Interventional Radiology
UFE

Uterine Fibroid Embolization

Uterine fibroid embolization, or UFE, is a technique for cutting off the blood supply of uterine fibroids to get them to shrink. It is sometimes referred to as Uterine Artery Embolization, or UAE. This procedure is performed exclusively by Interventional Radiologists -- doctors who are specially trained to do minimally invasive vascular procedures, such as angioplasty and embolization, to treat a variety of conditions.

UFE is performed in a manner similar to a heart catheterization, whereby a small catheter (plastic tube) is introduced into the right femoral artery through a tiny skin nick in your groin. The catheter is guided using an x-ray camera into each uterine artery, where microscopic particles are injected, killing all of the fibroids at the same time.

You will not be aware of anything happening on the inside and the groin area is thoroughly numbed before starting. You will also feel very relaxed from potent medicines given to you through an intravenous line and may fall asleep.

UFE is 90% effective in relieving symptoms. Risks are discussed in detail below. Please see the additional resources on page 6 for reputable websites and bring any unanswered questions to your appointment.

A consultation with us about UFE includes a full history and a limited physical examination (no pelvic exam), which are performed by a Nurse Practitioner or Physician Assistant and you will meet with the doctor following. Please fill out your medical history form completely in advance, as this will streamline your visit. Please write down all medications you are taking and bring this with you.

At your visit, your imaging studies will be reviewed and you will have the opportunity to ask any questions you have about the procedure. We are not able to determine whether you are a candidate for UFE or not without seeing the pictures themselves (the report alone is not sufficient). If your imaging was not done at Stanford, please bring a copy of your CD or films with you unless other arrangements have been made to send it to our office ahead of time.

Planning for your Procedure

If you are a good candidate for UFE and wish to proceed, a nurse will call you to schedule your procedure. Pick a date that works well with your schedule and prepare for 10-14 days for complete recovery time following. You will stay overnight after the procedure, and need to have a ride home the following day.

Insurance coverage is always a concern. We will contact your insurance company to obtain precertification for your procedure. This can take one to two weeks; so the earlier this process starts the less likely there is to be an impact on your procedure date. A phone call to your insurance company by you to ensure this is a covered benefit and to forewarn them of our precertification request may help move it along. You will be contacted if there are any problems getting authorization.

You will be given prescriptions for medications to be taken in advance of your procedure. The first is for Procardia XL, which is to start two days beforehand up until the morning of your procedure. This medicine, which is generally used to treat high blood pressure, helps the uterine arteries to relax and ensure a successful outcome. If it causes severe headaches or other unpleasant side effect, you may discontinue taking it.

The other medicine is a Scopolamine patch, which is to be placed behind your ear the afternoon before. It will help to prevent nausea, which might occur after UFE. If you experience extreme dry mouth, dizziness, or blurry vision, peel off the patch and your symptoms should ease up shortly afterward. If you are doing okay, you will be asked to keep the patch on after your procedure for 36 hours and take it off once you are home.

The Day Before

Eat light, drinking plenty of fluids. Please do not eat or drink after midnight the night before your procedure. If you have pills you need to take the morning of, you may take them with a small amount of water.

Your Procedure Day

When your procedure is scheduled, you will be instructed when to arrive at the hospital. Please be to the 3rd floor of the Advanced Medicine Center by this time. After you are checked in, you will be asked to change into a gown, have an IV placed. You may have some lab work drawn at this time if this has not already been arranged previously on a case-by-case basis.

During the procedure, you will be given pain medication and a sedative, but will remain awake and breathing for yourself. A patient controlled pain pump (PCA) will be connected to your IV at the end of the procedure to ensure you have adequate pain control following. Other medications will be available to you to treat symptoms such as nausea.

You will go to your hospital room after the procedure. Your PCA pump will stay connected usually until the following morning, but for as long as needed. Once it isn't necessary, oral pain medications will be started.

Once you are awake and feeling up to it, you will have food and drinks available to you. Slowly restarting these, first with water, is recommended to prevent nausea.

