A clinical failure of uterine fibroid embolization due to adenomyosis

Uterine-Sparing Laparoscopic Pelvic Plexus Ablation, Uterine Artery Occlusion, and Partial Adenomyomectomy for Adenomyosis

STUDY OBJECTIVE

To evaluate safety, feasibility, and long-term clinical effects of adding laparoscopic pelvic plexus ablation to uterine-sparing procedures (uterine artery occlusion and partial adenomyomectomy) for adenomyosis.

DESIGN

A prospective controlled study (Canadian Task Force classification II-1).

SETTING

A teaching hospital.

PATIENTS

A total of 112 patients with symptomatic adenomyosis were eligible for uterine-sparing laparoscopy.

INTERVENTIONS

Laparoscopic pelvic plexus ablation, uterine artery occlusion, and partial adenomyomectomy.

MEASUREMENTS AND MAIN RESULTS

After the exclusion of patients with malignant tumors or those lost to follow-up, 102 women underwent laparoscopic uterine artery occlusion and partial adenomyomectomy; 50 of these patients also had laparoscopic uterine pelvic plexus ablation (group A) with the remaining 52 patients serving as the control group (group B). Other than operative time (107.0 ± 15.4 vs 98.9 ± 20.2 minutes, p = .02), there were no statistical differences regarding other operative parameters between groups A and B. Relief of severe dysmenorrhea (Visual Analogue Scale score ≥ 7) at 36 months was higher in group A than in group B (100% vs 76.9%, p < .01). No patient suffered constipation or uroschesis in either group.

CONCLUSION

Adding laparoscopic uterine pelvic plexus ablation to laparoscopic uterine artery occlusion and partial adenomyomectomy was more effective in relieving dysmenorrhea.

Uterine Artery Embolization for Symptomatic Myomata

Fibroid disease is common and causes significant health problems in women of childbearing age. Over the past several years, uterine artery embolization (UAE) has emerged as a minimally invasive treatment for symptomatic uterine myomata. Embolotherapy is effective in relieving myoma-related symptoms in 80% to 90% of patients. It requires shorter hospitalizations than traditional surgical therapies for myoma disease and is associated with faster recovery and lower complication risks than surgery. Patient selection, the UAE procedure, and post-UAE management are reviewed.

Adenomyosis: Epidemiology, Risk Factors, Clinical Phenotype and Surgical and Interventional Alternatives to Hysterectomy

Adenomyosis is an important clinical challenge in gynecology and healthcare economics; in its fully developed form, hysterectomy is often used to treat it in premenopausal and perimenopausal women. Symptoms of adenomyosis typically include menorrhagia, pelvic pain and dysmenorrhea. Moreover, adenomyosis and leiomyomas commonly coexist in the same uterus, and differentiating the symptoms for each pathological process can be problematic. Although it has been recognized for over a century, reliable epidemiological studies on this condition are limited, because only postoperative diagnoses were possible in the past. Minimally invasive surgical techniques (endometrial ablation/resection, myometrial excision/reduction, myometrial electrocoagulation, uterine artery ligation) have had limited success in the treatment of adenomyosis, and the reported data for these procedures have been obtained from case reports or small case series with only short follow-up times. However, newer techniques including uterine artery embolization (UAE) and magnetic resonance imaging guided focused ultrasound (MRgFUS) show promise in treating adenomyosis. The data is strongest for UAE; these studies have the largest patient cohorts. However, none of the UAE studies were randomized or controlled. Thus, despite the clinical importance of adenomyosis, there is little evidence on which to base treatment decisions. The objective of this review is to summarize the epidemiology, risk factors, clinical phenotype and to evaluate the accrued experience with surgical and interventional alternatives to hysterectomy.

Is uterine artery embolization for patients with large myomas safe and effective? A retrospective comparative study in 323 patients

PURPOSE

To evaluate the effectiveness, safety, and complications of uterine artery embolization (UAE) in women with large fibroid tumors.

MATERIALS AND METHODS

From January 2005 to February 2011, 323 patients underwent UAE for symptomatic uterine leiomyomas without adenomyosis and were included in this study. Patients were divided into two groups: those with a large tumor burden (group 1; n = 63), defined as a dominant tumor with a longest axis of at least 10 cm or a uterine volume of at least 700 cm(3); and the control group (group 2; n = 260). Tumor infarction and volume reduction were calculated based on magnetic resonance imaging findings. Symptom status was assessed with a visual analog scale. Postprocedure complications and repeat interventions were recorded. The data were analyzed with appropriate statistical tests.

RESULTS

No significant differences were seen between the two groups in volume reduction of dominant tumors (46.5% in group 1 vs 52.0% in group 2; P = .082) or percentage volume reduction of the uterus (40.7% in group 1 vs 36.3% in group 2; P = .114). Also, no significant differences were seen between the two groups regarding satisfaction scores at immediate or midterm follow-up (P = .524 and P = .497) or in the presence of procedure-related complications (P = .193).

CONCLUSIONS

UAE outcomes in large fibroid tumors were comparable to those in smaller tumors, without an increased risk of significant complications. Tumor size may not be a key factor in predicting successful outcomes of UAE.

Noninvasive treatment of focal adenomyosis with MR-guided focused ultrasound in two patients

Adenomyosis is a common benign gynecological disorder presenting with dysmenorrhea, menorrhagia, and pressure symptoms. Magnetic resonance imaging–guided focused ultrasound surgery (MRgFUS) utilizes precisely focused USG waves to generate and maintain high temperatures within the targeted tissue to achieve protein denaturation and coagulative necrosis. The heat generated is monitored using MRI images acquired in real-time in three planes. We present two cases of focal adenomyosis treated with MRgFUS showing good symptomatic relief at 3 and 6 months follow-up.

Uterine artery embolization for the treatment of adenomyosis

Adenomyosis is a benign uterine disorder that causes menorrhagia and dysmenorrhea. Although it was once considered a contraindication to uterine artery embolization, several authors have examined whether adenomyosis can be treated with uterine artery embolization. This article reviews the pathophysiology of adenomyosis, its imaging characteristics, as well as recent studies evaluating the efficacy of uterine artery embolization for treatment of adenomyosis.

Uterine artery embolization for the treatment of adenomyosis: a review

During the past 10 years, uterine artery embolization (UAE) has been investigated as a possible therapy for adenomyosis. All publications available from 1999 through 2010 are included in this report. Levels of evidence and trial classifications were evaluated according to the guidelines developed by the United States Preventive Services Task Force. Long-term data are available from 511 affected women from 15 studies. Improvements were reported by 387 patients (75.7%). The median follow-up was 26.9 months. UAE as treatment for adenomyosis shows significant clinical and symptomatic improvements on a short- and long-term basis.

