Improvement in parameters of quality of life and uterine volume reduction after uterine fibroid embolization

Nathalia Almeida Cardoso da Silva Denis Szejnfeld Rafael Kogan Klajner Marcos Vinicius Maia da Mata Ricardo Aun Sergio Quilici Belczak About the authors

ABSTRACT

Objective

To evaluate improvement in quality of life, reduction of uterine volume, and the correlation between these two variables after uterine fibroid embolization.

Methods

Data on quality of life before and after uterine fibroid embolization were collected from 60 patients using the Uterine Fibroid Symptom – Quality of Life questionnaire. In 40 of these patients, uterine volume information on magnetic resonance imaging examinations performed before and after uterine fibroid embolization was collected, and compared using the nonparametric Wilcoxon test for paired data. Correlation between quality of life and uterine volume before and after procedure was measured using Spearman’s correlation coefficient.

Results

There was significant improvement in quality of life after uterine fibroid embolization on Uterine Fibroid Symptom – Quality of Life questionnaire, in both subscales scores and the total score. There was a significant median reduction of -37.4% after uterine fibroid embolization, but no correlations between uterine volume and quality of life scores were found before or after embolization.

Conclusion

Uterine embolization is an alternative to treat uterine fibroids, resulting in relief of symptoms and better quality of life. Although reduction in uterine volume plays an important role in the evaluation of therapeutic success, it does not necessarily have a definitive correlation with relief of symptoms.

Leiomyoma; Embolization, therapeutic; Quality of life; Treatment outcome

RESUMO

Objetivo

Avaliar a melhora na qualidade de vida e a redução do volume uterino, além da correlação entre essas duas variáveis, após a embolização de artérias uterinas.

Métodos

Foram coletados dados de 60 pacientes sobre qualidade de vida antes e depois da embolização de artérias uterinas com a aplicação do questionário Uterine Fibroid SymptomQuality of Life. Informações sobre o volume uterino em exames de ressonância magnética realizada antes e depois do procedimento foram coletadas em 40 dessas pacientes e comparadas por meio de teste não paramétrico de Wilcoxon para dados pareados. A correlação entre qualidade de vida e volume uterino antes e depois do procedimento foi determinada pelo coeficiente de Spearman.

Resultados

Houve melhora significativa na qualidade de vida das pacientes após embolização de artérias uterinas nos escores do questionário Uterine Fibroid SymptomQuality of Life, tanto das subescalas como do total. Houve redução mediana significativa (-37,4%) no volume uterino após embolização de artérias uterinas, embora não tenha sido estabelecida qualquer correlação entre volume uterino e escores de qualidade de vida antes e depois da embolização.

Conclusão

A embolização de artérias uterinas é alternativa para o tratamento de fibroide uterina, resultando na melhora dos sintomas e da qualidade de vida. Embora a redução do volume uterino seja fator importante na avaliação do sucesso terapêutico, não está necessariamente correlacionada com melhora de sintomas.

Leiomioma; Embolização terapêutica; Qualidade de vida; Resultado do tratamento

INTRODUCTION

Uterine fibroids, also called leiomyomas or fibroids, are the most prevalent tumors in gynecology. By definition, myoma is a benign neoplasm that affects 20% to 40% of women over the age of 30 years. Literature shows the prevalence of fibroids can reach up to 77%, with estimates of 6.5 tumors per affected uterus. Some factors such as age, parity, obesity, and ethnicity have been associated with a higher prevalence of fibroids. In addition, two or more affected first-degree relatives lead to an increase in its frequency of up to 2.2 times.(11. Kohi MP, Spies JB. Updates on uterine embolization. Semin Intervent Radiol. 2018;35(1):48-55.Review.)

Despite being mostly asymptomatic, it is estimated that 20% to 50% of fibroids do develop symptoms, which vary according to the size and location of the nodules. The number of fibroids can also interfere in intensity of symptoms. The presence of fibroids has a great impact on the quality of life of symptomatic patients. The main signs and symptoms that are usually caused by fibroids are menstrual changes, such as menorrhagia and/or metrorrhagia, resulting in anemia. In addition, there are also cases of intermenstrual bleeding, which tend to cause compressive symptoms, pain, and anatomical distortion of adjacent organs.(22. Parker WH. Etiology, symptomatology, and diagnosis of uterine myomas. Fertil Steril. 2007;87(4):725-36. Review.)

