{"paper_id":"4a6aa7ba-2a7a-4675-9646-568efba720ea","body_text":"E D U C A T I O N A L R E V I E W Open Access\nManagement of uterine adenomyosis:\ncurrent trends and uterine artery\nembolization as a potential alternative to\nhysterectomy\nRiham Dessouky 1*, Sherif A. Gamil 2, Mohamad Gamal Nada 1, Rola Mousa 1 and Yasmine Libda 1\nAbstract\nAdenomyosis is a challenging clinical condition that is commonly being diagnosed in women of reproductive age.\nTo date, many aspects of the disease have not been fully understood, making management increasingly difficult.\nOver time, minimally invasive diagnostic and treatment methods have developed as more women desire uterine\npreservation for future fertility or to avoid major surgery. Several uterine-sparing treatment options are now\navailable, including medication, hysteroscopic resection or ablation, conservative surgical methods, and high-\nintensity focused ultrasound each with its own risks and benefits. Uterine artery embolization is an established\ntreatment option for uterine fibroids and has recently gained ground as a safe and cost-effective method for\ntreatment of uterine adenomyosis with promising results. In this review, we discuss current trends in the\nmanagement of uterine adenomyosis with a special focus on uterine artery embolization as an alternative to\nhysterectomy.\nKeywords: Adenomyosis, Uterine artery embolization, Hysterectomy\nKey points\n/C15Uterine artery embolization (UAE) seems to be the\nmost promising uterine-sparing, minimally invasive\ntreatment option for adenomyosis.\n/C15Results of ongoing randomized controlled trial\n(QUESTA) will soon show whether UAE can be\nvalidated as a treatment option for adenomyosis.\n/C15Ability to preserve fertility will be one of the main\nfactors determining whether UAE can replace\nhysterectomy in treatment of adenomyosis, but\nfurther randomized controlled trials are needed.\nIntroduction\nAdenomyosis is defined by the abnormal location of\nendometrial tissue within the myometrium associated\nwith hypertrophy or hyperplasia of the myometrial\nstroma [ 1, 2]. Although pathogenesis and etiology of\nadenomyosis remain unknown, two main theories have\nbeen proposed: invagination of the endometrial basal\nlayer and metaplasia of embryonic stem cells [ 3]. Preva-\nlence of adenomyosis varies widely from 5 to 70% [ 4–7]\nwith recent studies showing about 20% prevalence [ 8–\n10] among which the majority were premenopausal.\nDespite the absence of specific (pathognomonic) diag-\nnostic features for uterine adenomyosis, typical symp-\ntoms include menorrhagia, chronic pelvic pain, and\ndysmenorrhea [ 11]. These symptoms are commonly en-\ncountered in other gynecological disorders including\nleiomyomas and endometriosis, often confounding the\nclinical diagnosis [ 12].\nFor more than a century, diagnosis was dependent on\nhistopathologic examination of post-hysterectomy speci-\nmens till the introduction of noninvasive ultrasound and\nMR techniques [ 13]. Since then, several studies have il-\nlustrated high sensitivities and specificities for both\ntwo-dimensional transvaginal sonography (TVS) and\nmagnetic resonance imaging (MRI) [ 13–17]. Current\n© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0\nInternational License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and\nreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to\nthe Creative Commons license, and indicate if changes were made.\n* Correspondence: rihamdessouky@gmail.com\n1Radiology Department, Faculty of Medicine, Zagazig University, Koliat Al Tob\nStreet, Zagazig 44519, Egypt\nFull list of author information is available at the end of the article\nInsights into ImagingDessouky et al. Insights into Imaging           (2019) 10:48 \nhttps://doi.org/10.1186/s13244-019-0732-8\n\ntreatment options for symptomatic adenomyosis include\nhysterectomy, medication, conservative surgery, or min-\nimally invasive techniques including uterine artery\nembolization [ 18]. To date, hysterectomy remains the\ndefinitive treatment. This is mainly due to difficult diag-\nnosis, the diffuse nature of the disease, and little\nevidence-based literature needed to standardize treat-\nments [ 19]. This consequently results in a management\ndilemma, particularly in symptomatic patients who wish\nto preserve their uterus [ 18].