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Uterine fibroids (leiomyomas): Treatment with uterine

artery embolization
Authors: Sanne M van der Kooij, MD, PhD, Wouter JK Hehenkamp, MD, PhD
Section Editors: Deborah Levine, MD, Robert L Barbieri, MD
Deputy Editor: Alana Chakrabarti, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jul 2021. | This topic last updated: Jun 01, 2021.

INTRODUCTION

Uterine artery embolization (UAE) was introduced for the treatment of symptomatic uterine
fibroids (leiomyomas) in 1995 [1,2]. UAE treatment of fibroids is performed worldwide. Fibroids
are a common gynecologic problem and result in symptoms that impact quality of life and may
result in anemia or other adverse effects. There are many options for treatment, including
hormonal therapy, hysteroscopic or abdominal myomectomy, and hysterectomy. UAE provides
a minimally invasive and uterine-sparing treatment option.

This topic reviews UAE for uterine fibroids. The diagnosis and general principles of
management of fibroids are discussed in detail separately. (See "Uterine fibroids (leiomyomas):
Epidemiology, clinical features, diagnosis, and natural history" and "Uterine fibroids
(leiomyomas): Treatment overview".)

RELEVANT ANATOMY

The majority of the blood supply to the uterus derives from the uterine arteries, and there is
also collateral perfusion from the ovarian arteries ( figure 1). The uterine arteries originate
from the anterior division of the internal iliac arteries in the retroperitoneum ( figure 2). They
may share a common origin with the obliterated umbilical artery, internal pudendal, or vaginal
artery. The ovarian arteries arise from the abdominal aorta. The right ovarian vein returns to
the inferior vena cava while the left ovarian vein returns to the left renal vein. (See "Surgical
female pelvic anatomy: Uterus and related structures", section on 'Vasculature'.)

PATIENT SELECTION

Indications — UAE is a treatment option for patients with symptomatic uterine leiomyomas.

There are many treatment options for uterine fibroids and the clinician must guide the patient
through this choice. (See "Uterine fibroids (leiomyomas): Treatment overview".)

Ideal candidates for UAE include patients with all of the following characteristics [3-5]:

● Heavy menstrual bleeding or dysmenorrhea caused by intramural fibroids

● Premenopausal
● No desire for future pregnancy

For patients with these characteristics, a high symptom control rate, satisfaction, and quality of
life can be achieved for up to 10 years after treatment [5-8]. (See 'Efficacy' below.)

If bulk-related symptoms (eg, sensation of pressure in the lower abdomen, nocturia, urinary
frequency, and urinary incontinence) are the only symptoms, the efficacy of UAE is questionable
[9,10]. The embolization versus hysterectomy randomized trial (EMMY) showed no significant
improvement compared with baseline in bulk-related complaints [3]. Some prospective cohort
studies have found, however, a significant improvement in bulk-related symptoms even in the
long-term [11,12]. It is also not usually used to treat infertility related to fibroids, since a desire
for future childbearing is a relative contraindication. (See 'Efficacy' below.)

UAE is also a potential option for treatment of uterine adenomyosis, but the data are limited
regarding efficacy for this indication [13]. A literature review included 1049 patients with
adenomyosis treated with UAE and reported significant improvement in symptoms in 83.1
percent of patients [13]. Uteri with adenomyosis combined with fibroids tend to have better
results than uteri with only adenomyosis. However, these were low-quality data from series with
no control group. Management of uterine adenomyosis is discussed in detail separately. (See
"Uterine adenomyosis".)

Prognostic factors — There are limited data regarding prognostic factors to predict the
effect of UAE on fibroid volume, symptoms, and need for reintervention. The largest studies did
not show strong predictors, and some smaller studies have reported predictors, but these may
be underpowered. Prognostic factors that have been described include:

● Preprocedure:
 • Predictors of a greater improvement in symptom score following the procedure include
a presenting symptom of heavy menstrual bleeding (rather than other symptoms),
smaller leiomyoma size, and submucosal location [14].

• Hypervascular fibroids, detected with contrast-enhanced imaging, before UAE predict a

high regrowth-free interval [15]. Another study found the opposite: poorly vascularized
fibroids had a lower chance of recurrence than highly vascularized fibroids, even
though initial volume reduction was less in hypovascular fibroids [16]. In our practice,
we use magnetic resonance imaging, but Doppler ultrasound or contrast-enhanced
ultrasound may also be used.

• Larger fibroids and more numerous fibroids predict higher symptom recurrence [17].

● During the procedure:

• Unilateral UAE predicts failure (failure defined as subsequent hysterectomy) [18].

Contraindications — UAE is absolutely contraindicated in patients who currently have the

following conditions:

● Asymptomatic fibroids
● Pregnancy
● Pelvic inflammatory disease
● Uterine malignancy

Several relative contraindications have been proposed:

● Desire for future pregnancy – Myomectomy has been the standard approach for patients
with symptomatic fibroids who wish to conceive. When UAE was introduced as a treatment
for fibroids, a desire for future pregnancy was considered an absolute contraindication
because there was concern that poor uterine perfusion following UAE would negatively
impact fertility and result in obstetric complications or adverse fetal effects. There are some
reassuring data from patients who have undergone UAE and then become pregnant.
However, high-quality comparative data are lacking. (See 'Reproductive outcomes' below.)

