Ovarian failure after uterine artery embolization for treatment of myomas

A comprehensive review of the new FIGO classification of ovulatory disorders

BACKGROUND

The World Health Organization (WHO) system for the classification of disorders of ovulation was produced 50 years ago and, by international consensus, has been updated by the International Federation of Gynecology and Obstetrics (FIGO).

OBJECTIVE AND RATIONALE

This review outlines in detail each component of the FIGO HyPO-P (hypothalamic, pituitary, ovarian, PCOS) classification with a concise description of each cause, and thereby provides a systematic method for diagnosis and management.

SEARCH METHODS

We searched the published articles in the PubMed database in the English-language literature until October 2022, containing the keywords ovulatory disorders; ovulatory dysfunction; anovulation, and each subheading in the FIGO HyPO-P classification. We did not include abstracts or conference proceedings because the data are usually difficult to assess.

OUTCOMES

We present the most comprehensive review of all disorders of ovulation, published systematically according to the logical FIGO classification.

WIDER IMPLICATIONS

Improving the diagnosis of an individual's ovulatory dysfunction will significantly impact clinical practice by enabling healthcare practitioners to make a precise diagnosis and plan appropriate management.

Unsuccessful Uterine Artery Embolization Requiring Subtotal Hysterectomy: A Case Report

Introduction: The purpose of this case report is to present the case of a 49-year-old female individual with uterine fibroids, who underwent a subtotal hysterectomy after prior unsuccessful uterine artery embolization. Uterine artery embolization is a minimally-invasive technique used as an additional option for the treatment of symptomatic fibroids. The method is a promising technique, indicated for female individuals of reproductive age wishing to preserve their uteri.

Case Presentation: The patient presented symptoms of bloating and menorrhagia. Magnetic Resonance Imaging revealed uterine enlargement and elongation, with several fibroids and urinary bladder deformation caused by the enlarged uterus and the numerous fibroids compressing the uterine apex. She was referred for uterine artery embolization. In the three-year follow-up imaging, no alteration of the uterus’ size was observed, while two fibroids were noted, suggesting necrosis or malignancy based on imaging findings, which led to the conduction of partial hysterectomy while leaving the cervix intact.

Discussion: Uterine artery embolization is regarded as a safe and successful procedure. However, in case of ineffectiveness, full or partial hysterectomy is considered as the ultimate treatment of choice.

Conclusion: According to the available literature, uterine artery embolization is promoted to be an efficient alternative option to surgery. Patients should be offered adequate medical consultation on all the treatment options and possible complications.

Variables that prolong total operative time for robotic-assisted laparoscopic myomectomy: A 10-year tertiary hospital study in Korea

STUDY OBJECTIVE

To identify factors that prolong total operative time (TOT) in robotic-assisted laparoscopic myomectomy (RALM).

DESIGN

Retrospective cohort study.

SETTING

Tertiary university hospital.

PATIENTS

Women who underwent RALM between April 2009 and May 2019 conducted by a single high-volume gynecologic surgeon.

INTERVENTIONS

Patients' demographic data and intraoperative records were obtained. The association between the perioperative characteristics and TOT was analyzed.

MEASUREMENTS AND MAIN RESULTS

A total of 584 cases met the inclusion criteria, with a mean TOT of 231.6 ± 86.7 min. The mean patient age was 36.3 ± 5.5 years, and the patients had a mean of 4.2 ± 4.0 myomas. The dominant myoma had a mean diameter of 7.6 ± 2.6 cm. The mean total weight of the extracted myomas removed was 202.2 ± 152.6 g. From multiple regression analysis, the following perioperative factors were intimately associated with the TOT: ① body mass index, ② the number of myomas, ③ weight of total myomas, ④ location of dominant myoma, ⑤ type of da Vinci robot system, ⑥ endometrial cavity opening during the operation, ⑦ intraoperative blood loss, and ⑧ patient hospitalization period. The number of myoma was most closely related to the TOT, with an R² value of 0.330. All of the above factors with the exception of the type of robot system and location of dominant myoma were related to the console time. Age, parity, history of previous abdominal surgery, surgical indication, diameter, and FIGO classification were not associated with the TOT.

CONCLUSION

With an accurate identification of the perioperative parameters above, we can improve the quality of RALM by counselling, selecting an appropriate patient selection, and preoperative planning.

Pregnancy outcomes in nulliparous women after ultrasound ablation of uterine fibroids: A single-central retrospective study

To explore the impact of high-intensity focused ultrasound (HIFU) ablation of uterine fibroids in nulliparous women on subsequent pregnancy and delivery. A retrospective analysis was conducted of nulliparous women who received HIFU treatment at Chongqing Medical University, Chongqing,China, from January 1, 2010, to January 1, 2015. A total of 189 cases were enrolled, the median follow-up time was three years. Among them,there were 131 cases pregnancy with a total of 133 times,the pregnancy rate was 69.3% (131/189),and the spontaneous conception rate was 95.4% (125/131). Of 131 pregnant women, 19 were on-going pregnancy, terminated pregnancy 114 times,which include 93 times successfully delivery with a 76.3% (87/114) full-term birth rate,and the cesarean section rate was 72.0% (67/93). Of 94 newborns,the average birth weight was (3.3 ± 0.4)kg (range:1.5–4.8 kg), and a pair of them were identical twins. The incidence of complications during pregnancy and delivery were 10.8% (10/93) and 7.5% (7/93),respectively,except one woman failed on-going pregnancy and one woman suffered hysterectomy due to the complications,others all successful pregnant and delivered. Multiple-factor regression analysis found that age and infertility history were the important factors that may affect pregnancy after HIFU (P < 0.01). Nulliparous women who undergo HIFU treatment for uterine fibroids can subsequently have successful pregnancy and delivery safely.

