To have a womb, or not to have a womb, this is the question!

Overview

An article posted on the 29th of May 2020 prompted me to write this reflection, the title of the article is called; “Huge disparity” between UAE and surgery numbers worldwide. This article was published in Interventional News. Here are some significant numbers from this article

‘On average in France 2,000 uterine artery embolisations are performed each year. In contrast, 40,000 patients have had hysterectomies in the same period.”[1]

‘James Spies (Georgetown University hospital, Washington, DC, USA) reports that, “despite some of the progress in reducing the number of hysterectomies for benign conditions such as fibroids, with about a 10% reduction in the past decade, there is still 8 to 9 times the number of hysterectomies as UAEs for fibroids performed in the USA.’

A world map showing the ‘huge disparity’ between the # of UFE/UAEs and the number of uterine surgeries performed annually in Spain, France, Australia, and at one institution in El Salvador.

 In 2020 when there are so many other treatment pathways for women, why is the disparity between Uterine Fibroid Embolisation (UFE) and Hysterectomies so vast? Is the issue one of education of the women who need these procedures? Or is the issue with physicians who are involved in a turf war as to where the patient is treated? Or is it because many of the doctors involved in the treatment decisions are men? Is this caused by a conflict over budget, revenue or is it really because losing your womb once and for all, is the best treatment for a woman with fibroids? This article takes a look at both Hysterectomies and Uterine Fibroid Embolisations as treatments for women, its intent is to be balanced, sharing the clinical benefits of both treatment pathways. But in the end, the question that needs to be raised on behalf of many women is, where is UFE in the discussion with your physician? Are all the treatment pathways being discussed with women at their consultation? Is the consent procedure really informed?

Fibroids can be a debilitating condition for women who suffer with it, from heavy menstrual cycles, to chronic anaemia that can impact the patient’s quality of life, and wellbeing. It is also shown that fibroids impact infertility, and can prevent couples from starting a family. 1. It is recorded that fibroids distort the uterine wall preventing sperm from reaching the fallopian tubes and, 2. preventing eggs that are coming from the ovaries when fertilised, from attaching to the endometrium of the womb correctly, and as a result causing infertility.

A description of fibroids in relation to their location in the uterus.[2]

Fibroids are traditionally classified according to their anatomical location and they are divided into Submucosal lesions which are inside the uterus, which can distort the uterine cavity. Intramural masses do not always distort the uterine cavity, with less than fifty percent of the tumour protruding into the serosal or outside surface of the Uterus. Then there are Subserosal masses, where more than fifty percent of the fibroid is protruding outside of the uterus. The type that is most commonly associated with increased menstrual bleeding is Submucosal.

The author wishes to make it clear at this juncture, this article is not about telling women that hysterectomies are not a good treatment option, it is about raising the matter of informed choice.

The dilemma and The Crisis

Back in the early 2000s many of the clinical papers that were written, spoke of UFE as a novel and interesting procedure not suitable for the treatment or management of fibroids. Early imaging challenges made it more difficult to distinguish between Fibroids, which is a tumour with well-defined margins, and Adenomyosis which can also occur in the uterus. Adenomyosis is a condition where the cells of the lining of the womb (endometrium) are found in the muscle wall of the womb (myometrium). Around one in 10 women will have adenomyosis. It can occur in any woman who still has periods but is most common in women aged 40-50 and in women who have had children. [3]Adenomyosis has less well-defined margins and presents as a mass of cells within the uterine wall. Both can occur at the same time in the Uterus, and both can cause the Uterus to become enlarged and bulky, and impact menstrual cycles. However, over the last decade imaging technologies in both Ultrasound and Magnetic Resonance Imaging (MRI) have improved significantly making the correct visualisation and mapping for UFE and surgical approaches much more accurate.

Today the primary treatment for Fibroids would be one of two surgical approaches, 1. Myomectomy where the physician removes the fibroid from the Uterus, but at the same time seeks to preserve it. 2. Hysterectomy, where the patient’s uterus is removed. The first of these two surgical procedures is uterine saving, but the second is not. UFE is always uterine saving, and it can be used to help a woman wishing to control her menstrual cycle, or have children or simply seeking to debulk the fibroids in her Uterus and remove symptoms.

The USA Fibroid Centers, puts it like this on their website; “When it comes to UFE vs. Hysterectomy, it can be difficult to determine which is right for you. If you’re experiencing painful or uncomfortable uterine fibroid symptoms, you may have heard that surgery is your only option for relief. Over 62% of Americans Women at risk for fibroids have never heard of non-surgical fibroid treatment options, and more than 20% of fibroid sufferers believe that hysterectomy is their only treatment recourse. In fact, many patients say they avoid treating their Fibroids because they are unaware of other options. Many are shocked to learn that non-surgical treatments have been available for years[4].”

