Uterine Fibroid Embolization (UFE)

What is Uterine Fibroid Embolization (UFE)?

Uterine fibroid embolization (UFE) is a minimally invasive treatment for fibroid tumors in the uterus.

Fibroid tumors, also known as myomas, are masses of fiber and muscle tissue in the wall of the uterus. Although these tumors are not cancerous, they may cause heavy menstrual bleeding, pain in the pelvic region and pressure on the bladder or bowel.

In a uterine fibroid embolization procedure, physicians use image guidance to place a synthetic material called an embolic agent inside one or more of the blood vessels that supply the fibroid tumors with blood. As a result, these vessels become occluded, or closed off, and the fibroid tissue shrinks. In most cases, symptoms are relieved.

What are some common uses of the procedure?

Uterine fibroid embolization is most often performed to:

• treat symptoms caused by fibroid tumors.
• stop severe bleeding caused by malignant gynecological tumors or associated with childbirth.

Because the effects of uterine fibroid embolization on fertility are not yet known, the ideal candidate is a pre-menopausal woman with symptoms from fibroid tumors who no longer wishes to become pregnant but wants to avoid having a hysterectomy, in which the uterus is surgically removed. Uterine fibroid embolization may be an excellent alternative for women who, for reasons of health or religion, do not want to receive blood transfusions, which may be necessary during open surgery. The procedure also benefits women who, for any reason, cannot receive general anesthesia.

How should I prepare?

Imaging of the uterus by magnetic resonance imaging (MRI) or ultrasound will be performed prior to the procedure to ensure that fibroid tumors are the cause of symptoms and to fully assess the size, number and location of the fibroids.

Occasionally, your gynecologist may want to take a direct look at the uterus by performing a laparoscopy. If bleeding is a major symptom, a biopsy of the endometrium, the inner lining of the uterus, may be performed to rule out cancer.

You should report to your doctor all medications that you are taking, including herbal supplements, and if you have any allergies, especially to anesthesia or to contrast materials (also known as "dye" or "x-ray dye"). Your physician may advise you to stop taking aspirin or a blood thinner for a specified period of time days before your procedure.

Also inform your doctor about recent illnesses or other medical conditions.

Women should always inform their physician or x-ray technologist if there is any possibility that they are pregnant. Many imaging tests are not performed during pregnancy because radiation can be harmful to the fetus. If an x-ray is necessary, precautions will be taken to minimize radiation exposure to the baby. See the Safety page for more information about pregnancy and x-rays.

You may be instructed not to eat or drink anything after midnight before your procedure. Your doctor will tell you which medications you may take in the morning.

You should plan to stay overnight at the hospital following your procedure.

You will be given a gown to wear during the procedure.

What does the equipment look like?

In this procedure, x-ray equipment, a catheter and a variety of synthetic materials and medications called embolic agents are used.

The equipment typically used for this examination consists of a radiographic table, an x-ray tube and a television-like monitor that is located in the examining room or in a nearby room. When used for viewing images in real time (called fluoroscopy), the image intensifier (which converts x-rays into a video image) is suspended over a table on which the patient lies. When used for taking still pictures, a drawer under the table holds the x-ray film or image recording plate that captures the images.

A catheter is a long, thin plastic tube, about as thick as a strand of spaghetti.

Several different types of embolic agents are used for uterine fibroid embolization. Most are small, synthetic particles, including:

• polyvinyl alcohol, a material resembling coarse sand
• Gelfoam™, a gelatin sponge material
• microspheres.

All of these have been shown to be safe and effective for uterine fibroid embolization.

Other equipment that may be used during the procedure includes an intravenous line (IV) and equipment that monitors your heart beat and blood pressure.

How does it work?

A uterine fibroid embolization procedure involves inserting a catheter through the groin, maneuvering it through the uterine artery, and injecting an embolic agent (small synthetic particles) into the arterial branches that are supplying blood to the fibroids. Blocking blood flow to the fibroids causes them to shrink.

