UTERINE FIBROID EMBOLIZATION: AN UNDERUTILIZED TREATMENT ALTERNATIVE By Virag Tunya A thesis submitted to the School of Radiologic Sciences in collaboration with a research agenda team In partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN RADIOLOGIC SCIENCES (MSRS) WEBER STATE UNIVERSITY Ogden, Utah December 15, 2023 THE WEBER STATE UNIVERSITY GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Virag Tunya This thesis has been read by each member of the following supervisory committee and by majority vote found to be satisfactory. ______________________________ Dr. Tanya Nolan, EdD Chair, School of Radiologic Sciences ______________________________ Dr. Laurie Coburn, EdD Director of MSRS RA ______________________________________________________________________ Christopher Steelman, MS Director of MSRS Cardiac Specialist Abstract Uterine fibroid embolization (UFE), introduced in 1995, is a well-documented and minimally invasive treatment option for uterine fibroids. Despite its proven record of achievement, UFE remains underutilized compared to invasive surgical options. Our research confirms that UFE is a suitable treatment alternative for large (>10 cm) uterine fibroids, consistently demonstrating its safety and effectiveness. There are no significant differences recorded in the results between large and small fibroids treated with UFE, and the procedure leads to shorter hospital stays and significant savings compared to hysterectomy. Wider use of UFE could potentially bring considerable savings to both patients and health care systems. The primary obstacle to greater adoption of UFE as the first-line treatment for uterine fibroids is low awareness and knowledge of the procedure. Misconceptions about UFE are fueled by inaccurate online information and suboptimal social media practices by interventional radiology. Another challenge is the hesitancy of gynecologists to refer their patients to interventional radiology for minimally invasive options. To increase awareness and utilization of UFE, we propose the creation of multidisciplinary fibroid clinics, the use of high-quality patient decision aids, and the implementation of improved social media strategies providing accurate information about the procedure. Further research could explore the potential benefits of a more frequent screening schedule and earlier intervention once fibroids are diagnosed. Keywords: uterine fibroid, leiomyoma, uterine fibroid embolization, UFE, interventional radiology procedure Acknowledgments I would like to acknowledge my professors, Laurie Coburn and Christopher Steelman, for guiding me through this thesis project. I would like to thank my friend Andrea Gillespie for her expertise and for helping me organize my concept into a great paper. I would like to thank Dr. Aaron Fischman for allowing me to use information published in his YouTube video for my thesis defense presentation. Table of Contents Uterine Fibroid Embolization: An Underutilized Treatment Alternative ..................1 Chapter 1: Introduction ................................................................................................7 Background ..................................................................................................................................... 8 Statement of the Problem ................................................................................................................. 9 Purpose of the Study ...................................................................................................................... 11 Research Questions ....................................................................................................................... 12 Definition of Key Terms ................................................................................................................. 12 Nature of the Study ........................................................................................................................ 12 Significance of the Study ................................................................................................................ 13 Chapter 2: Clinical Background ................................................................................. 14 Introduction................................................................................................................................... 14 Etiology and Epidemiology ............................................................................................................ 14 Pathophysiology ............................................................................................................................ 15 History and Physical...................................................................................................................... 16 Evaluation ..................................................................................................................................... 17 Treatment / Management Options .................................................................................................. 17 Uterine Fibroid Embolization ........................................................................................................ 20 Complications ............................................................................................................................... 22 Summary ....................................................................................................................................... 23 Chapter 3: Literature Reviews .................................................................................... 24 Documentation .............................................................................................................................. 24 General Literature Review ............................................................................................................. 25 UFE for Large Fibroids: A Case for its Extended Use .................................................................... 25 Dispelling Misconceptions: The Power of Knowledge in Promoting Uterine Fibroid Embolization . 28 Enhancing Interdisciplinary Communication for Improved Patient Outcomes ................................. 31 Summary ....................................................................................................................................... 34 Chapter 4: Research Method ...................................................................................... 36 Research Methods and Design ....................................................................................................... 39 Limitations .................................................................................................................................... 40 Summary ....................................................................................................................................... 40 Chapter 5: Findings ..................................................................................................... 42 Results........................................................................................................................................... 42 Evaluation of Findings................................................................................................................... 44 Summary ....................................................................................................................................... 44 Chapter 6: Implications, Recommendations, and Conclusions ................................. 45 Implications................................................................................................................................... 45 Recommendations .......................................................................................................................... 46 Conclusions ................................................................................................................................... 47 References ..................................................................................................................................... 49 APPENDICES ............................................................................................................. 53 Appendix A: Case study #2 From diagnosis to UFE: Lab Values Chart ............. 53 Appendix B: Uterine Fibroid Option Grid™ ....................................................... 54 Chapter 1: Introduction Uterine fibroid embolization (UFE) is a minimally invasive procedure performed by interventional radiology for the treatment of uterine fibroids, which are the most common benign tumor of the uterus. Uterine fibroids can cause a variety of symptoms in women of reproductive age, sometimes even after menopause, including severe menstrual bleeding, anemia, fatigue, pelvic pressure, urinary incontinence or retention, and pain. Fibroids can also be linked to subfertility, infertility, or miscarriage. 