It is interesting! How is the uterine artery embolization in the PMC (video from the operating room). Now you can see everything with your own eyes.
Hello Dmitrii Mikhailovich, we are glad to welcome you again on the pages of our site. Today we would like to talk about a very common gynecological problem – uterine fibroids. First of all, what is uterine fibroids? How common? What are the symptoms that are noticeable to the patient? What actually threatens or does not threaten uterine fibroids? What are the myths about uterine fibroids dispelled by modern science?
Hello. Uterine fibroids are actually a very serious problem not only in gynecology, but also in the life of a woman. It was previously believed that uterine fibroids occur in 30% of women over the age of 35 years. In fact, the prevalence of the disease is much greater. According to modern studies of uterine fibroids occurs in 85% of women. These figures were obtained as a result of postmortem studies, in which the uterus of women (who died as a result of various causes) was “cut” after 2 mm and many myomatous nodes were found. Also, the difference in numbers is due to the fact that in most cases uterine fibroids are asymptomatic – it just gradually grows, and if a woman does not visit a gynecologist and does not undergo an ultrasound, the uterine fibroids may not be diagnosed, and after menopause, the fibroids regress and again manifests itself.
The wide availability of ultrasound also made it possible to more often diagnose uterine fibroids, which themselves do not manifest themselves and which cannot be determined by hand with a simple examination on the chair. Thus, uterine fibroids is a very common disease.
Most recently, I formulated a new definition of this disease: uterine fibroids is a chronic, progressive disease of the muscles of the uterus, limited in time to the reproductive period of a woman.
Note that the definition does not contain the word “tumor”. That tumor was considered uterine fibroids until recently. In fact, uterine fibroids are similar to benign tumors, but they are not. This is a tumor-like state. I also wanted to draw attention to the phrase “time-limited female reproductive period” – this is an important fact, since uterine fibroids do not appear before the onset of the first menstruation and stop their development after menopause.
Uterine fibroids is a disease of the myometrium (muscles of the uterus), a local pathology of this organ. Previously it was assumed that hormonal disorders lead to the development of this disease – this is another myth. The growth of myoma node begins with a defect in a single muscle cell, which, when divided, forms a node. As in the uterus, as a rule, the set of nodes each node grows from a separate cell. You ask about the myths regarding this disease – in fact, quite a lot of them have already accumulated, and what is sad, many doctors firmly believe in them. Here are some pretty common misconceptions:
Myths and delusions about uterine myoma
1. Uterine fibroids can be reborn into a malignant tumor – this is not the case, it has been repeatedly proved that uterine fibroids are not malignant and the development of uterine sarcoma (this is a malignant tumor from the uterus muscle cells) is not associated with the presence of myomatous nodes in the uterus. This is generally one of the rarest tumors that develops on its own. 2. Uterine fibroids occur as a result of hormonal disorders – this is also not true – uterine fibroids are a disease of the uterine lining of the uterus, which is sensitive to hormones, and hormones stimulate the growth of myoma nodes, but do not trigger the process of their formation. A node begins to grow from a single cell that receives a defect. The hormonal background may not be disturbed in any way. 3. The growth of uterine fibroids is stimulated by estrogens and therefore it is necessary to use progesterone “counterhormone” to treat this disease, and therefore Duphaston is widely prescribed – in fact, this is a global misconception. Estrogens and progesterone are not in an antagonistic relationship, but rather complement each other: estrogens prepare the ground for progesterone activity. The most powerful hormone that stimulates the growth of uterine fibroids is just progesterone and therefore Duphaston and Utrogestan (two drugs that are analogs of progesterone) stimulate the growth of uterine fibroids and they are absolutely contraindicated in the treatment of this disease. 4. Uterine fibroids are a factor of infertility – this is also not quite true. Pregnancy can normally proceed and end with childbirth even with many myomatous nodes in the uterus, while some nodes can reach enormous sizes. Against the background of uterine fibroids, abortion occurs more often, so the uterine myoma is still considered as a factor in miscarriage. Uterine fibroids can cause infertility if the node or nodes deform the uterine cavity, the so-called “submucous” nodes, and in cases where all other causes of infertility are eliminated – fibroids can be considered as a possible cause of pregnancy non-occurrence. But still we must remember that pregnancy occurs regardless of the presence of myoma nodes in the uterus, since the nodes do not affect the process of the onset of pregnancy. 5. Myoma of the uterus can be completely cured with medication – this is impossible. The fact is that uterine fibroids are fibrous-muscular formations that grow in the muscle and cannot be “dissolved” in the muscle by a “fibrous ball” in size, for example, 5 cm. Some medications can temporarily reduce the size of nodes or stop their growth , but not more. 6. Uterine myoma cannot cure or in any way influence it biologically active supplements like “Indinol” and “Epigalate” – like all other herbs and homeopathy. It is important to understand that uterine fibroid is not a runny nose or diarrhea – uterine fibroid is a dense formation sometimes reaching 15–20 cm in diameter, consisting of muscle and connective tissue fibers (in fact, a piece of meat), which cannot dissolve and leave the body under exposure to drugs. 7. There are no popular methods for treating uterine fibroids – most often you hear about a “boron uterus” – a preparation for all gynecological diseases. Any so-called “effectiveness” of folk methods and herbal medicine is based on two points: there is a “placebo effect” (this is when the “dummy” shows the effect of the drug only because the patient believes in its effectiveness), and we must also remember that the dynamics growth of uterine myoma nodes is unpredictable, and some nodes may not grow for a long time, vary in size depending on the phases of the cycle and
These are probably the most basic myths regarding this disease. I think that further in the course of the interview I will touch upon other errors.
