{"paper_id":"de8f84e0-36d7-4a51-b804-d9dfdbdf3f14","body_text":"© 2020 The Arab Journal of Interventional Radiology | Published by Wolters Kluwer - Medknow 117\nAddress for correspondence:  \nDr. Ibrahim Alrashidi, \nPrince Sultan Military Medical \nCity, Riyadh, Saudi Arabia. \nE‑mail: dr.Ialrashidi@gmail.\ncom\nAccess this article online\nWebsite: www.arabjir.com\nDOI: 10.4103/AJIR.AJIR_30_19\nQuick Response Code:\nAbstract\nAim: The aim of the study was to assess clinical outcomes following uterine artery \nembolization (UAE) in the treatment of dysmenorrhea and menorrhagia related to pure adenomyosis. \nMaterials and Methods:  This was a retrospective analysis of 14 patients with dysmenorrhea and \nmenorrhagia related to pure adenomyosis treated with UAE using polyvinyl alcohol (PV A) between \nJanuary 2017 and September 2019. The baseline and 3-month and 12-month postintervention \noutcomes were assessed using Uterine Fibroid Symptom-Health-Related Quality of Life \nQuestionnaire (UFS-QOL), Symptom Severity Score (SSS), and magnetic resonance imaging \nfindings. The median age of the patients was 47 years (28–55). The main clinical presentation \nwas dysmenorrhea and menorrhagia, with a median duration of symptom of 24 (12–84) months. \nAll patients received combined estrogen-progestin and nonsteroidal anti-inflammatory drugs prior \nto UAE without clinical improvement. Results: According to UFS-QOL and SSS results, the score \nfor distress level was statistically significantly reduced from baseline 4.6 (3.6–5) to 2.25 (1–3.37) \n(P = 0. 018) after 3 months, and remained stable 12 months later. The score of symptom level \nwas statistically significantly reduced from 4 (3.6–5) at baseline to 1.6 (1–3.58) (P = 0. 018) after \n3 months with maintained clinical satisfaction after 12-month follow-up. The junctional zone was \nstatistically significantly reduced from baseline with a median of 33.5 mm (19–79 mm) to 25 mm \n(8–77 mm) after 3 and 12 months (P = 0.046). The incidence of post-UAE permanent amenorrhea is \n71% with a mean age of 49 years. No patient underwent hysterectomy during the follow-up period. \nConclusion: UAE using PV A can improve the quality of life in patients with menorrhagia and \ndysmenorrhea related to adenomyosis. However, larger prospective studies are needed to establish \nthe long-term outcomes and risk of amenorrhea.\nKeywords: Adenomyosis, dysmenorrhea and uterine fibroid symptom and health‑related quality of \nlife, menorrhagia, uterine artery embolization\nUterine Artery Embolization Improves Quality of Life in Patients with Pure \nAdenomyosis: A Single‑Center Experience\nOriginal Article\nIbrahim Alrashidi1, \nHayat Alharthy2, \nFaisal Alahmari1, \nSultan Alammari1, \nHatim Alobaidi1, \nAbdulwaeed \nAlruhaimi1, \nAbdulaziz \nAlmat’hami1, \nAbdulrahman \nAlkhalifah1,  \nFares Garad1\nDepartments of 1Radiodiagnostics \nand Medical Imaging and \n2Obstetric and Gynecology, \nPrince Sultan Military Medical \nCity, Riyadh, Saudi Arabia\nHow to cite this article:  Alrashidi I, Alharthy H, \nAlahmari F, Alammari S, Alobaidi H, Alruhaimi A, \net al. Uterine artery embolization improves quality of \nlife in patients with pure adenomyosis: A single-center \nexperience. Arab J Intervent Radiol  2020;4:117-20.\nThis is an open access journal, and articles are \ndistributed under the terms of the Creative Commons \nAttribution-NonCommercial-ShareAlike 4.0 License, which \nallows others to remix, tweak, and build upon the work \nnon-commercially, as long as appropriate credit is given and \nthe new creations are licensed under the identical terms.