Health

Saving the womb

A new way of removing benign tumours may eliminate the need for many hysterectomies

Mark Nichols November 13 2000
Health

Saving the womb

A new way of removing benign tumours may eliminate the need for many hysterectomies

Mark Nichols November 13 2000

Saving the womb

Health

A new way of removing benign tumours may eliminate the need for many hysterectomies

Mark Nichols

When Yvonne Skura experienced heavy bleeding during prolonged menstrual periods three years ago, a gynecologist diagnosed non-cancerous tumours, known as fibroids, in Skura’s uterus. He recommended a hysterectomy, and Skura, a pharmacist from Brandon, Man., agreed. Later, she had second thoughts. “I didn’t like the way he made it sound as though a hysterectomy was the only thing to do,” she recalls. She cancelled the operation and went hunting for an alternative, which emerged when she heard—on a TV talk show—of something called uterine fibroid embolization (UFE). Skura did some research on the Internet and in March of last year flew to London, Ont., where doctors at St. Joseph’s Health Centre performed the relatively simple procedure that shrinks and tames troublesome fibroids by choking off their blood supply. “It was an easy, even pleasant experience,” says Skura, 54, who was conscious during the 60minute operation and recovered quickly enough to leave hospital and fly home two days later.

That is in sharp contrast to the average four days in hospital and eight weeks of recuperation needed after a hysterectomy—the surgical removal of a woman’s womb that many physicians consider standard treatment for problem fibroids. More than a third of the

Fibroids and hysterectomies

• More than 35 per cent of Canadian women have hysterectomies by age 60, compared to 15 to 25 per cent in some European countries.

• More than a third of the 60,000 hysterectomies in Canada each year are because of fibroids.

60,000 hysterectomies that gynecologists carry out in Canada annually are performed because of fibroids. And a growing number of critics argue there are better, less invasive ways of dealing with the problem. The newest, and— according to some experts—most promising option, is UFE, which controls fibroids while leaving the uterus intact. “I think within about 10 years, it will be the first-line therapy for fibroids,” says Dr. Andrew Common, a Toronto physician who is co-leader of a study under way in eight Ontario hospitals. “I really feel using a hysterectomy to deal with fibroids is like taking a sledge hammer to a mosquito.”

While UFE is currently being used to treat problem fibroids at hospitals in half a dozen Canadian cities, it is still technically in the testing stage and can be performed only in medical studies

investigating its safety and effectiveness. So far, says Dr. Lindsay Machan, a Vancouver physician who has performed the procedure more than 200 times, UFE appears to be a promising alternative to hysterectomies. “But,” he adds, “we don’t have good data to prove that yet.” Even so, with glowing reports of UFE’s effectiveness spreading on the Internet and by word of mouth, women like Skura are demanding the operation.

Part of the reason is a growing tendency for women to challenge the traditional medical attitude that the uterus is a disposable organ in women past child-bearing age. “The uterus is probably not just for having babies,” says Gaylene Pron, a University of Toronto epidemiologist who is coleader of the Ontario study. “There’s growing evidence that it has a role in sexual function,” she adds, including enhancing the quality of orgasms.

Although several alternative therapies have emerged during the past decade, most gynecologists still consider hysterectomies the best solution to fibroids, which develop in the wombs of about a quarter of all women between the ages of 15 and 50. In about half of those women, treatment isn’t necessary. But among the others, fibroids that sometimes grow to the size of grapefruits can produce symptoms that include excessive menstrual bleeding, anemia, lower-abdominal pressure and severe pain. They can also complicate pregnancy and trigger miscarriages.

Problem fibroids have to be treated. But critics say North American hysterectomy rates are far higher than they should be. More than 35 per cent of Canadian and American women have hysterectomies by the age of 60 for all causes, including chronic pain and menstrual problems that may be triggered by hormonal imbalances. That rate, says Dr. George Vilos, a London, Ont., gynecologist, is “excessive, compared to some European countries,

embolization outweigh the negatives.” Carolyn Maydonik, a Burlington, Ont., homemaker and mother of a 14year-old son, has nothing but praise for the procedure. Two years ago, a baseball-sized fibroid at the top of her uterus was causing problems that included urinary tract infections and

where only 15 to 25 per cent of women have hysterectomies. If were going to make a dent in that, we have to look at other ways of treating fibroids.”

First reported by French physicians during the mid-1990s, UFE is a minimally invasive procedure that relies on fluoroscopy—moving X-ray images projected on a TV screen—to guide physicians. Specialists like Machan and Common, who are interventional radiologists, perform the procedure because they are used to working with fluoroscopes. In a typical operation, the radiologist inserts a snake-like plastic catheter into one of the patient’s arteries that supplies the uterus with blood, and releases clusters of tiny plastic particles. The blood flow carries the particles into the uterus, where they block fibroids’ blood supply, causing the lumps to shrink by an average of 40 to 50 per cent within a year—enough in most cases to prevent further problems.

Still, there are some concerns over UFE’s long-term effectiveness. Because the procedure is so new, doctors cannot be sure yet that fibroids starved of nutrients will not eventually find a new blood supply and grow back. According to Machan, regrowth has been reported in some women who become pregnant after undergoing UFE. And physicians in the Ontario study, who have performed more than 500 uterine fibroid embolizations during the past 2)h years, have reported several cases of regrowth, which Common thinks were related to the anatomical peculiarities of individual patients. “I don’t think,” adds Common, “that we’re going to see this in a lot of cases.”

There are other risks. In less than one per cent of cases, says Machan, infections that set in following UFE can make hysterectomies necessary. And in a small percentage of cases involving women over 45, embolization can backfire by damaging the ovaries and triggering the onset of menopause. Moreover, embolization sometimes does not shrink large fibroids enough to relieve pressure on the uterus. “Women need to be told these things, ” adds Machan. “But usually, they still think the advantages of

painful pressure. After a gynecologist told her a hysterectomy was the only treatment available, Maydonik, like Skura, searched for alternatives and underwent UFE at St. Joseph’s Flealth Centre in London in February of last year. “After that,” says Maydonik, 53, “my symptoms cleared up completely. I haven’t had any problems since.” Enough outcomes like that could point to a bright future for a promising but unproven therapy. EÛ3