What is uterine fibroid embolization, which patients are appropriate candidates, and what is the typical recovery timeline and post‑procedure care?

Uterine Fibroid Embolization and Recovery

What is Uterine Fibroid Embolization?

Uterine artery embolization (UAE) is a minimally invasive procedure using a transfemoral or transradial arterial approach to introduce embolic materials (gelatin, microspheres, or coils) into the uterine arteries, causing arterial occlusion, ischemic necrosis, and involution of fibroids. 1

Technical Procedure Details

• Both uterine arteries are selectively catheterized and embolized, with the catheter advanced distal to nontarget branches 1
• The goal is complete occlusion of all distal uterine artery branches feeding the leiomyomas 1, 2
• The procedure is typically performed under conscious sedation 1
• Particulate embolic agents are used to achieve distal embolization 1

Appropriate Candidates for UAE

Indications

UAE is indicated for women with symptomatic uterine fibroids causing bulk symptoms (pressure, pain, fullness, bladder or bowel symptoms) and/or heavy menstrual bleeding. 1

Pre-Procedure Requirements

• Full gynecologic workup including Pap smear every 3 years 1, 2
• Endometrial biopsy if menometrorrhagia is present 1, 2
• Cross-sectional imaging, preferably MRI, to confirm leiomyoma diagnosis and exclude other pelvic pathology 1, 2

Absolute Contraindications

• Viable pregnancy 1, 2, 3
• Active pelvic inflammatory disease 1, 2, 3
• Known or suspected gynecologic malignancy 3, 4

Relative Contraindications and Special Considerations

• Women unwilling to have hysterectomy under any circumstances should be counseled about the small but important risk of requiring emergency hysterectomy for complications 3
• Women desiring future fertility should receive full disclosure about limitations and lack of long-term data, though recent evidence shows high live birth rates (73-81%) 1
• The FEMME trial found no significant difference in ovarian reserve biomarkers between UAE and myomectomy 1

Recovery Timeline and Post-Procedure Care

Immediate Post-Procedure Period (0-48 Hours)

Patients require close monitoring for the first 24-48 hours after discharge for adequacy of pain and nausea control and to assess for potential complications. 1, 2, 5

• Pain in the first 24 hours affects almost all patients 6
• Post-embolization syndrome (flu-like syndrome with pain, nausea, fevers, and leukocytosis) is common and typically resolves within the first week 1, 5
• Significantly shorter hospitalization and faster return to work compared to surgical options 2

Activity Restrictions

• Avoid heavy lifting (>10 pounds) for at least 7-10 days after the procedure 5
• Sexual intercourse should be avoided for 1-2 weeks following UAE 5
• Vessel injury may require additional activity restrictions 2, 5

Follow-Up Schedule

• Reevaluation at 3-6 months after the procedure to assess treatment efficacy 1, 2, 5
• Follow-up imaging may be performed to determine fibroid volume reduction and assess for incomplete fibroid infarction 1, 5
• MRI after UAE is specifically recommended to ensure adequate fibroid infarction and exclude underlying leiomyosarcoma 1, 2

Expected Outcomes

Symptom Relief and Fibroid Reduction

• Clinical success rates of 81-100% have been reported 1
• Average fibroid size reduction exceeds 50% at 5 years 1, 2
• Persistent decreases in pain and heavy menstrual bleeding since first published study in 1995 1
• Patient satisfaction rates exceed 90% at 2-year follow-up, comparable to hysterectomy 2
• Most fibroid size reduction occurs within the first 6 months, with continued decrease between 6-12 months 7

Comparative Effectiveness

• UAE is equally effective at reducing heavy menstrual bleeding compared to myomectomy at 4 years 1
• UAE is associated with decreased risk of blood transfusion and shorter hospital stays compared to myomectomy 1
• Rates of new fibroid formation are significantly lower with UAE than with myomectomy 1
• Quality of life scores and reintervention rates at 4 years are not significantly different between myomectomy and UAE 1

Long-Term Reintervention Rates

• Secondary hysterectomy rates of 28% at 5 years and 35% at 10 years (from EMMY trial that did not permit repeat embolization) 1
• Reintervention rate at 5 years is 28% 2

Common Pitfalls and Complications

Potential Complications to Monitor

• Pelvic pain 1
• Vaginal expulsion of submucosal fibroids (5% of patients; all at-risk patients can be identified at preembolization hysteroscopy) 1, 6
• Post-embolization syndrome 1, 5
• Ovarian failure or amenorrhea (1-7% in literature) 4, 8
• Premature menopause (usually in women in late 40s, may occur in 1% of cases) 8, 6
• Rarely, venous thromboembolism 4

Critical Safety Considerations

• Approximately 1 in 350 women undergoing treatment for presumed fibroids has unsuspected uterine sarcoma 1, 2
• MRI follow-up is essential to exclude leiomyosarcoma, not just assess treatment efficacy 2
• Genitourinary infection is the predominant cause of serious morbidity and mortality 3
• Hysterectomy may be urgently required and potentially lifesaving in rare cases of major complications 3

Fertility Considerations

• Pregnancy is possible after UAE and patients should be counseled accordingly 1
• Recent prospective studies demonstrate high live birth rates (10/12 pregnancies) with low miscarriage rates (1/12) 1
• Retrospective cohort study showed live birth rate of 73% (109/148) with miscarriage rate of 17.5% 1
• Women who desire pregnancy should be cautioned about potential complications during pregnancy 8