Uterine artery embolisation for symptomatic adenomyosis--mid-term results

Factors associated with dysmenorrhoea and menorrhagia improvement in patients with adenomyosis after uterine artery embolisation

BACKGROUND

This study examined the improvement of dysmenorrhoea and menorrhagia after uterine artery embolisation (UAE) in women with symptomatic adenomyosis and identified factors that could predict the improvement of dysmenorrhoea and menorrhagia.

METHODS

This retrospective study included women with adenomyosis who underwent bilateral UAE between December 2014 and December 2016. The percentage of the volume of the absence of contrast enhancement on T1-weighted images was evaluated 5-7 days after UAE. A receiver operating characteristic (ROC) analysis was used to determine a cut-off point and predict the improvement of dysmenorrhoea and menorrhagia.

RESULTS

Forty-eight patients were included. At 24 and 36 months after UAE, the improvement rates for dysmenorrhoea and menorrhagia were 60.4% (29/48) and 85.7% (30/35), and the recurrence rates were 19.4% (7/36) and 9.1% (3/33), respectively. Only the percentage of the volume of the absence of contrast enhancement on T1-weighted images was associated with the improvement of dysmenorrhoea (p = 0.001, OR = 1.051; 95% CI: 1.02-1.08) and menorrhagia (p = 0.006, OR = 1.077; 95% CI: 1.021-1.136). When the cut-off value of the ROC analysis was 73.1%, sensitivity, specificity, positive predictive value, and negative predictive value for the improvement of dysmenorrhoea were 58.6%, 94.7%, 94.4%, and 60%, while they were 58.9%, 80%, 100%, 100%, and 45.5% for the improvement of dysmenorrhoea.

CONCLUSION

Bilateral UAE for symptomatic adenomyosis led to good improvement of dysmenorrhoea and menorrhagia. The percentage of the volume of the absence of contrast enhancement on T1-weighted images of the uterus in postoperative magnetic resonance imaging might be associated with the improvement of dysmenorrhoea and menorrhagia.

Adenomyosis and Abnormal Uterine Bleeding: Review of the Evidence

BACKGROUND

Thomas Cullen described bleeding abnormalities and dysmenorrhea as the "expected" presentations of adenomyomas. Adenomyosis is included within the FIGO classification of structural causes of abnormal uterine bleeding (AUB). Nevertheless, this long-standing association has been questioned by some authors who reported a high incidence of adenomyosis in uteri removed for indications other than AUB or dysmenorrhea. Here, we examine evidence for the link between adenomyosis and AUB.

METHODS

A comprehensive Medline literature review of all publications to October 2023.

RESULTS

Sixty-three articles were identified and included in the review. Despite a large body of studies, the available literature does not provide conclusive evidence of a link between adenomyosis and AUB. This is because of unsuitable study design, or poor characterization of the study population or of the inclusion or exclusion criteria. Additional challenges arise because of the lack of agreed criteria for diagnosing adenomyosis and the often absence of detailed assessment of menstrual blood loss. Adenomyosis often coexists with other conditions that have also been linked to similar symptoms, and many cases of adenomyosis are asymptomatic.

CONCLUSION

Most of the existing literature and studies that addressed treatment outcome of adenomyosis started from the premise that a link between the condition and AUB had been proven. Yet, published information shows that aspects such a relationship is still uncertain. Further research is needed to address the relation between AUB and adenomyosis burden (or subtypes), distribution, and concomitant pathology.

Treatment of adenomyosis, abdominal wall endometriosis and uterine leiomyoma with interventional radiology: A review of current evidences

Interventional radiology shows promises in the field of women's health, particularly in pelvic interventions. This review article discusses the latest advancements in interventional radiology techniques for pelvic conditions affecting women including adenomyosis, abdominal wall endometriosis and uterine leiomyoma. Extraperitoneal endometriosis involving the abdominal wall may be treated by percutaneous thermal ablation, such as cryoablation, whereas uterine leiomyoma and adenomyosis can be managed either using percutaneous thermal ablation or using uterine artery embolization. Continued research and development in interventional radiology will further enhance the minimally-invasive interventions available for women's health, improving outcomes and quality of life for this large patient population of women.

Asherman Syndrome after Uterine Artery Embolization: A Cohort Study about Surgery Management and Fertility Outcomes

STUDY OBJECTIVE

To study the severity of intrauterine adhesions (IUA) after uterine arterial embolization and to evaluate fertility, pregnancy, and obstetrical outcomes after hysteroscopic treatment.

DESIGN

Retrospective cohort.

SETTING

French University Hospital.

PATIENTS

Thirty-three patients under the age of 40 years who were treated by uterine artery embolization with nonabsorbable microparticles between 2010 and 2020 for symptomatic fibroids or adenomyosis, or postpartum hemorrhage.

INTERVENTIONS

All patients had a diagnosis of IUA after embolization. All patients desired future fertility. IUA was treated with operative hysteroscopy.

MEASUREMENTS AND MAIN RESULTS

Severity of IUA, number of operative hysteroscopies performed to obtain a normal cavity shape, pregnancy rate, and obstetrical outcomes. Of our 33 patients, 81.8% had severe IUA (state IV et V according to the European Society of Gynecological Endoscopy or state III according to the American fertility society classification). To restore fertility potential, an average of 3.4 operative hysteroscopies had to be performed [CI 95% (2.56-4.16)]. We reported a very low rate of pregnancy (8/33, 24%). Obstetrical outcomes reported are 50% of premature birth and 62.5% of delivery hemorrhage partly due to 37.5% of placenta accreta. We also reported 2 neonatal deaths.

CONCLUSION

IUA after uterine embolization is severe, and more difficult to treat than other synechiae, probably related to endometrial necrosis. Pregnancy and obstetrical outcomes have shown a low pregnancy rate, an increased risk of preterm delivery, a high risk of placental disorders, and very severe postpartum hemorrhage. Those results have to alert gynecologists and radiologists to the use of uterine arterial embolization in women who desire future fertility.