If we talk about the symptoms of uterine fibroids – they are few – most often it is abundant prolonged menstruation (often with clots), pain and a feeling of heaviness in the lower abdomen, impaired urination and less frequently bowel movements. As I noted above, uterine fibroids are often asymptomatic and can only be detected by ultrasound, and sometimes this finding is sad, since uterine fibroids are already quite large. Often, patients come to me for an appointment who have not visited a gynecologist for years with only one complaint – that their abdomen has increased. Such an increase in the abdomen of the patient is initially regarded as what they recovered, but upon examination it turns out that it is uterine fibroid, corresponding, for example, to 15-16 weeks of pregnancy (this is how the size of uterine fibroids is estimated, since the nodes increase the overall size of the uterus).
There may be a question – if uterine fibroids may be asymptomatic for a long time – how great is its significance for the woman’s body. The fact is that uterine fibroids asymptomatically grows, reaching a certain critical moment when symptoms appear and treatment must be resorted to. So, if uterine fibroids are small, treatment may not be as aggressive and radical as it happens with gigantic uterine myoma. And when a patient comes, who has not been to a doctor for many years, and it turns out that she has a huge uterine fibroid and the only treatment is amputation of the uterus – we have to admit that time is simply lost, because several years earlier the treatment could be carried out without removing the organ. Another common situation: – A woman is planning a pregnancy and comes for a visit, and then it turns out that there are many myomatous nodes in the uterus that can interfere with the pregnancy. Thus, uterine fibroids are a rather insidious disease, which often turns into an unpleasant surprise, and in order not to face this, one rule must be clearly remembered – every woman of reproductive age must undergo an ultrasound examination once a year.
Probably many of your patients ask the question: “Doctor, what did I do wrong, why did this happen to me?” Are the causes of uterine fibroids established today? Is it really our payment for social activity and the refusal to perform the genital function in full?
Alas, but so far the exact causes of uterine fibroids have not been established. There are hypotheses and theories. As I noted above, everything begins with the appearance of a defect in the cell of the uterine muscle membrane. This cell begins to divide and forms myoma node. Some researchers compare the development of myoma node with the “pregnancy of a single muscle cell”, since by its characteristics the cell, the beginning growth of the myoma node is similar to the cells of the uterus muscle during pregnancy.
What is the theory of the origin of progenitor cells of uterine fibroids? There are two of them, and they explain the appearance of two different types of uterine myomas. There are so-called “juvenile fibroids”, which are formed in young girls and ordinary fibroids, which are most often diagnosed in women closer to 30 years. In the case of juvenile myomas, the cells get a defect during the intrauterine development of the uterus and in fact only the onset of menses is enough for them to start forming a myomatous node. Ordinary fibroids are formed from cells that receive a defect during the reproductive period of a woman and the main damaging factor is, strange as it sounds, the multitude of menses that a woman experiences.
Here I would like to make a small “lyrical digression.” Remember, a hundred years ago, in a normal family, 6-8-10 children were born, that is, a woman was in a constant reproductive cycle: pregnancy, childbirth, breastfeeding, 1-2 periods, and all over again. Thus, during her life a woman experienced about 30 menstruation. A modern woman giving birth to two children experiences about 400 menstruation for the life. Obviously, the body is not designed for such a number of serious tests for the body as menstruation, and in 100 years has not had time to restructure itself to such a rhythm. It is a big mistake to think that menstruation is a normal function of the female body. Menstruation occurs due to the fact that there is no pregnancy in this menstrual cycle, it is an “emergency reset” of all the settings that the body makes in order to start a pregnancy.
It is known that the majority of gynecological diseases faced by the modern woman were rare 100 years ago, for example, endometriosis, polyps of the uterine lining, ovarian cysts, and in particular uterine fibroids. All of these diseases have become so prevalent as a result of the fact that the woman does not perform reproductive function, but simply menstruates regularly. Returning to the subject of uterine fibroids, I should note that many precursor cells are formed as a result of repeated menstrual cycles. Of course, there is a system that eliminates these defective cells from the body, but it does not always work. In the end, defective cells are constantly formed and destroyed in the uterus muscle, but due to the high menstrual activity of the woman, some of the cells begin to form uterine fibroids. Additional factors that can influence this process are: abortion, inflammatory diseases, injuries from medical interventions and adenomyosis.
Therefore, you are absolutely right, uterine fibroids, like a number of other gynecological diseases, is a retribution for social activity and a refusal to perform the reproductive function. You know, this idea as a whole is not new, the old saying “Don’t give birth to Yeremu, give birth to myoma” is well known, like this ….