The effects of uterine artery embolization on ovarian reserve

OBJECTIVE

To evaluate the effects of UAE for symptomatic uterine fibroids on ovarian reserve based on AMH.

STUDY DESIGN

This was a retrospective study conducted between March 2011 and October 2014. All women underwent UAE. At baseline and at the 3-month and 12-month follow-up visits, serum anti-Müllerian hormone (AMH), follicle stimulating hormone (FSH), luteinizing hormone (LH), and estradiol (E2) levels were assessed, and ovarian volume and antral follicle count (AFC) were evaluated in each patient.

RESULTS

There were no statistically significant differences in serum E2, LH, or FSH levels or in ovarian volume 3 or 12 months after UAE (P=0.8194, P=0.3976, P=0.4766, and P=0.6822, respectively). However, AMH and AFC were significantly different 3 and 12 months after the procedure (P=0.00, P=0.029 and P=0.00, P=0.00, respectively). AMH levels remained low after 12 months of follow-up compared to the expected AMH levels. A statistically significant recovery of serum AMH at 12 months compared to at 3 months in those <40 years of age (P=0.00), but not in those ≥40 years (P=0.837).

CONCLUSIONS

Ovarian reserve appears to be affected by UAE in premenopausal women. However, younger ovaries (according to biological ovarian age) exhibit a greater capacity for recovery after ovarian damage. Therefore, larger studies are needed for more conclusive results.

A case of placental polyp treated with an intraoperative injection of prostaglandin F2α followed by hysteroscopic resection

A 27-year-old woman had massive genital bleeding after an artificial abortion. Color Doppler ultrasonography showed a hypervascular mass. Hysteroscopy revealed a placental polyp. Serum hemoglobin level was decreased to 7.7 g/dl. Although uterine artery embolization (UAE) followed by hysteroscopic resection has been used for treatment of a placental polyp, UAE may not be an ideal option for patients with intent for future pregnancy because of the risk of ovarian function failure. This report presents a case of a placental polyp managed successfully with intracervical injection of prostaglandin F_2α, as an alternative UAE, followed by hysteroscopic resection.

Amenorrhea and resumption of menstruation after uterine artery embolization for fibroids

OBJECTIVES

To determine whether women will experience permanent amenorrhea following uterine artery embolization for fibroids, and whether rates of onset differ in the long term according to age at the time of the procedure.

METHODS

Over 77 months, 211 consecutive eligible women were grouped by age (group A, <40 years [n=39]; group B, 40-44 years [n=98]; and group C, > or =45 years [n=74]) and the cumulative rates of onset of permanent amenorrhea were compared between the groups.

RESULTS

The likelihood of incurring permanent amenorrhea was significantly higher in group C. The cumulative rates in groups A, B, and C were 0%, 1.4%, and 19.7% at 3 years and 0%, 11.2%, and 40.4% at 6 years.

CONCLUSION

The rates of onset of permanent amenorrhea changed over time and differed according to age at the time of the procedure, with little likelihood of permanent amenorrhea at 6 years for women younger than 40 years at the time of the procedure.

Hysteroscopy after uterine fibroid embolization in women of fertile age

AIM

Uterine artery embolization for fibroids is a controversial issue for women with incomplete reproductive plans. Ovarian failure and uterine infection are the most dreaded complications of this procedure. The purpose of the present study was to assess the types and the frequency of intrauterine abnormalities and the histological features of the endometrium after embolization.

METHODS

Uterine artery embolization was performed on 51 women (average age 34.5 years) with intramural fibroid/s larger than 4 cm. Hysteroscopy and endometrial biopsy was performed from 3 to 9 months later in the luteal phase of the cycle.

RESULTS

Despite all women having no major symptoms prior to hysteroscopy, only 19 (37%) had completely normal hysteroscopic findings. There was intrauterine protrusion of fibroid/s in 19 cases (37%), yellowish coloration of the endometrium in 14 (28%), intrauterine or cervical adhesions in seven (14%), and communication between the myoma and the uterine cavity in five cases (10%). A normal, functional endometrium was histologically verified in 44 women of 49 (90%) who could be evaluated. Regressive changes (necrosis or hyalinization) of leiomyoma or of indefinite origin were found in 17 patients and embolization particles in five, including one patient with microspheres inside the endometrial vessel. No case of Asherman syndrome or endometrial atrophy was observed.

CONCLUSION

The frequency of abnormal hysteroscopic findings after embolization is surprisingly high. The clinical significance, reversibility, and impact on fertility of abnormal hysteroscopic findings after embolization remain unclear. Regardless, hysteroscopy should be strongly recommended to all patients after uterine fibroid embolization, prior to conception.

Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy

The purpose of this study was to compare the midterm results of a radiological and surgical approach to uterine fibroids. One hundred twenty-one women with reproductive plans who presented with an intramural fibroid(s) larger than 4 cm were randomly selected for either uterine artery embolization (UAE) or myomectomy. We compared the efficacy and safety of the two procedures and their impact on patient fertility. Fifty-eight embolizations and 63 myomectomies (42 laparoscopic, 21 open) were performed. One hundred eighteen patients have finished at least a 12-month follow-up; the mean follow-up in the entire study population was 24.9 months. Embolized patients underwent a significantly shorter procedure and required a shorter hospital stay and recovery period. They also presented with a lower CRP concentration on the second day after the procedure (p < 0.0001 for all parameters). There were no significant differences between the two groups in the rate of technical success, symptomatic effectiveness, postprocedural follicle stimulating hormone levels, number of reinterventions for fibroid recurrence or regrowth, or complication rates. Forty women after myomectomy and 26 after UAE have tried to conceive, and of these we registered 50 gestations in 45 women. There were more pregnancies (33) and labors (19) and fewer abortions (6) after surgery than after embolization (17 pregnancies, 5 labors, 9 abortions) (p < 0.05). Obstetrical and perinatal results were similar in both groups, possibly due to the low number of labors after UAE to date. We conclude that UAE is less invasive and as symptomatically effective and safe as myomectomy, but myomectomy appears to have superior reproductive outcomes in the first 2 years after treatment.

La chirurgie tubaire et utérine a-t-elle un effet délétère sur la fonction ovarienne?

Changes in menstrual pattern after tubal sterilisation have been reported for more than 50 years. Hence all tubal surgeries have been suspected of altering the ovarian reserve, by damage to the ovarian blood vessels. Recent studies showed that tubal surgery has no significant adverse effect on doppler flow indice and hormonal markers. Hysterectomy and uterine artery embolization seem to decrease ovarian reserve in perimenopausal women. Uterine artery embolization does not seem to have adverse effects on normally functioning ovaries.

A Prospective Comparison of the Impact of Uterine Artery Embolization, Myomectomy, and Hysterectomy on Ovarian Function

PURPOSE

To prospectively compare uterine artery embolization (UAE) versus myomectomy and hysterectomy with regard to ovarian function as measured by postprocedure follicle-stimulating hormone (FSH) levels and symptoms.

MATERIALS AND METHODS

Fifty-five patients were prospectively enrolled in the study: 33 patients who underwent UAE, seven who underwent myomectomy, and 15 who underwent hysterectomy. Patients had serum FSH and estradiol levels measured on the third day of the menstrual cycle before their procedure and at regular follow-up visits for as long as 6 months. At these intervals, patients were also surveyed regarding menopausal symptoms.

RESULTS

Although a mild transient increase in mean FSH level after UAE was noted at 3 months, there were no statistically significant differences among the three groups in mean FSH levels at 1 month, 3 months, or 6 months of follow-up. Menopausal symptoms arose in the UAE and hysterectomy groups, but there was no statistically significant difference or permanent effect in either group.

CONCLUSION

There is no significant difference in impact on ovarian function after UAE, hysterectomy, or myomectomy at follow-up for a maximum of 6 months.

Gene therapy and uterine leiomyoma: a review

Leiomyomas (fibroids) are common estrogen-dependent uterine tumours that cause significant morbidity for women and a substantial economic impact on health delivery systems. Currently, there is no effective medical treatment option for this condition-hysterectomy is the mainstay of management. This is not an attractive choice for many women, especially patients desiring to preserve their fertility potential. Gene therapy is becoming a clinical reality, with more than 600 clinical trials worldwide. Researchers have recently attempted to develop a gene-therapy-based approach for the ablation of uterine fibroids. The localized nature of this condition and its accessibility using different imaging or endoscopic techniques make it an attractive target for direct delivery of gene-based vectors. Recent work from our laboratory suggests the potential use of a dominant-negative form of estrogen receptor (ER) to inactivate estrogen signalling in leiomyoma cells and induce apoptosis. Our in vivo data in a mouse model demonstrate the ability of an adenovirus-expressing dominant-negative ER to arrest leiomyoma growth. We and others also have described the utility of the herpes simplex virus-thymidine kinase (HSV-TK) plus ganciclovir (GCV) suicide gene-therapy system to effectively eradicate leiomyoma cells by utilizing the bystandard effect phenomena and the high expression of gap-junction protein in these tumours. Further work on rat models will pave the way for future leiomyoma gene-therapy clinical trials and allow the realization of gene therapy as a viable non-surgical option for this common problem in women's health.

Near-fatal uterine hemorrhage during induction chemotherapy for acute myeloid leukemia: a case report of bilateral uterine artery embolization

Severe transfusion-dependent uterine hemorrhage is a relatively uncommon complication of induction chemotherapy for acute myeloid leukemia (AML). Even less common is the failure of systemic conjugated estrogens in this setting. We report a case of life-threatening uterine hemorrhage in a 38-year-old woman in the setting of transfusion-refractory thrombocytopenia after completing induction chemotherapy for AML. She experienced dramatic breakthrough uterine hemorrhage despite multiple platelet transfusions, conjugated estrogens, recombinant factor VIIa, epsilon-aminocaproic acid, and intracavitary thrombin-soaked gauze tamponade. At the point of near-exsanguination in the setting of hypotension, hematocrit of 14%, and a platelet count of 3,000/microL, she underwent bilateral uterine artery embolization which proved immediately successful. We review the literature and indications for this procedure in the oncologic patient care setting.

