Surgery Not Always Needed For Fibroids

A nonsurgical approach to the treatment of uterine fibroids is a reasonable alternative to surgery such as hysterectomy, a new study shows.

Researchers compared outcomes among women who received either surgery or the nonsurgical treatment, known as uterine embolization, for fibroids that produce symptoms such as painful menstrual periods and heavy menstrual bleeding.

Fibroids are benign tumors of the uterus.

On the plus side, women who opted for embolization had much shorter hospital stays and recovery times than surgery patients. But they also had higher treatment failure rates.

Within a year of initial treatment, about one out of 10 embolization patients required either a second embolization procedure or a hysterectomy to treat continued uterine bleeding or other symptoms.

Within three years of treatment, one in five patients who had embolizations had symptoms that required further treatment.

The findings are published in the Jan. 25 issue of The New England Journal of Medicine.

"Like many other minimally invasive medical treatments, there is a trade-off with uterine embolization," researcher Jonathan G. Moss, MBChB, tells WebMD.

"If the only concern is symptom relief, then it is hard to beat a hysterectomy. But many women don't want to lose their uteruses, or they have other reasons for not wanting surgery. Embolization may be an option for them."

In the decade since radiologists began performing the procedure in the United States, uterine embolization has become a common treatment for fibroids. In November 2004, Secretary of State Condoleezza Rice had the nonsurgical treatment.

Unlike surgery, which involves fibroid removal, embolization starves fibroids by choking off the blood supply that feeds them. Most fibroids shrink dramatically within six weeks, but symptom relief often occurs much sooner.

Comparing Embolizations to Surgery

The newly published study included 157 women treated for symptomatic fibroids at 27 hospitals within the U.K.

Roughly two-thirds of the women had uterine embolizations and the remaining third had surgery. Forty-three of the surgery patients had hysterectomies and eight had fibroids removed without removal of the uterus.

As measured by responses to a standardized questionnaire, the researchers found no significant differences in quality-of-life scores among the two groups a year after treatment.

The median hospital stay for the surgery patients was five days vs. one day for the women who had the nonsurgical procedure. The median time away from work was 62 days for the surgery patients and 20 days for embolization patients.

Ten out of 106 patients in the embolization group did not achieve adequate symptom control and required either a repeat procedure or hysterectomy within one year. An additional 11 patients required additional treatment within three years.

The researchers will follow the women in the study for at least five years to determine if treatment failure rates increase over time, Moss says.

"Certainly fibroids can grow back, but most of the women in this study were in their late 30s and early 40s so it may not be a big issue," he says.

The thinking is that most women in this age group who have uterine embolization procedures will enter menopause before new fibroids cause symptoms, Moss explains.

What About Fertility?

The big unanswered question about uterine embolization is whether it is an appropriate treatment option for women who want to preserve their fertility, Moss says.

Currently, surgical fibroid removal without removing the uterus is considered the treatment of choice for women with symptomatic fibroids who wish to conceive.

But Montreal gynecologist and reproductive endocrinologist Togas Tulandi, MD, says uterine embolization may prove to be a better approach for women who are not good candidates for this surgery, known as myomectomy.

In n editorial accompanying the study, Tulandi wrote that concerns that uterine embolization leads to early menopause have not been borne out by the clinical evidence.

But he tells WebMD that the clinical picture is less clear regarding other concerns related to fertility and childbirth.

Only about 150 pregnancies have been reported among women who have had uterine embolization procedures.

Tulandi is the associate director of the McGill Reproductive Center at Quebec's McGill University.

"There are suggestions that miscarriage and premature delivery rates are higher among these women, and that postpartum bleeding may be a problem," he says. "At this point, I think it is still premature to say that embolization is a reasonable treatment for women who want to preserve their fertility."

SOURCES: The New England Journal of Medicine, Jan. 25, 2007; vol 356: pp. 360-370. Jonathan G. Moss, MBChB, Cartnavel General Hospital, Glasgow, Scotland. Togas Tulandi, MD, associate director, McGill Reproductive Center, McGill University, Montreal.