Risk of Recurrence and Reintervention After Uterine-Sparing Interventions for Symptomatic Adenomyosis: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the risk of recurrence and reintervention after uterine-sparing treatment options for symptomatic adenomyosis, including adenomyomectomy, uterine artery embolization (UAE), and image-guided thermal ablation.

DATA SOURCES

We searched electronic databases such as Web of Science, MEDLINE, Cochrane Library, EMBASE, ClinicalTrials.gov, and Google Scholar from January 2000 to January 2022. The search was conducted using the following search terms: "adenomyosis," "recurrence," "reintervention," "relapse," and "recur."

METHODS OF STUDY SELECTION

All studies that described the risk of recurrence or reintervention after uterine-sparing interventions for symptomatic adenomyosis were reviewed and screened according to the eligibility criteria. Recurrence was defined as the reappearance of symptoms (painful menses or heavy menstrual bleeding) after significant or complete remission, or the reappearance of adenomyotic lesions confirmed by ultrasonography or magnetic resonance imaging.

TABULATION, INTEGRATION, AND RESULTS

The outcome measures were presented as the frequency with percentage and pooled with 95% CI. A total of 42 studies (single-arm retrospective and prospective studies) that represented 5,877 patients were included. The recurrence rates after adenomyomectomy, UAE, and image-guided thermal ablation were 12.6% (95% CI 8.9-16.4%), 29.5% (95% CI 17.4-41.5%), and 10.0% (95% CI 5.6-14.4%), respectively. The reintervention rates were 2.6% (95% CI 0.9-4.3%), 12.8% (95% CI 7.2-18.4%), and 8.2% (95% CI 4.6-11.9%) after adenomyomectomy, UAE, and image-guided thermal ablation, respectively. Subgroup analysis and sensitivity analysis were performed, and the heterogeneity was reduced in several analyses.

CONCLUSION

Uterine-sparing techniques were successful in treating adenomyosis with low reintervention rates. Uterine artery embolization had higher recurrence and reintervention rates than other techniques; however, patients treated with UAE had larger uteri and larger adenomyosis, indicating that selection bias may influence these results. More randomized controlled trials with a larger population are needed in the future.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021261289.

An update on uterine artery embolization for uterine leiomyomata and adenomyosis of the uterus

Uterine artery embolization (UAE) is an established technique to treat benign diseases of the uterus such as uterine leiomyomata (fibroids) and adenomyosis. This article reviews the use of UAE in these conditions and summarizes the evidence regarding safety and efficacy of the technique based on the current literature.

Efficacy of patient-controlled hydromorphone analgesia in those undergoing uterine fibroid artery embolization via the right radial artery

Objective

To evaluate the efficacy and safety of patient-controlled analgesia (PCA) with hydromorphone as perioperative analgesia during uterine artery embolization (UAE) via the right radial artery.

Patients and methods

A total of 33 patients with uterine fibroids, who underwent UAE at the authors' hospital between June 2021 and March 2022, were selected. Hydromorphone (10 ​mg) was dispensed into a 100 ​ml PCA pump with normal saline. Pump administration was initiated 15 ​min before the start of the procedure, and the intraoperative dose was adjusted according to patient pain level. A numerical rating scale was used to evaluate pain immediately after embolization, 5 ​min after embolization, at the end of the procedure, and 6, 12, 24, 48, and 72 ​h after the procedure. Side effects were also observed.

Results

Thirty-three patients underwent uterine artery embolization via the right radial artery. Patient pain was well controlled at all time points surveyed, and patients reported satisfaction with analgesia. The median length of hospital stay was 5 days. There were 7 cases of adverse reactions, but no serious side effects were observed.

Conclusion

Patients reported positive experiences with arterial embolization of uterine fibroids via the right radial artery. Hydromorphone PCA effectively controlled pain. The PCA pump is easy to operate, has a low incidence of adverse reactions, and offers economic benefits at the patient and institutional levels.

Long-term durability of uterine artery embolisation for treatment of symptomatic adenomyosis

BACKGROUND

Failing conservative therapies, uterine artery embolisation (UAE) has been proposed as a uterine-sparing option for treatment of symptomatic adenomyosis. UAE appears effective at short-term; however long-term durability is less well established.

AIMS

To evaluate the long-term clinical efficacy of UAE for treatment of adenomyosis.

MATERIALS AND METHODS

One hundred and four women with initial clinical success following UAE for adenomyosis (results previously published) were further followed with a two-part online survey. Part one inquired about menopause, symptom recurrence, need for further intervention and overall satisfaction. Part two comprised the Uterine Fibroid Symptom and health-related Quality of Life (UFS-QOL) questionnaire. Maintenance of clinical success was defined as remaining 'happy' or 'very happy' with overall outcome, no recurrence of symptoms, or need for further intervention.

RESULTS

Of those women with initial success, 91/104 (88%) participated in this long-term study at mean 52 months following UAE. Maintenance of clinical success was demonstrated in 82/91 (90%) women. For the remaining 9/91 (10%) women, mean time to failure was 31 months. There were 53/91 (58%) women who reached menopause at mean age of 51.5 years, occurring at mean 30 months post-UAE. UFS-QOL demonstrated significant decrease in symptom severity from 58.9 to 20.0 (P < 0.001); and significant increase in QOL from 40.3 to 86.3 (P < 0.001).

CONCLUSIONS

Long-term durability of UAE for treatment of adenomyosis was demonstrated, with cumulative success rate of 80% at mean 52 months. UAE did not appear to bring forward menopause. UAE should be considered as an alternative to hysterectomy to treat adenomyosis.

