Fibroids are benign, non cancerous, fibrous growths of the muscular part of the uterus (womb). They are very common.

The diagnosis is made with an ultrasound scan or an MRI scan. Other tests such as blood tests, a gynaecological examination  or internal biopsy may also be necessary.

Many fibroids do not cause any symptoms at all, and don’t require treatment as they are benign. Often fibroids are found by chance as part of an examination for other reasons, e.g. pregnancy scanning.

The most common symptom is heavy and prolonged periods, which may be more painful than usual. This can cause anaemia (a lack of red blood cells or the chemical haemoglobin, which is found in the blood). It can make you feel tired and faint or cause headaches.

Large fibroids can cause symptoms because of their size putting pressure on the bladder leading to a constant urge to urinate. They may also push on your spine or back passage causing constipation and bloating. Occasionally, fibroids may be so large that they are visible as a swelling in the abdomen.

Fibroids are also associated with infertility and miscarriage.

If the gynaecologist does advise treatment, options include:

• Drug treatment: A variety of hormonal drugs can be used to manage the symptoms of fibroids and sometimes even allow them to shrink. Often these medications can be started and monitored by your GP. The decision about whether this is right for you will depend on your specific symptoms and personal preferences for treatment
• Intrauterine contraceptive device: A Mirena coil releases progestogens and may help to reduce heavy bleeding. The coil can be left in place if you are to proceed to UFE.
• Myomectomy: In some cases it may be possible to surgically remove fibroids (myomectomy) without taking the uterus itself. This means that future pregnancyremains possible. However, it is important to understand that hysterectomy (removal of the uterus) may very occasionally be necessary at the time of myomectomy.
• Fibroids may regrow after myomectomy, and in the long term about 1 in 10 people require further surgery. Myomectomy may be performed as an open operation, or by a keyhole technique. This procedure is particularly successful if there are one or two symptomatic fibroids, but is less successful if there are multiple fibroids.
• Hysterectomy: This is the surgical removal of the uterus, usually including the cervix. Future pregnancy is impossible. The operation usually requires about 2-3 days in hospital and 4-6 weeks off work afterwards Uterine Fibroid Embolisation (UFE): as discussed next.

Fibroid embolisation is a procedure designed to shrink uterine fibroids and reduce bleeding. A small plastic tube is placed into a blood vessel (artery) in the groin or the wrist and used to access the blood supply to the uterus and the fibroids. This blood supply is then blocked with extremely tiny beads made of polyvinyl alcohol (PVA) and will permanently stay in the small arteries within the fibroids.

• There are now good long-term studies of the results of fibroid embolisation. Over 80% of people will be relieved of their symptoms after UFE.
• On average, UFE shrinks the fibroids by about half and this usually gives an improvement in symptoms relating to the size of the fibroids or pressure.
• Unlike other surgical treatments for fibroids, UFE treats all the fibroids in a person’s uterus.
• Successful pregnancy can be possible after fibroid embolisation.

You will need to have a blood test a few days before the procedure to check your kidney function and your haemoglobin levels. This may be arranged to take place at your GP surgery.

You can continue taking your normal medication. If you are on any medication which thins the blood (e.g. aspirin, clopidogrel, warfarin, rivaroxaban, dabigatran, apixaban) we ask you to call the Imaging Department using the number on your appointment letter as we may need to adjust your medication before undergoing this procedure.

• You should not eat anything from 6 hours before your procedure but you may continue to drink water up to 2 hours beforehand.
• You will arrive at the Imaging Department (Gate 19) and be accompanied into our day case area.
• You may take your normal medication unless instructed otherwise.
• Please inform us if you have any allergies.
• A radiologist (X-ray doctor) will discuss the procedure with you. You will have an opportunity to ask questions about the procedure and your treatment. If you choose to have the procedure you will need to sign a consent form (this may already have been filled out in an earlier clinic consultation).
• You will be asked to change into a hospital gown and a small plastic tube (cannula) will be put into a vein in your arm to allow us to administer medications or intravenous fluids during the procedure.
• A drip containing strong pain killers (patient controlled analgesia - PCA) will be connected to your cannula, which will allow you to manage your own pain after the procedure by pushing a button that injects a small dose of morphine into your vein. We will give you an extra pain killer via a pessary (diclofenac) as well.
• Once all the checks have been performed and consent signed, you will be taken to the procedure room on the trolley. There will be nurses, a radiographer and the radiologist with you throughout the procedure.

