By Maria Rivlin

I caught up with neuroradiologist Suzanne LeBlang, an early adopter of MR-guided focused ultrasound (MRgFUS) as a treatment for a common women’s health condition known as uterine fibroids.

Dr. LeBlang has been treating patients using MRgFUS for more than 10 years. She is based in Boca Raton, Fla., and is affiliated with multiple hospitals in the area, including JFK Medical Center and West Boca Medical Center. She received her medical degree from the University of Miami Miller School of Medicine. As the chief medical officer at the Focused Ultrasound Foundation, LeBlang organizes working groups to devise clinical protocols, serves as a liaison to the clinical research community and presents information on MRgFUS at medical conferences.



MR: What are uterine fibroids?
SL: Fibroids are benign (noncancerous) growths of the uterus. There are four types of uterine fibroids classified by location. Intramural, the most common type of fibroid, grow within the uterine wall. Subserosal fibroids grow on the outside of the uterine wall. As they grow larger, they can cause pain due to their size or pressure put on nearby organs. Submucosal fibroids grow on the inside of the uterus wall, and distort the uterus cavity. This type can lead to heavy bleeding and infertility. Pedunculated fibroids grow on small stalks inside or outside the uterus. Keep in mind that a patient can have more than one type of fibroid.

MR: How common are fibroids, and what are the symptoms?
SL: Fibroids are quite common. It’s estimated that up to 80 percent of women in the U.S. will have fibroids by the time they turn 50. Patients can start having symptoms in their early 20s, and when they get older, these symptoms become more prevalent. African American and Hispanic women are more likely to develop fibroids for reasons that are not fully understood. Sometimes fibroids stay small, like the size of a pea, and don’t present any symptoms. But sometimes these fibroids can grow over time to be the size of a plum or even a grapefruit.

As fibroids grow, they can cause more symptoms, and depending on the location of the fibroid, they can become more problematic. The size and location of the fibroids can also impact the severity of the symptoms. Heavy bleeding is the most common symptom, but other symptoms may include urinary frequency, pelvic fullness or pressure on the pelvic area, constipation or difficulty in getting pregnant. Some women may even look as though they’re pregnant due to the size of their fibroids.

MR: How do fibroids affect a woman’s fertility?
SL: We all know that the endometrium is the central cavity where a baby grows. If that is curved at all due to a fibroid pushing on it or growing within it, a woman’s ability to conceive can be impacted. An embryo needs a nice, smooth place to implant and fibroids can affect that. Intramural fibroids, for example, may have a negative impact on implantation and clinical pregnancy rates possibly through altered uterine muscle contractility.

MR: What are the most common treatments for fibroids, and what are the pros/cons of each?
SL: It’s important for women to have a choice, and know all the pros and cons of each treatment, so they can decide together with their gynecologist which one is best suited for them. As a physician, I tend to look at everything through a risk-benefit ratio.



For older women who are mildly symptomatic, one option is to take medications. Medications such as Lupron can reduce the size of the fibroid. However, one side effect of these medications is that they put the patient in a “temporary menopause,” so they stop getting their period. This is a short-term solution, as patients can only take it for six months. While patients are taking the drug, the fibroids will shrink or disappear, but as soon as they come off, the fibroids will come back. Lupron is a good option to reduce a fibroid size prior to surgery or other treatment. It’s the shortest treatment, and the least invasive.

The most commonly performed treatment is also the most invasive: total hysterectomy. With a hysterectomy, the uterus is completely removed and fibroids have no chance of growing back. However, patients should know that it’s a major operation, whether done open or laparoscopically. In most cases, since the uterus has been removed, and in some cases, also the ovaries, this may result in early menopause including symptoms like moodiness, changes in sexual feelings or desire, vaginal dryness, trouble sleeping and so on. With surgery, there are also the risks associated with anesthesia, bleeding, infections and adhesions. In addition, many patients are fearful that removing the uterus will make them lose that sense of what makes them feminine. Not to mention, once the uterus is removed, there is no chance of having children. So, a woman who is not yet family complete would have some apprehension on this course of treatment.

Another procedure called uterine artery embolization is minimally invasive. A catheter is inserted to deliver small particles to block the blood vessels supplying blood to the fibroids. This is a good option for women with multiple fibroids. However, it’s typically quite painful. Cutting off the blood supply to the fibroids causes pain and contractions, and the recuperation period is between two to six weeks. Aside from this, it’s possible that when supply is cut off to fibroids, it can also cut off supply to ovaries, causing permanent menopause. Further, it could decrease blood supply to the uterus, which could affect the ability to carry pregnancy to term.

MR-guided focused ultrasound is another treatment option that is appealing to patients because it targets and treats only the fibroids. During treatment, the patient lies on a treatment bed inside an MR imaging scanner, not an operating room. The treating physician directs ultrasound beams through the skin with no incision directly into the fibroid to heat and ablate, or destroy the fibroid tissue, leaving healthy adjacent tissue around it intact. There are no incisions and no catheters. The treatment is normally an outpatient procedure, so patients can go home the same day. I’ve had patients who can do yoga, or go running the next day. This is a good option for women who want their fibroids treated, but want to preserve their reproductive organs. There is a very low risk of skin burns.

And finally, there is a procedure called a myomectomy, which is a surgical procedure that enables removal of only the fibroids. Depending on the location of the fibroids, a myomectomy can be performed with an abdominal incision, laparoscopically or vaginally. Each has its own pros and cons. This is an option for women who want to preserve their reproductive organs. However, patients can develop scar tissue, which would make pregnancy challenging.

http://www.fibroideducation.com/quiz.html

About the author: Maria Rivlin is the vice president of women’s health at INSIGHTEC and is responsible for developing the global market for women's health. She focuses on increasing awareness for noninvasive MR-guided focused ultrasound for symptomatic uterine fibroids.