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Uterine Fibroid Embolisation (UFE) – What is Involved?

Dr Nigel Hacking

By Dr Nigel Hacking BSc MBBS, FRCP, FRCR
Consultant Interventional Radiologist

Article last updated: May 2nd 2009

Uterine Fibroid Embolization (UFE)

This is a non-surgical, minimally-invasive, procedure that blocks off the arteries that supply the fibroids with blood (the uterine arteries), therefore shrinking the fibroids.

It is performed with the patient conscious, but sedated.
It is carried out by an Interventional Radiologist (IR), a doctor who has been specially trained in using x-ray equipment, interpreting the images produced and performing operations using X-Ray or other modern imaging equipment for guidance.
It was first performed in France in the early 1990’s, although radiologists have been embolising uterine arteries for more than 20 years to control bleeding from the womb, especially after childbirth.
80-96% of women are satisfied with the treatment and its result, and most patients rate the procedure as “very tolerable”.
The shrinkage in fibroid size averages 60% but varies from 20-100%.
Most women start getting relief of symptoms immediately, although fibroids that have taken years to develop will take months, or even years, to shrink to their final size.
Over 150,000 women world-wide have undergone fibroid embolisation (UFE).

Before UFE

You will have an ultrasound, and an MRI scan, to determine whether your fibroids are suitable for embolisation.
You will be pre-assessed by a member of the UK Fibroid Experts team and your Gynaecologist.
You will be admitted to the ward or Radiology Day Case Unit (RDCU) on the day you have UFE performed.
You should not eat or drink for at least 4 hours before the procedure. You may be given an intravenous drip (into a vein) to avoid dehydration.
You will need to shave both sides of your groin.
You will be given an Antibiotic tablet and a Voltarol suppository to prevent infection and help with pain relief.
You will need to put on a hospital gown.

The Procedure itself (see Fig.2)

Fig. 2. Showing uterine artery supply to fibroids

You will be taken on a trolley from your ward, or walk from the RDCU, to the Interventional Radiology procedure room or ‘Cath Lab’, where you will lie flat on your back on the X-ray table.
You will be given relaxing injections, if you are anxious, through a cannula in a vein in your arm. Pain-killing injections (Morphine) will be given during the procedure to allow them to work in time to control the anticipated pain from fibroids dying within the first hour after the procedure ends.
A device to monitor your oxygen levels and heartbeat will be placed over your finger.
A blood pressure cuff will be wrapped around your arm and will automatically tighten and record your blood pressure every 5 minutes.
You will be given oxygen through small tubes up your nose if sedated.
The skin over your groin and surrounding areas will be cleaned with Iodine antiseptic (or Chlorhexidine, in the case of Iodine allergy).
Surgical drapes are applied over your body with a small window left over the right side of the groin.
A local anaesthetic is injected into the groin.

Fig 3. Shows catheter tip placed in left uterine artery via a puncture into the femoral artery in the right groin.

The Interventional Radiologist (IR) feels for the arterial pulse and then makes a minute nick (around 1mm), in the skin over the right groin, and inserts a needle into the artery. Once in place, a sterile guide wire is placed through the needle into the artery. The needle is withdrawn, allowing fine plastic tubes (a sheath and catheter) to be placed over the wire and into the artery. (see Fig. 3)
The catheter is steered to the arteries feeding the uterus using X-rays to see where it is going. X-ray dye (contrast medium) is injected down the catheter into the uterine arteries (this will feel hot, but is not painful). Once the uterine blood supply has been established, tiny plastic or Gelatin sponge particles, like grains of sand or wallpaper paste, are injected through the catheter into the uterine arteries.


	Fig 4. Shows a close up of the catheter tip. Small particles of PVA are injected through the catheter into the artery until flow slows or stops.

