by Janine Logan
Director of Communications
Nassau-Suffolk Hospital Council

Embolization for the shrinkage of uterine fibroids came about in an indirect manner when a French gynecologist sent his patients who were waiting for a surgical date for their hysterectomy to the radiologist for pre-op studies and this procedure. Subsequent improvement in their condition led these patients to cancel their surgeries. French medical results of the success of fibroid embolization were published in 1995, and American physicians began utilizing the procedure here in the United States two years later. Fibroid embolization was first studied in the United States by Scott Goodwin, MD, of the University of California at Los Angeles.

"The procedure itself has been used for 20 years to control heavy post-partum bleeding," said Craig Greben, MD, chief, Division of Vascular and Interventional Radiology at North Shore University Hospital (Manhasset, NY). Between two and three uterine artery embolization procedures are performed each month at North Shore and approximately 4,000 cases have been performed worldwide thus far, according to Dr. Greben.

Fibroid embolization is considered to be very safe, say interventional radiologists who perform the procedure. Complications occur in fewer than three percent of patients. These include infection, amenorrhea, and injury to the uterus as a result of decreased blood supply.

The procedure is a minimally invasive alternative to surgery and allows women to preserve their uterus, while correcting the bothersome and painful problem of fibroids. These abnormal but benign growths of muscle tissue in the uterus can cause heavy bleeding, pelvic pain, pressure on the bladder and bowel, and even interfere with fertility. "This procedure is definitely a patient-driven modality," said William Forman, MD, chairman, Department of Radiology at Mercy Medical Center (Rockville Centre, NY). "It has caught on faster with patients than with the medical community." Numerous web sites (www.fibroid.com and www.sirweb.org) offer prospective patients complete information about the procedure and its effectiveness.

Uterine fibroids are a common problem, affecting about 20 percent of women in their 20s, 30 percent in their 30s, and 40 percent in their 40s. From 20 percent to 40 percent of women age 35 and older have uterine fibroids of a significant size. However, most fibroids don't cause symptoms.

The ideal candidate is a woman who has finished her family, wants to avoid the long post-operative recovery that comes with a hysterectomy, and who wants to preserve her uterus. Patients with very large, pedunculated fibroids are not considered candidates for the procedure, according to Dr. Greben.

Patients are evaluated first by they gynecologist and also undergo a pelvic MRI and endometrial biopsy, before being cleared for the procedure. Alan Garely, MD, associate director of urogynecology and pelvic reconstructive surgery for the North Shore-Long Island Jewish Health System, assists in evaluating patients and their condition. "Because there is the potential for amenorrhea, we don't recommend the procedure for someone who wants to become pregnant, " said Dr. Garely.

There is little controversy surrounding this procedure other than the fact that some gynecologists believe fibroids should always be removed surgically via a myomectomy, says Dr. Garely. In addition, the care and treatment of patients is taken out of the hands of the gynecologist and given to the radiologist with this procedure. That could be a source of tension, he believes. "The ultimate goal, however, is that the patient comes first."

Safe and well-tolerated, the procedure is usually performed at a university medical center and requires an overnight stay to manage pain. A tiny catheter is inserted into the femoral artery in the leg by the interventional radiologist and is guided to the uterine artery at a point where it divides in the multiple vessels supplying blood to the fibroids. Tiny plastic (polyvinyl alcohol or PVA) or gelatin sponge particles the size of grains of sand are injected into the vessels. These particles block the blood supply to the fibroids, literally starving them and causing them to shrink. A 40 to 60 percent shrinkage is seen within a six month period. According to Mercy's Dr. Forman, between 85 to 95 percent of patients get the outcome they desire - their bleeding is controlled and the uterus that was enlarged shrinks by about 50 percent. Dr. Forman, who was involved with a Mount Sinai Medical Center collaborative study effort between a group of interventional radiologists and gynecologists, was one of the first to promote embolization for the shrinkage of uterine fibroids.

"As an alternative to hysterectomy or surgical removal of fibroids, uterine artery embolization appears to be an extremely effective technique," said Sidney Glanz, MD, chief, Interventional Radiology at Winthrop-University Hospital (Mineola, NY). "Because our results over the past two years have been so positive, the procedure is now being considered as a possible treatment for women who would like to preserve their fertility."

Article reprinted with the permission of the Nassau-Suffolk Hospital Council. Original article appeared in the Hospital and Health News, Vol. 11 No. 12