Uterine
Fibroid
Embolization

Uterine fibroids are benign (noncancerous) tumors that grow on or within the muscle tissue of the uterus. Approximately 20 to 40% of women 35 years and older have fibroids, which can also occur in younger women ages 20 to 35. While some women do not experience any symptoms, the location and size of fibroids can cause symptoms that can affect a woman’s quality of life. Of the 600,000 hysterectomies performed annually in the United States, one-third are due to fibroids.

During menopause, the levels of estrogen decrease dramatically, causing fibroids to shrink. However, women taking hormone replacement therapy (HRT) during menopause may not experience any symptom relief because the estrogen in this regime may cause fibroids to persist and symptoms of urinary frequency, pelvic bloating, and constipation continue.

The size of fibroids ranges from very small (walnut size) to as large as a cantaloupe or even larger. Additionally, there can either be one dominant fibroid or many fibroids.

Fibroids are classified according to their location within the uterus. There are four primary types of fibroids:

• Subserosal fibroids develop in the outer portion of the uterus and continue to grow outward. These typically do not affect a woman’s menstrual flow but can cause pain due to their size and pressure on other organs.
• Intramural fibroids are the most common type and develop within the uterine wall and expand, which enlarges the uterus. Symptoms associated with intramural fibroids are heavy menstrual flow, pelvic pain, back pain, frequent urination, and pressure.
• Submucosal fibroids develop just under the lining of the uterine cavity. The least common type of fibroid, it often causes symptoms such as very heavy, prolonged menstrual periods.
• Pedunculated fibroids occur when the fibroid grows on a stalk. Pedunculated fibroids can either extend into the endometrial cavity or protrude outside of the uterus.

Fibroids may also be referred to as myoma, leiomyoma, leiomyomata, and fibromyoma.

Fibroid tumors of the uterus are benign but can cause symptoms. If a woman is diagnosed with uterine fibroids, embolization may be recommended when the condition causes:

• Heavy menstrual bleeding that does not respond to conventional treatment
• Excessive pain not relieved by other treatment
• Pressure and discomfort in the bladder or intestines

Since uterine fibroid embolization may affect fertility, the procedure is not recommended for women who may wish to become pregnant in the future. However, it is an ideal treatment for a woman who wants to avoid having surgery.

There have been numerous reports of pregnancies following uterine fibroid embolization, but prospective studies are needed to determine the effects of UFE on the ability of a woman to have children. One study comparing the fertility of women who had UFE with those who had a myomectomy showed similar numbers of successful pregnancies. However, this study has not yet been confirmed by other investigators.

Detecting uterine fibroids with magnetic resonance imaging (MRI)

When it comes to uterine fibroids, interventional radiologists provide patients and their healthcare providers with better diagnosis and nonsurgical treatment options

Women typically have an ultrasound at their gynecologist’s office as part of the evaluation process to determine the presence of uterine fibroids. It is a basic imaging tool that often does not show other underlying diseases or all the existing fibroids. For this reason, MRI is the standard imaging tool used by interventional radiologists.

Magnetic resonance imaging (MRI) improves the ability of physicians to determine which patients should receive nonsurgical uterine fibroid embolization (UFE) for treatment. Interventional radiologists can use MRI to determine if a tumor can be embolized, detect alternate causes for the symptoms, identify pathology that could prevent a woman from having uterine fibroid embolization, and avoid ineffective treatments. By working with a patient’s gynecologist, interventional radiologists can use MRI to enhance patient care through better diagnosis, education, treatment options, and outcomes.

Get a second opinion prior to a hysterectomy.

For true informed consent before surgery, patients should be aware of all of their treatment options. Patients considering surgical treatment can also get a second opinion from an interventional radiologist, who is most qualified to interpret the MRI and determine if they are candidates for the interventional procedure.

Once you have been diagnosed with fibroids, your provider will discuss the various treatment methods. These methods range from “watchful waiting” to pharmaceutical therapy for fibroids that may have recently been diagnosed or may have some associated symptoms but do not interfere with daily living. However, many patients may require additional treatment options to manage more severe symptoms. Your provider may advise you of minimally invasive uterus-sparing therapy, such as uterine fibroid embolization, as well as surgical interventions, such as hysterectomy and myomectomy. It is important to discuss all of these options with your provider to see what the best option is for you.

Diagnosis and watchful waiting

If your fibroids do not cause symptoms, there is no need to treat them. Your doctor may want to watch them and monitor for any fibroid growth at each of your annual examinations. Some women may have fibroids but do not experience symptoms.

