Uterine fibroid embolization - Essay Example

UTERINE FIBROID EMBOLISATION This is a study on uterine fibroid embolization done with a view to providing health information for women. UFE is a fairly newly developed non-surgical technique used in the treatment of uterine fibroids. UFE is a procedure by which the blood vessels feeding the fibroid are blocked, thereby cutting their blood supply. This causes the fibroid to shrink. UFE is minimally invasive as compared to hysterectomy. UFE is performed under local anesthesia and hence recovery time is much shorter than that required for surgery under general anesthesia. Blood loss is also minimal. UFE does not require any surgical incision. Chances are really rare that the fibroids regrow after a UFE. UFE is not without its risks and disadvantages. UFE may cause damage to the arteries. There is a low risk of bleeding and/or infection at the puncture site. The specific aim of this project was also to learn the different factors that go into producing a patient information leaflet. The whole project was an endeavour at learning extensively about an increasingly common medical condition in women, i.e., uterine fibroids, and then simplifying the knowledge and presenting it for the education of the layperson. The efforts included extensive research of knowledge sources, interviews with health professionals including obstetricians, gynaecologists, fertility specialists, general physicians, interventional radiologists and nursing staff, interviews with women who have been diagnosed with uterine fibroids including those who are anticipating treatment, those who are considering treatment and those who have undergone treatment. Interviews were done of women who were not diagnosed with the condition also to gauge the general awareness on the topic and to determine to what extent the layperson should be educated. Several sample works on similar topics were also referred to help bring out an appropriate leaflet. 1. Introduction This study has been conducted to define and explain the procedure of uterine fibroid embolisation (UFE) or uterine artery embolisation (UAE) and to analyse the advantages and disadvantages of the procedure with a view to creating health information to enhance the health awareness of the masses in general and the women in particular. UFE is a procedure by which the blood vessels feeding the fibroid are blocked, thereby cutting their blood supply. This deprives the fibroid of the oxygen it requires to grow, causing the fibroid to shrink (Uterine artery embolization 2004). Though arterial embolisation has been in use for a long time as an effective treatment method for abdominal and pelvic haemorrhage, the technique of embolisation started being used for the treatment of uterine fibroids only recently. The main objective of embolisation is elimination of symptoms, and "fibroid shrinkage is an additional advantage" (Walker & Pelage 2002, p.1269). The recovery is rapid and the improvement durable. The treatment is usually well tolerated with a high degree of satisfaction and remarkable shrinkage of the fibroid volume both by ultrasound and magnetic resonance imaging assessment. As compared to other treatments for fibroids, UFE is more effective with less complications and failure rate. According to Pelage et al. (1999), women who are treated with UAE, "can expect excellent midterm results with regard to menorrhagia and the size reduction of leiomyomas". UAE provides significant reductions in uterine volume and dominant fibroid volume, and a significant increase in health-related quality of life (Scheurig et al. 2006). These changes have been found to be stable over time. 1.1 Background The most common reason for hysterectomy are uterine fibroids. The alternative options for treatment of uterine fibroids are myomectomy, hormonal therapy, myolysis, cryomyolysis, endometrial ablation and resection, and focused ultrasound therapy. Myomectomy is the surgical removal of the fibroid, and myolyis is the procedure of inserting surgical instruments through tiny incisions and, using a special probe, a high-frequency electrical current is sent to the fibroid which causes the blood vessels to become very small or close down, thus cutting off the blood supply to the fibroid. Cryomyolysis is a procedure that freezes the fibroid to death (Dionne 2002, p.86). Endometrial ablation and resection and focused ultrasound therapy are also used in the treatment of uterine fibroids. In this setting, "UFE can be considered an effective and safe alternative to classic surgical therapy for women with symptomatic fibroids" (Raikhlin et al.2007, p.255). Women having uterine fibroids with severe symptoms like bleeding and pain are increasingly turning away from surgery and seeking other alternatives (Pron et al. 2002b, p.118). 