Uterine Artery/Fibroid Embolisation (UAE)

Fibroids are benign (non-cancerous) tumours of the uterus (womb). They are very common, affecting about half of all women at some stage in their lives. Most women with fibroids have no symptoms and may not even know they have them. However, but a lot of women suffer with pain and bleeding.

Fibroids are made up of disorganised muscle fibres of the uterus and have a large supply of blood to them. No one knows for sure what causes fibroids, but they are certainly influenced by hormones, and most likely to grow faster when oestrogen is highest in a woman’s middle life. They are rare in teenagers and are most common in 30-50 year olds; they shrink naturally after the menopause.

Ultrasound and/or MRI scans are used to confirm the diagnosis of fibroids and map them out to guide treatment. For instance, some women have only one big fibroid while others may have many, and this may determine which treatment options (if any) are most appropriate.

Adenomyosis is a condition where the cells that form the inner lining of the womb (endometrium) are found in the muscle layer (myometrium) where they are not normally present. This is also common, affecting one in every five women who see a gynaecologist. As with fibroids, many women will not know they have adenomyosis. Other women will experience heavy and/or painful periods. Ultrasound and/or MRI can confirm the diagnosis.

More information on both these conditions can be found in our information leaflets entitled “Fibroids” and “Adenomyosis”

UAE is a procedure to temporarily block the blood supply to the uterus and any of its fibroids. It is performed using X-rays for guidance. Unlike surgery for fibroids, it does not require a cut on your tummy, but instead accesses to the blood supply to your uterus and fibroids via an artery in your arm or groin.

Fibroids generally shrink by 40 to 70% in size after treatment. It is often very successful in treating symptoms: eight out of 10 women report that they either have no symptoms or significantly improved symptoms after one year.

For adenomyosis, eight out of 10 women report long-term improvement in pain and bleeding after UAE.

This treatment is not currently recommended for women planning to have future pregnancies, as the impact on fertility and future pregnancies is uncertain. However, there are many examples of women who have had UAE and gone on to have healthy pregnancies.

The risks of UAE are low, but any procedure that involves placement of a catheter inside a blood vessel (artery) carries certain risks. These risks include:

• Mild bruising/bleeding at the access site in the groin or wrist is to be expected.
• Very rarely (1 patient in 500), there is a chance that the embolic (blocking) particles can lodge in the wrong place and cause pain/damage to other tissues.
• As with any operation using X-ray contrast ‘dye’ (e.g., a CT scan) 1 patient in 10,000 may have an allergic reaction to the X-ray contrast ‘dye’ used during uterine fibroid embolisation. The effect may range from mild itching to severe reactions.
• A vaginal discharge is common after embolisation (sometimes passing small pieces of fibroid tissue) and may persist for some weeks. Rarely a larger fibroid is passed, and you may need to see your Gynaecologist to assist in its removal.
• There is a 2–4% chance that the procedure will lead to premature menopause. This occurs usually in women who are 45 years or older. Most women find it takes about six to nine months to resume a regular menstrual cycle.
• Late risk of infection (four to six weeks after procedure) of the uterus. (1 patient in 500) This is very rare and treated with antibiotics. Severe infection requiring hysterectomy has been reported at no greater frequency than infection after myomectomy operation.
• In 10-15% of women, the blood supply to the fibroid uterus is so strong and drawn from many alternative arteries such that the fibroids are not destroyed and can regrow. In over half of these cases a further UAE procedure completes the treatment of the fibroids. A small number of women may have to then consider hysterectomy.

There are many non-hormonal and hormonal medical treatments for fibroids and adenomyosis. There are also surgical treatments such as myomectomy and hysterectomy. Many women do not need or want any treatment at all.

How appropriate each option is for you will depend on the size and location of your fibroids, your symptoms and any surgery you have had before as well as your preferences.

For more information, please refer to the following UCLH leaflets:

‘Fibroids’

‘Adenomyosis’

You will be fully involved in the decisions about your care and treatment. If you decide to go ahead with procedure, by law we must ask for your consent and will ask you to sign a consent form. A consent form is signed by both you and the interventional radiologist, confirming that you have discussed the procedure and been informed of the risks, benefits, alternatives and have agreed to have the UAE procedure. (You can have a copy of this form to take with you).

