Uterine Fibroid Embolization
Successful patient selection is difficult, but it makes all the difference.
Uterine fibroid embolization (UFE) is becoming increasingly accepted as a nonsurgical treatment option for patients with uterine fibroids due to its success in addressing the symptoms associated with this condition. More specifically, 81% to 94% of patients report improvement of menorrhagia, and 64% to 96% report improvement of bulk-related symptoms (such as pelvic pain, abdominal distension, and urinary frequency) after UFE.1-6 These results may suggest that UFE is an option for every patient with fibroids. However, the combined experience of interventionalists studying this procedure has raised questions regarding its applicability for distinct subsets of patients, due either to an increased risk of treatment failure or complications, or to uncertainty regarding the desired clinical outcome. In particular, the role of UFE remains uncertain in patients with adenomyosis, patients with pedunculated fibroids, and patients wishing to preserve their fertility after UFE.
ADENOMYOSIS MAY NOT RULE OUT UFE
Adenomyosis, a benign uterine disease characterized by ectopic growth of endometrial glands and stroma into the myometrium, has been implicated as a potential cause of treatment failure after UFE.7 The condition affects 10% to 30% of women and is associated with uterine fibroids, making adenomyosis common in patients presenting for UFE. Hysterectomy is currently the definitive treatment for adenomyosis. Because women presenting for UFE are usually seeking a nonsurgical treatment option, a strategy for managing these patients in the context of a UFE practice is necessary.
Obtaining an accurate diagnosis is the first hurdle. Adenomyosis is difficult to diagnose because its clinical presentation (abnormal uterine bleeding, dysmenorrhea, and uterine enlargement) is similar to other benign uterine disorders. In my practice, patients presenting with heavy, socially limiting bleeding are considered likely to have adenomyosis. Although a focused, transvaginal ultrasound examination can potentially aid the diagnosis of adenomyosis, I rely on MRI for a more definitive preprocedure diagnosis. Diagnostic criteria on MRI include diffuse or focal widening of the junctional zone as well as bright foci or linear striations within the myometrium on T2-weighted images (Figure 1).
Initial reports regarding embolization in patients with adenomyosis were not favorable, with treatment failure or symptomatic recurrence the most frequently reported outcomes. However, recent studies have demonstrated that embolization may successfully address symptoms of patients with adenomyosis alone or in association with uterine fibroids.8-10 This success, which has often been dramatic in my experience, clearly makes embolization a nonoperative treatment option for these patients. In light of the seemingly conflicting results, I counsel patients that centers studying the effects of embolization in women with adenomyosis have all witnessed successful clinical outcomes, but that treatment failure has been reported in the same population. I believe that the incidence of treatment failure in patients with adenomyosis is likely higher than that seen in patients with fibroids alone, but that this is not a foregone conclusion.
In my experience, patients initially seeking a nonsurgical treatment option for fibroids continue to desire a nonsurgical treatment after adenomyosis is diagnosed. Furthermore, most women making the decision to undergo embolization are pleased with the outcome of this treatment.
PEDUNCULATED FIBROIDS: WIDTH MATTERS
Pedunculated fibroids (those connected to the uterus via a stalk) can be located in a submucosal or subserosal position. Ischemic changes induced by embolizing a pedunculated fibroid may disrupt the stalk, thereby releasing the fibroid into either the peritoneal (subserosal) or endometrial (submucosal) cavity. The potential for fibroid release has led some interventionalists to consider the presence of a pedunculated fibroid to be a relative contraindication to UFE.
Disrupting the stalk of a pedunculated subserosal fibroid can result in the fibroid’s release into the peritoneal cavity. This development can potentially cause chemical peritonitis, leading to prolonged pain after embolization. In addition, there has been one case of bowel inflammation after embolization of a pedunculated subserosal fibroid resulting in a partial bowel resection and a hysterectomy.11 This risk of stalk disruption has led some interventionalists to evaluate the width of the fibroid’s attachment to the uterus before considering a patient as a UFE candidate (Figure 2). Recommendations have varied, but a stalk width greater than one-third to one-half the diameter of the fibroid is considered acceptable to most interventionalists. These recommendations are based on the premise that safety increases directly with the width of the stalk. At the present time, however, no studies have been performed to validate these criteria.
