Following a recent review which surveyed global access to uterine artery embolization (UAE) across each continent, Interventional News speaks to multiple clinicians who trace misunderstandings, miscommunication and multidisciplinary dysfunction at the core of symptomatic fibroid care.
Uterine fibroids are a common benign tumour affecting between 40–60% of women of reproductive age. Although many fibroids remain asymptomatic, a significant portion of women experience heavy bleeding, pain and/or infertility. Despite hysterectomy being the long-standing definitive treatment for symptomatic fibroids—or myomectomy for women wishing to preserve fertility—over the last two decades UAE has established its role as a minimally invasive alternative based on findings from the EMMY and FEMME randomised controlled trials, among others.
Despite level-one evidence, access to and awareness of UAE remains limited with varying severity depending on geographic, socioeconomic and healthcare system factors. This was the broad finding of the global UAE review published in CardioVascular and Interventional Radiology (CVIR) Endovascular for which interventional radiologist Sara Lojo-Lendoiro (Hospital Arquitecto Marcide, Ferrol, Spain) was a study investigator.
“The challenge today is less scientific than cultural and organisational,” Lojo-Lendoiro tells Interventional News. “The question is no longer whether UAE works, we answered that years ago. The question today is whether every woman who could benefit from UAE is actually given the opportunity to consider it.”
Who benefits from UAE?
Defining which patients would benefit from UAE relies heavily on shared decision making. Lojo-Lendoiro describes that these are often patients “who are looking for a treatment that is effective but also minimally disruptive to their lives”. She states that these are women with demanding jobs, caregiving responsibilities, multiple fibroids, previous surgeries, or significant comorbidities who may particularly appreciate avoiding a major operation and prolonged recovery.
Recovery time following UAE is approximately four to five days, but most patients return home the same day or the following morning. “From a patient experience point of view, that’s a huge difference,” highlights Dania Daye, associate professor of radiology and physician-scientist at University of Wisconsin School of Medicine and Public Health (Madison, USA), sharing her clinical experience treating fibroids with UAE.
Although procedurally UAE appears favourable, treatment effect and symptom relief are factors which significantly influence patient preference. In women who experience heavy menstrual bleeding (HMB) as a main symptom of fibroids, Daye explains that the effects of UAE can be relatively quick, although hysterectomy instates an immediate effect.
Fertility fears
Aside from shrinking fibroids, UAE offers women the possibility of symptom relief without resorting to irreversible treatment—a consideration which may matter greatly to women seeking fertility preservation. Lojo-Lendoiro describes that, historically, many physicians adopted a cautious approach because long-term reproductive outcomes after UAE were not as well understood as they are today. Although caution is “justified”, she warns that “caution can sometimes evolve into paternalism; for clinicians, fertility concerns create uncertainty and, in patients, they often create fear”.
“There is a difference between saying: ‘We don’t know everything’ and ‘We don’t know everything, therefore you shouldn’t have access to this treatment’. Younger women deserve honest conversations about uncertainty, not automatic exclusion from treatment options,” Lojo-Lendoiro notes. “The recent data—including long-term follow-up studies—increasingly suggest that many younger women can achieve excellent fertility outcomes after UAE. The goal should not be to convince every young woman to choose UAE. The goal should be to trust women with the information necessary to decide for themselves.”
The misinterpretation that UAE is contra-indicated in women wishing to become pregnant is compounded by the fact that chronic disease in women has a natural recurrence rate, explains Warren Clements (The Alfred Hospital, Melbourne, Australia), principal investigator of the CVIR Endovascular global UAE review.
“There is a 20% chance of a woman needing a repeat treatment on their uterus after UAE, and this recurrence rate has been coopted as a reason to suggest the treatment’s ‘failure’,” Clements says. “In reality, UAE is a uterus-preserving treatment that exists on a continuum between conservative management and surgery.” Yet, women are still not being made aware of their options, adds Clements, pointing to the median age of his patients being 45 years as an indicator of continuing reluctance to refer younger women for UAE.
“Whenever a treatment challenges traditional ownership of a disease pathway, controversy tends to persist longer than the evidence would justify” – Sara Lojo-Lendoiro
‘Outdated’ clinical understanding
Results from the CVIR Endovascular review demonstrated that, despite broad availability of UAE in several geographies, the procedure is rarely employed. Alongside misapprehensions of UAE and fertility, Clements believes that the treatment’s intrinsic association with IR—and the lack of IR’s recognition as an independent specialty—has meant access to mandatory clinical services is lacking, such as outpatient clinics, admitting rights, and a team of junior staff.
“Without these, it is very difficult to offer a holistic and rounded clinical service, and we know that simply offering a technical service is not enough,” says Clements. “Patients and other doctors are then left not knowing what services are available to them.”
