News for Your Practice

Uterine artery embolization for abnormal bleeding

OBG Manag. 2005 July;17(7):48-59

How to treat women with fibroids or adenomyosis, the most common myometrial causes of premenopausal abnormal uterine bleeding.

PDF Download

References

1. Ravina JH, Herbreteau D, Ciraru-Vigneron N, et al. Arterial embolisation to treat uterine myomata. Lancet. 1995;346:671-672.

2. Worthington-Kirsch RL, Siskin GP. Uterine artery embolization for symptomatic myomata. J Intensive Care Med. 2004;19:13-21.

3. Bradley EA, Reidy JF, Forman RG, et al. Transcatheter uterine artery embolisation to treat large uterine fibroids. Br J Obstet Gynaecol. 1998;105:235-240.

4. Worthington-Kirsch RL, Popky GL, Huchins FL, Jr. Uterine artery embolization for the management of leiomyomas: quality-of-life assessment and clinical response. Radiology. 1998;208:625-629.

5. Goodwin SC, Vedantham S, et al. Preliminary experience with uterine artery embolization for uterine fibroids. J Vasc Interv Radiol. 1997;8:517-526.

6. Walker WJ, Pelage JP. Uterine artery embolisation for symptomatic fibroids: clinical results in 400 women with imaging follow-up. BJOG. 2002;11:1262-1272.

7. Pron G, Bennett J, Common A, et al. The Ontario Uterine Fibroid Embolization Trial. Part 2. Uterine fibroid reduction and symptom relief after uterine artery embolization for fibroids. Fertil Steril. 2003;79:120-127.

8. Spies JB, Ascher SA, Roth AR, et al. Uterine artery embolization for leiomyomata. Obstet Gynecol. 2001;98:29-34.

9. Chen C, et al. Uterine arterial embolization in the treatment of adenomyosis. Zhonghua Fu Chan Ke Za Zhi. 2002;37:77-79.

10. Pelage JP, Jacob D, et al. Midterm results of uterine artery embolization for symptomatic adenomyosis: initial experience. Radiology. 2005;234:948-953.

11. Andrews RT, Spies JB, Sacks D, et al. Patient care and uterine artery embolization for leiomyomata. J Vasc Interv Radiol. 2004;15:115-120.

12. Broder MS, et al. Uterine Artery Embolization: A Systematic Review of the Literature and Proposal for Research. Santa Monica, Calif: Rand; 1999. Publication MR-1158.

13. Siskin GP, Tublin ME, Stainken BF, et al. Uterine artery embolization for the treatment of adenomyosis: clinical response and evaluation with MR imaging. AJR Am J Roentgenol. 2001;177:297-302.

14. Rosch J, Dotter CT, Brown MJ. Selective arterial embolization. A new method for control of acute gastrointestinal bleeding. Radiology. 1979;102:303-306.

15. Outwater EK, Siegelman ES, Van Deerlin V. Adenomyosis: current concepts and imaging considerations. AJR Am J Roentgenol. 1998;170:437-441.

16. Byun JY, Kim SE, Choi BG, Ko GY, Jung SE, Choi KH. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. 1999;19:S161-S170.

17. Spies JB, Spector A, Roth AR, et al. Complications after uterine artery embolization for leiomyomas. Obstet Gynecol. 2002;100:873-880.

18. Goldberg J, Burd I, et al. Leiomyosarcoma in a premenopausal patient following uterine artery embolization. Am J Obstet Gynecol. 2004;191:1733-1735.

19. Rajan DK, Beecroft JR, Clark TW, et al. Risk of intrauterine infectious complications after uterine artery embolization. J Vasc Interv Radiol. 2004;15:1415-1421.

20. Vashisht A, Studd J, Carey A, Burn P. Fatal septicemia after fibroid embolisation [letter]. Lancet. 1999;354:307-308.

21. Kerlan K, Jr, Coffey JO, Milkman MS, et al. Massive vaginal hemorrhage after uterine fibroid embolization. J Vasc Interv Radiol. 2003;14:1465-1467.

22. McLucas B, Goodwin S, Adler L, Rappaport A, Reed R, Perrella R. Pregnancy following uterine fibroid embolization. Int J Gynaecol Obstet. 2001;74:1-7.

23. Goldberg J, Pereira L, Berghella V. Pregnancy after uterine artery embolization. Obstet Gynecol. 2002;100:869-872.

24. Goldberg J, Pereira L, Berghella V, et al. Pregnancy outcomes after treatment for fibromyomata: uterine artery embolization versus laparoscopic myomectomy. Am J Obstet Gynecol. 2004;191:18-21.

