Uterine Artery Embolization - Current Treatment Options

Treatment Options

Uterine fibroids that are not causing symptoms do not require specific therapy, other than periodic examinations by a gynecologist. Usually the diagnosis is made by physical examination confirmed by either ultrasound examination or MRI. Once diagnosed, the growth of fibroids may be monitored by physical examination.

Medical Management

Once symptoms develop, medical management is usually the first therapy. This might include treatment with non-steroidal anti-inflammatory agents (such as Motrin or Naprosyn), birth control pills, or progesterone agents. If these fail to control the symptoms, the decision for further medical management depends on the patient's age, the size of the fibroids, the desire for future pregnancy, and the severity of symptoms.

Another medication that may be used in certain circumstances is a Gonadotropin Releasing Hormone (GnRH) agonist. This group of medications block the production of hormones, particularly estrogen, by the ovary. The most commonly used GnRH agonist in this country is Lupron, which is given by injection either once a month or every three months depending on the dose. Because these medications decrease estrogen levels and because fibroid growth depends on estrogen, fibroids usually shrink when treated with Lupron or other GnRH agonists. These drugs may cause hot flashes and mood changes in some patients, similar to those experienced with menopause. These symptoms may be controlled with small doses of supplemental estrogen. A potentially more serious side effect of these medications is a decrease in the density of bones, which can lead to osteoporosis if used long term. For this reason, the use of these medications is usually limited to 6 months. Unfortunately, fibroids usually regrow after GnRH agonists are stopped. There is ongoing research studying the intermittent use of Lupron and similar drugs, or use in combination with other medications, to determine if symptoms are controlled long-term while avoiding bone loss.

Hysteroscopy

If the fibroids are submucous (inside the uterus, just below the lining) and projecting into the uterine cavity, a hysteroscopic resection may be possible. Hysteroscopy is a procedure in which a fiber-optic scope is advanced into the uterus through the vagina and cervix. It is commonly used in conjunction with a dilatation and currettage (D and C) to diagnose abnormal bleeding.

A hysteroscope may also be used to remove polyps or submucosal fibroids. Larger submucosal fibroids can sometimes be removed or partially removed with a hysteroscopic device that shaves off pieces of tissue. These methods may be combined with techniques to ablate or remove the lining of the uterus to control bleeding. Endometrial ablation is the intentional destruction of the uterine lining and is intended to permanently stop menstrual bleeding. If successful, it will prevent future pregnancy.

In the hands of a skilled operator, hysteroscopic procedures are safe and effective. They are usually performed in the operating room under general anesthesia, but a patient is typically discharged on the same day as surgery and may return to normal activities within a few days.

Hysteroscopic removal of fibroids is usually only done after a GnRH agonist is given for three to six months. This causes the fibroid to shrink and decreases its blood supply, which reduces bleeding at the time of the surgery and improves the chance for success.

Surgical procedures

The two conventional surgical choices are myomectomy and hysterectomy. Myomectomy is an operation in which the fibroid or fibroids are removed leaving the rest of the uterus in place. This is most commonly used in younger women who wish to maintain their ability to have a child. While bleeding and other complications are somewhat higher than with hysterectomy, myomectomy appears to be successful in controlling symptoms in about 80% of women. Fibroids may regrow after myomectomy, with recurrence rates of between 10% and 30% by 3 to 5 years after treatment. The procedure may cause extensive pelvic scarring which may make future surgery very difficult and may contribute to future fertility problems. Long-term studies of myomectomy patients attempting to become pregnant have shown pregnancy rates between 40 and 60%. In recent years, there has been the development of less-invasive techniques, such as laparoscopy, for performing myomectomy and these may represent alternatives to conventional surgery in some patients.

Hysterectomy is effective in essentially all cases in which bleeding is the primary symptom and usually it resolves the pain or urinary symptoms which women may have as well. It is a safe procedure, with a very low complication rate in experienced hands. It is the standard therapy for fibroids that fail to respond medical therapy in women who do not wish to have further children. While it is a major surgical procedure, with a four to six week recovery, studies have shown that the patient's quality of life after hysterectomy is normal for most patients within 2 months of the surgery. Recent large studies have confirmed that hysterectomy is effective and safe, with a very low complication rate.

One common question about hysterectomy is whether it will have any effect on sexual functioning. A recent study addressed this question and found that for the large majority of patients, sexual functioning is actually improved after hysterectomy. The reason is the symptoms caused by fibroids are often severe enough to significantly impact sexual interest and enjoyment. Once the symptoms are gone, sexual interest and enjoyment increase.

There are patients who will have depression and other psychological effects from hysterectomy and others whose sex lives will be worse after the surgery. Since it is major surgery, there can be complications and it takes several weeks to recover. For these and many other reasons patients have long sought an alternative to surgery for control of symptoms caused by fibroids.

Uterine Artery Embolization (UAE)

Uterine artery embolization is a treatment for fibroids that has developed over the past decade. It was originally performed in France and first reported in the medical literature in 1995. Since that time, numerous centers in the United States have begun uterine embolization programs.

Embolization is a medical term for a procedure in which a physician injects small particles through a catheter placed in the uterine artery. The particles block the blood supply to the fibroids, resulting in the death of the fibroid tissue. This leads to shrinkage of the fibroids and relief of symptoms for most patients, without the need for surgery or removal of the uterus. For additional information on this procedure, please review the page on UAE.