Uterine artery embolisation for symptomatic fibroids: the University of Malaya Medical Centre experience
1 Department of Obstetrics and Gynaecology,
Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
2 Department of Biomedical Imaging, Faculty of
Medicine, University of Malaya, Kuala Lumpur, Malaysia
Background: Transcatheter uterine artery
embolisation (UAE) for the treatment of symptomatic fibroids has been performed
in several centres in the United States, Western Europe and Asia with promising
results. This study reports the authors' experience with UAE at the University
Malaya Medical Centre. Method: Fifty women with symptomatic uterine
fibroids who declined surgery were treated by transcatheter UAE. The uterine
arteries were selectively catheterised and embolised with polyvinyl alcohol
particles. Post-procedure analgesia was administered via patient-controlled
analgesic pump. The patients were followed up at an interval of 6/12 clinically
and with MRI. Results: Transcatheter UAE was performed on all 50
patients with no major complications. 49 patients had both uterine arteries
embolised while 1 patient had only the right uterine artery embolised on
account of hypoplasia of the left uterine artery due to previous myomectomy. The
mean hospital stay was 3.5 days (range, 2 to 7). At a mean follow-up of 24/52,
all patients reported improvements in their presenting symptoms. Objective
improvement in terms of reduction of uterine and fibroid sizes was determined
on MRI. One patient, who initially responded with a decrease in uterine and
dominant fibroid size, became symptomatic (menorrhagia) after 6 months and subsequent
endometrial sampling revealed cystic glandular hyperplasia for which total abdominal
hysterectomy was performed. Two other patients had no change in symptoms and
after hysterectomy, the pathology revealed concurrent adenomyosis. Another 2
patients with cervical fibroids were treated with hysterectomy as there was no
gross reduction in the size of fibroid following UAE. Overall, 90% of the
patients had dramatic improvement of anaemia and symptoms at 1 year follow-up. Conclusion:
Out of the 50 patients, 17 patients had total disappearance of their
fibroids and 28 patients had more than 50% reduction in the size of fibroids
after 1 year. 5 patients ended up with total abdominal hysterectomy. These
results suggest that UAE is an appealing alternative to hysterectomy or
myomectomy for many women with symptomatic fibroids. � 2010 Biomedical
Imaging and Intervention Journal. All rights reserved.
The most common tumour in women of the reproductive age
group are uterine fibroids. They are symptomatic in about 50% of women and
produce a variety of symptoms. These symptoms include menstrual disturbances,
pelvic pain, pressure symptoms and compromised reproductive function . The
standard therapy for fibroids has been surgical removal by hysterectomy or
myomectomy, if medical therapy fails.
In 1995, Ravina et al. introduced the use of
transcatheter uterine artery embolisation. (UAE) as the primary treatment of
uterine fibroids with encouraging results . Since then, it has gained
popularity as a minimally invasive, uterine-sparing procedure and currently
more than 100,000 procedures have been performed worldwide [3,4]. UAE is not a
new vascular intervention technique as it has been recognised as a superior
first-line alternative to surgery for control of obstetric haemorrhage since
the 1990s . The utilisation of UAE for the primary treatment of fibroids is,
however, a more recent phenomenon. This study reports preliminary experience
with UAE in the local population as this has never been done before in this
Materials and Methods
The patients were recruited from the gynaecology clinic of
the centre. All of them presented with symptomatic fibroids, having declined,
or been deemed medically unfit for surgery. Their symptoms were found to be due
to fibroids and were of sufficient severity to warrant surgical management.
The patients were selected, screened and investigated
relevantly in the Department of Gynaecology and treated in collaboration with
the Interventional Radiologists. All patients were treated according to the
protocol approved by the institution�s ethics committee and with informed
consent. The inclusion criteria included healthy pre-menopausal women between
the ages of 38 and 55 years, not desirous of pregnancy, with large uteri
(>12 weeks� size) due to fibroids, and with at least one of the following
symptoms: i) anaemia, ii) menorrhagia, iii) dysmenorrhoea, and iv) mass per
abdomen with pressure symptoms. Underlying gynaecological malignancy was
excluded by endometrial sampling.