Use of dienogest in endometriosis: a narrative literature review and expert commentary

Objective: Endometriosis affects up to 10% of women of reproductive age, and the main goal of treatment is to relieve symptoms. Progestins have been the mainstay of endometriosis suppression, of which dienogest has become an important option in many parts of the world. This is an expert literature review, with recommendations on the use of dienogest in the context of various clinical considerations when treating endometriosis.Methods: A search of PubMed was conducted for papers published between 2007 and 2019 on the use of dienogest in endometriosis. Experts reviewed these and included those they considered most relevant in clinical practice, according to their own clinical experience.Results: Evidence regarding the long-term use (>15 months) of dienogest for the management of endometriosis is presented, with experts concluding that the efficacy of dienogest should be assessed primarily on its impact on pain and quality of life. Fertility preservation, the option to avoid or delay surgery, and managing bleeding irregularities that can occur with this treatment are also considered. Counseling women on potential bleeding risks before starting treatment may be helpful, and evidence suggests that few women discontinue treatment for this reason, with the benefits of treatment outweighing any impact of bleeding irregularities.Conclusions: Overall, the evidence demonstrates that dienogest offers an effective and tolerable alternative or adjunct to surgery and provides many advantages over combined hormonal contraceptives for the treatment of endometriosis. It is important that treatment guidelines are followed and care is tailored to the woman's individual needs and desires.

Asherman syndrome in adenomyosis treated with uterine artery embolization: incidence predictive factors

PURPOSE

To investigate Asherman syndrome (AS) related to potential factors during uterine artery embolization (UAE) treatment of adenomyosis.

MATERIALS AND METHODS

This is a retrospective analysis of 195 women with adenomyosis who underwent UAE treatment from 2009 to 2016. All preoperative and intraoperative risk-related potential factors of AS were recorded. And AS events were carefully monitored during follow-up (range, 0-15 months). Potential risk-related factors of AS events were determined via univariate and multivariate logistic regression analyses.

RESULTS

The rate of AS events after UAE for adenomyosis was 12.82% (25/195). The univariate and multivariate analyses revealed the association of low vascularity with a significant risk for AS (P = 0.019).

CONCLUSION

Patients with low vascularity of adenomyosis at the time of UAE are more likely to have AS. And adenomyosis patients with low vascularity should be carefully selected to undergo UAE treatment.

Predisposing factors for predicting the therapeutic response of adenomyosis after uterine artery embolization: serum CA125 levels and accompanying endometriosis

PURPOSE

We aimed to identify predisposing factors that could help predict the therapeutic response of adenomyosis after uterine artery embolization (UAE).

METHODS

This was a retrospective, single-center study of patients admitted to the hospital for adenomyosis between 2013 and 2015. Sixty-eight patients with adenomyosis who underwent UAE with tris-acryl gelatin microspheres were divided into two groups based on their therapeutic response (complete or incomplete necrosis of lesions), and pre- and postprocedural pelvic magnetic resonance imaging (MRI) data. Patients were followed up for 12 months after UAE. Improvements in dysmenorrhea and menorrhagia were evaluated based on the symptom relief criteria. Improvement rates in both groups were analyzed and compared. Multivariate logistic regression analysis was used to identify the predisposing factors from retrospectively gathered baseline data that might affect the therapeutic response, including MRI features, clinical symptoms, biochemical index, and accompanying diseases of adenomyosis. Then, a prognostic model was established, and the receiver operating characteristic (ROC) curve of identified factors was drawn to determine their predictive value.

RESULTS

Following UAE, 46 patients (67.6%) showed complete necrosis, while 22 patients (32.4%) showed incomplete necrosis. At 12-month follow-up, dysmenorrhea symptom improvement was seen in 94.7% of complete necrosis and 50% of incomplete necrosis group (P < 0.001); menorrhagia symptom improvement was seen in 96.2% of complete necrosis and 57.1% of incomplete necrosis groups (P = 0.004). Multivariate logistic regression analysis determined serum cancer antigen 125 (CA125) levels (odds ratio [OR], 1.006; 95% confidence interval [CI], 1.002-1.010; P = 0.005) and accompanying endometriosis (OR, 6.869; 95% CI, 1.881-25.016; P = 0.004) as predisposing factors. The areas under the ROC curve of CA125, endometriosis, and these two indicators combined were 0.785, 0.708, and 0.845, which corresponded to sensitivities of 95.5%, 66.7%, and 68.2% and specificities of 52.2%, 80.0%, and 87.0% at optimal cutoff values, respectively.

CONCLUSION

Symptom relief of dysmenorrhea and menorrhagia for patients with complete necrosis was significantly better than that for patients with incomplete necrosis. Serum CA125 levels and accompanying endometriosis can effectively distinguish complete necrosis from incomplete necrosis.

Uterine Artery Embolization Versus Hysterectomy in the Treatment of Symptomatic Adenomyosis: Protocol for the Randomized QUESTA Trial

Background

Adenomyosis is a benign uterine disease characterized by invasion of endometrium into the myometrium resulting in heavy menstrual bleeding and pain (dysmenorrhea). Hysterectomy is established as the final treatment option when conservative treatment fails. Uterine artery embolization (UAE) in patients with symptomatic adenomyosis has demonstrated to reduce symptoms and improve quality of life. However, randomized controlled trials are lacking.

Objective

With this study, we aim to evaluate the impact of UAE on Health-Related Quality of Life (HRQOL) in a randomized comparison to hysterectomy in patients with symptomatic adenomyosis.

Methods

This is a multicenter non-blinded randomized controlled trial comparing UAE and hysterectomy. Eligible patients are symptomatic premenopausal women without the desire to conceive and who have symptomatic magnetic resonance imaging (MRI)–confirmed pure adenomyosis or dominant adenomyosis accompanied by fibroids. After obtaining informed consent, patients will be randomly allocated to treatment in a 2:1 UAE versus hysterectomy ratio. The primary objective is HRQOL at 6 months following the assigned intervention. Secondary outcomes are technical results, pain management, clinical outcomes, HRQOL, and cost effectiveness during 2 years of follow-up. In addition, transvaginal ultrasound (TVUS) and MRI will be performed at regular intervals after UAE.

Results

Patient enrollment started November 2015. The follow-up period will be completed two years after inclusion of the last patient. At the time of submission of this article, data cleaning and analyses have not yet started.

