Uterine artery embolization
Uterine artery embolization (UAE) utilizes a single small incision in the groin and radiographic guidance of catheters and embolic agents to the uterine arteries bilaterally. Thus multiple fibroids can be targeted simultaneously. UAE requires sedation and typically is performed as an overnight admission or same-day procedure.
Multiple RCTs have demonstrated the efficacy of UAE in women with fibroids. The quality of evidence has been high for a significant volume reduction that continued for 5 years and improvements in AUB-L along with moderate evidence for an improvement in quality of life.5 When compared to hysterectomy and myomectomy, risk of transfusion with UAE was drastically reduced (OR 0.07, 95% CI, 0.01-0.52). Women undergoing UAE also recovered more rapidly and had fewer major complications, but more minor complications requiring no or nominal therapy, including overnight admission for observation, were noted when UAE was compared to hysterectomy but not when compared to myomectomy.16 In the RCT between UAE and hysterectomy, postembolization and vaginal discharge were the most frequent minor complication following UAE and infection and hemorrhage the most common following hysterectomy; the median length of stay was 1 day for UAE and 5 days for hysterectomy possibly affecting readmission for observation.17
Concerns regarding UAE are associated with a higher rate of subsequent surgical intervention with estimates of 7% for myomectomy and hysterectomy versus 15% to 32% for UAE.5 However, studies have not reported whether failures of UAE are due to concomitant diseases such as adenomyosis, which is also treated with hysterectomy but not uterine-sparing approaches. In a study based on insurance claims, the chance of a complication requiring a subsequent procedure was substantially higher following myomectomy compared to UAE in a propensity-matched group (24.6 vs. 18.1%, HR 1.38 (95% CI, 1.25-1.52).6
Another concern of UAE is the potential impact on ovarian reserve, fertility, and pregnancy complications. A systematic review that compared obstetric outcomes in women following UAE to age-matched women with fibroids who did not undergo myomectomy reported an increased risk of miscarriage (OR 2.8, 95% CI, 2.0-3.8), cesarean delivery (OR 2.1, 95% CI, 1.4-2.9), and postpartum hemorrhage (OR 6.4, 95% CI, 3.5-11.7), but no difference in other obstetric outcomes.18 Studies have demonstrated there is no significant difference in ovarian failure rates at long-term follow-up and there is very-low-level evidence that there is a decrease in fertility following UAE compared to myomectomy.16 Finally, there are numerous reports of successful pregnancy following UAE and some national guidance recommending UAE for fertility preservation.19
High-intensity focused ultrasound ablation (HIFU) is a noninvasive method that uses ultrasound energy to create coagulative necrosis in a well-defined area through the anterior abdominal wall. HIFU can be performed under magnetic resonance imaging (MRI) or ultrasound guidance; however, only the device that uses MRI guidance is approved in the United States. Both procedures are performed on an outpatient basis with sedation and no incisions.
Overall, HIFU has been shown to be effective for decreasing fibroid size/volume.5 Recent investigation has shown that other important patient outcomes are also improved. A large cohort study compared 1353 women undergoing ultrasound-guided HIFU to hysterectomy (N=472) or myomectomy (N=586).20 Quality of life improved more quickly after HIFU compared to surgical intervention and HIFU had only 0.2% major adverse outcomes compared to 12.6% in the surgical cases (P < 0.001). Despite multiple differences in patient demographics between the treatment groups, with the patients undergoing HIFU being younger, better educated, and wealthier compared to the surgery groups, the authors concluded there is less morbidity when patients undergo HIFU compared to surgery.20 A case control study analyzing approximately 10,000 women who underwent HIFU demonstrated successful rates of ablation with a mean volume ablation rate of 83.1% ± 15.6% (range, 25%-100%) for patients with fibroids.21 The authors found that with conscious sedation and analgesia there were minimal side effects and very few severe complications.21 Case series have documented successful pregnancy outcomes following MRgFUS.22,23
The Fibroid Interventions: Reducing Symptoms Today and Tomorrow (FIRSTT) study analyzed patients randomized into UAE or MRgFUS groups and a parallel group declining randomization.24 Both groups had improved fibroid symptoms and quality of life for up to 2 years but improvement was significantly better for women who underwent UAE and risk of needing another fibroid procedure was higher (HR 2.81, 95% CI, 1.01-7.79, P = .047) for women undergoing MRgFUS.24
Radiofrequency ablation (RFA)
Introduced in 1999, laparoscopic, intra-abdominal-guided radiofrequency ablation (RFA) is another surgical modality developed to be less invasive. Benefits of this procedure include ease of use as it does not require laparoscopic suturing and there is no dissemination of tissue in the abdomen, which can occur with laparoscopic hysterectomy/myomectomy. A RCT by Bruker et al. demonstrated a shorter hospital stay and decreased blood loss when comparing RFA to laparoscopic myomectomy.25 While this is an attractive option we have limited evidence about long-term outcomes for RFA and it still requires a laparoscopy. A transcervical, intrauterine sonography-guided RFA device has been studied and is approved for use outside the United States but is not FDA-approved.26
In the not too recent past, surgical intervention represented the only strategy for symptomatic and/or large fibroids. With our growing appreciation of high fibroid incidence and burden, we are continuing to develop less-invasive strategies to improve symptoms and patient quality of life. Overall, there is good evidence that demonstrates that GnRH agonists and PRMs result in reduction of fibroid volume and improvement in quality of life for women with fibroids. UAE has also been shown to reduce uterine and fibroid volume with improvement in quality of life with more data needed to verify the procedure’s safety in patients planning to conceive in the future. While OCs have been first-line therapy in the past, there is a paucity of data supporting their benefit and, therefore, other strategies should be explored. Lastly, HIFU has been shown to reduce fibroid volume but more rigorous studies are needed to determine long-term outcomes and assess fertility following treatment.
