Post Menopausal Patients
Unfortunately I see too many patients , with large fibroid pelvic masses,who have not had their fibroids treated pre menopausally in the hope they will shrink after ‘the change). This is a myth except in a small minority of cases. Assuming a patient is not on hormone replacement therapy (HRT) there is no oestrogen stimulation so they don’t usually grow and simply remain the same size. Often continuing to cause distressing syptoms due to compression and a protuberant abdomen. Occasionally benign fibroids can grow even quite rapidly in patients not on HRT for reasons unclear.
Fibroid embolisation is very effective in treating post menopausal patients and below are the results of our series. The procedure is far safer than hysterectomy particularly in this age group with a much lower complication rate. Care must be taken to ensure the fibroids are benign which is the case in the majority of patients.
24 women over 50 years of age with uterine fibroids receiving uterine artery embolisation were identified in thes single centre study, of which, I did not wish to take part. Median age was 59 years old (Range 52-72). 21 patients completed a pre-assessment questionnaire. This identified that the majority complained of pressure and discomfort (20). Other common complaints were urinary symptoms (7) and dyspareunia (4).
15 patients were post-menopausal. 6 had regular periods. 2 had irregular bleeding. 1 had continuous bleeding. 4 patients underwent uterine surgery in order to improve their symptoms in the past and this included 3 transcervical resections of fibroids and 2 uterine artery embolisations (1 patient had tried both procedures in the past). Interestingly all the patients except for one had information about uterine fibroid embolisation from the gynaecologist and only one had sought information about this procedure independently prior to consultation.
A transvaginal ultrasound and an MRI Pelvis were performed for all the patients prior to the procedure. The volume of the uterus ranged from 900 ml to 800 ml. The majority of embolisation procedures were performed for a uterus between 1,000 ml and 3,000 ml (16/23). 4 of 23 patients had a uterus with a volume above 3 litres. Overall reduction of uterine size 8 weeks following the procedure, identified 12 of 23 had a reduction betwee 50% and 64%. 35% of patients (8/23) experienced a reduction of >65% of uterine volume. Only on 2 occasions was the reduction in size below 50%.
At 8 weeks a patient questionnaire was completed by 19 of the participants. All of these found that the information given before the procedure was comprehensive and 84% (16/19) found the embolisation itself better than expected. Pain symptoms were better than expected for 10 patients (52%) whereas 7 patients found it worse than expected. All the treated patients were happy with the two day length of stay and 13 patients (68%) experienced bruising at the incision site.
In the majority of participants (13/19) regular analgesia was required for less than 5 days and only in 2 cases was oral analgesia necessary for more than 10 days. 3 patients experienced post embolisation syndrome that was treated in all cases with simple Paracetamol and Ibuprofen. 15 patients went back to regular day to day activities in less than 3 weeks.
A common side effect of Uterine Artery Embolisation is vaginal discharge. This was experienced by 14 patients. In 4 patients the discharge was still ongoing at the time of the 8 week reviews and was offensive in 2 of these cases.
Spontaneous passage of fibroid occurred in 2 patients. 6 months post-procedure the uterine volume was checked using an MRI pelvis. 13 of 23 patients had a reduction between 50% and 64%. 35% of participants (8/23) experienced a reduction of >65% of uterine volume. Only in 1 case the reduction in size was below 50%.
Following this procedure we contacted the patients and we asked them if, looking back, they would recommend this operation. 20 0f 23 said they would recommend it. When asked how the symptoms had improved on a scale of 0-5, with 0 indicating 'No Change' and 5 'Complete Resolution', 12 of 23 had a total resolution of symptoms, 1 reported no change (who subsequently went on to have a hysterectomy) and 10 described varying levels of improvement.