\nFor reprints contact: WKHLRPMedknow_reprints@wolterskluwer.com\nIntroduction\nAdenomyosis is defined by Bird \nin 1972 as “the benign invasion of \nendometrium into the myometrium, \nproducing a diffusely enlarged uterus \nwhich microscopically exhibits ectopic \nnonneoplastic, endometrial glands and \nstroma surrounded by the hypertrophic and \nhyperplastic myometrium.” [1] Adenomyosis \ncan be asymptomatic. However, patients \nfrequently present with symptoms of \nmenorrhagia, dysmenorrhea, and other \npossible symptoms, such as dyspareunia, \nchronic pelvic pain, and irritation of the \nurinary bladder. The condition is typically \nfound in women between the ages of 35 \nand 50, but also affects younger women. \nTreatment options consist of hormonal \ntherapy, endometrial ablation, and uterine \nartery embolization (UAE). However, when \nthese therapies fail, hysterectomy may be \nconsidered as a definitive treatment. [2,3] \nUAE was first described in 1995 for the \ntreatment of uterine fibroids (UFs).[4] It has \nbeen established as a valuable treatment \noption for patients with symptomatic \nUFs.[5,6] Since then, UAE has been tried as \na possible treatment option for adenomyosis \nand seems to have a favorable outcome in \nmultiple case series. [7,8] The purpose of this \nstudy is to assess the clinical outcomes \nof UAE in the treatment of symptomatic \nadenomyosis.\nThe symptoms of adenomyosis are \nquite similar to that of UF, and their \nnegative impact on health-related quality \nof life (HRQoL) makes women seek \ntherapy for adenomyosis. Therefore, \npatient-reported outcome measures are \nconsidered appropriate tools to measure \nReceived: 12-11-2019\nRevised: 03-04-2020\nAccepted: 10-04-2020\nOnline Published: 17-08-2020\nArticle published online: 2021-03-26\n\nAlrashidi, et al .: Uterine artery embolization improves quality of life in patients with pure adenomyosis: A single‑center experience\n118 The Arab Journal of Interventional Radiology | Volume 4 | Issue 2 | July-December 2020\nthe impact and outcome of interventions. [9] The Uterine \nFibroid Symptom and Health-Related Quality of Life \nQuestionnaire (UFS-QOL) is widely used to evaluate \npatient-reported UF symptoms and their impact on HRQOL, \nwhich is the only disease-specific instrument developed \nand validated in a population of women with UFs, which \nis believed to be used in adenomyosis study with similar \nsymptoms.[9] This procedure was developed based on \nqualitative input from patients with UFs; the original \nvalidation demonstrated its ability to discriminate between \nwomen with and without UFs and also between varying \npatient-reported disease severity as well. [10] Moreover, the \nUFS-QOL has been shown to be highly responsive and \nadaptive to change following treatment. [9]\nMaterials and Methods\nThe institutional review board has approved this \nretrospective study, and informed consent was waived. \nPatients who underwent UAE for adenomyosis between \nJanuary 2017 and September 2019 were included. This \nsingle-study experience aims to evaluate the role of UAE as \na treatment option to relieve clinical symptoms associated \nwith adenomyosis in patients who failed combined \nestrogen-progestin and nonsteroidal anti-inflammatory drug \ntreatment, and in women who sought to preserve the uterus \nor in nonsurgical candidate treatment.\nA total of 14 women were enrolled with adenomyosis; two \nof them were single, nulliparous patients. The median age \nof the women was 47 years (28–55 years). All participants \nhad menorrhagia and dysmenorrhea with a median \nduration of 24 months (12–84). All women had persistent \nsymptoms after receiving combined estrogen-progestin \nand nonsteroidal anti-inflammatory drug treatment for an \naverage of 12 months.\nPatients were diagnosed with adenomyosis with a median \njunctional zone thickness of 33.5 mm (19–79), based \non magnetic resonance imaging (MRI) with a follow-up \nperiod of 3 months or longer. The mean follow-up period \nfollowing UAE was 6.5 months (range 3–12 months). \nShort-term post-UAE follow-up consisted of an outpatient \nvisit and pelvic MRI at 3 and 12 months. The diagnosis \nwas established clinically and confirmed with MRI.