Uterine fibroids: when to consider embolisation

[00:00:00] Welcome to the Medical Forum podcast. This is general information for health practitioners only, and you can claim the time as part of your CPD. Welcome back to the Medical Forum podcast with me, Dr. Joe Kostrich, GP and Clinical Editor of Medical Forum. And today, very happy to be joined by Dr. Matt Clifford, Interventional Radiologist. Matt, welcome to the podcast and thanks for coming in today. Thanks for having me.

[00:00:28] So we're going to talk about embolisation of uterine fibroids, but before getting into that, for the listeners and viewers who might not be familiar with you, tell us a little bit about your background and how you've come to be doing what you're currently doing. Yep. So I'm a Perth boy, born here, same as my dad, my son, you know, his dad as well, my dad's dad. Um, and I studied at UWA medicine there and finished that in 2012.

[00:00:57] Um, interned and resident at Royal Perth, Royale, my, my, um, my spiritual home, I guess. Yeah. Um, for at least, you know, those are really formative years. I know, um, but everyone who's gone through an internship, it's, it's a transformative experience. Um, yeah. And this was no different. Yep. Yes. Yeah. Where'd you do yours? I actually did it at Royal Perth a fair while ago, but yeah, you go from literally one day you finish up and you've got no responsibility. And the next day you rock up and they thrust a chart.

[00:01:26] Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. Yeah. And you suddenly figure out how little medical school actually prepares you for, um, practicing medicine. Yeah. Yeah. I didn't say that. No, exactly. Like it doesn't matter how many RCTs, you know, if you can't sign the form correctly, you're not useful. Yeah. Um, yeah. And then I, uh, I actually went to the kids hospital PMH back then for a couple of years.

[00:01:50] I thought about, um, pediatrics and then, uh, from there I did, um, uh, realize it wasn't quite the right, um, fit on its own for me. Uh, and then went into radiology, did radiology in Perth. Yeah. Um, and then, but went back to the kids hospital quite a bit throughout my training, you know, I already knew the guys there and, and, um, uh, you know, they've, they've supported me a lot through, through my training in radiology.

[00:02:16] Um, and I'm back there working there as a consultant in, in interventional radiology and radiology now. Okay. At Perth kids hospital. Yep. At PCH. Separate to your, uh, to your private. Yep. Separate. Yeah, yeah, exactly. Um, and, but I finished, I did finish my, my, uh, radiology training in 2023. I think it was no 20. Yeah. Oh goodness. I don't remember now. It's about then. Yeah, exactly. These days. 2022 or 23 is one of those. I think it was 22. Yeah.

[00:02:46] Anyway. Um, and then I did a fellowship in interventional radiology at, at Charlie's. Um, uh, and I sat the, the, uh, accreditation, that sort of an international, um, accreditation process there. It's, it's not strictly speaking, um, required and, uh, but it's a good sort of platform for learning about all the things to do with interventional radiology. And then I went over, I applied for a fellow job over in Brisbane.

[00:03:15] Uh, and the director there said, Oh, why don't you just come as a consultant? You're sort of ready now you've done your qualifications. Yeah. You got your stripes. Yep. Yep. And, um, and I negotiated, no, I said, no, I want to do a fellowship. I want to learn some more. It's at the Wesley with a guy, Nick Brown is fantastic. Um, operator. Uh, and so he said, look, how about you come here as a, as a sort of a fellow, sort of a consultant, a bit of both. And it was a perfect experience for me, you know, very well supported consultant or, or a sort of a fellow with a long leash.

[00:03:43] Uh, and that was mostly focused on embolization therapies. So yeah. Okay. Well, that's, that's a really good segue because we're going to be talking about embolization of fibroids. Obviously fibroids are common. Um, some are symptomatic, some aren't, but, uh, again, when, when we're talking off air before we came on about, you know, med school. Um, I mean, certainly in my day and yes, it is literally in the last century.

[00:04:09] Um, you know, essentially it was in those days hysterectomy. There really wasn't much else. Um, so yeah, tell us a bit about, you know, obviously that the background of fibroids, like most of us will be familiar, but never hurts to be reminded. Um, and then, um, you know, they're, they're leading to, to, towards symptoms. Mm hmm. And, um, I suppose that's the next thing lets into, well, where do you come in? Yeah. Yeah, sure.