1 The prevailing attitude of physicians is clinical surveillance; however, excessive fibroid growth can cause severe symptoms and impairment of quality of life.2 The presence of fibroids can affect multiple physiological systems, including the gastrointestinal, genitourinary, vascular, and nervous systems. The presence of large or multiple fibroids can complicate diagnostic radiographic studies, such as colon or small bowel studies, hysterosalpingograms, and cystograms. The treatment of fibroids can be approached with surgical, pharmaceutical, or minimally invasive imaging-guided interventional techniques. The most common suggestion from physicians is ‘watchful waiting;’ however, when symptomatic, most patients elect some sort of treatment. Uterine fibroid embolization (UFE) has been used since 1995 and, since its inception, multiple case studies have documented the effectiveness of the procedure in the treatment of fibroids. Background The topic of using uterine fibroid embolization (UFE) for large fibroids is still relevant for research, as the condition of uterine fibroids affects a significant portion of the population. The lifetime prevalence of uterine fibroids in premenopausal women is greater than 80% among black women and reaches 70% among white women. 3 According to a 2012 study, the estimated direct costs associated with the condition can reach up to 9.4 billion dollars annually.4 The indirect costs to the US economy are even greater. To rectify these issues, a recent bill, if passed into law, would fund federal research projects and educational programs on the condition.5 Since its introduction in 1995, UFE has been successfully and purposefully used for the treatment of fibroids smaller than 10 cm; however, the prevailing attitude when it comes to larger fibroids is still often surgical intervention.6 The reasoning behind this recommendation was based on some older case reports where UFE resulted in infection, uterine injury, sepsis, and death, although UFE has less documented major or minor complications than hysterectomy or myomectomy. 7,8 Case studies in patients who were not surgical candidates or declined surgical treatment have shown the efficacy of UFE for large fibroids.9,10 Multiple comprehensive studies have also confirmed its broader success in treating complex uterine fibroid cases.11,12 Even in light of this extensive scientific support, UFE remains mostly underutilized as a first-line fibroid treatment.13 Public awareness of the condition of uterine fibroids and UFE is also lacking. The results of the USA Fibroid Health Survey showed that 47% of the respondents had never heard of fibroids, and that number increased to 63% among those who did not participate in annual wellness exams.14 Efforts have been made to identify the reasons behind the lack of public awareness and acceptance. In a recently published report, “an analysis of Google search and medical publication trend data provided evidence that trends in public search and research activity for UFE has lagged behind myomectomy for treatment of symptomatic uterine fibroids despite an early spark in public interest.”15 Another recent study concluded that the quality and reliability of YouTube videos on uterine fibroid embolization are of low value, and advised physicians to be aware of highly viewed material to be able to adequately address misconceptions and have informed discussions with their patients.16 Initiatives to increase visibility of interventional radiology have been attempted in recent years; however, follow-up on these projects shows most of them abandoned.17 Statement of the Problem Uterine fibroid embolization (UFE) has demonstrated remarkable effectiveness in the treatment of uterine fibroids, offering a minimally invasive alternative to surgery. Despite its 30-year positive track record and proven benefits, UFE remains underutilized, especially for larger fibroids (>10 cm), where surgical interventions - myomectomy or hysterectomy – are still often recommended. This underuse is exacerbated by a lack of public awareness of UFE, referral bias from obstetrics and gynecology to interventional radiology, and the need for integrated patient care across medical specialties. 6 Uterine fibroids, the most common benign uterine tumors, affect a significant segment of premenopausal women, with a higher prevalence among black women. The economic burden of this condition is substantial, with estimated direct costs in the billions of dollars annually.4 Furthermore, uterine fibroids can significantly reduce quality of life with a range of debilitating symptoms, including severe menstrual bleeding, anemia, fatigue, pelvic discomfort, urinary problems, and pain. Fibroids have also been associated with subfertility, infertility, or miscarriage, further affecting women's reproductive health.1,3-5 Physicians typically recommend clinical surveillance, but when symptoms become severe, patients seek treatment. Although UFE has been established as an effective treatment for smaller fibroids, it is still often overlooked for larger fibroids due to historical concerns about procedural complications and safety. 6-12 The prevalent perception that surgical interventions are superior for larger fibroids is rooted in older case reports of adverse events associated with UFE. However, recent case studies and larger investigations have consistently demonstrated the efficacy and safety of UFE for larger fibroids. Despite this scientific support, UFE remains underutilized as the primary treatment option. 6-12 Additionally, public awareness of uterine fibroids and UFE remains low, hindering informed decision-making by patients. Google search and publication trends indicate a lag in public interest in UFE compared to surgical options. Misconceptions are magnified by low-quality and unreliable information available on platforms like YouTube.13-16 Addressing these challenges requires better awareness of interventional radiology options, improved collaboration between primary care, gynecology, and interventional radiology, and ensuring that patients and primary care physicians are well informed about fibroids and the variety of treatment options available for their treatment, including minimally invasive UFE. Consequently, this study aims to investigate the safety and effectiveness of UFE for large fibroids, identify barriers to its utilization, and propose strategies to promote its adoption as a viable and cost-effective treatment option for uterine fibroids. Purpose of the Study The purpose of this review of existing literature and case studies is to investigate and address the underuse of uterine fibroid embolization (UFE) as a treatment option for large fibroids, with a focus on improving patient care, increasing public awareness, and improving medical decision making. This research aims to: 1. Assess the safety and effectiveness of UFE: Evaluate the safety and efficacy of UFE as a viable treatment for large fibroids (>10 cm) through a review of case studies and existing research findings. 2. Identify barriers to UFE utilization: Explore the underlying factors, historical and psychological concerns that contribute to the preference for surgical options over UFE for large uterine fibroids. 3. Enhance public awareness: Investigate the current state of public awareness of uterine fibroids and UFE, identifying gaps and misconceptions in knowledge dissemination. 4. Promote integrated patient care: examine opportunities to improve collaboration between medical specialties, including primary care, gynecology, and interventional radiology, to ensure comprehensive patient care and education. 5. Propose strategies for adoption: Develop recommendations and strategies to increase the adoption of UFE for large fibroids, focusing on its costeffectiveness and benefits for both patients and health care systems. Research Questions As the review of the current literature, case studies and informal investigation revealed, most patients with large fibroids are initially referred to surgical procedures and UFE is not often offered. Q1. Is uterine fibroid embolization an appropriate treatment option for large fibroids? Q2. What are the current barriers to UFE as a primary treatment for uterine fibroids? Q3. What methods could be used to increase awareness and use of UFE? Definition of Key Terms Term 1. Uterine fibroid embolization (UFE) is a more specific term used for what is technically known as uterine artery embolization (UAE).18 Nature of the Study The study design most suitable for finding answers to the proposed research questions is qualitative. A comprehensive and multidisciplinary retrospective review of the relevant literature is used to better understand the clinical and psychosocial issues surrounding this complex problem. Yin’s theory of case study design dictates that all phases of a case present various supporting sources of data and evidence.17 Our stated case is that UFE is appropriate for the treatment of large fibroids, a position highlighted by two embedded case studies, as well as previously documented cases and research. Significance of the Study The importance of this study lies in the significant problem of decision-making surrounding fibroid treatment, particularly in cases involving large fibroids. This challenge often arises when following the most recommended clinical surveillance approach. Even with the vast amount of correct information available on the internet about UFE, social networks, a popular