During the procedure

• You will be asked to lie on your back on an X-ray table for the duration of the procedure.]
• The skin near the groin/wrist will be cleaned with an antiseptic solution and covered with sterile drapes.
• Using an ultrasound machine, the radiologist will then inject local anaesthetic into the skin and deeper tissues over the groin/wrist artery. This will briefly sting and then go numb. Most people will feel a pushing sensation.
• A small tube (catheter) is inserted into the artery and navigated inside your blood vessels with the help of the X-ray machine to select the arteries responsible for the blood supply of the fibroid(s).
• An X-ray dye will be injected into your arteries several times during the procedure to help outline your anatomy.
• During these injections you may be asked to hold your breath and keep very still. The injection of the X-ray dye can cause a hot sensation in your pelvic area which is normal and temporary.
• Once the catheter is in the correct position, tiny PVA beads are slowly injected to block the arteries supplying the fibroid(s).
• It might be necessary to access the arteries in both groins in order to block the arteries on both sides of the uterus which are supplying the fibroid(s).
• When the procedure is complete, the catheter is removed from the artery and pressure by hand or a special stitch is applied at the puncture site to prevent bleeding.
• The procedure itself usually takes around 1-2 hours.

What to expect after the procedure

• You will be taken back to the day case area, so that nursing staff may monitor you closely.
• You will be required to lie flat for 2 hours to allow the small hole in your artery to heal but you can mobilise 4 hours after the procedure.
• You may experience pain similar to period cramping in your lower abdomen, but this can be controlled with your PCA morphine pump. Additional pain killers can be given if required.
• Later on you will be transferred to the gynaecology ward (Cotswold ward) where you will stay at least 1 night so we can ensure adequate pain relief is available to you.
• Most patients are normally discharged just after lunch the following day.
• There may be a small bruise in the groin/wrist around the puncture site but this is quite normal.

Will I feel any pain?

You will be given strong painkillers before, during and after the procedure designed to minimise any pain. If you are in pain at any point this medication can be adjusted to ensure your pain is controlled. The local anaesthetic used to numb groin/wrist may sting for about 20 seconds.

Mild pain or discomfort is usual for some days after the procedure, which can be managed with standard pain killers like paracetamol and ibuprofen.

Some patients experience a thick yellow/green vaginal discharge. Use sanitary towels rather than tampons as these could increase the risk of infection.

You may have a slightly raised temperature for up to a week afterwards, sometimes with feverish symptoms.

You may feel tired and we advise you to rest for one to two weeks depending on your recovery. You can then resume your usual activities. We usually recommend taking up to 2 weeks off work but some people recover more quickly and are able to return to work within a week.

You will be followed up via in person or telephone clinic by the radiologist in 4-6 months after the procedure.

It takes time for fibroids to shrink after UFE. It is common for the first period after UFE to be a little different from usual.

Gradual improvement can be expected for up to 6 months afterwards.

UFE is generally very safe however as with any procedure there are some risks.

