What are the options for radiological management of uterine fibroids?

Radiological Management of Uterine Fibroids

Uterine artery embolization (UAE) is the primary radiological treatment for symptomatic uterine fibroids, achieving >50% fibroid volume reduction at 5 years with high patient satisfaction rates comparable to hysterectomy, while magnetic resonance-guided focused ultrasound surgery (MRgFUS) serves as an alternative non-invasive option for appropriately selected patients. 1

Primary Radiological Treatment: Uterine Artery Embolization

Patient Selection and Pre-Procedure Requirements

• All patients require comprehensive gynecologic workup including Pap smear (every 3 years) and endometrial biopsy if menometrorrhagia is present 1
• Cross-sectional imaging is mandatory, with MRI preferred over ultrasound, to confirm leiomyoma diagnosis and exclude other pelvic pathology 1
• Absolute contraindications that must be excluded: viable pregnancy and active pelvic inflammatory disease 1

Technical Procedure Details

• Performed under conscious sedation using unilateral or bilateral common femoral artery approach 1
• Both uterine arteries are selectively catheterized with advancement distal to nontarget branches 1
• Goal is complete occlusion of all distal uterine artery branches feeding the leiomyomas using particulate embolic agents 1

Expected Outcomes and Efficacy

• Average fibroid size reduction exceeds 50% at 5 years, typically sufficient to relieve bulk symptoms including bladder compression 2
• UAE causes arterial occlusion, ischemic necrosis, and fibroid involution 2
• Patient satisfaction rates exceed 90% at 2-year follow-up, comparable to hysterectomy 1
• Significantly shorter hospitalization and faster return to work compared to surgical options 1

Reintervention Rates

• 28% reintervention rate at 5 years and 35% at 10 years 2
• Meta-analysis demonstrates increased long-term reintervention percentage compared to hysterectomy, though short-term benefits favor UAE 1

Post-Procedure Management

• Close monitoring for 24-48 hours after discharge for pain control and potential complications 1, 3
• Avoid heavy lifting (>10 pounds) for 7-10 days 3
• Avoid sexual intercourse for 1-2 weeks 3
• Post-embolization syndrome (fever, pain, nausea) is common and typically resolves within the first week 3

Follow-Up Protocol

• Reevaluation at 3-6 months to assess treatment efficacy 1
• Follow-up imaging recommended to determine fibroid volume reduction and assess for incomplete infarction 1
• MRI after UAE is specifically recommended to ensure adequate fibroid infarction and exclude underlying leiomyosarcoma 1

Alternative Radiological Treatment: MR-Guided Focused Ultrasound Surgery (MRgFUS)

Indications and Limitations

• Non-invasive alternative to UAE for appropriately selected patients 1, 4
• Limited evidence exists regarding use in patients with concurrent adenomyosis 1
• Patient selection criteria are more restrictive compared to UAE 4

Special Population: Adenomyosis with Fibroids

UAE in Adenomyosis

• Prospective cohort studies support UAE for patients with adenomyosis and fibroids who fail conservative measures and desire uterus-preserving therapy 1
• Improvement in quality of life and symptom scores demonstrated, especially when fibroids predominate 1
• 18% hysterectomy rate for persistent symptoms at up to 7-year follow-up 1
• Meta-analysis shows 94% short-term (<12 months) and 85% long-term (>12 months) symptom improvement with 7% hysterectomy rate 1

Fertility Considerations

• Successful pregnancy reported after UAE for adenomyosis with fibroids 1
• Comprehensive fertility and pregnancy data is lacking; patients require appropriate counseling 1

Comparative Effectiveness: UAE vs. Hysterectomy

Quality of Life Outcomes

• No significant difference in quality-of-life scores at 2-year and 5-year follow-up between UAE and hysterectomy 1
• No statistical difference in sexuality or body image scores at 2 years 1
• Multicenter prospective study demonstrated significantly better health-related quality-of-life advantage for hysterectomy despite all three therapies (hysterectomy, myomectomy, UAE) being extremely effective 1

Short-Term vs. Long-Term Benefits

• UAE provides significantly greater short-term benefits: shorter hospital stay, decreased blood loss 1
• Patients undergoing surgery had significantly better symptom scores at 12 months, though quality-of-life scores were equivalent 1

Common Pitfalls and Caveats

Critical Exclusions

• Approximately 1 in 350 women undergoing treatment for presumed fibroids has unsuspected uterine sarcoma 1
• MRI follow-up is essential to exclude leiomyosarcoma, not just assess treatment efficacy 1

Complications to Monitor

• Ovarian failure or amenorrhea (infrequent but significant) 5
• Fibroid expulsion (particularly submucosal fibroids) 2
• Venous thromboembolism (rare) 5
• Vessel injury requiring activity restrictions 3

Fertility Preservation Context

• For women wishing to conceive, the role of UAE remains unclear based on current evidence 6
• Hysteroscopic myomectomy is preferred for pedunculated submucosal fibroids <5 cm in fertility-desiring patients 1