{"paper_id":"1178c535-a255-4f89-9c9f-e0efc43dd67f","body_text":"Ini’ et al. CVIR Endovascular            (2026) 9:87  \nhttps://doi.org/10.1186/s42155-026-00727-2\nREVIEW ARTICLE Open Access\n© The Author(s) 2026. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which \npermits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the \noriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or \nother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line \nto the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory \nregulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this \nlicence, visit http://creativecommons.org/licenses/by/4.0/.\nCVIR Endovascular\nUterine artery embolization \nfor the treatment of symptomatic adenomyosis: \na systematic review\nCorrado Ini’1*  , Concetta Timpanaro1, Pietro Valerio Foti1,2,3, Francesco Tiralongo1, Renato Farina1, \nFederica Libra1, Davide Giuseppe Castiglione1, Francesco Vacirca1, Roberto Milazzotto4, Corrado Spatola1,4, \nMaria Chiara Lo Greco5, Giuseppe Messina1, Emanuele David1, Stefano Palmucci6 and Antonio Basile1 \nAbstract \nBackground Adenomyosis is a benign uterine condition characterized by the presence of glands and endometrial \nstroma in the myometrium, with hypertrophy of the smooth muscle cells and uterine enlargement, and causing \nchronic pelvic pain, dysmenorrhea, and abnormal uterine bleeding, resulting in significant impairment of quality \nof life. In the last decades, the role of interventional radiology has expanded the range of treatment options of this \ncondition, and uterine artery embolization (UAE) has emerged as a minimally invasive therapy in the management \nof symptomatic adenomyosis. This systematic review aims to evaluate the efficacy and safety of UAE in patients \nwith symptomatic adenomyosis.\nMethods A systematic literature search was conducted across PubMed, Embase, Cochrane Library, Google Scholar, \nand Medline database, including studies published up to December 2025. Eligible articles included prospective \nand retrospective observational cohort studies with more than ten patients reporting UAE outcomes for adenomyo-\nsis; case report, case series, narrative or systematic review, meta-analysis, and guidelines were considered as not eli-\ngible and were therefore excluded. The data analyzed included patient characteristics, technical and clinical success, \nsymptom improvement, imaging outcomes, reintervention rate, and complications, the latter classified according \nto the new modified CIRSE classification grading system.\nResults Twenty-two studies met the inclusion criteria and we collected data on 1701 patients who underwent uter-\nine embolization for therapy-resistant adenomyosis. UAE has demonstrated high technical success rates across studies \nwith 1301/1701 (76.4%) patients experienced significant improvement in heavy menstrual bleeding, dysmenorrhea, \nand bulky-related symptoms at short- and mid-term follow-up. Imaging assessments showed reductions in uterine \nvolume and junctional zone thickness; reintervention and hysterectomy rates were low. Reported complications were \npredominantly minor, with a low incidence of major adverse events. The mortality rate post-procedure was 0%.\nConclusions Based on available literature, UAE represents a safe and effective uterus-preserving minimally inva-\nsive treatment for selected patients with symptomatic adenomyosis; it represents a step on the treatment pathway \nbefore hysterectomy, and women should have access to consult with interventional radiologists when making any \ntreatment decision, in order to achieve a personalized treatment plan.\n*Correspondence:\nCorrado Ini’\ncorrado.ini@gmail.com\nFull list of author information is available at the end of the article\n\nPage 2 of 15Ini’ et al. CVIR Endovascular            (2026) 9:87 \nKeywords Adenomyosis, Uterine artery embolization, Radiology interventional, Abnormal menstrual bleeding, \nChronic pelvic pain\nIntroduction\nAdenomyosis is a common nonneoplastic gynecologic \ncondition characterized by the presence of ectopic endo -\nmetrium within the myometrium, with hyperplastic/\nhypertrophic smooth muscular tissue around ectopic \nendometrial glands. First observed by Rokitansky in \n1860 as “cystosarcoma adenoides uterinum” , and then \ndescribed by Von Recklinghausen, Cullen, and Frankl, \nthe definition of adenomyosis proposed by Bird et al. in \n1972, describing adenomyosis as the benign invasion of \nendometrial tissue into the myometrium, resulting in a \ndiffusely enlarged uterus with ectopic endometrial glands \nand stroma surrounded by hypertrophic and hyperplastic \nmyometrium, remains widely accepted today [1–3].\nEpidemiology and risk factors\nAdenomyosis typically affects multiparous women in \npremenopausal stage and it can manifest with dysmen -\norrhea and heavy menstrual bleeding. The prevalence \nof adenomyosis in hysterectomy specimens varies from \n8 to 70%, and the disease is increasingly diagnosed in \nyounger women, including those experiencing infertil -\nity, pelvic pain, or abnormal uterine bleeding [4]. How -\never, epidemiologic data are fragmented due to differing \ndiagnostic criteria (histological definition or the imaging \nmodality used), the primary reliance on hysterectomy for \ndiagnosis, and the absence of general population screen -\ning [5]. According to the latest studies, the development \nof adenomyosis is associated with risk factors, such as \nhigh estrogen levels, early age of starting menstruation, \nshorter menstrual cycles, higher body mass index (BMI), \nendometriosis, use of tamoxifen for breast cancer treat -\nment, uterine surgeries, or genetic and epigenetic altera -\ntions. Protective factors against the condition have also \nbeen identified, although they are still subject to debate, \nin particular smoking and breastfeeding (associated with \nlower estrogen levels and reduced risk among parous \nwomen).\nEtiopathogenesis\nThe exact cause of adenomyosis is unknown, but differ -\nent pathogenetic theories were postulated on how endo -\nmetrial glands directly invade the myometrium.\nThe “invagination theory” suggests that adenomyosis \ndevelops when endometrial basalis cells or cell groups \ninvade into the myometrium through an injured or \nabnormal junctional zone, forming ectopic adenomyotic \nlesions and affecting the myocytes in the inner myome -\ntrium and outer myometrium. Migration of endometrial \ncells into the myometrium is facilitated by enhanced \ninvasion capacity of endometrial stromal fibroblasts, \nespecially when exposed to myocytes from women with \nadenomyosis [6]. The irregular distribution of myocytes \nand disruptions in the nuclear membrane within the \ninner myometrium, associated with adenomyosis, sug -\ngest that this compartment may play a role in the dis -\nease’s development. This has led to the proposition that \nboth physical and physiologic trauma, often referred to as \n“microtrauma” , to the endometrial-myometrial interface \ncontribute to adenomyosis pathogenesis [6]. Although \nthe endometrial invagination theory is widely supported \nas the main mechanism behind adenomyosis, other \npathways may also be at play. For instance, adenomyosis \nlesions have been found in the myometrium of patients \nwith Rokitansky-Kuster-Hauser syndrome, where func -\ntional endometrium is absent. This suggests that adeno -\nmyosis might develop through