This topic was discussed at the NIH conference (Advances in Uterine Leiomyoma Research: 2^nd NIH International Congress, Feb. 24-25, 2005, Bethesda, MD), trying to figure out causality. We’re still very weak in the theories and the knowledge of what causes fibroids.

“More and more women have been contacting me about UAE as a treatment alternative, not just to preserve their uterus, but also to preserve or enhance their fertility.”

In general, the older you get, the more commonly they are found. Several large population-based surveys with ultrasound (includes women with and without fibroid symptoms) have recently been published. In these studies, a very high prevalence of fibroids was found: 60 to 70 percent of women had fibroids. The prevalence of fibroids in these studies, as is well known, was highest in black women. I am not aware of prevalence studies in other ethnic groups.

There is no known pathway, but fibroids and endometriosis can coexist, and when they do, they can create more problems and be a cause for treatment failure.

You may notice a paper by Jacques Ravina on your list of high citations (Ravina J.H., et al., "Arterial embolization to treat uterine myomata," Lancet 346[8976]:671-672, 1995). He discovered the usefulness of embolization for fibroids by accident. Basically, they were performing myomectomies (surgical removal of the fibroids) and because the procedure can be very bloody, requiring transfusions, they wondered if embolization performed before the surgery would, in effect, devascularize or dry up the fibroids, decreasing the need for transfusions. Embolization had been used for a variety of obstetrical reasons at that time. What happened, however, was that the women improved so much after the embolization, they cancelled their surgery. UAE has taken off from that point and this whole process is a good example of medical progress by accident or serendipity. It’s always interesting to me that many of the most important advances in science and medicine are not the result of highly thought out or planned outcomes of any strategic mission, but rather are due to chance happenings. In medicine, too, maybe particularly in medicine, we have to be attuned and quick enough to follow forward from those fortuitous events.

In Europe, Dr. Ravina’s work propagated. It caused a firestorm in the U.S. when Scott Goodwin, an interventional radiologist in California, repeated these findings in a small group of women (Goodwin S.C., et al., "Preliminary experience with uterine artery embolization for uterine fibroids," Journal of Vascular and Interventional Radiology 8[4]:517-526, 1997). Not only did he publish them, but he also had a press conference to inform the general public! He’s known as the grandfather of the procedure here in North America.

Several years ago, when I was at a health technology conference in Europe, knowing how common fibroids are and the problems that they cause, I thought that if this new procedure from France could really help a lot of women, this would be a tremendous advance. When I returned, I discussed this with our interventional radiologists in our Toronto hospitals. I found that it wasn’t being commonly performed. We decided to evaluate the treatment in a multicenter trial in order to rapidly acquire a large sample and be able to generalize our findings. We have published the findings in several journals and they are known as the Ontario UFE (uterine fibroid embolization) Trial.

Fibroids are a very common public health problem. They have a devastating impact on women’s lives: the heavy menstrual bleeding, even extensive bleeding lasting in some cases for several weeks. The kind of menstrual bleeding we’re talking about is extreme. The anemia and the fatigue factor from these menstrual irregularities are unbelievable. There can be a lot of pain and cramping or pressure from the fibroids. Fibroids can create pressure on the bladder, resulting in urinary frequency and urgency. Women can also have greatly distended abdomens from enlarged fibroids, causing them to appear pregnant and often causing back pain. Fibroids can also have adverse effects on pregnancies, and many women have miscarriages.

Not only is it a major public health issue—this is a major practice issue for gynecologists. In terms of their practices, hysterectomy is the most common surgery performed on women next to C-section. It’s also a growing practice issue for interventional radiologists, who perform the treatment; it’s transforming their practices. The clinical impact is huge, as well. Because of all of this, I think that’s why there are many people from several medical specialties writing (and reading) about UAE.

We have a new paper that’s just come out and wouldn’t be cited yet (Pron G., Mocarski E., Bennett J., Vilos G., Common A., Vanderburgh L., "Pregnancy after uterine artery embolization for leiomyomata: The Ontario Multicenter Trial," Obstetrics & Gynecology 105:67-76, 2005). I think it’s a blockbuster paper. While we were following women up in our Ontario UFE Trial, we were looking at this procedure for effectiveness versus hysterectomy, so we were very surprised to find a number of pregnancies occurring in our study. The average age (of the women in the study) was about 43. In our minds, the issue or objective of our study was to determine if women were able to avoid having a hysterectomy, could they maintain their uterus? While we were conducting followup, we observed a number of pregnancies—24 to be exact. We weren’t looking for this. The average age (of the women who became pregnant) was 34, and some were 40. The women had undergone UAE for large, symptomatic fibroids and had been generally advised to have a hysterectomy. Many of these women had had previous multiple pregnancy losses and several had prior surgeries to remove fibroids. The fact that they achieved pregnancies after this procedure was absolutely amazing.

There has been a lot of misinformation that UAE ends fertility or that pregnancy was not possible after UAE. This report counters that claim. Women can get pregnant. It also underscores the fact that women should continue to use contraception after UAE if they don’t want to get pregnant. It was of note that although we only had a few pregnancies, most of the women delivered at term with healthy babies. The other message from our study was that three of the women had placentas located in the wrong position. Their deliveries had to be C-sections rather than a vaginal delivery. Because our study wasn’t designed to look at pregnancies and because we only had a few pregnancies, we can’t say whether these events are higher or lower than what we’d expect if the women had had myomectomies, the surgical treatment option for fibroids that preserves the uterus. However, we have recommended that if women get pregnant after undergoing UAE, they should be followed closely with ultrasound to make sure the placenta is in the right position. I’m pretty sure that it won’t be too long before this paper is highly cited, as it’s the first detailed paper on pregnancies occurring after embolization. This would be attributable to the strong desires of women and physicians to have as much information as possible on fertility and pregnancy outcomes after treatment alternatives to hysterectomy. Women no longer want to just preserve their uterus; they want a treatment that preserves or enhances their fertility.

