Improving Access to UFE: What Are the Barriers?

Uterine fibroids, or leiomyomas, are benign tumors of the smooth muscle of the uterus that are commonly found in women of childbearing age. They can be found in up to 70% of White women and over 80% of women of African descent.¹ Although most women are asymptomatic, others will experience pelvic pain, menorrhagia, metrorrhagia, anemia, infertility, or bulk symptoms (urinary frequency, constipation, bloating, pressure, and/or dyspareunia). Uterine fibroid embolization (UFE) is a minimally invasive option to treat symptomatic uterine fibroids. Multiple randomized studies have been performed showing similar long-term outcomes between surgery (hysterectomy and myomectomy) and UFE in health-related quality of life up to 10 years postprocedure.^2-5 The FIBROID registry found a durable improvement in quality of life when examining both short- and long-term outcomes after uterine artery embolization, with only a small number of patients requiring subsequent surgical intervention.^6,7

UFE has been shown to have multiple benefits over surgical options. UFE is minimally invasive with no incisions and preserves the uterus. The actual procedure duration has been shown to be shorter than myomectomy or hysterectomy, and the postprocedure recovery is quicker, allowing patients to get back to activities of daily living.^8-10 UFE is also less costly than surgical alternatives,^11-13 and although UFE was once thought to be contraindicated in patients desiring children, recent studies have shown that fertility can be preserved after UFE with similar rates to myomectomy, making this a viable option for those desiring future pregnancy.^14-16

UFE AWARENESS

Despite the great outcomes and benefits, interventional radiology has struggled to get the word out about UFE to the medical community and patients. Many patients remain unaware of this as a treatment option for fibroids. The Society of Interventional Radiology (SIR) had a campaign called the Fibroid Fix to assess the current state of knowledge regarding UFE and increase awareness. As part of the Fibroid Fix, a Harris Poll was conducted online from June 23 to 27, 2017, of 1,176 women in the United States aged ≥ 18 years.¹⁷ This study found a lack of awareness and knowledge regarding uterine fibroids in general; 28% of respondents had never heard of uterine fibroids, 57% did not think they were at risk of fibroids, and 19% believed them to be cancerous and require a hysterectomy.¹⁷ This survey also found that approximately 70% of women aged 18 to 34 years had never heard of UFE, including a surprising 44% of women with fibroids. Of those who had heard about UFE, only 27% found out about it from their obstetrician-gynecologist.¹⁷ This finding was supported by a recent study on shared decision-making for uterine fibroid treatment, which found that some women were only presented with surgical treatment options even when this did not align with their personal goals or desired future fertility. Only one woman in this study underwent UFE.¹⁸

Outreach struggles regarding the benefits of UFE are not limited to the United States; similar findings have been found in Europe and Australia.^19,20 In 2013, UFE was added to the guidelines for management of heavy menstrual bleeding in the Netherlands.²¹ However, a follow-up study found that this did not change the low number of UFE (only 6.9%) performed in the Netherlands for symptomatic uterine fibroids.²¹ Additionally, gynecologists continued to question the effectiveness of UFE and felt they had insufficient information to counsel patients.²¹ Another study in the United Kingdom found that only 2% of women with symptomatic fibroids underwent UFE.²²

A large number of hysterectomies are performed annually for benign causes. One study found that nearly 40% of patients with benign indications did not have alternative therapy prior to hysterectomy, and 18% did not have pathology supporting the indication for hysterectomy.²³ Hysterectomy has been shown to be associated with an increased risk of future cardiovascular disease, metabolic conditions, anxiety, and depression.^24,25 According to the Nationwide Inpatient Sample (NIS), the number of hysterectomies performed for fibroids in the United States has declined from 373,629 in 2002 to 195,735 in 2010, but the number still remains high.²⁶ This highlights not only the lack of awareness of options to treat fibroids among our patients but also our colleagues.

ACCESS IN RURAL COMMUNITIES

Although there is an overall lack of awareness of UFE as an option to treat symptomatic fibroids, a study performed out of the University of Miami showed that this is not uniform, and there is a disparity in use of UFE in rural communities. The study was presented at the SIR 2017 annual meeting.²⁷ The 2012 to 2013 NIS was analyzed using billing codes to identify patient locations. It was found that only 2,470 UFEs were performed for fibroids compared to 167,650 hysterectomies. Further breakdown of the data showed that 9.4% of hysterectomies were performed at rural hospitals versus only 0.4% of UFEs. Additionally, 67% of UFEs were performed at larger tertiary hospitals. This further highlights not only the overall lack of knowledge regarding UFE as a great option to treat fibroids but also the disparities depending on patient location.²⁷ These findings are supported by a second study that examined hysterectomy versus UFE using the National Hospital Discharge data from 2004 through 2008 and found that 9.8% of abdominal hysterectomies were performed in rural settings for fibroids; however, only seven UFE procedures were performed in rural settings during the same time period.²⁸

CONCLUSION

UFE is a safe, effective, uterine-preserving, minimally invasive treatment for symptomatic uterine fibroids. It has been shown to have equivalent long-term quality-of-life outcomes when compared to surgical options, shorter hospital stays, less recovery time, and is cost-effective. Yet, interventional radiology continues to struggle to increase awareness of UFE both to our patients and our referring providers. The lack of awareness and utilization is accentuated in rural settings. The data to support UFE as a treatment of fibroids are there. Physicians need to work together to increase awareness and dispel myths to provide patients with all options before choosing a treatment.

