THERAPEUTIC PROCEDURES FOR ABNORMAL BLEEDING
| UTERINE ARTERY EMBOLIZATION (UAE)—Paul A. Neese, MD, Assistant Professor, Department of Radiology,
Division of Interventional Radiology, Texas A&M University System Health Science Center, College of Medicine,
Temple, TX
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| General considerations: indications—hemostasis, therapy (eg, cancer, arteriovenous malformation, pelvic congestion,
uterine fibroids); traditional methods of hemostasis—local measures (eg, control of bleeding vessel, pressure
packing, hemostatic agents); hysterectomy; because collateral pathway of pelvis significant, major vessels can
be removed without death of organ; hypogastric ligation— first described in 1893 by Kelly, who tied off hypogastric
artery in patient bleeding from uterine cancer; Burchell discovered end organ death did not occur because hypogastric
artery ligation does not stop blood flow completely, but rather slows flow (by ≈50%); patient must have
clotting ability; factors to consider for embolization—identification of specific area of bleeding; determine
whether blockage of blood flow temporary or permanent (eg, acute vs chronic bleeding, tumor vs bleeding caused
by trauma); complications associated with embolization—end-organ ischemia; nerve damage; impotence; necrosis;
Mount Sinai Medical Center protocol for pregnant patients who are bleeding—if fetus nonviable, embolization
performed before evacuation of uterine content to control bleeding; if fetus viable, procedure performed in
operating room with fluoroscopy
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| Indications: acute bleeding—performed preferably in angiography suite using common femoral artery approach;
particulate emboli injected based on area; microcoils used selectively; tumor embolization—performed since
1970s; effective only for local control of bleeding; tumor effect with intra-arterial delivery of chemotherapeutic
agents (decreased systemic effects); arteriovenous malformations—congenital and acquired (secondary to
trauma); pelvic congestion—Capasso et al reported ≈50% response rate; preserves fertility; careful patient selection
necessary; requires large vein, uterine venous engorgement, and absence of arteriovenous malformation; technical
success rate of interventional radiologist should be >95%; treatment rationale for pelvic congestion same as
for varicoceles; research data—Ravina (1995) looked at preoperative UAE to prevent or decrease operative blood
loss; showed UAE improved patients’ symptoms while awaiting surgery; Goodwin (1997) studied 11 patients, with
follow-up in 9; 3 patients reported complete relief of symptoms; 4 had significant improvement; 1 patient reported
slight improvement; 1 patient required hysterectomy due to pyometria; uterine leiomyomata (fibroids)—≈1 in 5
women >35 yr of age have symptomatic uterine fibroids; patients with symptoms (bleeding or pressure) should be
treated; conservative management includes hormonal therapy (eg, leuprolide); surgery and UAE other treatment
options; myomectomy most studied surgical option for fibroids and probably first choice for patient wishing to preserve
fertility; hysterectomy or endometrial ablation options for patient not wishing to preserve fertility; speaker
believes hysterectomy remains reasonable option for patient with symptomatic fibroids who has completed childbearing
(consider cultural sensitivity when discussing hysterectomy as option)
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| Preprocedural considerations: is patient symptomatic? UAE not first choice for asymptomatic fibroids; is future
childbearing an issue? consider myomectomy if feasible; patient with active infection, renal failure (contrast material
nephrotoxic), malignancy, or prior pelvic irradiation (risk for microangiopathy) not candidate for procedure;
important to consider patient’s treatment preference; thorough history and physical examination; endometrial biopsy
(EMB; eg, infection, cancer, adenomyosis); exclude pregnancy; ultrasonography (US) or magnetic resonance
imaging to document size of fibroids
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| Procedure: begins with pelvic arteriography; bilateral common femoral artery embolization shortens procedure; microspheres
(Tris-acryl gelatin) generally used; good response with polyvinyl alcohol particles (ground plastic) but associated
with spasm and incomplete embolization; analgesia—procedure most often performed under conscious
sedation; patient-controlled anesthesia (PCA) pump for postoperative pain control (speaker believes smoothes transition
to oral pain control medication); nonsteroidal anti-inflammatory drugs (NSAIDs) important postoperatively;
prophylactic antibiotics given preoperatively; postoperative care—overnight observation; transition to oral pain
medication; ibuprofen for 5 to 7 days and narcotic for breakthrough pain; acetaminophen (eg, Tylenol) for fever;
patient should report increased fatigue, pain, or vaginal discharge; follow-up office visit in 1 to 2 wk, 6 wk, and 6
mo; counsel patient that bleeding may persist for several weeks (first 2 to 3 periods after procedure can be irregular,
light, or heavy); patient may pass submucosal fibroid tissue; readmission to hospital may be necessary for symptoms;
complications—nontarget embolization; 1% to 2% risk for premature ovarian failure (risk higher in patients
>45 yr of age); no report of allergic reaction to embolics; ≈4% infection rate; ≈1% hysterectomy rate; exposure to
radiation minimal; no concise data about impact on fertility; ≈18% to 20% miscarriage rate; malpresentation and
placentation abnormalities reported
