Modern management of myomas by Dr. McLucas

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Modern management of myomas by Dr. McLucas

What are myomata?

Myomata of the uterus are the most common benign tumor occurring in either men or women. Although they are benign, myomata can cause debilitating and often life-threatening symptoms. They are muscular growths which usually occur within the myometrium and may migrate either to the endometrial cavity [submucous] or to the serosal surface [sub serous]. Submucous myomata commonly cause menorrhagia, and may interfere with implantation of embryos [1]. Subserous myomas will commonly present with pressure on the bowel and bladder, and back pain, when the uterus enlarges to the size of a twelve week gestation. Sarcoma occur in less than 1/800 patients who present with supposed myomata.

Health care implications

Myomas occur in at least 40% of women over the age of 40. They are more common in African American females, but occur in women of all races. Discharge data indicate that myomata are the cause for more than 40% of the 600,000 hysterectomies performed annually in the US. In addition, women will undergo an estimated 250,000 myomectomies each year in this country. The morbidity of both these procedures may be over 40%, from atelectesis to pulmonary embolus. Time off work will be an average of six weeks. Women who undergo hysterectomy often complain of depression post operatively [2]. Women who wish to retain their uterus face the possibility of a recurrence rate of 50%, and scar tissue formation after myomectomy.

Non surgical alternatives for myoma treatments

Progesterone, either in intrauterine devices, or taken orally, has been shown to decrease the size of myomata. Leuprolide creates an artificial menopause and temporarily shrinks the dimension of myomas. Image guided ultrasound has recently been described as effective in shrinking myomas [3].

Uterine artery embolization

Uterine artery embolization [UAE] was discovered by Jacques Ravina, a Parisian gynecologist, and reported in The Lancet in 1995 [4]. its discovery is an interesting story. Ravina was attending at the Hospital Lariboisiere, a triage unit for patients requiring endovascular procedures in northern France. His team embolized patients with symptomatic myomata who were too anemic to donate autologous blood prior to their surgery. On follow up, Ravina learned that not only did he stop the patients’ menorrhagia, but the surgeries were deemed no longer necessary. The myomata had shrunk an average of 50%. McLucas and Goodwin reported on the first series performed in the US in 1997 [5].

What is the technique of UAE? Embolization of the uterine arteries is performed under fluoroscopic guidance. The artery, a branch of the anterior division of the internal iliac artery, [see Figure 1] has a distinctive appearance, coursing medial and anterior from its take off. Many different types of particles from poly vinyl alcohol to spherical particles have successfully blocked the uterine arteries. Both sides must be embolized as the blood supply to myomata is bilateral. In general, the uterine arteries are the sole supply to these tumors [see Figure 2 ]. UAE is performed under sedation, often as an outpatient procedure. The patient will return to work in less than five days. Compared to myomectomy, UAE offers a bloodless, adhesion free procedure for most patients. UAE is successful in stopping menorrhagia in almost 100% of patients. Shrinkage of close to 50% of all myomata takes place in six months or more. Embolization works in approximately 90% of patients. Failure may be caused by under embolization or spasm of the uterine artery during UAE. Another reason for failure is a blood supply from another artery other than the uterine. This may occur in patients with uterus larger than 20 weeks pregnancy size.

Embolization and fertility

Embolization has been recognized as effective by the American College of Obstetricians and Gynecologists [6]. The college recommended further study concerning use of this technique on women desiring fertility. McLucas, et al, reported a 39% term pregnancy rate in women under 40 who desired fertility [7]. His work has been confirmed by others. Notably, patients who underwent UAE prior to conception suffered no growth retarded pregnancies or higher than normal rates of fetal distress in labor. This indicates that the blood flow to the myometrium remains satisfactory after UAE.

Risks of UAE

Embolization has been used in both obstetrics to treat post partum hemorrhage,[8] and in gynecology to treat post operative bleeding, and inoperable cervical cancer [9]. The risks associated with UAE have been shown to be consistently lower than major surgery [6]. Having said that, there are risks to any operative procedure, including UAE. Premature menopause has been noted in as many as 15% of women over the age of 45 [7]. Likely, this results from non target embolization of the ovarian arteries either by reflux or through anastomosis between these two arteries.

Prolapse of submucous myomata may occur when the myoma is pedunculated. This post operative complication is easily dealt with dilation and curettage, and is heralded by the presence of malodorous discharge and cramping.

Summary

Uterine artery embolization offers patients suffering from the common problem of uterine myomata an outpatient, low risk alternative to surgery. Compared to myomectomy, embolization has no risks of blood loss, no scar tissue formation, and no recurrence risk. The UAE procedure is covered by all insurance plans, and recognized as effective by the American College of Obstetricians and Gynecologists.

[1] Lumsden MA, Wallace E, Clinical presentation of uterine fibroids. Baillieres Clin Obstet Gynaecol 1998;12(2)177-195.

[2] Annath J. Hysterectomy and depression. ACOG 1978:52;724-730.

[3] Funaki K, Fukunishi H, Funaki T, Kawakami C. Mid-term outcome of magnetic resonance-guided focused ultrasound surgery for uterine myomas: From six to twelve months after volume reduction. J Minim Invasive Gynecol 2007;14:616-621.

[4] Ravina JH, Herbreteau D, Ciraru-Vigernon N, et-al. Arterial embolisation to treat uterine myomata. Lancet 1995:346:671-672.

[5] Goodwin SC, Vendantham S, McLucas B, Forno AE, Perrella R. Preliminary experience with uterine artery embolization for uterine fibroids. J Vas Interv Radiol 1997;8:517-526.

[6] American College of Obstetricians and Gynecologists. Alternatives to hysterectomy in the management of leiomyomas. ACOG Practice Bulletin No. 96. Washington, DC: American College of Obstetricians and Gynecologists; 2008.

[7] McLucas B, Goodwin S, Adler L, et al. Pregnancy following uterine fibroid embolization. BJOG 2001;74:1-7.

[8] Hansch E, Chitkara U, McAlpine J, et al. Pelvic arterial embolization for control of obstetric hemorrhage: A five-year experience. Am J Obstet Gynecol 1999;180:1454-160

[9] Vendantham S, Goodwin SC, McLucas B, et al. Uterine artery embolization: an underused method of controlling pelvic hemorrhage. Am J Obstet Gynecol 2007;176:938-48.

Modern management of myomas by Dr. McLucas

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