1. Giuliani E, As-Sanie S, Marsh EE. Epidemiology and management of uterine fibroids. Int J Gynaecol Obstet. 2020;1491:3-9. doi: 10.1002/ijgo.13102

2. Moss JG, Cooper KG, Khaund A, et al. Randomised comparison of uterine artery embolisation (UAE) with surgical treatment in patients with symptomatic uterine fibroids (REST trial): 5-year results. BJOG. 2011;118:936-944. doi: 10.1111/j.1471-0528.2011.02952.x

3. de Bruijn AM, Ankum WM, Reekers JA, et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 10-year outcomes from the randomized EMMY trial. Am J Obstet Gynecol. 2016;215:745.e1- e12. doi: 10.1016/j.ajog.2016.06.051

4. Mara M, Maskova J, Fucikova Z, et al. Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy. Cardiovasc Intervent Radiol. 2008;31:73-85. doi: 10.1007/s00270-007-9195-2

5. Edwards RD, Moss JG, Lumsden MA, et al. Uterine-artery embolization versus surgery for symptomatic uterine fibroids. N Engl J Med. 2007;356:360-370. doi: 10.1056/NEJMoa062003

6. Goodwin SC, Spies JB, Worthington-Kirsch R, et al. Uterine artery embolization for treatment of leiomyomata: long-term outcomes from the FIBROID Registry. Obstet Gynecol. 2008;111:22-33. doi: 10.1097/01.AOG.0000296526.71749.c9

7. Spies JB, Myers ER, Worthington-Kirsch R, et al. The FIBROID registry: symptom and quality-of-life status 1 year after therapy. Obstet Gynecol. 2005;106:1309-1318. doi: 10.1097/01.AOG.0000188386.53878.49

8. Hehenkamp WJ, Volkers NA, Donderwinkel PF, et al. Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids (EMMY trial): peri- and postprocedural results from a randomized controlled trial. Am J Obstet Gynecol. 2005;193:1618-1629. doi: 10.1016/j.ajog.2005.05.017

9. van der Kooij SM, Bipat S, Hehenkamp WJ, et al. Uterine artery embolization versus surgery in the treatment of symptomatic fibroids: a systematic review and metaanalysis. Am J Obstet Gynecol. 2011;205:317.e1-18. doi: 10.1016/j.ajog.2011.03.016

10. Worthington-Kirsch R, Spies JB, Myers ER, et al. The Fibroid Registry for outcomes data (FIBROID) for uterine embolization: short-term outcomes. Obstet Gynecol. 2005;106:52-59. doi: 10.1097/01.AOG.0000165828.68787.a9

11. van der Kooij SM, Hehenkamp WJ, Volkers NA, et al. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial. Am J Obstet Gynecol. 2010;203:105.e1-13. doi: 10.1016/j.ajog.2010.01.049

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13. Clements W, Moriarty HK, Koukounaras J, et al. The cost to perform uterine fibroid embolisation in the Australian public hospital system. J Med Imaging Radiat Oncol. 2020;64:18-22. doi: 10.1111/1754-9485.12982

14. Ghanaati H, Sanaati M, Shakiba M, et al. Pregnancy and its outcomes in patients after uterine fibroid embolization: a systematic review and meta-analysis. Cardiovasc Intervent Radiol. 2020;43:1122-1133. doi: 10.1007/s00270-020-02521-6

15. Ludwig PE, Huff TJ, Shanahan MM, Stavas JM. Pregnancy success and outcomes after uterine fibroid embolization: updated review of published literature. Br J Radiol. 2020;93:20190551. doi: 10.1259/bjr.20190551

16. Pisco JM, Duarte M, Bilhim T, et al. Spontaneous pregnancy with a live birth after conventional and partial uterine fibroid embolization. Radiology. 2017;285:302-310. doi: 10.1148/radiol.2017161495

17. Society of Interventional Radiology. The fibroid fix: what women need to know. Accessed December 13, 2021. www sirweb.org/fibroidfix

18. Riggan KA, Stewart EA, Balls-Berry JE, et al. Patient recommendations for shared decision-making in uterine fibroid treatment decisions. J Patient Exp. 2021;8:23743735211049655. doi: 10.1177/23743735211049655

19. Makris GC, Butt S, Sabharwal T. Unnecessary hysterectomies and our role as interventional radiology community. CVIR Endovasc. 2020;3:46. doi: 10.1186/s42155-020-00138-x

20. Clements W. Uterine fibroid embolisation: advocating women’s choice for uterine salvage. CVIR Endovasc. 2020;3:78. doi: 10.1186/s42155-020-00161-y

21. de Bruijn AM, Huisman J, Hehenkamp WJK, et al. Implementation of uterine artery embolization for symptomatic fibroids in the Netherlands: an inventory and preference study. CVIR Endovasc. 2019;2:18. doi: 10.1186/s42155-019-0061-5

22. Geary RS, Gurol-Urganci I, Kiran A, et al. Factors associated with receiving surgical treatment for menorrhagia in England and Wales: findings from a cohort study of the National Heavy Menstrual Bleeding Audit. BMJ Open. 2019;9:e024260. doi: 10.1136/bmjopen-2018-024260

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26. Wright JD, Herzog TJ, Tsui J, et al. Nationwide trends in the performance of inpatient hysterectomy in the United States. Obstet Gynecol. 2013;122:233-241. doi: 10.1097/AOG.0b013e318299a6cf

27. Narayanan A, Gonzalez A, Echnique A, Mohan P. Nationwide analysis of hospital characteristics, demographics and cost of uterine fibroid embolization [abstract 106]. Presented at: SIR Annual Scientific Meeting; March 4-9, 2017; Washington, DC.

28. Glass Lewis M, Ekundayo OT. Cost and distribution of hysterectomy and uterine artery embolization in the United States: regional/rural/urban disparities. Med Sci (Basel). 2017;5:10. doi: 10.3390/medsci5020010