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Paper Information



Author(s):  GHANAATI H.*

Uterine fibroids are benign tumors occurring in 20-50% of women in their reproductive age. They are the most frequent indication for hysterectomy at Pre-menopausal age. Fifty percent of fibroids are asymptomatic and require no treatment, but the rest may cause menorrhagia, dysmenorrhoea, dyspareunia, abdominal distension, pressure effects, pregnancy loss and infertility. Unfortunately all the primary treatments for fibroma, (including hysterectomy, myomectomy and hormonal therapy) have substantial disadvantages. Hysterectomy has the risks associated with major surgical procedures and eliminates fertility. Besides, the psychological aspects of uterine sacrifice are significant. Myomectomy also has similar risks, with approximately 20-25% recurrence of symptoms. Hormonal therapy is effective in the short term, and is associated with side-effects such as hot flashes, mood swings, insomnia and dyspareunia. 4 Uterine artery embolization (UAE) as a primary therapy for fibroids was reported for the first time by Ravina in 1995. larger studies then confirmed the safety and efficacy of this technique. The clinical success rate has beenreported at 80-94%. The mean decrease in uterine volume varies from 35% to 48%, and fibroid size varies in the range of 45-78 %. Our university affiliated hospital is currently the main referring center that has been applying UAE for symptomatic fibroids since September 2001 in our country. In this study, we report our experience with the embolization of fibroids in a population of Middle- Eastern women and compare the outcome with the studies from western nations.
Discussion: The average reduction in the volume of the fibroid and the mean uterine size comply well with many other reports (p=0.93). Menorrhagia in Georgetown’s 200 patients showed improvement in 87% at month 3 and 89% at month 6. Similar results were reported by Hutchins and Worthington -Kirsch; in their report, menstrual improvement occurred in 85% after 6 months, which supports our results (p=0.4). Improvement of urinary symptoms by UAE was approximately 87% after six months, and improvement of bulk- related symptoms was 93 %; very similar to other reports. The results from the published series and those of our patients are similar in the degree of symptom improvement, but fibroid shrinkage after UAE shows much better results in our patients than many other reports. Although for patients with a desire for future pregnancy we only included patients who were candidates for extensive myomectomy or hysterectomy, the average age of our patients was lower than many other studies. Our technical success rate was slightly lower than other studies. This might due to by the unilateral uterine artery embolization in 11 patients at the beginning of our experience. It shows that the failure rate has a linear correlation with the experience of the radiologist. No serious complication occurred after UAE in our patients. We did not have any mortality in our patients. The major adverse effect following UAE was pain, which was controlled by pethidine or morphine sulfate. It is therefore important to forewarn women about the pain they will experience, and which will probably last for several days. Several reports have described the relationship between improvement in menorrhagia and primary tumor size. Katsumori et al. reported that improvement in menorrhagia was unrelated to initial uterine size. Spies et al. reported that bleeding outcome demonstrated a trend toward improvement with smaller baseline uterine and fibroid volumes. In our study, the improvement in menorrhagia at one year after embolization had no association with the primary size of fibroids. Our study confirms that clinical success after bilateral uterine artery embolization is not related to the size of the fibroid. However, we did not perform embolization in patients with fibroids larger than 2618 cm3. Katsumori demonstrated that there was no statistical difference between fibroid volume reduction rate two groups of patients with fibroids maller and larger than 10 cm. Spies et al. reported that smaller baseline fibroid size is more likely to result in a positive imaging outcome. In our study, similar to Katsumori, there was no statistical difference between baseline fibroid volume and reduction in fibroid size after one year. UAE has several potential advantages over hysterec-tomy, myomectomy and hormonal suppression. Unlike myomectomy or hysterectomy, UAE involves virtually no complications of major surgery. Recovery time is several weeks shorter than with hysterectomy or open myomectomy (7 days versus 6 weeks). Early menopause-like symptoms, which are often seen with GnRH therapy, are rarely induced as a result of UAE. UAE has the advantages of allowing preservation of uterine function (i.e., normal menses and even pregnancy). In addition, the patients do not suffer the psychological problems of uterine sacrifice. The procedure is well tolerated by patients. A clinical advantage is that if UAE fails, the full range of other options for treatment of fibroma will be still available. And if necessary, surgery will be easier and safer because of the preoperative embolization. Hysterectomies have higher facility costs than UAE because of longer hospital stay, procedure duration and recovery time. One of the disadvantages associated with UAE is that it is currently somewhat difficult for women to learn about the procedure or its accessibility in their area. Some gynecologists may be unfamiliar with it or may counsel the patients to stay with the tried and trusted surgical procedures. According to our results, we can conclude that UAE is a safe and effective method in treatment of uterine fibroids. This conclusion has been approved in other reports too. However, there are a number of additional questions that require further studies. For example, the long-term effects on ovarian function and future fertility are yet to be determined. Successful pregnancy after this procedure has been reported but as of yet, the pregnancy rate cannot be calculated because it is not known how many patients treated with UAE have attempted to become pregnant. It is likely that a large multi-centric long-term study will be required to answer these questions.

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