If you’re a woman searching for relief from symptomatic uterine fibroids, you may be left wondering which treatment is best for you. Of the many therapies out there, myomectomy and uterine fibroid embolization (UFE) may stand out as very effective, yet different approaches that still allow a woman to keep her uterus. How each treatment accomplishes this is based on a set of pros and cons that women should consider carefully.
Myomectomy, or the surgical removal of fibroids, can be done one of three ways: through an incision made in the abdomen, laparoscopically through a small scope, or removing fibroids through the vagina (hysteroscopic myomectomy). On the other hand, UFE—a minimally invasive procedure in comparison—blocks blood flow to these noncancerous growths, resulting in fibroid shrinkage with subsequent symptom relief.
The biggest advantage myomectomy may have over UFE is fertility preservation. Although conception rates of myomectomy and UFE are comparable, hovering around 46 and 48 percent respectively1, myomectomy is considered the standard fibroid treatment for women wanting to get pregnant.
“When it comes to myomectomy, we know much more about the fertility outcome than we do UFE,” said Dr. Richard Shlansky-Goldberg, Interventional Radiologist and Professor of Radiology, Obstetrics and Gynecology, and Surgery at the Hospital of the University of Pennsylvania in Philadelphia. “If a woman comes in with a few fibroids and is primarily interested in getting pregnant—I usually suggest she first has a myomectomy in order to better preserve circulation to the uterus and ovaries.”
For reasons not yet entirely understood, when UFE blocks blood flow to the fibroids, it may compromise circulation to the ovaries, resulting in a decline in ovarian function. However, this almost exclusively occurs in women closer to menopause who are over age 451
Healthy pregnancies are possible following each treatment but are associated with specific complications.
Myomectomy is linked with the rare but serious complication of uterine rupture during pregnancy or labor2 But in comparison to UFE, it was shown to have better reproductive outcomes in the first two years after treatment—specifically among women with fibroids larger than four centimeters.3
UFE is considered risky due to complications like miscarriage and preterm delivery1, but it’s unclear if these risks are related to the procedure, the fibroids, or other factors like age. “Many of the women getting pregnant after UFE tend to be older,” Dr. Shlansky-Goldberg said. “These risks may have more to do with a woman’s age than the procedure.”
As seen with UFE, the advantages of myomectomy may be limited due to fibroid recurrence. For each treatment, the long-term risk of symptoms returning or the need for an additional treatment is similar with some studies placing UFE at a rate of up to 28 percent4 and myomectomy slightly lower around 20 percent.1,5
And yet, myomectomy recurrence rates may be difficult to pinpoint.
Fibroids removed through myomectomy are basically the ones a surgeon can feel and at times small fibroids are missed. Therefore, it may be a challenge to differentiate between old and new fibroids. Also, according to Dr. Shlansky-Goldberg, some fibroids may be left behind for fear that their removal may result in the need to do an unplanned hysterectomy.
“This isn’t the case with UFE,” Dr. Shlansky-Goldberg continued. “With embolization, we know that the more fibroids we can infarct or kill, the better our outcomes will be. It doesn’t really matter if you have one or 20 fibroids—the approach is the same. Recurrence may still be an issue—about 2 to 3 percent per year—but overall success rates are still nearly 90 percent.”
What’s more, recurrence statistics should be considered carefully. “Lower rates of myomectomy reintervention could also be due to women not wanting to undergo another surgery in comparison to UFE patients who have recovered quickly,” Dr. Shlansky-Goldberg reasoned.
Avoiding surgery—especially hysterectomy—is a significant factor in the decision-making process for women who are concerned with going under the knife. Some women worry about surgery itself and also the added risk of losing their uterus—which to them may be a part of their femininity. UFE could be the ideal procedure for these women because it’s minimally invasive and the likelihood of a good outcome is very high with a relatively quick recovery.
When deciding between myomectomy or UFE, another factor to consider is volume loss. Both procedures are quick to relieve bulk symptoms, but after the incision and fibroid removal of myomectomy, women can experience it immediately.
Although not as quickly, Dr. Shlansky-Goldberg pointed out, UFE patients often experience bulk symptom relief within a few weeks because of a decrease in both fibroid size and firmness. He went on to clarify that even without shrinkage, fibroids may get softer relieving a woman of pelvic pressure symptoms “similar to letting air out of car tire.” According to a recent study6 by Bérczi et al., women with fibroids larger than 10 centimeters still experienced relief after UFE.
