Uterine Fibroid Embolization

Uterine fibroid embolization (UFE, also known as uterine artery embolization UAE) is a procedure performed by an interventional radiologist (IR). The technique involves placing a catheter into the artery and guiding it to the uterus. The IR then injects small particles of plastic (polyvinyl alcohol or PVA) into the artery. The PVA blocks the blood supply feeding the fibroids and this results in embolization. The whole procedure takes about an hour and you are sedated but awake the entire time.

Within minutes after the procedure the fibroids begin dying. Generally, (but not always) there is an overnight stay in the hospital because many women have felt intense abdominal cramping and pain. Post-procedural pain is usually controlled through the use of a combination of narcotics but some IRs have started using epidurals (spinal anesthesia) to block all pelvic region pain for 12 hours or so. Ninety-nine percent (99%) of the women who undergo this procedure go home after only 1 night in the hospital.

Recovery is 1-2 weeks. Most women are up and around within a couple of days. The majority return to work after only 1 week of recovery. I returned to work after 6 days off but probably could have waited and returned after the second week. However, there was no traumatic surgery to recover from, no hormonal whammies from having anything "removed", and no psychological stress involved regarding the removal of the uterus.

Ideal Patient

The ideal patient for this procedure meets four basic requirements:

1. they have fibroids
2. the fibroids are symptomatic
3. there is no cancer
4. future pregnancies are not desired.

Although some interventional radiologists have additional requirements, it is not proven that any of these requirements have a basis in scientific data collected thus far. For instance, one interventional radiologist states that he doesn't accept patients that have a fibroid uterus that has grown above the navel in size -- any fibroid uterus roughly larger than a 16-20 week pregnancy is unacceptable. In his experience, the percentage of shrinkage from this size of fibroid uterus is not significant enough to warrant doing the procedure. However, his experience may include fewer than a dozen patients with fibroids of this size. Collectively, the data simply hasn't been reviewed yet for efficacy of UFE in relationship to size of fibroid uterus. Who knows whether or not his exclusionary patient selection process is valid? Maybe it is. Maybe it isn't.

Still other IRs are turning women away because they are 50 years of age or more. Since the average age of menopause is 51, they've somehow determined that doing nothing and simply waiting out menopause is a more appropriate course to take for these women. Nevermind that 51 is the average age of menopause. (The women in my family didn't hit menopause until they were nearly 60 or so.) Nevermind that the women are bleeding like there's no tomorrow.

Someone needs to tell these docs that the word AVERAGE means there's a span of difference with a low and a high and the numerically totaled and divided middle point is the AVERAGE. Geez.

The average age of menopause is 51, give or take 1 to 15 years. Capiche?

Come on guys. Don't make me draw a bell curve here. Appropriate testing can be done that would determine a little more accurately where a woman is on the spectrum from peri-menopause to post-menopause.

Some additional concerns and considerations might include:

a) the presence of submucosal fibroids which can or should be resected hysteroscopically
b) the presence of pedunculated subserosal fibroids more effectively treated by removing them via myomectomy.

UFE treats all uterine fibroids at the same time and is, therefore, an extremely effective, all encompassing treatment option. However, submucosal fibroids not removed before UFE may infarct once they die and cause the uterus to attempt to get rid of the fibroid. If the fibroid is too large for the uterus to expel, serious infection could result. This can be extremely painful and potentially dangerous. It is important for women with submucosal fibroids to discuss this possibility with their gynecologist and determine how to handle the care of their submucosal fibroids before the UFE.

Pedunculated subserosal fibroids may also infarct and break off from the uterus once they necrotize. This has been known to create a temporarily painful condition treatable with pain medication but, so far, no additional problems have been encountered. Only more time will tell us whether or not this is a complication with additional concerns.

Success, Failures, and Complications

Doctors are currently tracking success and failure of this procedure by two different standards: technical failure and clinical failure. Knowing the difference between these two kinds of failures will give you a better understanding of what the success statistics actually mean to you when you read them. In addition, complications can occur during the procedure which result in injury, a less than desired outcome, or unanticipated results.

Technical Failure Rates

Technical failures currently occur 1-2% of the time and are primarily related to the following items.

1. skill of interventional radiologist
2. abnormalities of the uterine artery
3. shared blood flow from a single uterine artery and ovarian artery (with both feeding the fibroids) -- a blood flow situation called anastomoses
4. use of progestin or GnRH agonists (Lupron) pre-UFE
5. any number of additional odd circumstances that present themselves during the procedure.

Clinical Failure Rates

Clinical failure rates are another cup of tea entirely. Typically these have nothing to do with the interventional radiologist and his/her embolization of your artery but rather your own physical response to the embolization. If the embolization is a technical success but the symptoms the fibroids were causing are not significantly or satisfactorily reduced post-UFE, then this is considered a clinical failure. For example, if the fibroids don't shrink "enough" or excessive bleeding doesn't subside then the UFE would be considered a clinical failure.

You won't see the term "clinical failure rates" in medical literature, however. Instead, you'll see numbers that tout the statistics of how many women report "shrinkage" or reduced bleeding. Like this:

"...80-90% of all women undergoing UFE report...".

Sort of "reverse statistics" to get you to focus on the positive side of things. Here's the reality: 80-90% success rates invert to equate to 10-20% failure. Yep. 10-20% clinical failure rate. (Some IRs report 10-15% and others 15-20% -- statistics haven't really been pooled across the board yet with the results published.) The numbers look different to you now, don't they?

