Researchers Take Aim at Uterine Fibroids

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New Techniques Expand Treatment Options to Help Women Avoid Major Surgery

By Gail McBride, Special to The Washington Post
April 6, 1999

They may affect up to half of women of childbearing age and can cause bleeding, pain and perhaps infertility. Yet until recently, medical research paid scant attention to those benign growths in the uterus called fibroids.

Now a range of new procedures–from a technique that blocks blood vessels in the uterus to experimental drugs–may allow many women more options besides major surgery to treat uterine fibroids. For years, the principal treatment has been hysterectomy, in which the whole uterus is removed, or another operation called myomectomy in which the individual fibroids are cut out. But increasingly it looks like fibroids may be forced into submission in other ways.

The newest treatment shrinks fibroids by cutting off their blood supply. Called uterine artery embolization (UAE), it was first performed in Paris in 1991 by gynecologist Jacques-Henri Ravina. Today it is done in many countries, including the United States.

In this procedure, a catheter is inserted into an artery in the groin. With X-ray guidance, a specially trained “interventional radiologist” directs the catheter into the two arteries that supply the uterus and the fibroids with blood. Small plastic or gel particles are injected through the catheter into the arteries, causing the blood to clot. The result is closure of the arteries, marked shrinkage of the fibroids and cessation of bleeding.

The procedure takes 60 to 90 minutes, according to interventional radiologist Scott Goodwin, who with gynecologist Bruce McLucas has performed more than 200 of them at UCLA Medical Center. Patients are sedated but do not have to undergo general anesthesia. Afterward, there is considerable cramp-like pelvic pain, and pain medication is necessary. Infections occasionally occur. Patients are encouraged to take a week off from work or other daily routines.

For some women, this treatment is a welcome alternative to a hysterectomy. “My uterus was full of fibroids, and I had been to four or five gynecologists,” said Susan DeBoismilon of Orinda, Calif. “They all urged me to have a hysterectomy.” Then she heard about McLucas’ work. “The procedure made sense to me, and I had it done a month later. It’s definitely the best course.”

Goodwin said that about 80 percent of the 2,000 women worldwide who underwent UAE have had relief of symptoms, shrinkage of fibroids and no need for a hysterectomy.

Six patients of Goodwin and McLucas have become pregnant and had normal or C-section deliveries after UAE, but no one really has kept close track of patients’ attempts to get pregnant until very recently. There is some concern, Goodwin said, that the blood supply to the ovaries may be damaged by UAE in 1 percent to 2 percent of cases, and he warns women about this if they want to maintain fertility.

Until the uncertainties about long-term results and pregnancy are resolved, the procedure “probably will be best for women at the end of their reproductive lives,” said Bryan Cowan, professor of obstetrics and gynecology and director of the division of reproductive endocrinology at the University of Mississippi in Jackson.

“On the other hand, someone needs to be out there doing new procedures.”

Another relatively new procedure destroys fibroids by zapping them with electricity or a laser. Called myolysis, it was introduced in the United States in 1990 by gynecologist Herbert Goldfarb of Montclair, N.J., and Manhattan.

In this approach, a woman first takes drugs such as Lupron to suppress the production of estrogen, known to enlarge fibroids, for about three months. Then after surgery to remove the uterus’s inner layer, the patient undergoes a laparoscopic procedure, in which the surgeon makes small incisions in the abdomen and uses tiny instruments employing magnification to guide the operation.

With the patient under general anesthesia, each fibroid is treated individually by repeated application of an electric current (which Goldfarb uses) or a high-intensity laser beam that destroys cells on contact. There is some pain and discomfort with the one-day procedure, Goldfarb said, although less than with UAE. Goldfarb reports a success rate of nearly 90 percent in the 400 patients he has treated.

The problem with myolysis is that scar tissue may form after the surgery and entangle internal structures, including fallopian tubes. This can interfere with pregnancy. Some gynecologists advise women who want to become pregnant to do so as soon as possible after myolysis.

Charles March, professor of obstetrics and gynecology at the University of Southern California, is cautious about both myolysis and UAE. “They are probably best suited to carefully selected patients who are not concerned about fertility or who don’t want to undergo major abdominal surgery,” he said. “Certainly, only doctors with a lot of experience should be doing them.”

Meanwhile, researchers are also looking into gene therapy and experimental drugs. At Brigham and Women’s Hospital’s Center for Uterine Fibroids in Boston, cell biologist Romana Nowak is studying two substances called growth factors that stimulate the formation of collagen or new blood vessels and accelerate the growth of tumors. Several agents that inhibit both growth factors are being considered for fibroid treatment, Nowak said.

Just what causes fibroids is not known. Cynthia Morton, a molecular geneticist at Harvard Medical School and Brigham and Women’s Hospital is looking for genetic clues. She and her colleagues are investigating two of the chromosomal abnormalities that occur in 40 percent of fibroids. In addition, they and others at the Center for Uterine Fibroids are recruiting sisters or other close family members who have fibroids in an effort to identify a common genetic factor.

Doctors point out that many women with fibroids have no symptoms. As March noted, “it’s only necessary to remove fibroids when they are causing symptoms.” Many women with symptomatic fibroids try to hang on until menopause, hoping the fibroids will shrink as their hormone levels decrease. Fibroids are sensitive to both estrogen and progesterone, said cell biologist Janet Andersen of the State University of New York at Stony Brook. After menopause, when levels of these hormones decline, many women experience relief.

For women whose symptoms require treatment, hysterectomy remains the only true cure: no uterus, no fibroids. However, hysterectomy carries the risks of all major surgical procedures. Also, recovery requires a lot of “down time,” and some patients contend there are lasting adverse effects on health and sexual function.

Moreover, many women just don’t want to lose their uteri. The only surgical alternative is myomectomy, but this operation is not always successful. Blood transfusions may be needed during surgery, and fibroids recur in 30 percent of cases. In addition, the operation can lead to problems from scar tissue.

For women who still want children, myomectomy has been the only route, although Caesarean section is required for delivery because the uterus is too weak. Now there are alternatives.

Are they better than myomectomy? “Let’s put it this way,” said McLucas. “If myomectomy were a better procedure, I wouldn’t be advocating UAE–or even myolysis. New procedures may come alon
g in a few years, but right now, if I were a woman who wanted to become pregnant, I’d consider UAE as my first alternative.”

Resources

There are at least three fibroid web sites in the Internet:

* www.fibroids.net is maintained by the Center for Uterine Fibroids, Brigham and Women’s Hospital, Boston.

* www.fibroidcorner.com is maintained by gynecologist Francis L. Hutchins Jr. and interventional radiologist Robert L. Worthington-Kirsch, both of the Philadelphia area.

* www.fibroids.org is maintained by the UCLA Medical Group Uterine Artery Embolization team.

Fibroid Tumors at a Glance

Uterine fibroids are benign tumors. They occur in more than 20 percent of women of childbearing age, although symptoms do not generally develop until the patient is in her late thirties or forties.

Fibroids are the most common cause of hysterectomies. They are named for their position in the uterus. Submucosal or intramural fibroids are often associated with abnormal bleeding, while pelvic and back pain are frequently caused by intramural and subserosal fibroids.

Source: Georgetown University Medical Center

As an educational service, members of the FTC provide questions and answers regarding fibroids. Please note that the questions and answers are not medical advice and there is no substitute for diagnosis and, where appropriate, treatment by a qualified and licensed physician of your own choosing.