FEMIC (Fibromes Embolis�s aux MICrosph�res calibr�es): Uterine Fibroid Embolization using Tris-acryl Microspheres. A French Multicenter Study

PURPOSE

A French multicenter registry was set up to confirm the safety and efficacy of large calibrated tris-acryl gelatin microspheres for embolization of symptomatic fibroids.

METHODS

Technical recommendations included embolization using large microspheres (>500 microm) with no secondary embolization agent. Postprocedural pain, clinical improvement and adverse events were prospectively evaluated during a follow-up period of at least 6 months.

RESULTS

Eighty-five women complaining of fibroid-related symptoms entered the study. In seven women, a secondary embolization agent was used in addition to microspheres. Complete resolution of menorrhagia was achieved in 84% of women at 24 months and significant uterine and fibroid volume reductions were noted after 6 months (37% and 73%, respectively). Three women experienced definitive amenorrhea (4%) and two women required hysteroscopic resection of a fibroid. Eight women were treated by hysterectomy because of treatment failure. In seven of these women, treatment failure was explained by an additional cause of symptoms including diffuse adenomyosis, endometrial hyperplasia or ovarian artery supply to the fibroids.

CONCLUSION

Limited uterine artery embolization using large microspheres has good clinical success rate with low postprocedural pain and complications. Women can expect excellent midterm results with a high level of symptom control and significant fibroid volume reduction. Confidence in the end-point recommended here may require the experience of several cases.

Midterm follow-up study of laparoscopic dissection of uterine vessels for surgical treatment of symptomatic fibroids

BACKGROUND

This study aimed to assess laparoscopic dissection of uterine vessels (LDUV) for symptomatic fibroids in women.

METHODS

A total of 69 women entered the study between March 2000 and June 2003. In this case series, 68 consecutive women underwent LDUV using ultrasonically activated sheers or electrosurgery for the treatment of fibroids over 3 years (median follow-up period, 14.5 months). Ultrasound or magnetic resonance imaging was carried out 3, 6, 12, 24, and 36 months after treatment. The tissue markers, gonadotropin, and estrogen levels were studied postoperatively.

RESULTS

Almost all the patients (98.5%) had a successful LDUV with a low rate (7.3%) of postoperative complications. The time of surgery ranged from 15 to 50 min (mean, 30.8 min). The blood loss was minimal (mean, 14.7 ml), and the hospital stay was 2.4 days. Symptom improvement (menorrhagia or dysmenorrhoea) was 93.2%, and the average reduction in the dominant myoma was 57.8% during a follow-up period longer than 12 months. All the patients with anemia had normal red cell counts after 3 months.

CONCLUSIONS

Uterine volume and the dominant fibroid were significantly reduced and symptoms were improved by LDUV. The laparoscopic procedure is associated with insignificant tissue damage and normal gonadotropin and estrogen levels.

Childbirth and Myoma Treatment by Uterine Artery Occlusion: Do They Share a Common Biology?

When the uterine arteries are bilaterally occluded, either by uterine artery embolization or by laparoscopic obstruction, women with myomas experience symptomatic relief. After the uterine arteries are occluded, most blood stops flowing in myometrial arteries and veins, and the uterus becomes ischemic. It is postulated that myomas are killed by the same process that kills trophoblasts: transient uterine ischemia. When the uterine arteries are bilaterally occluded, either by uterine artery embolization (UAE) or by laparoscopic obstruction, women with myomas experience symptomatic relief. After the uterine arteries are occluded, most blood stops flowing in myometrial arteries and veins, and the uterus becomes ischemic. Over time, stagnant blood in these arteries and veins clots. Then, tiny collateral arteries in the broad ligament (including communicating arteries from the ovarian arteries) open, causing clot within myometrium to lyse and the uterus to reperfuse. Myomas, however, do not survive this period of ischemia. This is unique organ response to clot formation and ischemia. What allows the uterus to survive a relatively long period of ischemia while myomas perish? Childbirth appears to be the predicate biology. Following placental separation, the uteroplacental arteries and the draining veins of the placenta are torn apart at their bases in the junctional zone of the myometrium and bleed directly into the uterine cavity. Left unchecked, every woman would bleed to death in less than 10 minutes after placental delivery. Most women do not bleed to death because vessels in the uterus clot after placental delivery. During pregnancy, clotting and lytic factors in blood increase many fold. Following delivery, uterine contractions continue, intermittently, periodically slowing the velocity of flowing blood through myometrium. The combination of slowed blood flow, elevated clotting proteins, and torn placental vessels (known as Virchow's triad) causes blood in myometrial arteries and veins to clot. Fibrinolytic enzymes later lyse clot in arteries and veins not associated with placenta perfusion, and the uterus is reperfused. Remnant placental tissue - primarily uteroplacental arteries and veins - does not survive this period of ischemia. Placental tissue dies and over weeks is sloughed into the uterine cavity. At the same time, residual endometrial tissue grows under the sloughing placental tissue thus re-establishing the endometrial lining. It is postulated that myomas are killed by the same process that kills trophoblasts - transient uterine ischemia.