Dmitry Mikhailovich, is it necessary to treat a myoma or you can only observe, or maybe “there is a hope that it will pass by itself”, are there any conditions, for example, pregnancy, when the treatment of fibroids cannot be performed?
There are situations when uterine fibroids do not grow and are not accompanied by any symptoms, the woman does not plan a pregnancy, there is not much time left until the menopause. In such situations, observation is permissible. But watching the growth of uterine fibroids – is criminal!
There has long been a strange “enterprise” in gynecology: gynecologists in women’s clinics grow uterine fibroids (putting patients on record and watching the growth of nodes annually without doing anything), and then, when they reach sufficient size, the patient goes to the hospital where other gynecologists – surgeons habitually and without hesitation cut off the “mature” uterus with myomatous nodes. Such a “collective farm” still exists today with complete impunity.
Think about it, it is considered criminal to release the patient with a cough in order to “observe” and, if pneumonia develops, be hospitalized in the clinic and carry out serious treatment, and record the growth of myomatous nodes year after year waiting for the uterus to reach 12 weeks of pregnancy, and send the patient to the complete removal of the organ – normally and physically … At the same time, to misinform the patient that there are no other methods of treatment other than medication and surgery, to tell “horror stories” about uterine artery embolization, not even understanding how this method works, without ever seeing how it is performed and without encountering patients, transferred this operation.
Complementing the picture is another terrible situation – this is the ubiquitous prescription of a fetus for fasting uterine fibroids. Many years ago, when it was mistakenly thought that uterine fibroids are growing due to estrogens, and progesterone – the hormone of the opposite action, the testimony of “uterine fibroids” was placed in the annotation to the drug Duphaston. Time passed, and it was convincingly shown that progesterone is the basis of the hormone that causes the growth of myoma nodes and duphaston (which is its complete analogue) – causes the growth of nodes. The most depressing thing is that in clinical practice, doctors saw that after the appointment of duphaston, the nodes began to grow rapidly and you thought what explanation was offered for it, but very simple: “You see, the background of treatment started to grow, no matter how there was some kind of oncology – let’s rather amputate the uterus “… Surrealism is neither given nor taken …. Indeed, in the dry residue it turns out – they passively observe, sometimes they prescribe a treatment that only accelerates growth and ultimately cuts off the uterus, while misinforming the patient that there is some other way and other approaches to the treatment of her disease. It’s not yet possible to break this system, despite the fact that the “battles” have been going on for more than 15 years.
Some of the patients are lucky and they manage to go through their reproductive period and get to menopause without loss – sometimes simply by refusing to remove the uterus or the proposed treatment, someone can find doctors who have modern ideas about this disease and they manage to carry out a competent treatment. Thus, in some cases, the patient with uterine myoma is able to “slip through” and end up before menopause without any treatment.
You asked, under what conditions do they not treat uterine fibroids? During pregnancy, uterine myomas are not treated except in rare cases when emergency situations arise (blood supply to certain sites of localization, etc.), but this happens rarely fortunately. Uterine fibroids grow during pregnancy – the first 2 trimesters (on average by 25-30%), and in the third, when the level of progesterone decreases in the body – it begins to decrease. Some nodes that were observed before pregnancy may not be detected after.
Another period in a woman’s life when the treatment of uterine fibroids is not carried out is menopause, since at this time the uterine fibroids regress and are no longer dangerous and do not give any symptoms. However, there are exceptions – the growth of uterine fibroids after menopause (which is rare) is an indication for surgery.
Are there ways of peaceful coexistence with myoma? What rules can you follow to prevent further growth of myoma nodes or relapse of an already treated disease?
Peaceful coexistence with uterine fibroids can not be. Uterine fibroids must be removed or “killed” or conditions must be created under which its growth is significantly slowed down.
The only proven way to prevent the formation of myoma nodes is long-term use of monophasic hormonal contraceptives if you do not take into account the reproductive behavior of women (in other words, the best prevention is to give birth to as many children as possible and to breastfeed them for a long time). What contraceptives do – they are in fact a surrogate for pregnancies that a modern woman refuses.
While taking contraceptives, there are no cyclic processes in the body, there is no ovulation and no corpus luteum is formed, and therefore the body does not prepare for pregnancy every month, and menstruation with contraceptives is actually an artificial phenomenon (it is called a menstrual-like reaction). Taking contraceptives significantly reduces the likelihood of uterine fibroids – this has been proven as a result of large studies conducted by WHO. Contraceptives are also able to slow down the growth of small myomatous nodes to 1-1.5 cm, so when such nodes are detected, passive observation is not shown, but contraceptives are prescribed in that case, of course, if a woman does not plan pregnancy.
What else accelerates the growth of myomatous nodes is all that enhances the blood supply to the pelvic organs, since it is obvious that the uterus myoma is better supplied with blood, the more opportunities there are for further growth, since all the necessary substances are supplied with blood. Therefore, visits to baths, saunas, active tanning, massage of the buttock and lumbar areas, as well as various physiotherapy on the lower abdomen are contraindicated in patients with uterine myoma. Some of these restrictions are lifted after uterine fibroid treatment of the uterine arteries, but only one year after the procedure.
