric thermal ablation of myomas,” Journal of Minimally Invasive Gynecology. 2014; 21(5):767-774
  3. Chudnoff, S. et al. “Outpatient procedure for the treatment and relief of symptomatic uterine myomas”, Obstetrics and Gynecology. 2013; Vol. 121(5):1075-1082
  4. Guido, R. et al. “Radiofrequency volumetric thermal ablation of fibroids: a prospective, clinical analysis of two years’ outcome from the Halt trial”, Health Quality Life Outcomes. 2013; Vol. 11(139):1-8
  5. Lee, B. et al. “Ch. 9: Radiofrequency Volumetric Thermal Ablation of Symptomatic Uterine Fibroids: The Acessa Procedure.” In Leiomyomas: Risk Factors, Clinical Manifestations and Treatment Options, edited by A. Al-Hendy and S. Salama, p. 186-190. Nova Science, 2015.
  6. Macer, J. “For uterine-sparing fibroid treatment, consider laparoscopic ultrasound-guided radiofrequency ablation”, OBG Management. Nov. 2013; Vol. 25(11):50-55

 

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Fibroid Treatments Demystified, Part I: Uterine Artery Embolization

Many women of reproductive age seek uterine-sparing methods of fibroid treatment: uterine artery embolization (UAE), sometimes called uterine fibroid embolization (UFE), is one of the hysterectomy alternatives available to women with fibroids.

How UAE Works

Uterine artery embolization (UAE) is a minimally-invasive procedure that is performed by an interventional radiologist. UAE treats fibroids “in situ”, meaning ‘in place’, by cutting off their blood supply and causing them to die from what is known as “ischemic necrosis”. To do so, an interventional radiologist inserts a catheter through the femoral artery (located in the upper thigh) and into the uterine artery, which supplies blood to the uterus. A type of material known as an “embolic agent” is then injected through the catheter, into the blood vessels that supply blood to the fibroids. Typical embolic agents include polyvinyl alcohol (PVA), gelatin sponge plegets, or gelatin microspheres. Once injected, particles of the agent block the blood supply to the tiny arteries that carry blood to the fibroids. Without adequate blood flow, the fibroids shrink and, ultimately, die.

Treatment Outcomes

UAE is successful in diminishing fibroids and associated symptoms in an estimated 85% of cases. For patients who are looking for a minimally invasive fibroid treatment, embolization’s non-surgical approach is appealing. The recovery period is generally short, though it is notoriously painful. Fred Burbank, author of Fibroids, Menstruation, Childbirth, and Evolution, states “nearly all women who undergo [UAE] have severe pelvic pain generally lasting 4 to 6 hours, but others, lasting up to a day” (p.124). The American Society For Reproductive Medicine also notes, “patients typically experience several days of pain after the procedure”. Many women are hospitalized overnight for pain control.

The incidence of fertility-compromising outcomes has called into question the appropriateness of the procedure for women seeking to get pregnant, though additional research is needed to assess the risk. Here’s what researchers do know: once the embolic agent has been injected, the particles stay in the body. In some cases, those particles can migrate to the ovarian blood supply, compromising fertility and triggering the onset of menopause. Burbank describes the physiological process after injection of the embolic agent:

Anatomically, connections exist that allow particles injected into the uterine artery to reach any structure supplied by branches of the uterine artery. The physiology of blood flow from the uterine artery to its branches determines the relative number of particles that reach the myometrium, fibroids, and the ovaries. Injected particles are indifferent to where they go.(p.111) A significant number of women who undergo UAE become amenorrheic (cease to have periods)as a result of the procedure; however, research has indicated that younger patients see fewer complications of this nature. A longitudinal study by Goodwin et. al found that, at 36 months post-procedure, approximately 85% of patients had no intervention but 28.6% of UAE patients were amenorrheic with the largest proportion(78.9%) of patients over the age of 45.

UAE isn’t right for everyone: women with fibroids should talk to a gynecologist about the risks and benefits of UAE and other available fibroid treatment options, before seeking treatment. However, as one of the less invasive methods for treating fibroids, UAE helps meet the growing demand for alternatives to hysterectomy.

SOURCES:

  1. American Society for Reproductive Medicine, “Treatment of Uterine Fibroids”, ReproductiveFacts.org: 2011. Retrieved May 25, 2015, from http://www.reproductivefacts.org/FACTSHEET_Treatment_of_Uterine_Fibroids/
  2. Goodwin, S. et al./Fibroid Registry for Outcomes Data (FIBROID) Registry Steering Committee and Core Site Investigators.”Uterine Artery Embolization for the Treatment of Leiomyomata: long term outcomes from the FIBROID Registry”, Obstetrics & Gynecology, Jan 2008; Vol 11(1):22-33
  3. Burbank, F. Fibroids, Menstruation, Childbirth, and Evolution, p. 110. Wheatmark, 2009. Tucson, AZ.

 

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