Uterine artery embolization for fibroids does not have adverse effects on ovarian reserve in regularly cycling women younger than 40 years

OBJECTIVE

To evaluate the impact of uterine artery embolization (UAE) for fibroids on ovarian reserve in women younger than 40 years.

DESIGN

Prospective study.

SETTING

University-based reproductive endocrinology unit.

PATIENT(S)

Twenty regularly cycling women aged 33-39 years undergoing UAE for fibroids. All had cycle day 3 FSH levels <10 mIU/mL.

INTERVENTION(S)

Measurements of serum FSH and E2 levels and of the total ovarian volume and antral follicle number by transvaginal ultrasonography on day 3 of the menstrual cycle preceding UAE and on day 3 of the cycles occurring in months 3, 6, and 12 after UAE.

MAIN OUTCOME MEASURE(S)

Preprocedural and postprocedural hormone levels, ovarian volumes, and antral follicle numbers.

RESULT(S)

There were no significant changes from baseline in the mean day 3 FSH and E2 levels, ovarian volume measurements, and antral follicle numbers measured at 3, 6, and 12 months after UAE.

CONCLUSION(S)

Although this study might be not sensitive enough to conclude that UAE for fibroids does not interfere with a woman's ovarian status, these data indicate that in this series of reproductive-aged women UAE did not have short- or mid-term effects on ovarian reserve as assessed by hormonal and sonographic parameters.

Uterine artery embolization: state of the art

Since the first report in 1995, there has been rapid expansion of uterine artery embolization as a therapy for symptomatic uterine fibroids. The published literature and clinical experience show that this procedure is safe and effective. This article discusses the history of the procedure, current issues in procedure technique, and the state of the literature regarding outcomes of embolization. Current and future research topics also are discussed.

Contrast-enhanced sonography during uterine artery embolization for the treatment of leiomyomas

Uterine artery embolization (UAE) is a successful and safe treatment for symptomatic leiomyomas. However, rare complications such as premature menopause and uterine necrosis can arise because of embolization of non-target tissues. We studied the feasibility of using contrast-enhanced sonography with intravenous SonoVue just before, during and after complete occlusion of both uterine arteries. In a patient with multiple, large, symptomatic leiomyomas, contrast-enhanced imaging established that the UAE was technically successful and that myometrial vascularity was not reduced. Our case suggests that ultrasound contrast agents may have a role in monitoring UAE and thus may help prevent ischemic complications. Further studies are required to confirm this.

Embolization of uterine fibroids

Since the first description of uterine artery embolization for the treatment of symptomatic fibroids of the uterus in 1994, this minimally invasive procedure has been increasingly performed in many Western countries. The method is characterized by a high technical success rate of about 85%, a highly significant relief of symptoms, and a very low rate of complications that make this method an appealing alternative to classic treatment options of surgical or laparoscopic myomectomy or hysterectomy. These characteristics have made the procedure well accepted by affected women. Nevertheless, indications and potential contraindications have to be evaluated carefully, especially in patients of childbearing age whenever a considerable number of deliveries is reported after uterine fibroid embolization. This article discusses the clinical background, indications and contraindications, angiographic techniques, potential complications and side effects, and the mid-term results known at present.

Uterine artery embolization for the treatment of symptomatic myomas in Brazilian women

CONTEXT

Uterine myomas are benign tumors that mostly occur in women of reproductive age at a frequency ranging from 20 to 25%. The symptoms are increased menstrual flow, pain and compressive signs. New treatments have been proposed and uterine artery embolization is one of them.

OBJECTIVE

To evaluate the effects of treatment by embolization of the uterine artery, in women with symptomatic myomas. Uterine and dominant myoma volumes and the major symptoms were evaluated before treatment and 12 weeks later.

TYPE OF STUDY

Open clinical trial.

SETTING

A tertiary-care women's hospital.

PARTICIPANTS

The study was conducted on 32 women with symptomatic single or multiple myomas of the uterine body, seen at the outpatient unit from May 2000 to September 2001.

MAIN MEASUREMENTS

The patients were submitted to gynecological examination and abdominal and endovaginal pelvic ultrasonography, and the examinations were repeated 12 weeks after the first procedure. Uterine artery embolization using PVA (polyvinyl alcohol) particles of 355-700 was performed by catheterization of the right femoral artery in 30 women and by bilateral catheterization in two.

RESULTS

Before embolization, the mean uterine volume of the 32 women was 455 cm and the mean volume of the dominant myoma was 150 cm . Twelve weeks after embolization, the mean uterine volume was 256 cm and the mean volume of the dominant myoma was 91 cm , with p < 0.01 in both cases. Twelve weeks after the treatment, all the women answered a questionnaire, which showed that 71% had improvement in menstrual regularity, 90% decreased menstrual volume and 81% shortened menstrual duration. The most frequent immediate post-procedure symptoms, established as complications, were pain (100%) and fatigue (34%). One woman had myoma degeneration and was submitted to myomectomy.

