Dr. Van Meter's Interview
Dr. Wallner's Interview
Dr. Travis Van Meter is currently the medical director at Methodist Dallas Medical Center, Department of Radiology. He attended medical school in Houston, Texas and went on to a residency in Radiology at Emory University in Atlanta, Georgia. Following residency, he stayed on at Emory for additional fellowships in Mammography and Interventional Radiology. Today, he is part of a large private practice group performing full time Interventional Radiology in Dallas, Texas.
Fibroids1: What attracted you to the field of Interventional Radiology?
Dr. Van Meter: Interventional Radiology (IR) is a very interesting and dynamic field that is always changing and evolving. New techniques are always being developed and it’s very exciting to be a part of such a field. Twenty years ago, IR was basically just angiograms. Now we perform so many different types of treatments. Fibroids are a growing part of our practice, but it’s still a small part of what we do as Interventional Radiologists.
Fibroids1: What is the most frequently asked questions you get from your patients about the uterine embolization procedure?
Dr. Van Meter: All the patients want to know if it will work for them. Patients are looking for an effective treatment that is less invasive with a shorter recovery than the standard hysterectomy or myomectomy treatment options.
Fibroids1: How do you answer their concerns?
Dr. Van Meter: We offer uterine fibroid embolization as an option for those patients who are eligible candidates. For some women, a hysterectomy is a viable option and for others myomectomy is also an option. But I think that women who are considering a hysterectomy are finding that fibroid embolization a very good alternative. It has a short recovery time with a high success rate. Many patients have full-time careers and they don’t want to be away from their work for four to six weeks. They want something with a short recovery, with the least effect on their routine.
Fibroids1: How well informed are your patients?
Dr. Van Meter: Most of the women that we see are well informed. Those who are self-referred have read up about UFE on the Internet or seen it on the news and have usually investigated all their choices. A lot of the time, the patient has been referred to us by an OB/GYN after they have asked about the procedure. Sometimes the OB/GYN is not as familiar with the procedure as we are, so they will send them to us for a consultation and an in-depth discussion.
Fibroids1: Considering the other options, are most of your patients relieved to find out about this procedure?
Dr. Van Meter: I think a lot of them are. Most women who come to us know this is an option and are coming to explore it further. If it’s something they qualify for, they are relieved and excited they have an alternative.
Fibroids1: When you are discussing the uterine embolization procedure what’s the biggest knowledge gap that you see?
Dr. Van Meter: I think the biggest knowledge gap involves the details of the procedure and aftercare. Most of the patients are pleasantly surprised that it doesn’t take four to six weeks to get back to work and that most can get back to work the following week if desired. They are happy there are other options available. Some of them are surprised they haven’t heard about it sooner and the lack of general information about the procedure. Everyone has heard of a hysterectomy, but not many people know about uterine fibroid embolization.
Fibroids1: Do you find it easier to create a treatment plan when your patient is well educated and knowledgeable?
Dr. Van Meter: I think patients who have fibroids understand the bigger picture better than some patients with other conditions. Most of our patients are very motivated and want to get better as soon as possible.
Fibroids1: What advice do you give to patients looking at embolization?
Dr. Van Meter: I recommend to them to consider all their options. Sometimes a hysterectomy or myomectomy is the best option given certain circumstances. However, often the less invasive procedure, uterine fibroid embolization, offers women an effective treatment with a short recovery.
Fibroids1: Who would be a good candidate?
Dr. Van Meter: Patients who have symptoms of excessive bleeding that are caused by fibroids are good candidates. Women who have large fibroids pushing on their urinary bladder causing frequency of urination are also good candidates. Women who have other conditions that produce symptoms that mimic those of fibroids, are not good candidates. Sometime women with endometrial hyperplasia, endometriosis, or adenomyosis can have symptoms that are similar to those of patients with fibroids. However, these patients are not candidates for the procedure. Part of the evaluation we do for women with symptoms of fibroids is a history and physical exam, as well as an MRI. Both fibroids and the conditions that mimic fibroids are seen on the MRI.
Fibroids1: How do you tell a patient that she isn’t a good candidate when she was expecting to have the treatment?
Dr. Van Meter: Most of the time, the patient understands. After all, 10 years ago, there really weren’t many options and a lot of women grew up thinking a hysterectomy was the only choice. Often, they are a little disappointed, but understand that some of the newer technologies are focused on specific diseases and don’t treat all causes of heavy menstrual bleeding.