These particles block the blood vessels supplying the uterus and fibroids and get wedged there, causing the cells within the fibroid, but not the uterus, to die. The uterus is very resistant to temporary loss of blood and will receive an alternate blood supply within minutes from other surrounding arteries. (see Fig 4.)
Both the right and left uterine arteries need to be blocked in this way. Usually it can all be done from the right groin. Some Radiologists prefer to perform the procedure using separate right and left groin punctures.
The procedure finishes when there is no more blood flow into the fibroid. The catheter is withdrawn and the IR or nurse presses on the groin puncture site to prevent bleeding and then may put a small Elastoplast over the wound.
On average, the procedure takes about 30 minutes.

Common Concerns.

What happens straight after UFE?

You will be taken back to the recovery area or RDCU on a trolley where you will be looked after by nurses who will take your pulse and blood pressure and check the wound.
You will need to lie still in bed for a few hours to reduce any chance of bleeding from the groin.
Most patients experience some degree of pelvic pain. This ranges from very mild to severe, crampy, period-like pain. It is controlled with a cocktail of strong painkillers, which you will give yourself through the cannula (PCA - Patient Controlled Analgesia) that was inserted in your arm before the procedure as well as anti-cramping and anti-sickness drugs. The pain is worst in the first 8-12 hours.
The painkillers and sedatives may mean that you sleep for a few hours afterwards.
The drip and PCA will be discontinued the following morning to be replaced by the same cocktail of drugs in tablet form.
Most women stay in hospital for one night, although if you do need to stay in longer than a day, this is not a problem.
Most patients get a slight fever after the procedure. This is normal and is a good sign as it is due to the fibroid breaking down. The anti-inflammatory painkillers will help to control this fever.
The pain will probably still be present when you go home. You will be given painkillers to take home with you and you should rest for 3-4 days, drink plenty of fluids and stay as mobile as you can.

How long will it take me to get back to normal life?

Women can go back to normal activities, including sport and sexual activity, as soon as they feel able.
Unlike most surgery, there is no muscle-cutting involved in UFE, so you are not at risk of bursting a wound or causing a hernia.
In order to avoid infection, it is advised that you do not use tampons or swim in non-chlorinated water if you have a discharge.
Most women are ready to go back to work after 3-14 days. It is probably best to allow for being off work for a fortnight.

How quickly will I start to feel the benefits? - (see Figs. 5a & 5b)

Fig. 5a. This image shows a 7cm Subserosal Fibroid pre UFE

Immediately after UFE, the fibroids become soft.

Pressure symptoms on the bladder and bowel and heavy periods usually respond within days.

Average reduction is 40% at 3 months, and 60% at one year.

Fig. 5b. 1 year Post UFE. Mass no longer palpable. Symptom free.

Follow-up after UFE

Usually an ultrasound scan after 1 month and an MRI scan after 3 and 12 months. If there is cause for concern or any worrying side effects earlier scanning can be performed.

Are all fibroids suitable for UFE?

It is usually the position, blood supply and location of fibroids that determine success.
The richer the blood supply to the fibroids, the better the response.
Submucus fibroids respond best, although intramural and sub-serosal ones also respond well.
Pedunculated fibroids (those with a stalk) can be successfully embolised as long as the width of the stalk is not too thin in relation to the size of the fibroid.
UFE can be combined with myomectomy using hysteroscopic, laparoscopic or abdominal routes to combine the success of these two complimentary treatment options.

What are Embolic Agents?

They are the particles used to block the uterine arteries.
There are various different types, some of which dissolve and others which remain in the body.
They can never be ‘dislodged’. Vigorous exercise, which increases the heart rate and therefore blood flow, will only jam the particles further into the blood vessel.
Tiny blood vessels in the uterus remain intact and keep the womb alive, while the fibroids, which are far more susceptible to a shortage of blood, die.
As yet, none of these embolic agents (listed below) has been proven to be more effective than the others.

