What is uterine fibroid embolisation (UFE)?

What are the advantages of uterine fibroid embolisation?

How is uterine fibroid embolisation performed?

How effective is uterine fibroid embolisation?

What are the risks?

Can I loose my period?

Is uterine fibroid embolisation painful?

Can I still get pregnant after uterine fibroid embolisation?

What are the pre-procedural evaluations required?

Do I need to see a gynaecologist?

What are the preparations needed?

How do I recover after uterine fibroid embolisation?

What are the follow-ups required after uterine fibroid embolisation?

What do I need to watch for potential problems?

Other Useful Links

What is uterine fibroid embolisation (UFE)?

UFE is also known as UAE (uterine artery embolisation). It is a minimally invasive procedure performed by interventional radiologist to embolise (block) the blood supply to the uterus. By limiting blood supply to the uterus, the fibroids will shrink and the associated symptoms subside. It is a non-surgical alternative to hysterectomy.

Uterine Fibroid Embolisation Uterine Fibroid Embolisation

What are the advantages of uterine fibroid embolisation?

It is highly effective in treating the symptoms of fibroids without having to surgically remove the fibroid or uterus. It is a procedure performed under local anaesthetic, and therefore it is much less invasive than hysterectomy. Compare to hysterectomy, UFE requires shorter hospital stay (typically 1-2 days versus 2-7 days) and much shorter convalescence (typically 1 week versus 4-6 weeks) before returning to work or normal activities.

How is uterine fibroid embolisation performed?

The procedure is performed in an angiography suite. The patient is conscious but sedated with IV medications. Local anaesthetic is given at the groin where a tiny nick in the skin is made. Catheter (a small tube 1-2 mm in diameter) is inserted into the femoral artery at the groin and guided under X-ray to reach the uterine arteries. Tiny plastic particles (0.3-0. 5mm) are mixed with X-ray dye, and injected under X-ray control to block the uterine arteries.

How effective is uterine fibroid embolisation?

Studies suggest UAE is as effective as hysterectomy in controlling primary symptoms of heavy period, bulk related symptoms and period pain. UFE and surgery are equivalent in improvement of quality of life. On average, 85-90 % of women who have had the procedure experience significant or total relief of heavy bleeding, pain and/or bulk-related symptoms. Our own success rate at Sydney Adventist Hospital is higher than 90%. The procedure is effective for multiple fibroids and large fibroids. Recurrence of treated fibroids is very rare. Short and mid-term data show UFE to be very effective with a very low rate of recurrence. In one study in which patients were followed for six years, no fibroid regrew after embolisation.

What are the risks?

UFE is a minimally invasive procedure. It is very safe compare with major surgery. Spillage of particle away from uterine artery, vessel injury at the groin are all very rare complications, each occuring in less than 1 %. We did not have any significant procedural related complications at the Sydney Adventist Hospital.

Infection of the uterus (endometritis) is rare (3 %). Pain, fever and vaginal discharge are the symptoms. This is usually managed with prompt administration of IV antibiotics.

Fibroid expulsion through the cervix occurs in < 3%. In majority of cases, the fibroid fragments can be passed successfully. Some may require a minor procedure to remove the fibroid fragments.

Can I loose my period?

Transient amenorrhea occurs in 5-10 % of patient after UFE. Younger patient tends to regain periods within 6 months. Permanent amenorrhea (menopause) occurs in less than 3% of women younger than age 45, but more frequent (7-14%) in age > 45. This may reflect the fact that women in mid 40s or older is already nearing menopause.

Is uterine fibroid embolisation painful?

The procedure itself is essentially pain free. The local anaesthetic at the groin stings for about ten seconds before taking effect.

Soon after embolisation, the fibroids are strangulated (cut off of blood supply) and pain maybe experienced. The degree varies between individuals. We have a robust pain control protocol that has worked well for our patients. You will be given a PCA (patient controlled analgesia) through the IV drip. The pain is usually worst for the first 6 to 8 hours. PCA are usually no longer required the following day. Pain is then controlled with oral medications, typically regular Panadol and Nurofen or Mobic. Pain should subside within 4 to 5 days. Patient should anticipate returning to work and normal activities around 7 days after the procedure.

Can I still get pregnant after uterine fibroid embolisation?

This is a complex issue. Presence of fibroids can make you difficult to get pregnant, potentially cause miscarriage and difficulties in normal vaginal delivery. Traditionally myomectomy is recommended if fibroids are thought to be interfering with fertility and pregnancy. Myomectomy however is still a major surgery, usually more technically challenging than hysterectomy. The risk of blood transfusion is higher than hysterectomy. There is also risk of hysterectomy if the surgeon is not able to preserve the uterus.

