November 30, 2004

Alternative Fibroid Treatment Slowly Gains Awareness Here [Corrected 11/30/04]

Local interventional radiologists are hoping national security adviser Condoleeza Rice will shed some light on what they call a well-kept secret in women's health.

On Friday, Rice had a uterine fibroid embolization, a nonsurgical procedure to treat fibroids, noncancerous growths that develop in the muscular wall of the uterus. Between 20 percent and 40 percent of all women -- and 50 percent to 80 percent of black women -- will have uterine fibroids, although only 10 percent to 20 percent of women with uterine fibroids have symptoms and need treatment. The fibroids can cause heavy bleeding, pelvic pain, urinary problems or constipation, and, if large enough, can even protrude into the abdomen.

Traditionally, fibroids have been treated with hysterectomy, surgical removal of the uterus. In fact, a third of the 600,000 hysterectomies performed in the United States each year are to treat fibroids. The second-most common treatment is myomectomy, in which a gynecologist makes an incision in the abdomen and goes in to remove the fibroids, sparing the uterus.

But many women in this area haven't heard of uterine fibroid embolization, which spares a patient both the loss of her uterus and the long recovery time associated with surgery.

"Traditionally, hysterectomy takes six weeks to heal and 11 days to two weeks in the hospital," said interventional radiologist Dr. James Mark Brumit of Vista Radiology, which offers the procedure at Fort Sanders Regional and Park West medical centers. "With UFE, you're in the hospital a day, and you're traditionally back to your normal routine in ... the national average is 11 days."

During the procedure, an interventional radiologist makes a quarter-inch incision in the groin and inserts a catheter into the femoral artery in the leg. The radiologist guides the catheter into the uterine arteries that run up each side of the uterus and supply blood to the fibroid tumors, then releases tiny particles, smaller than a grain of sand, into the uterine arteries. The particles block blood flow to the fibroids, effectively "starving" them; they shrink and begin to die, sometimes forming scar-like tissue. National statistics say more than 90 percent of women who have UFE have significant or total relief of their symptoms, and the recurrence rate of fibroids appears to be at least as low as that of myomectomy.

Patients aren't usually put under anesthesia for the procedure, which typically takes between 45 and 90 minutes. They generally have an overnight hospital stay and are given pain medicine for the intense cramping that occurs when the fibroid tissue begins to die.

Reports from doctors document that several premenopausal women have gotten pregnant following UFE, but the procedure hasn't been done long enough in the United States for its long-term effects on fertility to be studied, so it's not currently recommended for women who still want to have children. Myomectomy is still recommended to preserve fertility because fibroids are surgically removed, rather than leaving the body to deal with dying tissue.

Though it's new enough that long-term follow-up data isn't available, UFE is not a new procedure. First done by a French doctor in 1994, it's been regularly done in the United States since 1996. And radiologists have used the embolization procedure since the 1970s to stop uterine bleeding in emergencies.

But UFE, now common in other parts of the country, has taken awhile to catch on in this area. Brumit and four colleagues at Vista have done the procedure for about 16 months; they've done about 30 so far. A graduate of Quillen College of Medicine at East Tennessee State University, Brumit had done UFEs during a fellowship in vascular and interventional radiology at Duke University before coming to Knoxville.

"It's a very good option for women (who) don't want to have surgery and want to have their uterus," Brumit said.

In the two years he's been doing UFE, interventional radiologist Dr. Bradley Strnad of Knoxville Cardiovascular Group and the University of Tennessee Medical Center's Heart Lung Vascular Institute estimates he's done the procedure -- which he calls "superior" -- around 36 times. Strnad said he thinks that in time, UFE will be preferred over other treatment options for uterine fibroids.

"I offer it as an alternative" to surgical and hormone treatments, Strnad said. "The majority of my patients find me on the Internet."

Jennifer Carpenter, 36, was one of Vista's first Knoxville UFE patients. She came to the radiology practice already knowing she wanted UFE, which she said was common in other parts of the Deep South where she'd lived.

"I was to the point where I was bleeding ... three weeks every month," Carpenter said. "The tumor was so large it was actually impacting my spine."

Carpenter had already tried hormone therapy, which failed to shrink her fibroids. She found UFE attractive because she didn't have to be put under general anesthesia; she'd have less chance of infection than she would with a procedure that required a large incision; and she found the shorter recovery time attractive. She was in the process of adopting a baby girl, now 18 months old.

"What I knew is that I did not want a hysterectomy," Carpenter said. "I'm very active. I still play soccer. It wasn't for me."

Yet by the time Carpenter had UFE in April 2003, she'd fought two years with two different insurance companies to get them to cover it. Waiting that two years to have the procedure is her only regret, Carpenter said. She's had no long-term effects and no recurrence of fibroids.

