Uterine leiomyoma (fibroid) embolization

Authors
Ducksoo Kim, MD
Stephen D Baer, MD
Section Editors
Deborah Levine, MD
Robert L Barbieri, MD
Deputy Editor
Sandy J Falk, MD
Disclosures
All topics are updated as new evidence becomes available and
our peer review process is complete.
Literature review current through: Oct 2013. | This topic last
updated: Jan 30, 2013.
INTRODUCTION Uterine fibroid embolization (UFE) is a
nonsurgical treatment option for premenopausal women with
bothersome fibroid-related symptoms who wish to retain their
uterus, escape side effects associated with prolonged medical
therapy, and avoid surgery (eg, myomectomy) [ 1,2 ]. The
procedure is based upon the hypothesis that bilateral reduction of
uterine arterial blood flow will result in infarction of fibroids and
control bothersome fibroid-related symptoms, while sparing
normal myometrium [ 3 ].
INDICATIONS AND CONTRAINDICATIONS Uterine fibroid
embolization (UFE) is indicated for relief of bothersome bulkrelated symptoms and abnormal uterine bleeding due to fibroids.
(See "Epidemiology, clinical manifestations, diagnosis, and
natural history of uterine leiomyomas (fibroids)" .)
The procedure is rarely indicated in postmenopausal women since
fibroids naturally regress after menopause [ 4 ]. Other relative
contraindications to UFE include: current use of gonadotropin
releasing hormone (GnRH) agonists, submucosal fibroids,
extensive adenomyosis, previous internal iliac artery ligation, and
plans for future pregnancy. Many of these relative
contraindications are subjective, based on the judgment and
experience of the clinician (see 'Pregnancy after UFE' below and
'Ovarian dysfunction' below).
Large fibroids do not appear to be a contraindication to UFE. As
an example, a series of 71 women with a large fibroid burden
(dominant fibroid of >10 cm and/or a uterine volume of >700

cm) who underwent UFE had no serious complications after an

average of 48 months [ 5 ]. However, some studies have found
extremely large fibroids (>24 weeks uterine gestation size or
multiple fibroids larger than 10 cm in diameter) to be a relative
contraindication because of serious complications such as severe
abdominal pain, infection, sepsis, and ischemic uterine injury
requiring emergent hysterectomy [ 6-10 ].
Myomectomy is generally the preferred approach to pedunculated
tumors since they do not respond well to UFE, and procedurerelated complications (necrosis, separation, torsion) are more
common than after UFE of intramural fibroids. However, some
data suggest that UFE can be performed successfully in women
with pedunculated fibroids [ 11 ].
Hysteroscopic resection is the optimal approach to managing
submucosal tumors. Women with extensive uterine
adenomyomatosis also may be better served by a surgical
approach (hysterectomy). (See "Uterine adenomyosis" .)
GnRH agonists are a relative contraindication because they
decrease uterine artery caliber and uterine artery blood flow. The
decrease in caliber makes it more difficult to catheterize the
uterine artery, while the decrease in blood flow limits the
deposition of plastic beads into the target fibroid.
Absolute contraindications include pregnancy, active
genitourinary infection, malignancy, significant
immunosuppression, severe vascular disease limiting access, and
high risk of complications from contrast media [ 12 ].
The American College of Obstetricians has recommended UFE as
a safe and effective option for women who wish to retain their
uterus [ 13 ].
ALTERNATIVES Fibroids can also be treated medically or
surgically (hysterectomy, myomectomy). A detailed discussion of
the various options for treatment of fibroids can be found
separately. (See "Overview of treatment of uterine leiomyomas
(fibroids)" .)
PREPROCEDURE ISSUES
Differential diagnosis A reasonable effort to ensure an
accurate diagnosis is important before uterine fibroid
embolization (UFE), since symptoms attributable to fibroids may
be due to other pathology. One concern is that there may be a
delay in diagnosis of malignancy (eg, ovarian or endometrial
cancer, uterine sarcoma) since no tissue is obtained for

