TWO PATIENTS IN ONE
UTERINE ARTERY EMBOLIZATION FOR THE TREATMENT OF SYMPTOMATIC FIBROIDS
Akhila Ankem , MS , & Sohail Contractor , MD
FIBROIDS
Uterine fibroids ( leiomyomas ) are benign yet common growths in the muscular wall of the uterus . By the age of 50 , fibroids can affect well over 50 % of women in the U . S . 1 Symptoms caused by fibroids vary and may include heavy menstrual bleeding , pelvic pain and bulk symptoms ( uterine pressure , bloating , increased urinary frequency , constipation ). 1 , 2 The number , size and location of fibroids play a role in the severity of clinical presentation . 3 For many women , these symptoms cause discomfort to the point where quality of life is significantly impaired , and intervention to manage their fibroids is required .
TREATMENT OPTIONS
A fibroid diagnosis is confirmed with ultrasound or MRI in the appropriate clinical scenario . While hysterectomy / fibroidectomy might be considered the curative treatment for fibroids , there are several uterine-sparing and less invasive options available . Medical therapies include gonadotropin releasing hormone ( GnRH ) analogues , selective progesterone receptor modulators ( SPRMs ), and aromatase inhibitors ( AIs ). 3 Medications can control and minimize symptoms ; however , they do not completely resolve fibroids . Other alternatives include radiofrequency ablation , magnetic resonance-guided focused ultrasound ( MRgFUS ) and uterine artery embolization ( UAE ). 4 The American College of Obstetrics and Gynecology ( ACOG ) has recently updated its treatment recommendations , based on long-term follow up , to include UAE as an option for women with symptomatic fibroids . 5 Each option carries both benefits and side effects ; treatment should be tailored to individual patient goals .
UTERINE ARTERY EMBOLIZATION - PROCEDURAL DETAILS
Uterine arteries supply nutrients and oxygen for fibroids to grow . 2 , 4 UAE has been performed for over 20 years now , the goal of this technique is to induce ischemic necrosis and limit blood supply to shrink and soften fibroids . 4 , 6
Under fluoroscopic guidance and sedation , access via either the femoral or radial artery is obtained . 2 A thin catheter is guided through the artery where contrast material is used to roadmap and select the uterine artery . Next , embolic agents , like polyvinyl alcohol , Gelfoam™ , or microspheres are delivered to selectively block both the right and left uterine arteries . The catheter can be repositioned if there are other arteries ( ovarian , pelvic ) feeding the fibroid that might require embolization . Once the procedure has concluded , the catheter is removed , and pressure is applied to the incision . This minimally invasive treatment usually takes 60-90 minutes to complete , and patients are usually observed in the recovery area for four to six hours and discharged home . Rarely they are admitted overnight for post procedural symptom control for pain and nausea . A follow-up office visit with the interventional radiologist at one week and 30 days is standard . 2 , 7
Patients who are pregnant , have an active infection or gynecologic malignancy are not suitable candidates for UAE . Risks and adverse events associated with this procedure include bleeding and infection at incision site ; post embolization syndrome consisting of pain , nausea / vomiting , and fever - this usually occurs between three and 10 days post procedure and is managed with symptom relief medications 2-7 ; rarely uterine infarction and abscess may occur . While menstruation resumes in the majority of cases , there is 1-5 % risk of early menopause , especially in women older than 45 . 7
UAE - ADVANTAGES & OUTCOMES
Regarding UAE eligibility , careful patient selection , education and individualized patient preferences should be taken into consideration . There are several notable advantages to UAE : it is nonsurgical , uterus-sparing and significantly less painful than a hysterectomy . Furthermore , the procedure is associated with shorter hospital stays , quicker recovery time and boasts a favorable cost profile . 2 , 7 , 9
A Cochrane Review by Gupta et al . reports that UAE produces quality of life outcomes similar to conventional surgical options . 1 After the first post-procedure menstrual cycle , bleeding will be noticeably reduced . Subsequent menstrual cycles should stabilize .
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