Conclusions

This trial will provide insight for caretakers and future patients about the effect of UAE compared to the gold standard hysterectomy in the treatment of symptomatic adenomyosis and is therefore expected to improve patients’ wellbeing and quality of life.

Trial Registration

Netherlands Trial Register NTR5615; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5615 (Archived by WebCite at http://www.webcitation.org/6xZRyXeIF)

Minimally invasive treatment of adenomyosis

The aim of the present review is to give a comprehensive overview of minimal invasive treatment options and suggest a minimally invasive approach in women with adenomyosis (AD). A review of relevant literature on medical and surgical treatment options is performed. Surgical options include endometrial ablation, hysteroscopic endometrial and adenomyoma resection, laparoscopic resection of AD, high-intensity focused ultrasonography (HIFU), and uterine artery embolization (UAE). This review summarizes treatment strategies for the management of AD and highlights the present lack of knowledge, which makes suggestions of evidence-based treatment difficult.

Uterine Artery Embolization for the Treatment of Adenomyosis: A Systematic Review and Meta-Analysis

The effect of uterine artery embolization (UAE) on symptomatic adenomyosis was evaluated in a systematic review and meta-analysis. Four groups were evaluated: short-term (< 12 months) pure adenomyosis, short-term adenomyosis with fibroids (combined adenomyosis), long-term (> 12 months) pure adenomyosis, and long-term combined adenomyosis. Improvement of symptoms occurred in 83.1% (872/1,049) of patients. Reported symptom reduction was 4.8% greater in the short-term combined group (P = .169) and 11.4% greater in the long-term combined group (P = .003). Uterine volume was reduced in all patients at 3 months. The effects of UAE on symptom improvement and uterine volume reduction in patients with adenomyosis are encouraging.

Uterine-Sparing Laparoscopic Pelvic Plexus Ablation, Uterine Artery Occlusion, and Partial Adenomyomectomy for Adenomyosis

STUDY OBJECTIVE

To evaluate safety, feasibility, and long-term clinical effects of adding laparoscopic pelvic plexus ablation to uterine-sparing procedures (uterine artery occlusion and partial adenomyomectomy) for adenomyosis.

DESIGN

A prospective controlled study (Canadian Task Force classification II-1).

SETTING

A teaching hospital.

PATIENTS

A total of 112 patients with symptomatic adenomyosis were eligible for uterine-sparing laparoscopy.

INTERVENTIONS

Laparoscopic pelvic plexus ablation, uterine artery occlusion, and partial adenomyomectomy.

MEASUREMENTS AND MAIN RESULTS

After the exclusion of patients with malignant tumors or those lost to follow-up, 102 women underwent laparoscopic uterine artery occlusion and partial adenomyomectomy; 50 of these patients also had laparoscopic uterine pelvic plexus ablation (group A) with the remaining 52 patients serving as the control group (group B). Other than operative time (107.0 ± 15.4 vs 98.9 ± 20.2 minutes, p = .02), there were no statistical differences regarding other operative parameters between groups A and B. Relief of severe dysmenorrhea (Visual Analogue Scale score ≥ 7) at 36 months was higher in group A than in group B (100% vs 76.9%, p < .01). No patient suffered constipation or uroschesis in either group.

CONCLUSION

Adding laparoscopic uterine pelvic plexus ablation to laparoscopic uterine artery occlusion and partial adenomyomectomy was more effective in relieving dysmenorrhea.

Cesarean Scar Pregnancy: Comparing the Efficacy and Tolerability of Treatment with High-Intensity Focused Ultrasound and Uterine Artery Embolization

The aim of this study was to investigate the clinical efficacy of high-intensity focused ultrasound (HIFU) for the treatment of a cesarean scar pregnancy compared with uterine artery embolization (UAE) and intra-arterial methotrexate infusion combined with uterine curettage. In this retrospective cohort study, 31 patients were treated with HIFU (HIFU group), and 45 patients were treated with UAE (UAE group). We compared the treatment and recovery of the patients, including follow-up. After UAE treatment, serum levels of the β subunit of human chorionic gonadotropin declined significantly on the first day, and the residual lesions disappeared in 3-17 wk. One patient underwent hysterectomy; intrauterine adhesions were found by hysteroscopic examination after 6 mo in 2 patients, whose menstrual function did not return to normal. The remainder of the 42 patients recovered normal menstrual functioning during the 3- to 18-wk follow-up. In the patients who underwent HIFU treatment, serum β-HCG levels did not decline rapidly; serum β-HCG levels increased in many patients and then declined to normal steadily within 2-12 wk. Lesions detached in 3-14 wk in all patients, and menstrual functioning was recovered in 3-9 wk without uterine curettage. Compared with the UAE group, the HIFU group had less pain and fewer complications; the patients in the HIFU group were not hospitalized or anesthetized and had lower costs. HIFU is an efficient, tolerable and non-invasive treatment.

Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases

Purpose

To study the therapeutic effects of uterine artery embolization (UAE) on adenomyosis and to investigate the association between uterine blood supply and artery embolization treatment outcomes.

Methods

Using digital subtraction angiography (DSA) imaging data, we retrospectively evaluated the vascular features of 252 adenomyosis patients treated with UAE. The cases were classified based on the equality of uterine blood supply (equal and unequal subgroups) and the degree of vascularity at the adenomyosis lesion site (hypervascular, isovascular and hypovascular subgroups). Patients were followed-up for 5 years after UAE. Improvements in dysmenorrhea and menorrhagia were evaluated based on the relief of the patients’ symptoms. The improvement rates among the different subgroups were analyzed and compared.

Results

The improvement rates of dysmenorrhea and menorrhagia were 74.0% and 70.9%, respectively, at the short-term (12-month) follow-up and 70.4% and 68.8%, respectively, at the long-term (5-year) follow-up. No statistically significant differences were observed in the improvement rates for dysmenorrhea or menorrhagia between the equal and unequal blood supply subgroups at either the short- or long-term follow-up. The improvement rates for dysmenorrhea among the hypervascular, isovascular and hypovascular subgroups were 86.5%, 71.8% and 58.8%, respectively, at the short-term follow-up (p = 0.002) and 83.6%, 67.3% and 52.8%, respectively, at the long-term follow-up (p = 0.005). The improvement rates for menorrhagia in the hypervascular, isovascular and hypovascular subgroups were 81.0%, 68.3% and 60.7%, respectively, at the short-term follow-up (p = 0.024) and 79.4%, 61.4% and 62.2%, respectively, at the long-term follow-up (p = 0.052).

