Expert Answers: Embolization for Endometriosis, Adenomyosis, and Fibroids, Part 2

Read Part 1 of our interview with 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 are some scenarios in which a patient would not be a good candidate for this embolization and might need a more invasive surgical procedure instead?

“Well, if they have primarily abdominal and pelvic endometriosis, in which the endometrial implants or the endometrial cysts are outside the uterus, inside the abdomen or pelvis – say on bowel, on the bladder, things like that – that needs surgical treatment. Those patients would go to a gynecologist for surgery. But you can have patients with mixed disease. I have treated patients that had adenomyosis of the uterus, and they had horrible, painful cycles, bloating, painful intercourse. And they also had – you could see when you did the MRI – cystic lesions inside the pelvis filled with blood products. They're called endometriomas, or "chocolate cysts." If they were looking to avoid having a hysterectomy, they would need to have both embolization and surgery, usually laparoscopic surgery, to use a laser to obliterate the endometrial implants and to remove the endometrial cysts. Surgery will get rid of the abdominal-pelvic symptoms, but it will not get rid of the painful heavy cycles and the bloating if they also have adenomyosis. So some patients end up having a combination of surgery and embolization.

Also, some patients we see, they just have pelvic pain. They don't have any bleeding. We do an MRI. They don't have fibroids. They have very minimal adenomyosis. But we don't see endometrial implants or endometrial cysts. Those patients we would not treat. If they don't have a gynecologist, we refer them to one of our gynecologists we work with that have good laparoscopic skills for them to look into surgical treatment for that.”

Why hasn’t my doctor suggested embolization before?

“Well, for patients with fibroids or adenomyosis, the majority of gynecologists will offer them hysterectomy as their only option. And there's a number of reasons for that, and every physician is different. But in a nutshell, when somebody goes to a physician and they have a problem, and the physician wants to treat that problem, they're going to look inside their own toolbox. They're not going to look inside somebody else's toolbox to solve a problem. So, that's 1 of the reasons why they may say hysterectomy is the only option – because they don't perform this procedure and they're not familiar with it, or they just think that surgery is the best option. Then there's a subset of physicians who may want to perform surgery, but they explain all the options to their patients. And then the patients go looking for somebody who performs this procedure.

We view embolization as a great option for patients looking to avoid surgery. If patients aren't getting that information from locations where they normally should get the information, we feel obligated to push that information directly to the patients and let them decide what's the best option for their own particular case.”

What are your tips for getting a second opinion or finding treatment options?

“I would actually direct patients to social media groups. We get a lot of patients who come to us through these independent Facebook groups. There are Facebook groups in the local area composed of women with fibroids and women with endometriosis and adenomyosis. Once you have a few patients who are very active in social media that have had the procedure, they use their prior experience to really help out their community members. Social media groups are a great way to get information, and that's really helped get the word out about uterine fibroid embolizations. Members of those groups typically will have recommendations of who to go to and sometimes recommendations of who not to go to.”

What are some reasons that a surgeon might hesitate to perform multiple surgeries for endometriosis or want to delay surgical treatment for younger patients?

“If a patient has pure abdominal or pelvic endometriosis, laparoscopic surgery may be beneficial. Every time you operate and go inside the abdomen or pelvis, there's the potential to form scar tissue otherwise known as adhesions. That could lead to infertility and other issues. Every time you go into the pelvis, no matter if it's for laparoscopic surgery or for hysterectomy, down the road you create this situation called a "hostile pelvis," where you have to go in a third or fourth time, and each successive surgery becomes extremely more difficult. I get referrals for patients who could be a myomectomy candidate for fibroids, but they've already had 3 or 4 myomectomies, and the gynecologist is reluctant to operate on them again, because the last pelvic surgery they performed on this patient was exceedingly difficult. And so that's 1 reason why younger patients are typically trying to put off surgery as long as possible. There's really no good workaround in that regard, if you have abdominal-pelvic endometriosis. For pure adenomyosis or predominantly adenomyosis, we actually offer younger patients embolization treatment once they have failed medical therapy, including a Mirena IUD, because we're not treating it in a surgical fashion that can lead to scar tissue in the pelvis.”