SAN DIEGO - Uterine fibroid embolization (UFE) has become accepted as a safe and effective alternative to hysterectomy for treating uterine fibroids. And interventional radiologists are beginning to develop a better understanding of the outcomes produced by UFE, as indicated by a series of studies presented at this week's Society of Cardiovascular and Interventional Radiology meeting in San Diego.
Some 30% to 40% of women over the age of 35 develop uterine fibroids, with the gold standard of treatment being hysterectomy. Over a third of the 600,000 hysterectomies performed each year are due to fibroids, according to the SCVIR. Surgical removal of the fibroids, or myomectomy, preserves fertility, but is more invasive than UFE.
Despite the advantages of UFE, many of the procedure's outcomes are not fully understood, such as its impact on ovarian function, or the relationship (or lack of same) between post-procedure pain and therapy success rates. Interventional radiologists are also seeking to improve UFE by applying new modalities, such as MRI, to provide baseline information about fibroid type and location in the uterus.
UFE was found to have minimal impact on the fertility of women younger than 45 years of age, according to a study presented by Dr. James Spies of Georgetown University Medical Center in Washington, DC. Spies and colleagues studied 27 patients age 45 or older, and 35 patients under 45.
They measured changes in ovarian function using serum follicle stimulating hormone (FSH) levels, which tend to rise in response to decreasing ovarian follicle sensitivity. One baseline measurement was taken prior to embolization, and measurements are being collected at three-month and six-month intervals after the procedure.
Preliminary results indicate that only 1 patient in the under 45 age group (3%) had a significant change in FSH levels into the peri-menopausal range at three months after embolization. In the older group, 4 of 27 patients (15%) had a change in hormone levels into the peri-menopausal range three months later.
The researchers added that the mechanism that causes ovarian dysfunction following UFE is not understood and warrants further study. Further research is also needed to determine if the results found at three months and six months after treatment are permanent.
Researchers at Northwestern University Medical Center in Chicago investigating the impact of UFE on the resumption of menses and ovarian function found a higher rate of ovarian failure in older women, but no impact on those under 45.
The study, which was presented by Dr. Howard Chrisman, found that premature ovarian failure (POF) occurred in 7 of 21 patients (33%) 45 and older, while none of the 45 patients younger than 45 encountered POF. Regular menses resumed following an average of 25 days in 86% of the women, while menses did not resume in 9 women (14%). Clinical and biochemical findings consistent with menopause were seen in 7 of the 9.
Chrisman said his group wasn't sure why they found a higher rate of ovarian failure than the Georgetown researchers. The findings indicate that more research is needed on the impact of UFE on women over 45, he said.
No pain, no gain?
Two other presentations on UFE found no correlation between the severity of pain the patient feels after a procedure and the outcome of the therapy. One study, conducted at Georgetown and presented by Spies, studied 81 patients, and assessed their post-procedure pain.
The researchers measured the administration of morphine to the patient via patient-controlled analgesia, and also used questionnaires asking patients to rate their pain. The assessments failed to match the initial volume of reduction following embolization of the uterus, or of the two largest fibroids.
The results were confirmed by a group from the Hospital of the University of Pennsylvania, which also found that pain doesn't correlate with outcome. Of the 43 patients studied, there was no statistical correlation between procedural success and pain, according to Dr. Atul Gupta, who presented the study.
In one other study, researchers from Beth Israel Deaconess Medical Center in Boston compared the use of MRI rather than ultrasound to acquire a baseline image prior to UFE. Using a 1.5-tesla scanner with gadolinium enhancement, 74 patients with a mean age of 44 were assessed for uterine volume, extent of fibroid involvement and location in the uterus.
MRI was able to identify pathology that might have been mistaken for fibroids with ultrasound, according to Dr. David Brophy. MR scans resulted in significant new diagnoses in 4 patients, and altered the treatment plan in 5, he said.
Concluding the session was a discussion by Dr. Lindsay Machan of the University of British Columbia in Vancouver. Machan pointed out that UFE could potentially have an enormous impact on interventional radiology due to widespread prevalence of uterine fibroids. At the same time, interventional radiologists most likely will have the UFE market to themselves, as gynecologists at present aren't inclined to begin performing the procedure themselves.
But at the same time, interventional radiologists must provide the data that proves to gynecologists that UFE is an effective alternative to surgical procedures. "If we don't do [UFE], gynecologists are going to do it," Machan said. "We have an interest in making sure this kind of data is collected in a very scientific way."
By Brian Casey
AuntMinnie.com staff writer
March 28, 2000
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