Fibroid Treatment: Background

Uterine fibroids (leiomyomata) represent the most common gynecological tumor in women of reproductive age and are responsible for over 200,000 hysterectomies per year. They can cause a variety of symptoms including menometrorrhagia, dysmenorrhea, pelvic pain, reproductive failure, and compression of adjacent pelvic viscera, or be totally asymptomatic. A large array of treatment options exist for this disorder. Surgical treatments include hysterectomy, abdominal myomectomy, laparoscopic myomectomy, myolysis, and more recently MRI-guided ultrasound ablation. Non-surgical treatments include medical therapy (e.g., gonadotropin-releasing hormone agonist) and uterine artery embolization (UAE).

For the last 20 years, therapeutic embolization has been successfully performed on various parts of the body. In more recent years, this technology has been applied to uterine fibroids in an effort to eliminate the nagging symptoms associated with uterine fibroids and offer women an alternative to hysterectomy and myomectomy. This outpatient procedure, which may require an overnight admission for pain control, uses angiographic techniques and fluoroscopic guidance to embolize the uterine arteries, similar to the methods used to control postoperative and post-partum hemorrhage. The embolization, consisting of tiny particles of polyvinyl alcohol (500 to 700 micron size), occludes the blood supply to the fibroids, which results in their ischemic infarction and subsequent degeneration over a period of weeks and months. Average fibroid volume reduction is approximately 50% in three months and 65% at one year. Uterine volume decreases by approximately 40% in three months. The reduction in the fibroid's size leads to a decrease or resolution in the symptoms they cause. The procedure takes approximately 1-2 hours and it is anticipated that most women can return to work 7 days after the procedure.

The initial studies that have been published to date suggest that both menorrhagia and symptoms caused by the bulk of these fibroids will be significantly improved or will resolve in 80-90% of patients on short-term follow-up. The patients in these series have tolerated the procedure well and patient satisfaction is high, but they all require careful post-procedural pain management. While severe ischemic injury to the uterus has been feared, the literature suggests that this occurs in only 1-2 % of patients. Unlike myomectomy, all fibroids can be treated simultaneously, regardless of their location or size in the uterus. Unlike Lupron, the literature indicates that premature menopause is rarely induced. It has been shown that if the procedure is not successful and surgery is needed, this surgery is rendered easier, with a likelihood of less bleeding.

However, long-term follow-up on a larger number of cases will be required before any definitive statement can be made about the ultimate role of embolization in the treatment of uterine fibroids as compared to the other available therapies. The long-term outcome is not known, in that recanalization of the arteries could occur or collateral vessels could be recruited which might allow re-growth of the fibroids. Post-procedure fertility and the ability to carry a pregnancy to term are not presently known since most patients in published series have not sought to become pregnant. The effect on ovarian function has been a question, given the sporadic reports of amenorrhea after treatment. It is not known whether ovarian infarction occasionally occurs to affect function or whether merely decreasing uterine flow is sufficient to affect ovarian function. Further, it is not clear whether ovarian function is affected in only a few patients or whether it is more common and just not apparent clinically.

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