Uterine Fibroid Embolization (UFE) as an Alternative to Hysterectomy
Uterine Fibroid Embolization (UFE) is a non-surgical method of uterine fibroid treatment. The method is based on blocking the blood flow to all fibroids, which leads to their independent extinction.
UFE has many advantages, but the main one is that UFE allows to keep the patient’s uterus fully functional without risks and complications of a fibroid surgery. This minimally invasive procedure allows a woman to return to a normal life in a short time.
How Does the UFE or UAE Procedure Work?
UFE (Uterine Fibroid Embolization) and UAE (Uterine Artery Embolization) are terms used for the same procedure. There is no difference between them.
The rock-like fibroids need a blood supply to stay alive and grow. During the UFE procedure, this blood supply is purposely blocked. This causes the fibroids to die off. They will first start to soften and liquefy, and eventually they will shrink. While some fibroids will disappear completely, it is not necessary for them to do so. Often the fibroids will still be present on imaging (for example, MRI or ultrasound), but since they are now soft (like bags of water rather than rocks) they can no longer cause the significant symptoms anymore. For example, a woman had increased urinary frequency with waking up multiple times to urinate because of a fibroid compressing the bladder.
After UFE, even if the fibroid does not shrink very much, it is now a bag of water and the bladder can push it out of the way and fill normally. The patient now sleeps through the night without waking up and she urinates much less often. The average reduction in volume of the fibroid after UFE is 40% by 3 months and 65% by 6 months. Therefore, we usually get both significant symptom improvement (~90%) and significant size improvement, but sometimes we only get significant symptom improvement.
The approach for UFE is like a heart catheterization. Patients are asleep during the procedure which takes less than an hour to perform. They receive conscious (intravenous) sedation like you would get during a colonoscopy. Local anesthetic is placed in the right groin/top of the thigh area. A catheter is positioned under x-ray guidance into the blood supply of the uterus.
This blood supply can be thought of as a tree with leaves. The trunk is the main uterine artery and the leaves are the branches that supply the fibroids. Tiny particles are injected which are specifically sized for the fibroid vessels. These vessels become blocked, resulting in pruning of the tree. The trunk stays open and supplies the normal uterine tissue, but the fibroids will start to wither away, soften, and eventually shrink in size.
Remember that women who have no symptoms, do not need any treatment. They might have fibroids, but if they don’t have any symptoms, they don’t need treatment of any kind.
What to Expect During the Uterine Fibroid Embolization (UFE)
Unlike hospital teaching facilities, which can use residents or fellows who are training under the supervision of an attending physician, Dr. Lipman himself performs all of the procedures at the Center. With over 8,000 UFE procedures performed during his career, Dr. Lipman is the world’s most experienced individual provider of UFE procedures. He developed a custom-designed, state-of-the-art outpatient facility to specifically serve UFE patients, keeping their safety and comfort foremost in mind.
You are encouraged to be well hydrated (drink lots of fluids) the day before the procedure. Nothing is to be taken by mouth after midnight the night before the procedure. One exception to this is if you take blood pressure medicine in the morning, this can be taken with small sips of water. Prepare your bedside table the night before (tissues, heating pad, thermometer, loose-fitting nightgown, important phone numbers of doctors, pharmacy). You will need someone to drive you home mid to late afternoon on the day of the procedure.
During the Procedure
You will feel no pain during this 30-45 minute procedure, and you will sleep comfortably during this time. Intravenous sedation (fentanyl and versed) is used. After the procedure patients may experience a crampy pain like heavy menstrual cramps. This can last several hours and is significantly improved by the following morning. Patients are discharged home on the day of the procedure. Patients are given a prescription for the following four medications upon discharge:
- 1. Ibuprofen
- 2. Oxycodone for pain, which is usually taken during the first 48 hours, and only when needed
- 3. Docusate Sodium-stool softener to be taken 2X/day for 5 days
- 4. Promethazine suppository for nausea as needed.
The recovery period is usually 3-4 days, although I suggest patients take 1 week off from work if possible. The only restrictions after the procedure are:
- No bathing for 2 weeks (you can shower).
- No tampons for one cycle (use pads then can switch back).
- No intercourse for 2 weeks.
- No heavy lifting or exercise for 2 weeks.