\nPelvic MRI consisted of T2- and T1-weighted \ncontrast-enhanced images and was performed before \nembolization and at 3–12 months post-UAE. MRI findings \nwere blindly reviewed by two radiologists, and the \nfollowing standardized criteria were used for the diagnosis \nof adenomyosis: low myometrial signal intensity on \nT2-weighted images and diffuse or focal thickening of the \njunction zone exceeding 12 mm with or without high signal \nintensity foci corresponding to myometrial cysts. [1,2] At \n3- and 12-month follow-up, the decrease in junction zone \nwas measured on the MRI post treatment. MRI was used \nto assess the uterine volume at baseline and at 3–12 months \npost-UAE, using the formula of an ellipsoid which uses \nthree mutually perpendicular axes that intersect at the center.\nUAE was performed after selective catheterization of both \nuterine arteries through right common femoral approach using \n355–500-µ ( n = 11 patients)/500–700-µ ( n = 3 patients) \npolyvinyl alcohol (PV A) (Contour, Boston Scientific, \nNatick, USA) particles until complete stasis. During and \nafter UAE, intravenous narcotics and antiemetic drugs \nwere administered for adequate pain control and to reduce \nsymptoms, such as nausea and vomiting. All patients \nreceived intravenous 1 g cefazoline 1 h before UAE and \nciprofloxacin 500 mg orally, twice daily for 10 days after \nUAE as prophylaxis.\nOn the day of admission, immediately prior to UAE, \nbaseline clinical status was assessed using the UFS-QOL, \nwhich consists of a Symptom Severity Score (SSS) \nand HRQOL score. [9-11] The UFS-QOL questionnaire \nconsists of an 8-item symptom severity scale containing \nquestions addressing topics, such as menstrual bleeding \ncharacteristics, pelvic pain, urinary discomfort, and \nfatigue. It also contains 29 HRQoL items comprising the \nfollowing six domains: concern, activities, energy/mood, \ncontrol, self-consciousness, and sexual function. [3,4] The \nsame questionnaire was used at post-UAE period of 3 and \n12 months. Women with a SSS <20 in combination with \nan overall health-related QOL score >80 were considered \nasymptomatic.\nData results were analyzed by using descriptive and \ninferential statistics through IBM  SPSS version 20 \n(IBM Corp., Armonk, NY , USA). Descriptive statistics, \nincluding median (minimum–maximum), were calculated \nfor continuous variables such as age, uterus volume, \njunctional zone, and duration of symptoms. Categorical \nvariables such as clinical presentation, hormonal therapy, \nand MRI imaging findings were presented as frequencies \nand percentages, n (%). Uterine volume and junctional \nzone reduction 3 and 12 months following UAE were \ncompared to baseline. A  Wilcoxon signed-rank test was \napplied to compare variables across pre- and post-UAE \nafter a follow-up period of 3 and 12 months.  P <0.05 was \nconsidered statistically significant.\nResults\nUAE procedures are 100% technically successful; no \nimmediate complication has been recorded.\nThe baseline score for distress level was high prior \nto UAE procedure, reaching 4.6 (3.6–5) according to \nUFS-QOL, which was significantly reduced to 2.25 \n(1–3.37) (P = 0.018) 3 months after UAE, and remained \nstable (2.19 [1–3.39]) after 12-month follow-up [Figure 1]. \nThe score of symptoms level statistically significantly \nreduced ( P = 0.018) from baseline 4 (3.6–5) to 1.6 \n(1–3.58) 3 months following UAE and remained stable \n(1.7 [1–3.62]) after 12-month follow-up [Figure 2].\n\n\nAlrashidi, et al .: Uterine artery embolization improves quality of life in patients with pure adenomyosis: A single‑center experience\nThe Arab Journal of Interventional Radiology | Volume 4 | Issue 2 | July-December 2020 119\nThe uterine volume showed no statistically significant \nchange between baseline with a median of 462 ml and \n3 months following UAE with a median of 205.4 ml \n(P = 0.176), and these results are skewed by the single case \nof very large volume. The junctional zone (mm) showed \nstatistically significant reduction from baseline (19–79 mm) \nto (8–77 mm) (P = 0.046) after 3 and 12 months as shown \nin Figure 3 and Table 1.