Question:
I just turned 39. I had the fibroid embolization surgery in January 2005, and it went well. I had regular periods immediately after the surgery, but I have not had a period since my gynecologist removed many dead fibroids on January 5, 2006. My last period was December 26, 2005 and I am worried about my fertility.

Dr. Shlansky-Goldberg responds:
You should discuss this with your gynecologist. There is a percentage of patients that will go into menopause immediately after the procedure. It is age-dependent and at 39 the percentage is low. Since you had normal periods after the UAE and stopped after the surgery, I would discuss this with your gynecologist.

Dr. Clarisa R. Gracia responds:
It may be helpful to have some blood tests performed to see whether this reflects menopause. There are other tests that may be useful as well to determine the cause of your not having periods.

Question:
I just had an MRI performed and my fibroids were 22 centimeters. My doctor said that I would not be a good candidate for UAE because of the size of the fibroids- what does he mean?

Dr. Shlansky-Goldberg responds:
A 22-centimeter fibroid is extremely large and depending on your symptoms, UAE might not help. I would review your images with an Interventional Radiologist if you have not done that to discuss the risks and benefits of the procedure. When you say a “good candidate” it really depends on what your symptoms are.

Question:
I went to my OB/GYN because my period cramps were so painful that I felt as if I were in labor. I had shooting pain in my rear end and my cramps were so bad I felt like I was going to faint or throw up, yet there was very little blood. My doctor’s first thought was that I had a cyst on my ovary, but when he checked he couldn't find my left ovary because it was hidden by my uterus.

My uterus is enlarged and hurts terribly when touched, and although I did not have any cyst of any kind I did have an infection because my uterus is not shedding its lining during my period. What is the cause of this, and will it go back to normal with the antibiotics and yeast medicine he gave me? My husband and I are trying to have our third child and we are having a difficult time conceiving. Could this be a possible reason?

Dr. Shlansky-Goldberg responds:
If "this" is fibroids, they could give some of the same symptoms but other things could also. A gynecologist would be best at working out your complaints.

Dr. Clarisa R. Gracia responds:
It sounds as if your gynecologist is treating you for a pelvic infection. If this is the cause of your symptoms, they should get better with antibiotics. However, at this point it is difficult for me to know why you are having difficulty conceiving. If you have been trying to conceive unsuccessfully for a year, you should seek care from a fertility specialist.

Question:
My OB/GYN said my uterus is slightly enlarged and that it could be normal for someone my age (43) after three kids or it could be fibroid tumors. I have had some spotting four to five days before my periods for the last two years but had it checked two years ago and everything was fine. Aside from fibroid tumors, what else could cause an enlarged uterus? I’m having an ultrasound soon but I’m scared that my enlarged uterus could be caused by something worse.

Dr. Shlansky-Goldberg responds:
This is question best answered by a gynecologist. An ultrasound would be the first thing used to sort this out. If questions remain, an MRI could also be used.

Dr. Clarisa R. Gracia responds:
Two conditions that often cause an enlarged uterus are fibroids and adenomyosis. Cancerous tumors of the uterus are rare. An ultrasound is a good first step to figure out why your uterus is enlarged.

Question:
I am 40 years old, and I had uterine embolization in February of last year. After a recent MRI scan I was told by my doctor that most of my external fibroids are “dead” and that my uterine size has been reduced by 65%, but that there is still one fibroid on the outside of my uterus (measuring about 2 centimeters) that is partially “alive.” I also have one dominant fibroid that is centrally located in my uterus, and my doctor said I might consider removal by hysteroscopy resection.  

By “dead,” does my doctor mean that the fibroids will no longer continue to grow? How does my current condition (status of fibroids and age) affect my ability to have children? Once you have the UAE, does it take longer for you to heal if you are over 40?

Dr. Shlansky-Goldberg responds:
If the fibroid is completely dead with no blood flow shown by MRI then it should not grow anymore, and new fibroids rarely develop. There is no data to suggest that healing time is different dependent upon age. Fertility is a difficult question to answer; it would best be discussed with a gynecologist specializing in fertility.

