Nonsurgical Management of Uterine Fibroids

Fibroids are the most common benign tumors of the uterus. These noncancerous growths are present in 20-40% of women over the age of 35. In some women, the fibroids can become enlarged and cause symptoms of excessive bleeding and pain. While the classic treatment of symptomatic fibroids has been surgical removal of the fibroids (myomectomy) or the uterus (hysterectomy) recent advances now afford a nonsurgical treatment. For many years, interventional radiologists have controlled various causes of bleeding by blocking the arteries supplying the bleeding site, a minimally invasive procedure called embolization. Within recent years, technical advances have allowed the application of this standard technique to symptomatic uterine fibroids. For most patients, bleeding will decrease dramatically within days. Menstrual flow will decrease to normal or less. Over the following weeks, most patients experience a decrease in the pain or abdominal fullness caused by the fibroids.

Preprocedure Evaluation

The appropriateness of uterine artery embolization as treatment for your symptoms will be assessed by our Interventional Radiologists and Gynecologists. A telephone screening interview will be conducted at no charge. If you are deemed suitable, you will be referred to one of our participating gynecologists for an evaluation which may include history, physical examination, PAP smear and endometrial aspiration biopsy. These are all simple office procedures. If these results confirm your eligibility, you will have an ultrasound examination of your uterus to document the size and number of your fibroids in order to assess treatment success. If, after a discussion of the benefits, potential complications and alternatives, you consent, you will then be scheduled for the procedure. An additional ultrasound or CT scan will be performed about two months after the procedure to assess treatment.

The Procedure

The morning of the procedure, you will be admitted to the Same Day Surgery Unit. You will be transported to the Interventional Radiology Suite where our Interventional Radiology Team of physicians, nurses and technologists will again explain the procedure to you and answer any questions you may have.

The uterine arteries to be embolized are accessed through an artery near the hip, where the leg joins your body. After preparing your skin with antiseptic solution, a local anesthetic is administered to the skin over the area of the artery to be entered. The radiologist enters the artery with a needle that allows exchanges for a catheter, a thin plastic tube that will ultimately be positioned into the arteries to the uterus and fibroids. Once the catheter has been positioned in the arteries to the uterus, x-ray contrast material is injected into the arteries to demonstrate the exact location and size of the fibroids. This injection causes a brief faint sensation of warmth. The arteries to the fibroids are then blocked with a mixture of x-ray contrast material and polyvinyl alcohol (PVA). PVA is an inert plastic substance used to block arteries for many years. You will be unaware of its presence in your body.

Once the arteries to the fibroids have been successfully blocked, the catheter will be withdrawn from your body. Pressure will be applied to the access site for about ten minutes. This prevents bleeding from the arterial puncture site. Depending upon your response to the procedure, you will either be observed for several hours and then discharged or transferred to a room for an overnight stay. The vast majority of patients go home the same day on oral medications.

Pain Management

In order to assure your comfort during the procedure, you will receive pain medication and sedation. The blockage of the arteries to the fibroids is frequently associated with pain similar to intense menstrual cramps which can last several hours. During the procedure, medications such as Versed (similar to Valium) and Demerol will relieve and pain. Following the procedure, various medications are employed to assure your comfort. Most patients begin on oral pain medication and go home by the evening. Others require somewhat stronger intravenous medication and hence may be admitted overnight. These patients are invariably discharged the next day on oral medications such as Tylenol #3 or Motrin.

Potential Complications

As in any invasive procedure, there are several potential complications. Fortunately, these complications are infrequent and readily treatable.

An allergic reaction to the x-ray contrast material can range from itching and hives to a life-threatening response. Severe reactions occur in less than 1 in 10,000 people.

Bleeding or accumulation of blood at the arterial puncture site can occur. This can be treated readily by compression at the puncture site. It occurs in less than 1 in 100 people and is usually of limited consequence.

Damage to the arteries entered during the procedure can result in clotting, readily treated by clot dissolving medications or surgical removal of the clot. Blockage of a vessel can also occur, treatable with balloon angioplasty or surgery.

During the blockage of the vessels going to the fibroids, particles can inadvertently go to other unintended sites. While this can create serious problems, the occurrence is extremely rare and frequently self-limited when performed by experienced Interventional Radiologists. Every precaution is taken to assure release of the particles only into the uterine arteries. Infection of the uterine fibroids is an additional possibility, readily treated with antibiotics. This can occur because of the selective destruction of the fibroid tissue. Most occurrences are treatable by nonsurgical drainage. On rare occasion, an infection may require a hysterectomy.

Long Term Expectations for the Patient

After undergoing the embolization, most women experience a marked decrease in the amount of menstrual bleeding. This effect should be almost immediate. Furthermore, shrinkage of the fibroids over several weeks should bring relief from the associated pain and pressure. This will be a gradual process. Ultrasound and/or CT scan will be performed about two months after the procedure to document effectiveness.

Uterine artery embolization affects both the uterus and the fibroids. Hence, as after myomectomy, some women may expect to become infertile. The exact percentage is not yet known. Hence, should you wish to retain your reproductive potential, this possible side effect should be kept in mind. Similarly, should you not desire pregnancy, contraception must be continued.

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