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Uterine Fibroids

Uterine Artery Embolization?
Diagram shows the catheter in the uterine
artery and embolic particles moving toward
the arterial supply to the fibroids

What is Uterine Artery Embolization?

Uterine artery embolization (UAE) is a minimally invasive treatment for fibroid tumors of the uterus. Fibroid tumors, also known as myomas, are benign tumors that arise from the muscular wall of the uterus. It is extremely rare for them to turn cancerous. More commonly, they cause heavy menstrual bleeding, pain in the pelvic region, and pressure on the bladder or bowel.

How does the procedure work?

The procedure involves inserting a catheter through the groin, maneuvering it through the uterine artery, and injecting embolic agent into the arteries that supply blood to the uterus and fibroids. As the fibroids die and begin to shrink, the uterus fully recovers.

How is the procedure performed?

UAE is an image-guided, minimally invasive procedure that uses a high-definition x-ray camera to guide the interventional radiologist to introduce a catheter into the uterine arteries to deliver the particles. The procedure is typically performed in a cath lab or occasionally in the operating room.

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.

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 is inserted into your femoral artery, which is located in the groin area. A contrast material provides a roadmap for the catheter as it is maneuvered into your uterine arteries. The embolic agent is released into both the right and left uterine arteries by repositioning the same catheter that was originally inserted. Only one small skin puncture is required for the entire procedure.

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. This procedure is usually completed within 90 minutes. You will most likely remain in the hospital overnight so that you may receive pain medications and be observed.


How should I prepare for the procedure?

Imaging of the uterus by magnetic resonance imaging (MRI) or ultrasound is performed prior to the procedure to determine if fibroid tumors are the cause of your 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 you are bleeding heavily in between periods, 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 local anesthetic medications, general anesthesia or to contrast materials (also known as “dye” or “x-ray dye”). Your physician may advise you to stop taking aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) or a blood thinner for a specified period of time 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 so as not to expose the fetus to radiation. If an x-ray is necessary, precautions will be taken to minimize radiation exposure to the baby.

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 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 your UAE, and possibly mild nausea and low-grade fever as well. The cramps are most severe during the first 24 hours after the procedure and will 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 will be given prescriptions for pain and other medications to be taken by mouth. You should be able to return to your normal activities within one to two weeks after UAE.

Afterward, it is common for menstrual bleeding to be much less within two - three cycles and to stabilize to a new level that is usually greatly improved as compared to before the procedure. Occasionally you may miss a cycle or two or even rarely stop having periods altogether. Relief of bulk-related symptoms usually takes two to three weeks to be noticeable and over a period of months the fibroids to continue to shrink and soften. By six months, the process has usually finished and the amount of symptom improvement will stabilize.


What are the limitations of UAE?

UAE 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. UAE 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 (which contains iodine) should be offered a different treatment option.


What are the benefits vs. risks?

Benefits

  • UAE, done under local anesthesia, is much less invasive than open surgery done to remove uterine fibroids or the whole uterus (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 UAE is minimal, the recovery time is much shorter than for hysterectomy, and general anesthesia is not required.
  • Follow-up studies have shown that nearly 90 percent of women who have their fibroids treated by UAE experience either significant or complete resolution of their fibroid-related symptoms.
  • Follow-up studies over several years have shown that it is rare for treated fibroids to regrow or for new fibroids to develop after UAE.

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.
  • The chance of any of these events occurring during UAE 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 UAE. Women undergoing UAE are carefully monitored by a physician and a nurse during the procedure, so that any allergic reaction can be detected immediately and addressed.
  • Approximately two to three percent of women will pass small pieces of fibroid tissue after UAE. 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 UAE, normal menstrual cycles resume after the procedure. However, in approximately one percent to five percent of women, menopause occurs after UAE.
  • Although the goal of UAE 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 UAE is low—less than one percent.

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Copyright © 2009 Radiological Society of North America, Inc. (RSNA)