Early results of magnetic resonance-guided focused ultrasound surgery of adenomyosis: analysis of 20 cases

STUDY OBJECTIVE

To evaluate the thermal ablative effects of magnetic resonance-(MR) guided focused ultrasound surgery (MRgFUS) on adenomyosis and to assess improvement in clinical parameters.

DESIGN

Twenty patients with adenomyosis were treated with MRgFUS. Extensive adenomyosis (6 cases) was treated with 2 applications. Uterine volume was evaluated by MR imaging before and immediately after MRgFUS. Ablation of adenomyosis and the architecture of nonperfused areas were evaluated immediately after MRgFUS. Improvement in patient symptoms was assessed through the symptom severity score questionnaire (Canadian Task Force classification II-3).

SETTING

Department of gynecology at a Japanese general hospital.

PATIENTS

Premenopausal women at least 18 years of age with symptomatic adenomyosis.

INTERVENTIONS

Thermal ablation by MRgFUS.

MEASUREMENTS AND MAIN RESULTS

We classified the nonperfused lesions on contrast-enhanced MR images immediately after MRgFUS into 3 types: lesions with round margins (type R), serrated margins (type S), and honeycomb architecture (type H). Type R was the most common (16/20 patients). Most adenomyosis lesions could be sufficiently ablated close to the serosal surface or to the endometrium by MRgFUS. The mean uterine volume 6 months after therapy was decreased by 12.7%. Symptom severity score improved significantly during 6 months of follow-up. No serious complications were observed.

CONCLUSION

These early results indicate the safe and effective ablation of adenomyosis tissue by MRgFUS. The procedure also resulted in the improvement in clinical symptoms during the 6 months of follow-up.

Uterine artery embolisation for symptomatic adenomyosis--mid-term results

PURPOSE

To evaluate the role of uterine artery embolisation (UAE) in the treatment of adenomyosis.

MATERIALS AND METHODS

27 women with symptomatic adenomyosis diagnosed on magnetic resonance imaging (MRI) underwent UAE between 1998 and 2004. Clinical evaluation using a standardised questionnaire was made at regular intervals after embolisation to assess patient outcome.

RESULTS

The diagnosis of adenomyosis was confirmed histologically by transvaginal biopsy in 5 women. There were 14 women with associated uterine fibroids. Diffuse adenomyosis was identified in 18 women. A focal adenomyoma was present in another 8 women. In 1 patient adenomyosis was not classified. All patients except one underwent bilateral uterine artery embolisation. There was an initial favourable clinical response, with improvement of menorrhagia in 79% (13/16) of patients at 12 months. Follow-up data was available on a total of 14 patients at 2 and 3 years after embolisation. 45.5% (5/11) reported a deterioration in menorrhagia symptoms at 2 years.

CONCLUSION

UAE for symptomatic adenomyosis is effective in the short-term but there is a high rate of recurrence of clinical symptoms 2 year following treatment.

Uterine artery embolization for symptomatic adenomyosis with or without uterine leiomyomas with the use of calibrated tris-acryl gelatin microspheres: midterm clinical and MR imaging follow-up

PURPOSE

To evaluate clinical and magnetic resonance (MR) imaging results after uterine artery embolization (UAE) in women with symptomatic adenomyosis with or without uterine leiomyomas.

MATERIALS AND METHODS

Thirty-eight women with symptomatic adenomyosis with or without uterine leiomyomas were treated with UAE with calibrated tris-acryl gelatin microspheres. Based on MR findings, women were categorized as having pure adenomyosis (group A; n = 15), adenomyosis dominance with fibroid tumors (group B; n = 14), or fibroid tumor dominance with adenomyosis (group C; n = 9).

RESULTS

Heavy menstrual bleeding, pain, and bulk-related symptoms at last follow-up at a median of 16.5 months (range, 3-38 months) were compared with baseline symptoms. With follow-up MR imaging at a median of 12 months (range, 3-36 months), changes in uterine volume, leiomyoma volume, junctional zone thickness, and contrast enhancement of adenomyosis were assessed. After embolization, adenomyosis infarction could be depicted on contrast medium-enhanced MR in 44.1% of cases. Median reductions of uterine volume, fibroid tumor volume, and junctional zone thickness were 44.8%, 77.1%, and 23.9%, respectively. In group A, three patients needed additional surgery after UAE, in addition to two in group B and one in group C. In the remaining 32 patients, except for one patient in group C, all preexisting symptoms (eg, bleeding, pain, bulk-related symptoms) improved or resolved after UAE. Overall, 84.2% of women were satisfied with the results of UAE.

CONCLUSION

In this study, midterm results (at a median of 16.5 months) showed that UAE in symptomatic adenomyosis with or without uterine leiomyomas is effective. Hysterectomy was avoided in the vast majority of patients. MR imaging showed reduction of uterine volume and junctional zone thickness.

Long-Term Results of Uterine Artery Embolization for Symptomatic Adenomyosis

OBJECTIVE

Controversy exists regarding the effectiveness of uterine artery embolization (UAE) in the management of symptomatic adenomyosis. The aim our study was to determine the long-term clinical efficacy of UAE in the management of symptomatic adenomyosis without fibroids.

MATERIALS AND METHODS

The cases of all patients who underwent UAE for adenomyosis without fibroids between 1998 and 2000 were analyzed. This study was a retrospective review of a prospectively collected database. Of the 66 patients, 54 patients with a follow-up period of 3 years or longer were enrolled in the study. Twelve patients were lost to follow-up. The patients' ages ranged from 29 to 49 years (mean, 40.2 years). The mean follow-up period was 4.9 years (range, 3.5-5.8 years). The primary embolic agent was polyvinyl alcohol particles (250-710 microm). All patients underwent MRI before UAE. Long-term follow-up MRI was performed on 29 patients; 22 of these patients had undergone short-term (3.5 months) follow-up MRI. Uterine volume was calculated with MR images. Symptom status in terms of menorrhagia and dysmenorrhea was scored on a scale of 0-10, 0 being no symptoms and 10 being the baseline, or initial symptoms.

RESULTS

Thirty-one (57.4%) of the 54 women who underwent follow-up had long-term success. Four had immediate treatment failure, and 19 had relapses. Changes in mean menorrhagia and dysmenorrhea scores at long-term follow-up were -5.3 and -5.1, respectively (p < 0.001), representing significant relief of symptoms. The time between UAE and recurrence of symptoms ranged from 4 to 48 months (mean, 17.3 months). Five patients underwent hysterectomy because of symptom recurrence. Mean reduction in volume of the uterus was 26.3% at short-term follow-up and 27.4% at long-term follow-up.