If you experience some or many of the symptoms previously indicated, there are several other treatment options that may be available to you. These include drug therapies, minimally invasive non-surgical options, and surgical options. Your doctor should discuss all the alternatives with you based on your condition.

The non-surgical option (UFE) saves the uterus and stops the fibroids

Uterine fibroid embolization (UFE) is a procedure in which an interventional radiologist uses a catheter to deliver tiny particles that block the blood supply to the fibroids. This is a minimally invasive, nonsurgical therapy that treats all fibroids that are present. Clinical data suggest that patients treated with uterine fibroid embolization return to work and daily activities on average within 7-11 days. There are many benefits to having UFE:

• Preservation of the uterus
• Decrease in menstrual bleeding from symptomatic fibroids
• Decrease in urinary dysfunction
• Decrease in pelvic pain and/or pressure
• No risk of injury to the ureter, bladder, or bowl as there is in surgery
• Virtually no blood loss
• Covered by most insurance companies
• Outpatient procedure (sometimes an overnight hospital stay)
• More confidence with less chance of bleeding events
• Overall significant improvement in the patient’s physical and emotional well-being

Overall, uterine fibroid embolization is a safe procedure for treating symptomatic fibroids with minimal risk. 90 to 95% of patients indicated that they are happy with their outcome and would recommend UFE to a friend. Most reported risk factors and complications associated with UFE are transient amenorrhea, irregular periods for a few months, vaginal discharge/infection, possible fibroid passage, and post-embolization syndrome.

Pharmaceutical treatments

Many medical providers will prescribe birth control pills to control excessive bleeding caused by fibroids. Non-steroidal anti-inflammatory agents (NSAIDs) may be prescribed for pain relief. Certain birth control pills may help to control fibroid symptoms. There are several potential side effects of the use of birth control pills, including the risk of high blood pressure, development of blood clots, increased risk of heart disease, and/or liver disease.

GnRH agonists can be prescribed by physicians when birth control pills do not control symptoms or can be prescribed as a first attempt at controlling fibroid symptoms. Generally, they cannot be taken for longer than six months. GnRH agonists are used to decrease the production of estrogen in the ovaries, which may reduce the size of fibroids and help manage the associated symptoms. Because of the decrease in estrogen production, there may be menopausal-like side effects, such as hot flashes or mood swings. Furthermore, some bone loss may be associated with prolonged use of GnRH agonists. In addition, data indicate that fibroids re-grow after this treatment ends.

Surgical treatments

Hysterectomy is defined as the “surgical removal of the uterus.” It is one of the most common of all surgical procedures and can also involve the removal of the fallopian tubes, ovaries, and cervix. Following this operation, you will no longer have periods, nor will you be fertile or able to have children.

The most common way is to remove the uterus through an incision in the lower abdomen. Another way is to remove the uterus through a cut in the top of the vagina, and there are also laparoscopic and robotic-assisted techniques. Each operation lasts between one to two hours and is performed in the hospital under general anesthesia.

There are different types of hysterectomies:

1. A total hysterectomy removes the entire uterus, including the cervix. This is the operation most commonly performed.
2. A subtotal hysterectomy removes the uterus, leaving the cervix in place. If you have this operation, you will need to continue to have pap smear tests.
3. A total hysterectomy with a bilateral or unilateral oophorectomy removes the uterus, cervix, fallopian tubes, and one or both of the ovaries. If you have not had your ovaries removed and you have not gone through menopause before your operation, there is a 50% chance that you will go through menopause within five years of having this operation.

Physically, a number of issues are common to all women having a hysterectomy. You will not have any more periods and will be unable to have children. If you have your ovaries removed, you will go through menopause regardless of your age. Menopause is not related to age but to the production of the female sex hormone, estrogen. Your physician should discuss hormone replacement therapy (HRT) with you to help you understand its pros and cons.

Myomectomy is the surgical removal of fibroids. While this procedure keeps your uterus intact, it can be a surgically challenging procedure and is not performed by all physicians. In addition, only certain fibroids may be treated with this therapy. An abdominal myomectomy is performed through a horizontal incision through the abdomen – similar to a “bikini cut” used in a cesarean section. Most types of fibroids, even very large ones, can be removed in an abdominal myomectomy. The recovery time varies with each patient but typically lasts 4 to 6 weeks. Pedunculated and subserosal fibroids can be removed via a laparoscopic myomectomy, which is performed through three small incisions. When a resectoscope is used to remove submucous fibroids, this is called a hysteroscopic myomectomy. In addition to abdominal and hysteroscopic myomectomy, there are also laparoscopic and robotic-assisted myomectomy approaches.

