Uterine Artery Embolization
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What is uterine artery embolization?
Uterine artery embolization (UAE) is a procedure that offers an alternative to traditional surgical removal of uterine fibroid. The procedure may also be referred to as uterine fibroid embolization (UFE).
Uterine artery embolization shrinks fibroids by blocking off their blood supply. The blood supply is blocked by injecting very small particles into the arteries that supply the fibroids. The particles stick to the vessel wall and cause a clot to develop, blocking off the blood supply. Once the blood supply is gone, the fibroids shrink and symptoms usually decrease or disappear. The most commonly used particle agent is polyvinyl alcohol (PVA), a substance that has safely been used in medical procedures for many years.
Uterine artery embolization is a minimally-invasive (without a large abdominal incision) technique which involves identifying which arteries supply blood to the fibroids and then blocking off those arteries.
Uterine artery embolization is performed by an interventional radiologist, a physician specializing in the field of radiology that treats a wide range of internal body conditions without making a surgical incision. Various small instruments or tools, such as catheters or wires, are used, along with various x-ray and imaging techniques (e.g., computed tomography (CT scan), magnetic resonance imaging (MRI), fluoroscopy, and ultrasound). Interventional radiology offers an alternative to the surgical treatment of many conditions and can eliminate the need for hospitalization, in some cases.
What are female pelvic organs?
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The organs and structures of the female pelvis are:
- endometrium - the lining of the uterus.
- uterus - also called the womb, the uterus is a hollow, pear-shaped organ located in a woman's lower abdomen, between the bladder and the rectum. The uterus sheds its lining each month during menstruation, unless a fertilized egg (ovum) becomes implanted and pregnancy follows.
- ovaries - two female reproductive organs located in the pelvis in which egg cells (ova) develop and are stored, and where the female sex hormones estrogen and progesterone are produced.
- cervix - the lower, narrow part of the uterus located between the bladder and the rectum, forming a canal that opens into the vagina, which leads to the outside of the body.
- vagina - the passageway through which fluid passes out of the body during menstrual periods. Also called the "birth canal," the vagina connects the cervix and the vulva (the external genitalia).
- vulva - the external portion of the female genital organs.
Other related procedures that may be performed to diagnose or treat problems of the uterus include cervical biopsy, colposcopy, dilation and curettage (D and C), endometrial ablation, endometrial biopsy, hysterectomy, hysteroscopy, laparoscopy, loop electrosurgical excision procedure (LEEP), and pelvic ultrasound. Please see these procedures for additional information.
The primary reasons for performing a uterine artery embolization include:
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- fibroid tumors
Fibroids, also known as uterine myomas, leiomyomas, or fibromas, are firm, compact tumors that are made of smooth muscle cells and fibrous connective tissue that develop in the uterus. It is estimated that between 20 to 50 percent of women of reproductive age have fibroids, although not all are diagnosed. Some estimates state that up to 30 to 77 percent of women will develop fibroids sometime during their childbearing years, although only about one-third of these fibroids are large enough to be detected by a physician during a physical examination.
In more than 99 percent of fibroid cases, the tumors are benign (non-cancerous). These tumors are not associated with cancer and do not increase a woman's risk for uterine cancer. They may range in size from the size of a pea to the size of a softball or small grapefruit.
- excessive uterine bleeding
In general, bleeding is considered excessive when a woman soaks through enough sanitary products (sanitary napkins or tampons) to require changing every two hours. In addition, bleeding is considered prolonged when a woman experiences a menstrual period that lasts longer than seven days in duration.
Other reasons for performing a uterine artery embolization include, but are not limited to, the following:
- anemia (low blood count) from the excessive uterine bleeding
- abdominal/pelvic fullness or pain
- an enlarged uterus
- abnormally enlarged abdominal size
- bladder pressure leading to a constant urge to urinate
- pressure on the bowel, leading to constipation and bloating
- pain during sexual intercourse
- pain in the back or legs as the fibroids press on nerves that supply the pelvis and legs
There may be other reasons for your physician to recommend a uterine artery embolization.
As with any procedure, complications may occur. Some possible complications include, but are not limited to, the following:
- hemorrhage (abnormal bleeding)
- injury to the uterus
- infection of the uterus or the puncture site in the groin
- hematoma (large accumulation of blood such as with a bruise) at the puncture site in the groin
- injury to the artery being manipulated
- blood clots
- amenorrhea (loss of menstrual periods)
Some women experience postembolization syndrome. Symptoms of this condition may include, but are not limited to, the following:
- pelvic pain and cramping
- nausea and vomiting
- low-grade fever
- fatigue and discomfort
Symptoms of postembolization syndrome last approximately 2 to 7 days. Pain medications and anti-inflammatory medications may be prescribed, as well as agents to help with nausea.
The first clinical study of uterine artery embolization for the treatment of uterine fibroids was published in 1995. Since then, studies assessing both short and long-term effectiveness and outcomes have found UAE to be safe and effective option for many women. Compared with surgical methods such as hysterectomy or myomectomy, most women had less post-surgery pain, and had a quicker recovery after a UAE procedure. However, some long-term studies found women undergoing UAE were more likely to need another future treatement or surgery, compared to women who had surgical procedures such as hysterectomy for treating uterine fibroids.