Dr. Clarisa R. Gracia responds:
Your fertility status is difficult to determine. While pregnancies have been reported after UAE, it is not clear if this procedure makes it more difficult for a woman to conceive and carry a child. In addition, we know that it becomes more difficult to conceive as you age, especially after age 40. Finally, if you have a fibroid within the uterine cavity, this may contribute to infertility. It may be wise to seek further counseling from an infertility specialist.

Mars asks:
I just found out about a month ago by my Ob/Gyn that I have a enlarged fibroid as big as a softball in my uterus. I had a miscarriage almost ten years ago and I was not ready to get pregnant again. Now I am 33 years old and ready. But now I have this.

My doctor suggested that I get a second opinion to see a fertility specialist. My doctor had stated that there might be a 50 percent chance I might lose my uterus. I do not know what I should be doing.

Response:
An infertility specialist, also know as a reproductive endocrinologist, is a Gyn that has the expertise to help you optimize your chances for a successful pregancy. This may require a myomectomy which is the procedure that would remove your fiborid.

Uterine artery would not be the best option for several reasons and is not usually the first line therapy for a patient who desires fertility. An appointment with doctor from Penn Fertility Care would be useful.

If you would like to schedule an appointment, you can do so by calling
1-800-789-PENN (7366) or you can also request an appointment online.

Nenna asks:
I just had a sonogram and just discovered that the fibroids are all over my uterus, both inside and outside the walls of my uterus. The biggest one is as big as a four-month fetus. Am I still a candidate for
embolization?

Dr. Richard Shlansky-Goldberg responds:
Position is not usually a problem except under certain rare circumstances. Many Interventional Radiologists would obtain an MRI make sure of your anatomy with respect to the fibroids.

Faylicia asks:
Can a living fibroid cause odor in the uterous?

Dr. Richard Shlansky-Goldberg responds:
Usually a fibroid will not cause odor. An odor may be due to an infection and should be evaluated by a gynecologist. For more information or to make an appointment with a Penn specialist, contact 1-800-789-PENN (7366) or schedule an appointment online.

Cibyll asks:
What could cause an enlarged uterus?

Dr. Scott Trerotola responds:
Benign tumors of the uterus called fibroids are the most common cause of an enlarged uterus. An ultrasound test can help determine the cause of an enlarged uterus when one is detected on physical examination by a gynecologist. If fibroids are the cause of the enlargement, one of several treatment options is uterine artery embolization.

Red asks:
What is the percentage of women getting a repeat embolization
for fibroids?

Dr. Richard Shlansky-Goldberg responds:
That number is very small since the success rate of UAE is relatively high so that repeat embolization is not needed. In addition, once the uterine artery is blocked, it is usually can not be re-embolized. Most often new bleeding is caused by other vessels.

Chandra asks:
My wife has fibroids. Can UAE be an alternative to hysterectomy? What are the criteria for UAE? Is it a same-day procedure and what are the risks and complications?

Dr. Richard Shlansky-Goldberg responds:
The answer to the first question is a definite yes. The criteria includes symptoms attributable to the fibroids in a patient generally no longer interested in having children. The risk are generally lower than undergoing a hysterectomy. The patient should consult with an interventional radiologist to go through the entire procedure including risks and benefits.

Jersey Girl asks:
I'm 41 with a very large fibroid, single no children. My periods are extremely heavy for two days and taper off, I can feel my fibroid at my naval. I'm scheduled for embolization next week. I am a high risk for myomectmy and hystrectomy because of adhesion from appendix removeed as a small child. Bulk and just feel sick most days if my problem. When should I expect to feel relief, and start to feel like my old self?

Dr. Richard Shlansky-Goldberg responds:
If the patient is asking as a result of the embolization if she is at a high risk for a myomectomy or hysterectomy due to her appendectomy, the short answer is there is no correlation. If she is asking if there is an increased risk to have a myomectomy or hysterectomy with a previous appendectomy instead of an embolization, she should check with her surgeon. It is hard to predict when she will feel relief but usually by 3 months most patients feel better.

Andrea asks:
I am 35 and I had the UAE done March 2005 and I am glad I had it done. I have very little pain however, my discharge has changed sometimes it is smelly and sometimes clear and no odor at all. Does dead fibroid cause odor?

Elis asks:
When the fibroid dies after a UAE proceedure, Do you discharge them? If so What will they look like?