1.2 UFE versus myomectomy Women who have menorrhagia as a major problem due to uterine fibroid do better with UFE than with uterus-sparing abdominal myomectomy (Razavi et al. 2002, p.1573). Myomectomy sometimes may not remove the culprit fibroid. When there is a mass effect, myomectomy may be a better option than UFE because UFE does not physically remove a fibroid, and it takes weeks before significant reduction in size of the fibroid is noticed after UFE. If the treatment is for cosmetic reasons, then UFE is not the appropriate choice. UFE requires a shorter hospital stay and has a quicker recovery time. UFE is not advised for women who wish pregnancy in the future because the effects of UFE on fertility and pregnancy have not been thoroughly studied. Probability for regrowth of fibroids is more for myomectomy than for UFE. 1.3 UAE versus hysterectomy According to a study done by Spies et al. (2004), patients who underwent UAE for leiomyomas had reduced blood loss than those who were treated with hysterectomy. The degree of improvement for symptoms and quality of life were similar for patients who underwent both treatment methods, with an advantage for hysterectomy for pelvic pain at 12 months. Complications were slightly more frequent in patients who were treated with hysterectomy than with those who were treated with embolisation. According to a study done by Pinto et al. (2002), patients who underwent UAE had a shorter hospital stay and more number of emergency room visits than those treated with hysterectomy, though the former had far milder complications than the latter. So the reason the number of visits were more could be because of post-procedural instructions to report for the slightest sign of any symptom. Patients who underwent UAE could resume normal activities within a shorter period than those who underwent hysterectomy. 1.4 UAE versus hormonal therapy Hormonal therapy using gonadotrophin-releasing hormone agonists is a non-surgical option for the treatment of uterine fibroids. Though there is dramatic improvement of symptoms and significant reduction in fibroid size with this method, the fibroids regrow to their original size in a few months of discontinuing the medication. Long-term use of GnRH has the side effects of osteoporosis, menopausal symptoms and amenorrhea (Joint Working Party 2000, p.5). 1.5 The procedure This is a minimally invasive procedure performed by an interventional radiologist. A nick is made on the skin of the patient in the groin. Using x-ray guidance technique, a catheter is inserted into the femoral artery and advanced via the uterine arteries to reach the site of the fibroids. A single catheter can be used for bilateral selective embolization of the uterine arteries, "thus avoiding bilateral puncture and multiple catheters" (Pelage et al. 1998, p.575). Then the blocking agent is injected into the catheter to block the supply of blood through the arteries to the fibroid. The candidate is intravenously and locally sedated for the procedure. At the conclusion of the procedure, the catheter is removed, leaving just the nick on the skin which will be dressed. The procedure takes just 90 minutes and the patient will be observed overnight and released (Uterine fibroid embolization (uterine artery embolization) 2008). 1.6 Patient discomfort during UFE The patient feels a gentle prick as the needle is inserted for the intravenous line and also while injection of the local anesthetic. The intravenous sedation makes the patient feel relaxed and sleepy (Uterine fibroid embolization: A new way 2005). Under deep sedation, the patient may even sleep. There is a slight feeling of pressure when the catheter is inserted but no extreme discomfort. The contrast agent that is injected into the body to map the course of the catheter gives the patient a feeling of warmth. After embolisation, patients experience a postembolisation syndrome which is self-limited and consists of pelvic pain, nausea, vomiting, fever, leukocytosis and general malaise (Siskin et al. 2000b, p.308). Pain post procedure will be controlled by medication. "Post-embolization pain can be severe and a patient-controlled opiate pump or even epidural analgesia is recommended" (Burn et al.1999, p.161). 