Q&A: Uterine fibroid embolization underrecognized alternative to hysterectomy

In the United States, one in three women undergoes hysterectomy by age 60 years, according to the CDC.

Previous research has shown that many of these procedures may be unnecessary. One study published in the American Journal of Obstetrics and Gynecology determined that 18.3% of women who had hysterectomies did not have pathology to support the procedure.

Additionally, studies have identified racial disparities in the procedure. According to a study published in Obstetrics & Gynecology, a larger proportion of Black women underwent open hysterectomy and experienced more postoperative complications compared with white women.

Healio Primary Care spoke with Yan Katsnelson, MD, founder of USA Vein Clinics, Vascular and Fibroid Centers, to learn more about the burden of unnecessary hysterectomies and alternative treatment options.

Q: When should a woman undergo hysterectomy?

A: A women should not undergo a hysterectomy for fibroid disease 99% of the time because fibroid disease is a benign condition, benign tumor, and it can be healed with a percutaneous, minimally invasive office-based procedure called uterine fibroid embolization (UFE). The main reason that women undergo a hysterectomy is that they just don’t get the right advice and don’t consider the most appropriate option.

Fibroid disease is very common; up to 80% of Black women and about 50% to 60% of white women and Latino women develop fibroid disease by the age of 50. In the United States, more than 40 million women have a symptomatic fibroid disease, and about 10 million have a severely symptomatic fibroid disease.

There are clear data that show the choice of treatment depends on the first provider that the patient consults. If they discuss the condition with a gynecologist, the obvious recommendation is surgery, because that’s what gynecologists know how to do. They don’t perform minimally invasive procedures like uterine fibroid embolization, which is done by an interventional radiologist. If this woman goes to a gynecologist — and that’s 99% how it happens because that’s where women go with any female problems — and asks the gynecologist, “What should I do with my fibroids?”, gynecologists have a few options. The most common option is hysterectomy. Some do a more minimally invasive procedure, but still a surgical procedure. With myomectomy, when tumors are removed, there’s still a tremendous chance — 50% or more — that the fibroids will come back.

The only nonsurgical procedure that can be done for fibroids that’s really helpful and doesn’t require incision is uterine fibroid embolization. During this procedure, a 2 mm catheter is inserted through the groin or wrist. The catheter goes toward the artery that feeds the fibroids, and then embolic material is injected and clogs that artery. Without blood supply, fibroids shrink and are basically absorbed by the body. It’s a very effective treatment in our hands, and when performed at USA Fibroid Centers, less than 2% of patients will require a repeated treatment. Within a few days, the patient feels great. Because those treatments are done by interventional radiologists — physicians who are usually not interacting with these patients — this treatment is underutilized. I think that it’s critical for women to know that fibroid condition is common, and it’s treatable without the need for hysterectomy.

Q: What are the health implications of unnecessary hysterectomies?

A: After hysterectomy, new problems start. Many women have pain and are at risk for complications like infections, in addition to pain medications. Nine percent of women develop a narcotic dependency because of the pain medications they take after hysterectomy. Other complications are rectal prolapse and urinary incontinence. Although it’s very common, nobody talks about urinary incontinence. It just shouldn’t happen. That’s why I think it’s critically important to popularize uterine fibroid embolization — a treatment that’s minimally invasive, can be done in 30 to 40 minutes in the office and provides a tremendous cure for such a common condition. The treatment has been established for practically 20 years. But still, less than 5% of women who undergo treatment have this procedure, and the vast majority have an unnecessary hysterectomy. 500,000 women have hysterectomy in this country — the majority are unnecessary for this benign condition. Something must be done, and I think the solution is education, education, education. First, education of the patients, and second, education of providers. Medical professionals should be able to understand the difference and provide advice to the best interest of the patients and not necessarily suggest procedures that they can do personally.

Q: What costs — to patients and to the health care system — are associated with unnecessary hysterectomies?

A: The cost of fibroid disease to the health care system is more than the cost of breast cancer and ovarian cancer put together; it costs round $35 billion or more. There are different components, of course. One is the direct cost of the unnecessary treatment — hysterectomies — and that’s in the billions because it’s a very common procedure.. There are also costs of constantly visiting doctors, or emergency rooms or urgent care, because of the pain. There’s the cost of medications, hygiene supply and employment absenteeism. Patients cannot go to work so they don’t get paid. So, the cost is very high.

Q: Why are hysterectomies performed more often than uterine fibroid embolization in the United States?

A: Hysterectomy is disproportionate compared to uterine fibroid embolization in all women. I think that the combination of lack of awareness and decreased access to care are two main reasons, and they both are fixable. We need to work on this. We need to work to improve awareness, and then we need to work with the health plans to make sure that they have a sufficient number of specialists, such as interventional radiologists, provide adequate access to care.

Q: What are some other alternative treatment options to hysterectomies that physicians should consider?

A: The No. 1 option is uterine fibroid embolization. If the disease is mild, it can be controlled with ibuprofen. If a patient is having more symptoms, such as significant pain associated with the menstrual period, including anemia, the best procedure is uterine fibroid embolization. Why is that? Because it can be done in the outpatient setting, it doesn’t require general anesthesia, there’s no incision, patients can go back to work in a few days, you leave the uterus intact — so women can become pregnant again avoiding issues of bladder incontinence — and it’s easier and less expensive for patients and cost-saving for our health care system.

Myomectomy is quite common, but it is difficult for me to understand the rationale of why it’s common. We can consider myomectomy or hysterectomy when the tumor is of extraordinary size. The recurrence of disease after myomectomy is about 50%, and the recurrence of disease after uterine fibroid embolization is very, very little. And myomectomy is a surgery, whereas uterine fibroid embolization is a minimally invasive procedure.

I think helping women fulfill their lives and potential and to relieve them from painful and heavy menstrual periods should be a very focused goal for the community, health care organizations and insurance companies. This will yield a tremendous transformation, not just in one woman’s life, but for her family, her surrounding community and the country. It starts with patient education and continues with the provider education, and then health insurers’ education.

References:

Alexander A, et al. Obstet Gynecol. 2019;doi:10.1097/AOG.0000000000003209.

Cardozo, ER. Am J Obstet Gynecol. 2011;doi:10.1016/j.ajog.2011.12.002.

CDC. Women’s reproductive health. https://www.cdc.gov/reproductivehealth/womensrh/index.htm#hysterectomy. Accessed July 10, 2020.

Corona LE, et al. Am J Obstet Gynecol. 2014;doi: 10.1016/j.ajog.2014.11.031.

Womenshealth.gov. Hysterectomy. https://www.womenshealth.gov/a-z-topics/hysterectomy. Accessed July 13, 2020.