Uterine Artery Embolization for Leiomyomata

Abstract & commentary

Synopsis: Uterine artery embolization is a safe and effective means of treating uterine fibroids.

Source: Spies JB, et al. Obstet Gynecol. 2001;98:29-34.

Spies and colleagues report 200 consecutive patients with uterine fibroids who underwent uterine artery embolization. Prior to treatment all women had symptoms of heavy menstrual bleeding, pelvic pain and pressure, or urinary symptoms. For this study, Spies et al combined pelvic pain and pressure with urinary symptoms into a category called "bulk" symptoms. There were a number of exclusionary criteria, the most important being pregnancy, easily resectable fibroids, and women with a uterus larger than 24 weeks gestational size. Except for the first 14 patients, all others received a magnetic resonance imaging (MRI) study. Repeat MRIs were scheduled at 3 months and 12 months following the procedure. Based on the MRI results, the volume of both the uterus and the dominant fibroid were calculated.

Spies et al performed bilateral embolization with polyvinyl alcohol; both major and minor complications were recorded.

Spies et al mailed symptom questionnaires to all of the patients at 3, 6, and 12 months after treatment.

Only 2 of the 200 patients could not be treated. Ninety-three percent of the patients were admitted to the hospital overnight for observation and pain control. Four patients were readmitted for 1 night for pain control and 3 others were seen in the emergency department. The average number of days required before returning to work was 8. The mean duration of follow-up was 21 months. All patients were followed for at least 12 months following the procedure. A large majority of patients returned the follow-up questionnaires.

Prior to the procedure, 85% of the patients complained of menorrhagia. This was improved for more than 80% of the patients, with only 3% and 2% reporting worse symptoms 3 months and 12 months following the procedure.

Of the patients, 83% reported pelvic pain and/or pressure and 54% urinary symptoms prior to the procedure. These "bulk" symptoms were improved in more than 90% of the patients with only 3% reporting worse symptoms at 3 months and 2% at 1 year postoperatively. Overall only 3% of the patients were dissatisfied with the procedure 3 months postoperation.

Postprocedure imaging showed that uterine volume was reduced by 27% at 3 months and 38% at 12 months following the procedure. In addition, the dominant fibroid volume was reduced by 44% at 3 months and 58% at 12 months.

Of the patients, 10.5% required some type of gynecologic surgical intervention during the follow-up. This included 9 hysterectomies, none of which were performed to treat complications of the procedure. Seven of the hysterectomies were performed for failure of symptom improvement. Only one major complication occurred, a pulmonary embolism 2 days following the procedure.

Comment by Kenneth L. Noller, MD

Leiomyomata are the leading indication for hysterectomy in the United States. In recent years some decrease in symptomatology has been accomplished through medications, though the long-term benefit has been somewhat disappointing. More recently, the use of uterine artery embolization to reduce or eliminate the symptoms of leiomyomata has been gaining popularity.

This article represents the largest single series of patients treated with this procedure. The study is generally well conceived. The 21-month average follow-up is much longer than many of the published series, but we will need to wait for the 5 and 10-year follow-ups to know for certain that the procedure results in true long-term improvement.

I was quite surprised (and impressed) with the low level of complication experienced by these patients. Pain remains the biggest postoperative problem. In my experience, the pain experienced by these patients during the first 24 hours is not trivial. Many/most require substantial amounts of narcotics. However, after 24 hours few continue to have more pain than can be controlled with nonsteroidals.

I hope our profession does not miss its opportunity to evaluate this procedure correctly. So far all of the published studies (including this one) are "show and tell" papers. That is, they are merely case series. What is desperately needed is a prospective, randomized trial comparing uterine artery embolization to hysterectomy for the treatment of uterine leiomyomata. We will have one opportunity—now—to perform such a study. If it is not done soon, uterine artery embolization and hysterectomy will both be done for fibroids without one ever knowing which is better.