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Randomized Controlled Trial
. 2025 Aug;104(8):1558-1574.
doi: 10.1111/aogs.15165. Epub 2025 May 26.

Quality of life 1 year after uterine artery embolization vs hysterectomy for symptomatic adenomyosis (QUESTA study)

Lisa M Trommelen  1   2 , Annika Semmler  1   2 , Annefleur M de Bruijn  1   2 , Marissa Harmsen  1   2 , Marieke Smink  3 , Petra F Janssen  3 , Ilse van Rooij  3 , Jeroen van Bavel  4 , Peggy Geomini  5 , Jacques W M Maas  5 , Celine M Radder  6 , Paul van Kesteren  6 , Janet Kwee  6 , Erica Bakkum  6 , Marleen de Lange  1   2 , Robert A de Leeuw  1   2 , Freek Groenman  1   2 , Velja Mijatovic  1   2 , Anne Timmermans  1 , Rutger Lely  7 , Armand Lamers  7 , Douwe Vos  8 , Gretel van Hoecke  9 , Otto Elgersma  10 , Huib A A M van Vliet  11 , Lonneke S F Yo  12 , Andries R H Twijnstra  13 , Frank W Jansen  13 , Catharina S P van Rijswijk  14 , Han Kruimer  15 , Carroll M E S N Tseng  15 , Sjors Coppus  16 , Mark Arntz  17 , Aloys F J Wust  18 , Joost G A M Blomjous  18 , Laurens van Boven  19 , Alexander Venmans  20 , Jos W R Twisk  21 , Judith A F Huirne  1   2 , Paul N M Lohle  20 , Wouter J K Hehenkamp  1   2
Affiliations
Randomized Controlled Trial

Quality of life 1 year after uterine artery embolization vs hysterectomy for symptomatic adenomyosis (QUESTA study)

Lisa M Trommelen et al. Acta Obstet Gynecol Scand. 2025 Aug.

Abstract

Introduction: Uterine artery embolization (UAE) is a less-invasive alternative for hysterectomy in therapy-resistant symptomatic adenomyosis. Comparative data are lacking. Our objective is to evaluate the non-inferiority of UAE compared with hysterectomy in improving health-related quality of life (HRQOL) for symptomatic adenomyosis, 1 year post-treatment.

Material and methods: This multicenter randomized controlled trial was converted into a prospective cohort study. It was prospectively registered at 27-07-2015 (NL-OMON55436, https://onderzoekmetmensen.nl/en/trial/55436). From November 2015 to March 2022 participants with symptomatic adenomyosis eligible for hysterectomy were included and offered UAE as an alternative treatment. Primary endpoint was difference in 1-year HRQOL scores between UAE and hysterectomy, using WHO-QOL-Bref and SF-12. Non-inferiority margin was set at five points. Secondary endpoints: WHO-QOL-100 facets "Pain and Discomfort" and "Sexual Activity", adenomyosis-related symptoms, and satisfaction. Multivariable linear mixed models were used. All outcomes were analyzed in the per-protocol population, and repeated in the intention-to-treat population.

Results: Of 101 participants, 51 chose hysterectomy and 50 UAE. Both treatment groups were comparable at baseline, except for employment status, dysmenorrhea score, uterine volume, hemoglobin and CA125 (all adjusted for). Both treatments led to a significant increase in all HRQOL scores after 1 year. The effect differences between UAE and hysterectomy on all HRQOL domains in the per-protocol population were: SF-12 physical β -4.20, (95% CI -9.53 to 1.12), SF-12 mental β -4.95 (95% CI -10.83 to 0.94); WHO-QOL-Bref physical β -7.42 (95% CI -18.51 to 3.68), psychological β -4.28 (95% CI -13.30 to 4.74), social relations β -2.23 (95% CI -13.09 to 8.63) and environment β 0.35 (95% CI -8.39 to 9.09). Non-inferiority of UAE was not demonstrated within the predefined margin. Both hysterectomy and UAE improved "Pain and Discomfort" and "Sexual Activity", with greater effect on pain after hysterectomy (β 17.17, 95% CI 4.94 to 29.41, p = 0.007). More participants were satisfied after hysterectomy (95%) than after UAE (73%).

Conclusions: Both UAE and hysterectomy significantly increased HRQOL for symptomatic adenomyosis. Neither non-inferiority nor inferiority of UAE could be established. One-year HRQOL scores were comparable; some secondary outcomes were in favor of hysterectomy. UAE is a valid less-invasive alternative to hysterectomy, with preservation of the uterus. Hysterectomy remains the treatment of choice for patients seeking a definite solution.

Keywords: adenomyosis; hysterectomy; quality of life; uterine artery embolization.

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Conflict of interest statement

Wouter J.K. Hehenkamp and Paul N.M. Lohle received research funding from Boston Scientific and Merit Medical consecutively. It was investigator‐initiated; the sponsors were not involved in data gathering, analysis, interpretation, or writing. They approved the study protocol beforehand and agreed on the publication of the results, irrespective of the outcome. Both sponsors were manufacturers of embolization material; their product was used during their sponsoring period. The remaining authors report no conflict of interest.

Figures

FIGURE 1
FIGURE 1
Flow diagram.
FIGURE 2
FIGURE 2
Forest plots of effect difference between UAE, with 95% CI, for all HRQOL outcomes at 52 weeks in per protocol population. Dotted vertical line is the non‐inferiority margin (delta 5). <0 favors hysterectomy, >0 favors UAE. Non‐inferiority of UAE can be claimed when the lower bound of the 95% CI does not exceed −5. UAE is inferior when the upper bound of the 95% CI is lower than −5.
FIGURE 3
FIGURE 3
Graphs show the estimated adjusted means (95% CI) at the different timepoints of the different health‐related quality of life (HRQOL) scores as a result of the linear mixed model analyses in the per protocol population. All HRQOL scores range from 0 to 100. Asterisk (*): Significant (p ≤ 0.05) effect difference.
FIGURE 4
FIGURE 4
Graphs show the plotted adjusted means with 95% CI of WHO‐QOL‐100 facet Pain and Discomfort (A) and facet Sexual Activity (B) in per protocol population. A lower score in facet Pain and Discomfort means higher quality of life; a higher score in facet Sexual Activity scores higher in quality of life. Significant differences between groups per time point are marked with an asterisk (*). All HRQOL scores range from 0 to 100.
FIGURE 5
FIGURE 5
Plotted adjusted pain scores (NRS) at different time points for UAE and Hysterectomy in per protocol population. Average NRS score (A) and NRS score at time of questionnaire (B) improved significantly at every time point for both groups. Significant differences between groups per time point are marked with an asterisk (*).
FIGURE 6
FIGURE 6
Severity of symptoms (no, less, same or more symptoms) at different follow‐up moments in comparison to before the intervention (Per‐protocol population). (A) Pain now (at time of filling out questionnaire). (B) Pain average in the last 6 weeks. (C) Pelvic pressure in the last 6 weeks. (D) Problems with defecation. (E) Urinary incontinence. (F) Micturition frequency.
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