Interventional Radiology · Supplementary · from Interventional Radiology

Case 2: Uterine Fibroid Embolization

Patient Presentation

Demographics: 38-year-old female marketing executive

Chief Complaint: "My periods are extremely heavy and painful, and I'm tired of taking time off work every month"

History of Present Illness: This 38-year-old female marketing executive presents with a 2-year history of progressively worsening menorrhagia and dysmenorrhea. Her menstrual periods now last 8-10 days with passage of large clots, requiring her to change super-absorbency pads every 1-2 hours on her heaviest days. She describes severe cramping pain that begins 2 days before her period and persists throughout menstruation, rated 8/10 in severity. She has missed an average of 2-3 days of work per month due to bleeding and pain.

She also reports a sensation of pelvic pressure and urinary frequency, needing to urinate every 1-2 hours during the day. She occasionally experiences urinary urgency but denies incontinence. She reports progressive abdominal bloating with her pants size increasing from a 6 to a 10 over the past year. She was recently found to have iron deficiency anemia with a hemoglobin of 9.8 g/dL.

Pelvic ultrasound demonstrated a bulky uterus with multiple fibroids. She has been offered hysterectomy but strongly desires uterine preservation as she hopes to conceive in the future, though she understands that uterine fibroid embolization (UFE) may affect future fertility. After counseling regarding all options including myomectomy and UFE, she has chosen to proceed with UFE.

Past Medical History:

• Symptomatic uterine fibroids (diagnosed 2 years ago)
• Iron deficiency anemia (secondary to menorrhagia)
• Mild anxiety
• No prior surgeries
• G0P0

Medications:

• Iron sulfate 325 mg twice daily
• Ibuprofen 800 mg three times daily during menses
• Tranexamic acid 1300 mg three times daily during menses
• Sertraline 50 mg daily
• Combined oral contraceptive pill (discontinued 3 months ago with no improvement)

Social History:

• Non-smoker
• Occasional alcohol (2-3 drinks/week)
• Marketing executive, high-stress job
• In a stable relationship, desires future pregnancy
• Regular exercise (running, cycling)

Family History:

• Mother had hysterectomy for fibroids at age 45
• Maternal aunt with fibroids
• No family history of gynecologic malignancy

Physical Examination

• Vital Signs: BP 122/78 mmHg, HR 82 bpm, RR 14/min, Temp 36.9°C, SpO2 99% on room air, BMI 24.8
• General: Well-appearing female in no acute distress. Pale conjunctivae
• Cardiac: Regular rate and rhythm, grade I/VI systolic flow murmur (secondary to anemia)
• Lungs: Clear to auscultation bilaterally
• Abdomen: Soft, non-tender. Palpable firm, irregular midline mass arising from the pelvis, extending to the level of the umbilicus. Non-mobile
• Pelvic: Enlarged, irregularly shaped uterus approximately 16-week size on bimanual examination. Cervix appears normal. No adnexal masses
• Extremities: No edema, mild koilonychia of fingernails

Workup and Results

Laboratory Studies:

Imaging/Additional Studies:

• Pelvic ultrasound: Uterus measures 16 x 12 x 10 cm. Multiple fibroids identified: dominant intramural fibroid of the posterior wall (8 x 7 cm), anterior intramural fibroid (4 x 3.5 cm), fundal subserosal fibroid (5 x 4 cm), and two small submucosal fibroids (2 cm and 1.5 cm). Endometrial stripe partially obscured. Ovaries normal bilaterally
• MRI pelvis with contrast: Confirms ultrasound findings. All fibroids demonstrate avid enhancement suggesting good vascularity and suitability for embolization. No evidence of adenomyosis. No suspicious features to suggest leiomyosarcoma (homogeneous T2 signal, no rapid growth). Endometrial cavity distorted by the submucosal fibroids
• Endometrial biopsy: Proliferative endometrium, no hyperplasia or malignancy

Clinical Image

Diagram illustrating the uterine fibroid embolization procedure showing catheter access through the femoral artery, selective catheterization of the uterine arteries, and delivery of embolic microspheres to devascularize fibroids. Source: Educational illustration.

Diagnosis

Symptomatic Uterine Leiomyomata with Menorrhagia, Iron Deficiency Anemia, and Bulk Symptoms — Planned Uterine Fibroid Embolization

Key Diagnostic Criteria:

• Multiple uterine fibroids confirmed on ultrasound and MRI
• Symptomatic with severe menorrhagia, iron deficiency anemia, pelvic pressure, and urinary frequency
• MRI confirming avid fibroid enhancement (good embolization candidate)
• Endometrial biopsy excluding malignancy
• Patient preference for uterine-sparing procedure

Treatment Plan

1. Pre-procedure optimization: IV iron infusion (ferric carboxymaltose 750 mg x2 doses) to improve hemoglobin before procedure. Discontinue NSAIDs 5 days before procedure
2. UFE procedure: Right common femoral artery access under ultrasound guidance. Selective catheterization of bilateral uterine arteries using a 5F Roberts uterine catheter via a Waltman loop. Embolization with 500-700 μm and 700-900 μm calibrated tris-acryl gelatin microspheres (Embosphere) to near-stasis endpoint. Completion angiography confirming devascularization of fibroid blush with preservation of ovarian arterial flow
3. Post-procedure pain management: PCA morphine for 12-24 hours, transition to oral ibuprofen and acetaminophen. Ondansetron for nausea. Post-embolization syndrome (pain, fever, nausea) expected for 5-7 days
4. Discharge: Same-day or next-morning discharge with oral analgesics, 1-2 weeks off work
5. Follow-up: MRI at 3-6 months to assess fibroid volume reduction (expected 40-60% volume reduction). Clinical assessment of symptom improvement at 1, 3, and 6 months
6. Fertility counseling: Discuss that UFE may impact future fertility; myomectomy is generally preferred for women actively planning pregnancy, though successful pregnancies after UFE have been reported

Key Learning Points

• UFE achieves significant symptom improvement in 85-90% of patients with menorrhagia and 60-80% with bulk symptoms, with average fibroid volume reduction of 40-60% at 6 months
• MRI is the preferred pre-procedure imaging modality for UFE planning as it provides precise fibroid mapping, identifies adenomyosis (which responds less well to UFE), and can raise concern for leiomyosarcoma
• The most common complication is post-embolization syndrome (pain, low-grade fever, nausea) lasting 5-7 days; serious complications such as non-target embolization, uterine infection, or premature ovarian failure occur in <3% of cases
• UFE is relatively contraindicated in women actively pursuing pregnancy; myomectomy remains the preferred uterine-sparing procedure for fertility preservation, though evidence on fertility after UFE is evolving
• Pedunculated subserosal fibroids with a stalk <50% of the fibroid diameter are a relative contraindication for UFE due to risk of detachment and peritoneal complications

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