Conclusion

UAE is effective in treating patients with adenomyosis in both the short and long term. The outcomes of patients with adenomyosis were significantly correlated with lesion vascularity.

Laparoscopic Radiofrequency Thermal Ablation for Uterine Adenomyosis

BACKGROUND AND OBJECTIVES

Symptomatic uterine adenomyosis, unresponsive to medical therapy, is a challenging condition for patients who desire to preserve their uterus. This study was an evaluation of the feasibility and efficacy of laparoscopic radiofrequency thermal ablation of symptomatic nodular uterine adenomyosis.

METHODS

Fifteen women with symptomatic nodular adenomyosis, who had no plans for pregnancy but declined hysterectomy, underwent radiofrequency thermal ablation. Ultrasonography was performed at baseline and at postoperative follow-ups at 3, 6, 9, and 12 months. The impact of uterine adenomyosis-related symptoms was assessed according to the visual analog scale.

RESULTS

The median number of nodular lesions treated per patient was 1 (range, 1-2). The median baseline volume of the adenomyosis area was 60 cm(3) (range, 18-128). The median reduction in volume was 32, 49.4, 59.6, and 65.4% at 3, 6, 9, and 12 months, respectively. A significant progressive improvement in the symptoms score was observed at the 4 follow-ups.

CONCLUSION

In this study, laparoscopic radiofrequency thermal ablation reduced uterine adenomyosis-related symptoms and volume, with significant relief of symptoms.

Uterine Artery Embolization for Adenomyosis: Percentage of Necrosis Predicts Midterm Clinical Recurrence

PURPOSE

To evaluate the effect of degree of necrosis after uterine artery embolization (UAE) on symptom recurrence at midterm clinical follow-up in patients with adenomyosis.

MATERIALS AND METHODS

Women (N = 50) who underwent UAE for symptomatic adenomyosis were retrospectively analyzed. All patients underwent contrast-enhanced magnetic resonance (MR) imaging at baseline and 3 months after UAE and were followed clinically for at least 18 months. The type of adenomyosis was classified as focal or diffuse. The uterine volume and the percentage of necrosis after embolization were measured three-dimensionally on MR imaging. The percentage of the necrosis cutoff point for predicting recurrence was estimated. Patients were divided into 2 groups according to the cutoff point. The rate of recurrence was compared between groups, and risk factors for recurrence were identified.

RESULTS

During the follow-up period (range, 18-48 mo), symptom recurrence occurred in 12 of 50 patients. A necrosis cutoff point of 34.3% was calculated to predict recurrence (area under the curve = 0.721; 95% confidence interval [CI] = 0.577-0.839; P = .004). Patients with < 34.3% necrosis (group A, n = 12) were at a significantly higher risk of recurrence than patients with > 34.3% necrosis (group B, n = 38; hazard ratio = 7.0; 95% CI = 2.2, 22.4; P = .001). Initial uterine volume and type of adenomyosis were not associated with recurrence.

CONCLUSIONS

The percentage of necrosis in patients with adenomyosis after UAE may predict symptom recurrence at midterm follow-up. The cutoff percentage of necrosis required to predict symptom recurrence was 34.3% in this study.

Clinical Predictors of Long-term Success in Ultrasound-guided High-intensity Focused Ultrasound Ablation Treatment for Adenomyosis: A Retrospective Study

The long-term outcomes of ultrasound-guided high-intensity focused ultrasound (USgHIFU) ablation treatment for adenomyosis and the relevant factors affecting the durability of symptom relief were assessed in this study.A total of 230 women with adenomyosis who were treated with USgHIFU ablation between January 2007 and December 2013 were retrospectively analyzed. The contrast-enhanced ultrasonography (CEUS) was performed immediately after the treatment to evaluate the ablation effect, and the nonperfused volume (NPV) ratio was then calculated. Regular follow-up was conducted and the visual analog scale (VAS) score was used to assess the changes in dysmenorrhea. The effect of treatment was evaluated after an average follow-up length of 3 months and the factors affecting clinical success and symptom relapse were identified.Of the 230 treated patients, 208 (90.4%) were followed up regularly, with a median follow-up length of 40 months (range, 18-94 months). Mean value of the NPV ratio calculated immediately after the treatment was 57.4 ± 24.4%. Varying degrees of symptomatic relief of dysmenorrhea based on the VAS scores were observed in 173 (83.2%) patients and 71.0% of the patients were asymptomatic during follow-up. Women with higher NPV ratio (OR = 0.964, 95% CI = 0.947-0.982, P = 0.000) and older age (OR = 0.342, 95% CI = 0.143-0.819, P = 0.016) were more likely to achieve clinical success. Dysmenorrhea recurred in 45 (26%) out of 173 cases; the median recurrence time was 12 months after treatment. The lower BMI (OR = 1.221, 95% CI = 1.079-1.381, P = 0.001) and the higher acoustic power (OR = 0.992, 95% CI = 0.986-0.998, P = 0.007) were associated with less risk of relapse. Twelve of the 14 patients who were retreated by USgHIFU ablation after experiencing dysmenorrhea recurrence achieved clinical success.USgHIFU ablation is an effective uterus-conserving treatment for symptomatic adenomyosis with an acceptable long-term success rate. Higher chance of clinical success can be achieved in patients with larger NPV ratio and older age, whereas higher BMI and lower acoustic power may result in a higher chance of recurrence. These factors are helpful in selecting suitable patients for USgHIFU and in predicting the durability of symptom relief.