[00:04:37] Um, so, so fibroids themselves just, yeah, as you said, a refresher, really common. Uh, so a few studies have shown that about 75% of women by age 50 have got fibroids. 75%? 75%. That's three and four. Yeah. Whoa. Yeah. So very, very common and, you know, most common, um, uh, tumor, benign tumor, uh, of the female, uh, genital tract. Um, and yeah, so very common, uh, but the majority of these are asymptomatic.

[00:05:05] So we know that they're, they're diagnosed in less than 5% of women. Right. So, uh, well, that's UK data, but similar over here. Yep. Um, so now from that, you can guess that the majority of them are asymptomatic, but also probably there are some that are symptomatic, but just aren't, aren't diagnosed. Um, but very common. Yep. Yep. Uh, so, and fibroids are a common cause of, um, problems.

[00:05:30] Uh, the main one that is, is caused, uh, by fibroids is, uh, that bleeding. So heavy menstrual bleeding. Heavy periods. Yep. Exactly. And because they are responsive, hormone responsive, they tend to increase over time and they get worse throughout menarche. Right. Okay. Uh, so often, uh, it's sort of the frog in the pot a little bit. Yeah. These women have been getting worse and worse for a long time.

[00:05:54] So they've been getting painful periods maybe since they're high 20, for example, maybe before, and it just gets a little bit worse, but they don't think that much of it. It's just, I've always had it. Yeah. Yeah. And don't sort of really think as much about it as perhaps they should. Yeah. And, and it's sort of, uh, as well as that, so painful periods as well, that's, that's one thing that can happen. Uh, but it's, it's definitely more so the menorrhage. Yes. Uh, the heavy bleeding. Yeah. And, um, and then also pressure symptoms as well.

[00:06:24] So these things can be really big. Right. Yeah. I, as we were saying just before I treated one yesterday, there was about the size of a, uh, you know, a honeydew or rock melon. So really big. And you imagine you've got that in your pelvis. It's going to cause a lot of pressure symptoms is push on the bladder. Yeah. So urinary frequency, um, and you know, bowel symptoms as well, and sort of a fullness in the pelvis. Uh, so, uh, that would be, and so menorrhage are first, then pressure symptoms, then, you know, pain is sort of, um, uh, I guess after that.

[00:06:52] And then there are a few other things distorting the endometrial cavity that can affect some fertility as well there. Um, so, and it's sort of increased over time. Yeah. Okay. Yeah. And diagnosis is predominantly just straight up ultrasound. Yeah. So, I mean, obviously history examination as well, as you, as you well know, the, um, uh, but yeah, you're going to find out exactly what it is with the, with the ultrasound. Um, and that's really good at differentiating different causes of menorrhage.

[00:07:22] Uh, and so a good quality ultrasound will show fibroids. Um, in fact, often just a standard ultrasound, you know, um, will show fibroids, but the higher quality ultrasounds will, um, delineate where they are and sort of help, uh, whoever's treating them to know how best to treat them. Um, uh, so yeah, that's, that's usually at the point patients have had that sort of history examination and it's usually the first ultrasound before they get to their gynecologist or me or both. Um, yeah. At that point.

[00:07:52] Okay. And with menorrhage being the predominant, um, uh, thing that I end up seeing them for. Okay. As well as pressure symptoms. Yeah. So I'm, I'm in the surgery. Yeah. If you've come in, we've, we've got, um, you know, I've done the history examination. Yeah. Absolutely. Done the scan, got some fibroids. Uh, she's got some classic symptoms. Yeah.

[00:08:14] I mean, how, who might be suitable to send to you versus to a gynecologist or is it more, I send them to the gynae and then they might send them to you if they think it's, it's appropriate. So how does that sort of tease out? Yeah. So look, I'll say it is, it is a little bit, um, there are a few more steps than often another few procedures.

[00:08:38] So firstly, I think you, you might've even noticed in your own practice that a lot of women come to you and they've, they've, you know, once they've, they know their diagnosis and they say they've done their Googling. And they, they will come to you. Or their AI searches. Yeah, exactly. Yeah. Yeah. And they will often come to you and say, I want to see this person, you know, and I want to have this procedure. And then you have to, you know, sort of often unwind a bit and say, look, here's, you know, for example, it's asymptomatic.

[00:09:04] We don't actually have to do anything about it or, um, you know, okay, I don't know that person. Maybe I'll look into it or, you know, this is someone who I've been referring to for a while. I'm comfortable with. Uh, so, uh, then now if they come to you and they asking about, uh, finding this from a lot of my GP colleagues and friends that they, they are asking me, what is a fibroid embolization? Yes. Well, yeah. Because their patients saying, can you refer me for this? And they, you know. They're not familiar with it. Exactly. It wasn't around when you graduated.

