Managing Uterine Fibroids: Alternatives to Hysterectomy

William H. Parker, MD

Disclosures

July 20, 2012

In This Article

Uterine Artery Embolization

Uterine artery embolization can be an effective treatment for uterine fibroids, especially in women whose symptoms are sufficiently bothersome to warrant myomectomy or hysterectomy. Because the effects of uterine artery embolization on fertility and pregnancy are unclear, many interventional radiologists advise against the procedure for women considering future pregnancy.

Although very rare, complications of uterine artery embolization may necessitate life-saving hysterectomy; therefore, women who would not accept hysterectomy even for a life-threatening complication should not undergo this procedure. Other contraindications to uterine artery embolization include active genital infection, genital tract cancer, compromised immune status, severe vascular disease limiting access to the uterine arteries, allergy to intravenous contrast, and impaired renal function.

Percutaneous cannulation of the femoral artery is performed to gain access to and embolize the uterine artery and its branches. Total radiation exposure is similar to that of 1-2 CT scans or barium enemas. Management of postprocedural pain often requires a 1-day hospital stay, followed by 1-2 weeks of nonsteroidal anti-inflammatory medications. Many women return to normal activity within 1-3 weeks.

In a large prospective study, 555 women with heavy menstrual bleeding, pelvic pain, and urinary frequency underwent uterine artery embolization. Three months after the procedure, heavy bleeding improved in 83% of the women, dysmenorrhea in 77%, and urinary frequency in 86%.[26] A 33% reduction of volume in the dominant fibroid was reported, but improvement in heavy bleeding was not related to initial fibroid volume or to the degree of postprocedural volume reduction. Only 1.5% of the women required hysterectomy owing to complications of uterine artery embolization.

A prospective randomized trial comparing hysterectomy and uterine artery embolization in 177 women with symptomatic fibroids found that hospital stay was significantly shorter for women who had uterine artery embolization (2 days for uterine artery embolization vs 5 days for hysterectomy).[27] Although uterine artery embolization was associated with more readmissions for pain or fever (9 vs 0 for hysterectomy), major complications were rare in both groups.[27]

Worldwide, it is estimated that 12 deaths (2 from septic shock, 8 from pulmonary embolus, and 2 from uncertain causes) have occurred in association with more than 100,000 uterine artery embolization procedures (Spies J, personal communication, June 2011). Thus, the estimated mortality rate of 1 per 10,000 women for uterine artery embolization is lower than the mortality rate of approximately 3 per 10,000 women for hysterectomy.

The American College of Obstetricians and Gynecologists recommends that women who are considering uterine artery embolization have a thorough evaluation with a gynecologist to facilitate collaboration with an interventional radiologist and that responsibility for patient care be clear.[28]

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