Karen* almost always feels drowsy and barely has any energy. Her menstrual periods last up to 12 days, and given the heavy flow, she constantly has to change tampons and pads. After a visit with her nurse practitioner for a complete history and physical, Karen undergoes several diagnostic tests. Her blood work indicates a low blood count with resulting iron-deficiency anemia. A transvaginal ultrasound followed by a pelvic MRI reveals several large uterine fibroids. Her gynecologist offers the options of medical management with hormones or the surgical removal of her uterus and fibroids. The gynecologist also discusses the relatively new option of uterine fibroid embolization (UFE), a procedure in which blood vessels that supply the uterus are blocked, resulting in shrinkage of the fibroids. Karen does not relish the idea of hormonal manipulation or invasive surgery, so she chooses UFE to shrink her fibroids, stop her heavy menses, and eliminate the source of her anemia.

Some women with fibroids have no bothersome symptoms. For others, like Karen, the condition can be extremely debilitating, with pain, increased menstrual blood flow, anemia, and diminished quality of life. Nurses need to stay current on the treatment options, including UFE, for these women in order to offer accurate patient education and, depending on their practice settings, provide appropriate patient care before, during, and after procedures for fibroids.

The all-too-common fibroid

Uterine fibroids www.nlm.nih.gov/medlineplus/uterinefibroids.html, the most common benign pelvic tumors, are also known as myomas, fibromyomas, or leiomyomas. They’re the most common gynecologic condition among women of childbearing age. Uterine fibroids occur in about 25% of women over 30, with African-American women more commonly affected.¹ Other factors associated with an increased risk of fibroids are obesity, nulliparity, and family history. Uterine fibroids are classified as subserosal (external), intramural (within the myometrium), or submucosal (projecting inside the uterine cavity). Many women develop fibroids in several of these sites. Fibroids may occur as small single entities or may manifest as large, multiple tumors.

Uterine fibroids are composed of smooth muscle cells and extracellular products, such as collagen, proteins, and other fibrous tissues. Fibroids are estrogen-dependent. They are not seen in prepubescent girls or postmenopausal women, but occur frequently in women with increased serum estrogen levels. For example, women on estrogen therapy, obese women, and those who are pregnant are at greater risk for developing fibroids.² When women reach menopause and experience a lack of estrogen, fibroids may shrink and sometimes disappear. The contributions of progesterone, insulin-like growth factors, and prolactin to fibroid development are unclear but are under investigation.

The traditional solutions

Observation, medical management, and surgical treatments have been the mainstay of uterine fibroid therapy for many years.

Observation: In mild cases of uterine fibroids, “watchful waiting” is employed: Medical treatment is not started until the bothersome symptoms of fibroids, such as pain and bleeding, disrupt the patient’s quality of life. When the symptoms do require therapy, several medical and surgical options are available.

Medical management: The pelvic pain and heavy menses of uterine fibroids may be treated with a variety of nonsteroidal anti-inflammatory drugs. NSAIDs exert an anti-prostaglandin effect on the uterus that may relieve abdominal cramping and reduce menstrual bleeding. Over-the-counter agents, such as ibuprofen (Motrin) or naproxen (Aleve), are commonly recommended as a first-line therapy. If stronger medication is needed, many types of prescription-strength NSAIDs are available. Nurses should instruct patients to take these agents with food and watch for signs of GI bleeding, such as epigastric pain and dark stools.

Oral contraceptives (particularly low-dose) may help control heavy menses and slow the growth of uterine fibroids.³ Regular menstrual cycles may also be achieved with the prescription of oral contraceptives. Added benefits of these agents obviously include birth control, and some agents may also reduce acne.

Iron-deficiency anemia, commonly associated with uterine fibroids, may be relieved with oral iron therapy or a diet high in iron-rich foods www.bnl.gov/hr/blooddrive/iron-rich.asp, such as red meat, oatmeal, raisins, etc. Typically, ferrous sulfate (325 mg per day) is recommended; however, patients should be advised to take iron supplements with vitamin C rich foods. Constipation, a common adverse effect of iron supplements, may be avoided or minimized by increasing fluids and fiber in the diet. Physical activity can help, too.

