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2002 Selected Articles

Diagnosis and Management of Long-term Complications of Uterine Artery Embolization

Nelson H. Stringer, MD

According to a membership survey conducted in October 2000 by the Society of Cardiovascular and Interventional Radiology (SCVIR), 10,501 uterine artery embolization (UAE) procedures have been performed worldwide, 8,664 of these in the United States. UAE is an alternative to laparoscopic myomectomy,^1-3 open myomectomy,² hysteroscopic resection,⁴ hysterectomy, and other surgical procedures for the treatment of myomas.⁵ It appears to be safe for symptomatic myomas, and only a few minor complications and adverse events were noted initially.^6,7 However, several major complications have been reported recently, including a prolapsing myoma requiring hysterectomy,⁸ septicemia,^9-11 pulmonary embolism,¹² and death.^12,13 The exact frequency and extent of complications associated with UAE have yet to be thoroughly documented.

Certain immediate postprocedure complications, such as allergic reactions to contrast media, bleeding at the catheter insertion site, and catheter perforation of a vessel, can be managed by the interventional radiologist. However, many of the complications of UAE occur several weeks or months after the procedure. These long-term complications, (ie, those occurring at 3 months or later), are usually managed by the gynecologist. Three of this author’s patients have experienced late-onset complications following UAE that are important for OB/GYNs to recognize. These include ischemic uterine rupture requiring hysterectomy, failure of UAE in the case of an unrecognized tubal myoma, and premature ovarian failure (premature menopause) following UAE.^14-16 Gynecologists must know the proper diagnostic techniques and clinical management of the long-term complications and therapeutic failures of UAE. The following practical clinical management guidelines, review of the literature, and case reports will assist gynecologists in the diagnosis and management of these unusual cases.

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UTERINE RUPTURE

The first step in diagnosing and managing post-UAE uterine rupture is to maintain a high index of suspicion. A computerized search of the literature showed the case cited here (Case Report No. 1) to be the second report of ischemic uterine rupture following UAE, and the first report from the United States. As in this case, the previous report of uterine rupture also occurred 3 months after the UAE procedure.¹⁷ Rupture of the uterus following UAE or any procedure is a very serious gynecologic complication requiring immediate surgical intervention to prevent death. The only treatment for a septic ruptured uterus is abdominal hysterectomy. The antibiotics ampicillin, gentamicin, and metronidazole were effective against the bacteria cultured from this patient. Drainage of the surgical site with secondary closure is probably also mandatory with this degree of infection. A computerized search of the literature revealed two reports of death following UAE,^12,13 neither of which was due to uterine rupture. One patient died 24 hours post-UAE from pulmonary embolism,¹² and the other died of septicemia and disseminated intravascular coagulation 21 days after UAE.¹³

 

CASE REPORT No. 1. Ischemic Uterine Rupture Requiring Hysterectomy A 44-year-old woman, gravida 0, para 0, with a 3-year history of menometrorrhagia underwent uterine artery embolization (UAE) with 355- to 500-m polyvinyl alcohol (PVA) particles. The procedure was completed without difficulty, and the patient was discharged the next day. Postprocedure follow-up was performed by the interventional radiologist. During the first month, the patient experienced moderate vaginal bleeding and a malodorous vaginal discharge. She also continued to have abdominal pain that required oral ibuprofen, 800 mg tid. Two months after the procedure, the patient was referred back to her gynecologist for evaluation of the chronic pain. The diagnosis was probable necrosing myomas, and she was advised to continue ibuprofen use. Her condition improved, her vital signs and laboratory values were normal, and she returned to work 1 week after follow-up with the gynecologist. Three months after UAE, the patient presented to the emergency department with severe diffuse abdominal pain, absent bowel sounds, abdominal rigidity, and “coffee grounds” emesis. Laboratory evaluation showed a hematocrit value of 30% and a white cell count of 21,400/mm2. An admission KUB radiograph revealed free air under the diaphragm, and a general surgeon was consulted. With a presumptive diagnosis of a perforated peptic ulcer secondary to ibuprofen, exploratory laparotomy was performed 2 hours after admission by the general surgery and gynecology services. Exploratory laparotomy revealed 1000 mL of pus in the abdominal cavity with no evidence of gastric or duodenal perforation. Examination of the pelvis revealed a necrotic uterus that was enlarged to 16 cm, with a 12-cm subserosal myoma protruding into the right broad ligament. There was a 1-cm perforation in the uterine fundus with areas of necrosis adjacent to the largest fundal myoma. A total abdominal hysterectomy was performed. The patient received 3 U of packed red blood cells and 2 U of fresh frozen plasma. She was given IV ampicillin, gentamicin, and metronidazole. Intraoperative cultures yielded moderate peptostreptococcus and anaerobic gram-negative bacilli, with viridans streptococci and gram-positive bacilli. The incision site was left open and a vaginal T-tube drain placed. The patient was observed in the intensive care unit for 2 days. Her incision site was secondarily closed on postoperative day 6, and she was discharged on the seventh day. The gross surgical specimen revealed a 16-cm uterus with a 1-cm fundal uterine perforation surrounded by infracted uterine tissue (Figure 1). The histopathology report revealed infracted uterine tissue, intravascular fibrin and thrombi, inflammation, and a transmural uterine infract adjacent to the perforation site. Click to enlarge Figure 1. Gross surgical specimen revealing a 16-cm-sized uterus with a 1-cm fundal uterine perforation (arrow 1) surrounded by infracted uterine tissue (arrow 2). The histopathology report revealed infracted uterine tissue, intravascular fibrin, thrombi, and inflammation with a transmural uterine infract adjacent to the perforation site. (Photo reproduced with permission from http://www.fibroid.com.)

