Jan. 3, 2008 -- Can women with painful fibroids get long-term relief without surgery?
Yes, suggests a study of 1,278 women who underwent uterine fibroid embolization (UFE, also known as uterine artery embolization or UAE). Three years after the minimally invasive procedure, fewer than 15% of women needed surgery or a repeat UFE.
The study was led by UFE pioneer Scott C. Goodwin, MD, who chairs the department of radiological sciences at the University of California, Irvine. Goodwin, who prefers the more precise term UAE, says the procedure offers "very good" long-term outcomes.
"The quality of life after UFE is good. And you have quicker recovery and fewer complications than with the surgical alternatives," Goodwin tells WebMD.
Moreover, Goodwin notes that the women in the study were treated at all kinds of medical centers, not just those highly experienced at performing UFE.
"That was important," Goodwin says. "You can conclude that UFE done by someone with the proper credentials will have the same outcome wherever it is done."
While 86% of the women who chose UFE said they'd recommend it to a friend or family member, not all of them remained symptom free. Three years after the procedure, about 13% of the women underwent surgery for fibroid symptoms and another 2% underwent another UFE.
That rate is comparable to the rate seen in patients who undergo myomectomy, surgical removal of fibroids. Each year after myomectomy, about 5% of patients see their fibroids return.
Worldwide, some 25,000 women undergo UFE each year. Goodwin introduced the procedure to the U.S. in 1996.
But the procedure is still considered "developmental" by many gynecologists, including Bryan Cowan, MD, chair of the University of Mississippi Medical Center department of gynecology and a spokesman for the American College of Obstetricians and Gynecologists.
"The three-year follow-up is short," Cowan tells WebMD. "I tell patients repeatedly: I can take your fibroids out but I cannot change you. After myomectomy, one-fourth of you will see them come back -- but that is five or six years later. So these people in the Goodwin study have not entered that time threshold."
Fibroid Symptoms, Fibroid Treatments
Fibroids are benign tumors -- not cancers -- that grow inside the uterus; doctors call them uterine myomas or leiomyomata. They usually don't cause symptoms. But when they do, women may suffer excessive or painful bleeding during menstruation, bleeding between menstrual periods, abdominal pressure, frequent urination, pain during sex, and/or low back pain.
Removal of the uterus -- hysterectomy -- is the only sure way to get rid of fibroids and to make sure they never come back. Fibroids are the reason for up to 40% of the 150,000 to 200,000 hysterectomies performed each year in the U.S.
Hysterectomy results in sterility. If a woman does not want her uterus removed, and her fibroids are not too numerous or too large, she may opt for myomectomy -- removal of the fibroids.
Surgery is not the only option. The most commonly chosen nonsurgical treatment for fibroids is UFE. Other options under development include destroying fibroids via freezing, microwaves, or focused ultrasound.
During UFE, an interventional radiologist inserts a small tube into a leg artery and guides it into the blood vessels feeding the uterus. Small plastic beads released through the tube go inside the uterus and block off the blood supply feeding the fibroids. This kills the fibroids, which usually are absorbed back into the body after they die.
"The important thing is that people tend to recover more quickly after UFE than after surgery," Goodwin says. "You are talking two weeks; that is a big plus for UFE. And some studies show fewer complications than surgical alternatives."
Some women appear to do better than others. In the Goodwin study, patients who reported the best outcomes:
- Had heavy bleeding as their main fibroid symptom
- Had fewer symptoms
- Had smaller fibroids
- Were older
- Weighed less
Fibroids and Pregnancy
What if a woman needs relief from fibroid symptoms but still wants to become pregnant?
Cowan says there's only one option: myomectomy.
"If a patient with fibroids wants a pregnancy, I recommend myomectomy," Cowan says. "And not laparoscopic [minimally invasive] myomectomy, either. There might be six to 10 doctors who can do it and secure the uterus intact, but I am not one of them. And I am not willing to compromise the ultimate outcome for the patient, which is to carry a pregnancy to term."
What about UFE? Goodwin notes that UFE can lead to failure of the ovaries. In women in their late 40s, he says, this happens about a third of the time. But Goodwin says that only 1% of women under age 35 have ovarian failure after UFE.
"For younger women, UFE would be a reasonable alternative to myomectomy for preserving fertility," Goodwin says. "But a woman in her mid 40s -- who will have a lot of fertility problems anyway -- may wish to consider myomectomy."
In its most current policy statement, written in February 2004, the American College of Obstetricians and Gynecologists argues against UFE for women who wish to remain fertile. That advice still stands, Cowan says.
Cowan argues that women suffering fibroid symptoms should be under the care of a gynecologist.
"Yes, I would recommend UFE to patients," he says. "But I sit down with my patients and discuss all the options. If they want UFE, I back them 100%. I get them an interventional radiologist, and we will make this happen."
Goodwin agrees that doctors should discuss all fibroid treatment alternatives with patients. But he says patients often don't learn all the facts about UFE from their doctors.
That may be changing. Goodwin notes that his report -- and earlier reports on this study -- appears in Obstetrics & Gynecology, published by the American College of Obstetricians and Gynecologists.