\nUterine artery embolization (UAE) was first described\nin 1995 by Ravina et al. [ 20] then later established as an\neffective treatment option for patients with symptomatic\nuterine fibroids [ 21, 22]. Since then, UAE has been in-\nvestigated as a noninvasive treatment option for adeno-\nmyosis with initial promising results [ 23, 24]. What\nremains to be known is whether UAE can be validated\nas a safer, noninvasive, uterine-sparing alternative to\nhysterectomy. This article summarizes current trends in\nmanagement of uterine adenomyosis with special focus\non the emerging role of UAE.\nEtiology\nThe precise etiology and pathophysiology leading to the\ndevelopment of adenomyosis remains undetermined.\nSeveral theories have been introduced, including trau-\nmatic, immunological, hormonal, metaplastic, and stem\ncell [ 25]. Traumatic and immunological theories suggest\ndisruption of endometrial-myometrial interface with in-\nvagination of eutopic (normally located) endometrial\ncells [ 26, 27], while hormonal, metaplastic, and stem cell\ntheories rely on the altered behavior of atopic (displaced)\ncells [ 28–30]. These mechanisms, in addition to various\nrisk factors, such as age, parity, previous uterine surgery,\nsmoking, ectopic pregnancy, antidepressant, and tamoxi-\nfen therapies, are believed to contribute to the develop-\nment of adenomyosis [ 19]. Regardless of etiology,\nhistopathologic features remain the same, and definitive\ndiagnosis is established by the presence of “ectopic,\nnon-neoplastic, endometrial glands and stroma sur-\nrounded by hypertrophic and hyperplastic myometrium ”\non hysterectomy specimens [ 1].\nDiagnosis\nAdenomyosis remains an underdiagnosed condition.\nThis is largely due to lack of pathognomonic symptoms\nrelated to this condition [ 31]. Symptomatic patients\nvaryingly present with menorrhagia, dysmenorrhea,\nchronic pelvic pain, dyspareunia, and subfertility [ 32–\n34], and up to 30% of patients are asymptomatic [ 34].\nFurthermore, confounding coexisting pathologies (usu-\nally fibroids and endometriosis) add to the difficulty of\ndiagnosis, as both entities present with similar clinical\nfeatures [ 31].\nRole of ultrasound and MRI in diagnosis\nWith the introduction and advancement of ultrasound\nand MR techniques, various criteria have been utilized\nin the noninvasive narrowing of the clinical differen-\ntial [ 15, 35, 36], determining the depth of myometrial\ninvasion and monitoring treatment response [ 37].\nTransvaginal ultrasound (TVS) represents a cost-effective\ninitial screening modality for adenomyosis. Ultrasound fea-\ntures of adenomyosis can be divided into direct or indirect\nfeatures (Fig. 1). Direct features are due to the presence of\nendometrial tissue within the myometrium, and indirect\nfeatures are due to a hypertr ophied myometrium as de-\nscribed by Atri et al. [ 38]. T able1 describes ultrasound fea-\ntures of adenomyosis as described in previous literature\n[14, 16, 38–43]. To report the diagnostic accuracy of TVS\nin adenomyosis, several meta-analyses have been published\n[17, 44–46]. Estimated pooled sensitivities of 72 to 82%,\npooled specificities of 81 to 85%, and pooled positive likeli-\nhood ratios 3.7 to 4.67 have been reported [ 17, 44]; how-\never, one meta-analysis suggested that variability between\nstudies does not allow for accurate statistical pooling [ 45].\nWith the introduction of col or and power Doppler ultra-\nsound, three-dimensional TVS and elastography techniques\nto the work-up of adenomyosis, there is promise for further\nimprovement in diagnostic accuracy [46].