In March, the Society of Interventional Radiologists (SIR) held a research consensus panel, bringing together all the experts to decide the most important next area of research for UAE. In this area, I have been pushing that we now need to do a trial in this area—specifically, should women have myomectomy or embolization? There’s going to be only one way to answer this: we have to do a major randomized trial. If ever there was an area of women’s health important enough to conduct a full-scale randomized trial, this would be one of them. To conduct a randomized trial, women would have to agree to be randomized and we would also have to have gynecologists and interventional radiologists agree to randomize their patients. Previously, when we looked at women deciding between embolization and hysterectomy, that was no contest. If you gave women a choice of being randomized to embolization and hysterectomy, you would have to approach more than 50 women before you found one who would agree to being randomized—most prefer any alternative to hysterectomy.

In preparation of feasibility considerations for a major trial, I really wanted to tap into women’s thinking, especially on the idea of being randomized. If we’re going to tell a patient we’re going to randomize them, we’re going to have to explain in a way that they will understand the need to perform randomization.

In collaboration with the National Uterine Fibroid Foundation, which is run by Carla Dionne, we put together a small survey that was sent out on her website and chat group. We basically started to sample women’s opinions about whether they would agree to participate in that trial and if they had a preference for the surgery (myomectomy) or embolization and why. Although this was obviously a highly select group, it was a really quick and dirty way to get opinions from women. That survey is going live now.

One of the things that we started to see from these respondents was that over three-fourths of the respondents were white. As everybody knows, there’s a disproportionate occurrence of fibroids in black women, and we did not appear to be getting their opinions. For black women, it’s more uncommon to not have fibroids. They also have more intense menstrual symptoms that occur at earlier ages, have bigger fibroids, and experience fertility losses. In our study, we had one woman who had nine prior pregnancy losses. We weren’t hearing from black women on the website where we put this survey.

Because fibroids occur so commonly in black women, they stand to benefit greatly from finding answers to the best treatment options. We also need to have black women participate in the study in order to determine that the treatment works as well for them as it does for other women. Fibroids tend to occur earlier in black women. When you’re in your 20s and they’re talking about hysterectomy, this is very serious. One dramatic case in our study underscores the impact of fibroids on women’s lives. One of our case studies was a young woman, 18 years old. Her family took her to the emergency room in the middle of the night because she was hemorrhaging. The doctors told her, "To save your life we’ll have to do a hysterectomy." Fortunately, the young woman lucked out. She was at one of our study sites and the hospital had a young interventional radiologist who was participating in our clinical trial. Those are the kinds of choices that a young black woman and her family faced in the middle of the night.

There are many reasons why women are still undergoing hysterectomy. One of the reasons involves the lag we often see between advances in science and medicine and their application in day-to-day practice. This has been referred to as translational barriers. Even though we have a major advance in fibroid treatment, it will take time until it diffuses out or is taken up in general practice. Many people are beginning to question why it takes so long for advances to have an impact on practice or, in this case, why there are still so many hysterectomies for fibroids. It’s well known that it can take between 10 to 20 years for advances to have an impact on practice patterns. I don’t think women should have to wait that long for access to a treatment that would dramatically alter their health.

Women hear about new health treatments, including UAE, from a variety of sources—the Internet, health magazines, other women. In many cases, they hear about it by accident and at the last minute. I’ve had calls from women on the way to the hospital for surgery. Their desperation is incredible.

More and more women have been contacting me about UAE as a treatment alternative, not just to preserve their uterus, but also to preserve or enhance their fertility. The other day, a young woman called me. She was just recovering. She had fibroids and she had just lost her baby. She was 36. This was her first pregnancy. Her doctors had advised her to take a conservative approach: try to achieve pregnancy and we’ll see how it goes from there. She did achieve a pregnancy and, at six months, she lost the pregnancy. She had heard of UAE and wondered if that was a treatment option for her. She’s already had a loss later on in pregnancy, which is more difficult than having a loss at a month or two. She knows that another conservative approach is not an option and that her fibroids need to be treated. She’s wondering if she should have a myomectomy or embolization. As she was 36, time was running out; it was pressing. Unfortunately we do not have the evidence that would help this woman and her doctors decide what to do next. We just don’t have those data yet. What I did tell her was, in general, we don’t know which one is better: UAE or myomectomy. We have encouraging information from a number of pregnancies after embolization. We know there are risks and complications for both (procedures). If anyone tells you that one side is superior to the other, then you’re not getting valid information. This is the first time I felt, as a researcher, that people want and need to have answers right now. That patient’s situation has stuck with me. I did refer her for counseling to a gynecologist who performs myomectomy and who collaborated with us on our Ontario UAE trial and is familiar with the risks and unknowns of both procedures. I felt that would be the least I could do for the young woman and her husband.

There are many ways to cite a paper. It was a lot of work to complete those papers and it is very rewarding to know that so many other researches found my work useful and worthy of reference. However, one of the most pleasurable citations involved a form of a secondary or nonscientific citation. Last year, when I attended a conference as an invited speaker, an interventional radiologist I met said he regularly used the information in our 2003 Fertility and Sterility paper when he counseled women for UAE. He said that we had reported on so many women undergoing UAE safely and successfully was helpful and reassuring for his patients. He was using our information to inform and guide his patients. My study results had a direct impact on patient care. It has been worth the hard work.