Doctor, it is known that the most ancient and, as we understand, 100% treatment of uterine fibroids was the removal of the uterus itself. The result of which was absolute infertility and hormonal imbalance in the female body? What alternative methods have emerged in recent decades? After all, today it is not at all necessary to remove the uterus for the treatment of fibroids (and in many cases, removal of the uterus to treat fibroids is comparable to cutting off the head for the treatment of headaches)? Can you write us a small comparative table of methods of treatment of fibroids.
You are absolutely right in your formulations – the treatment of uterine fibroids from the position of “no organ – no problem” – is cruel and devoid of common sense. Paradoxically, the same thoughts were expressed in the early 20th century by well-known surgeons. I will cite two rather bright quotes: To preserve the organ, or a part of it, is the noble task of the surgeon. Complete removal of organs that have functional significance and play a certain role in the balance of the body is a crippling, disfiguring operation, ”wrote an outstanding obstetrician-gynecologist Golubchin
A real revolution in the treatment of uterine fibroids was the emergence of a new treatment method – uterine artery embolization. This method has been actively used in Russia since 2002 in Europe and America since 1994, and in 2004 this method of treatment was chosen to treat uterine fibroids to the United States Secretary of State Kondaliza Rise, which she gave in detail in her interview. And what do you think, what is the fate of this method of treatment in Russia – the typical one can say – the method is still denigrated by the majority of gynecologists; terrible rumors have been dismissed around this method, and this method intimidates patients. And this is despite the fact that most gynecologists cannot even approximately tell what the essence of the method is and how it is performed and what it leads to.
In many ways, this situation is supported by gynecologists and surgeons, who see this method as a “competitor” and a threat to remain without “clients”. The fact is that the embolization of the uterine arteries itself is not performed by gynecologists, but by doctors of another specialty — endovascular surgeons. Nobody wants to give 60-80% of their operations into the hands of doctors of another specialty. But in this “struggle” the main thing is lost – the patient’s fate, her health, and this is tragic. In fact, now there is a sufficient arsenal of means for treating uterine fibroids without removing the organ, and in the vast majority of cases, treatment allows for the restoration of reproductive function, if required by the patient. Removal of the uterus remains among the methods of treatment of this disease, but still this method should be used only in extreme cases when the disease is very neglected and uterine fibroids reach gigantic proportions. Such situations are fully the fault of the patients themselves, who for years have not gone to the gynecologist and have not done an ultrasound.
What threatens the baseless use of the uterus amputation method, other than absolute infertility? Is it true that some doctors say that “if you do not plan to give birth more, then you will be better off without a womb”?
This is fundamentally not true. In fact, the uterus is integrated into the reproductive system of a woman, and it is not only a “fruit ward”, as some doctors say about it.
Here are some facts: studies have shown that after a woman has her uterus removed, a woman’s risk of developing breast and thyroid cancer increases; when the uterus is removed (without ovaries), damage to the ovarian artery always occurs, resulting in impaired blood supply to the ovary. The lack of oxygen entering the ovary triggers a cascade of reactions that aggravate the damage to the ovary, so despite the fact that after the uterus is removed, the ovaries remain, their function often decreases, which leads to the development of posthysterectomy syndrome (in fact, menopausal syndrome, but perhaps more severe course) In other words, some women begin to age quickly, and new diseases appear (most often cardiovascular diseases). Removal of the uterus can be said on the sexual life of a woman (it all depends on the type of orgasm that the patient received), in some women the vaginal orgasm disappears and the sensation is generally reduced. I think this list of possible consequences will be enough to show that from the doctor who said the phrase: “Woman, why do you need a uterus, are you not going to give birth anymore, that you clung to this unnecessary muscle bag, let’s quickly delete everything laparoscopically, 3 days at home and heal like a man “must run as soon as possible.
Based on the analysis of the methods used to treat uterine fibroids, it becomes clear that the method of uterine artery embolization today is most relevant as a method where the ratio of the effectiveness and the volume of surgical intervention is most optimal. Doctor, could you tell us more details
As I said above, the appearance of uterine artery embolization caused a revolution in the treatment of uterine fibroids. The term “embolization” means the closure of the lumen of the vessels that feed the organ or tumor in it, using various materials that are inserted through the catheter.
The principle of closing the vessels of an organ has been known and applied since the end of the 70s. It has been proposed to stop massive bleeding. The technique of uterine artery embolization was used until 1994 to prevent blood loss during surgery to remove uterine fibroids, that is, as a preoperative preparation. It so happened that several patients underwent EMA, but after that they did not go for an operation for various reasons, and appeared later, after a few months. It turned out that these patients eliminated the need for an operation, since their periods had normalized, and the size of the uterus and nodes was significantly reduced.
All this was noted by the French doctor Jacques Henri Ravin. He first suggested using this method not as a preventive measure for bleeding, but as an independent method of treating patients with uterine myoma. In 1994, he published the first results in the journal Lancet. Since then, the EMA has been performed all over the world, and the number of procedures is increasing annually and is currently being performed hundreds of thousands of EMAs per year.