One previous case of ischemic uterine rupture following UAE was reported in the United Kingdom (UK).¹⁷ This patient had chronic postprocedure pain, with an intermittent vaginal discharge and low-grade fever.¹⁷ Blood cultures and uterine biopsy revealed the presence of Escherichia coli, which appeared to respond to intravenous (IV) antibiotic therapy. The patient was discharged and then readmitted with an exacerbation of pain occurring more than 3 months after the UAE procedure. At laparotomy, there was a fundal perforation, with a portion of the fibroid prolapsing through the uterine wall into the abdominal cavity.¹⁷

The case presented here and the case from the UK are similar in that the rupture occurred in the uterine fundus 3 months postprocedure. Ischemic necrosis and rupture of the uterus can theoretically occur several weeks or months after UAE. Additional reports must be collected and analyzed to determine the typical interval for the occurrence of uterine rupture or other factors that may predispose the uterus to rupture following UAE. Other side effects of UAE may also be occurring during this period, thus complicating the diagnosis. The gynecologist must be familiar with the common side effects associated with UAE, such as pelvic pain, nausea, vomiting, elevated temperatures, passage of small submucosal myomas, and elevated white blood counts.^14,18 These symptoms do not require surgical intervention and must be differentiated from uterine rupture, which requires immediate exploratory laparotomy and hysterectomy. An immediate admission kidney, ureter, and bladder (KUB) radiograph was essential for the timely diagnosis and management of uterine rupture in this case. The obvious air under the diaphragm, emesis, and history of ibuprofen use in this particular patient necessitated inclusion of a perforated peptic ulcer in the differential diagnosis and consultation with the general surgical service. However, this did not delay appropriate follow-up and surgical management. This also is the first report of post-UAE uterine rupture presenting with air under the diaphragm as a preoperative finding.¹⁶ While there are several reports of sepsis following UAE procedures necessitating total abdominal hysterectomy, none of these uteri ruptured.^9-11,17 In the UK case, the uterus was embolized with 150- to 250-m and 355- to 500-m particles. Particle size does not appear to have caused the ischemic rupture in the case here, as the procedure was performed with 355- to 500-m particles.

Certain age groups of women may be at higher risk for post-UAE ischemic necrosis and uterine rupture. The ovaries of perimenopausal women aged 45 to 50 years appear to be more sensitive to the degree of nontargeted embolization (ischemia) that occurs during the procedure.¹⁴ This patient was 44 years old when her uterus ruptured, but the patient in the UK was 34 years old.¹⁷ Additional reports and studies of ischemic uterine rupture following UAE are necessary to evaluate the frequency and role of age, if any.

