Fibroids. Very Common! Benign smooth muscle tumors of the myometrium 20-80% of women develop fibroids by age 50* 151 million women affected**

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Bertina Magdalene Wells
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2 Fibroids Very Common! Benign smooth muscle tumors of the myometrium 20-80% of women develop fibroids by age 50* 151 million women affected** * Uterine Fibroids Fact Sheet Office on Women s Health 2015 ** Global Burden of Disease Study 2015 Lancet Oct 2016

3 Fibroids Only treat when symptomatic Symptoms Heavy menstrual bleeding (w or w/o anemia) Bulk symptoms such as Pelvic pain, pressure Urinary frequency, hesitancy, retention Painful intercourse Constipation Back, flank or leg pain

5 Treatment of Fibroids Medical NSAIDS Iron (if anemic) Other Medications: Birth Control Hormones, Gonadotropinreleasing hormone agonists (Lupron) and antagonists (Elagolix), etc. IUD (progestin-releasing) Minimally Invasive MRI-guided focused ultrasound UFE (Uterine Fibroid Embolization) Endometrial Ablation Surgical Hysteroscopic Fibroid Removal Myomectomy Laproscopic RFA Fibroids Hysterectomy

6 Uterine Fibroid Embolization Proven with subjective and objective data Developed in the late 1990s Continues to improve Outpatient minimally invasive procedure Treats ALL of the fibroids Optimum next option for those who have failed conservative medical measures

7 Uterine Fibroid Embolization Success is high and complications are low Success: 90% satisfied w/ bleeding yr & 80% satisfied w/ bulk 1 yr: Summary data 86% satisfied at 3 years: Fibroid registry 78% years: EMMY trial 40-70%: Shrinkage of each fibroid and the uterus measured at 6 mo MRI Large Fibroids >10 cm can be treated successfully without increased complication

8 Uterine Fibroid Embolization Successfully treated fibroids progressively reduce in volume over time, beyond 6 months

9 Complications Permanent amenorrhea < 45y 0-3%; >45y 20-40% Prolonged vaginal discharge 2-17% Transcervical leiomyoma expulsion 3-15% Sepsis 1-3% DVT/PE <1% Non-target embolization <1% Standards of Practice: Quality Improvement Guidelines for Uterine Artery Embolization for Symptomatic Leiomyomas JVIR AUG 2010

10 Uterine Fibroid Embolization Pre-Procedure Evaluation Clinical History and Physical Exam (w Barbeau test) UFS-QOL score (Uterine Fibroid Symptom and Quality of Life Evaluation) Prior medical care: Up to date pap smear, mammogram, etc Labs: FSH, CBC, Creatinine, Coags, LD isozymes, poss AMH, poss preg test, etc. Imaging: MRI with Gadolinium Endometrial bx: Not essential unless other worrisome features

13 Target Uterine Arteries via Radial Artery

14 UFE technique Pre-procedure meds: Scopolamine patch, IV acetaminophen, IV Ibuprofen, IV Ancef, EMLA cream and Nitro paste on left wrist Pre-procedure nerve block: Superior Hypogastric Nerve Block Intra-procedure meds: Zofran, Versed, Fentanyl, Dexamethasone, IA lidocaine 1% Entry: Left radial artery with ultrasound guidance Place left radial artery 4F sheath Select both uterine arteries w/ small 4F & micro catheters Embolize with micron Tris-Acryl or PVA particles (sometimes +/- particle size) Apply Stat seal and TR compression band to wrist after removal of catheter/sheath

15 UFE Technique Radial artery entry..(vs femoral) No closure device or manual compression needed No foley Easier in obese patients Patients can walk immediately which decreases risk of DVT No sequential compression devices for DVT prevention Easier if there is nausea or vomiting Patients love it! Radial entry preferred over femoral entry* *Fischman, A et al. Uterine Artery Embolization Using a Transradial Approach: Initial Experience and Technique; JVIR 2014 Cooper, CJ et al. Effect of transradial access on quality of life and cost of cardiac catheterization: A randomized comparison ; AHJ 1999

16 Fibroids can rarely have ovarian artery supply, too, which can be embolized if needed

17 Uterine Fibroid Embolization Post Procedure Care Control pain and nausea which is greatest in the first 6-12 hours Anti-emetic medications: Scopolamine patch, Ondansetron (Zofran) IV Pain medications: Opioids po or IV Ambulation, which is easy with radial artery entry Discharge: po NSAIDS and stool softeners PRN Anti-emetics and opioids f/u IR clinic 2 weeks

18 Sample Case: Radial Uterine Artery Embolization with Pre-procedure Superior Hypogastric Nerve Block

26 MRI Images Before and After UFE

27 PRE POST

28 Pre 16 months Post

29 Pre 8 months post

30 Pre 8 mo post

31 Pre 3 years post

33 1 year 3 years

34 PRE POST

35 Before UAE After UAE

36 Pre History of significant retention Post

37 Conclusions UFE is a well established effective non-surgical minimally invasive outpatient option for fibroid patients that have significant bulk and/or bleeding symptoms Fibroids shrink 40-70% (measured by MRI at 6 mo) and they continue to shrink for years Large fibroids can be treated without increased risk or pain

38 Conclusions Radial artery entry has numerous benefits including improved patient comfort and satisfaction with the procedure UFE is a good option for patients with adenomyosis as well as fibroids UFE is a great next step if more conservative medical options have failed.

Management of Uterine Myomas

Management of Uterine Myomas Deidre D. Gunn, MD Assistant Professor Division of Reproductive Endocrinology & Infertility February 16, 2018 Disclosures I have no relevant financial relationships to disclose.