• There is a minor risk of bleeding or bruising at the groin/ wrist or injury to the arteries.
• Most patients feel some pain afterwards. This ranges from very mild pain to severe cramp, period-like pain. This pain is usually most severe during the first 12 hours, and will be controlled with strong painkillers. By time of discharge home the following day, ‘over the counter’ painkillers are usually adequate to control the pain.
• Infection is a risk with any operation. Currently there is a quoted risk of about 2%. Antibiotics are given at the time of the UFE to minimise this risk but late infection some weeks afterwards has been reported. Most infections can be treated with antibiotics at the time but rarely patients will need to have a hysterectomy for infection. If you feel you would not like to have a hysterectomy under any circumstances then it is probably best not to have a fibroid embolisation.
• You may experience post-embolisation syndrome. This is caused by the breakdown of the fibroid within the body and is very common. People experience a mild fever and flu-like symptoms. It usually passes on its own and anti-inflammatory medicines (ibuprofen) can help. If your symptoms continue, please contact us so we can make sure you don’t have an infection.
• There is a small risk of blocking blood vessels to other organs inside your pelvis (including urinary bladder, bowel or genitals). This could result in reduced blood supply to the affected organ and could potentially be a serious complication, however in most cases it settles down by itself. A special CT scan of your blood vessels will be used during the procedure to reduce this risk to a minimum.
• Rarely a patient may have an allergic reaction to the X-ray contrast (dye) used during UFE. This reaction could be mild with itching to severe affecting breathing or blood pressure. Patients undergoing UFE are carefully monitored throughout the procedure so any allergic reaction can be detected immediately and treated.
• About 1% of patients have an early menopause as a result of UFE. This risk is smaller in younger people and higher in patients who are approaching the menopause.
• Rarely patients may pass bits of fibroid after the UFE. If a larger fibroid is passed you may need to see your gynaecologist who can help to remove it.
• Some patients experience vaginal discharge, which usually lasts up to 2 weeks and on occasion up to 4 weeks.

It is possible to have a successful pregnancy after fibroid embolisation. Current advice is to wait at least 1 year after the procedure before trying to conceive. Approximately 50% of people trying to conceive after fibroid embolisation will be successful.

There is evidence that the rate of spontaneous abortion or miscarriage is higher among patients having fibroid embolisation than in patients who have a surgical myomectomy. If you want to conceive then depending on the anatomy of your uterus and fibroids, myomectomy may be a better procedure.

You may find the following information useful after going home from hospital after a UFE.

Eating and drinking

You should not eat or drink until the conscious sedation medication has entirely worn off. The antibiotics may make you feel nauseated, so it is best to avoid alcohol for 24 hours.

Driving

You should not drive or operate machinery for at least 2 days after this procedure; this means you should ask for a relative or friend to drive you home from hospital. It is important you ensure you can perform an emergency stop prior to any driving.

Your groin

If we do the procedure through the artery in your groin,  You may have bruising or swelling in the first few days at the puncture site. If you are worried about this call the ward.

Vaginal discharge

It is common for patients to experience a moderate vaginal discharge after this procedure, which may be blood stained or contain small pieces of fibroid. If the discharge becomes more offensive and smelly it is important that you contact the ward as this may indicate you are developing an infection.

Pain

The purpose of staying overnight in hospital after UFE is to ensure you are pain free. Make sure you have paracetamol and ibuprofen at home. The ward will give you further painkillers to take home with you should you need them. Should the pain worsen following discharge home call the ward for further advice.

Fever

It is common to experience a low grade temperature for up to 1 week after this procedure. You may have flu like symptoms. If you have a high temperature (above 37.5°C) more than 7 days after the procedure it may indicate that you are developing an infection so you should contact the hospital.

Sexual intercourse and contraception

You can resume sexual activity when you feel ready and once the discharge has settled.

It is important to use appropriate contraception for one year after UFE.

If you do not want to get pregnant you will still need to use contraception.

Please check with your travel insurance if you wish to travel within 4 weeks of your procedure

Finally we hope this information is helpful.

If you have any questions either before or after the procedure the staff in the Imaging department will be happy to answer them.

The phone number for the Imaging department can be found on your appointment letter.
 

The decision was made by your urologist and an interventional radiologist who is going to perform the procedure.

Interventional radiologists are doctors specially trained to perform minimally invasive treatments of various diseases with guidance of an x-ray machine, avoiding the need for open surgery. This includes inserting and navigating special catheters inside blood vessels.

