Uterine fibroid embolization reduces pain, may enhance women's sex lives

As many as 40 percent of women 35 and older develop nonmalignant fibroid tumors. Most of them don't experience any serious symptoms from these uterine growths, but about 25 percent have fibroids that become large and cause pain, heavy and prolonged menstrual bleeding and an uncomfortable bloated feeling in the abdomen.

According to studies reported at the 26th Annual Scientific Meeting of the Society of Cardiovascular & Interventional Radiology (SCVIR), UFE not only stops the heavy menstrual bleeding caused by fibroids, it also does so with less pain and faster recovery than more invasive surgery. It might also improve sexual function in some women.

Comparing UFE to myomectomies
According to researcher Mahmood K. Razavi, MD, who conducted the first direct comparison of UFE to abdominal myomectomy with gynecologist Bertha H. Chen, MD, the embolization group did much better than the abdominal surgery group in controlling bleeding. “My feeling is that UFE shouldn't be a second alternative, it should be the first alternative for bleeding patients,” he said.

In the collaborative study, the researchers compared data from 76 UFEs and 36 myomectomies they performed over a three-year period.

• Myomectomy patients reported more improvement in uterine pressure symptoms, while UFE patients reported less postprocedural pain.
• UFE patients used pain medication for three to four days, compared to a week for the myomectomy group.
• UFE patients returned to normal activity in about seven days compared to 35 days for those who underwent open surgery.
• Complications were reported by about 4 percent of UFE patients compared to more than 19 percent of the myomectomy patients.

Effect of treatment on sexual experience
Symptoms aren't the only thing that improves after UFE, according to a small study conducted at Georgetown University by Jackeline Gomez-Jorge, MD, assistant professor of interventional radiology at the University of Miami in Florida, who said, “UFE does not adversely affect patients' sex lives, and, in fact, may improve them. ”

Gomez-Jorge gave a nine-item questionnaire to 115 premenopausal patients who underwent UFE. About 50 percent of the women responded as follows:

• 64 percent had no change in strength of orgasms
• 6 percent reported stronger orgasms; 6 percent reported no orgasms
• 56 percent reported internal orgasms with uterine contractions
• 80 percent reported continued sexual desire more than once per week, vs. 8 percent who had no interest in sex
• 34 percent reported sex more than five times in the last month

“Keeping the anatomy involved in sexual response intact may be an advantage,” Gomez-Jorge said. “This is particularly true for women who experience uterine contractions as part of their sexual response.”

Michael G. Wysoki, MD, assistant professor of radiology, Yale University School of Medicine, also studied sexual function in women who underwent UFE. In a telephone survey to which 21 premenopausal patients responded, his team found that after UFE, 43 percent had increased sexual desire. There was decreased pain during intercourse in 60 percent of women, and 27 percent reported increased frequency of orgasms after having UFE. “No patients reported a deterioration in sexual function,” he said.

More than 180,000 American women undergo hysterectomies each year to treat excessive bleeding and pain resulting from uterine fibroids. According to a 1999 survey conducted by the Society for Women's Health Research, as many as one-third of the women who have this surgery do so without discussing potential alternatives with their doctors.

What are fibroids?
Fibroids are benign, solid, round growths in the wall of the uterus that develop in 30-50 percent of women as they get older. We're not sure what causes them. There appears to be an age-related increase in fibroid development as well as a familial and ethnic tendency. About 50 percent of African-American women develop fibroids. Most women may see their tumors shrink as they go through menopause.

Most women with fibroids do not experience significant discomfort, but if the fibroids are very enlarged, they can press on the bladder and cause obstruction of the kidneys, which can be painful. They may also result in heavy bleeding, painful intercourse and an enlarged uterus similar to a four- to five-month pregnancy or larger.

Hysterectomy
Hysterectomy is the surgical removal of the uterus and it is the most common treatment for women with symptomatic fibroids. While it is a very effective treatment—once the fibroids are gone, the symptoms are gone—it is also a major operation that significantly impacts a woman's health and well being.

This major surgery requires general anesthesia, a six-week recovery period and may have psychological and sexual consequences as well. There is about a 20-40 percent risk of complication following hysterectomies—most of them minor, such as bladder infections and fever, but more major ones include risk of injury to the bladder, bowel or ureter, as well as bleeding.

Myomectomy
One alternative to hysterectomy in the treatment of uterine fibroids is myomectomy—surgical removal of the fibroid only, leaving the uterus in place. While myomectomy is frequently successful in controlling the symptoms—long-term studies show it has an 80 percent success rate—it too, is significant surgery with a long recovery period. And the more fibroids that are present, the less successful the treatment. In 10 to 30 percent of cases, fibroids grow back in several years.

UFE: less invasive, shorter recovery
For several years a less invasive procedure, called uterine fibroid embolization (UFE), which leaves the uterus intact, has been used to treat fibroids. It is a fairly simple procedure that has been safely done for more than 20 years to stop heavy bleeding after childbirth.

A small incision (less than 1/8 of an inch) is made in the groin and a thin tube called a catheter is then guided through an artery to the uterus while the interventional radiologist watches the progress of the procedure using X-ray imaging. The patient is sedated and feels no pain. Small particles are then inserted into the artery that is supplying blood to the fibroid tumor (or tumors) to cut off the blood flow. Cutting off the blood flow to fibroids causes them to shrink or die.

Fibroid embolization usually requires a hospital stay of one night. Many women return to normal activity in three to seven days, compared to more than 35 days for myomectomy patients and six weeks or more for hysterectomy patients.

The success rate is very high. Between 85 and 95 percent of women who have UFE will not need any other treatment. For bleeding, it is 95 percent effective. There is also less pain following UFE, as the study presented at the SCVIR annual meeting indicated.

Who is not a good candidate for UFE?
I would say that absolute contraindications for this procedure are cancer of the uterine lining or wall. We also don't have sufficient evidence to determine if fertility is affected by UFE, so women who want to have children need to discuss this treatment in depth and strongly consider myomectomy. However, there have been many normal pregnancies documented in women who have undergone UFE.

Another contraindication for UFE is renal insufficiency or underfunctioning kidneys. Also, very large fibroid tumors outside of the uterus may not shrink sufficiently with UFE and women with these kinds of fibroids might be better candidates for a myomectomy.

What should you do if you have painful fibroids?
If you have symptomatic fibroids, first visit your gynecologist to obtain a diagnosis. Your physician may try hormone therapy, which can temporarily shrink tumors in some women. Fibroids often grow back, however, once hormone therapy is discontinued. If your physician recommends a hysterectomy to treat your fibroids, ask him or her about UFE. If you sense your physician is hesitant in discussing this alternative, you may want to consider consulting with an interventional radiologist for a second opinion.