How is it performed?

Image-guided, minimally invasive procedures such as uterine fibroid embolization are most often performed by a specially trained interventional radiologist in an interventional radiology suite or occasionally in the operating room.

You will be positioned on the examining table.

You will be connected to monitors that track your heart rate, blood pressure and pulse during the procedure.

A nurse or technologist will insert an intravenous (IV) line into a vein in your hand or arm so that sedative medication can be given intravenously. You may also receive general anesthesia.

The area of your body where the catheter is to be inserted will be shaved, sterilized and covered with a surgical drape.

Your physician will numb the area with a local anesthetic.

A very small nick is made in the skin at the site.

Using x-ray guidance, a catheter (a long, thin plastic tube) is inserted through the skin into your femoral artery. A contrast material may be injected through your IV to map a route for the catheter as it is maneuvered into your uterine arteries. Once the catheter has reached the site of the fibroids, the embolic agent is injected until blood flow in the uterine arteries feeding the fibroids is blocked. In most cases, both uterine arteries can be treated during a single catheter insertion.

At the end of the procedure, the catheter will be removed and pressure will be applied to stop any bleeding. The opening in the skin is then covered with a dressing. No sutures are needed.

Your intravenous line will be removed.

You will most likely remain in the hospital overnight so that you may receive pain medications and be observed.

This procedure is usually completed within 90 minutes.

What will I experience during and after the procedure?

Devices to monitor your heart rate and blood pressure will be attached to your body.

You will feel a slight pin prick when the needle is inserted into your vein for the intravenous line (IV) and when the local anesthetic is injected.

The intravenous (IV) sedative will make you feel relaxed and sleepy. You may or may not remain awake, depending on how deeply you are sedated.

You may feel slight pressure when the catheter is inserted but no serious discomfort.

As the contrast material passes through your body, you may get a warm feeling.

While you are in the hospital, your pain will be well-controlled with a narcotic.

After staying overnight at the hospital, you should be able to return home the day after the procedure.

You may 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 pain medication delivered through your IV.

Once you return home, you may take pain medication taken by mouth. You should be able to return to your normal activities within one to two weeks after uterine fibroid embolization.

It usually takes two to three months for the fibroids to shrink enough so that symptoms such as pain and pressure improve. It is common for heavy bleeding to improve during the first menstrual cycle following the procedure.

Who interprets the results and how do I get them?

The interventional radiologist will interpret the results and will coordinate appropriate follow-up care with your primary care physician or gynecologist.

What are the benefits vs. risks?

Benefits

• Uterine fibroid embolization, done under local anesthesia, is much less invasive than open surgery done to remove uterine fibroids or surgically removing the uterus itself (a hysterectomy).
• No surgical incision is needed—only a small nick in the skin that does not have to be stitched closed.
• 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.
• 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 for women with heavy bleeding and for those with bulk-related symptoms such as pelvic pain or pressure. On average, fibroids will shrink to half their original size six months after uterine fibroid embolization.
• 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 early-stage masses that may be too small to see on imaging studies, are treated during the procedure. Uterine fibroid embolization 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

• Any procedure that involves placement of a catheter inside a blood vessel 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.
• Any procedure where the skin is penetrated carries a risk of infection. The chance of infection requiring antibiotic treatment appears to be less than one in 1,000.
• There is always a chance that an embolic agent can lodge in the wrong place and deprive normal tissue of its oxygen supply.
• 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 UFE are carefully monitored by a physician and a nurse during the procedure, so that any allergic reactions can be detected immediately and reversed.
• 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 dies 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.
• 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.
• 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.
• 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.
• 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 who have had the procedure. Because of this uncertainty, physicians may recommend that a woman 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 UFE 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.

What are the limitations of Uterine Fibroid Embolization (UFE)?

Uterine fibroid embolization should not be performed 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 women who are pregnant or in women whose 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.