In this issue:
• Uterine Artery Embolization: A Proven Alternative to Surgery for the Treatment of Uterine Fibroids
• Frequently Asked Questions

Introduction
Uterine artery embolization (UAE), also known as uterine fibroid embolization (UFE), was introduced into clinical practice in 1997. Since then, hundreds of studies have been published regarding its clinical outcomes, technique, complications, and economic impact. The procedure has advanced technically and now is widely used in practice. In 2008, it was recognized by an ACOG Practice Bulletin as a safe and effective alternative to hysterectomy for the treatment of uterine fibroids.¹

The Procedure
UAE is a minimally invasive treatment that is based on angiographic techniques. Using a femoral artery puncture site, a catheter is advanced into the uterine artery. Small plastic beads, called embolic agents, are injected into the vessels. Because fibroids have large feeding vessels, the embolic material is carried by the arterial flow to those vessels first. The embolization is stopped when those vessels are occluded and the main uterine artery is still patent.

Fibroids are very sensitive to ischemia, while the normal myometrium is very resistant. The fibroids infarct, but the normal myometrium is not injured. The procedure takes approximately 1.5 to 2 hours and the patient usually remains in the hospital overnight. Following the procedure, patients typically experience moderate pain for several hours, however, administration of anti-inflammatories and parenteral narcotics generally resolve this pain over several hours. Patients tend to have cramping and fatigue for several days, but can usually return to full normal activity in about 7 to 10 days.

Clinical Outcomes
As a result of the fibroid infarction, the fibroids shrink and turn to scars over several months. Most studies have shown about 90% of patients will experience improvement in both their heavy menstrual bleeding and pressure and pain symptoms, usually within 2 to 3 menstrual cycles.

To date, there have been three major randomized trials comparing uterine embolization with surgery. For most patients, the improvement in symptoms with UAE is very similar to that occurring after surgery; there are also corresponding improvements in health-related quality of life. In the studies that have compared UAE with hysterectomy, there is a greater likelihood of reinterventions after UAE. These reflect an initial failure to improve (~10% of patients), development of new fibroids after several years, or occasionally for the management of adverse events. Once a patient reaches menopause, new fibroids do not develop and most patients do not require any additional treatment. Overall, 20% to 25% of patients may need reintervention at five years after treatment, which is similar to the retreatment rate after myomectomy.

Adverse events have been very infrequent, with most studies reporting similar or lower rates of complications with UAE when compared with surgery. Uterine ischemic injury has been very infrequent, but it is known that embolization can lead to a loss of ovarian reserve, particularly in women over the age of 45 years. Very infrequently, the onset of menopause may be precipitated by UAE. This occurs in about 5% of patients, nearly all over the age of 45. One of the most troublesome complications is fibroid expulsion, which can be associated with vaginal discharge, infection and bleeding. Although very infrequent, fibroid expulsion can lead to the need for gynecologic intervention.

Patient Selection
A recommendation for UAE is based on consideration of the extent of the fibroids, the patient’s clinical circumstances, and her preferences. Most women with fibroids are good candidates for embolization, although results are best in those with uterine size of less than 24 cm and fibroids smaller than ~15 cm. Both single and multiple fibroids can be treated. This procedure does not have the limitations of surgery in terms of patient comorbidities as general anesthesia is not necessary. Absolute contraindications are current pregnancy, suspected gynecologic malignancy, and current infection.

A common question about uterine embolization is whether the procedure should be done in women who may wish to have children in the future. Many pregnancies have been reported after embolization, most without complication. However, the presence of fibroids does complicate both becoming pregnant and carrying a pregnancy. For these reasons, myomectomy is the standard approach for a woman seeking to become pregnant, and at least one randomized trial suggests that pregnancy rates will be higher after that myomectomy than after UAE. Despite this, the choice of therapies depends on the extent of the fibroids, whether there have been prior interventions, and the patient’s other comorbidities and preferences. The options should be considered carefully in this subgroup of patients.

Summary
Uterine embolization is a safe and effective widely available choice of treatment for women with symptomatic fibroids.² It should be considered for all women who need treatment for uterine fibroids and certainly patients should be informed of this less invasive option. The best means of determining the suitability of this treatment is through a patient consultation with an interventional radiologist familiar with UAE.

1. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol. 2008;112(2 pt 1):387-400.
2. Goodwin SC, Spies JB. Uterine fibroid embolization. N Eng J Med. 2009;361(7):690-697.
   
   

Question #1 | Which patients do best with uterine embolization?

Answer to Question #1 | Most patients with symptomatic fibroids will have excellent symptomatic control with embolization. There are a few anatomic and clinical limitations that are best evaluated during a consultation with an interventional radiologist.

Question #2 | How effective is the symptom control compared to hysterectomy?

Answer to Question #2 | Most patients have excellent symptom control after UAE. There are about 10% of patients who have not improved sufficiently, usually for technical or anatomic reasons. Hysterectomy is more durable, in that the patient cannot get new fibroids, but is not an acceptable choice for patients who do not wish to lose their uterus.

Question #3 | Where can I refer my patients for evaluation?

Answer to Question #3 | Most medium to large hospitals have an interventional radiologist familiar with this procedure. An interventional radiologist in your area can be identified using the Society of Interventional Radiology website, (www.sirweb.org), which has a physician finder. It is best to talk with the interventional radiologist before referring a patient to ensure he or she is experienced with the procedure.

Question #4 | What if the patient’s symptoms are not controlled by the procedure?

Answer to Question #4 | This procedure does not preclude any other treatment options, so in the small percentage of patients who are not improved, other treatments, such as endometrial ablation, myomectomy or hysterectomy, can still be performed easily.  

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