Response:
About 5% of women will expel part or all of a fibroid after Uterine Artery Embolization. Essentially, the dead fibroid breaks off into the uterine cavity instead of being reabsorbed by the body over time. The piece (or the whole fibroid) that breaks off is dead, so you may notice a foul-smelling discharge, and you may have crampy pain as your uterus tries to expel the fibroid. Eventually, the fibroid may pass (or your gynecologist might need to help with that) through your vagina. The tissue will look whitish or greyish and look very different from your usual menses.

Expulsion can occur within a few weeks of UAE or many months later. If you think you might be passing a fibroid, contact your interventional radiologist. An MRI can help determine if this is occurring, and a course of antibiotics may be prescribed. It is important to note that almost all expulsion can be managed without hysterectomy.

Expulsion is a good news/bad news sort of thing. The bad news is it may be uncomfortable while passing it, but the good news is that it is gone completely once it passes; often the MRI will look normal or show only a small defect where the fibroid used to be.

For more information or to make an appointment with a Penn specialist, please contact 1-800-789-PENN (7366) or schedule an appointment online.

Kay2 asks:
I'm 33 years old with an 8 cm fundal fibroid. I would like to have children, however I have been unsuccessful to date. Would UAE be an option for me and would there be a risk of more problems with fertility from the procedure?

Response:
Uterine artery embolization (UAE) is typically performed in women who are no longer interested in childbearing. Probably the most important reason for this is that the procedure does not remove the fibroids but eliminates the symptoms such as bleeding and pain. Myomectomy is the procedure of choice for patients with fertility problems. This surgical procedure removes the fibroid which may be causing the infertility.

If you have a single fibroid, this would be the procedure that would most likely optimize your chances of getting pregnant. UAE can be used in some patients interested in pregnancy when a myomectomy is not a option usually because the number present within the uterus. Patients may become pregnant after UAE but given our current knowledge, myomectomy would improve your chances the best. You may want to discuss your situation with a gynecologist who specializes in infertility and reproductive medicine.

For more information or to make an appointment with a Penn specialist, please contact 1-800-789-PENN (7366) or schedule an appointment online.

Debi asks:
I have large fibroids that have inlarged my uterus. Would I be a candidate for this procedure? My fibroid is pedunculated.

Response:
It probably depends on a couple of things. Pedunculated means that it has a stalk. Determining the width of the stalk will help decide whether you are a candidate. We perform MRIs on our patients in order to evaluate for the presence of pedunculated fibroids. In addition, it also depends on what your symptoms are from the fibroid. We have successfully treated many patients with pedunculated fibroids with bulk and/ or bleeding symptoms.

For more information or to make an appointment with a Penn specialist, please contact 1-800-789-PENN (7366) or schedule an appointment online.

Dana asks:
Will you perform UAE on patients who have very large intracavitary fibroids or should these be surgically removed first before treating the remainder of the fibroid uterus.

Response:
Some people think that intracavitary fibroids slightly increase the risk of expulsion, that is passing parts or all of a dead fibroid. This risk is about 5% for all comers, so we're still not talking about a big risk. In my opinion you would still be a candidate for UAE.

Martha asks:
I am 47 years old and had an embolization July 2004. The procedure worked will for the bleeding, but my fibroids did not shrink at all (grapefruit size), in fact my uterus has grown to 17cm, 2 cm larger since a January 2005 MRI. Will a second embolization shrink my fibroids more? I believe they are 33% 'dead.' My bladder has no holding capacity and I look quite pregnant.

Response:
The results of uterine fibroid embolization (UFE) for bulk symptoms similar to yours are not as good as for bleeding although approximately 75% of patients get partial or complete relief of bulk symptoms. We use residual perfusion (blood flow) in the fibroids on MRI to predict longer term results, especially for bulk symptoms. If there is still 67% flow to the fibroids, you might benefit from repeating the procedure.

Lana asks:
I have been told that one of my fibroids is dead. What does that mean and what are the complications?

Response:
Fibroids may out grow their blood supply and die. This is a normal process. After menopause, without hormone supply, additional fibroids may die. Complications from dead fibroids are rare.

For more information or to make an appointment with a Penn specialist, please contact 1-800-789-PENN (7366) or schedule an appointment online.

