Fibroid disease affects as many as 30% to 40% of women over age 35. Symptoms can be
broadly divided into two groups, the first of which is commonly characterized by
menorrhagia or menometrorrhagia. Some women have such severe bleeding that they may be
housebound for several days each month and/or become anemic. The other group of symptoms
is bulk-related disease caused by the presence of a uterine mass and includes urinary
frequency, physical discomfort directly from the mass, constipation, and less well-defined
symptoms such as dysmenorrhea.back to top
Fibroid disease is the most
frequent indication for hysterectomy, accounting for at least half of the estimated
600,000 hysterectomies performed annually in the U.S. A total of 500,000 surgical
procedures may be performed in the U.S. every year solely or primarily for fibroid
disease.
Many old and new treatment options
for fibroid disease are available, but most of the newer treatments address only a portion
of the patient's fibroid burden. They include myomectomy (abdominal or laparascopic),
myolysis, and hysteroscopic resection. These procedures have the disadvantages of
requiring general anesthesia, with resultant prolonged recovery periods. And because they
treat only a portion of the fibroids present, they have fairly high late failure rates as
fibroids regrow.
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Two well-established treatment
modalities address the entire fibroid burden of the uterus. Hysterectomy has been
performed for fibroid disease for years and is the gold standard by which other treatments
are judged. However, regardless of the approach used, it has the disadvantage of being
major surgery with consequent recovery periods of four to six weeks, morbidity rates
between 5% and 20%, loss of fertility, and (more controversially) possible untoward
changes in sexuality. Hormonal manipulation with leuprolide and other agents is effective
for many patients, but can be associated with intolerable side-effects. Hormonal therapies
are effective only for relatively short periods of time, and their effects reverse after
the agent is withdrawn.
Embolization of the uterine
arteries is an established therapy for acute hemorrhage, usually in the postsurgical or
postpartum patient and is well documented as a safe, effective procedure. In the early
1990s Jacques Ravina, a French gynecologist, began to explore the utility of
uterine artery embolization (UAE) as a presurgical adjunct to minimize intraoperative
bleeding during fibroid surgeries. He serendipitously discovered that UAE alone is
effective in controlling symptoms of fibroid disease, particularly menorrhagia. UAE for
fibroid disease is generating tremendous interest among interventional radiologists, as
well as among the general public.
UAE treats the entire fibroid
burden of the uterus, providing reliable relief of both menorrhagia and bulk-related
symptoms of fibroids. As a minimally invasive therapy, it has a lower morbidity rate than
more invasive surgical options and is associated with faster recovery.
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PATIENT SELECTION
The indications for fibroid
treatments are well accepted in the gynecologic community. Treatment is indicated for
women with fibroids who have symptoms (bleeding and/or bulk related) that limit their
lifestyle or well-being. In addition, some authorities believe that fibroids above a
certain size should be treated even in the absence of symptoms.
When considering UAE, the
indications for treatment of fibroids are the same as for other therapies, but some
contraindications specifically apply. The most important is infection: If there is any
suspicion of an active infectious process in the pelvis, UAE is contraindicated unless the
infection is eradicated. Patients with other pelvic pathology, in particular
endometriosis, may also be poor candidates for UAE, as they may not obtain sufficient
relief of symptoms from a therapy that addresses only fibroid disease. Patients with known
contrast reaction or other contraindications to arteriography may also not be candidates
for UAE.
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Since fibroid disease is usually
only life-limiting rather than life-threatening, almost all fibroid treatments are
elective. Given the diagnostic issues, evaluation and treatment selection rest in the
hands of the gynecologist, who is most familiar with all diagnostic and treatment options
for fibroid disease. This necessitates the development of a close working relationship
between the interventional radiologist and the gynecologist.
HOW IT'S DONE
The procedure of UAE has been well
described in the literature. The uterine arteries are selectively catheterized and
embolized to the point of cessation of flow with particulate emboli. Most interventional
radiologists experienced with the procedure use standard angiographic catheters and
polyvinyl alcohol for the embolization material. A number of protocols are in use, which
differ slightly in choice of catheter and specific embolic agent. None of these has been
shown to have advantages over the others, and there may never be a clearly ideal protocol.
Postprocedure management is the
most challenging issue confronting the interventional radiologist performing UAE. Patients
develop considerable postprocedure cramping, which usually requires IV narcotics for
control. This cramping is an issue for only the first 10 to 15 hours after UAE, however,
and all patients are discharged the day after the procedure. Recovery is rapid, with 80%
of patients returning to full activity within four days of the procedure.
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Patients must be followed after
discharge for postembolization syndrome, which occurs in about 40% of women undergoing
UAE. Many patients also develop a vaginal discharge after UAE, apparently due to the
sloughing of infarcted myomata. These and other follow-up issues are best managed
cooperatively by the interventional radiologist and gynecologist in a team approach.
OUTCOMES
The technical success rate for UAE
is over 98%. The rare technical failures result from extreme vessel tortuosity that
prevents selective catheterization anatomic anomalies of the uterine arteries, and
ligation of the uterine arteries in previous surgeries. All symptoms, whether bleeding- or
bulkrelated complaints, are successfully controlled in 80% to 90% of patients. Dramatic
reductions in menstrual flow occur with the first period after UAE. Decrease in bulk
symptoms occurs more gradually, over three to six weeks.
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In addition to resolution of
symptoms, patients experience substantial reduction in uterine volume. At three months
after UAE, the volume of the entire uterus is decreased by an average of 48%, with the
majority of women experiencing volume reductions of 30% to 60% (Figure 2). The volume of
individual fibroids typically decreases by 60% or more; in many patients, volume reduction
continues for up to a year after UAE.
These results appear to be durable.
No late failure of UAE has been reported, in distinct contrast to the late failure rate of
myomectomy, which is reported as high as 40% two years after surgery.
Fertility appears to be preserved
after UaE. It is well documented that embolization for other indications has not
interfered with fertility. At least 12 women have become pregnant after UAE for fibroids,
with pregnancy outcomes no different than those of the general population. However,
amenorrhea after UAE has occurred in a small percentage of patients, particularly those
over 45.
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Complications have been rare. Minor
problems, typically groin hematomata, are seen in fewer than 5% of cases. In the entire
U.S. experience, only one infectious complication requiring surgery has been reported. No
symptomatic misembolization has been reported, although this is an ever-present
possibility.
Sloughing of whole submucosal
fibroids has been reported in less than 5% of patients, occurring between two and eight
months after UAE.
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DR. WORTHINGTON-KIRSCH is head of interventional radiology at
Delaware Valley Imaging in Bala Cynwyd, PA. |
