Uterine artery embolisation (UAE)

(also known as fibroid embolisation)

Uterine fibroids are the most common type of benign tumour and can be found in 50 to 77% of all women – primarily those aged between 30 and 50. These are firm muscle nodes that grow in the muscles of the uterus itself and can develop to quite considerable sizes.

These fibroids, however, only cause symptoms in around a quarter of women. The typical symptoms are:

  • Heavy and prolonged menstrual bleeding which can lead to anaemia with corresponding tiredness and reduced physical capacity
  • Increased urge to urinate
  • Constipation
  • Pain during sexual intercourse
  • As the size of the uterus increases due to the fibroid nodes, the abdomen bulges forwards noticeably.

Fibroids that are not causing symptoms do not require treatment. Mild symptoms can usually be controlled by taking the pill or having a coil inserted. If the symptoms are more severe and cannot be controlled with medication, doctors still most often recommend having the uterus removed altogether (hysterectomy).

Fibroid embolisation is an effective, organ-preserving alternative form of treatment in such instances. The first fibroid embolisation in Germany was carried out in 2000 at the Berlin Charité.

Through the blood stream, tiny plastic spheres are floated into the fibroid, shutting off the supply of nutrients and causing the fibroid to die.

The procedure is intended to provide the patient with as much relief as possible from the symptoms of uterine fibroids (see above).

Virtually all patients with symptomatic uterine fibroids can be treated with UAE. We recommend this minimally invasive procedure when the patient’s lifestyle is too burdened by the fibroids but they do not want to have their uterus removed, for whatever reason. Where women want to have children, organ-sparing surgical options should be considered first, since the treatment is associated with X-ray exposure to the ovaries and the low risk of early menopause from failed embolisation in the ovaries. In order to provide our patients with the best possible advice on this, we at the Charité work closely with the Fibroid Clinic at the Department of Gynaecology at the Virchow-Klinikum Campus.

Factors that would generally go against UAE include a suspected malignancy, pregnancy or acute inflammation in the genital area.

In principle, the location, number and size of the fibroids as well as the nature and severity of the symptoms are not as important as they have been regarded in the past in relation to the feasibility and success of fibroid embolisation.

Patients are admitted to our unit for around 3 to 5 days for the treatment.

Beforehand

In preparation for the treatment, an MRI scan is carried out to determine the size, location and number of fibroid nodes and their blood supply, and to rule out any possible contraindications to embolisation.

We should also have the results of an up-to-date PAP smear.

A pregnancy test and other blood test also form part of the investigations. Preliminary gynaecological examinations can be carried out for example at the Department of Gynaecology’s Fibroid Clinic, or by your gynaecologist.

During

On the day of treatment, you will given medications both in tablet form and intravenous form which will help to ensure the procedure is as painless and tolerable as possible. General anaesthesia and its attendant risks can be avoided with fibroid embolisation.

A small incision (approx. 2 mm) is made in the right groin, through which a narrow catheter is advanced into the pelvic blood vessels. An even finer catheter (approx. 1 mm diameter) is then manoeuvred through this into the uterine artery. The correct position is checked with X-rays and through the administration of contrast medium. We take particular care to ensure that patients’ exposure to radiation is as limited as possible. Small plastic particles are then floated via the bloodstream into the fibroid nodes until the blood stops flowing to them.

After

Around the time of the procedure and also for a week afterwards, adequate pain control is of major importance. To achieve this, intravenous medications are needed which are given only during and immediately after the procedure. From the day after the procedure, we switch the pain relief to oral tablet form only. This can then be continued for a further week if necessary.

After this there should be no further symptoms or limitations.

Unlike after surgical treatment, patients recover very quickly after fibroid embolisation and are able to return to their everyday lives very soon afterwards.

The results of the treatment can only be reliably assessed a few weeks later. If there has been no significant improvement in symptoms after three months, the reason for this will need to be determined. This is generally done with an MRI scan.

Long-term treatment success with a significant improvement in symptoms or freedom from symptoms has been observed in around 80% of patients. Since the uterus remains in situ, however, and the potential for further fibroid formation still exists, it may be necessary even years later to repeat the treatment, although this is generally a straightforward procedure.

The frequency and severity of complications following fibroid embolisation are low. They include persistent pain in the lower abdomen (3 to 4%) requiring treatment with medication. In women approaching the usual age of menopause, menstrual periods can stop (around 4%). A small number of patients develop vaginal discharge or pass old fibroid tissue with their first menstrual bleeds after the treatment (3 to 8%), and some develop genital infections (2 to 3%).

No lasting damage or impairment is expected after fibroid embolisation.

Here you can see the images of a patient with heavy menstrual bleeding and evidence of a large uterine fibroid. This can be seen clearly on the MRI scan before the embolisation.

Figure a shows the fibroid from the side (white star). The very bright structure below the uterus with the fibroid is the urinary bladder (black arrow). This close proximity explains why large uterine fibroids can also cause urinary symptoms.

Figure b shows the same structures, this time following the administration of contrast medium. The entire uterus, along with the fibroid (black star), shows up bright. The fibroid is therefore just as well vascularised as the rest of the uterus.

During the embolisation procedure, the uterine artery is explored with a very fine catheter and, with the aid of contrast medium, the vessels of the uterine fibroid are visualised (Figure c, black arrow) and then sealed off.

Following successful embolisation, the tumour vessels can no longer be seen (Figure d).

Soon after this, the patient was completely symptom-free and around 1 year later a follow-up MRI scan (Figures e and f) showed that the uterine fibroid had become significantly smaller and, following the administration of contrast medium, remains significantly darker than the surrounding muscles of the uterus. This means that the tumour’s blood supply had been permanently cut off. (Figures from: Kröncke TJ et al. Transarterielle Embolisation bei Uterus myomatosus: klinische Erfolgsrate und kernspintomographische Ergebnisse. Rofo. 2005 Jan;177(1):89-98)

Contact


Minimally Invasive Tumour Therapy (MITT)
Charité Campus Virchow-Klinikum (CVK)
Department of Radiology
Augustenburger Platz 1
13353 Berlin

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Froeling V, Meckelburg K, Schreiter NF, et al. Outcome of uterine artery embolization versus MR-guided high-intensity focused ultrasound treatment for uterine fibroids: Long-term results. Eur J Radiol. 2013

Habilitationsschrift von PD Dr. Thomas J Kröncke zum Thema: Die Uterusarterienembolisation (UAE): Ein neues Verfahren zur Behandlung des symptomatischen Uterus myomatosus. Technische Durchführung, klinische Ergebnisse und peri-interventionelle Bildgebung. 2008

Habilitationsschrift von PD Dr. Christian Scheurig-Münkler zum Thema: Die Uterusarterienembolisation (UAE) in der Behandlung symptomatischer Gebärmuttermyome und der Adenomyosis uteri – Klinischer Langzeitverlauf und Einflussfaktoren auf den Therapieerfolg. 2014