alternative mechanisms, \nsuch as metaplasia or differentiation of embryonic or \nadult endometrial stem cells within the myometrium. \nDuring the development and merging of Mullerian ducts, \nsome embryonic tissue remnants might get displaced \ninto the myometrium, potentially leading to adenomyo -\nsis later in life. These remnants could undergo meta -\nplastic changes, giving rise to ectopic endometrial tissue \n[6]. Apart from the direct migration of stem cells from \nthe endometrial basalis into the myometrium, there is \nanother potential pathway involving retrograde menstru-\nation. Perivascular endometrial mesenchymal stem cells \n(eMSCs) found in both the basalis and functionalis lay -\ners of the endometrium are present in menstrual blood as \nwell. Chapron et al. proposed the “from outside to inside \ninvasion” theory, suggesting that adult endometrial cells \nor stem cells carried in retrograde menstrual flow could \ninfiltrate the uterine serosa and penetrate into the outer \nmyometrium, giving rise to intramyometrial endometrial \nimplants or adenomyotic foci. This theory finds support \nin the frequent coexistence of posterior focal adenomy -\nosis and deep infiltrating endometriosis nodules in the \nposterior compartment among patients with endometri -\nosis/adenomyosis [6].\nDiagnosis\nThe diagnosis of adenomyosis, particularly in rela -\ntion to abnormal uterine bleeding (AUB), has become a \n\nPage 3 of 15\nIni’ et al. CVIR Endovascular            (2026) 9:87 \n \nsignificant component in the FIGO (International Fed -\neration of Gynecology and Obstetrics) PALM-COEIN \nclassification, closely associated with excessive menstrual \nbleeding [7]. The gold standard for the diagnosis of aden-\nomyosis was mainly based on histologic analysis after \nthe removal of the uterus, looking for specific signs such \nas the presence of misplaced endometrial glands and a \npeculiar stroma at a minimum depth of 2.5 mm below \nthe surface of the endometrium, along with changes in \nthe surrounding muscle tissue [8]. Nowadays, the diag -\nnosis of this condition is also possible without the use of \ninvasive procedure. Transabdominal sonography (TAS) \nand transvaginal sonography (TVS) are commonly used \nas the initial imaging modality for patients with clinically \nsuspected adenomyosis, with a low reported sensitivity \nfor the former and high specificity for the latter [9, 10]. \nMagnetic resonance imaging (MRI) is an accurate, non -\ninvasive modality for diagnosing adenomyosis, with a \nhigh sensitivity and specificity, identifying the location \nand extent of the disease, and distinguishing adenomyo -\nsis from leiomyoma and other pathological conditions \nowing to its exceptional tissue contrast resolution and \nmultiparameter properties [5, 11–14]. Computed tomog -\nraphy (CT) has low sensitivity for adenomyosis but may \nsuggest the diagnosis based on uterine enlargement, \nthickened inner myometrium, and/or myometrial cysts. \nCT is also useful for identifying other abdominal and pel-\nvic conditions [15].\nTreatment\nUterine adenomyosis has a great impact on patients’ \ndaily life, it can affect fertility and pregnancy, and it could \nheighten the likelihood of adverse outcomes in pregnancy \nand for newborns, such as preeclampsia, preterm birth, \nand small-for-gestational-age (SGA) patients. Treatment \nof adenomyosis encompasses both medical and surgi -\ncal therapies. Among the first, oral contraceptives (OCs) \nare prescribed to alleviate menstrual bleeding by induc -\ning decidualization and subsequent endometrial atrophy. \nThis treatment approach can be particularly beneficial \nfor patients experiencing dysmenorrhea and heavy men -\nstrual bleeding, as it often leads to amenorrhea, pro -\nviding relief from symptoms. Gonadotropin-releasing \nhormone agonists (GnRH-a), controlled by the hypotha -\nlamic–pituitary–gonadal axis, effectively ease chronic \npelvic pain from adenomyosis, lessen menstrual flow, and \nenhance chances of conception. Commonly used GnRH-\na types include leuprorelin acetate, goserelin acetate, and \ntriptorelin. Mifepristone, an established systemic steroid, \nemerges as a promising therapeutic option for adeno -\nmyosis, exerting its effects through multifaceted mecha -\nnisms involving cell viability, apoptosis, migration, and \nuterine volume reduction [16]. Hysterectomy is currently \nthe only definitive therapy for adenomyosis, reserving for \npatients with severe pain not responding to other thera -\npies and in whom fertility is no longer desirable. In recent \ndecades,  hysterectomy has been replaced by conserva -\ntive uterine-saving methods and reproductive-sparing \ntherapies. High-intensity focused ultrasound (HIFU) \nemploys ultrasound beams to induce coagulative necrosis \nin targeted adenomyotic lesions, offering a noninvasive \napproach; however, its suitability depends on lesion vis -\nibility, making it less effective for diffuse adenomyosis. In \nrecent years, the role of interventional radiology in clini -\ncal practice has expanded the range of treatment options \navailable for adenomyosis. Uterine artery embolization \n(UAE) allows, through a minimally invasive approach, \nto alleviate adenomyosis symptoms by closing off uter -\nine blood vessels and reaching a state of hypoxia and \nischemia of the ectopic endometrium, resulting in necro -\nsis and absorption of proliferative cells and connective \ntissue. These events achieve the purpose of relieve or dis -\nappear of clinical symptoms [17, 18].\nEven if potential utero-ovarian anastomoses can facili -\ntate the embolization of the ovarian artery by decreas -\ning blood supply, the impact of UAE on ovarian reserve \nis not significant [19]. In fact, recent studies have shown \nthat FSH and LH levels post-UAE return to normal after \n12 months, indicating a low incidence rate of ovarian \ndysfunction, particularly in young women, since they can \nexhibit a greater capacity for recovery from ovaries dam -\naged on the long-term follow-up [20, 21]. UAE has the \nadvantages of less trauma, rapid recovery, uterine normal \nphysiological and reproductive preservation, and reduc -\ntion of costs and length of hospitalization compared to \nmore invasive alternative therapies. Furthermore, UAE \nallows the release of therapeutic agents into the target \nlesions, reducing systemic toxicity, complication rate, \nuterine volume, and relieving dysmenorrhea [22].\nThe purpose of our study is to analyze and review tech-\nniques, common clinical practice, outcomes, and safety \nof UAE for the treatment of uterine adenomyosis. This \nmanuscript systematically reviews most recent clinical \ntrials, prospective and retrospective studies concerning \nthis topic.