Please feel free to ask any questions that you may have and, remember that even at this stage, you can decide against going ahead with the procedure if you so wish.

A few weeks before your surgery you will be asked to attend a preoperative assessment appointment, this can be by telephone

or in the hospital. You will be asked questions about your health, medical history and home circumstances. Some blood tests will also be required. You will be given information about the morning of your procedure: when to stop eating and drinking, and if you need to stop taking any of your regular medications.

Please make sure that you have had any intra-uterine devices (Mirena® or copper coil) removed prior to this treatment.

Please tell the doctor who refers you for this procedure, if you are taking Clopidogrel™, Warfarin™ or other blood thinning medication.

You should use a reliable form of contraception prior to the procedure as UAE cannot be performed on pregnant women.

Make sure you are not constipated before you come in for your operation as it will cause discomfort during your recovery.

Buy pain medication; paracetamol and ibuprofen, to use when you return home. The hospital will not supply non-prescription medicines on discharge, but you will need them for your recovery.

We recommend you have a thermometer at home, to check your temperature during your recovery.

Plan how you will travel home after your procedure. Your arrangements will need to be flexible as you may be well enough to go home earlier, or you may have to stay in hospital longer if you require further hospital care.

UAE can be a day case or an overnight hospital stay. Even if you are booked as a day case, we recommend you bring a small overnight bag in case there is a medical need for you to stay.

Please remove nail varnish before your procedure.

On the day of your procedure

You must not eat for six hours before the procedure; we encourage you to drink clear fluids up to two hours prior to your appointment. Clear fluids are water (non-fizzy), black coffee and black tea (without milk).

You will need to come to the Imaging Department at the time instructed on your appointment letter.

Location: 2nd Floor Podium

To get to the Imaging Department, please use the Podium lifts to the left of the main reception desk on the ground floor.

You are welcome to bring a relative to escort you to the hospital but must be aware they are unable to be present during your procedure.

You will be welcomed by the nursing staff who will check your observations (blood pressure, temperature, pulse) and give you an identity bracelet to wear. You will have a pregnancy test to confirm that you are not pregnant. You will be given a hospital gown to put on for your procedure and you may be asked to remove your underwear if the procedure is planned for the femoral artery approach.

You will see the radiologist who will explain the procedure and confirm your consent (permission) for the UAE. You will also see the anaesthetic associate who will explain to you how the sedation will work and discuss the options available to control your pain after the procedure. This will be an opportunity for you to ask any questions you still have. If you have any allergies, you must let your doctor know. If you have previously reacted to intravenous contrast medium (the dye used for kidney x-rays and CT scans), then you must also tell your doctor about this.

Sometimes procedures may be delayed or cancelled if you need to stay in hospital overnight and a ward bed is unavailable for you after your procedure. We know this is distressing and we will do everything we can to avoid it and keep you informed during any delays.

You will have this procedure under sedation, this will make you feel relaxed and sleepy but still aware of your surroundings.

An anti-inflammatory pain killer suppository (medication inserted into your rectum) may be given just prior to the procedure. Other pain medication will be given intravenously.

You will lie on the X-ray table, generally flat on your back. You will have monitoring devices attached to your chest and finger and will be given oxygen by a mask.

The procedure is performed under sterile conditions and the interventional radiologist and radiology nurse will wear sterile gowns and gloves.

There are two approaches to access the uterine artery: the femoral artery approach (in your groin) and the radial artery approach (in your wrist). The choice of access will be discussed with you and selected depending on your suitability and comfort. Local anaesthetic is injected into the selected access site, your wrist or groin. This may sting slightly going in, but the area will soon go numb.

The radiologist uses X-ray equipment to guide the catheter into the arteries, which are feeding the fibroids, ‘uterine arteries’. A dye, called a contrast agent, is injected down the catheter to help visualise the uterine arteries. This injection of dye may give you a hot feeling in the pelvis.