"I was not thrown into menopause," she said. "I'm still playing soccer ... and running around after an 18-month-old. It's great."

While a few years ago it was common for women to have difficulty getting their insurance carriers to pay for UFE over hysterectomy or myomectomy, both Brumit and Strnad report they no longer have trouble getting carriers to cover it.

That's heartening to interventional radiologist Dr. John Goodwin of Knoxville Radiology Group at Baptist Hospital of East Tennessee, Baptist Hospital West and Baptist Hospital of Cocke County. Goodwin began doing UFE about a year ago but has done only a couple of patients. Many times when women seek him out for the procedure, he refers them to colleagues in Atlanta who do UFE multiple times daily.

"I can certainly do them; emobolization isn't a new technique," Goodwin said. "But we're just not seeing a lot of referrals. ... My friends in Atlanta, that's all they do."

Goodwin had envisioned Baptist Hospital for Women, which opened in 2002, as the perfect setting for regular UFEs, but so far his practice hasn't seen local demand. He expects UFE to be the preferred treatment in the future and was happy to hear that other radiology practices in Knoxville were doing them almost weekly.

"It's a beautiful outpatient procedure for a fairly common problem," he said.

Yet, like Strnad, Goodwin said most women who come to him for information about UFE are not referred by their gynecologists. Instead, they learn about UFE on the Internet and sometimes confide to him, "My doctor told me how dangerous this was, and that I'd have horrible pain."

In fact, the procedure is very safe, a variety of research concludes. Particles such as those used in UFE have been used in surgical procedures for 25 years. The risk of infection and post- operative bleeding with UFE is minuscule -- less than 1 percent of women have these problems. Women occasionally develop bladder infections from the use of the Foley catheter; those are easily treated with antibiotics. Cramping pain from dying tissue usually lasts only a day or two. Brumit said his practice has had a "100 percent success rate" with UFE, though as the number of patients increases, he expects, statistically, to see at least one or two women with complications.

Inventional radiologists have said UFE is a "turf war," that gynecologists, who traditionally are the ones to perform other treatments for UFE are hesitant to hand their patients off to another specialist for UFE. While initially it may have been due to caution with a new procedure, now many interventional radiologists feel that gynecologists simply aren't offering it to their patients.

"It takes revenue off their tables," Brumit said, bluntly.

That may be true of some individual practitioners, but in January of this year, the American College of Obstetricians and Gynecologists issued an official opinion on UFE.

In that statement, ACOG said it "strongly recommends that women who wish to undergo uterine artery embolization have a thorough evaluation with an ob-gyn to help facilitate optimal collaboration with interventional radiologists and ensure that the procedure is appropriate."

"UAE for the treatment of symptomatic fibroids, when performed by experienced physicians, appears to provide good short-term relief among appropriate candidates," the statement said. "However, there are insufficient data at this time to ensure that UAE is safe for women who may wish to become pregnant in the future."

Strnad said some gynecologists are trying to learn the procedure themselves. But patients' preconceptions play a part, too, especially in this area, he said.

"A lot of people have the mindset that their grandmother had her uterus out, their mother had her uterus out, and now it's time for them to have their uterus out," he said.

Kristi L. Nelson may be reached at 865-342-6434. She is health writer for the News Sentinel.


* Hysterectomy: Surgical removal of all or part of the uterus, cervix, fallopian tubes and ovaries. Fibroids account for one-third of all hysterectomies in the United States.

* Dilatation and Curettage (D&C): Scraping of the lining of the uterus to remove excess tissue; spoon-shaped instrument is inserted through the cervix.

* Myomectomy: Surgical removal of fibroids; can be done with incision through the abdomen into the uterus or, sometimes, laparoscopically (a telescope-like instrument is inserted through a tiny incision in the abdomen and used to remove the fibroid without open surgery).

* Uterine fibroid embolization: A catheter is inserted into the femoral artery through a small incision in the groin, then small particles are injected into the uterine arteries to block blood flow to fibroids, causing them to shrink and die.

* Endometrial ablation: Outpatient procedure in which hysteroscope is used to remove uterine lining by scraping and burning.

* Myolysis: Uses a laparoscopically delivered laser to clot the blood supply to the fibroids, blocking blood flow and causing them to shrink and die.

* Cryomyolysis: Uses a laparoscopic probe to deliver a freezing agent, such as liquid nitrogen, to the fibroid, causing it to shrink and die.

* Hormonal therapies: Two categories of hormone therapy drugs -- GnRH agents and antagonists -- are used to stop the growth of fibroids by controlling estrogen production. Sometimes oral contraceptives, which alter natural hormone levels in the body, are also used to slow or stop fibroid growth. Fibroids may be shrunk with hormone therapy, then removed by other methods.

Sources: American Academy of Family Physicians; Society of Interventional Radiologists;