CONCLUSION

We found that UAE is effective in the management of symptomatic adenomyosis and has an acceptable long-term success rate. UAE should be considered a primary treatment method for patients with symptomatic adenomyosis. However, all patients should be given an explanation of the possibility of treatment failure, recurrence, and the need for hysterectomy.

Therapeutic options for adenomyosis: a review

BACKGROUND

To review the literature on various therapeutic modalities for uterine adenomyosis.

METHODS

Reviews, case-controlled studies and reports from November 1949 until August 2006 written in English or summarized in English abstracts retrieved from Medline and Pubmed using the key words: adenomyosis and adenomyosis therapy.

RESULTS

Symptoms of adenomyosis may be alleviated by antiprostaglandins, sex hormones, danazol and GnRH analogs. Minor surgical procedures for therapy include endomyometrial ablation, laparoscopic myometrial electrocoagulation and adenomyoma excision. Patient's age and symptoms, desired fertility, site and extent of lesion and surgeon's skills should be considered in choosing the appropriate procedure. Endomyometrial ablation is effective for lesions deeper than the endometrial-myometrial junction whereas the efficacy of hysteroscopic ablation is limited to foci 2-3 mm deep. Focal and diffuse disease may be managed by laparoscopic electrocoagulation or myometrial excision with preservation of fertility but risk of recurrence exists. Uterine artery embolization assumingly invokes infarction and necrosis. Encouraging results reported in some cases warrant expanding its use for more experience. Hysterectomy is the ultimate solution for women with deep myometrial involvement or if future fertility is not desired.

CONCLUSIONS

Various therapeutic options for adenomyosis, including few minimally invasive procedures became available in the last two decades but need evaluation and improvement.

Comparison of MRI and Sonography in the Preliminary Evaluation for Fibroid Embolization

OBJECTIVE

The purpose of our study was to evaluate whether pelvic MRI provides additional clinically relevant information after sonography in the preprocedure evaluation of uterine artery embolization of fibroids.

MATERIALS AND METHODS

Forty-nine women who presented for consultation for uterine artery embolization were retrospectively reviewed. The MRI and sonography scans were independently evaluated and compared for uterine size, fibroid size and location (categorized as paraendometrial, intramural, subserosal, or pedunculated) of the four largest fibroids in each patient, and the total number of fibroids present.

RESULTS

One hundred twenty-two fibroids were measured. The uterine volume was significantly smaller as measured on MRI compared with sonography (p = 0.01). We found good MRI and sonography correlation of the volume of the single largest fibroid in each patient (R = 0.87) but poor correlation of fibroid location (R = 0.17). MRI detected 31 paraendometrial fibroids and three pedunculated fibroids that were thought to be intramural fibroids on sonography. Five fibroids thought to be paraendometrial on sonography were confirmed to be subserosal or intramural on MRI. Discrepancy in the total number of fibroids was noted, with additional fibroids found on MRI in 31 of 49 patients and erroneously suspected on sonography in five of 49 patients. Pelvic MRI affected management in 11 of 49 patients, leading to cancellation of uterine artery embolization in four patients. In another seven patients who were originally thought to be poor candidates on the basis of sonographic findings, uterine artery embolization was performed. MRI did not alter the management plan in 38 patients.

CONCLUSION

MRI provided considerable additional information compared with sonography and affected clinical decision making in a substantial number of patients. MRI should be considered in all patients being evaluated for uterine artery embolization.

New interventional techniques for adenomyosis

This chapter demonstrates that new interventional techniques have been introduced over recent years in order to find an adequate non-invasive therapy for adenomyosis. There is no evidence-based medicine to guide us in the treatment of adenomyosis with minimally invasive therapy. In fact, most data regarding adenomyosis and these evolving therapies comes from the inadvertent treatment of adenomyosis in studies designed to treat uterine leiomyomas. Essentially, all data are from case reports or small case series. The problem is compounded by the fact that there is no agreed imaging definition of adenomyosis, and so therapies that do not excise the uterus have no 'gold standard' for comparison. Nonetheless, there are some reports suggesting that there may be efficacy in techniques such as medicated intrauterine devices, uterine artery embolization, and MRI-guided focused ultrasound surgery. Larger studies specifically treating adenomyosis are clearly required. As with every new approach, the widespread success of these techniques will depend on the general adoption of adequate diagnostic solutions and improvements in the technical parameters of these new regimens. Since the techniques presented in this chapter are new, they have not yet undergone the necessary thorough scientific scrutiny and discussion that is needed for their general acceptance. In the past, adenomyosis was mainly a 'post-factum' pathological diagnosis after extensive surgery. Based on the evidence presented in this chapter it seems that adenomyosis has become an entity that might be treatable by new, minimally invasive or non-invasive treatments.

MRI of Adenomyosis: Changes with Uterine Artery Embolization

OBJECTIVE

Our objective was to describe the MRI features of patients with pure or dominant adenomyosis treated with uterine artery embolization (UAE) and to correlate imaging features with symptoms.

SUBJECTS AND METHODS

Nineteen patients with symptomatic pure or dominant adenomyosis on MRI were referred for UAE. All 19 patients had repeat MRI 4 months after UAE. The MR images obtained before and after UAE were evaluated for maximal junctional zone thickness, junctional zone-myometrial ratio, uterine volume, and the presence of avascular regions. Patients were asked to complete a questionnaire about their symptoms before and 3 and 12 months after UAE.

RESULTS

Uterine volume decreased significantly after UAE (p < 0.01). The mean uterine volume reduction was 25.1%. Junctional zone thickness decreased significantly (p < 0.001). The junctional zone-myometrial ratio did not decrease significantly (p = 0.526). Fourteen (73.7%) of the 19 patients showed devascularized change within the adenomyotic region. Eighteen patients completed a questionnaire at 3 months. Sixteen (88.9%) of the 18 reported an improvement in symptoms, whereas the two remaining patients (11.1%) reported no change (p < 0.001). Of the 16 patients with clinical improvement, 11 had devascularized areas after UAE and five did not. Eleven of the 18 patients who completed a questionnaire 3 months after UAE also completed a questionnaire 12 months after UAE. Ten of these 11 patients still reported continued improvement, and one patient reported a worsening of symptoms.

CONCLUSION

UAE in patients with pure or dominant adenomyosis results in decreased uterine volume and regions of devascularization. Most patients reported an improvement in clinical symptoms within 3 months after UAE. Some patients reported benefit for at least 1 year; however, the long-term durability of symptomatic relief remains unknown.

