Research Information Every Woman Should Know About

July 7, 2011

One of the most effective treatments for bleeding is to stop the blood supply to the area that is bleeding by blocking the vessels from the inside, this is known as “embolization”. Embolization of the arteries to the uterus has been used as a treatment for severe uterine bleeding after surgery or childbirth since at least the late 1970s, and is used as a treatment for uterine fibroids.

What is Uterine Artery Embolization (UAE)(i.e. Uterine Fibroid Embolization - UFE)?

One of the most effective treatments for bleeding is to stop the blood supply to the area that is bleeding by blocking the vessels from the inside, this is known as “embolization”.  Embolization of the arteries to the uterus has been used as a treatment for severe uterine bleeding after surgery or childbirth since at least the late 1970s, and is used as a treatment for uterine fibroids. 

Reference: 
Ravina JH, Herbreteau D, Ciraru-Vigneron N, Bouret JM, Houdart E, Aymard A, MerlandJJ, Arterial Embolization to Treat Uterine Myomata; Lancet September 9, 1995, (PubMed).
 

What is an Interventional Radiologist?

Interventional Radiologists (IR) are trained to perform radiologist and surgical procedures.  In 2002 the Society of Cardiovascular and Interventional Radiology changed its name to the Society of Interventional Radiology.  Before the change, those named Fellows of the organization had the option of appending FSCVIR after their titles (just like Gynecologists use FACOG).  Those who have become Fellows since the name change use FSIR.

 

Reference:  To locate an Interventional Radiologist in your area – web site URL (www.sirweb.org).
 

How is the UAE procedure performed?

The Angiography Suite is where the procedure is performed.  The Interventional Radiologist sterilizes the skin lying on top of a large artery located in the groin area with an iodine solution and numbs it with a local anesthetic.  The injection for the anesthetic may sting and burn for a few seconds.  A needle is inserted into the artery and exchanged for a plastic catheter about the thickness of a strand of spaghetti. 

Watching under X-ray the Interventional Radiologist then maneuvers the catheter into the main arteries supplying the uterus and injects small plastic particles to plug up the blood vessels supplying the fibroids.  X-ray dye is injected through the catheter to show the vessels during this process, and the patient may feel sensations of warmth from these injections.

Once the catheter is in position, the IR injects particles of a special plastic that block the blood vessels supplying the uterine fibroids.  The particles are round and are about the same size as grains of salt. 

When the procedure is over, the catheter is removed from the artery and pressure is applied at the small puncture site to stop the bleeding.  The patient is wheeled to her room and must stay in bed for several hours to avoid any bleeding at the puncture site (the patient can sit up, eat, read, or watch television). The patient is allowed to get out of bed after this period, which is typically about six hours.
 

What tests need to be performed for the UAE?

 Sometimes a Doctor will order an endometrial biopsy.  An endometrial biopsy involves placing a small suction tubing through the cervix, and "vacuuming" a small amount of the endometrium (lining of the uterus).  The test is helpful in detecting cancer. Some Gynecologist’s will numb the cervix (Para cervical block) before doing the procedure, which is painless to do, and greatly decreases the discomfort of the procedure. The Doctor may advise the patient (unless there is some reason why they shouldn't) to take 800 mg of ibuprofen or similar medicine 2 hours before the procedure.
 

Magnetic Resonance Imaging (MRI) and/or Ultrasound tests:  

- MRI before as part of the consultation/pre-UAE evaluation.
- Ultrasound the day of the UAE procedure.
- Ultrasound at Post UAE three months.
- Ultrasound at Post UAE one year, and then annually.
- Contrast-enhanced MRI if there is any recurrence of symptoms or problems.
 

Questions to ask the Interventional Radiologist (IR)?

One should ask about the physician’s training and experience with embolization procedures in general and UAE in particular.  It would be helpful to ask if the Doctor’s experience fulfills the published training standards for UAE.  The other important issue is to be sure that the IR takes the responsibility to care for the UAE patient after the procedure is completed.

Reference: “Patient Care and Uterine Artery Embolization for Leiomyom
ata", J Vasc Interv Radiol.  2004National Guideline Clearinghouse.
 

Interventional Radiologist UAE Training Standards and Board Certifications?

 All physicians who perform the UAE procedure should have the following training:  Fifteen hours of formal Continuing Medical Education (CME) accredited study in the basic principles of the diagnosis and management of fibroid disease.

(1) Fellowship in Interventional Radiology involves a full year of training in just IR, which includes the full range of procedures including sophisticated vascular catheterization and embolizations.  Training in skills of recognizing pitfalls that can lead to serious complications during UAE procedures and how to manage the problems.

