Spotting. Itching. Tenderness. When below-the-belt symptoms crop up, your first impulse is probably to slip into a pair of pajamas and curl up on
the couch. Holing away for a night or two is fine, but what if your symptoms last for weeks or even months?

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The American College of Obstetricians and Gynecologists Practice Bulletin:
Alternatives to Hysterectomy in the Management of Leiomyomas
Stewart, Elizabeth MD, ACOG Committee on Practice Bulletins. AMERICAN COLLEGE OF OBSTETRICIANS
AND GYNECOLOGISTS. 2008 Vol. 112, No. 2, Part 1, pp 387‐400.

Summary
Uterine Leiomyomas (also known as fibroids) are the most common solid pelvic tumors in women and
the leading indication for hysterectomy. While many women have no symptoms and do not require
treatment, some require more active measures. Hysterectomy remains the most common surgical
treatment for leiomyomas because it is the only definitive treatment and does not allow recurrence.
Many women seek an alternative to hysterectomy because they desire future childbearing or wish to
retain their uteri even if done with childbearing. As alternatives to hysterectomy become more
available, it is important to evaluate the efficacies and risks of these treatments. This bulletin reviews
literature about alternatives to hysterectomy and offers treatment recommendations.

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As the most common gynecological tumor in women, uterine fibroids can affect fertility and the chances of conception. Though the minimally invasive treatment, called uterine fibroid embolization, has been slow to catch on in the United States, there are benefits to the procedure. Dr. Bruce McLucas, of the Fibroid Treatment Collective at the UCLA Hospital and Medical School, shares with host Kim Hahn the details behind the treatment process, the costs, and how pregnancy is handled post-embolization.

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Despite 600,000 hysterectomies, fibroids remain the number one reason women undergo surgery. While removal of the uterus may be the best treatment, uterine artery embolization may be a non-surgical option for many women with symptomatic fibroids. Dr. Lauren Streicher speaks with Dr. Bruce McLucas, clinical professor in the department of obstetrics and gynecology at UCLA, to discuss candidate evaluation for a successful uterine artery fibroid embolization, and the efficacy of gynecologists in performing the procedure.

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Chances are, you know someone who has battled uterine fibroids – abnormal, benign growths within the muscles of the uterus that can cause painful, heavy menstrual bleeding, constipation and lower back pain. After all, at least 25 percent of women in the U.S. between the ages of 25 and 50 suffer fibroids, with the percentage almost doubling among African American women, according to the National Institutes of Health.

Up until a few decades ago, women with fibroids faced with only one treatment option – a hysterectomy. But thanks to further research and advanced technology, less radical options are now available, including the noninvasive, uterus-saving uterine artery embolization. Here is a closer look at that procedure, as well as more info on fighting fibroids.

DO YOU HAVE FIBROIDS?

It is hard to miss some of the symptoms of fibroids -- excessive pain in the pelvis, heavy bleeding, pressure on the bowel or bladder and infertility. But not everyone experiences these overt signs.

“Sometimes I see patients who have no other symptoms other than the fact that they can’t fit into their clothes even though they’ve been exercising like a fanatic,” says Dr. Bruce McLucas, a professor of obstetrics and gynecology at the University of California-Los Angeles and founder of the Fibroid Treatment Collective in Los Angeles. He adds, “Fibroids can cause the uterus to swell, but it’s easy to mistake that for a little weight gain.”

This reiterates the importance of regular check-ups with your gynecologist for routine pelvis exams that can detect fibroids, if you happen to have them.

A NON-SURGICAL APPROACH

If you find out you have fibroids, do not fear. You do not have to have a hysterectomy or undergo a similarly scary surgery.

“Forty percent of hysterectomies are due to fibroids, and most are unnecessary. So many women do not have to lose their uterus,” says McLucas. Rather, you can opt for uterine artery embolization, a relatively new procedure that injects microscopic plastic particles into the uterine arteries via a catheter, blocking the flow of blood to the fibroids.