1.7 Indications for UAE "UAE should be only recommended to women with symptomatic fibroids who might otherwise be advised surgical treatment" (Joint Working Party 2000, p.7). The problems associated with symptomatic fibroids include menorrhagia, dysmenorrhoea, dyspareunia and sensation of pressure from the fibroid on the urinary or gastrointestinal tract. UAE is the ideal option for women who have contraindications for surgery, or who do not wish receive a blood transfusion or who have had previous failed surgery. A study by McLucas et al. (2001), however, concluded that earlier surgery was a factor predicting failure of UFE (p.101). UAE has been found to be effective in the management of symptomatic adenomyosis with "an acceptable long-term success rate" (Kim et al.2005). The patient, however, should be informed of the possibility of failure of treatment, recurrence and the need for hysterectomy. Again, Siskin et al. (2001) concluded after a study that UAE may be a promising treatment option for menorrhagia related to adenomyosis and that patients with uterine fibroids and adenomyosis should not be excluded from undergoing UAE (p.302). 1.8 Eligibility for UAE UFE is ideal in cases where the woman suffers from severe bleeding due to uterine tumours and severe bleeding associated with childbirth. UFE is ideal for premenopausal women who suffer problems from the fibroids, who wish to avoid surgical removal of the uterus and do not wish to get pregnant, as the effects of UFE on fertility are not yet known (Uterine fibroid embolization 2008). It is ideal for women who wish to avoid blood transfusion and also for those who cannot receive general anesthesia. UFE is an ideal and effective treatment option for women with multiple fibroids and large fibroids. 1.9 Contraindications for UAE UAE is not considered to be an appropriate option for "women who are infertile or who may wish to become pregnant subsequently" (Joint Working Party 2000, p.7). GnRH analogues should not have been administered within the two months preceding embolisation. There should not be any evidence of infection, current or recent, in the genital tract. Pedunculated subserous fibroids and very large fibroids do not respond too well to UAE. UAE has been found to be less successful in treating older women and those with a large uterus (Jha et al. 1999, p.234). 1.10 Clinical advantages of UFE Uterine arterial embolisation allows preservation of the uterus and the uterine functions like normal menses and pregnancy (Worthington-Kirsch et al.1998, p.628). Though UAE does not interfere with fertility, whether it can restore fertility in cases of infertility due to myoma has yet to be established. The embolisation procedure is well tolerated by patients with usually a shorter recovery time than surgical procedures. In case of failure of UAE, the other treatment methods are still possible options. It is even considered that a preoperative embolisation renders surgery safer and easier. In women younger than 45, who have undergone UAE, ovarian failure is a "rare event" (Walker & Barton-Smith 2006, p.466). Symptoms of constipation resolve or improve with UAE. There have been cases where women have become pregnant following UAE and there is no evidence to suggest that fibroid-induced infertility is a contraindication for UAE. Pregnancies described after UFE with polyvinyl alcohol, according to a study by Siskin (2000b), show that fertility is potentially preserved. According to a report by Pron et al. (2005), many nulliparous women with previous miscarriages have achieved successful pregnancies after UAE (p.73). Another study by Katsumori et al. (2001) found that using gelatine sponge particles as embolic agent for UFE was as safe and efficient as using polyvinyl alcohol particles. UAE carries high success rates and low complication rates that are sustained in the long term (Walker & Barton-Smith 2006, p.467). According to Pron et al. (2002a), UAE reduced fibroid uterine volumes with significant symptomatic relief, particularly for menorrhagia, and very high degree of "patient satisfaction with short-term treatment outcomes after UAE" (p. 126). UAE provides durable symptom relief, with a 25% chance of failure or recurrence over the course of a 5-year follow-up (Spies et al. 2005, p.933). Symptom recurrence rate 30 months after UAE is 17.2% (Marret et al. 2004). 