Uterine artery embolization is a relatively simple, minimally-invasive procedure for removing fibroids, or non-cancerous uterine masses that occur in roughly half of women of reproductive age.i During the procedure, fibroids are essentially starved from blood supply via catheter-mediated injection of embolic products. Though uterine artery embolization has been shown to be both safe and effective at improving symptoms and has been recommended by the American College of Gynecologists,ii,iii,iv the management of intraprocedural pain poses a significant challenge, so much so that uterine artery embolization is not widely offered throughout medical practices. Thus, pain management for uterine artery embolization is crucial for the normalization of an effective procedure as well as improvement of patient welfare.
Research has suggested that altering procedural methodology may prevent the experience of severe pain. Reducing the aggression of embolization, for example, mitigates discomfort while maintaining procedural efficacy.v Instead of aiming for complete uterine artery stasis, interventional radiologists now commonly recognize that embolization to a 5- to 10-beat stasis is adequate. Research also suggests that less extensive embolization may reduce the number of procedure-related emergency room visits.vi
Pre-procedural anesthesia is an important aspect of pain reduction during uterine artery embolization. Physicians commonly prescribe a dose of hydromorphone hydrochloride and then allow for patient-controlled analgesia; however, options may vary by patient and practice. An intramuscular injection of ketorolac provides around 8-10 hours of analgesia, though very thin patients may find this process too painful and prefer intravenous ketorolac. Given that the majority of patients do not experience pain until after the procedure, long-acting narcotics are preferable. These must be administered around half an hour in advance to be effective.
During the procedure, a variety of anesthetic options are available. Administration of buffered lidocaine hydrochloride at the femoral artery access site allows for ease of placement. Ultrasound-guided administration of local anesthesia at the procedure site is also very common. However, in their paper, “Clinical and Periprocedural Pain Management for Uterine Artery Embolization,” Elizabeth Spencer et al. provide anecdotal evidence that patients consistently report improved pain outcomes with a superior hypogastric nerve block (SHNB). An additional study found that administration of anti-inflammatories in patients treated with a SHNB reduced overall pain as well as the need for narcotics.vii Following the procedure, the physician may discuss a short-term pain management plan with their patient.
There are a variety of options when it comes to pain management for uterine artery embolization. Though different practices may have their preferred methods, it seems that the reasoning for this may be largely anecdotal. Therefore, these findings suggest that further research is necessary to determine which pain management strategies are the most efficacious.
i Wallach EE, Vlahos NF. Uterine myomas: an overview of development, clinical features, and management. Obstet Gynecol. 2004;104(2):393–406. doi: 10.1097/01.AOG.0000136079.62513.39
ii Andersen P E, Lund N, Justesen P, Munk T, Elle B, Floridon C. Uterine artery embolization of symptomatic uterine fibroida. Initial success and short-term results. Acta Radiol. 2001;42(2):234–238.
iii Brunereau L, Herbreteau D, Gallas S. et al. Uterine artery embolization in the primary treatment of uterine leiomyomas: technical features and prospective follow-up with clinical and sonographic examinations in 58 patients. AJR Am J Roentgenol. 2000;175(5):1267–1272.
iv American College of Obstetricians and Gynecologists. ACOG practice bulletin. Alternatives to hysterectomy in the management of leiomyomas. Obstet Gynecol. 2008;112(2 Pt 1):387–400.
v Spies JB, Allison S, Flick P, McCullough M, Sterbis K, Cramp M, Bruno J, Jha R. Polyvinyl alcohol particles and tris-acryl gelatin microspheres for uterine artery embolization for leiomyomas: results of a randomized comparative study. J Vasc Interv Radiol. 2004 Aug; 15(8):793-800.
vi Spies JB. Recovery after uterine artery embolization: understanding and managing short-term outcomes. J Vasc Interv Radiol. 2003 Oct; 14(10):1219-22.
vii Rasuli P, Jolly E E, Hammond I. et al. Superior hypogastric nerve block for pain control in outpatient uterine artery embolization. J VascIntervRadiol. 2004;15(12):1423–1429.