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What Every Woman Should Know
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Uterine Artery Embolization (UAE) by
Paul D. Indman, MD, USA, |
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Introduction:
Uterine fibroid embolization represents a fundamentally new approach to the
treatment of fibroids. Embolization is a minimally invasive means of blocking
the arteries that supply blood to the fibroids. It is a procedure that uses
angiographic techniques (similar to those used in heart catheterization) to
place a catheter into the uterine arteries. Small particles are injected into
the arteries, which results in the blockage of the arteries feeding the
fibroids. This technique is essentially the same as that used to control
bleeding that occurs after birth or pelvic fracture, or bleeding caused by
malignant tumors. The procedure was first used in fibroid patients in France as
a means of decreasing the blood loss that occurs during myomectomy. It was
discovered that after the embolization, while awaiting surgery, many patient's
symptoms went away and surgery was no longer needed. The blockage of the blood
supply caused degeneration of the fibroids and this resulted in resolution of
their symptoms. This has led to the use of this technique as a stand-alone
treatment for symptomatic fibroids.
The Procedure:
The procedure is usually done in the hospital with an overnight stay after the
procedure. The patient is sedated 
and very sleepy during the procedure. The uterine arteries are most
easily accessed from the femoral artery, which is at the crease at the top of
the leg as shown in the figure. Initially, a needle is used to enter the artery
to provide access for the catheter. Local anesthesia is used, so the needle
puncture is not painful. The catheter is advanced over the branch of the aorta
and into the uterine artery on the side opposite the puncture. A second arterial
catheter is then placed from the opposite femoral artery to the other uterine
artery. Before the embolization is started, an arteriogram (x-ray) is performed
to provide a road map of the blood supply to the uterus and fibroids.
After
the arteriogram, particles of polyvinyl alcohol (PVA) are injected slowly with
X-ray guidance. These particles are about the size as grains of sand. Because
fibroids are very vascular, the particles flow to the fibroids first. The
particles wedge in the vessels and cannot travel to any other parts of the body.
Over several minutes the arteries are slowly blocked. The embolization is
continued until there is nearly complete blockage of flow in the vessel. Once
one side is completed, the other side is embolized. After the embolization,
another arteriogram is performed to confirm the completion of the procedure.
Arterial flow will still be present to some extent to the normal portions of the
uterus, but flow to the fibroids is blocked. The procedure takes approximately 1
to 1 1/2 hours.
Side Effects:
Most patients will experience several hours of moderate to severe pain after the
procedure. There may also be nausea, and possibly fever. The pain and nausea is
controlled with intravenous medications, usually with a pump that allows
self-administration of the medications. After an initial period of bed rest for
six to eight hours, those patients with mild to moderate symptoms may be
discharged. Most patients are hospitalized overnight. Most symptoms are
substantially improved by the next morning allowing discharge from the hospital.
After discharge, most patients will have periodic moderate to severe cramping
over several days. Pain medications are prescribed to control these symptoms.
These cramping episodes usually diminish over several days. Most patients will
feel tired and may have a fever or nausea periodically. All these symptoms
usually resolve over several days, but may last longer. Most women can
anticipate returning to work 7 to 14 days after the procedure.
Complications:
Complications are anticipated in less than 3% of patients. Serious possible
complications include injury to the uterus from decreased blood supply or
infection. Fortunately, this is quite rare and hysterectomy to treat either of
these complications occurs in less than 1% of patients. Injuries to other pelvic
organs is possible but has not yet occurred and the chance of other significant
complications is less than 1%.
Long-term complications are not expected, although several questions about
potential side effects remain. X-rays are used to guide the procedure and this
raises a concern about potential long-term effects. In a study measuring the
X-ray exposure during uterine embolization, the exposure was found to be below
the level that would be expected to cause any health effect to the patient
herself or to future children.
Pregnancy after Uterine Artery
Embolization:
It is also uncertain what effect blocking the uterine arteries will have on the
ability to become pregnant or to carry a pregnancy to term. The large majority
of the patients that had this procedure are finished with childbearing and so
few women have tried to become pregnant after this procedure. Thus far, at least
a dozen patients have become pregnant after this procedure worldwide. This
includes a normal cesarean twin delivery and several normal single vaginal
deliveries in France. There has been one reported miscarriage and other patients
are pregnant at this time. It is also known that patients who have had this
procedure for other reasons, such as bleeding after childbirth, have
successfully carried pregnancies. However, most patients that have been treated
for fibroids thus far are not interested in having a baby and have not sought to
become pregnant. Therefore, without further study, we will not know what
percentage of patients that wish to become pregnant will be able to do so. As
the outcome of pregnancy following UAE is not know, we cannot recommend the
procedure for women who plan to have children.