\nMaterials and methods\nSystematic review\nBased on the “PICOS (Population/Problem, Interven -\ntion, Comparison, Outcome, and Study design)” criteria \nand “Preferred Reporting Items for Systematic Review \nand Meta-Analysis (PRISMA)” guidelines, an extensive \nsystematic literature search in the field of uterine artery \nembolization for adenomyosis was performed. The lit -\nerature search included PubMed, Embase, Cochrane \nLibrary, Google Scholar, and Medline databases and the \n\nPage 4 of 15Ini’ et al. CVIR Endovascular            (2026) 9:87 \nfollowing medical subject headings (MeSH) and key -\nwords, associated with Boolean operators, without trun -\ncation/wildcards, were used to identify main articles \nrelevant to our purpose: “adenomyosis embolization” OR \n“adenomyosis UAE” AND “uterine artery embolization \nfor adenomyosis” OR “uterine artery embolization for the \ntreatment of adenomyosis” OR “interventional radiology. ”\nThe “PICOS” items formed the basis of the research \nquestion and included the following information: P \n(patients with diagnosis of adenomyosis on imaging), I \n(minimally invasive treatment), C (comparison between \ndifferent interventional radiology techniques), O (effec -\ntiveness outcomes, adverse effects, and adverse effects \nlimiting effectiveness of treatment), S (retrospective \nstudy, clinical trial phase III, randomized controlled \nphase III trial, phase II trial reports, prospective pilot \nstudy, retrospective cohort analysis, multicentric rand -\nomized trial, other prospective studies).\nEligibility criteria\nStrict inclusion and exclusion criteria were applied. Only \nhuman studies, articles written in English, and those \nwhere the entire content was accessible were included \nin the present review. No interval in the literature search \nperiod was specified and the authors screened studies \nup to December 2025.  Prospective, retrospective obser -\nvational or cohort studies with more than ten patients \nwere included, while case report, case series with fewer \nthan ten patients, narrative or systematic review, meta-\nanalysis, and guidelines were considered as not eligible \nand were therefore excluded. Articles not compatible \nwith the aims of our research due to the use of not spe -\ncific MeSH and keywords and recurring articles from the \nsame authors on the same procedure were excluded.\nPatients\nThe study population inclusion criteria were as follows: \nadult female of childbearing age (aged 18 or older) with \na diagnosis of adenomyosis on imaging; patients with \nfailure of medical therapies; patients desiring for uterine \npreservation without fertility impairment. The exclusion \ncriteria were as follows: pregnancy; patients with uter -\nine malignant tumors; patient with pelvic inflammatory \ndisease, autoimmune disorders, or immunosuppressed; \npatients without pelvic imaging; patients with an East -\nern Cooperative Oncology Group (ECOG) performance \nstatus > 2.\nIntervention\nIn the present systematic review, only studies focusing \non UAE with minimally invasive approach were included. \nStudies focusing on both adenomyosis and fibroid \ntreatments were also included if only they provided spe -\ncific results related to adenomyosis.\nOutcome measures\nTreatment techniques and materials used were analyzed \nfor each procedure. Whenever available, data on tech -\nnical and clinical success were recorded. Technical suc -\ncess was achieved with stasis of contrast in the distal \nascending segment of the uterine artery on both sides \nafter embolization. The statistics on technical and clini -\ncal success, complications, and adverse events were also \ncompared when specified. Outcome parameters evalu -\nated were as follows: symptom improvement after UAE \n(chronic pelvic pain, menstrual disorders, dysmenor -\nrhea, menometrorrhagia, dyspareunia), morphological \nchanges post-treatment (uterine volume reduction, junc -\ntional zone changes—thickness, necrosis), reintervention \nrate, pregnancy rate after first UAE. Symptoms were eval-\nuated using different quality of life questionnaires and \npain scales. Complications and adverse events, with or \nwithout clinical implications, were analyzed during the \nfollow-up period and standardized using the modified \nCIRSE classification grading system [23]. Adverse events \nand complications were also divided into minor (grade \n1–2–3) and major (grade 4–5–6).\nStudy selection\nStudy selection was conducted using Rayyan.ai (https:// \nwww. rayyan. ai), an online platform designed to facilitate \nthe screening process of the articles [24]. All included \narticles based on inclusion and exclusion criteria, key -\nwords, and MeSH were examined by two different \nreviewers among authors and disagreement over the lit -\nerature data were settled through discussion among the \nother authors. Prioritization feature of Rayyan.ai was \nused solely to support the screening process by rank -\ning studies according to their predicted relevance based \non the eligibility criteria; all final screening decisions \nwere made exclusively by human reviewers. Data were \nrecorded using Microsoft Excel database (Microsoft Cor -\nporate, version 2403, Redmond, WA, USA), indicating \nfirst author, year of publication, design of the study, num-\nber of patients enrolled, outcomes, and complications. \nBased on the aforementioned search criteria, 355 records \nwere identified and of which 20 were removed because \nthey were duplicated or written in a language other than \nEnglish or because the full-text was not available. Fifty-\nfive articles were removed because they were systematic \nreview or meta-analysis, and 27 articles were excluded \nbecause they were case reports or case series or editorials \nor guidelines. After the analysis of titles and abstract of \nfull-text articles, 237 studies were removed as they were \nnot relevant for the purpose of our review, since they did \n\nPage 5 of 15\nIni’ et al. CVIR Endovascular            (2026) 9:87 \n \nnot meet inclusion criteria. Articles considered for our \nresearch were therefore reduced to 16 papers; further 6 \narticles have been added analyzing cross-references from \nprevious included studies. The systematic review of the \nliterature was finally conducted on a total of 22 articles \n[25–46]. A flowchart, illustrated in Fig.  1, summarized \nthe whole process of selecting studies based on the inclu -\nsion and exclusion criteria.\nOur study did not directly involve humans and there -\nfore did not require the Institutional Review Board \napproval of our institution.\nQuality assessment and risk of bias\nThe Newcastle–Ottawa scale was used to assess the qual -\nity and risk of bias of non-randomized studies (case con -\ntrol studies and cohort studies) (Tables 1, 2) [47, 48].\nDefinitions\nIn last years, minimally invasive therapies have provided \na viable alternative to more invasive surgical therapies in \ndifferent fields of medicine. This approach offers a safe \nand effective option for appropriately selected women, \nreducing costs and the length of hospitalization. UAE \ntechnique in adenomyosis is similar to that used in \nfibroids. The procedure is performed under conscious \nsedation, with a minimally invasive arterial vascular \naccess, under fluoroscopic guidance, and with selective \nand super selective arteriography of both uterine arter -\nies and their branches. The standard approach for UAE \nis via the femoral artery; in fact, femoral artery is a large \nvessel that is easy to approach allowing artery emboliza -\ntion being performed repeatedly. However, this approach \ncould limit the patient’s quality of life and increase the \nrisk of complications, such as deep vein thrombosis, arte-\nrial bleeding, and formation of pseudoaneurysm. The \ntransradial artery approach has become the gold stand -\nard in coronary interventions, and promising results \nwere also obtained in UAE. By accessing the distal radial \nartery, this approach reduces pain, radiation exposure, \nand access site complications, offering faster recovery \nFig. 1 