1. Each patient should have a pelvic examination by her gynecologist within six months of the procedure. We will need a copy of the records for the most recent gynecology office visit.
2. We also need the results of the most recent Pap smear, which must be within the last year and should be normal.
3. For patients with abnormal uterine bleeding (periods lasting longer than 10 days or periods more frequently than every 21 days) , an endometrial biopsy should be done, preferably within the preceding 3 to 6 months. This is to be certain that endometrial carcinoma or hyperplasia is not present. We usually decide if an endometrial biopsy is needed at the time of the interventonal radiology consultation.
4. If the patient has a history of pelvic infection within 2 years, cultures for Gonorrhea and Chlamydia should be obtained.

This evaluation may be done by your gynecologist: you do not need to be seen by a Georgetown Gynecologist.

1. All patients will be required to have a pre-procedure evaluation by the interventional radiology staff at Georgetown. This allows us to obtain a gynecologic and general medical history, perform a brief physical examination, review the imaging findings and to discuss the procedure with the patient.
2. The patient must not be pregnant. We will confirm this with a pregnancy test the day of the procedure.
3. A blood count and follicle stimulating hormone blood test will be obtained on the day of the procedure. If the patient has a history of kidney disease or coagulation defect, further laboratory testing may be required.
4. An MRI of the pelvis must be obtained. We prefer that this be done at Georgetown to ensure uniformity of imaging. We have instituted a reduced charge for this study. If the MRI is done at another site, the study must be done with and without contrast and include length, width, and depth of the uterus and the dimensions of the identifiable dominant fibroids. The study must also be of sufficient quality to allow adequate detail of the fibroids and the lining of the uterus. If these are not done, the study will have to be repeated.

Preparing for the Procedure
On the day of your procedure, you should not have anything to eat or drink by mouth (unless we have given you special instructions to the contrary). This will allow us to give medication to sedate you during the procedure. You may take any prescription medications by mouth with a sip of water.

We will give you a specific time to arrive, usually 2 hours before your procedure is to start. This will allow time for you to register and to be changed into a hospital gown. We will need time to start an intravenous line, to obtain blood and urine tests, and to answer any last minute questions you may have.

We usually obtain a blood sample to check your blood count on the day of the procedure. In special circumstances, we might obtain other blood tests. If you are more than 10 days from the start of your last period, we will need to confirm you are not pregnant with a urine pregnancy test.

We also need to place a catheter in your bladder, so that the bladder will remain empty during the procedure. Since the bladder is directly in front of the uterus, it is important that it does not fill during the procedure or it would obscure our view.

The Procedure
The procedure is usually done in the hospital with an overnight stay post-procedure. The patient is sedated and very sleepy during the procedure. Initially, a needle is used to enter the artery to provide access for the catheter. Local anesthesia is used, so the needle puncture is not painful. The catheter is advanced over the branch of the aorta and into the uterine artery on the side opposite the puncture. At Georgetown, a second arterial catheter is placed from the opposite femoral artery to the other uterine artery and the embolizaton of the fibroids is done from both sides simultaneously.

We routinely use polyvinyl alcohol particles or Embospheres to block the fibroid arteries. In recent months, we have begun to favor Embospheres as they allow for a more controlled embolization and it is easier to preserve flow to the normal parts of the uterus. We have used gelfoam for uterine embolization in only one patient and it was in a patient with primary adenomyosis. While others have used it more frequently, there is not yet any data that confirms that the uterine artery is likely to open up after embolization. For a more detailed discussion of the various substances used to block the arteries, please review the page on embolic agents.

After the embolization is complete, a final arteriogram is performed to be sure the fibroid flow is blocked. Usually we will obtain images of the ovarian arteries in addition to be sure there is no contribution of blood flow to the fibroids.

When the procedure is finished, the catheters are removed and the puncture sites are compressed for 15 to 20 minutes. The patient must remain at bedrest for 6 hours after the procedure in order to prevent bleeding from the puncture sites. As an alternative to compression and bed rest, we are now on some occasions using a closure device to seal the puncture sites. If these devices are used, no compression is needed and the patient is able to get up 2 hours after the procedure.

Post-Procedure: What to expect

Pain
Most patients will experience several hours of moderate to severe pain after the procedure. It is believed that this pain is due to the death (infarction) of the fibroids, similar to a heart attack. Temporary decrease in the blood supply to the normal portions of the uterus may also contribute to the pain.

