Uterine Fibroid Embolization (UFE)

Uterine fibroid embolization, also known as uterine artery embolization, is a minimally-invasive, non-surgical, and highly effective treatment for fibroid symptoms. Here's all you need to know about uterine fibroid embolization.

What is uterine fibroid embolization?

During the procedure, doctors inject tiny particles into the arteries supplying fibroids in order to block their blood supply. Without blood supply, the fibroid will slowly shrink or disappear over the course of a few weeks to months as the body heals naturally.

Highlights

• Same-day procedure
• No hospital stay required
• As effective as surgery
• 3-7 day recovery
• Minimal if any blood loss

Did you know?

88% of women would recommend uterine fibroid embolization to a friend. Source.

Procedure Overview

1. A very small needle stick is made in the upper thigh or arm (see above for a size comparison). A local anesthetic is used to numb the area.
2. Using an x-ray imaging method called fluoroscopy, your interventional radiologist will insert a very thin catheter-thinner than pencil lead-into your uterine arteries.
3. Tiny beads are injected through this catheter and into the arteries supplying blood to the fibroids, blocking their blood flow. The catheter is then removed.
4. Now that their blood flow is stopped, the fibroids will shrink, usually over a period of 3 months, and your symptoms will decline.

Who is a candidate for uterine fibroid embolization?

Ideal UFE candidates:

• Have been diagnosed with uterine fibroids
• Are suffering from symptoms related to fibroid overgrowth (see below)
• Are looking for ways to treat these issues without invasive surgery

Major symptoms of fibroid overgrowth are:

• Heavy menstrual bleeding or periods that have become painful
• Passing blood clots during your period or in-between periods
• Change in the length of your period
• Frequent urination or inability to control urination-fibroids often compress the bladder
• New persistent pain or heaviness in the pelvis, referred to as "bulk symptoms". These symptoms are typically worse around the time of menstruation. The most common bulk symptoms are pressure, haviness, or bloating.

Other factors that can make you an ideal candidate are:

• Not wanting to have your entire uterus removed (hysterectomy).
• Looking to restore fertility.
• Having numerous uterine fibroids. One of the major advantages of UFE is the ability to treat numerous fibroids with a single procedure. The average affected uterus has six to seven fibroids.
• Looking for a fast recovery. Patients undergoing UFE usually go home the same day whereas patients undergoing hysterectomy usually require a 3-5 day hospital stay.
• Looking to avoid surgical complications like blood loss requiring a transfusion.

Did you know?

A 2017 study including 359 women with uterine fibroids who were unable to conceive showed that UFE restored fertility in 41.5% of women.

What are the benefits of UFE?

1. High Success Rate
   After uterine fibroid embolization, 80-90% of patients report significant improvement in their symptoms and 88% of women say that they would recommend their treatment to a friend. Maximum symptom relief after fibroid embolization is achieved over a 3 month time period.‍
2. Preserves the Uterus
   Uterine fibroid embolization (UFE) offers women who would like to preserve their uterus a safe and effective alternative to hysterectomy. A recent study published by Mayo Clinic demonstrated that women who undergo hysterectomy are at a higher risk for developing anxiety and depression, which supports the growing notion that removing the uterus may have more effect on physical and mental health than previously thought.
3. Fewer Complications
   Uterine fibroid embolization carries fewer major complications when compared to surgeries like myomectomy (surgical removal of fibroids). The chance of requiring a blood transfusion during myomectomy is approximately 10% and with hysterectomy that risk increases to approximately 13%. The chance of requiring a blood transfusion during UFE is approximately 1%.
4. Faster Recovery
   After fibroid embolization, most women go home the same day, return to work within 3-5 days, and are fully recovered after 2 weeks. For comparison, a 3-5 day hospital stay is usually required after hysterectomy and full recovery usually takes 6-8 weeks. The Cochrane collaboration meta-analysis demonstrated that patients who received uterine fibroid embolization had a shorter hospital stay and a faster return to baseline activity compared to surgery.
5. Fertility Preservation
   Unlike hysterectomy where a woman can no longer become pregnant, women can bear children after uterine artery embolization. UFE and myomectomy both preserve fertility after treatment. A 2019 study showed that 86% of women were able to have a successful pregnancy after UFE. We recommend that all patients who are looking to get pregnant talk to their doctor before any procedure performed on the uterus. It is estimated that 1 in every 4 women with fibroids has fertility issues. New evidence suggests that fibroid embolization may restore the ability to become pregnant in some women. In 2017, a clinical study showed that embolization in women with fibroids who were previously unable to become pregnant, lead to an increased probability of becoming pregnant.