We recommend not performing UAE in patients who desire future pregnancy. Exceptions to
this may include patients who have severe anemia or symptoms associated with fibroids,
have failed conservative measure and have contraindications to surgery, or those who
consent to UAE within an approved research protocol; appropriate counseling about
potential risks to the patient and a fetus should be given.
 The American College of Obstetricians and Gynecologists states that the effect of UAE on
pregnancy remains understudied but makes no recommendation of whether desire for a
future pregnancy is a contraindication [19-21]. (See 'Reproductive outcomes' below.)

● Postmenopausal status – The procedure is indicated primarily for premenopausal patients

since fibroids tend to decrease in size and symptoms improve or resolve after menopause.
An enlarging uterus after menopause should raise the suspicion of a malignancy and
careful follow-up is warranted.

● Fibroid characteristics:

• Location – Subserosal or submucosal fibroids that are pedunculated and have a narrow
stalk (stalk <50 percent in diameter in comparison with the largest diameter fibroid) are
considered a relative contraindication because these fibroids may detach either
intraperitoneally or within the uterine cavity; submucosal fibroids that detach may be
expelled vaginally [22]. Detachment may be associated with sterile peritonitis or
intrauterine infection.

• Size or number of fibroids – The volume of necrosis after UAE in a large fibroid uterus
can be substantial with a proportionate level of postprocedural pain and risk of
infection. However, no clear threshold for the size of the uterus or size or number of
fibroids has been established as a contraindication. The only study to address this
question was a case series of patients with a dominant fibroid of >10 cm and/or a
uterine volume of >700 cm that found no increase in the risk of serious complications
[23].

● Contraindications to radiologic contrast agents.

PREPROCEDURE EVALUATION

History and physical examination — The patient should be asked regarding fibroid-related

symptoms (eg, heavy or prolonged menstrual bleeding, pelvic pain, bulk-related symptoms). A
medical history should be taken, including an obstetrics and gynecology history and medical
and surgical history relevant to the procedure. Patients should be asked about the impact of
symptoms on quality of life and what their goals and expectations for the procedure are. They
should be asked whether they are planning a future pregnancy.

A pelvic examination is performed to assess the size and mobility of the uterus. The
examination for a fibroid uterus is discussed in detail separately.
The evaluation of patients with fibroids is discussed in detail separately. (See "Uterine fibroids
(leiomyomas): Epidemiology, clinical features, diagnosis, and natural history", section on
'Diagnostic evaluation'.)

Laboratory testing — Laboratory tests prior to UAE are:

● Hemoglobin/hematocrit – This should be ordered in all patient with heavy or prolonged

menstrual bleeding.

● Serum creatinine, with calculation of glomerular filtration rate – This is required because
renally cleared contrast is used.

Some experts also ensure that cervical cancer screening is current and perform an endometrial
biopsy prior to embolization to exclude endometrial pathology [24]. While such testing is not
specifically required by guidelines, it is clinically reasonable.

Pelvic imaging — The first-line imaging study to evaluate for uterine fibroids is pelvic
ultrasound.

Many protocols include magnetic resonance imaging (MRI) before UAE in order to properly
determine size and location and ensure that the uterine masses are consistent with uterine
fibroids. In our view, in many cases, an MRI is not necessary if ultrasound provides a clear
diagnosis and can identify fibroid location according to the International Federation of
Gynecology and Obstetrics classification system ( figure 3) [25].

MRI is superior in cases of large uteri where the whole uterus cannot be visualized with
ultrasound. We order an MRI prior to UAE when the uterus is too large to evaluate reliably by
ultrasound or an experienced pelvic sonologist is not available [26,27]. Furthermore, there is
some evidence that an MRI before UAE may decrease procedure time. And also, an MRI might
be used to assess for ovarian arterial flow and thus stratify those at highest risk for ovarian
insufficiency [28-30].

While pelvic imaging can characterize a lesion as likely to be a benign fibroid, imaging generally
cannot exclude occult malignancy, such as leiomyosarcoma, within a fibroid.

PREPROCEDURE PREPARATION

Informed consent — Patients with symptomatic uterine leiomyomas should be counseled

about medical and surgical treatment options. (See "Abnormal uterine bleeding: Management
in premenopausal patients" and "Uterine fibroids (leiomyomas): Treatment overview".)
Patients should be counseled about potential complications of the procedure and about the
likelihood of recurrence of fibroids or symptoms. (See 'Complications' below.)

This discussion should be documented in the medical record and on the procedure consent
form.

Antibiotic prophylaxis — For patients undergoing UAE for treatment of leiomyomas, we

suggest not giving prophylactic antibiotics to prevent surgical site infection.

There are no standard guidelines on prophylactic antibiotics for UAE. Policy on prophylactic
antibiotics varies among clinics and in publications on UAE. This issue has not been evaluated in
randomized trials.

On average, post-embolization infection prevalence is estimated to be <1 percent [10].

Pathophysiologically, infection may take longer to develop, since infection may not develop
until necrosis is present. Also, submucosal fibroids may be more likely to become infected, due
to exposure to ascending infection in the uterine cavity; however, this is a theoretical concern
and has not be investigated.

Given the lack of evidence and the low risk of infection, routine preoperative prophylactic
antibiotics are not required. The exception to this may be in patients with large submucosal
fibroids, but this issue requires further study.