The authors report no potential conflicts of interest with regard to this article.
- Stewart EA, Cookson CL, Gandolfo RA, Schulze-Rath R. Epidemiology of uterine fibroids: a systematic review. BJOG. 2017;124:1501-1512.
- Merrill RM. Hysterectomy surveillance in the United States, 1997 through 2005. Med Sci Monitor. 2008;14:CR24-31.
- Cardozo ER, Clark AD, Banks NK, Henne NB, Stegmann BJ, Segars JH. The estimated annual cost of uterine leiomyomata in the United States. Am J Obstet Gynecol. 2012;206:211 e1-9.
- Ezzati M, Norian JM, Segars JH. Management of uterine fibroids in the patient pursuing assisted reproductive technologies. Womens Health (Lond). 2009;5:413-421.
- Hartmann KE, Fonnesbeck C, Surawicz T, et al. Management of uterine fibroids. Agency for Healthcare Research and Quality Evidence-Based Report. Rockville (MD). Available at: www.effectivehealthcare.ahrq.gov/reports/final.cfm.
- Borah BJ, Yao X, Laughlin-Tommaso SK, Heien HC, Stewart EA. Comparative effectiveness of uterine leiomyoma procedures using a large insurance claims database’ Obstet Gynecol. 2017; 130:1047-1056.
- Sangkomkamhang US, Lumbiganon P, Laopaiboon M, Mol BW. Progestogens or progestogen-releasing intrauterine systems for uterine fibroids. Cochrane Database Syst Rev. 2013;CD008994.
- Ishikawa HK, Ishi V, Serna A, Kakazu R, Bulun SE, Kurita T. Progesterone is essential for maintenance and growth of uterine leiomyoma, Endocrinology, 2010;151(6):2433-2442.
- Murji A., Whitaker L, Chow TL, Sobel ML. Selective progesterone receptor modulators (SPRMs) for uterine fibroids, Cochrane Database Syst Rev, 2017;4: CD010770.
- Tristan M, Orozco LJ, Steed A, Ramirez-Morera A, Stone P. Mifepristone for uterine fibroids. Cochrane Database Syst Rev: 2017;CD007687.
- Moroni RM, Martins WP, Ferriani RA, et al. Add-back therapy with GnRH analogues for uterine fibroids. Cochrane Database Syst Rev. 2017;CD010854.
- Perry CM, Brogden RN. Goserelin. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic use in benign gynaecological disorders. Drugs. 1995;51:319-346
- Sinai Talaulikar V, Belli AM, Manyonda I. GnRH agonists: do they have a place in the modern management of fibroid disease? J Obstet Gynaecol India. 2012;62:506-510.
- Osuga Y, Enya K, Kudou K, Tanimoto M, Hoshiai H. Oral gonadotropin-releasing hormone antagonist relugolix compared with leuprorelin injections for uterine leiomyomas: a randomized controlled trial. Obstet Gynecol. 2019;133:423-33.15.
- Carr BR, Stewart EA, Archer DF, et al. Elagolix alone or with add-back therapy in women with heavy menstrual bleeding and uterine leiomyomas: a randomized controlled trial. Obstet Gynecol. 2018;132:1252-1264.
- Gupta JK, Sinha A, Lumsden MA, Hickey M. ‘Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database Syst Rev. 2012;CD005073.
- Edwards RD, Moss JG, Lumsden MA, Wu O, Murray LS, Twaddle S, et al. Uterine artery embolization versus surgery for symptomatic uterine fibroids. N Engl J Med. 2007;356(4):360-370.
- Homer H, Saridogan E. ‘Uterine artery embolization for fibroids is associated with an increased risk of miscarriage. Fertil Steril. 2010;94:324-330.
- Shalina RI, Krasnova AS, Simukhina MA, Kubataeva AK. Uterine artery embolisation (UAE). Pregnancy, delivery and perinatal outcomes. BJOG. 2013;120:50.
- Chen J, Li Y, Wang Z, et al. Evaluation of high-intensity focused ultrasound ablation for uterine fibroids: an IDEAL prospective exploration stud., BJOG. 2018;125:354-364.
- Chen J, Chen W, Zhang L, et al. Safety of ultrasound-guided ultrasound ablation for uterine fibroids and adenomyosis: A review of 9988 cases. Ultrasonics Sonochemistry. 2015;27:671-676.
- Zou J, Chen L, Wu C, Hu C, Xiong Y. Pregnancy outcomes in patients with uterine fibroids treated with ultrasound-guided high-intensity focused ultrasound. BJOG. 2017;124(S3): 30-35.
- Rabinovici J, David M, Fukunishi K, et al. Pregnancy outcome after magnetic resonance-guided focused ultrasound surgery (MRgFUS) for conservative treatment of uterine fibroids. Fertil Steril. 2010;93(1):199-209.
- Laughlin-Tommaso S, Barnard EP, AbdElmagied AM, et al. FIRSTT study: randomized controlled trial of uterine artery embolization vs focused ultrasound surgery. Am J Obstet Gynecol. 2019;220:174 e1-74 e13.
- Brucker SY, Hahn M, Kraemer D, Taran FA, Isaacson KB, Kramer B. ‘Laparoscopic radiofrequency volumetric thermal ablation of fibroids versus laparoscopic myomectomy’, Int J Gynaecol Obstet. 2014;125:261-265.
- Brolmann H M. Bongers JG, Garza-Leal J, et al The FAST-EU trial: 12-month clinical outcomes of women after intrauterine sonography-guided transcervical radiofrequency ablation of uterine fibroids. Gynecol Surg. 2016;13:27-35.