- Airline and long car travel discouraged for 2 weeks.
If you are tolerating taking liquids by mouth, exhibit no bleeding from the point of entry in the groin, and the oral pain medicine is adequate in controlling the discomfort, you can go home. You will be discharged on an anti-inflammatory (like Motrin) which you need to take for 5 days and a pain pill which is taken only as needed. The oxycodone (narcotic for pain) tends to cause constipation, so use a laxative if this occurs. The discomfort of constipation can add to the expected post-procedural discomfort. You can resume your normal light activities as you feel able which should be within 48-72 hours after the procedure. Don’t overdo it, and use pain/discomfort as your guide. Eat healthy foods and drink plenty of fluids. Boxer shorts are recommended over briefs (less irritating). Heating pads can be helpful for the discomfort. No aspirin or aspirin-like products should be used during the 5 days on the prescribed medications. Should you have any questions, day or night there is always a physician (Interventional Radiologist) on call to help you.
An Alternative to Hysterectomy
Today, uterine fibroid embolization (UFE) is the best alternative to hysterectomy. It saves the patient’s uterus and completely eliminates many dangerous risks of a surgery.
Hysterectomy has a 30% complication rate while in the hospital (typically, infection or fever), and an additional risk of more serious complications such as hemorrhage (requiring transfusion), or injury to the bladder, ureter or bowel. One-third of patients who underwent hysterectomy, undergo another related surgery within 2 years (examples: adhesions, bowel obstructions). Surgically removing an enlarged fibroid uterus weakens the pelvic floor muscles, which often lead to urinary leaking or incontinence. Other risks include:
- 1. Injury to adjacent organs: most commonly injured are the bladder, ureter, and bowel
- 2. Post-operative bleeding requiring blood transfusion
- 3. Infections or wound issues
- 4. Long-term side effects: many women suffer side effects long after their hysterectomies. Hysterectomy can affect women psychologically (like a man being castrated), sexually (loss of libido or orgasm), can cause increased bone loss, weight gain, and can elevate cardiovascular risks (leading to high blood pressure, heart attack, stroke).
Your doctor may recommend uterine fibroid embolization (UFE) as an alternative to hysterectomy, which is essentially fibroid treatment without surgery.
What are the Benefits of UFE over Other Fibroid Therapies?
Minimally invasive: There is no general anesthesia, no inpatient hospitalization, and no surgical incision. A tiny nick in the skin (which is covered by the pad of a bandaid) is the only footprint that any procedure was performed. This is usually completely invisible within a few days.
Highly successful: In our experience, over 90% of patients have found significant improvements in all of their symptoms, or the symptoms are completely gone. The remaining 10% of patients are usually only slightly better or unchanged (i.e. not worse). These patients typically have adenomyosis which is harder to treat than fibroids or have ovarian branches that are also feeding the fibroids in addition to the uterine branches. These ovarian branches keep the fibroid alive and therefore the symptoms remain after the initial UFE. If a woman is not interested in fertility and has these ovarian branches feeding the fibroid, she can undergo a 2nd embolization to treat this rather than undergoing hysterectomy. UFE is a global therapy (like hysterectomy) in the fact that it treats all of the fibroids. Myomectomy only treat some of the fibroids, and Endometrial Ablation does not treat any of the fibroids (tries to treat the bleeding symptom but does nothing to the actual fibroid(s) causing this symptom).
Outpatient procedure: All patients discharged the same day.
Shorter recovery time: Average recovery 4 days, and one week away from work versus 6 to 8 weeks for hysterectomy or myomectomy.
Less risk: No general anesthesia or surgical incisions. For the risks of UFE see separate discussion in this section.
The advantages of UFE compared to surgery are:
- 1. No hospital stay
- 2. Safer
- 3. Less Invasive
- 4. Short recovery
- 5. No general anesthesia
- 6. No blood loss
What Are the Risks of UFE?
From a risk profile, UFE is safer than the surgical options for fibroids treatment. The main risks of the procedure are as follows:
1. Menopause: Roughly 2% of women will go into menopause after UFE. The large majority of these women are over 45 years of age. A much smaller percentage of women enter menopause after UFE that are between 40 and 45 years of age. No one under 40 years of age, in our experience, has experienced menopause after UFE treatment.