Some women, especially those older than 45 to 50 years of age, will go into menopause after UAE.
One advantage of UAE over some surgical treatments for fibroids is that the uterus is not removed, leaving the option for a future pregnancy. However, more studies are needed to determine the effects of this procedure on future fertility and pregnancy.
There may be other risks depending upon your specific medical condition. Be sure to discuss any concerns with your physician prior to the procedure.
- Your physician will explain the uterine artery embolization procedure to you and offer you the opportunity to ask any questions that you might have.
- You will be asked to sign a consent form that gives permission to do the procedure. Read the form carefully and ask questions if something is not clear.
- In addition to a complete medical history, your physician may perform a complete physical examination to ensure you are in good health before undergoing the procedure. You may undergo blood tests or other diagnostic tests.
- You will be asked to fast for eight hours before the procedure, generally after midnight.
- If you are pregnant or suspect that you may be pregnant, you should notify your physician.
- Notify your physician if you are sensitive to or are allergic to any medications, iodine, latex, tape, or anesthetic agents (local and general).
- Notify your physician of all medications (prescription and over-the-counter) and herbal supplements that you are taking.
- Notify your physician if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.
- You will be sedated for the procedure and will be given local anesthetic at the groin site.
- You should arrange for someone to help around the house for a day or two after the procedure.
- Based upon your medical condition, your physician may request other specific preparation.
Uterine artery embolization may be performed as an outpatient procedure or may require an overnight stay in a hospital. Procedures may vary depending on your condition and your physician's practices.
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Generally, a uterine artery embolization follows this process:
- You will be asked to remove any jewelry or other objects that may interfere with the procedure.
- You will be asked to remove clothing and be given a gown to wear.
- An intravenous (IV) line will be inserted in your arm or hand.
- You may be given an antibiotic prior to the procedure.
- You will be positioned on the procedure table lying flat on your back.
- A catheter (thin, narrow tube) will be inserted into your bladder to drain urine.
- Your heart rate, blood pressure, breathing, and blood oxygen level will be continuously monitored during the procedure.
- The groin area will be cleansed with an antiseptic solution.
- A sheath (small tube) will be inserted into your groin area to be used as a guide for inserting the catheter to the area to be embolized (blocked off).
- In order to locate the specific artery location to be embolized, contrast dye will be injected into the catheter. This contrast dye causes the blood vessels to appear opaque on the x-ray image, thus allowing the physician to better visualize the arteries under examination. Using x-ray guidance, the physician will visualize the vessels which supply blood to each fibroid.
- After the artery is visualized, a tiny catheter will be inserted into the femoral (groin area) artery. Very small particles will be injected into the vessels which provide the blood supply to the fibroids. The particles may be made of polyvinyl alcohol (PVA), tris-acryl gelatin, or gelatin sponge.
- Additional x-ray images will be taken to verify blockage of the arteries.
- Some physicians will use one groin site to treat both the left and right uterine arteries if needed; others may use two groin sites to insert the treatment catheters into both uterine arteries.
- The sheath and catheter will be removed after embolization has been completed.
In the hospital:
Continuous pressure will be applied to the catheter insertion site in the groin for as long as needed to control the bleeding from the puncture site, generally about 20 minutes.
You will then be taken to the recovery room for observation. You will be instructed to lie flat for four to six hours. Your recovery process will vary depending upon the type of sedation that is given. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room or discharged home if appropriate.
Abdominal cramping may occur after the procedure. You may receive pain medication as needed, either by a nurse or by administering it yourself through a device connected to your intravenous line.
You may have small to moderate amounts of vaginal drainage for several days. The nurse will check the sanitary pads periodically to monitor the amount of drainage.
You will be encouraged to get out of bed within a few hours. In addition, you should perform coughing and deep breathing exercises as instructed by your nurse.
Depending on your situation, you may be given liquids to drink a few hours after the procedure. Your diet may be gradually advanced to more solid foods as tolerated.
Arrangements will be made for a follow-up visit with your physician, usually one to two weeks after the procedure. At that time an ultrasound or MRI may be scheduled within six months of the procedure to determine its effectiveness.
Once you are home, it is important to keep the groin incision clean and dry. Your physician will give you specific bathing instructions. If adhesive strips are used, they should be kept dry and generally will fall off within a few days.
The incision, abdominal, and pelvic muscles may ache, especially after long periods of standing. Take a pain reliever for soreness as recommended by your physician. Aspirin or certain other pain medications may increase the chance of bleeding. Be sure to take only recommended medications.
Walking and limited movement are generally encouraged, but strenuous activity should be avoided. Your physician will instruct you about when you can return to work and resume normal activities.
Avoid becoming constipated by including fiber and plenty of liquids in your diet, as straining to have a bowel movement may cause problems. Your physician may recommend a mild laxative.
You should not use a douche, tampons, engage in sexual intercourse, or return to work until your physician advises you to do so.
Notify your physician to report any of the following:
- fever and/or chills
- redness, swelling, or bleeding or other drainage from the incision site(s)
- increased pain around the incision site(s)
- abdominal pain, cramping, or swelling
- increased vaginal bleeding or other drainage
Following a uterine artery embolization, your physician may give you additional or alternate instructions, depending on your particular situation.