At present, when UAE is performed with 300- to 500- m particles, ischemic uterine rupture is probably an unpredictable event. Therefore, the occurrence of uterine rupture necessitating total abdominal hysterectomy must be a consideration in informed consent for women who desire future pregnancy. Although pregnancies have been reported after UAE,^18,19 this author does not currently perform UAE in women who desire future pregnancy. Until the exact frequency of post-UAE ischemic uterine rupture requiring hysterectomy and other complications^8-16 is established, this author will continue to recommend surgical removal (laparoscopic myomectomy, open myomectomy, or hysteroscopic resection) of myomas in young women and others who desire to retain their fertility.

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UAE FAILURE DUE TO PEDUNCULATED OR ADNEXAL MYOMAS

Failures of UAE may require surgery several months postprocedure. The case outlined here (Case Report No. 2) represents a clinical failure of UAE that required laparoscopic myomectomy to remove a myoma growing from the serosa of the fallopian tube. To our knowledge, this is the first report of laparoscopic myomectomy performed due to failure of UAE to shrink a fibroid and alleviate pain 6 months after the procedure.¹⁵ Pedunculated myomas are very easy to remove via outpatient laparoscopic myomectomy. For surgeons with the requisite skills, this may be the preferred method for removing both narrow- and broad-based pedunculated myomas. This case clearly illustrates a previously unreported limitation of UAE, (ie, treatment failure for certain pedunculated myomas that may grow away from the uterus and gain blood supply from adjacent vascular sources such as the serosa of the fallopian tube). Gynecologists must be aware of these limitations when recommending UAE for treatment of symptomatic myomas.

 

CASE REPORT No. 2. Post-UAE Failure and Laparoscopic Myomectomy due to a Tubal Fibroid This patient experienced continuing growth of a broad-based pedunculated myoma 6 months post-UAE. Preprocedure ultrasonography revealed a uterine size of 4.6 x 3.4 x 5.4 cm (volume 84.5 cm3) and a broad-based, right-sided fibroid measuring 4.3 x 3.2 x 4.3 cm (volume 59.2 cm3). She was offered all available therapeutic options and selected UAE for treatment of this fibroid, which was consistent with her desire to avoid general anesthesia and invasive surgery. Uterine artery embolization was performed via right femoral artery access under conscious sedation and local anesthesia. Two weeks after the procedure, the patient felt significant relief of her pain. However, the right-sided pain gradually increased in intensity. Ultrasonography 2 months after UAE showed a uterus measuring 4.8 x 3.0 x 4.0 cm (volume 57.6 cm3), reflecting a 31.8% decrease in uterine volume. The fibroid measured 4.3 x 3.5 x 3.9 cm (volume 58.7 cm3), showing only a 0.8% decrease in fibroid volume. Thus, there was essentially no significant change in the size of the fibroid. Secondary to the continuing severity of the pain and the patient’s desire for immediate relief, laparoscopy was performed 6 months after UAE. A 7-cm pedunculated fibroid was found attached directly to the anterior surface of the right fallopian tube (Figure 2). The uterus appeared normal in color and size, and there was no evidence of the previous embolization procedure. The fibroid was removed without gonadotropin-releasing hormone (GnRH) pretreatment.1-3, 20-22 The myoma was stabilized with a 5-mm laparoscopic screw, and injected at the base with vasopressin. The myoma was dissected from the serosa of the fallopian tube using an ultrasonic scalpel, and then fragmented and removed with a Diva Powered Morcellator. The On-Q System was inserted for postoperative pain relief.17 Blood loss was less than 50 mL, and the procedure was completed in 1 hour and 52 minutes. The patient has been pain-free since the laparoscopic myomectomy. 2A 2B 2C 2D Click to enlarge Figure 2. At laparoscopy, a 7-cm pedunculated myoma was found growing from the serosa of the fallopian tube (2A). The myoma was injected with vasopressin and dissected with the Ultrasonic Scalpel (2B). Hemostasis was achieved with the ball tip of the Ultrasonic Scalpel (2C). The surgical site was covered with Intercede to prevent adhesion formation (2D). (Photo reproduced with permission from http://www.fibroid.com.)

This type of myoma is extremely rare; this author had never previously seen a large myoma growing directly from the serosa of the fallopian tube. Myomas can grow from any serosal surface in the abdomen, but without diagnostic laparoscopy or magnetic resonance imaging (MRI), it is probably impossible to differentiate this type of fibroid from a broad-based pedunculated myoma in the lateral portion of the uterus, which would respond to UAE. Failures of UAE can occur despite successful embolization if the myoma is receiving blood from the ovarian arteries, ²³ which also supply the fallopian tubes.