Another unresolved question is the effect, if any, of this procedure on the
menstrual cycle. The overwhelming majority of women who have had embolization of
fibroids have had decreased bleeding with normal menstrual cycles. There have
been a few women (most of whom are near the age when menopause would be
expected) who have lost their menstrual periods after uterine embolization. It
is uncertain whether these cases are a result of decreased ovarian function from
the procedure. This question will require further study. Based on this limited
information, it appears that this procedure may result in loss of menstrual
cycles (premature menopause) in a very small number of patients.
Expected Results:
As of this time, approximately 2000 to 3000 patients have had this procedure
world-wide. Initial results suggest that symptoms will be improve in 90% of
patients with the large majority of patients markedly improved. Most patients
have rated this procedure as very tolerable. The expected average reduction in
the volume of the fibroids is 50% in three months, with reduction in the overall
uterine volume of about 35%. The long-term outcome is not known, in that the
arteries could reopen or collateral vessels could be recruited which might allow
regrowth of the fibroids. As of yet this has not been reported in the published
series but only short term follow-up is available. Therefore, it is not yet
known if the fibroids can regrow.
This section was written to provide patients with an overview of
uterine fibroid embolization. If you are interested in a more detailed
discussion of the reported results, we encourage you to read our references.
If you would like to consider this procedure at the Fibroid Medical Center of
Northern California, please feel free to contact us.
For More Information:
If you or your gynecologist are interested in information on this procedure, we
invite them to review our Physician's Resource. They may also call us; we would
be happy to discuss this procedure with them.
Acknowledgement: We wish to thank Dr. James B. Spies
for permission to reproduce material from the Georgetown University web site.
References:
Ravina JH, Herbreteau D, Ciraru-Vigneron.
Arterial embolization to treat uterine myomata. Lancet
1995;346:671-672.
Goodwin SC, Vendantham S, McLucas B, Forno AE, Perella R.
Preliminary experience with uterine artery embolization for uterine fibroids.
JVIR 1997;8:517-526.
American College of Obstetrics and Gynecology Technical Bulletin. Uterine
Leiomyomata. Number 192. May 1994.
Wilcox LS, Koonin LM, Pokras R, Strauss LT, Xia Z, Peterson HB.
Hysterectomy in the United States, 1988-1990. Obstet Gynecol1994;
83:549-555.
Greenberg MD, Kazamel TIG. Medical and socioeconomic impact of uterine
fibroids. Obstetrics and Gynecology Clinics of North America
1995;22:625-636.
Buttram VC, Reiter RC.
Uterine Lyomata:etiology, symptomatology, and management. Fertil
Steril 1981; 36:433-445.
Vollenhoven BJ, Lawrence AS, Healy DL. Uterine Fibroids: a clinical
review. Brit J Obstet Gynecol 1990; 97:285-298.
Friedman AJ, Hoffman DI, Comite F, Browneller RW, Miller JD, For the Leuprolide
Study Group.
Treatment of Leiomyomata Uteri with Leuprolide Acetate Depot: A double-blind,
Placebo-controlled, multicenter study. Obstet Gynecol 1991;
77:720-725.
Derman SG, Rehnstrom J, Neuwirth RS.
The
long-term effectiveness of hysteroscopic treatment of menorrhagia and leiomyomas.
Obstet Gynecol 1991; 77:591-594.
Hutchins FL. Abdominal myomectomy as a treatment for symptomatic uterine
fibroids. Obstetrics and Gynecology Clinics of North America
1995;22:781-789.
Carlson KJ.
Outcomes of hysterectomy. Clin Obstet Gynecol 1997; 40:939-46.
Spies JB, Scialli AR, Jha RC, Fraga VM, Imaoka I, Ascher SM, Barth KH.
Initial results from uterine artery embolization for symptomatic leiomyomata.
Presented at Radiologic Society of North America, Chicago, November 29,
1998.
Nikolic B, Spies JB, Lundsten M. Patient radiation dose associated with
uterine artery embolization for leiomyomas. Presented at Radiologic
Society of North America, Chicago, November 29, 1998.
Editor's Note: Because of deaths and other major complications of uterine artery embolisation in the UK it is only given a category C rating (must only be done in a randomised controlled trial) by SERNIP, UK regulating body.