IN THIS ARTICLE

Preoperative imaging: An enormous fibroid and adenomyosis
Imaging: Before and after Angiography MRI

DISCHARGE INSTRUCTIONS WALLET INFO-CARD When to call your doctor

Fast Track

The ideal patient is premenopausal, has symptomatic fibroids and/or adenomyosis, has failed therapy, and wants or needs to avoid surgery

MRI enables classification of masses as submucosal, intramural, or subserosal

The patient should have a normal Pap test (in the past year) and should undergo endometrial biopsy to rule out cancer

Abnormal bleeding improves in 77% to 90% of fibroid cases, and bulk-related symptoms resolve in 86% to 91%

Of 400 consecutive fibroid patients:

1.25% serious complications
5% periprocedural morbidity
0 deaths or major permanent injuries

Successful pregnancies have followed UAE, but so have higher rates of cesarean, miscarriage, and preterm birth

UAE advantages: less invasive, local anesthesia plus conscious sedation, virtually no blood loss, no adhesions

LISA’S CASE

Ablation fails to ease symptoms

Lisa is a 38-year-old mother of 2 who initially reported menometrorrhagia, dysmenorrhea, urinary frequency, pelvic pressure, and increasing abdominal girth. These symptoms worsened over 3 years before Lisa saw a physician and was diagnosed with uterine fibroids. When offered hysterectomy or endometrial ablation (cryomyolysis), she chose the latter. However, her fibroids failed to shrink, and her symptoms returned 5 months after the procedure.

Lisa heard about uterine artery embolization (UAE) through the media and now asks about it. Her uterus is 20-week size with an irregular contour. Magnetic resonance imaging (MRI) shows a single large fibroid filling the uterus. Her hematocrit is 22.

Is uterine UAE right for her?

ANGELINA’S CASE

Menorrhagia and a “boggy” uterus

Angelina, 35, has 2 children and a 10-year history of menorrhagia, dysmenorrhea, and anemia. Pelvic examination reveals a 10-week size, “boggy” uterus, and MRI shows global enlargement of the uterus with a thickened junctional zone, which is characteristic of adenomyosis.

Her previous physician recommended hysterectomy after medical therapy failed, but Angelina is reluctant to undergo surgery.

Is UAE an option?

Both women are very likely to benefit from UAE, since the ideal candidate is premenopausal with symptomatic fibroids and/or adenomyosis and has either failed medical or surgical therapy or wants or needs to avoid surgery.^1-11

This article describes the therapeutic role of UAE in women with abnormal uterine bleeding (AUB) due to uterine fibroids and/or adenomyosis—the most frequent myometrial causes of premenopausal AUB.

Other, less frequent myometrial disorders (eg, hypervascular pathologies such as intramyometrial and parametrial vascular malformations or neoplasms) can also be treated using embolization techniques. The main advantages of UAE in treating these diseases:^1-8,12,13

Less invasive than surgery, with substantially less recovery time and lower morbidity
Usually performed under local anesthesia and intravenous conscious sedation
No worry about adhesions
Virtually no blood loss or need for transfusion; UAE may be especially attractive for patients who refuse or cannot receive blood products for health or religious reasons.

Impressive success rates

UAE has demonstrated excellent technical (98% to 100%) and high clinical success rates (80% to 95%) in the treatment of fibroids.^1-8,13 The clinical success rate is lower for adenomyosis (56% to 92%), but UAE often provides sufficient clinical relief to obviate surgery.^9,10,13

Although UAE was not initially recommended for women desiring future fertility—because of the 4% risk of premature menopause—the pendulum is now swinging in the other direction. If the risks of myomectomy are great due to the anatomic size or position of fibroids or adenomyosis, the risk-benefit ratio may shift to UAE to allow preservation of reproductive capacity.^1-8,11

Though embolization has been performed since the early 1970s for acute and chronic bleeding associated with various medical conditions,¹⁴ the first report of UAE did not come until 1995.¹ Since then, the procedure has seen rapid growth worldwide, with approximately 50,000 cases performed. About 14,000 cases were performed in the US last year.²

Although our practice has no fixed size limitation, ideally a uterus less than 20 weeks’ gestational size is preferred.

Contraindications

Viable pregnancy
Active pelvic infection
Presence of an intrauterine device (though the IUD may be removed before the rocedure)
Undiagnosed pelvic or adnexal mass
Pelvic malignancies such as ovarian or endometrial carcinoma
History of pelvic radiation, since UAE may cause ischemic necrosis of the uterus and adjacent organs due to preexisting radiation-induced vasculitis with diffuse vascular narrowing.

Relative contraindications

Renal insufficiency, though we have used gadolinium, a nonnephrotoxic MRI contrast medium, for women with high blood creatinine levels
History of severe allergic reaction to iodinated contrast medium, though gadolinium can also be used in these patients
Coagulopathy
Desire to preserve fertility, since it cannot be assured based on current data. However, uncomplicated pregnancies and normal deliveries have been reported after UAE, so this procedure may still be preferred for women who refuse or cannot undergo myomectomy.¹¹