CONCLUSION

The significant reduction in uterine and dominant myoma volume confirms the validity of the treatment of symptomatic myomas by the technique of uterine artery embolization in Brazilian women. There was significant reduction in menstrual flow and duration, as well as better cycle regularity in the women studied. The few adverse effects observed in the sample studied mainly involved pain immediately after embolization.

Embolisation des fibromes utérins : résultats sur 454 cas

OBJECTIVE

To determine the effectiveness of uterine arterial embolization (UAE) as primary treatment in the management of symptomatic leiomyomas.

PATIENTS AND METHOD

UAE was performed on 454 patients (age range: 21-68) with menorrhagia, bulk-related symptoms or both, due to leiomyomas. The effectiveness of this therapy in the control of symptoms and reduction of uterine and leiomyoma volume was measured by clinical and imaging controls at 3, 6 and 9 months after the procedure.

RESULTS

Four hundred and thirty-three patients were evaluated, and 42 failures were observed (9.6%). Six months after the procedure, 391 patients were symptom-free. Follow-up ultrasonic examination showed an average reduction of 55% in dominant myoma volume at 6 months, 70% at 1 year. Twenty-seven women became pregnant (30 pregnancies). Complications related to procedure, and requiring surgery, occurred in three cases. Principal complications are amenorrhoea and fibroid sloughs. Severe complications are rarely found.

DISCUSSION AND CONCLUSION

UAE is an efficient therapy in the management of symptomatic myomas and proves to be a valid alternative to surgical procedure. The future of this mini-invasive and conservative technique appears to be a very promising one.

Sonography of delayed effects of uterine artery embolization on ovarian arterial perfusion and function

OBJECTIVE

We aimed to assess the delayed effects of uterine artery embolization on ovarian arterial perfusion and function by performing ovarian sonography immediately before and after uterine artery embolization, as well as several months later.

CONCLUSION

Although persistent loss of detectable arterial perfusion after uterine artery embolization occurs in some women, most patients reestablish arterial perfusion and do not develop symptoms of ovarian failure.

Embolização uterina para tratamento de mioma sintomático: experiência inicial revisão da literatura

OBJETIVO: Apresentar os resultados da experiência clínica inicial de 100 casos de mulheres portadoras de miomatose sintomática que foram submetidas a embolização das artérias uterinas como forma de tratamento principal. Apresenta-se, também, extensa revisão bibliográfica sobre o tema, para determinar as indicações e contra-indicações, bem como as eventuais complicações do método. MATERIAL E MÉTODO: Cem pacientes com miomatose sintomática foram submetidas a embolização das artérias uterinas como única forma de tratamento. O principal sintoma que indicou a intervenção foi o aumento do fluxo menstrual em 79 pacientes e dor associada à miomatose em 21. O diagnóstico de miomatose foi realizado por meio de ultra-sonografia em 75 pacientes, e pela associação de ultra-sonografia e ressonância magnética em 25 pacientes. O volume uterino médio avaliado por esses métodos de imagem resultou em 487 cm³. Os procedimentos foram realizados em duas instituições hospitalares: uma pública, onde foram atendidas 56 pacientes dependentes do Sistema Único da Saúde (SUS), e outra particular, onde foram atendidas 46 pacientes com plano de assistência médica. Setenta e seis pacientes foram avaliadas clinicamente após 12 semanas da realização da embolização uterina. RESULTADOS: O procedimento foi completado com sucesso em 97% dos casos, utilizando-se técnica convencional. O acompanhamento e a avaliação clínica após 12 semanas evidenciou que houve melhora dos sintomas em mais de 90% das pacientes. Verificou-se, ainda, redução de volume uterino de 52%. Não foram observadas complicações técnicas ou clínicas relevantes. CONCLUSÃO: A técnica de embolização uterina para tratamento da miomatose sintomática é um método simples, eficiente e seguro.

Fatal sepsis after uterine artery embolization with microspheres

A case report of fatal sepsis after uterine artery embolization (UAE) with microspheres is presented. At autopsy, microspheres were found not only in arteries in the leiomyomata and myometrium but also in the parametria and the vagina, leading to a necrotic vaginal wall and uterine cervix. At present, polyvinyl alcohol particles are usually used in UAE. Recently, study results of the use of microspheres in embolization procedures have become available. The rationale for the choice of a specific embolization particle and the clinical implications of possible sepsis after UAE are discussed.

Selective uterine artery embolization in the management of uterine myomas

OBJECTIVE

To evaluate the effectiveness of uterine artery embolization in women with uterine myomas in terms of the clinical results for the relief of related symptoms.

DESIGN

A pilot study on 26 women affected by uterine single myoma.

SETTING

Tertiary level care in an university hospital.

PATIENT(S)

Twenty-six patients, aged 32 to 54 years, suffering of menorrhagia, pelvic pain, and abdominal mass for single myoma, intramural localization.

INTERVENTION(S)

Selective uterine artery embolization performed under peridural anesthesia.

MAIN OUTCOME MEASURE(S)

We measured the x-ray dose to which patients were exposed. Color power Doppler ultrasound examinations were performed during the follow-up evaluations at 1 to 6 months and 1 year after the procedure.

