Did you know that one in three women will have a hysterectomy (surgical removal of the uterus) by age 60? It is the second most common surgical procedure among women in the United States. But the question is: are they all necessary? I had a fascinating interview with Dr. Elizabeth Stewart from the Mayo Clinic about some of the reasons behind the potential excess of this type of surgery. You may be surprised to learn that insurance reimbursement guidelines may have something to do with it.
Dr. Val: Women often undergo hysterectomies to treat painful fibroids (benign growths in the uterus). What do women need to know about their fibroid treatment options?
Dr. Stewart: They need to know that they have many different treatment options for uterine fibroids. A hysterectomy is not their only choice. Women should ask their doctor to explain all their options and also make sure that they have the correct diagnosis – menstrual cramping and heavy bleeding doesn’t necessarily mean you have fibroids.
Nowadays we can treat fibroids with hysterectomy, uterine artery ablation, or MRI-guided focused ultrasound surgery (MRgFUS). MRgFUS is a nearly painless procedure where we use focused ultrasound waves to destroy fibroid tissue via heat transfer. I know one woman who went back to work 2 hours after the procedure. Recovery from a hysterectomy or uterine artery ablation can take weeks to months.
Dr. Val: What are some of the advantages and disadvantages of treating fibroids with focused ultrasound?
Dr. Stewart: Focused ultrasound surgery is the only treatment technique that doesn’t require any incision into the body or anything inserted into the body. This gives it a major advantage over other techniques. Women might only take off 1-2 days from work rather than 1-2 weeks or 1-2 months depending on their recovery from the other options.
The major disadvantage is that the fibroids can recur in different parts of the uterus. Also, not everyone is a good candidate for the procedure. For example, obese women with BMIs over 40-41 may not be able to undergo the procedure due to the inability of the sound waves to fully penetrate through the fatty layer. Women with extensive fibroids throughout the uterus may not be good candidates for MRgFUS.
Dr. Val: Why aren’t more women opting for a non-invasive treatment over a hysterectomy?
Dr. Stewart: The major barrier to women receiving MRgFUS is insurance. Currently, very few insurance companies provide reimbursement for the procedure. As a physician it’s awkward when you know your patient is a good candidate for the procedure, but their insurance provider will not authorize payment for it.
Dr. Val: Why aren’t insurers paying for this procedure? It would seem to me that they’d save money on paying for a procedure that has a low complication rate and rapid recovery time.
Dr. Stewart: Well, the insurance companies don’t really save money – it’s the disability costs and indirect costs that are saved. Insurers are the ones who pay for the procedure, but employers are the ones who benefit from the savings. Large employer self-insured groups are eager to cover MRgFUS because it means fewer work days lost, and therefore higher worker productivity. Insurance companies often argue that they’d rather cover a hysterectomy than a MRgFUS procedure, because a hysterectomy is definitive procedure – the fibroids can’t come back, so women will never need another intervention down the road. Of course, that doesn’t mean that there won’t be interventions required because of the side effects of hysterectomy – for example there can be problems with prolapse, and if you also remove the ovaries you have to undergo long term hormonal replacement.
Another problem is that because of the newness of focused ultrasound, we don’t have long term follow up studies to demonstrate its efficacy 5 years out. At this point, we have published data that suggests that the durability can extend to at least 24 months. Our research group prepared an abstract which showed that the treatment can last 36 months. However what insurers want to see is long term data from multiple different sites. That’s also been a challenge because the technology is not available at many different centers since it is so new (and since it’s not reimbursable by insurance, cash-strapped hospitals are hesitant to invest in the technology – you can see the catch 22 here).
Dr. Val: But isn’t MRgFUS a way to preserve fertility in women who need fibroid treatment?
It is. At the Mayo Clinic, we just completed a large scale clinical trial on pregnancy rates after MRgFUS fibroid treatment. We studied 54 women who went on to become pregnant after MRgFUS, and we saw no increased rate in low birth weight or pre-term delivery. We are also doing a follow up trial to compare fertility rates after myomectomy (surgical removal of the fibroid) compared to focused ultrasound treatments. However, it may be challenging to recruit enough women to enroll in this study because they’re unlikely to hear about it from their doctors.
It’s alarming to me that women in their childbearing years (who have never had children) are being told that their only treatment option for their fibroids is hysterectomy. They are not always fully counseled about the risks and benefits and aren’t aware that there may be a better treatment available.
**For more information about MRgFUS, please contact the Focused Ultrasound Surgery Foundation**
**View my post at BlogHer**