Submucosal pedunculated fibroids also carry a risk of becoming detached from the uterus, but the implications of devascularizing the stalk are different than those seen with subserosal fibroids. When submucosal fibroids lose their attachment to the uterus, they are at increased risk for expulsion from the uterus. Although expulsion is usually not associated with clinically significant sequelae, cervical impaction and uterine obstruction can occur if the fibroid does not completely pass through the cervix.12 In these cases, hysteroscopy and dilation and curettage may be required to remove retained tissue, which may otherwise become secondarily infected leading to endometritis, pyometra, and possibly sepsis.
Raising patient awareness regarding the previously mentioned potential complications should be mandatory in every case in which a pedunculated fibroid with a narrow stalk width is identified. Physicians should also discuss therapeutic alternatives (such as laparoscopic resection for subserosal pedunculated fibroids and hysteroscopic resection for submucosal pedunculated fibroids) with these patients and their referring gynecologists prior to making the decision to offer UFE.
FERTILITY PRESERVATION IS UNCERTAIN
Patients desiring to preserve their fertility represent the most challenging population for interventionalists performing the UFE procedure. This is largely because at the present time, it is uncertain what effect UFE will have on a patient’s ability to become pregnant or to carry a pregnancy to term. In addition, physicians cannot provide patients with a “pregnancy rate” after UFE because at this time, the true number of patients actively trying to become pregnant after embolization is unknown.
Pregnancies have been reported when uterine artery embolization has been performed for indications other than uterine fibroids (such as postpartum hemorrhage). Pregnancies have also been reported after UFE, demonstrating that embolization does not definitely interfere with future fertility.13,14 These pregnancies, however, do not by any means support the widespread use of this procedure in patients desiring future children.
Although it is uncertain what effect successful UFE may have on future childbearing, there is little doubt that potential complications can interfere with fertility. First, known complications such as infection or uterine infarction may lead to hysterectomy, which would obviously have devastating implications for a woman desiring children. Second, permanent amenorrhea can occur after UFE and although the incidence is known to increase with age (particularly >45 years of age), this can affect younger patients as well.15 Possible ovarian failure, such as the previously listed complications, will also have significant impact on a patient wishing to preserve her fertility.
At the present time, it is reasonable to consider UFE as an alternative for patients desiring future fertility if they are not candidates for myomectomy and are facing hysterectomy if treatment is pursued. At the Institute for Vascular Health and Disease, in Albany, New York, my colleagues and I typically use gelfoam as the embolization agent in patients strongly desiring children, primarily due to its previously demonstrated ability to preserve fertility after uterine artery embolization procedures for other indications.16 Gelfoam has also been shown to effectively address the symptoms associated with uterine fibroids.17 However, support still does not exist in the literature to recommend this procedure for all patients with symptomatic fibroids wishing to have children after treatment. Although opinions differ regarding the appropriateness of UFE in patients with childbearing plans, counseling is mandatory to make sure that these patients are aware of the potential risks and benefits as well as the unanswered questions pertaining to fertility after UFE.
PROCEED WITH CAUTION
There is still a great deal of information to be learned about UFE. Interventionalists should use caution when considering this procedure for certain patients, including those with adenomyosis, those with pedunculated fibroids, and those wishing to preserve fertility. I recommend an open discussion highlighting the potential benefits and risks, as well as the uncertainty associated with UFE for their clinical situation. We must provide patients with the information they need to make a safe and appropriate treatment decision.
Gary P. Siskin, MD, is Associate Professor of Radiology at the Institute for Vascular Health and Disease at Albany Medical Center in Albany, New York. Dr. Siskin may be reached at (518) 262-5149; email@example.com.
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