Angela M, a 33-year-old museum
curator, was shocked when her doctor suggested that a
hysterectomy was the best way to relieve her pelvic pain.
However safe and effective the procedure may be at resolving
chronic abdominal pain, cutting out major organs to kill
the pain seemed more like overkill to Angela — particularly
as she hadn't hit menopause yet and hadn't ruled out having
kids if Mr Right came along.
FIGHTING
FIBROIDS
Surprisingly, pelvic pain is the primary reason for
hysterectomy in Canada. There are alternatives to hysterectomy,
such as myomectomy, the removal of uterine fibroids
(myomas), and more recently, uterine fibroid embolization
(UFE) has made the scene. UFE is a nonsurgical technique
used to block blood supply through the release of tiny
sand-like particles into blood vessels via a catheter.
Although it involves no radiation whatsoever, it's generally
performed by a trained radiologist. Embolization, however,
remains very much a minority treatment because of doubts
about longterm efficacy.
But the procedure won't be doomed
to relative obscurity for much longer — not if
the Society of Interventional Radiology has anything
to say about it. At their annual meeting this month,
poster session after poster session raved about the
benefits of UFE. Perhaps the most influential data came
from the first longterm followup of UFE patients. "Some
gynecologists have been waiting for longterm data before
being comfortable recommending the UFE procedure, and
now that we have that data, I think patients will be
hearing more about UFE as a nonsurgical option," says
Dr James Spies, Professor of Interventional Radiology
at Georgetown University Medical Center in a press release
from the meeting. Similarly, the long awaited data comes
as welcome news to Canadian gynecologists and their
patients too.
In the study, 73% of 182 patients
followed for five years achieved symptom control while
20% had treatment failure, defined as no symptom control,
repeated embolization, or need for myomectomy or hysterectomy.
"The results are comparable to myomectomy, a procedure
in which the fibroids are surgically removed, but the
uterine fibroid embolization is less invasive, and women
recover from it more quickly," explains Dr Spies. "With
any of the uterine-sparing treatments, growth of new
fibroids is possible, and we saw this occurring in some
patients during the later part of followup in this study.
The same phenomenon is seen with myomectomy, with reintervention
rates in the same range," he adds.
Another reason for the under use
of UFE some argue is because not all pelvic pain is
due to uterine fibroids. But the proponents of embolization
had a good deal to say about that as well. Two studies
presented at the meeting concluded that a major undiagnosed
cause of chronic pelvic pain in women without fibroids
is pelvic and ovarian varicose veins. The solution?
You guessed it — embolization.
UFE
USE IN THE SAME VEIN
A study conducted at the Intermountain Vein Center in
Utah found that, of 160 women with leg varicose veins,
16% had pelvic congestion syndrome, largely due to venous
reflux in ovarian or pelvic veins. Two-thirds of these
patients reported significant or complete pain relief
following embolization.
Researchers from Johns Hopkins
Medical University achieved almost identical results
using embolization to treat 131 women with chronic pelvic
pain due to pelvic congestion. Researcher Dr Kevin Kim
commented: "Many women are needlessly suffering and
often told their pain is all in their head. Women need
to know that embolization is an effective treatment
for reducing pelvic pain — in our study, 85% of
the women had significant longterm symptom improvement."
So embolization, like myomectomy,
might be the ideal treatment for the growing subset
of younger patients who haven't definitively abandoned
the possibility of becoming pregnant. Unfortunately,
the kind of small studies presented at conference poster
sessions can tell us little about these patients' future
prospects for childbirth. One study, for example, reported
six pregnancies in 86 women subsequent to UFE. Three
finished normally, one was ectopic, two were aborted.
Another reported two pregnancies in 85 women with a
mean age of 42; both resulted in miscarriages. Clearly,
no reliable predictions can be made from such sparse
data. We can only hope researchers take the advice of
Dr Spies: "The next step in fibroid research is to design
direct comparative studies between the various therapies
to provide data as to which patients are best suited
for each treatment."
Research presented at the Society
of Interventional Radiology meeting April 2005
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