Going Home

Your nurse will go over discharge instructions specific to you and give you several prescriptions. To help you prepare, these instructions are summarized below.

Prescriptions

For Pain: Strong pain reliever, usually Vicodin or Percocet. You can take one or two of these every six hours, but only as needed.

For Fever and Inflammation: Naprosyn (prescription strength Aleve), is a non-narcotic pain medicine and anti-inflammatory. Take this medicine at breakfast, lunch, dinner, and bedtime, regardless of your pain level for 7 days. This medicine specifically targets the pain producing cells in the uterus. It may also be helpful for your first menstrual period to take Naprosyn if you have cramping.

Stool Softener: Senokot or Dulcolax are stool softeners that will prevent or help with constipation. Take this twice a day, morning and night. A number of factors may tend to make you constipated, such as pain pills, a decrease in food and water, and a tendency to be less active. After two or three days, if you haven't moved your bowels, you will need to get two Fleets enemas from your local pharmacy. If the first has little or no effect, take the second after a half hour or so. Continue to take the stool softener until you are having regular bowel movements.

For Nausea: Phenergan may be taken every 6 hours, only if you are having nausea. This medication may make you drowsy, please do not drive.

Activity

Expect to be tired for the first week or two after the procedure and gradually gaining strength back. Do not plan anything active or requiring your close attention for the first few days following discharge from the hospital. Avoid lifting more than 10 pounds for 48 hours. Strenuous exercise, including activities that increase blood flow to abdomen (some yoga positions) is discouraged for one week.

Bathing

You may shower 24 hours after the procedure. Gently wash the catheter insertion site with soap and water, do not scrub. Do not bathe or soak in water for 5 days following the procedure.

Follow Up

Most women do not need a follow up visit in Interventional Radiology after this procedure, but we will be in contact with you several times by telephone during your recovery. We want to be contacted if you experience any unpleasant side effects not relieved by your discharge medications, especially fever, cramps, abdominal pain and/or vaginal discharge. These could indicate an infection.

It is not uncommon to experience a change in your menstrual periods after the procedure. Abnormally heavy periods usually become much lighter, or you may miss a period or two altogether. If your fibroids are submucosal, you may find that you are passing clots during and even in between your periods. Sometimes you will even see bits of fibroid tissue pass. Most of the time, this will happen without any additional discomfort. Occasionally, however, a large portion of the fibroid will break off and passes slowly or even become lodged. If you feel crampy abdominal pain that lasts longer than a few hours or there is foul-smelling discharge, please contact us immediately. Usually oral medications will suffice, but occasionally we will need to have you return for evaluation and possibly admit you to the hospital.

Additional Sources of Information

Society of Interventional Radiology

Ask4UFE.com

Radiological Society of North America

Stanford Unversity Deparment of Radiology

Possible Adverse Events

Fortunately, complications following uterine fibroid embolization (UFE) are rare. They can be divided into the seven following categories: complications of angiography, infection, ischemic complications, thromboembolic events, radiation injury, adverse drug reactions, and other.

Complications of Angiography

Access site bleeding/hematoma: minor adverse events include a small amount of bleeding or bruising at the access site or a small hematoma. A hematoma is a contained collection of clotted blood outside the artery. Access site hematomas are usually small and require no specific therapy. They occur in less than 3% of patients.

A hematoma is considered a major complication if any of the following occurs: a blood transfusion is required; surgical evacuation is necessary; readmission to the hospital; prolonged hospital stay. Major bleeding complications are rare and have not yet been reported in UFE patients.

Vascular Damage: Injury to the arterial wall can occur during introduction and/or manipulation of the catheter, which is a small plastic tube. Serious complications resulting in hospitalization, surgery or other invasive intervention, or hospital readmission are rare. There have been anecdotal reports of two cases, which required a minor procedure to correct the situation, which were successful in both cases.

Contrast-Related: Iodinated radiographic contrast can result in temporary or permanent renal failure. This typically occurs in patients who already have compromised renal function, such as patients who are diabetic. The small amount of contrast used during UFE is not considered to represent a risk for injury to the kidneys in otherwise healthy adults.

