In some cases, extensive endometriosis is the cause of menorrhagia or dysmenorrhea, often coexisting with fibroids, and UAE may not be beneficial.11
Finally, a subserosal leiomyoma that is sufficiently pedunculated (attachment point 50% of the diameter) can be at risk for detachment from the uterus, a situation that may necessitate surgical intervention.11
Preop exam and imaging
At the physical examination, the fibroid uterus usually is enlarged with an irregular contour, and adenomyosis usually presents as a globally enlarged, “boggy” uterus (typically 6- to 10-weeks’ gestational size).
MRI is the preferred imaging
We prefer MRI since fibroids can be missed with ultrasound due to the limited field of view. MRI more accurately defines the size, location, and extent of disease. It also may better differentiate fibroids from adenomyosis.
MRI clearly depicts uterine zonal anatomy and enables accurate classification of individual masses by their locations: submucosal, intramural, or subserosal.
When adenomyosis is present, T2-weighted MRI demonstrates diffuse adenomyosis (about 66%) with global enlargement of the uterus and diffuse thickening of the junctional zone (at least 12 mm, highly predictive finding) with homogeneous low signal intensity. Focal adenomyosis (33%) can be seen as an illdefined, poorly marginated focal mass (adenomyoma) of low signal intensity within the myometrium.15,16
Transvaginal ultrasound
In women with fibroids, ultrasound usually demonstrates an enlarged uterus with lobulations, contour abnormality, or mass effects.
In women with adenomyosis, it usually demonstrates ill-defined, heterogeneous echotexture and small anechoic areas within the myometrium of asymmetrically enlarged uteri, with indistinct endometrial-myometrial borders and subendometrial halo thickening.15
Include endometrial biopsy
The patient should have a normal Pap test during the 12 months leading up to UAE,11 and should undergo endometrial biopsy to exclude carcinoma.
Laboratory tests should include a complete blood count, blood urea nitrogen/creatinine, follicle-stimulating hormone, human chorionic gonadotropin, and coagulation tests.
Technique
UAE begins with insertion of a small catheter (4-5 French) through a femoral artery in conjunction with percutaneous angiography. The catheter is guided into the uterine arteries—left first, then right— and contrast medium is injected into each artery to confirm the position of the catheter and the presence of fibroids or adenomyosis, which appear as hypervascular lesions in angiograms (see above, right).
UAE usually requires 1 to 2 hours.
Embolic agents
Polyvinyl alcohol (PVA) particles or trisacryl gelatin microspheres, usually 500 to 700 and/or 700 to 900 microns in size, are released through the catheter into the uterine arteries. These agents block the blood vessels that feed the fibroids and/or adenomyosis, causing them to shrink. The agents are biocompatible and have been approved by the US Food and Drug Administration.
Other, less frequently used embolic agents include gelatin sponge particles (which are temporary) and coils (which are permanent). Coils are generally used for conditions such as arteriovenous malformations or fistulae, which have large feeding vessels (iliac or enlarged uterine or ovarian vessels). This fluoroscopy-guided procedure usually is performed under local anesthesia and conscious sedation or, less often, epidural anesthesia.
Patient care
Conscious sedation, NSAIDs, and antibiotics
Intravenous conscious sedation in conjunction with nonsteroidal anti-inflammatory drugs (NSAIDs) usually provides sufficient pain relief.
In addition, intravenous broad-spectrum antibiotics are used as prophylaxis for infection linked to the embolization itself and to subsequent ischemia of the fibroids and uterus.
Managing postop pain syndrome
More than 90% of women experience postembolization syndrome, which includes moderate to severe abdominal pain/cramping and nausea and vomiting in the first several hours following the procedure. As a result, they may require hospitalization (less than 24 hours) for pain management. In our experience, few women stay in the hospital more than 1 day.
A patient-controlled analgesia pump and NSAIDs are used in women with abdominal/pelvic cramping and pain (more than 90% of cases) if epidural anesthesia is not used for pain.
Low-grade fever and leukocytosis are not uncommon after embolization, and are usually treated with acetaminophen. Other symptoms are anorexia and fatigue, but they gradually subside within 3 to 4 days.
After discharge
Oral NSAIDs and narcotics are often needed for several days. Many women resume light activities in a few days, and most return to normal activities within 1 week.11
Give her comprehensive discharge instructions on taking medications, what to expect, and when to contact a doctor. Follow-up visit in 1 to 4 weeks. We schedule an outpatient visit 1 to 4 weeks after the procedure. At this visit, we confirm healing of the puncture sites, screen for unusual symptoms or potential problems, and repeat follow-up instructions.11
We then follow the patient periodically (3, 6, and 12 months) to monitor her for symptoms and complications such as late infections, expulsion of infarcted fibroids, chronic endometritis, chronic vaginal discharge, and cessation or irregularity of menses, all of which have been observed after UAE.11