2. Fibroid slough: Roughly ~1 in 500 patients will slough fibroid tissue with menses after UFE. The material is from a fibroid that is near the lining and falls into the cavity and passed in pieces after the UFE. This is not concerning, except that it is important to tell patients about this so that they are not alarmed if they see this after UFE. On very rare occasions (~1 in a 1,000 patients), the material is in the cavity, but a woman cannot pass it. Symptoms of sudden, sharp pain, fever, and a foul malodorous discharge alert the women of this occurrence and the Interventional Radiologist should be immediately notified. The patient is placed on antibiotic therapy and watched closely for ~24 hours. If she passes the material, no further steps are taken. If she cannot pass the material, an elective outpatient D&C with her gynecologist may be necessary.
3. Allergy to the contrast: Rarely, patients will be allergic to the x-ray contrast. In the very rare event that a reaction occurs, patients are given medicine to reverse and stop it.
4. Undetected cancer: Rarely, cancer can be present in the uterus and is not detected by any test or imaging. (Approximately 1 in 2,000 cases).
How Do I Know if I Am a Candidate for UFE?
To know for sure, you would need a consultation with Dr. Lipman in his office. We would obtain a pelvic MRI prior to your consultation, which our office will arrange for you. The consult takes about 45 minutes and Dr. Lipman will discuss your symptoms, treatment options, and go over your MRI pictures with you. In general, patients that have been told that they are candidates for other fibroid treatments (exs. hysterectomy, myomectomy, endometrial ablation, etc.) are usually candidates for UFE. Rarely, a fibroid may not be suitable for UFE and it is one of the reasons for obtaining the MRI.
I had a pelvic ultrasound in my gynecologist’s office. Is this satisfactory imaging, or do I still need a MRI?
While we will look at the ultrasound reports that you have had, it is still necessary to obtain a pelvic MRI. There are conditions that mimic fibroids and are hard to diagnose just on ultrasound (see Adenomyosis).
I have had a myomectomy, can I still be considered for UFE?
Yes. Myomectomy is the removal of the largest fibroid or collection of fibroids and attempts to sew the uterus back together. Fibroids are often multiple and reside in multiple areas of the uterus. It is not possible to remove all of the fibroids and still be able to have a uterus left intact (a number of patients that undergo myomectomy wake up with a hysterectomy). Therefore, after myomectomy, there is still a significant fibroid burden which will continue to grow after surgery and the symptoms will recur. It recurs at a rate of 10% per year (i.e. over half of the patients will recur within 5 years, over 1/3 within 3 years). UFE treats all of the fibroids that are in the uterus and therefore the recurrence rate after UFE is much lower than that seen with myomectomy.
I have had an endometrial ablation, can I still be considered for UFE?
Yes. Endometrial Ablation burns the lining of the uterus through different forms of heat (exs. Scalding hot water in a balloon, microwave energy, etc.). This treatment ONLY treats the lining of the uterus, not the actual fibroids.
How is the Atlanta Fibroid Center Different from Other Facilities That Offer UFE?
The Center is outfitted with state-of-the-art equipment, including the GE Innova IGS 540, the centerpiece of our procedure room. Equipment like this is rarely seen in other outpatient centers. Other outpatient centers use much less expensive and lower grade equipment, and use much less expensive and lower grade C-arm technology to perform UFE procedures. These are adequate for dialysis management, for which they were originally popularized, but are not the optimal equipment for fibroid embolization.
While the proper technical equipment is critical to performing UFE procedures, we have taken several further steps to ensure patients are safe and comfortable. The recovery area of our procedure suite is designed to provide a comfortable setting for patients to rest and gradually recover from the UFE procedure. Each patient receives her own private recovery room with a wide-screen television, a door to ensure privacy, and a comfortable chair for the person accompanying the patient. Our nursing staff are specifically hired and trained by Dr. Lipman himself to provide a welcoming and quiet environment, while ensuring that each patient receives personalized 1:1 care.
If you have been diagnosed with fibroids and are experiencing symptoms, please call Atlanta Fibroid Center at 770-214-4600 or make an appointment online. Our office staff will order a pelvic MRI exam for you at a nearby MRI center, and your consultation at our office will be scheduled immediately afterwards or within the next few days of having the MRI.