In 2013, the Dutch national guidelines on heavy menstrual bleeding were updated to include, for the first time, a recommendation that uterine artery embolization (UAE) be part of counselling for patients with symptomatic fibroids. Despite this, no increase in the number of UAEs being performed in The Netherlands was observed between 2012 and 2014, according to a recent report published in Cardiovascular and Interventional Radiology (CVIR) Endovascular by Annefleur de Bruijn (Amsterdam University Medical Center, Amsterdam, The Netherlands) and colleagues.
The study authors aimed to evaluate the implementation of UAE in The Netherlands and investigate influential factors concerning gynaecologists’ preference, counselling differences and knowledge. “The UAE/hysterectomy ratio in 2014 was 6.9”, they report, a calculation the authors deem “unacceptably low for a procedure with solid scientific level 1 evidence”.
Indeed, de Bruijn et al write that some “‘urban embolization myths’ tend to persist”, with 40% of gynaecologists in hospitals that do not perform UAE doubting the effectiveness of the procedure. In hospitals that do perform UAE, nearly half of the gynaecologists overestimate the chance of a surgical intervention after the minimally invasive procedure.
This research is specific to The Netherlands, but the authors say that “Although there is no scientific evidence from other European countries, oral communications at scientific meetings seem to support” their findings.
Approximately 10–30% of fertile women suffer from heavy menstrual bleeding, and in 40% of these women, fibroids are present. Although multiple randomised controlled trials have concluded that UAE is a valid, safe, and effective alternative to hysterectomy for patients with symptomatic uterine fibroids, when de Bruijn et al initiated their study, they believed the procedure was “offered infrequently” and that its implementation seemed “slow”.
The 2013 national guidelines published in The Netherlands recommend informing the patient of the following outcomes five years after the initial treatment (UAE versus hysterectomy):
- An improved quality of life comparable to that of patients who underwent hysterectomy
- Faster recovery and return to work after UAE compared to hysterectomy
- In 75% of patients who underwent successful UAE, no hysterectomy was needed
The study investigators asked all 82 Dutch UAE performing and non-UAE performing hospitals to send their annual reports detailing the number of hysterectomies performed. Information about the number of UAEs performed over the same time period was requested from the interventional radiology departments of each hospital. Of 30 requests sent out to UAE performing hospitals, 29 (91%) returned the desired information; 36 of 52 (69%) non-UAE performing hospitals returned the data. The calculated UAE/hysterectomy ratios were 7%, 7% and 6.9% in 2012, 2013, and 2014, respectively.
Additionally, de Bruijn and colleagues sent out questionnaires to the hospitals’ gynaecologists—they received a response from 43 gynaecologists at UAE performing hospitals and from 43 gynaecologists at non-UAE performing hospitals.
The survey indicates that gynaecologists working at UAE performing hospitals counsel more patients for UAE compared to their colleagues at non-UAE performing hospitals. Those working at hospitals that did conduct UAE estimated they counselled a median of 20 patients a year, as opposed to just 10 patients a year at non-UAE performing centres. Furthermore, where UAE was performed, 64% of the hospitals (18 out of 28) involved interventional radiologists in the counselling process. At the remaining 10 institutions that do not involve the interventional radiologists in patient counselling but which do perform UAE, 57% of the gynaecologists thought it should be standard practice to include them.
Over a third of gynaecologists at non-UAE performing hospitals (37%, or 16 of 43) think interventional radiologists should not be involved with patient counselling. At non-UAE performing hospitals, 26% (11 of 43) of gynaecologists think interventional radiologists should not be involved in the patient counselling process; an additional 28% (12 of 43) think they should be involved only if that is the patient’s preference.
The authors advocate for the involvement of interventional radiologists in the counselling process. Over half (51% in UAE+ hospitals and 52% in UAE- hospitals) the gynaecologists working across all the hospitals surveyed mentioned that the patient declines UAE when counselled. de Bruijn and colleagues blame the lack of interventional radiologists in the counselling process, pointing to the fact that gynaecologists from all hospitals tend to overestimate the risk of reintervention. To illustrate this, they highlight how the gynaecologists indicated the statement “the secondary hysterectomy rate is 50%” to be true. de Bruijn et al respond: “Literature (and also the guidelines) state there is a secondary hysterectomy rate of 28% after five years of follow up and 31% secondary hysterectomies after 10 years. Apparently this has not reached the surveyed gynaecologists”.
They suggest “Good counselling should be based on facts and should be free of personal preferences of the health care professional. In the case of UAE, counselling is mostly performed by the physician that does not execute the actual procedure. This could be a major influence [on patients turning down UAE]”.
To overcome this knowledge gap, and to promote the possibility of UAE as a treatment option for patients with symptomatic fibroids, the study authors propose the development of an option grid or decision making tool “in order to offer independent counselling and encourage shared decision making”. They also recommend a standard multi-disciplinary consultation for patients with fibroids.