The evaluation of uterine artery embolization as a nonsurgical treatment option for adenomyosis

OBJECTIVE

To evaluate the safety and efficacy of uterine artery embolization (UAE) for the treatment of adenomyosis.

METHODS

A prospective study was performed at Yuhuangding Hospital, China, between January 2012 and December 2013, enrolling premenopausal patients diagnosed with adenomyosis. All patients were treated with bilateral UAE using 500-700-μm tris-acryl gelatin microspheres. At baseline, and 3, 6, and 12months after UAE, magnetic resonance imaging was used to assess uterine volume and patient-assessed improvements in dysmenorrhea were recorded. Any complications and adverse events were reported.

RESULTS

In total, 117 patients with adenomyosis were enrolled. The bilateral UAE procedure was successful in 115 (98.3%) patients, who were able to return to normal activity within 1week of treatment. At 12-month follow-up, a median 51.0% reduction in uterine volume from baseline was recorded (P=0.005). Marked and moderate improvements in dysmenorrhea symptoms were reported by 64 (55.7%) and 31 (27.0%) participants, respectively. Pelvic pain of varying intensity was reported by 112 (97.4%) patients but was managed with analgesia. Persistent amenorrhea was experienced by 2 (1.7%) individuals following treatment. Patients did not encounter any new gynecologic or general complications following UAE treatment.

CONCLUSION

UAE could be considered as a minimally invasive treatment option for patients with adenomyosis. Further research to compare the efficacy and safety of UAE with conventional hysterectomy is warranted.

Efficacy of laparoscopic adenomyomectomy using double-flap method for diffuse uterine adenomyosis

Background

Adenomyomectomy has recently been considered the priority option for the treatment of adenomyosis, however, the surgical efficacy and modes are still debated. We aimed to evaluate the efficacy of laparoscopic adenomyomectomy using a double-flap method for the treatment of uterine diffuse adenomyosis when compared with conventional laparoscopic adenomyomectomy.

Methods

Laparoscopic adenomyomectomy using the conventional method (group A, n = 48) and the double-flap method (group B, n = 46) to treat diffuse uterine adenomyosis, respectively. Visual analog scale (VAS), menstrual amount, serum CA125 levels, and uterine volume were comparatively analyzed in both groups.

Results

The VAS scores, menstrual amount, serum CA125 levels, and uterine volume at 12 or 24 months after surgery significantly reduced in group B than in group A (P < 0.05); these parameters were statistically decreased in both groups after surgery compared with those obtained before surgery (P < 0.001). Moreover, serum CA125 levels and uterine volume at six months of follow up were significantly lower in group B than in group A (P < 0.01). In addition, blood loss during surgery was similar in groups A and B (P > 0.05), although the operative time was significantly longer in group B than that in group A (P < 0.05).

Conclusions

Laparoscopic adenomyomectomy using the double-flap method may be an effective technique to treat uterine diffuse adenomyosis.

An unexpected diagnosis of adenomyosis in the subfertile woman

A 38-year-old nulliparous female presented to an assisted conception clinic with subfertility and a long-standing history of dysmenorrhoea. Transvaginal ultrasound revealed two lesions in the body of the uterus, which were presumed to be fibroids. A decision was made to remove these lesions prior to attempting in vitro fertilisation (IVF). However, on laparotomy, deeply penetrating adenomyosis was discovered, resulting in an unexpected hysterectomy and significant blood loss. Based on our experience, we highlight the importance of suspecting a diagnosis of adenomyosis preoperatively and the methods by which this diagnosis can be made, in order to avoid potential unforeseen outcomes as described in this case. We discuss conservative management options for this condition, particularly in women wishing to preserve fertility.

National German Guideline (S2k): Guideline for the Diagnosis and Treatment of Endometriosis: Long Version - AWMF Registry No. 015-045

In this guideline, recommendations and standards for optimum diagnosis and treatment of endometriosis are presented. They are based on the analysis of the available scientific evidence as published in prospective randomized and retrospective studies as well as in systematic reviews. The guideline working group consisted of experts from Austria, Germany, Switzerland, and the Czech Republic.

A matched cohort study comparing the outcome of intrauterine adhesiolysis for Asherman's syndrome after uterine artery embolization or surgical trauma

STUDY OBJECTIVE

To compare the outcome of hysteroscopic adhesiolysis in women who had Asherman's syndrome after uterine artery embolization (UAE) with those who had Asherman's syndrome caused by surgical trauma.

DESIGN

A retrospective cohort study matched for age and intrauterine adhesion score (Canadian Task Force classification II-2).

SETTING

A tertiary hysteroscopic center in a teaching hospital.

PATIENTS

Nineteen women with Asherman's syndrome after UAE and 57 women with Asherman's syndrome caused by surgical trauma.

INTERVENTIONS

Hysteroscopic adhesiolysis was followed by a second-look hysteroscopy 1 month later. The scoring system proposed by the American Fertility Society was used to evaluate intrauterine adhesion during hysteroscopy.

MEASUREMENTS AND MAIN RESULTS

In the UAE group, only 42.1% of women experienced improvement in menstruation defined as a subjective increase in menstrual flow after surgery, which was significantly lower than that of 86.0% observed in the non-UAE group. In the UAE group, the reduction of the American Fertility Society (AFS) score after intrauterine adhesiolysis was 30%, which was significantly lower than that of 80% in the non-UAE group. The pregnancy rate and live birth rate in the UAE group (5% and 0%, respectively) were significantly lower than the corresponding rates in the non-UAE group (33% and 25%, respectively).

CONCLUSION

The outcome of hysteroscopic adhesiolysis in women with Asherman's syndrome after UAE was worse than in women with Asherman's syndrome caused by surgical trauma.