\nMagnetic resonance imaging (MRI) represents a\nsecond line, detailed imagin g modality for the detec-\ntion of adenomyosis (Fig. 2). Similar to ultrasound,\nvarious direct and indirect features can be used to\ndescribe adenomyosis, but need more knowledge of\nuterine anatomy and its cyclic variations [ 36]. Table 1\ndescribes MRI features of adenomyosis as described\nin previous literature [ 14–16, 35, 47]. Few prospective\nstudies have evaluated the diagnostic accuracy of MRI\nin the diagnosis of adenomyosis [ 15, 16, 48]. These\nstudies have reported sen sitivity between 70 and 93%\nand specificities between 86 and 93%. Despite being\nless operator dependent, MRI needs more reader ex-\nperience and optimization of imaging technique to\nachieve higher diagnostic accuracy [ 36].\nClassification of adenomyosis\nThe use of complex imaging techniques has revealed\nvarious subtypes of adenomyosis, often associated with\nhistopathologic variation in glandular and muscular\ncomponents [ 31]. Furthermore, initial studies have\nlinked various imaging criteria to symptoms of adeno-\nmyosis [ 49–51]. Therefore, the need for a more holistic\napproach to identify various disease characteristics incorp-\norating symptomatology, morphology, and pathologic fea-\ntures is rising in order to improve the diagnostic accuracy\nand adequately guide treatment decisions. Important fac-\ntors to be included in classification systems would be the\nsite and location of pathology, configuration, and size/\nDessouky et al. Insights into Imaging           (2019) 10:48 Page 2 of 9\n\nvolume relative to the total myometrial thickness [ 31].\nMost recent ultrasound and MR classification and report-\ning systems have been developed by Van den Bosch et al.\n[52] and Bazot [ 36, 53] respectively, but the clinical rele-\nvance remains to be tested.\nTreatment\nAs with many aspects of adenomyosis, treatment re-\nmains controversial. Important factors to be considered\nand discussed with patients are age, symptom severity,\ndesire for future conception, and associated comorbidi-\nties [ 32, 54, 55]. Recent studies estimate a prevalence of\nadenomyosis among females younger than 40 years to be\nabout 20–30%, while in the rest of the patients, diagnosis\nis usually established in the fourth or fifth decade [ 55–57].\nFurthermore, diffuse adenomyosis, depth of invasion, and\ncoexisting fibroids and/or endometriosis are associated\nwith increased frequency/severity of symptoms and repro-\nductive complications [ 31, 49, 58–60]. Currently, treat-\nment is on a case by case basis, and hysterectomy remains\nthe definitive treatment in patients who are willing and do\nnot wish for future fertility. With the introduction of\nassisted reproductive techniques, delayed age of concep-\ntion, and availability of minimally invasive treatment op-\ntions, the shift from hysterectomy as the “go to ” option\nseems inevitable.\nMedical treatment\nMedical treatment is the first-line treatment option\nfor adenomyosis aiming to relieve symptoms and\nmaintain fertility with the least possible side effect.\nThis is achieved by disrupting pathways leading to\nFig. 1 Direct and indirect imaging features of adenomyosis on ultrasound. a Small posterior wall myometrial cysts (open arrows). b Poorly\ndefined endo-myometrial interface (solid arrow). c Diffuse myometrial heterogeneity with hyperechoic linear striations (three arrows). d Diffuse\nasymmetric widening of the posterior myometrial wall with hyperechoic nodules (four arrows)\nTable 1 Direct and indirect imaging features of adenomyosis\nImaging\nfeature\nUltrasound description MR description\nDirect\nfeatures\nTiny myometrial cysts Tiny myometrial cysts\nHyperechoic nodules or striations Myometrial foci of high signal intensity on T1-\nweighted imagesPoor definition of the endometrial-myometrial