To surgically remove large fibroids, the most common route is an abdominal myomectomy. With a large incision comes the risk of developing adhesions—or scar tissue—that can cause pain and impair fertility. Infection, blood loss, and the need for a transfusion during surgery are other possibilities, alongside a much longer recovery time of about six weeks.
In contrast, UFE is a minimally invasive outpatient procedure. Women can go home the same day and recover fully in about two weeks. “UFE’s number one advantage is recovery time. It’s a lot faster than recovering from surgery,” Dr. Shlansky-Goldberg told Ask4UFE. “A faster recovery may be important for women who can’t take a lot of time off from work.”
Not without its own need for recovery, UFE patients may experience post-embolization syndrome (PES). After the procedure, women can have pain (often compared to menstrual cramping), nausea, vomiting, and fatigue. Reportedly, cramps worsen within the first two to three hours but then lessen significantly after 12 hours7 PES can be managed easily with medications such as pain relievers and anti-nausea medication.
Other rare complications associated with UFE include vaginal expulsion of an infarcted fibroid, uterine infection, and pulmonary embolism. Despite the risks, multicentre clinical trials consistently show that the rate of major complications following UFE is significantly lower than those related to surgery8
As important as comfort is during recovery, many women may wonder what life will be like in the months to come. Good news is, when it comes to life after myomectomy and UFE, both were given high quality of life scores.
Manyonda and a team of researchers of the Department of Gynecology at St. George’s Hospital in London compared quality of life scores between 81 women who underwent myomectomy versus 82 who had UFE. Results published in CardioVascular and Interventional Radiology9 showed significant and equal improvements in both groups of women. The authors noted that UFE allowed for shorter recovery time and fewer major complications, while myomectomy showed to have a lower reintervention rate.
Given all the information, which treatment is best?
Dr. Shlansky-Goldberg explained that this question is impossible to answer because every woman is different. “Talk to your doctor and ask questions. It really depends on what a woman wants, needs, and expects to get from her treatment.”
ABOUT THE AUTHOR Alicia Armeli is a Health Freelance Writer, Registered Dietitian Nutritionist, and Certified Holistic Life Coach. She has master’s degrees in English Education and Nutrition. Through her writing, she empowers readers to live optimally by building awareness surrounding issues that impact health and wellbeing. In addition to writing, she enjoys singing, traveling abroad and volunteering in her community.
ABOUT THE DOCTOR Richard Shlansky-Goldberg is an interventional radiologist and professor of Radiology, Obstetrics and Gynecology, and Surgery at the Hospital of the University of Pennsylvania in Philadelphia. Recognized by Best Doctors in America, as Castle Connolly’s America’s Top Doctors, and showcased in Philadelphia Magazine’s Top Docs issue—Dr. Shlansky-Goldberg specializes in helping women with uterine fibroids find relief. Collaborating with the department of obstetrics and gynecology at the University of Pennsylvania allows him to ensure every woman knows and understands all her treatment options, ensuring the best patient care possible.
1. McLucas, B., Voorhees Iii, W. D., & Elliott, S. (2015). Fertility after uterine artery embolization: a review. Minimally Invasive Therapy & Allied Technologies, 2: 1-7.
2. Claeys, J., Hellendoorn, I., Hamerlynck, T., Bosteels, J., & Weyers, S. (2014). The risk of uterine rupture after myomectomy: a systematic review of the literature and meta-analysis. Gynecological Surgery, 11: 197-206. doi: 10.1007/s10397-014-0842-8
3. Mara, M. Maskova, J., Fucikova, Z., Kuzel, D., Belsan, T., & Sosna, O. (2008). Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy. CardioVascular and Interventional Radiology, 31(1): 73-85.
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9. Manyonda, I. T., Bratby, M., Horst, J. S., Banu, N., Gorti, M., & Belli, A. M. (2011). Uterine artery embolization versus myomectomy: impact on quality of life–results of the FUME (Fibroids of the Uterus: Myomectomy versus Embolization) Trial. CardioVascular and Interventional Radiology, 35(3): 530-536. doi: 10.1007/s00270-011-0228-5