As a result, the fibroid tissue shrinks, ultimately relieving symptoms and increasing fertility. Further, pregnancies following fibroid treatment do not appear to carry excess risk. Today more than several hundred thousand women worldwide have found relief with uterine artery embolization. “The entire procedure takes about 20 minutes, but the results can last a lifetime,” says McLucas.

RECOVERY TIME

A noninvasive procedure, recovery after a uterine artery embolization is minimal. “Sometimes we require patients to spend one night in the hospital for observation, but many go home the same day. You should be back up to speed within a week,” says McLucas. An added bonus is that there are no wounds or scars since the incision in your upper thigh is as small as a freckle.

SUCCESS RATE

The Fibroid Treatment Collective center boasts an extremely high success rate for uterine artery embolization. McLucas explains, “Over 99 percent of our patients have immediate relief from heavy bleeding, 94 percent experience up to 60 percent fibroid shrinkage, and 33 percent are able to successful conceive following the procedure.”

ANOTHER FIBROID TREATMENT OPTION: MYOMECTOMY

Myomectomy – the surgical removal of fibroids from the wall of the uterus via small incisions through the abdomen or the vagina – is another alternative to a hysterectomy. However, due to risky side effects and a higher reoccurrence rate, McLucas stresses looking into embolization first.

“With myomectomy you face complications like blood loss, uterine scarring, and a 30 percent chance of regrowth,” he says. “Go for an embolization first, and if that doesn’t work, you can always undergo a myomectomy. Embolization doesn’t burn any bridges.”

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AMSTERDAM, Feb. 26 -- Although uterine artery embolization and hysterectomy are both effective approaches to symptomatic fibroids, each has certain advantages, a study here found. Action Points
explain to patients who ask that for embolization, recovery time is faster and more importantly the uterus is preserved, whereas hysterectomy patients need not worry that fibroids will return.

Fibroid tumors are benign (non-cancerous) growths. They appear on the muscular wall of the uterus. They range in size from microscopic to masses that fill the entire abdominal cavity. Fibroids consist of dense, fibrous tissue, which are nourished and sustained by a series of blood vessels.

For patients who want absolute certainty, hysterectomy may be the better choice, reported Wouter J.K. Hehenkamp, M.D., of the Academic Medical Center, and colleagues in the March issue of Radiology.

But for women who wish to retain their uterus and want a shorter hospital stay and a faster recovery, embolization may be the better way to go, the researchers added.

"On the basis of these results, we determined that uterine artery embolization is a good alternative to hysterectomy," the researchers said.

The Dutch multicenter randomized Embolization versus Hysterectomy Trial included 177 women with uterine fibroids and heavy menstrual bleeding who were scheduled for a hysterectomy. After informed consent, 88 women were randomized to embolization and 89 to hysterectomy.

The researchers measured outcomes up to 24 months, using health-related quality-of-life questionnaires. Outcomes included mental and physical health, urinary and defecatory functions, and overall patient satisfaction.

At two years, the trial showed that 90% of the patients in both groups reported that they were at least moderately satisfied with their treatment Yet the hysterectomy patients reported a higher level of satisfaction (P=0.02), possibly because they no longer experienced menstrual cycles or worried that their symptoms would recur, the researchers said.

In the U.S. most of the 600,000 hysterectomies each year are done to treat bleeding or enlarged uterine fibroids, the researchers wrote. But even though uterine artery embolization has been used in practice for more than a decade, the researchers said the risks and benefits of the procedure had been largely unknown.

Health-related quality of life was measured six times during a 24-month follow-up with the Medical Outcome Study Short Form 36 (SF-36) mental component summary and physical component summary.

Also used were the Health Utilities Index Mark 3, EuroQol 5D, urogenital distress inventory, incontinence impact questionnaire, and defecation distress inventory.

Satisfaction with the treatments was assessed with a seven-point Likert scale.

