Uterine Fibroid Embolization (UFE)
What are typical symptoms of uterine fibroids?
Symptoms can be diverse bur may include menorrhagia (abnormal bleeding with menses), dysmenorrhea (painful menses), and bulk symptoms such as pain and pressure. Other symptoms include infertility, urinary urgency and incontinence, and constipation.
What clinical workup is required before undergoing uterine fibroid embolization (UFE)?
Workup should include a thorough history focusing on the presence of symptoms compatible with uterine fibroids. A physical examination is performed directed at evaluating the fibroid uterus. Laboratory evaluation includes a Pap smear and endometrial biopsy depending on symptoms, complete blood count, serum creatinine, and coagulation factors.
What imaging is required before UFE?
Cross-sectional imaging is performed before UFE. This can be either with US or preferably with contrast-enhanced MRI. The purpose of imaging is to evaluate fibroid size and location and to determine the possibility of adnexal disease that may alter management of the patient. Knowledge of the size and location of fibroids is important because submucosal fibroids are usually associated with bleeding and are at risk for being expelled after embolization. Large intracavitary fibroids may be a relative contraindication because of the risk of infection. The presence of fatty or hemorrhagic/red degeneration of a fibroid, which is seen as increased T1-weighted signal intensity on pretreatment MRI, is a negative predictor of successful treatment after UFE. MRI is also useful to detect the presence of ovarian arterial collateral supply to the uterus, which may lead to UFE treatment failure.
How is a patient followed after undergoing UFE?
Patients are followed closely in the immediate postembolization period to help manage pain. Usually MRI is obtained 3 to 6 months after the procedure to ascertain the degree of fibroid infarction and to correlate imaging findings with changes in symptoms.
What are the risks associated with UFE?
Aside from the risks that are common to any angiographic procedure, such as bleeding and reaction to intravenous contrast material, complications associated with UFE include infection or infarction of the uterus that might result in hysterectomy, fibroid expulsion, or premature menopause.
What are the alternatives to UFE?
Medical management consisting of hormonal therapy exists, but most patients presenting for UFE have already failed this treatment. Myomectomy is an option for patients seeking therapy for infertility. Hysterectomy is an option for patients with fibroids when pregnancy is not a consideration.
How do symptoms typically respond to UFE?
There is a success rate of 85% to 90% in controlling bleeding and bulk symptoms. Urinary symptoms may not respond as well.
Are there any other indications for UFE other than fibroids?
Uterine embolization can be used to treat bleeding emergencies such as postpartum hemorrhage, uterine atony, and cervical ectopic pregnancy. Uterine embolization may also be used for other conditions such as adenomyosis, although its success may not be as durable as with the treatment of fibroids.
What type of embolic agent is typically used?
Polyvinyl alcohol (PVA) particles or trisacryl particles (Embosphere) have been shown to have the best success to date for UFE. Absorbable gelatin sponge (Gelfoam) has been shown to work when used for treatment of acute bleeding.
Is there a correlation between postprocedure pain and clinical outcomes?
There is no correlation between degree of pain and clinical outcomes. Patients usually return to normal activities within 1 to 2 weeks after UFE.
What is a typical analgesia protocol for patients undergoing UFE?
Patients receive intravenous ketorolac tromethamine (Toradol) periprocedurally and are managed with fentanyl (Fentora) and midazolam (Versed) during the procedure. Postprocedure, a patient-controlled analgesia pump with morphine or hydromorphone (Dilaudid) along with an oral nonsteroidal anti-inflammatory drug (NSAID) is used to control pain. Some authorities advocate the use of epidurals during hospitalization. Patients are discharged with an oral narcotic such as oxycodone with acetaminophen and an NSAID such as ibuprofen.
What are the indications for discharge from the hospital after UFE?
Patients may be discharged when they are able to tolerate oral intake, and pain is controlled with oral medications.
Describe the vascular anatomy relevant to UFE.
Although anatomic variations exist, the paired uterine arteries are typically the first branches of the anterior division of the internal iliac arteries. Embolization is usually performed with the tip of the catheter in the horizontal segment of the uterine artery that is past the cervical-vaginal branch. The ovarian arteries usually arise from the abdominal aorta and can also supply the uterus in a small proportion of patients.
What is the risk of premature menopause related to UFE?
The risk is low for patients younger than 45 years old and increases after this age. The rate of premature menopause may be 40% in patients older than 51 years.
Is pregnancy possible after UFE?
Yes, although the incidence of placental location abnormalities, such as placenta previa, may be increased. There may also be a higher rate of miscarriage, but it is uncertain if this is related to a history of UFE or the higher maternal age in this specific patient population.