(2) Practice experience of 100 arteriograms, of which at least 50 must include placement of the catheter into specific branches of the vessels supplying the bodily organs.  Perform at least 25 embolization procedures and show documentation on these procedures.

(3)Proctorship – trained under the guidance of an experienced physician in UAE procedures completes 100 arteriographic procedures without significant complications.  Catheterize both uterine arteries in minimum of 25 patients successfully and safely.  In addition anyone who wishes to perform UAE should have a minimum of five hours of CME study in the specific area of Radiation Protection and Safety.

Board Certification:  Interventional Radiologists have base training as Diagnostic Radiologists, and should be Board Certified. 

In addition, both the American Board of Radiology (for MDs) and the American Osteopathic Board of Radiology (for DOs) have a subspecialty board certification for Interventional Radiologists. A fully-trained Interventional Radiologist should have this subspecialty board certification.

Reference:  
Training Standards for Physicians Performing Uterine Artery Embolization for Leiomyomata:  consensus statement developed by the Task Force of Uterine Artery Embolization and the standards division of the Society of Cardiovascular and Interventional Radilogy- August  2000”, JVIR, Jan. 2001 (PubMed).

Fibroid Radiation Dose - to embolize or not to embolize?

The data from the FIBROID Registry shows that, for an experienced operator, UAE should take an average of about 40-50 minutes total procedure time, with 7-8 minutes of fluoroscopy. Radiation doses have been calculated and published in a few articles. Radiation dose for a typical UAE is comparable to 2 CT scans of the pelvis or a barium enema - well within the accepted range for patient exposures. There is one (and possibly a second) report of patients who have developed radiation burns from procedures that were unusually long - but this is out of a total of well over 250,000 procedures worldwide (probably approaching 400K at this point).

I would expect to have no real concerns about excessive fluoroscopy time/radiation dose provided the UAE is performed by an experienced IR.

Reference:  O. Glomset a; J. Hellesnes a; N. Heimland a; G. Hafsahl a; H. J. Smith a, a Department of Radiology and the Interventional Centre, Rikshospitalet University Hospital. Oslo. Norway.  "Assessment of Organ Radiation Dose Associated with Uterine Artery Embolization", Acta Radiol. 2006 Mar;47(2):179-85. (PubMed

Fibroid Registry Research

As of December 31, 2002, 3,319 uterine artery embolization cases had been entered into the registry by 72 sites; number of patients entered by individual sites ranged from 1 to 514. Of these patients, 95.4% consented to participation in the short-term outcomes registry. Forty-eight percent of patients were African American, and 44.4% were white and non-Hispanic. Heavy menstrual bleeding was the single most bothersome symptom in 64.3% of patients. Compared with white non-Hispanic women, African-American women were significantly younger, more likely to be obese, had larger uteri and more numerous leiomyomata, more severe symptoms, and poorer quality-of-life scores before treatment.

Reference:  Myers E, Goodwin SC, Landow W, Mauro M, Peterson E, Pron G, Spies JB, Worthington-Kirsch RL. "Prospective Data Collection of a New Procedure by a Specialty Society: The FIBROID Registry", Obster Gynecol 2005: 106:44-51 (PubMed)

How are the ovarian arteries and uterine arteries evaluated during the procedure?

Reference - The physicians were trying to see if there was any way to predict how many patients would need evaluation of the ovarian arteries in addition to the uterine arteries, since the ovarians sometimes supply the uterus. They recommend that an injection of the aorta be performed after embolization of the uterine arteries, and the ovarian arteries examined selectively if they look large.  I think that this is a reasonable protocol for those with less UAE experience. Personally I do not routinely do this, but rely on my ability to judge whether or not I have embolized the entire uterus.

Reference: Abbara S, Nikolic B, Pelage JP, Banovac F, Spies JB. "Frequency and extent of uterine perfusion via ovarian arteries observed during uterine artery embolization for leiomyomas". (PubMed)  

Some things to watch for after the procedure (ask your Doctor for a list and instructions)

·         Temperature greater than 100.5

·         Vaginal discharge

·         Passing any fibroid tissue

·         An odor from the discharge that creates a foul smell.

·         Constipation

·         Women who decide on the spinal anesthesia sometimes develop a headache after the procedure – calling the Doctor (IR) and pushing fluids and caffeine may be suggested.

·         Pain that the pain medication did not get rid of.

·         Continue to maintain a calendar diary of what you are experiencing after the UAE (bleeding, how many pads, size of the pads, how often did you have to change the pads, discharge, fibroid tissue discharge, temperature, how often and how much pain medication, etc.).  The calendar diary is a good way for you to keep a record of how you are feeling in case you need to talk to your Doctor. 

Note:  When you have a question, call your Doctor for instructions.

References:

Fibroid Resource Center & Discussion Forum

Website: www.igsapc.com