Antibiotic prophylaxis for gynecologic procedures is shown in the table ( table 1) and
discussed separately. (See "Overview of preoperative evaluation and preparation for
gynecologic surgery", section on 'Surgical site infection prevention'.)

Thromboprophylaxis — Thromboprophylaxis, in general, is only applicable for intravascular

procedures when a patient is at increased risk for thromboembolic disease [31].

Thromboprophylaxis is discussed in detail separately. (See "Prevention of venous

thromboembolic disease in adult nonorthopedic surgical patients".)

PROCEDURE

UAE is a percutaneous angiographic procedure performed with video fluoroscopic imaging.

UAE is performed by a trained interventional radiologist.

Procedure setting — Percutaneous transcatheter embolization procedures are typically

performed under fluoroscopic guidance in the radiology suite. The duration of the procedure
depends on the volume and the number of the myomas and skills of the radiologist.

Anesthesia — UAE is performed under local anesthesia (sometimes combined with epidural

anesthesia for postoperative pain relief). Local anesthesia is injected at the planned puncture
site in the groin. Sedation can be given if the patient wishes. Lidocaine injected into the uterine
arteries during or after UAE reduced postprocedural pain and narcotic agent dose after UAE.
There were more cases of incomplete necrosis when lidocaine was mixed with the particles [32].

The administration of single-dose intravenous dexamethasone as an adjunct to fentanyl-based

intravenous patient-controlled anesthesia is effective in reducing inflammation and pain during
the first 24 hours after UAE, although the effect is small. Dexamethasone had a positive effect
on severe nausea and vomiting in the same trial and no evident side effects, thereby possibly
worth considering administering [33].

Catheter placement — The patient is placed in the supine position. The Seldinger technique is
used to introduce a catheter into the femoral artery ( figure 4A-B) [34]. The catheter is then
advanced into the uterine artery, depending upon the indication for the procedure. After
subselective catheterization, diagnostic angiography of the artery is obtained to confirm proper
position and look for extravasation suggestive of acute bleeding ( image 1A-D).

The catheter is then moved to the contralateral uterine artery and the procedure is repeated
[35,36].

Embolization — The most commonly used embolic agents for UAE are nonspherical polyvinyl
alcohol (PVA) ( figure 4B), spherical PVA, acrylamido PVA, tris-acryl gelatin microspheres, and
polyzene-F hydrogel microspheres. No clear distinction in treatment efficacy can be made
between the embolic materials. Most large randomized trials of UAE used mainly polyvinyl
alcohol particles, but other materials were used in other studies [3,4,37]. A systematic review
including five randomized trials and five observational comparative studies did not find one
material to be associated with superior clinical outcomes (eg, fibroid devascularization, uterine
and dominant fibroid volume reduction) [38].

The embolic material is injected and is carried by the arterial blood flow to the vessels feeding
the fibroid. These vessels are preferentially occluded, since they are larger and have a higher
flow than myometrial branches that do not perfuse vascular lesions like fibroids. The procedure
is terminated when the fibroid blood supply is occluded but there is still sluggish flow in the
uterine artery.

COMPLICATIONS
Common complications of UAE include pelvic pain, fever, and vaginal discharge, but these are
self-limited in most patients. Some patients may develop ovarian insufficiency.

The most serious potential complications are introduction of embolic agents into inadvertent
vessels, necrosis of the gluteus maximus or limb, or pulmonary embolism. Mortality after UAE is
very rare, but there are several published case reports [39-42]. Cause of these deaths were
sepsis because of necrotic myoma or pulmonary embolism after UAE.

Morbidity after UAE can be divided in periprocedural (first 24 hours), early complications (within
30 days), and late complications (beyond 30 days).

Periprocedural — Periprocedural complications are uncommon (<5 percent) and include groin

hematoma, arterial thrombosis, and, infrequently, (pseudo)aneurysm [6]. Groin hematoma is
managed expectantly, arterial thrombosis is treated with anticoagulants, and
(pseudo)aneurysm is treated by interventional radiologist if needed or managed expectantly.

Early complications — Common early complications include fever, nausea, pain, and malaise;
as a set of issues, these comprise post-embolization syndrome [6].

Patients may experience pelvic pain following UAE; postprocedural pain is typically self-limiting
[43]. Pain is due to necrosis of tissue and seems to be associated with fibroid volume and is
usually most severe during the first 24 hours. Pain during the first 24 hours can be managed
with patient-controlled analgesia, this can then be transitioned to oral pain medications, usually
nonsteroidal anti-inflammatory drugs [44]. In a small randomized controlled trial,
dexamethasone (10 mg intravenous) was found to be effective in reducing inflammation and
pain after UAE [33]. Future studies are required to validate these findings.

If severe pain persists, readmission for pain control may be necessary (up to 9 percent of cases)
[6]. A recurrence of severe pain after a period of milder pain may indicate fibroid expulsion and
warrants evaluation. UAE results in more readmissions than hysterectomy or myomectomy. In a
meta-analysis of seven randomized trials, UAE compared with hysterectomy resulted in a
significantly higher rate of unscheduled visits or readmissions within six weeks (odds ratio 2.79,
95% CI 1.41-5.49, one trial, 157 subjects [43]) [7].

Another complication that is also relatively common (16 to 20 percent) is vaginal discharge [45].
This can last for months and is usually self-limiting, provided that the discharge is not purulent
and fever is absent.