[00:09:33] So, well, in common. It was actually, um, initially, initial studies out of France in, uh, the seventies were done. The seventies? Yeah, exactly. But it's never quite taken off. Well, it has taken off a little bit, I guess. So we've now got, yeah, like you said, 50 years of data on this and it's been building over that time. Um, and also the skillset and the devices that are used, they've, they've been building over that timeframe.

[00:09:58] And this is a little bit of a tangent, but I mean, is it, has it been more common in other jurisdictions, like you mentioned France, in some jurisdictions and hasn't taken off or been as well adopted in, in others such as Australia? Yes. Yeah, it is. Uh, so we know that, um, and there are sometimes good reasons for that and sometimes reasons for that. Um, so there are areas where, um, the, the countries that do it more frequently often in Europe.

[00:10:23] Um, so I know Holland, they've done quite a few of the early studies as well, and they've been early adopters of this. Mm-hmm. And there are complex reasons for that, you know, the, the relationship between, um, departments, um, and professionals, you know, like ultimately relationships always going to be the important thing. Politics potentially. Politics potentially. Yeah. You know, there's a lot of different things, um, around this and you know, yeah, it's still about, it's still less than 2% or less than 3% of all treatments for fibroids are, um, embolizations.

[00:10:54] Yeah. So who, who was a good candidate if you like for embolization? Yeah. There are, as I sort of touched on before, menorrhage is, why are we doing it? Mm-hmm. Who's not a good candidate is someone who doesn't have symptoms. They, they shouldn't be, if you don't have symptoms for fibroids. It's not going to improve your quality of life. Yeah, exactly. We are doing this to treat symptoms. If you don't have any, then we can only make it worse, right? Yeah. So these are symptomatic individuals with fibroids.

[00:11:21] Um, and the, I guess sort of what you are, um, what we touched on before is that, you know, these are patients, they need to know their full set of options. Mm-hmm. So they, they should, all patients need to see a gynecologist. And we sort of, um, touched on that before, but they need to see a gynecologist. Yeah. And sometimes I get patients referred directly to me and I will then look at them, talk to them about you, Fee, and then say, look, this is probably your next best option. Yeah. Um, or this is maybe even a better option for you.

[00:11:49] And then I send them to a gynecologist who does that sort of thing. Um, but ultimately they have to see a gynecologist and that's a Medicare requirement. Okay. So really for me as a GP, I should be sending them to, to the gyne rather than to you. Okay. That also sort of simplifies my life because otherwise I'm trying to figure out who to send to what. So that's really helpful. Yeah. Um, so that's, so the gynecologist and there's, um, I think in also an answer to something

[00:12:17] you sort of touched on earlier, why is it not being adopted? A lot of gynecologists, I mean, you have, these are your patients. The gynecologists take this very seriously, obviously. And they, they don't want to refer them to someone who they don't know. They don't really know if the procedure, the ins and outs of it, or that they're going to be taken care of. So it just takes a little while. And what I've found, uh, time and time again is that, well, what, how it usually happens is that GP sends it to a gynecologist. The patient says, I want to have this procedure. Yeah. And the gynecologist says, oh, I don't know, but okay.

[00:12:47] All right. Fine. If you insist. Exactly. And you know, for, for, I think good reason, uh, cause they, you know, don't know how it's going to go. And then that patient goes back to the gynecologist says, this was great. Um, and then, then that's what starts that relationship. Um, so that's where, uh, yeah, that's why it's in my practice, um, going, going, uh, Yeah. We're doubling and doubling every few months, the numbers that we're doing. All right. Yeah.

[00:13:16] So, or maybe to turn it on its head, are there any, um, you know, women with fibroids who would not be, be suitable for embolization versus surgical treatment? Yeah. Yeah. So, so one of the things that we know from the data is that, uh, if you want a definitive once off, you'll, you do it and it's done. Yeah. You go for a hysterectomy, right? Yep. Um, that is, you're never going to have a re-intervention, right? Okay. Once you've got the hysterectomy out. So that's, that's the first case.