“Non-IR doctors don’t keep abreast of the most recent evidence and clinical practice guidelines that govern UAE,” Clements states, underscoring that only interventional radiologists know the indications and suitability of UAE and can council a patient as to treatment appropriateness.
Clements continues: “It is not feasible for a doctor of another specialty to fully understand UAE, and as such it is rarely offered, or glossed over as a non-viable treatment approach. Many non-IR doctors haven’t read IR literature and make decisions based on data from over 20 years ago.
“Doctors aren’t super-human, they can’t know everything. If a woman is being considered for surgery, then she should equally be given an opportunity to consider UAE, and the only way this can be achieved is through consultation with an interventional radiologist. This would then allow for access to unbiased information and true informed consent regardless of whether she chooses UAE or surgery.”
Gynaecological “gatekeeping” and treatment pathway issues
Among other barriers to access, speakers shared that women are often not able to be directly connected with an interventional radiologist, which they posit is an issue that starts at the primary care level.
Clements explains that, in the case of HMB, there is a “misconception” that all women must first see a gynaecologist to access second line care. He acknowledges that general practitioners (GPs) play an important role in the investigation of the early causes of HMB, however notes that when a diagnosis is made and the symptoms are refractory to simple treatments, women should be offered the opportunity to discuss UAE with an interventional radiologist and concurrently see a gynaecologist to discuss surgery.
Using data from their global review, Clements highlights a trend which shows women are “almost exclusively” sent to a gynaecologist first. “Unfortunately, this creates a gatekeeping role and only very select patients make it to an interventional radiologist,” he adds. “This means many women miss out on a specialist opinion, advice, and an opportunity to consider a less invasive treatment approach.”
To this Lojo-Lendoiro agrees, stating that often it is the first specialist a woman sees that largely determines the treatment she is offered. “That fact should make us uncomfortable,” she says, adding that UAE sits at the intersection between specialties which causes referral difficulties.
“Whenever a treatment challenges traditional ownership of a disease pathway, controversy tends to persist longer than the evidence would justify,” states Lojo-Lendoiro. “Ultimately, I don’t think the debate is really about UAE anymore. I think it is about whether we are willing to move towards genuinely multidisciplinary fibroid care.”
UAE ‘reflective’ of women’s health inequities
In 2025, a cross-sectional study published in the journal JAMA Network found that UAE was underutilised with significant disparities across socioeconomic factors. The study, led by Tarig S Elhakim (Perelman School of Medicine, Philadelphia, USA), utilised the 2016 to 2022 National Inpatient Sample obtained from the US Healthcare Cost and Utilization Project (HCUP).
As corresponding author for this study, Daye details that results showed African American women were less likely to receive UAE compared to other ethnicities. Similarly, Hispanic patients were also less likely to receive a UAE and more likely to receive a hysterectomy or myomectomy. When comparing metropolitan versus non-metropolitan areas, Daye and colleagues found that UAE was more likely to be performed in metropolitan areas, while in rural areas, there are still more hysterectomies and myomectomies—a result that was expected, Daye adds.
“We also saw some interesting trends when we looked at the payers. We are seeing more patients on Medicaid, for example, receive UAE compared hysterectomy, which was something that was very surprising to us,” says Daye. “Overall, that paper taught us that access to UAE is not uniform across the country or different patient groups. We need to do better, and we need to understand why certain populations have more access to procedures and not others.”
Although Lojo-Lendoiro promotes caution when interpreting treatment utilisation patterns as evidence of equity, she believes that “fibroid care often reflects broader social inequities affecting women’s health”, which can “rarely” be assigned a single explanation.
“Race, income, insurance status and geography continue to influence what treatments women receive and when they receive them. The fact that these disparities persist in 2026 should remind us that improving technology is not enough,” Lojo-Lendoiro tells Interventional News.
Guideline inclusion
Currently, UAE is not officially included in many practice guidelines, although grants such as the Society of Interventional Radiology (SIR) Foundation’s Scott C Goodwin Grant for adenomyosis seek to expand clinical knowledge of the procedure.
“The grant reflects national recognition that we simply don’t have enough data to support the evidence base,” says Daye. “Frankly, we need randomised trials. We need larger, gold-standard clinical trials to support inclusion in clinical guidelines. We need to generate the evidence that drives medical decision-making, but right now, we don’t have enough high-quality randomised clinical trial evidence yet.”
To Clements, access and awareness of UAE is multifactorial, but interventional radiologists play an important role in ensuring that current governance supports evidence-based practice. “This means a top-down approach to ensure that UAE is built into all relevant guidelines—government, college, societal, and at a local hospital level,” he states.
Once established, Clements hopes that the guidelines—written by interventional radiologists and supported by major IR societies—will be readily accessible to GPs and other primary care providers who can easily review for advice on a daily basis. “Ideally, interventional radiologists should be available to consult via direct referral and IR outpatient clinics made available for patients,” he adds, to provide a rounded, evidence-based approach to fibroid care.
