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Fibroid embolization: the jury's still out

Embolization is a procedure that's been around for 20 years or more to treat abnormal bleeding in various parts of the body, but it has only recently been applied to the uterine artery to cut the flow of blood to fibroids.

How embolization works
Fibroid embolization entails inserting a catheter into the leg pushing it into the uterine artery. Plastic pellets are then injected, clogging up these arteries. Because fibroids require a large blood supply to grow, these fibroids will shrink in size following embolization of the uterine arteries.

There has been a wave of interest in this procedure, which is understandable considering about 10 million women experience abnormal uterine bleeding caused frequently by the presence of fibroids. About one out of five women under age 50 are affected by fibroids and their removal accounts for about three out of every 10 hysterectomies performed in the U.S each year.

We have a long history of investigating alternatives to hysterectomy at Yale-New Haven, and we have been doing uterine embolizations here on an investigation basis since last fall. We do, however, have concerns about the increasing numbers of uterine embolizations being done because the procedure is still experimental. We currently have very limited information about the short-term results of this procedure and no information about its long-term results. There is little information regarding complications, although one death has been reported in the United Kingdom.

YNHH experience
We are doing embolizations at Yale-New Haven, particularly on women with very large fibroids, because we think it may be a reasonable alternative to some of the other surgeries we do. Our experience is that it reduces, for example, a 10-centimeter fibroid to about eight centimeters, which may or may not be enough to relieve symptoms such as bleeding or pressure on the bladder.

We do, however, follow a strict protocol and make sure women who are interested in this procedure understand its experimental nature. It is important to understand that although uterine embolization entails no abdominal incision, it does require an incision in the groin through which the catheter is threaded. The same kinds of sedation are used as in minor surgery and pain medication is required. Fibroid embolization can be painful. The method by which it works, depriving muscle (the fibroid) of blood, is similar to the mechanism of a heart attack. The pain experienced may, in fact, be similar.

Options increase
There are several alternatives to hysterectomy available to women with fibroids. Myomectomies, in which only the fibroids are removed, can be done through a medium abdominal incision as well as laparoscopically through a very small incision. We were pioneers in cryomyolysis, an approach that freezes fibroids, and we are increasingly using a surgical procedure called outpatient endometrial resection and ablation (OPERA).

OPERA uses surgical instruments that allow us to remove fibroids and the endometrial lining of the uterus more quickly and easily than before. OPERA results in infertility and is used on women who do not want to bear additional children. A similar procedure, which only removes fibroid tissue, known as submucous myomectomy, does not impair fertility.

Many new procedures prove over time to be major advances. Uterine embolization may be shown to be safe and effective. Our concern at this time is that there is very little scientific data available. Carefully controlled studies need to be done to compare it to other treatment methods. I feel strongly women need to understand and weigh the risk and benefits of all procedures with their physicians before making a decision for themselves.

Dr. Olive is chief of reproductive endocrinology and infertility at Yale-New Haven Hospital and a professor of obstetrics and gynecology at Yale University School of Medicine.