Studies have shown that UFE does not appear to affect ovarian function in younger women. Menopause after UFE tends to occur in older women close to natural menopause. There are theoretical concerns about negative impact on ovarian and uterine function after UFE. However, there are numerous reports of pregnancies following UFE. Dr Walker from UK has a large series of 105 pregnancies following UFE. His result has influenced the way in which patients with fibroids wanting to become pregnant should be counselled. For fibroids interfering with fertility, especially those not suitable for myomectomy or hysteroscopic resection, UFE should be considered as an option for treatment with advice that a successful pregnancy outcome is possible after UFE.

It should be emphasised that the aim of UFE is to treat fibroid symptoms with a minimally invasive technique to avoid hysterectomy. UFE is not intended to maintain uterine viability for pregnancy, although pregnancy is possible after UFE.

What are the pre-procedural evaluations required?

1. All patients will be required to have a pre-procedure consultation by the interventional radiologist. This allows us to obtain a gynaecologic and general medical history, to review the imaging findings and to discuss the procedure with the patient.

2. A MRI of the uterus is preferred. We prefer this be done at facilities familiar with fibroid imaging and reporting. The MRI helps the interventional radiologist to rule out fibroids unsuitable for embolisation. The MRI is also used as a baseline for follow-up evaluation at 6 month.

Do I need to see a gynaecologist?

We believe in multidisciplinary approach to deliver the best care for your fibroid related problems, therefore we share the care with your GP and gynaecologist.

You need to see your own gynaecologist or we can recommend a gynaecologist who is familiar with UFE.

You GP and gynaecologist may perform some of the following assessment:
1. A pelvic examination within six months of the procedure.
2. A Pap smear within the last year and should be normal.
3. If you have abnormal uterine bleeding (such as bleeding in between periods, periods lasting longer than 10 days or more frequently than every 21 days), an endometrial (inner lining of the uterus) biopsy is needed, preferably within the preceding 3 to 6 months. This is to be certain that the bleeding is not due to abnormal growth.
4. If you have a history of pelvic infection, cultures for Gonorrhoea and Chlamydia need to be obtained.

Your gynaecologist and GP will also take part in your follow-up, as well as your on-going well women care.

What are the preparations needed?

On the day of your procedure, you need to avoid solid food from midnight. Clear fluid and medications are allowed up to the time of procedure. We will start an intravenous line to give you fluid, sedatives and pain relief medications. You must not be pregnant. A pregnancy test is needed if there is possibility of pregnancy and the procedure is done more than 10 days since the beginning of your last menstrual cycle.

We also need to place a catheter in your bladder, so that the bladder will remain empty during the procedure. Since the bladder is in front of the uterus, X-ray dye collected in the bladder will obscure our view.

How do I recover after uterine fibroid embolisation?

After the procedure, you need to lie still for four hours to prevent bleeding in the groin. You will be given PCA (patient controlled analgesia) pump that allows yourself to administer the dose you need. You might experience varying degree of pain, nausea and fever. Medications are prescribed to control these symptoms. Please ask the nurses if you require them. You may eat and drink soon after the procedure. The bladder catheter and the IV drip are usually removed the next day.

We keep you in the hospital for 1-2 nights, mainly for pain control. After discharge, you may still experience some cramping pain, dull ache, fatigue, and possibly fever for few more days. Most symptoms subside within 4 to 5 days. You should anticipate returning to work and normal activities around 7 days after the procedure. Condoleezza Rice (former US Secretary of State) in 2004 had her UFE on a Friday afternoon and went back to work in the White House on Monday morning.

What are the follow-ups required after uterine fibroid embolisation?

You will need to see the interventional radiologist to check your recovery at about 1 week after discharge from hospital. Since we have not removed your uterus, it is important to follow you up for up to two years. The follow-up schedule with the interventional radiologist consists of clinic visits at 3, 6, 12 and 24 months. All patients are required to have a 6-month MRI. For patients with large fibroids, ultrasound at 3, 12 and 24 months maybe required to monitor changes.

You will need to liaise with your GP and gynaecologist to tailor your follow-up schedule depending on your situation.

What do I need to watch for potential problems?

Resurgence of pelvic pain and fever, or development of foul smelling vaginal discharge might indicate sloughing of fibroid and infection. You may require urgent medical assessment. If any of these symptoms occur, please try to contact us immediately, or present to your GP or gynaecologist. If the symptoms are serious and urgent (e.g. after hours), you should present to emergency department for assessment and ask the emergency doctors to contact interventional radiologist or your gynaecologist for advice. Blood tests are usually required to check for serious infection. IV antibiotics need to be given promptly. Very rarely a minor procedure (D&C) is required to clear the fibroid slough. Hysterectomy is highly unlikely to be necessary.

Other Useful Links

UFE and Pregnancy: Dr Walker's Pregnancy Data on more than 105 pregnancies following UFE. Dr Walker's paper on the topic can also be found on the website.
http://www.fibroids.co.uk/fibroid_embolisation/walkers_series.html