Spongistan Gelfoam

1mm thick sponge is cut up into approximately 1mm cubes. This is dissolved in X-ray contrast agent to produce a slurry like wallpaper paste.
This is likely to block large and medium-sized uterine arteries, but leaves smallest arteries patent to allow maximum blood supply to the normal uterine tissue.
It dissolves in a few days or weeks, but completely ‘dead’ fibroids cannot regrow.
It has been in common use for over 20 years. It is more likely to leave the uterine arteries blocked than the other agents.
It may cause less post-procedural pain than PVA and other agents.

PVA

Different sized particles are used, usually 0.3-0.5mm or 0.5-0.7mm in size. In theory, these will block arteries down to these sizes, but in reality particles clump together to block the arteries, for example, if three 0.5mm particles clump together, they will block an artery of 1.5mm diameter. The level of arterial blockage may be similar to that seen with Spongistan slurry. The uterine arteries are more likely to re-open within 3 months.
This has also been in common use for over 20 years and is the most common agent used in the UK.

Embospheres

The first of the ‘Spherical’ embolic agents, these are 0.5-0.9mm non-dissolvable particles. They do not clump and therefore block arteries at a smaller diameter. The main uterine arteries usually remain open.

Bead Block
Blue coloured spherical PVA, commonly used in 0.7-1.2mm sizes. Less likely to permanently block uterine arteries, but may be less effective than the other agents in killing all the fibroids.

Embozenes
Colour coded Polyzene-F coated spherical embolic. Used in 0.7-1.3mm sizes. Leaves arteries open and may be as effective as PVA, Embospheres and Gelatin sponge, but no definitive studies as yet.

What are the benefits of UFE compared to other treatments? (See Figs 6a & 6b).

Fig. 6a. Size of uterus 1 day post UFE.{br}No scar. Uterus up to umbilicus. Heavy periods with anaemia. (Click to enlarge)

Fig. 6a. Size of uterus 1 day post UFE.
No scar. Uterus up to umbilicus. Heavy periods with anaemia.

You retain your uterus.

There is no cutting and therefore no stitches or scar.

No blood transfusion is required.

The likelihood of fibroids growing back is only around 20- 25% 5 years after treatment

Only 1-2 nights in hospital.

Approximately 2 weeks off work, often less.

No General Anaesthetic required and you are conscious throughout the procedure.

If further treatment is necessary, myomectomy is a more successful operation if UFE has been performed first as the chance of uncontrollable bleeding, which can lead to hysterectomy, is much less likely.

Fig. 6b. Size of uterus shown in overlay 3 months post UFE. Periods now normal and marked reduction in uterine size.

What are the possible complications of UFE?

There are risks attached to every medical procedure. The important thing is to weigh up the benefits of being treated against the risks of a rare complication happening to you. The risks of fibroid embolisation include:

Death

Deaths have occurred with hysterectomy and myomectomy. Usually mortality figures of 1 in 1,500-3,000 for these two surgical techniques are quoted.
Death following UFE has been reported in 5 cases worldwide due to severe infection in 2, pulmonary embolus in 2 and unexpected shunting and multiple organ embolisation in 1 case. This is from a total of between 150,000 and 200,000 cases performed worldwide, giving a mortality of 1 in 30,000 - 40,000.
It must be stressed that death is a very rare complication of all these procedures.

Infection

True uterine infection is very rare, probably less than 1 in 1,000.
More commonly dead fibroid material can become lodged in the uterine cavity and if untreated can become infected. Signs of this include an unpleasant, foul smelling discharge, pain and fever.
This can often be predicted after embolising large submucosal or intracavity fibroids and can happen at any time up to 9 months after UFE. Detailed advice will be given to the patient, her Gynaecologist and GP about this possibility. The Interventional Radiologist should be contacted urgently to arrange antibiotics and scanning and if appropriate an urgent Gynaecological assessment.
True uterine infection will require antibiotics and probably urgent hysterectomy, but usually the uterus is intact and if the problem is one of fibroid passage then antibiotics and pain killers will usually suffice and if not delivery of the fibroid by the Gynaecologist or hysteroscopy with fibroid clearance will usually be possible.
Your Interventional Radiologist will ask you before UFE whether you would have a hysterectomy if your uterus became infected. If you would not, under any circumstances, then your Radiologist is likely to advise you not to undergo embolisation.

