Uterine Fibroid Embolisation (UFE)

Fibroids are benign, non cancerous, fibrous growths of the muscular part of the uterus (womb). They are very common.

The diagnosis is made with an ultrasound scan or an MRI scan. Other tests such as blood tests, a gynaecological examination  or internal biopsy may also be necessary.

Many fibroids do not cause any symptoms at all, and don’t require treatment as they are benign. Often fibroids are found by chance as part of an examination for other reasons, e.g. pregnancy scanning.

The most common symptom is heavy and prolonged periods, which may be more painful than usual. This can cause anaemia (a lack of red blood cells or the chemical haemoglobin, which is found in the blood). It can make you feel tired and faint or cause headaches.

Large fibroids can cause symptoms because of their size putting pressure on the bladder leading to a constant urge to urinate. They may also push on your spine or back passage causing constipation and bloating. Occasionally, fibroids may be so large that they are visible as a swelling in the abdomen.

Fibroids are also associated with infertility and miscarriage.

If the gynaecologist does advise treatment, options include:

• Drug treatment: A variety of hormonal drugs can be used to manage the symptoms of fibroids and sometimes even allow them to shrink. Often these medications can be started and monitored by your GP. The decision about whether this is right for you will depend on your specific symptoms and personal preferences for treatment
• Intrauterine contraceptive device: A Mirena coil releases progestogens and may help to reduce heavy bleeding. The coil can be left in place if you are to proceed to UFE.
• Myomectomy: In some cases it may be possible to surgically remove fibroids (myomectomy) without taking the uterus itself. This means that future pregnancyremains possible. However, it is important to understand that hysterectomy (removal of the uterus) may very occasionally be necessary at the time of myomectomy.
• Fibroids may regrow after myomectomy, and in the long term about 1 in 10 people require further surgery. Myomectomy may be performed as an open operation, or by a keyhole technique. This procedure is particularly successful if there are one or two symptomatic fibroids, but is less successful if there are multiple fibroids.
• Hysterectomy: This is the surgical removal of the uterus, usually including the cervix. Future pregnancy is impossible. The operation usually requires about 2-3 days in hospital and 4-6 weeks off work afterwards Uterine Fibroid Embolisation (UFE): as discussed next.

Fibroid embolisation is a procedure designed to shrink uterine fibroids and reduce bleeding. A small plastic tube is placed into a blood vessel (artery) in the groin or the wrist and used to access the blood supply to the uterus and the fibroids. This blood supply is then blocked with extremely tiny beads made of polyvinyl alcohol (PVA) and will permanently stay in the small arteries within the fibroids.

• There are now good long-term studies of the results of fibroid embolisation. Over 80% of people will be relieved of their symptoms after UFE.
• On average, UFE shrinks the fibroids by about half and this usually gives an improvement in symptoms relating to the size of the fibroids or pressure.
• Unlike other surgical treatments for fibroids, UFE treats all the fibroids in a person’s uterus.
• Successful pregnancy can be possible after fibroid embolisation.

You will need to have a blood test a few days before the procedure to check your kidney function and your haemoglobin levels. This may be arranged to take place at your GP surgery.

You can continue taking your normal medication. If you are on any medication which thins the blood (e.g. aspirin, clopidogrel, warfarin, rivaroxaban, dabigatran, apixaban) we ask you to call the Imaging Department using the number on your appointment letter as we may need to adjust your medication before undergoing this procedure.

