Frequently Asked Questions about Fibroids and UFE/UAE
- What is UFE?
- How does the UFE or UAE procedure work?
- How do you perform a UFE procedure?
- How do I know if I am a candidate for UFE?
- What are the benefits of UFE over other fibroid therapies?
- I had a pelvic ultrasound in my gynecologist’s office. Is this satisfactory imaging, or do I still need a MRI?
- Does the size and number of fibroids matter?
- I have had a myomectomy, can I still be considered for UFE?
- I have had an Endometrial Ablation, can I still be considered for UFE?
- How long does the procedure take?
- Do I need to go to a hospital or plan to stay overnight at the Center?
- Who will perform the procedure?
- Will I need a bladder catheter?
- How is the Atlanta Fibroid Center different from other facilities that offer UFE?
- What to expect after the UFE procedure?
- What is the recovery period at home and how long will I be out of work?
- How will my menstruations change after UFE?
- How about my sexual life after UFE?
- What are the risks of UFE?
- What is MRI-guided Focused Ultrasound (MRgFUS)?
- Why is my gynecologist against the UFE procedure?
1. What is UFE?
UFE (Uterine Fibroid Embolization) is a minimally invasive non-surgical procedure for the treatment of uterine fibroids, which reduces the risks of complications and relapse of the disease to almost zero, allowing a woman to return to her usual life back in a short time, preserving the patient’s fully functioning uterus, and the ability to become pregnant and bear a child.
Uterine fibroid embolization is a very safe procedure, the risk of any complications is several times lower than after surgical treatment and does not exceed 1%. According to a series of studies, complications after UFE arise about 20 times less often than after any surgical treatment of uterine fibroids.
2. How does the UFE or UAE procedure work?
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 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 the 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. That’s what is most important. 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.
3. How do you perform the UFE procedure?
UFE is performed by a radiologist in a specially equipped X-ray room. 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 as you would get during a colonoscopy. A local anesthetic is placed in the right groin/top of the thigh area to access the right common femoral artery.
After preliminary local anesthesia, through a small (1.5 mm) puncture of the skin in the upper thigh, a thin catheter (1.2 mm) is inserted into the artery, which is carried out directly into the uterine arteries under the control of X-ray television. Then, a solution with tiny embolic agents is injected through the catheter, it blocks the vessels that feed the fibroids. The patient leaves the radiologist’s cabinet only with a band-aid.
The blood supply of the uterus 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 the 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.
Despite its apparent simplicity, UFE is a technically complex procedure that requires a highly qualified radiologist and narrow professional knowledge (including in the field of X-ray anatomy of the uterus and pelvic organs), special care, and high accuracy. This largely determines the success of UFE and the minimal risk of negative consequences.
4. 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 (e.g. 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.
There are some cases in which UFE is the only method for the effective treatment of uterine fibroids with minimal consequences. For example, in relapses after myomectomy. Embolization is also indicated in a situation where there are many nodes and they are located in areas difficult to access for surgery. The procedure also allows patients with heart disease and respiratory failure, which are contraindicated in abdominal surgery.
The radiologist decides on the appropriateness of the procedure, taking into account related factors: the age of the patient; severity of symptoms, their nature; the size of nodes and their localization; upward trend in nodes; the woman’s intention to become pregnant in the future, etc.
5. 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 (see Adenomyosis) 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 the 2nd embolization to treat this rather than undergoing a hysterectomy.UFE is a global therapy (like hysterectomy) in the fact that it treats all of the fibroids. Myomectomy only treats 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 a separate discussion in this section.
6. I had a pelvic ultrasound in my gynecologist’s office. Is this satisfactory imaging, or do I still need an 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).
7. Does the size and number of fibroids matter?
No. Patients that are told that they are not candidates for UFE because they have too many fibroids or that they are too big are being given false information. UFE can be performed at any stage of the disease, regardless of the number of nodes and their size.
8. 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 that 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.
9. 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.
10. How long does the procedure take?
The procedure at our Center takes 30-45 minutes. Next, the patient is transferred to the ward, where she is given analgesic therapy. 2.5 hours after the procedure, a woman can bend her legs, after 6-7 hours, get out of bed and eat.
Because of our experience in providing the UFE procedure, along with our specialized equipment and layout that is optimized for the UFE procedure, we are able to minimize the time you spend in the procedure room. This permits you to begin recuperating sooner in one of our private recovery rooms, and return to the comfort of your home that afternoon.
