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A 44-year-old woman, presented to the interventional radiology service with progressive, severe menorrhagia over a 12-month period resulting in iron deficiency anaemia. She had attended her GP with a story of prolonged menstrual bleeding requiring ‘jumbo pads’ over the first three days of menstruation, in particular on a background of fibroid uterus diagnosed during one of her three successful pregnancies. She had no history of pelvic surgery, pelvic inflammatory disease, deep venous thrombosis or pulmonary embolism.
She was prescribed norethisterone and tranexamic acid, with initial improvement. However, subsequent progressive symptoms and lethargy related to iron deficiency anaemia (Hb 8g/dl) resulted in gynaecological referral. Severe uterine bleeding remained refractive to a levonorgestrel-releasing intrauterine system.
A temporary, menopause-inducing, gonadotropin-releasing hormone analog (leuprorelin) depot injection was required to abate symptoms and given as preparation for hysterectomy surgery. Ultrasound had confirmed a 12cm transmural uterine fibroid. At this stage, the patient considered alternatives to hysterectomy and asked about fibroid embolisation. Her gynaecologist then referred her to the interventional radiology consultation service. Fibroid embolisation was performed. There was a single severe bleed three weeks post-embolisation associated with passage of fragmented ‘tissue’.
Subsequently, regular menses returned to a low flow normal two-day event with resolution of anaemia, resolution of lethargy and follow-up imaging confirming no residual fibroid disease — spontaneous, complete fragmented passage of infarcted fibroid likely being the cause of the ‘bleed’ three weeks post-embolisation.
Figure 1: Good blood supply to 12cm fibroid (pre)
Since first being described as a successful treatment for symptomatic uterine fibroids by Jacques Ravina in 1995, uterine fibroid embolisation (UFE) has become an accepted alternative to hysterectomy and myomectomy. As a minimally-invasive percutaneous therapeutic procedure, UFE is used to treat symptomatic fibroids by causing devascularisation of the fibroids, causing them to shrink and in turn reduce associated symptoms.
Uterine fibroids (leiomyomata) are the most common tumours of the female reproductive system and traditionally have been the leading indication for hysterectomy.
The incidence of fibroids has been recorded as 29.7 per 100 patient years, with the highest incidence for those women in their early-to-mid 40s.
Uterine fibroids are benign monoclonal tumours of the uterus composed of smooth muscle cells and an extracellular matrix of collagen, fibronectin and proteoglycan. As they grow, fibroids cause enlargement of the uterus.
Fibroids are often defined by their location in the uterine wall. When located in a submucosal position, as well as intramural fibroids that abut the endometrial lining, fibroids can be associated with heavy menstrual bleeding. Local pressure effects and pain are caused by large fibroids that cause overall enlargement of the uterus.
These benign tumours can cause considerable symptoms and can significantly impact on quality-of-life, though only a third of fibroid patients have symptoms severe enough to justify intervention.
Menorrhagia is the most commonly-occurring symptom, with subsequent iron deficiency anaemia occurring as a result. Patients can also experience dysmenorrhoea, pelvic pain and pressure, dyspareunia, urinary frequency and urgency, and other pelvic symptoms. Fibroids may even contribute to infertility by hampering implantation.
Symptoms are frequently severe enough to warrant surgical management. Hysterectomy remains the definitive treatment for fibroids; however, it carries a significant mortality and morbidity risk. Treatment of symptomatic fibroids by embolisation of the uterine arteries is an alternative treatment.
Symptom relief and improved health-related quality-of-life
UFE is a percutaneous procedure, where embolisation and thus occlusion of the perifibroid vessels takes place, ischaemic infarction of the fibroid then ensues, causing the fibroid to shrink over the course of several months. For patients receiving UFE for symptoms of menorrhagia, menstrual bleeding is reduced by the second or third menstrual cycle; this also remains the case for the symptoms of pelvic pain, dysmenorrhoea, pressure or urinary symptoms. Overall, by three months most patients have relief of symptoms.
On occasion, the fibroid burden is incompletely infarcted but typically this too is associated with symptomatic relief. Incomplete infarction can lead to recurrent symptoms in three-to-seven years. Menopause, nature’s treatment of fibroid symptoms, can intervene in this interval for patients treated in their mid-to-late 40s, thus UFE acting as a bridge to menopause. For younger patients, recurrent symptoms related to progressive viable fibroid can be definitively treated with repeat UFE with good outcome.