confirmation of the diagnosis. We ensure that the patient has had

an endometrial biopsy and recent pap smear to screen for uterine
malignancy prior to the procedure.
Laboratory testing Pregnancy should be excluded, including
the possibility of luteal phase pregnancy. This can be ascertained
by performing the procedure in the early follicular phase or
anytime in patients using a reliable form of contraception.
We also test for bacteriuria and sexually transmitted infection in
patients at risk and obtain a baseline complete blood count, BUN,
creatinine, and prothrombin time/international normalized ratio
(INR).
Imaging Magnetic resonance imaging (MRI) has become the
standard imaging tool in women planning UFE [ 14,15 ]. Most
women with symptoms or physical examination findings
suggestive of uterine fibroids undergo pelvic ultrasonography for
confirmation of the presence of myomas. However,
ultrasonography does not perform as well as MRI in determining
fibroid characteristics. Another benefit of MRI is superior
detection of adenomyosis, which may interfere with UFE efficacy.
(See 'Indications and contraindications' above and "Uterine
adenomyosis", section on 'Diagnosis' .)
MRI allows the differentiation of fibroids from other pelvic tumors
and is superior to ultrasound in the imaging of fibroids because it
can provide improved spatial and contrast resolution, along with
freedom from the effects of acoustic shadowing [ 15-17 ].
Fibroid size, number, and location are three potential predictors
of successful UFE [ 18-20 ]. As an example, UFE in women with
submucosal or pedunculated subserosal fibroids is associated
with an increased risk of complications. Information provided by
MRI regarding these fibroid characteristics may affect clinical
decision making. A retrospective study of 49 women who
underwent evaluation for UFE with both sonography and MRI
reported that the correlation between the two imaging modalities
for identification of the largest fibroid was high (correlation
coefficient 0.87), but was low for fibroid location (0.17);
discrepancies were also noted in the number of fibroids [ 14 ].
MRI results showing a difference in fibroid size or location from
that seen on ultrasound resulted in a change in management in
11 patients (22 percent), UFE was cancelled in four patients and
was performed in another seven patients thought to be poor
candidates based upon sonography results. A limitation of this

study is that clinical outcomes were not reported.

Tissue viability within a fibroid is another factor that is useful in
pre-UFE decision-making [ 15,21 ]. This can be determined using
contrast-enhanced MRI, but not sonography.
Further study is needed to confirm the role of MRI for evaluation
of women prior to UFE.
In addition, in patient follow-up after embolization, contrastenhanced MRI can be used to predict any regrowth of uninfarcted
fibroid tissue and to select patients for repeat embolization [
15,22,23 ].
Patient preparation If an intrauterine contraceptive device
(IUD) is in place, it has been traditionally recommended to
remove it because it can be a risk factor for postprocedural
infection [ 12 ]. However, a small retrospective study involving
20 women with an IUD who underwent UFE and had no infectious
complication after a mean follow-up of 20.5 months [ 24 ]
suggests that the presence of an IUD might not be considered a
contraindication for UFE. Nevertheless, in our practice, we
remove IUDs when clinically feasible.
PROCEDURE A general description of the procedure for
embolization of pelvic arteries is described in detail separately; a
summary of uterine artery embolization is provided below. (See
"Interventional radiology in management of gynecological
disorders", section on 'Transcatheter embolization procedure' .)
The procedure is performed under local anesthesia. The most
common approach to percutaneous embolization is via the right
or left femoral artery. Initially, an arteriogram is performed to
visualize the pelvic vasculature, especially identification of the
uterine artery, its origin, and any anatomic variations [ 25 ]. It is
also important to note whether any branches of the ovarian
artery are supplying the fibroids, and the size of these branches,
as they are a potential cause of treatment failure [ 26 ]. When
feasible, in our practice, we attempt to embolize any significant
uteroovarian connections by means of superselective
catheterization to avoid non-target embolization of the ovaries.
Each patient is counseled prior to the procedure and presented
with a decision tree, should the above situation arise.
Sometimes, the patient with significant ovarian contribution must
weigh the prospect of ovarian embolization with possible
premature ovarian failure versus incomplete embolization
resulting in unsatisfactory clinical outcome.

