Uterine artery embolisation for treating adenomyosis

# Recommendations
Current evidence on uterine artery embolisation for treating adenomyosis shows that the procedure is efficacious for symptom relief in the short and medium term for a substantial proportion of patients. There are no major safety concerns. Therefore this procedure may be used provided that normal arrangements are in place for clinical governance, consent and audit.
During the consent process patients should be informed, in particular, that symptoms may not be relieved, that symptoms may return and that further procedures may be needed. Patients contemplating pregnancy should be informed that the effects of the procedure on fertility are uncertain.
Patient selection should be carried out by a multidisciplinary team, including a gynaecologist and an interventional radiologist.
NICE encourages further research into the effects of uterine artery embolisation compared with other procedures to treat adenomyosis, particularly for patients wishing to maintain or improve their fertility.# Indications and current treatments
Adenomyosis is a benign condition characterised by the presence of ectopic endometrial glands and stroma within the myometrium. It frequently occurs coincidentally with fibroids. Adenomyosis may cause no symptoms but some women with adenomyosis experience heavy, prolonged menstrual bleeding with severe cramps, pelvic pain and discomfort.
Treatment for symptomatic adenomyosis includes anti-inflammatory medications, hormone therapy and endometrial ablation. For severe symptoms that do not respond adequately, hysterectomy has been the conventional surgical treatment. Uterine artery embolisation may be an alternative option for patients who do not wish to have hysterectomy and/or who wish to preserve their fertility.# The procedure
The aim of uterine artery embolisation for treating adenomyosis is to block the blood supply to the adenomyosis, causing it to shrink. The intended benefits of the procedure are that it offers a less invasive alternative to hysterectomy, and fertility may be preserved.
With the patient under sedation and local anaesthesia, a catheter is inserted into the femoral artery (bilateral catheters are sometimes used). Fluoroscopic guidance is used to manipulate the catheter into the uterine artery. Small embolisation particles are injected through the catheter into both uterine arteries.
Various embolisation agents can be used for this procedure.# Efficacy
This section describes efficacy outcomes from the published literature that the Committee considered as part of the evidence about this procedure. For more detailed information on the evidence, see the overview.
In a case series of 54 patients with adenomyosis, 78% (42/54) of whom presented with menorrhagia, resolution of menorrhagia was reported in 26% (10/39) of patients at a mean follow-up of 5 years. In a case series of 40 patients (90%  presenting with menorrhagia), symptoms had resolved in 78% (28/36) of patients at a median follow-up of 40 months.
In a case series of 27 patients, complete resolution of dysmenorrhoea was reported in 38% (7/18), 57% (9/16), 36% (4/11) and 64% (7/11) of patients at 6, 12, 24 and 36 months respectively.
In the case series of 54 patients with adenomyosis, 43% (23/54) presented with bulk-related symptoms. Complete resolution of these symptoms was reported in 35% (8/23) of patients at a mean follow-up of 5 years. In the case series of 27 patients, complete resolution of bulk-related symptoms was reported in 38% (7/18), 31% (5/16), 46% (5/11) and 55% (6/11) of patients at 6, 12, 24 and 36 months respectively.
In a case series of 15 patients, a significant improvement in quality of life was reported at a mean follow-up of 8 months in the following domains: ability to perform activities of daily life, ability to socialise outside the home, overall energy level, pain or cramping during menstruation (p<0.001), and pain during sexual intercourse (p=0.02).
In the case series of 54 patients with adenomyosis, 5 patients became pregnant (3 delivered successfully and 2 opted for abortion).
In a case series of 18 patients with adenomyosis, 44% (8/18) of patients had subsequent treatments because of treatment failure or recurrent symptoms. Twenty-eight per cent (5/18) of patients underwent hysterectomy (4 months after the procedure in 1 patient because of treatment failure, and between 9 and 27 months after the procedure in 4 patients because of recurrent symptoms). Eleven per cent (2/18) of patients needed additional treatments and 6% (1/18) of patients needed endometrial balloon thermocoagulation because of recurrent symptoms (timing unclear).
The specialist advisers listed key efficacy outcomes to be quality of life, symptom resolution and need for further treatment.# Safety
This section describes safety outcomes from the published literature that the Committee considered as part of the evidence about this procedure. For more detailed information on the evidence, see the overview.
Severe cramping pain (4 days after the procedure; treated successfully by analgesia) was reported in 1 patient in the case series of 18 patients.
Worsening of symptoms was reported in 82% (9/11) of patients in the case series of 27 patients at 3 years follow-up. Three patients opted for hormonal therapy to help with symptom relief and none chose hysterectomy.
Amenorrhoea was reported in 4% (2/54) of patients (aged 41 and 44 years) immediately after the procedure in the case series of 54 patients (no further details available).
Transient increased vaginal discharge was reported in 8% (3/40) of patients in a case series of 40 patients (timing unclear).
The specialist advisers noted that adverse events from uterine artery embolisation used for adenomyosis are unlikely to differ significantly from those occurring when the procedure is used for fibroids. They include post-embolisation syndrome and non-target embolisation.# Further information
For related NICE guidance, see the NICE website.

# Information for patients
NICE has produced information on this procedure for patients and carers (Information for the public). It explains the nature of the procedure and the guidance issued by NICE, and has been written with patient consent in mind.# About this guidance
NICE interventional procedures guidance makes recommendations on the safety and efficacy of the procedure. It does not cover whether or not the NHS should fund a procedure. Funding decisions are taken by local NHS bodies after considering the clinical effectiveness of the procedure and whether it represents value for money for the NHS. It is for healthcare professionals and people using the NHS in England, Wales, Scotland and Northern Ireland, and is endorsed by Healthcare Improvement Scotland for implementation by NHSScotland.
This guidance was developed using the NICE interventional procedures guidance process.
We have produced a summary of this guidance for patients and carers.
Your responsibility
    This guidance represents the views of NICE and was arrived at after careful consideration of the available evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.
Copyright
     National Institute for Health and Care Excellence 2013. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.
ISBN: 978-1-4731-0379-5