What's the Best 'Uterine-Sparing' Treatment for Fibroids?
Two "uterine-sparing" treatments for fibroids can improve women's quality of life -- though one might be more effective than the other, a new clinical trial suggests.
Fibroids are non-cancerous growths in and around the wall of the uterus that are usually harmless. But when they cause significant problems, like persistent pain and heavy menstrual bleeding, treatment may be necessary.
Traditionally, the go-to has been hysterectomy, or surgical removal of the uterus.
"Fibroids are incredibly common, and they're the leading reason women have hysterectomies," said Dr. Elizabeth Stewart, a reproductive endocrinologist at the Mayo Clinic in Rochester, Minn.
However, there are reasons hysterectomy should not be the "one-size-fits-all" approach, according to Stewart.
Women who plan to become pregnant need an alternative. Plus, she said, there is evidence linking hysterectomy to an increased chance of developing heart disease down the road -- possibly because it may lower estrogen production, even when a woman retains her ovaries.
Despite that, Stewart said, there's been relatively little research comparing the effectiveness of "uterine-sparing" options.
The new trial did just that: Researchers randomly assigned women with uterine fibroids to have either a myomectomy or uterine-artery embolization. During a myomectomy, only the fibroids are removed, leaving the uterus intact. Embolization involves injecting tiny particles into the small arteries supplying the fibroids. The particles block the fibroids' supply of nutrients, causing them to shrink.
Overall, the trial found, both approaches worked.
"Both uterine-artery embolization and myomectomy are effective for improving quality of life," said researcher Jane Daniels, a professor at the University of Nottingham, in the United Kingdom.
But surgery proved more helpful. On average, women who had a myomectomy reported greater gains in quality of life over two years, according to the new report.
It's not clear why, Daniels said. But it did seem that women in the surgery group had fewer "residual" symptoms in the year after treatment, compared to women who had embolization.
Does that mean myomectomy is the clear winner? No, said Stewart, who wrote an editorial published with the study in the July 30 issue of the New England Journal of Medicine.
Both treatments "provide substantial symptom relief," she said. So for any one woman, she added, the decision boils down to a discussion of risks and benefits with her doctor.
Myomectomy can be done through a large abdominal incision (as most were in this trial) or through minimally invasive surgery using a laparoscope. It involves more blood loss than embolization, Stewart noted, and there's a greater chance of needing a blood transfusion.
In all, 29% of surgery patients and 24% of embolization patients had a complication, like major bleeding or infection, the study authors found.
One thing that's unclear is whether either procedure is better for preserving a woman's fertility. Only a handful of women in each treatment group became pregnant, and Daniels said it's not possible to draw conclusions based on the small numbers.
That, however, is noteworthy, since there are recommendations against doing embolization in women who plan to become pregnant.
"Some clinicians are concerned there may be a reduction in blood flow to the ovaries, and this has been proposed to decrease ovarian function," Daniels explained.
But, she said, that idea is disputed.
"Recent research of female sex hormones that predict ovarian function have not found any difference between women who've had [embolization] to similar women who have not," Daniels said.
The trial involved 254 women with uterine fibroids -- half had myomectomy, the other half embolization. Over the next two years, both groups completed standard questionnaires on fibroid symptoms and quality of life.
By the end, quality-of-life ratings had roughly doubled: Before treatment, the average score in both groups hovered near 40, on a scale of 0 to 100. Two years later, that had risen to 80 in the embolization group, and nearly 85 in the surgery group.
A big remaining question, Stewart said, is what happens in the long run: How often do fibroids return after each treatment?
Daniels said her team is still following the trial participants and will report their longer-term results. As for the fertility question, she said these findings "should reduce barriers" to running a new clinical trial focused specifically on women who plan to become pregnant.
The American College of Obstetricians and Gynecologists has more on uterine fibroids.
SOURCES: Jane Daniels, PhD, professor, clinical trials, faculty of medicine and health sciences, University of Nottingham, U.K.; Elizabeth Stewart, MD, gynecologist/reproductive endocrinologist, Mayo Clinic, Rochester, Minn.; New England Journal of Medicine, July 30, 2020
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