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A Woman's Options ; Less Invasive Alternatives to Hysterectomy May Help Some Women Treat Fibroid Problems

Posted on: Friday, 5 November 2004, 03:00 CST

Long and heavy menstrual periods, pelvic and back pain, bellies that protrude and look like pregnancy, and constant fatigue drive many women to have hysterectomies.

An estimated 600,000 to 650,000 of the operations - surgery to remove the uterus - are done every year in the United States at a cost of approximately $2 billion.

Some feel that number is too high in light of newer, less invasive procedures that can fix the problems but leave the uterus, or womb, intact.

The No. 1 reason for hysterectomies is fibroids, noncancerous uterine tumors that can grow as big as small melons and cause the problems listed above. Newer treatment options get rid of the fibroids or other problems without major surgery.

"There are too many hysterectomies performed in this country," said Dr. Gregg Weinberg, an interventional radiologist with Commonwealth Radiology in the Richmond area. Interventional radiologists specialize in using imaging techniques to see inside the body, and they insert instruments through small incisions to treat the problems.

Because fibroids are benign, or noncancerous, Weinberg believes they do not always require a hysterectomy, which is almost always indicated when women have a problem such as uterine cancer.

Since 1998, Weinberg has been doing a procedure called uterine artery embolization to treat fibroids.

In the procedure, a catheter, or long narrow tube, is threaded through an artery in the groin up to the arteries around the fibroids. Small plastic particles about the size of sand are injected into those arteries, blocking blood supply and causing the fibroids to wither.

"Embolization will work about 85 percent to 93 percent of the time" to remove fibroids, Weinberg said, citing statistics similar to those quoted by the Society of Interventional Radiology.

"When I say it works, patient symptoms will get completely better or go away. Some patients it does not work for. We don't know why.

"I tell every patient, if you want something 100 percent, get a hysterectomy," Weinberg said. "It's three to four nights in the hospital and four to six weeks of recovery at home. It is major surgery. Contrast that with uterine embolization. You stay overnight one night. Recovery is typically one to seven days. ... Complications are rare, but as with every medical procedure, it is not zero."

Judy Richmon, 49, of Henrico County was one of Weinberg's first uterine artery embolization patients.

"I was in my early 40s," said Richmon, who works in her husband's elevator business. "I was not ready for a total hysterectomy."

She had the procedure in 1999 to treat a fibroid about the size of a doorknob. That fibroid was making her stomach poke out and causing her menstrual periods to be long and heavy, she said.

After the procedure, "all my problems ceased," she said.

***

As with any medical procedure, there is a risk of complications. In the case of uterine artery embolization, that can include fever and infection.

The procedure "is still considered investigational by the American College of Obstetricians and Gynecologists," said Dr. Christine Isaacs, a physician with West End Obstetrics and Gynecology and Henrico Doctors' Hospital.

"There are post-op issues of pain and fever. The fibroids don't always go away but shrink and become less problematic. Nonetheless, it is an option in appropriately selected patients," she said.

Isaacs' views are in line with ACOG's as noted on the organization's Web site, where there is a position paper on hysterectomy alternatives.

That there is some disagreement between the radiologists who do embolization and gynecologists who treat most female reproductive- health issues was the focus of a recent Wall Street Journal article. It focused on medical politics that may be keeping the number of hysterectomies high and the cases of uterine artery embolization relatively low, at about 13,000 to 14,000 procedures a year.

The gist: Some interventional radiologists maintain that gynecologists do not want to give up the revenue from doing hysterectomies, so they are not telling patients about alternatives.

ACOG's statement, issued in August 2003 before the Journal story, rejects that line of thought. It states that allegations that obstetrician-gynecologists are "motivated to perform hysterectomies for financial gain are not only untrue claims against physicians devoting their lives to improving women's health, but they are patently absurd in today's medical liability climate."

The organization's bottom line: Women advised by a doctor to have a hysterectomy should always get a second opinion and discuss what other treatment options are available.

Among the other choices for dealing with fibroids or the symptoms: myomectomy, in which the tumors are cut out but the uterus is left intact; birth-controls pills, IUD or endometrial ablation to reduce bleeding and/or shrink fibroids; and gonadotropin-releasing hormone agonists (GnRHa) that block estrogen production, which in turn causes fibroids to shrink.

Even newer is the ExAblate 2000 System that was approved by the Food and Drug Administration last month.

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The technology uses magnetic resonance imaging to pinpoint and map fibroids and then uses ultrasound beams to destroy them.

An FDA advisory panel voted 8-5 to recommend the system's approval. Some panel members did not think there was sufficient data that the device worked well enough. Another drawback: It may mean up to three hours in the confinement of an MRI machine.

There is no one-size-fits-all solution when it comes to fibroids, said Carla Dionne, executive director of the National Uterine Fibroids Foundation, an advocacy and education group she founded because of her own experience with fibroids.

