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Today, interventional radiologists worldwide perform uterine-artery embolization. Most of them embolize the uterine arteries bilaterally and not only the branch supplying blood to a particular fibroid (Figure 1). In observational studies, embolization has been followed by a significant reduction in uterine volume, a decrease in excessive uterine bleeding, a low rate of subsequent hysterectomy, and a high rate of sustained symptom control (up to 80%) 5 years after the procedure.2,3,4 However, comparisons of uterine-artery embolization with other treatments on the basis of observational data are limited by the inherent differences in women who are referred for one treatment instead of another.
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Do these results imply that surgery should be used only as a second-line treatment for uterine fibroids after uterine-artery embolization? Not necessarily. The answer varies with the clinical situation, including a patient's age, her treatment preference, her wish to conceive, and the type of surgery planned.
In two other randomized trials, uterine-artery embolization was compared with abdominal hysterectomy.6,7 Less invasive hysterectomies, such as laparoscopic and vaginal procedures, have not been compared directly with embolization. The latter approaches are associated with less pain, a shorter hospital stay, and faster recovery than is abdominal hysterectomy.8,9 Although the decision regarding the surgical approach depends mainly on the surgeon's skill and preference, laparoscopic and vaginal hysterectomies are expected to result in postoperative courses that resemble the aftermath of embolization more than that of laparotomy.
Embolization is associated with particular concerns in young women who have not yet completed childbearing. One concern is the possibility of premature ovarian failure, which has been reported in rare cases after embolization, possibly owing to ovarian ischemia related to decreased blood flow in the utero-ovarian collaterals. In general, the changes in menstrual function are transient. Menopause occurs in less than 1% of women immediately after embolization, and most of these women are 40 years of age or older. Two prospective studies have shown no significant difference in serum follicle-stimulating hormone levels on day 3 (a marker of ovarian reserve) before and after embolization.10,11 Moreover, one observational study reported that 33 of 108 women who attempted to conceive after embolization were able to do so, including some women who had had difficulty conceiving before the procedure.12
However, it remains unclear whether pregnancy outcomes are affected by uterine-artery embolization, since fewer than 150 such pregnancies have been reported in the literature. Moss et al.5 rightfully informed their patients about the unknown effects of embolization on subsequent pregnancy. Of seven pregnancies they reported occurring after embolization, there were four miscarriages, two live births, and one unexplained intrauterine death. Although available data are observational and limited by small numbers of patients and the lack of matched controls, the results suggest that the miscarriage rate may be higher after embolization (17 to 30%) than after myomectomy (15%),12,13,14 although this rate may be partially explained by the older age of women undergoing embolization. The rate of preterm delivery also has been reported to be higher after embolization (16 to 22%) than after myomectomy (3%), and high rates of postpartum hemorrhage (approximately 18%) have been reported after embolization in two studies,13,14 perhaps related to abnormal placentation.
Before undergoing uterine-artery embolization, patients should be informed that approximately 1 in 10 patients so treated may continue to have excessive uterine bleeding or abdominal pain5,15 that may require further treatment, such as myomectomy or hysterectomy. In the study by Moss et al., either hysterectomy or repeated embolization was required for recurrent or persistent symptoms in 10 patients in the embolization group during the first 12 months and in 11 others during a median of 22 months of additional follow-up (i.e., in 20% of the patients overall).5
If the possible effects of uterine-artery embolization on fertility and pregnancy are considered, myomectomy should be the first line of treatment for women with symptomatic uterine fibroids who wish to conceive. Conversely, embolization should be offered to women who are at high surgical risk, such as women with previous multiple laparotomies or women with diffuse uterine fibroids in whom myomectomy might not be technically feasible. Hysterectomy remains a reasonable alternative to embolization for women who want definitive treatment without having to worry about further bleeding or the need for another procedure.
Dr. Tulandi reports receiving lecture fees from Ethicon. No other potential conflict of interest relevant to this article was reported.
Source Information
From the Department of Obstetrics and Gynecology, McGill University, Montreal.
References
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