In addition to the standard tests for prostate enlargement, you will need to have a special CT scan (CT angiogram) to help us visualise the arteries in your pelvis. This will help the radiologist to decide if the anatomy of your arteries is suitable for the treatment. If tests have shown that you are suffering from an enlarged prostate gland you probably have already been told about the more traditional treatment options, including a

TURP (trans urethral resection of prostate) operation and medication by your urologist or GP.

In your case, a decision was made that you are likely to benefit from an alternative non-surgical treatment option: prostate artery embolisation.

• You will need to have a blood test a few days before the procedure to check your kidney function, that you are not at increased risk of bleeding and that it will be safe to proceed. This may be arranged to take place at your GP surgery.
• You can continue taking your normal medication. If you are on any medication which thins the blood (e.g. aspirin, clopidogrel, warfarin, rivaroxaban, dabigatran, apixaban) we ask you to call the imaging department using the number on your appointment letter as we may need to adjust your medication before undergoing this procedure.

• You should not eat anything from 4 hours before the procedure but you may continue to drink water.
• You will arrive at the Imaging Department and be accompanied into our day case area.
• You may take your normal medication unless instructed otherwise.
• Please inform us if you have any allergies.
• A radiologist will discuss the procedure with you. You will have an opportunity to ask questions about the procedure and your treatment. If you choose to have the procedure you will need to sign a consent form.
• You will be asked to change into a hospital gown and a small plastic tube (cannula) may be put into a vein in your arm to allow us to administer medications or intravenous fluids during the procedure.
• Once all the checks have been performed and consent signed, you will be taken to the angiography suite on the trolley. There will be a nurse, radiographer and a radiologist with you throughout the procedure.

• You will need to lie on your back on an X-ray table for the duration of the procedure.]
• The skin near the groin will be cleaned with an antiseptic solution and covered with sterile drapes.
• Using an ultrasound machine, the radiologist will then inject local anaesthetic into the skin and deeper tissues over the groin artery. This will briefly sting and then go numb. Most people will feel a pushing sensation.
• A small tube (catheter) is inserted into the artery and navigated inside your blood vessels with the help of the x-ray machine to select the arteries responsible for the blood supply of the prostate gland. An x-ray dye will be injected into your arteries several times during the procedure to aid the navigation of the catheter. During these injections you may be asked to hold your breath and keep very still. The injection of the x-ray dye can cause a hot sensation in your pelvic area which is normal and temporary.
• Both the left and right prostate arteries can usually be reached with accessing only one groin artery but sometimes we may need to use the artery in your other groin.
• Once the catheter is in the correct position, tiny particles are slowly injected into the prostate gland. When the injection into both left and right prostate arteries is complete, the catheter is removed from the artery and pressure by hand or a special stitch is applied at the puncture site to prevent bleeding. You will be asked to remain still for another few hours after the procedure.
• Insertion of a urinary catheter may be necessary for this procedure. This is usually removed after the procedure before discharge.

• You will be taken back to the radiology day case unit, so that nursing staff may monitor you closely.
• If you are in pain tell the nursing staff so you can be given appropriate painkillers.
• You will be required to stay in our day case unit for about 4 hours. Occasionally one night stay in the hospital might become necessary.
• There may be a small bruise in the groin around the puncture site but this is quite normal.
• You will have antibiotics prescribed to be taken for 5-7 days following the procedure.
• You should be able to resume most normal daily activities within 24-48 hours. However, we recommend avoiding driving and all strenuous activities for 48 hours.
• The prostate gland should begin to shrink over the next few weeks and over 70% of men will notice an improvement in their symptoms after PAE.
• You will be reviewed at a follow up appointment in 3 months’ time.
• If you had a long-term bladder catheter before the procedure, recent studies have shown the majority of patients can have their catheters removed after 7-10 days.
• Please check your travel insurance if you wish to travel within 4 weeks of your procedure.

Prostate artery embolisation is a relatively new procedure for treatment of prostate enlargement. The current evidence from research data has been reviewed by the National Institute for Health and Care Excellence (NICE) and clearly shows that the procedure is safe and an effective treatment option. 