In November 2010, the National Institute for Health and Care Excellence, issued guidelines on Fibroid embolisation[5]. It captures some top-line results of randomised clinical trials and registries. In one registry women experienced a 40% reduction in Fibroid diameter. One of the Randomised Clinical Trials reviewed concluded that 50% of women who were treated by UFE went on to conceive and have a child.

Evidence for Surgical Approach

Somigliana et al in their paper titled “Fibroids and Female reproduction: a critical analysis of the evidence[6]”, concludes that drawing up clear guidelines for the management of fibroids in infertile women, when comparing surgery and UFE is difficult; because of the lack of large randomised clinical trials aimed at elucidating which patient may benefit from surgery, or other treatments. It is believed, that this view is somewhat general, and each patient should have a comprehensive personalised approach, with the patient at the centre of the decision-making process identifying with physicians the best option for the individual woman. Where women fall into a grey area for decision makers, in these cases Somigliana suggests the adoption of a personalised attitude, clearly exposing the pros and cons of myomectomy to the patient, including the risks associated to fibroids during pregnancy on the one hand, and those associated with surgery on the other hand.

Younas et al concludes, that the medical management of Fibroids using medical treatments and UFE is effective in alleviating the symptoms associated with uterine Fibroids, but some of these techniques require further research regarding long term outcomes. He also states that the surgical procedure of Myomectomy should be considered as the gold standard for traditional resection of submucosal Fibroids[7]. And Dr Mary Lumsden concludes that even though that surgical and the UFE have comparable results in the short to medium term, there is still not enough randomised trial evidence to recommend UFE as a first line treatment for early onset of menopause and fertility[8]. Dr Lumsden also indicates that for women who have completed their ‘fertility’, hysterectomy was associated with the highest rate of satisfaction. Also Post Embolisation Syndrome does occur with symptoms similar to sepsis, which presents on some occasions post UFE. Also, some caution should be advised for women with large Fibroids choosing to have UFE alone, Bradley et al 1998[9]. The thought is that as large fibroids necrose they can release toxcins into the blood that may lead to sepsis. Alongside this literature documents that UFE has a higher re-intervention rate than myomectomy of 10-15%.

Evidence for Uterine Fibroid Emobilsation (UFE)

First of all, let's explain what fibroid embolisation procedure entails, and what do all these terms mean. UFE is a non-surgical way of treating fibroids by blocking off the arteries that feed the fibroids, causing the fibroids to shrink. It is performed by an interventional radiologist, and is an alternative to an operation. UFE was first documented by Ravina in 1995[10], and since then over 200,000 women have had the procedure performed, world-wide.  Sometimes in literature you will find the term Uterine Fibroid Embolisation (UFE), and then in other documents you will find the term Uterine Arterial Embolization (UAE). These procedures are one and the same. The first one describes where the embolic material is going (i.e. to the fibroid) and the second describes how the embolic material gets to the uterus (i.e. via the uterine arteries).

In the early days of UFE, Somigliana et al 2007[11] suggested that UFE is a good treatment pathway for women who wanted a uterine sparing treatment pathway, but who were not proceeding or wanting to have children or further children. This was the early thinking of many gynaecologists and interventional radiologists, but since these times the techniques have improved, and the outcomes also.

Bulman et al 2012[12], wrote the following and concluded in their paper, “UFE has been demonstrated to be a safe and effective treatment for uterine Fibroids and at this time can be considered a first line therapy. UFE produces symptom relief similar to that of surgery with fewer major complications. Clearly, uterine embolisation is an attractive option for the patients who are finished with childbearing and who are interested in a minimally invasive uterine sparing therapy”. Somigliana, conceded in his article, that “conversely more evidence has been accumulating with regards to the effectiveness of UFE, but at the time of his writing in 2007, overall there are some concerns as to whether UFE was the correct treatment for women seeking to become pregnant”. In more recent years that concern has been dispelled to some degree by such authors as Wells et al 2018[13], who captured in their instructive paper ‘The Stoke Protocol’, that “not only was UFE a good treatment pathway for women who wanted to continue having children, but that this procedure could be carried out as a day case procedure where UFE was performed via trans radial approach”.

Discussion

The clinical condition of uterine fibroids is common in women of all ethnicities , and it is confirmed in literature that this condition can start when a woman is of child bearing age. The mean age for the onset of fibroids appears to initiate somewhere between the ages of 40 - 50 years of age. The gold standard for the treatment of Fibroids has been surgery, which consists of two procedures 1. Myomectomy which is the removal of fibroids without removing the womb and is a uterine sparing procedure. 2. Hysterectomy which is the removal of the Uterus. For the purposes of this article, the medical pharmacological pathways have been scoped out to bring focus to the rate at which hysterectomies are being executed. The medical pharmacological pathways are also a uterine sparing, but the author has focused on surgical and interventional radiology procedures because it aligns with his professional experience.

