Volume 12 Issue 5 - May 2014
                       
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Coordinated Care for Patients with Symptomatic Leiomyomas
     
  Women with symptomatic leiomyomas (fibroids) can be treated in several ways, including medical management, uterine artery embolization (UAE), myomectomy, and hysterectomy

  A multidisciplinary approach enables coordinated care for women seeking treatment of fibroids

  Examination by a gynecologist and an interventional radiologist facilitates selection of the optimal treatment

  In patients who select UAE, symptomatic relief is observed in 64-93% after three months and in 91-92% one year after the procedure

  Further treatment (hysterectomy, myomectomy, or repeat UAE) may be necessary within three years in approximately 14% of patients treated with UAE


Patient Selection
Uterine Artery Embolization
The UAE Procedure
Outcome
Scheduling
Further Information
References

Figure 1. T1-weighted gadolinium contrast-enhanced MR image prior to treatment shows presence of a hypervascular intramural mass suitable for UAE.
Figure 1. T1-weighted gadolinium contrast-enhanced MR image prior to treatment shows presence of a hypervascular intramural mass (arrows) suitable for UAE.

Uterine fibroids or leiomyomas are common tumors in women of reproductive age and are symptomatic in 25-50% of these women. Symptoms can include pain, menorrhagia (which can result in anemia), bulk effects, urinary problems, reduced fertility, and obstetrical complications. For those that cannot be treated successfully by medical management, several treatment options are available including uterine artery embolization (UAE), laparoscopic or abdominal myomectomy, and hysterectomy.

Data is currently lacking on which treatment strategies are more effective than others in managing symptoms and addressing patient preference for reproductive options. Therefore, patients and their clinicians must often choose a plan of action without strong scientific evidence to guide them. However, coordinated care that involves both gynecologists and interventional radiologists is generally recognized as optimal.

For this reason, the Massachusetts General Hospital has recently launched a multidisciplinary fibroid program that combines the expertise of these two specialties to provide one point of access to a range of treatment and services for patients. Goals of the program include 1) provide women with resources to make more informed decisions about treatment options; 2) develop clinical protocols; and 3) develop a research agenda with focus on patient-reported outcomes.

Patient Selection
Selection of the most appropriate therapy requires a thorough gynecologic evaluation and medical history to identify co-morbidities, rule out other pathological conditions that may be causing the symptoms, and determine the patient’s reproductive goals.

MRI is an essential step during the evaluation prior to treatment (Figure 1). It is used to evaluate the location of the fibroids within the uterus, their size and number, and the presence or absence of contrast enhancement (an indicator of vascularity). In addition, it can rule out other conditions that may present with similar symptoms, such as adenomyosis, endometriosis, and malignancies.

Uterine Artery Embolization
Patients who consider UAE as a treatment option meet with an interventional radiologist for assessment. Women may prefer this option because they wish to preserve their uterus and avoid surgery. Although successful pregnancies have been reported following UAE, the success rate for child bearing is higher in patients who undergo myomectomy; therefore, UAE is not recommended for women who want to preserve their fertility. UAE, also known as uterine fibroid embolization, has been considered a primary treatment in the management of symptomatic uterine fibroids since 1995. It has been shown to be a safe and effective treatment for fibroids of any size and compares favorably with the alternative surgical treatments, hysterectomy, or myomectomy.

There are few absolute contraindications to UAE, including ongoing pregnancy, active infection, and suspicion of ovarian or uterine cancer. Relative contraindications include patients with coagulopathy, severe allergy to contrast agents, renal impairment, immunocompromization, previous pelvic irradiation or surgery, and chronic endometriosis. Adenomyosis, which may occur alone or together with fibroids, can also be treated with UAE.

Figure 2. Static focused ultrasound image in a 17-year-old girl demonstrates an anechoic well-circumscribed mass consistent with a benign simple cyst
Figure 2(A,B).Digital subtraction arteriography of the right uterine artery (black arrow) during UAE. (A) Pre-embolization image shows numerous small vessels (white arrows) supplying the fibroid. (B) After embolization, those small vessels are no longer visible.


The UAE Procedure
UAE is an angiographic procedure that is performed under conscious sedation and local anesthesia at the site of catheterization in the femoral artery. Although the risk of infection is very low (<0.1%), prophylactic antibiotics are routinely administered to minimize this risk. Under fluoroscopic guidance, a catheter is advanced into a uterine artery. When the correct position of the catheter has been confirmed, embolic materials (tris-acryl gelatin microspheres) are slowly injected into the uterine artery (Figure 2) to occlude the vessels in the fibroid, which is confirmed by fluoroscopy. The catheter is then routed into the contralateral uterine artery, and the embolization is repeated. Because the blood vessels entering fibroids are enlarged, the blood flows preferentially into the fibroids; it is possible to occlude these vessels without completely occluding blood flow to the uterus, resulting in infarction of the fibroids without damage to the uterus.

Radiation exposure during fluoroscopy is low. Skin injuries are unlikely to occur, the ovarian doses are below the threshold for temporary or permanent sterility, and the stochastic risk for cancer and genetic injury is not considered substantial.

After the procedure, the patient is kept in hospital overnight with a patient-controlled analgesia pump supplying narcotics. The pain is similar to bad menstrual cramps and is well controlled with medication. Following UAE, the rate of recovery is faster, the period in which medications are necessary to control pain is shorter, and there are fewer complications than after hysterectomy.

