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.

Dr. Parker,

I am 49 yrs. old in good physical health. I walk or run several times a week, and am slim(5ft.115 lbs) and look youthful. However, I have a lot of stress-6 children, 2 with drug addictions, a difficult marriage, etc. I have a 10 cm fibroid that is putting pressure on my rectum. I had bleeding and huge clots but taking progesterone 10 days of my cycle has alleviated that. My gyn recommends hysterectomy. I am scheduled for this Thursday, Dec.16, but have a lot of anxiety about it, because I am depressed and worried about how it will affect my emotional state which is already terrible. When I called my gyn he was in his other office further away, and could not call me back. He told his office manager that he already went over everything with me, and to tell me a hysterectomy was the best course of action. He said a myomectomy would thin the lining of my uterus too much. He never mentioned UFE. He seems perturbed that I did go to another gyn for a second opinion. The other gyn said hysterectomy also, not mentioning UFE. I called an interventional radiologist and they said they could see me. Have I broken the doctor-patient trust factor? Will he treat me differently now?

L,

Doctors should welcome a second opinion. You need to do what is best for you and getting a second opinion when surgery is recommended is always a good idea. UAE works very well for heavy bleeding and shrinks fibroids about 40%, so if this would help you, you should see the interventional radiologist to see what they recommend. Myomectomy is always possible and it will not thin the uterine lining no matter what the size of your fibroid. A 10 cm fibroid can be removed laparoscopically as an outpatient by a skilled laparoscopic surgeon.

If the doctor does treat you badly because you got a second opinion, you should consider getting another doctor.

Bill Parker, MD

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

Study from: Georgetown University Hospital Department of Radiology, Washington, DC

Problem: Despite the very common occurrence of fibroids, very few studies have evaluated the severity of symptoms caused by uterine fibroids, their effect on health-related quality-of-life, or the changes in symptoms after treatment compared with women who do not have fibroids.

Study: Groups of women with fibroids who were scheduled for hysterectomy, myomectomy, or uterine artery embolization, as well as women without fibroids were assessed using questionnaires designed to measure quality of life and symptoms, including physical functioning, pain, sexual function, vitality, energy/mood, social functioning and mental health. Questionnaires were completed before treatment and again at 6 and 12 months after treatment.

Results: A total of 375 women Participated in the study: 101 without fibroids, 107 who had embolization, 61 who had a myomectomy, and 106 who had a hysterectomy. Before treatment women with fibroids had more severe symptoms than women without fibroids. At both 6 and 12 months after treatment, women having treatment for their fibroids had as few symptoms as women who did not have fibroids. One year after treatment, the women who had a hysterectomy reported less symptoms and better health-related quality of life than women who had embolization or myomectomies. However, the majority of the benefit of hysterectomy was attributed to the absence of menstrual periods.

Authors’ Conclusions: At 12 months after treatment, all three leiomyoma therapies resulted in substantial symptom relief, to near normal levels, with the greatest improvement after hysterectomy due to the absence of menstrual periods.

Dr. Parker’s Comments: Since myomectomy, embolization and hysterectomy all reduce symptoms to the levels seen with women without fibroids, all three treatments should be very effective for women who have bothersome symptoms related to fibroids. Therefore, a woman’s choice for treatment should depend on other individual factors including the desire for fertility, the desire to preserve her uterus, willingness to undergo surgery and anesthesia, willingness to undergo embolization, etc. The other point here is that the women choosing to have treatment had significant symptoms; most women with minor symptoms will often choose watchful waiting and wait for menopause when fibroids shrink and bleeding stops.

Authors: Pisco JM, Duarte M, Bilhim T, Cirurgião F, Oliveira AG.

Study from: Department of Radiology, St. Louis Hospital; New University of Lisbon, Portugal.

Problem: The safety of pregnancy following embolization (UAE) is uncertain because there have been few publications examining this issue.

Study: In a single hospital in Portugal, UAE was performed in 74 patients who wanted to become pregnant.

Results: Of the 74 women who wanted to become pregnant, 44 of them became pregnant (59.5%). Thirty-nine women completed pregnancies resulted in 33 successful live births (84.6%), four miscarriages (10.3%), one induced abortion, and one stillbirth. Two women delivered early, at 36 weeks (6.1%), and five babies were low birth-weight. At the time of publication, five other women had ongoing pregnancies.

Authors’ Conclusions: Pregnancy after UAE appears to be safe.

Dr. Parker’s Comments: Although this is a small study (only 44 pregnant women), it is reassuring. An earlier study from Toronto found a slightly higher risk of bleeding from the placenta or difficulty removing the placentas after delivery in women who had UAE. The current study did not find these problems. Unfortunately, there are very few studies of women who have had a myomectomy before getting pregnant to see if there were any problems with their pregnancies.

Many interventional radiologists do not perform UAE for women who wish to get pregnant and I wonder if this new information will change their opinions. Personally, I will advise women about this study and suggest that there is less reason to be nervous about getting pregnant after UAE. It would be nice to have more information to help advise women regarding the outcomes of pregnancies for women who get pregnant with fibroids, and for women who have had UAE or myomectomies.

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.