Noelle asks:
I had a uterine fibroid embolization two months ago. I had extreme bleeding before the procedure. I have had a medium level of spotting every day since the procedure and in the last week am bleeding again. My fibroid is on the uterine wall. Can you tell me why I seem to be getting worse than getting better?

Response:
Spotting after the uterine artery embolization (UAE) is normal and usually resolves by the first or second period following the procedure. The quantity of bleeding with your period usually improves by the second month. If the bleeding is not getting better, I would discuss this with your Interventional Radiologist.

We usually see patients after three months and obtain a follow-up MRI. If their symptoms are not improved, we evaluate the MRI to see if we have eliminated all of the fibroids. If some of the fibroids survived, this is most likely due to additional vessels that are supplying them with blood. We will usually offer an attempt at embolizing these additional blood vessels. The success rate for UAE is 90%. Unfortunately, that means that not all patients will be improved.

Juhli asks:
I have a uterus filled with fibroids, the largest being 18 cm. I am 56 years old and still get a monthly period. The bleeding keeps me at home 3 days per month and the enlargement is so big as to be uncomfortable and now tender. What can I expect from this process and what are the costs involved? Can you recommend a hospital in Colorado?

Dr. Scott Trerotola responds:
Uterine artery embolization works best for bleeding, and pretty well for the other symptoms you describe, collectively known as "bulk symptoms", though not as well as for bleeding. You can expect about a 90% success rate in controlling bleeding. About 80% of women getting UFE will have partial or complete resolution of bulk symptoms. Also, the larger the fibroids, the longer it takes for bulk symptoms to improve. With those caveats, I think you're probably a candidate for the procedure.

As for costs, they vary widely. Most insurance companies cover UFE, and you should check with whoever is going to do it about how much it costs in your area.

As far as a doctor performing the procedure in your area: you may search on sirweb.org or ask4ufe.com to find physicians in your area. Best of luck.

Andrea asks:
I had my UAE in February 2003 - the fibroids consisted of two very large in size 9 & 10cm and several smaller but all growing. The UAE was very successful (there had only been about 50 operations performed here at the time I had mine) and last month the ultrasound showed significant shrinkage with what looks like calcification surround the two larger fibroids. What I am wondering about is what happens to this calcification (scar tissue)should I become pregnant?

Dr. Scott Trerotola responds:
Calcification occurs naturally, and commonly, in fibroids as they degenerate, even if UFE has not been done. I am not aware of any problems relating to pregnancy, but the best person to ask about that would be your obstetrician. I'm glad to hear your UFE was successful, and best of luck with getting pregnant!

Francis asks:
I had the UAE procedure in November, my fibroid was 8 cm. My stomach was distorted. When can I expected shrinkage of the fibroid. I still have frequent urnination and some back pain.

Dr. Scott Trerotola responds:
When fibroids are treated with Uterine Artery Embolization (UAE) for "bulk symptoms", the results are not as good as for bleeding. Also, it takes longer to see results, often many months. The best test of whether the fibroid is completely treated is the MRI done at 3 months. The results of that study help to predict whether the fibroid is "dead" and will shrink over time.

Also, please note that urinary symptoms, because they can have so many causes, are the least responsive to UAE. Back pain can also have many causes. If the MRI shows good results you should keep waiting; if there is still flow to the fibroids, you might consider having the procedure repeated.

Becky asks:
My sister has been told her uterus is tearing away and sluffing off. She must be very careful and watch for hemmoraging if a certain vessel in the uterus ruptures. Where is this artery and what would cause this?

Response:
Thank you for your question. Our physician has requested additional information regarding this. Did the symptoms occur after a Uterine Artery Embolization (UAE)? If this did not occur after a UAE, it is recommended that your sister follow-up with her gynecologist.

Mary asks:
What happen when the uterus has a division and what are the factors involved?

Response:
This question is not specific enough to be able to answer. We suggest you talk to your gynecologist if you have questions.

Brooklyn asks:
I have two more questions. First, I read that embolic agent Emboshperes Microspheres cause less pain after UAE because it is more likely than other types of particles to block the fibroid vessels without closing the entire uterine arteries. If you have used these particles with patients, has their pain been less? Second, if you find that a patient has an ovarian artery feeding her uterian fibroids, what do you do?