[00:13:43] Um, now with fibroid embolization, you know, from different studies, it's, it's about the 10 to 30% will go on to have another procedure at some point. So if you want it done. And that's because it's reformed or they've got new ones that have come up? Unfortunately, the studies haven't gone into a lot of the, um, the specifics of which of their, their symptoms are, are the thing that's leading to that. But I think my impression is that, and also from my own practice, this works really well for men in a ranger.

[00:14:12] It works good for, for the pressure symptoms. It works well. Uh, it doesn't work as well for the pressure symptoms though. Okay. So, you know, you look looking at about, I think greater than 90% of women who have it done for menorrhagia have an excellent result. Right. Um, whereas for pressure, you're looking at more like 70%. So those, uh, women have it for those reasons. You're still in the majority are going to have a great result, but some of them might say, look, I'm improved, but, um, I still want to have it out.

[00:14:40] And then you also have other women who want to have a hysterectomy and, but the, the gynecologist says, this is just too big. We can't take this out, um, without doing a midline laparotomy. I'm going to send you to Matt to get it shrunk and then we'll do the hysterectomy. So that's a, that's another one. Okay. So we'll shrink the fibroid down and then we can do laparoscopic surgery. Yeah. Yeah, exactly. Or a smaller incision. Um, and so we're getting on average, uh, you know, between 40 and 70% reduction in

[00:15:09] volume of the fibroids. So that can really help a surgeon out as well. Um, so in, uh, other patients who shouldn't be having this, um, if you, if there's something sinister, you know, cause yeah, if you, if we're not sure that this is just a fibroid and if you cut it out, you're going to see what it is. Okay. So, uh, most of my patients I'll organize an MRI for, um, and then, um, these are reported

[00:15:35] by specialist, like subspecialists, radiologists, and they'll be looking very hard to make sure that this is typical. If there are atypical features, then they might be better in a bucket. Mm-hmm . You know, the, um, the, the uterus. Yeah. That's another one. Um, look, there are different types of fibroids. So you can imagine they can occur anywhere from the myometrium and some of them stick into the, the endometrial cavity. Mm-hmm . And there's a, you know, if they, uh, then die and fall off, they can block up the internal os.

[00:16:03] So, um, and then that causes that, that's a risk factor for endometritis. So often we'll get those resected, um, and, um, um, you know, by the gynecologist. And that's a, from what I understand, having never done it, it's fairly straightforward procedure. So if that's their only one, then they can just get that one taken out. Yeah. And there's one other one as well. There's one other bit. So the, um, pregnancy, you know. Yeah. Okay. Yeah.

[00:16:29] Pregnancy is, uh, so, um, this is, this is an area that's changed a little bit. Okay. So, um, it used to be if you want to, if the patient is, um, hasn't finished their family, you don't do it. That used to be the old way of thinking about this. It's, it's changed a little bit. Um, it's, it's more nuanced than that. We know that if you have a uterine artery embolization, you can fall pregnant. Uh, and obviously with a hysterectomy, you can't, right?

[00:16:59] So we're now talking about, um, embolization versus myomectomy. So cutting out just the fibroids. And there's much, there's better data on myomectomy for, um, in terms of the volume of data. And then also the numbers, there's, there's a bit of conflicting data there, but in general, most of the evidence would suggest that pregnancy rates and also live birth rates are better with myomectomy. Yeah. Okay.

[00:17:27] So, so then you'd say someone who wants to fall pregnant, uh, if they can have a myomectomy to treat their symptoms and you go for that. Yes. Or you, if they can't have a myomectomy, then you think, well, can they just wait until they finish their family? That's, but if it's a no to both of those, then you can consider it. Yeah. Okay. But the patients just, you just need to have that conversation. And I'm, you know, that's what I have. I have a frank conversation with them.

[00:17:52] Look, if you have had three kids, you're thinking about a fourth and this might be a, an idea. I know that's uncommon. I'm one of the people, the only people foolish enough to have four kids. But, um, anyway. Yeah. But, um, if you are, you know, you're early on in that journey, you know, you want to have kids, maybe, maybe you should be looking at something else. Yeah. Okay. So what is like for the, the, the, the woman coming in or what, how would you describe sort of like the patient experience? Yeah. What can they expect?

[00:18:22] Um, how long does it take? Yeah. When are, when are they up and about? Yeah. So, um, so in general, so I see them in clinic and then we're booking for, for the procedure. Um, it's done in a, in a theater. Uh, I have an anesthetist there for all of these procedures. Uh, the, um, what I recommend for all of them is a spinal block at the start of the procedure. My anesthetist does that for me and that lasts for about 24 hours. That's important. Um, I'll come back to that.