At six weeks of follow-up, there were no differences between the groups, with the exception of the physical component summary, which was higher for the embolization patients (P<0.001).

All the scores were improved significantly in both groups at six months and afterward (P<0.05), with the exception of the defecation-distress inventory, which improved significantly in the embolization patients, but not the hysterectomy group.

Use of laxatives decreased from 10% at baseline to 1% at 24 months, but only in the embolization group. This was the only significant difference between the groups, the researches said.

Improvement in the physical component summary at the 24-month follow-up was significantly higher for patients who were employed at baseline (P=0.035).

Although these findings suggest an enduring improvement in quality of life after both treatments, if new fibroids develop, as they might, especially in younger patients, the quality-of-life assessment might decrease for embolization patients. Future research is needed to explore this possibility, the researchers said.

Patients who had embolization and subsequently required hysterectomy (25%) had lower physical component scores at repeated measurements (P=0.021), although not for their mental component scores. At 24 months there was no significant difference between the groups.

Study limitations include the fact that sample size was based on the primary endpoint (fewer than 25% of patients had a secondary hysterectomy and embolization) and not the quality-of-life score.

Also validated disease-specific quality-of-life measures, such as for fibroids, are needed. Actually, the researchers said, a fibroid-specific questionnaire has been developed, but it was not available when this trial was designed.

Both uterine artery embolization and hysterectomy improved the women's health-related quality of life, and no differences were observed between groups at the 24-month follow-up.

This study was funded by the Netherlands Organization for Health Research and Development. Boston Scientific (Heek, The Netherlands) partly sponsored the embolic agent used in this trial and provided a small unconditional financial grant for study purposes. None of the authors is employed by or has a commercial interest in the Netherlands Organization for Health Research and Development or Boston Scientific.

Dr. Hehenkamp reported no financial disclosures.

By Jennifer Bihm

There is a safer, easier alternative to hysterectomy in the treatment of fibroids according to specialist Dr. Bruce McLucas founder of the UCLA- based Fibroid Treatment Collective. Emboliza-tion, a procedure that essentially involves “choking” off the blood supply to the fibroids, is performed by inserting small pellets through the arteries. Unfortunately, according to health reports, “Too many African American and other women of color, do not know about uterine fibroid embolization.

“This is an important revolution in fibroid treatments, but many women do not have access to state of the art or alternative treatments that avoid hysterectomy. They may not be told about embolization because their doctor does not know how to perform it, but rather, is more skilled as a surgeon...”

Fibroid tumors are benign (non-cancerous) growths. They appear on the muscular wall of the uterus. They range in size from microscopic to masses that fill the entire abdominal cavity. Fibroids consist of dense, fibrous tissue, which are nourished and sustained by a series of blood vessels.

Common symptoms include pelvic pain excessive bleeding abdominal swelling, pressure on the bowel or bladder and infertility. Fibroids affect 40 percent of all women in America and have a high rate of incidence among African Americans. There is a possible link between uterine fibroid tumors and estrogen production, McLucas said.

Myomectomy and commonly hysterectomy (removal of the uterus) are common treatments.

“But,” McLucas pointed out, “[With hysterectomy] you’re really throwing out the baby with the bath water. There’s really never any reason to remove the uterus.”

In fact, removal of the uterus can have several negative side effects. These include: surgically-induced menopause, decreased ovarian function, including the production of progesterone and for premenopausal women, having a complete hysterectomy will result in changes in hormonal balance since the ovaries are no longer able to provide any hormone production.

“Most women come to us because they want to keep their uterus,” McLucas said.

“They say to me, ‘I want to be whole.’”

Uterine fibroid embolization is an outpatient procedure, resulting in less time off work, no blood loss, no risk of hepatitis or AIDS and no scar tissue. And, unlike myomectomy, a procedure that also saves the uterus by surgically removing fibroids, there is no risk of recurrence.

For more information visit www.fibroids.com/what-we-do.aspx or call (866) 362-6463 or (310) 208-2442.