The selection of the correct treatment, whether invasive or not, depends on the precise definition of fibroid size, number, and location. Magnetic resonance imaging (MRI) is a widely used test for uterine myomatosis because of its greater mapping ability when compared to ultrasonography, especially in cases of large (>375mL) or multiple (>4) fibroids.(33. Nasser F, Affonso BB, Jesus-Silva SG, Coelho DO, Zlotnik E, Messina ML, et al. Embolização de mioma uterino em mulheres portadoras de miomas volumosos. Rev Bras Ginecol Obstet. 2010;32(11):530-5.)Magnetic resonance imaging, as a non-operator-dependent exam, with low interobserver variability in routine interpretation of pre- and post-operative analyses, is a highly advantageous procedure.(44. Maciel C, Tang YZ, Sahdev A, Madureira AM, Vilares-Morgado P. Preprocedural MRI and MRA in planning fibroid embolization. Diagn Interv Radiol. 2017;23(2):163-71.)

Regarding current treatment, there is a range of possible interventions, which may vary according to the patient’s wishes. Uterine embolization appears as a conservative choice for patients with symptomatic fibroids, whose surgical treatment is contraindicated, or who do not wish to undergo the surgical risks of a hysterectomy.(55. Kröncke T, David M. Uterine artery embolization (UAE) for fibrosis treatment: results of the 7th Radiological Gynecological Expert Meeting. Geburtshilfe Frauenheilkd. 2019;79(6):688-92.)This method was first proposed as a treatment for myoma by Ravine, in France, in 1995. He found that in 90% of the cases, when choosing this treatment, patients had their myoma size reduced from 20% up to 70%.(66. Brito LG. Fatores motivacionais da mulher portadora de leiomioma uterino para a realização da histerectomia. Rev Bras Ginecol Obstet. 2012;34(6).

7. Brito LG, Panobianco MS, Sabino-de-Freitas MM, Barbosa HF, Azevedo GD, Brito LM, et al. Uterine leiomyoma: understanding the impact of symptoms on womens’ lives. Reprod Health. 2014;11(1):10.

8. Lohle PN, De Vries J, Klazen CA, Boekkooi PF, Vervest HA, Smeets AJ, et al. Uterine Artery embolization for symptomatic adenomyosis with or without uterine leiomyomas with the use of calibrated tris-acryl gelatin microspheres: midterm clinical and MR imaging follow-up. J Vasc Interv Radiol. 2007;18(7):835-41.
-99. Lacayo EA, Richman DL, Acord MR, Wolfman DJ, Caridi TM, Desale SY, et al. Leiomyoma Infarction after uterine artery embolization: influence of embolic agent and leiomyoma size and location on outcome. J Vasc Interv Radiol. 2017;28(7):1003-10.)

Great advantages in uterine fibroid embolization (UFE) have been highlighted in the literature: it is a minimally invasive procedure with positive results in preserving the uterus. Reduced size of fibroids and uterus, resumption of normal menstrual flow, shorter recovery time, and fertility preservation capability were reported.(1010. Grube M, Neis F, Brucker SY, Kommos S, Andress J, Weiss M, et al. Uterine fibroids: current trends and strategies. Surg Technol Int. 2019;34:257-63. Review.,1111. Rossetti A, Sizzi O, Chiarotti F, Florio G. Developments in techniques for laparoscopic myomectomy. JSLS. 2007;11(1):34-40.) Studies reported the success rate for this method ranges from 87% to 90%, with a reduction in myoma size varying from 40% to 65%.(77. Brito LG, Panobianco MS, Sabino-de-Freitas MM, Barbosa HF, Azevedo GD, Brito LM, et al. Uterine leiomyoma: understanding the impact of symptoms on womens’ lives. Reprod Health. 2014;11(1):10.)Other studies demonstrated the effectiveness of embolization in reducing symptoms and improving quality of life,(88. Lohle PN, De Vries J, Klazen CA, Boekkooi PF, Vervest HA, Smeets AJ, et al. Uterine Artery embolization for symptomatic adenomyosis with or without uterine leiomyomas with the use of calibrated tris-acryl gelatin microspheres: midterm clinical and MR imaging follow-up. J Vasc Interv Radiol. 2007;18(7):835-41.,99. Lacayo EA, Richman DL, Acord MR, Wolfman DJ, Caridi TM, Desale SY, et al. Leiomyoma Infarction after uterine artery embolization: influence of embolic agent and leiomyoma size and location on outcome. J Vasc Interv Radiol. 2017;28(7):1003-10.) including some results considered comparable to hysterectomy.(1212. Worthington-Kirsch RL, Popky GL, Hutchins FL Jr. Uterine arterial embolization for the management of leiomyomas: quality-of-life assessment and clinical response. Radiology. 1998;208(3):625-9.)