"One woman might have five women in her family who all had cancer and would be scared of anything but hysterectomy," said Dionne, whose foundation is based in Colorado.

"The other woman may say her symptoms are not too bad and choose to do nothing. One woman who is an executive and does not want to lose any time at work may readily say, `I want an embolization and be back at work in a few days.'"

All the procedures come with risks, she said, even doing nothing. Dionne said there have been women who have bled so heavily from fibroids that they have bled to death.

"Once fibroids are diagnosed, the only forms that have no risks are those that are nonsymptomatic," she said.

The foundation, she said, tries to collect unbiased data on the risks and benefits of the different procedures so women can compare the options, talk to their doctors and make good choices.

***

For some women, hysterectomy is the choice.

"They gave me just a horrible time," Randa Jackson, 33, of Powhatan County said of the fibroids she was first diagnosed with in her early 20s. Her periods, she said, were severe long, irregular, heavy and painful.

She had a hysterectomy three years ago, a decision she came to after considering her family history of ovarian cancer and fibroids.

After surgery, doctors told her they counted 11 fibroid tumors in her uterus. Going in, they thought she had maybe three, Jackson said.

Stephanie Werner, 38, has a decision to make. As with Richmon and Jackson, fibroids are causing problems.

Late last year she had a period that lasted seven weeks, sending her to a doctor who put her on birth-control pills. That helped get her period back on schedule for a while.

She is at the point, she said, where she feels like her body is betraying her. The blood loss caused anemia, which made her lose her breath climbing stairs and feel tired all the time. An ultrasound showed a 4-centimeter fibroid.

"It's not huge. It's just really wreaking havoc with my hormones," Werner said. She plans to have uterine artery embolization, but like many women, she wants to know what causes fibroids in the first place. She won't get any good answers from medical science.

Researchers are, however, studying all aspects of the benign tumors.

The Fibroid Growth Study, which is sponsored by the National Institute of Environmental Health Sciences and the National Center for Research on Minority Health and Health Disparities, is trying to find out why some fibroids cause problems while others do not. Based at University of North Carolina Hospitals, the study will enroll about 300 women with fibroids and look at issues such as fibroid growth, symptoms, lifestyle and hormone factors.

Other studies are trying to find genetic markers that may help doctors identify women for whom fibroids will cause problems.

"When you look at family history, when you have a first-degree relative who has fibroids, you have a 31 percent higher chance of having fibroids," said Dr. Valerie Montgomery Rice, chairwoman of the obstetrics and gynecology department at Meharry Medical College in Nashville, Tenn.

Meharry will take part in research to try to identify some of those genetic factors and markers. A fibroid genomic study will enroll women who have hysterectomies because of fibroids. Blood samples, normal uterine and fibroid tissue samples, and the patient's hormone profile will be analyzed.

Eventually, said Rice, "you would like to be able to take the person's blood and say they have an overexpression of this gene, which is associated with an increased growth of fibroids." With that information, she said, doctors and patients could plan the best treatment for the patient.

For help

Treatments for uterine fibroids and/or excessive menstrual bleeding

Hysterectomy: Uterus is surgically removed. Woman can no longer have children.

Myomectomy: Fibroid tumors are surgically removed, but the uterus is left intact.

Endometrial ablation: The uterine lining, or endometrium, is destroyed by heat, electrical energy or cold, which reduces bleeding. Not a treatment for fibroids. Doctors advise it only for women who no longer want children.

Uterine artery embolization: The blood supply to fibroids is blocked by small particles inserted via a catheter, causing fibroids to shrink. Doctors advise it only for women who no longer want children.

1Mirena intrauterine device: Releases the hormone levonorgestrel into the lining of the uterus, which can reduce bleeding and shrink fibroids.

Medication: Gonadotropin-releasing hormone agonists (GnRHa) injected or taken intranasally decreases estrogen production, causing fibroids to shrink. May lose effectiveness over time. Side effects, such as loss of bone density, hot flashes and mood swings, affect usefulness.

Facts

Some uterine fibroids facts:

Black women have a greater risk than white women of developing fibroids.

Women who are overweight have a greater risk of developing fibroids.

Fibroids can interfere with a woman's ability to get pregnant.

Women who have given birth appear to have a lower risk of fibroids.

Fibroids account for about twice the number of hysterectomies among black women than among white women.

SOURCES: www.fda.gov/womens/getthefacts/fibroids.html; www.4woman.gov/faq/fibroids.htm; www.fda.gov/fdac/features/2001/ 601_tech.html

On the Internet

National Uterine Fibroid Foundation: www.nuff.org

Society of Interventional Radiology: www.sirweb.org

National Women's Health Information Center: www.4woman.gov/faq/ fibroids.htm

Fibroid Growth Study: www.niehs.nih.gov/fibroids/home.htm

Source: Richmond Times - Dispatch

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