source of information for patients, still allow serious misconceptions to develop. This study hopes to address these misconceptions, outline the reasons why UFE is an excellent option for fibroid treatment, and propose the need to include fibroid screening in women’s wellness exams. Chapter 2: Clinical Background Introduction Uterine leiomyomata (UL), or fibroids, are the most common benign smooth muscle tumors in the uterus that affect up to 80% of premenopausal women.3 Once symptomatic, UL causes a variety of symptoms that seriously affect a woman’s quality of life, including excessive and painful menstruation, pelvic pain, urinary frequency and urgency, and sciatica.2 Large fibroids can cause more serious problems such as intestinal obstruction and adhesion.19 Clinical surveillance is recommended for asymptomatic fibroids; however, once symptomatic, most patients elect some sort of treatment. The management of fibroids can be approached with surgical, pharmaceutical, or minimally invasive imaging-guided interventional techniques. Etiology and Epidemiology Of unknown etiology, uterine fibroid tumors are extremely common. The prevalence of uterine fibroids has increased 67.07% over the past 30 years, with incidence cases reaching 9.64 million in 2019 worldwide, with reproductive women aged 35-39 at the highest risk.20 The estimated cumulative incidence of fibroids is >80% for black women and >70% for white women, with black women affected in greater numbers at an earlier age.21 Established risk factors for the development of fibroids are: Age: cumulative incidence increases with age, but the rate of increase slows at older ages; African American heritage: higher incidence and earlier onset than in white women; Early age of menarche; Parity: pregnancy was shown to have a protective effect 22; Genetic predisposition 23; and Vitamin D deficiency.24 In light of these risk factors, it becomes increasingly important to understand uterine fibroids, a common condition with a growing global presence. Pathophysiology Uterine fibroids are monoclonal tumors originating in smooth muscle cells of the myometrium. Categorized based on location, there are subserosal, transmural, intramural, or submucosal fibroids. Subserosal fibroids grow on the outer surface of the uterus. Intramural fibroids are contained within the muscular wall of the uterus, while transmural fibroids bulge into the uterine cavity, involving the submucosa. Pedunculated fibroids grow on a stalk or pedicle. Pedunculated submucosal fibroids refer to those that grow within the uterus; while pedunculated subserosal fibroids arise from the smooth outer layer of the uterus.25 Fibroids can be single or multiple in number, with sizes documented to reach more than 50 cm.26 Another important anatomical feature of fibroids that influences treatment planning is the vascular layout of the female reproductive system. The uterine artery is a branch of the internal iliac artery. The blood supply to the uterus is mainly from the uterine artery; however, the presence of anastomoses between the uterine and ovarian arteries can make embolization of the uterine fibroids more challenging. Variations in vascular flow through the uterine and ovarian arteries are shown to be heavily affected by hormonal changes during the female reproductive cycle. 27 Targeted selection of small vessels for embolization is often made difficult by the tortuous nature of the uterine vasculature. The highly vascular nature of uterine fibroids plays a key role in their growth rate. A prospective cohort study utilizing 3D power Doppler ultrasound evaluations found that a 1% increase in fibroid vascularization was correlated with a 7 cm growth of fibroid volume at 12 months.28 Quiet and asymptomatic growth of these benign tumors is possible because the large size and flexibility of the abdominal cavity can accommodate its slow growth.26 History and Physical Uterine leiomyomas or fibroids are frequently asymptomatic. Premenopausal women often first present with heavy menstrual bleeding. 16 Heavy menstrual bleeding with iron deficiency and iron-deficiency anemia is frequently overlooked in clinical practice; however, it is commonly associated with the development of uterine fibroids. 29 Patients often present for evaluation once symptomatic. Common symptoms include abnormal bleeding, pelvic pain, dyspareunia, obstructive effects on gastrointestinal and urinary structures, and infertility.30 Laboratory tests can reveal low levels of iron and ferritin associated with anemia. A rare and counterintuitive finding associated with uterine fibroids is elevated red blood cell counts indicating polycythemia, a condition that requires frequent phlebotomy to reduce the risk of stroke, pulmonary emboli, and heart attacks, as demonstrated in one of our following case studies. Evaluation Diagnostic imaging is crucial for a precise diagnosis of the condition and for treatment planning. The primary modality for diagnosing uterine fibroids is ultrasound, utilizing both transabdominal and transvaginal scanning methods. Ultrasound imaging is most used at the time of initial diagnosis due to the ease of access and low cost compared to other modalities such as magnetic resonance imaging (MRI). 31 Ultrasound imaging demonstrates the number and size of fibroids, and scans performed by skilled technologists can detect lesions as small as 5 mm in size. 1 MRI is employed in more complex cases and for procedural planning. Fibroids are also often incidentally discovered on CT scans, prompting further investigation with US and MRI as clinically indicated. The vascular layout, as well as the number and type of fibroids, can also be assessed before the procedure, either with a MR angiogram or a pelvic CT angiogram if MRI is contraindicated. MRI is also valuable to differentiate fibroids from other types of masses; however, an endometrial biopsy is still necessary for pathological evaluation prior to interventional procedures.1,32 Treatment / Management Options Patients with asymptomatic fibroids are usually initially advised clinical surveillance. Discussions about treatment appear once patients are symptomatic and symptoms negatively affect their quality of life. The condition is often diagnosed by primary care physicians and, most commonly, patients are referred to gynecology for treatment. Most women (72.8%) initially only are informed of two treatment options, hormonal therapy and hysterectomy. It often takes a second or third opinion to get a wider range of options, with UFE offered about 50% of the time. 33 As case studies demonstrate, the primary reason UFE is not initially offered is the referral of fibroid patients to gynecology for further treatment. Gynecologists, while aware of alternative treatment options such as UFE, are more comfortable with the treatments they offer, such as hormonal therapy and myomectomy or hysterectomy. 32 It is unclear whether this is intentional referral bias or subconscious preference for the treatment methods offered by gynecologists themselves to keep patients under their own care. A study organizing a multidisciplinary fibroid clinic showed an increase in referral from gynecology to interventional radiology, whether for UFE or other minimally invasive procedures. Interestingly, even with this increase in referral, the number of relative UFE procedures performed decreased during the study, while the number of surgical procedures increased.34 This anomaly could be due to some of the negative misconceptions and limited knowledge of UFE. Case Study #1 From Diagnosis to Hysterectomy A 39-year-old woman returned to her primary care physician for increasing complaints of hypermenorrhea, dysmenorrhea, pelvic pain, back pain, sciatica, urinary frequency and urgency, severe abdominal pain in the left lower quadrant with constipation, and abnormal uterine bleeding. On a physical exam, the patient was found to have a pelvic mass. US imaging showed what appeared to be a solitary intramural uterine fibroid measuring 10 cm in diameter. The endometrial biopsy completed by the gynecologist proved it to be a benign process. The two treatment options offered by the gynecologist were surgical or pharmaceutical. On the patient's request, the physician explained that a UFE procedure would likely not provide adequate volume loss to significantly reduce bulk symptoms. The patient elected laparoscopic supracervical hysterectomy, which was completed 3 months later. During surgery, the fibroid uterus measured 20 cm in diameter, with extensive colonic adhesions in the left lower quadrant. The patient made a full recovery in two weeks, using only over-the-counter pain management. No postoperative complications were reported. Case Study #2 From Diagnosis to UFE A 48-year-old woman presented to her gynecologist for a routine visit. On a physical exam she was diagnosed with a uterine fibroid, confirmed on ultrasound imaging, and measuring 9 cm diameter at its widest. At this point, the patient was asymptomatic. The gynecologist advised clinical surveillance if the symptoms were not bothersome and explained that menopausal hormonal changes would likely shrink the fibroid. The only other option offered to her at this time was a hysterectomy, which