After accessing the uterine arteries, embolic (blocking) particles are injected into the arteries via the catheter to stop the blood flow to the fibroids (embolisation).

You may develop cramp-like pelvic pain toward the end of the procedure, this is treated with intravenous painkillers.

At the end of the treatment, the catheter is removed and the Radiologist will press firmly on the skin site for several minutes to prevent bleeding.

Every patient’s is different, and it is not always easy to predict the exact duration of the procedure. On average the procedure lasts one hour.

fter the procedure, you will be taken to the recovery area on a trolley. A recovery nurse will carry out routine observations, such as taking your pulse and blood pressure, to make sure that there are no problems. They will also regularly check your skin at the access point (wrist or groin) to make sure there is no bleeding from the artery.

You will need to stay lying on the trolley for four hours, two hours laying flat and two hours sitting up. This is to prevent bleeding.

You will be allowed to eat and drink after the procedure if all your observations are normal and you have recovered from the sedation.

Once the recovery nurses are satisfied you are well, you will be either sent to the ward for your overnight stay or you will be sent home.

The radiologist will talk to you after the procedure before you leave the imaging department and will write a detailed report on the findings straight afterwards. This written report will be available to your referring doctor.

Your recovery

Wound

To prevent bleeding please avoid any heavy lifting, strenuous activity or driving for at least three days. Tenderness may last for a week, bruising may go on to two weeks and a small lump may appear which can last up to six weeks. Mild oozing from wound site and bruising is expected but if you notice increasing bruising or swelling at the access site (wrist or groin), you may need an ultrasound scan to check the blood vessel has healed fully.

If you have a dressing covering your procedure site, please keep it dry for the first 48 hours. When you take a bath or shower after this time, remove the dressing first. Do not soak the dressing or allow it to stay wet for a long period. Pat the area try with a clean towel and if necessary, replace the dressing.

Pain

It is normal to feel some pain after the procedure due to uterine spasm (similar to strong period pains). This is expected to last approximately three days but can last longer.

A combination of pain medication provides the best pain relief after surgery. Taking “regular painkillers” throughout the day and “rescue painkillers” if you need them.

Regular pain killers:

• Paracetamol (four times a day)
• Ibuprofen or Diclofenac (three times a day)
• Hyoscine Butylbromide (four times a day)

Rescue pain killers

• Dihydrocodeine

We recommend you take all the regular pain relief for three days or until you no longer need to use rescue painkillers, then start reducing your regular pain killers. You will also be given a gentle laxative (to keep your stool soft) and prevent constipation while taking dihydrocodeine.

It can be helpful to write down the time you have taken your different medication. This can help you spread your pain killers evenly through the day to give you the best pain relief.

Temperature

A slight raised temperature is common up to two weeks after UAE, it is a natural reaction to the fibroid tissue being destroyed in the body. A persistent high temperature 38 °C or above or temperature longer than two weeks after UAE may be a sign of infection.

Vaginal bleeding and discharge

A brownish pink discharge is common for several weeks after UAE. If the discharge is causing vulval irritation or has a bad smell this could be a sign of infection and you should be seen by your GP.

You may pass small fragments of fibroid tissue. Passing a complete fibroid is rare, it is usually accompanied by fresh vaginal bleeding and increased abdominal pain.

We would recommend using period pads until the discharge has settled and your period resumes.

Your normal menstrual period may not return for several cycles.

Sexual intercourse

You won’t be able to have sexual intercourse immediately post procedure but there is no evidence to suggest a specific time frame for when you can safely resume sexual activities.

Returning to normal activity and work

You may feel very tired for up to two weeks and we encourage you to rest for three to four days. Most women have returned to their normal activities and work within two weeks. If you need a sick certificate for time off work, please let the nursing staff know and a two week certificate will be provided before you leave the hospital. If you find you are not ready to return to work after two weeks please contact your GP.

Driving

Avoid driving for three days after UAE.

For any further advice, please contact the recovery nurse phoneline.

Follow-up appointment

Follow up will be arranged by your gynaecology team.