RESULT(S)

Uterine artery embolization was successfully performed in 100% of cases. The mean fluoroscopy time was of 20 minutes during the procedure. The mean dose of x-ray absorbed by the ovary was estimated at 18.7 cGy and the mean dose of x-ray absorbed by the skin was 126.7 cGy. A reduction of myoma volume of 55% was found at 6 months' ultrasound examination and 75% at the 1-year examination.

CONCLUSION(S)

Patients are well satisfied and have short recovery times with this procedure. Uterine artery embolization may be a valid alternative to traditional surgery.

Cost analysis of myomectomy, hysterectomy, and uterine artery embolization

OBJECTIVE

The purpose of this study was to compare inpatient hospital costs of different treatments of uterine fibroid tumors, including myomectomy, hysterectomy, and uterine artery embolization in a teaching hospital.

STUDY DESIGN

We reviewed the hospital database of 545 women with uterine fibroid tumors who were treated with abdominal myomectomy, total abdominal hysterectomy, vaginal hysterectomy, and uterine artery embolization between April 1997 and October 2001.

RESULTS

Women who underwent hysterectomies and uterine artery embolization were significantly older than the women who underwent myomectomy. Uterine artery embolization was associated with the shortest hospital stay, although the hospital stay in the vaginal hysterectomy group was shorter than in the abdominal myomectomy and the total abdominal hysterectomy groups. Compared with other groups, the inpatient cost of nursing in the uterine artery embolization group was the lowest. The total inpatient cost of uterine artery embolization ($1,007.44 +/- $60.65 [Canadian dollars]) was significantly lower than the cost of total abdominal hysterectomy ($1,933.37 +/- $47.68 [Canadian dollars]), abdominal myomectomy ($1,781.73 +/- $47.16 [Canadian dollars]), and vaginal hysterectomy ($1,515.39 +/- $66.72 [Canadian dollars]; P <.001). Sixteen of the 85 patients (18.8%) were hospitalized after uterine artery embolization, mainly for abdominal pain.

CONCLUSION

Compared with abdominal myomectomy, abdominal hysterectomy, and vaginal hysterectomy, uterine artery embolization is associated with a lower hospital cost and a shorter hospital stay. Hospitalization after uterine artery embolization is mainly for abdominal pain after the procedure. A better method of pain control to reduce the rate of hospitalization and its cost is needed.

Laparoscopic uterine artery ligation for treatment of symptomatic adenomyosis

STUDY OBJECTIVE

To investigate the effect of laparoscopic uterine artery ligation on symptomatic adenomyosis.

DESIGN

Prospective pilot study (Canadian Task Force classification II-2).

SETTING

Tertiary care major teaching hospital.

PATIENTS

Twenty women with symptomatic adenomyosis.

INTERVENTION

Laparoscopic ligation of bilateral uterine arteries with hemoclips and electrocoagulation of bilateral uterine ovarian vessels.

MEASUREMENTS AND MAIN RESULTS

Patients underwent sonographic measurement of uterine size, and recorded amount of menstruation and dysmenorrhea preoperatively and postoperatively. Six months postoperatively, mean uterine size had decreased by an amount ranging from 0.4% to 74.0%. Two of nine women achieved remission of the mass effect of an enlarged uterus. Thirteen of 16 patients achieved bleeding control and 5 returned to eumenorrhea or hypomenorrhea. Twelve of 16 patients achieved control of dysmenorrhea and 6 were analgesic free. However, nine women experienced nonmenstrual pain after surgery, three of whom underwent hysterectomy later. Treatment was rated as satisfactory by 15% of patients, but 45% were dissatisfied. Seventeen women would have refused to undergo the procedure if they could make the decision again.

CONCLUSION

Poor satisfaction in this preliminary study suggests that symptomatic adenomyosis may not be effectively treated by laparoscopic uterine artery ligation.

Successful pregnancy after transient ovarian failure following treatment of symptomatic leiomyomata

OBJECTIVE

To report a case of transient ovarian failure after treatment of symptomatic leiomyomata and review other iatrogenic causes of transient ovarian failure.

DESIGN

Case report and literature review.

SETTING

University-affiliated private practice.

PATIENT(S)

A 35-year-old woman with symptomatic leiomyomata.

INTERVENTION(S)

Bilateral uterine artery embolization with subsequent abdominal myomectomy to treat unchanged regular heavy menstrual flow.

MAIN OUTCOME MEASURE(S)

Ovarian function.

RESULT(S)

Because medical therapy failed to control her menorrhagia, the patient proceeded with uterine artery embolization. She had persistent menorrhagia after bilateral uterine artery embolization and underwent exploratory laparotomy and myomectomy. After surgery, she had amenorrhea, hot flushes, and elevated FSH levels for 3 months. Ovarian function recovered after a short course of oral contraceptives, and the patient conceived without assistance.

CONCLUSION(S)

Several interventions can affect normal ovarian function and can lead to permanent or transient ovarian failure. Possible causes of transient ovarian failure are radioactive iodine treatment, radiation, chemotherapy, pelvic surgery, stress, and uterine artery embolization. Before these interventions are applied, the possibility of ovarian failure and available preventive measures should be discussed with the patient.

