Editorial: If your patient has asymptomatic myomas, is UAE an option?

Taking a closer look at the research

Until recently, this debate has suffered from a lack of well-designed studies. A large observational series of 400 cases suggested that myoma-induced abnormal uterine bleeding and dysmenorrhea were reduced 84% and 79%, respectively, by UAE.³ Another series reported similar findings with improvement in menorrhagia and pelvic pain/pressure in 89% and 96% of patients, respectively, and a decrease in median uterine volume of 48% after 1 year.⁴ On the other hand, case reports and series began to appear describing a myriad of uncommon (1%–2%) but potentially serious complications including allergic reactions, femoral artery hematomas, pelvic abscesses, and endomyometritis.⁵ Moreover, about 40% of patients develop postembolization syndrome consisting of diffuse abdominal pain, malaise, anorexia, nausea, vomiting, low-grade fever and leukocytosis, and lasting several days.⁵ Another 5% to 10% of women experienced painful transcervical expulsion of necrotic submucous myomas. Of more concern was the reported occurrence of transient or permanent ovarian failure in 3% to 10% of patients, particularly those over 40 years of age, and reports of five deaths from sepsis or pulmonary embolism. However, it is difficult to assess the magnitude of these UAE risks, side effects, and sequelae without a direct comparison to surgical alternatives.

Broder and colleagures compared 51 patients who had undergone UAE with 30 patients treated with abdominal myomectomy and noted that the former patients were more likely to require subsequent invasive treatment for myomas (29% vs. 3%).⁷ However, again because there was no formal randomization, multiple pretreatment clinical differences were present between the groups preventing meaningful and direct comparisons of efficacy. A second problem with these "comparative" studies is that they do not compare UAE to the optimal surgical approach. For older, highly symptomatic women, who have no desire to maintain fertility but want definitive therapy, hysterectomy rather than myomectomy is likely to be the preferred option.

SEVERAL SMALL RANDOMIZED trials have compared the clinical outcomes of UAE to hysterectomy and myomectomy.^8-10 The clinical success rate of UAE for fibroid-related menstrual blood loss was over 80% with a mean dominant fibroid volume reduction of 30% to 46%. While clinical outcomes were generally quite similar, only short-term follow-up was available.