What are fibroids?
by Eric Fassler, MD
Focused ultrasound is a new treatment for women with symptomatic fibroids. The uterus is an organ that is comprised of smooth muscle. Fibroids are smooth muscle tumors of the uterus. Approximately 30% of women develop fibroids. Because fibroids are estrogen-dependent tumors, only women who are producing estrogen with normal functioning ovaries can develop fibroids. Fibroids can be present from a very early age, or may not appear until a woman is in her thirties or forties. The size of a fibroid tumor may remain stable for years, and the patient may never have symptoms, or it can undergo gradual growth that causes it to become bothersome. Once a woman is menopausal and is no longer producing estrogen, fibroids will typically regress. How quickly that regression occurs varies, and menopausal women will still occasionally need some type of treatment due to persisting symptoms Also, many women have fibroids and never develop symptoms or their symptoms remain minor and they never require treatment.

What are the symptoms that fibroids cause?
Fibroid tumors are typically round in structure and very hard. They also can be quite vascular, and this is what typically leads to the symptoms that women experience. These symptoms include:

• When fibroids push into the cavity of the uterus, heavy or prolonged periods or bleeding in between periods may occur.
• Fibroids can put pressure on the bladder that makes a woman feel that her bladder is always full.
• Fibroids can cause the bladder to spasm, causing the patient to feel that she may not make it to the bathroom in time.
• Fibroids can cause pain with intercourse.
• When fibroids are large and located in the back of the uterus, women can have low back pain or pain radiating down the back of their legs.
• Fibroids can get big enough to cause pressure on the bowels, causing symptoms of constipation.
• If large enough, fibroids can cause the abdomen to become enlarged, and be mistaken for weight gain or pregnancy.

What are treatment options for fibroids?
Presently, there are a number of treatments for symptomatic fibroids. The traditional, and still most common, procedure for fibroids is hysterectomy. When done through an abdominal incision, a hysterectomy typically requires a hospital stay of three to five days and a recovery period of four to six weeks. Another option is a myomectomy, for women who want to preserve their uterus. This procedure usually involves an abdominal incision with the same recovery period of four to eight weeks. Sometimes, the procedure can be done laparoscopically, but again usually requires hospitalization, and a recovery period of two to four weeks.

Another less invasive procedure is Uterine Artery Embolization (UAE). This procedure is done in a radiology department at a hospital. Synthetic beads are placed into the arteries that supply the uterus and adjacent fibroids. With decreased blood flow, the tumors gradually shrink in size, causing fewer symptoms. Women typically require hospitalization for one to two days for pain control and an additional one to two weeks of recovery. Longer term data suggests that as time passes, the fibroids begin to grow again.

Magnetic Resonance Focused Ultrasound (FUS) is another treatment option now available to women for the treatment of fibroids. It is the least invasive of any of the available treatments, requiring no incisions, no post-operative pain control, and little or no recovery.

FUS is ultrasound energy that is passed through the skin and focused into the fibroid. Once focused, it creates heat that destroys the fibroid cells, leading to its shrinkage and symptom relief. During the procedure a patient lays on her stomach on a special table that houses the ultrasound. The table is attached to an MRI machine. This allows the doctor who is performing the procedure to get constant information about the position of the fibroid and destroy (ablate) fibroids inside the uterus without making an incision. Focused high-frequency, high-energy sound waves are used to target and destroy the fibroids.

Who is a candidate for Focused Ultrasound?
Approximately 60-70% of fibroids can be treated with FUS. To determine whether someone with fibroids is a candidate, a screening MRI is performed to identify the size, location and number of fibroids. If a woman's uterus is small enough, and there are six or fewer symptomatic fibroids, she is usually a candidate.

How is Focused Ultrasound (FUS) performed?
Before the procedure begins, you will be placed on your stomach on the ultrasound table. You will then be moved into the MRI machine. Even claustrophobic patients generally tolerate the procedure well, because the head and shoulders remain outside of the MRI machine. Ultrasound energy is turned on in 20 second intervals to heat the fibroid (sonication) and cause it to shrink. To treat a fibroid, about 50 sonications are required. If the fibroid is very large, two separate sessions may be required to complete the treatment.

The ultrasound procedure typically lasts 3 to 4 hours. During this time a technologist will be with you to make sure you are comfortable and not feeling pain. Because the internal parts of the MRI scanner produces repetitive tapping, earplugs or music through headphones will be provided. Patients typically receive intravenous sedation to keep them relaxed and comfortable during the procedure. The sensations patients who have had the procedure commonly report are warmth on their skin, or a brief deep pelvic ache during an ultrasound treatment.

After the procedure is finished, you will stay in a recovery area until sedation has worn off. You will then be able to go home and resume your daily activities without any restrictions. Because patients who have received intravenous sedation are not allowed to drive, you will need to make arrangements to have a friend or family member drive you home.

What to expect after the procedure?
Most women will notice an improvement in symptoms within a couple of weeks after the procedure. The fibroids shrink gradually, with maximum shrinkage occurring at about 3 to 4 months. There is usually no abnormal discharge or bleeding. Of women who have undergone this treatment for fibroids, 96% have been satisfied with the result.

Who should not have the procedure done?
There are very few reasons the procedure cannot be performed. For women with more than six fibroids, the time involved in treatment may be prohibitive. Women who cannot lie on their stomachs for up to 4 ½ hours because of some physical limitation would not be candidates. Patients who are not candidates for MRI examination, such as those with joint replacements, cannot undergo the procedure.