[00:18:50] And then they can be as awake or asleep as they want to be. So, uh, I'd leave that between them and the anesthetist. Yeah. They can, most of them will go for a little bit of sedation. Some of them will, will want to have a general anesthetic and I don't really mind. Um, in terms of the patient move, I've done this with patients moving around a fair bit and it's actually fine. Yeah. It's, it's not a particularly challenging procedure. I do other things like prostate, artery embolization. So they gotta be still for that. Um, whereas this one is fairly straightforward. Right.

[00:19:19] Um, and so then the procedure itself, it takes me about an hour. Um, I, I do them both through a femoral approach and a radial approach. I used to do them all femoral. Uh, so the common femoral artery. Yeah. Uh, and then I went to all radial and now I do a bit of both and a bit of, um, reasoning for that. And it's about the afterwards. Yeah. And I suppose it depends on, on, on the individual. It depends on the individual. Um, it also, so the growing from the wrist, they, at the end of it, they just get a wrist

[00:19:47] watch sort of thing that pushes on the hole and they can sort of move around in bed as they like if they're uncomfortable. Yeah. Um, whereas, uh, from the groin, you have to lie flat, um, for two hours minimum and then a bit of an incline. Um, and so if they're in, if they're in discomfort at that point, it can sort of add to it. There's the, there's a scary thing that there's a theoretical risk of a symptomatic stroke. I shouldn't say theoretical. We think that it's probably about a one in 10,000 risk of a symptomatic stroke. So that's, that's, um, uh, every procedure has potential.

[00:20:17] It does have potential risk. Yeah. That's just life. And then there's, there's a bit of other data that's come out that maybe there are these little hits that are happening from the radial artery as well. So I've started to say, look, they're both easy enough for me. They're both options. They're both done regularly around the world. And, and I leave it after they know that. And what I'm hearing is there's, there's with everything. There's pluses and minuses. Exactly. Exactly. And they're both feasible and easy enough to do. So they'll typically go home the same day or own hospital overnight. Yeah.

[00:20:45] So, um, so the, the procedure itself is near painless. Um, it's a local anesthetic at the puncture site and that's it. But the, the ischemia caused by the embolization. So what we're doing is we're getting catheters into the uterine arteries and, um, we're embolizing with these, these microspheres that are calibrated in size. There are 300, 500 microns. Um, sorry, 500 to 700 microns.

[00:21:11] Um, the, the, the vascularity around the, the fibroids is about 300, 500 microns. So we're giving spheres that are slightly larger than that. And so they block up the arteries that supply the fibroids. All right. Yeah. There's an artery from the left and from the right. And you check both those and embolize that. So, but that ischemia causes pain and that pain basically it peaks a few hours after the procedure and it can be really severe. If you don't give any pain relief, it's really severe.

[00:21:37] And it lasts for about 12 hours and we've done a, I've done this a whole bunch of different ways. Cause this has been the problem of, um, fibroid embolization for a while is that, that 12 hour period afterwards is quite unpleasant. Okay. But, uh, does the spinal block help with that? So that actually came from, um, our anesthetist. They suggested, Hey, why don't we try this? We've now done about probably about 30 cases of the, with the spinal. We were doing PCAs beforehand and that was, that was helped.

[00:22:07] It was better, but the spinal has changed the game. I mean, from my perspective. Yeah. Um, so patients, it, it has a great overlap. It lasts for about 12 to 24 hours, which is exactly that peak. Yeah. You said it was that peak period over the first 12 hours. So if the block's lasting 24, you're, and again, some people still have obviously pain later, but that's covering that time. Yes, exactly. And that peak pain. Um, and so it overlaps really well cause it starts after a couple of hours and you know,

[00:22:34] my procedure is done by then or as in the, the, it really works very well. Disadvantaged, they do have to have a catheter. Um, and they have a trial avoid the next morning. Uh, but then next morning we send them home. We've got a bit of anti-nausea medications, some baseline, simple analgesia, plus some breakthrough pain killers. And then, uh, the week or two afterwards they'll, they'll feel a bit, um, they'll feel a bit rundown. So it's often, it's like a, it's almost like having a bit of a flu. Yeah.

