UTERINE FIBROID EMBOLIZATION

Mary Pukite, MD | University of Minnesota Obstetrics, Gynecology and Women’s Health

Sharon Lehmann, MS, APRN, CNS, CRN | University of Minnesota Interventional Radiology and Imaging

Greg Horsley, MD | Essentia Health Interventional Radiology

Obstetrics, Gynecology and Women’s Health Autumn Seminar

September 22, 2017

LEARNING OBJECTIVES

• List the indications and contraindications for Uterine Fibroid Embolization (UFE) in

patients with uterine fibroids and appropriate work-up

• Review pre-procedure, intra-procedure and post-procedure care of the UFE patient

• Review alternatives to hysterectomy in the management of leiomyomas

AN INTERDISCIPLINARY APPROACH

Mary Pukite, MD

University of Minnesota

Obstetrics, Gynecology & Women’s Health

PERSPECTIVE FROM OB/GYN

Mary Pukite, MD

Women’s Health Specialist Clinic

University of Minnesota

Department of Obstetrics, Gynecology and Women’s Health

- I have no financial disclosures, I will be discussing off-label use of medications.

PRESENTATION AND DIAGNOSIS

Presenting Symptoms

1. None

2. Abnormal uterine bleeding

3. Pelvic pressure

Urinary frequency/nocturia

Constipation

4. Pelvic mass

5. Pelvic pain/dyspareunia

6. Infertility/miscarriage

7. Pregnancy related

Diagnosis

1. Pelvic exam

2. Ultrasound

3. Saline Infused Sonohysterogram (SIS)

4. MRI

5. Hysteroscopy

Sabry M, Al-Hendy A., UpToDate. Uterine Leiomyomas

40%Percentage of women who experience significant morbidity related to uterine fibroids

during their reproductive years.

Khan A, Shehmar M, Gupta J

ALTERNATIVES TO HYSTERECTOMY

While the only definitive treatment, women even after completion of

childbearing want treatment choices.

• Common medical management

• Innovative medical management

• Endometrial ablation

• Myomectomy

• MRI focused ultrasound surgery

• Uterine Artery Embolization

MAINSTAYS OF MEDICAL MANAGEMENT

• Contraceptive steroids (combined estrogen/progestin & progestin alone)

• Often first line therapy for AUB and dysmenorrhea in women with and without fibroids

• May decrease the risk of developing clinically significant leiomyomas

• Unlikely to impact uterine or fibroid size and therefore unlikely to benefit bulk symptoms

• Levonorgestrel Intrauterine system

• Management of AUB, no significant difference in myoma/uterine volume

• Higher expulsion rates (depends on size and location of myomas)

• NSAIDs for dysmenorrhea

• Gonadotropin-Releasing Hormone Agonists

• Amenorrhea in most women

• 30-65% reduction in myoma volume within 3 months

• Temporary effect, regrowth within months of cessation

• Limited length of use secondary to bone loss and menopausal symptoms

ACOG Practice Bulletin #96, Khan A,

Shehmar M, Gupta J

NEWER MEDICAL MANAGEMENT OPTIONS

ACOG Practice Bulletin #96, Khan A, Shehmar M, Gupta J

• Progesterone Modulators: Mifepristone & Ulipristal

• Similar reduction in myoma size to GnRH agonists, slower rate of recurrent growth

• Limited availability of dosing, increasing endometrial hyperplasia without atypia

• Aromatase Inhibitors

• Rapid effect vs GnRH agonists, concern re ovarian stimulation in premenopausal pts

• SERMs: Raloxifene

• Cochrane review of 3 studies showed no consistent evidence of reduction in size or

improved clinical outcomes

MYOMECTOMY

Gold standard alternative to

hysterectomy

• Hysteroscopic

• Laparoscopic

• Abdominal (open)

UpToDate. Abdominal myomectomy

HYSTEROSCOPIC MYOMECTOMY

• 85-95% success at initial hysteroscopy

• 5-15% reoperation rate (most often second

hysteroscopy)

• Percentage of myoma within cavity is most

predictive of surgical success

• Myomas larger than 3 cm more likely to

require multiple procedures

• Post UFE to remove necrotic submucous

myoma

• Preoperative UFE to increase tissue

extraction

• May be limited by fluid absorption and length

of case

ACOG Practice Bulletin #96, Mazzon I, et al, Myosure.com

UTERINE FIBROID EMBOLIZATION

Preprocedure workup includes:

