Addressing Disparities in Care in Women’s Reproductive Health - Episode 5

A Changing Treatment Paradigm in UF

Dr Ayman Al-Hendy details the shift from surgical options to medical therapy for patients with UF.

Ayman Al-Hendy, MD, PhD, FRCSC, FACOG, CCRP: In terms of treatment of fibroids and what would be considered first line, unfortunately there’s no clear guidance. For example, the ACOG, the American College of Obstetricians and Gynecologists, released updated guidance in June 2021; the previous 1 before that was in 2008. For 13 years, there was no update, but there was a lot of new development in the field. Finally, ACOG decided to issue an update. There was a general description of the different treatment options available, but there was no algorithm or clear guidance on what the first line is. As a gynecologist and a minimally invasive surgeon, I think that’s good because it kept the field open for new development. We were able to do a patient-centered approach to cater treatment for the patient’s needs, but it also instilled confusion on some of that.

I’d like to divide the treatment option for fibroids into 3 categories: surgical, procedure, and medical therapy. The surgical group includes hysterectomy, removing the whole uterus with the fibroid in it; myomectomy, removing the fibroid and then suturing the uterus back together; and endometrial ablation, where we burn or ablate the lining of the uterus and endometrium, to control bleeding. We don’t touch anything else, so the fibroid is still there. But we control the bleeding, which is the most common symptom. Under the procedure, which has mostly been developed by our colleagues in radiology, there are things like uterine artery embolization, which cuts the blood supply to the fibroid with the hope that they’ll shrink, and MRI-guided focused ultrasound. In the medical group, that’s the exciting and expanding group. It includes anything that you prescribe to the patient to take by mouth or by injection that can help alleviate the symptoms and improve the patient’s quality of life.

I counsel my patients by presenting it like this: fibroid should be considered like any other disease. With each resident and medical student, you should always try to start with simple medical treatment options. If they’re available, they’re effective and safe. Only if they fail, or if the patient isn’t eligible for those, then you’ll go to the more invasive and involved treatment options, like procedure and surgery. Until 2 years ago, there were no FDA-approved medical treatment options for fibroids, so surgery was developed as the first line of treatment. This was either in the form of hysterectomy or myomectomy. Hysterectomy is more common. In the United States, we do more than 600,000 hysterectomies every year. It’s the second most common surgery after Cesarean section, so ob-gyns do the first and second most common surgery—not a record we’re proud of. For myomectomies, we do about 30,000 every year in the United States. They developed to be the first line, which in my opinion isn’t appropriate. It’s probably 1 of the only diseases that we always start a surgery with. With the availability of FDA-approved long-term treatment options that are safe and reliable, we must rearrange this algorithm and advocate for medical treatment options first and then surgery for those who failed medical treatment.

This transcript has been edited for clarity.