The exclusion criteria included contraindications to
Magnetic Resonance Imaging (MRI), severe allergy to iodinated contrast media,
undiagnosed vaginal bleeding, subserosal pedunculated fibroids, patients on
anticoagulation therapy or having clotting disorders, infection,
immuno-compromised patients and patients who had not completed their family. A
history of current and previous medical therapy for fibroids was recorded. An
ultrasound of the pelvis was initially performed at the Gynaecology clinic to
confirm the presence of uterine fibroids. An MRI using a 1.5 Tesla Siemens
Magnetom Vision machine was subsequently carried out as a pre-requisite to the
procedure. The MRI protocol used was a T1- and T2-weighted axial, T2-weighted
sagittal and post-contrast T1-weighted axial and sagittal images. The patients
who presented with menorrhagia were analysed based on the haemoglobin levels
and duration of menorrhagia (use of sanitary napkins exceeding 12 per day).
Pre-procedural blood tests included full blood count,
coagulation profile, as well as creatinine and electrolyte levels. All the
selected cases were discussed with the interventional radiologist. The patients
were also referred to the Acute Pain Service for evaluation by an anaesthetist
and instructed on the use of patient-controlled analgesia (PCA).
The procedure was performed during the first 10 days
of the patient�s menstrual cycle, after carefully excluding pregnancy. A urine
pregnancy test was carried out in all sexually active patients in the
reproductive age group. The patient was admitted a day before the procedure and
was required to fast for 6 hours prior to the procedure. Prophylactic
broad-spectrum intravenous antibiotic (Cefuroxime) was administered an hour
before the procedure. Intra-procedural sedation and analgesia were administered
by the attending radiologist. The standard protocol for analgesia was the
administration of a bolus dose of 3 mg of morphine before the start of the
procedure followed by 2 mg before embolisation of each side.
The right common femoral artery was punctured using a
one-part needle and a 5F Robert�s uterine catheter was advanced into the left
uterine artery. A diagnostic contrast run was done to evaluate the vascularity
of the fibroid and to identify the ovarian arteries. The tip of the catheter
was then advanced beyond the origin of the ovarian artery. Subsequently the
left uterine artery was embolised with polyvinyl alcohol (PVA) particles (300
to 500 microns in size). The procedure was repeated on the right side. There
were no microcatheters used in all our patients. A post-embolisation run was
done prior to removal of the catheter.
All patients were observed as in-patients for at least 24
hours after the procedure. The PCA was set at morphine 1mg/bolus with a
5-minute lockout at a maximum of 10mg/h. The amount of morphine required,
length of hospital stay and occurrence of any complication was noted. They were
discharged with non-steroidal anti-inflammatory drugs (NSAIDs) or mefenamic
acid of a week's duration. After discharge from the hospital, the patients were
reviewed at 3, 6 and 12 months respectively. The severity of the presenting
symptoms was reassessed. A follow-up MRI was performed at 6 and 12 months.
Fifty women aged between 38 and 52 years (mean, 43)
were referred for UAE for the treatment of symptomatic fibroids. Menorrhagia
was present in 35 (70%) women, dysmenorrhoea in 12 (24%) women, pressure
symptoms in 3 (6%) women, and anaemia in 32 (64%) women. The mean
haemoglobin level was 9.9 mg/dL. The subjects had previously received
medical treatment, namely hormonal therapy (progestogen) and NSAIDs. Six patients
had undergone previous myomectomy. There were eight women with chronic medical
disorders such as diabetes mellitus, hypertension, bronchial asthma, thalassaemia
minor and idiopathic thrombocytopenic purpura (ITP).
Forty percent of the women had received previous treatment
with blood transfusions, oral progestogens (NET), gonadotropin (zoladex) and
previous myomectomy (six women). Ninety percent of the patients reported that menorrhagia
had a heavy impact on their lifestyle in terms of interfererence with sleep,
being housebound or having to be close to a washroom during menstruation.