• Pelvic exam

• Comprehensive evaluation of

abnormal uterine bleeding

• Screening for anemia and iron

deficiency

• Endometrial biopsy or sampling

(D&C)

• Pap smear should be up to date

• MRI with and without contrast

UpToDate, Office Endometrial Biopsy Instruments

FIBROIDS AND FERTILITY

• Myomectomy is gold standard for treatment in women desiring future fertility

• Removal of myomas within or which distort the uterine cavity

• Removal of myomas greater than 5 cm

• Pregnancy rate 40-60% in 1-2 years after abdominal myomectomy (otherwise

unexplained infertility)

• Risks associated with myomas and pregnancy

• Pain

• Miscarriage

• Placental abruption

• Preterm labor

• Fetal growth restriction

• Malpresentation

ACOG Practice Bulletin #96, UpToDate Pregnancy in Women with Uterine Leiomyomas

RISKS ASSOCIATED WITH PREGNANCY AFTER UFE

• Infertility secondary to diminished ovarian reserve

• Increased miscarriage rate

• Abnormal placentation (12% risk in Ontario cohort)

• Fetal growth restriction

• Uterine rupture

• Postpartum hemorrhage

Pooled analysis of 21 studies of pregnancy after UFE

• Pregnancy rate 58.6%

• Miscarriage rate 28%

ACOG Practice Bulletin #96, Pron, et al., McLucas et al, Czuczwar et al.

UTERINE FIBROID EMBOLIZATION

Sharon Lehmann, MS, APRN, CNS, CRNClinical Nurse SpecialistInterventional Radiology

M Health, University of Minnesota Physicians

PATIENT SELECTION: WHO TO TREAT

• Symptomatic fibroids

• Single or multiple fibroids

• Uterine size preferably < 20 weeks (cm)

• Patients done with childbearing or no immediate plans for pregnancy

• Post menopausal with fibroids that have a blood supply

PATIENT SELECTION: WHO TO TREAT

• Menorrhagia (with or without anemia)

• Chronic pelvic, back, or leg pain or discomfort that is related to the fibroids

• Bulk related symptoms:

• Pelvic pressure, heaviness or discomfort

• Abdominal bloating

• Urinary frequency or incontinence

• Ureteral compression

• Rectal pressure

• Constipation or diarrhea

PATIENT SELECTION: WHEN NOT TO EMBOLIZE

• Very large uterus, > 24 week size

• Large or dominant pedunculated subserosal fibroids,< 50% attachment (however

could perform pre procedure UFE)

• Post-menopausal bleeding

• Hysteroscopic resectable submucosal fibroid, < 3 cm

PATIENT SELECTION: WHEN NOT TO EMBOLIZE

• Caution in patients who have:

- Severe atypical pain or bleeding

- Indeterminate endometrial abnormalities

- Adenomyosis alone (however there will be always exceptions to the

guideline)

• Active pelvic infection

LUPRON

• 1 month dose

• Wait until the patient has had her first menses, usually takes 4-6 weeks

• 3 month dose

• Wait until the patient has her menses

• Severe narrowing of the uterine vessels during uterine fibroid embolization is cited as

one of the causes of technical failure

PRE-PROCEDURE PREP

• Blood work: creatinine/GFR, CBC/P, INR.

• NSAID’s

• NPO

• Antibiotic

• Scopolamine patch

• Foley

INTRA-PROCEDURE CARE

• Angiogram, femoral artery or radial artery stick

• Conscious sedation with Versed and Fentanyl

• Give IV Toradol at the start of the case and after the 1st side has been

embolized (pay attention to kidney function)

• Give Zofran at start of case

• Start PCA towards end of the case

POST-PROCEDURE CARE

• Bedrest for 2-6 hours—possible Angioseal at puncture site for femoral puncture, up and out of bed soon after with the radial artery approach

