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Uterine Artery Embolization for Adenomyosis: Looking at the Glass Half Full

¹ Department of Obstetrics and Gynecology, Jefferson Medical College, 834 Chestnut Street, Suite 400, Philadelphia, PA 19107. e-mail: jaygoldbergmd{at}yahoo.com

Editor:

In the March 2005 issue of Radiology, Dr Pelage and colleagues published the midterm results in women with symptomatic adenomyosis, without coexisting uterine fibroids, who were treated by means of uterine artery embolization (1). Of the 18 women studied, there was improvement in menorrhagia in 94% at 6 months. After 2 years, however, only 56% of women with follow-up information available still had improvement in menorrhagia. The other 44% of the women required additional treatment for failure of treatment or recurrence, with 28% of women undergoing hysterectomy. Dr Pelage and colleagues concluded that the midterm results were disappointing because only slightly more than half of the treated patients showed clinical improvement after 2 years.

As an obstetrician/gynecologist frustrated by the lack of treatment options other than hysterectomy available for women with symptomatic adenomyosis refractory to medical therapy, however, I look at these 2-year results in a more positive light. The results of this study now allow me to offer patients with adenomyosis a treatment option that will successfully treat over 50% of patients, allowing a substantial number to avoid hysterectomy. Uterine artery embolization may be especially valuable in the subsets of patients with symptomatic adenomyosis desiring future fertility, in those who have increased surgical risk due to adhesive disease, or in those absolutely desiring uterine preservation.

Reference

1. Pelage JP, Jacob D, Fazel A, et al. Midterm results of uterine artery embolization for symptomatic adenomyosis: initial experience. Radiology 2005;234:948–953.[Abstract/Free Full Text]

Dr Pelage and colleagues respond:

Jean-Pierre Pelage, MD, PhD^*, Denis Jacob, MD and Olivier Le Dref, MD

^* Department of Radiology, Hôpital Ambroise Paré, 9 avenue Charles-de-Gaulle, 92104 Boulogne Cedex, France
Department of Gynecology, Clinique Bizet, Paris, France
Department of Body and Vascular Imaging, Hôpital Lariboisière, Paris, France. e-mail: jean-pierre.pelage{at}apr.ap-hop-paris.fr

We have read the comments of Dr Goldberg on our article entitled "Midterm Results of Uterine Artery Embolization for Symptomatic Adenomyosis: Initial Experience" with great interest (1).

In our experience, uterine artery embolization is very effective for treating patients with pure adenomyosis during the first 2 years. After an initial clinical improvement, approximately 50% of patients will have symptomatic recurrence (1). Compared with the published experiences in women with fibroids and adenomyosis or with fibroids only, these results may be considered disappointing (2–4). However, as stated by Dr Goldberg, there is currently no effective conservative treatment in women with severe adenomyosis.

On the basis of the results of this study, we have changed our clinical practice. When, as an interventional radiologist, you carefully inform a 48-year-old woman with severe adenomyosis-related menorrhagia and pelvic pain that embolization may be effective in only 50% of cases, with a risk of clinical recurrence, she will choose to be treated by means of hysterectomy in most cases. Conversely, if a patient with the same exact symptoms is only 38 years old with desire for future fertility, she will consider the 50% chance of being clinically improved at 2 years. We fully agree with Dr Goldberg's statement, and we currently offer embolization for adenomyosis mainly in young women desiring future fertility or those absolutely desiring uterine preservation. Our advice to the patient is then to try to get pregnant after the usual 6-month clinical and imaging evaluation.

Whether or not uterine artery embolization should be offered to young women desiring future pregnancy is another controversial topic.

We are glad to see that Dr Goldberg has looked at the glass half full whereas, from a different perspective, we have looked at the same glass half empty.

References

1. Pelage JP, Jacob D, Fazel A, et al. Uterine artery embolization for symptomatic adenomyosis: initial experience. Radiology 2005;234:948–953.
2. Siskin GP, Tublin ME, Stainken BF, Dowling K, Dolen EG. Uterine artery embolization for the treatment of adenomyosis: clinical response and evaluation with MR imaging. AJR Am J Roentgenol 2001;177:297–302.[Abstract/Free Full Text]
3. Jha RC, Takahama J, Imaoka I, et al. Adenomyosis: MRI of the uterus treated with uterine artery embolization. AJR Am J Roentgenol 2003;181:851–856.[Abstract/Free Full Text]
4. Pron G, Bennett J, Common A, et al. The Ontario uterine fibroid embolization trial: uterine fibroid reduction and symptom relief after uterine artery embolization for fibroids. Fertil Steril 2003;79:120–127.[CrossRef][Medline]

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