For uterine fibroid embolization (UFE), a catheter is passed into

the distal portion of one of the uterine arteries under fluoroscopic
guidance, followed by infusion of the embolizing agent ( figure
1A-B ). The infusion is continued until flow to the fibroids ceases,
but slight antegrade flow is still present in the uterine artery. The
procedure is then repeated on the other uterine artery ( image
1A-D ). Unilateral UFE is associated with a significantly higher
risk of failure (ie, need for subsequent hysterectomy or repeat
UFE procedures) than bilateral UFE (39 versus 18 percent) [ 27 ].
Bilateral embolization results in ischemic necrosis and hyaline
and calcific degeneration of the fibroids [ 28,29 ]. Technical
failure is rare (<1 percent) and is generally due to very difficult
uterine artery anatomy or dominant blood supply to fibroids from
ovarian arteries.
The average procedure time is about an hour [ 30 ].
POSTPROCEDURE ISSUES
Follow-up After uterine fibroid embolization (UFE), we see
the patient at two weeks, three months, six months, and then
yearly to monitor her for bulk-related symptoms and abnormal
uterine bleeding. We perform imaging studies if clinically
indicated.
Pain Virtually all women experience postprocedure pain,
which is believed to be due to ischemia of the fibroids and uterus
[ 31 ]. The degree of pain ranges from mild to severe cramping.
Options for pain control depend on the severity and include
patient-controlled analgesia, oral or parenteral opiates, and
nonsteroidal anti-inflammatory drugs. In our experience, the
risk/benefit to use of epidural anesthesia does not seem justified.
Epidural anesthesia is effective, but carries additional risks, such
as possible spinal headache, and increase in the cost of the
procedure. We have found that intravenous conscious sedation
during the procedure followed by PCA (patient controlled
anesthesia) suffices for postprocedural pain management.
Vaginal discharge Some women experience a bloody
discharge that typically lasts two weeks, but may persist for
months [ 12 ]. While discharge of short duration is common,
prolonged discharge is uncommon.
Postembolization syndrome Following the procedure, most
women experience postembolization syndrome, which consists of
pelvic pain and cramping, nausea, vomiting, fever, fatigue,
myalgias, malaise, and leukocytosis [ 12 ]. These symptoms

occur within the first 48 hours of the procedure and gradually

improve over seven days. Patients who do not gradually improve
should be evaluated for other conditions, such as sepsis.
Although UFE can be performed as an outpatient procedure, most
services admit patients for management of postembolization
symptoms [ 32 ]. Patient-controlled analgesia, oral or parenteral
opiates, nonsteroidal anti-inflammatory drugs, antipyretics, and
antiemetics can be started preemptively in the recovery room.
(See "Management of postoperative pain" .)
Complications Serious complications are rare, but are more
likely when there is a single large leiomyoma [ 7,33,34 ]. There
have been two case reports of fatal septic complications
associated with UFE procedures [ 7,35 ]. In addition, a fatal
nontarget embolization resulted from an intrafibroid
arteriovenous fistula in conjunction with presence of a patent
foramen ovale [ 36 ]. Venous thromboembolic complications have
been reported occurring at an estimated rate of 0.4 percent [ 37
] and are usually not fatal. However, there has been one case
report of a fatal pulmonary embolus occurring after UFE [ 38 ].
Nevertheless, mortality does not appear to be higher than that
associated with hysterectomy for treatment of leiomyomas [ 39
].
The type and rate of other reported complications depend, in
part, on whether criteria used were from the Society of
Interventional Radiology (SIR) or the American College of
Obstetricians and Gynecologists (ACOG) [ 30,40 ].
An overview of the most common complications follows:

Fever (2 to 4 percent)
Vaginal passage of a leiomyoma (2.5 to 5 percent).
Readmission (2.4 to 3.5 percent)
Need for unplanned surgical procedure (1 to 2.5 percent)
Allergic reaction/rash (2.5 percent)
Hemorrhage (0.15 to 0.75 percent)
Life-threatening event (0.2 to 0.5 percent)
Submucosal myomas may become endocavitary after UFE and be
expelled vaginally [ 41 ]. One study reported that this was most
likely to occur with submucosal fibroids that were less than 66 ml
in volume [ 42 ]. In another study, the authors assessed the ratio
between the largest endometrial interface and the maximum