• Moderately intense pain for 6-8 hours after the procedure

• Pain severity does not relate to uterine or fibroid size

• Managed with Toradol IV and PCA narcotics

• Nausea/vomiting can also occur

• Spend one night in the hospital; some centers send home the same day

• Foley out when off bedrest

AT HOME RECOVERY

• Recovery 7 to 10 days, with 3 to 5 days of cramps and flu-like syndrome

• Post-embolization syndrome

• Loss of appetite, occasional nausea/vomiting

• More important to stay well hydrated

• Myalgia, low-grade fever

• Intermittent cramps

• Routine NSAID’s for 3 days, with supplemental narcotics

• Stool softeners

COMPLICATIONS

• Angiogram procedure itself, < 1%

• Hematoma at the puncture site

• Dissection of an arterial wall

• Pseudoaneurysm

• Reaction to the contrast

• Non-target embolization

• Ovaries, urinary bladder, intestine, muscles, nerves

• Possible S/S: pain and or infarction, temporary or permanent

COMPLICATIONS

• DVT/PE only 2 PE have been reported

• Endometritis

• Leiomyoma infection

• Uterine infection

• Transcervical leiomyoma expulsion 5%

• Premature ovarian failure

• Failed embolization

• Deaths: only 4 have been reported

FOLLOW-UP

• Return to Clinic

• MRI

• For submucosal fibroid IR and gyn should work together. Recommend that the

patient have a hysteroscopy within 2 weeks following the procedure to get rid of the

fibroid

CASE STUDY

• 42 year old, G3P3003

• Menorrhagia, worse over the past 6 months, change a pad and tampon every 45 min for 2 days, up at night, have accidents

• Light headedness

• RLQ pain, uses NSAID

• Tried OCP, did not like side effects

• Hgb 11

• US: 6 cm fibroid distorting endometrial cavity

• Referral to Gyn/Fibroid Clinic

CASE STUDY

• Endometrial biopsy

• Negative for hyperplasia, atypia and malignancy

• Pap smear performed at same time, normal

• MRI pelvis with and with contrast

• 4.1x3.5x3.8 cm submucosal fibroid

• UFE

4.1x3.5x3.8 cm submucosal

submucosal with broad endometrial interface

showing homogenous enhancement

AFTER UFE

• Moderate pain over night, home the next day

• Recovery as expected

• Started passing brown tissue within two days of the procedure, wearing a pad,

changing every 2-3 hours

• Went for hysteroscopy 2 weeks following the procedure

WHAT TO EXPECT DURING AND AFTER THE PROCEDURE

Gregory Horsley, MDVascular and Interventional Radiologist

Department of Radiology | Essentia Health

32 Y/O FEMALE WITH HEAVY PERIODS TO THE POINT OF PASSING OUT AND REQUIRING BLOOD TRANSFUSION

Catheter

inside

artery

11.7 cm (4.5

inch) Fibroid

32 Y/O FEMALE NO MORE HEAVY PERIODS AFTER THE PROCEDURE

3 month Follow-up MRI with contrast

Fibroid

smaller and

less blood

flow

https://www.researchgate.net/figure/50866022_fig2_Figure-2-Technique-of-ulnar-

compression-TR-band-inflated-with-maxi-mum-18-ml-of-air

Wrist

compression

band at artery

access site

sirweb.org/fibroidfix

• 600,000 hysterectomies/year

(removal of uterus)

• 40% of women who got a

hysterectomy to treat a

noncancerous condition did

not receive other

treatments before

undergoing the

hysterectomy

Corona L,. et al. Use of other treatments before hysterectomy for benign

conditions in a statewide hospital collaborative. Am J Obstet Gynecol 2015;

212(3): 304. e1-7.

• Fasting

• Sedation (breathing on your own but

relaxed and sleepy)

• Access into artery from groin or wrist

• Choice of music

• Procedure length of 1-2 hours

• Discharge in 6 – 24 hours

RECOVERY AFTER THE PROCEDURE

• Return to work 1.5 weeks after

procedure

• Return to normal activity after 2

weeks

• Cramping as fibroids adjust to less

blood flow

After several days of rest following the treatment,

Kim felt well enough to have dinner out with her

family and was back to work shortly thereafter.

Kim experienced some mild cramping during the

next phase when the fibroids began to shrink.

These subsided after the first month. Kim now

experiences what she calls normal period

cramping and said, "even that pain is much less

than it ever used to be."

Kim is exuberant now saying, “At one month I was

totally back to normal … like I never even had

fibroids!”