Uterine Artery Embolization as a Treatment Option for Uterine Myomas

Information is still being collected on the long-term clinical responses and appropriate patient selection for UAE. Prospective RCTs have not been performed to compare the clinical results from UAE with more conventional therapies for symptomatic uterine leiomyomata. At least three attempts at conducting such RCTs have been unsuccessful because of poor patient accrual that related to differing patient expectation and desires, clinical bias, insurance coverage, and the tendency that patients who have exhausted other treatment options may be disposed more favorably to less invasive treatments. Other comparative studies have serious limitations. For example, the retrospective study that compared outcomes after abdominal myomectomy with UAE suggested that patients who received UAE were more likely to require further invasive treatment by 3 years than were recipients of myomectomy. Lack of randomization introduced a selection bias because women in the group that underwent UAEwere older and were more likely to have had previous surgeries. A prospective study of "contemporaneous cohorts," which excluded patients who had sub-mucosal and pedunculated subserosal myomas, sought to compare quality of life measures and adverse events in patients who underwent UAE or hysterectomy. The investigators concluded that both treatments resulted in marked improvement in symptoms and quality of life scores, but complications were higher in the group that underwent hysterectomy over 1 year. In this study,however, a greater proportion of patients who underwent hysterectomy had improved pelvic pain scores. Furthermore, hysterectomy eliminates uterine bleeding and the risk for recurrence of myomas. Despite the lack of controlled studies that compared UAE with conventional surgery, and despite limited extended outcome data, UAE has gained rapid acceptance, primarily because the procedure preserves the uterus, is less invasive, and has less short-term morbidity than do most surgical options. The cost of UAE varies by region, but is comparable to the charges for hysterectomy and is less expensive than abdominal myomectomy. The evaluation before UAE may entail additional fees for diagnostic testing, such as MRI, to assess the uterine size and screen for adenomyosis. Other centers have recommended pretreatment ultrasonography, laparoscopy, hysteroscopy, endometrial biopsy, and biopsy of large fibroids to evaluate sarcoma. Generally,after UAE the recovery time and time lost from work are less; however, the potential need for subsequent surgery may be greater when compared with abdominal myomectomy. Any center that offers UAE should adhere to published clinical guidelines,maintain ongoing assessment of quality improvements measures, and observe strict criteria for obtaining procedural privileges. After McLucas advocated that gynecologists learn the skill to perform UAE for managing symptomatic myomas, the Society of Interventional Radiology responded with a precautionary commentary on the level of technical proficiency that is necessary to maintain optimum results from UAE. The complexity of pelvic arterial anatomy, the skill that is required to master modern coaxial microcatheters, and the hazards of significant patient radiation exposure were cited as reasons why sound training and demonstration of expertise be obtained before clinicians are credentialed to perform UAE.A collaboration between the gynecologist and the interventional radiologist is necessary to optimize the safety and efficacy of UAE. The primary candidates for this procedure include women who have symptomatic uterine fibroids who no longer desire fertility, but wish to avoid surgery or are poor surgical risks. The gynecologist is likely to be the primary initial consultant to patients who present with complaints of symptomatic myomas. Therefore, they must be familiar with the indications, exclusions, outcome expectations, and complications of UAE in their particular center. When hysterectomy is the only option, UAE should be considered. Appropriate diagnostic testing should aid in the exclusion of most, but not all, gynecologic cancers and pregnancy. Other contraindications include severe contrast medium allergy, renal insufficiency, and coagulopathy. MRI may be used to screen women before treatment in an attempt to detect those who have adenomyosis; patients should be aware that UAE is less effective in the presence of solitary or coexistent adenomyosis. Because some women may experience ovarian failure after UAE, additional studies to determine basal follicle-stimulating hormone and estradiol before and after the procedure may provide insight into UAE-induced follicle depletion.UAE is a unique new treatment for uterine myomas, and is no longer considered investigational for symptomatic uterine fibroids. There is international recognition that data are needed from RCTs that compare UAE with surgical alternatives. Current efforts to provide prospective objective assessment of treatment outcomes and complications after UAE will help to optimize patient selection and clinical guidelines. FIBROID should provide critical data for the assessment of safety and outcomes measures for women who receive UAE for symptomatic uterine myomas.

Failure of uterine fibroid embolization

OBJECTIVE

To assess the outcomes of patients who underwent uterine fibroid embolization (UFE) and to evaluate factors associated with failure of UFE.

DESIGN

Retrospective study.

SETTING

University teaching hospital.

PATIENT(S)

Two hundred thirty-three consecutive patients who underwent UFE from November 1997 to February 2004.

INTERVENTION(S)

Uterine fibroid embolizations were performed by three interventional radiologists using 355-500-mu polyvinyl alcohol particles.

MAIN OUTCOME MEASURE(S)

Hysterectomy rate, myomectomy rate, and repeat UFE rate.

RESULT(S)

With a mean follow-up of 13 months, a total of 22 patients underwent surgery after UFE (9.4%); 16 had hysterectomies (6.9%), and 6 had myomectomies (2.6%). This included 3 patients who underwent repeat UFE and subsequently required surgical intervention. The mean (+/- SEM) time interval between UFE and subsequent treatment was 12.5 +/- 2.0 months. Among patients who required surgery, 13 (59.1%) presented with recurrent menorrhagia, and 5 (22.7%) complained of persistent abdominal pain. Histopathologic examination revealed concomitant findings of adenomyosis in 25% of hysterectomy specimens. Patients who failed UFE were more likely to have had a previous myomectomy (13% vs. 2.4%) and significant reduction in the uterine size 6 months after UFE (57.1% vs. 25.2%).

CONCLUSION(S)

The overall failure rate of UFE is 9.4%. Failure is mainly due to persistent menorrhagia and abdominal pain. Shrinkage of the uterus after UFE does not necessarily correlate with long-term success of UFE.

Uterine Fibroid Vascularization and Clinical Relevance to Uterine Fibroid Embolization

Embolization has become a first-line treatment for symptomatic uterine fibroid tumors. Selective catheterization and embolization of both uterine arteries, which are the predominant source of blood flow to fibroid tumors in most cases, is the cornerstone of treatment. Although embolization for treatment of uterine fibroid tumors is widely accepted, great familiarity with the normal and variant pelvic arterial anatomy is needed to ensure the safety and success of the procedure. The uterine artery classically arises as a first or second branch of the anterior division of the internal iliac artery and is usually dilated in the presence of a uterine fibroid tumor. Angiography is used for comprehensive pretreatment assessment of the pelvic arterial anatomy; for noninvasive evaluation, Doppler ultrasonography, contrast material-enhanced magnetic resonance (MR) imaging, and MR angiography also may be used. After the uterine artery is identified, selective catheterization should be performed distal to its cervicovaginal branch. For targeted embolization of the perifibroid arterial plexus, injection of particles with diameters larger than 500 mum is generally recommended. Excessive embolization may injure normal myometrium, ovaries, or fallopian tubes and lead to uterine necrosis or infection or to ovarian failure. Incomplete treatment or additional blood supply to the tumor (eg, via an ovarian artery) may result in clinical failure. The common postembolization angiographic end point is occlusion of the uterine arterial branches to the fibroid tumor while antegrade flow is maintained in the main uterine artery.

