Hysterectomies are not the only option
Angela Hofmann had no trouble asking questions.
At 47, she knew her body and wanted to know why she was experiencing problems during her menstrual cycle, problems that worsened over the last seven years.
It was the answers that bothered her.
For starters, her doctors told her that she had uterine fibroids. Though benign, they were the cause of excessive bleeding and the protrusion in her stomach. The pain and discomfort were often too much to handle.
“I couldn’t leave the house,” the architect said. “I couldn’t go to work.”
She went to a gynecologist, but didn’t like what she advised. So she went to another, then another and then still another.
“For five years, I ran around from doctor to doctor, but they all told me the same thing — that I needed a hysterectomy,” she said.
And she told each and every one of them the same thing.
“I’m not having surgery,” she said. “You can forget that.”
For years, hysterectomy — the procedure that removes the entire uterus and leaves a woman unable to bear children — has reigned supreme as the treatment of choice for uterine fibroids. Of the 600,000 hysterectomies performed each year, it is estimated that at least one-third are for fibroids.
The reason is clear. Hysterectomy is the only procedure that completely eliminates fibroids.
In other procedures, surgeons may not be able to remove all of the tumors, explains Dr. Nia Robinson, a gynecologist at Brigham and Women’s Hospital.
“Only the hysterectomy can completely and permanently solve the problem,” Robinson said.
But now many doctors feel that the number of hysterectomies is too high.
And with good reason.
Other less surgically intrusive treatments have become viable alternatives. Uterine fibroid embolization (UFE) is one such treatment.
The approach is similar to heart catheterization. A catheter is inserted into an artery in the groin and then snaked into the arteries of the uterus. Particles are released that block the flow of blood to the fibroids, causing them to soften and decrease in size by 50 percent or more.
Even the American College of Obstetricians and Gynecologists has endorsed UFE as an acceptable option — a significant move since interventional radiologists, rather than gynecologists, generally perform the procedure. Interventional radiologists are physicians trained in non-surgical treatment of vascular conditions.
Robinson admits that some doctors may have a preference for one procedure over another, and are therefore more reluctant to recommend alternate treatments.
She has a different approach.
“I tell my patients all the options,” she said. “You need to know why one procedure is preferable over another. Understand that surgery is a risk. If you’re unsatisfied, get a second opinion. Get educated. Knowledge is key.”
UFE has a lot of star power behind it. Beverly Johnson, the first African American model to appear on the cover of American Vogue magazine, is the spokesperson for ask4tell4, a campaign to increase awareness of uterine fibroids and their treatment.
Johnson was diagnosed with the condition in her 30s and admitted that she knew little about it. She eventually underwent a myomectomy, a procedure that removes the fibroids and leaves the uterus intact.
But within two years, they grew back. She finally had a hysterectomy and suffered severe complications. She was offered no other option. Her mission is to prevent her daughter and other women from going through the same ordeal.
Former U.S. Secretary of State Condoleezza Rice also had a UFE. Rice had the procedure on a Friday, was discharged home on Saturday and returned to work on Monday, according to a White House press release.
“The demands of her critical position in our government made it necessary for her to have a treatment that would allow her to get back to work as soon as possible,” the release stated. “After considering her options, she chose UFE.”
Unfortunately, some gynecologists didn’t get the memo.
In a study of 105 patients in the Atlanta metro area presented last year at the Society of Interventional Radiology’s scientific meeting, only 18 percent were told about UFE by their gynecologist. Some surgeons may not be familiar with UFE or consider it experimental.
But the treatment has been around for more than 10 years. Roughly 20,000 procedures are performed each year. It is covered by most insurance companies and is widely available across the country.
According to Dr. Susan O’Horo, an interventional radiologist at Brigham and Women’s Hospital, not all women are candidates for the procedure. The ideal candidate is a woman who has symptoms of uterine fibroids, is not planning to have children, is averse to surgery or a poor surgical risk and has no other abnormality in the pelvis, such as cancer.
O’Horo stressed the importance of a pelvic MRI to confirm a woman’s candidacy for UFE.
“MRIs change the diagnosis and treatment in 20 percent of the patients,” she said. “Some women will do better with a hysterectomy or myomectomy.”
But she is quick to point out that she “considers the whole person.”
“Some women really do not want surgery,” she said. “[But] if the UFE fails, a woman can more easily accept the surgery.”
The results of UFE are well documented. “Fifty percent of women are back to normal after one week, and 90 percent after two weeks,” said O’Horo.
Another procedure that has not gained as much attention is Magnetic Resonance-Guided Focused Ultrasound Surgery (MRgFUS).
The term “surgery” is actually a misnomer. MRgFUS is the only nonmedical treatment for fibroids that does not require an incision of any kind. In this procedure high-intensity ultrasound waves are used to obliterate the tumors.
Although approved by the Food and Drug Administration in 2004 and reports of positive outcomes for the majority of women who had the procedure, most insurance companies do not pay for MRgFUS. They argue that long-term results are necessary before they would consider reimbursement.
To date, United Healthcare is one of the only large insurance carriers that have elected to reimburse for the treatment.
Lack of endorsement by insurance did not deter Angela Hofmann. She jumped at the chance to have an MRgFUS.
“It was so easy,” she said. “There was no pain. You go in and lie down in an MRI machine for about an hour.”
According to Hofmann, the results have been better than expected. Her periods are normal and her stomach has returned to its normal size.
And she doesn’t regret her decision to avoid having a hysterectomy.
“I watched my mother go through it,” she said. “I knew I didn’t want to do that.” |
| Condoleezza Rice, secretary of state under the Bush administration, opted for uterine fibroid embolization for the treatment of her uterine fibroids. Associated Press photo by Susan Walsh. |
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