If patients present with purulent vaginal discharge after UAE in combination with fever, they
should be evaluated for pelvic or systemic infection with vital signs, physical examination, a
white blood cell count, C-reactive protein, culture of vaginal or cervical discharge, and pelvic
ultrasound [31]. Ultrasound can show a prolapsing fibroid or evidence of pelvic inflammatory
disease. Magnetic resonance imaging is used in rare cases where ultrasound findings are
inconclusive. Blood cultures should be ordered if systemic infection is suspected, but we have
rarely seen a patient with positive blood cultures after UAE.

If examination or laboratory testing is consistent with infection, we treat with antibiotics.

Endometrial infection occurs in 0.5 percent of cases (mostly with submucosal fibroids) [31]. The
antibiotic treatment regimen is the same as in pelvic inflammatory disease (see "Pelvic
inflammatory disease: Treatment in adults and adolescents"), unless the cultures find specific
bacteria.

Persistent vaginal discharge combined with abdominal tenderness or pain, but without fever,
may be due to a submucosal intracavity necrotic fibroid being expelled through the cervix into
the vagina. Vaginal expulsion of a fibroid (or fibroid tissue) is a relatively common phenomenon,
and in general it can be managed expectantly, but sometimes it is necessary to perform a
hysteroscopy to remove the fibroid [31].

Late complications — Ovarian insufficiency following UAE occurs more frequently in patients

older than 45 years, and patients may develop menopausal symptoms and/or amenorrhea.
Arterial flow to the ovary is likely to be transiently occluded during UAE but may be re-
established in the longer term. UAE appears to be unlikely to decrease ovarian reserve in
patients younger than 40 years [46].

In the embolization versus hysterectomy randomized trial (EMMY), 156 premenopausal patients
were treated with either UAE or hysterectomy [47]. At 24 months, there was no significant
difference in menopausal symptom scores or anti-müllerian hormone (AMH) levels between
groups, but the UAE group had a significantly lower AMH values than age-adjusted levels in the
general population based on age. Another study showed that ovarian reserve appears to be
affected by UAE in premenopausal patients [48]. 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.

FOLLOW-UP

We see patients for a follow-up visit several weeks after UAE. Patients are counseled about the
signs and symptoms of minor and major complications. In case of pain that does not respond
to nonsteroidal anti-inflammatory drugs, fever, or foul-smelling vaginal discharge, the patient is
advised to contact the clinician for evaluation for complications [18].

Follow-up imaging studies are not done routinely but performed as needed based on persistent
or recurrent symptoms or concern about complications. Decisions regarding reintervention are
made based upon symptoms (eg, good response in terms of volume reduction but unchanged
heavy menstrual bleeding might result in reintervention, whereas the opposite situation might
not).

OUTCOMES

Efficacy — The efficacy of UAE is determined by symptom relief for patients with uterine
fibroids. Major symptoms are heavy menstrual bleeding, dysmenorrhea, pelvic pain or
pressure, and other bulk-related symptoms:

● Heavy menstrual bleeding – It has been shown that most patients (73 to 90 percent)
reported improvement or disappearance of heavy menstrual bleeding symptoms up to 10
years after treatment [8,49]. In the embolization versus hysterectomy randomized trial
(EMMY), 156 premenopausal patients were treated with either UAE or hysterectomy and
156 underwent treatment [3,8,50]. At two years, 62 percent of patients in the UAE group
reported that menorrhagia had completely resolved. At five years, 83 percent of patients in
the UAE group reported no menorrhagia or great or moderate improvement. The
subsequent cumulative hysterectomy rate was 24 percent at two years, 28 percent at five
years, and 35 percent at 10 years. Secondary hysterectomies were performed for persisting
symptoms in all cases except one (for prolapse).

● Pelvic pain or dysmenorrhea – The effect of UAE on lower abdominal pain or dysmenorrhea
has also been described and shows an improvement in up to 80 percent of patients. In the
EMMY trial, there was a comparable proportion of patients in the UAE compared with
hysterectomy group (85 versus 78 percent) who reported at least moderate improvement in
lower abdominal pain at two years [3]. The Ontario Uterine Fibroid Embolization Trial was a
multicenter prospective study that reported improvement in dysmenorrhea in 77 percent
of 538 patients undergoing bilateral UAE [51].

● Pelvic pressure or bulk-related symptoms – The effect of UAE on bulk and pressure
complaints is less well studied, but in large cohort studies, up to 90 percent of patients
reported improved bulk complaints [9,10]. In the EMMY trial, there were comparable rates
 of improvement in bulk-related symptoms in the UAE and hysterectomy groups at two
years (66 versus 69 percent) [3].

Many studies have evaluated patient satisfaction rather than relief of specific symptoms. In a
meta-analysis of seven randomized trials including 793 patients, there was no significant
difference in the pooled data in patient satisfaction at two or five years with UAE compared with
hysterectomy or myomectomy, although there was a wide variation across studies ranging
from 41 percent lower to 48 percent higher [7]. Another systematic review comparing UAE and
surgery showed that, even after five years of follow-up, health-related quality of life was
significantly higher than baseline, without differences between the study groups [6]. In the
EMMY trial, at 10 years, generic health-related quality of life remained stable, without
differences between both groups [8]. Satisfaction in both groups remained comparable. The
majority of patients declared being (very) satisfied about the received treatment (UAE: 78
percent versus hysterectomy 87 percent).