Percutaneous uterine artery embolization for the treatment of symptomatic fibroids: current status

Uterine artery embolization (UAE) is increasingly being used as an alternative treatment to hysterectomy for symptomatic fibroids. Symptoms of pelvic pressure, urinary frequency and menorrhagia are controlled in 73-98% of patients who undergo UAE. At the 1-year follow-up, the uterus may shrink by up to 55% but re-growth of fibroid may however occur. The rate of major complications and amenorrhoea following this procedure is low, ranging in most series from 1 to 3.5% and 1 to 7%, respectively. Nevertheless, the rate of amenorrhoea in women over 45 seems to be higher. In order to completely block the arterial supply to the fibroid, UAE is typically performed in both uterine arteries. Different embolic agents are used such as polyvinyl alcohol, gelfoam and more recently gelatine tris-acryl microspheres. After UAE, perfusion of the uterus is maintained. Uterine function is therefore conserved and although women who become pregnant after UAE seem to be at risk for malpresentation, pre-term birth, cesarean delivery and postpartum hemorrhage, successful pregnancies after UAE have been reported in some series. A major technical problem with UAE remains the possible presence of fibroid blood supply from other sources, such as the ovarian arteries or other pelvic branches, which can lead to failure of the procedure. In conclusion, although randomized trials are still underway, UAE appears a good option for those patients who whish to conserve their fertility or when surgery is contra-indicated. However, to evaluate the long-term effects of UAE longer follow up is required.

Predictive factors for fibroids recurrence after uterine artery embolisation

OBJECTIVES

To assess clinical failure and symptom recurrence after uterine artery embolisation (UAE) and to define predictive factors.

DESIGN

Prospective study of a case series.

SETTING

Gynaecology and radiology departments of a French University Hospital.

POPULATION

Eighty-five women who underwent embolisation for the treatment of uterine fibroids.

METHOD

Vascular access was obtained via the right common femoral artery. Free-flow embolisation was performed using 150-250 mum polyvinyl alcohol particles and an absorbable particle sponge.

MAIN OUTCOME MEASURES

Clinical failure was defined as persistence of symptoms at three months of follow up and recurrence as return of symptoms. The main outcome measure was the need for further treatment after UAE.

RESULTS

Results are available for 81 patients. Median follow up was 30 months. There were 15 clinical failures and recurrences requiring further treatment (eight hysterectomies, five hysteroscopic resections for submucous fibroids, one second embolisation and one woman refusing further treatment). Recurrence-free survival rate at 30 months (no clinical failure, no recurrence) was 82.8% (95% CI 73.7-91.8%). Multivariate analysis identified two predictive factors: dominant fibroid size on ultrasound imaging (each 1 cm increase: HR = 1.68, 95% CI 1.10-2.69) and number of fibroids (each additional fibroid: HR = 1.34, 95% CI 1.08-1.66).

CONCLUSIONS

Symptom recurrence rate 30 months after fibroid embolisation was 17.2%. Fibroid size and number were predictive factors for recurrence. As most recurrences occurred after two years, we recommend that patients be monitored clinically and that imaging be for more than two years after UAE.

Midterm Results of Uterine Artery Embolization for Symptomatic Adenomyosis: Initial Experience

PURPOSE

To prospectively evaluate the midterm results of uterine artery embolization for symptomatic adenomyosis.

MATERIALS AND METHODS

The study protocol was approved by the institutional review board, and all participants gave written informed consent. Eighteen women (mean age, 44.3 years) with symptomatic adenomyosis were treated with bilateral embolization of the uterine arteries. The diagnosis of diffuse adenomyosis was based on heterogeneous abnormal myometrial echogenicity with myometrial cysts at ultrasonography (US) or on enlarged junctional zone and myometrial cysts at magnetic resonance (MR) imaging. Focal adenomyosis was diagnosed if there was a circumscribed nodular lesion mimicking intramural fibroid. All patients with associated uterine fibroids were excluded. Embolization was offered as an alternative to hysterectomy in all women. Clinical evaluation was made at regular intervals to assess patient outcome. Follow-up US or MR imaging was performed 6 months after embolization to assess uterine volume reduction.

RESULTS

Bilateral uterine artery embolization was achieved in all but one woman by using polyvinyl alcohol particles or trisacryl microspheres. All women resumed normal menstruation after the procedure. After 6 months, 15 (94%) of 16 women reported improvement in menorrhagia. Follow-up images at 6 months depicted a slight decrease (mean, 15%) in uterine volume in 17 (94%) of 18 women. After 1 year, 11 (73%) of 15 women had improvement in menorrhagia, and eight (53%) of 15, complete resolution. After 2 years, five (56%) of nine women had complete resolution of menorrhagia. Eight (44%) of 18 women required additional treatment during follow-up for failure or recurrence; five women (28%) underwent hysterectomy.

CONCLUSION

Even if short-term results of uterine artery embolization to treat adenomyosis appear encouraging, midterm results are disappointing, with only 55% of treated patients showing clinical improvement after 2 years.

Les fibromes utérins. Embolisation : pratiques actuelles

Uterine artery embolization is a radiological procedure consisting in occluding the perifibroid arterial plexus to induce fibroid ischemia. To date, with more than 50,000 women treated worldwide, embolization seems to be a valuable alternative to hysterectomy and multiple myomectomies particularly in women with severe menorrhagia. Embolization should ideally be performed in case of intramural or submucosal uterine fibroids. It must be preferrably realized in case of multiple fibroids, be they intramural or submucosal (when hysteroscopic resection is not feasible). Complication rates are low if large calibrated microspheres are used to perform embolization and if pedunculated subserosal fibroids are excluded. In case of associated adenomyosis clinical recurrence seems more frequent. The role of embolization as an alternative to a single myomectomy, particularly in young women desiring future pregnancy remains a matter of debate and should be evaluated with clinical randomized trials. Pluridisciplinary management of women is the key to a widespread acceptance of uterine artery embolization in the management of uterine fibroids.