The anatomic relationships of the ovarian and uterine arteries are important considerations when performing UAE.¹⁴ The uterine arteries run a tortuous course between two layers of the broad ligament along the lateral side of the uterus, and turn laterally at the junction of the uterus and fallopian tube.²⁴ The uterine arteries then run toward the hilum of the ovary and terminate by joining the ovarian artery.²⁰ The ovarian artery supplies blood to the distal and proximal portions of the fallopian tube. Evaluation for ovarian or other variant fibroid blood supply is not routinely performed by interventional radiologists during UAE procedures because selective catheterization of the ovarian arteries is technically too difficult and time-consuming. In this particular case, even though the uterine artery was successfully embolized, the myoma increased in size from 4 cm to 7 cm.

Myomas can also grow from the broad ligament. Pedunculated, broad-based myomas of the lateral portions of the uterus may be indistinguishable from those arising from the fallopian tubes or broad ligament on ultrasonography. Pretreatment MRI has been used to predict the success of UAE procedures,²⁵ and may also be helpful for selecting appropriate UAE candidates and determining prognosis in patients with lateral, pedunculated, broad-based myomas. ²⁵

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OVARIAN FAILURE FOLLOWING UAE

There have been reports of menstrual irregularities and transient amenorrhea following UAE, but there has been no hormonal documentation of ovarian failure. The patient presented in Case Report No. 3 had elevated follicle-stimulating hormone (FSH) levels and vasomotor symptoms within 4 weeks post-UAE for the treatment of uterine fibroids. This appears to be the first case report in the literature of ovarian failure after UAE confirmed by comparing baseline preprocedure FSH levels with postprocedure elevated serial FSH levels over a 12-month period.¹⁴

 

CASE REPORT No. 3. Ovarian Failure Following UAE The patient was a 45-year-old woman, gravida 1, para 1, with a history of regular menstrual periods with severe menorrhagia and dysmenorrhea. Pelvic examination revealed a uterus comparable in size to 28 weeks’ gestation that measured 29 cm on physical examination. Endometrial biopsy revealed proliferative endometrium. The baseline FSH level was 4 mIU/mL; LH levels were not obtained. Baseline pelvic ultrasonography was performed to measure uterine dimensions, followed by UAE performed with 355- to 500-m PVA particles. Postprocedure arteriography revealed stasis of flow within both proximal uterine arteries (Figure 3), and there were no immediate complications. The patient experienced normal postprocedure pain that was treated with IV morphine through a self-administered, patient-controlled analgesic (PCA) pump. She was admitted for overnight observation and discharged the next morning with oxycodone, 2 tabs q 4 to 6 hours (she was allergic to ibuprofen). The patient experienced severe nausea and vomiting for 5 days postprocedure, and was readmitted to the hospital. Kidney and bladder studies, laboratory findings, and clinical examination were consistent with severe postembolization syndrome. Therapy consisted of promethazine, 50 mg intramuscularly (IM); belladonna elixir; and trimethobenzamide, 200 mg rectal suppositories, which alleviated the symptoms. However, the patient began complaining of daily vasomotor symptoms (hot flashes) within 4 days. A repeat FSH test revealed a level of 56 mIU/mL, rising to 64 mIU/mL 1 month later. Ultrasonography 4 weeks later revealed that the uterine volume had decreased from 1,585 mL to 1,103 mL, a reduction of 3l%. By 8 months after UAE, clinical evaluation revealed the patient was still complaining of daily vasomotor symptoms, the uterus had decreased to a clinical size comparable to 16 weeks, and the dysmenorrhea and menorrhagia had disappeared. During the next 2 months, the patient continued to complain of increasing vasomotor symptoms. The uterus remained comparable to 16 weeks in size on pelvic examination, and measured 17 cm on physical examination. She had no other complaints, and has experienced amenorrhea since the procedure. Testing revealed an FSH level of 79 mIU/mL, an LH level of 42 mIU/mL, and a serum estradiol level of 17pg/mL. The vasomotor symptoms persisted 6 months later, and the uterus was comparable to 14 weeks in size on pelvic examination and measured 14 cm. The FSH, LH, and serum estradiol levels were 84 mIU/mL, 56 mIU/mL, and less than 15 pg/mL, respectively, confirming ovarian failure and menopause. A B C D Click to enlarge Figure 3. Preembolization views of 29-cm-sized uterine fibroid and right (A) and left (B) uterine arteries. Postembolization views of right (C) and left (D) uterine arteries clearly reveal complete embolization. (Photo reproduced with permission from http://www.fibroid.com.)

