Uterine-Sparing Procedures for Leiomyomas Have Trade-offs

Bridget M. Kuehn

October 11, 2017

Among women with uterine leiomyomas (fibroids), those who undergo uterine artery embolization have a higher risk for additional procedures including hysterectomy, but a lower risk for complications compared with those undergoing myomectomy, a study found. The rates of adverse reproductive outcomes are similar, the researchers write.

Bijan Borah, PhD, a health economist and associate professor at the Mayo Clinic in Rochester, Minnesota, and colleagues published their findings online October 10 in Obstetrics & Gynecology.

"[T]he real-world evidence on the comparative effectiveness between alternative procedural treatments for leiomyoma-related bulk symptoms is sparse," the authors write. "Specifically, extant evidence demonstrates substantial variation in the reintervention rates and reproductive outcomes between different leiomyoma treatment procedures."

The researchers analyzed data from a commercial insurance database on 135,522 women aged 18 to 54 years who underwent hysterectomy (82%), myomectomy (14.7%), uterine artery embolization (3.1%), or magnetic resonance-guided, focused ultrasound surgery (0.0003%). The primary objective was to compare the risk for reintervention among various uterine-sparing leiomyoma procedures.

As only 47 women in the cohort underwent the focused ultrasound therapy, the authors conducted a more limited analysis of those data and focused the comparative analyses on myomectomy and artery embolization.

The women who underwent uterine artery embolization had a higher rate of later fibroid-related procedures (17.1%) compared with women who had myomectomy (15.0%; P value = .02). Uterine artery embolization was also linked to a higher rate of subsequent hysterectomy than myomectomy (13.2% vs 11.1%; P < .01), but a lower rate of procedure-related complications (18.1% vs 24.6%; P < .001).

"[O]ur study found a substantially higher reintervention rate for uterine artery embolization than previously reported," the authors note.

Pregnancy rates were higher among those who chose myomectomy (7.5%) compared with uterine artery embolization (2.2%). Among women who became pregnant, the rates of poor pregnancy outcomes were comparable for both procedures.

"The lower pregnancy rate for uterine artery embolization was likely attributable in part to both patient and health care provider preference toward myomectomy for pregnancy optimization, which is also supported by the American College of Obstetricians and Gynecologists," the authors write.

The study did not capture information on women's reproductive intentions, making it difficult to draw firm conclusions. In addition, black women were underrepresented and accounted for only 10% of the women in the study, so the results may not be applicable to this population. The authors note more studies focusing specifically on black women are needed, particularly because as many as 80% of black women may experience leiomyomas, and this study found that black women opted for uterine artery embolization at a higher rate than other groups.

In the meantime, the study provides real-world insights that may aid clinicians counseling their patients about alternatives to hysterectomy for managing fibroids.

"Compared with the myomectomy cohort, women who underwent uterine artery embolization had a higher risk of reintervention, lower risk of other surgical procedure, but a similar rate of adverse reproductive outcomes," the authors conclude.

One coauthor reports receiving research funding from Truven Health Analytics, and Insightec for a focused ultrasound ablation clinical trial. Another coauthor reports receiving consulting fees from AbbVie, Astellas Pharma, Bayer Health Care, Gynesonics, and Viteava related to uterine leiomyoma; from GlaxoSmithKline related to adenomyosis, and from Welltwigs related to infertility. The remaining authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2017;130:1047-1056. Abstract

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