1.11 Complications of UAE UFE is not without its risks and disadvantages. The embolic agent may get lodged in the wrong place thus blocking the supply to that region. The chances of this occurring are also very rare. A patient, in seldom cases, may have a reaction to the contrast agent, which can range from mild itching to extreme reactions. The candidate undergoing UFE is closely monitored and allergic reactions, if any, are curtailed at the outset. For women who are older than 45, sometimes UFE is shortly followed by menopause. This occurs in only one to five percent of women. After UFE, some women still eventually end up undergoing a surgical removal of the uterus; the likelihood of this happening is less than one percent. Exposure to x-ray is another risk of UFE, though the exposure levels are below those that call for concern (Uterine fibroid embolization 2008). Vaginal discharge has been noted as significant complication of UAE. This is caused by the "shedding of fibroid material into the endometrial cavity" (Walker & Barton-Smith 2006, p.466). The risks of UAE also include late complications of ovarian damage due to impaired ovarian blood flow and infection leading to Fallopian-tube damage and death (Joint Working Party 2000, p.9). An impaired placental blood supply, which is a risk that is highly unlikely, would lead to restricted intrauterine growth, premature labour and postpartum haemorrhage with long-term complications for the child. Women who undergo UAE are advised not to conceive after the procedure, as the effects of embolisation on pregnancy and the resulting offspring are not known. Sexual dysfunction possibly related to nontarget embolization of the cervicovaginal branch may occur in a small percentage of patients (Goodwin et al. 2003, p.S471&S473). One of the most common complications requiring hospitalization is leiomyoma tissue passage associated with pain, infection or bleeding, which can occur even one year after embolization (Spies et al. 2002). Transcervical expulsion of myomas is not uncommon, associated with uterine contractions, abdominal pain, heavy vaginal bleeding or discharge months after UAE. Infarcted fibroid may render the uterine wall weak with the risk of uterine rupture later on. Remnants of a fibroid within a local defect may also pose the risk of ulceration. However, according to Kroencke et al. (2003), "expulsion or disintegration of fibroids following UFE may lead to a nearly complete architectural restoration of the uterine cavity". Endometritis is also not uncommon, which can occur days to two weeks post UAE. Retention of necrotic fibroid tissue and the subsequent possibility of infertility is a possible complication of UAE. Embolisation could also "result in an alteration to the uterine cavity and uterine gestational capacity" (Ng et al. 2005, p.382). This calls for close evaluation of the uterine cavity integrity in women who undergo this procedure. Post embolisation, there is an increased risk, albeit small, of delivery by caesarean section, though there is no other major obstetric risk (Carpenter & Walker 2004, 324). Major complications following UAE are rare and the overall periprocedural complication rate, including both major and minor complications, is about 8% with an infection-related complication rate of 2% (Ghai et al.2005, p.1167). The overall failure rate of embolization is 9.4% (Huang et al. 2003). Failure is mostly due to persistent menorrhagia and abdominal pain. Shrinkage of uterus does not necessarily correlate with long-term success of embolization. Higher readmission rates after UAE stress the importance of close postprocedural surveillance (Hehenkamp et al. 2003). The possibility of infectious complications following UAE is very low (1.2%), however careful followup is warranted following UAE "given the morbidity of this complication" (Rajan et al. 2004, p.1420). 1.12 Prophylactic measures Fibroid embolisation procedures are not advisable in the presence of an early pregnancy and should be maximum avoided at such a time (Joint Working Party 2000, p.10). Embolisation can be carried out at any stage of the menstrual cycle if adequate contraceptive precautions have been taken; if not, the procedure should be carried out only in the early- to mid-follicular phase of the cycle. Urinary tract infection, if present, should be treated and resolved before treatment with embolisation. If the woman undergoing embolisation is using an intrauterine contraceptive device, it should be removed prior to the procedure. A study by Brunereau et al. (2000) has recommended monitoring patients with clinical and sonographic followup for more than two years post embolisation (p.1272). MR imaging is useful in assessing volume reduction of fibroleiomyomas after embolization. A high-signal-intensity leiomyoma on T1-weighted images predicts poor response while that on T2-weighted images predicts a good response to embolization (Burn et al. 1999, p.733). 