Fibroid embolization still faces uncertain verdict

March 8, 2008

Uterine artery embolization was put on trial at the ECR. Evidence in favor of this minimally invasive procedure for women with symptomatic fibroids is mounting, but the case against its widespread use remains equally strong. What interventional radiologists must now decide is how to translate this qualified support into clinical practice.

Uterine artery embolization was put on trial at the ECR. Evidence in favor of this minimally invasive procedure for women with symptomatic fibroids is mounting, but the case against its widespread use remains equally strong. What interventional radiologists must now decide is how to translate this qualified support into clinical practice.

More than 150,000 women have undergone UAE since 1995, Dr. Anthony Nicholson told delegates at the special focus session. Most evidence on the efficacy of UAE has only just appeared, however. Before 2005, it would have been impossible to weigh the procedure's validity, but the evidence base is now much more robust and secure, giving interventional radiologists the green light to discuss the therapy with patients, he said.

"We still don't know absolutely about long-term efficacy," said Nicholson, a consultant radiologist at Leeds General Infirmary in the U.K. "But since June 2007, we have had three very fine randomized controlled trials and a very large comparative trial, all reporting that UAE was as safe as, and almost as efficacious as, hysterectomy or the best surgical alternative."

Speakers agreed that UAE should not be considered for women with asymptomatic fibroids. The most common indication is multiple intramural fibroids, the dominant mass being smaller than 10 cm in diameter, said Dr. Jean-Pierre Pelage, n associate professor of radiology at the Université Paris Ouest. Large, pedunculated subserosal fibroids should not be treated by UAE.

It is important to consider if the patient wants to become pregnant in the future, said Dr. Willem Ankum, a gynecologist at the Academic Medical Centre in Amsterdam. Clinical trial data revealed a lower post-therapy pregnancy rate in patients who underwent UAE (50%) compared with those receiving myomectomy (78%). The myomectomy group also experienced fewer miscarriages.

"It is quite clear from these results that you should not embolize women who still want to get pregnant," he said.

Data showed that UAE lets women get back to work far more quickly than if they had undergone hysterectomy. They will also spend less time in the hospital, though approximately 20% of UAE patients will need to have a subsequent hysterectomy. Comparisons of postprocedural pain and minor complications remain inconclusive.

Whatever the theoretical arguments for and against UAE, the opinions of prospective patients should not be overlooked, said Victoria Norton, founder of Forum Myome, a web-based support group for women with symptomatic uterine fibroids. Her views are based on personal experience. Norton suffered with heavy menstruation for eight years before fibroids were diagnosed. Seven years later - after much campaigning - she became one of the first women in Germany to undergo UAE.

She acknowledged that hysterectomy is rated highly by many women as an effective way of combating fibroid pain or easing menstrual problems. The question is whether that same symptomatic relief could be achieved with a far less drastic solution.

"Imagine you had suffered with a terrible toothache for 16 years, and someone took that tooth out. You'd be happy," she said. "But what would you do if someone else offered to take that pain away and leave you with the tooth?"

Opting for UAE over hysterectomy allows women to resume an active lifestyle more speedily, Norton said. Physicians should also be aware that childless women in their early forties might still want to start a family. Then there is the question of recreational sex, an issue seldom raised at scientific conferences but one that has to be considered by prospective hysterectomy candidates.

Norton called on interventional radiologists who offer UAE to provide good postprocedural care. She recalled pacing the corridor in considerable discomfort after undergoing UAE. On-duty nursing staff were unable to provide adequate pain relief drugs and unwilling to call a doctor.

Panelists agreed that duty of care to UAE patients was a paramount concern, but this can be difficult to achieve in practice. Interventional radiologists may not even have their own offices in which to see patients, said Prof. Jim Reekers, a professor of interventional radiology at the Academic Medical Centre in Amsterdan. The most successful practices are those where gynecologists have been brought on board.

"It is a great worry for many interventional radiologists. We are not seen as primary care-givers in Europe. We have a very weak position," he said. "We are not full-time clinicians, so we could end up with a situation where a patient has an infection, but there is no gynecologist willing to help them out."