MR-Focused Ultrasound for fibroids is a technique that uses magnetic resonance for guidance that sends highly focused ultrasound waves to the precise location of the fibroids, destroying with heat while sparing the surrounding tissue. It is limited by the location, size, and number of fibroids it can treat.

Laparoscopic radiofrequency ablation for fibroids uses a special ultrasound tool to visualize the location of fibroids, after which they are individually heated, sparing the healthy surrounding tissue. Over a period of a few months, fibroids shrink to about 40% to 50% of their original size.

Benefits

• UFE is a minimally invasive procedure that can significantly or completely relieve fibroid symptoms in over 90% of patients.
• UFE may allow patients to avoid more invasive surgery (such as hysterectomy or laparoscopic surgery) for treatment.
• UFE is nonsurgical, fast, and safe, requiring only a small skin incision to access the vascular system. There is almost no blood loss.

Risks

• Uterine fibroid embolization uses a very small dose of radiation, and the benefit of an accurate diagnosis and successful treatment far outweighs the risk. Please see ARA’s information on Radiation Safety.
• There is a very small risk of contrast allergy. If you have had an allergic reaction to contrast material in the past, your doctor may recommend taking medication for 24 hours before the procedure to reduce risk.
• The American College of Radiology (ACR) says that current information suggests that breastfeeding is safe after the use of intravenous contrast. Please discuss your breastfeeding options with your physician.
• Women should always inform the scheduler, physician, and technologist if they are pregnant.
• In very rare cases, catheterization may injure a vessel, which can cause bleeding or vessel blockage. This may require additional procedures to clear the vessel or stop the bleeding.
• About 2 to 3 percent of women will pass detached pieces of fibroid after the procedure. This may lead to the need for a procedure called dilatation and curettage (D&C) to remove the pieces.
• UFE does not eliminate the possibility that a patient will need a hysterectomy in the future for fibroids or other disorders.
• Some patients may experience “post-embolization” syndrome, which can include flu-like symptoms such as mild nausea and low fever. If these symptoms occur, they will happen within a few hours or a few days of the procedure.
• The impact of UFE on fertility and pregnancy is not clear, although many women have become pregnant after the procedure. Before scheduling the procedure, you should speak to your interventional radiologist.

• Uterine fibroid embolization is typically done in an ARA outpatient interventional suite or a hospital. The procedure takes about 90 minutes.
• You may be asked to remove all metal and jewelry, and you will be asked to change into a gown.
• Before the exam, a paramedic or nurse will start an intravenous (IV) line in your arm or hand.
• Electrodes may be placed on your chest to monitor your heart function during the procedure.
• You will be positioned comfortably on the exam table. At this point, a dose of sedative may be delivered through the IV to help you relax. The area where the catheter will be inserted may be shaved, cleaned, and numbed with a local anesthetic, which may sting briefly.
• The radiologist will make a tiny nick in your skin and guide the catheter into the artery (the femoral artery in the groin or radial artery in the wrist), then guide the catheter through the blood vessels until it reaches uterine arteries, which supply blood to the fibroids.
• At this point, contrast material is injected. You may feel a warm sensation as the contrast material enters your bloodstream. Contrast material helps make the vessels appear more clearly in the image.
• During the procedure, a fluoroscope (X-ray camera) will create moving images which can be viewed in real-time on a monitor by the interventional radiologist and used to guide the catheter.
• Once the catheter reaches the area to be treated, tiny particles will be released from the catheter tip to block the arteries feeding the fibroids.
• More images may be taken to make sure the embolization was completed effectively.
• When the procedure is finished, the catheter is removed, and pressure is applied to the incision site.
• You may experience pelvic cramps, nausea, and a mild fever after the procedure. Your doctor can prescribe medication to minimize symptoms.

• Please let your physician and your scheduler know of all medications you are taking and if you have allergies, especially to iodinated contrast material. Also, inform your physician and scheduler about recent illnesses or ongoing medical conditions.
• If you take any blood-thinning medications, aspirin, or products containing aspirin, please contact our office for instructions on discontinuing the medications prior to your procedure.
• You will be asked to remove clothes over the examined area and wear a gown.
• Women should always inform the scheduler, referring provider, and technologist if they are pregnant.
• Some doctors recommend that breastfeeding women wait 24 to 48 hours until the contrast clears from their system before breastfeeding again.
• If your exam plans include giving you a sedative, you may be instructed not to eat or drink for 6 hours before the exam. You can take scheduled medications with small sips of water.
• You will be kept for observation at the facility until you are cleared to leave. Please arrange for a family member or friend to drive you home since you will receive moderate sedation.

To schedule a consult for uterine fibroid embolization, please call our interventional team at (512) 467-9729.

You can also request a consultation online.