UAE was successfully performed on all patients. 49 patients
had both uterine arteries embolised; while 1 patient had only the right uterine
artery embolised on account of hypoplasia of the left uterine artery.
The mean procedure time was 60 min (range, 30 to 90). There
were no complications associated with the procedure itself (contrast media,
groin haematomas). Nine patients developed fever and four developed urinary
tract infection. Two of the patients developed blood-stained discharge for
about a week after the procedure. Post-procedural pain was well-controlled in
all women. The mean hospital stay was 3.5 days (range, 2 to 7). All
patients were followed up at 3, 6 and 12 months. 90% of the patients
reported improvement in the presenting symptoms. On follow-up at the clinic,
they were questioned regarding their menstrual cycle, change in lifestyle and
overall well-being. A standard quality-of-life score was not utilised.
Objective improvement, in terms of reduction of uterine and fibroid sizes, was
determined by MRI. There was more than 50% reduction in the size of the fibroid
in 28 (56%) patients and total disappearance of the fibroid in 17 (34%)
participants. Uterine and fibroid volumes were calculated based on MRI including
maximum diameters in three planes (longitudinal [D1], anterior posterior [D2],
and transverse [D3]). Measurements were only taken of the dominant or largest fibroid.
Uterine and fibroid volumes were calculated using the formula
V=0.5233xD1xD2xD3. The number and location of fibroids were also recorded. Majority
of the women who participated in this study had single fibroid (39 women) and about
11 women had more than 5 fibroids. Pre-embolisation uterine volume was about 520
Five patients had total abdominal hysterectomy following
UAE. Two patients had concurrent adenomyosis, one had persistent menorrhagia
with cystic glandular hyperplasia and two patients with cervical fibroid showed
no reduction in the size with persistence of pressure symptoms. Two women, aged
47 and 52 years, experienced transient amenorrhoea at 12 and 24 weeks,
respectively, after UAE, but did not have symptoms associated with menopause.
The transient amenorrhoea in both these patients lasted for about 9 months
and they had resumed their normal menstrual cycle at the one-year follow-up.
Uterine leiomyomata is a major health problem that
afflicts at least about 20-40% of women in the reproductive age group
worldwide. The symptoms vary from abnormal bleeding to pain and pressure
symptoms . The true prevalence of fibroids is relatively unknown as they are
only symptomatic in about 50% of women who develop them . About 20-30% of
hysterectomies are performed as a treatment for uterine fibroids. Another
alternative treatment option is the use of gonadotrophin-releasing hormone
agonists, either alone or in combination with conservative surgical treatments
like myomectomy . However, studies show that there is a significant rate
(20-30%) of recurrence in fibroids after a myomectomy . In fact, in this
series, 6 women had previous myomectomy with recurrence of fibroids and
Over the past decade, uterine artery embolisation (UAE)
has been described as an alternative to invasive surgical procedures. Many
studies have addressed this treatment option over the past 10 years. UAE is a
percutaneous, image-guided procedure which is performed by a trained
interventional radiologist. It involves the placement of a catheter into the
uterine arteries via a common femoral artery approach and injection of embolic
material (polyvinyl alcohol particles or gelfoam) into both uterine arteries
until the flow becomes sluggish [2, 9-12]. The mechanism by which UAE acts is
by reducing blood flow to the fibroid thus inducing irreversible ischaemia
which leads to necrosis and shrinkage. The normal myometrium, however, recovers
well from this ischaemic event .
The procedure generally takes about an hour. Immediately
after the procedure, most patients experience cramping pain. This ischaemic
pain generally lasts for 8-12 hours post-procedure . Patients are usually
kept overnight for pain management. In this centre, patients are instructed on
the use of Patient Controlled Analgesia which is administered by an
anaesthetist. The study also follows a protocol of 3 mg of morphine i/v before
the start of the procedure and 2 mg before embolisation of each side. This
protocol has been tolerated well by the patients in this series and they have
been pain-free during the first 24 hours. They are discharged home with oral
anaelgesics and do not report any pain-related complications on follow-up.
