Empowering Women
By Rebecca Montz, EdD, MBA, CNMT, PET, RT(N)(CT), NMTCB RS
Radiology Today
Vol. 26 No. 4 P. 22
Alternatives to Surgery for Uterine Fibroids
Uterine fibroids, or leiomyomas, are benign tumors of the uterus that, although noncancerous, can severely affect a woman’s health, often going unnoticed until symptoms become overwhelming. Affecting 70% to 80% of women by age 50, fibroids impact both white and Black women, with a notably higher prevalence in Black women.
While many women remain asymptomatic, 25% to 50% will face disruptive symptoms such as heavy menstrual bleeding, pelvic pain, frequent urination, and pressure on surrounding organs. When medical management is insufficient, potential treatments for uterine fibroids include hysterectomy, myomectomy, and uterine artery embolization (UAE), among others.
Given the severity of these symptoms, early detection and timely intervention are crucial, especially as treatments such as UAE remain underutilized. Despite their prevalence, many women delay seeking treatment until symptoms worsen, highlighting the need for proactive detection. Medical imaging techniques such as ultrasound and MRI are essential in diagnosing fibroids, helping clinicians assess key factors such as size, location, and characteristics to guide effective treatment decisions.
UAE: Underutilized Treatment Option
UAE, a minimally invasive, nonsurgical procedure performed by interventional radiologists, offers an effective treatment for uterine fibroids. Through a small incision in the wrist or thigh, a catheter is guided to the fibroids, where tiny particles are injected to block blood flow, causing the fibroids to shrink. UAE effectively reduces heavy bleeding, alleviates uterine pain, and improves energy levels, with a faster recovery compared with traditional surgeries. It also helps prevent complications such as early menopause and sexual dysfunction. Despite its proven effectiveness for over 20 years, the Society of Interventional Radiology (SIR) reports that 74% of women are unaware of UAE, underscoring the need for health care providers to offer comprehensive information to help women make informed treatment choices.
UAE remains surprisingly underutilized as a treatment for uterine fibroids. Several key barriers hinder its widespread adoption. First, there is a significant lack of awareness among both patients and health care providers. Many gynecologists, more familiar with traditional surgical options such as hysterectomy or myomectomy, may prefer these well-established treatments due to their long-term outcomes. Nikki Keefe, MD, an interventional radiologist at the University of North Carolina, points out that biases in medical decision making and limited collaboration between gynecologists and interventional radiologists play a significant role in the lack of awareness surrounding uterine fibroid treatment options. The need for referral to a specialist and misconceptions about the outcomes of UAE result in it being offered less frequently than alternatives such as myomectomy, despite evidence showing that UAE provides comparable quality-of-life outcomes and long-term efficacy, based on the FEMME and EMMY trials.
Financial and insurance issues also play a significant role in the underuse of UAE. While UAE is less costly than traditional surgeries, the procedure is performed by interventional radiologists and, therefore, typically requires referral from another specialty/practice for consultations. Financial incentives associated with treating with surgery may deter gynecologists from referring patients to an interventional radiologist for a less invasive and less costly UAE.
Moreover, limited access to specialized technology, especially in rural or underserved areas, exacerbates the issue. The availability of IR services is crucial for performing UAE, and without these resources, patients may face significant challenges in accessing the treatment. Cultural and societal factors, including misinformation surrounding nonsurgical treatments, further contribute to the underutilization of UAE.
Nicole Lamparello, MD, an interventional radiologist at Weill Cornell Medicine, emphasizes the importance of increasing education to combat misconceptions about the safety and efficacy of UAE. She points out that recent studies have demonstrated that pregnancy is achievable after UAE, addressing concerns about fertility preservation that may deter referrals. Both Keefe and Lamparello underscore the need for greater awareness among patients and clinical knowledge among health care providers about UAE relative to other available treatment options. By addressing these barriers, more women can be offered UAE as a viable and effective treatment option, empowering them to make more informed decisions about their care.
Questions About Access
Several barriers contribute to this disparity, highlighting the need to address these challenges to improve access to care. Lamparello notes the complex disparity in access to UAE between low- and high-income women: Broader health care inequalities, such as differences in insurance coverage, geographic access, financial resources, education, and overall health, significantly contribute to the problem.
Access to advanced health care treatments is often unequal, particularly for low-income women and those in rural or underserved areas. Generally, access to the most advanced medical care is closely tied to insurance status— patients with commercial insurance are more likely to receive cutting-edge treatments. This is economically logical, as providers are inclined to locate advanced services in settings where the payer mix is more favorable.
