Uterine Fibroid Embolization
What is Uterine Fibroid Embolization?
Uterine fibroid embolization (UFE) is a new way of treating fibroid tumors
of the uterus. Fibroid tumors, also known as myomas, are masses of fibrous
and muscle tissue in the uterine wall which are benign, but which may cause
heavy menstrual bleeding, pain in the pelvic region, or pressure on the
bladder or bowel. With angiographic methods similar to those used in heart
catheterization, a catheter is placed in each of the two uterine arteries
and small particles are injected to block the arterial branches that supply
blood to the fibroids. The fibroid tissue dies, the masses shrink, and
in most cases symptoms are relieved. Uterine fibroid embolization, done
under local anesthesia, is much less invasive than open surgery done to
remove uterine fibroids. The procedure is performed by an experienced interventional
radiologist, a physician specially trained to perform uterine fibroid embolization
and similar procedures.
Uterine fibroid embolization was first used to limit blood loss during surgical
removal of fibroid tumors. It was found that after embolization and while
awaiting surgery, many patients no longer had symptoms, and frequently
the operation itself proved not to be necessary. Today uterine fibroid
embolization is used as a stand-alone treatment for women who have symptom-producing
uterine fibroids.
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What are some common uses of the procedure?
By far the most common reason for embolizing the uterine arteries is to
treat symptoms caused by fibroid tumors. This is accomplished by stopping
the growth of fibroid tumors and attempting to shrink them. Because the
effects of uterine fibroid embolization (UFE) on fertility are not yet
known, the ideal candidate is a premenopausal woman with symptoms from
fibroid tumors who no longer wishes to become pregnant, but wants to avoid
having a hysterectomy (surgical removal of the uterus). Uterine fibroid
embolization may be an excellent alternative for women who, for reasons
of health or religion, do not want to receive blood transfusions—as
may be necessary if open surgery is carried out. The procedure also benefits
women who for any reason cannot receive general anesthesia.
Embolization of the uterine arteries also may be used to halt severe bleeding
following childbirth or caused by malignant gynecological tumors.
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How should I prepare for the procedure?
A woman considering uterine fibroid embolization needs a gynecological work-up
to make sure that fibroid tumors are the actual cause of her symptoms.
Imaging of the uterus by magnetic resonance imaging (MRI) or ultrasonography
is performed to fully assess the size, number and location of the fibroids.
Occasionally your gynecologist may want to take a direct look by performing
laparoscopy. If bleeding is a major symptom, a biopsy of the endometrium—the
inner lining of the uterus—may be done to rule out cancer.
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What does the equipment look like?
Several different types of particles are available for uterine fibroid embolization.
These include polyvinyl alcohol (a material resembling coarse sand), gelatin
sponge (Gelfoam), and microspheres. All of these types of embolization
agents have been shown to be safe and effective for uterine fibroid embolization.
Regardless of the type of particles used, they wedge in the uterine vessels,
avoiding the risk that they will travel to distant parts of the body.
How does the procedure work?
By blocking blood flow to the fibroids, uterine fibroid embolization in
effect "starves" them of the blood they need to grow. When deprived
of blood, the tumor masses die, and then develop into scar tissue and shrink
in size. The symptoms they previously caused become less bothersome or
disappear altogether. Multiple fibroids may be treated at the same session
by uterine fibroid embolization, and even very large ones can be effectively
treated by this procedure.
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How is the procedure performed?
Uterine fibroid embolization is carried out in an angiography suite equipped
with an x-ray machine, where sterile conditions are maintained. Your heart
rate, blood pressure, electrocardiogram, breathing and blood oxygen level
will be monitored constantly during the procedure, which typically takes
between 60 and 90 minutes.
After injecting a sedative to make you sleepy and a local anesthetic to
numb the skin at the groin, the interventional radiologist will make a
small nick in the skin less than a quarter inch long and thread a thin
tube (catheter) into the femoral artery. Using x-ray guidance, and periodic
injections of radiographic contrast material to map the blood vessels,
the catheter is threaded into the uterine arteries. Under x-ray observation,
the particles are injected until blood flow in the uterine arteries is
blocked. In most cases, both uterine arteries can be treated through a
single catheter insertion. After completing uterine fibroid embolization,
the site of skin puncture is cleaned and bandaged.
What will I experience during the procedure?
Most patients having uterine fibroid embolization remain overnight in the
hospital for pain control and observation. Patients typically experience
pelvic cramps for several days after uterine fibroid embolization, and
possibly mild nausea and low-grade fever as well. The cramps are most severe
during the first 24 hours after the procedure, and improve rapidly over
the next several days. While in the hospital, the discomfort usually is
well controlled with a narcotic pump, which dispenses intravenous pain
medication. Oral pain medication will be provided when you are discharged
home the following day. Most patients will recover from the effects of
the procedure within one to two weeks after uterine fibroid embolization,
and will be able to return to their normal activities.