Gynecologists probably cannot diagnose ovarian failure following UAE until at least 12 months postprocedure. OB/GYNs must inform women of this potential complication of UAE when performed for the treatment of uterine myomas, which is a consideration for patients who desire future pregnancy and who are younger than 30 years of age. In anticipation of this possibility, a baseline FSH level should be included in the preprocedure laboratory evaluation of all patients. The exact frequency of ovarian failure following UAE has yet to be documented. Elevated FSH levels for 12 months or longer post-UAE are consistent with ovarian failure. The laboratory definition of menopause is a 10- to 20-fold increase in FSH levels and an approximate 3-fold increase in luteinizing hormone (LH) levels, reaching maximum levels 1 to 3 years after cessation of menses.²⁶ Elevated levels of both hormones are considered conclusive evidence of ovarian failure.²⁶

Elevated FSH levels in a perimenopausal woman after UAE do not necessarily mean that ovarian failure has occurred, as it is normal for FSH levels to begin rising before menopause²⁷; they may rise even in premature perimenopause (age 25 to 35 years). It is believed that FSH is partly under the negative feedback control of the peptide inhibin, which is produced by granulosa cells. As the remaining follicles begin to respond to rising gonadotropin levels during the perimenopausal period, inhibin production may be inadequate, and the patient may have elevated FSH levels despite continued regular menstrual periods.²⁶ Transient amenorrhea and menstrual irregularities have been reported after UAE in women aged 45 to 50 years.²⁸

Theoretically, the ovaries at that age may be more sensitive to the degree of nontargeted embolization that occurs during UAE. This patient was 45 years old, and continued to have elevated FSH levels and vasomotor symptoms 12 months postprocedure. There is no specific management approach for ovarian failure after UAE. Patients who experience post-UAE ovarian failure should not receive hormone replacement therapy because the estrogen may cause the fibroids to regrow. Vitamin E and regular exercise resolved the vasomotor symptoms in the patient presented here.

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CONCLUSION

While the three late-onset complications of UAE cited here are quite rare, they must be included in the informed-consent process and considered in follow-up OB/GYN examinations for 1 to 2 years postprocedure. As uterine perforation requires immediate surgery and UAE failure necessitates additional therapy for fibroids, it is important not to dismiss post-UAE symptoms without thorough evaluation. An appropriate index of suspicion, even in the presence of an apparent cure, is the OB/GYN’s best tool for diagnosing these uncommon and unexpected sequelae in the most timely manner.

Nelson H. Stringer, MD, is director of the Fibroid Uterine Treatment Center, senior professor of obstetrics and gynecology in the department of obstetrics and gynecology at Rush Medical College, and obstetrician-gynecologist attending physician at Louis A. Weiss Memorial Hospital of the University of Chicago, all in Chicago, Ill.

