“If there's anything controversial in this procedure, it's whether patients who desire fertility are better off with an embolization or a myomectomy.”

We did the first cases and the first report of uterine artery embolization (UAE) in the United States. If you’re writing a paper on using this technique in the United States, you have to cite the first cases in the States. The first cases in the world were those by Jacques Ravina in France, who wrote a brief communication (J.H. Ravina, et al., "Arterial embolization to treat uterine myomata," Lancet 346[8976]:671-672, 1995). He’s definitely the father of this procedure. If anything, we’re the disciples who spread it to the United States.

Fibroid embolization is a stand-alone procedure, which could possibly affect hundreds of thousands of women. The number of hysterectomies in the United States have held steady at 600,000 to 700,000 annually. On top of that, unreported myomectomies—removing fibroids and leaving the uterus—are 300,000 procedures per year.

As the number of embolizations rise, you’ll see that it will have an effect on both hysterectomy and myomectomy. We’re still seeing the growth of this procedure nationwide. You’re looking at one-third of the hysterectomies being done for fibroids. Approximately 200,000 hysterectomies would be replaced and we should see an erosion in the number of hysterectomies, which is definitely the voice of the patient speaking. Most patients who come to us say that their doctor recommended a hysterectomy but they don’t want it.

There was an article published in The Wall Street Journal in August, which stated that on any number of occasions, gynecologists were not offering UAE to women as an alternative to hysterectomies (K. Helliker and L. Etter, "Silent treatment: hysterectomy alternative goes unmentioned to many women; gynecologists often don’t cite less-invasive procedure to treat fibroid tumors; bailiwick of other specialists," Wall Street Journal, A1, August 24, 2004). A gynecologist may not recommend or is not familiar with embolization. It’s still an impediment many times. The gynecologists are either not familiar with or not supportive of embolization. This is contrary to the position paper of the American College of Obstetrics and Gynecology, which wrote a technical bulletin in support in February 2004 (http://www.acog.org). If there’s anything controversial in this procedure, it’s whether patients who desire fertility are better off with an embolization or a myomectomy.

The problem with myomectomy, among other problems, is the number of reoccurrences. A third of the time, fibroids reoccur after myomectomy. When you’re talking to someone in her 30’s, reoccurrence is much more likely than in someone closer to the menopause. This embolization interrupts the blood supply to both small and large fibroids.

Most of our patients are busy housewives or busy professionals. The six weeks off (for a hysterectomy) are more a downside to major surgery than a lack of risk. I do keep reminding my gynecology audience that this was originally a procedure invented for people who were too sick for surgery. It was used in inoperable cervical cancer to stop bleeding. The risks for this procedure are miniscule, compared to the risk for hysterectomy.

Right now, it’s being done by interventional radiologists. I’m a gynecologist; we’re also doing this procedure. It’s a large commitment of time to learn how to do a procedure that we weren’t taught in our residencies. On the other hand, most of us had to learn how to use a laparoscope once we were already in practice.

Ultimately, it would be nice if there would be within every practice a member of the group who was able to do interventional procedures. I think the continuity of care is important: if this is the right procedure for the patient, having a discussion about alternative procedures, having to manage the patient after the procedure. It would be better if gynecologists would be able to carry out the procedure and follow the patient afterwards.

The benefit of learning about interventional techniques carries out into a lot of other patient care in obstetrics and gynecology. This will lead to women getting a lot more benefit from other forms of therapy. One such example is post-partum hemorrhage. Right now we surgically ligate the uterine arteries, but it only works 50 percent of the time. Using Gelfoam for post-partum hemorrhage is almost 100 percent effective. This will save women from hysterectomy. In Japan, chemotherapy for ovarian cancer is being delivered via indwelling catheters using techniques similar to UAE. If embolization really stands out in medical history as anything, it’s going to be one of these times that we as surgeons have realized we can use nonsurgical techniques to solve problems. It’s similar to the breakthrough that led us to understand that gastric ulcers were caused by bacteria and were treatable with methods other than surgery.

I have had a lot more interest in this procedure since Secretary of State Condoleezza Rice had this procedure in November. Black women have more fibroids than any other group.

Probably, the new kid on the block as far as technology is using magnetic resonance-guided focused ultrasound to destroy fibroids. Some studies were done out of Boston. It’s becoming a technique people are asking me about, so the public knows more about it. It’s too early to say this new technique will allow the same nonrecurrence of fibroids that you get with UAE. This is not a new method—there were articles 10 years ago on using focused ultrasound in prostate cancer—but it’s new for treating uterine fibroids.

Bruce McLucas, M.D.
University of California, Los Angeles
Los Angeles, CA, USA