Correspondence
Treatment of Symptomatic Uterine Fibroids
N Engl J Med 2007; 356:2218-2219May 24, 2007
- Article
To the Editor:
In their report on the Randomized Trial of Embolization versus Surgical Treatment for Fibroids (REST), Edwards et al. (Jan. 25 issue)1 carefully discuss the benefits of uterine-artery embolization as compared with hysterectomy but do not address some important potential concerns associated with embolization. The lack of tissue availability for histopathological examination after uterine-artery embolization has been reported to delay diagnosis of a concomitant cancer2 or a malignant mass initially misdiagnosed and treated as a uterine fibroma. Furthermore, concern has been expressed about a decrease in ovarian function after embolization. Women with anastomoses of the uterine and ovarian arteries (an uncommon condition) seem to have a predisposition to this adverse outcome.3 Studies to determine basal follicle-stimulating hormone and estradiol before and after the procedure3,4 have been suggested in order to monitor patients for embolization-induced follicle depletion, particularly when preservation of fertility is an important consideration.
4 ReferencesAmitabh Parashar, M.D.
Anjali Varma, M.D.
Carilion Clinic, Roanoke, VA 24018
aparashar@carilion.com Sudha Bedi, M.D.
69 Leroy Ave., Valhalla, NY 105951
The REST Investigators
Full Text | Web of Science | Medline2
Papadia A ,Salom EM ,Fulcheri E ,Ragni N . Uterine sarcoma occurring in a premenopausal patient after uterine artery embolization: a case report and review of the literature. Gynecol Oncol 2007;104:260-263
CrossRef | Web of Science | Medline3
Kim HS ,Tsai J ,Lee JM ,Vang R ,Griffith JG ,Wallach EE . Effects of utero-ovarian anastomoses on basal follicle-stimulating hormone level change after uterine artery embolization with tris-acryl gelatin microspheres. J Vasc Interv Radiol 2006;17:965-971
CrossRef | Web of Science | Medline4
Marshburn PB ,Matthews ML ,Hurst BS . Uterine artery embolization as a treatment option for uterine myomas. Obstet Gynecol Clin North Am 2006;33:125-144
CrossRef | Web of Science | Medline
To the Editor:
The global question of fibroid management discussed by Edwards et al. can be looked at in another way. Today, laparoscopic and vaginal approaches should be preferred to the open route for surgical treatment of symptomatic uterine fibroids.1 Vaginal hysterectomy is now recognized as the method of choice for benign gynecologic disease because of its effectiveness, feasibility, and postoperative advantages over open surgery (significantly shorter hospital stay and better postoperative recovery).2 In selected cases, laparoscopically assisted vaginal hysterectomy or total laparoscopic hysterectomy can be performed to avoid the open route; the potential risk of complications does not preclude consideration of these procedures.3 Comparison of uterine-artery embolization with vaginal or laparoscopic approaches in a new randomized trial would better define the role of embolization in the treatment of women with symptomatic uterine fibroids.
3 ReferencesBruno Borghese, M.D.
Charles Chapron, M.D.
University Hospital Cochin, 75014 Paris, France
charles.chapron@cch. aphp. fr 1
Chapron C ,Dubuisson JB . Laparoscopic hysterectomy. Lancet 1995;345:593-593
Web of Science | Medline2
Johnson N ,Barlow D ,Lethaby A ,Tavender E ,Curr E ,Garry R . Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2006;2:CD003677-CD003677
Medline3
Chapron C ,Fauconnier A ,Goffinet F ,Breart G ,Dubuisson JB . Laparoscopic surgery is not inherently dangerous for patients presenting with benign gynaecologic pathology: results of a meta-analysis. Hum Reprod 2002;17:1334-1342
CrossRef | Web of Science | Medline
Author/Editor Response
Parashar et al. discuss the possibility of missing a malignant tumor with uterine-artery embolization. Although the report that they cite acknowledges that the incidence of malignant tumors is unlikely to be greater than that for other nonsurgical treatments or no treatment, this factor is always a concern, and all patients in our study underwent imaging before inclusion. Although such imaging might still miss a leiomyosarcoma, the incidence of such tumors in premenopausal women is extremely low.1 We also acknowledge the concern regarding damage to ovarian function after embolization, and this topic is the subject of ongoing research. Available data suggest that there is no long-term increase in gonadotropin levels, as would be expected with ovarian failure.2 We assessed levels of follicle-stimulating hormone (in many although not all instances on cycle day 3) at baseline and at the 12-month follow-up visit in a subgroup of 73 women in our study. We found a significant but small increase in mean levels of follicle-stimulating hormone after embolization (increase from baseline to 12 months, 6.70 to 7.80 IU per liter; P=0.01). The levels of follicle-stimulating hormone rose significantly more in women who were 45 years of age or older (8.80 to 10.10 IU per liter) than in those under the age of 45 years (5.35 to 6.10 IU per liter, P=0.02), suggesting a greater effect of embolization in older women (unpublished data).
Borghese and Chapron discuss the surgical approach to both hysterectomy and myomectomy. In our trial, all surgeries were performed by the open route, not because of the protocol but because that was the normal practice in the centers involved. A total of 75% of hysterectomies are performed by the abdominal route. Studies suggesting that vaginal hysterectomy should be preferred generally have not included women with an enlarged uterus3 and therefore describe a different group of patients. The majority of hysterectomies are performed abdominally, particularly when there are large fibroids, not because the surgeons are incompetent but because they feel it is in the patient's interest. An analogy might be the cesarean delivery of a baby when it could be delivered vaginally only with effort, risk, and probable morbidity.
3 ReferencesJon Moss, M.B., Ch.B.
North Glasgow University Hospitals, Glasgow G12 0YN, United Kingdom
jon.moss@northglasgow. scot. nhs. uk Mary Ann Lumsden, M.D.
University of Glasgow, Glasgow G31 2ER, United KingdomKevin Cooper, M.D., M.Sc.
Aberdeen Royal Infirmary, Aberdeen AB25 2ZN, United Kingdom1
Schwartz PE ,Kelly MG . Malignant transformation of myomas: myth or reality? Obstet Gynecol Clin North Am 2006;33:183-198
CrossRef | Web of Science | Medline2
Hovsepian DM ,Ratts VS ,Rodriquez M ,Huang JS ,Aubuchon MG ,Pilgram TK . A prospective comparison of the impact of uterine artery embolization, myomectomy and hysterectomy on ovarian function. J Vasc Interv Radiol 2006;17:1111-1115
CrossRef | Web of Science | Medline3
Garry R ,Fountain J ,Mason S , et al. The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic and vaginal hysterectomy. BMJ 2004;328:129-133[Erratum, BMJ 2004;328:494.]
CrossRef | Web of Science | Medline
