The recovery process
Over the next several days you are likely to have cramps that come and go as well as feeling as if you have the flu, with low energy, intermittent nausea, and possibly fever. These are all normal side effects of the procedure as your body reacts to the death of the fibroid tissue. Usually these symptoms are most pronounced in the first 2 or 3 days and by the fourth or fifth day after the procedure you will start to feel better. It is unusual for these symptoms to last longer than 7 days. The cramps may continue for a few days longer. Because of the flu-like symptoms, most patients will need about 1 week off from work. While you will progressively feel better over several days, you should anticipate a generalized lack of energy and should gauge you activity accordingly. We do not recommend travel plans for two weeks (except for those patients from out of the Washington area who are returning home) and would not recommend overseas travel for 1 month or until you feel completely recovered. With this overview, we discuss specific problems below.

Follow-up Care

We will call you the day after your discharge to check your progress and to answer any questions. At that time, we will schedule a follow-up visit for the following week. We will call you 30 days after the procedure to be sure that there have not been any problems.

At 3 months post-procedure, we will send you a brief questionnaire and a prescription for an MRI. We would encourage you to have a brief follow-up visit at that time to review the films and your symptom status.

You should continue your normal gynecologic well-woman care with your gynecologist.. This includes monthly self-breast exams and yearly pelvic exams with Pap smear as suggested by your gynecologist.

Puncture Sites
Arterial punctures were performed at the top of both legs and Band-Aids are in place over those puncture sites. You may shower today and each day. For the next two days after each shower remove the wet Band-Aids and replace them with dry, clean Band-Aids. This will promote healing. If you notice any swelling or active bleeding from the puncture sites, you should use direct pressure by placing your fingers and a clean cloth or paper towel over the site. Immediately call for assistance and report to the nearest emergency room for evaluation. This is extremely rare and occurs in less than 1 in 500 patients.

There may be some bruising at the puncture sites and this is normal. This bruising may spread out over several days. This is the normal way in which a small amount of blood under the skin is reabsorbed. This should not be of concern.

You may notice small knots under the skin at the puncture sites, usually about the size of a large pea. These are part of the healing process and will usually fade away within a few months.

Infrequently, patients will notice continuing pain at the puncture sites or in the upper thigh. This is usually due to irritation of the nerve branch that passes by the puncture site. If this is bothersome, you may continue to take Motrin or Advil, which will usually reduce the discomfort. While it is possible for this discomfort to continue for several weeks or longer, this is very rare. Should this occur, please contact us.

Diet and Activity
Resume your normal diet and medications. You should slowly increase your activity over the next three to four days. You may have unrestricted activity, including sexual activity and exercise, 7 days after the procedure. Do not drive until you are no longer taking the prescription pain medications (Percocet or Dilaudid). These medications may make you sleepy. Because of this, do not operate any machinery or kitchen appliances while you are taking them.

Medications
You have been given a number of prescriptions to help manage pain and nausea that may occur in the first several days post-procedure. For convenience, we have provided the following table of the generic and trade names of the prescription drugs we usually use.

ACTION	GENERIC NAME	BRAND NAME
Anti-inflammatory	Ibuprofin	Motrin
Pain relief	Oxycodone	Percocet
Pain relief -- severe	Hydromorphone	Dilaudid
Anti-Nausea	Ondansetron HCl	Zofran

Post-procedural Pelvic Pain and/or Cramps
You should expect to have pelvic pain and cramping over the next several days to two weeks. Usually this lasts for 3 to 4 days. It is most intense the day after the procedure and decreases each day thereafter. You have been given Motrin (Ibuprofen) which is an anti-inflammatory medication. You will take one pill (800 mg) every 6 hours for 4 days. In addition, you have been given narcotic pain medications to assist with pain control. Percocet (Oxycodone) is a narcotic pain reliever and generally provides substantial relief for most patients. You may take one or two tablets every four hours as needed for pain. You have also been given a stronger narcotic pain reliever called Dilaudid (Hydromorphone). If you do not receive any relief from the Percocet, you may use Dilaudid instead of the Percocet. Take the Dilaudid, one tablet every four hours as needed for pain.