Women in higher income brackets are more likely to have comprehensive insurance and access to health care providers offering specialized treatments such as UAE. Conversely, lower-income women often face delays in diagnosing uterine fibroids and encounter challenges such as limited health literacy and lack of support systems, which make it harder to navigate the medical system and advocate for minimally invasive treatments. To address these disparities, Lamparello underscores the importance of systemic changes that ensure equitable access to innovative treatments like UAE for all women, regardless of their income.
Eric Christensen, PhD, research director at the Harvey L. Neiman Health Policy Institute, says market dynamics often influence where and how advanced care is delivered. However, the “twist” is that this pattern does not hold true for UAE. In this case, the “treat-or-refer” decision uniquely alters access: Unless a patient is already aware of UAE and actively advocates for it, she may never be offered the option— regardless of her insurance status.
Keefe observes significant trends in the utilization of UAE, emphasizing the distinct and paradoxical difference in use between the highest and lowest income quartiles. Interestingly, the largest number of patients receiving UAE are from the lowest income quartile, while the fewest come from the highest income quartile. This shift correlates with a decline in private insurance patients and an increase in Medicaid patients over the past decade. Keefe suggests that this growing discrepancy is likely due to Medicaid patients being more often treated in inpatient settings, whereas those with private insurance, especially in higher income brackets, are typically treated as outpatients or may not even be offered UAE as a viable option.
A Paradox
A recent study revealed an interesting fact by connecting UAE access to physician reimbursement levels, which can influence whether a gynecologist, who diagnoses uterine fibroids, decides to operate on a patient via hysterectomy or myomectomy, or if they refer the patient for a less invasive UAE. Christensen notes that financial incentives may cause gynecologists to disproportionately retain patients with commercial insurance and treat them with a hysterectomy or myomectomy, while disproportionately referring Medicaid patients, with lower payment rates, to interventional radiologists for UAE. The study by Christensen and colleagues, published in the Journal of the American College of Radiology, revealed that women with Medicaid are more likely to undergo UAE for uterine fibroids than those with commercial insurance. The analysis of data from over 579,000 women found that Medicaid patients were 38% more likely to receive UAE compared with women with commercial insurance.
Lead author Pratik Shukla, MD, an interventional radiologist at Rutgers New Jersey Medical School, further explains that gynecologists often face a “treat-or-refer” decision when medical management fails. “Ideally, these clinical decisions should be guided solely by patient needs and not influenced by reimbursement considerations,” he says. “However, our findings suggest that financial incentives may play a role in shaping referral patterns. Specifically, commercial insurance typically reimburses at higher rates than Medicaid, which can make patients with Medicaid coverage less financially attractive to providers. As a result, these patients may be more likely to be referred to other specialties or services, rather than being treated directly by the initial provider.” Shukla emphasizes the importance of increased collaboration between gynecologists and interventional radiologists to ensure that patients are fully informed about all treatment options, minimizing the impact of reimbursement on decision-making.
Geographic challenges add another layer to this issue. Women in rural or underserved areas often lack access to specialists, such as interventional radiologists, who perform UAE. In contrast, women in urban areas are more likely to have access to these specialists, further widening the gap in health care availability between rural and urban populations. As a result, many low-income women face significant barriers in accessing the specialized care required for treatments such as UAE. The Neiman Institute study found that women living in micropolitan and rural areas were 40% to 60% less likely to have a UAE procedure than women in metropolitan areas.
In addition to geographic limitations, cultural and educational barriers also contribute to inequities in access to care. Low-income women may not have access to information about nonsurgical options like UAE or be informed about it by their gynecologist, leaving them unaware that such treatments are available. This is why it is essential for gynecologists to provide the patient with a comprehensive understanding of their choices and facilitate more informed decision-making across all applicable treatment options.
It would typically be expected that women who have commercial insurance would be better informed and, therefore, have better access to UAE than Medicaid patients because health literacy is higher among higher income patients. Paradoxically, UAE is more common among women who have Medicaid, demonstrating the crucial nature of gynecologists’ treat-or-refer decisions in determining the treatment received by different patient groups. In light of these issues, addressing the barriers to accessing UAE is essential for ensuring that all women, regardless of income or geographic location, have equal access to effective, minimally invasive treatments.