Now I’ll tell you more about what is uterine atrium embolization. The essence of the technique is to stop the blood supply to all myomatous nodes in the uterus, as a result of which they “shrink”, decrease in size and no longer grow, actually die, while the uterus does not suffer at all. Nodes located in the uterus, as well as growing in the uterine cavity after EMA are “born”, that is, they leave the uterus and the uterus is freed from them.
Technically, this happens as follows: the patient arrives at the clinic on the morning of the procedure, after the paperwork and preparation in the ward is lifted into a special operating room, which has equipment that allows for intravascular interventions. General anesthesia is not necessary because the procedure is painless. The patient is conscious and actively communicates with the doctor. As before the dental treatment, the dentist makes an anesthetic injection, and local anesthesia is also performed before the puncture of the femoral artery.
The whole procedure usually takes about 15 minutes (of course, in trained hands). During this time, an endovascular surgeon (note, not a gynecologist) with the help of special thin catheters passes through the vascular channel first into one, then into the other uterine arteries and introduces a special substance (small balls, 500-700 microns in size, essentially representing bubbles, filled physiological fluid, and the bubbles themselves consist of a special polymer that does not react with the body).
As a result, the vessels feeding all myomatous nodes are closed and the nodes begin to die. Emboli (so called these bubbles), also fall into the vessels supplying the uterus, but there they are temporary and do not cause damage to the uterine tissue. This is due to the peculiarities of the blood supply to the uterus, which has a rich and very extensive network of vessels.
It should be noted here that in our work we use only one type of Bead Block emboli (Bid Block, produced by the Japanese company Terumo), which were created specifically for embolization of the uterine arteries. Earlier, the so-called PVA (USA) was most often used, but later it was shown that they cause more pronounced damage to the normal tissue of the uterus and are also inferior to the Bead Block drug due to a number of other very important characteristics.
After the procedure is completed, a special adhesive tape is applied to the place of the femoral artery puncture with a plastic cartridge, which swells up and presses on the puncture site. There is essentially the same situation as when taking blood from a vein – after this procedure you are asked to bend your arm and hold it in this position for some time. Since the femoral artery is thicker than the cubital vein and the blood pressure in it is greater, a special device is required for its closure and 6 hours. In these 6 hours you can not bend the leg.
At the end of the procedure, the patient enters the ward, where she spends time until the morning. In the near future, after the end of the procedure, abdominal pain begins. There is quite a lot of information on the Internet that the pain after EMA is very intense and comparable to labor pains. In fact, this can be so only if you do not conduct adequate pain relief. Anesthesia after uterine artery embolization is a separate issue.
We managed to develop an anesthesia scheme, which allows almost completely relieve pain after EMA. In our scheme, we prescribe painkillers the day before the procedure, in the morning on the day of the procedure, and we introduce quite a lot of painkillers just before EMA. In the future, several drugs are included in the anesthesia scheme, some of which have a hypnotic effect, and the patient just sleeps most of the time.
The essence of this scheme is quite simple – we saturate the body with painkillers beforehand, there is no pain yet and thus we do not allow it to fully form and further anesthetize “prophylactically”, that is, the drugs are introduced not at the moment when the pain begins to increase, but shortly before as the effect of the previously administered drugs begins to end. This pain relief scheme is fundamentally different from other methods of administering patients after an EMA, since most often pain relief is only when the patient already complains of severe pain, it is obvious that it is more difficult to extinguish the pain that has been played out and the anesthetic effect on the same drugs will be weaker. In addition, the problems of conventional public hospitals with potent painkillers are well known – there are practically none.
Here, actually, how to solve the problem of pain after EMA. Thus, the pain after embolization is actually strong, but with a competent approach to solving the problem, they can be minimized. Pain syndrome usually lasts from 2-10 hours. In the morning, the patient feels well and is usually discharged from the hospital by 12 o’clock.
In the following days, the so-called “postembolization” syndrome begins to develop. Since the irreversible process of their death is started up in the nodes of the uterus mimes, this is accompanied by pain syndrome (of much lower intensity), fever, weakness and the presence of discharge from the genital tract. It should be noted that when using the pain relief scheme developed by us and the subsequent management of the patient, the severity and duration of this syndrome are reduced.
In the event that the patient had nodes located in the uterus or growing into the uterus — after embolization, such nodes can be “born”, their expulsion occurs. What this means: after some time (it can vary greatly from a few days to a year, most often it is about several months), specific secretions appear and the temperature may rise. The node begins to “melt” and flow in the form of these secretions. At some point, it just goes out of their vagina, for example, during menstruation or going to the toilet.
Ultimately, in the uterus of this node is no more. That is, such nodes are “cured” completely. Nodes located in the wall of the uterus and not bordering the cavity most often simply decrease in size by an average of 50% or more and do not grow, since in fact they begin to be the “ball” of connective (scar) tissue. You can make a comparison with a juicy apricot, which turns into dried fruit.
