By: Alex Sher, MS4, Icahn School of Medicine at Mount Sinai

Uterine fibroids are benign tumors that carry significant prevalence in women reaching the age of 50. They can result in significant morbidity including menorrhagia, anemia, fertility issues, complicated pregnancies, bulk symptoms, as well as obstructive symptoms. These symptoms can have significant effects on a woman’s quality of life. In women who no longer desire to be child-bearing, hysterectomy is the most common and definitive treatment. As an open or laparoscopic procedure, hysterectomy comes with significant morbidity, mortality, in addition to the increased economic cost to our health care system. Uterus-sparing surgery such as myomectomy is another alternative, but again comes with significant operative risks, costs, and risk of recurrence with the potential need of an additional procedure. In an effort to develop a more conservative and minimally invasive procedure, uterine fibroid embolization (UFE) has been established as a safe and effective method of reducing symptoms [1]. But how many patients are aware of UFE?

The history of UFE is relatively short. Initial results were exciting and were reported over 20 years ago in a 1995 edition of the Lancet [2]. In 1997, the first case series in the United States included 11 patients treated with UFE [3]. After more than two decades from its introduction, the use of UFE continues to grow. However, it remains vastly outnumbered by alternatives such as hysterectomy and myomectomy. It is estimated that roughly 600,000 hysterectomies occur each year [4]. A study presented at the 2017 Society of Interventional radiology (SIR) national conference used data from the 2012 and 2013 nationwide inpatient sample (NIS) and found that UFE procedures were far outnumbered by hysterectomies (2,470 vs. 167,650) for symptomatic fibroids, especially in rural and smaller hospital settings. Why is this case? Several factors, namely access, ongoing clinical trials, hesitance of gynecologists to refer patients to IR, and lack of patient or even physician awareness all likely play a role. Many smaller health communities, especially in rural areas, may lack resources including equipment or trained physicians comfortable performing UFE. Secondly, given that results from ongoing trials have not fully elucidated the effects of UFE some physicians may resort to offering more time-honored therapies. The most common reservations cited are risk of uterine infection and threat of subsequent hysterectomy or premature ovarian failure – yet both are rare complications. A common misconception is that the entire uterus necroses after UFE, when in fact it is the hypervascular fibroids that become ischemic allowing the uterus to receive blood from collaterals off other vessels. Perhaps a poor understanding or misconceptions regarding the procedure may be limiting its use. Currently, we are not absent of evidence demonstrating the safety of UFE and the benefits (improved cost, bleeding and other symptom improvement, increased quality of life, faster recovery time, less intra-operative risk). In fact, UFE is generally performed under minimal sedation with the patient able to leave the same-day with only a small bandage over the wrist or groin. This offers patients an alternative to surgery that comes with similar rates of patient satisfaction. The difference in use remains too wide. It appears UFE is being underutilized, especially compared to myomectomy or hysterectomies which come with significantly higher operative risk. Many women do not know that UFE may be a viable uterus-sparing possibility for reducing or resolving their symptoms. A recent report “The Fibroid Fix” published by the Society of Interventional Radiology found that 44% of women with fibroids have never heard of UFE [5]. In the same report, 1 in 5 women believe hysterectomy is the only treatment option [4]. Such a large difference in use and a lack of patient knowledge about UFE begs the question – are women are being presented with all of the possible treatment options? This is important because just as not all women are candidates for UFE not all women are ideal candidates for surgery. Undergoing UFE does not prohibit surgery if unsuccessful. Strategies to improve awareness of UFE through mass media and interpersonal sources such as friends, colleagues, as well as their gynecologist (usually their primary or secondary medical contact) should be advanced as they can be instrumental for women deciding on their best treatment option. After all, if a safe, effective, and less invasive procedure is available – shouldn’t women at least hear about it?

For more information about uterine fibroids and available treatment options:

Society of Interventional Radiology — Uterine Fibroids

Office of Women’s Health, U.S. Department of Health and Human Services — Uterine Fibroids

National Institute of Health U.S. National Library of Medicine — Uterine Fibroids

References

1. Gupta, J.K., A. Sinha, M.A. Lumsden, and M. Hickey, Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database Syst Rev, 2014(12): p. Cd005073.

2. Ravina JH Herbreteau DCiraru-Vigneron N et al Arterial embolisation to treat uterine myomata. Lancet. 1995; 346: 671-672.

3. Goodwin, S.C., S. Vedantham, B. McLucas, A.E. Forno, and R. Perrella, Preliminary experience with uterine artery embolization for uterine fibroids. J Vasc Interv Radiol, 1997. 8(4): p. 517-26.

4. Centers for Disease Control and Prevention. Data and Statistics: Hysterectomy. 2017. Retrieved from https://www.cdc.gov/reproductivehealth/data_stats/

5. SIR 2017: Uterine fibroid embolization vastly underutilized, especially in rural U.S. Appl Radiol. By Staff News Brief | April 05, 2017.

6. The fibroid fix. (2017, August 29). Retrieved April 22, 2019, from http://www.sirweb.org/patients/fibroud_fix2/fibroid-fix-report/