Ovarian failure / premature menopause
This is due to accidental embolisation of the arteries to the two ovaries and is often the result of different arrangements of blood vessels in some patients. The greater the experience your Interventional Radiologist has and the use of larger embolic particles has made this complication very unlikely. The chances of premature menopause are less than 2% under the age of 45, rising each year up to around 15% at age 50. About 3 times as many patients have no periods for a month or two after UFE.

Passing a fibroid through the vagina
This happens in approximately 3-4% of all patients and usually occurs 6 weeks - 3 months afterUFE. It is most


Fig. 7a. Pre Embo. 10cm Sub mucous fibroid

common with submucous fibroids, particularly if largely intra-uterine. Fibroids can either pass in large pieces or break up and pass unknowingly. The MRI scans in these cases can show a remarkably normal uterus on follow up imaging.


	Fig. 7b. 1 yr post UFE normal uterus

(See Figs 7a & 7b).
After passage of a fibroid and prior to attempting to become pregnant it is wise to have a check hysteroscopy to observe and if present treat and significant intrauterine adhesions.

Vaginal discharge
This happens in about 4% of patients and is usually due to the fibroid breaking down. It normally lasts for around 2 weeks, though can go on intermittently for several months. If it is accompanied by fever, you should contact your Interventional Radiologist and Gynaecologist as soon as possible. You might need to have an internal exam to make sure the dead fibroid has not fallen down into the vagina or become stuck in the cervix, as this could cause infection.

Haematoma (bruise around entry point)
A small bruise is quite normal, but if it becomes bigger, it may need treating with antibiotics to prevent infection.

Fibroids fed by an additional blood supply (usually the ovarian arteries)
This happens in about 5 - 10% of cases. The ovarian arteries can be embolised but this is more likely to result in premature menopause if both ovarian arteries are blocked. This option can be considered for women who have no further fertility wishes. Your Interventional Radiologist will talk to you about such wishes if it is found that the ovarian arteries are supplying the fibroids with blood.

Fertility after embolisation

The average age of women undergoing UFE is around 40, so natural fertility is already starting to decrease, even without the fibroids.
The Royal Colleges of Radiology (RCR) and Royal College of Obstetrics and Gynaecology (RCOG) currently advise women wanting to get pregnant, to obtain myomectomy for a large single or a small number of fibroids especially when they are subserosal or intramural. When they are small and submucosal or intracavity hysteroscopic myomectomy is preferable in experienced hands. UFE is probably now an acceptable alternative with large or particularly multiple fibroids and can be combined with myomectomy.
There have now been over 100 successful pregnancies after UFE. There may be a slightly higher risk of miscarriage and Caesarean section, as with untreated fibroids.

Having UFE on the NHS

An increasing number of centres are now offerring UFE. This is a technique with quite a long learning curve and so experienced operators should be sought out wherever possible. For UFE at Southampton you will need a referral to an Interventional Radiologist from either your GP or your Gynaecologist. If you wish to see an Interventional Radiologist out of your geographical area, you will need to ask the doctor who is referring you to obtain funding from his PCT.

Having UFE privately

All private insurance companies now cover for UFE. MRI scans will usually be charged on top of the usually quoted figures. UFE is available at the Princess Grace Hospital in London.

UFE for the overseas visitor

A number of institutions will now quote for overseas patients. Travel arrangements and full costs should be included wherever possible.

Contact Dr Hacking.

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If you found this article useful you should also read our further information as to surgical options for uterus preserving operations.

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Uterine Fibroid Embolisation (UFE) – What is Involved? Dr Nigel Hacking