interface\nIndirect\nfeatures\nDiffuse myometrial heterogeneity associated thin hypoechoic linear striations within a\nheterogeneous myometrium\nJunctional zone thickening\nAbnormal myometrial signal intensity\nDiffuse asymmetric or symmetric widening of the myometrial walls Large, regular, asymmetric uterus without\nleiomyomas\nDessouky et al. Insights into Imaging           (2019) 10:48 Page 3 of 9\n\ninflammation, neuroangiogenesis, and impaired apoptosis\n[61]. Currently, several hormonal and non-hormonal op-\ntions, namely gonadotropin-releasing hormone (GnRH)\nanalogues, progestins, combined oral contraceptives, and\nnon-steroidal anti-inflammatory drugs are being used in\nan “off label ” manner for the symptomatic treatment of\nadenomyosis [57, 62]. Also, newer drugs, such as aroma-\ntase inhibitors, have been investigated by Badawy et al.\nand Tosti et al. [ 63, 64], while other therapies such as se-\nlective progesterone receptor modulators, GnRH antago-\nnists, valproic acid, and anti-platelet therapies are still\nunder investigation [55].\nThe main advantage of medication is symptomatic re-\nlief without the need for surgical treatment. Neverthe-\nless, many drawbacks still need to be addressed. This\nincludes the temporary relieve of symptoms, and the\ncommon (i.e., menopausal symptoms, irregular bleeding,\namenorrhea) and occasionally severe (i.e., thrombo-\nembolic) side effects of some drugs. Lack of evidence\nneeded to base choice of drugs also raises the need to\nperform research into the comparative efficacy of cur-\nrently used drugs and develop a more standardized ap-\nproach for patients wanting to conceive while using\nmedication. With a better understanding of pathogenetic\nmechanisms of adenomyosis, advances in drug develop-\nment will soon be possible [ 55].\nMinimally invasive techniques\nThese are second-line treatment options aiming to cure\nsymptoms and preserve the uterus in patients with failed\nmedical therapy. Conservative surgical treatments aim to\nremove adenomyosis and preserve the remaining normal\nuterine muscles through laparotomy, laparoscopy, hys-\nteroscopy, or combined approach. Excisional adenomyo-\nmectomy involves the complete removal of focal lesions\n(adenomyomas), while myometrectomy is the surgical\ndebulking of diffuse adenomyosis. Non-excisional treat-\nments aim to induce necrosis of focal or diffuse\nadenomyosis through selective vascular occlusion or fo-\ncused ultrasound/thermal energy without direct tissue\ndissection. In some cases, a combination of surgical and\nnon-excisional methods, i.e., hysteroscopic resection/ab-\nlation, are used to achieve maximum cytoreduction and\nreduce myometrial tissue damage.\nConservative surgical treatment\nDebulking/cytoreductive surgeries aim to remove visibly\ndiseased tissue with repair of the remaining myometrial\ntissue [ 65]. Several laparotomic techniques have been\ndescribed, including wedge resection and its modifica-\ntions, transverse H-shaped incision [ 66], wedge-shaped\nuterine wall removal [ 67], double and triple flap [ 68, 69],\nand asymmetric dissection methods [ 70]. Laparoscopic\ntechniques have also been described in more focal path-\nology, where longitudinal or transverse incisions [ 71, 72]\nare used to access adenomyotic lesions followed by re-\nsection using monopolar needle or laser knife [ 73, 74],\nbag removal, and repair in layers or using double flaps\n[72, 75]. To date, there is no consensus on the best sur-\ngical method, but initial results are promising. In a sys-\ntematic review by Grigoris et al., dysmenorrhea\nreduction, menorrhagia control, and pregnancy success\nrates ranged from 81 to 82%, 50 to 69%, and 47 to 61%\namong partial versus complete adenomyosis excisions\nrespectively [ 76], and a recent review by Younes et al.