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| Conclusion: 400,000 women worldwide treated with UAE; high technical success rate; 80% to 90% response rate
in selected series; lower response rate in patients with adenomyosis; 30% to 40% uterine volume reduction ≈50%
for individual fibroids
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| THERAPEUTIC OPTIONS FOR TREATING ABNORMAL UTERINE BLEEDING —Peter Takacs, MD, PhD,
Associate Professor, Department of Obstetrics and Gynecology, Miller School of Medicine, University of Miami, FL
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| General considerations: abnormal uterine bleeding (AUB) affects 20% to 25% of healthy women; occurs most
often in fifth decade of life; accounts for 30% to 35% of hysterectomies; 2% to 10% of women presenting with
AUB have fibroids, polyps, or underlying medical condition; endometrial cancer occurs in younger women (30 to
34 yr of age); incidence increases 3-fold by 35 yr of age and almost 6-fold in women 35 to 40 yr of age
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 | Diagnostic dilation and curettage (D and C): original gold standard; first described in 1843; 10% of endometrial lesions,
80% of polyps, and 60% of hyperplasia missed; Stock and Kanbour (1975) reported <50% of uterine cavity
sampled in 60% of women undergoing D and C and <25% of endometrial cavity sampled in 16% of women
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| Vabra aspirator: use initiated in 1970s; 86% accuracy for cancer (improved pathology contributed to increase in
accuracy of procedures); samples only 11% of endometrial surface
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| Pipelle sampling: some studies report 75% accuracy, but varies depending on incidence of cancer in particular age
group; samples only 4% of endometrium; study looking at sensitivity—65 patients with known endometrial cancer
underwent Pipelle sampling; 63 had adequate tissue for analysis; 54 correctly identified as having endometrial
cancer; 11 false-negative results (5 confined to polyp, 3 tumors localized to small area of endometrial
cavity); investigators concluded endometrial cancer can go undetected by Pipelle if cancer confined to polyp or
small area
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| Transvaginal sonography: associated with less expense, discomfort, and risk; EMB cannot be adequately performed
5% to 15% of time; measure endometrial thickness on sagittal image of uterus (basalis to basalis); factors
affecting adequacy of study (eg, obesity, fibroids) should be reported; diagnostic modalities and treatments vary
based on menopausal status of woman; modalities less effective in accurately detecting cancer in premenopausal
women; endometrial stripe measure in premenopausal woman of little benefit; meta-analysis of 35 studies
showed using 5-mm threshold to define abnormal endometrial thickening revealed 96% of women with cancer
had abnormal result, whereas 92% of women with endometrial disease had abnormal result; investigators concluded
that in postmenopausal women with vaginal bleeding and 10% pretest probability of endometrial cancer,
probability of cancer 1%
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| Saline infusion sonohysterography: avoids hysteroscopy; less expensive and less painful than hysteroscopy; meta-
analysis showed good sensitivity and specificity; 7% of abnormalities not identified; more difficult to perform in
postmenopausal woman because of stenotic os
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| Hysteroscopy: ≈78% sensitivity and 95% specificity; 3% false-negative rate; 7% to 10% failure rate; meta-analysis
of 65 studies showed 86% sensitivity for cancer and 78% sensitivity for endometrial disease; probability of positive
result ≈72%; good negative predictive value; retrospective study involving 332 women with endometrial hyperplasia
undergoing hysteroscopy showed sensitivity and specificity slightly less than what meta-analysis
showed (may be due to fact that recognizing abnormality may be difficult, especially for untrained eye); sensitivity
and specificity of hysterosonography with EMB or hysteroscopy with EMB almost identical
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| Comparison of 3 modalities: overall sensitivity and specificity—transvaginal US poor (sensitivity 0.69 and specificity
0.83); hysteroscopy (sensitivity 0.84 and specificity 0.88) and sonohysterography (sensitivity 0.83 and
specificity 0.9) similar; all failed to identify some form of pathology; hysteroscopy and hysterosonography excellent
for identifying submucosal fibroids
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| Hysteroscopic polypectomy: high patient satisfaction rate; at 24 mo, satisfaction lessens; no difference whether
procedure performed under local or general anesthesia; complication rate <1%; average operating time 22 min;
2% to 3% persistence rate, especially if vascularity of polyp not destroyed; treatment of polyps—study of 430
women undergoing hysteroscopic polypectomy; polyp correctly identified in 96% of cases; 11% of polyps had
hyperplasia without atypia; 3% of polyps had hyperplasia with atypia; 3% of polyps showed evidence of cancer;
investigators determined risk factors menopausal status and polyp size; polyp size >1.5 cm significant predictor
of malignancy; polyp in postmenopausal woman should be removed; symptomatic polyp or polyp >1.5 cm
should be removed if woman premenopausal; evidence that small polyps regress and disappear, so follow-up optional
for premenopausal woman
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| Hysteroscopic myomectomy: study of 288 women, median follow-up of 4 yr; independent prognostic factors uterine