[00:23:01] Um, so they'll have, uh, like low grade, uh, fever sometimes. Okay. And this is because of the tissue necrosis. Yeah, exactly. And from the apoptosis as well. Um, and those cellular contents, like what's happening with the virus, you're getting that, those cellular contents are causing you, um, that response. And so they'll often have a low grade fever, muscle aches, a little bit of a foggy sort of feeling. So I say to them, look, just, just don't make any important decisions in that way. Just sort of take it, take it easy.

[00:23:29] I say to the husbands or the partners or whatever, I say to them, look, you're doing the dishes. Yeah. There's none of that. Yeah. And that's actually, I, um, I'm, as much as, you know, society has changed. Unfortunately, um, um, a lot of our female enlistments will know that sometimes some things haven't changed anyway. So, um, they're, they're taking it easy that week. Yep. They're out of hospital the next day. So, um, and sometimes it's two weeks, but yeah, it's about that mark.

[00:23:56] Two, uh, I have had one patient who discharged herself that night and went for a long run, um, which I wouldn't recommend, but some patients will have a very minor course, but most patients are in that week of, of, um, yeah, to relax. I give them two weeks med surgery. Like any, I suppose any procedure where you had any form of anesthetic, spinal or general, yeah, you're going to have a period of recovery and some people bounce back faster than others. Yeah. Some people have got brown eyes. Some people got blue eyes. Yeah, exactly. Exactly. Some people have got one.

[00:24:25] Um, in terms of sort of the outlook, and I suppose there's two parts to this one sort of short term, I suppose for me as a GP, somebody, a woman's had this procedure on the Tuesday, what potentially, um, might they come in to see me with on a Friday? Like what are the short term potential, uh, complications or problems? Yeah. So there's puncture site issues. Uh, so, um, a little bruise is expected. You always get a small bruise, but a large bruise or a spreading bruise or exquisitely

[00:24:55] tender puncture site. Those are, those are things that we need to, um, investigate. Yeah. Uh, so, um, especially this is for patients on blood thinners. Now that's usually not, um, this cohort, but, uh, those are patients who might have a pseudo aneurysm. It's about a 1% risk of that sort of thing. Okay. Um, or potentially an infection in that site. I've not seen that yet. Um, but I'm sure eventually, um, uh, I'll say that. Um, and then the other thing is, look, there is this about a 1% risk of causing endometritis,

[00:25:25] which is, um, you know, it's very serious. Um, and they'll need, uh, they'll get worse until they get a hysterectomy basically. Um, now, uh, so for that reason, I, I make sure that that's in the consent. And some patients who are absolutely, you will not take my uterus for any reason. They're probably not suitable for this if they won't. Yeah, absolutely. Yeah. Um, so, but that's usually a bit later, uh, you know, after that first week.

[00:25:49] So, um, the, the, uh, the, the expected symptoms in the week after are usually not a sign of endometritis. Um, and that would be an offensive purulent discharge that would, um, that would, uh, sort of indicate that. Now you can have sloughing of the, um, uh, well, you will have sloughing of the endometrium as well as sometimes little bits of fibroids, um, uh, in that, that time period. And that's not to be confused with, with, uh, with an infection. Yeah.

[00:26:17] And to turn to the positive, when, um, I suppose what sort of benefits of all goes vaguely according to plan can a woman expel? I'm guessing I know we know the answer, but, and over what sort of period of time, like at what point to look back and say, yeah, I'm through the, the down part. Um, you know, I'm, I'm, I'm better than when I came in. Yeah. So, uh, that, that happens, especially for men in Asia, it happens really quite quickly. So within a month or two. Essentially the next period. Yeah, exactly.

[00:26:46] So I, what I say to them is that your periods will be a bit irregular for a, for a month or two, maybe three, and then you'll find a new normal. Um, and that's where I follow them up so I can, you know, um, see how they've gone at the three month mark. Um, and they're the most satisfying patients to see because they, um, overwhelmingly have had a great response and they, um, I mean, I, I haven't, I don't know, maybe they've read this, but so many of them have just said the same thing to me. I feel like I've got normal light periods again. Mm.

[00:27:14] And it's really satisfying because you have, I've had patients who can't work anymore. Like, um, people who are flight attendants who, you know, they don't know how long their period's going to be. Yeah. Uh, they need to be right next to a toilet. People who work away and who need to have an aisle seat because they're going to be rushing off to the toilet. Or people who might be on the road as reps, for example. Exactly. So, um, this is, uh, it really does change, change their lives.