\nshowed 75% symptom relief on short-term follow-ups\n[77]. The main issue with conservative surgical methods\nis the high risk for complications, i.e., uterine rupture\nand complicated pregnancy [ 54, 65] (especially in diffuse\nlesions and on long-term follow-up), making this option\nsafer in focal adenomyomas.\nHysteroscopic resection/ablation\nHysteroscopic resection/ablation is a combined treatment\nmethod involving the dissection and or coagulation of cys-\ntic adenomyotic lesions and crypts [ 78–82]. Hysteroscopic\nFig. 2 Coronal (a) and sagittal ( b) T2W 1.5-T pelvic MRI images of a 42-year-old female with persistent pelvic pain following cesarean section\nshow focal thickening of the posterior uterine wall transitional zone (asterisk) with tiny myometrial cyst (solid arrow head), suggesting\nfocal adenomyosis\nDessouky et al. Insights into Imaging           (2019) 10:48 Page 4 of 9\n\nresections can be performed using yttrium aluminum gar-\nnet (YAG) laser, rollerball resection, thermal balloon abla-\ntion, cryoablation, circulated hot fluid ablation, microwave\nablation, bipolar radiofrequency ablation, and electro-\ncoagulation [19].\nHigh-intensity focused ultrasound (HIFU)\nHigh-intensity focused ultrasound (HIFU) is the use of\nintense ultrasound energy directly targeting abnormal\ntissues and their vascularity through heating and cavita-\ntion, sparing the normal surrounding tissues. This\nprocess can be guided and monitored through MRI or\nultrasound [ 83]. High-intensity focused ultrasound has\nbeen used since 2008 for the treatment of adenomyosis\n[84]. Since then, literature has shown promising results\nregarding symptom relief and uterine preservation with\nfew reported complications (namely pain, numbness, va-\nginal or urinary discharge, fever, skin burn, or contact\ndermatitis) [ 83]. Recent studies have also investigated\nthe use of ultrasound contrast agents (microbubbles)\nand hormonal (GnRH) and non-hormonal (metformin)\ntreatments to enhance the efficacy of HIFU. Microbub-\nbles are believed to improve the ablative effects of HIFU\nby changing the acoustic characteristics, thus increasing\nenergy deposition in target tissues, while GnRH and\nmetformin inhibit cellular proliferation and induce apop-\ntosis [ 85–87]. Limited literature on treatment outcomes\nfor HIFU in adenomyosis has shown highly variable re-\nsults regarding symptom and uterine volume reduction\n[88–97]. Rates of menorrhagia, dysmenorrhea, and uter-\nine volume reduction varied widely from 12.4 to 44.8%,\n25 to 100%, and 12.7 to 54% respectively, increasing\ngradually overtime (from 1 to 24 months). Nevertheless,\npaucity of literature comparing HIFU to other minimally\ninvasive treatment options, limited availability, overall\ncost, unknown fertility outcomes, and strict indications,\nincluding lesions no more than 10 cm in diameter [ 88,\n90], no pelvic adhesions [ 84, 89, 90, 93], body weight less\nthan 100 kg [ 98], and abdominal wall thickness less than\n5c m [ 93] may limit its widespread use.\nUterine artery embolization (UAE)\nUterine artery embolization is the use of transarterial\ncatheters aiming to induce more than 34% necrosis\nwithin adenomyotic tissues [ 99, 100]. The technique\nfor UAE in adenomyosis is similar to that used in fi-\nbroids. In many parts of the world, UAE is performed\nunder conscious sedation. Vascular access is gained\nt h r o u g haf e m o r a lo rr a d i a la r t e r yp u n c t u r eu s i n g4–\n6-French (F) arterial sheath for femoral [ 99, 101]a n d\n4-F sheath for radial access [ 102]. Under fluoroscopic\nguidance, aortography is followed by selective and\nsuper selective arteriography using 4 –5-F catheters for\nthe internal iliac and 2 –3-F microcatheters for the\nuterine artery and its branches respectively.\nEmbolization is usually performed using variable-sized\npermanent particulate agents [ 103, 104]. Special atten-\ntion is paid to visualization of the cervicovaginal and\novarian artery branches (Fig. 3). Distal embolization\navoids vaginal necrosis and unwanted reflux of micro-\nspheres into the ovarian artery [ 105].