Need for subsequent treatment — Subsequent hysterectomy for failure or recurrence of

symptoms after UAE was reported to be 27 percent (51 of 187) at five years in a meta-analysis of
four randomized trials [6]. A meta-analysis of seven randomized trials found a significantly
higher rate of further intervention within two years for UAE than myomectomy or hysterectomy
(odds ratio [OR] 3.72, 95% CI 2.28-6.04) [7].

Other possible subsequent procedures to treat heavy menstrual bleeding after UAE include
dilation and curettage, hysteroscopy, endometrial ablation, myomectomy (5 percent), or repeat
UAE [6,52]. In the EMMY trial, at five years after treatment, 23 secondary hysterectomies and 5
other reinterventions were reported for heavy menstrual bleeding (curettage, endometrium
ablation, or myomectomy) in the 81 UAE patients, whereas they reported 8 reinterventions in
the 75 hysterectomy patients [4]. Another study reported 28 reinterventions (not specified) in
the 106 UAE patients and 1 in the 50 hysterectomy patients. In the UAE group, 82.7 percent of
the participants reported to be symptom-free or to experience improvement [5].

Uterine artery embolization versus surgery — Although UAE has several short-term

advantages to surgery, the long-term advantages are less clear.

In meta-analyses of randomized trials comparing UAE with surgery (hysterectomy and

myomectomy [7]; hysterectomy, myomectomy, laparoscopic uterine artery occlusion [53]), UAE
resulted in:

● Faster resumption of daily activities and return to work [7].

● Lower rates of blood transfusion (OR 0.07, 95% CI 0.01-0.52) [7].

 ● Lower risks of major complications (risk ratio [RR] 0.45, 95% CI 0.22-0.95) [53].

● Higher risks of minor complications (RR 1.65, 95% CI 1.32-2.06) [53].

● Higher rates of reintervention after two years (83/436 versus 16/355 patients, RR 3.7) and
five years (56/171 versus 9/118 patients, RR 5.0) [53]. In the embolization versus
hysterectomy randomized trial (EMMY), which was not included in the analysis, at 10 years,
28 of 81 patients (35 percent) required secondary hysterectomy [8].

Quality of life was not assessed in the analyses, but in a subsequent randomized trial of 254
patients, quality of life and symptom severity were less favorable after UAE compared with
myomectomy (abdominal, laparoscopic, or hysteroscopic); the magnitude of improvement on
health-related questionnaires, evaluating quality of life and symptom severity two years
postoperatively, was lower in the UAE group (mean differences of 8.0 and -3.8 points,
respectively) [54]. While overall symptom severity was higher in the UAE group, both groups
demonstrated a substantial improvement of symptoms compared with baseline.

Uterine artery embolization versus other minimally invasive treatments — UAE is the best
studied minimally invasive treatment option for fibroids. Other minimally invasive treatments
have emerged over the last few years with positive outcomes in case series and cohorts. There
are few comparative studies, but some are starting to emerge in the literature [55].

A meta-analysis of uterus-sparing options for fibroids included 85 studies (8 were randomized

trials; 14 studies compared between different procedures) with over 17,000 participants [56].
The risk of reintervention after 60 months of follow-up for each method was: UAE (14.4
percent), high intensity focused ultrasound (using localization with magnetic resonance
imaging [MRI] or ultrasound; 53.9 percent), myomectomy (12.2 percent), and hysteroscopy (7
percent). All methods were associated in improved quality of life, but high intensity focused
ultrasound showed the lowest degree of improvement.

A systematic review evaluating UAE, MRI-guided focused ultrasound (MRgFUS), and

radiofrequency ablation (RFA) included 81 observational studies; only one study directly
compared two modalities [55,57]. Pooled data for each modality showed the following mean
fibroid volume reduction at 12 months: UAE (66 percent), MRgFUS (28 percent), and RFA (75
percent).

UAE was compared with MRgFUS in the Fibroid Interventions: Reducing Symptoms Today and
Tomorrow study (FIRSTT); the study combined analysis of randomized trial data in 57 patients
and observational data in 34 (participants who refused randomization) [58]. MRgFUS compared
with UAE resulted in a higher rate of reintervention for symptomatic fibroids (30 versus 12.5
percent) within three years. Reintervention was more likely when treatments occurred at
younger ages and in patients with higher pretreatment anti-müllerian hormone (AMH) levels.
AMH levels at 24 months were lower in the UAE group. Both treatment arms improved in quality
of life scores and pain, although the effect was larger in the UAE group. The decrease in AMH
levels reconfirms our caution regarding use of UAE in patients who desire future fertility. (See
'Fertility' below and "Uterine fibroids (leiomyomas): Treatment overview", section on 'Uterine
artery embolization'.)

Observational studies that directly compared UAE with MRgFUS have also found a lower
reintervention rate with UAE, consistent with the FIRSTT study [59,60].

UAE has also been compared with uterine artery occlusion in several randomized comparisons.
First, two pilot studies were performed with 20 and 14 patients who were randomized to either
UAE or uterine artery occlusion [61,62]. These pilots demonstrated good clinical (short-term)
results with less pain after the occlusion technique. Thereafter, two larger trials were done
[63,64]. In one randomized trial (n = 69), satisfaction with menstrual blood loss was comparable
between the two treatments but tended to remain improved more than 12 months after UAE
[63]. Another trial (n = 66) compared UAE with uterine artery occlusion and found that UAE was
superior in terms of recurrence rate (48 versus 17 percent) and volume reduction (51 versus 33
percent) after 48 months of follow-up [64].

