Authors: Spies JB, Bradley LD, Guido R, Maxwell GL, Levine BA, Coyne K.

Study From: Georgetown University Hospital, Cleveland Clinic, University of Pittsburgh, Walter Reed Army Medical Center, and United BioSource Inc.

Journal: Obstet Gynecol. 2010;116:641-52.

Problem: There are very few studies that measure how women feel after treatment for fibroids.

Study: Four medical centers collaborated to measure fibroid symptoms and quality-of- life both before and after hysterectomy, myomectomy, or uterine artery embolization (UAE) compared to each other and to women without fibroids.

Findings: 101 women without fibroids, 107 women having an embolization for fibroids, 61 having a myomectomy and 106 women having a hysterectomy for fibroids participated in the study. At the beginning of the study, the women filled out questionnaires asking about their level of activity, energy level, sexual function, pain, social functioning, general health and mental health. Women with fibroids scored much worse than women without fibroids.

With treatment, no women in any group died or had a permanent injury.

Six and 12 months later, questionnaires showed that, after any of the three fibroid treatments, most women felt as good as women without fibroids. At 12 months, women who had a hysterectomy had fewer symptoms (no bleeding) than women who had myomectomies or UAE.

Authors’ Conclusions: One year after treatment, all three fibroid treatments resulted in substantial symptom relief, to near normal levels, with the greatest improvement after hysterectomy. The authors felt this was because after hysterectomy women had no further bleeding.

Dr. Parker’s Comments: UAE, myomectomy and hysterectomy all make women feel better than before they had treatment and most women return to feeling normal. There were a few short-comings of the study, though. First, the study is a statistical analysis of groups of women and it is not possible to tell from the article if some women did not improve or had bothersome side-effects after treatment. Also, each woman chose her treatment and, therefore, might be inclined to score the questionnaires higher to support her choice. However, this is what happens in real life and if you feel better, who cares what the scientists think??

I am a 46 year old women who has had fibroids about 15 years. They now have disrupted my life significantly. My uterus measures 13.0 x 6.7 x 9, I have approx. 12-16 fibroids from very small to 7 being 2.4 cm or larger. I have anemia and have been on prescription iron for 2 years. I have significant pain for 2-4 days a month, but my worst symptom is the excessive bleeding. For 72 hours, I cannot leave my home. My pad plus super tampon fill immediately and when I stand up, I gush.

One gynecologist recommended hysterectomy and my current gynecologist has recommended 6 months of a depo-lupron shots or embolization. I am considering the depo shots as I have a long-planned cruise w/ my family the beginning of April and worry that I will be cabin-bound for 1/2 of the trip – I am worried that the menopausal reactions to these shots will also interfere w/ my quality of life. I am scheduled to meet w/ the radiologist next week to consult about the embolization, but worried that the 5 weeks from now until vacation will not be enough recovery. I just don’t know what to do – the bleeding is consuming how I live.

R.

R,

Embolization certainly sounds like a reasonable option and most women recover in a few weeks. But, discuss this with the interventional radiologist.

The Lupron will cause heavy bleeding about two weeks after the shot, but then bleeding should stop. There are definitely side-effects: hot flashes, trouble sleeping, vaginal dryness, and they will last until a month after the last injection. The interventional radiologist will not want you to take the Lupron, since it makes the UAE procedure more difficult to do. So, discuss this with him as well. Abdominal myomectomy is also an option to remove all the fibroids.

I hope this is helpful,

Bill Parker, MD

Problem: There are a number of small studies that show either a small risk or no risk for pregnancies conceived after UAE. Small studies are hard to interpret because the statisticians cannot make sense out of small numbers of women. Also, no study has ever compared the results to women with similar fibroids who had not been treated.

Study: These authors combined the results of many already-published studies and analyzed the information as if it was one, larger study (called a meta-analysis). They compared the results of 227 women who got pregnant after UAE with 4,454 women who were the same ages and who had similar fibroids, but who had not been treated before they got pregnant.

Results: Miscarriage rates were higher in UAE pregnancies (35.2%) compared with women who had fibroids but no treatment fibroid (16.5%). The women who had UAE before their pregnancies were also more likely to experience excessive bleeding after delivery (13.9% after UAE vs. 2.5% in women with fibroids but no treatment). There were no differences in the rates of early delivery, underweight babies, or breech babies.

Conclusions: For women who get pregnant after UAE, the risk of miscarriage and the risk of excessive bleeding after delivery seem to be greater.

Dr. Parker’s Comments: While studies with just a few women are hard to interpret, a study such as this (meta-analysis) isn’t perfect either. Since the authors never see ANY of the women in the outside studies, it is possible that differences in the separate groups of women were present, but not reported in the original articles. Nevertheless, since it is unlikely that any interventional radiologist will have 227 women in their practice who will get pregnant after UAE, this kind of study may be the best information we can get.
Most interventional radiologists in the US advise women not to get pregnant after UAE. This advice is given not because they know that UAE causes harm during pregnancy, but mostly because there is not enough experience with UAE and pregnancy to tell women everything should be OK. For now, that advice is likely to stay the same as before.

Authors: Popovic M, Berzaczy D, Puchner S, Zadina A, Lammer J, Bucek RA.
Journal: American J Roentgenology. 2009;193:267-71.
Study from: Department of Cardiovascular and Interventional Radiology, Medical University of Vienna

Problem: The first use of embolization to treat women with fibroids was performed in France in 1997, so the long-term effectiveness of the procedure is still being investigated. These authors wanted to see how patients they treated over the past 10 years have done with regards to their quality-of-life following UFE.

Study: All 53 women from an earlier publication of UFE were questioned about their quality-of-life and symptoms following the procedure. Thirty-nine women (75%) responded to the questionnaire.

Results: The average time since treatment was 7 years. Reduced bleeding was reported in 90% of the women, reduced pain in 79%, reduced bulk-related symptoms in 90%, reduced fatigue in 77%, reduced limitations of social life in 93%, and reduced depression in 79%. The general quality-of-life for these women improved significantly.

Six women (15.4%) had a hysterectomy at an average of 32 months after UFE. Thirty-two women (82%) were satisfied with UFE, and 30 patients (77%) said they would recommend uterine fibroid embolization to other women. The authors concluded that UFE seems to lead to significant long-term relief of fibroid-associated symptoms.

Dr. Parker’s Comments: Although this is a small number of women, and 14 of the original study patients did not respond to the survey, the long-term results are very reassuring. There was a high satisfaction rate reported by the women over the long follow-up period of 7 years. Only 15% of the women needed to have a hysterectomy after UFE (myomectomy following UFE was apparently not considered). One of the early questions about UFE was whether the results would last over time. I agree with the article that the answer is yes.