Nausea
It is not unusual to experience nausea after the procedure. You have been given a prescription for an anti-nausea medication. This is either Phenergan (promethazine) or Zofran (ondansetron hydrochloride). You may take this medication according to the label directions every four to six hours as needed for nausea. If the medication you have been given does not relieve the nausea, call us and we can prescribe an alternate.

Heartburn and Constipation
While taking the Motrin it is important to protect your stomach from irritation. Try and eat some food before taking the medication and to take it with a full glass of water. It is best to remain in an upright sitting position for at least 30 minutes after taking the Motrin.

A common side effect of the prescription pain medicine is constipation. Feel free to use Milk of Magnesia or warm a glass of prune juice prior to drinking your morning coffee. Also, remember to drink at least 8 glasses of water a day.

Fever
A mildly elevated temperature is a common side effect of the uterine artery embolization and occurs in approximately 20-25% of patients. The fever is a side effect of the fibroids dying and does not indicate infection in most cases. This should be treated with regular Tylenol. You may take 2 tablets every 4 hours while the fever is present. Motrin will also relieve fever.

High temperatures (greater than 102º), a fever that persists for more than 3 days, or a fever arises more than a week after the procedure might indicate infection and you should call the Interventional Radiology Service as described in the bottom of this instruction set. In general, infections that might develop would be much more likely to develop in a week to several weeks after the procedure.

Menstrual Periods, Vaginal Discharge or Spotting
A brown or reddish brown vaginal discharge or spotting after the embolization is considered normal and may continue for a few weeks or until your first period. You may use a sanitary napkin until it resolves. We would prefer you not use a tampon for the first week after the procedure.

Occasionally, patients will have a clear watery discharge for several weeks or months post-procedure. This does not indicate infection. Of greater concern is a thick or foul smelling discharge, particularly if it is accompanied by fever or pelvic pain. This may indicate an infection and you need to contact us.

On occasion, the procedure causes you to start a menstrual cycle early or you may skip a period or two. If heavy bleeding was one of the symptoms caused by your fibroids, often your periods will be better right away. However, some patients will not improve for 2 or 3 cycles, so don't be discouraged if there is no immediate improvement. Regardless of whether bleeding or pressure and pain were symptoms, most patients will have improvement by the 3rd month after the procedure.

The first and possibly the second menstrual periods may be more uncomfortable than typical. Some patients tend to have increased cramps during these periods. This should resolve as the fibroids shrink. The fibroids take several months to significantly shrink and therefore short-term improvement in the size of the uterus should not be expected.

Hormonal Changes
Some patients may experience symptoms as a result of changes in their hormonal balance after the procedure. Fibroids are estrogen driven. As the fibroids die, there may be a sudden change in hormones. Some women experienced mild depression, which subsides within a few days. Others experienced “hot flashes” and/or night sweats and these may persist for a few weeks. In our experience here at Georgetown, we found these symptoms to be self-limiting and resolved without treatment.

Signs of Potential Problems
Symptoms that might indicate problems include swelling or active bleeding form the puncture sites, pain that arises several days or weeks after the initial pain resolved, a temperature several days to weeks after the initial procedure or an irregular vaginal discharge (particularly if foul smelling or copious). This might indicate either an infection or partial passage of a portion of the fibroid and may require gynecologic evaluation. If any of these symptoms occur, please contact the Interventional Radiology service to assess the symptoms and to make further treatment recommendations.

Research Protocols
As you are aware, we have an active research program on Uterine Embolization here at Georgetown University Hospital. You may have agreed to participate in one or another of the studies that are ongoing. We ask that you assist in that effort by promptly completely the follow-up questionnaires and imaging studies as required. In order to answer the key questions regarding the outcome of this procedure, we need high quality and complete data. You are the source of that data and, without you, we will not be able to answer those questions for our future patients