Update on Endovascular Therapy for Fibroids and Adenomyosis

Abstract

Uterine fibroids and adenomyosis are prevalent benign neoplasms that can lead to serious deleterious health effects including life-threatening anemia, prolonged menses, and pelvic pain; however, up to 40% of women remain undiagnosed. Traditional treatment options such as myomectomy or hysterectomy can effectively manage symptoms but may entail longer hospital stays and hinder future fertility. Endovascular treatment, such as uterine artery embolization (UAE), is a minimally invasive procedure that has emerged as a well-validated alternative to surgical options while preserving the uterus and offering shorter hospital stays. Careful patient selection and appropriate techniques are crucial to achieving optimal outcomes. There have been advancements in recent times that encompass pre- and postprocedural care aimed at enhancing results and alleviating discomfort prior to, during, and after UAE. Furthermore, success and reintervention rates may also depend on the size and location of the fibroids. This article reviews the current state of endovascular treatments of uterine fibroids and adenomyosis.

Keywords: adenomyosis; embolization; fibroid; interventional radiology; uterine artery embolization.

Fig. 1

The subtypes of fibroids according to FIGO classification are categorized into two groups based on the presence or absence of submucosal components. Fibroids with submucosal components include Type 0 (pedunculated intracavitary), Type 1 (submucosal component ≥50%), Type 2 (submucosal component <50%), and hybrid fibroids (Types 2–5). On the other hand, fibroids without submucosal components include Type 3 (intramural fibroids with endometrial contact), Type 4 (intramural fibroids with no endometrial contact), Type 5 (intramural fibroids with ≥50% subserosal component), Type 6 (intramural fibroids with <50% subserosal component), Type 7 (pedunculated subserosal), and Type 8 (nonmyometrial location, such as cervical, broad ligament, or parasitic fibroids). EIA, external iliac artery; IIA, internal iliac artery. (Digital illustration by Merve Ozen, MD.)

Fig. 2

( a ) Type 1 refers to the most common scenario where the uterine artery arises from the inferior gluteal artery. ( b ) In Type 2, the uterine artery is the second or third branch of the inferior gluteal artery, while other branches like the internal pudendal artery may be the first. ( c ) Type 3 is characterized by the inferior gluteal, superior gluteal, and uterine arteries all originating at the same level (trifurcation). ( d ) Finally, Type IV is when the uterine artery originates before the inferior gluteal and superior gluteal arteries. (Digital illustration by Merve Ozen, MD.)

Fig. 3

A 34-year-old woman presented with heavy and prolonged menstrual bleeding, pelvic pain, and pressure symptoms. She conducted her own research after being presented with only hysterectomy as a treatment option and came to our clinic seeking care. ( a ) Pre-UAE (uterine artery embolization) sagittal T1-weighted fat-saturated contrast-enhanced (CE) image shows multiple enhancing fibroids. ( b ) Preembolization digital subtraction angiography (DSA) of the left UA from the transverse UA segment (arrow) shows hypertrophic UA and opacification of multiple fibroids. ( c ) Postembolization left UA DSA shows occluded UA and patent cervico-vaginal branch (arrow). ( d ) Six-month follow-up CE MRI shows the decreased size of the uterus and no enhancement of the fibroids consistent with cystic degeneration. During the clinic follow-up, she expressed resolved heavy, prolonged bleeding and bulk symptoms.