Gonadotropin-releasing hormone www.webmd.com/hw/health _guide_atoz/aa76766.asp (GnRH) agonists may be prescribed to block estrogen production; this induces an artificial menopause state. Expected results of GnRH therapy are amenorrhea, fibroid shrinkage, and reduced uterine blood flow. The lack of menses may help correct the anemia resulting from heavy menstrual flow; however, this method is reserved for a select population of women such as perimenopausal and presurgical candidates. Maximum shrinkage of the tumors is usually achieved in two to three months, and the tumors will return to previous size three to six months after GnRH therapy is discontinued. Long-term treatment with GnRH (over six months) is not recommended because of the increased risk of estrogen deficiency-induced osteoporosis.⁴

Surgical treatments: Several surgical options are available for the removal of uterine fibroids. Myomectomy, the surgical removal of fibroid tumors, is suggested for women with few or small tumors or those who may want to preserve their uterus. Myomectomy is most often performed via laparotomy. However, small tumors may be removed via a laparoscopic procedure.⁵ While myomectomy is a good surgical alternative, particularly in women of childbearing age, it carries the usual risk of surgery and of tumor recurrence, particularly in women with multiple or large fibroids.

Hysterectomy is the only treatment of uterine fibroids that guarantees a cure, and uterine fibroids are the most common reason for hysterectomies performed in the U.S.⁶ The surgery may be performed abdominally or vaginally, depending on the size and site of the tumors, previous patient history of abdominal surgeries, and the patient’s physical condition. Removal of the ovaries at the time of hysterectomy is recommended only for women who are perimenopausal or suffering with ovarian abnormalities. If the ovaries are removed before menopause, estrogen therapy should be considered (unless contraindicated due to patient history) to avoid bone loss and menopausal symptoms. While removal of the uterus is certainly a successful treatment for fibroids, it is not without the risks of a major surgical procedure, complications of anesthesia, and postoperative infection, as well as hospitalization. In addition, many women wish to preserve their uterus and thus prefer therapies other than hysterectomy.

The newest alternative: UFE

Uterine fibroid embolization has been available since the 1970s in various forms to treat postpartum hemorrhage.⁷ In the late 1980s, a French gynecologist began to investigate UFE as a preoperative maneuver to prevent intraoperative and postoperative hemorrhage in women who were scheduled for hysterectomies. He found that frequently women would cancel the hysterectomy, claiming the UFE had cured their problems of bleeding and abdominal pain.⁸

UFE is a minimally invasive procedure typically performed by an interventional radiologist. It has recently been reconsidered as a less invasive alternative to surgical methods for alleviating bleeding and other bothersome symptoms of uterine fibroids. This method is especially attractive for women who are poor surgical candidates secondary to morbid obesity, hypertension, or diabetes.

Before a UFE, a woman undergoes a thorough gynecologic evaluation to determine that uterine fibroids are directly responsible for her symptoms.⁷ Pregnancy is ruled out typically, and an ultrasound or MRI of the uterus is requested to differentiate uterine from ovarian masses. Frequently a CA-125 is ordered to aid in discriminating between benign and malignant tumors. Patients with menorrhagia (excessive menstrual blood flow) may also undergo an endometrial biopsy before UFE to exclude endometrial carcinoma from the diagnosis.

UFE is contraindicated for women who have pelvic infections, arterial-venous malformations (http://en.wikipedia.org/wiki/Arteriovenous_malformation), severe contrast allergy, and renal disease (since the contrast dye is excreted renally) or those who are immunocompromised. Women should discuss the risks vs. benefits with their healthcare providers regarding these possible contraindications.

UFE is usually done in the hospital with an overnight stay postprocedure due to preoperative and intraoperative sedation and potential postoperative complications. Prophylactic antibiotics and antiemetics are frequently used. Conscious sedation or spinal anesthesia may be given; however, the uterine arteries are typically accessed via the femoral artery using a local or epidural anesthetic, needle puncture, and then introduction of a catheter. Before the embolization is started, an arteriogram is performed to clearly outline the blood supply to the uterus and the fibroids. After the arteriogram, particles of polyvinyl alcohol (PVA), gelfoam, or acrylic microspheres are injected slowly with radiologic guidance. The particles lodge in the blood vessels that feed the fibroids and ultimately block blood flow to the tumors. The type of material used depends on the medical center where the procedure is performed. Of these emboli options, acrylic microspheres are the only devices that the Food and Drug Administration has cleared for use in UFE.⁹ These tiny particles flow to the fibroids first because of the vascular nature of fibroids. The particles wedge in the vessels and cannot travel to other parts of the body. Normal myometrium is unharmed because it is supplied with multiple collateral arteries. Over several minutes, the arteries are slowly blocked, and blood flow to the fibroids ceases. The embolization process continues until there is complete blockage of blood flow to the fibroids. After embolization, another arteriogram is performed to confirm the blockage of blood flow. Arterial blood flow to the normal portions of the uterus is maintained. The entire UFE procedure typically takes one to two hours. The majority of women who undergo UFE report marked reduction in the severity of fibroid specific symptoms and significant improvement in their quality of life.¹⁰

Follow-up

The interventional radiologist who performs UFE takes responsibility for follow-up and management of any complications after the procedure. The nurse working in interventional radiology typically telephones patients 24-48 hours after discharge and schedules them for an office visit two weeks postprocedure.⁸ Some providers continue to follow up with patients at three and 12 months postprocedure; however, some prefer to refer patients back to their gynecologists for monitoring.