Dr. Scott Trerotola responds:
I use Embospheres exclusively so I really can't say whether they cause less pain, since I have not used particles for UAE for years. I use them because they are reasonably well studied and FDA approved for UAE. Nearly all of my patieints tell me the pain was less than they expected and was well worth it to get the results.

As for ovarian artery, I personally don't pursue it at the initial visit for many reasons. However, if a patient has persistence of a fibroid documented to be due to ovarian artery supply, we'll have a conversation with the patient about the added risks of ovarian artery embolizaion (ie, ovarian failure/menopause) and together we'll decide whether to proceed.

Brooklyn asks:
What is your opinion on a successful outcome of treating a women with a uterus that is filled with appproximately seven fibroids, some of which are large. I can feel the top of my uterus nad it is approximately two inches above my belly button. Also, does a large uterus filled with multiple fibroids increase the rate of infection after UAE?

Dr. Scott Trerotola responds:
A lot depends on the symptoms. If bleeding is the main problem, we still expect a greater than 90% success rate. If bulk symptoms are the main problem (urinary problems, pain, etc), the success rate is less but still in the 75% range. The number of fibroids does not matter, in fact this is a distinct advantage of uterine artery embolization (UAE) over other treatments such as focused ultrasound.

Large size does not increase the risk of infection. Large size fibroids do take longer to respond to therapy, sometimes up to a year; some women do prefer hysterectomy for large fibroids with bulk symptoms because it's 100% effective in treating the symptoms and the response to therapy is obviously quicker. That's a personal choice.

Cal asks:
I have a submucosal fibroid. Would I be considered a candidate for UAE?

Dr. Scott Trerotola responds:
In almost all cases, yes, you would be considered a candidate for uterine artery embolization. Your risk of expelling the fibroid may be slightly higher, but that is easily managed in most patients.

For more information or to make an appointment with a Penn specialist, please contact 1-800-789-PENN (7366) or schedule an appointment online.

Question:
I have had a huge fibroid, past the navel, for approxamitely 8 months. In the past, I have been told that it is too large for UAE. Now I have been told that blocking particles are improved. I need minimal shrinkage to have colon surgery? How much / how long are effects of shrinkage?

Response:
Fibroids of any size can be treated with Uterine Fibroid Embolization (UFE). While results of UFE are best for bleeding problems, the majority of women with bulk symptoms will also experience partial or complete relief. Shrinkage does occur, but can take a long time -- months to more than a year, as the body reabsorbs the dead fibroid after embolization.

If you would like to make an appointment with a Penn specialist, please contact 1-800-789-PENN (7366) or visit pennhealth.com to schedule an appointment online.

Question:
Do your fibroids need to be under a certain size for any possibility of shrinkage? If they aren't can they start to grow again at a later date requiring more treatment?

Response:
Uterine artery embolization is effective for treatment of heavy menstrual bleeding due to fibroids, as well as what we call "bulk symptoms" (bloating, problems with urination or moving bowels) due to the size of the fibroids. The best results are achieved for bleeding, regardless of the size of the fibroids, but excellent results are achieved for bulk symptoms as well. While it is true that very large fibroids may not respond as quickly or as well to embolizaion, we still believe that treating even very large fibroids is worthwhile, and have many very happy patients who have undergone the procedure for treatment of large fibroids with bulk symptoms.

While it is possible for fibroids to grow after the procedure, or come back after shrinking, or even for new ones to grow, this is rare. Also, the procedure can be repeated if this occurs.

Please feel free to call 1-800-789-PENN (7366) for further information.

Question:
What happens to the tiny, plastic sponge-like particles after the procedure?

Response:
The particles mechanically block the blood flow in the uterine artery, essentially "plugging up" the artery. The nutrients and oxygen that are carried by the blood can no longer get to the fibroid causing them to die and shrink. The particles remain in the artery. This is somewhat similar to what is done during surgery when a surgeon ties off the blood vessel with a plastic suture. The suture remains around the vessel.

The process of uterine artery embolization is analogous to tying off the vessel from the inside, through a tiny little puncture, the size of a pencil tip, in the groin. The success rate of the procedure in decreasing menstrual flow is around 85-90%. The success rate is not 100% because sometimes the fibroids may have additional extra blood supply from other structures in the pelvis that may prevent the fibroids from dying. In certain cases we can block this additional flow when needed.