2. Aims 2.1 Project objectives The general aim of the project was to gather information on the topic as part of a project for building awareness and for the education of women, especially women who are laypersons and cannot understand the medical jargon that are used in most literature and web sites. As a result they remain ill informed on the topic and are incompetent in taking care of and making appropriate decisions regarding their own health care. Based on the research findings, the aim was to develop a patient information leaflet to be made available for women who visit health clinics, diagnostic centres, hospital laboratories, nursing homes, health and fitness centres, parlours, educational institutions, etc. 2.2 Learning objectives The specific aim of this project was to learn the different factors that go into producing a patient information leaflet. The aim was to gain adequate and appropriate skills of searching the internet, researching for details, hunting for different sources of data, picking the right information, reviewing literature, collecting and organising data, communicating the right message, presenting in a pleasing and effective form, improving the writing skills and developing an eye for picking and developing accurate information. 3. Methods 3.1 Interviews To gain an overview and insight into the topic under study, several health professionals including gynaecologists, obstetricians, fertility specialists, general physicians and interventional radiologists were interviewed. One-on-one discussions and interviews with several women who have been diagnosed with uterine fibroids, including those whose conditions are symptomatic and asymptomatic, women who have undergone UFE, women who are awaiting embolisation and those who are considering embolisation, were carried out. Their experiences, doubts, fears and misgivings regarding the procedure were sought. 3.2 Data sources Information on UFE was collected from several sources, which gave an in-depth study of the subject, its implications, alternative treatment options, its advantages, disadvantages, and risks as compared to the different treatment options, etc. Some of the sources reviewed were American Journal of Roentgenology, the British Journal of Radiology, Radiology, BJOG: an International Journal of Obstetrics and Gynaecology, RadioGraphics, Journal of Vascular and Interventional Radiology, American Journal of Obstetrics & Gynecology, Fertility & Sterility, Oxford Journals: Human Reproduction and the Journal of the American College of Surgeons. 3.3 Leaflet production The first draft of a patient information leaflet was made. The content of the leaflet was based on the research done on UFE. The information gathered was written in a simple, straight and uncomplicated manner targeting women who may not be familiar with medical terminology. For deciding on the format for the leaflet, several other samples of patient health information leaflets were studied. Some of them were accessed from web sites including those of Patient UK at http://www.patient.co.uk/showdoc/40000064/ and CKS (Clinical Knowledge Summaries) at http://cks.library.nhs.uk/information_for_patients. 3.4 Testing the leaflet To test the efficacy and usefulness of the leaflet, copies of the leaflet were presented to the health professionals. Leaflets were also distributed among women who were diagnosed with uterine fibroids. Leaflets were also given to women who did not have the disease condition, to study their response as regards the usefulness of it. 4. Results All the information gathered from various literature, websites, interviews and surveys were then organised so as to facilitate easy comprehension. The data were divided into simple heads. The content for the leaflet was chosen from these findings, reorganised, simplified and presented. The format chosen was also very simple and uncomplicated. The survey has thrown light on a lot of facts. It was found that most of the women, including the educated ones, were not really aware what 'fibroids' meant. A lot of them were under the impression that they were precancerous, if