STUDY: Popular procedure may have hidden risks,studies find

JOURNAL: Obstetrics & Gynecology

AUTHORS: Dr. Evan Myers

ABSTRACT: An increasingly popular treatment promises to rid women of painful, bleeding uterine fibroids without standard surgery’s risks. But new research has some doctors questioning how long the treatment helps — and if it’s too risky for women who hope to become pregnant.

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COMMENTARY: Part of the problem is that this new “uterine artery embolization” has never been fully studied to see how it compares with uterine-sparing surgical removal of fibroids.

But the controversy highlights a bigger issue: “We really don’t know very much at all about how to manage fibroids,” says Dr. Evan Myers of Duke University — even though the uterine growths plague more than a million women a year and are the leading cause of hysterectomies.

Nearly 40 percent of women in their 30s and 40s develop fibroids, non-cancerous growths of muscle fibers inside the uterus. No one knows what causes fibroids, and tiny ones usually cause no symptoms. But they can grow to cantaloupe size, causing severe pain, heavy bleeding and infertility or pregnancy complications.

More than 150,000 hysterectomies — surgical uterus removal — each year are due to fibroids.

For women who still want children, options are limited. Drugs shrink fibroids only temporarily. About 35,000 women a year undergo myomectomy, where surgeons remove fibroids while leaving the uterus intact. But it’s painful, fibroids sometimes grow back, and women who later become pregnant usually require Caesarean deliveries.

Uterine artery embolization, or UAE, is a far less invasive alternative.

Doctors squirt tiny plastic pellets into certain uterine arteries, cutting off the blood supply feeding the fibroids. Over the next three months to a year, the fibroids shrink.

About 85 percent of patients get relief, fueling UAE’s growing popularity. Some 30,000 embolizations have been performed since UAE was first tried in 1995, says Myers, who calls it a promising procedure.

But studies published this month in Obstetrics & Gynecology raise questions about how long that relief lasts — and stress that contrary to public perception, UAE isn’t risk-free.

The University of California, Los Angeles, tracked 59 UAE patients and another 38 who had a myomectomy. Three years later, 29 percent of the UAE patients needed further fibroid treatment; only 3 percent of myomectomy patients did.

Infection, bleeding and blood-vessel clots are considered serious but rare risks of UAE — at least two deaths have been reported since 1995 — although no one knows how often complications occur.

Georgetown University Hospital tracked 400 embolization patients treated there since 1997, and concluded the overall risk of side effects was a low 5 percent. Most were minor — but five patients required days of hospitalization for infection, bleeding or clots. One needed a hysterectomy four months after her UAE, for heavy bleeding when her body expelled a shrunken fibroid. Researchers at Thomas Jefferson University analyzed the 50 published cases of pregnancy after UAE and concluded those women had higher risks of miscarriage, post-delivery hemorrhage, premature birth, breech babies and Caesarean sections than do healthy women. Other researchers say infertility also may be a risk if UAE accidentally blocks blood flow to the ovaries.

Meanwhile, any of the options is reasonable for a woman no longer considering pregnancy, but know that retreatment rates for both UAE and myomectomy remain in question, Myers says.

If women want to become pregnant, they “really need to know they’re taking a chance” with UAE, he adds. Georgetown’s Spies recommends myomectomy in particular for anyone wanting a baby within two years, because UAE shrinks fibroids so slowly.

"Do a little digging” before picking a doctor, adds Cynthia Pearson of the National Women’s Health Network, which urges better fibroid research. “No matter how fabulous things were at Georgetown, a woman can’t assume her results will be the same” if her doctor hasn’t performed many UAEs.