The severity of pain is quite variable. Approximately 20% of patients have little or no pain after the procedure. About 20% of patients will have severe pain that may last for several hours. Most patients have pain some where in between the two extremes. We have completed a study at Georgetown to determine the severity of the pain after UAE and whether its severity can be predicted. Unfortunately, the severity of pain is not predictable based on the size of the uterus or the size of the fibroids. Some patients with very large fibroids have minimal pain and some with small fibroids have severe pain. The pain usually begins to diminish after 4 to 6 hours. Parenthetically, the severity of the pain also does not predict outcome. Severe pain does not correlate with a better outcome.

Since pain does not have any value in predicting outcome, it should be treated aggressively to ensure that the patient has a tolerable procedure. Most centers use a combination of anti-inflammatory medicines (such as Motrin) and narcotics (such as morphine) to control the pain. The most common means of providing the narcotics is via a PCA pump, which is a device attached to the patient's intravenous line. PCA stands for patient controlled analgesia. If pain occurs, the patient is able to press a button and administer a dose of pain medication. Many studies have demonstrated that PCA pumps are more reliable in controlling pain than nurse administered doses. The large majority of patients at Georgetown and elsewhere are managed with PCA pumps after the procedure. This is not to say that there are not effective alternatives. There has been research on the effectiveness of using an "all oral" medication regimen, without any injected drugs.

Some centers, including Georgetown, offer the alternative of epidural pain control. With epidural pain control, a tiny tube is placed in the spinal canal outside the sac where the nerves lie. This is usually done by an anesthesiologist. It is the same procedure that is commonly used during labor, but the legs are not numbed. After the procedure, pain medications are given via the epidural catheter. Although the use of an epidural catheter is more invasive than an intravenous line, the pain control may be better. As of yet a study has not been completed comparing the two methods of pain management.

Nausea and Vomiting
Another frequent side effect of uterine embolization is nausea and vomiting. This may be caused by the death of the fibroid tissue or as a result of the pain control medications. The nausea can usually be controlled by medications and most physicians performing uterine embolization provide standing orders for nausea medicine if needed.

Because the severity of the symptoms from uterine embolization is very variable, many centers routinely observe patients in the hospital overnight. Under most insurance plans, this is still considered an outpatient procedure, because the length of stay is less than 24 hours.

After discharge from the hospital: What to expect
Most patients will have recurrent cramping pelvic pain over several days after discharge. Usually this pain feels like menstrual cramps. On occasion, the pain may become severe. At Georgetown, patients are given an anti-inflammatory medicine to take continuously for four days. This is supplemented by oral narcotics as needed.

Nausea may also recur and medication is also provided for this. Fever is common and is a side effect of the death of the fibroid tissue. Most patients feel as if they have the flu for several days. All these symptoms begin to improve after 4 to 5 days and most patients are ready to return to work 7 to 10 days after the procedure.

For a more detailed discussion of the post-procedure recovery, review our post-discharge instructions.

Georgetown University Follow-up Protocol
We call the patient the day after discharge to be sure that there are no unusual problems and to answer any questions the patient may have. We will also arrange for a follow-up visit 1 week after the procedure. At that visit we will check the puncture sites and intravenous site to be sure they have healed and we will review the progress of your recovery. At that time we usually release a patient to return to full activity. We will call the patient 30 days after the procedure to be sure that no problems or gynecologic procedures have been required.

To follow the progress of the symptoms, we will send questionnaire 3 months post-procedure. Follow-up imaging with MRI is at 3 months. If symptom improvement has occurred and the images shows the fibroids have died and are shrinking, then further follow-up is on an as needed basis. For many of our research protocols, we have longer and more detailed follow-up.

We ask that all the patients we treat allow us to anonymously submit baseline and procedure data to the national FIBROID registry. A fibroid-specific symptom and quality of life questionnaire and a short questionnaire will be sent to a randomly selected group of patients at 6 months, 12 months and 24 months after the procedure. We hope to obtain federal funding to continue follow-up for up to five years in this registry.

We consider this procedure and the MRI before and 3 months after the procedure to be standard medical care and therefore bills will be submitted to the patient's insurance as usual. Any additional imaging that is done for research purposes will be provided at no charge to the patient.

For more information

If you would like to consider this procedure or would like more information, you may call James B. Spies M.D. of Georgetown Interventional Radiology at (202) 784-5478 to make an appointment. You may also contact him via email FIBROIDINFO@gunet.georgetown.edu. We would also be happy to discuss uterine embolization with your gynecologist.