2. • Asymptomatic
• Heavy uterine bleeding
• Pain
• Dyspareunia
• Pressure symptoms
Uterine Leiomyomas - Fibroids
• Benign monoclonal tumours
• 9% of women < 44 years old
• 40% of women > 40 years old
3.
4. • Myomectomy
• 35,000 a year (US)
• Hysterectomy
– 300,000 a year (US)
NICE: Symptomatic Fibroid(s) >3cm:
• Gonadotrophin releasing
hormone (GnRH) analogue
• Uterine artery embolisation
5.
6. Uterine artery embolisation
• Day case
• Sedation – Diazemuls (5mg/min IV infusion)
• Analgesia - Paracetamol (500mg IV)
• Local anaesthesia - Lidocaine
• Morphine (5mg IV)
• Metoclopramide (10mg IV)
13. Evidence Base
• Introduced in 1997
• 4 RCTs (n= 403)
• 1 Comparative study
• 3 Case series
• UK registry (n= 1387)
• US registry (n= 2112)
14. • SymptomsSymptoms improved in 85 – 95% of patients
• 30 – 48% decrease in fibroid volumefibroid volume (all studies)
• Improved quality of lifequality of life 39/100 (US registry n=2112)
• 91% would recommendrecommend to a friend (HOPEFUL n=649)
• 90% < 2 nights2 nights in hospital (Gabriel-Cox n=562)
Efficacy
15. Complications
Procedure
•Early: 6.9% (Mara n=58)
•1st
month: 20.7% (Mara n=58)
•1 year: 17.6% (HOPEFUL 649)
Non target emboli
•Amenorrhea
•Buttock/Bladder
•1 death
(Goodwin 2009)
Failure
•11% required further
treatment (UK registry n= 1387)
Fertility
•27 women
•37 pregnancies
•19 live births
(HOPEFUL n= 649)
16.
17.
18. References
• Dutton S, Hirst A, McPherson K, et al. (2007) A UK multicentre retrospective cohort study
comparing hysterectomy and uterine artery embolisation for the treatment of symptomatic
uterine fibroids (HOPEFUL study): main results on medium-term safety and efficacy. BJOG
114: 1340–51.
• Edwards RD, Moss JG, Lumsden MA, et al. (2007) Uterine-artery embolization versus surgery
for symptomatic uterine fibroids. New England Journal of Medicine 356: 360–70.
• Gabriel-Cox K, Jacobson GF, Armstrong MA, et al. (2007) Predictors of hysterectomy after
uterine artery embolization for leiomyoma. American Journal of Obstetrics & Gynecology
196: 588.e1–588.e6.
• Goodwin SC, Spies JB, Worthington-Kirsch R, et al. (2008) Uterine artery embolization for
treatment of leiomyomata. Obstetrics & Gynecology 111; 22–33.
• Goodwin, S.C. & Spies, J.B. (2009) Uterine Fibroid Embolization. The New England Journal of
Medicine. 361:690-697
• Gupta, J.K., Sinah, A., Lumsden, M.A. & Hickey, M. (2009) Cochrane Review – Uterine artery
embolization for symptomatic fibroids. The cochrane collaboration.
• Hirst A, Dutton S, Wu O, et al. (2008) A multi-centre retrospective cohort study comparing
the efficacy, safety and cost-effectiveness of hysterectomy and uterine artery embolisation
for the treatment of symptomatic uterine fibroids. The HOPEFUL study. Health Technology
Assessment 12 (5).
19. References
• Mara M, Maskova J, Fucikova Z, et al. (2008) Midterm clinical and first reproductive results of
a randomized controlled trial comparing uterine fibroid embolization and myomectomy.
Cardiovascular & Interventional Radiology 31: 73–85.
• Marshall LM, Spiegelman D, Barbieri RL, Manson JE, Colditz GA, Willett WC, et al.Variation in
the incidence of uterine leiomyoma among pre menopausal women by age and race.
Obstetrics & Gynecology 1997;90:967–73.
• Moss JG, Lumsden MA, Murray GD, et al. (2010) Long term (3-5 year) follow up and MRI
imaging of the REST trial cohort. Unpublished personal communication.
• O’Grady EA, Moss JG, Belli AM, et al. (2009) UK uterine artery embolisation for fibroids
registry 2003–2008. The British Society of Interventional Radiology.
• Spies JB, Bruno J, Czeyda-Pommersheim F, et al. (2005) Long-term outcome of uterine artery
embolization of leiomyomata. Obstetrics & Gynecology 106: 933–9.
• Volkers NA, Hehenkamp WJK, Birnie E, et al. (2007) Uterine artery embolization versus
hysterectomy in the treatment of symptomatic uterine fibroids: 2 years’ outcome from the
randomized EMMY trial. American Journal of Obstetrics & Gynecology 196: 519.e1–519.e11.
• Walker WJ, McDowell SJ. (2006) Pregnancy after uterine artery embolization for
leiomyomata: a series of 56 completed pregnancies. American Journal of Obstetrics &
Gynecology 195: 1266–71.
Editor's Notes
Affected by sex steroid hormones – don’t see in children and tend to regress after the menopause
Nurses health study 2 incidence rates confirmed by USS or hysterectomy
Heavy bleeding in turn causesiron deficiency anaemia
Heavy bleeding especially if fibroid is growing into endometrial cavity and increasing surface area
Symptomatic fibroids – due to the fibroid itself or related eg anaemia/hydronephrosis from ureteric obstruction
Hysterectomies for fibroids cost $1.5 billion in 2000 in US
UAE originally devised to reduce bleeding due to post partum haemorrhage
Perfusion from ovarian artery
Additional supply from ovarian artery is seen in 5 – 10% of cases
Anastamoses between left and right uterine arteries occurs in 10%
Treated fibroids shrink over several months to a year
PVA is suspended in contrast so you can see where it is going
Pinto n = 57, UAE Vs Hysterectomy
EMMY n = 177, UAE Vs Hysterectomy
Mara n = 63, UAE Vs Myomectomy
REST n = 106 UAE Vs Surgery
Symptoms include menorrhagia, pelvic pain
Improved quality of life according to UFS-QOL questionnaire HRQoL score)
EMMY trial (RCT) showed mean hospital stay for UAE was 2.7 days Vs 5.1 days for hysterectomy)
Post procedural pain, post embolisation syndrome, Fibroid infection 5.9%
Almost all who have permanant amenorrhea are perimenopausal
Non target embolisation death – uterine arteriovenous shunting and a patent foramen ovale
Further treatment – 3% hysterectomy, 1% Myomectomy, 5% repeat UAE (UK registry 1387)
Fertility. Number of women that became pregnant only represented 8.5% of those that expressed a possible wish to become pregnant.
In US study, 30% of those attempting to become pregnant became pregnant. Of these, 58% had a successful outcome
Fibroid reduction – evidence of fibroid on USS after 1 year
HOPEFUL
Drawbacks to UAE – larger single fibroids show less improvement – may not be the case, morphological considerations – broad ligament, cervical or narrow based pedunculated fibroids. Little evidence to support this
Contraindications pregnancy, Pelvic cancer, infection
(2) Mara (2008)
Fibroid reduction – evidence of fibroid on USS after 1 year
HOPEFUL
Drawbacks to UAE – larger single fibroids show less improvement – may not be the case, morphological considerations – broad ligament, cervical or narrow based pedunculated fibroids. Little evidence to support this
Contraindications pregnancy, Pelvic cancer, infection
(2) Mara (2008)