Since UFE was first introduced into the US in 1997, multiple observational studies have consistently shown that menorrhagia improved in 85-95 per cent of patients with the symptoms of pelvic pain, pressure and urinary symptoms also improving.
The Randomised Trial of Embolisation vs Surgical Treatment for Fibroids (REST), a multicentre study of 157 patients in the UK, showed that no difference was found in health-related quality of life between the two groups after treatment. More major adverse events occurred in the surgical group than in the embolisation group during the initial hospital stay.
The Uterine Artery Embolisation (UAE) vs Hysterectomy for Uterine Fibroids trial, which was a multicentre, randomised trial in which UFE was compared with hysterectomy, showed that patients in the embolisation group had a more rapid recovery and a shorter hospital stay than those in the hysterectomy group (2.7 vs 5.1 days in the hospital). However, both groups had substantial and similar improvements in health-related quality-of-life.
Indications and contraindications
If the patient requires interventional treatment for symptomatic fibroids, the current options are hysterectomy, myomectomy, endometrial ablation and UFE. The treatment option depends on the patient’s age, symptoms, coexisting conditions and reproductive plans, as well as the specific characteristics of the fibroids.
For those in whom intervention is required, UFE is a reasonable option in most patients. However, there is some evidence that larger, single fibroids and larger uteruses may have less improvement and less satisfaction with the results.
UFE may be performed in those who have had previous pelvic surgery and in those who might be high risk or unsuitable for surgery, eg, obese patients, patients with hypocoagulable states or patients who wish to avoid blood transfusion. Pregnancy, suspected pelvic cancer, active infection or indeterminate endometrial or adnexal abnormalities requiring further evaluation are clear contraindications, with otherwise few contraindication to UFE.
The relationship and use of this technique with respect to fertility remains controversial.
When a patient desires future pregnancy, UFE is not the treatment of first choice.
After the procedure, ovarian function may infrequently be impaired, along with uncertain influences on the endometrium and embryo implantation, as well as the course of pregnancy.
Procedure and post-procedural course
UFE is a percutaneous, angiographic technique and should be performed by an appropriately trained and experienced interventional radiologist in a radiographic suite with the use of video fluoroscopic imaging. Before the procedure, all patients should have a gynaecological evaluation and pelvic examination. Pre-procedure imaging with MRI and ultrasound is vital to evaluate the location, number and size of the fibroids. Relevant bloods tests, the most important being a pregnancy test and coagulation screen, are performed on all patients prior to the procedure.
After administering sedation to the patient, access is obtained at the common femoral artery. After insertion of a guide wire, a small-bore angiographic catheter is advanced over the guide wire to the aortic bifurcation and into the opposite hypogastric artery. A small-bore microcatheter can then be placed through the primary catheter and advanced into the uterine artery to reach the distal transverse artery. An arteriogram is obtained in order to visualise the anatomy of the arterial plexus supplying the fibroid.
Embolisation is performed with the use of particulate embolisation material; commonly-used embolic agents include polyvinyl alcohol particles, trisacryl gelatin microspheres and gelatin sponge. After the embolic material is injected, it is carried by the arterial blood flow preferentially to the vasculature supplying the fibroid.
These vessels have a higher flow than normal myometrial branches and since they are larger, are preferentially occluded. When the fibroid blood supply is occluded but there is still sluggish flow in the uterine artery, the procedure is stopped. The procedure is repeated in the opposite uterine artery, moving the catheter to the ipsilateral hypogastric artery and then ipsilateral uterine artery.
Post-procedure, patients are admitted for overnight stay in hospital for observation and pain management.
Most patients experience moderate-to-intense pelvic pain during the first six-18 hours post-procedure. For this reason, overnight hospitalisation is advised to allow IV opioid and NSAID treatment. The severity of the pain can vary significantly between patients but typically reduces to a lower level easily controlled with NSAIDs by the time of discharge 24 hours post-procedure. Mild fever is experienced by a third of patients, but only 2 per cent of patients have a temperature higher than 38.5°C. Typical post-procedure symptoms also include malaise, fatigue and myalgia for several days. It is not uncommon to have light vaginal bleeding, spotting, or a brownish vaginal discharge for several days, often until the first menstrual cycle. The majority of patients return to work and other normal activities within seven-to-14 days after the procedure. There may also be some short-term menstrual irregularity but most women return to normal menstruation within two-to-three months after treatment.
