Doc-to-Doc: Uterine Fibroid Embolization
Dr. David Hovsepian is professor of radiology and chief quality and safety officer for the department of Radiology at Stanford University. He specializes in the diagnosis and treatment of vascular malformations and all aspects of gynecological intervention, especially uterine fibroidembolization. To contact Dr. Hovsepian about speaking engagements, please call 650-498-6783 or email [hovsepian] For patient referrals, contact the Referring Physician Concierge Service by phone at 866-
742-4811, via fax at 650-320-9443, or send an email [referral stanfordmed.org]
It has been estimated that there are 5.5 million women in the U.S. with symptomatic uterine fibroids, and approximately 250,000 of them undergo a hysterectomy every year for this reason. Far fewer will choose uterine-sparing myomectomy; usually the goal in that situation is to preserve fertility. However, technical challenges and the prospect of recurrent disease are sufficient that the definitive operation is preferred with a 5-fold higher frequency. There is another option, one that women often have to discover on their own, known as uterine artery embolization, or uterine fibroid embolization (UFE).
The procedure has its roots in the early 1990's in Paris, France, when a nationwide blood shortage posed a serious threat to the safety of myomectomy surgery. Pre-operative embolization was requested to prevent excessive blood loss, but it quickly became apparent that fibroid symptoms greatly improved after embolization alone and surgery was often canceled. Since then, the procedure has been performed in perhaps as many as 250,000 women worldwide, with satisfying results. Large clinical trials have repeatedly demonstrated effective control of symptoms, few complications, and a recurrence rate that is comparable to or lower than that for myomectomy, depending on the age of the patient. For at least 85% of UFE patients, menstrual or bulk-related symptoms are improved to the point that no further treatment is sought. Hysterectomy after UFE is almost always an elective choice, months to years after the initial treatment and not on an urgent basis.
There are very few women who are not candidates for UFE. The contraindications, such as contrast allergy or renal insufficiency, are almost all relative. The standard of care for most patients considering UFE is to undergo a pelvic MRI scan to assess the fibroids and their location, viability, and likelihood of causing symptoms. Uterine abnormalities, such as adenomyosis, and extrauterine conditions, including endometriosis, tubal disease, and ovarian pathology are discovered not infrequently and may alter the treatment plan in up to 15% of cases.
The embolic agents are FDA approved for this indication, and the techniques for successful catheterization and embolic delivery were established decades ago for post-partum hemorrhage, trauma, and other gynecological conditions, with the expected advancements that come with modern technology. The recovery is quicker than for conventional surgery, with just a few days of period-like cramps, which rarely require more than an overnight stay in the hospital. Return to work can be expected within a week or two, depending on the level of post-operative fatigue that normally accompanies the breakdown of fibroid tissue. Symptomatic improvement can be expected within a few weeks as the fibroids start to shrink and soften. Follow-up imaging is usually necessary only if symptoms fail to resolve or the patient develops worsening pain, fever, or vaginal discharge, which may herald infection or passage of a fibroid.
The advent of UFE has catalyzed a paradigm shift in interventional radiology. Patients are routinely evaluated in advance in a clinic setting and admitted to the radiology service after their procedure. Follow-up and problem solving are the responsibility of the radiologist. The goal of treatment is to return a healthy, satisfied patient back to the care of her primary physician or gynecologist.
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