Uterine Artery Embolization of Fibroids
A brief summary for physicians

Georgetown University Experience
In 1997 we began performing UAE at Georgetown. Since then we have treated nearly 600 patients. We present the results of our experience to date, including the details of our published experience in our first 200 patients (Obstetrics and Gynecology 2001; 98:29-34.).

Published Georgetown University Research on UAE
This section summarizes some of the research on UAE that we have completed at Georgetown and that has been published in the medical literature.

Literature Review
A comprehensive review of the published data and a selected review of important scientific presentations.

Physician's Guide for Patient Protocol
Review the details of our protocol at Georgetown, including pre-procedure gynecolgic and radiologic evaluation and referral information.

The Procedure
The procedure is done as an outpatient, with a 23 hour overnight admission. It is performed with conscious sedation and local anesthesia. The common femoral arteries are the access sites and, at Georgetown University, both are used. The uterine arteries are most easily accessed from the contralateral femoral artery. After selective catheterization of the uterine arteries, an arteriogram is performed. A typical example is shown in the figure below, left (Pre-embolization Angiogram) with large abnormal fibroids vessels indicated with arrows.

Next, particles of polyvinyl alcohol (Contour, Boston Scientific, Natick, MA) or tris-acryl microspheres (Embospheres, Biosphere Medical, Rockland, MA) are injected slowly with fluoroscopic guidance. These particles wedge in the fibroid vessels and occlude them. Both uterine arteries are occluded. After the entire study, another arteriogram is performed. After embolization, all the fibroid vessels are gone with only very sluggish flow present in the uterine arteries (black arrows in the figure on right -- Post-Embolization Angiogram). Normal myometrial branches are spared (white arrows). The procedure takes approximately 1-2 hours.

Side Effects
Most patients will experience 4 to 5 days of symptoms after the procedure. This includes pelvic pain, nausea, and possibly fever. After an initial period of bed rest for six hours, patients are hospitalized overnight to control pain. The pain after the procedure usually lasts 6 to 8 hours and is moderately severe and usually requires intravenous narcotics. In nearly all cases, the pain is gone or minimal the day after the procedure. Rarely, a second night of hospital care is needed for pain control.

Cramping pain, fatigue, and possibly fever are common side effects during the subsequent few days, but most symptoms resolve within 4 to 5 days and a patient might anticipate returning to work 7 days after the procedure.

Major procedural complications (<30 days) have been reported in less than 4% of patients. An ischemic injury to the uterus of such severity that a hysterectomy is required is possible but occurs in only .05% of patients. Pyometrium has also been reported, which may necessitate a hysterectomy. Less severe infections have been reported and treated with intravenous antibiotics. Injuries to other pelvic organs have not occurred. Another rare, but potentially severe complication, is pulmonary embolus, which has been noted in 1 in 500 patients. To date, there have been 4 deaths reported after uterine embolization in the world's experience, 2 from sepsis (1 in England, 1 in the Netherlands) and the others from pulmonary embolus (1 in Milan, Italy, 1 in Alabama, USA).

Another potential side effect is diminished ovarian function. A 1-5% of patients have been reported to have lost their menstrual periods after this procedure. Nearly all have been at the age at which menopause typically occurs. In our experience, 5 patients of the first 400 treated became menopausal as a result of UAE. We have completed a study of basal FSH levels pre and post-procedure to determine if is there is a change in ovarian function in the majority of patients or whether any effects are limited to those who already peri-menopausal. There were changes in basal FSH in 15% of patients over the age of 45. Additional details are given in the section on Research on UAE at Georgetown University.

Expected Results
After the embolization, the fibroids infarct and degenerate over a period of weeks and months. Average fibroid volume reduction is approximately 43% at three months and 65% at one year. Uterine volume decreases by approximately 34% in three months. Two cases are shown in the accompanying figures.

The first case shows MRI's before and three months after embolization in a patient with multiple fibroids. The patient presented with severe menorrhagia, back pain and painful periods. Three months after embolization, the fibroids are infarcted and by measurement, the uterine volume decreased by 66% and the two dominant fibroids decreased by 86 and 91%. Her symptoms resolved.

The second case shows a large single submucosal fibroid in a patient with severe menorrhagia. At three months after embolization, her symptoms had resolved and the fibroid had decreased 61% in volume. At one year, it had decreased 88% in volume. At two years, only a tiny scar remains of the fibroid. Her menstrual periods have remained normal in the 4.5 years since treatment.

The studies that have been published to date suggest that symptoms will be significantly improved or will resolve in 80-90% of patients. The patients in these series rated the procedure as very tolerable. An evidence table has been included at the end of the Literature Review, detailing the reported results. The long-term outcome is not known, although mid-term results from several centers show that the fibroids successfully treated do not recur, with MRI evidence of hemorrhagic infarction. Post-procedure fertility and the ability to carry a pregnancy to term is not known. Some of the patients in published series have successfully carried pregnancies but most patients have not sought to become pregnant and therefore the percentage that will be able to become pregnant is not known. For more detailed discussion of the published and presented data, we invite you to review the Literature Review.