What is the difference between uterine artery embolization (UAE) and
uterine fibroid embolization (UFE)?
These are different names for essentially the same procedure. UAE applies generically to any procedure where the uterine arteries are embolized, such as for emergency post-partum or post-operative bleeding, or in this case, electively for fibroids. UFE applies specifically to embolizing the uterine arteries for the purpose of treating symptomatic fibroids. Either name is correct; UFE is more specific and is used throughout this website.
What is an Interventional Radiologist (IR)?
An IR is a medical specialist who uses state of the art radiologic imaging to guide tiny catheters through the body to treat a wide variety of conditions that once required surgery. The American Board of Radiology certifies general radiologists. Those with additional training and expertise are eligible to take an examination for a Certificate of Added Qualification (CAQ) in Vascular and Interventional Radiology. Most IRs performing UFE will be CAQ certified.
Can my gynecologist perform UFE?
Not likely. Unless the gynecologist underwent Interventional Radiology training it is unlikely that he or she would be competent to perform UFE. However, gynecologists are an extremely important part of the team as their expertise in the evaluation and treatment of pelvic masses, abnormal uterine bleeding, and the surgical management of complications is invaluable. UFE should not be performed without the support of a gynecologist.
Is UFE "experimental or investigational" like some insurance companies claim?
UFE is not an "experimental or investigational" procedure, but is an expansion of indication for a procedure that is known to be safe and effective, and has been used for twenty years to treat emergency, life threatening bleeding. All devices, medications, and materials used during the procedure are within FDA labeling guidelines. The procedure is now widely available in the US and Europe and is being taught in Interventional Radiology fellowship training programs throughout the US. At most sites the procedure is performed without IRB (Institutional Review Board) monitoring and without the need to obtain special hospital privileges. The experimental / investigational label is used by some insurance companies as an excuse to avoid paying for the procedure.
Does rapid growth of fibroids signify cancer?
A rapid increase in size (an increase of 2-4 weeks size on examination by the same examiner, done 2-3 months apart, or an increase of 6 weeks size over one year) has been thought to be associated with malignancy (sarcoma). Fortunately, this does not seem to be the case. In one study of over 1300 women operated on for presumed fibroids the incidence of uterine sarcoma was only 0.23%. Of the 371 women operated on specifically for "rapidly growing fibroids" only 0.27% were found to have sarcoma.
Leiomyosarcoma, the malignancy that sounds similar to fibroids (leiomyomata), is a de novo tumor that does not represent degeneration of a preexisting benign fibroid. These tumors more typically arise in postmenopausal women (the 5th or 6th decade of life), usually associated with a pelvic mass, abnormal bleeding and pelvic pain. UFE is not usually offered in postmenopausal women. The incidence has been estimated at <1%, closer to 0.1% in premenopausal women. There is no screening test that can reliably detect this malignancy.
The other gynecologic malignancies of concern include cervical, endometrial, and ovarian cancer. Since UFE is a uterine sparing treatment it is important to exclude these diagnoses prior to the procedure. The Pap smear is used to screen for cervical cancer. An endometrial biopsy is for excluding endometrial cancer and other non-fibroid causes of abnormal uterine bleeding. Ultrasound and MRI are both helpful in evaluating for ovarian cancer, especially when large fibroids obscure evaluation of the ovaries on physical examination.
Will the drug lupron interfere with UFE?
Lupron is a synthetic hormone that causes a "chemical menopause" with a marked reduction in estrogen levels. This drug effectively shrinks fibroids and the overall uterine size by about 50%. The drug works by shrinking the blood supply of the fibroids. Unfortunately, the effect is only temporary as fibroids rapidly regrow following cessation of the drug. Side effects usually limit the use of lupron to a few months.
During UFE it is desirable to have enlarged blood vessels feeding the fibroids so there is a more effective embolization of the tumors. Therefore, it is recommended that UFE be postponed until at least 8 weeks after the last lupron injection.
Is UFE effective for multiple fibroids? Does it matter where the fibroids are located in the uterus?
UFE is a global treatment of the entire uterus treating all fibroids simultaneously regardless of size, number, or location. Pedunculated fibroids may be the exception. They occur on a stalk and may project from the outer surface of the uterus. While they may respond to UFE many IRs believe they are best treated by other means, such as laparoscopic removal, due to concerns about a higher complication rate following UFE. Pedunculated fibroids projecting into the uterine cavity are probably best treated by hysteroscopic resection.