There are few accounts of the Brazilian experience on this issue, but none evaluating quality of life using a specific and validated instrument.(1313. Belczak SQ, Szejnfeld D, Cardoso da Silva NA, Klajner RK, Ogawa LC, Mata MV. Symptoms improvement after uterine artery embolization for myoma management. J Vasc Med Surg. 2017;5(4).)In view of the poorer quality of life of symptomatic fibroid patients, and the increasing indications of therapeutic embolization, we evaluated the improvement in quality of life after the procedure. For a more technical assessment of the results of embolization, we measured the reduction in uterine volume on MRI and correlated with quality of life.

OBJECTIVE

To assess improvement in quality of life and its correlation with uterine volume after uterine fibroid embolization.

METHODS

A retrospective longitudinal study carried out with patients submitted to UFE for treatment of myoma at Instituto Belczak de Cirurgia Vascular e Endovascular, from January 2014 to December 2016. Patients were selected regardless of their age group. Patients with associated diseases causing bleeding and pelvic pain, such as myomatosis or endometriosis, or other associated abdominal conditions causing pain that could interfere in the results, and those submitted to uterine surgical procedures after embolization were excluded from the study.

Initially, 90 patients were contacted and invited to participate in the study. Those who showed interest in participating were called to the office of the principal investigator. Of these patients, 18 did not attend, and 7 informed they did not want to take part in the study. Of the remaining patients, two underwent myomectomy after embolization, two underwent hysterectomy, and one was diagnosed with uterine carcinomatosis and myoma, and were excluded from the study. Thus, 60 patients aged 35 to 53 years were finally included.

All patients underwent uterine embolization with microspheres. The technique was performed by right femoral artery puncture, followed by bilateral catheterization of the uterine artery with microcatheters, and release of 500μm to 700μm spheres. After spherical release, angiographic control was performed, and arteries not presenting distal flow were considered satisfactory.

Quality of life assessment

During the first visit, all terms and objectives of the study were explained, and the Informed Consent Form was presented, explained in detail, and signed by the patients.

The Uterine Fibroid Symptom – Quality of Life (UFS-QoL) questionnaire(1414. Harding G, Coyne KS, Thompson CL, Spies JB. The responsiveness of the uterine fibroid symptom and health-related quality of life questionnaire (UFS-QOL). Health Qual Life Outcomes. 2008;6(1):99.

15. Spies JB, Coyne K, Guaou Guaou N, Boyle D, Skyrnarz-Murphy K, Gonzalves SM. The UFS-QOL, a new disease-specific symptom and health-related quality of life questionnaire for leiomyomata. Obstet Gynecol. 2002;99(2):290-300.
-1616. Silva RO, Gomes MT, Castro RA, Bonduki CE, Girão MJ. Uterine fibroid symptom - quality of life questionnaire translation and validation into Brazilian Portuguese. Rev Bras Ginecol Obstet. 2016;38(10):518-23.)was used to collect retrospective data (prior to embolization) and current data (after procedure). The time between the procedure and the application of UFS-QoL ranged from 3 months to 3 years. In order to reduce recall bias, retrospective data from up to 3 years prior to the study were collected, taking into account that 50% of the critical details of a recognized event are unrecoverable after 5 years.(1717. Bradburn NM, Rips LJ, Shevell SK. Answering autobiographical questions: the impact of memory and inference on surveys. Science. 1987;236(4798):157-61.)Some strategies, such as giving participants enough time before responding, to reflect and think through a sequence of events in their life history, were also adopted using standard protocols for data collection.(1818. Hassan ES. Recall bias can be a threat to retrospective and prospective research designs. IntJ Epidemiol. 2005;3(2):1-7.)

The UFS-QoL contains 8 questions that quantify the severity of myomatous disease symptoms, and 29 questions related to quality of life in women’s health, focusing on concerns, energy, mood, control, self-awareness, and sexual function.

