Journal: British Journal of Obstetrics and Gynecology  2011;118:936–944.

Study From: North Glasgow University Hospitals, Glasgow, UK

Problem: Women with uterine fibroids now have a number of treatment options available. Very few studies have compared the results of treatment with different options.

Study: This study was designed to compare the results for women who had uterine artery embolization with women who had surgery (myomectomy or hysterectomy) five years after treatment.  Women filled out quality-of-life questionnaires and the authors recorded any complications from treatment or the need for women to have additional treatment for fibroids during the 5 years of follow-up.

Results: 106 women were randomized to UAE and 51 to surgery (42 had abdominal hysterectomy and 9 had abdominal myomectomy).  Symptom reduction and patient satisfaction with both treatments were very high and there were no significant differences between the UAE and surgery groups.

Rates of adverse events were similar in both groups.  In the surgery groups there were 5 wound problems (either infections or blood collections), 2 surgeries with excessive blood loss, and 2 anesthetic complications.  In the UAE group there were 2 women with pain and infection needing readmission to the hospital, 4 with fibroid expulsion, 1 pelvic abscess requiring hysterectomy, 2 with persistent pain requiring hysterectomy and 1 woman with heavy bleeding that required blood transfusion.

The need for further treatment during the 5 years was 32% for UAE and 4% for surgery.  In the UAE group, 4 women had repeat UAE and 13 women had hysterectomies.  In the surgery group, 1 woman had a hysterectomy due to technical difficulties (I imagine due to surgeon inexperience?) during her myomectomy.

Authors’ Conclusions: UAE is a satisfactory alternative to surgery for fibroids. The less invasive nature of UAE needs to be balanced against the need for further treatment in almost a third of patients. The choice should lie with the informed patient.

Dr. Parker’s Comments: This study shows that most women will do well with either UAE or surgery as treatment for fibroids.  Although not discussed in this paper, the recovery from UAE is usually much easier than from abdominal surgery and a bit easier than from laparoscopic or robotic surgery.  On the other hand, this study found that more women required additional procedures after UAE than after surgery.

The author’s last sentence is a guiding principle: “the choice of treatment should lie with the informed patient”.  For any patient, each of these treatment options is going to have pros and cons.  I see my job as a physician as one figuring out what the pelvic examination plus imagining studies (MRI or ultrasound) reveals about the sizes and positions of the fibroids.  Then my role is helping each woman understand which symptoms are caused (or not caused) by her fibroids.  I then describe the different treatment options and how they might help her situation.  Then, the decision of which option to choose, including watchful waiting, is up to the patient.

Authors: Bagaria M, Suneja A, Vaid NB, Guleria K, Mishra K.

Study from: Department of Obstetrics and Gynaecology, University College of Medical Sciences, Delhi, India.

Problem: So far, no medication has worked to relieve symptoms of fibroids. In early studies, one drug that appeared to be promising was Mefipristone (RU-486).  Progesterone causes fibroid cells to grow and Mefipristone blocks this effect.

Study: The study included 40 women with bothersome symptoms from fibroids; 20 women were taking mifepristone and 20 were taking a placebo. None of the women or their doctors knew what pill they were taking.

Fibroid-related symptoms, the size of the uterus and size of the largest fibroid were measured with ultrasound at the beginning of the study and every month for three months. A biopsy of the uterine lining cells was done at the beginning and again at the end of treatment.

Results: Women who were taking Mefipristone had a 95% decrease in menstrual blood loss after three months   Complete relief of menstrual cramping occurred in 80%, but only 33% patients were free of pelvic pain.  Women taking the placebo pills had no change in any symptoms. Backache, bladder problems and pain with intercourse were not better in either group.

The size of the uterus and size of the largest fibroid were about 30% smaller by the end of the third month of therapy. Women taking Mefipristone had an increase in haemoglobin (red blood cells) from 9.5 to 11.2 . However, 63% of women taking mefipristone had benign overgrowth of the uterine lining cells (endometrial hyperplasia without atypia).

Authors’ Conclusions: A low dose of mifepristone taken for three months is effective in reducing menstrual bleeding and reducing uterine and fibroid sizes, but has the side-effect of causing uterine lining cell overgrowth.

Dr. Parker’s Comments: It would be great if there was a pill available to treat the symptoms of fibroids with few side-effects.  So far, all the tested medications have either not worked or had bothersome side-effects. Mefipristone is given orally and has few side-effects.  It is well-known that progesterone causes fibroids to grow.  Mefipristone works by blocking the action of progesterone and has been shown to shrink fibroids and decrease bleeding.  However, progesterone decreases the growth of the uterine lining cells and since mefipristone blocks this action it allows the lining cells to overgrow.  After just 3 months almost 2/3 of women had benign overgrowth. While benign overgrowth does not turn into precancer or cancer, the worry is that longer treatment with Mefipristone could stimulate actual cancer cells to form.  Further study will be needed, but this study is discouraging.

For more about medical treatment for fibroids see: http://www.fibroidsecondopinion.com/treatment-for-fibroids/

Study: Among 240 women who had UAE, 16 women had fibroids on a stalk on the outside of the uterus. The average size of the fibroid was about 7 cm (3 inches) in diameter. The average width of the stalk was 2.7 cm (1 inch) and 6 fibroids had a stalk less than 2 cm in width.

Results: None of the 16 women had a pedunculated fibroid detach as a result of UAE. The average reduction in size of the fibroid was 39%, the same results that have been published for other types of fibroids.

Dr. Parker’s Comments: These results are very encouraging and will allow more women to have UAE. The only problem with the study is that it is possible, in fact likely, that some women with large fibroids on long or thin stalks were not recommended for UAE in the first place. So, the recommendation for UAE will depend on the interpretation of the MRI by the interventional radiologist.  More about UAE can be found here: http://www.fibroidsecondopinion.com/uterine-artery-embolization/