myomectomy have been the traditional ‘ gold standard ’ definitive therapies for symptomatic fibroids . However , not all women wish to have a surgery and might like to consider non-surgical alternatives such as medical management or radiological interventions .
Over the last few decades , new medical and minimally invasive treatments have become available for symptomatic uterine fibroids . The choice of treatment needs to be individualised depending on underlying symptoms , fibroid size and location , impact on fertility , history of previous treatments and the possible need for repeat interventions .
Radiological interventions Over the last two decades , uterine artery embolisation ( UAE ) and magnetic resonance imaging-focused high intensity ultrasound ( MRgFUS ) are two modalities that have emerged as viable alternatives to surgical treatments for uterine fibroids .
UAE UAE involves the placement of an angiographic catheter into the uterine arteries via a common femoral artery approach and injection of embolic particles , such as polyvinyl alcohol particles , until the flow becomes sluggish in both uterine arteries . The fibroids shrink as a result of ischaemic necrosis but blood supply to the uterus is preserved via collateral vessels . Because the technique aims to achieve fibroid shrinkage rather than removal , it is less effective in the case of large fibroids associated with pressure symptoms . Most patients experience moderate to severe ischaemic pain up to 12 hours after the procedure , which then gradually decreases over the next 12 hours . Patients can usually return to normal activities within one to two weeks . Main complications of UAE include ‘ post embolisation syndrome ’ ( fever , nausea , vomiting and pain ), vaginal expulsion of an infarcted fibroid ( approximately 10 % of cases ) and intrauterine infection (< 1 % of procedures ). 3 , 4 Other concerns associated with UAE are its effects on the reproductive system . The use of the procedure needs to be balanced against the possible loss of ovarian reserve with scarce data on pregnancy outcomes . It has been suggested that UAE could reduce blood flow to the normal uterine tissue and ovaries resulting in reduced ovarian reserve , impaired placentation and increased risks of miscarriage / post-partum haemorrhage . 3
Although the rates of induction of premature ovarian insufficiency following UAE remain very infrequent , there are concerns about subclinical diminution of ovarian functional reserve . Data from randomised trials and prospective case series suggest that degradation of ovarian function may occur after UAE , and is concentrated in women older than 45 years , with little evidence of impact in women younger than 40 years of age . 5
Evidence A Cochrane review assessed the benefits and risks of UAE versus other medical or surgical interventions for symptomatic uterine fibroids . 6 Seven randomised controlled trials ( RCTs ) including 793 women were included in this review . Three trials compared UAE with
The choice of treatment needs to be individualised depending on underlying symptoms , fibroid size and location , impact on fertility , history of previous treatments and the possible need for repeat interventions
173 HHE 2018 | hospitalhealthcare . com abdominal hysterectomy , two trials compared UAE with myomectomy , and two trials compared UAE with either type of surgery ( 53 hysterectomies and 62 myomectomies ). Patient satisfaction rates were up to 41 % lower or up to 48 % higher with UAE compared with surgery within 24 months of having the procedure ( odds ratio ( OR ) 0.94 ; 95 % confidence interval ( CI ) 0.59 – 1.48 ; six trials , 640 women , moderate quality evidence ). Findings were also inconclusive at five years of follow-up ( OR 0.90 ; 95 % CI 0.45 – 1.80 , two trials , 295 women , moderate quality evidence ). There was some indication that UAE may be associated with less favourable fertility outcomes than myomectomy , but it was very low quality evidence from a subgroup of a single study and should be regarded with extreme caution ( live birth : OR 0.26 ; 95 % CI 0.08 – 0.84 ; pregnancy : OR 0.29 ; 95 % CI 0.10 – 0.85 , one study , 66 women ). 6
Similarly , for several safety outcomes there was evidence of a substantially higher risk of adverse events in either arm or of no difference between the groups . This applied to intraprocedural complications ( OR 0.91 ; 95 % CI 0.42 – 1.97 , four trials , 452 women , low quality evidence ), major complications within one year ( OR 0.65 ; 95 % CI 0.33 – 1.26 , five trials , 611 women , moderate quality evidence ) and major complications within five years ( OR 0.56 ; CI 0.27 – 1.18 , two trials , 268 women ). However , the rate of minor complications within one year was higher in the UAE group ( OR 1.99 ; CI 1.41 – 2.81 , six trials , 735 women , I ( 2 )= 0 %, moderate quality evidence ) and two trials found a higher minor complication rate in the UAE group at up to five years ( OR 2.93 ; CI 1.73 – 4.93 , two trials , 268 women ). 6
UAE was associated with a higher rate of further surgical interventions ( re-interventions within two years : OR 3.72 ; 95 % CI 2.28 – 6.04 , six trials , 732 women , moderate quality evidence ; within five years : OR 5.79 ; 95 % CI 2.65 – 12.65 , two trials , 289 women ). The evidence suggested that women in the UAE group were less likely to require a blood transfusion than women receiving surgery ( OR 0.07 ; 95 % CI 0.01 – 0.52 , two trials , 277 women ). UAE was also associated with a shorter procedural time ( two studies ), shorter length of hospital stay ( seven studies ) and faster resumption of usual activities ( six studies ) in all studies that measured these outcomes . 6
The authors concluded that patient satisfaction rates at up to two years following UAE versus surgery ( myomectomy or hysterectomy ) were not different . Findings at five-year follow-up were similarly inconclusive . There was very low quality evidence to suggest that myomectomy may be associated with better fertility outcomes than UAE . There was no clear evidence of a difference between UAE and surgery in the risk of major complications , but UAE was associated with a higher rate of minor complications and an increased likelihood of requiring surgical intervention within two to five years of the initial procedure . This increase in the surgical re-intervention rate may balance out any initial cost advantage of UAE . 6
UAE is an option for women with symptomatic fibroids , who are not planning a pregnancy in the future and wish to avoid surgery or have a high risk of surgical or anaesthetic complications .