REPRODUCTIVE OUTCOMES

Pregnancy — UAE has been associated with an increase in some adverse obstetric outcomes
but not so in others, and further study is needed.

A meta-analysis that included 227 pregnancies after UAE from nine mainly observational
studies (there was one randomized trial) and compared these with pregnancies in controls from
other studies with fibroids matched for age and fibroid location [19]. Pregnancies after UAE had
significantly higher miscarriage rates (35 versus 17 percent, odds ratio [OR] 2.8, 95% CI 2.0-3.8)
and were more likely to have a cesarean delivery (66 versus 49 percent, OR 2.1, 95% CI 1.4-2.9)
and to have postpartum hemorrhage (14 versus 3 percent, OR 6.4, 95% CI 3.5-11.7). UAE and
control pregnancies showed no significant difference in rates of preterm delivery (14 versus 16
percent, OR 0.9, 95% CI 0.5-1.5) and intrauterine growth restriction (7 versus 12 percent, OR 0.6,
95% CI 0.3-1.3); however, the study lacked sufficient statistical power to detect a difference in
these outcomes.
Fertility — The effect of UAE on fertility has not been well investigated; available data suggest a
modest to minimal negative impact on fertility. In general, there are few studies of the impact
of UAE on fertility as most patients are counseled not to become pregnant after UAE due to
concerns about adverse obstetric outcomes. (See 'Pregnancy' above.)

Fibroids, particularly those that impinge upon the endometrium, may affect fertility by
interfering with implantation over the myoma site, rapidly distending the uterus in early
pregnancy, or impairing uterine contractility. It is uncertain whether treatment of fibroids with
UAE has a beneficial impact on fertility.

UAE may decrease ovarian reserve and even result in premature ovarian failure, particularly in
patients older than 40 years, as noted above [19,20]. At three months following UAE, there is a
decrease in anti-müllerian hormone (AMH) and antral follicle count, but at six months, an
increase in AMH and antral follicle count is observed, especially in patients <40 years of age
[48]. (See 'Late complications' above.)

Traditionally, myomectomy has been the procedure of choice for patients with fibroids who
desire future pregnancy. Fertility was assessed in one randomized trial for a subset of patients
who tried to conceive (n = 66) [20]. UAE had significantly lower rates of pregnancy (50 versus 78
percent) and delivery than myomectomy (19 versus 48 percent) and significantly higher
abortion rates (64 versus 23 percent). (See "Uterine fibroids (leiomyomas): Treatment overview",
section on 'Patients desiring fertility'.)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Uterine fibroids
(leiomyomas)" and "Society guideline links: Gynecologic surgery".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the
Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Beyond the Basics topics (see "Patient education: Uterine fibroids (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● Uterine artery embolization (UAE) is a minimally invasive treatment for uterine fibroids
(leiomyomas). The procedure is a percutaneous angiographic procedure performed with
video fluoroscopic imaging with injection of embolic agents into the uterine artery. (See
'Introduction' above.)

● Ideal candidates for UAE include patients with heavy menstrual bleeding or dysmenorrhea
caused by intramural fibroids, who are premenopausal, and who have no desire for future
pregnancy. If pelvic pain/pressure or bulk-related symptoms are the only symptom, efficacy
of UAE is questionable. (See 'Indications' above.)

● We recommend not performing UAE in patients who desire future pregnancy (Grade 1C).
Exceptions to this may include patients who have severe anemia or symptoms associated
with fibroids, have failed conservative measure and have contraindications to surgery or
those who consent to UAE within an approved research protocol; appropriate counseling
about potential risks to the patient and a fetus should be given. (See 'Contraindications'
above and 'Reproductive outcomes' above.)

● Subserosal or submucosal fibroids that are pedunculated and have a narrow stalk (stalk
<50 percent in diameter in comparison with the largest diameter fibroid) are considered a
relative contraindication to UAE. (See 'Contraindications' above.)

● The volume of necrosis after UAE in a large fibroid uterus can be substantial with a
proportionate level of postprocedural pain. However, no clear threshold for the size of the
uterus or size or number of fibroids has been established as a contraindication. (See
'Contraindications' above.)

● The first-line imaging study to evaluate for uterine fibroids is pelvic ultrasound. Many
protocols include magnetic resonance imaging before UAE in order to properly determine
 size and location and ensure that the uterine masses are consistent with uterine fibroids.
(See 'Pelvic imaging' above.)

● Most patients (73 to 90 percent) reported improvement or disappearance of heavy

menstrual bleeding symptoms up to ten years after treatment. Lower abdominal pain or
dysmenorrhea shows an improvement in up to 80 percent of patients. Approximately 28
percent of patients undergo hysterectomy within five years after UAE. (See 'Efficacy' above
and 'Need for subsequent treatment' above.)

● Common complications of UAE include pelvic pain, fever, and vaginal discharge, but these
are self-limiting in most patients. Some patients may develop ovarian insufficiency. The
most serious potential complications are introduction of embolic agents into inadvertent
vessels, necrosis of the gluteus maximus or limb, or pulmonary embolism. (See
'Complications' above.)

