UTERINE FIBROID EMBOLIZATION (UFE) – Protocol
Indications: At the present time, we are performing UFE on women with symptomatic uterine fibroids who are seeking a non-surgical treatment option. The symptoms associated with fibroids include abnormal uterine bleeding (heavy flow during and/or in-between menstrual periods with or without anemia), painful periods, abdominal distension or bloating, frequent urination due to bladder compression, pain during intercourse, and back or leg pain which is felt to be related to the presence of fibroids. We are also offering UFE to patients desiring future fertility after fibroid treatment after they have been evaluated for or considered myomectomy as a first choice treatment option.
Pre-Procedure Gynecologic Evaluation: Every patient being considered for UFE must be under the care of a gynecologist or family practitioner that is taking responsibility for the gynecologic care of the patient. If a patient is not under the care of a gynecologist, we will be happy to arrange for a referral to an appropriate physician. We are in agreement with the statement issued by the American College of Obstetrics and Gynecology on January 30, 2004 that a thorough evaluation with a gynecologist will help facilitate optimal collaboration with an interventional radiology and help ensure that embolization is the most appropriate procedure to perform. Prior to consultation for UFE, we will request records documenting the following:
- Pelvic examination performed within 12 months of the procedure
- PAP Smear performed within 12 months of the procedure
- Endometrial Biopsy: This is often recommended for patients with very long periods, a short duration of time in between periods, or bleeding in between periods. It is done to be certain that endometrial carcinoma or hyperplasia is not present. We will work with a patient’s gynecologist to determine if an endometrial biopsy is required prior to UFE.
- Ultrasound or MRI performed to document the presence of fibroids
Pre-Procedure Radiology Evaluation: A consultation with one of our interventional radiologists is required prior to this procedure being performed. During this consultation a history will be obtained, a physical examination will be performed, and the patient’s medical records will be reviewed to determine if UFE is appropriate. This consultation will also give us the chance to review the procedure and all treatment options with the patient, and to make sure that all of the patient’s questions are answered. Other aspects of the pre-procedure evaluation include the following:
- Blood Work: A blood count and blood chemistries to evaluate kidney function are obtained in all patients prior to the procedure. In some patients, an FSH level may be obtained to evaluate function of the ovaries.
- Pelvic MRI: It has been our practice to obtain an MRI of the pelvis in all patients. This test may be performed at any of our Image Care Centers. The MRI is performed for the following reasons:
- To confirm the diagnosis of fibroids and to determine if these fibroids, given both their size, number, and position within the uterus, can be responsible for the presenting symptoms. UFE can be performed on patients with one or many fibroids and with fibroids in any part of the uterus. However, patients with submucosal fibroids (fibroids within the cavity of the uterus) may be at risk for these fibroids passing through the vagina after embolization.
- To obtain baseline measurements of the uterus and fibroids. At the present time, there is no upper size limit of a fibroid to be considered for UFE. Based on our experience and the experience of others, however, patients with a uterine size estimated at >20 weeks (above the belly button) need to have realistic expectations as to the ability of this procedure to adequately decrease the size of the fibroids and the uterus.
- To rule out the presence of coexisting disorders that may explain presenting symptoms. One of these disorders is adenomyosis, an overgrowth of the glands and tissue surrounding the cavity of the uterus that can cause bleeding and pain similar to uterine fibroids. While our experience at Albany Medical Center has been positive in patients with adenomyosis, there have been reports of treatment failure in these patients. Therefore, patients with adenomyosis found on MRI are counseled regarding both the potential clinical benefit and the reports that they may be at increased risk for treatment failure after embolization.
- To evaluate the viability of the fibroids. With MRI, we are able to tell the fibroids inside the uterus are living or not. Since the desired endpoint for UFE is to kill or devascularize the fibroids, patients with fibroids that are already dead may not be good candidates for this procedure.
- Medications: Many patients with symptomatic uterine fibroids are treated with Lupron or other gonadotropin releasing hormone (GnRH) agonists. One of the effects of this medication is to reduce the size of the uterine arteries, which have been shown to return to normal size after the same 12 week period of time. Because the embolization procedure is technically simpler to perform in patients with larger arteries, we recommend that patients be off of Lupron and other similar medications for 8-12 weeks before UFE is performed.
Follow-Up Protocol: No special visits with the patient’s gynecologist are required in association with the UFE procedure although we do believe strongly that patients should be under the care of a gynecologist or family practitioner before undergoing this procedure. Our interventional radiology team is responsible for all aspects of the patient’s follow-up care that is related UFE. Patients should remember to continue seeing their gynecologist at their regularly scheduled appointments. There are two follow-up visits with our team after UFE, although additional visits can be arranged should the need arise:
- 3-Week Office Visit: We typically see our patient within 3 weeks of the UFE procedure in order to be certain that recovery is going as expected and to assess patients prior to resumption of normal activity.
- 6-Month Office Visit: This visit is typically arranged after a follow-up MRI is performed so that we will have the opportunity to review the results of the test with the patient. This MRI is an integral part of the follow-up process. It is performed with use of IV dye, which will enable us to tell if the fibroid has been completely treated by the embolization procedure. If dye is seen to collect within a treated fibroid, it may mean that the fibroid has the potential to grow and possibly cause additional problems in the future. Therefore, additional follow-up care may be required. The patient’s gynecologist will be sent a letter after this visit to summarize the outcome after UFE.
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