is the most common treatment used for uterine fibroids, accounting for almost 75% of fibroidrelated surgeries in the United States despite the increasing availability of alternative solutions.35 She decided to wait and attempted simple solutions suggested to potentially shrink fibroids, such as dietary changes and herbal supplements. Two years later she became symptomatic: heavy periods, abdominal distention, back pain, abdominal pain, sciatica, severe acid reflux, urinary frequency and urgency, and low levels of iron and ferritin. Additionally, she was diagnosed with secondary polycythemia, which put her at an increased risk for strokes and heart attacks and required frequent phlebotomy. On US imaging, the fibroid enlarged to 17.5 cm at its widest diameter. Subsequently, the patient was referred for an MRI, which showed a benign solitary large intramural fibroid. After careful consideration, in-depth internet search, and various fibroid related social network group discussions, the patient elected to undergo UFE. Previous research has indicated that smaller baseline size and submucosal location have shown greater improvement on imaging 36, but no strong correlations were found between fibroid size and improvement of symptoms.11 The UFE procedure was completed via the radial approach, using gelfoam for embolization. Post-procedure pain management was necessary for 8 days following the intervention, with the patient returning to normal activity on day 11. The patient’s bulk symptoms improved within 3 months. Laboratory values corrected to optimal levels at nine months after the procedure, with red blood cells, ferritin, and iron within normal ranges (Appendix A). No postprocedural complications were reported. Uterine Fibroid Embolization Uterine artery embolization (UAE) for the treatment of fibroids, commonly known as uterine fibroid embolization (UFE), has a rich history spanning three decades and is supported by numerous studies that confirm its safety and efficacy. A quick, hourlong procedure completed under moderate sedation; the UAE involves the insertion of an angiographic catheter into the uterine arteries. The procedure is performed by an interventional radiologist in a specialized interventional radiology suite. The patient is supine on the angiography table, with a C-arm fluoroscopy system used for X-ray imaging and guidance. The catheter is introduced through the common femoral or the radial artery. The transradial approach is preferred with less risk of bleeding, faster recovery and increased comfort for both the patient and operator alike.37 Contrast material, a non-radioactive, water-soluble substance containing iodine, is used to visualize the vascular layout and facilitate the cannulation of target arteries. Once the uterine arteries are successfully accessed, embolic agents are injected to inhibit blood flow to the fibroids. Common embolic agents employed are polyvinyl alcohol particles or trisacryl gelatin microspheres. The HydroPearl Microsphere, a newer and frequently preferred brand, is notable for its precise particle calibration, allowing for improved luminal packing and a reduction of non-target embolization 38. Another promising addition to the field is the Optisphere, the latest embolization agent, comprised of spherical, resorbable gelatin-based particles. Like Gelfoam, these particles begin to degrade around 4 weeks, fully absorbing within 12 weeks. 1,39 The embolic agents used for UAE are not radioactive, a common misconception among patients. Radiation exposure during a UAE procedure is comparable to a diagnostic radiographic test, particularly when opting for the transradial approach. A further reduction in radiation dose can be achieved by completing a pre-procedure MRA mapping the vascular layout.37 This thoughtful approach ensures that radiation exposure remains as low as reasonably achievable, while maintaining the diagnostic precision and therapeutic value of the procedure. Complications Before discussing the complications of treatments, it is vitally important to address the complications arising from the condition of uterine fibroids. As common as uterine fibroids are, these complications are rare, but when they do occur, they have serious health implications. Some acute conditions caused by uterine fibroids are thromboembolism, torsion of pedunculated fibroids, urinary retention, renal failure, red degeneration, sudden interruption of blood supply to the fibroid causing severe pain, vaginal or intraperitoneal hemorrhage, mesenteric vein thrombosis leading to intestinal gangrene, and intestinal obstruction.40 Surgical treatments for uterine fibroids often carry the risk of infectious complications. Vaginal hysterectomy is at highest risk, at 13%, primarily in the form of vaginal cuff cellulitis. Pelvic infections with abscess formation, urinary tract infection, and even respiratory infections have been associated with hysterectomy. As with any intraabdominal surgical procedure, there is a risk of venous thromboembolism, gastrointestinal or genitourinary tract injuries, and nerve injuries.41 Myomectomy carries additional risks of possible fibroid regrowth, with the need for a hysterectomy later in the future. In addition, there is a greater risk of bleeding complications compared to hysterectomy, because the surgeon does not cut and ligate the vascular supply to the uterus as with hysterectomy.42 The risks of uterine fibroid embolization are similar to the risks of other minimally invasive procedures. The most common risks are bleeding and infection. Infection has been described as the most important complication encountered after uterine fibroid embolization, with rates reported up to 7.5% in a recent study. Furthermore, this study also identified an increased incidence of postprocedural infectious complications with higher BMI and larger volumes of fibroids, requiring emergency hysterectomy in less than 1% of cases.43 However, a different study did not show correlation between fibroid size and infection rates after uterine fibroid embolization.44 A possible reason for this discrepancy is that with such a low number of infections in these cohorts, it is difficult to further categorize the cases into additional groups of small versus large fibroids, and any specific result is likely to be random. 43 The choice of trans-radial approach can minimize the risk of bleeding. The inherent risk of any x-ray guided procedure is radiation exposure; however, as discussed previously, radiation doses are relatively small. Pre-procedure mapping of vasculature with MRA or CTA can greatly reduce the need for intraprocedural imaging. A recent study has found that contrast-enhanced ultrasound can also adequately assess vascularity of fibroid tumors prior to interventional procedures. 45 A unique concern specific to UFE is the potential for inadvertent embolization of nontarget arteries. However, this risk can be mitigated using microcatheters for superselection of the target-arteries.46 Summary The clinical context on uterine fibroid reveals that once symptomatic, the risks of having fibroids are similar, if not more pronounced, than the risks associated with surgical or minimally invasive interventions. In particular, uterine fibroid embolization boasts an even lower incidence of postprocedural complications than the surgical options of myomectomy or hysterectomy. Chapter 3: Literature Reviews Documentation During our search for relevant material, the primary resource was Weber State University Stewart Library’s OneSearch database. Additional sources included the database of the Journal of Interventional and Vascular Radiology/Society of Interventional Radiology. For the literature review, our search was limited to peerreviewed scholarly articles using various combinations of the search terms fibroid, uterine fibroid, embolization, large fibroid, huge fibroid, uterine artery embolization, uterine fibroid embolization, interventional radiology, hysterectomy, case study, cost, referral, and family history. The discipline filter of medicine was applied throughout these searches, testing various subject-term filters to narrow down the results. The criteria for the literature to be included in the review were as follows: (a) medicine related articles, (b) relevance to uterine fibroid/leiomyoma or its treatment, (c) written in English, and (d) published within the last ten years. An additional search was later conducted to identify solutions to the problems presented during our research, namely the underutilization and low awareness of UFE. This search was also conducted on the Weber State University OneSearch database, and included the search terms behavio*, patient*, decision*. The search was narrowed to articles published since 2013. No discipline filter was applied, hoping to capture interdisciplinary solutions to a clinical problem. General Literature Review This qualitative study aims to investigate the safety and efficiency of uterine fibroid embolization (UFE) as a viable treatment approach for large fibroids. Our primary objectives are to rectify the underuse of UFE, elevate patient care and education standards, and refine the medical decision-making process. UFE for Large Fibroids: A Case