FEMIC (Fibromes Embolis�s aux MICrosph�res calibr�es): Uterine Fibroid Embolization using Tris-acryl Microspheres. A French Multicenter Study

PURPOSE

A French multicenter registry was set up to confirm the safety and efficacy of large calibrated tris-acryl gelatin microspheres for embolization of symptomatic fibroids.

METHODS

Technical recommendations included embolization using large microspheres (>500 microm) with no secondary embolization agent. Postprocedural pain, clinical improvement and adverse events were prospectively evaluated during a follow-up period of at least 6 months.

RESULTS

Eighty-five women complaining of fibroid-related symptoms entered the study. In seven women, a secondary embolization agent was used in addition to microspheres. Complete resolution of menorrhagia was achieved in 84% of women at 24 months and significant uterine and fibroid volume reductions were noted after 6 months (37% and 73%, respectively). Three women experienced definitive amenorrhea (4%) and two women required hysteroscopic resection of a fibroid. Eight women were treated by hysterectomy because of treatment failure. In seven of these women, treatment failure was explained by an additional cause of symptoms including diffuse adenomyosis, endometrial hyperplasia or ovarian artery supply to the fibroids.

CONCLUSION

Limited uterine artery embolization using large microspheres has good clinical success rate with low postprocedural pain and complications. Women can expect excellent midterm results with a high level of symptom control and significant fibroid volume reduction. Confidence in the end-point recommended here may require the experience of several cases.

Uterine artery embolization for adenomyosis without fibroids

AIM

To evaluate the potential usefulness of transcatheter uterine artery embolization as a treatment for symptomatic adenomyosis in patients without uterine fibroids.

MATERIALS AND METHODS

Uterine artery embolization using polyvinyl alcohol particles sized 250-710 mm was performed in 43 patients (mean; 40.3 years, range; 31-52 years) with dysmenorrhoea, menorrhagia, or bulk-related symptoms (pelvic heaviness, urinary frequency) due to adenomyosis without fibroids. All patients underwent pre-procedural and 3.5 months (range 1-8 months) follow-up magnetic resonance imaging (MRI) with contrast enhancement. Clinical symptoms were also assessed at the time of MRI before and after embolization.

RESULTS

Significant improvement of dysmenorrhoea (95.2%) and menorrhagia (95.0%) was reported in most patients. Contrast-enhanced MRI revealed non-enhancing areas suggesting coagulation necrosis of adenomyosis in 31 patients (72.1%), decreased size without necrosis in 11 patients (25.6%), and no change in one patient (2.3%). The mean volume reduction of the uteri after uterine artery embolization was 32.5% (from 321.7+/-142.9 to 216.7+/-130.1 cm(3)).

CONCLUSION

Transcatheter uterine artery embolization is an effective therapy for the treatment of symptomatic pure adenomyosis, and may be a valuable alternative to hysterectomy.

Childbirth and Myoma Treatment by Uterine Artery Occlusion: Do They Share a Common Biology?

When the uterine arteries are bilaterally occluded, either by uterine artery embolization or by laparoscopic obstruction, women with myomas experience symptomatic relief. After the uterine arteries are occluded, most blood stops flowing in myometrial arteries and veins, and the uterus becomes ischemic. It is postulated that myomas are killed by the same process that kills trophoblasts: transient uterine ischemia. When the uterine arteries are bilaterally occluded, either by uterine artery embolization (UAE) or by laparoscopic obstruction, women with myomas experience symptomatic relief. After the uterine arteries are occluded, most blood stops flowing in myometrial arteries and veins, and the uterus becomes ischemic. Over time, stagnant blood in these arteries and veins clots. Then, tiny collateral arteries in the broad ligament (including communicating arteries from the ovarian arteries) open, causing clot within myometrium to lyse and the uterus to reperfuse. Myomas, however, do not survive this period of ischemia. This is unique organ response to clot formation and ischemia. What allows the uterus to survive a relatively long period of ischemia while myomas perish? Childbirth appears to be the predicate biology. Following placental separation, the uteroplacental arteries and the draining veins of the placenta are torn apart at their bases in the junctional zone of the myometrium and bleed directly into the uterine cavity. Left unchecked, every woman would bleed to death in less than 10 minutes after placental delivery. Most women do not bleed to death because vessels in the uterus clot after placental delivery. During pregnancy, clotting and lytic factors in blood increase many fold. Following delivery, uterine contractions continue, intermittently, periodically slowing the velocity of flowing blood through myometrium. The combination of slowed blood flow, elevated clotting proteins, and torn placental vessels (known as Virchow's triad) causes blood in myometrial arteries and veins to clot. Fibrinolytic enzymes later lyse clot in arteries and veins not associated with placenta perfusion, and the uterus is reperfused. Remnant placental tissue - primarily uteroplacental arteries and veins - does not survive this period of ischemia. Placental tissue dies and over weeks is sloughed into the uterine cavity. At the same time, residual endometrial tissue grows under the sloughing placental tissue thus re-establishing the endometrial lining. It is postulated that myomas are killed by the same process that kills trophoblasts - transient uterine ischemia.

Embolization of uterine fibroids

Since the first description of uterine artery embolization for the treatment of symptomatic fibroids of the uterus in 1994, this minimally invasive procedure has been increasingly performed in many Western countries. The method is characterized by a high technical success rate of about 85%, a highly significant relief of symptoms, and a very low rate of complications that make this method an appealing alternative to classic treatment options of surgical or laparoscopic myomectomy or hysterectomy. These characteristics have made the procedure well accepted by affected women. Nevertheless, indications and potential contraindications have to be evaluated carefully, especially in patients of childbearing age whenever a considerable number of deliveries is reported after uterine fibroid embolization. This article discusses the clinical background, indications and contraindications, angiographic techniques, potential complications and side effects, and the mid-term results known at present.

Leiomyoma Recurrence after Uterine Artery Embolization

PURPOSE

The purpose of this study was to evaluate the rate of leiomyoma recurrence after uterine artery embolization (UAE) for symptomatic uterine leiomyomas.

MATERIALS AND METHODS

A prospective study of UAE of uterine leiomyomas has been ongoing at the authors' hospital since 1997. The recurrence rate was assessed in June 2002. Vascular access was obtained via the right common femoral artery and free-flow embolization was performed with use of 150-250- micro m polyvinyl alcohol particles and an absorbable particle sponge. Follow-up included clinical and ultrasound (US) examinations at 3, 6, and 12 months, and once per year thereafter.

RESULTS

Eighty-five UAE procedures were performed between January 1997 and June 2000. Five patients were lost to follow-up. Median follow-up was 30 months (range, 2-57 months). There were six immediate failures: one technical failure, three cases of concomitant disease (one case of endometrial cancer and two cases of adenomyosis), and two cases of large subserosal leiomyomas. There were eight late failures or recurrences: one case of leiomyoma progression, seven cases of new leiomyomas. Mean time to recurrence was 27.4 months.