ACKNOWLEDGMENT

The authors and editors would like to recognize Ducksoo Kim, MD, and Stephen D Baer, MD,
who contributed to an earlier version of this topic review.

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 3299 Version 30.0

GRAPHICS

Uterine blood supply

Graphic 54737 Version 2.0

Female pelvic blood supply

The blood supply to the pelvis.

(A) The sagittal view of the pelvis without the viscera.

(B) The blood supply to one pelvic viscera.

Reproduced with permission from: Berek JS. Berek & Novak's Gynecology, 15th ed, Lippincott
Williams & Wikins, Philadelphia 2012. Copyright © 2012 Lippincott Williams & Wilkins.

Graphic 83008 Version 1.0

PALM-COEIN subclassification system for leiomyomas

FIGO leiomyoma subclassification system. System 2 classification system including the FIGO leiomyoma subclassification system. T
that includes the tertiary classification of leiomyomas categorizes the submucous group according to the original Wamsteker et al s
and adds categorizations for intramural, subserosal, and transmural lesions. Intracavitary lesions are attached to the endometrium
stalk (≤10% or the mean of three diameters of the leiomyoma) and are classified as Type 0, whereas Types 1 and 2 require a portion
lesion to be intramural: with Type 1 being less than 50% of the mean diameter and Type 2 at least 50%. Type 3 lesions are totally int
also about the endometrium. Type 3 are formally distinguished from Type 2 with hysteroscopy using the lowest possible intrauterin
necessary to allow visualization. Type 4 lesions are intramural leiomyomas that are entirely within the myometrium, with no extens
endometrial surface or to the serosa. Subserous (Types 5, 6, and 7) leiomyomas represent the mirror image of the submucous leiom
with Type 5 being at least 50% intramural, Type 6 being less than 50% intramural, and Type 7 being attached to the serosa by a stal
≤10% or the mean of three diameters of the leiomyoma. Classification of lesions that are transmural are categorized by their relatio
both the endometrial and the serosal surfaces. The endometrial relationship is noted first, with the serosal relationship second (eg,
An additional category, Type 8, is reserved for leiomyomas that do not relate to the myometrium at all, and would include cervical le
(demonstrated), those that exist in the round or broad ligaments without direct attachment to the uterus, and other so-called "para
lesions.

FIGO: International Federation of Gynecology and Obstetrics.

Reference:
1. Wamsteker K, Emanuel MH, de Kruif JH. Transcervical hysteroscopic resection of submucous fibroids for abnormal uterine bleeding: Results r
degree of intramural extension. Obstet Gynecol 1993; 82:736.

From: Munro MG. Abnormal Uterine Bleeding. Cambridge: Cambridge University Press, 2010. Copyright © 2010 M. Munro. Reprinted with the permi
Cambridge University Press.

Updated with information from: Munro MG, Critchley HOD, Fraser IS, FIGO Menstrual Disorders Committee. The two FIGO systems for normal and ab
uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. In J Gynaecol Obstet

Graphic 91085 Version 3.0

Antimicrobial prophylaxis for gynecologic and obstetric surgery in adults*

ACOG preferred Alternative

Procedure Dose Dose
regimen ¶[1,2] regimens Δ[3,4]

Hysterectomy Cefazolin, cefoxitin or Cefazolin: Regimen:

(abdominal, including cefotetan <120 kg: 2 g IV Ampicillin- 3 g IV
supracervical, vaginal,
≥120 kg: 3 g IV sulbactam
laparoscopic, or
robotic)
Regimen:
Cefoxitin or cefotetan:
Pelvic reconstruction Clindamycin OR 900 mg IV ◊
procedures, including 2 g IV
Vancomycin ¶ 15 mg/kg IV (not to
colporrhaphy or those
exceed 2 g per dose)
involving mesh or
vaginal sling placement PLUS one of the following:

Gentamicin OR 5 mg/kg IV (if

overweight or obese,
based on adjusted
body weight) §

Aztreonam OR 2 g IV

Fluoroquinolone ¶ ¥  

Regimen:

Metronidazole 500 mg IV

PLUS one of the following:

Gentamicin OR 5 mg/kg IV (if

overweight or obese,
based on adjusted
body weight) §

Fluoroquinolone ¶ ¥  

Cesarean delivery Cefazolin <120 kg: 2 g IV Clindamycin 900 mg IV ◊

(intact membranes, not ≥120 kg: 3 g IV PLUS
in labor)
Gentamicin 5 mg/kg IV (if
overweight or obese,
based on adjusted
body weight) §

Cesarean delivery (in Cefazolin <120 kg: 2 g IV Clindamycin 900 mg IV

labor, ruptured >120 kg: 3 g IV
membrane)
PLUS PLUS

Azithromycin 500 mg IV Gentamicin 5 mg/kg IV (if

overweight, or obese,
based on adjusted
body weight)

PLUS

Azithromycin 500 mg IV

Uterine evacuation Doxycycline 200 mg orally    

(including surgical
abortion, suction D&C,
and D&E)

Hysterosalpingogram, Not recommended ‡

including
chromotubation or
 saline infusion
sonography

Laparotomy without Consider cefazolin <120 kg: 2 g IV    

entry into bowel or ≥120 kg: 3 g IV
vagina

Laparoscopy Not recommended

(diagnostic, tubal
sterilization, operative
except for
hysterectomy)
Other transcervical
procedures:
Cystoscopy †
Hysteroscopy
(diagnostic or
operative)
Intrauterine
device insertion
Endometrial
biopsy
Oocyte retrieval
D&C for non-
pregnancy
indication
Cervical tissue
biopsy, including
LEEP or
endocervical
curettage

ACOG: American College of Obstetricians and Gynecologists;

IV: intravenous;
D&C: dilation and curettage;
D&E: dilation and
evacuation;
LEEP: loop electrosurgical excision procedure;
IDSA: Infectious Diseases Society of America;
ASHP: American Society of
Health-System Pharmacists;
HSG: hysterosalpingogram;
PID: pelvic inflammatory disease.