for its Extended Use Uterine fibroid embolization (UFE) has emerged as a valuable, minimally invasive option in the treatment of uterine fibroids. However, concerns have been raised about its suitability for large fibroids. In this section, we will dive into why UFE is a viable and safe approach, drawing on some specific case studies that have unintentionally proved its therapeutic value. UFE’s effectiveness in treating large fibroids is a testament to its importance in the field of fibroid management. Large fibroids often present unique challenges due to their size, causing significant symptoms and discomfort in patients. UFE, the targeted embolization of blood vessels that feed the fibroid, results in its gradual shrinking and alleviation of symptoms. Case studies describing situations in which the preferred method of treatment was hysterectomy, but UFE was performed instead provide perfect examples. For example, in the case of a 45-year-old Jehovah’s Witness patient suffering from multiple large uterine fibroids and severe anemia, uterine artery embolization was a critical intervention because the patient was not a surgical candidate due to critically low hemoglobin values. UFE was completed as an alternative intervention, and it successfully stopped her hemorrhaging large uterine fibroids. Following UFE, her hemoglobin levels improved quickly, underscoring the effectiveness of this method in managing her condition.9 In another case, a 30-year-old patient with typical fibroid symptoms was diagnosed with multiple medium-sized uterine fibroids and a large subserosal fibroid. Two successful UFE treatments have substantially reduced or completely resolved her bulk symptoms. Given her overall improvement, no further intervention was planned, and her condition was managed conservatively.10 Not only can UFE treat large fibroids, but it can do so while preserving fertility. A case study describing a 28-year-old woman with severe fibroid symptoms, including previous miscarriage, received UFE as the treatment for her large fibroids. Selective embolization of the vessels feeding each tumor was completed. Postoperatively, she experienced significant relief from symptoms, improved quality of life, and reported complete satisfaction with the results. 10 These three examples show excellent results of UFE for the treatment of large fibroids, proving that the treatment should not be discounted for similar cases. One of the main reasons for advocating the use of UFE for large fibroids is its potential to save a substantial number of patients from undergoing hysterectomy. Traditionally, large fibroids have commonly been treated with hysterectomy, a major surgical procedure associated with risks, longer recovery times, and significant emotional impacts on patients. The organ-sparing nature of UFE allows women to retain their reproductive potential and avoid possible social stigma. A study showed that hysterectomy had an average postoperative infection rate of around 11%. Common types of infection in this context include vaginal cuff cellulitis, infected hematoma or abscess, infections, urinary tract infections, respiratory infections, and febrile morbidity.41 In contrast, a different study demonstrated that infectious complications after UFE are around 7%, with fewer than 1% of patients requiring additional interventions to address these issues.43 By offering this less invasive option, UFE helps patients avoid the need for more radical surgical interventions, which can have rare but profound consequences. Critics of UFE have raised concerns about its safety, particularly when compared to surgical alternatives. However, research consistently demonstrates that UFE does not significantly increase risks compared to other interventions. The rate of complications associated with UFE is generally low and the procedure has been shown to be safe and effective for a wide range of patients, including those with large uterine fibroids. A retrospective cohort study comparing patients who underwent UFE or myomectomy for symptomatic uterine fibroids found that there were no statistically significant differences in the rates of secondary interventions between the two groups. However, there was a higher incidence of post-procedure complications in the myomectomy group, including the need for post-procedure blood transfusions.47 This lower risk profile makes UFE a valuable option for patients seeking treatment for their fibroids, regardless of the size of the fibroid. The theme of advocating for the continued and even increased use of UFE for large fibroids carries enormous significance in the realm of women’s health. It highlights the potential of this minimally invasive, relatively low-risk procedure as the perfect uterine-sparing, short recovery alternative to a riskier hysterectomy. Furthermore, by dispelling concerns about risks, UFE provides a safe and viable alternative to more invasive interventions, even for large uterine fibroids. Dispelling Misconceptions: The Power of Knowledge in Promoting Uterine Fibroid Embolization Misconceptions about medical procedures can hinder their utilization and effectiveness. Uterine fibroid embolization is no exception, as misconceptions among patients and health care providers alike limit its adoption and lead to limited options for fibroid management. In this section, we will explore the significance of increasing knowledge about the UFE procedure to dispel misconceptions. Reasons for its importance include its potential to boost UFE utilization, mitigate referral bias, enhance patient awareness and cooperation, and reduce the number of surgical procedures. One of the primary reasons for the dissemination of knowledge about UFE is its potential for increased utilization. Misconceptions about the procedure often lead patients and healthcare providers to more familiar or traditional treatments, even when UFE may be a more appropriate option. Often, the main source of information for patients is the internet, including social media platforms. A study aimed at evaluating the quality of information in YouTube videos on uterine fibroids found some data to support the claim that information from the internet should be carefully scrutinized. The researchers used the DISCERN Scale to measure video quality and the Video Power Index to gauge their popularity. They found that the average quality of the 31 videos was relatively low, with no correlation between popularity and quality. Videos with board-certified physicians were not significantly more popular, but those with board-certified interventional radiologists were less popular. In conclusion, YouTube is not a reliable source of information on uterine fibroid treatment, and doctors should be aware of this when discussing treatment options with patients.16 Further examining the issue of information dissemination in the current online environment, another study investigated strategies employed by interventional radiologists on various social media platforms. The findings showed an importance of crafting better hashtags, including images, and publishing posts in the morning hours to get better engagement. By enhancing their online presence, interventional radiologists can curate their own content and replace outdated or inaccurate information prevalent on third-party websites, which currently dominate search engine results.48 It is crucial to recognize that the internet, including social networks, plays a pivotal role in shaping patients’ decisions about uterine fibroid treatments. As the quality of information on the internet varies widely, healthcare providers must actively engage in improving their online presence to ensure accurate and up-to-date information reaches patients seeking information on their medical journey. Referral bias, in which healthcare providers are more likely to refer patients to more familiar treatments, can significantly impact patient outcomes. A recent multistate survey of more than 100 obstetrics and gynecologists collected some interesting data on their treatment options for symptomatic uterine fibroids. Medical therapy was the most commonly offered option, with an exceptionally low frequency of UFE referrals. The severity of symptoms was the strongest driving force behind their recommendation for medical therapy or myomectomy. The most cited reasons against UFE were the preservation of fertility and the unknown effects of UFE. These providers, experts in their field providing medical and surgical solutions, had reservations about the efficacy of UFE. Concerns included post-procedure pain and its management, fertility issues, perceived non-definitive treatment, effectiveness, access difficulties, delayed benefits, and necrotic fibroids. Most of the respondents have established relationships with interventional radiologists, but rarely recommended UFE as the first-line treatment for symptomatic uterine fibroids.49 Increasing knowledge of UFE among health care providers can help mitigate this bias. When providers have a better understanding of the procedure and its benefits, they are more likely to consider it as a viable option, resulting in a more balanced and personalized approach to fibroid management. Better informed patients tend to be more