Adenomyosis: Epidemiology, Risk Factors, Clinical Phenotype and Surgical and Interventional Alternatives to Hysterectomy

Adenomyosis is an important clinical challenge in gynecology and healthcare economics; in its fully developed form, hysterectomy is often used to treat it in premenopausal and perimenopausal women. Symptoms of adenomyosis typically include menorrhagia, pelvic pain and dysmenorrhea. Moreover, adenomyosis and leiomyomas commonly coexist in the same uterus, and differentiating the symptoms for each pathological process can be problematic. Although it has been recognized for over a century, reliable epidemiological studies on this condition are limited, because only postoperative diagnoses were possible in the past. Minimally invasive surgical techniques (endometrial ablation/resection, myometrial excision/reduction, myometrial electrocoagulation, uterine artery ligation) have had limited success in the treatment of adenomyosis, and the reported data for these procedures have been obtained from case reports or small case series with only short follow-up times. However, newer techniques including uterine artery embolization (UAE) and magnetic resonance imaging guided focused ultrasound (MRgFUS) show promise in treating adenomyosis. The data is strongest for UAE; these studies have the largest patient cohorts. However, none of the UAE studies were randomized or controlled. Thus, despite the clinical importance of adenomyosis, there is little evidence on which to base treatment decisions. The objective of this review is to summarize the epidemiology, risk factors, clinical phenotype and to evaluate the accrued experience with surgical and interventional alternatives to hysterectomy.

Study of the impact of uterine artery embolization (UAE) on endometrial microvessel density (MVD) and angiogenesis

PURPOSE

To investigate the influence of uterine artery embolization (UAE) on endometrial microvessel density (MVD) and angiogenesis.

METHODS

Sixty female guinea pigs were divided into two groups, the control group (n = 15) and the UAE treatment group (n = 45). In the UAE group, tris-acryl gelatin microspheres were used to generate embolization. Animals were further divided into three subgroups, A1, A2, and A3 (n = 15 for each subgroup), with uterine specimens collected at 7-15, 16-30, and 31-45 days after UAE, respectively. Immunostaining for factor VIII and CD105 was performed to identify total endometrial MVD (MVDFVIII) and CD105-positive angiogenesis (MVDCD105) at the indicated time points after UAE.

RESULTS

Quantitative analysis revealed that MVDFVIII significantly decreased in the A1 (11.40 ± 2.76, p < 0.05) and A2 (15.37 ± 3.06, p < 0.05) groups compared to the control group (19.40 ± 2.50), and was restored to normal in the A3 group (18.77 ± 2.69). UAE caused a temporal up-regulation of MVDCD105-positive angiogenesis in the A1 group (9.33 ± 2.37, p < 0.05) and the A2 group (11.63 ± 1.56, p < 0.05) compared to the control group (7.12 ± 1.67), and the MVDCD105 value returned to normal in the A3 group (8.07 ± 1.97).

CONCLUSION

UAE caused a temporal decrease in endometrial MVD that reversed over time as a result of the increase of CD105-positive angiogenesis. Although the UAE-induced reduction of endometrial MVD was reversible, its long-term effect on endometrial receptivity still needs further study.

An update on adenomyosis

Adenomyosis is a common benign uterine pathology that is defined by the presence of islands of ectopic endometrial tissue within the myometrium. It is asymptomatic in one third of cases, but when there are clinical signs they remain non-specific. It can often be misdiagnosed on sonography as it may be taken to be multiple uterine leiomyomata or endometrial thickening, both of which have a different prognosis and treatment. Adenomyosis is often associated with hormone-dependent pelvic lesions (myoma, endometriosis, or endometrial hyperplasia). It is less commonly connected to infertility or obstetrical complications and indeed any direct relationship remains controversial. The purpose of imaging is to make the diagnosis, to determine the extent of spread (focal or diffuse, superficial or deep adenomyosis, adenomyoma), and to check whether there is any associated disease, in particular endometriosis. The aim of this article is to provide assistance in recognising adenomyosis on imaging and to identify the pathologies that are commonly associated with it in order to guide the therapeutic management of symptomatic patients. Pelvic ultrasonography is the first line investigation. Sonohysterography can assist with diagnosis in some cases (pseudothickening of the endometrium seen on sonography). MRI may be used in addition to sonography to back up the diagnosis and to look for any associated disease.

Adenomyosis: a challenge in clinical gynecology

Adenomyosis is a prevalent, benign gynecologic condition in which endometrial tissue invades the myometrium, causing myometrial inflammation and hypertrophy. Although some women with adenomyosis are asymptomatic, the condition often causes menorrhagia and dysmenorrhea. This article provides women's health providers with a review of causes and risk factors for developing adenomyosis, clinical presentations of women with the condition, diagnostic modalities and criteria, and medical and surgical treatment options.

Uterine artery embolization to treat uterine adenomyosis with or without uterine leiomyomata: results of symptom control and health-related quality of life 40 months after treatment

PURPOSE

To evaluate the clinical outcome for uterine adenomyosis with or without uterine leiomyomata 40 months after uterine artery embolization (UAE).

METHODS

Forty women aged 39-56 years (median 46 years) with symptomatic uterine adenomyosis and magnetic resonance imaging findings of uterine adenomyosis with or without combined uterine leiomyomata underwent UAE. Self-perceived changes in clinical symptoms were assessed, and residual symptom severity and health-related quality of life (HRQOL) after UAE were evaluated. Clinical failure was defined as no symptomatic improvement or second invasive therapy after UAE. Results were stratified by the extent of uterine adenomyosis at baseline magnetic resonance imaging.

RESULTS

Patients were followed for a median of 40 months (range 5-102 months). UAE led to symptomatic control after UAE in 29 (72.5%) of 40 patients while 11 women underwent hysterectomy (n=10) or dilatation and curettage (n=1) for therapy failure. No significant difference between women with pure uterine adenoymosis and women with uterine adenomyosis combined with uterine leiomyomata was observed. Best results were shown for UAE in uterine adenomyosis with uterine leiomyomata predominance as opposed to predominant uterine adenomyosis with minor fibroid disease (clinical failure 0% vs. 31.5%, P=0.058). Throughout the study group, HRQOL score values increased and symptom severity scores decreased after UAE. Least improvement was noted for women with pure adenomyosis.

CONCLUSIONS

UAE is clinically effective in the long term in most women with uterine adenomyosis. Symptomatic control and HRQOL were highest in patients with combined disease of uterine adenomyosis but leiomyomata predominance.