Uterine volume assessment

Patients were also asked to bring their MRI exams performed before and after the surgery. In accordance to the service protocols, all patients underwent MRI before and 6 months after embolization for documentation purposes, and also because the decrease in uterine volume is used as reference to measure success of the procedure. Twenty patients who wanted to participate in the study, but did not bring their MRI or did not make their results available for analysis, were included exclusively in the analysis of symptoms and quality of life. Thus, 40 patients were assessed regarding uterine volume before and after UFE.

This study was conducted at Instituto Belczak de Cirurgia Vascular e Endovascular, according to CAAE: 70170817.3.0000.0071, and approval by the Research Ethics Committee of the Hospital Israelita Albert Einstein (HIAE), São Paulo (SP), Brazil, under number 2.180.478. All patients included in the study signed the Informed Consent Form.

Statistical analysis

The comparisons between the pre- and post- timeframes for quality of life scores and uterine volume were made using the Wilcoxon non-parametric test for paired data. The correlation between post-embolization variation in the UFS-QoL questionnaire scores and uterine volume, as well as the correlation between greater previous uterine volume and worse quality of life in UFS-QoL before embolization, were analyzed using Spearman’s correlation test. Analyses were performed by means of the (SPSS) and R software, version 3.4.1, GAMLSS package, and a 5% level of significance was considered.

RESULTS

Quality of life

The scores for the symptom severity subscale, quality of life subscales, and total score of the UFS-QoL questionnaire applied to 60 patients were calculated according to the validated questionnaire for the Brazilian Portuguese. here was a significant improvement (p<0.001) between pre- and post-embolization in all scores of UFS-QoL, both for symptom severity and quality of life subscales (Table 1). There was a significant reduction in the symptom severity subscale scores as well as a significant increase in the other scores obtained after embolization.

Table 1
Total and subscale scores of the Uterine Fibroid Symptom Quality of Life questionnaire before and after uterine fibroid embolization (n=60)

Uterine volume

Pre- and post-embolization MRI scans of 40 women submitted to the procedure were available. The three dimensions of the uterus were measured before and after embolization (Table 2), and the volume was calculated for each evaluation using the formula length × width × height × 0.523, assuming the ellipsoid shape of the uterus; differences between pre- and post-embolization measurements were calculated for all patients. There was a significant reduction by 37.4% (p<0.001) in the uterine volume after embolization (Table 2). One (2.5%) patient presented with an increase in uterine volume after UFE.

Table 2
Uterine volume (cm3) in pre- and post-embolization evaluations (n=40)

Correlation between uterine volume and Uterine Fibroid Symptom Quality of Life questionnaire scores

To analyze the correlation between post-embolization variations, differences between pre- and post-embolization were considered as absolute values for both uterine volume and symptom severity scores. The correlation coefficients obtained indicated no correlation between changes in uterine volume and UFS-QoL scores. Also, no correlation was found between the uterine volume and UFS-QoL scores in the pre-embolization evaluation (Table 3).

Table 3
Correlation coefficients between uterine volume and Uterine Fibroid Symptom – Quality of Life questionnaire scores (n=40)

DISCUSSION

Since embolization was proposed as an alternative treatment for uterine myomatosis in 1995, it has been possible to spare the reproductive organ through a less invasive procedure, improve symptoms and accelerate recovery. Although some important studies have already shown improved quality of life after UFE, this is the first Brazilian study using a validated instrument to assess uterine fibroid symptoms and quality of life, as the UFS-QoL questionnaire.