engaged and cooperative in their care. The proliferation of information on the internet has raised concerns, as people readily trust what they see and read there, even when it is false. Research shows that only a small percentage of patients verify the source and timeliness of online health information. It is essential to rely on reputable medical organizations and trusted publications for accurate and up-to-date information. Patients are encouraged to verify the information they find online by consulting their healthcare providers; however, only a small percentage do so.47 It is extremely important for medical organizations to improve their online platforms by presenting streamlined, relevant, and easily comprehensible information. By dispelling misconceptions and providing clear and accurate information about UFE, healthcare providers can foster a sense of trust and cooperation with their patients. This, in turn, can lead to better adherence to treatment, improved patient outcomes, and a more positive overall experience for people seeking care for uterine fibroids. Misconceptions about UFE can lead to a continued preference for surgical solutions such as myomectomy or hysterectomy for the treatment of uterine fibroids. These surgeries typically involve higher costs, longer recovery times, and more significant physical and emotional costs for patients. Increasing knowledge about UFE as a minimally invasive alternative can help reduce the number of unnecessary surgical interventions, offering patients a less invasive and more patient-centered option. The power of knowledge in promoting UFE cannot be understated. Dispelling misconceptions among patients and providers alike is a vital step towards achieving a more complete understanding of all available treatment options. Healthcare systems can optimize treatment choices, reduce unnecessary surgical procedures, and improve overall quality of care for patients with uterine fibroids. This theme is not just about information, but about patient empowerment and the potential to shape the future of fibroid management. Enhancing Interdisciplinary Communication for Improved Patient Outcomes Uterine fibroids are a common medical condition that affects many women. Their management often requires a multidisciplinary approach due to the complexity of symptoms, various treatment options, and patient preferences. Improving interdisciplinary communication in the context of uterine fibroid care is of critical importance. We will highlight the reasons for its importance, including increased referrals for UFE, improved patient care and management in multiple modalities, and facilitating better shared decision-making, similar to tumor boards in oncology. One of the main reasons for improving interdisciplinary communication in uterine fibroid care is the need for increased referral to the currently underutilized UFE. Inadequate communication between gynecologists, interventional radiologists, and other medical providers often leads to a lack of awareness of UFE. By improving communication channels, healthcare providers can ensure that UFE or other noninvasive options are at least considered in the decision-making process. The coexistence of multiple modalities that offer treatments can create both collaboration and competition. Multidisciplinary clinics have shown some potential benefits. A recent study creating such a multidisciplinary fibroid clinic involving minimally invasive gynecologic surgeons and interventional radiologists (IR) found that the collaborative effort did not change the general perception about fibroid treatment, however, it did improve IR referral rates. During the study, there was an increased total number of fibroid treatment procedures performed, with an actual lower number of UFEs, but an increased number of collaborative interventions for complex cases. This new shared space and new shared identity improved provider self-perception and allowed for better patient care.34 Regardless of the patient’s ultimate treatment choice, a discussion with the interventional radiologist about minimally invasive options should be a basic element of uterine fibroid care. Effective interdisciplinary communication is fundamental to providing patient care and management. Uterine fibroids can present with a wide range of symptoms and complications, making it essential that specialists of various disciplines collaborate seamlessly. Whether it is about pain management, fertility concerns, or other associated conditions, improved communication ensures that patients receive complete and coordinated care. A study highlighted the issues surrounding patients’ lack of confidence in health care providers regarding their care of uterine fibroids. Many participants have been dealing with fibroid symptoms for years before seeking treatment. They were often told that heavy bleeding was due to a family history and they were also unaware that other symptoms such as frequent urination and abdominal pain could be caused by uterine fibroids. These patients had different experiences with their healthcare providers. Some felt that the providers addressed their symptoms appropriately and discussed treatment options. However, most patients described delays in evaluation and diagnosis, often having their symptoms dismissed by providers as normal menstrual bleeding and pain, not fibroid-related complications. Participants also felt that oral contraceptives were recommended without a thorough work-up, and that male providers were less empathetic and understanding of symptom severity. Some of these perceptions caused lengthy delays in seeking care, cycling through multiple providers, and later presenting with a greater fibroid burden. Patients expressed dissatisfaction and sought second or even third opinions when health care providers offered a surgical option, particularly hysterectomy, as the only available option. Some participants reported refusing further care from providers unwilling to discuss other treatment options and turning to alternative medical advice online and on social media. Many of the participants in this study have eventually undergone surgical procedures, primarily due to a decline in their quality of life and their desire to get relief from symptoms. Interestingly, most of these patients cannot recall having a discussion with their providers about quality-of-life concerns. Patients recommended that healthcare providers increase their knowledge about uterine fibroids and available treatment options, especially less invasive ones. They also expressed the desire for earlier patient education and awareness, and routine ultrasound screenings to make prompt treatment choices.50 These suggestions, in an effective interdisciplinary collaboration, can result in better symptom management, reduced treatment delays, and an overall enhanced quality of life in patients with symptomatic uterine fibroids. In complex uterine fibroid cases, collaboration approaches, such as tumor boards, in oncological care could play a pivotal role in shared decision-making. These cases often require the input of gynecologists, interventional radiologists, fertility specialists, and other experts based on the medical histories of the patients. As described before, a multidisciplinary fibroid clinic can create the perfect setting for such complex cases. For example, interventional radiologists during that study were able to provide solutions in other areas of gynecological care, such as superior hypogastric nerve blocks for postmyomectomy pain control. Instead of competing for the same cases, providers were able to work collaboratively, allowing growth and increased volumes for both specialties. 34 Through effective communication and teamwork, the 'fibroid board' can evaluate the full spectrum of treatment options and tailor interventions to meet the unique needs and preferences of each patient. This empowers patients to make informed decisions and ensures optimized treatment plans while increasing physician satisfaction. In conclusion, improving interdisciplinary communication in the care of uterine fibroid improves the referral to UFE, expanding access to this minimally invasive and effective treatment. In addition, it nurtures trust between patients and providers and promotes comprehensive, coordinated care, improving patient outcomes and quality of life. The discussion of complex cases also promotes precision and improves decisionmaking for patient-centered care. Summary This section of the research studies discusses the importance of improving interdisciplinary communication in the care of uterine fibroids, addressing misconceptions about UFE, and advocating for its use in the treatment of large fibroids. It emphasizes the significance of these themes in improving patient outcomes, reducing surgical procedures, and promoting patient-centered care. By dispelling misconceptions, increasing knowledge, and fostering collaboration among healthcare providers, we can transform the landscape of uterine fibroid management, offering patients more informed choices and better care. Chapter 4: Research Method Uterine fibroid embolization (UFE) has shown remarkable effectiveness in treating uterine fibroids, offering a minimally