Q: What is the difference between uterine artery embolization (UAE) and uterine fibroid embolization (UFE)?
A: 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. UAE is the term used when embolizing adenomyosis and not fibroids and our center has been a pioneer of successful embolization for adenomyosis.
Q: Can my gynecologist perform UFE?
A: 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 options is invaluable.
Q: Is UFE experimental or investigational?
A: 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. It is considered a first line therapy for treating symptomatic uterine fibroids by the American College of Gynecology (ACOG) based on long term safety and efficacy data. More than 700,000 UFE procedures have been performed worldwide. It is estimated that 22,000 UFE procedures are performed each year in the US.
Q: What is an Interventional Radiologist (IR)?
A: 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.
Q: Does rapid growth of fibroids signify cancer?
A: 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. 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.
Q: Will the drug lupron interfere with UFE?
A: 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 up to 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.
Q: Is UFE effective for multiple fibroids? Does it matter where the fibroids are located in the uterus?
A: UFE is a global treatment of the entire uterus treating all fibroids simultaneously regardless of size, number, or location. The location of the fibroids is important as demonstrated on the MRI, as this will help your physician choose the best, individualized treatment for you.
Q: Is there a size limit for the procedure?
A: 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, 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, and our center has had success treating up to 28 week sizes.
Q: Is the procedure painful? How will my pain be managed?
A: 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 discomfort varies greatly from patient to patient and is difficult to predict in advance. Most women describe it as being similar to moderate-severe menstrual cramps. The cramping is usually well controlled with a PCA (patient controlled analgesia) pump that allows delivery of IV morphine by pushing a button. By the next morning the cramping will be much improved and can be managed with oral medications. Some centers routinely offer spinal or epidural anesthesia for post procedure discomfort. While certainly effective, these techniques do add another level of risk, and in the vast majority of cases are unnecessary.
Q: What happens to the Embosphere particles? Can they move to other parts of the body and cause problems?
A: Polyvinyl alcohol (PVA) particles have been used for embolization procedures for over 20 years without reports of adverse or allergic reactions. At Weill Cornell Medical Center, we have used Biosphere Medical Embosphere particles exclusively Since April 2003 with excellent results. The injected particles will flow until they encounter a precisely chosen sized artery, and they will wedge in place in that position. They do not dissolve or get absorbed and they cannot migrate to other parts of the body.
Q: What happens to the fibroids following embolization?
A: 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. On average, individual fibroids and the overall uterus shrink by ~50%.
Q: What happens to the rest of the uterus after embolization?
A: We know from worldwide experience of more than 700,000 UFE cases that the uterus tolerates embolization very well. The particles preferentially enter the fibroids, as their blood vessels are larger and have lower resistance to flow. While some normal uterine tissue is inevitably embolized, it is able to recruit collateral blood supply from the cervix, vagina, and ovaries. In less than 1% of cases this collateral circulation is inadequate, usually signified by continuing pain, and results in hysterectomy.
Q: When can I expect to resume normal activities following UFE?
A: The first 2-3 days following UFE can sometimes be difficult, with intermittent crampy pelvic pain and fatigue. This is caused by the breakdown of the fibroids and is a necessary step toward recovery. Most patients are back to their usual activities by 7-8 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.
Q: Will UFE affect my sexual response?
A: 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. A cervico-vaginal branch of the uterine artery is identified in many patients and we take care in our center to try not to embolize this branch to avoid theoretical effects on sexual pleasure. Despite the added expense, we routinely use microcatheters that are placed past these branches to try to preserve them.
Q: Will fibroids recur after UFE?
A: 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 few reported 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.