We found a significant median reduction of 53.1 points in the subscale of UFS-QoL symptom severity, and a significant improvement of 52.6 points in total quality of life score after UFE. These results were more expressive than those found in African women, after a 1-year follow-up, with reduction of 29.6 points in the symptom severity score, and an improvement of 35.7 points in quality of life, using the same questionnaire.(1919. Mariara C, Obura T, Hacking N, Stones W. One year symptom severity and health-related quality of life changes among Black African patients undergoing uterine fibroid embolisation. BMC Res Notes. 2017;10(1):240.) Multicenter studies, such as FIBROID Registry, found reduction rates of 40.5 points in the severity of symptoms score, and a 39.67-point increase in quality of life.(2020. Spies JB, Myers ER, Worthington-Kirsch R, Mulgund J, Goodwin S, Mauro M; FIBROID Registry Investigators. The FIBROID Registry: symptom and quality-of-life status 1 year after therapy. Obstet Gynecol. 2005;106(6):1309-18.)Other large studies, including the EMMY (EMbolization versus hysterectoMY) trial, also reported improvement in quality of life at the 2-year follow-up after embolization, but used a less specific tool (the 36-Itens Short Form Health Survey questionnaire) for assessing quality of life.(2121. vander Kooij SM, Hehenkamp WJ, Volkers NA, Birnie E, Ankum WM, Reekers JA. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial. Am J Obstet Gynecol. 2010;203(2):105.e1-13.) The high rates of improvement in symptoms and quality of life found in our study could be explained by the large proportion of women (81.6%) presenting with massive menstrual bleeding prior to embolization, a symptom considered as an isolated predictor for improvement of symptom scores.(2121. vander Kooij SM, Hehenkamp WJ, Volkers NA, Birnie E, Ankum WM, Reekers JA. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial. Am J Obstet Gynecol. 2010;203(2):105.e1-13.,2222. Smeets AJ, Nijenhuis RJ, van Rooij WJ, Weimar EA, Boekkooi PF, Lampmann LE, et al. Uterine artery embolization in patients with a large fibroid burden: long-term clinical and MR follow-up. Cardiovasc Intervent Radiol. 2010;33(5):943-8.)

The improvement of sexual function after treatment of fibroids is a frequent concern for both women submitted to this procedure and their partners.(2323. Kovacsik HV, Herbreteau D, Bommart S, Beregi JP, Bartoli JM, Sapoval M; French Society of Interventional and Cardiovascular Imaging (SFICV) research group. Evaluation of changes in sexual function related to uterine fibroid embolization (UFE): Results of the EFUZEN Study. Cardiovasc Intervent Radiol. 2017;40(8):1169-75.)In this study, there was a significant improvement in the UFS-QoL sexual function subscale, in wich initial scores with a median of 37.5 points jumped to a median of 100 after UFE. It is important to emphasize that the UFS-QoL evaluates only some of the psychological aspects of sexual function, and does not collect data on desire, arousal, orgasm, and pain during sexual intercourse. Studies focused on these data reported improvement at the 1-year follow-up after embolization.(2323. Kovacsik HV, Herbreteau D, Bommart S, Beregi JP, Bartoli JM, Sapoval M; French Society of Interventional and Cardiovascular Imaging (SFICV) research group. Evaluation of changes in sexual function related to uterine fibroid embolization (UFE): Results of the EFUZEN Study. Cardiovasc Intervent Radiol. 2017;40(8):1169-75.

24. Hehenkamp WJ, Volkers NA, Bartholomeus W, de Blok S, Birnie E, Reekers JA, et al. Sexuality and body image after uterine artery embolization and hysterectomy in the treatment of uterine fibroids: a randomized comparison. Cardiovasc Intervent Radiol. 2007;30(5):866-75.
-2525. Hehenkamp WJ, Volkers NA, Birnie E, Reekers JA, Ankum WM. Symptomatic uterine fibroids: treatment with uterine artery embolization or hysterectomy:--results from the randomized clinical Embolisation versus Hysterectomy (EMMY) trial. Radiology. 2008;246(3):823-32.)

It is worth mentioning that some strategies(1818. Hassan ES. Recall bias can be a threat to retrospective and prospective research designs. IntJ Epidemiol. 2005;3(2):1-7.) were used in this study for reducing recall bias, given that part of the data was collected up to 3 years after the UFE, which could result in more than 20% irretrievable critical details of a recognized event.(1717. Bradburn NM, Rips LJ, Shevell SK. Answering autobiographical questions: the impact of memory and inference on surveys. Science. 1987;236(4798):157-61.)Although there is a higher risk of recall bias in retrospective studies, it is quite difficult to forget a significant clinical improvement after a surgical procedure in just 3 years, especially when impacting the quality of life so effectively.