Is there a size limit for the procedure?
Virtually all fibroids respond to UFE (except those that have already degenerated and calcified). The question is will there be enough shrinkage to relieve symptoms? Average reduction of uterine volume following UFE is ~50%. For patients with a very large uterus prior to UFE, a 50% reduction may be inadequate for symptom relief. These patients may be better treated with hysterectomy.
While patients with near term size uteri have been treated with UFE, in practice, 22-24 weeks gestational size seems to be the upper limit where a good response can be anticipated. This size limit is far from absolute and each case needs to be evaluated individually.
Is the procedure painful? How will my pain be managed?
The actual embolization procedure is not painful at all. Almost all patients develop some degree of crampy pelvic pain for the first 6-10 hours after the procedure, as the fibroids are breaking down. The amount of pain varies greatly from patient to patient and is difficult to predict in advance. In most patients the pain is well controlled with a PCA (patient controlled analgesia) pump that allows delivery of IV narcotic pain medication by pushing a button. By the next morning the cramping will be much improved and can be managed with oral medications, allowing discharge home.
Some centers routinely offer spinal or epidural anesthesia for post procedure pain control. While certainly effective, these techniques do add another level of risk and expense, and in the majority of cases are unnecessary. If you are particularly concerned about pain this should be discussed in advance with your Interventional Radiologist and either spinal or epidural anesthesia can be arranged.
What happens to the PVA particles? Can they move to other parts of the body and cause problems?
Polyvinyl alcohol (PVA) particles have been used for embolization procedures for over 20 years without reports of adverse or allergic reactions. The injected particles are too large to pass through the capillary bed of the uterus or fibroids. As the flow in the uterine artery becomes stagnant the particles become incorporated in a blood clot and they remain in the clot as it becomes organized. They do not dissolve or get absorbed and they cannot migrate to other parts of the body.
What happens to the fibroids following embolization?
Once the fibroid blood supply is disrupted the tissue infarcts (dies), softens, and slowly shrinks as it is reabsorbed by the body. Eventually the fibroid is replaced by scar tissue, "good scar". This tissue is no longer sensitive to hormonal changes during the menstrual cycle.
What happens to the rest of the uterus after embolization?
We know from worldwide experience of more than 10,500 UFE cases that the uterus tolerates embolization very well. The PVA particles preferentially enter the fibroids, as their blood vessels are larger and have lower resistance to flow. The normal uterine tissue is able to recruit collateral blood supply from the vagina, ovaries, and pelvic floor. In less than 1% of cases this collateral circulation is inadequate, usually signified by continuing pain, and resulting in hysterectomy.
When can I expect to resume normal activities following UFE?
The first 2-3 days following UFE can sometimes be difficult, with intermittent crampy pelvic pain and fatigue. This iscaused by the breakdown of the fibroids and is a necessary step toward recovery. Most patients are back to their usual activities by 7-10 days after the procedure. Rarely, symptoms persist for 2-3 weeks following UFE.
Sexual activity can be resumed after your first checkup, usually in 7-10 days. For those who typically use tampons, another form of protection is advised for the first cycle after UFE.
Will UFE affect my sexual response?
The answer to this question is not definitely known, as it has not been carefully documented in the available studies. Most patients report either no change or improvement in their sexual desire and response after UFE. Those women with dyspareunia (pain during intercourse) caused by fibroids usually improve.
Some women experience intense, pleasurable uterine contractions during orgasm (called internal orgasm, and qualitatively different than clitoral orgasm), and a few have noted a decrease in this response after UFE. The exact reason for this is uncertain but may be related to an ischemic injury of nerves supplying the cervix. A cervico-vaginal branch of the uterine artery is identified in some patients and when seen care should be taken to avoid embolizing this branch. Concerns about effects of UFE on sexuality should be discussed with your Interventional Radiologist during the initial consultation.
Will fibroids recur after UFE?
A successful UFE procedure treats all fibroids that are present on the day of the procedure, regardless of size, number, or location. Once the fibroids infarct they are dead and do not regrow. For women who have initially responded to UFE there are very few recurrences of fibroids. Once menopause is reached there is usually no further growth of fibroids. For women treated in their 40s this may be a fairly short time. As we extend the procedure to younger women there is a higher likelihood that new fibroids will have time to develop prior to menopause. Longer follow-up data is needed to more certainly quantify the risk of recurrence.
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