Flowchart illustrating selection process of the articles included in the systematic review\n\nPage 6 of 15Ini’ et al. CVIR Endovascular            (2026) 9:87 \nand quicker patient mobilization rather than femoral \nartery approach. The most frequent complication of tran-\nsradial approach is the vessel spasm after puncture and \nthe occlusion of the radial artery in the snuffbox, which \ncan be prevented through administration of nitroglycerin \n[49]. To date, further studies are needed to demonstrate \nthe superiority of the transradial approach over the trans-\nfemoral approach for UAE of adenomyosis [50]. The \nembolic material is introduced into the bloodstream in \na fractionated manner (free-flow embolization) once the \nTable 1 Risk of bias based on Newcastle–Ottawa scale\nFirst author, \nyear\nSelection Comparability Outcome Total\nExposed \nrepresentation\nSelection \nof non-\nexposed \ncohort\nAscertainment \nof exposure\nOutcome \nof interest \nnot present \nat start of \nstudy\nAssessment \nof outcome\nSufficient \nfollow-up \ntime\nAdequacy \nof \nfollow-up \nof cohort\nBratby, 2009 \n[25]\n +  −  +  −  −  +  +  − 4\n De Bruijn, \n2017 [26]\n +  +  +  −  −  +  +  − 5\n Froeling, \n2012 [27]\n +  −  +  −  −  +  +  − 4\n Guo, 2021 \n[28]\n +  −  +  −  −  +  +  − 4\n Hu, 2024 \n[29]\n +  −  +  −  −  +  +  − 4\nKim M.D., \n2007 [30]\n +  −  +  −  −  +  +  − 4\nKim M.D., \n2011 [31]\n +  −  +  −  +  +  +  − 5\n Kitamura, \n2006 [32]\n +  −  +  −  −  +  +  + 5\n Liang, 2018 \n[33]\n +  −  +  −  −  +  +  − 4\n Manduca, \n2025 [34]\n +  −  +  −  +  +  +  + 6\n Mitranovici, \n2025 [35]\n +  +  +  −  +  +  +  + 7\n Nijenhuis, \n2015 [36]\n +  −  +  −  −  +  +  − 4\n Pelage, 2005 \n[37]\n +  −  +  −  −  +  +  − 4\n Siskin, 2001 \n[38]\n +  −  +  −  −  +  +  − 4\n Smeets, \n2012 [39]\n +  −  +  −  −  +  +  − 4\n Trommelen, \n2025 [40]\n +  +  +  −  +  +  +  + 7\nTurtòczki, \n2024 [41]\n +  −  +  −  −  +  +  − 4\nWang S., \n2016 [42]\n +  −  +  −  −  +  +  − 4\nWang Y., \n2020 [43]\n +  −  −  −  −  +  +  − 3\n Wei, 2025 \n[44]\n +  −  +  −  +  +  +  − 5\n Yuan, 2021 \n[45]\n +  −  +  −  −  +  +  − 4\n Zhou, 2016 \n[46]\n +  −  +  −  −  +  +  − 4\n\nPage 7 of 15\nIni’ et al. CVIR Endovascular            (2026) 9:87 \n \ncatheter is positioned in the horizontal segment of the \nuterine artery, and the angiogram indicates satisfactory \nflow. Occasionally, spasm leads to the complete halt of \nflow, which should be managed with the intra-arterial \nadministration of nitroglycerin or tolazoline [15]. Embo -\nlization is usually performed using variable-sized perma -\nnent particulate agents. Extensive experience has been \ndocumented with polyvinyl alcohol (PVA), Gelfoam, and \ntris-acryl gelatin-coated microspheres (TAGM). Par -\nticles of non-spherical shape, measuring 350–750 μm, \nand microspheres ranging in size from 500 to 900 μm are \nalso utilized [15]. The angiographic endpoint achieved \nwith non-spherical PVA is blood stasis, indicating com -\nplete blockage of the flow in uterine arteries [15]. Special \nattention is paid to visualizing the cervicovaginal and \novarian artery branches. Distal embolization avoids vagi -\nnal necrosis and the unwanted reflux of microspheres \ninto the ovarian artery. After completing embolization \non the opposite side, the uterine artery on the same side \nis catheterized either by creating a Waltman loop or by \nusing a curved catheter, such as the Rösch inferior mes -\nenteric catheter, which functions as a hook and it can be \ninserted into the internal iliac artery with ease [15].\nThe aim of UAE is to relieve symptoms, mainly pain, \nwhile preserving normal physiological and reproduc -\ntive functions of the uterus. UAE induces more than 34% \nnecrosis within adenomyotic tissues. In fact, by emboliz -\ning the uterus and focal blood supply, the ectopic endo -\nmetrium enters a state of hypoxia and ischemia, resulting \nin necrosis dissolution and absorption of proliferative \nTable 2 Overall risk of bias based on Newcastle-Ottawa scale [25–46]\n\nPage 8 of 15Ini’ et al. CVIR Endovascular            (2026) 9:87 \ncells and connective tissue. These events lead to symp -\ntom relief and uterine morphological changes.\nResults\nAccording to the inclusion and exclusion criteria, 22 \nstudies were selected for inclusion in the present system -\natic review, encompassing a total of 1701 female patients \ntreated with UAE for adenomyosis. The mean age of the \nentire population included in the study was 42.9 years \n(range, 27–64 years). Fifteen out of 22 articles (68.1%) \nwere retrospective studies and 7/22 articles (31.8%) \nwere prospective studies. Eleven out of 22 (50%) articles \nreported patients with pure adenomyosis and adenomyo-\nsis associated with fibroids, 1/22 (4.5%) articles reported \npatients with adenomyosis associated with endometrio -\nsis and 10/22 (45.4%) articles reported patients with pure \nadenomyosis. Six out of 22 articles (27.2%) focused on \ndifferentiating the various forms of adenomyosis, which \ncan be focal, diffuse, symmetrical, or asymmetrical. Sym -\nmetric diffuse adenomyosis was defined as uniform wid -\nening of the junctional zone, whereas asymmetric diffuse \nadenomyosis was diagnosed when adenomyosis was dif -\nfuse but dominant on one side of the endometrial canal. \nFocal adenomyosis, or adenomyoma, was diagnosed \nwhen the region of adenomyosis was more localized and \nappeared as an oval poorly marginated mass-like lesion \non imaging. In all studies, the main symptoms evaluated \nwere heavy menstrual bleeding, dysmenorrhea, pelvic \npain, and bulk-related symptoms (sensation of pressure \non the bladder and/or rectum, abdominal swelling, uri -\nnary frequency, constipation). Heavy menstrual bleed -\ning was the prevalent symptom among patients with an \nincidence more than 70%, followed by dysmenorrhea and \nbulky symptoms. Adenomyosis was diagnosed through \ncross-sectional imaging (MRI and US) in all studies and, \nin particular, with only US in one study, with MRI in 17 \nstudies, and with a combination of MR and US in 4 stud -\nies. In one study, five patients underwent transvaginal \nbiopsy to confirm the diagnosis.\nThe UAE technique used among studies was tran -\nscatheter selective embolization of uterine arteries, and \ntechnical success was achieved in 99.8% procedures. In \n14/22 studies, a transfemoral artery approach was used \nto gain arterial access, while in 2/22 studies a transra -\ndial artery approach was used; in 6/22 studies, the type \nof arterial puncture was not specified by the authors. \nAll procedures were conducted under local anesthesia \nTable 3 Main characteristics of the studies included in the systematic review\nPVA polyvinyl alcohol, TAGM tris-acryl gelatin microspheres\nFirst author, year Type of study design Number of \npatients\nType of \ntreatment\nEmbolic material (dimensions)\nBratby, 2009 [25] Retrospective 27 UAE PVA (355–500 µm)\n De Bruijn, 2017 [26] Prospective 29 UAE Polyzene F-coated hydrogel microsphere (–)\n Froeling, 2012 [27] Retrospective 40 UAE TAGM, PVA (355–900 µm)\n Guo, 2021 [28] Retrospective 76 UAE TAGM (500–900 µm)\n Hu, 2024 [29] Retrospective 48 UAE TAGM (500–900 µm)\nKim M.D., 2007 [30] Retrospective 66 UAE PVA (250–710 µm)\nKim M.D., 2011 [31] Prospective 40 UAE PVA (150–500 µm)\n Kitamura, 2006 [32] Prospective 19 UAE TAGM, PVA (355–700 µm)\n Liang, 2018 [33] Retrospective 117 UAE PVA (300–700 µm)\n Manduca, 2025 [34] Retrospective 76 UAE Embosphere (300–700 µm)\n Mitranovici, 2025 [35] Retrospective 25 UAE PVA (150–250 µm)\n Nijenhuis, 2015 [36] Prospective 29 UAE Polyzene F-coated hydrogel microsphere (500–900 µm)\n Pelage, 2005 [37] Prospective 18 UAE TAGM (355–900 µm)\n Siskin, 2001 [38] Retrospective 15 UAE PVA (355–500 µm)\n Smeets, 2012 [39] Retrospective 40 UAE Embosphere (500–900 µm)\n Trommelen, 2025 [40] Prospective 50 UAE Embosphere (300–700 µm)\nTurtòczki, 2024 [41] Retrospective 15 UAE PVA (500–700 µm)\nWang S., 2016 [42] Prospective 115 UAE TAGM (500–700 µm)\nWang Y., 2020 [43] Retrospective 195 UAE PVA (–)\n Wei, 2025 [44] Retrospective 382 UAE Embosphere (100–700 µm)\n Yuan, 2021 [45] Retrospective 27 UAE PVA (100–300 µm)\n Zhou, 2016 [46] Retrospective 252 UAE PVA (355–710 µm)\n\nPage 9 of 15\nIni’ et al. CVIR Endovascular            (2026) 9:87 \n \nor conscious sedation. Different types of embolic agents \nwere analyzed in all studies. Calibrated microparticles \n(sizes ranging from 100 to 710 µm) have been used in \nall procedures. In 12/22 articles, polyvinyl alcohol parti -\ncles (PVA) with a diameter ranging from 100 to 700 µm \nwere used as the main embolic agent for UAE. In some \ncases, the particle size was increased during the proce -\ndure to achieve complete embolization of target vessels. \nIn 10/22 studies, tris-acryl gelatin microspheres (TAGM) \nwere used by authors for adenomyosis embolization, and, \nin two studies, polyzene F-coated hydrogel microspheres \nwere used [26, 36]. The main characteristics of the stud -\nies included in this systematic review are summarized in \nTable 3.\nTwenty-one out of 22 articles (95.4%) reported the \nduration of follow-up, ranging from 3 months to 7.4 years \n(mean follow-up duration of 28.4 months). The follow-up \nwas conducted through imaging (MRI, US) and/or ques -\ntionnaires. Symptoms of adenomyosis were evaluated \nbefore and after treatment and their improvements (pri -\nmary outcome) were tested through different scales and \nquestionnaires (VAS, HRQOL, UFS-QOL, QoF, SSS). \nAbnormal menstrual bleeding was also assessed with \nhealth-related quality of life (HRQOL) questionnaire \nand symptom severity scores (SSS) scale in 7/22 articles \n(31.8%), and with Quality of Life (QoF) questionnaire in \n8/22 articles (36.3%), while pelvic pain and dysmenorrhea \nwere assessed with Visual Analogue Scale (VAS). In two \nstudy, Chronic Pain Grade questionnaire and American \nFertility Society (AFS) scoring system were used as out -\ncome assessor, and in one study the type of questionnaire \nwas not specified. All studies (100%) reported type and \nrate of symptom improvement after UAE.\nSymptom improvement was observed in at least 50% \nof the patients, reaching up to 96% in some cases. Over -\nall, 1301/1701 patients experienced significant symptom \nimprovement, with an average percentage of 76.4%. Most \nstudies (> 50%) showed an improvement in symptoms in \nmore than 70% of patients who underwent UAE. Abnor -\nmal menstrual bleeding was the main symptom improved \nafter treatment both in a short- and long-term follow-up, \nfollowed by dysmenorrhea and bulky symptoms.\nIn 5/22 studies (22.7%), a secondary attempt of embo -\nlization was performed to treat persistent symptoms, \nand in 13/22 (59%) studies secondary hysterectomy was \nreported in 55/1701 patients (3.2%) after UAE for recur -\nrence of symptoms.\nMorphological changes (uterine volume, maximal \njunctional zone thickness) were analyzed in 16/22 stud -\nies (72.7%) and were considered as outcome param -\neters for the treatment. Uterine volume and junctional \nzone thickness significantly decreased after UAE. The \nuterine volume before treatment was reported in 16/22 \n(72.7%) studies and ranged from 236 to 790  cm3, with a \nmean uterine volume of 396.6  cm3, and after treatment \nranged from 151 to 569  cm3, with a mean uterine volume \nof 240.3  cm3. The mean percentage reduction in uterine \nvolume was 36.2%. Maximal junctional zone thickness \nbefore treatment was reported in 11/22 studies (50%) and \nranged from 12 to 70 mm, with a mean value of 27.9 mm. \nIn 8/22 studies (36.3%), authors measured junctional \nzone thickness after UAE, with a mean reduction of 8.7 \nmm (34.4%). Adenomyosis necrosis was considered as \na predictor of good outcomes after UAE and was meas -\nured as an area of absence of contrast enhancement on \nT1-weighted images. However, this data was present only \nin 4/22 articles (18.8%) with a complete necrosis in 71.6% \nof cases of adenomyosis and partial necrosis in 68.8, 73.6, \nand 5% of cases in three different studies respectively. \nPost-operative outcomes and morphological changes \navailable for the studies analyzed in the present system -\natic review are summarized in Tables 4 and 5.\nPost-procedure complications were divided into minor \n(grade 1–2–3) and major (grade 4–5–6), according to the \nnew modified CIRSE classification system, based on addi-\ntional post-procedure therapy or prolonged hospital stay, \nTable 4 Mean follow-up times and clinical response following \nUAE\nFirst author, \nnumber of \npatients\nSymptom \nimprovement, \nn (%)\nFollow-up \n(months)\nSecondary \nhysterectomy, \nn (%)\nBratby, 27 24 (88%) 36 2 (7%)\nDe Bruijn, 29 21 (74%) 88 5 (17%)\nFroeling, 40 92 (72%) 40 10 (25%)\nGuo, 76 59 (78%) 12 –\nHu, 48 31 (64%) 36 –\nKim M.D. 2007, 66 50 (76%) 57 5 (8%)\nKim M.D. 2011, 40 19 (47%) 14 –\nKitamura, 19 16 (84%) 12 –\n Liang, 1170 102 (87%) 22 6 (5%)\nManduca, 76 71 (93%) 7 7 (9%)\nMitranovici, 25 23 (92%) 6 1 (4%)\nNijenhuis, 29 22 (76%) 37 1 (3%)\nPelage, 18 12 (67%) 24 5 (28%)\nSiskin, 15 12 (80%) 8 –\nSmeets, 40 29 (72%) 65 7 (17%)\nTrommelen, 50 28 (56%) 13 –\nTurtòczki, 15 14 (93%) 65 1 (7%)\nWang S., 115 108 (94%) 12 –\nWang Y., 195 124 (63%) 15 4 (2%)\nWei, 382 151 (39%) 3 –\nYuan, 27 26 (96%) 42 1 (4%)\nZhou, 252 134 (53%) 60 –\n\nPage 10 of 15Ini’ et al. CVIR Endovascular            (2026) 9:87 \nand permanent sequelae, including death. The analysis \nof complications was available in 15/22 studies (68.2%), \nwhile in 7/22 studies (31.8%) the type of complication \nwas not analyzed, limiting safety conclusions. Patients \nexperienced a minor grade of post-procedure complica -\ntions and pelvic pain was the main symptoms after UAE \n(127/1701, 7.4%), followed by nausea and abnormal uter -\nine/vaginal bleeding; infection (endometritis, urinary \ntract infections) was reported in 9/1701 patients (0.5%). \nIn one patient, a major grade of complication occurred \n(uterine necrosis) and in 25/1701 patients (1.4%) uter -\nine synechiae and intrauterine adhesions (Asherman \nsyndrome) were associated with infertility. Permanent \namenorrhea occurred in 45/1701 patients (2.6%) during \nfollow-up, but was not perceived as a complication by \nmost patients. No mortality rate was reported among the \nstudies. The number, rate, and type of complications in \nthe individual studies are summarized in Table 6.\nDiscussion\nClinical and imaging presentations of adenomyosis pose \nsignificant medical challenge in women. In some peo -\nple, adenomyosis causes no symptoms or only mild \ndiscomfort, while for others, symptoms can be disabling, \ndrastically worsening patients’ quality of life. Even if \nthe exact cause of adenomyosis is unknown, its growth \ndepends on the hormone estrogen. Endometrial glands \ndirectly invade the myometrium resulting in vessel angio-\ngenesis, smooth muscle hyperplasia, and hypertrophy. \nThese changes prevent uterine contractions from tam -\nponing bleeding myometrial arterioles, leading to heavy \nmenstrual bleeding.