Examining the Evidence
Q Does uterine artery embolization offer long-term relief?
<huc>A</huc> Yes, it provides durable relief from fibroid-related symptoms and reduces uterine size in three quarters of patients. The other 25% have recurrent symptoms or a diminished response over 5 years.
In the United States, more than 100,000 uterine artery embolizations have been performed over the past decade, but gynecologists have been appropriately cautious about embracing the procedure as an alternative to myomectomy and hysterectomy. The reasons for this caution are varied, but include a lack of data on long-term efficacy, though many shortterm studies have shown favorable outcomes.
That brings us to the study by Spies and colleagues, who convincingly and effectively demonstrated that 73% of 200 patients were satisfied with uterine artery embolization after 5 years. This compares favorably with myomectomy and other therapeutic options as an alternative to hysterectomy. However, the likelihood of symptom recurrence was 25%, with 25 hysterectomies (13.7%), 8 myomectomies (4.4%), and 3 repeat embolizations (1.6%) performed in women with recurrent symptoms.
Why do symptoms recur?
Large fibroids, collateral vessels. Women whose symptoms returned were likely to have baseline leiomyoma volume larger than the median (152 mL) and/or only modest leiomyoma volume reduction (<30%) after short-term follow-up. In our practice, my colleagues and I also have noticed that embolization tends to be incomplete in women with large fibroids because collateral vessels are more frequently involved, especially the ovarian arteries. Because 78% of the women in the study by Spies et al were older than 40 years and thus not likely to be concerned about childbearing, one novel idea might be performing embolization of 1 or both ovarian arteries in this population. We agree that better anatomical, pathological, hemodynamic, and morphological understanding of fibroids will reduce the failure rate.
The specific agents and particle sizes used are among other factors that may contribute to symptom recurrence.
Skewed data? The high rate of postprocedure amenorrhea (23%) in the women undergoing embolization may skew the comparison with myomectomy, which is generally performed on younger women.
Limitations and unanswered questions
The Spies study did not sufficiently differentiate predominant symptoms. Perhaps future studies will elucidate success rates based on presenting symptoms, eg, menorrhagia versus bulk-related symptoms, as menorrhagia appears to respond better.
Long-term relief for most women
Clinicians can rest assured, meanwhile, that uterine artery embolization provides long-term symptom relief in most women with fibroids.
The author reports no financial relationships relevant to this article.