Complications

Short-term complications may include allergic reactions to the injected dye; puncture site complications, such as bleeding, infection, or hematoma formation; severe pain; vaginal discharge; and cramping and nausea for four to six hours after the procedure.¹¹ Most patients can resume normal daily activities two to four days after UFE.

Reports of serious postprocedural infections have been rare.^7,10 Occasionally, submucosal fibroids become necrotic after UFE with subsequent expulsion from the uterus. Other serious complications include injury to the femoral uterine arteries, infection or injury to the uterus, blood clots, and injury to the ovary.¹² There have been three deaths reported within 30 days of UFE.¹³

Over the long term

The procedure of UFE has not existed for very long, so long-term effects are unknown. Patients often have questions about the possibility of future pregnancies and menstrual cycle irregularities. No solid data exists about the effect of UFE on pregnancy chances.¹² It may reduce the chance of becoming pregnant for some women due to decreased blood flow to the uterus. In other women, the reduction of fibroid mass and increased blood flow to the normal parts of the uterus may increase their chances of pregnancy.⁴ Patients who become pregnant after UFE are recommended to have early sonograms to assess the site of implantation and the integrity of the uterine wall. At this time, UFE is not recommended for young women who want to preserve their fertility.

In rare situations, collateral circulation sufficiently develops after UFE and fibroids return. In these cases, UFE may be repeated to treat the new fibroids. While most women experience vastly reduced bleeding and normal menstrual cycles after UFE, a potential effect of UFE is the loss of menstrual cycles and the onset of menopause. In a small segment of women (most who were near menopause age), menses ceased after UFE. The reasons are unclear, and menses cessation very rarely occurs in women under age 45.¹⁴Evidence about the long-term resolution of fibroids is lacking. But it’s known uterine fibroids can recur in 10% to 30% of women who have undergone surgical myomectomy.⁷

In a small study of 305 UFE patients, 86% indicated improvement of symptoms with the procedure.³ In a five-year study of 200 patients who had undergone UFE, only 20% experienced recurrence of fibroids.¹⁵ More research is needed to determine whether UFE is as successful as other procedures in permanently eliminating bothersome fibroids. Many of the questions about the long-term safety and efficacy of UFE are being examined by projects, such as the SIR FIBROID Registry www.sirfoundation.org/ uae.shtml, the Toronto UFE study www.womenshealthmatters. ca/news/news_show.cfm?number=222, and a randomized controlled trial of UFE versus surgery being conducted in Scotland and Holland.⁸

The pros and cons

UFE has several advantages over the traditional options of hysterectomy, myomectomy, and hormonal manipulation. Unlike the other surgical approaches, UFE does not involve the risks and complications of general anesthesia or surgical incisions. Extended hospitalizations are avoided in UFE because it is minimally invasive. UFE is a more economical option than traditional surgical approaches. In UFE, all fibroids are treated at once, which is not the case with myomectomy.⁷ Recovery from UFE typically takes several days, while recovery from hysterectomy or myomectomy may take up to six weeks. Thus, quality of life indicators such as time away from work outside the home, housekeeping activities, and child-rearing responsibilities are minimized with UFE.¹⁶ The bone loss and other problems of estrogen withdrawal that accompany treatment with GnRH agonists therapy are avoided with UFE.

One of the disadvantages of UFE is that too few health professionals know that it’s available. In many communities, interventional radiologists, not gynecologists, perform UFE. A woman being treated for fibroids by her gynecologist may not learn about UFE. A nurse’s greatest contribution can be to be aware of local options for UFE and to inform colleagues and patients. A directory of physicians performing UFE in North America is available through the Society of Interventional Radiology www.sirweb.org. Many insurance companies cover UFE for uterine fibroids.

Helping patients through UFE

Once a patient is informed about UFE and decides on this option, nurses can perform a variety of interventions depending on the work setting. Nurses in outpatient settings can help provide education about the procedure, risks, contraindications, complications, and postprocedure recovery. Nurses working in interventional radiology or inpatient surgical centers can provide direct preprocedural care, assistance during the embolization, and postprocedure interventions in the form of surveillence for postoperative complications, pain and nausea management, fluid and electrolyte support, and discharge instructions.

Uterine fibroids affect a great number of premenopausal women. Some women can be managed with conservative medical treatment, but for those with debilitating symptoms, UFE represents a viable alternative to the past standard of care. Nurses must be informed about the availability of this option for their patients and provide the necessary patient education.