11. Do I need to go to a hospital or plan to stay overnight at the Center?
The UFE procedure is performed on an outpatient basis at our facility, therefore an overnight stay is not required. In the very rare event, an overnight stay or additional care is needed, the patient can be transported to a nearby hospital.
12. Who will perform the procedure?
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 7,000 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.
13. Will I need a bladder catheter?
No, unlike most clinics and hospitals performing the UFE procedure and require the insertion of a catheter into your bladder, we feel it is not necessary.
14. 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 is 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.
15. What to expect after the UFE procedure?
Even considering the fact that UFE is an almost painless procedure, some pulling pains in the lower abdomen can appear after a couple of hours. This is due to a decrease in blood supply in fibroid cells, and this indicates the effectiveness of the procedure. Painful sensations last only a few hours and are reduced by appropriate medication.
The most common consequence of UFE is the appearance of a small hematoma on the thigh at the site of the puncture. This is a minor complication and as a rule, you do not need to do anything; it disappears on its own within a couple of weeks. On the first day after the procedure, body temperature usually rises slightly. In some cases, it can last up to seven days.
16. What is the recovery period at home and how long will I be out of work?
The typical recovery period is 4-5 days. After that, a woman can continue her usual lifestyle, but without unpleasant symptoms of uterine fibroids.
As for pain, although uterine fibroid embolization is a painless procedure, after 1-2 hours pulling pains occur in the lower abdomen. These sensations are the result of ischemia of fibroid cells and it reflects the effectiveness of the procedure. The pain lasts only a few hours and can be stopped with painkillers. Also, the temperature may increase in the first days after UFE. Weakness and a feeling of malaise are possible, too.
In the first week after the procedure, the patient must follow some rules at home:
- Observe bed rest for several days.
- To relieve pain (if any), you can take painkillers prescribed by your doctor.
- Monitor body temperature.
- After the procedure, it is recommended to increase fluid intake, especially in the first week.
- In the first days after the UFE, you cannot take a hot bath (it is better to shower), go to sauna or pool.
- For a few weeks after the procedure, it is not recommended to use tampons.
- No intense physical activity for a few weeks.
17. How will my menstruations change after UFE?
The first menstruation after uterine fibroid embolization can be painful, with the release of blood clots. Then everything will return to normal. The volume of bleeding will decrease, the cycle will become regular. A decrease in the volume of the uterus and fibroid nodes can be fixed after a month. After this period, the UFE does not impose any restrictions on the further life of a woman. She can continue to work, play sports, maintain sexual activity and try to conceive a child six months after the procedure. Dozens of women have already become mothers after the UFE.
18. How about my sexual life after UFE?
It is usually recommended not to have sex for about a month after the procedure, but this is a recommendation, not a rule. For a couple of months after UFE, it is recommended to use barrier contraceptives.
After the procedure, the doctor will notify you when you need to come for an examination again. You may need a couple of follow-up visits. The first of them is usually scheduled 3 months after the UFE.
In most cases, if the doctor confirms the effectiveness of the procedure at the examination after 3 months, a woman can begin to plan pregnancy and try to conceive. As a rule, by this time the patient has already returned to her usual lifestyle.
19. 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).
20. What is MRI-guided Focused Ultrasound (MRgFUS)?
MRgFUS is a non-surgical treatment for uterine fibroids. It was FDA approved in October 2004.
The MRgFUS procedure uses ultrasound waves (much more powerful than those used for diagnostic imaging) which are focused on a small spot about the size of a jellybean. There is enough energy in that spot to destroy the fibroid while leaving all the healthy tissue outside the fibroid unharmed. Many jellybean-sized spots are used to treat the entire fibroid.
Unfortunately, Atlanta Fibroid Center no longer provides this procedure, as it is not reimbursed by most insurance companies.
21. Why is my gynecologist against the UFE procedure?
It often happens that a woman learns about the UFE method, decides to try it, and the gynecologist discourages her. These can be stories about serious complications or the inability to have children in the future. The OB/GYN may insist on surgical treatment, and there are several reasons for this.
The main reason is that embolization is not performed everywhere; special medical equipment and tools are needed, which are available only in equipped medical centers. In addition, the procedure is carried out not by Gynecologists but by an experienced Interventional Radiologist like Dr. John Lipman.
If your gynecologist discourages you from the UFE procedure, contact Dr. Lipman for a second opinion. Find out if you are a candidate for the procedure before you opt for a surgical solution to avoid the risks of surgery.