Here's something the numbers won't tell you:

Even with high clinical failure rates, women (even those who sustained clinical failure) are reporting that they would STILL choose UFE over hysterectomy or even myomectomy if they had to do it all over again.

Why is that? Why do women who've had "less than success" with their UFE still perceive it to be a better option? From my own personal experience, I would say it's because even though the procedure wasn't a complete success, it was enough to restore life back to an acceptable level of existence. And, at minimal surgical (technical) risk to me -- particularly compared to hysterectomy or even myomectomy.

Complications

Complications currently occur 1-2% of the time. Less than 1 in 200 women will acquire an infection that requires an immediate hysterectomy. Other items that contribute to the complication rate are:

1. Finding that the woman has only a single uterine artery and the ovarian artery is feeding the fibroids (or, the uterine artery is feeding the ovary--the blood can actually flow in either direction). Doctors do one of two things in this case:

a) they partially embolize the ovarian artery (which may cause premature menopause) or

b) they go ahead and embolize the uterine artery and that's all (the fibroids continue to receive blood from the ovarian artery so the overall amount of "shrinkage" to the fibroids is reduced significantly--or, if the blood is actually flowing to the ovaries from the uterus, they've just shut off its blood supply--instant menopause).

Misembolization Misembolization is typically referred to as "non target embolization" in medical literature. I prefer the term "misembolization" but several IRs have pointed out that this implies there's been a "mis-take" when, in fact, there was simply an embolization of something non targeted and it could have been a mistake or simply materials going awry. It's a finer point to make and differentiate--one I think that is completely lost on most women. Hey--something got embolized that shouldn't have. End of story. Misembolization.

2. Complete misembolization of the ovarian artery. Results in menopause.
   
   
3. Misembolization of other areas that were not "targeted." Areas that would, oh for example let's say, impact your buttocks or legs. None have been reported to date--but it has occurred. What doctors do and what doctors "officially" report are not always the same thing. Effects of misembolization are generally temporary but can be quite serious, depending on what, exactly, the doctor misembolized.
   
   
4. Femoral hematoma. A deep bruising of the puncture site (for arterial catheterization) in the groin.
   
   
5. Death. While there have been no deaths reported in the United States from UFE, there has been one death in England and possibly a second death in Italy associated with UFE. Statistically, this represents a tiny fraction of the number of women (over 6,500) who have undergone this procedure worldwide. UPDATE
   
   
6. Miscellaneous side effects. Doctors are still figuring these out as they are so infrequent that only time and long range data collection will give them a more complete list. Please ask your interventional radiologist for a more complete list of complication possibilities during your initial appointment.
   
   One of the side effects of UFE may well be some level of sexual dysfunction. (You can read about my own experience with this in My Journal.) If you are a woman who experiences uterine contractions or internal pelvic orgasms during sex and the blood flow to the cervix is altered because of uterine artery embolization, you may experience a loss of those contractions or internal orgasms. Although most women are reluctant to discuss this with their physician, I am aware of a number of cases (besides my own) where loss of internal orgasms and/or uterine contractions has, in fact, occurred. Several of us are nearing the one year mark post-UFE and have shown no signs of improvement. Clitoral orgasms and intensity of feeling in the vagina have also been reported as less intense with some women post UFE but in all cases that I am aware of to date these have returned to "normal" within 3 or 4 months. Until more women choose to openly discuss the issue of sex with their physicians both pre and post procedure we will not know how often sexual dysfunction actually occurs as a result of this procedure.

History of UFE

There have been thousands of UFEs performed over the last 8 years for the specific treatment of uterine fibroids. Prior to that, uterine artery embolization (UAE) was reserved for women who began hemorrhaging following childbirth or after pelvic surgery (such as myomectomy).

UAE is a procedure that has been around for about 20 years and medical literature has detailed it as an effective means of stopping uncontrollable bleeding since 1979 or so. (Although the SCVIR recently changed the name of this procedure to represent it's specific treatment application for uterine fibroids, technically UAE and UFE are the same procedure.)

About 10 years ago (1989), an ob/gyn in Paris, France (Dr. Jacques-Henri Ravina) read the medical literature indicating that UAE was an effective means of stopping uncontrollable bleeding and decided to start using UAE PRE-myomectomy to cut down on the bleeding that patients would experience during the procedure. He was quite surprised to start finding women canceling out on their myomectomies. They no longer needed the myomectomy because their bleeding had subsided and their fibroids had actually begun to shrink.

From there, it took another 7 years before the procedure was introduced into the United States by Dr. Scott Goodwin at the UCLA Medical Center. Since introducing this procedure in 1996, there have been over 4,000 uterine fibroid embolizations performed in the United States. Nonetheless, it has been an uphill struggle to get gynecologists to recognize this promising procedure in the United States because it directly cuts into the revenue they currently receive from performing so many hysterectomies.

The Doctors and Web Links

The following web links will lead you into a rather fascinating world of interventional radiology. You'll find an entirely different "breed" of doctors than the gynecologists you're probably accustomed to and you will be quite surprised at the information that many of them are choosing to present to women in an effort to ensure that you truly do understand all of the choices available for treatment of your uterine fibroids. For firsthand information about my own experiences with this choice, you can, of course, read My Journal. In addition, for ongoing discussions among women on this topic, please join us at the uterinefibroids chat group.

Search WWW Search uterinefibroids.com

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This page last updated Wednesday, April 10, 2002