size and number of submucous fibroids; at 5 yr, 90% of patients did not require surgery
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| Findings from Cochrane Database of Systematic Reviews: looked at medical treatment vs surgery; meta-analysis
of 8 trials involving 821 women randomized to medical or surgical treatment; showed 58% of women randomized
to medical treatment had surgery by 2 yr; levonorgestrel-releasing intrauterine system (LNG-IUS) vs conservative
surgery or hysterectomy shows no statistically significant difference in quality of life or patient
satisfaction, but adverse effects significantly less likely with conservative surgery; women undergoing hysterectomy
less likely to have bleeding or related complications 2 yr posthysterectomy; 2 trials found conservative surgery
significantly more effective than LNG-IUS in controlling bleeding at 1 yr
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| Global endometrial ablation technologies: endometrial resection significantly more effective in controlling bleeding
than oral medication and significantly less likely to cause side effects; devices—Gynecare ThermaChoice,
Hydro ThermAblator (HTA) System, Her Option office cryoablation therapy, NovaSure System, and Microwave
Endometrial Ablation (MEA) System
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| Indications and contraindications: indications—disabling intrauterine bleeding unresponsive to medical or traditional
therapy; contraindication to medication; poor surgical risk for hysterectomy; patient desires to preserve
uterus; contraindications—genital tract malignancy; woman wishes to preserve fertility; pelvic inflammatory
disease (PID); any anatomic or pathologic condition in which weakness of myometrium could exist (eg, history
of cesarean delivery or transmural myomectomy); measuring of myometrial thickness before procedure recommended;
procedure should not be done if myometrial thickness <8 mm
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| Success rates of devices: Gynecore ThermaChoice—rate of amenorrhea after procedure 15% to 20%; pretreatment
with leuprolide (eg, Lupron Depot) and D and C recommended (data support outcome improvement); NovaSure
System—higher amenorrhea rate after procedure than ThermaChoice (no randomized controlled trial data comparing
devices); Hydro ThermAblator (HTA) System— amenorrhea and success rates similar to other devices;
Her Option office cryoblation therapy—amenorrhea rate lower than other options; similar patient satisfaction
rates; Microwave Endometrial Ablation (MEA) System—probably highest amenorrhea rate after procedure; similar
success rate as other options
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| Summary: evaluate endometrium using TVS or EMB approach; office hysteroscopy or sonohysterography recommended
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Suggested Reading
Capasso P et al: Treatment of symptomatic pelvic varices by ovarian vein embolization. Cardiovasc Intervent Radiol.
20:107, 1997; Dueholm M et al: Evaluation of the uterine cavity with magnetic resonance imaging, transvaginal
sonography, hysterosonographic examination, and diagnostic hysteroscopy. Fertil Steril 76:350, 2001;
Farquhar C et al: A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for
the investigation of abnormal uterine bleeding in premenopausal women. Acta Obstet Gynecol Scand 82:493, 2003;
Goldstein RB et al: Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored
Consensus Conference statement. J Ultrasound Med 20:1025, 2001; Goodwin SC et al: Preliminary
experience with uterine artery embolization for uterine fibroids. J Vasc Interv Radiol 8:517, 1997; Guido RS
et al: Pipelle endometrial sampling. Sensitivity in the detection of endometrial cancer. J Repro Med 40:553, 1995;
Marjoribanks J et al: Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst Rev
29:CD003855, 2006; Nathani F et al: Uterine polypectomy in the management of abnormal uterine bleeding: A
systematic review. J Minim Invasive Gynecol 13:260, 2006; Smith-Bindman R et al: Endovaginal ultrasound to
exclude endometrial cancer and other endometrial abnormalities. JAMA 280:1510, 1998.
Educational Objectives
| The goal of this program is to improve treatment of abnormal uterine bleeding by providing practical information
about diagnostic and therapeutic modalities. After hearing and assimilating this program, the clinician will be better
able to:
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| 1. State common uses for embolization.
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| 2. Identify appropriate candidates for uterine artery embolization (UAE).
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| 3. Describe how UAE is performed and its pre- and postprocedure considerations.
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| 4. Discuss the efficacy of diagnostic tests used to investigate abnormal uterine bleeding.
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| 5. Discuss the indications for global endometrial ablation technologies.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgments
Dr. Neese was recorded at The Female Patient, sponsored by Scott and White, and held on June 19-23, 2006, on South
Padre Island, TX. Dr. Takacs was recorded at 2007 New Concepts in Obstetrics and Gynecology Conference, sponsored
by the Miller School of Medicine, at the University of Miami, held on February 28 to March 2, 2007, in Miami
Beach, FL. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of
this program.
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