Ischemic uterine rupture and hysterectomy 3 months after uterine artery embolization

The exact frequency and extent of complications after uterine artery embolization (UAE) have yet to be documented in the literature. Ischemic necrosis and rupture of the uterus is a theoretical concern of this procedure. Rupture of the uterus from any cause is a very serious gynecologic complication requiring immediate surgical intervention to prevent death. Ischemic necrosis and rupture of the uterus can occur months after UAE. In our patient they occurred 3 months after UAE for treatment of symptomatic uterine myomas, and required hysterectomy. To our knowledge, this is the first report of ischemic uterine rupture after UAE in the United States.

I. Uterine fibroid embolization: preprocedure assessment

Increasing clinical experience with uterine fibroid embolization (UFE) has improved the ability of interventionalist radiologists to discern who is and who is not an appropriate candidate for this procedure. Initial evaluation should be directed at obtaining answers to the following key questions: (1) Does the patient have uterine fibroids that account for her symptoms and are they severe enough to require invasive treatment? (2) Does she desire future childbearing? (3) Are there any clinical indications or imaging signs of uterine malignancy? (4) Are there any medical or anatomic features that would favor a particular therapeutic modality? (5) What are her own preferences regarding treatment? Ultrasound and magnetic resonance imaging are vital elements to the assessment and planning of the appropriate course of action. Given the lack of prospective comparative trials between UFE and surgical treatment, recommendations are often highly influenced by patient preference.

Alternative treatment for symptomatic fibroids

The present review discusses treatment options for symptomatic fibroids. Although the standard treatment of fibroids has been surgical hysterectomy, an increasing number of reports indicate that uterine artery embolization with preservation of the uterus is a promising alternative. Other surgical and medical approaches reported during the past year are also addressed. The review summarizes patient selection, contraindications, results, complications and future considerations. Complications following uterine artery embolization treatment for symptomatic fibroids have been minor in comparison with those following hysterectomy. Although patient satisfaction is good, none of the studies included control individuals and further studies are needed to optimize patient selection and to evaluate long-term results of treatment.

The vascular impact of uterine artery embolization: prospective sonographic assessment of ovarian arterial circulation

PURPOSE

The etiology of premature ovarian failure after uterine artery embolization (UAE) is unknown. The authors prospectively assessed ovarian arterial circulation before and after UAE with use of ultrasonography (US). The authors hypothesize that nontarget embolization of the ovary occurs during routine UAE.

MATERIALS AND METHODS

Twenty-three women (mean age of 42.6 years; range, 35-51 y) participated in the study. Grayscale, color, and pulsed-wave Doppler US studies were performed immediately before and after UAE. Resistive index (RI) and pulsatility index (PI) were calculated. The proportion of women who developed increased vascular impedance after UAE was statistically assessed with use of the Yates-corrected chi(2) test.

RESULTS

Seventeen of 23 patients (74%) completed the study. Nine of 17 (54%) showed complete loss of ovarian arterial perfusion after UAE. Six of 17 (35%) had increases in RI and PI, whereas two of 17 (11%) had decreases in RI and PI. The increase in vascular impedance after UAE in 15 of 17 patients was significant (P <.0001).

CONCLUSION

Loss of detectable ovarian arterial perfusion occurs in the majority of patients undergoing UAE. Ovarian vascular impedance increases in nearly all patients as a result of UAE. The authors conclude that inadvertent nontarget embolization of the ovarian arterial bed occurs during routine UAE.

Vaginal expulsion of submucous myomas after laparoscopic-assisted uterine depletion of the myomas

STUDY OBJECTIVE

To determine the safety and side effects that may be caused by laparoscopic-assisted uterine depletion (LAUD) of submucous myomas.

DESIGN

Retrospective chart review and follow-up (Canadian Task Force classification II-2).

SETTING

University-affiliated tertiary referral center.

PATIENTS

Five hundred twenty women with symptomatic myomas warranting surgical treatment, who wished to retain their uteri.

INTERVENTION

Laparoscopic bipolar coagulation of uterine arteries and anastomotic sites of uterine arteries with ovarian arteries.

MEASUREMENTS AND MAIN RESULTS

Postoperative sonographs showed submucous myomas in 53 (10.2%) women. During follow-up for a mean of 8.6 months very few complications occurred; however, nine women (1.7%) experienced vaginal expulsion of myomas from 2 weeks to 5 months postoperatively. Four of them were readmitted within 43 days with high fever and fetid discharge, and cervical cultures revealed heavy growth of Escherichia coli in three. Vaginal myomectomy was performed in six patients, and one woman passed the myoma spontaneously. Histopathologic studies of these nine specimens showed that two had infarction, three had coagulative necrosis, and four had degeneration. After treatment, all nine women had normal menstruation and their symptoms resolved during follow-up of at least 3 months.

CONCLUSION

In our experience LAUD led to satisfactory symptomatic improvement and reduction in myoma volume and few complications. If vaginal expulsion of submucous fibroids can be viewed as a side effect, we should pay close attention to women with submucous myomas, especially within 2 months of LAUD. Otherwise, more dangerous complications could occur.