Uterine Fibroid Embolization
Known medically as uterine artery embolization, this is a fundamentally new approach to the treatment of fibroids that blocks the arteries that supply blood to the fibroids. It is a minimally invasive procedure, which means it requires only a tiny nick in the skin, and is performed while the patient is conscious but sedated — drowsy and feeling no pain.
While embolization to treat uterine fibroids has been performed for more than six years, embolization of arteries in the uterus is not new. The procedure has been used successfully by interventional radiologists in uterine arteries for more than 20 years to treat heavy bleeding after childbirth. Today, fibroid embolization is being performed at hospitals and medical centers across the country, in Canada and around the world. As of 2002, approximately 20,000 uterine fibroid embolization procedures have been performed worldwide, at least half of which have been performed in the United States.
The Uterine Fibroid Embolization Procedure
Fibroid embolization is usually done in a hospital by an interventional radiologist, a physician who is specially trained to perform this and other minimally invasive procedures.
The interventional radiologist makes a small nick in the skin (less than one-quarter of an inch) at the crease at the top of the leg to access the femoral artery, and inserts a tiny tube (catheter) into the artery. Local anesthesia is used so the needle puncture is not painful. The interventional radiologist steers the catheter through the artery to the uterus using X-ray imaging (fluoroscopy) to guide the catheter's progress. The catheter is moved into the uterine artery at a point where it divides into the multiple vessels supplying blood to the fibroids.
An arteriogram (a series of images taken while radiographic dye is injected) is performed to provide a road map of the blood supply to the uterus and fibroids.
The interventional radiologist slowly injects tiny plastic (polyvinyl alcohol or PVA) or gelatin sponge particles the size of grains of sand into the vessels. The particles flow to the fibroids first, wedge in the vessels and cannot travel to other parts of the body. Over several minutes, the arteries are slowly blocked. The embolization is continued until there is nearly complete blockage of the blood flow in the vessel.
The procedure is then repeated on the other side so the blood supply is blocked in both the right and left uterine arteries. Some physicians block both uterine arteries from a single puncture site, while others puncture the femoral artery at the top of both legs. After the embolization, another arteriogram is performed to confirm the results. The skin puncture where the catheter was inserted is cleaned and covered with a bandage.
As a result of the restricted blood flow, the tumor (or tumors) begin to shrink.
After the Uterine Fibroid Embolization Procedure
Fibroid embolization usually requires a hospital stay of one night, although some women do go home the same day. About six to eight hours of bed rest is typical after the procedure. Pain-killing medications and drugs that control swelling typically are prescribed following the procedure to combat cramping, which is a common side effect. Fever also is an occasional side effect, and is usually treated with acetaminophen. Total recovery generally takes one to two weeks, but can take longer.
Expected Results for Uterine Fibroid Embolization
Fibroid embolization was first studied in the United States by Scott Goodwin, MD, of the University of California Los Angeles, who reported his results in 1997. Since that time, a number of interventional radiologists have studied the procedure and have reported similar success with the technique reported by Dr. Goodwin.
The results of studies that have been published or presented at scientific meetings report that 78 percent to 94 percent of women who have the procedure experience significant or total relief of pain and other symptoms, with the large majority of patients considerably improved. The procedure has been successful even when multiple fibroids are involved. Most patients have rated the procedure as "very tolerable." The expected average reduction in the volume (size) of the fibroids is 50 percent after three months, with a reduction in the overall size of the uterus of about 40 percent, although some types of fibroids shrink more than others.
The long-term outcome is not known as only short-term follow-up is available. It is not yet known if the fibroids can re-grow, however no recurrences have occurred in women who have been followed for up to six years.
The majority of patients who have fibroid embolization are finished with childbearing and few women have tried to subsequently become pregnant, making fertility difficult to study. More than a dozen pregnancies have been reported, however, and patients who have had uterine arteries embolized for other reasons, such as bleeding after childbirth, have successfully become pregnant. Research is underway to study this issue, but because of concerns about blood supply to the developing fetus and a few cases of uterine rupture in pregnancy, it is currently not generally recommended in women who still wish to become pregnant.
There have been a few women whose menstrual periods have stopped after the procedure, which would result in infertility.
Side Effects/Complications for Uterine Fibroid Embolization
Fibroid embolization is considered to be very safe, however, there are some associated risks, as there are with almost any medical procedure. Most patients experience moderate to severe pain and cramping in the first several hours following the procedure; some experience nausea and, possibly, fever. These symptoms can be controlled with appropriate medications. Most symptoms are substantially improved by the next morning, however, there may be some pain and cramping for several days or more. Many women report returning to work within a week of having the procedure.
Complications occur in fewer than 3 percent of patients. Serious possible complications include injury to the uterus from decreased blood supply or infection. This is uncommon and hysterectomy to treat either of these complications occurs in less than 1 percent of patients. Injury to other pelvic organs is possible and the chance of other significant complications is less than 1 percent. No tissue is sampled so there is a small chance of delay in diagnosing a malignancy (cancer).
Long-term complications are not expected, although questions about potential side effects remain.
It is not known what effect, if any, fibroid embolization has on the menstrual cycle. The majority of women who have had embolization have had decreased bleeding with normal menstrual cycles. There have been a few women, most of whom are near the age of menopause, whose menstrual periods have stopped after the procedure. It is uncertain whether these cases are a result of decreased ovarian function resulting from the procedure. Based on this limited information, it appears that the procedure may cause premature menopause in a very small number of patients under 40 but a higher percentage of women over 45 (as high as 40 percent in some studies).
A number of insurance companies are paying for fibroid embolization procedures. You will want to talk with your interventional radiologist about this before your procedure. The surgical procedures are almost always covered by insurance companies.
Gynecology patients are seen at the Hospital & Seattle Medical Center, as well as our medical centers in Bellevue, Federal Way and Lynnwood. For more information about uterine fibroid embolization, call (206) 223-6191.