\nPermanent amenorrhea, defined as the absence of menstrual \nperiods for at least 12 months post-UAE, occurred in \n10/14 patients (71%), with a mean age of 49 years. No \npatient underwent hysterectomy during the follow-up \nperiod.\nDiscussion\nThe most noticeable improvement of HRQOL in \npatients with adenomyosis occurred in the first 3 months \npost-UAE and remained stable at 12 months. This finding \nis concordant with a meta-analysis of 15 studies, which \nshowed symptomatic improvement in 75.7% (387/511) at a \nmedian follow-up of 26.9 months. [7]\nPV A particles measuring 355–500 µ have been used in \npatients with symptomatic adenomyosis with promising \nclinical results. [12] This study has demonstrated that PV A \ncan be used with similar good clinical response in patients \nwith symptomatic adenomyosis. PV A was selected for three \nreasons: availability, operator familiarity, and cheaper price \ncompared to other embolic agents, and the small particle \nsize was chosen for deeper penetration into the small \narterioles to achieve the required tissue penetration. In this \nsmall sample study, 10 of 14 women experienced primary \namenorrhea 3–6 months following UAE, with a mean \nage of 49 years. This is higher than what was previously \nreported in the meta-analysis by Popovic  et al. (20.9%)[7] \nand the meta-analysis by de Burijn  et al ., which showed \npersistent amenorrhea in 28 of 445 patients (6.3%) in \n13 studies. However, patients who suffered amenorrhea in \nthe prior studies were older than 45 years[7] and 40 years of \nage,[8] and this may explain the higher rate of amenorrhea \nin the present study due to the older mean age. In this small \nsample study, the symptom and distress level associated \nwith adenomyosis clinically subsided according to \npost-UAE UFS-QOL, which is concordant with Popovic’s \nmeta-analysis review.[7]\nThis study has a number of limitations including its \nretrospective nature, small number of patients, and the \ninherent section bias. Therefore, strong conclusions cannot \nbe drawn about what type of adenomyosis or symptoms \nmay respond best. Second, many patients experienced \npost-UAE amenorrhea that could be related to the older \nmean age.\nThe third limitation is the absence of long-term data, \nlimiting the ability to measure the durability of UAE \nto other medical or surgical treatments. However, UAE \ncan improve the symptoms and distress associated with \nadenomyosis, which, in turn, can improve the patient’s \nquality of life. Larger prospective studies are needed to \nestablish the long-term outcomes and risk of amenorrhea.\nFigure 1: Distress level scores using Uterine Fibroid Symptom‑Health‑Related \nQuality of Life Questionnaire: Pre (baseline) and post (after 3 and 12 months) \nuterine artery embolization follow‑up\n0\n0.5\n1\n1.5\n2\n2.5\n3\n3.5\n4\n4.5\n5\nBaseline Median 0 Medain After 3 Months medin after 12 months\nPre and Post UAE Distress levels scores using UFS–QOL\nFigure 2: Symptom level scores using Uterine Fibroid Symptom and \nHealth‑Related Quality of Life Questionnaire pre (baseline) and post \n(after 3 and 12 months) uterine artery embolization follow‑up\n0\n0.5\n1\n1.5\n2\n2.5\n3\n3.5\n4\n4.5\nBaseline Median 0M edian After 3 Months medin after 12 months\nPre-and-Post UAE Symptom levels scores using UFS–QOL \nFigure 3: A  45‑year‑old patient with dysmenorrhea and menorrhagia \nrelated to adenomyosis sagittal pelvic magnetic resonance imaging \nT2. (a) Preuterine artery embolization junctional zone measures 19 mm \n(two‑head arrows), (b) 3‑month postuterine artery embolization junctional \nzone measures 8 mm (red line)\nba\n\n\nAlrashidi, et al .: Uterine artery embolization improves quality of life in patients with pure adenomyosis: A single‑center experience\n120 The Arab Journal of Interventional Radiology | Volume 4 | Issue 2 | July-December 2020\nConclusion\nUAE using PV A can improve the quality of life in \npatients with menorrhagia and dysmenorrhea related to \nadenomyosis. However, larger prospective studies are \nneeded to establish the long-term outcomes and risk of \namenorrhea.