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Fixing Fibroids

Two new ways to fix fibroids.

Pilates studio owner Tonya Amos needs her body to run her business. However, the former professional dancer started feeling intense pain. A visit to her doctor revealed the cause.
“She said, ‘Does this hurt’ and she pushed on my abdomen, and I said, ‘Yeah that hurts’, and she said, ‘Yeah that’s a fibroid,’” Amos told Ivanhoe.
Amos had several fibroids. One of them was as large as a grapefruit.
“What I heard over and over was ‘you need a hysterectomy,’” Amos explained. “That was not an option for me.”
Dr. Vanessa Jacoby is studying new ways to shrink fibroids, without major surgery. With MR-guided focused ultrasound, an ultrasound beam focuses on the fibroid and creates heat.
“That heat burns the fibroid cells and destroys them,” Vanessa Jacoby, MD, MAS, Assistant Professor Obstetrician/Gynecologist, Dept. of Obstetrics, Gynecology, and Reproductive Services, University of California, San Francisco, told Ivanhoe.
Another method, laparoscopic radiofrequency ablation, requires three tiny incisions. A probe is placed in the fibroid.
“We use radiofrequency energy to burn the fibroid cells,” Dr. Jacoby explained.
With a hysterectomy, there’s a three- to six-week recovery. The ablation is about a week. The ultrasound therapy is just two days.
Amos had the ultrasound treatment. It shrunk her fibroids.
“It feels like my body again,” Amos said. “I got my body back!”
Doctor Jacoby says not all patients with fibroids are candidates for these two new treatments. It depends on the size, location, and number of fibroids.

BACKGROUND: Uterine fibroids are benign tumors made up of muscle cells and other tissue that grow within the wall of the uterus. The tumors can vary in size and number and are more common in African American women. Fibroids are the most common type of uterine tumor affecting 25 percent of childbearing women. Some estimates say up to 75 percent of women will have a fibroid at some point in their life. Signs and symptoms of fibroids include heavy or abnormal bleeding, pain, pelvic cramping or pressure and bloating. Uterine fibroids have been associated with infertility, miscarriage and early onset of labor. (www.mayoclinic.com)
TYPES: There are three different types of uterine fibroids that can occur:
* Inramural: The most common type of fibroid. They are found in the wall of the uterus and cause heavier than normal menstrual bleeding, pelvic pain, back pain or generalized pressure.
* Submucosal: This is the least common type of fibroid, but often times the most problematic. Submucosal fibroids are found in the muscle beneath the inner lining of the uterus.
* Subserosal: These fibroids grow on the outside of the uterus' wall and can become very large. They typically don't affect menstrual cycle, but then can cause significant pelvic and back pain as well as generalized pressure. (Source: www.womenshelath.gov)

NEW TECHNOLOGY: There are now two new ways to treat fibroids, so patients don’t have to choose between a hysterectomy and a myomectomy. One of the treatments is called MR-guided focused ultrasound. Using an MRI machine, an ultrasound beam is focused on the fibroid. The high heat kills the fibroid cells, and will slowly shrink it over a period of a few months. The other technique is called laparoscopic radiofrequency ablation. Doctors cut two tiny incisions in the abdomen and insert an ablation tool. Again using an MRI, the doctors determine where the ablation needs to take place, then use radiofrequencies to destroy the fibroid cells. It’s generally an out-patient procedure, and patients go home the same day. Recovery time is usually about a week. (Source: Dr. Vanessa Jacoby)
FOR MORE INFORMATION, PLEASE CONTACT:

Stephanie Lemp
Research Coordinator
University of California, San Fransisco
(415) 297-3114
lemps@obgyn.ucsf.edu

If this story or any other Ivanhoe story has impacted your life or prompted you or someone you know to seek or change treatments, please let us know by contacting Marjorie Bekaert Thomas at mthomas@ivanhoe.com

Vanessa Jacoby, MD, MAS, Assistant Professor, Obstetrician/Gynecologist Department of Obstetrics, Gynecology, and Reproductive Sciences University of California, San Francisco, talks about two new ways to fix fibroids.