Kim’s Story

SUMMARY

• The gynecologist and interventional radiologist are important collaborators when

treating uterine fibroids

• Uterine fibroid embolization is a safe and effective way to treat symptomatic uterine

fibroids by interventional radiology

• UFE is an option for women who may desire future fertility

REFERENCES

• Sabry M, Al-Hendy A. Innovative oral treatments of uterine leiomyoma. Obstet Gynecol Int. 2012.

• Khan A, Shehmar M, Gupta J. Uterine fibroids: current perspectives. Int J Wom Health. 2014.

• ACOG Practice Bulletin number 96, August 2008, reaffirmed 2016.

• ACOG Practice Bulletin number 81, May 2007, reaffirmed 2015.

• Mazzon I, et al. Predicting success of single step hysteroscopic myomectomy: A single centre large cohort study of single myomas. Int J Surg. 2015.

• McLucas B, et al. Fertility after uterine artery embolization: a review. Min Inv Ther. 2016.

• Czuczwar P, et al. The influence of uterine artery embolisation on ovarian reserve, fertility, and pregnancy outcomes- a review of literature. Men Rev 2016.

• Pron G, et al. Pregnancy after uterine artery embolization for Leiomyomata: the Ontario multicenter trial. Ob Gynecol. 2005.

• UpToDate, Fairview Health Services.

• Shveiky, D., Iglesia, C. B., Antosh, D. D., et al. (2013). The effect of uterine fibroid embolization on lower urinary tract symptoms. IntUrogynecol J, Aug; 24(8): 1341-1345.

• Lee, S. J., Kim, M. D., Kim, G. M. (2016). Uterine artery embolization for symptomatic fibroids in postmenopausal women. Clin Imaging, Jan-Feb; 40(1): 106-109.

REFERENCES

• Ruuskanen, A., Hippeläinen, M., Sipola, P., et al. (2010). Uterine artery embolization versus hysterectomy for leiomyomas: primary and 2-year follow-up results of a randomised prospective clinical trial. Eur Radiol, Oct; 20(10): 2524-2532.

• Shlansky-Goldberg, R., Coryell, L., Stavropoulos, W., et al. (2011). Outcomes following fibroid expulsion after uterine artery embolization. J Vasc Interv Radiol, Nov; 22: 1586-1593.

• Kaump, G. & Spies, J. (2013). The impact of uterine artery embolization on ovarian function. J Vasc Interv Radiol, Apr; 24(4): 459-467

• Xu, J. (2015). Effectiveness of embolization of the internal iliac or uterine arteries in the treatment of massive obstetrical and gynecological hemorrhages. European Review for Medical and Pharmacological Sciences, 19(3), 372-374

• Spies, J. (2016). Current role of uterine artery embolization in the management of uterine fibroids. Clinical Obstetrics and Gynecology, 59(1): 93-102. doi: 10.1097/GRF.0000000000000162. HTTPS://WWW.NCBI.NLM.NIH.GOV/PUBMED/26630074

• Islam, M., Segars, J., Castellucci, M., & Ciarmela, P. (2017). Dietary phytochemicals for possible preventive and therapeutic option of uterine fibroids: Signaling pathways as target. Pharmacological Reports, 69(1): 57–70. doi: 10.1016/j.pharep.2016.10.013. HTTP://WWW.SCIENCEDIRECT.COM/SCIENCE/ARTICLE/PII/S1734114016302973

• Memtsa, M., & Homer, H. (2012). Complications associated with uterine artery embolisation for fibroids. Obstetrics and Gynecology International, 2012; 2012:290542. doi: 10.1155/2012/290542. HTTPS://WWW.HINDAWI.COM/JOURNALS/OGI/2012/290542/

• Corona, L., et al. Use of other treatments before hysterectomy for benign conditions in a statewide hospital collaborative. Am J Obstet Gynecol 2015; 212(3):304.e1-7.

• Bernat, Ivo & Bertrand, et al. (2011). Efficacy and Safety of Transient Ulnar Artery Compression to Recanalize Acute Radial Artery Occlusion After TransradialCatheterization. The American journal of cardiology. 107. 1698-701. 10.1016/j.amjcard.2011.01.056.

• www.sirweb.org/fibroidfix

• Survey Details: The survey was conducted online within the United States by Harris Poll on behalf of the Society of Interventional Radiology between June 23 and 27, 2017 among 1,176 U.S. women ages 18+