Uterine Fibroid Embolization – What to Expect
By: Jean Johnson for Fibroids1
“Some patients contact the radiology department in an agitated even aggressive state, demanding information about the procedure,” wrote Lioba Howatson-Jones, R.G.N. in a 1999 Nursing Standard article titled “Arterial embolisation of uterine fibroids.”
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Uterine fibroid embolization has established a successful track record in America since the mid- to late-1990s.
UFE is a relatively quick and comfortable procedure.
Pain and cramping during and after embolization are managed by both morphine and other types of pain medication.
Recovery times for UFE are speedy, ranging from one to two weeks.
Uterine fibroid embolization (UFE) has come a long way since the 1999 article appeared in the British journal, and the procedure is now performed on a regular basis in the United States and Europe. Still there remains an aura of mystery about uterine fibroid embolization. In order to shed some light on the subject, the following is a step-by-step accounting of what the average patient having UFE might expect to encounter before, during and immediately after.
First, though, a recap of the history helps demonstrate that even though uterine fibroid embolization is fairly new, uterine arterial embolization has been practiced for 30 years. Indeed, embolization of the arteries to the uterus in order to control bleeding associated with childbirth or surgery has been used since the 1970s. More, the French started using embolization in the late 1980s and early 1990s to treat fibroids, and by 1996 Los Angeles physicians were performing UFE. Thus, as the decade came to a close UFE had gained sufficient credence at research hospitals like Johns Hopkins that increasing numbers of specialists were attracted to the field.
With the idea that UFE has a solid track record behind it, then, what can a patient planning to undergo the procedure expect to happen? After all, this minimally-invasive approach to treating fibroids is not like surgery where you need a general anesthetic.
After initial consultations, women interested exploring embolization need to forward relevant medical records and imaging studies (often an MRI is preferred) from their gynecologist, and make an appointment to visit the UFE specialist or interventional radiologist as they are termed. These experts on the circulation system will then be able to determine if the patient is an appropriate candidate for embolization.
If all parties involved decide UFE is a good choice, insurance companies are contacted for authorization, and a date is scheduled. The night before the embolization, women are instructed to not eat anything after midnight, although they can continue to have water. Procedures are often scheduled early in the morning, and after admission to the hospital, patients can expect to have blood drawn and a urinary catheter inserted so the bladder doesn’t interfere with the radiologist’s ability to see the fibroids via real-time imaging. An IV is started and prophylactic antibiotics administered. A blood pressure cuff along with heart and oxygen monitors are connected as well to check on vital signs during sedation. After whatever shaving is necessary, the hip area is first scrubbed with a sterilizing soap and then draped.
Note: If the shaving part got your attention, according to interventional radiologist at the Hershey Medical Center in Pennsylvania, Harjit Singh, M.D., “We will only shave hair that may interfere with a sterile prep in the groin region. We would do this for any arteriogram.” Singh adds, that this usually means “just from the crease in the groin to a couple of inches from the mons.” By mons, Singh refers to the mons pubis or the rounded fleshy area that covers the pubic bones and becomes covered with hair during puberty.
Embolization generally takes place in angiography suites and lasts at least an hour. The interventional radiologist numbs the groin with a local anesthetic, so once that sting is endured, patients feel only pressure in the hip area as first a single, tiny incision (1/8 to 1/4 inch) is made and then a small plastic catheter the thickness of a piece of spaghetti is inserted into the large artery. By watching on a real-time X-ray monitor, the interventional radiologist guides the catheter into the main arteries supplying the uterus.
According to interventional radiologist Robert Worthington-Kirsch, M.D. who founded Image Guided Surgery Associates in Philadelphia, “once the catheter is in position, particles of a special plastic that block the blood vessels supplying the uterine fibroids are injected. The particles are round and about the size of grains of sand.” Called poly-vinyl alcohol (PVA) particles, the technology “has been used as an embolic material since the 1970s (at least), and has an excellent safety profile. It is extremely biocompatible – there are no reports of allergic reaction or other similar complications of its use,” Worthington-Kirsch states.
Throughout the embolization procedure, women must lay flat with their legs straight out. While in patients with lower back issues, this may cause some discomfort, pain and cramping associated with embolization itself is managed with sedation and morphine. Harjit Singh notes that the irregular shapes of the PVA particles “have been tied to pain after embolization. This hasn’t been absolutely proven,” he said, “so I use a combination of smooth and irregular particles to help decrease pain while maintaining the effectiveness of the embolization.”
Physicians like Singh manage post-procedure pain with a small push-button medication drip that feeds an opiate like morphine into an IV. This allows women to maintain reasonable levels of comfort while they continue to lie flat for another six hours to prevent any bleeding at the entry site in the groin. While many women spend a night in the hospital to make sure pain levels are under control, the Dotter Institute at Oregon Health Sciences Institute in Portland has a policy that states if patients “continue to be relatively comfortable over the next two hours, we will send you home with prescriptions for Vicodin and Toradol.” Dotter Institute literature is careful to add that “If at any point, your comfort level is not adequate, we will increase your medications and admit you to the hospital overnight.”
Interventional radiologists across the country agree that women can expect on the average of three days of cramping and pain after embolization. Fever is also sometimes present along with flu-like symptoms and a loss of appetite. Other than that, recovery times are speedy compared to traditional surgery, and most women are back to work in two weeks if not sooner. No wonder the procedure has taken off since the late 1990s.