Uterine artery embolization

Overview

Uterine artery embolization is a minimally invasive treatment for uterine fibroids, noncancerous growths in the uterus. In uterine artery embolization — also called uterine fibroid embolization — a doctor uses a slender, flexible tube (catheter) to inject small particles (embolic agents) into the uterine arteries, which supply blood to your fibroids and uterus. The goal is to block the fibroid blood vessels, starving the fibroids and causing them to shrink and die.

Why it's done

Uterine fibroids can cause severe symptoms in some women, including heavy menstrual bleeding, pelvic pain and swelling of the abdomen. Uterine artery embolization destroys fibroid tissue and eases these symptoms. And it provides an alternative to surgery to remove fibroids (myomectomy).

You might choose uterine artery embolization if you're premenopausal and:

• You have severe pain or heavy bleeding from uterine fibroids
• You want to avoid surgery, or surgery is too risky for you
• You want to keep your uterus
• Optimizing a future pregnancy isn't your chief concern

Risks

Rarely, major complications occur in women undergoing uterine artery embolization. The risk of complications from uterine artery embolization is about the same as those for surgical treatment of fibroids. These may include:

• Infection. A degenerating fibroid can provide a site for bacterial growth and lead to infection of the uterus (endomyometritis). Many uterine infections can be treated with antibiotics, but in extreme cases, infection may require a hysterectomy.
• Damage to other organs. Unintended embolization of another organ or tissue can occur, although it's not as high a risk as with surgery. Whether you have embolization or surgery, disruption of the ovarian blood supply is a possibility because the ovaries and uterus share some blood vessels. If you're nearing menopause (perimenopausal), such a disruption could lead to menopause ― but that's rare if you're age 40 or younger.

• Possible problems in future pregnancies. Many women have healthy pregnancies after having uterine artery embolization. However, some evidence suggests pregnancy complications, including abnormalities of the placenta attaching to the uterus, may be increased after the procedure.

  If you want to have children, talk to your doctor about the risks of surgery and how uterine artery embolization might affect your fertility and future pregnancy.

Reasons to avoid this procedure

Avoid uterine artery embolization if you:

• Are pregnant
• Have possible pelvic cancer
• Have an active, recent or chronic pelvic infection
• Have a condition that affects your blood vessels (vascular disease)
• Are allergic to contrast material containing iodine

Most fibroid sizes and locations can be treated with uterine artery embolization. However, extremely large fibroids can be so big that they cause complications and require another method to remove them.

Some fibroids that are primarily inside the uterus (pedunculated submucosal) may be expelled vaginally following the procedure. Finally, if the fibroids have already lost their blood supply (degenerated), uterine artery embolization won't provide any benefit.

Discuss the benefits and risks of uterine artery embolization with your obstetrician-gynecologist or an interventional radiologist ― a doctor who uses imaging techniques to guide procedures that would be impossible with conventional surgery.

How you prepare

Uterine artery embolization usually is performed by an interventional radiologist or a specialist in obstetrics and gynecology who has training in uterine artery embolization.

Food and medications

On the evening before the procedure, don't eat or drink after midnight or after whatever time your doctor advised. If you're taking medications, ask your doctor if you should stop taking them before or after the procedure.

What you can expect

To see your uterus and blood vessels, the radiologist uses a fluoroscope. This device is a pulsed X-ray beam that produces moving images of internal structures and displays them on a computer monitor.

Before the procedure

In the radiology procedure room, you'll have an intravenous (IV) line placed in one of your veins to give you fluids, anesthetics, antibiotics and pain medications.

During the procedure

The procedure includes:

• Anesthesia. Typically you'll receive a type of anesthesia that reduces pain and helps you relax, but leaves you awake (conscious sedation).
• Blood vessel access. The doctor makes a small incision in the skin over your femoral artery, a large blood vessel that passes lengthwise through your groin. Then your doctor inserts a catheter into the artery and guides the catheter to one of the two uterine arteries. Generally, the doctor can access both uterine arteries through one incision.

• Blood vessel mapping and injection. An injected contrast fluid, usually containing iodine, flows into the uterine artery and its branches and makes them visible on the fluoroscope's monitor. The fibroids "light up" more brightly than other uterine tissue.

  The radiologist identifies the right area of the uterine artery and then injects the blood vessel with tiny particles made of plastic or gelatin. The particles are carried by the blood flow to block the fibroid vessels.

  After injecting more contrast into the uterine artery, the doctor checks additional images to make sure that blood is no longer reaching the fibroids. The same steps are then repeated in the second uterine artery.

After the procedure

In the recovery room, your care team monitors your condition and gives you medication to control any nausea and pain. When the effects of the anesthesia fade, they take you to your hospital room for overnight observation.

• Position. You must lie flat for several hours to prevent pooling of the blood (hematoma) at the femoral artery site.
• Pain. The primary side effect of uterine artery embolization is pain, which may be a reaction to stopping blood flow to the fibroids and a temporary drop in blood flow to normal uterine tissue. Pain usually peaks during the first 24 hours. To manage the pain, you receive pain medication.

• Observation. Post-embolization syndrome — characterized by low-grade fever, pain, fatigue, nausea and vomiting — is frequent after uterine artery embolization.

  Post-embolization syndrome symptoms peak about 48 hours after the procedure and usually resolve on their own within a week. Ongoing symptoms that don't gradually improve should be evaluated for more-serious conditions, such as an infection.

  By the next day, your urinary catheter is removed, and you're encouraged to walk around. Recovery is generally rapid, and complications are rare.

Recovery

Most women return home the day after the procedure with a prescription for oral pain medication. Pain usually ends within a day or two, but in some women it may last up to a few weeks.

Monitor your recovery for:

• Vaginal discharge. You might have a watery or mucus-like vaginal discharge for a few weeks to a month after uterine artery embolization. The discharge should stop without treatment. In a few women, remnants of fibroids are passed through the vagina.
• Infection. Return to your obstetrician-gynecologist or primary care doctor for a follow-up exam within four weeks of the procedure to make sure there's no infection. Signs and symptoms of infection include fever, chills and pain. Delayed infections and vaginal discharge are rarely reported weeks to months after the procedure.

Follow-up

You may have a magnetic resonance imaging (MRI) exam over the next year to monitor shrinkage or other changes in the fibroids or your uterus. Doctors usually schedule the first exam three months after the procedure.

Results

Uterine artery embolization typically provides significant relief of symptoms. It also affects your menstrual period and it may have an impact on fertility.

• Symptom relief. Most women get significant symptom relief in the first three months after treatment. In addition, some research shows that five years after treatment uterine artery embolization continues to reduce symptoms such as heavy bleeding, urinary incontinence and abdominal enlargement in most women. These results appear to be comparable to that of myomectomy, in which the fibroids are surgically removed and the uterus repaired.

• Menstruation. Your menstrual period may continue on its normal schedule. If you miss any periods, they will probably resume within a few months.

  A small number of women enter menopause after the procedure. The risk appears highest among women age 45 and older.

• Impact on fertility. Although the risk of entering menopause after the procedure is low, subtle ovarian damage may make getting pregnant more difficult. There also may be an increased risk of pregnancy complications, especially involving abnormal placement or attachment of the placenta. Despite these risks, many women have had successful pregnancies after uterine artery embolization.

  But, more long-term, larger studies are needed to determine the impact of uterine artery embolization on fertility and pregnancy — and the risks of uterine artery embolization must also be compared with the risks of surgery.