not cancereous. They were also confused regarding how fibroids affected fertility and pregnancy. Though some of the women had heard about embolisation, they were not exactly clear on the meaning of the term or the nature of the procedure. They were also under a lot of misconceptions as to the aftermath of embolisation. For example, many of them thought that an embolisation procedure left the woman debilitated. A lot of the women were not aware of the risks involved in the procedure as also as to who were the ideal candidates for a UFE and who were not eligible for it. The survey revealed that not many knew that embolisation was not entirely a new procedure, but has been performed in different contexts for over twenty years. This seemed to raise the hopes of a lot of women who were anticipating UAE. The survey also revealed that most of the women were intimidated by the complicated medical terminology which they found totally incomprehensible. 5. Discussion An in-depth study was undertaken to throw light on the topic, which helped in bringing out the significance of the procedure. Interviews with health professionals were very helpful in understanding the topic thoroughly which in turn helped in bringing out a very simple and effective patient information leaflet. Interviews with women who were diagnosed with uterine fibroids helped a great deal in gauging the present degree of awareness among women and producing a leaflet that answered their most important questions. Interviews with women who did not have the disease condition helped to understand to a great extent how much the general masses, especially the women, need to be educated on 'uterine fibroids,' which is becoming increasingly common among women across the world. The study of different samples of patient health information leaflets and other literature helped in learning from what angle the project should be approached, how the content should be dealt with and presented, about the importance of choosing the right logical sequence of data and, last but not at all the least, the rationale of thinking from the patient's standpoint. The physicians commended the efforts taken for bringing out the leaflet and appreciated the simple presentation of the fairly large wealth of information. Some points regarding the risks and advantages suggested by them were incorporated into the leaflet. The patients were overall pleased with the product though some still pointed out certain medical terms which they found difficult to comprehend. These terms were simplified and presented in the final version. 6. Conclusion In conclusion, this whole project was an endeavour at learning extensively about an increasingly common medical condition in women, i.e., uterine fibroids, and its treatment with UAE, and then simplifying the knowledge and presenting it for the education of the layperson. The efforts included extensive research of knowledge sources, interviews with health professionals and interviews with women who have been diagnosed with uterine fibroids. Interviews were done of women who were not diagnosed with the condition also to gauge their awareness of the topic and to determine to what extent the layperson should be educated. The interviews revealed the misconceptions and the ignorance of the women due to both lack of education as well as their inherent lack of ability in comprehending the situation. Several sample works on similar topics were also referred to help bring out an appropriate leaflet. 7. Reflection Overall, this project was a great experience in that I got the opportunity to educate myself on two different skills as well as the subject of UFE. The first skill was on researching and presenting data for a patient health information leaflet. This was interesting in that on the one hand it was a highly specialized topic with a lot of technical and medical jargon while on the other it had to be reproduced with the common man or a layperson in mind. The satisfaction was in educating oneself and then others. The second skill was in the actual creation of the leaflet. The comparative study of several sample leaflets was very educative. The simplifying of data and presenting in a straightforward manner was a strategy that I learnt with a whole new approach. Finally, the greatest satisfaction was in doing something that was a service to the society. The process of collecting data through interviews revealed just how much such endeavours are necessary for our society. In this age of communication and information, it would be really unadvisable, if not wrong, to submit blindly to healthcare professionals for taking care of and making decisions on one's own healthcare issues when knowledge is quite literally at our fingertips with the Internet providing easy accessibility to most of the information sources. 