It usually takes two to three months for the fibroids to shrink enough so
that bulk-related symptoms such as pain and pressure improve. It is common
for heavy bleeding to improve during the first menstrual cycle following
the procedure.
Most women are able to return to work one to two weeks after uterine fibroid
embolization, but occasionally patients take longer to recover fully.
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Who interprets the results and how do I get them?
The interventional radiologist who performs your procedure will interpret
the results and will work with your gynecologist or primary care physician
to ensure proper follow-up care.
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What are the benefits vs. risks?
Benefits
- Minimally invasive: Uterine fibroid embolization (UFE) is less invasive
than either open surgery to remove fibroid tumors, or surgically
removing the uterus itself. Patients ordinarily can resume their usual
activities weeks earlier than if they had a hysterectomy. Blood loss
during uterine fibroid embolization is minimal, the recovery time is
much shorter than for hysterectomy, and general anesthesia is not required.
- Relief of symptoms: Follow-up studies have shown that approximately
85 percent of women who have their fibroids treated by uterine fibroid
embolization experience either significant reduction or complete resolution
of their fibroid-related symptoms. This is true both for women with
heavy bleeding, and for those with bulk-related symptoms such as pelvic
pain or pressure. Overall, fibroids will shrink to half their original
size six months after uterine fibroid embolization.
- Durable effect: Follow-up studies lasting several years have shown
that it is rare for treated fibroids to regrow or for new fibroids
to develop after uterine fibroid embolization. This is because all
fibroids present in the uterus, even small early-stage masses that
may be too small to see on imaging studies, are treated during the
procedure. UFE is a more permanent solution than another option, hormone
therapy, because when hormonal treatment is stopped the fibroid tumors
usually grow back. Regrowth also has been a problem with laser treatment
of uterine fibroids.
Risks
- Catheter-related risks: Any
procedure that involves placement of a catheter inside a blood
vessel, including uterine fibroid embolization, carries certain
risks. These risks include damage to the blood vessel, bruising
or bleeding at the puncture site, and infection. When performed
by an experienced interventional radiologist, the chance of any of
these events occurring during uterine fibroid embolization is less
than one percent.
- Allergy to x-ray contrast
material: An occasional patient may have an allergic
reaction to the x-ray contrast material used during uterine
fibroid embolization. These episodes range from mild itching
to severe reactions that can affect a woman's breathing or
blood pressure. Women undergoing uterine fibroid embolization
are carefully monitored by a physician and a nurse during
the procedure, so that any allergic reactions can be detected immediately
and reversed.
- Passage of fibroid tissue: From two
percent to three percent of women may pass small pieces of fibroid
tissue after uterine fibroid embolization. This occurs when fibroid
tissue located near the lining of the uterus die and partially
detaches. Women with this problem may require a procedure called
D & C
(dilatation and curettage) to be certain that all the material
is removed so that bleeding and infection will not develop.
- Early onset menopause: In
the majority of women undergoing uterine fibroid embolization,
normal menstrual cycles resume after the procedure. However,
in approximately one percent to five percent of women, menopause occurs
shortly after uterine fibroid embolization. This appears to occur more
commonly in women who are older than 45 years when they have the procedure.
- Need
for hysterectomy: Although the goal of uterine
fibroid embolization is to cure fibroid-related symptoms
without surgery, some women may eventually need to have a hysterectomy
because of infection or persistent symptoms. The likelihood
of requiring hysterectomy after uterine fibroid embolization is
low—less
than one percent.
- X-ray exposure: Women are exposed to
x-rays during uterine fibroid embolization, but exposure levels
usually are well below those where adverse effects on the patient
or future children would be a concern.
- Future fertility: The
question of whether uterine fibroid embolization reduces
fertility has not yet been answered, though a number of healthy
pregnancies have been documented in women having the procedure. Because
of this uncertainty, physicians may recommend that a woman with symptom-producing
fibroids who wishes to have more children consider surgical removal
of the individual tumors rather than uterine fibroid embolization.
A majority of women who have uterine fibroid embolization are
no longer interested in childbearing. In some women, however, fibroid
tumors are the cause of infertility and the best treatment may be to
embolize them. For each individual it is difficult to predict whether
the uterine wall will be weakened enough by uterine fibroid embolization
to pose a problem during delivery of an infant. It may well be worthwhile
to do an ultrasound study in a pregnant woman who has had the procedure
so as to assess the state of the uterus.
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What are the limitations of Uterine Fibroid Embolization?
Uterine fibroid embolization (UFE) should not be done in women who have
no symptoms from their fibroid tumors; when cancer is a possibility; or
when there is inflammation or infection in the pelvis. Uterine fibroid
embolization also should be avoided in pregnant women and when the kidneys
are not working properly—a condition known as renal insufficiency.
A woman who is very allergic to contrast material containing iodine should
receive another treatment option.
At present, it remains difficult for women in some parts of the country
to learn about uterine fibroid embolization or make arrangements to have
the procedure. Not all gynecologists are familiar with this relatively
new method of treating uterine fibroids, and rely instead on the conventional
approach—surgery.
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