Uterine artery embolization for the treatment of adenomyosis

Adenomyosis is a benign uterine disorder that causes menorrhagia and dysmenorrhea. Although it was once considered a contraindication to uterine artery embolization, several authors have examined whether adenomyosis can be treated with uterine artery embolization. This article reviews the pathophysiology of adenomyosis, its imaging characteristics, as well as recent studies evaluating the efficacy of uterine artery embolization for treatment of adenomyosis.

Long-term follow-up of uterine artery embolization for symptomatic adenomyosis

INTRODUCTION

Long-term results of uterine artery embolization (UAE) for adenomyosis are largely unknown. We assess long-term outcome of UAE in 40 women with adenomyosis.

MATERIALS AND METHODS

Between March 1999 and October 2006, 40 consecutive women with adenomyosis (22 in combination with fibroids) were treated with UAE. Changes in junction zone thickness were assessed with magnetic resonance imaging (MRI) at baseline and again at 3 months. After a mean clinical follow-up of 65 months (median 58 [range 38-129]), women filled out the uterine fibroid symptom and quality of life (UFS-QoL) questionnaire, which had additional questions on the long-term evolution of baseline symptoms and adverse events.

RESULTS

During follow-up, 7 of 40 women (18%) underwent hysterectomy. Among these 7 women, the junction zones were significantly thicker, both at baseline (mean 23 vs. 16 mm, P = 0.028) and at 3-month follow-up (mean 15 vs. 9 mm, P = 0.034). Of 33 women with preserved uterus, 29 were asymptomatic. Four patients had symptom severity scores of 50 to 85 and overall QoL scores of 60 to 66, indicating substantial clinical symptoms. There was no relation between clinical outcome and the initial presence of fibroids in addition to adenomyosis.

CONCLUSION

In women with therapy-resistant adenomyosis, UAE resulted in long-term preservation of the uterus in the majority. Most patients with preserved uterus were asymptomatic. The only predictor for hysterectomy during follow-up was initial thickness of the junction zone. The presence or absence of fibroids in addition to adenomyosis had no relation with the need for hysterectomy or clinical outcome.

Feasibility of MRI-guided high intensity focused ultrasound treatment for adenomyosis

PURPOSE

To test the feasibility of MRI-guided high intensity focused ultrasound ablation for adenomyosis.

MATERIALS AND METHODS

Patients with symptomatic adenomyosis were treated with MRI-guided high intensity focused ultrasound (MRIgHIFU). Under conscious sedation, MRIgHIFU was performed by a clinical MRI-compatible focused ultrasound tumour therapeutic system (JM15100, Haifu® Technology Co. Ltd., Chongqing, China) which is combined with a 1.5 T MRI system (Magnetom Symphony, Siemens Healthcare, Erlangen, Germany). MRI was used to calculate the volume of the uterus and lesion. Non-perfused volume of the targeted lesions was evaluated immediately after MRIgHIFU. Patient symptoms were assessed using symptom severity score (SSS) and uterine fibroids symptoms and quality of life questionnaire (UFS-QOL).

RESULTS

Ten patients with mean age of 40.3±4 years with an average lesion size of 56.9±12.7 mm in diameter were treated. Non-perfused volume and the percentage of non-perfused volume obtained from contrast-enhanced T1 Magnetic resonance images immediately post-treatment were 66.6±49.4 cm3 and 62.5±21.6%, respectively. The mean SSS and UFS-QOL showed significant improvements of 25%, 16% and 25% at 3, 6 and 12 months follow up, respectively, to pre-treatment scores. No serious complications were observed.

CONCLUSION

Based on the results from this study, MRIgHIFU treatment appears to be a safe and feasible modality to ablate adenomyosis lesion and alleviate its symptoms.

Uterine artery embolization for the treatment of adenomyosis: a review

During the past 10 years, uterine artery embolization (UAE) has been investigated as a possible therapy for adenomyosis. All publications available from 1999 through 2010 are included in this report. Levels of evidence and trial classifications were evaluated according to the guidelines developed by the United States Preventive Services Task Force. Long-term data are available from 511 affected women from 15 studies. Improvements were reported by 387 patients (75.7%). The median follow-up was 26.9 months. UAE as treatment for adenomyosis shows significant clinical and symptomatic improvements on a short- and long-term basis.

Ultrasound-guided high-intensity focused ultrasound ablation for adenomyosis: the clinical experience of a single center

OBJECTIVE

To assess the midterm outcomes after ultrasound-guided high-intensity focused ultrasound (HIFU) ablation in treatment of patients with symptomatic adenomyosis.

DESIGN

A prospective clinical trial.

SETTING

University teaching hospital.

PATIENT(S)

Seventy-eight patients with symptomatic adenomyosis.

INTERVENTION(S)

A single treatment session of ultrasound-guided HIFU ablation for adenomyosis.

MAIN OUTCOME MEASURE(S)

Dysmenorrhea and menorrhagia scores and the incidence of complications.

RESULT(S)

In all 78 patients, 84.6% tolerated the treatment procedure well with pain scores between 0 and 4. Treatment was terminated in only one patient because of increased blood pressure persistently. Sixty-nine patients have finished at least an 18-month follow-up; the mean follow-up time was 24.2 months. Nonperfused regions in lesions were observed in 60 (87.0%) patients on the enhanced magnetic resonance imaging scans. Scores for menorrhea and dysmenorrhea decreased. Clinical effectiveness of the treatment was observed in 62 women (89.9%) with varying degrees of symptomatic relief of dysmenorrhea. Eight patients had relapses. Twenty-two patients (28.6%) had 27 complications. Of these, four had two or more complications. Twenty-three events (85.1%) did not need medical intervention (Society of Interventional Radiology class A). No serious complications including death or major permanent injuries were observed.

CONCLUSION(S)

Ultrasound-guided HIFU ablation may be a safe and effective noninvasive alternative in the treatment of symptomatic adenomyosis.