Uterine Fibroid Embolization

What is Uterine Fibroid Embolization (UFE)?

Uterine fibroid embolization (UFE) — also referred to as uterine artery embolization (UAE) — is a same-day, minimally-invasive, non-surgical procedure used to treat uterine fibroids. During the procedure, doctors inject tiny particles into the arteries supplying fibroids in order to block their blood supply. Without blood supply, the fibroid will slowly shrink or disappear over the course of a few weeks as the body heals naturally.

Many women are told the only option to treat uterine fibroids is hysterectomy (surgical removal of the uterus) or myomectomy (surgical removal of the fibroid); however, there is excellent data (level A) that uterine fibroid embolization is one of the safest and most effective alternatives to hysterectomy or myomectomy for women looking for a less invasive, non-surgical approach to treat symptomatic uterine fibroids.

Put simply, uterine fibroid embolization gives women the most minimally invasive means to treat symptomatic uterine fibroids without a major surgery (hysterectomy). Source

Who is a good candidate for UFE?

Ideal candidates for uterine fibroid embolization are women who:

  1. Have been diagnosed with uterine fibroids
  2. Suffering from symptoms related to fibroid overgrowth (discussed below); and are
  3. Looking for ways to treat fibroids without invasive surgery

Nearly all symptomatic uterine fibroids can be treated with uterine fibroid embolization. 

The major symptoms caused by uterine fibroids are:

  1. Heavy menstrual bleeding or periods that are becoming more painful
  2. Change in the length of your menstrual cycle
  3. Frequent urination or inability to control urination. Fibroids frequently compress the bladder. 
  4. New persistent pain or heaviness in the pelvis, referred to as a “bulk symptoms”. These symptoms are typically worse around the time of menstruation. The most common bulk symptoms are pressure, haviness, or bloating.

Other factors that make certain individuals ideal candidates for fibroid embolization are:

  1. Women who are NOT interested in hysterectomy (complete removal of the uterus)
  2. Women with numerous uterine fibroids. One of the major advantages of UFE is the ability to treat numerous fibroids with a single procedure. The average affected uterus has six to seven fibroids.
  3. Women who are looking for a fast recovery. Patients undergoing UFE usually go home the same day whereas patients undergoing hysterectomy usually require a 3-5 day hospital stay.
  4. Women who are nervous about potential complications related to surgery. 3% of patients required blood transfusion after myomectomy compared to less than 1% of patients after uterine fibroid embolization.

Benefits of UFE

High Success Rate

After uterine fibroid embolization, 80-90% of patients report significant improvement in their symptoms and 88% of women say that they would recommend their treatment to a friend.  Maximum symptom relief after fibroid embolization is achieved over a 3 month time period.

Preserves the Uterus

Uterine fibroid embolization (UFE) offers women who would like to preserve their uterus a safe and effective alternative to hysterectomy. A recent study published by Mayo Clinic demonstrated that women who undergo hysterectomy are at a higher risk for developing  anxiety and depression, which supports the growing notion that removing the uterus may have more effect on physical and mental health than previously thought.

Fewer Complications

Uterine fibroid embolization carries fewer procedural complications when compared to surgeries like myomectomy (surgical removal of fibroids). A recent study published in 2019 demonstrated 3% of patients required blood transfusion after myomectomy compared to 1% of patients after uterine fibroid embolization calculating to a 66% reduction in need for transfusion. 

Faster Recovery

After fibroid embolization, most women go home the same day, return to work within 2-5 days, and are fully recovered after 2 weeks. For comparison, a 3-5 day hospital stay is usually required after hysterectomy and full recovery usually takes 6-8 weeks. The Cochrane collaboration meta-analysis demonstrated that patients who received uterine fibroid embolization had a shorter hospital stay and a faster return to baseline activity compared to surgery.

Preserves Fertility

Unlike after a hysterectomy where a woman can no longer become pregnant, women can bear children after uterine artery embolization. UFE and myomectomy both preserve fertility after treatment. It is estimated that 1 in every 4 women with fibroids has fertility issues. New evidence suggests that fibroid embolization may restore the ability to become pregnant in some women. In 2017, a clinical study showed that embolization in women with fibroids who were previously unable to become pregnant, lead to an increased probability of becoming pregnant. 

Research and support for UFE

Uterine fibroid embolization has been performed for over 30 years and has excellent data supporting its usage in the treatment of symptomatic fibroids. Multiple randomized double blinded trials demonstrate that UFE is as effective as surgery for managing patients with symptomatic uterine fibroids.

  1. 10-year outcomes from EMMY Trial demonstrate that two thirds of women can avoid hysterectomy by undergoing uterine fibroid embolization
  2. New England Journal of Medicine trial demonstrated excellent relief of symptoms for UFE and surgery (hysterectomy or myomectomy). UFE resulted in the fastest recovery and return to work however a minority of patients (9%) required a second procedure for complete symptom control.