After embolization of the uterine arteries, the patient stops abundant menstruation that caused fibroids, and if the uterus with the nodes pressed on the bladder, this symptom also disappears. Nodes are reduced in size, some are “born”. In general, the whole process ends a year after the EMA, while the patient returns to normal after 3-7 days after the procedure, since the process of changes in uterine fibroids does not affect daily life and well-being.
This is how uterine artery embolization takes place. Once again I would like to draw your attention to the fact that much depends on how and by whom the procedure is carried out. Most rumors about the lack of effectiveness of EMA arise from the fact that the procedure was performed by insufficiently qualified doctors, with poor anesthesia, using outdated emboli.
Another very important point: since the embolization procedure seems “incomprehensible” as opposed to a surgical intervention (here the patient understands that she will be given anesthesia, she will fall asleep, the surgeon will remove all that is necessary and then she will have the incision and the stomach for several days) explain in detail to the patient all the nuances of this procedure. Only an understanding of what is going to happen to her will ensure the normal passage of this treatment. After a detailed explanation, the patient realizes that she develops abdominal pains and these pains do not “signal” that something is going wrong, and these pains accompany the process leading to a cure. Anxiety and fear, which are known to interfere with any treatment, escape from this.
So that our patients feel secure and calm – they have the opportunity around the clock to contact the attending physicians, in particular with me, by phone, and ask any question about their condition, consult. This is also our “exclusive”, because, as we know, only we provide such a “service”. It is important for us that the treatment carried out is not only effective, but also psychologically comfortable for patients.
Now about the time when conception can be planned, if such a goal was set by the patient. As I said above, all the processes in the uterine fibroids nodes end a year after the EMA, and therefore it is one year later that we recommend planning a pregnancy. But if the patient had a knot in the uterus and he was born in 2-3 months and there are no more knots in the uterus, you can become pregnant a couple of cycles after the birth of the knot. A full blood flow in the uterus is fixed within a few weeks after the procedure, so there are no other restrictions. Here I would like to note that some of our patients did not comply with recommendations for protection during the year after the procedure and “accidentally” got pregnant 2-3 months after EMA. Pregnancy in these patients proceeded normally, and no abnormalities were detected.
About indications for uterine artery embolization. You can answer shortly – technically, the EMA can be performed in the presence of any uterine fibroids from tiny to giant. BUT there is a question of the expediency of carrying out this method in a given situation. In some cases, EMA may be excessive (small nodule without growth), in others surgical treatment is more justified (a node on a thin base or a giant uterine myoma, when reducing the size of the uterus by even half, does not solve the problem). All this is decided in consultation. There are absolute contraindications for embolization: this is the presence of a malignant process in the genitals or precancerous diseases, by the way an allergic reaction to iodine (iodine is part of the contrast agent) is not a contraindication, in such cases EMA is done with gadolinium-containing contrast, some common diseases.
Thus, EMA is a highly effective method of treating uterine fibroids, which must simply be correctly applied – this is not only the technical side of the issue, but also the selection of patients.
There are whole groups of patients with uterine myoma, to whom the EMA is most indicated, since the alternative can only be the removal of the uterus or prolonged severe surgery to remove the nodes without guarantees of organ preservation. It is very annoying that when such patients come to doctors, in whose hands there are only surgical methods of treatment, they in every way “blacken” the embolization method, deliberately misinform, thereby trying not to let the patient go. It seems to me that this is not medical behavior, this is no longer medicine, but “business” with its “wolf laws”, but it has no place in medicine, where the patient’s interests and his health should come first. We know this well, because the patients themselves, who come to us at the reception, speak about this. Alas, but everyone decides to get a “second opinion”.
About complications of embolization. It is by complications that unscrupulous doctors most often “intimidate” patients, dissuading them from embolization of the uterine arteries. We must immediately say that the EMA is the safest procedure when compared with other interventions that are performed in gynecology. Say, routine curettage, which is performed dozens per day in any gynecological department, is accompanied by a significantly greater danger, not to mention a big surgery.
It is important to understand that the technique of vascular embolization itself, which has been carried out since the late 1970s, belongs to the category of standard medical procedures. This is what doesn’t put in the head of many “critics” of the method – why the closure of the arteries feeding the organ does not lead to its death “necrosis”. It is the necrosis of the uterus that most often “scares” patients. Such a “criticism” actually only shows ignorance, nothing more. The fact is that the uterus is an organ having several sources of blood supply besides the uterine arteries, therefore the cessation of blood flow through the uterine arteries is not fatal for this organ.
The uterus begins to receive blood supply from other arteries within a few hours after the end of the EMA, and the blood supply through the uterine arteries due to the formation of a new network of vessels is fixed in a month. It is precisely the absence of such abilities in uterine fibroids that makes this method effective. It should be added that every doctor knows that since the development of surgery there has been known and widely used a method for stopping bleeding from the uterus – ligation of the internal iliac arteries.
These are large arteries extending practically from the aorta, from which the uterine artery starts, as well as many other blood supplying organs of the small pelvis. Such a ligation does not lead to necrosis of all organs, including the uterus, since all these organs have additional sources of blood supply. That is, even this rough method is not dangerous for the uterus, and selective embolization of the uterine arteries is “cutting out with scissors” as compared to “chopping with an ax”; it is such a comparison that can be done by dressing large arteries. In addition, during the execution of the EMA, the purpose of embolization is precisely the arteries of the fibroid itself, located in its thickness, and not the artery of the healthy part of the uterus.