Six months after UAE:

• MRI scan
• Quality of life questionnaire send by MyCare at 6 months

Six to seven months after UAE:

• Gynaecologist appointment, this may be a telephone appointment of in the clinic.

If you have not received a follow up appointment you can contact Gynaecology enquiries.

Advice and support after discharge

Gynaecology Enhanced Recovery Nurse. A senior nurse, for advice on pain management and general recovery.

07815 642 930 - Monday to Friday 09:00 – 16:00.

If the call is not answered, please leave a voicemail with your:

1. full name
2. date of birth or hospital number
3. your contact number
4. a brief reason for your call

Consult your GP or 111 if you experience any of the following:

• Offensive smelling vaginal discharge.
• Moderate pain not relieved after following full discharge instructions for pain medication.
• Constipation not relived after taking regular laxatives.

Attend your nearest emergency department (A&E) if you experience any of these issues, taking discharge summary with you:

• a sudden feeling of shortness of breath and/or chest pain
• a temperature of 38°C or above
• severe pain or increasing pain, after following full discharge instructions for pain medication
• nausea and vomiting that is stopping you eating and drinking more than 24 hours
• unable to pass urine or passing very small amounts and not feeling your bladder is empty
• heavy bleeding from your vagina (two fully soaked night sanitary pads in two hours in a row)
• pain, swelling or redness in your leg
• bleeding from artery puncture site that does not stop after applying pressure for 10 minutes.

Some of your questions should have been answered by this leaflet but remember that this is only a starting point for discussion about your treatment with the doctors looking after you.

British Society of Interventional Radiology

www.bsir.org

The Royal College of Radiologists

www.rcr.ac.uk

Society of Interventional Radiology - Nonsurgical Treatments

www.sirweb.org

National Institute of Clinical Excellence

www.nice.org.uk

Royal College of Obstetricians and Gynaecologist

www.rcog.org.uk

UCL Hospitals cannot accept responsibility for information provided by other organisations.

If you have questions regarding your preparation or attendance for the procedure, please contact the radiology team

Interventional Radiology Clinical Nurse Specialist:

07374 875 629

Address:

Interventional Radiology Imaging Department

University College Hospital

2nd Floor

235 Euston Road

London

NW1 2BU

Radiology email: uclh.referrals.interventionalradiology@nhs.net

Radiology Admin enquiries phoneline: 020 3447 3267

If you would like to discuss your decision to go ahead with the procedure further, or you need follow-up after the procedure, please contact the gynaecology team.

Gynaecology enquiries: uclh.gynaeadmissions@nhs.net

Gynaecology enquiries phoneline: 020 3447 9411

Post procedure advice can be obtained from our enhanced recovery nurses . In an emergency, please phone 111, 999, or come to A&E.

Gynaecology Enhanced Recovery Nurse: 07815 642 930 (Monday to Friday 09:00 - 16:00)

Hospital contact details:

UCH Switchboard: 020 3456 7890

Website: www.uclh.nhs.uk

Procedures:

The Imaging Department, Level 2 Podium in the main University College Hospital building with the entrance on Euston Road (see map attached).

Travelling to the hospital

No car parking is available at the hospital. Street parking is limited and restricted to a maximum of two hours.

Please note the University College Hospital lies outside, but very close to the Central London Congestion Charging Zone.

Tube

The nearest tube stations, which are within two minutes’ walk are:

• Warren Street (Northern and Victoria lines)
• Euston Square (Hammersmith& City, Circle and Metropolitan lines)

Overground trains

Euston, King Cross & St Pancras and Kings Cross Thames link railway stations are within 10-15 minutes’ walk.

Bus

Further travel information can be obtained from http://www.tfl.gov.uk / 020 3054 4040

Hospital transport service

If you need (and are eligible for) transport, please call: 

020 3456 7010 (Mon to Fri 8am-8pm) to speak to a member of the Transport Assessment Booking Team.

If you have a clinical condition or mobility problem that is unlikely to improve you will be exempt from the assessment process. However, you will still need to contact the assessment team so that your transport can be booked. If your appointment is cancelled by the hospital or you cannot attend it, please call 020 7380 9757 to cancel your transport.

University College Hospital Area Map