\nTherapy of adenomyosis depends on the severity of \nsymptoms and the need to preserve fertility. First-line \ntherapy aims to control pain with conservative pharma -\ncological treatments, including nonsteroidal anti-inflam -\nmatories (NSAID), hormonal contraceptive medications, \nor intrauterine devices; the use of a levonorgestrel intrau-\nterine device has shown promising results in symptom \nrelief [51]. If conservative measures fail in controlling \nsymptoms, invasive options can be considered, with \nhysterectomy representing the definitive treatment \nchoice. However, nowadays patients and physicians are \nmore prone to opt for minimally invasive therapies. This \napproach has several advantages since uterus-preserv -\ning techniques allow to maintain fertility and reduce \nperioperative morbidity and the length of hospital stay \nTable 5 Morphological changes before and after UAE reported among studies\nJZ junctional zone, UAE uterine artery embolization\nFirst author Uterine volume (mean) \nbefore UAE\nUterine volume (mean) after \nUAE\nJZ thickness (mean) before \nUAE\nJZ thickness \n(mean) after \nUAE\nBratby 528  cm3 – – –\nDe Bruijn – – – –\nFroeling 381  cm3 – 31 mm –\nGuo – – – –\nHu 266  cm3 – 41 mm –\nKim M.D., 2007 [30] 279  cm3 188  cm3 – –\nKim M.D., 2011 [31] 347  cm3 197  cm3 – –\nKitamura 439  cm3 293  cm3 36 mm 31 mm\nLiang 296  cm3 198  cm3 23 mm 17 mm\nManduca 748  cm3 258  cm3 17 mm 4 mm\nMitranovici – – – –\nNijenhuis 351  cm3 231  cm3 24 mm 15 mm\nPelage 297  cm3 262  cm3 – –\nSiskin 455  cm3 231  cm3 30 mm 21 mm\nSmeets – – 19 mm 12 mm\nTrommelen 236  cm3 – 12 mm –\nTurtòczki 298  cm3 182  cm3 41 mm 29 mm\nWang S 790  cm3 485  cm3 – –\nWang Y 331  cm3 208  cm3 – –\nWei – – – –\nYuan 304  cm3 151  cm3 33 mm 24 mm\nZhou – – – –\n\nPage 11 of 15\nIni’ et al. CVIR Endovascular            (2026) 9:87 \n \nassociated with surgery. Ablative techniques, MR- or \nultrasound-guided high-intensity focused ultrasound \n(HIFU), and transcatheter embolization represent the \nmost recent uterine-sparing minimally invasive tech -\nniques. However, ablative therapies and HIFU are sub -\nject to certain limitations including availability, overall \ncost, and unknown fertility outcomes; more consolidated \nexperience is developing for UAE. Over the past 15 years, \nUAE has been studied for the treatment of symptomatic \nadenomyosis. Previous studies demonstrate long-term \nimprovement in patient symptoms and a short-term \ndecrease in uterine volumes, especially in vascular lesions \n[52].\nThis systematic review provides a comprehensive anal -\nysis of UAE for the treatment of adenomyosis, focusing \non technical aspects, clinical outcomes, and post-pro -\ncedural complications, assessing the current literature \navailable to date on this topic. The review meticulously \nsearched the major scientific databases using well-\ndefined keywords and MeSH, with a period covered from \nJanuary 2003 to December 2025, ensuring a thorough \nexamination of the updated literature without tempo -\nral bias. The inclusion criteria were stringent, focusing \non English-language studies with accessible full texts, \ninvolving adult female patients, and clearly citing sources. \nStudies that combined adenomyosis with fibroids were \nincluded only if specific adenomyosis-related outcomes \nwere reported. This rigorous selection process ensured \nthe relevance and reliability of the included studies. Our \nfinal search included 22 articles, and the study sample \ncovered a total of 1701 women with adenomyosis.\nUterine artery embolization is a minimally invasive \ninterventional radiological technique, first performed by \nRavina et  al. in 1995 for the treatment of fibroids, and \ndecreasing the arterial supply to the uterus to control \nabnormal bleeding symptoms. The embolization tech -\nniques varied, with most studies using polyvinyl alcohol \n(PVA) particles of different diameters, ranging from 100 \nto 710 µm, and some studies using additional materials \nsuch as tris-acryl gelatin microspheres and embospheres. \nThe choice of embolization material and particle size \ncould affect both the efficacy and safety of the procedure. \nTechnically, a complete stasis of flow within the uterine \narteries is the final endpoint. Calibrated microparticles \n(sizes ranging from 100 to 710 µm) were used in all pro -\ncedures, and in more than half of the studies analyzed, \nTable 6 Complication rate and adverse effects after UAE\n* Grading according to modified CIRSE classification system for complications reporting\n** Not available\nFirst author Grade 1 (a-b), grade 2* [n (%)] Grade 3 (a-b)* [n (%)] Grade 4–5* [n (%)] Grade 6* [n (%)]\nBratby N/A** N/A** N/A** N/A**\nDe Bruijn N/A** N/A** N/A** N/A**\nFroeling N/A** N/A** N/A** N/A**\nGuo 0 0 0 0 (0%)\nHu N/A** N/A** N/A** N/A**\nKim M.D., 2007 [30] N/A** N/A** N/A** N/A**\nKim M.D., 2011 [31] 0 0 0 0 (0%)\nKitamura 0 0 0 0 (0%)\nLiang 3 (2%): groin hematoma 3 (2%): endometritis, IVU 0 0 (0%)\nManduca 8 (10%): pelvic pain, urinary retention 0 0 0 (0%)\nMitranovici 0 0 1 (4%): uterine necrosis 0 (0%)\nNijenhuis 0 2 (7%): infection 1 (3%): pseudoaneurysm 0 (0%)\nPelage 0 7 (39%): pain, vaginal discharge 0 0 (0%)\nSiskin 0 15 (100%): nausea, vomiting, pain 0 0 (0%)\nSmeets 0 0 0 0 (0%)\nTrommelen N/A** N/A** N/A** N/A**\nTurtòczki 0 0 1 (7%): amenorrhea 0 (0%)\nWang S 64 (56%): nausea 112 (97%): pelvic pain 0 0 (0%)\nWang Y 3 (1%): pain 7 (4%): abnormal menstrual bleed-\ning, infection\n25 0 (0%)\nWei 0 0 0 0 (0%)\nYuan 0 1 (4%): endometritis 4 (15%): amenorrhea 0 (0%)\nZhou N/A** N/A** N/A** N/A**\n\nPage 12 of 15Ini’ et al. CVIR Endovascular            (2026) 9:87 \nembolization was started with smaller particles with sub -\nsequent upsizing [31]. However, currently studies on the \nefficacy of different embolizing materials or the superior-\nity of one over another are lacking, suggesting the need \nfor standardization in future research. Even if technically \nUAE procedure is similar for adenomyosis and fibroids, \na more aggressive approach to reach complete stasis of \nflow is the main endpoint for the treatment of adeno -\nmyosis; in fact, in adenomyosis, the afferent arterioles are \ngenerally smaller than in fibroids and the use of smaller \nparticles allows to first block these vessels, reaching bet -\nter results. On the other hand, patients have experienced \nmore intense pain after UAE for adenomyosis with this \ntechnique, suggesting the need to carry out the proce -\ndure under patient-controlled analgesia. Pelvic pain was \none of the most commonly encountered adverse events \nof UAE and it was probably the result of the ischemic \nalteration after embolization [42]. In all studies analyzed, \nlocal anesthesia or conscious sedation was performed \nduring procedure. Pain management is a critical com -\nponent of post-UAE care. In two different studies con -\nducted in 2013 and 2016 on pain management therapies \nafter UAE, Kim SY et al. investigated the use of dexme -\ndetomidine, demonstrating that its infusion reduced opi -\noid consumption and associated side effects, providing \nbetter analgesia and less nausea and vomiting, without \nsignificant hemodynamic instability. This suggests that \ndexmedetomidine could be a valuable adjunct in post-\nUAE pain management protocols. The use of dexameth -\nasone significantly reduced inflammation, pain, and the \nincidence of severe nausea and vomiting within the first \n24 h post-procedure. This supports the inclusion of dexa-\nmethasone as an adjunctive treatment to enhance patient \nrecovery and comfort post-UAE [53, 54].