dimension of the dominant submucosal fibroid (interface

dimension ratio) before and after UFE using contrast-enhanced
pelvic magnetic resonance imaging (MRI) in 49 women over a
two-year period [ 43 ]. They found that submucosal fibroids with
an interface-dimension ratio of greater than 0.55 are more likely
to migrate into the endometrial cavity after UFE. The majority of
these are expelled spontaneously without significant symptoms.
Rarely, submucosal fibroids greater than 6 cm in size that
become endocavitary may cause postprocedural complications
requiring further intervention and medical treatment. It should
be noted that passage of leiomyoma tissue can occur up to a
year following UFE and thus does not follow the expected time
course of surgical complications. Small fibroids undergo autolysis
and often present clinically by passage of tissue fragments with
or without discharge. Symptoms are minimal. Larger fibroids may
present with significant cramping/labor-type pains since
dilatation of the cervix is needed to pass the large volume of
tissue. Large fibroids may pass spontaneously, or require an
intervention.
Febrile morbidity may be related to endomyometritis
with/without pyometra, salpingitis, tuboovarian abscess, infected
fibroids, or infection at the groin insertion site [ 12 ]. Antibiotic
therapy may be effective, but if the infection does not respond,
surgical drainage (eg, dilatation and curettage) and/or resection
or hysterectomy is necessary.
In addition, there have been case reports of femoral nerve injury,
pulmonary embolism, bilateral iliac artery thrombosis, ischemic
infarction of the uterus, labial necrosis, focal bladder necrosis,
vesicouterine fistula, and development of uterine wall defects [
7,30,35,40,44-47 ].
Undetected sarcoma Since preoperative evaluation
(including endometrial biopsy and MR imaging) cannot
distinguish between benign leiomyomas and myometrial
neoplasms of low or high grade malignancy (eg, leiomyosarcoma)
with certainty, a misdiagnosed sarcoma may be treated by UFE
rather than surgical resection [ 48-50 ]. However, this risk is very
small, given the rarity of these tumors. A literature review noted
only six cases of uterine sarcoma in women who had undergone
UFE [ 50 ]. Because the risk of leiomyosarcoma increases with
age, UFE is not recommended for menopausal women with new
onset or worsening symptoms related to presumed leiomyomas.

(See "Uterine sarcoma: Classification, clinical manifestations, and

diagnosis" .)
Ovarian dysfunction Some, but not all [ 51,52 ], studies
have reported loss of ovarian function after UFE, manifested as
transient or permanent amenorrhea, possibly from nontarget
(unintentional) embolization into ovarian arteries [ 53-55 ]. This
complication appears to be age related. Instances of premature
menopause have been reported in 2 to 3 percent of patients
under the age of 45, and in approximately 8 percent of women
over the age of 45 following UFE [ 6,8,53,55-58 ]. Three-year
follow-up data from the UFE registry found that 1.6 percent of
women under 40 who underwent UFE were amenorrheic within
three years, although whether these patients' periods stopped
independently of the UFE was not determined [ 59 ]. In addition,
one case report described amenorrhea following UFE that was
secondary to endometrial atrophy despite normal ovarian
function [ 60 ].
There are few well-designed studies that compare rates of
ovarian dysfunction after UFE against the complication rates of
myomectomy or hysterectomy in similar patients [ 61 ]. In
general, the fertility rate after UFE appears to be similar to that
achieved by myomectomy [ 61 ]. In one randomized trial, antimullerian hormone showed diminished ovarian reserve at 24
months following treatment for both women undergoing
hysterectomy and UFE, with a trend toward greater impairment
in the UFE group [ 62 ]. Likewise, in follow-up from a randomized
controlled trial, reproductive outcomes at two years were better
following surgery than UFE [ 63 ].
For women desiring future fertility, more studies need to be done
before UFE can be recommended as the first-line approach for
women with fibroids who wish to preserve future fertility.
However, for those women who wish to preserve fertility, but are
unsuitable candidates for surgery, UFE offers an option to treat
their fibroid symptoms while also possibly preserving fertility.
Patients who desire fertility need to be fully counseled as to the
current data available regarding pregnancies after UFE (see
'Pregnancy after UFE' below).
For women desiring future fertility, studies examining subtle
forms of impairment of ovarian function that may lead to
subfertility need to be done before UFE can be recommended as
the first-line approach for women with fibroids who wish to

preserve future fertility.