Some people also have an allergy to contrast agents. Usually this is mild and the most common symptoms are a rash or hives which quickly go away or, if not, will respond to Benadryl. Approximately 1 in 4000 will have a more serious reaction, such as severe asthma or swelling of the airway, and may require intravenous medication and a longer period of observation. An extreme (anaphylactic) reaction that results in death is very rare and occurs in between 1 in 100,000 and 1 in 140,000 contrast administrations.

Infection

If patients are imaged (CT, US, or MR) in the initial post-procedure period, gas is frequently seen in the infracted fibroids. It may persist for several weeks after UFE. This is a normal finding and is not indicative of infection or abscess formation.

Uterine Infection

Uterine Infection is typically characterized by fever and escalating pain and either pus coming from the cervix and/or positive cervical or endometrial cultures. Uterine infection is usually related to contamination of a sloughing fibroid, possibly accompanied by endometritis (infection of the lining of the uterus), and has been reported in up to 1 in 200 women who have undergone UFE. Intravenous antibiotics may be curative, but possibly surgical removal of the fibroid or even hysterectomy may be necessary.

Urinary Tract Infection (UTI)

A UTI is characterized by microbial (usually bacterial) infection of any part of the urinary system. A UTI typically causes painful urination or increased urinary frequency. It is treated by oral or intravenous antibiotics depending on its severity. The risk of UTI is theoretically increased by the use of a Foley or other type of bladder catheter.

Bacteremia/Sepsis

Bacteria may enter the blood stream through degenerating fibroids. Bacteremia and sepsis (a more severe form) can be diagnosed by blood culture. Fever and systemic signs of infection have usually been present for at least 24 hours. There has been only one death reported in over 10,000 patients, which was attributable to sepsis, and the circumstances of that case were unique.

Wound Infection

An infection at or near the procedure incision site is theoretically possible, especially if a closure device has been used to seal the artery. This complication is rare and has not yet been reported in UFE patients.

Ischemic Complications

Ischemia (blockage of blood flow) is the intended result of embolization, depriving the fibroids of blood, oxygen, and nutrients. The uterus and/or ovaries are also potentially affected, although they have the capacity to recover and the fibroids do not.

Pelvic Pain

Crampy pelvic pain occurs in almost every patient following UFE. Rarely, someone will have no pain. It is important to remember that the presence or severity of pain is not correlated with clinical failure or success. Pain is usually moderate to severe, sometimes as severe as labor pain. The pain after UFE usually peaks within hours of the procedure, but may occasionally be severe even into the second day, and rarely the third day or later. Most pain will usually be gone within a few days and rarely will it require more than a week to completely resolve.

Fever

Up to 1/3 of patients will have a temperature of 100.4°F or higher following embolization as part of a well-known post-embolization syndrome. You have been given a prescription for a medication that will prevent your temperature from reaching uncomfortable levels. Fever is only worrisome if it is associated with chills or is higher than 101.5°F and fails to respond to aspirin or Tylenol. Please contact us immediately if this occurs.

Nausea/Vomiting

Nausea and/or vomiting are not uncommon following the procedure. Again, you have been given medications to help prevent this or treat it if it occurs.

Fibroid Sloughing

In the weeks that follow UFE, approximately 5% of patients will pass fragments of necrotic (dead) fibroids, or even a whole fibroid. It is more likely to occur when the fibroids are submucosal. Your doctor will discuss whether this is the case with you. Passage of fibroid material can happen as late as 8 to 10 weeks afterward and occasionally even after that. Sloughing of a fibroid is often experienced as a sudden onset of intense crampy pain and an odorous vaginal discharge. In most cases it will pass within 36 to 48 hours, with prompt resolution of symptoms. The positive side of this is that there is often a noticeable reduction in uterine size and improvement in bulk-related symptoms. If the piece of fibroid does not pass on its own after a day or two, you may require a procedure to help remove it.