Fibroids1: Do you find there is a lot of emotional charge to discussing the possibility of a hysterectomy?
Dr. Van Meter: Some patients are very sensitive to the fact that they are considering having their uterus removed. For other women, it is not so much an issue. The reaction is very individual. Some women are really concerned about having the surgery and what it will do with their hormone levels and sex drive. Some women just want it (the fibroids and uterus) out and so for them, hysterectomy is a good option. You have to listen to the patient and understand where they are coming from and respect their decision to do one or the other. I try to explain the options and then let the patient decide what best suits their personality and their situation.
Fibroids1: What percent of the patients end up receiving fibroid embolization treatment?
Dr. Van Meter: Probably greater than 90 percent of the women who come qualify for this type of procedure. It is a relatively small percentage of women that don’t qualify or for whom hysterectomy is strongly recommended. Many women have multiple options and it becomes their decision.
Fibroids1: How successful is the treatment?
Dr. Van Meter: It’s usually about 85 percent successful in treating the patient’s symptoms. The vast majority of patients are satisfied with their reduction in bleeding symptoms to the extent that no further treatments are needed.
Fibroids1: How would you explain the process in layman’s terms?
Dr. Van Meter: An angiogram is performed through a small nick in the skin by the groin. A small catheter is inserted in to the artery that feeds the blood to the fibroids. Small particles are then injected into the artery to stop the flow of blood to the fibroid. Once the flow of blood is stopped, the fibroid dies and over time will shrink. The patient’s symptoms improve after the blood flow to the fibroids is cut off. The uterus is not affected because its blood supply is not cut off.
Fibroids1: What are the side effects?
Dr. Van Meter: Everyone has cramping after the procedure to some degree. The cramping is just the fibroid’s way of saying it’s not getting enough blood. This is what we expect. The cramping is much less the next day and decreases further the next several days. By the following week, patients are off the medication altogether.
Fibroids1: Are patients worried about side effects?
Dr. Van Meter: Most of them are not really concerned. The materials are safe and durable so they don’t pose a risk in terms of allergic reactions. Most of the women know the risk for hysterectomy or myomectomy and major surgery. The complications for major surgery are much higher than a procedure done through a small catheter.
Fibroids1: Can this procedure be repeated, if needed?
Dr. Van Meter: The procedure can be repeated but that is really unusual. Sometimes if the fibroids don’t shrink, the reason is usually an alternative blood supply feeding them and keeping them alive. Often that blood supply is never identified and you can’t embolize it. Most women who have a good result early usually don’t need to have the procedure repeated. It’s very uncommon for women to develop new fibroids that would require this procedure, unless the treated woman was very young. Most of the women we see are between 35 and 45 and have had children. To develop new fibroids that would require treatment at this age is uncommon. After menopause, fibroids will shrink naturally due to the lack of hormonal stimulation.
Fibroids1: You work with four other interventional radiologists pooling your resources. How does that work, coordinating everything?
Dr. Van Meter: Well, we have a nurse and nurse practitioner working with all the IR doctors. They help with the patients, the clinic, follow-up phone calls, and help keep everything coordinated. The physicians work as a team to cover the practice. We all do the uterine embolization procedure so we are all familiar with the technique and how to handle the after care.
Fibroids1: Do you have a favorite piece of equipment that you couldn’t do without?
Dr. Van Meter: Yes. Some of the catheters that have been developed specifically for the procedure are really very unique and helpful. They make the procedure go quickly and effectively. Some of the techniques have been perfected over the last few years and have helped immensely.
Fibroids1: What kind of advances would you like to see five to 10 years down the road?
Dr. Van Meter: I think uterine fibroid embolization will be performed on an outpatient basis one day. You come in and leave the same day. I think that will develop into the standard because of advancements in medical management before, during and after the procedure. Women will be able to go home even sooner and be even happier with the procedure. I know the patients will just love it.
Contact Dr. Van Meter
Richard L. Wallner M.D. has practiced gynecology at Methodist Charlton Medical Center in Dallas since 1984. He has served as Department Chief and as President of the hospital staff. He currently maintains an active private practice in gynecology and gynecologic surgery.
Fibroids1: What are the most frequently asked questions that you hear from your patients?