[00:27:39] And, um, you know, women who've just been tired for so long cause they're iron deficient. Yeah. Um, uh, and so you can, so at that three month mark, you're, you're, uh, especially for the men of age, you're seeing excellent results and also for the pressure symptoms as well. So we're seeing reduction in size that you're getting about 90% of the reduction that you will get by three months. Um, and it still shrinks a little bit more after that. So those, and it also softens as well.

[00:28:05] So even with a modest reduction in size, it seems to have a quite a good effect on those pressure symptoms. Okay. Yeah. Are there some cases where you end up doing a redo? Like does one need to go back and do it again? Yeah. So, um, there's, there's good data on this, um, from out of the UK. They, they, um, looked at the, that percentage of patients. So who went, who had a UFI or, um, or someone's got a UAE. Yeah.

[00:28:33] Um, uh, they, who went on to have another procedure and, and they did cumulative data over seven years. And it's about 5% over that seven year period will go on to have a, a UTI and artery embolization again. Right. Um, and that's basically, I mean, if you've got the conditions for a fibroid to develop, um, then you can develop new fibroids. That's, that's one thing. Yeah. A bit like you've had one BCC, you might get another BCC. Yeah. That makes sense. Yeah.

[00:29:02] And even though that one that you've treated is, is gone, you're getting another one. You're still at risk. Yeah. So that's why they've got menarche. Well, they can develop new, um, fibroids. Um, and then, you know, that, but the same options are there. Hysterectomy, myomectomy, repeat, uh, UTI and artery embolization, UTI and fibroid embolization. Yeah. All right. The reason why I'm using those two terms is, um, so all UTI and fibroid embolizations are UTI and artery embolizations because we're embolizing that artery, right? Mm-hmm . Um, but you can embolize it for different reasons. Okay.

[00:29:31] So, um, there is data on adenomyosis as well, which, um, and often they'll coexist. And if that's the case, and I see that from the MRI, I do things slightly differently to treat the adenomyosis as well. Um, and then also in acute bleeding, like post, postpartum bleeding, then UTI and artery embolization. And that's the situation is also needed. Right. Yeah. Yeah. I'm just going to pause there for a moment. Is there anything, I'm just looking at lists here where we've sort of, it's good, we could, we've sort of wandered through all this.

[00:29:59] Is there anything in particular that you haven't covered or a point that you wanted to make that we haven't done? Um, uh, I guess we kind of touched on it. I wanted, I mean, I think the, an important point is that gynecologists are, you know, involved in this. Yeah. This has all been very, very interesting, Matt. Um, I've learned a lot, and I suspect a lot of the listeners will be in the same boat. Um, but when I come back to think like, I mean, in the practice, really what I'm hearing

[00:30:28] is that for women who were up diagnosed fibroids or, you know, high suspicion thereof, really for me, first port of call to send them to really is to the gynecologist. That hasn't changed. Yeah. That's correct. Yeah. No, that's right. Um, I mean, the gynecologists are, I mean, not just because it's a Medicare requirement, uh, but also the gynecologists are the specialists in this area. Um, and, you know, I work closely with them and then they're needed. Yeah. They need to be linked in with them as well.

[00:30:56] And that very rare can, uh, chance of those possibilities of, you know, complications. They need to be linked in with someone already. Um, yeah. So that's who you'd, you'd send them to first. Yeah. And to be honest to me, that's good because it means I'm not having to make that decision, which to be brutally honest, I don't feel I'll be in a position to make, I shouldn't be making that call. So much, much better that way around. Yeah. So before we finish up today, um, we've got two or three, maybe key, uh, takeaway

[00:31:25] messages for, um, uh, medical forum podcast, uh, listeners. Well, uh, I guess one of them, you do an artery embolization. It's well proven 50 years of data, you know, level one data, multiple meta analysis. It works. It's a good, uh, option for women with symptomatic fibroids. Um, and, uh, um, the, I guess the other thing, which is sort of a meta thing here is that, uh, the new brand of interventional radiology is that we, we take care of patients,

[00:31:55] um, and we see them and we follow them up, um, and we manage them and, and, um, we're a bit more hands on, I guess these days. You're not just at the other end of a, of a scan report. Yeah. Yeah. Exactly. Yeah. Although we do that as well. Got to keep, got to keep the edge. That's true. Yeah. All right. Look, Matt Clifford, that's been really good. Thank you for coming onto the podcast today and sharing this knowledge with our listeners. My pleasure. Absolute pleasure. Thank you.

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