\nDespite being established in fibroids as a cost-effective,\nshort recovery alternative to surgery with minimal com-\nplications [ 19, 23, 100], it was believed to have lower ef-\nficacy in adenomyosis [ 106]. In the past 15 years, UAE\nhas been considerably studied for the treatment of\nsymptomatic adenomyosis [ 107]. Earlier studies by\nPopovic, Keung, and Zhou et al. demonstrate long-term\nimprovement in patient symptoms (in over 60% of pa-\ntients) and a short-term decrease in uterine volumes (in\nover 20% of patients), especially in vascular lesions [ 23,\n107, 108]. Current literature by Dueholm and Bruijn et\nal. show up to 67% long-term (40 month) treatment suc-\ncess and up to and 72% patient satisfaction rates respect-\nively [ 24, 100]. In the latest systematic review and\nmeta-analysis by de Bruijn et al., patients were divided\ninto four groups to report short- and long-term out-\ncomes. Short-term improvement was achieved in 89.6%\nof patients with pure adenomyosis and 94.3% of patients\nwith adenomyosis with fibroids, while long-term im-\nprovement was achieved in 74.0% of patients with pure\nadenomyosis and 84.5% of patients with adenomyosis\nwith fibroids [ 109].\nOverall, UAE shows favorable clinical outcomes, but ran-\ndomized controlled trials are still lacking [ 110]. In an at-\ntempt to fill this gap in knowledge, the “Quality of Life after\nEmbolization vs Hysterectomy in Adenomyosis” (QUESTA)\ntrial was set up. This multicenter non-blinded randomized\ncontrolled trial is currently ongoing in the Netherlands. It\nhas started since November 2015, and its primary outcomes\nare expected by May 2020 [101]. The calculated sample size\nfor this trial was 96 patients (divided into 52 embolization\nand 34 hysterectomy, including a 10% expected drop-out)\nmade on assumptions from the embolization versus hyster-\nectomy (EMMY) trial outcomes [111].\nInclusion criteria were premenopausal women with\nsymptomati c pure adenomyosis or dominant adeno-\nmyosis when both adenomyosis and fibroids coexist\nand women with an indication for hysterectomy (ei-\nther failed or refused medical treatment). Exclusion\ncriteria were patients under 18 years of age, pelvic in-\nfection, suspected or confirmed malignancy, current\nor future desire to conceive, any absolute contraindi-\ncation to angiography, deep infiltrating endometriosis\nrequiring surgery or obstructing the bowel, or coexist-\ning hysteroscopically removable submucous fibroids.\nFollowing selection, TVUS and MRIs were performed\nto confirm the adenomyosis and eligible patients are\nDessouky et al. Insights into Imaging           (2019) 10:48 Page 5 of 9\n\ninformed of the trial. Patients with written informed\nconsents were randomly allocated (in a 2:1 ratio) be-\ntween both experimental intervention (UAE) and\nstandard care control groups (hysterectomy), while\npatients refusing randomization are given the stand-\nard of care (hysterectomy) [ 101].\nFollowing the procedure (UAE or hysterectomy), pa-\ntients are followed up immediately, then at 6 weeks, 3\nmonths, 6 months, 12 months, and 24 months using an\nonline questionnaire system. Three outcome parameters\nwere measured. Primary outcomes (quality of life) were\nmeasured at 6, 12, and 24 months using a combination\nof World Health Organization Quality of Life Scale and\nShort Form-12 Questionnaires. Secondary outcomes\n(clinical, symptom and quality of life, recovery related,\ncost utility analysis, laboratory, and pathology outcomes)\nwere measured at 6 weeks and 3, 6, 12, and 24 months.\nImaging outcomes were also determined to identify po-\ntential predictive parameters for therapy effect using\nspecific TVUS criteria (uterine size/fibroid volume re-\nduction in case of associated fibroids, vascular index by\n3D power Doppler) at baseline, 6 weeks, and 6 months\nand MRI criteria (uterine size/fibroid volume reduction\nin case of associated fibroids, junctional zone reduction,\ninfarction rate, and presence of endometriosis) at base-\nline and at 6 months postprocedure [ 101].