Therefore, necrosis of the uterus after EMA is a myth, and necrosis of uterine fibroids is exactly what we achieve, what we are doing this procedure for. This necrosis is not dangerous, it is aseptic, and does not extend to the uterus and other organs. And when another intimidating phrase “you will develop necrosis of nodes” sounds, you need to understand that this is the therapeutic effect of EMA, and necrosis in this case is good, not harm.
The second most common “horror story” in relation to uterine artery embolization is the risk of menopause, or rather damage to the ovaries. They say that x-ray radiation during the procedure is dangerous for the ovaries and this can affect subsequent offspring, and also claim that emboli fall into the ovaries and they stop working. As for X-rays, it is so small that it is equivalent to one or two fluorography performed, which each person must undergo once a year.
A number of Western studies measuring the radiation dose received by the pelvic organs have shown that this dose is extremely low and completely safe. I will say more that this dose is less than or equivalent to the dose that the ovaries receive during the x-ray of the tubal patency – a routine technique that has been used for many decades in women being examined for infertility.
The second point – emboli getting into the ovary is a complex issue that requires a long explanation with anatomical details. The fact is that there are several options for connecting the uterine and ovarian arteries, and in some embodiments, these two vessels are communicated quite closely. If the EMA procedure is carried out without taking these features into account, and without using various techniques and methods taking into account these features, there is a possibility of damaging the blood supply to the ovary.
Now this is all well known, is taken into account and therefore the probability of damage to the ovaries by an experienced doctor when using modern catheters and materials is negligible, and can be considered an accident. The onset of menopause in patients who are on the verge of menopause after embolization of the uterine arteries is more of a coincidence than a consequence of the procedure – the likelihood of its occurrence after EMA is not higher than without EMA In general, the onset of menopause at this age is even a blessing uterine fibroids do not grow, but regress.
It is also often said that during embolization emboli may get into various organs and damage them. In general, this is not possible if the procedure is performed correctly, since before the emboli are injected, a contrast agent is injected, which essentially paints the entire path that the emboli will follow. Simply put, if you throw the ball into the drain pipe, it will fall out at the end of the pipe at the base of the house, and it cannot turn sharply and fall into the apartment at the level of the third floor.
Emboli can not move anywhere, get out of the vessels and go on a journey through the body. They jam the lumen of small vessels inside the fibroids, forming a “plug”, after which the process of formation of a blood clot begins, which includes this embolus.
Emboli fly through the artery under the pressure of blood 120 mm Hg. therefore, they cannot move against the bloodstream, and they cannot enter the veins, since arteries and veins communicate with each other at the level of capillaries – vessels with a wall thickness of one cell, emboli are hundreds of times larger than the lumen of capillaries (average capillary size 5-10 microns, and the size of emboli – 500-900 microns).
Purulent and septic complications can develop only in those cases when a patient with an inflammatory process is taken for the procedure, and this is unacceptable. Despite the fact that all patients undergo a thorough examination before the procedure, we still prophylactically inject antibiotics in order not to give any chance for the development of this type of complications.
The remaining complications typical of any medical procedures and their occurrence can be equated to an accident (allergic reactions to drugs).
What are the costs for the patient in the treatment of fibroids by embolization? How expensive is it? It is known that in the absence of the uterus, the only way to have a baby is surrogate motherhood, the cost of which is from 1 million rubles, and this amount is of course not comparable with the cost of new gentle methods of treatment of fibroids, of course they are much cheaper. Therefore, what is the order of prices here (these are several thousand, several tens of thousands?).
Embolization of the uterine arteries, I must immediately say, is an expensive method of treating uterine fibroids. The high cost is mainly due to the high cost of consumables used in this method. All material is disposable, made of high-tech materials and is made only abroad. To reduce the cost of embolization through the use of consumables of dubious quality, I think is wrong, because it affects the quality of the EMA and the result, especially if the woman is planning a pregnancy.
I work on embolization of the uterine arteries in the Perinatal Medical Center on Sevastopolsky Prospekt, where a “uterine fibroid treatment clinic” is organized.
Perinatal Medical Center is the most modern obstetric and gynecological clinic in Russia, the so-called “full cycle”. The clinic, an area of 33 thousand square meters. meters includes a maternity hospital with all departments, gynecological department and department for newborns and children.
The clinic has an ultramodern operblock, an intensive care unit, and the situation itself can even be called chic – only single spacious chambers, restaurant meals and many, many other pleasant nuances. In general, the clinic is no different from expensive European clinics.
The uterine artery embolization is performed by Boris Y. Bobrov – an endovascular surgeon, a candidate of medical sciences, a laureate of the Russian Federation Government Prize in science and technology, but probably the most important aspect of the problem under discussion is the fact that Boris Bobrov has the greatest personal experience in uterine artery embolization in our country and most of Europe.