8. 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Baseline patient characteristics, fibroid burden, and impact on life', Fertility and Sterility, vol. 79, no. 1, pp.112-119, viewed 4 October 2008, http://www.biospheremed.com/ufe/international_publications/Pron_Canadian_Trial_part1.pdf Pron, G, Mocarski, E, Bennett, J, Vilos, G, Common, A & Vanderburgh, L 2005, 'Pregnancy after uterine artery embolization for leiomyomata: the Ontario multicenter trial', Obstetrics & Gynecology, vol. 105, no. 1, pp.67-76. Raikhlin, A, Baerlocher, MO & Asch, MR 2007, 'Uterine fibroid embolization: CME update for family physicians', Can Fam Physician 2007, vol. 53, pp.250-256. Rajan, DK, Beecroft, JR, Clark, TWI, Asch, MR, Simons, ME, Kachura, JR, Sved, M & Sniderman, KW 2004, 'Risk of intrauterine infectious complications after uterine artery embolization', JVIR 2004, vol. 15, pp.1415-1421, viewed 4 October 2008, http://www.drfibroid.com/pdf/JVIR14151421.pdf Razavi, MK, Hwang, G, Jahed, A, Modanloo, S & Chen, B 2002, 'Abdominal myomectomy versus uterine fibroid embolization in the treatment of symptomatic uterine leiomyomas', AJR 2003, vol. 190, p.1571-1575, viewed 2 October 2008, http://www.biospheremed.com/ufe/international_publications/razavi_UFE_v_myo.pdf Scheurig, C, Gauruder-Burmester, A, Kluner, C, Kurzeja, R, Lembcke, A, Zimmermann, E, Hamm, B & Kroencke, T 2006, 'Uterine artery embolization for symptomatic fibroids: short-term versus mid-term changes in disease-specific symptoms, quality of life and magnetic resonance imaging results', Human Reproduction, vol. 21, no. 12, pp.3270-3277, viewed 4 October 2008, http://humrep.oxfordjournals.org/cgi/content/full/21/12/3270 Siskin, GP, Englander, M, Stainken, BF, Ahn, J, Dowling, K & Dolen, EG 2000a, 'Embolic agents used for uterine fibroid embolization', AJR 2000, vol. 175, pp.767-773, viewed 3 October 2008, http://www.ajronline.org/cgi/content/full/175/3/767 Siskin, GP, Stainken, BF, Dowling, K, Meo, P, Ahn, J & Dolen, EG 2000b, 'Outpatient uterine artery embolization for symptomatic uterine fibroids: experience in 49 patients', JVIR 2000, vol. 11, pp.305-311. Siskin, GP, Tublin, ME, Stainken, BF, Dowling, K & Dolen, EG 2001, 'Uterine artery0020embolization for the treatment of adenomyosis: clinical response and evaluation with MR imaging', AJR 2001, vol. 177, pp.297-302, viewed 4 October 2008, http://www.ajronline.org/cgi/reprint/177/2/297.pdf Spies, JB, Bruno, J, Czeyda-Pommersheim, F, Magee, ST, Ascher, SA & Jha, RC 2005, 'Long-term outcome of uterine artery embolization of leiomyomata', Obstetrics & Gynecology, vol. 106, no. 5, pp.933-939. Spies, JB, Cooper, JM, Worthington-Kirsch, R, Lipman, JC, Mills, BB & Benenati, JF 2004, 'Outcome of uterine embolization and hysterectomy for leiomyomas: results of a multicenter study', American Journal of Obstetrics and Gynecology, vol. 191, pp.22-31. Spies, JB, Spector, A, Roth, AR, Baker, CM, Mauro, L & Murphy-Skrynarz, K 2002, 'Complications after uterine artery embolization for leiomyomas', Obstetrics & Gynecology 2002, vol. 100, pp.873-880, viewed 4 October 2008, http://www.greenjournal.org/cgi/content/full/100/5/873 Uterine artery embolization 2004, viewed 30 September 2008, http://www.uterine-fibroids.org/uae.html Uterine fibroid embolization, 2008, viewed 28 September 2008, http://www.radiologyinfo.org/en/info.cfmpg=ufe&bhcp=1 Uterine fibroid embolization: A new way to treat fibroids, 2005, viewed 29 September 2008, http://familydoctor.org/online/famdocen/home/women/reproductive/gynecologic/601.html Uterine fibroid embolization (uterine artery embolization), 2008, viewed 29 September 2008, http://www.fibroidworld.com/UAE.htm Walker, WJ, Barton-Smith, P 2006, 'Long-term follow up of uterine artery embolisation - an effective alternative in the treatment of fibroids', BJOG 2006, vol. 113, pp.464-468. Walker, WJ & Pelage, JP 2002, 'Uterine artery embolisation for symptomatic fibroids: clinical results in 400 women with imaging follow up', BJOG: an International Journal of Obstetrics and Gynaecology, vol. 109, pp.1262-1272. Worthington-Kirsch, RL, Popky, GL & Hutchins, FL, Jr 1998, 'Uterine artery embolization for the management of leiomyomas: quality-of-life assessment and clinical response', Radiology, vol. 208, pp.625-629, viewed 2 October 2008, http://radiology.rsnajnls.org/cgi/reprint/208/3/625 9. Appendix 2 (Patient information leaflet) Uterine Fibroid Embolisation What is uterine fibroid embolisation UFE is a minimally invasive treatment for fibroid tumours in the uterus. This is a procedure in which physicians use image guidance to place a synthetic material to block off the blood supply to the tumour with the result that the tumour gradually begins to shrink. Who are the candidates for UFE UFE is ideal in the following types of cases where the woman suffers from: severe bleeding due to uterine tumours severe bleeding associated with childbirth premenopausal women who suffer problems from the fibroids, who wish to avoid surgical removal of the uterus and do not wish to get pregnant women who wish to avoid blood transfusion women who cannot receive general anesthesia women with multiple or large fibroids. What is the procedure A nick is made on the skin of the patient in the groin. Using x-ray guidance technique, a catheter is inserted into the femoral artery and advanced via the uterine arteries to reach the fibroids. Then the blocking agent is injected into the catheter to block the supply of blood to the fibroid. The candidate is intravenously and locally sedated for the procedure. At the conclusion of the procedure, the catheter is removed, leaving just the nick on the skin. The procedure takes just 90 minutes and the patient will be observed overnight and released. What discomfort does the patient go through A gentle prick as the needle is inserted for the intravenous line and also while injection of the local anesthetic. Sedation makes the patient feel relaxed and sleepy. A slight feeling of pressure when the catheter is inserted but no extreme discomfort. The contrast agent that is injected to map the course of the catheter gives a warm feeling. Pain post procedure which will be controlled by medication. Post-procedure discomfort Pelvic cramps which will improve gradually and steadily over several days. Mild nausea. Low-grade fever. How long does it take for symptoms to improve The fibroids usually shrink by half within six months relieving the symptoms of pressure and pain. Improvement in the menstrual bleeding may be noticed even from the first menstrual cycle following the procedure. Advantages of UFE Uterine fibroid embolisation is minimally invasive as compared to hysterectomy. UFE is performed under local anesthesia and hence recovery time is much shorter. UFE does not require any surgical incision, nor any sutures. Convalescence period is far shorter than that required for a hysterectomy. Fibroids shrink by half within six months after UFE. Chances are really rare that the fibroids regrow after a UFE. UFE preserves the uterus. UFE, as compared to other treatment options, is a fairly simple procedure. UFE is safe and effective. Risks of UFE Damage to the arteries. Bleeding at and/or infection of the puncture site. The embolic agent may get lodged in the wrong place, blocking the supply to that region. The patient may have a reaction to the contrast agent. Some women after undergoing UFE may pass pieces of fibroid tissue after the procedure, and these will have to be removed by dilatation and curettage. For women who are older than 45, sometimes UFE is shortly followed by menopause. After UFE, some women still eventually end up undergoing a surgical removal. Exposure to x-ray is another risk of UFE, though the exposure levels are below those that call for concern. The probability for all the above risks is very low. Cautions The following categories of women are cautioned against undergoing UFE: Women who have no symptoms from their uterine fibroids. When the fibroids are precancerous or when cancer is a possibility. Women suffering from inflammation or infection of the pelvis. Women who are pregnant. Women who have kidney problems. Women who are allergic to contrast dyes. Some additional facts The embolic agent injected to block the uterine arteries is approved specifically by FDA. The embolic particles have been used in thousands of patients without long-term complications. Embolisation of the uterine arteries has been used to treat heavy bleeding post delivery by interventional radiologists for more than 30 years. Though there are not enough studies done on the effects of UFE on fertility, numerous women are known to have conceived following UFE. Read More