OUTCOME
Short-term outcomes Short-term outcomes have generally
been favorable when the procedure was performed by
experienced interventional radiologists [ 4 ]. Data compiled from
several large series show [ 6,9,30,64-68 ]:

The procedure could be completed in 98 to 100 percent of

patients
Improvement of abnormal bleeding occurred in 85 to 94 percent
of women
Improvement of dysmenorrhea occurred in 77 to 79 percent
Bulk-related symptoms were controlled in 60 to 96 percent
Mean uterine volume was reduced by 35 to 60 percent ( image
2A-B ). Submucosal location is a strong predictor of volume
reduction since these myomas are often expelled; mean
reduction in uterine volume is lower in women with only
intramural or subserosal myomas [ 57,69-72 ].
The Society of Interventional Radiology maintains a prospective
uterine fibroid embolization (UFE) registry involving more than
3000 women. Follow-up data on 1278 patients three years after
UFE are available; this series is the largest that has been
reported [ 59 ]:

95 percent of patients had significant improvement in symptoms

and quality of life
29 percent developed post-procedure amenorrhea; 21 percent of
amenorrheic patients were 45 years of age or younger
14.4 percent underwent an additional invasive procedure:
hysterectomy (9.8 percent), myomectomy (2.8 percent), repeat
UFE (1.8 percent)
Long-term outcomes Series with follow-up over five or
more years report higher rates of secondary intervention.
Although approximately 75 percent of patients reported uterine
bleeding was normal or improved five or more years after UFE,
approximately 20 percent reported having undergone a second
procedure (hysterectomy, myomectomy, repeat UFE) to control
fibroid-related symptoms [ 27,73-75 ].
Data from comparative studies A few comparative studies

have been performed; representative examples are illustrated

below [ 76-81 ]. In general, patients report high rates of
symptom control and satisfaction after UFE, hysterectomy, and
myomectomy. UFE has the shortest period of recovery. All of the
procedures have similar rates of complications, although the
complications are different for the various procedures.
Approximately 20 percent of women who undergo UFE will
undergo a subsequent procedure (reembolization, hysterectomy,
or myomectomy) because of persistent symptoms.
Systematic review A systematic review of 54 study
populations including 8159 women who underwent UFE found
that the rate of major complications was 2.9 percent and the rate
of readmission after the procedure was 2.7 percent [ 82 ]. The
rate of hysterectomy for resolution of a complication of UFE was
0.7 percent. The rate of reintervention (repeat UFE,
myomectomy, or hysterectomy) per patient-year was 5.3 percent
with follow-up ranging from 0.25 to 5 years.
Another systematic review of UFE versus hysterectomy found
that UFE took less time (weighted mean difference -16 minutes,
95% CI -26 to -7 minutes), had less blood loss (weighted mean
difference -405 mLs, 95% CI -512 to -298 mLs), a shorter
duration of hospitalization (weighted mean difference -3.3 days,
95% CI -3.8 to -2.8 days), and faster resumption to normal
activities (weighted mean difference -27 days, 95% CI -36 to -17
days), but more unscheduled visits after discharge (OR 1.8, 95%
CI 0.98-3.30) and a higher rate of readmission within 42 days
(OR 6.0, 95% CI 1.1-31.5) [ 83 ]. Both groups were satisfied
with their treatment.
The same systematic review identified only one randomized trial
(n = 121) comparing UFE versus open or laparoscopic
myomectomy, which showed that UFE had significant decreases
in operative duration (an average of 34 minutes shorter), hospital
stay (an average of 1.6 days less), and time to return to normal
daily activity (an average of 16 days less) [ 79,83 ]. Of note, this
trial combined the data for open and laparoscopic myomectomy,
making it difficult to apply these findings regarding operative
duration and recovery time. Few serious perioperative
complications occurred for either procedure (UFE: 3 of 30;
myomectomy: 1 of 33). The rate of improvement in symptoms at
six-months postoperatively was similar for both UFE and
myomectomy (88 and 93 percent). However, after an average of

