Each working day in the United States, the uterus is surgically removed from about 3,000 women. An American woman who reaches the age of 60 has something like a one in three chance of losing her uterus. Uterine leiomyoma is the single most common reason for hysterectomy. The large number of operations being performed to remove the uterus for a benign disease has increased interest in finding new approaches to the treatment of women with gynecologic disorders.
The first premise to be questioned is whether an asymptomatic woman with leiomyomata should undergo a hysterectomy under any circumstance. Leiomyomata are common tumors in which malignancy is rare. Although generations of gynecologists have been taught the “gospel” that a uterine size greater than that of a 12-week pregnancy requires intervention, there appears to be no scientific basis for this recommendation. The tenet “no symptoms, no surgery” is coming into ascendancy, and adherence to it should help reduce the number of hysterectomies performed on healthy women.
Leiomyomata can produce symptoms, however, and symptomatic women deserve to be offered treatment options. The question then arises, should hysterectomy be one of these options? The answer depends on how the physician and the patient view alternatives to hysterectomy. In this issue of American Family Physician, Dr. Steven Janney Smith reviews uterine fibroid embolization (UFE), one of the more recently introduced alternatives to hysterectomy.1
For many years, patients with hypervascular tumors in various parts of the body have been treated with arterial embolization when surgery was not practical or desired. The safety and efficacy of this procedure in treating many types of tumors and arteriovenous malformations have been amply demonstrated, with misembolization being the most significant adverse outcome. Because of the larger caliber of the uterine fibroid tumor vessels and the size of the particles injected during UFE, misembolization has been a highly unusual consequence of this procedure.
The effectiveness of UFE in the treatment of women with abnormal uterine bleeding and, to a lesser extent, the symptoms of pressure associated with leiomyomata uteri, has been impressive. Post-procedure pain and the so-called “post-embolization syndrome” (caused by tumor necrosis and characterized by pain and temperature elevation) are common but easily managed problems. Why, then, in the face of a procedure so efficacious and associated with so few important complications, are women still undergoing hysterectomies for leiomyomata uteri?
A large part of the answer is found in the attitude of physicians and patients. Hysterectomy is deeply embedded in the culture of gynecology and is, one could argue, the only “definitive” cure for leiomyomata uteri. Women who have undergone a hysterectomy report a high level of satisfaction with the results of the procedure but, of course, most of these women were probably not offered an alternative treatment. In some parts of the United States, hysterectomy is exceedingly common, and women expect the same treatment that was successfully administered to their mothers and aunts. Women may find the idea of undergoing UFE alarming because of the specter of radiation exposure and the injected particles that stay in their bodies forever.
As safe and effective as it appears to be, UFE is only one of the alternatives to hysterectomy for women with symptomatic leiomyomata. Oral contraceptives or progestin-only regimens can be an effective option for control of abnormal uterine bleeding associated with leiomyomata uteri, despite the fable that women with uterine fibroids cannot take hormones. Gonadotropin-releasing hormone (GnRH) agonists provide excellent symptom relief, and the addition of add-back hormone replacement therapy to GnRH agonist therapy permits repeated use of the latter without concerns about menopausal symptoms or bone mineral loss. Hysteroscopic techniques (e.g., myoma resection, endometrial ablation, endometrial destruction) are in-and-out procedures that offer women minimally invasive, long-term solutions to abnormal bleeding symptoms. And, of course, the standard alternative for many women is to do nothing: symptomatic leiomyomata almost always become non-problematic after menopause, and women in their late 40s or early 50s may choose to simply wait for time to take care of the problem.
With the wide array of effective and less morbid alternatives to hysterectomy, should the latter procedure continue to be offered to women with symptomatic leiomyomata? At present, the answer is yes, in part because even the most progressive gynecologists do not feel right withholding a time-honored and clearly effective choice from their patients. The argument can be made, however, that hysterectomy should be dethroned from its current position of preeminence in the gynecologic armamentarium, to be replaced by UFE, hormone therapies and the less invasive surgical options. Gynecologists who decline to accept non-hysterectomy options may end up being bypassed by family physicians and interventional radiologists who offer an expanded range of treatment options.