* Common pathogens: Enteric gram-negative bacilli, anaerobes, group B Streptococcus, enterococci.

¶ Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before the procedure. If vancomycin
or a fluoroquinolone is used, the infusion should be given over 60 to 90 minutes and started within 60 to 120 minutes before the initial
incision.

Δ An alternative regimen should be used in women with history of immediate hypersensitivity to beta-lactam agents. Due to increasing
resistance of Escherichia coli to ampicillin-sulbactam and fluoroquinolones, local sensitivity profiles should be reviewed prior to use.

◊ When clindamycin prophylaxis is warranted, UpToDate authors prefer a single dose of 900 mg based upon pharmacokinetic
considerations according to 2013 IDSA/ASHP surgical antibiotic prophylaxis guidelines. [3] However, a 600 mg dose consistent with ACOG
guidance may be sufficient. [1,2]

§ Gentamicin use for surgical antibiotic prophylaxis should be limited to a single dose given preoperatively. Based on evidence from
colorectal procedures, a single dose of approximately 5 mg/kg gentamicin appears more effective for the prevention of surgical site
infection than multiple doses of gentamicin 1.5 mg/kg every 8 hours. [4] For overweight and obese patients (ie, actual weight is >125% of
ideal body weight), a dosing weight should be used. A calculator to determine ideal body weight and dosing weight is available in
UpToDate.

¥ Ciprofloxacin 400 mg IV OR levofloxacin 500 mg IV OR moxifloxacin 400 mg IV. Fluoroquinolones are contraindicated in pregnancy
and in women who are breastfeeding.

‡ Antimicrobial prophylaxis is recommended for women undergoing HSG or chromotubation with a history of PID or abnormal tubes
noted on HSG or laparoscopy. For these women, an antibiotic prophylaxis regimen of doxycycline, 100 mg twice daily for 5 days, can be
considered to reduce the incidence of post-procedural PID. [5,6] For women undergoing chromotubation, a single preoperative 2 gram
dose of intravenous cefazolin is recommended, and the patient can be discharged on the same doxycycline regimen recommended for
abnormal HSG.

† Most clinicians exclude urinary tract infection with a urinalysis before cystoscopy, with subsequent urine culture performed to confirm
findings suggestive of infection. Patients with positive test results should be given antibiotic treatment.

References:
1. ACOG practice bulletin No. 195: Prevention of infection after gynecologic procedures. Obstet Gynecol 2018; 131:e172.
 2. ACOG practice bulletin No. 199: Use of prophylactic antibiotics in labor and delivery. Obstet Gynecol 2018; 132:e103.
3. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 2013; 70:195.
4. Zelenitsky SA, Silverman RE, Duckworth H, Harding GK. A prospective, randomized, double-blind study of single high dose versus multiple
standard dose gentamicin both in combination with metronidazole for colorectal surgical prophylaxis. J Hosp Infect 2000; 46:135.
5. Pittaway DE, Winfield AC, Maxson W, et al. Antibiotic prophylaxis for gynecologic procedures prior to and during the utilization of
assisted reproductive technologies: a systematic review. Am J Obstet Gynecol 1983; 147:623.
6. Pereira N, Hutchinson AP, Lekovich JP, et al. Antibiotic prophylaxis for gynecologic procedures prior to and during the utilization of
assisted reproductive technologies: a systematic review. J Pathog 2016; 2016:4698314.

Adapted from: Antimicrobial prophylaxis for surgery. Med Lett Drugs Ther 2016; 58:63.

Graphic 87200 Version 36.0

Fibroid embolization 2a

Diagram showing superselective catheter position in the right uterine artery via left
femoral arterial approach.

Graphic 62884 Version 1.0

Fibroid embolization 2b

Diagram showing embolic particles being released from the catheter and into the
uterine arterial branches supplying the fibroid.

Graphic 74642 Version 1.0

Left uterine angiogram

Left uterine angiogram before uterine fibroid embolization demonstrates dilated branches
of the left uterine artery supplying multiple hypervascular uterine fibroids (arrows) on the
left.

Graphic 63412 Version 2.0

Left uterine angiogram

Left uterine angiogram after uterine artery embolization demonstrates successful

occlusions of the left uterine artery and its branches (arrow).

Graphic 77132 Version 2.0

Right uterine angiogram

Right uterine angiogram before uterine fibroid embolization demonstrates dilated

branches of the right uterine artery supplying multiple hypervascular uterine fibroids
(arrows) on the right.

Graphic 56265 Version 2.0

Right uterine angiogram

Right uterine angiogram after uterine fibroid embolization demonstrates successful

occlusion of the right uterine artery and its branches (arrow). The patient's symptoms
subsided after the procedure.

Graphic 70070 Version 2.0