Dr. Wallner: Number one, if they don’t have symptoms from their fibroids, do they have to be treated? I see that quite a lot because in my patient population, I would say 30-40 percent of the women over 40 will have fibroids. We bring up the fibroids often as an incidental finding and patients really want to know if they have to be treated if they have no symptoms.
Fibroids1: And what’s your answer?
Dr. Wallner: My answer is no. They’re a common thing and if we’re relatively certain that nothing else is going on, such as an ovarian enlargement, I tell them we can just watch the fibroids. If they develop heavy bleeding or pain or significant pressure, then we can discuss other options.
Fibroids1: What percentage do need treatment?
Dr. Wallner: I would say approximately 25 percent need surgical, medical or embolic therapy.
One important group is those who have had reproductive problems due to fibroids. Occasionally we have to operate on women who have a history of recurrent pregnancy loss or premature delivery, because their fibroids have been associated with pregnancy loss or premature labor.
Fibroids1: What are some risks associated with fibroids, besides pain and discomfort?
Dr. Wallner: There is a very small chance, but one patients should be aware of, that they can be cancerous. Fibroids turn out to be sarcomatous less than 1 percent of the time. There have been reports of people being followed for fibroids and treated for fibroids when they actually have cancer. And that’s particularly of concern when fibroids grow very rapidly not in association with pregnancy.
The other risk would be confusion with an ovarian tumor. If a patient has an exam and the clinician thinks they have found a fibroid, there’s always the possibility that it’s an ovarian mass of some type that appears to be a fibroid.
Fibroids1: Do women know a lot about fibroids? What are the biggest knowledge gaps that you see?
Dr. Wallner: Women know about their menstrual cycle but when it comes to abnormalities, they are like anyone else, they know as much as they are told by their doctor. Generally patients rely on their physician for information, and it needs to be given in such a way that the patient can understand it. The American College of Obstetricians and Gynecologists has a Web site (www.acog.org). Patients can also search the Internet for information on fibroids.
Fibroids1: If you were the editor of Fibroids1.com, what kind of articles would you like to see?
Dr. Wallner: I think educating patients about what fibroids are, when they need treatment, and also giving them a choice of treatments that would be reasonable for them. That would include observation, bleeding control with hormones, surgery and embolization techniques.
Fibroids1: You work with an interventional radiologist. Can you tell me how that works? How do the two of you work together?
Dr. Wallner: I first evaluate patients by taking their history and doing a physical examination. Often times they will undergo an ultrasound, followed by a discussion of treatment options. Sometimes before they decide on therapy, I will set up a consultation with the interventional radiologist and have the patient determine which treatment they think is right for them, either surgery or embolization. Usually after they’ve gone to the interventional radiologist, they will return to me and we’ll have a conversation about it and go forward with therapy.
Fibroids1: What are the most common treatments?
Dr. Wallner: I would say concerning surgical treatment, number one is hysterectomy; number two, myomectomy; number three, embolization. Mainly because embolization is the newest. Some gynecologists are concerned about using embolization on people that want to have future childbearing because the number of studies that have been done on that topic is limited. Until recently most of our knowledge of the long-term results of embolization have been by case studies. There have been a couple larger studies the last few years that show that embolization over a five-year period is as effective as removing the fibroids. But the issue of whether those patients should become pregnant is still in question. But embolization, like the other treatments is a viable option and should be offered to patients when indicated.
Fibroids1: What do you think are the most important advances that you’ve seen for treating fibroids in the last five years and what are you looking forward to in the next five or 10 years?
Dr. Wallner: Embolization is really the only thing in the last five years that’s provided a viable option other than surgery. That’s really the thing you need to look at because it’s relatively free of risk and it’s obviously less invasive than surgery. The cost effectiveness also needs to be studied though because while the procedure itself is fairly expensive, the hospital costs are generally less expensive. The issue of long-term effectiveness of the procedure needs to be looked at. I think that’s one area that we’re going to concentrate on in medicine, alternative therapies for many conditions that exclude surgery.
Fibroids1: Are there any really important aspects of fibroids that we haven’t covered?
Dr. Wallner: The only thing I would add is I think more study needs to be undertaken in the area of how fibroids affect female reproduction. We need to know how fibroids affect pregnancy and when we should take them out or treat them prior to pregnancy. This also goes along with further study of embolization in regards to treatment of those fibroids when patients want future pregnancy.