Uterine Fibroid Embolization: Past, Present, and Future

Due to advancements in catheter-based therapies in interventional radiology, conditions that once required large open surgeries, months of recovery, and had many associated complications, are now being treated with minimally invasive procedures by radiologists. One such intervention is uterine fibroid embolization (UFE). Although UFE has been performed for almost 25 years, the procedure continues to evolve.

Uterine fibroids are the most common benign tumor of reproductive age women, and they can cause debilitating symptoms. In many instances, conservative medical management fails or is associated with an unfavorable side effect profile. In these cases, the gold standard has been either myomectomy or hysterectomy. However, both are major invasive surgeries, associated with significant costs, long hospitalizations/recovery, and significant morbidity. Given recent concerns regarding long-term effects on cardiovascular and hormonal health, uterine sparing therapies have grown in popularity.

UFE has emerged as a minimally invasive alternative after first being performed in the mid 1990s. The techniques have been borrowed from transcatheter embolization of the uterine arteries in pelvic trauma/bleeding. In this instance, the temporary occlusion of the uterine arteries supplying the uterus results in infarction of uterine fibroids. UFE has been shown to have numerous benefits, including shorter hospital stays, earlier return to normal activities, and the ability to use conscious sedation rather than general anesthesia^{(1, 2)}.

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Despite the fact that UFE has been shown to be a safe and effective treatment, the procedure remains under-utilized. A reported 65 times more hysterectomies are performed per year in the United States compared to UFE interventions⁽³⁾. This is partly due to patient awareness. A recent Society of Interventional Radiology report shows that only 62 percent of women have even heard of UFE treatment. Of the women who have heard of UFE, approximately three-fourths of those patients had not heard about it from their gynecologist⁽⁴⁾. Interventional radiologists need to play a larger role in the multidisciplinary team when discussing treatment options for symptomatic fibroids. There also needs to be a greater emphasis on patient awareness and marketing moving for UFE forward.

Treatment options for patients who wish to preserve their uterus and future fertility include myomectomy and UFE. In 2020, the FEMME trial (A Randomized Trial of Treating Fibroids with Either Embolization or Myomectomy to Measure the Effect on Quality of Life Among Women Wishing to Avoid Hysterectomy) was published in the New England Journal of Medicine, directly comparing the two therapies. This study served as the first robust multicenter, randomized label trial evaluating the topic⁽⁵⁾. The study demonstrated a four-point difference in the quality-of-life questionnaire score in favor of myomectomy at two years (84.6 vs 80.0), which was statistically significant but likely not a clinically meaningful difference. Furthermore, UFE patients had shorter hospital stay, quicker return to work, fewer bleeding adverse events, and similar pregnancy rates to myomectomy patients. Lastly, they also both had similar results in regard to willingness of women to have their particular procedure again⁽⁶⁾.

One of the main barriers to widespread adoption of UFE is post-procedural pain. Initial post-embolization pain can last up to 24 hours and can be severe in nature. Most commonly, it is managed with controlled analgesia or epidural anesthesia, requiring hospital admission. Secondary pain can last days after the initial procedure, and is commonly managed with narcotics. Recently, Superior Hypogastric Nerve Block (SHNB) interventions have been performed in conjunction with UFE and have been shown to be effective post-procedural pain suppressants. This enhanced procedure reduces overall pain scores, need for opioids, and allows for same day discharge⁽⁷⁾. The widespread use of SHNB may alleviate patient fears regarding the procedure and allow for further adoption of UFE as a first line therapy for symptomatic fibroids.

In summary, UFE has proven to be a safe and highly effective treatment for symptomatic uterine fibroids. Recent studies have proven that it compares favorably with myomectomy. Post-embolization pain has been a barrier to widespread adoption. However, the recent use of combined pain interventions, such as Superior Hypogastric Nerve Blocks in conjunction with UFE, have been shown as highly effective in reducing pain, ultimately allowing for same day outpatient procedures. These advancements, along with continued public exposure, and patient education, point towards the widespread adoption of UFE as a first line therapy for symptomatic uterine fibroids.

References:

1. Dariushnia SR, Nikolic B, Stokes LS, Spies JB; Society of Interventional Radiology Standards of Practice Committee. Quality improvement guidelines for uterine artery embolization for symptomatic leiomyomata. J Vasc Interv Radiol. 2014;25(11):1737-1747. doi:10.1016/j.jvir.2014.08.029

2. Poll H. 2017. The fibroid fix: What women need to know. Society of Interventional Radiology; Executive Report.

3. Gupta JK, Sinha A, Lumsden MA, Hickey M. Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database Syst Rev. 2012;(5):CD005073. Published 2012 May 16. doi:10.1002/14651858.CD005073.pub3

4. Makris GC, Butt S, Sabharwal T. Unnecessary hysterectomies and our role as interventional radiology community. CVIR Endovasc. 2020;3(1):46. Published 2020 Jul 14. doi:10.1186/s42155-020-00138-x

5. Manyonda I, Belli AM, Lumsden MA, et al. Uterine-Artery Embolization or Myomectomy for Uterine Fibroids. N Engl J Med. 2020;383(5):440-451. doi:10.1056/NEJMoa1914735

6. Caridi TM, Spies JB, Kohi MP. Myomectomy versus Uterine Artery Embolization: More Alike than Different. J Vasc Interv Radiol. 2020;31(11):1838-1839. doi:10.1016/j.jvir.2020.08.023

7. Yoon J, Valenti D, Muchantef K, et al. Superior Hypogastric Nerve Block as Post-Uterine Artery Embolization Analgesia: A Randomized and Double-Blind Clinical Trial. Radiology. 2019;292(1):269. doi:10.1148/radiol.2019194008

8. Pereira K, Morel-Ovalle LM, Taghipour M, et al. Superior hypogastric nerve block (SHNB) for pain control after uterine fibroid embolization (UFE): technique and troubleshooting. CVIR Endovasc. 2020;3(1):50. Published 2020 Sep 27. doi:10.1186/s42155-020-00141-2