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Thursday, May 17, 2012
Department: April 2007
Secret Disservice
If embolization treats uterine fibroids, why aren’t more doctors recommending it?
Story by Dell Richards
Like many women, Rhennie Boyle ended up with uterine fibroids and lived with the effects — the heavy bleeding, the anemia, the bladder and intestinal problems — for years. Unlike the women in her family, Boyle didn’t want the traditional solution: a hysterectomy. Nor did she want the lesser alternative, a myomectomy.
Boyle took the watchful-waiting approach for six years, until the symptoms became unbearable and she found an alternative: uterine fibroid embolization, or UFE. A relatively new and fairly unknown procedure, embolization cuts off the blood supply to the benign growths in the muscular walls of the uterus.
But finding information was like finding a needle in a haystack. “It was really hard to get people to talk about it,” says Boyle. “It’s like being in an underground spy network. Doctors don’t want to talk about it; [they] say there’s no research to back it up. I had to find a radiation interventionist to get information.”
“More women need to know about it,” says Dr. Patrick Vogel, an interventional radiologist who performed Boyle’s procedure. To date, approximately 25,000 UFEs have been done in the United States.
Obstetrician-gynecologists tend to recommend hysterectomies and myomectomies, which they make at least part of their living off of. It is thought that uterine fibroids account for 60 percent of the approximately 600,000 hysterectomies performed annually.
Fibroids are quite common. Between 20 to 40 percent of women over 35 have fibroids; black women are at an even higher risk. “Most of the patients are within 10 years of menopause,” says Dr. Brian Fellmeth. “Menopause will turn them off most of the time, whether treated or not.”
UFE gives women a bridge that, with any luck, will tide them over until the body stops estrogen production of its own accord. UFE cuts off the blood supply to the fibroid. A small catheter is inserted into the femoral artery and threaded into two uterine arteries. Beads of polyvinyl alcohol, each the size of a grain of sand, are injected into the fibroid bloodstream. PVA has been used for more than 20 years in people without significant reaction.
“It was really hard to get people to talk about it.”
— Rhennie Boyle, uterine fibroid embolization patient
At six months, results show a fibroid shrinkage of 48 to 78 percent, with an 85 to 90 percent rate of reduction in symptoms and a minimal recurrence rate. “The positive effects of the procedure appear to be durable,” says Fellmeth. “Most short-term successes evolve into long-term success.”
While maximum reduction usually takes four to six months, Boyle had an immediate lessening of symptoms and a nearly immediate return to her life. “I had the procedure on Wednesday and went back to work the following Monday,” says the elementary school music teacher.
Many women take hormone therapy to suppress estrogen production, which shrinks the fibroids but also throws women into early menopause, with the possibility of osteoporosis and higher risk of cardiovascular. If hormone therapy is discontinued, there is a rapid regrowth of the tumors.
In the past few years more women have turned to myomectomies, which conserve the uterus while taking out symptomatic fibroids, over hysterectomies.
Unfortunately, myomectomies are not a panacea. They have a transfusion rate of up to 20 percent from bleeding, up to a 38 percent risk of post-operative fever and illness, and a recurrence rate of up to 27 percent. Scarring may cause problems, and the recovery period is generally the same as a hysterectomy — six weeks or so.
Endometrial ablation, an outpatient procedure, has a shorter recovery period but tends to have a 32 percent failure rate with 52 percent risk of adenomyosis, a thickening of uterine tissue.
UFE requires a much shorter recovery period, an overnight hospital stay and a local anesthetic, three advantages it has over other procedures. “A hysterectomy usually requires several days of hospitalization, with a couple months to recover,” says Vogel. “The recovery and complication rates are higher with hysterectomy and myomectomy.”
Unfortunately, UFE is not risk-free. Most women have cramping in the first few hours; some have nausea and fever. Infections occur, as does injury to the uterus in 1 percent of the procedures, which can necessitate a hysterectomy after all. Some women go into early menopause soon after the procedure. Long-term effects on pregnancy are not known.
One ob-gyn who thinks women should have a choice is Stephen Hiuga, who has been in practice for 25 years. Hiuga feels he can recommend the procedure in many cases. “It has been perfected to the point where I feel comfortable referring patients to the radiologist for the procedure,” he says. “It has definitely evolved to the point where it is certainly an option.” Hiuga notes that some patients are precluded because of their fibroids or their anatomy.