\nUAE for adenomyosis significantly improves short-\nterm and long-term symptoms. In our study, symptom \nimprovement was reported in at least 50% of patients \nacross all studies, with an average of 76.4% experienc -\ning significant symptom relief. The primary symptoms \naddressed were heavy menstrual bleeding, chronic pel -\nvic pain, and bulk-related symptoms, and the majority of \npatients with therapy-resistant adenomyosis experienced \nimprovement of these symptoms and preservation of the \nuterus. Follow-up periods ranged from 3 to 88 months, \naveraging 31 months, confirming that UAE is a good ther-\napy for adenomyosis in the short-, mid-, and long-term \nperiod. Interestingly, in some studies, longer follow-up \nperiods often revealed a rebound in symptoms, highlight-\ning the importance of sustained post-procedural moni -\ntoring through imaging. Bratby and Walker reported a \nconsistent clinical response with an 80% improvement of \nheavy menstrual bleeding up to 1 year; on the other hand, \na 40% recurrence of abnormal menstrual bleeding was \nreported in women with adenomyosis after 2 years post-\nUAE [ 25]; however, none of these women has chosen \nhysterectomy. These data underscore the need for long-\nterm follow-up and possibly supplementary treatments \nto manage persistent symptoms. Hysterectomy was the \nmost common reintervention for recurrence of symp -\ntoms, followed by secondary embolization and curettage. \nFactors influencing reintervention rate included the pres-\nence of fibroids alongside adenomyosis and the higher \ninitial thickness of the JZ. Froeling et  al. highlighted \nthat patients with predominant uterine leiomyoma and \nadenomyosis were more likely to require reinterventions, \nemphasizing the need for personalized treatment plans \nbased on initial patient characteristics [27]. Smeets et al. \nidentified thicker JZ as a predictor for hysterectomy dur -\ning long-term follow-up, while no relation with the need \nof hysterectomy or clinical outcome was found in patient \nwith the coexistence of fibroids [39].\nMorphological changes such as uterine volume and \njunctional zone thickness reduction after UAE were con -\nsistently observed across all studies that evaluated it, with \nan average reduction in uterine volume of 36.5% and in \nJZ thickness of 37.2%. Most uterine volume reductions \nhave been confirmed by MRI within 3 to 12 months post-\nprocedure, suggesting that the effectiveness of UAE in \nreducing uterine volume might be time-dependent. This \naspect is crucial for clinicians in setting realistic expec -\ntations and planning follow-up care for patients. Uterine \nvolume reduction was also related with relief of bulky \nsymptoms. However, despite some authors hypothesized \nthat the reduction in uterine volume in patients with \nfibroids could be related to a reduction in the volume of \nthe fibroids themselves, others have demonstrated that \nthere was no difference in uterus volume between the \npatients with pure AD or AD combined with fibroids \nand that improvement of symptoms after UAE was not \nrelated to the presence of fibroids [45]. Increased endo -\nmetrial cavity and JZ thickness also contributes to abnor-\nmal menstrual bleeding because the higher vessel density \nassociated with adenomyosis; furthermore, total uterine \nsize may worsen bulky symptoms and pelvic pain. Zhou \net al. indicated the high grade of vascularity in adenomy -\nosis as a factor which could be predict a better response \nto UAE [46]. On the same direction, Hu et  al. analyzed \nthe improvement of dysmenorrhea and menorrhagia in \npatients with the absence of contrast enhancement on \nT1-weighted images of the uterus in postoperative MRI, \nsuggesting the necrosis of adenomyotic tissue as a pre -\ndictor for mid-term prognosis and for the absence of \nrecurrence at long-term follow-up [23–30]. Therefore, \nmorphological changes after UAE may explain, in part, \nalleviation of symptoms. Our data on change in uterine \n\nPage 13 of 15\nIni’ et al. CVIR Endovascular            (2026) 9:87 \n \nvolume and JZ falls within the range reported in the lit -\nerature [32, 41].\nPermanent amenorrhea occurred in 2.6% of patients \nacross 22 studies, and all those patients were > 40 years. \nThis complication might result from ovarian ischemia \ndue to non-targeted embolization through utero-ovar -\nian anastomoses. Thus, ovary function and the study of \nutero-ovarian anastomoses on DSA must be investigated \nbefore embolization [55].\nIn recent years, minimally invasive interventional radi -\nology techniques to treat symptomatic AD have gained \nattraction as a uterine-sparing therapy with low hospital \nstay and complication rate. To date, our work confirms \nprevious studies analyzing most recent large-scale stud -\nies on UAE of adenomyosis [56, 57].\nLimitations and future perspectives\nOur systematic review presents several limitations. The \nanalysis of the articles included in our study was mainly \nbased on retrospective studies, making clinical and statis-\ntic data inhomogeneous, and subjecting to bias common \nto all retrospective studies. Furthermore, randomized \ncontrolled trials (RCT) on this topic are still lacking, \nmaking it difficult to demonstrate the effectiveness of \nthe treatment. The only “Quality of Life after Emboliza -\ntion vs Hysterectomy in Adenomyosis” (QUESTA) mul -\nticenter randomized controlled trial was converted into \na prospective cohort study [40]. These aspects represent \nan important limit in terms of the scientific evidence. \nDifferent studies analyzed cohort of patients with both \nadenomyosis and fibrosis, making it difficult to distin -\nguish whether improvement of symptoms after UAE \nwas related to the treatment of adenomyosis, fibroids, \nor both. Regarding symptom control, the criteria for \nimprovement of heavy menstrual bleeding and/or dys -\nmenorrhea relied mainly on subjective patient assess -\nment, with no questionnaire that specifically evaluates \nadenomyosis. The use of different scales and question -\nnaires was not standardized among studies and a harmo -\nnization or sensitivity analysis of results was difficult to \nimplement. In this perspective, the impact of UAE on fer-\ntility and pregnancy rates, the association of adenomyosis \nand endometriosis, and the correlation between known \nimaging features with the clinical presentation of adeno -\nmyosis need to be studied and developed, representing \nimportant diagnostic and prognostic values of the dis -\nease. As part of this ongoing research, it will be beneficial \nto calculate the volume of ischemic myometrium in rela -\ntion to the total uterine volume. This measurement could \nprovide further insights into the efficacy of UAE and help \nrefine treatment protocols to achieve the best possible \noutcomes for patients with adenomyosis. These could \nrepresent interesting future perspectives and require fur -\nther studies on this topic.