Treatment Considerations
When determining the best treatment options for women with uterine fibroids, a comprehensive and collaborative approach is essential. This approach considers individual patient factors, symptom severity, and available therapies. Keefe emphasizes the importance of counseling patients on all available treatment options, including medical management, minimally invasive procedures such as UAE and endometrial ablation, and surgical options such as myomectomy and hysterectomy. Treatment decisions should be personalized, taking into account factors such as the size and configuration of the fibroids. Keefe highlights the significance of multidisciplinary care with gynecologists, especially for extremely large fibroids, as performing UAE first can reduce the size of a future hysterectomy incision and minimize blood loss during any subsequent surgeries, if needed.
Supporting this patient-centered approach, Lamparello emphasizes that the decision between UAE and more invasive procedures such as myomectomy or hysterectomy is a deeply personal one. UAE, in particular, is well-suited for women with symptomatic uterine fibroids or adenomyosis, especially those experiencing heavy menstrual bleeding and bulk symptoms. Ideal candidates for UAE typically include women with multiple fibroids under 12 cm in size, who prefer a minimally invasive, outpatient procedure with a shorter recovery time and lower complication rates. Ultimately, Lamparello stresses that the choice of treatment should align with the patient’s medical history, individual treatment goals, and personal preferences.
However, a significant barrier to making informed treatment decisions is the lack of awareness among patients about all available options. This gap in awareness is highlighted by a survey conducted by SIR, which revealed that only 17% of patients were presented with UAE as an option. Christensen says gynecologists often act as gatekeepers to treatment options, which can inadvertently limit patients’ understanding of alternatives. To address this issue, Shukla advocates for a more collaborative approach between gynecologists and interventional radiologists, ensuring that all treatment options, including UAE, are fully discussed, thus enabling patients to make well-informed decisions.
Further illustrating these concerns, a recent survey by The Harris Poll, commissioned by SIR, sheds light on significant gaps in awareness and treatment options for women with uterine fibroids. Over half (53%) of women diagnosed with fibroids were presented with hysterectomy as a treatment, while fewer than one in five were informed about less invasive options such as UAE (17%), oral contraceptives (17%), endometrial ablation (17%), or over-the-counter nonsteroidal anti-inflammatory drugs (19%). In fact, 17% of women mistakenly believe that hysterectomy is the only treatment, with 27% of women aged 18 to 34 holding this belief. The survey also found that 72% of women are unaware they are at risk for fibroids, despite 77% developing them in their lifetime. Fibroids disproportionately affect Black women, yet many women, including 50% of Hispanic women and 37% of Black women, are unfamiliar with the condition. Additionally, a significant portion of women believe they are not at risk, highlighting a critical knowledge gap.
This lack of awareness, particularly around treatments such as UAE, underscores the importance of a holistic and informed approach to addressing uterine fibroids. Treatment decisions should be made collaboratively, involving open discussions between patients and their health care providers. By ensuring that patients are fully informed of all available options, including minimally invasive treatments like UAE, health care providers can help women make the most appropriate choices tailored to their unique needs and preferences.
Unlocking Full Potential
To unlock the full potential of UAE as a treatment for uterine fibroids, it is crucial to address the barriers that hinder its widespread adoption. Medical imaging professionals play a key role in driving this change by leveraging their expertise to raise awareness, enhance referral systems, and tackle financial and technological obstacles. By educating both patients and health care providers about the benefits of UAE and the proper use of imaging techniques such as MRI and ultrasound, this minimally invasive procedure can be positioned as a preferred treatment option. In addition, streamlining the referral process through improved collaboration between gynecologists and interventional radiologists will ensure that patients are aware of all available treatments, enabling more informed and timely decisions. Finally, addressing misconceptions about UAE and presenting evidence on its long-term efficacy will help shift perceptions and encourage broader adoption.
This need for education and collaboration is echoed by Shukla, who highlights the ways that financial incentives can influence treatment decisions. While physicians may not intentionally base their choices on reimbursement, the impact of financial considerations becomes more pronounced when multiple treatment options are available. By focusing on education, improving referrals, expanding access, and changing perceptions, medical imaging professionals can help make this life-changing treatment more accessible, ultimately improving the health and quality of life for women suffering from uterine fibroids.
— Rebecca Montz, EdD, MBA, CNMT, PET, RT(N)(CT), NMTCB RS, has worked at the Mayo Clinic Jacksonville and University of Texas MD Anderson Cancer Center in Houston as a nuclear medicine and PET technologist.