It started with a case on Thanksgiving Day in 1994. I had been called in to embolize the uterine arteries on a patient who had a myomectomy and was bleeding heavily post-operatively. The Ob/Gyn called me and asked if I would come in and embolize her. That kind of work had been going for a while in terms of embolizing arteries in patients bleeding after childbirth or surgery. It turned on a light bulb for us, though.

A French group was the first to publish a study, in 1995 (J.H. Ravina, et al., "Arterial embolization to treat uterine myomata," Lancet 346[8976]:671-672, 1995). We took note of that paper, and the gynecologist and I discussed the idea of starting a uterine fibroid embolization practice. So we started that in 1996 and I presented our early results, the preliminary results, at the Society of Interventional Radiology meeting in 1997. That year we published the paper in the Journal of Vascular and Interventional Radiology. That was the first report in the U.S. and in the radiology literature in a peer-reviewed journal.

After our article a number of people got interested, most notably Robert Worthington-Kirsch and Jim Spies at Georgetown. And it’s sort of grown exponentially since then. The last time I looked maybe 30,000 of these procedures had been done worldwide, at least.

Patients had been embolized since the 1960s for bleeding from a variety of causes. It took a couple of decades until people started embolizing patients who had bleeding after childbirth or after gynecologic surgery. What happened was that this French group was referred patients to be embolized prior to myomectomy to reduce bleeding during surgery, and they noticed that some of their patients were canceling surgery because their symptoms had been resolved. So it was a serendipitous observation. They started embolizing patients with fibroid symptoms, as I understand, in 1989, and then they published that article in 1995 in The Lancet.

“As a global statement, I'd say the hardest thing about the procedure becoming successful has been overcoming the resistance of the gynecology community.”

As a global statement, I’d say the hardest thing about the procedure becoming successful has been overcoming the resistance of the gynecology community.

They’ll say it’s an investigative or experimental procedure. Finally the American College of Obstetrics and Gynecology (ACOG) and the gynecologists themselves have finally stopped saying that. They finally acknowledged last year that UAE has a legitimate role in these patients. It was viewed as a patient-care issue by gynecologists and ACOG for many years.

Hysterectomy, by far.

The largest risk is death, which happens approximately once in every 5,000 patients. But that’s in contradistinction to hysterectomy, where it is about one in 1,000. There’s now been a paper published comparing UAE to hysterectomy and one comparing it to myomectomy that’s been presented at national meetings, and they show that UAE is safer than either of the two.

It’s very similar. There are no significant differences in outcome measures in those studies. The same thing goes for quality-of-life studies. Whatever you want to measure, they’re similar.

The 1999 paper was the larger paper, with more patients and multiple years of follow-up.

I’m still involved in a number of studies here. I’m the lead author of a multi-institutional national trial comparing UAE to myomectomy. That’s in press in Fertility and Sterility right now. I’m also on the fibroid registry steering committee, and we have multiple papers in press right now on UAE outcomes in several thousand patients, and I’ll be the lead author on the two-year follow-up paper in that group. I’ll probably start working on that next year. Maybe late this year.

Well, actually I’d have to put it another way. I’m actually disappointed at how little inroad it’s made into the hysterectomy statistics. At least 200,000 women a year in the U.S. are getting hysterectomies for fibroid disease. So less than 10 percent of that number is getting UAE.

Patients aren’t told. The gatekeeper is the gynecologist, and many patients come to me and say they had to find out about the option on their own. They weren’t informed about it when they were told about hysterectomy or myomectomy. And if they are told, what they’re given is all negatives. Instead of having a fair comparison with hysterectomy or myomectomy, they’re just given a laundry list of all the complications that could occur with UAE.

I think we’d see tens of thousands more of these procedures performed annually.

The first paper, the preliminary results paper, I didn’t really know what the impact of that was going to be. I thought it was a minor paper, and the next thing I know I’m on all the national news programs. I didn’t realize what an enormous iceberg I had just taken a piece out of. That said, you could ask the same question about a lot of this work having been published in radiology journals. And part of the reason is because many of the papers have been turned down by the major journals and the gynecology journals, even the better papers. The same thing is true of grant applications. If you look in the Ob/Gyn literature, you’ll find that any report of complications on UAE was always published and sometimes even fast-tracked. When Jim Spies tried to publish his paper comparing UAE with hysterectomy, he spent years struggling with the Ob/Gyn journals. That finally did come out in an Ob/Gyn journal but it was a huge study. It took him a long time to get it accepted. The paper comparing UAE with myomectomy was turned down by both the New England Journal of Medicine and JAMA. Now I’m going to the Ob/Gyn literature. I think it will be published successfully, but that’s because I’ve talked to the editor at Fertility and Sterility who I know has an open mind. I’ve decided to bypass the two major Ob/Gyn journals because of Jim Spies’s experience with his paper.

They said there weren’t enough patients and not enough years of follow-up, and it wasn’t a randomized study. I was a little unhappy with that. My point was that it’s a novel technology that needed broader exposure, but that didn’t overcome their objections. To JAMA’s credit, they said if we come back in a couple of years with longer follow-up, they might be interested in publishing it.

It was enormous. Our paper in 1997 was carried by all the newswires and most major newspapers and news programs. There’s been some additional interest whenever another major paper breaks. The lay press has been much more favorably inclined than the medical literature outside of my particular field. Still, the lay public has no idea what’s going on out there in medicine. Their impression is that they’re going to walk into any doctor’s office on any street corner and they’ll get the best care, and that’s just not the case.

I don’t think we would have had anywhere near the success we’ve had without the Internet. I think it’s had an enormous impact on patients educating themselves, finding out for themselves what’s out there.

Just one thing. You asked me about complications, and I think one important thing to note is that I personally still don’t believe this should be the first-round therapy for women who desire fertility. That still has to be worked out, particularly for women past the age of forty. For those women, myomectomy is still the gold standard.