Fibroid method offers a choice

By: Lee Peterson

When doctors told Victoria Overton she needed a hysterectomy, she balked. She wanted to know the alternatives. But her first- and second-opinion gynecologists gave her no options. To them, a large uterine fibroid on her uterus meant that the entire organ would have to be removed.

The benign tumor was causing problems: heavy bleeding, a frequent need to urinate and pain during sex. Overton knew she had to do something. The surgery was scheduled. She was even about to bank some blood in preparation for the operation. Then the Playa del Rey woman after badgering another gynecologist, heard about an alternative, a treatment for fibroids called uterine artery embolization.

In the procedure, a doctor clogs the blood vessels leading to the tumors with tiny plastic pellets. Starved of a blood supply, the fibroids shrivel, but the uterus stays alive. The minimally invasive treatment usually is done with local anesthetic and a conscious sedation, requiring only a one-night hospital stay. It might sound like an easy choice, but the medical community is sharply divided over the new technique. The group of physicians who perform it struggle for acceptance in the eyes of gynecologists, who as a group say it is not a proven substitute for hysterectomy.

Proponents say women, at least, should be offered the choice. The only other uterus-saving operation in which a surgeon removes the fibroids but leaves the uterus was not an option for the 47-year-old software executive. Her tumor was too large. “I did not want to have surgery. I did not want to be put under anesthesia. I did not want to miss that much work,” Overton said.

Overton found Dr. Richard Reed, an interventional radiologist who performs embolization at Daniel Freeman Memorial Hospital in Inglewood, one of a handful of places where it is available in the Los Angeles area.

The American College of Obstetricians and Gynecologists said 165,000 to 175,000 hysterectomies for fibroids were performed in the United States in 1994, the most recent year reflected in the statistics. Reed said the number today is 200,000 to 250,000, with another 50,000 myomectomies in which just the fibroids are removed. While Reed and the Society of Cardiovascular & Interventional Radiology support embolization as an alternative to hysterectomy in many cases, gynecologists say there is a reason that they don’t recommend it to patients: No one has proved in a controlled, randomized study that it is safe and effective.

Radiologists argue that gynecologists, who perform hysterectomies, worry about losing part of their turf. The OB-GYNs dismiss that and say they want only what’s best for the patient.

Doctors at UCLA Medical Center performed the first uterine fibroid embolization in this country in 1995. So far, about 6,000 have been done in the United States, while a total of about 10,000 have been performed worldwide. Reed said he spends a great deal of time making the case for the procedure to health insurers, trying to show why uterine artery embolization should be covered.

The radiology society reports that about half of all health plans cover the procedure. The turf conflict is similar to how cardio-thoracic surgeons at first viewed angioplasty in which a catheter is used to reopen clogged coronary arteries of the heart, before it earned widespread acceptance. “It’s a shame,” Reed said, “that women are not at least being offered the choice between embolization and hysterectomy. There are women who suffer in silence who don’t want a hysterectomy. They bleed so much they have to stay in bed,” Reed said.

“Embolization has been used for two decades to control bleeding for other obstetrical and gynecological problems, such as postpartum hemorrhage,” Reed said. “Through those procedures, it was found that it could be used to cut off the flow of blood to fibroid tumors.”

The procedure requires a great deal of skill as the radiologist guides the catheter through a single opening in the femoral artery, through the groin’s winding arterial system, using a fluoroscope. The doctor must enter both the left and right uterine arteries, one at a time. The sterile plastic balls are sent through the tube into the uterine arteries. Care must be taken so that they do not spread to arteries supplying blood to the legs or other places where they could cause serious problems. Doctors generally use a particle of 500 microns in diameter, the size of a typical grain of sand. That’s the right size, Reed said, to block the arteries to the fibroids, but not clog vessels that will still supply the uterus with its blood.

Women who ask for embolization (non-surgical treatment for uterine fibroids) are informed that it’s going to hurt. In the first hours afterward, the pain can be very sharp as the fibroids lose their blood supply. Overton, the patient, said she had a lot of pain that first day. But it was worth it, she said, as the symptoms that had sent her to the doctor in the first place quickly faded. She spent one night in the hospital and was back to work in about a week.

Fibroid tumors are benign masses on or in the walls of the uterus, a problem common in women age 35 to 55. Even if there are no symptoms of bleeding or pain, they can cause infertility.

For fertility patients with fibroids, embolization is not offered. Instead, the woman would likely undergo myomectomy, which preserves the uterus. While embolization is not offered as a fertility treatment, Reed said there have been a number of successful, if unplanned, pregnancies after embolization.

Reed argues that unless there is a fertility issue, myomectomy is not a good alternative to hysterectomy. Doctors agree that it can leave tiny seedling fibroids that grow and require the procedure all over again. Although some gynecologists will refer patients to doctors like Reed, the OB-GYN community at large is not sold on uterin artery embolization.

It is common in Europe, doctors said, for women with fibroids to request procedures that preserve their uteri, but it is not the norm in this country. Some are trying to change cultural attitudes, however, and promote keeping the uterus the womb intact whenever possible. Gynecologists note that surgery for fibroids, whether hysterectomy or myomectomy, can be performed often in ways that make it less invasive, either laparoscopically or also in cases of hysterectomy, vaginally. This means a woman is not staying in the hospital as long and is not having to wait six weeks to drive again as with an open procedure through the abdomen.

Embolization does not have the track record nor a large, randomized study to persuade gynecologists to offer it, said Dr. Buell Miller, a clinical professor at the University of Vermont’s Maine Medical Center in Portland, Maine. As a past member of the board of directors of the American College of OB-GYNs, and as current chairman of the board of the Maine Medical Assessment Foundation, he has not been impressed with the data on embolization so far. It’s not been well-studied, Miller said. Reed said about 1,500 uterine artery embolization have been part of published medical reports, showing a complication rate of about 3 percent.

As for a large, randomized study, Reed said it would be difficult to recruit patients, because candidates would have to agree to have either hysterectomy or embolization, whichever was randomly chosen for them. And then the study’s results would take about six to 10 years to report.The jury is still out on embolization, said Dr. Jordan Phillips, chairman of the board of the American Association of Gynecologic Laparoscopists, a Sant
a Fe Springs-based organization. But Phillips expects that enough procedures will have been performed soon for the medical community to judge if it is safe and beneficial.

I’m sure that by next year, we’ll have a very clear picture of the relative benefits of this procedure, Phillips said.

If you are showing signs of fibroid symptoms and think you have fibroids, schedule an appointment for a professional diagnosis. One of our fibroid surgeons will talk to you about your symptoms and perform a pelvic exam. We may order further testing including an imaging procedure such as an ultrasound. If fibroids are diagnosed we will discuss the best fibroid treatment for you. Here at the Fibroid Treatment Collective, we offer free consultations in-office or over the phone. Feel free to contact us for more information. To learn more about fibroids, visit our homepage.