CONCLUSIONS

Although UAE is an effective primary treatment for leiomyomas, this study recorded a recurrence rate of 10% at just more than 2 years. Clinical and US examinations are needed before UAE to exclude pedunculated submucosal leiomyomas and cancers, and must be repeated for more than 2 years after UAE to monitor patients' progress. Longer follow-up and more events are needed to define risk factors for recurrence.

Adenomyosis: MRI of the uterus treated with uterine artery embolization

OBJECTIVE

The purpose of this study was to determine the MRI features seen after uterine artery embolization and to evaluate the clinical response in patients with adenomyosis.

MATERIALS AND METHODS

Thirty women with adenomyosis underwent uterine artery embolization and follow-up MRI for 1 year. Of the 30, 27 patients were diagnosed with uterine fibroids and adenomyosis on the basis of MRI before uterine artery embolization. In six of the 27 patients, the dominant disease was adenomyosis. Three of the 30 patients had adenomyosis alone. The distribution, thickness, and enhancement of adenomyosis were analyzed in each patient. Patients completed a symptom questionnaire.

RESULTS

After uterine artery embolization, the junctional zone-myometrial ratio did not change significantly. There were regions of devascularization of adenomyosis on contrast-enhanced images in 12 patients, all with a junctional zone thickness before uterine artery embolization of more than 20 mm (mean thickness, 39.2 mm). Eleven of the 12 patients had focal or asymmetric distribution patterns of adenomyosis. All three patients with pure adenomyosis and all six patients with dominant adenomyosis reported an improvement in symptoms.

CONCLUSION

In patients treated with uterine artery embolization, MRI shows changes in areas of adenomyosis with a decrease in junctional zone vascularity in patients with thickening of the junctional zone greater than 20 mm. Devascularization may be related to the distribution of adenomyosis. The presence of adenomyosis should not be used as a contraindication to uterine artery embolization because most patients show clinical improvement after undergoing this procedure.

Uterine fibroids: uterine artery embolization versus abdominal hysterectomy for treatment--a prospective, randomized, and controlled clinical trial

PURPOSE

To evaluate the effectiveness of uterine artery embolization (UAE) in the management of bleeding in patients with uterine fibroids and to compare UAE with hysterectomy, particularly with regard to length of hospital stay and associated complications (ie, safety).

MATERIALS AND METHODS

A prospective clinical trial was performed with patients who were randomly assigned to one of two groups: patients who were offered the option of undergoing either UAE or hysterectomy (group 1) and patients who were not informed of the alternative treatment-that is, UAE (group 2). The primary variables that were considered for evaluation of the effectiveness, efficiency, and safety of the two procedures were, respectively, bleeding cessation, total length of hospital stay, and resulting complications. The lengths of hospital stay in the two study arms were compared on an intent-to-treat basis. Owing to crossover between the treatment arms, however, effectiveness and safety were evaluated on the basis of the actual treatment received.

RESULTS

The clinical success rate for the patients who underwent UAE, which was based on the cessation of bleeding, was 86% (31 of 36 patients). The mean hospital stay for group 1 was 4.14 days shorter than that for group 2 (P <.001). Ten (25%) of the 40 patients who underwent UAE experienced minor complications, in contrast to four (20%) of the 20 who underwent hysterectomy and experienced major complications.

CONCLUSION

Compared with hysterectomy, UAE is safe and effective for treatment of bleeding fibroids, necessitates a shorter hospital stay, and results in fewer major complications.

Incomplete vaginal expulsion of pyoadenomyoma with sepsis and focal bladder necrosis after uterine artery embolization for symptomatic adenomyosis: case report

The major complications secondary to uterine artery embolization (UAE) are rare. We report a case involving a patient who underwent UAE for symptomatic adenomyosis, and experienced complications including incomplete vaginal expulsion of a large focal pyoadenomyosis, sepsis and focal bladder necrosis. The serial changes of uterine echogenicity reflected the intracavity sloughing tissue, and cystourethroscopy revealed a focal bladder necrosis. Administration of appropriate antibiotics and timely expulsion of the focal pyoadenomyosis vaginally resulted in successful preservation of the uterus and spontaneous recovery of focal bladder necrosis without surgical intervention. A review of the relevant literature was conducted to explore the mechanisms of bladder necrosis after UAE, summarize post-embolization intervention and the outcome of vaginally expelled myoma, and to discuss the value of UAE for adenomyosis.

The Ontario Uterine Fibroid Embolization Trial. Part 2. Uterine fibroid reduction and symptom relief after uterine artery embolization for fibroids

OBJECTIVE

To evaluate fibroid uterine volume reduction, symptom relief, and patient satisfaction with uterine artery embolization (UAE) for symptomatic fibroids.

DESIGN

Multicenter, prospective, single-arm clinical treatment trial.

SETTING

Eight Ontario university and community hospitals. Five hundred thirty-eight patients undergoing bilateral UAE.

INTERVENTION(S)

Bilateral UAE performed with polyvinyl alcohol particles sized 355-500 microm.

MAIN OUTCOME MEASURE(S)

Three-month follow-up evaluations including fibroid uterine volume reductions, patient reported symptom improvement (7-point scale), symptom life-impact (10-point scale) reduction, and treatment satisfaction (6-point scale).

RESULT(S)

Median uterine and dominant fibroid volume reductions were 35% and 42%, respectively. Significant improvements were reported for menorrhagia (83%), dysmenorrhea (77%), and urinary frequency/urgency (86%). Mean menstrual duration was significantly reduced after UAE (7.6 to 5.4 days). Improvements in menorrhagia were unrelated to pre-UAE uterine size or post-UAE uterine volume reduction. Amenorrhea occurring after the procedure was highly age dependent, ranging from 3% (1%-7%) in women under age 40 to 41% (26%-58%) in women age 50 or older. Median fibroid life-impact scores were significantly reduced after UAE (8.0 to 3.0). The majority (91%) expressed satisfaction with UAE treatment.

CONCLUSION(S)

UAE reduced fibroid uterine volume and provided significant relief of menorrhagia that was unrelated to initial fibroid uterine size or volume reduction. Patient satisfaction with short-term UAE treatment outcomes was high.