The Cochrane Collaboration completed a systematic review of seven high quality studies to determine if UFE is a safe and effective alternative treatment for women with uterine fibroids. The review concluded that there is excellent (Level A) data supporting uterine fibroid embolization for the management of uterine fibroids 

The American College of Obstetricians and Gynecologists Practice Bulletin on alternatives to hysterectomy in the management of fibroids reports there is level A data supporting the safety and efficacy of uterine fibroid embolization for women who wish to keep their uterus. 

The UFE Procedure Explained

The UFE procedure can be broken down into four key steps: 1) anesthesia; 2) blood vessel access; 3) blood vessel mapping; 4) fibroid embolization.

Anesthesia

The first step of the procedure it to make sure the patient is comfortable. For most minimally invasive procedures, conscious or twilight sedation is administered prior to beginning. With twilight sedation, medications to reduce pain and decrease anxiety are administered through an IV that is placed prior to the procedure. No breathing tube is required for twilight sedation as you will be able to breathe on your own. The goal of twilight sedation is to ensure the patient is very sleepy and comfortable. Most patients who receive twilight sedation sleep through the entire procedure. 

Blood Vessel Access

Think of blood vessels as miniature highways your doctor uses to navigate small devices throughout the body. Uterine fibroids derive their blood supply from the uterine arteries which are located deep within the pelvis. Because all of the arteries within the body connect to one another, doctors use an artery that is close to the skin surface and easily accessible to gain initial entry into the vast internal highway. Almost always, a small needle is introduced into the femoral artery (medium sized artery in the groin) or the radial artery (small artery in the wrist). In addition to the twilight anesthesia that has already been administered, your doctor will numb the tissues above the femoral or radial artery with lidocaine. It is important to note that no incisions have to be made where the blood vessel is accessed. After the procedure, a band aid will be placed over the region of vessel access.

Blood Vessel Mapping

Once either the radial or femoral artery has been accessed, the next step is to navigate a small tube called a catheter to the arteries feeding the uterine fibroids. In patients with fibroids, the uterine arteries are much larger than normal and look like winding pipes (have video of this) due to the extreme blood demand of uterine fibroids. Once the catheter has been positioned within the right and left uterine arteries, a dye is injected. Because fibroids steal so much blood, they “light up” more brightly than regular uterine tissue. 

Fibroid Embolization

Embolization is a medical technique where small particles are injected into blood vessels in order to shut off blood flow. The tissue or body part that is fed by the embolized vessel will eventually die or shrink due to a lack of oxygen delivery.  With uterine fibroid embolization, the goal is to shut off as much blood flow as possible to the uterine fibroids while preserving blood flow to the uterus. 

The uterus is a very unique organ because it gets its blood supply from numerous sources including the uterine arteries, ovarian arteries, and vaginal arteries. When an organ gets blood supply from numerous sources that organ is said to have collateral blood supply. Interestingly, fibroids derive their blood supply almost exclusively from the uterine arteries. Because of this fact, it is possible to completely shut down the uterine arteries (which will lead to fibroid death) without causing any damage to the uterus due to its collateral blood supply.

Once the catheter has been positioned within the right and left uterine arteries, tiny particles called embospheres are injected. The doctor will watch the embospheres flow towards the fibroids in real time. After the particles have been injected, your doctor will inject a small amount of dye. The procedure is complete when the fibroids no longer “light up” which confirms the blood supply to the fibroids has been shut off. 

Recovering from UFE

The amount of pain after fibroid embolization varies from patient to patient and is often defined as a cramping pain. Most patient’s report complete resolution of pain after 3-5 days, and doctors use multiple strategies to make the days after fibroid embolization as comfortable as possible. When surveyed, 88% of women state that they would recommend fibroid embolization to a friend, and most women can return to work within 3-5 days after fibroid embolization. Below are some of the common strategies doctors use to manage pain after fibroid embolization.

Nerve Blocks:  Many interventional radiologists perform a procedure called a superior hypogastric nerve block on women who receive fibroid embolization. The doctor injections anesthetic medication onto the hypogastric plexus which is the nerve bundle that delivers pain signals from the uterus. After hypogastric nerve block, 97% of women report significant pain control, and almost all women are able to leave the medical center 2 hours after their procedure was complete. 

Pain Medications: If breakthrough pain occurs during the first 2-3 days after the procedure, pain medications can be used. Most doctors will prescribe a 3-5 day course of either a mild opioid or non-opioid pain medication for breakthrough pain. An example of a commonly used opioid pain is Vicodin. An example of a commonly used non-opioid pain medication is Tramadol.