There is controversy in literature about the influence of uterine size on the intensity of symptoms presented prior to embolization. Corroborating recent publications,(99. Lacayo EA, Richman DL, Acord MR, Wolfman DJ, Caridi TM, Desale SY, et al. Leiomyoma Infarction after uterine artery embolization: influence of embolic agent and leiomyoma size and location on outcome. J Vasc Interv Radiol. 2017;28(7):1003-10.)we did not find a significant correlation between these findings. The median uterine volume before embolization was 343.74cm3, similar to values observed in the EMMY trial (321cm3), but smaller when compared to the means reported in other large studies – approximately 500cm3 to 700cm3.(99. Lacayo EA, Richman DL, Acord MR, Wolfman DJ, Caridi TM, Desale SY, et al. Leiomyoma Infarction after uterine artery embolization: influence of embolic agent and leiomyoma size and location on outcome. J Vasc Interv Radiol. 2017;28(7):1003-10.,1919. Mariara C, Obura T, Hacking N, Stones W. One year symptom severity and health-related quality of life changes among Black African patients undergoing uterine fibroid embolisation. BMC Res Notes. 2017;10(1):240.,2121. vander Kooij SM, Hehenkamp WJ, Volkers NA, Birnie E, Ankum WM, Reekers JA. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial. Am J Obstet Gynecol. 2010;203(2):105.e1-13.,2323. Kovacsik HV, Herbreteau D, Bommart S, Beregi JP, Bartoli JM, Sapoval M; French Society of Interventional and Cardiovascular Imaging (SFICV) research group. Evaluation of changes in sexual function related to uterine fibroid embolization (UFE): Results of the EFUZEN Study. Cardiovasc Intervent Radiol. 2017;40(8):1169-75.)

There was a 37.1% reduction in uterine volume in our sample, slightly lower than values reported in other Brazilian and international studies.(2323. Kovacsik HV, Herbreteau D, Bommart S, Beregi JP, Bartoli JM, Sapoval M; French Society of Interventional and Cardiovascular Imaging (SFICV) research group. Evaluation of changes in sexual function related to uterine fibroid embolization (UFE): Results of the EFUZEN Study. Cardiovasc Intervent Radiol. 2017;40(8):1169-75.,2626. Kisilevzky N. Uterine embolization for management of symptomatic fibroids: quality-of-life impact. Radiol Bras. 2007;40(5):289-96.

27. Lohle PN, Voogt MJ, De Vries J, Smeets AJ, Vervest HA, Lampmann LE, et al. Long-term outcome of uterine artery embolization for symptomatic uterine leiomyomas. J Vasc Interv Radiol. 2008;19(3):319-26.

28. Bernardo A, Gomes MT, Castro RA, Girão MJ, Bonduki CE, Yokoyama CA. Impact of the myoma arterial embolization by uterine volume, diameter myoma greater and in the ovarian function. Rev Bras Ginecol Obstet. 2011;33(8):201-6.
-2929. Zlotnik E, Messina ML, Nasser F, Affonso BB, Baroni RH, Wolosker N, et al. Predictive factors for pelvic magnetic resonance in response to arterial embolization of a uterine leiomyoma. Clinics (São Pualo). 2014;69(3):185-9.)Even with a smaller reduction in uterine volume, quality of life improvement scores were comparable to those of studies that had a greater reduction in uterine volume.(3030. Gupta JK, Sinha A, Lumsden MA, Hickey M. Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database Syst Rev. 2012;(5):CD005073. Review. Update in: CochraneDatabase Syst Rev. 2014;(12):CD005073.) As reported in previous studies,(99. Lacayo EA, Richman DL, Acord MR, Wolfman DJ, Caridi TM, Desale SY, et al. Leiomyoma Infarction after uterine artery embolization: influence of embolic agent and leiomyoma size and location on outcome. J Vasc Interv Radiol. 2017;28(7):1003-10.,2323. Kovacsik HV, Herbreteau D, Bommart S, Beregi JP, Bartoli JM, Sapoval M; French Society of Interventional and Cardiovascular Imaging (SFICV) research group. Evaluation of changes in sexual function related to uterine fibroid embolization (UFE): Results of the EFUZEN Study. Cardiovasc Intervent Radiol. 2017;40(8):1169-75.)there was no evidence of correlation between uterine volume changes and quality of life scores after UFE as well.

Therefore, significant reduction in uterine volume determines the technical success of UFE, without correlating with significant improvement in symptom severity/quality of life after the procedure. The efficacy of UFE as a less invasive alternative in the treatment of fibroids with improved quality of life seems to be proved. New studies should assess a possible better response to treatment, depending on the localization of the myoma (intramural, submucosal, or subserosal), or other factors that could predict treatment success.