• You should not eat anything from 6 hours before your procedure but you may continue to drink water up to 2 hours beforehand.
• You will arrive at the Imaging Department (Gate 19) and be accompanied into our day case area.
• You may take your normal medication unless instructed otherwise.
• Please inform us if you have any allergies.
• A radiologist (X-ray doctor) will discuss the procedure with you. You will have an opportunity to ask questions about the procedure and your treatment. If you choose to have the procedure you will need to sign a consent form (this may already have been filled out in an earlier clinic consultation).
• You will be asked to change into a hospital gown and a small plastic tube (cannula) will be put into a vein in your arm to allow us to administer medications or intravenous fluids during the procedure.
• A drip containing strong pain killers (patient controlled analgesia - PCA) will be connected to your cannula, which will allow you to manage your own pain after the procedure by pushing a button that injects a small dose of morphine into your vein. We will give you an extra pain killer via a pessary (diclofenac) as well.
• Once all the checks have been performed and consent signed, you will be taken to the procedure room on the trolley. There will be nurses, a radiographer and the radiologist with you throughout the procedure.

During the procedure

• You will be asked to lie on your back on an X-ray table for the duration of the procedure.]
• The skin near the groin/wrist will be cleaned with an antiseptic solution and covered with sterile drapes.
• Using an ultrasound machine, the radiologist will then inject local anaesthetic into the skin and deeper tissues over the groin/wrist artery. This will briefly sting and then go numb. Most people will feel a pushing sensation.
• A small tube (catheter) is inserted into the artery and navigated inside your blood vessels with the help of the X-ray machine to select the arteries responsible for the blood supply of the fibroid(s).
• An X-ray dye will be injected into your arteries several times during the procedure to help outline your anatomy.
• During these injections you may be asked to hold your breath and keep very still. The injection of the X-ray dye can cause a hot sensation in your pelvic area which is normal and temporary.
• Once the catheter is in the correct position, tiny PVA beads are slowly injected to block the arteries supplying the fibroid(s).
• It might be necessary to access the arteries in both groins in order to block the arteries on both sides of the uterus which are supplying the fibroid(s).
• When the procedure is complete, the catheter is removed from the artery and pressure by hand or a special stitch is applied at the puncture site to prevent bleeding.
• The procedure itself usually takes around 1-2 hours.

What to expect after the procedure

• You will be taken back to the day case area, so that nursing staff may monitor you closely.
• You will be required to lie flat for 2 hours to allow the small hole in your artery to heal but you can mobilise 4 hours after the procedure.
• You may experience pain similar to period cramping in your lower abdomen, but this can be controlled with your PCA morphine pump. Additional pain killers can be given if required.
• Later on you will be transferred to the gynaecology ward (Cotswold ward) where you will stay at least 1 night so we can ensure adequate pain relief is available to you.
• Most patients are normally discharged just after lunch the following day.
• There may be a small bruise in the groin/wrist around the puncture site but this is quite normal.

Will I feel any pain?

You will be given strong painkillers before, during and after the procedure designed to minimise any pain. If you are in pain at any point this medication can be adjusted to ensure your pain is controlled. The local anaesthetic used to numb groin/wrist may sting for about 20 seconds.

Mild pain or discomfort is usual for some days after the procedure, which can be managed with standard pain killers like paracetamol and ibuprofen.

Some patients experience a thick yellow/green vaginal discharge. Use sanitary towels rather than tampons as these could increase the risk of infection.

You may have a slightly raised temperature for up to a week afterwards, sometimes with feverish symptoms.

You may feel tired and we advise you to rest for one to two weeks depending on your recovery. You can then resume your usual activities. We usually recommend taking up to 2 weeks off work but some people recover more quickly and are able to return to work within a week.

You will be followed up via in person or telephone clinic by the radiologist in 4-6 months after the procedure.

It takes time for fibroids to shrink after UFE. It is common for the first period after UFE to be a little different from usual.

Gradual improvement can be expected for up to 6 months afterwards.

UFE is generally very safe however as with any procedure there are some risks.