However, as with any other medical procedures complications may arise:

• There is a minor risk of bleeding or bruising at the groin or injury to the arteries.
• In up to 10% of cases (1 in 10 people) the prostate arteries are too small or diseased and it will not be possible to safely access them with the catheter, meaning we are unable to treat the arteries.
• You may experience some discomfort in the lower abdomen and have some discomfort on urinating but this normally resolves after 10 days.
• The prostate can become more swollen immediately after the procedure which can make passing urine temporarily more difficult. On rare occasions, a urinary catheter may be necessary until the swelling settles down.
• There is a small possibility of experiencing pain when passing urine or having blood in the urine after the procedure but this should settle down by itself.
• Blocking arterial flow to the prostate makes the gland slightly more prone to infection. To avoid this, antibiotics will be prescribed for you to take when you arrive at the department and following the procedure.
• There is a small risk of blocking blood vessels to other organs inside your pelvis (including urinary bladder, bowel or genitals). This could result in reduced blood supply to the affected organ and could potentially be a serious complication, however in most cases it settles down by itself. A special CT scan of your blood vessels will be used before and during the procedure to reduce this risk to a minimum.
• Some patients may feel tired for up to a week following the procedure. We advise patients to take at least one week off work following PAE.

1. NICE (2018) “Interventional procedure overview of prostate artery embolisation for lower urinary tract symptoms caused by benign prostatic hyperplasia” https://www.nice.org.uk/guidance/ ipg611/evidence
2. Ray et al (2018) “Efficacy and safety of prostate artery embolization for benign prostatic hyperplasia: an observational study and propensity-matched comparison with transurethral resection of the prostate (the UK-ROPE Study)” BJU Int 2018; 122: 270-282
    

A lymphatic malformation is an abnormality of the lymphatic system that results in a collection of fluid filled spaces. These malformations are congenital (they were present when you were born). The cysts are filled with a clear fluid, similar to the fluid in a blister. Lymphatic malformations are not dangerous but can cause pain and swelling. 

Microcystic malformations contain lots of tiny cysts and usually cause problems because they are bulky, unsightly, or get infected. Sclerotherapy is a way of trying to reduce the size of the cysts so that they are smaller and less troublesome.
 

A venous vascular malformation is a collection of abnormal venous vascular spaces. These spaces will have some connections to nearby normal veins. 

Venous malformations are congenital (they were present when you were born). They contain vascular spaces with slow flowing blood and solid tissue.

Like lymphatic malformations venous vascular malformations are not usually dangerous, but can cause pain and swelling, particularly when blood clots form within the lesion. 

Bleomycin is a medicine that has been used for many years to treat other conditions such as cancer. More recently small doses of bleomycin have been found to be useful for treating vascular and lymphatic malformations. 

When it has been used in higher doses in cancer treatment and has been injected straight into the bloodstream, bleomycin can cause damage and changes to the lungs and how they function. This can happen during the treatment or afterwards. This is extremely unlikely to happen when bleomycin is being used in sclerotherapy, as the doses are much lower, and the medicine is not given in the same way.

However, always tell your doctor if after treatment with bleomycin you: 

• Develop a wheeze.
• Develop a cough.
• Have a fever.
• Feel breathless.

You should also let them know if any existing breathing problems get worse.

Before you attend for bleomycin sclerotherapy we will send you a clinic appointment to meet with the radiologist. Here they will assess your suitability for the procedure.

If necessary, we will arrange for you to have some breathing tests before you have bleomycin treatment.

You will need to have a blood test a few days before the procedure to check that you are not at increased risk of bleeding and that it will be safe to take to proceed with the bleomycin treatment. This may be arranged to take place at your GP surgery. 

You can continue taking your normal medication. If you are on any medication which thins the blood (e.g., aspirin, clopidogrel, warfarin, rivaroxaban, dabigatran, apixaban) please call the Imaging Department using the number on your appointment letter as we may need to adjust your medication.  