Despite limitations in our study, such as the fact that it was not completely prospective, did not reach an ideal number of patients, and did not include some baseline information such as number, site, and size of myomas, and reasons for embolization (bleeding, pain, increased abdominal volume and/or infertility), our findings can contribute as a Brazilian experience to corroborate the effectiveness of UFE in improved quality of life, assessed through a validated questionnaire developed exclusively for such a condition.

CONCLUSION

Uterine fibroid embolization is a therapy with significant reduction in uterine volume and improved quality of life, even though there is no correlation between uterine volume and symptom severity/quality of life before and after uterine fibroid embolization.

REFERENCES

  • 1
    Kohi MP, Spies JB. Updates on uterine embolization. Semin Intervent Radiol. 2018;35(1):48-55.Review.
  • 2
    Parker WH. Etiology, symptomatology, and diagnosis of uterine myomas. Fertil Steril. 2007;87(4):725-36. Review.
  • 3
    Nasser F, Affonso BB, Jesus-Silva SG, Coelho DO, Zlotnik E, Messina ML, et al. Embolização de mioma uterino em mulheres portadoras de miomas volumosos. Rev Bras Ginecol Obstet. 2010;32(11):530-5.
  • 4
    Maciel C, Tang YZ, Sahdev A, Madureira AM, Vilares-Morgado P. Preprocedural MRI and MRA in planning fibroid embolization. Diagn Interv Radiol. 2017;23(2):163-71.
  • 5
    Kröncke T, David M. Uterine artery embolization (UAE) for fibrosis treatment: results of the 7th Radiological Gynecological Expert Meeting. Geburtshilfe Frauenheilkd. 2019;79(6):688-92.
  • 6
    Brito LG. Fatores motivacionais da mulher portadora de leiomioma uterino para a realização da histerectomia. Rev Bras Ginecol Obstet. 2012;34(6).
  • 7
    Brito LG, Panobianco MS, Sabino-de-Freitas MM, Barbosa HF, Azevedo GD, Brito LM, et al. Uterine leiomyoma: understanding the impact of symptoms on womens’ lives. Reprod Health. 2014;11(1):10.
  • 8
    Lohle PN, De Vries J, Klazen CA, Boekkooi PF, Vervest HA, Smeets AJ, et al. Uterine Artery embolization for symptomatic adenomyosis with or without uterine leiomyomas with the use of calibrated tris-acryl gelatin microspheres: midterm clinical and MR imaging follow-up. J Vasc Interv Radiol. 2007;18(7):835-41.
  • 9
    Lacayo EA, Richman DL, Acord MR, Wolfman DJ, Caridi TM, Desale SY, et al. Leiomyoma Infarction after uterine artery embolization: influence of embolic agent and leiomyoma size and location on outcome. J Vasc Interv Radiol. 2017;28(7):1003-10.
  • 10
    Grube M, Neis F, Brucker SY, Kommos S, Andress J, Weiss M, et al. Uterine fibroids: current trends and strategies. Surg Technol Int. 2019;34:257-63. Review.
  • 11
    Rossetti A, Sizzi O, Chiarotti F, Florio G. Developments in techniques for laparoscopic myomectomy. JSLS. 2007;11(1):34-40.
  • 12
    Worthington-Kirsch RL, Popky GL, Hutchins FL Jr. Uterine arterial embolization for the management of leiomyomas: quality-of-life assessment and clinical response. Radiology. 1998;208(3):625-9.
  • 13
    Belczak SQ, Szejnfeld D, Cardoso da Silva NA, Klajner RK, Ogawa LC, Mata MV. Symptoms improvement after uterine artery embolization for myoma management. J Vasc Med Surg. 2017;5(4).
  • 14
    Harding G, Coyne KS, Thompson CL, Spies JB. The responsiveness of the uterine fibroid symptom and health-related quality of life questionnaire (UFS-QOL). Health Qual Life Outcomes. 2008;6(1):99.
  • 15
    Spies JB, Coyne K, Guaou Guaou N, Boyle D, Skyrnarz-Murphy K, Gonzalves SM. The UFS-QOL, a new disease-specific symptom and health-related quality of life questionnaire for leiomyomata. Obstet Gynecol. 2002;99(2):290-300.
  • 16