At the moment, they have already completed more than 2500 operations. He was one of the first to perform embolization in our country. Now Boris Bobrov operates in several Moscow clinics and regularly travels to various cities of Russia and the CIS countries to conduct master classes. If we talk about uterine artery embolization – Boris Bobrov – this is the number one surgeon in our country.
Embolization of the uterine arteries at the clinic of uterine fibroids of the Perinatal Medical Center is performed at the most modern level. We originally wanted to create a clinic of uterine fibroids, which used the most modern technology, would have a full range of services and the most comfortable conditions for patients. We were striving for the ideal and it looks like we did it.
For embolization, we use only the Japanese BidBlock preparation and only special catheters developed for this procedure. It is very important to note that we are engaged not only in uterine artery embolization. We carry out all types of treatment of uterine fibroids: myomectomy (by any access – laparoscopically and by open surgery), hysteroresectoscopy (removal of nodes in the uterus), medication. In other words, we do not intend all patients to embolize the uterine arteries. Since we have a wide range of medical opportunities, we can objectively select and carry out exactly the treatment method that suits a specific patient and reflects her needs. In our clinic, follow-up pregnancy and childbirth occurs. That is, the full cycle of patient management, and this distinguishes us from other clinics, which possessing only surgical methods of treatment, make a very biased conclusion about possible types of treatment, in every way criticizing the uterine artery embolization method, which they simply do not have.
Now about the price – the embolization of the uterine arteries in our clinic costs 150 thousand rubles and this is the full cost, as they say “turnkey”, that is, no additional fees are required. This is quite an adequate price for getting rid of uterine fibroids. It is important to note here that after performing the embolization of the uterine arteries, the patient “removes” the diagnosis of uterine fibroids and does not return to the treatment of that disease, unlike myomectomy, after which the disease often recurs and the treatment of uterine fibroids must be solved anew. It is also important to take into account psychological comfort, since the completed embolization of the uterine arteries makes it possible to no longer be in a “suspended” state — what to do next with the myoma — to observe or already operate. Many people go for years like this, after embolization this “mountain falls off the shoulders”.
And another very important question is whether a study was conducted on the effect of uterine artery embolization on the uteroplacental blood flow during pregnancy in women who had previously endured embolization? Can the previously transferred treatment of fibroids using embolization cause insufficient blood supply to the uterus during pregnancy and adversely affect the intrauterine nutrition and development of the baby?
From a theoretical point of view, one would assume that this is possible after embolization of the uterine arteries, but in practice this is not visible. The analysis of pregnancies after the performed EMA shows that they proceed without any peculiarities. The weight of babies is not less, some of our patients gave birth to fairly large children up to 4 kg.
I have already spoken about this – the normal blood flow in the uterus is fixed within a few weeks after the procedure. When the patient arrives at her first follow-up visit 1 month after the EMA, we will definitely evaluate the blood flow in the uterus and it is the same as it was before the procedure. Not all, without exception, pregnancies after embolization proceed to the end and end in childbirth – there are cases of abortion and other complications that occur with the same frequency in women who have not undergone EMA, but are in the same age category. Do not forget that uterine fibroids most often develops in women closer to 30-35 years, and this age itself is considered by obstetricians as an aggravating factor. In general, I can reliably say that in relation to this issue, practice is at variance with theory.
Dmitry Mikhailovich, do you think that the patient should choose the method of treatment of uterine fibroids, based on his knowledge, or act on the principle of “where to send”? Who should decide on the method of treatment of fibroids, what to do if the attending physician did not hear anything about such methods as embolization, but heard about laparoscopy, but in the nearest hospital there is no equipment and qualified specialists and the only thing they can offer is amputation of the uterus by abdominal operations? What to do in this case, as many of our users put it “where to run”? Where to find experienced professionals?
Alas, but “saving the drowning hands of the drowning people themselves,” I will quote a well-known quotation. Now is the time when patients have to independently understand the conclusions of doctors and evaluate them on the subject of “objectivity.” In the west, sites providing “information for patients” have been around for a long time. They can find detailed, reliable, and most importantly not biased information about all methods of treatment of a particular disease.
I want to encourage patients to be more attentive to the conclusion of doctors and always try to get another opinion of a specialist, and only then make a decision on the choice of a particular method of treatment. Few clinics have the capacity to carry out uterine artery embolization (the equipment is quite expensive, there are no trained endovascular surgeons), and the lack of the full range of therapeutic options leads to the fact that patients are given information in a distorted way, with a bias towards surgical treatment methods.
Once again I want to remind you that in Moscow on Sevastopolsky Prospekt there is a Perinatal Medical Center in which a uterine fibroid clinic is organized, in which all modern methods of treating uterine fibroids are used, therefore we can select the optimal treatment for you as a result of the examination It is in your particular situation, and also to provide a full cycle of treatment, including the management of pregnancy and childbirth, if you are interested in this.
Dear Dmitry, thanks for the informative interview. We hope that thanks to your advice, many women will be able to consciously choose the method of treatment of uterine fibroids and avoid infertility and other problems.
Uterine fibroids. About the disease. Treatment.