Anti-inflammatories: Anti-inflammatory pain medications are particularly helpful in managing pain after fibroid embolization. It is important to take anti-inflammatory pain medications on scheduled intervals for best results.  Most commonly, doctors will prescribe 800mg of ibuprofen 3 times daily for a total of 5 days after fibroid embolization.

What happens to the fibroid after UFE?

Once blood supply to the fibroid has been removed, the fibroid will either completely disappear or shrink over time. The best analogy to explain what happens to a fibroid after embolization is to think of how the earth composts organic materials like food, grass, and plants into soil over time. After fibroid embolization, your body naturally breaks down the fibroid overtime and replaces the empty space with normal uterine tissue. Most women achieve significant symptom relief after fibroid embolization that reaches a maximum within 3 months.

Who performs UFE?

Uterine fibroid embolization is performed by an Interventional Radiologist. Interventional Radiology is a board certified 6 year training program that occurs after medical school. Interventional Radiologists specialize in performing minimally invasive procedures that do not require surgical incisions. Usually medications, stents, or balloons are delivered to an area of the body through a small tube called a catheter. Interventional Radiologists position catheters in the right locations within the body through the use of low dose, realtime x-ray. Interventional procedures have revolutionized the field of medicine because of their excellent safety data and tolerability when compared to surgery.

Is UFE painful?

Fibroid embolization is performed under a type of sedation called “twilight sedation” or conscious sedation. With this form of sedation, an IV pain medication is combined with an anxiolytic (medication that decreases anxiety). These medications take effect within 2 to 3 minutes and make you very relaxed during the procedure. Importantly no breathing tube needs to be inserted during twilight sedation. With twilight sedation, most patients fall asleep for the entire procedure and may wake up for brief intervals during the procedure before falling back to sleep. Waking up during twilight sedation feels similar to waking up and falling right back to sleep on a day where you can sleep in. It is important to note that waking up during twilight sedation is okay as the purpose of twilight sedation is to ensure you’re very comfortable during the procedure. The goal is not to make you totally unconscious (unable to wake up under any circumstances) which is termed general anesthesia and usually requires insertion of a breathing tube. Your doctor and a nurse with dedicated sedation training will be monitoring you throughout the entirety of the procedure.

UFE risks

Major complications after fibroid embolization are rare and less than that of surgical procedures. A 2019 study demonstrated approximately a 1% chance of requiring a blood transfusion after fibroid embolization compared to a 3% chance of requiring a transfusion after myomectomy (surgical procedure where a fibroid is cut out of the body). Although very rare, potential complications of embolization include:

Infection

In rare instances, a degenerating fibroid can become infected and lead to an infection of the uterus termed endomyometritis. Almost all uterine infections can be treated with antibiotics, but in very rare cases, a hysterectomy may be required. The infection rate following fibroid embolization is approximately 0.4% to 1%.

Damage to other organs

Unintended embolization of another organ can occur; however, this risk is very low and less than that of surgery. Whether you’re undergoing fibroid embolization or surgery, there is a small risk that blood supply to the ovaries can be compromised. The estimated risk of damage to other organs during fibroid embolization is less than 1%.  In some women who are nearing menopause such disruption to ovarian blood supply could cause an early start to menopause. For women who are less than 45 years old, studies report there is a 0% to 3% chance of early menopause after fibroid embolization.

Possible problems with future pregnancy

Since the earliest days of fibroid embolization (30 years of experience), it has been shown that many women have healthy pregnancies after embolization. However, whenever a procedure is performed on the uterus, doctors are extra cautious to study potential impacts on pregnancy. A few small papers suggest there could be a slightly increased rate of certain pregnancy complications like abnormalities of placental attachment to the uterus after fibroid embolization. For women with symptomatic fibroids who are looking to remain pregnant, hysterectomy is not an option. When comparing fibroid embolization to myomectomy (uterine sparing surgery where the fibroid is surgically cut out of the uterus), it was concluded that there is very low evidence suggesting that myomectomy may be associated with better fertility outcomes. Most studies demonstrate a very similar fertility rate after fibroid embolization and myomectomy. 

It is well known that fibroids negatively impact female fertility. In fact, it is estimated that 1 in every 4 women with fibroids has fertility issues. New evidence suggests that fibroid embolization may restore the ability to become pregnant in some women. In 2017, a clinical study showed that embolization in women with fibroids who were previously unable to become pregnant, lead to an increased probability of becoming pregnant. Most importantly, if you’re interested in future pregnancy, you and your Interventional Radiologist should have a full discussion during the initial consultation.

Does insurance cover fibroid embolization?

The answer is yes. Fibroid embolization is a well validated treatment for uterine fibroids that is covered by medicaid, medicare, and nearly all private insurers. If you have any questions regarding insurance coverage, a PainTheory representative can help you understand your insurance plan.

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