\nAcknowledgments\n1. The UFS-QOL questionnaire was obtained from the \nSIR foundation. We would like to show our gratitude to \nthe SIR foundation for sharing their pearls of wisdom \nwith us during this research, although they may not \nagree with all of the interpretations/conclusions of this \narticle\n2. We thank Dr. Yahya Mahali, body imaging fellow, for \nassistance with the methodology\n3. We would also like to show our gratitude to Rawabi \nM. Alsayer, Research Officer in Scientific Research \nCenter at Prince Sultan Military Medical City, Riyadh, \nKingdom of Saudi Arabia, for helping us in the \nstatistical analysis during the course of this research.\nFinancial support and sponsorship\nNil.\nConflicts of interest\nThere are no conflicts of interest.\nReferences\n1. Bird CC, McElin TW, Manalo-Estrella P. The elusive \nadenomyosis of the uterus—revisited. Am J Obstet Gynecol \n1972;112:583-93.\n2. Li JJ, Chung JP, Wang S, Li TC, Duan H. The Investigation and \nmanagement of adenomyosis in women who wish to improve or \npreserve fertility. Biomed Res Int 2018;2018:6832685.\n3. Azziz R. Adenomyosis: Current perspectives. Obstet Gynecol \nClin North Am 1989;16:221-35.\n4. Ravina JH, Herbreteau D, Ciraru-Vigneron N, Bouret JM, \nHoudart E, Aymard A, et al. Arterial embolisation to treat uterine \nmyomata. Lancet 1995;346:671-2.\n5. de Bruijn AM, Ankum WM, Reekers JA, Birnie E, \nvan der Kooij SM, V olkers NA, et al. Uterine artery embolization \nversus hysterectomy in the treatment of symptomatic uterine \nfibroids: 10-year outcomes from the randomized EMMY trial. \nAm J Obstet Gynecol 2016;215:745.e1-e12.\n6. Goodwin SC, Spies JB, Worthington-Kirsch R, Peterson E, \nPron G, Li S,  et al . Uterine artery embolization for treatment of \nleiomyomata: Long-term outcomes from the FIBROID Registry. \nObstet Gynecol 2008;111:22-33.\n7. Popovic M, Puchner S, Berzaczy D, Lammer J, Bucek RA. \nUterine artery embolization for the treatment of adenomyosis: \nA review. J Vasc Interv Radiol 2011;22:901-9.\n8. de Bruijn AM, Smink M, Lohle PN, Huirne JA, Twisk JW, \nWong C,  et al. Uterine artery embolization for the treatment \nof adenomyosis: A  systematic review and meta-analysis. J Vasc \nInterv Radiol 2017;28:1629-42.e1.\n9. Coyne KS, Margolis MK, Bradley LD, Guido R, Maxwell GL, \nSpies JB. Further validation of the uterine fibroid symptom and \nquality-of-life questionnaire. Value Health 2012;15:135-42.\n10. Spies JB, Coyne K, Guaou Guaou N, Boyle D, \nSkyrnarz-Murphy K, Gonzalves SM. The UFS-QOL, a new \ndisease-specific symptom and health- related quality of life \nquestionnaire for leiomyomata. Obstet Gynecol 2002;99:290-300.\n11. Harding G, Coyne KS, Thompson CL, Spies JB. The \nresponsiveness of the Uterine Fibroid Symptom and \nHealth-Related Quality of Life Questionnaire (UFS-QOL). \nHealth Qual Life Outcomes 2008;6:99.\n12. Kim MD, Kim S, Kim NK, Lee MH, Ahn EH, Kim HJ, et al . \nLong-term results of uterine artery embolization for symptomatic \nadenomyosis. AJR Am J Roentgenol 2007;188:176-81.\nTable 1: Pre (baseline) and post (after 3- and 12-month follow-up) uterine volume and junctional zone\nVariable Median (minimum-maximum) P-Valuea\nPre Post 3-month follow-up Post 12-month follow-up\nWhole uterus (ml) 462 (381-3816) 205.4 (114.4-2714.7) 200.9 (110.7-2689.5) 0.176\nJunctional zone (mm) 33.5 (19-79) 25 (8-77) 24 (8-79) 0.046\naWilcoxon signed-rank test","source_license":"CC0","license_restricted":false}