It is clear from the literature that UFE is not a panacea for the treatment of fibroids, however, it is a credible alternative to myomectomy for some women. Myomectomy is presented as the gold standard by many physicians today without challenge. If a woman wishes to continue to bear children, then her options are Myomectomy or UFE. If a woman longer wishes to continue life as a fertile being, then hysterectomy is the right choice. The article that prompted this review, highlighted some challenging numbers not only from Europe, but also from the Americas, that confirms that many doctors today are querying the unfettered use of hysterectomies to manage the treatment of Fibroids. UFE in the hands of a good interventional radiologist, can not only reduce the burden of a menstrual cycle, but can also lead to women continuing their families post procedure. The literature shows, that the results of myomectomy are better than UFE in the longer term, however with UFE, the patient does not have to undergo a surgical procedure and does not have to deal with all of the recovery issues that comes with a surgical procedure.

If a woman presents with an infection or malignancy of any kind, then fibroid embolisation is not a treatment pathway that she should take; she should consult with her physician and seek alternative routes of treatment. But if a woman, is seeking simply to control the burden of a heavy menstrual cycle and wishes to have uterine sparing treatment that would give her the chance to bear children at a later date: UFE is a procedure that should be higher on the list during ‘informed consent’ with a healthcare professional.

When the author discussed these matters with women in his community, some women have cynically said, and suggested, with a smile on their faces , that ‘if men had wombs hysterectomy would not be as commonly used to deal with the issue of fibroids’. Also, it has to be noted, and it has not been dealt with in this article in any detail that women from African diaspora decent, or Asian decent in some literature are cited has being 2 to 3 times more likely to develop large and multiple fibroids even from an age or 30 years. In the current climate of change and the aftermath of the death of George Floyd, the author respectfully requests that the women from these communities speak and tell their stories. But note, that if you are woman of African diaspora descent, you are disproportionately affected by the condition of uterine Fibroids, and no one knows why. Consequently you are disproportionately impacted by the practise of removing wombs for the treatment of Fibroids.

Conclusions

1.     If you a woman seeking treatment for a heavy menstrual cycle due to Fibroids Myomectomy will be suggested, but Uterine Fibroid Embolisation, is a credible option. Ask the question.

2.     If you are a woman is seeking treatment to fulfil your purpose of bearing a child again Myomectomy will be suggested but Uterine Fibroid Embolisation is a credible option. There is evidence that 50% or more women after having Uterine Fibroid Embolisation procedure have gone on to have children.

3.     Women need to seek out these alternative treatment pathways and become better educated and made more aware of the choices they have in preserving their wombs. Whether the intent is for a better quality of life, child bearing or just to be whole.

The Authors Thoughts

It is bordering on immoral, when you see the number of Hysterectomies that is being conducted vs. the number of Uterine Fibroid Embolisations being conducted on women. Hopefully this article will prompt more women to ask the question and insist on being given the choice to keep their wombs.

Recommendations

1.     Many of the papers that have been referenced in this article indicate in their recommendations that further randomised clinical trials and registries need to be conducted in this area of Hysterectomy vs. Uterine Fibroid Embolisation. The author wholeheartedly agrees.

2.     A combined study of Uterine Fibroid Embolisation to debulk followed by Myomectomy should be explored. Sometimes a combined approach yields better results.

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References

[1] 2020, © Interventional News, https://interventionalnews.com/uae-surgery-disparity-worldwide/

[2] 2016, Younas et al, Obstetrician & Gynaecologist, A description of fibroids in relation to their location in the uterus.

[3] 2017, Guys’s and St Thomas’ NHS Trust, Leaflet number: 4337/VER1, Adenomyosis

[4] 2020, www.usafriboidcenter.com, ‘UFE vs. Hysterectomy: Fribroid Treament’

[5] 2010, www.nice.org.uk/guidance/ipg367, Uterine artery embolisation for fibroids.

[6] 2007, Somigliana et al, Human Reproduction Update, ‘Fibroids and female reproduction: a critical analysis of the evidence’

[7] 2016, Younas et al, Obstetrician & Gynaecologist, A description of fibroids in relation to their location in the Uterus.

[8] 2002, Lumsden, MA., Human Reproduction, ’Embolisation vs. myomectomy versus hysterectomy’.

[9] 1998, Bradley et al, Obstetrician & Gynaecologist, ‘Transcatheter uterine artery embolisation to treat large uterine Fibroids’.

[10] 1995, Ravina et al, The Lancet, ‘Aterial emboloisation to treat uterine myomata’

[11] 2007, Somigliana et al, Human Reproduction Update, ‘Fibroids and female reproduction: a critical analysis of the evidence’

[12] 2012, Bulman et al, RSNA, ‘Current concepts in Uterine Fibroid Embolisation’

[13] 2018, Wells et al, British Association of Day Surgery, ‘Uterine Fibroid Embolisation, Time for day case? The Stoke Protocol’