    Silva RO, Gomes MT, Castro RA, Bonduki CE, Girão MJ. Uterine fibroid symptom - quality of life questionnaire translation and validation into Brazilian Portuguese. Rev Bras Ginecol Obstet. 2016;38(10):518-23.
  • 17
    Bradburn NM, Rips LJ, Shevell SK. Answering autobiographical questions: the impact of memory and inference on surveys. Science. 1987;236(4798):157-61.
  • 18
    Hassan ES. Recall bias can be a threat to retrospective and prospective research designs. IntJ Epidemiol. 2005;3(2):1-7.
  • 19
    Mariara C, Obura T, Hacking N, Stones W. One year symptom severity and health-related quality of life changes among Black African patients undergoing uterine fibroid embolisation. BMC Res Notes. 2017;10(1):240.
  • 20
    Spies JB, Myers ER, Worthington-Kirsch R, Mulgund J, Goodwin S, Mauro M; FIBROID Registry Investigators. The FIBROID Registry: symptom and quality-of-life status 1 year after therapy. Obstet Gynecol. 2005;106(6):1309-18.
  • 21
    vander Kooij SM, Hehenkamp WJ, Volkers NA, Birnie E, Ankum WM, Reekers JA. Uterine artery embolization vs hysterectomy in the treatment of symptomatic uterine fibroids: 5-year outcome from the randomized EMMY trial. Am J Obstet Gynecol. 2010;203(2):105.e1-13.
  • 22
    Smeets AJ, Nijenhuis RJ, van Rooij WJ, Weimar EA, Boekkooi PF, Lampmann LE, et al. Uterine artery embolization in patients with a large fibroid burden: long-term clinical and MR follow-up. Cardiovasc Intervent Radiol. 2010;33(5):943-8.
  • 23
    Kovacsik HV, Herbreteau D, Bommart S, Beregi JP, Bartoli JM, Sapoval M; French Society of Interventional and Cardiovascular Imaging (SFICV) research group. Evaluation of changes in sexual function related to uterine fibroid embolization (UFE): Results of the EFUZEN Study. Cardiovasc Intervent Radiol. 2017;40(8):1169-75.
  • 24
    Hehenkamp WJ, Volkers NA, Bartholomeus W, de Blok S, Birnie E, Reekers JA, et al. Sexuality and body image after uterine artery embolization and hysterectomy in the treatment of uterine fibroids: a randomized comparison. Cardiovasc Intervent Radiol. 2007;30(5):866-75.
  • 25
    Hehenkamp WJ, Volkers NA, Birnie E, Reekers JA, Ankum WM. Symptomatic uterine fibroids: treatment with uterine artery embolization or hysterectomy:--results from the randomized clinical Embolisation versus Hysterectomy (EMMY) trial. Radiology. 2008;246(3):823-32.
  • 26
    Kisilevzky N. Uterine embolization for management of symptomatic fibroids: quality-of-life impact. Radiol Bras. 2007;40(5):289-96.
  • 27
    Lohle PN, Voogt MJ, De Vries J, Smeets AJ, Vervest HA, Lampmann LE, et al. Long-term outcome of uterine artery embolization for symptomatic uterine leiomyomas. J Vasc Interv Radiol. 2008;19(3):319-26.
  • 28
    Bernardo A, Gomes MT, Castro RA, Girão MJ, Bonduki CE, Yokoyama CA. Impact of the myoma arterial embolization by uterine volume, diameter myoma greater and in the ovarian function. Rev Bras Ginecol Obstet. 2011;33(8):201-6.
  • 29
    Zlotnik E, Messina ML, Nasser F, Affonso BB, Baroni RH, Wolosker N, et al. Predictive factors for pelvic magnetic resonance in response to arterial embolization of a uterine leiomyoma. Clinics (São Pualo). 2014;69(3):185-9.
  • 30
    Gupta JK, Sinha A, Lumsden MA, Hickey M. Uterine artery embolization for symptomatic uterine fibroids. Cochrane Database Syst Rev. 2012;(5):CD005073. Review. Update in: CochraneDatabase Syst Rev. 2014;(12):CD005073.

Publication Dates

  • Publication in this collection
    21 Sept 2020
  • Date of issue
    2020

History

  • Received
    23 Oct 2019
  • Accepted
    16 Feb 2020
Instituto Israelita de Ensino e Pesquisa Albert Einstein Avenida Albert Einstein, 627/701 , 05651-901 São Paulo - SP, Tel.: (55 11) 2151 0904 - São Paulo - SP - Brazil
E-mail: revista@einstein.br