\nUAE as an alternative to hysterectomy\nTo date, UAE seems to be the most investigated and\nhighest potential minimally invasive treatment option\nfor adenomyosis. Results of ongoing randomized con-\ntrolled (QUESTA) trial will soon show whether UAE can\nbe validated as a treatment option for adenomyosis. Al-\nthough comparative information regarding quality of life,\npatient satisfaction, side effects, and complications post\nUAE versus hysterectomy will soon be available, ques-\ntions regarding fertility post UAE remain to be an-\nswered. Current American College of Obstetrics and\nGynecology and Society of Interventional Radiology\nguidelines still consider desire for future fertility a rela-\ntive contraindication to UAE, but conflicting reports re-\ngarding effects of UAE on fertility [ 112] still give room\nfor debate. Nevertheless, further randomized studies are\nstill needed to give a clear answer for physicians and pa-\ntients alike.\nIn conclusion, lack of information is the main hur-\ndle to overcome the complexity in management of\nadenomyosis. With randomized controlled trials and\nFig. 3 Digital subtraction angiography (DSA) images (of the same patient in Fig. 2) with selective injections of the left ( a)u t e r i n ea r t e r y\ndemonstrate with multiple tortuous uterine artery branches and ( b) lesion blush (most prominent at the anatomic site of the posterior\nuterine wall). Right uterine artery injection (not shown) was unremarkable for pathology. Post-embolization DSA images show occlusion of\ntoursous feeding vessels ( c) with absence of lesion blush ( d)\nDessouky et al. Insights into Imaging           (2019) 10:48 Page 6 of 9\n\nmore evidence-based research, optimal treatment pro-\ntocols can be developed according to patient needs.\nWhether or not UAE can replace hysterectomy will\nlargely depend on the results of ongoing QUESTA\ntrial and other randomized trials comparing fertility\noutcomes among minimally invasive therapies.\nAbbreviations\nEMMY: Embolization versus hysterectomy; GnRH: Gonadotropin-releasing\nhormone; HIFU: High-intensity focused ultrasound; QUESTA: Quality of Life\nafter Embolization vs Hysterectomy in Adenomyosis; UAE: Uterine artery\nembolization; YAG: Yttrium aluminum garnet\nAcknowledgements\nThe authors would like to acknowledge Prof. Adel Gamil for providing\nultrasound images for this manuscript.\nFunding\nNo funding was received for this work.\nAvailability of data and materials\nNot applicable.\nAuthors’ contributions\nRD contributed to the manuscript preparation and revision. SAG and MGN\ncontributed to the manuscript editing and revision, image collection, editing,\nand preparation. RM and YL contributed to the preparation of the\nmanuscript draft and editing and revision of final manuscript. All authors\nsignificantly contributed to the preparation of this manuscript. All authors\nread and approved the final manuscript.\nEthics approval and consent to participate\nNot applicable.\nConsent for publication\nNot applicable.\nCompeting interests\nThe authors declare that they have no competing interests.\nPublisher’sN o t e\nSpringer Nature remains neutral with regard to jurisdictional claims in\npublished maps and institutional affiliations.\nAuthor details\n1Radiology Department, Faculty of Medicine, Zagazig University, Koliat Al Tob\nStreet, Zagazig 44519, Egypt. 2Radiology Department, Al-Ahrar Teaching\nHospital, Zagazig, Egypt.\nReceived: 15 December 2018 Accepted: 14 March 2019\nReferences\n1. 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J Vasc Interv Radiol 24:925 –930 https://doi.org/10.\n1016/j.jvir.2013.03.014\nDessouky et al. Insights into Imaging           (2019) 10:48 Page 9 of 9","source_license":"CC0","license_restricted":false}