MUSINGS: The Real Scoop on Uterine Artery Embolization

Have you ever noticed how easily misinformation develops and how eagerly it is spread by the ill informed? Of late I have heard and read all manner of seemingly authoritative pronouncements on uterine artery embolization (UAE) for the management of uterine myomas. I even saw an "authority" recently on OPRAH stating that UAE was experimental and not useful for tumors larger 4 cms. Where did these facts come from? I suppose that the current situation has arisen because of the small amount of material published on this topic to date. Those of us who have been active in evaluating this procedure we are frantically trying to correct this problem by submitting manuscripts to scientific journals as rapidly as we can. In the meantime, I will take the opportunity of this my first MUSINGS column to give an overview of what has been observed thus far. Definition: Uterine artery embolization for the treatment of fibroids is a procedure, which uses selective pelvic angiography to occlude each of the two uterine arteries. It thereby causes acute degeneration of the fibroids and cessation of heavy menstrual bleeding.

Candidates For UAE

Technically woman who has fibroids can be considered a candidate for UAE. Practically speaking, however, these women should have symptoms to justify being treated. Nevertheless, I expect that prophylactic treatment will likely be used in special circumstances in the future. Contrary to what has been rumored, we have noted no unique problems associated with embolizing large tumors. We have thus far not found them to be predictably less responsive or to produce more symptoms than that seen with smaller tumors. Smaller tumors such as those associated with the more modestly enlarged uterus, on the other hand, are in many situations treated equally well and sometimes more efficiently with hysteroscopic resection or endometrial ablation.

Contraindications

The only universally accepted contraindications to UAE are:

• Current pregnancy
• Active pelvic infection
• Arterio-venous fistulas
• Severe contrast allergy

Note that desire for future pregnancy is not excluded. There is no evidence that UAE or any other form of occlusion of the blood supply to the uterus caused either infertility or complications of pregnancy. The problem is that there is no significant body of data that conclusively proves that UAE does not interfere with future reproductive performance. There have been a number of reports of pregnancy after embolization with no problem but the numbers of pregnancies so far have been small. There needs to be further long-term follow-up of a significant number of women to answer this question. It is our belief that this procedure will ultimately be proven to be at least as effective as traditional myomectomy. For now, all women who are about to undergo UAE should be advised that conclusive information about its effect on future fertility does not exist.

Results With UAE

The most remarkable aspect of UAE is that the results reported from various centers have all been quite similar. Control of bleeding generally exceeds 90%. Reduction in size of the fibroid uterus is 50-60%. Patient acceptance as indicated by positive response to the question "Would you have it again?" has been 85%. The effect on size and bleeding seems to be permanent with follow up from 1-6 years. In addition, it is marked by short hospital stay of 24 hours and average recuperation of 7-10 days

There seems to be little question that this is a treatment that will play a major role in the management of fibroids for the foreseeable future. It certainly represents a very attractive alternative to major surgical procedures such as hysterectomy.