Non-Target Embolization

Non-target embolization occurs when the embolic agent passes into a circulation other than where it is intended; with UFE that would be outside the uterus. The ovary shares blood supply with the uterus in many women and is the organ most frequently affected by non-target embolization. Premature menopause or permanent loss of menses (periods) can occur in up to 5% of patients. It rarely occurs in women who are under 45 years of age. Approximately 5-10% of women have a decrease or even transient loss of menses, but their periods will return, usually lighter than before. Hot flashes and/or other menopausal symptoms may accompany this. Other, more rare examples of non-target embolization would be occlusion of adjacent branches such as to the bladder or rectum. Such instances have not been reported for UFE.

Fertility

As discussed above, some patients may experience premature ovarian failure. However, many patients have become pregnant and delivered health babies after UFE. Statistics on the affects of UFE on fertility are not known.

To date, there have been no reports of birth defects or intrauterine growth retardation. A note of caution should be made: there is one anecdotal case of a woman who had uterine rupture during labor at a point of weakness in the uterine wall where a transmural (through-the-wall) fibroid had infracted (died).

Sexual Dysfunction

Approximately 15% of women normally report having sensations of strong uterine contractions during orgasm. There is one case report in the world literature describing a woman who lost this sensation following UFE. The authors of the case report hypothesized that this might have been related to non-target embolization of the cervix and/or the adjacent neural plexus. However, there were three studies on sexuality after UFE presented at a recent scientific meeting, which found no change and even an improvement in sexual experience after UFE.

Thromboembolic Events

Deep Vein Thrombosis (DVT)

These are blood clots within the deep veins of the pelvis. Pelvis DVT may occur in women who have large uteruses; as a result of direct pressure on the veins causing compromised flow. Women who are taking hormone supplements are at greater risk for DVT. Blockage of the arterial inflow to the uterus by UFE may also contribute to stagnation and clotting of the venous drainage. DVT extending into the legs has not yet been reported, but there have been incidents of blood clots traveling to the lungs (pulmonary embolism), which presumably arose in the pelvis. Such blood clots and their effects are a well-known risk following many types of pelvic surgery, so UFE is quite similar to surgery in this regard.

Radiation Injury

X-rays are used during the procedure to guide the passage of the catheter into the uterine arteries and the injection of the particles during embolization. A radiation burn to the skin is a theoretical risk during a very prolonged UFE procedure, but this occurrence has not been reported to date. The amount of radiation that the ovaries receive is approximately 2 to 20 Rads, which varies substantially depending on the anatomy, angiographic equipment, and operator experience. However, the amount of radiation used (even at the higher range of exposures) is not expected to affect fertility, cause cancer, or induce genetic mutations should pregnancy occur after UFE.

Adverse Drug Reaction

Multiple medications are used for comfort and relaxation during and after the procedure. Just as with contrast agents, allergic symptoms can occur, ranging from mild to severe, including anaphylaxis. However, the most commonly used agents rarely have any side effects other than dry mouth and urinary retention.

Urinary Retention: occasionally, a patient will have urinary retention requiring temporary catheterization following the procedure. It is usually medication-related and resolves with time. Only occasionally is repeat catheterization or a longer-term catheter necessary.

Other

Permanently Implanted Material

The embolic agents, polyvinyl alcohol (PVA) or Embospheres are designed to be permanent. Both PVA and Embospheres have long track records of use and their safe biocompatibility ahs been well documented. To date, there have been no reports of adverse reactions or long-term effects referable to either of these agents.

Death

The incidence of death following UFE is approximately 1 in 5,000-7,000 cases. One patient died from an infection that proceeded to sepsis and multiorgan system failure. Two other patients died from pulmonary embolism following the procedure. To put UFE into perspective, the 30-day mortality from elective hysterectomy (excluding obstetrical emergencies and cases of malignancy) is approximately 1 in 1,000 cases.

For additional detailed information about UFE, please watch our video.

Patient Education Series: Uterine Fibroid Embolization

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