Patients usually require oral pain medication (e.g., hydromorphone, hydrocodone and acetaminophen, or oxycodone and acetaminophen) for a few days after UAE and are back to their normal routine activities in 1-2 weeks. Ibuprofen is also recommended because it specifically targets the pain-producing cells in the uterus. During the first week after UAE, many women experience low-grade fever, elevated white blood cell count, nausea, vomiting, loss of appetite, and malaise. After two weeks, the patient returns to the interventional radiologist for follow-up and it is recommended that she see her gynecologist after 4-6 weeks. Follow-up MRI, to check the necrosis of the fibroids (Figure 3), is recommended after 1 and 6 months.

Figure 3. T1-weighted gadolinium contrast-enhanced MR image of same woman as in Figure 1, nine months after UAE, demonstrating successful treatment and necrosis of the fibroid.
Figure 3. T1-weighted gadolinium contrast-enhanced MR image of same woman as in Figure 1, nine months after UAE, demonstrating successful treatment and necrosis of the fibroid (arrows).

Outcome
UAE results in necrosis and gradual shrinkage of the fibroid. Clinical studies have documented that UAE alleviates symptoms of menorrhagia in 79–93% of treated women. Although relief from pressure symptoms is not immediate, various studies have documented relief in 64–93% of women within three months after embolization and in 91–92% one year after the procedure. This time period corresponds to the reduction in the volume of fibroids, which results in a 42–44% reduction in median fibroid volume in 2–4 months and up to 83% in one year. A meta-analysis of several small studies of UAE treatment of patients with pure adenomyosis indicated that success rates were 83% in the short term (nine months) and 65% in the long term (40 months). Further treatment (hysterectomy, myomectomy, or repeat UAE) may be necessary within three years in approximately 14% of patients treated with UAE. Repeat intervention does not necessarily imply inadequate treatment because new fibroids may develop over time.

The risks associated with UAE include those associated with any form of angiographic procedure, such as bleeding or infection at the puncture site or adverse reactions to contrast agents. It carries a small risk of amenorrhea, which is more likely to be permanent in women over the age of 45. However, the effect of UAE on ovarian function still remains understudied.

Rarely, expulsion of large fibroids can occur after the procedure and can be associated with abdominal cramping or infection. Detachment of the necrotic fibroid may occur in up to 3% of individuals with sub-mucosal fibroids, and the tissue is usually eliminated via the vagina without complications. However, in some instances the extruded fibroid can obstruct the cervical os, in which case patients require further treatment to avoid a serious endometrial infection.

Scheduling
The Mass General Fibroid Program was created in 2013 as a collaboration between the Department of Obstetrics & Gynecology and the Department of Radiology. The program, which is located in Suite 4E of the Yawkey Building on the main campus in Boston, provides access to a team of specialists from both gynecology and radiology that collaborates to determine the most suitable treatment for each patient. Appointments for evaluation of uterine fibroids can be made through CRMS (for clinicians within Partners), an online appointment request form, or by calling 857-238-4733. UAE procedures are performed by interventional radiologists on the main campus of Massachusetts General Hospital in Boston. Surgical procedures are performed by the gynecologists.

Further Information
More information on the Mass General Fibroid Program can be found at http://www.massgeneral.org/fibroids/. For further questions, please contact one of the co-directors: Gloria M. Salazar, MD, interventional radiologist, Massachusetts General Hospital, at 617-643-0074 or John C. Petrozza, MD, Director of the Vincent Reproductive Medicine and In Vitro Fertilization Program, Massachusetts General Hospital, at 617-724-6850.

We would like to thank them for their assistance and advice on this issue.


References

(2008) ACOG Practice Bulletin. Obstetrics and Gynecology 112: 387-400

Bulman JC, et al. (2012). Current concepts in uterine fibroid embolization. Radiographics 32:1735-50

Goodwin, SC, Spies, JB, Worthington-Kirsch, R, et al. (2008) Uterine artery embolization for treatment of leiomyomata: long-term outcomes from the FIBROID Registry. ObstetGynecol 111: 22-33

Hirst, A, Dutton, S, Wu, O, et al. (2008) A multi-centre retrospective cohort study comparing the efficacy, safety and cost-effectiveness of hysterectomy and uterine artery embolisation for the treatment of symptomatic uterine fibroids. The HOPEFUL study. Health Technol Assess 12: 1-248, iii

Hovsepian, DM, Ratts, VS, Rodriguez, M, et al. (2006) A prospective comparison of the impact of uterine artery embolization, myomectomy, and hysterectomy on ovarian function. J VascIntervRadiol 17: 1111-5

Ganguli S, et al. (2008). Postembolization syndrome: changes in white blood cell counts immediately after uterine artery embolization. J Vasc Interv Radiol 19:443-5

Popovic M, et al. (2011). Uterine artery embolization for the treatment of adenomyosis: a review. J Vasc Interv Radiol 22:901-9

The REST Investigators. (2007) Uterine-Artery Embolization versus Surgery for Symptomatic Uterine Fibroids. N Engl J Med 356: 360-70

Stokes LS, et al. (2010). Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomas. J Vasc Interv Radiol 21:1153-63

Volkers, NA, Hehenkamp, WJ, Birnie, E, et al. (2007) Uterine artery embolization versus hysterectomy in the treatment of symptomatic uterine fibroids: 2 years' outcome from the randomized EMMY trial. Am J ObstetGynecol 196: 519



©2014 MGH Department of Radiology

Janet Cochrane Miller, D. Phil., Author
Raul N. Uppot, Editor


 

 

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