Factors affecting early surgical intervention after uterine artery embolization

Uterine artery embolization (UAE) is an effective technique for the management of uterine myoma. However, complications of this procedure can be serious, including uterine infection and bowel necrosis in conjunction with necrosis of subserous or pedunculated myomas. Treatment failure is more likely to occur in the presence of submucosal myoma associated with a uterine infection or a large myoma of more than 8 cm. Accordingly, patients whose primary symptoms include submucosal myoma and menorrhagia are best treated with a hysteroscopic myomectomy or hysterectomy. The role of the gynecologist is crucial for most effective management and safe use of uterine artery embolization.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to list the complications of uterine artery embolization for fibroids, to describe postembolization syndrome, and identify the myomas that are more likely to fail uterine artery embolization.

Uterine artery embolisation for symptomatic fibroids: clinical results in 400 women with imaging follow up

OBJECTIVE

To evaluate the mid-term efficacy and complications of uterine artery embolisation in women with symptomatic fibroids. To assess reduction in uterine and dominant fibroid volumes using ultrasound and magnetic resonance imaging.

DESIGN

Prospective observational single-centre study.

SETTING

A district general hospital in Surrey and a private hospital in London.

METHODS

Four hundred consecutive women were treated between December 1996 and February 2001. Indications for treatment were menorrhagia, menstrual pain, abdominal swelling or bloating and other pressure effects. Uterine artery embolisation was performed using polyvinyl alcohol particles and platinum coils.

MAIN OUTCOME MEASURES

Imaging was performed before embolisation and at regular intervals thereafter. Clinical evaluation was made at regular intervals after embolisation to assess patient outcome.

RESULTS

Bilateral uterine artery embolisation was achieved in 395 women, while 5 women had a unilateral procedure. With a mean clinical follow up of 16.7 months, menstrual bleeding was improved in 84% of women and menstrual pain was improved in 79%. Using ultrasound, the median uterine and dominant fibroid volumes before embolisation were 608 and 112 cc, respectively, and after embolisation 255 and 19 cc, respectively (P = .0001). Three (1%) infective complications requiring emergency hysterectomy occurred. Twenty-three (6%) patients had clinical failure or recurrence. Of these, nine (2%) had a hysterectomy. Twenty-six (7%) women had permanent amenorrhoea after embolisation including four patients under the age of 45 (2%). Of these, amenorrhea started between 4 and 18 months after embolisation, and only three had elevated follicle stimulating hormone levels when amenorrhea developed. Thirteen (4%) women had chronic vaginal discharge considered as a major irritant. Thirteen pregnancies occurred in 12 patients. Ninety-seven percent of women were pleased with the outcome and would recommend this treatment to others.

CONCLUSIONS

Uterine artery embolisation is associated with a high clinical success rate and good fibroid volume reduction. Infective complications requiring hysterectomy, amenorrhoea under the age of 45 and chronic vaginal discharge may complicate the procedure.

The effect of pelvic MR imaging on the diagnosis and treatment of women with presumed symptomatic uterine fibroids

PURPOSE

To determine if magnetic resonance (MR) imaging significantly alters the diagnostic thinking and treatment plans of interventional radiologists during the evaluation of women for uterine fibroid embolization (UFE) for presumed uterine fibroids.

MATERIALS AND METHODS

At a single institution, interventional radiologists prospectively completed questionnaires (n = 60) before and after MR imaging was performed in their evaluation of women presenting for potential UFE. The questionnaires asked these physicians the probability (0%-100%) of their most likely diagnosis before MR imaging and after receiving the MR imaging information. They were also asked their anticipated and final treatment plans. Diagnostic confidence gains and the proportion of patients with changed initial diagnoses or anticipated management were calculated. The Wilcoxon signed-rank test was used to assess gains in diagnostic confidence.

RESULTS

MR imaging caused a mean gain in diagnostic confidence of 22% (P <.0001). MR imaging changed initial diagnoses in 11 patients (18%). Immediate clinical management changed in 13 patients (22%). UFE was not performed in 11 of 57 women (19%) who were anticipated before MR imaging to receive UFE.

CONCLUSIONS

MR imaging significantly alters the diagnoses and treatment plans of interventional radiologists evaluating women with presumed symptomatic fibroids. MR imaging should be considered in all patients before UFE.

Successful pregnancy after transient ovarian failure following treatment of symptomatic leiomyomata

OBJECTIVE

To report a case of transient ovarian failure after treatment of symptomatic leiomyomata and review other iatrogenic causes of transient ovarian failure.

DESIGN

Case report and literature review.

SETTING

University-affiliated private practice.

PATIENT(S)

A 35-year-old woman with symptomatic leiomyomata.

INTERVENTION(S)

Bilateral uterine artery embolization with subsequent abdominal myomectomy to treat unchanged regular heavy menstrual flow.

MAIN OUTCOME MEASURE(S)

Ovarian function.

RESULT(S)

Because medical therapy failed to control her menorrhagia, the patient proceeded with uterine artery embolization. She had persistent menorrhagia after bilateral uterine artery embolization and underwent exploratory laparotomy and myomectomy. After surgery, she had amenorrhea, hot flushes, and elevated FSH levels for 3 months. Ovarian function recovered after a short course of oral contraceptives, and the patient conceived without assistance.

CONCLUSION(S)

Several interventions can affect normal ovarian function and can lead to permanent or transient ovarian failure. Possible causes of transient ovarian failure are radioactive iodine treatment, radiation, chemotherapy, pelvic surgery, stress, and uterine artery embolization. Before these interventions are applied, the possibility of ovarian failure and available preventive measures should be discussed with the patient.

Fibroid embolization

The most common surgical treatment for fibroids is hysterectomy and approximately 30,000 are carried out annually in the UK for this condition. The operation, however, carries a significant complication rate. Since the first case was carried out in 1989 there has been increasing interest in the interventional radiological procedure called fibroid embolization where angiographic techniques are used to occlude the vascular supply of fibroids. This article is a review of the world experience of fibroid embolization, its development, techniques, indications, results and complications. So far evidence indicates very promising mid-term results but more long-term comprehensive data is needed from large trials.

I. Uterine fibroid embolization: preprocedure assessment

Increasing clinical experience with uterine fibroid embolization (UFE) has improved the ability of interventionalist radiologists to discern who is and who is not an appropriate candidate for this procedure. Initial evaluation should be directed at obtaining answers to the following key questions: (1) Does the patient have uterine fibroids that account for her symptoms and are they severe enough to require invasive treatment? (2) Does she desire future childbearing? (3) Are there any clinical indications or imaging signs of uterine malignancy? (4) Are there any medical or anatomic features that would favor a particular therapeutic modality? (5) What are her own preferences regarding treatment? Ultrasound and magnetic resonance imaging are vital elements to the assessment and planning of the appropriate course of action. Given the lack of prospective comparative trials between UFE and surgical treatment, recommendations are often highly influenced by patient preference.