• You should not eat anything from midnight the night before the procedure. You may drink clear fluids until 7am on the day of the procedure.
• You will arrive at the Imaging Department, Gate 19, and be accompanied into our day case area.
• You may take your normal medication unless instructed otherwise.
• Please inform us if you are allergic to anything.
• The radiologist will discuss the procedure with you. You will be given an opportunity to ask questions. If you want to go ahead with the procedure you will be asked to sign a consent form.
• You will be asked to change into a hospital gown and a small plastic tube (cannula) may be put into your arm.
• Once all the checks have been performed and consent signed, you will be taken to the X-ray room on the trolley. There will be a radiologist, nurses and a radiographer with you throughout the procedure.
• The radiologist will use an ultrasound machine to look at the malformation to find the correct area to be treated.
• Your skin will be cleaned with an antiseptic solution and covered with sterile drapes.
• The radiologist will then inject local anaesthetic into the area selected, which will briefly sting and then go numb. The radiologist may then inject X-ray dye into the malformation to confirm the needle position and that it is safe to inject bleomycin. The bleomycin will then be injected through one or several small needles into the malformation under ultrasound and sometimes X-ray guidance.
• The procedure is likely to take about 30 minutes.
• Once the procedure is complete the needle(s) will be removed, and the radiologist will apply a dressing if necessary. 

• You will be taken back to the day case area, so that nursing staff may monitor you closely.
• If you are in pain, tell the nursing staff so you can be given appropriate painkillers.
• You will be advised to stay in our day case area for up to 4 hours.
• You will be able to eat and drink as normal.
• If everything is satisfactory, you will be free to go home. 

Bleomycin sclerotherapy is usually a safe procedure. Potential complications include:

• In the first 24 hours following bleomycin sclerotherapy, the area is likely to be swollen. You may take over the counter pain medication as necessary to keep the inevitable associated pain under control. The pain will resolve within a few days, but it may take several weeks for the swelling to settle completely.
• There is a slight risk of the malformation developing an infection after the treatment. You will need a short course of oral antibiotics if this happens.
• Very rarely, bleomycin can cause some discolouration of the skin or nails or make some hair fall out. This usually gets better with time. We think that the skin is more likely to be affected if there are monitoring leads or plasters stuck to the skin at the time of treatment. We will try to put these on parts of the skin that are less noticeable.
• In some cases, when bleomycin has been used in much higher doses straight into the bloodstream for treating cancers, patients have developed scarring of their lungs, causing breathing problems. This has only been reported for high dose treatment with bleomycin, not at the doses used for sclerotherapy of vascular malformations.
• If the bleomycin spreads beyond the malformation it may cause damage to nearby normal tissues. 
  This is a rare complication but can cause permanent damage to the affected tissues. One example could be damage to the overlying skin which may ulcerate and cause scarring of the area. Other structures that could be affected depend on where in the body the malformation is, but could include muscle or nerve damage which may be permanent. 

If you experience any symptoms you are concerned about, please contact the Imaging Department directly on the number on your appointment letter or alternatively contact your GP or the Emergency Department.

Sclerotherapy is the best treatment option for many malformations as it can be an effective treatment and usually carries lower risks than open surgery. However, as every malformation is different, sclerotherapy may not always be the best option. 

Alternative options may include having no treatment, surgery or a combination of surgery and sclerotherapy. Your doctor will explain the options for treatment suitable for you.

You might need several sclerotherapy procedures to reduce the malformation. Sclerotherapy will not ‘cure’ the malformation, but it should shrink it significantly. 

We will also review you at an outpatient clinic appointment around 2 - 3 months after treatment.

Again, if you experience any symptoms you are concerned about, please contact the Imaging Department directly on the number on your appointment letter or alternatively contact your GP or the Emergency Department.

Finally, we hope this information is helpful. If you have any questions either before or after the procedure the staff in the Imaging Department will be happy to answer them.

NICE | The National Institute for Health and Care Excellence

Bleomycin sclerotherapy | Great Ormond Street Hospital (gosh.nhs.uk)

Vascular Malformations | BSIR

Intralesional bleomycin injection - South Tees Hospitals NHS Foundation Trust