Expert Answers: Embolization for Endometriosis, Adenomyosis, and Fibroids, Part 1

Dr. Hardee
According to our 2020 Endometriosis In America data, 36 percent of endo warriors are also diagnosed with adenomyosis. To learn about the treatment and management of endometriosis and adenomyosis, we spoke to Dr. Eric Hardee, board-certified vascular interventional radiologist and co-founder of Houston Fibroids and Texas Endovascular Associates. Dr. Hardee has been performing uterine fibroid embolizations in the Houston, Texas, area for over 20 years.

What can you tell us about endometriosis, adenomyosis, and fibroids?

“Adenomyosis is a subset of endometriosis. Endometriosis, in general, is ectopic islands of endometrium growing where it should not be growing. If it grows inside the abdomen or pelvis and gets on the surface of the bladder, the inner lining of the abdomen, or on intestinal loops, it is called endometriosis. That will lead to abdominal and pelvic pain and painful cycles. It can also lead to other issues, like scarring inside the abdomen, that can lead to bowel obstruction or bladder issues. Pure endometriosis is usually a surgical disease process, in which gynecologists, typically with laparoscopic surgery, insert scopes through a few ports in the abdominal wall, they find endometrial implants, and they burn them off with a laser. If there are fluid-filled cystic masses inside the abdomen or pelvis, called endometrioma, these are sometimes called "chocolate cysts," because basically, it's a cyst containing blood products. When these cause pain and other symptoms, they are typically treated with surgical removal.

Adenomyosis is a subset of endometriosis in which endometrial implants grow directly in the wall of the uterus. The uterus is a muscular organ made up of smooth muscle cells. It's made of smooth muscle cells like your heart is, like your blood vessels are. Adenomyosis, which is sometimes called endometriosis of the uterus, is where the endometrial implants can grow directly into the muscular wall of the uterus instead of the abdomen or pelvis. These islands of endometrium are trapped within the muscular wall of the uterus, and they expand and hemorrhage, leading to very painful heavy menstrual cycles along with other symptoms.”

What is your experience treating these conditions?

“Once a patient has endometrial implants inside the uterine muscular wall, it will cause a lot of symptoms, which can overlap with fibroid symptoms such as heavy, painful menstrual cycles. One of the classic additional symptoms of adenomyosis is bloating, which can occur around the time of the menstrual cycle. Also, it's common to experience painful intercourse. These symptoms overlap a lot with the symptoms fibroids cause. So, in our practice, if we see a hundred patients with fibroids that seek us out for uterine fibroid embolization, probably about 20 percent or 25 percent will also have adenomyosis as well as fibroids. A small subset, probably 5 percent of our patients, were told before they have only fibroids, but we do an MRI and, lo and behold, they have no fibroids at all, but they have pure adenomyosis or endometriosis of the uterus.”

How can interventional radiology be applied to treating endometriosis or adenomyosis?

“The treatment we do for adenomyosis is the same as for uterine fibroid embolization, for which we shut the blood flow down to the fibroids by injecting these tiny particles during an angiogram-type procedure. We basically insert a tiny catheter into an artery in the body, either the groin or the wrist. The catheters are so small nowadays, we prefer the wrist because it's more comfortable for the patient. We guide the catheter using x-rays into the pelvis and thread a very tiny microcatheter into the uterine artery. There's 1 uterine artery on each side of the pelvis. Once the catheter is in the uterine artery, we inject these tiny, inert particles that shut down the blood flow to the fibroids. You can also do the same procedure to treat adenomyosis by injecting a different kind of particle smaller in size, and you basically plug up all the tiny blood vessels that supply the adenomyosis tissue that is inside the muscular wall of the uterus. For adenomyosis, I think that embolization is a very good option. It's not a hundred percent, but with embolization there is over 80 percent long-term freedom from hysterectomy."

What are the success rates for embolization?

“Embolization has very promising short- and long-term results for adenomyosis. Studies of the end results show 97 percent success after 3 years and 82 percent after 7 years. Success here is defined as freedom from hysterectomy. So, at 3 years after the embolization, only 3 percent of patients ended up going on to have a hysterectomy. In 97 percent of patients, at 3 years, their symptoms were relieved enough that they did not need anything else done. Long-term follow-up for 7 years, which is more what I like to look for, embolization had a success rate of 82 percent. So, after 7 years, only 18 percent of patients treated went on to have a hysterectomy. In other words, if you do this procedure for patients with adenomyosis, 82 percent can avoid having a hysterectomy.”

So, is hysterectomy the only treatment option for adenomyosis?

“Medical therapy is usually the first thing tried in patients with adenomyosis. Hormonal therapies and anti-inflammatory medications can be given a trial. There is also a hormone-releasing IUD or intrauterine device that works in some patients with adenomyosis. If these treatments fail, patients are usually told they need a hysterectomy. Nowadays, hysterectomy is not the only option, though. The procedure we do for adenomyosis is the same procedure as uterine fibroid embolization. With adenomyosis, the endometrial tissue that they have in the uterus is very vascular. And if you shut the blood flow down to it, that tissue dies off and the uterine muscular tissue, the normal uterine muscle tissue, survives. With proper technique and protocols, embolization can prevent over 80 percent of these patients from going on to hysterectomy.

How long does the embolization procedure take? What’s recovery like?

“My partner and I do a lot of these, and we have become quite efficient over the years. The procedure typically takes 45 minutes, and patients usually go home an hour and a half to 2 hours after we're done. And they're usually back at work 7 days ... seven days is average. Some patients go back to work a few days earlier, some a few days later.

You have pretty significant cramping for the first couple of days that we manage with a combination of a nerve block and oral pain medications. But the cramping resolves within 2, 3, sometimes 4 days. Even after the cramping goes away, patients still feel kind of tired and washed out for several days afterward. People start resuming normal activity, go back to work, around 7 days afterward. There are no scars. There are no stitches. Patients like that, they have no body parts being removed, and the recovery time is extremely quick.”

Can embolization improve fertility or treat infertility?

“No, it does not improve fertility. We do not treat patients with endometriosis, adenomyosis, or fibroids to improve their fertility. We treat them to alleviate their symptoms. The procedure relieves symptoms, and it restores quality of life. Fertility rate is the same, and there's no really good study or meta-analysis for adenomyosis patients. We do know anecdotally that patients can become pregnant who have adenomyosis, who we treated with embolization. There is very good data in several meta-analyses of performing embolization for fibroid patients. Fertility rate is the same before and after embolization, if you treat fibroid patients.”

Read Part 2 of our interview with Dr. Hardee

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