\nConclusions\nThis systematic review underscores the effectiveness of \nUAE as an alternative treatment in managing therapy-\nresistant adenomyosis, particularly in providing signifi -\ncant symptom relief, substantial morphological changes, \nand long-term preservation of the uterus. Fertility pres -\nervation in patients with adenomyosis also offers an addi-\ntional chance of becoming pregnant compared to other \npharmacological or surgical treatments. Improvements \nin heavy menstrual bleeding, chronic pelvic pain, and \nbulk-related symptoms in up to 96% of patients, associ -\nated with low complication rate following UAE, contrib -\nute to a better quality of life for patients during short- and \nlong-term follow-up. Pain management strategies show \nconsiderable promise in enhancing post-procedural \noutcomes.\nFuture research should aim to standardize emboliza -\ntion techniques and materials, and exploring long-term \noutcomes will be crucial in optimizing patient care and \nmanagement strategies. These findings support the \nneed for personalized treatment plans and suggest that \nwomen should have access to consult with interventional \nradiologists when making any treatment decision for \nadenomyosis.\nAbbreviations\nUAE  Uterine artery embolization\nAUB  Abnormal uterine bleeding\nTAS  Transabdominal sonography\nTVS  Transvaginal sonography\nMRI  Magnetic resonance imaging\nPOI  Premature ovarian insufficiency\nPVA  Polyvinyl alcohol particles\nTAGM  Tris-acryl gelatin microspheres\nUV  Uterine volume\nJZ  Junctional zone\nHRQOL  Health-related quality of life questionnaire\nSSS  Symptom severity scores\nQoF  Quality of Life questionnaire\nVAS  Visual Analogue Scale\nDSA  Digital subtraction angiography\nAcknowledgements\nNot applicable.\nAuthors’ contributions\nCorrado Ini’: Conceptualization; Data curation; Resources; Formal analysis; \nInvestigation; Methodology; Project administration; Supervision; Validation; \nVisualization; Writing – original draft; Writing – review and editing. Concetta \nTimpanaro: Conceptualization; Data curation; Resources; Formal analysis; \nInvestigation; Methodology; Project administration; Supervision; Validation; \nVisualization; Writing – original draft; Writing – review and editing. Pietro \nValerio Foti: Conceptualization; Data curation; Resources; Formal analysis; \nInvestigation; Methodology; Project administration; Supervision; Validation; \nVisualization; Writing – original draft; Writing – review and editing. Francesco \nTiralongo: Conceptualization; Investigation; Methodology; Supervision; \nValidation; Visualization; Writing – original draft; Writing – review and editing. \nRenato Farina: Conceptualization; Investigation; Methodology; Supervision; \n\nPage 14 of 15Ini’ et al. CVIR Endovascular            (2026) 9:87 \nValidation; Visualization; Writing – original draft; Writing – review and editing. \nFederica Libra: Conceptualization; Investigation; Methodology; Supervision; \nValidation; Visualization; Writing – original draft; Writing – review and editing. \nDavide Giuseppe Castiglione: Conceptualization; Investigation; Methodology; \nSupervision; Validation; Visualization; Writing – original draft; Writing – review \nand editing. Francesco Vacirca: Conceptualization; Investigation; Methodology; \nSupervision; Validation; Visualization; Writing – original draft; Writing – review \nand editing. Roberto Milazzotto: Conceptualization; Investigation; Methodol-\nogy; Supervision; Validation; Visualization; Writing – original draft; Writing \n– review and editing. Corrado Spatola: Conceptualization; Resources; Investi-\ngation; Methodology; Supervision; Validation; Visualization; Writing – original \ndraft; Writing – review and editing. Maria Chiara Lo Greco: Conceptualization; \nResources; Investigation; Methodology; Supervision; Validation; Visualiza-\ntion; Writing – original draft; Writing – review and editing. Giuseppe Messina: \nResources; Investigation; Supervision; Validation; Visualization; Writing – review \nand editing. Emanuele David: Conceptualization; Resources; Investigation; \nMethodology; Supervision; Validation; Visualization; Writing – original draft; \nWriting – review and editing. Stefano Palmucci: Conceptualization; Resources; \nInvestigation; Methodology; Supervision; Validation; Visualization; Writing – \noriginal draft; Writing – review and editing. Antonio Basile: Conceptualization; \nResources; Investigation; Methodology; Supervision; Validation; Visualization; \nWriting – original draft; Writing – review and editing.\nFunding\nThe authors received no financial support for the research, authorship, and/or \npublication of this article.\nData availability\nThe datasets used and/or analyzed during the current study are available from \nthe corresponding author on reasonable request.\nDeclarations\nEthics approval and consent to participate\nNot applicable.\nConsent for publication\nNot applicable.\nCompeting interests\nThe authors declare that they have no competing interests.\nAuthor details\n1 Department of Medical Surgical Sciences and Advanced Technologies \n“G.F. Ingrassia” – Radiology I Unit, University Hospital Policlinico “G. Rodolico-\nSan Marco” , Via Santa Sofia 78, Catania 95123, Italy. 2 NANOMED-Research \nCentre for Nanomedicine and Pharmaceutical Nanotechnology, University \nof Catania, Catania 95125, Italy. 3 Centro di Ricerca Multidisciplinare “Chirurgia \ndelle Sindromi Malformative Complesse della Transizione e dell’Età Adulta” \n(ChiSMaCoTA), Department of Medical Surgical Sciences and Advanced Tech-\nnologies “G.F. Ingrassia” , University of Catania, Catania 95123, Italy. 4 Radiation \nOncology Unit, University Hospital Policlinico “G. Rodolico-San Marco” , Cata-\nnia 95123, Italy. 5 Radiation Oncology Unit, Department of Biomedical, Dental \nand Morphological and Functional Imaging Sciences, University of Messina, \nMessina 98122, Italy. 6 UOSD I.P .T.R.A., Department of Medical Surgical Sciences \nand Advanced Technologies “GF Ingrassia” , University of Catania, University \nHospital Policlinico “G. Rodolico-San Marco” , Catania, Italy. \nReceived: 31 January 2026   Accepted: 19 June 2026\nReferences\n 1. Bulun SE, Yildiz S, Adli M, Wei JJ. Adenomyosis pathogenesis: insights from \nnext-generation sequencing. Hum Reprod Update. 2021;27(6):1086–97.\n 2. Genc M, Genc B, Cengiz H. Adenomyosis and accompanying gynecologi-\ncal pathologies. Arch Gynecol Obstet. 2015;291(4):877–81.\n 3. Levy G, Dehaene A, Laurent N, Lernout M, Collinet P , Lucot JP , et al. An \nupdate on adenomyosis. Diagn Interv Imaging. 2013;94(1):3–25.\n 4. Taran F, Stewart E, Brucker S. Adenomyosis: epidemiology, risk factors, \nclinical phenotype and surgical and interventional alternatives to hyster-\nectomy. Geburtshilfe Frauenheilkd. 2013;73(9):924–31.\n 5. Vannuccini S, Petraglia F. Recent advances in understanding and manag-\ning adenomyosis. F1000Res. 2019;8:283.\n 6. Zhai J, Vannuccini S, Petraglia F, Giudice LC. Adenomyosis: mechanisms \nand pathogenesis. 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Roop S, Patel S, Zhang M, et al. Uterine artery embolization for adeno-\nmyosis: a review of imaging, techniques, complications and outcomes. \nCurr Obstet Gynecol. 2023;12:186–97.\nPublisher’s Note\nSpringer Nature remains neutral with regard to jurisdictional claims in pub-\nlished maps and institutional affiliations.","source_license":"public-domain-us","license_restricted":false}