How common are fibroids?  
Dr. Jacoby: Fibroids are extremely common. They’re actually the most common pelvic tumor in women.  About 30 percent of reproductive-aged women have fibroids and they are actually much more common in some groups of women than others. So for instance, African-American women probably have two to three times higher rate of fibroids than any other group of women.  Amongst African-American women, by the time they’re 50, about 80 percent of African-American women have fibroids. 
Why is that?  
Dr. Jacoby: Why the differences between them?  There is a lot of research into why different groups of women have more or less fibroids. It’s probably in part genetic and maybe also in part environmental exposures. 
Can they be bad for your health?
Dr. Jacoby: So although many women have fibroids, only about half of the women who have fibroids will actually have symptoms. And the symptoms of fibroids, are very heavy periods; sometimes requiring a blood transfusion or resulting in really significant anemia. The next symptom is pelvic pressure or discomfort; sometimes a lot of urinary frequency, or having to get up at night to urinate because the fibroid growths put pressure on the bladder. Some women have discomfort with intercourse; some women have uncomfortable periods because of their fibroids. 
A lot of hysterectomies are performed because of fibroids, right?   
Dr. Jacoby: Hysterectomy is the most common major surgery among women who are not pregnant in the United States. There’re probably about 600,000 hysterectomies a year and fibroids are the number one reason for hysterectomies. There are about 250,000 hysterectomies a year just for women with fibroids. 
Do most of them have a hysterectomy because of the pain?
Dr. Jacoby: Usually, it’s from the symptoms of fibroids that lead women to have a hysterectomy either really heavy bleeding or some of the pressure, discomfort, urinary frequency symptoms that I was talking about; because fibroids can be as small as a pea and then they can grow as large as a watermelon size.  And so the size, the number, and the location of the fibroids really tend to dictate what a woman’s symptoms are. 
And up until recently, it’s been a hysterectomy or nothing for treatment, right?
Dr. Jacoby: Well no, the traditional mainstay of treatment for fibroids has been surgical and that has been hysterectomy which is to remove the entire uterus or myomectomy which is just to remove the fibroids. Those are the traditional surgical approaches to fibroid treatment. There are also medical approaches to treatment, so some women can use medicines to help with heavy bleeding for instance, but if you also have those symptoms, we call them bulk symptoms, when you have pressure and discomfort in the pelvis, there is not great medicine to treat that because you really need to either remove the fibroid or shrink the fibroid. 
How is ultrasound being used to treat them? 
Dr. Jacoby: So one of the newer treatments is a nonsurgical treatment called MR-guided focused ultrasound and what that treatment does is it uses the power of ultrasound to destroy fibroid cells. An ultrasound is placed under the abdomen of a women as she lies on her stomach and the ultrasound beam is focused really tightly into one tiny spot, the size of a grain of rice, and when you do that, you create a lot of heat and that heat burns the fibroid cells and destroys them.  And when you destroy the fibroid cells, the fibroid then will slowly, over a few months, shrink down in size and decrease symptoms. 
How hot is the heat and is there a risk of burning other tissue?  
Dr. Jacoby: It does get very hot, but during the procedure, the woman is in an MRI machine, a magnetic resonance imaging machine, so the physician performing the procedure can see exactly where the fibroids are and where the ultrasound beam is going. So, although it’s a theoretic risk that the ultrasound beam will not just target the fibroid in general, it’s a very safe procedure and the beam is directed only towards the fibroid. 
How long does it take for the fibroid to disappear? 
Dr. Jacoby: So, the fibroid doesn’t disappear.  There is really two approaches to fibroid treatment besides hysterectomy; one is to remove the fibroid completely which is myomectomy and then the newer more minimally invasive treatments are to leave the fibroid in your body, but destroy the cells and shrink the fibroid and if you shrink the fibroid, it doesn’t disappear, but with its shrinking, the symptoms will improve. 
How long does it take until you see shrinkage? 
Dr. Jacoby: The maximum shrinkage happens about three months after these procedures, so the fibroid cells start to, are destroyed and then your body’s own immune system actually comes and reabsorbs the dead fibroid cells and the fibroid shrinks about 30 to 50 percent. 
Okay, so let’s talk about radiofrequency ablation; that has a lot to do with the ultrasound where it burns, right?  
Dr. Jacoby: Right, so, laparoscopic radiofrequency ablation is another very new, exciting, minimally invasive approach to treat fibroids. The idea with this is that you have a laparoscopic surgery where you have just two small incisions in the abdomen and then we use an ultrasound during surgery inside the abdomen to visualize the fibroids and then we take a really small probe, about the size of a pencil and we place it into the fibroid and we use radiofrequency energy to burn the fibroid cells. And then the surgery is done. The patient goes home the same day and the recovery is quite fast, so women are usually back to their usual activities in about a week.
So why would you use it instead of the ultrasound? 
Dr. Jacoby: Depending on your symptoms, and the location, number and size of your fibroids, you would be a candidate for one or the other treatment.  Sometimes, women are candidate for both, but in general it really depends on your symptoms, size, number, location of your fibroids.   
So would one almost be for larger probably and harder to reach and see kind of fibroids? 
Dr. Jacoby: I’m not trying to avoid your question, I promise, it’s just kind of a nuanced answer.  When I see a woman with fibroids, I work really closely with her to get an individualized treatment plan based on her fibroid related symptoms, the characteristics of her fibroid and what her pregnancy and fertility plans are also going forward.  
Is there anything we are missing? 
Dr. Jacoby: The one thing we didn’t talk about is a lot of people ask about pregnancy and how fibroids can affect pregnancy. This impacts who’s a candidate for which treatment. Uterine artery embolization which I mentioned has been around for many years and is a very effective treatment. The reason that we have newer treatments is because uterine artery embolization has some concerns for women who want to get pregnant in the future. So, there have been some studies that show that women who get this treatment may have some adverse pregnancy outcomes or difficulty getting pregnant in the future.  We do not recommend uterine artery embolization for women who want to get pregnant in the future.  We’re always seeking treatments that are minimally invasive, but safe for pregnancy and fertility. And for radiofrequency ablation, one of our newer treatments, it has not been studied in women who want to get pregnant in the future, but that’s one of the areas that we’re actively studying because we hope that this will be a treatment that can serve women who want to get pregnant in the future.  And similarly for MR-guided focused ultrasound; they’re too early in their use to have great information about women who want to get pregnant, but that’s a really active area that we’re researching.






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