• There is a minor risk of bleeding or bruising at the groin/ wrist or injury to the arteries.
• Most patients feel some pain afterwards. This ranges from very mild pain to severe cramp, period-like pain. This pain is usually most severe during the first 12 hours, and will be controlled with strong painkillers. By time of discharge home the following day, ‘over the counter’ painkillers are usually adequate to control the pain.
• Infection is a risk with any operation. Currently there is a quoted risk of about 2%. Antibiotics are given at the time of the UFE to minimise this risk but late infection some weeks afterwards has been reported. Most infections can be treated with antibiotics at the time but rarely patients will need to have a hysterectomy for infection. If you feel you would not like to have a hysterectomy under any circumstances then it is probably best not to have a fibroid embolisation.
• You may experience post-embolisation syndrome. This is caused by the breakdown of the fibroid within the body and is very common. People experience a mild fever and flu-like symptoms. It usually passes on its own and anti-inflammatory medicines (ibuprofen) can help. If your symptoms continue, please contact us so we can make sure you don’t have an infection.
• There is a small risk of blocking blood vessels to other organs inside your pelvis (including urinary bladder, bowel or genitals). This could result in reduced blood supply to the affected organ and could potentially be a serious complication, however in most cases it settles down by itself. A special CT scan of your blood vessels will be used during the procedure to reduce this risk to a minimum.
• Rarely a patient may have an allergic reaction to the X-ray contrast (dye) used during UFE. This reaction could be mild with itching to severe affecting breathing or blood pressure. Patients undergoing UFE are carefully monitored throughout the procedure so any allergic reaction can be detected immediately and treated.
• About 1% of patients have an early menopause as a result of UFE. This risk is smaller in younger people and higher in patients who are approaching the menopause. 
• Rarely patients may pass bits of fibroid after the UFE. If a larger fibroid is passed you may need to see your gynaecologist who can help to remove it.
• Some patients experience vaginal discharge, which usually lasts up to 2 weeks and on occasion up to 4 weeks.

It is possible to have a successful pregnancy after fibroid embolisation. Current advice is to wait at least 1 year after the procedure before trying to conceive. Approximately 50% of people trying to conceive after fibroid embolisation will be successful.

There is evidence that the rate of spontaneous abortion or miscarriage is higher among patients having fibroid embolisation than in patients who have a surgical myomectomy. If you want to conceive then depending on the anatomy of your uterus and fibroids, myomectomy may be a better procedure.

You may find the following information useful after going home from hospital after a UFE.

Eating and drinking

You should not eat or drink until the conscious sedation medication has entirely worn off. The antibiotics may make you feel nauseated, so it is best to avoid alcohol for 24 hours.

Driving

You should not drive or operate machinery for at least 2 days after this procedure; this means you should ask for a relative or friend to drive you home from hospital. It is important you ensure you can perform an emergency stop prior to any driving.

Your groin

If we do the procedure through the artery in your groin,  You may have bruising or swelling in the first few days at the puncture site. If you are worried about this call the ward.

Vaginal discharge

It is common for patients to experience a moderate vaginal discharge after this procedure, which may be blood stained or contain small pieces of fibroid. If the discharge becomes more offensive and smelly it is important that you contact the ward as this may indicate you are developing an infection.

Pain

The purpose of staying overnight in hospital after UFE is to ensure you are pain free. Make sure you have paracetamol and ibuprofen at home. The ward will give you further painkillers to take home with you should you need them. Should the pain worsen following discharge home call the ward for further advice.

Fever

It is common to experience a low grade temperature for up to 1 week after this procedure. You may have flu like symptoms. If you have a high temperature (above 37.5°C) more than 7 days after the procedure it may indicate that you are developing an infection so you should contact the hospital.

Sexual intercourse and contraception

You can resume sexual activity when you feel ready and once the discharge has settled.

It is important to use appropriate contraception for one year after UFE.

If you do not want to get pregnant you will still need to use contraception.

Please check with your travel insurance if you wish to travel within 4 weeks of your procedure

Finally we hope this information is helpful.

If you have any questions either before or after the procedure the staff in the Imaging department will be happy to answer them.

The phone number for the Imaging department can be found on your appointment letter.