invasive alternative to surgery. Despite its 30-year positive record of accomplishment and proven benefits, UFE remains underutilized, especially for larger fibroids (>10cm), where surgical interventions myomectomy or hysterectomy – are still often recommended. This underutilization is exacerbated by a lack of public awareness of UFE, referral bias from obstetrics and gynecology to interventional radiology, and the need for integrated patient care in medical specialties.6 Uterine fibroids, the most common benign uterine tumors, affect a significant segment of premenopausal women, with a higher prevalence among black women. The economic burden of this condition is substantial, with estimated direct costs in the billions of dollars annually. Furthermore, uterine fibroids can cause an inferior quality of life with a range of debilitating symptoms, including severe menstrual bleeding, anemia, fatigue, pelvic discomfort, urinary problems, and pain. Fibroids have also been linked to subfertility, infertility, or miscarriage, further affecting women's reproductive health.1,3-5 Physicians typically recommend clinical surveillance, but when symptoms become severe, patients seek treatment. Although UFE has been established as an effective treatment for smaller fibroids, it is still often overlooked for larger fibroids due to historical concerns about procedural complications and safety. 6-12 The prevailing perception that surgical interventions are superior for larger fibroids is rooted in older case reports of adverse events associated with UFE. However, recent case studies and larger investigations have consistently demonstrated the efficacy and safety of UFE for larger fibroids. Despite this scientific support, UFE remains underutilized as the primary treatment option. 6-12 Additionally, public awareness of uterine fibroids and UFE remains low, hindering informed decision-making by patients. Google search and publication trends indicate a lag in public interest in UFE compared to surgical options. Misconceptions are magnified by low-quality and unreliable information available on platforms like YouTube.13-16 Addressing these challenges requires improving awareness of interventional radiology options, enhancing collaboration between primary care, gynecology, and interventional radiology, and ensuring patients and primary care physicians are well informed about fibroids and the variety of treatment options available for their treatment, including minimally invasive UFE. Consequently, this study aims to investigate the safety and effectiveness of UFE for large fibroids, identify barriers to its use, and propose strategies to promote its adoption as a viable and cost-effective treatment option for uterine fibroids. The purpose of this qualitative study is to investigate and address the underutilization of uterine fibroid embolization as a treatment option for large fibroids, with a focus on improving patient care, increasing public awareness, and improving medical decision making. This research aims to: 1. Assess the safety and effectiveness of UFE: Evaluate the safety and efficacy of UFE as a viable treatment for large fibroids (>10cm) through a review of case studies and existing research findings. 2. Identify barriers to UFE utilization: Explore the underlying factors, historical, and psychological concerns that contribute to the preference for surgical options over UFE for large uterine fibroids. 3. Enhance public awareness: Investigate the current state of public awareness of uterine fibroids and UFE, identifying gaps and misconceptions in knowledge dissemination. 4. Promote integrated patient care: examine the opportunities to improve collaboration among medical specialties, including primary care, gynecology, and interventional radiology, to ensure comprehensive patient care and education. 5. Propose strategies for adoption: Develop recommendations and strategies to increase the adoption of UFE for large fibroids, focusing on its costeffectiveness and benefits for both patients and health care systems. According to the review of the current literature, case studies, and informal investigations revealed, most patients with large fibroids are initially referred to surgical procedures, and UFE is not often offered. Q1. Is uterine fibroid embolization an appropriate treatment option for large fibroids? Q2. What are the current barriers to UFE as a primary treatment for uterine fibroids? Q3. What methods could be used to increase awareness and use of UFE? Research Methods and Design The study design most suitable to find answers to the proposed research questions is qualitative. A multidisciplinary, overarching review of relevant literature is utilized to better understand both the clinical and psychosocial issues surrounding this complex problem. Yin’s theory of case study design dictates that all phases of a case present various supporting sources of data and evidence.17 This investigation’s stated case is that UFE is appropriate for the treatment of large fibroids, a statement that is supported by two embedded case studies, as well as previously documented cases and research. During our search for relevant material the primary resource was Weber State University Stewart Library’s OneSearch database. Additional sources included the database of the Journal of Interventional and Vascular Radiology/Society of Interventional Radiology. For the literature review, search was limited to peer-reviewed scholarly articles using various combinations of the search terms fibroid, uterine fibroid, embolization, large fibroid, huge fibroid, uterine artery embolization, uterine fibroid embolization, UFE, interventional radiology, hysterectomy, case study, cost, referral, and family history. The search was narrowed to articles published since 2003, since our research wanted to review historical and current data. The discipline filter of medicine was applied throughout these searches, testing various subject term filters to narrow down the results. The criteria for the literature to be included in the review were as follows: (a) medicine related articles, (b) relevance to uterine fibroid/leiomyoma or its treatment, (c) written in English, and (d) published within the last twenty years. An additional search was later conducted to identify solutions to the problems presented during our research, namely the underutilization and low awareness of UFE. This search was also conducted on the Weber State University OneSearch database, and included the search terms behavio*, patient*, decision*. The search was narrowed to articles published since 2013. No discipline filter was applied, with the hope of capturing interdisciplinary solutions to a clinical problem. Limitations When discussing uterine fibroids and uterine fibroid embolization techniques, a topic that frequently arises is the impact on fertility and the potential for subsequent successful pregnancies. Our search did not address these matters that warrant their own dedicated research. Furthermore, our research did not include cases of patients undergoing uterine fibroid embolization with significant known comorbidities. There have been research studies focusing on such patients, but we felt that the results of those studies would skew the perception of an average patient considering uterine fibroid embolization without understanding the implications of the additional medical conditions. Summary This qualitative study aimed to explore the safety and effectiveness of uterine fibroid embolization (UFE) as a treatment for large fibroids. The study’s primary objectives included rectifying underutilization of UFE, improving patient care and education, and refining the medical decision-making process. The text highlights the viability and safety of minimally invasive UFE as a treatment for uterine fibroids while avoiding more invasive surgical procedures. Examples are also provided to demonstrate the success of the procedure in treating large fibroids. Chapter 5: Findings The purpose of the research study was to verify that UFE is an appropriate treatment for large uterine fibroids. Barriers to UFE as the primary treatment option were identified, including misconceptions and low knowledge of the procedure among patients and providers. Our research then identified methods to increase awareness and utilization of UFE. Results Appropriateness of UFE in the treatment of large fibroids Multiple case studies were identified that showed the effectiveness of UFE for large uterine fibroids. One such case study in obstetrics and gynecology described a patient with multiple large uterine fibroids. Surgical treatment was the preferred option; however, due to low hemoglobin levels, the patient was not a surgical candidate. UFE was completed with excellent results.9 Another case from interventional radiology describing a patient with 3 prominent fibroids, one as large as 14.9 cm x 11 cm x 11 cm, showed successful embolization with a significant improvement in bulk symptoms and improvement in quality of life three weeks post-procedure.10 Our ‘Case Study #2: From Diagnosis to UFE’ also demonstrated a significant reduction of fibroid uterus size and complete resolution of symptoms after the procedure. A larger study involving