Uterine Fibroid Embolization
Uterine fibroid embolization (UFE) or uterine artery embolization is a procedure that involves specific, targeted blockage of blood flow to uterine fibroids. The procedure is minimally invasive, meaning it only requires a small incision in the skin. UFE has been used for uterine fibroids in the US since 1996. This treatment has been available in Europe for more than 10 years, and has shown great promise. Approximately 6500-8500 women worldwide have had this procedure.
The use of embolization in the body is not a new concept. For at least 20 years, physicians have treated heavy bleeding after childbirth with embolization. Other body areas that hemorrhage (bleed excessively) are also treated with embolization.
In 1996, Scott Goodwin, MD, and his colleagues began using this procedure at UCLA in California. Other physicians noted the success of this innovative technique and began to study and adopt the practice. Interventional radiologists at Mount Sinai are specially trained to perform this procedure.
Patient Eligibility and Considerations
The ideal candidates for uterine fibroid embolization (UFE) are premenopausal women who have been screened for the presence of adenomyosis, endometriosis, and other potential causes of their symptoms.
Patients diagnosed with adenomyosis and/or endometriosis are not candidates for uterine artery embolization. Gynecologists treat these conditions with either medication or surgery.
Women who wish to avoid transfusion for health or religious reasons may prefer uterine fibroid embolization due to its lowered risk of bleeding. Women who want to bear children should discuss and consider the potential effect of UFE on fertility with their physician (see side effects section below). Patients who have uterine enlargement greater than 24-weeks gestation size may not benefit from this treatment, since a larger reduction in uterine size may be needed to obtain symptom relief.
UFE should not be performed in women who are pregnant or postmenopausal or in those who have cancer or active infection. Women with a severe allergy to contrast dye should not have the procedure. Those at risk for kidney problems associated with the use of contrast dye should be carefully screened before considering this procedure.
Advantages of UFE include the ability to treat multiple fibroids at one time, permanent death of fibroid tissue (no re-growth), the safety and effectiveness of the procedure, and the minimal invasiveness and rapid recovery time associated with UFE.
To ensure a safe and appropriate procedure, all patients considering UFE need a thorough health evaluation before the actual procedure.
The first step in the pre-procedure evaluation involves consultations with the gynecologist and the interventional radiologist. The treatment team will discuss the procedure and any other options with you. Thorough prescreening includes record of a normal Pap smear within the last year and your last two pelvic exams, one within the last 6 months. An endometrial biopsy should be performed for patients who have had abnormal levels of menstrual bleeding (more often than every 21 days or longer than 10 days at a time). Patients with a history of pelvic-area infection are tested for gonorrhea and chlamydia. The interventional radiologist will review your gynecologic and medical history as well as your diagnostic test results.
Every patient is scheduled for an MRI of the pelvis before the UFE. The MRI helps to pinpoint the current size, location, and extent of the fibroids and rules out the possibility of other conditions that may cause similar symptoms. Blood and urine samples are also taken to evaluate blood counts and blood clotting values, the possibility of pregnancy, and kidney function.
Description of the Procedure
The night before the procedure, you will receive instructions to abstain from eating and drinking so that we may safely sedate you on the day of the procedure. You may take sips of water with your regularly scheduled medication.
You will be asked to arrive 1-2 hours before the scheduled procedure. A nurse will start an intravenous line and take blood samples if needed. You will also have a urinary catheter inserted, so that the bladder is not full and will not block the view of the uterus during the procedure. Your groin area will be shaved and cleansed with betadine prior to the procedure.
You will receive sedation during the procedure, which means that you will be awake but drowsy. You will also receive local anesthesia or numbing of the groin area.
The interventional radiologist makes a small nick in the skin at the groin to access the femoral artery. The doctor then inserts a tiny tube called a catheter that moves through the artery to the uterus, using X-ray images to watch the tube as it moves. Contrast dye is injected so that the doctor can see a road map of the blood vessels, uterus, and fibroids. When the tube arrives in the uterine artery, the doctor directs it to the branches of the artery that allow blood to flow to the fibroids.
The doctor slowly injects tiny particles the size of a grain of sand into the area. The particles are made of polyvinyl alcohol (PVA) or gelatin sponge. The particles flow toward the fibroids and wedge in the blood vessels that feed the fibroids, blocking off blood flow to the fibroids. The doctor uses X-ray imaging to watch while the blood flow is blocked and make sure the blockage is complete. After this, the blood vessels on the other side of the body also need to be occluded. Sometimes this involves entering the groin area on the other side of your body. The fibroid tumors will begin to shrink once the blood flow is blocked. The entire procedure takes approximately 1-2 hours.
Immediately after the procedure, you will be asked to rest in bed for about 6-8 hours. This will allow the punctured artery to heal. Most women stay overnight in the hospital.
Most women report satisfaction with the procedure and with the results of the procedure. The rate of successful embolization is greater than 98 percent. Patients report improvement of symptoms within 6-8 weeks. Fibroids shrink by about 40 percent to 70 percent during this time, and the uterus size is decreased by up to 50 percent.
The most common side effect after the procedure is pelvic cramping. You will be given pain medicine. Some patients may have a patient-controlled analgesia (PCA) pump that allows them to safely administer their own pain medicine by pressing a button. Cramping may continue for several days following the procedure.
Other possible side effects include nausea, vomiting, and fever. These symptoms can be treated with medication. You may also have bleeding or bruising where the catheter was inserted in your groin area. Less common side effects include infection of the uterus or injury to the uterus.
In a severe case, a hysterectomy would be needed to correct these problems. It is also possible that the femoral artery could be damaged and could result in decreased blood flow to the leg. These problems occur in less than 1percent of patients.
Most women experience decreased menstrual flow following the procedure.
As you recover, fibroid tissue that has died may sometimes exit through the vaginal opening.
In 1-5 percent of patients, premature menopause can occur after the procedure. This usually occurs in patients who are already close to the time of menopause.
Since few women choosing this procedure have intended to have more children, there is limited information on the ability to conceive following this procedure. However, it has been documented that some women have conceived and given birth to children following this procedure.
Information on long-term side effects of UFE is limited, as the procedure is relatively new in the United States.
You will be asked to return for a visit within about 1 week. The doctor will check the puncture sites on your groin and where your intravenous line was inserted. You will be asked how you are feeling and whether you are having any problems or side effects. At this meeting, your doctor will review the results of your procedure and will schedule you for follow up evaluations of your fibroids.
You will be asked to keep track of your symptoms and your menstrual bleeding, so that the medical team can evaluate the results of your procedure.
You will be scheduled for evaluations at 3, 6, and 9 months and 1 year. At about 6 months to a year following the procedure, the doctor will repeat an MRI to compare the image of your uterus with your preoperative picture.