Research and Support for UFE

Uterine fibroid embolization has been performed for over 30 years and has excellent data supporting its usage in the treatment of symptomatic fibroids. Here are some findings from robust, double-blind studies done on UFE.

Physician insight

A "meta-analysis" is a study where researchers aggregate findings from all previous relevant studies to formulate stronger conclusions.

• 66% of women can avoid hysterectomy with UFE
• 10-year outcomes from the EMMY Trial demonstrated that 66% of women can avoid hysterectomy by undergoing uterine fibroid embolization.
• Faster recovery than surgical options
• 10-year outcomes from the EMMY Trial demonstrated that 66% of women can avoid hysterectomy by undergoing uterine fibroid embolization.
• Excellent data across 7 robust studies supports UFE
• The Cochrane Collaboration completed a systematic review of seven high quality studies to determine if UFE is a safe and effective alternative treatment for women with uterine fibroids. The review concluded that there is excellent (Level A) data supporting uterine fibroid embolization for the management of uterine fibroids
  The American College of Obstetricians and Gynecologists Practice Bulletin on alternatives to hysterectomy in the management of fibroids reports there is level A data supporting the safety and efficacy of uterine fibroid embolization for women who wish to keep their uterus.

What is the UFE process like?

UFE can be broken down into 4 steps:

1. Anesthesia
   The first step of the procedure it to make sure you're comfortable. For most minimally invasive procedures, conscious or twilight sedation is administered prior to beginning. With twilight sedation, medications to reduce pain and decrease anxiety are administered through an IV that is placed prior to the procedure. No breathing tube is required for twilight sedation as you will be able to breathe on your own. The goal of twilight sedation is to ensure the patient is very sleepy and comfortable. Most patients who receive twilight sedation sleep through the entire procedure.
2. Blood Vessel Access
   Think of blood vessels as miniature highways your doctor uses to navigate small devices throughout the body. Uterine fibroids derive their blood supply from the uterine arteries which are located deep within the pelvis. Because all of the arteries within the body connect to one another, doctors use an artery that is close to the skin surface and easily accessible to gain initial entry into the vast internal highway. Almost always, a small needle is introduced into the femoral artery (medium sized artery in the groin) or the radial artery (small artery in the wrist). In addition to the twilight anesthesia that has already been administered, your doctor will numb the tissues above the femoral or radial artery with lidocaine. It is important to note that no incisions have to be made where the blood vessel is accessed. After the procedure, a band aid will be placed over the region of vessel access. ‍
3. Blood Vessel Mapping
   Once either the radial or femoral artery has been accessed, the next step is to navigate a small tube called a catheter to the arteries feeding the uterine fibroids. Doctors navigate the catheter to the appropriate arteries by using an imaging technique called fluoroscopy where low-dose x-ray is used to see inside of the body rather than having to create surgical incisions to see inside the body. In patients with fibroids, the uterine arteries are much larger than normal and look like winding pipes (video below)
4. Fibroid Embolization
   Embolization is a medical technique where small particles are injected into blood vessels in order to shut off blood flow. The tissue or body part that is fed by the embolized vessel will eventually die or shrink due to a lack of oxygen delivery. With uterine fibroid embolization, the goal is to shut off as much blood flow as possible to the uterine fibroids while preserving blood flow to the uterus.
   
