Treating fibroids the gentle way

Although uterine fibroid embolization (UFE) does not involve surgery or general anesthesia, only 12,000 UFE’s per year are performed in the USA to treat symptomatic fibroids.

Time for a wake-up call among gynecologists and primary care physicians, believes Dr. Ducksoo Kim, Professor and Chief of Cardiovascular and Interventional Radiology at Boston Medical Center.

Fibroids, also known as leiomyomas, myomas or fibromas, are benign growths in the uterine wall composed of smooth muscle and fibrous cells. They are firm, round growths and range in size from a small pea to a cantaloupe, with the largest reported fibroid weighing 140 pounds. They are the most common growths arising from the female pelvis, occurring in at least 20 to 40 percent of women.

Hysterectomy and myomectomy have been standard therapies for women with fibroids. 300,000 hysterectomies or myomectomies are performed each year for this indication. While hysterectomy involves the removal of the uterus, myomectomy allows the uterus to be left in place and preserves fertility. Both procedures, however, involve major surgery. Dr. Ducksoo Kim explains: “These surgeries require general anesthesia and a large incision to remove the uterus or fibroids. As with any major surgery, there is also a chance of significant blood loss. The postoperative hospital stay is two to three days. In addition, the patient undergoes six to eight weeks of limited activity to fully recuperate from the trauma suffered by the pelvic floor during surgery. Incontinence, depression, and lower sexual enjoyment are other common problems women experience after these surgeries.”

Combined gynecology and radiology

The long list of disadvantages and lack of alternative treatments led Dr. Ducksoo Kim and Dr. Stephen Baer, Former Chief of the Obstetric and Gynecology Department at Harvard Vanguard Medical Associates and Harvard Medical School Faculty, to create the Fibroid Center in Boston. In 1997, they combined their radiology and gynecology expertise to offer women a new treatment option: uterine fibroid embolization (UFE), which does not involve surgery or general anesthesia. During this procedure, the interventional radiologist inserts a catheter into a blood vessel in the groin. Using fluoroscopy as a guide, the catheter is threaded up to the uterine artery. Once the uterine vessel is located, polyvinyl alcohol or Embosphere is injected. The injected particles block the flow of blood to the uterus and fibroid. This process is repeated on the opposite side of the uterus to ensure the complete blockage of the fibroid vessels. The entire procedure takes approximately one hour. Over 95 percent of patients are discharged within one day after the procedure with prescriptions for medications to reduce post-procedural symptoms such as transient pelvic pain and nausea. Compared to hysterectomy and myomectomy, the complication rate is much lower. It also costs less than the surgical options.

The advantages of UFE couldn’t be more obvious. Still, it ranks at the bottom of the procedures list. “This,” says Kim, “is due to two major problems: a conflict of interest and the lack of awareness. Gynecologists don’t wish to lose their patients and would rather perform a hysterectomy or myomectomy than refer their patients to a radiologist for a UFE. If gynecologists and radiologists work together, then patients would benefit from having more options available to them.”

Patient advocates

In a team with Baer, Kim doesn’t experience these conflicts. “Since Dr. Baer and I work together, we choose what is best for the patient without allowing financial concerns to affect our decisions. There is no conflict, and the patient is the winner.” Primary care physicians, Kim believes, should not have the same conflicts of interest either. “They should be patient advocates and advise them on UFE in addition to the more traditional treatment options; however, less than 30 percent of primary care physicians are aware of UFE,” estimates Kim. Lack of awareness amongst doctors as well as patients is a major challenge. The lack of manpower is also a factor. Kim calculates only about 10 radiologists who can perform this procedure in Boston, a city of one million.

Although it took almost five years for insurance companies to recognize UFE, most of them now cover the cost of this non-invasive procedure. To speed up progress, Kim calls for more collaboration between gynecologists and radiologists. While actively promoting UFE, he would also like to raise awareness about other minimally invasive outpatient procedures, such as ovarian vein embolization for treating chronic pelvic congestion syndrome, vertebroplasty for compression fractures of the spine, and laser treatment of varicose veins in the legs. “Minimally invasive procedures are underrated by many physicians even though they are the future. It’s just a matter of time.”

Dr. Ducksoo Kim: “Dr. Kim's experience consists of 25 years as a radiologist and 23 years teaching experience at various medical centers, including Harvard Medical School, where he was an Associate Professor. Since 2006, he has been a Professor of Radiology at Boston University School of Medicine and Chief of Cardiovascular and Interventional Radiology at Boston Medical Center. He has extensive experience in interventional radiology.”

Dr. Ducksoo Kim: “Minimally invasive procedures are underrated by many physicians even though they are the future. It’s just a matter of time.”