COMMENTARY

Is Uterine Artery Embolization a Good Alternative to Hysterectomy for Patients With Fibroids?

Peter Kovacs, MD, PhD

Disclosures

January 20, 2017

Uterine Artery Embolization vs Hysterectomy in the Treatment of Symptomatic Uterine Fibroids: 10-Year Outcomes From the Randomized EMMY Trial

de Bruijn AM, Ankun WM, Reekers JA, et al
Am J Obstet Gynecol. 2016;215:745.e1-745.e12

Background

The benefit of a medical intervention can be measured in multiple ways, primarily whether it is successful in managing symptoms. Secondary outcomes such as short-term complications, long-term complications, cost effectiveness, impact on quality of life (QOL), and overall patient satisfaction are considered when patients are counseled.

Fibroids are common benign uterine tumors that can be detected in up to 25%-30% of women.[1] Definitive therapy is hysterectomy. Other options are removing the fibroids via various surgical routes, using medications to reduce myoma size, or using a radiologic solution.

Uterine artery embolization (UAE) cuts off the main blood supply feeding the fibroids and has been shown to be effective, but there's little known about the long-term effects.[2] This paper is a 10-year follow-up to a randomized trial comparing hysterectomy and UAE.

Summary

The EMMY trial randomly assigned reproductive-age women with symptomatic fibroids to unilateral or bilateral UAE (n=81) vs hysterectomy (n=75). This current analysis assesses overall health-related QOL, urinary symptoms, changes in defecation habits, and satisfaction. In order to obtain data, standardized and validated questionnaires were mailed out. The response rate was 84%.

  • After 10 years of follow-up, 28 women (35%) undergoing UAE required hysterectomy for persistent recurrent or new symptoms. The risk increased with body mass index and history of smoking.

  • Within 6 months after the initial intervention, significant improvement in QOL was observed in both groups. The improvement subsequently stabilized and remained similar in the two groups.

  • Urinary symptoms also significantly improved in both groups and have remained comparable for up to 10 years.

  • Urinary incontinence was up from baseline frequency, but there was no difference between the two groups.

  • Defecation symptoms improved significantly in the short term, but by 10 years the improvement was no longer present.

  • Most participants were satisfied with their intervention, and over 80% would recommend their intervention to friends.

Viewpoint

Hysterectomy is the definitive solution for fibroids but may have long-term side effects affecting urinary symptoms, defecation, sexual life, and, therefore, overall QOL.

The alternative surgical, medical, or radiologic treatments may, however, require repeat interventions later on. In this study, 35% of women who initially had undergone UAE required surgery for persistent recurrent or new symptoms. Not all surgeries were done for the same primary indication; and, therefore, not all surgeries were due to intervention failures.

Some urinary and defecation scores showed no improvement from baseline. This could be due to aging and to some of the participants entering menopause.

After 10 years of follow-up, close to 70% of UAEs were considered successful interventions. Overall, satisfaction was similar to surgery. In general, I would recommend UAE as treatment of symptomatic fibroids to those who do not plan future pregnancies, are far from menopause, or are at above-average surgical risk.

Abstract

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