17 months, the rate of reintervention was significantly higher for

UFE (37 versus 6 percent). Further randomized trials comparing
UFE with open or laparoscopic myomectomy or hysterectomy are
needed.
REST trial The Randomized Trial of Embolization versus
Surgical Treatment for Fibroids (REST trial) trial compared the
outcome of UFE versus surgery in women with symptomatic
fibroids [ 84 ]. In this trial, 106 women were assigned to UFE and
51 women were assigned to surgical therapy; women in the
latter group decided whether the surgical intervention would be
hysterectomy (43 women) or myomectomy (8 women).
Compared to surgical therapy, UFE was associated with
significantly shorter duration of hospitalization (1 versus 5 days)
and time until return to work (20 versus 62 days). The overall
frequency of adverse events was similar for both groups;
however, adverse events were more likely to occur during
hospitalization in women who underwent surgery versus after
discharge in women who underwent UFE.
Twenty-one women in the UFE group subsequently underwent
reembolization or hysterectomy due to treatment failure; 10 of
these procedures were in the first year after UFE. In the surgery
group, one myomectomy was converted to a hysterectomy
intraoperatively. Quality of life scores were similar for both
groups at 12 months follow-up. Although 20 percent of women
treated with UFE ultimately underwent a second procedure, initial
treatment was successful in most women and enabled a more
rapid return to usual activities.
EMMY trial The EMbolization with hysterectoMY (EMMY) trial
randomly assigned 177 women with symptomatic
fibroids/menorrhagia who were eligible for hysterectomy to
uterine fibroid embolization (UFE) or hysterectomy [ 76,77,85 ].
In the short-term, the rate of major complications was not
significantly different for the two procedures (less than 5
percent). UFE was associated with more minor complications and
readmissions, but shorter hospital stay and shorter duration to
resumption of usual activities. UFE procedural failures were
mainly due to difficult anatomy and absence of a uterine artery [
77 ].
At five-year follow-up, 28 percent of UFE patients had
subsequently undergone hysterectomy; health-related quality of
life measures improved and were similar in both treatment

groups [ 86 ].
Pregnancy after UFE The safety of pregnancy after UFE has
not been established; therefore, the procedure is usually
reserved for women who are not contemplating future
childbearing. A systematic review and several case series of
pregnancies following UFE have reported adverse outcomes in
some pregnancies following UAE, including miscarriage, preterm
delivery, placental problems, and malpresentation [ 61,63,87-92
]. Some of the increased risk of adverse pregnancy outcome
could be explained by confounders, such as a higher prevalence
of advanced maternal age and infertility in the women who
underwent UFE.
REPEAT PROCEDURES Repeat uterine fibroid embolization
(UFE) can be performed, but data on these procedures are
limited. In one series, 24 women underwent repeat embolization
for recurrent or persistent symptoms 6 to 66 months post UFE
and 90 percent had successful symptom control after the second
procedure [ 93 ]. MR imaging before repeat embolization
revealed incomplete infarction of tumors present before the first
embolization in 22/24 patients and new tumors in 12/24 patients
(2/12 had new tumors only). During repeat UFE, nine patients
required ovarian artery embolization to occlude ovarian supply to
the uterus.
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 5 th to 6 th 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 10 th to 12 th 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.)

Basics topic (see "Patient information: Uterine artery

embolization (The Basics)" )
Beyond the Basics topics (see "Patient information: Uterine
fibroids (Beyond the Basics)" )
SUMMARY AND RECOMMENDATIONS

Uterine fibroid embolization (UFE) reduces uterine arterial blood

flow, which results in infarction of fibroids and reduction in
fibroid-related symptoms. (See 'Introduction' above.)
UFE is indicated for relief of bothersome bulk-related symptoms
and abnormal uterine bleeding due to fibroids in premenopausal
women. We suggest avoiding this procedure in premenopausal
women with large pedunculated or submucosal fibroids (>6 cm),
extensive adenomyosis, an extremely large fibroid uterus (>24
weeks of pregnancy in uterus size or multiple fibroids larger than
10 cm in diameter), or plans for future pregnancy ( Grade 2C ).
UFE should also be avoided in postmenopausal women. (See
'Indications and contraindications' above.)
We suggest magnetic resonance imaging (MRI) with and without
contrast medium before UFE. MRI is useful for excluding large
pedunculated fibroids and other disease processes that might be
better treated by another modality. (See 'Preprocedure issues'
above.)
We suggest bilateral uterine artery embolization as unilateral
procedures are associated with a significantly higher risk of
failure ( Grade 2C ). (See 'Procedure' above.)
The most common side effects and complications of UFE are pain,
postembolization syndrome, fever, allergic reaction, vaginal
passage of a leiomyoma, readmission, and need for an unplanned
procedure. Misdiagnosis of a leiomyosarcoma and postoperative
ovarian dysfunction are additional serious concerns. (See
'Postprocedure issues' above.)
Five or more years after UFE, approximately 75 percent of
patients report uterine bleeding is normal or improved,
approximately 20 percent report having undergone a second
procedure (hysterectomy, myomectomy, repeat UFE) to control
fibroid-related symptoms. (See 'Outcome' above.)
The safety of pregnancy after UFE has not been established;
therefore, the procedure is usually reserved for women who are

not contemplating future childbearing. (See 'Pregnancy after UFE'

above.)