The indication for treating women with fibroids should be to
significantly improve or cure their symptoms, or to address a specific
clinical concern (eg, difficulty conceiving or recurrent pregnancy loss).
In this particular example, the patient has menorrhagia and
subsequent iron-deficiency anemia. This has resulted in chronic fatigue,
migraine headaches, decreased quality of life, and depression.
A study by Lee et al estimated that ½ million women in this country
have clinically significant fibroids. These women have a
diminished quality of life, and if untreated, have a poorer health status.(1) Therefore, expectant management of this patient is not a good option.
There are a number of possible therapeutic options for this patient.
Medical management (eg, OCP, Mifepristone, Leonorgestrel-IUD) is often a
first-line option, but her symptoms warrant a more definitive option. A
Cochrane collaborative review from 2006 stated that "evidence-based
reviews suggest that current medical therapies tend to give only short-
term relief, and the crossover rate to surgical therapies is high."(2)
Uterine Artery Embolization (UAE) would be an excellent option for
this patient. The August 2008 Practice Bulletin of the American College of
Obstetricians & Gynecologists stated that based on long- and short-
term outcomes, UAE is a safe and effective option for women who wish to
retain their uteri. The patient would need to see an Interventional
Radiologist for a second opinion. The benefits of a multidisciplinary
approach to fibroid treatment is the subject of a recent Ob/Gyn
publication.(3) The strengths of UAE are that it can be an outpatient
procedure with high clinical success rates and high patient satisfaction.(4,5) The patient avoids the surgical risks and the longer surgical
recovery. It is also a global therapy (i.e. treats all the fibroids)
rather than a local therapy (eg, myomectomy and MR-guided Focused
Ultrasound [MRgFUS]). In this particular case, the patient has seen that
myomectomy did not provide long-term relief, and she has had a prompt
return of her symptoms.
MRgFUS is also an option. There are short-term studies that show
safety and efficacy, and improvements in UFS-QOL.(7) However, long-term
studies are needed to see if the results are comparable to other treatment
options beyond 2 years. If the 2 fibroids in the ultrasound image are
the only fibroids to speak of, this therapy becomes more of an option than
if there are numerous additional fibroids present in the uterus.
The patient’s desire to avoid another “big” surgery, and the capacity
to bear children, eliminate hysterectomy, open myomectomy, and endometrial
ablation from consideration. Laparoscopic myomectomy would be an option,
although studies report recurrences from 12.7% at 1 year to 27% at 2 ½
years.(8) According to Reed et al, the cumulative risk for a second
surgery (which is typically hysterectomy) after myomectomy is high (~5%
per year).(9)
In summary, as stated in a report from the Agency for Healthcare Research and Quality (AHRQ) in 2007, “there is a
remarkable lack of high quality evidence supporting the effectiveness of
most interventions for symptomatic fibroids."(10) With that said, I would
discuss the above options with the patient, but the two best in my opinion
for this patient would be UAE or MR-gFUS. Of these two options, UAE is
likely the more complete and durable procedure, but MRgFUS is an
attractive option for selected patients with a limited fibroid burden who
wish to have a non-invasive therapy. At this time, most insurers do not
yet reimburse for MRgFUS, and therefore, her decision may need to be made
with that in consideration.
John C. Lipman, MD, FSIR
Director, Image-Guided Medicine, Emory-Adventist Hospital
Atlanta, Georgia
References
1. American College of Obstetricians and Gynecologists. Uterine
Fibroids. www.acog.org/publications/patient_education/bp074.cfm.
2. Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical
therapy for heavy menstrual bleeding. Cochrane Database of Systemic
Reviews 2006, Issue 2. Art. No.: CD003855. DOI:
10.1002/14651858.CD003855.pub2.
3. Fischer JH and Zurawin RK. Expert Exchange: How to Formulate the
Relationship Between the Ob/Gyn and the Interventional Radiologist for the
Treatment of Uterine Fibroids. Contemporary Ob/Gyn 2008; April: 1-8.
4. Hutchins F, Worthington-Kirsch R, Berkowitz R. Selective uterine
artery Embolization as primary treatment for symptomatic leiomyomata
uteri. J Am Assoc Gynecol Laparosc 1999; 6: 279-84.
5. Spies J, Ascher SA, Roth AR, et al. Uterine Artery Embolization
for Leiomyomata. Obstet and Gynec 2001; 98: 29-34.
6. Stewart EA, Rabinovici J, Tempany CM, et al. Clinical outcomes of
focused ultrasound surgery for the treatment of uterine fibroids. Fertil
Steril 2006; 85 (1): 22-9.
7. Viswanathan M, Hartmann K, McKay N, et al. Management of Uterine
Fibroids: An Update of the Evidence. Agency for Healthcare Research &
Quality US Dept of Health & Human Services. 2007 Contract # 290-02-
0016, July #154.
8. Rosetti A, Sizzi O, Soranne L, et al. Long-term results of
laparoscopic myomectomy: recurrence rate in comparison with abdominal
myomectomy. Hum Reprod 2001; 16 (4): 770-4.
9. Reed SD, Newton KM, Thompson LB, et al. The Incidence of Repeat
Uterine Surgery following Myomectomy. J Women’s Health 2006; 15: 1046-52.
10. Viswanathan M, Hartmann K, McKay N, et al. Management of Uterine
Fibroids: An Update of the Evidence. Agency for Healthcare Research &
Quality US Dept of Health & Human Services. 2007 Contract # 290-02-
0016, July #154.
No relevant financial interests
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