Another issue to consider is that of fertility. The effect
of UAE on subsequent fertility and pregnancy has been understudied and
therefore it is not recommended in women desirous of future pregnancies .
Transient or permanent amenorrhea, with symptoms of ovarian failure, have been
reported in about 5% of patients after UAE. This has been attributed to ovarian
embolisation via collaterals resulting in ovarian ischaemia . Due to this
concern, many studies were carried out to evaluate ovarian reserve by measuring
the FSH levels before and after UAE. It was reassuring that there was no change
detected in the ovarian reserve, but long-term studies have been recommended to
further address this issue . In this study, all patients who had not
completed their family were excluded.
There are some limitations in this study that have to be
addressed. Firstly, the follow-up period of 1 year is too short. Most of the
patients did not return for a follow-up after the 1-year period and there is no
data regarding their long-term clinical outcome. According to Hehenkamp et
al. (2008), about 25% of patients in the EMMY trial had secondary
hysterectomy after UAE at 24 months . Currently, there are only 7 patients,
out of the 50 in this series, who are still on regular follow-up and are doing
well. Secondly, this study did not use a standard quality-of-life (QOL)
questionnaire on follow-up. The patients were asked about their symptoms based
on their menstrual cycle history. The authors recommend that a standard QOL
score be done for further studies in the future.
The mid-term results of UAE for the treatment of
symptomatic fibroids in our hospital indicate this to be a safe and effective
therapeutic option. A longer period of follow-up with a greater number of
patients in this ongoing study will be needed to confirm that UAE is a viable
option, acceptable to both patients and clinicians. This study illustrates that
large numbers of women with symptomatic fibroid disease are averse to surgery
despite their burden of suffering, and are actively seeking alternatives to
hysterectomy. UAE is a nonsurgical option for management of fibroid related
symptoms that has shown excellent technical and clinical success. Although
there have been many similar studies done globally over the past 10 years,
there has not been any published South-East Asian series and the authors feel
that this preliminary experience would be helpful to clinicians in this region.
Figure 1 Prevalence of symptoms: 70% of the patients presented with menorrhagia, 24% presented with pain and 6% presented with pressure symptoms. Concurrently about 64% of the patients were found to be anaemic.
Figure 2 This figure shows the outcome of the 50 patients at 1-year follow up. 56% of patients had 50% reduction of volume as measured on MRI. 34% of the patients had complete absence of the fibroid and 10% had hysterectomy done.
Figure 3 (a) The initial contrast run into the right uterine artery. The tortuous and enlarged right uterine artery and the rich blood supply to the fibroid can be seen; (b) the post-embolisation contrast run which shows staining of the fibroid and no opacification of the arteries seen in the previous run.
Figure 4 A 50-year-old woman presented with menorrhagia for the past three months. An initial MRI (a) showed the presence of an anterior intramural fibroid. She underwent a UAE and a follow-up MRI at 1 year (b) showed complete absence of the fibroid.
Figure 5 A 45-year-old woman presented with a two-month history of menorrhagia which required repeated blood transfusion. She was advised to have surgery but declined. Her initial MRI (a) showed the presence of a large submucosal fibroid. Due to her clinical status, a decision was taken to do a UAE. Her follow-up MRI at 1 year (b) shows complete absence of the fibroid.
Table 1 The outcome at 6 months clinical follow-up
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|Received 12 August 2009; received in revised form 21 January
2010, accepted 23 January 2010
Correspondence: Department of Obstetrics and Gynaecology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur, Malaysia. Tel.: +603-79492069; Fax: +603-79581973; E-mail: email@example.com (Anushya Vijayananthan).
Please cite as: Subramaniam RN, Vijayananthan A, Omar SZ, Noor Azmi MA, Nawawi O, Abdullah BJJ,
Uterine artery embolisation for symptomatic fibroids: the University of Malaya Medical Centre experience, Biomed Imaging Interv J 2010; 6(3):e27