   The uterus is a very unique organ because it gets its blood supply from numerous sources including the uterine arteries, ovarian arteries, and vaginal arteries. When an organ gets blood supply from numerous sources, that organ is said to have collateral blood supply. Interestingly, fibroids derive their blood supply almost exclusively from the uterine arteries. Because of this fact, it is possible to completely shut down the uterine arteries (which will lead to fibroid death) without causing damage to the uterus due to its collateral blood supply.
   Once the catheter has been positioned within the right and left uterine arteries, tiny particles called embospheres are injected. The doctor will watch the embospheres flow towards the fibroids in real time. After the particles have been injected, your doctor will inject a small amount of dye. The procedure is complete when the fibroids take up no more dye (video below) which confirms the blood supply to the fibroids has been shut off.

‍

What are embolic particles?

Embospheres (tri-acyl gelatin microspheres) are made of tiny spherical pieces of gelatin derived from collagen, similar to gelatin food products. A single embosphere is smaller than a fine grain of salt. Three acyl groups "tri-acyl" are added to stabilize the gelatin so that it does not dissolve. This makes it so the embolized blood vessels remain shut down over time which is important for treatment success. Tri-acyl gelatin is completely biocompatible and has no interaction with human tissue. The image below shows an embosphere in a blood vessel after six years. Because embospheres have no interaction with the human body, the embosphere is completely unchanged. Gelatin has been used to shut down blood vessels for over 50 years.

What's recovery like?

The amount of pain after fibroid embolization varies from patient to patient and is often defined as a cramping pain. Most patient's report complete resolution of pain after 3-5 days, and doctors use multiple strategies to make the days after fibroid embolization as comfortable as possible. Below are some of the common strategies doctors use to manage pain after fibroid embolization.

• Nerve Blocks:
  Many interventional radiologists perform a procedure called a superior hypogastric nerve block on women who receive fibroid embolization. The doctor injects anesthetic medication onto the hypogastric plexus which is the nerve bundle that delivers pain signals from the uterus. After hypogastric nerve block, 97% of women report pain control, and almost all women are able to leave the medical center 2 hours after their procedure is complete.
  
• Pain Medications:
  If breakthrough pain occurs during the first 2-3 days after the procedure, pain medications can be used. Most doctors will prescribe a 3-5 day course of either a mild opioid or non-opioid pain medication for breakthrough pain.
  
• Anti-Inflammatories:
  Anti-inflammatory pain medications are particularly helpful in managing pain after fibroid embolization. It is important to take anti-inflammatory pain medications on scheduled intervals for best results. Most commonly, doctors will prescribe 800mg of ibuprofen 3 times daily for a total of 5 days after fibroid embolization.
  

What happens to fibroids after UFE?

Once blood supply to the fibroid has been removed, the fibroid will either completely disappear or shrink over time. The best analogy to explain what happens to a fibroid after embolization is to think of how the earth composts organic materials like food, grass, and plants into soil over time. After fibroid embolization, your body naturally breaks down the fibroid overtime. Most women achieve significant symptom relief after fibroid embolization that reaches a maximum within 3 months.

Who Performs UFE?

Uterine fibroid embolization is performed by an Interventional Radiologist. Interventional Radiology is a board certified 6 year training program that occurs after medical school. Interventional Radiologists specialize in performing minimally invasive procedures that do not require surgical incisions. Usually medications, stents, or balloons are delivered to an area of the body through a small tube called a catheter. Interventional Radiologists position catheters in the right locations within the body through the use of low dose, realtime x-ray. Interventional procedures have revolutionized the field of medicine because of their excellent safety data and tolerability when compared to surgery.

Is UFE covered by insurance?

Uterine fibroid embolization is covered by most major insurers:

• Medicare.
• Medicaid (varies based on the state).
• Nearly all private payers.

Did you know?

Many physicians offer out-of-pocket discounts for patients who do not have insurance but would still like to pursue treatment. Generally, the out-of-pocket cost is significantly lower for patients who do not have insurance.

Am I Sedated for UFE?