In a registry of 3,160 women undergoing UFE, major complications (as defined by the Society of Interventional Radiology Clinical Practice Guidelines) occurred in 0.66 per cent during the initial hospitalisation and in 4.8 per cent during the first month after the procedure. More than half of these complications consisted of persistent or recurrent pain or nausea.
In another single-centre study of 400 consecutive patients, during the first year, the event rate for major complications was 4.3 per cent.
Post-embolisation syndrome is the most common phenomenon and consists of malaise, fever and pelvic pain. This can be symptomatically managed with antipyretics and analgesics. In the minority of cases, the patient may require prolonged hospitalisation or rehospitalisation due to the constellation of symptoms being very severe. Infection is a less-frequent complication, but one that is serious, and therefore it is important to distinguish post-embolisation syndrome from post-procedure infection. Minor infection occurs in approximately 5.9 per cent of patients, whereas major infection, sometimes necessitating surgery, occurs in 2.6 per cent of patients. Prophylactic antibiotics are routinely administered during embolisation to reduce the risk of subsequent infection.
Pulmonary embolism was reported to occur in one-in-300 patients in one study, thought to be related to transient hypercoagulability, which is similar to that seen after surgery.
After UFE, transcervical expulsion of a fibroid or of fibroid tissue is reported to occur in 2.2-7.7 per cent of women. This is usually well tolerated and indeed is considered by most as a desired effect. Rarely, hysteroscopic resection may be required to complete removal of a particularly large infarcted fibroid fragment associated with symptoms.
Non-target embolisation of the ovaries can cause a subsequent reduction in ovarian reserve and can cause transient or permanent amenorrhoea. Amenorrhoea is seen in 2-5 per cent of women, with permanent amenorrhoea occurring in less than 2 per cent of women, nearly all of whom are of perimenopausal age.
Other non-target embolic complications have been very rare and include minor ischaemia to the buttock, bladder, vagina or adjacent structures.
No deaths have been reported in any of the large clinical studies.
UFE has several potential advantages over hormonal suppression, myomectomy and hysterectomy. UFE involves virtually no blood loss or risk of blood transfusion. General anaesthesia and surgical incisions are avoided. Recovery is weeks shorter than recovery from hysterectomy or open myomectomy (seven-to-10 days versus six weeks), and early menopause-like symptoms are rarely induced as a result of UFE, as are often seen with gonadotropin-releasing hormone (GnRh) therapy. All fibroids are treated at once, which is not the case with myomectomy. Overall, UFE recurrence rates appear to be lower than those of myomectomy.
Both the Royal College of Obstetricians and Gynaecologists and the American College of Obstetricians and Gynaecologists (ACOG) have now recommended the use of UFE as an alternative to hysterectomy and myomectomy. The Society of Interventional Radiology and the Cardiovascular and Interventional Radiological Society of Europe state that uterine artery embolisation “is indicated for the presence of uterine leiomyomata that are causing significant lifestyle-altering symptoms, specifically mass effect on the bladder or intestines, and/or dysfunctional uterine bleeding that is prolonged, associated with severe dysmenorrhoea, or is causing severe anaemia”.
The ACOG concludes: “Based on good and consistent evidence (level A)” that “uterine artery embolisation is a safe and effective option for appropriately-selected women who wish to retain their uteri, both the UK National Institute for Health and Care Excellence (NICE) and ACOG recommend caution when considering embolisation in women who desire to retain their ability to conceive, as the effects of UFE on fertility and pregnancy remain uncertain.”
In a selected patient population, UFE is a safe and highly effective treatment option for women with symptomatic uterine fibroids. It is important that GPs and gynaecologists are fully aware of this interventional radiology procedure and include UFE as a treatment option if hysterectomy and myomectomy are being considered.
Uterine Fibroid Embolisation. Scott C, Goodwin, MD, and James B Spies, MD, MPH, N Engl J Med 2009;361:690-7.
Clinical Recommendations of the Use of Uterine Artery Embolisation in the Management of fibroids, Royal College of Obstetricians and Gynaecologists, The Royal College of Radiologists (2013). www.rcog.org.uk/globalassets/documents/…/23-12-2013_rcog_rcr_uae.pdf.
Uterine artery embolisation for fibroids. NICE interventional procedure guidance (November 2010). www.nice.org.uk/guidance/ipg367.
Alternatives to hysterectomy in the management of leiomyomas. Obstetrics and Gynaecology 2008;112(2):387-400.