a total of 303 UFE procedures did not show significant differences in effectiveness and outcomes between fibroids <10 cm compared to those >10 cm.11 Current barriers to using UFE Barriers in using UFE for fibroid treatment included low knowledge among both patients and providers alike. Internet searches often yield low-quality information from questionable sources, such as social networks, which was found to be a primary source of information for many patients. This point is well demonstrated by a study analyzing YouTube videos, which identified the quality of the information as low value and the videos of inadequate quality.16 Referral bias was also recognized as an obstacle to a wider implementation of UFE for fibroid treatment. A study of 132 obstetricians and gynecologists found that UFE was rarely recommended as a treatment for symptomatic uterine fibroids. Medical therapy and hysterectomy were the preferred treatments offered, keeping the care of patients within the realm of their respective specialties.49 Methods to Increase Awareness and Utilization of UFE A proven method found to increase utilization and referral to interventional radiology was the creation of a multidisciplinary fibroid clinic. During this study, the actual number of UFE procedures performed decreased; however, there was a significant increase in referrals.34 After investigating current social media practices by interventional radiology, a study concluded that social media posts showed better engagement if they were published during the morning hours, included images, and had specific hashtags. It was noted that interventional radiology is active on social media; however, posts are less patientcentered than those of other modalities.48 Another study investigated the use of patient decision aids (PDA), such as the uterine fibroid option grid (Appendix B), which allows for a quick overview of the various treatment options. These can be used during provider visits to discuss various options and find the best solution for the patient’s unique needs. The use of PDAs aims to improve the delivery of healthcare to women, increasing their knowledge of the available options, thus allowing for improved decision-making.51 Evaluation of Findings Based on the findings, the use of uterine fibroid embolization procedures can be expanded to include large uterine fibroids. The formation of interdisciplinary teams or fibroid boards can improve patient care by increasing patient awareness, cultivating interdisciplinary care, thus improving patient outcomes. Awareness and understanding of UFE can be improved by increasing interventional radiology-created content with up-todate, accurate information. Social media posts with the specified recommended guidelines can be tested to improve knowledge dissemination and patient engagement. Summary Multiple case studies confirm the efficacy of UFE in treating large fibroids, with successful outcomes in cases initially recommended for surgery. Barriers to UFE include low awareness among patients and providers, as well as referral bias. Strategies for increased UFE utilization include creating multidisciplinary fibroid clinics, optimizing the social media presence of interventional radiology, and using patient decision aids to improve knowledge and decision making. Chapter 6: Implications, Recommendations, and Conclusions In this study, we address the underutilization of UFE for the treatment of large fibroids, emphasizing the need to improve patient care, public awareness, and medical decision making. We explore the safety and efficacy of UFE for large uterine fibroids through case studies, identify barriers to its use as a first-line treatment, and assess the current state of public awareness. The study highlights the importance of bridging the gap between medical specialties to ensure comprehensive patient care. Implications Is uterine fibroid embolization an appropriate treatment option for large fibroids? Based on the reviewed literature, the answer is yes. UFE is an appropriate treatment option for large fibroids, and research clearly shows that it is safe and effective. No significant outcome differences were reported for large fibroids compared to smaller fibroids treated with UFE.11 Furthermore, data also showed that UFE resulted in shorter hospital stays and a lower hospital bill, approximately $12,000 less expensive than hysterectomy.52 Adopting a wider use of UFE to treat fibroids could mean cost benefits for patients and health care systems alike. What are the current barriers to UFE as a primary treatment for uterine fibroids? Our research has identified low knowledge of the procedure as the primary barrier in the wider adoption of UFE as a primary treatment. Patients and providers alike were plagued by misconceptions about the procedure. Low quality information on the internet and inappropriate social media practices by interventional radiology were identified as challenges to positive learning experiences.16,48 Another potential barrier was found to be referral bias. Obstetricians and gynecologists show a clear preference to manage treatments and services in-house, rarely referring their patients to interventional radiologists for consultation on minimally invasive treatment options.49 Recommendations What methods could be used to increase awareness and use of UFE? Implementing multidisciplinary fibroid boards. Although it is important to acknowledge the delicate interplay of collaboration and competition of the various medical specialists, the overall result proved to be positive for patient care. Fostering collaboration between gynecologists and interventional radiologists improved patient care and satisfaction. The referenced study on the interdisciplinary fibroid clinic experiment found that the collaboration increased job satisfaction among the clinicians involved. Shared mental models among clinicians can result in higher-quality patient-centered care, where treatment options are tailored to individual patient needs and preferences. This in turn leads to better patient outcomes and higher patient satisfaction.34 Increasing awareness and helping patients make better decisions by providing high-quality information such as the uterine fibroid Option Grid™ could be another way to increase utilization of UFE.51 Implementing this simple tool could be as easy as creating a website that loads the uterine fibroid Option Grid™ when a patient searches for ‘uterine fibroid’ on a health care system website. The uterine fibroid Option Grid™ includes multiple options and allows the patient to get a broader view rather than being directed to a specific solution, even if that solution is embolization. Empowering patients and allowing them to choose the best solution for themselves creates trust and has been proven to improve patient outcomes. 34 This patient decision aid could also be implemented at the initial diagnosis and utilized by primary care physicians when determining referral to specialists.51 Additional research could explore the enhancement of screening protocols and the potential for improved outcomes through earlier intervention. Existing gynecologic screening recommendations advocate for reducing screenings to every 5 years starting at age 30. This age coincides with the slow increase in uterine fibroid incidence.1 An argument could be made for maintaining the 3-year screening schedule, allowing for earlier diagnosis and treatment of uterine fibroids. Treatment of uterine fibroids in the stages of earlier growth could save the patient further pain and preserve their quality of life. Earlier intervention also provides a wider range of treatment options with potentially superior outcomes and better-quality pain management. For example, embolization of a smaller uterine fibroid could include the option of superior hypogastric nerve block at the time of the procedure. This is only possible if there is clear access to the L5 vertebral body, which is the target of the nerve block, and is usually obstructed by larger fibroids. 53 Conclusions In this study, we emphasize the underutilization of UFE for large fibroids and advocate for improved patient care, awareness, and medical decision making. Our research confirms the appropriateness of UFE for the treatment of large uterine fibroids, offering a cost-effective and organ-sparing option to hysterectomy. Key barriers include lack of awareness and referral bias, primarily due to misconceptions and low-quality information. 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Minimally invasive, less expensive treatment for uterine fibroids underutilized. ScienceDaily. Accessed September 9, 2023. https://www.sciencedaily.com/releases/2017/03/170306092746.htm 53. Pereira K, Morel-Ovalle LM, Taghipour M, et al. Superior hypogastric nerve block (SHNB) for pain control after uterine fibroid embolization (UFE): technique and troubleshooting. CVIR Endovasc. 2020;3:50. doi:10.1186/s42155-020-00141-2 APPENDICES Appendix A: Case study #2 From diagnosis to UFE: Lab Values Chart LAB VALUES RBC Ferritin Iron Pre-UFE 6.4 x106/µL 6 ng/mL 29 ng/mL 9 months post-UFE 4.3 x106/µL 110 ng/mL 103 ng/mL Appendix B: Uterine Fibroid Option Grid™ https://creativecommons.org/licenses/by/4.0/