Fibroid embolization is performed under a type of sedation called "twilight sedation" or conscious sedation. With this form of sedation, an IV pain medication is combined with an anxiolytic (medication that decreases anxiety). These medications take effect within 2 to 3 minutes and make you very relaxed during the procedure. Importantly no breathing tube needs to be inserted during twilight sedation. With twilight sedation, most patients fall asleep for the entire procedure and may wake up for brief intervals during the procedure before falling back to sleep. Waking up during twilight sedation feels similar to waking up and falling right back to sleep on a day where you can sleep in. It is important to note that waking up during twilight sedation is okay as the purpose of twilight sedation is to ensure you're very comfortable during the procedure. The goal is not to make you totally unconscious (unable to wake up under any circumstances) which is termed general anesthesia and usually requires insertion of a breathing tube. Your doctor and a nurse with dedicated sedation training will be monitoring you throughout the entirety of the procedure.

What are the risks of UFE?

Major complications after fibroid embolization are rare and less than that of surgical procedures. Although rare, potential complications of embolization include:

• Hematoma:
  A hematoma is a small blood collection that develops at the site where a needle is inserted into a blood vessel. Hematomas are uncommon, and when they do occur, they usually resolve on their own and do not require additional treatment. Most hematomas cause bruising around the site of vessel access and pain for 1-2 weeks. Performing fibroid embolization through the radial artery in the wrist, termed trans-radial uterine fibroid embolization or TRUFE, virtually eliminates the risk of a hematoma afer the procedure.
  
• Infection:
  In rare instances, a degenerating fibroid can become infected and lead to an infection of the uterus termed endomyometritis. Most uterine infections can be treated with antibiotics, but in very rare cases, a hysterectomy may be required. The infection rate following fibroid embolization is approximately 0.4% to 1%.
  
• Damage to Other Organs:
  Unintended embolization of another organ can occur; however, this risk is very low and less than that of surgery. Whether you're undergoing fibroid embolization or surgery, there is a small risk that blood supply to the ovaries can be compromised. The estimated risk of damage to other organs during fibroid embolization is less than 1%. In some women who are nearing menopause such disruption to ovarian blood supply could cause an early start to menopause. For women who are less than 45 years old, studies report there is a 0% to 3% chance of early menopause after fibroid embolization.
  
• Possible Pregnancy Risks:
  Since the earliest days of fibroid embolization (30 years of experience), it has been shown that many women have healthy pregnancies after embolization. However, whenever a procedure is performed on the uterus, doctors are extra cautious to study potential impacts on pregnancy.
  
  After any procedure involving the uterus, there are slightly increased rates of certain pregnancy complications like abnormalities of placental attachment to the uterus after fibroid embolization. For women with symptomatic fibroids who are looking to remain pregnant, hysterectomy is not an option. When comparing fibroid embolization to myomectomy (uterine sparing surgery where the fibroid is surgically cut out of the uterus), it was concluded that there is low level evidence suggesting that myomectomy may be associated with better fertility outcomes. Many studies demonstrate similar fertility rates after fibroid embolization and myomectomy.
  It is well known that fibroids negatively impact female fertility. In fact, it is estimated that 1 in every 4 women with fibroids has fertility issues. New evidence suggests that fibroid embolization may restore the ability to become pregnant in some women. In 2017, a clinical study showed that embolization in women with fibroids who were previously unable to become pregnant, lead to an increased probability of becoming pregnant. Most importantly, if you're interested in future pregnancy, you and your Interventional Radiologist should have a full discussion during the initial consultation.

How do I pick a good doctor?

Here at Helped, we take the guesswork out of this process. Our partner clinics are well reviewed and our doctors are experts in uterine fibroid embolization. Here are some steps for finding a great doctor for UFE if we're not in your area.

1. Pick a doctor who performs UFE regularly
2. You want someone that has significant procedural skill and judgement. When you call the clinic, don't hesitate to ask the front desk personnel how frequently the doctor performs uterine fibroid embolization.
3. Look for a doctor who is fellowship-trained
4. Look for doctors who are fellowship-trained in women's health and minimally invasive procedures. These doctors are usually highly skilled in the diagnosis and treatment of uterine fibroids.