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REFERENCES

1. Stringer NH. Laparoscopic myomectomy with the harmonic scalpel: a review of 25 cases. J Gynecol Surg. 1994;4: 241-245.
2. Stringer NH, Walker JC, Meyer PM. Comparison of 49 laparoscopic myomectomies with 49 open myomectomies. J Am Assoc Gynecol Laparosc. 1997;4(4):457-464.
3. Stringer NH. 100 laparoscopic myomectomies with ultrasonic energy: surgical review of a new energy source. Gynaecol Endosc. 1998;7(2):85-93.
4. Phillips DR, Milim SJ, Nathanson HG, Hasel JS. Experience with laparoscopic leiomyoma coagulation and concomitant operative hysteroscopy. J Am Assoc Gynecol Laparosc. 1997;4(4):425-433.
5. Zreik TG, Rutherford TJ, Palter SF, et al. Cryomyolysis, a new procedure for the conservative treatment of uterine fibroids. J Am Assoc Gynecol Laparosc. 1998;5(1):33-38.
6. Andersen PE, Lund N, Justesen P, et al. Uterine artery embolization of symptomatic uterine fibroids. Initial success and short-term results. Acta Radiol. 2001;42(2):234-238.
7. Lund N, Justesen P, Elle B, et al. Fibroids treated by uterine artery embolization. A review. Acta Obstet Gynecol Scand. 2000;79:905-910.
8. Pollard RR, Goldberg JM. Prolapsed cervical myoma after uterine artery embolization. A case report. J Reprod Med. 2001;46:499-500.
9. Braude P, Reidy J, Nott V, et al. Embolization of uterine leiomyomata: current concepts in management. Hum Reprod Update. 2000;6(6):603-608.
10. Pelage J, Le Dref O, Soyer P, et al. Fibroid-related menorrhagia: treatment with superselective embolization of the uterine arteries and midterm follow-up. Radiol. 2000;215(2):428-431.
11. Vashisht A, Studd JW, Carey AH, et al. Fibroid embolisation: a technique not without significant complications. Br J Obstet Gynaecol. 2000;107:1166-1170.
12. Lanocita R, Frigerio LF, Patelli G, et al. A fatal complication of percutaneous transcatheter embolization for treatment of uterine fibroids [abstract], National Cancer Institute of Milano, Italy. 11th Annual Scientific Meeting, Boston, September 1999.
13. Vashisht A, Studd J, Carey A, Burn P. Fatal septicaemia after fibroid embolisation. Lancet. 1999;354:307-308.
14. Stringer NH, Grant T, Park J, Oldham L. Ovarian failure after uterine artery embolization for treatment of myomas. J Am Assoc Gynecol Laparosc. 2000;7(3):395-400.
15. Stringer NH, DeWhite A, Park J, et al. Laparoscopic myomectomy after failure of uterine artery embolization. J Am Assoc Gynecol Laparosc. 2000;8(4):583-586.
16. Shashoua AR, Stringer NH, Pearlman JB, et al. Ischemic uterine rupture and hysterectomy three months after uterine artery embolization: a case report and review of the literature. J Am Assoc Gynecol Laparosc. 2002;9(2):217-220.
17. Walker W, Green A, Sutton C. Bilateral uterine artery embolisation for myomata: results, complications and failures. Min Invas Ther & Allied Technol. 1999;8(6):449-454.
18. Hutchins FL, Worthington-Kirsch R, Berowitz RP. Selective uterine artery embolization as primary treatment for symptomatic leiomyomata uteri. J Am Assoc Gynecol Laparosc. 1999;6(3):279-284.
19. Ravina JH, Vigneron NC, Aymard A, et al. Pregnancy after embolization of uterine myoma: report of 12 cases. Fertil Steril. 2000;73(6):1241-1243.
20. Stringer NH. Laparoscopic myomectomy in African-American women. J Am Assoc Gynecol Laparosc. 1996;3:375-381.
21. Stringer NH, Levy ES, Kezmoh MP, et al. New closure technique for lateral trocar sites. A report of 80 closures. Surg Endosc. 1995;9:838-840.
22. Stringer NH, Rodino KL, Edwards M, et al. On-Q system for managing trocar site pain after operative laparoscopy. J Am Assoc Gynecol Laparosc. 2000;7(4):552-555.
23. Nikolic B, Spies JB, Abbara S, Goodwin, SC. Ovarian artery supply of the uterine fibroids as a cause of treatment failure after uterine artery embolization: a case report. J Vasc Interv Radiol. 1999;10:1167-1170.
24. Farrer-Brown G, Beilby JO, Tarbit MH. The blood supply of the uterus. J Obstet Gynaecol Br Commonwealth. 1970;77: 673-680.
25. Jha RC, Ascher SM, Imaoka I, et al. Symptomatic fibroleiomyomata: MR imaging of the uterus before and after uterine artery uterine arterial embolization. Radiol. 2000; 217(1):228-235.
26. Speroff L, Glass RH, Kass NG. Clinical Gynecologic Endocrinology and Infertility. Baltimore: Williams & Wilkins; 1989.
27. Sherman BM, Korenman SG. Hormonal characteristics of the human menstrual cycle throughout reproductive life. J Clin Invest. 1975;55:699.
28. Spies JB, Scialli A, Jha RC, et al. Initial results from uterine fibroid embolization for symptomatic leiomyomata. J Vasc Interv Radiol. 1999;10:1149-1157.

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