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University of California, Los Angeles Los Angeles, CA
90024
Wilshire Outpatient Radiology Los Angeles, CA 90403
We read with interest a recent article published in your journal [1]. The treatment of adenomyosis by embolization will not fare as well as the authors suggest in the long run. We have noted the presence of adenomyosis in many patients who eventually failed embolization and required hysterectomy [2]. These patients were diagnosed by biopsy as having adenomyosis before embolization [3].
Patients who have both myomata and adenomyosis will initially experience improvement from shrinkage of myomata. However, the blood supply to adenomyosis does not lend itself to embolic blockade. Ultimately, many of these patients will experience generalized growth and will return for surgery.
Because the only treatment for adenomyosis is hysterectomy [4], a procedure many of our patients wish to avoid, we will treat patients who have both conditions. We do so with the patients' understanding that the overall success rate is 50% and not the 90% success rate that is achieved by embolization for myomata alone.
We appreciate the excellent review of MRI findings of adenomyosis explained by the authors.
References
Georgetown University Medical Center Washington, DC 20007
We thank Drs. McLucas and Perrella for their comments regarding our preliminary work [1] with uterine artery embolization and adenomyosis. The long-term efficacy of uterine artery embolization for the treatment of adenomyosis is not known. Numerous studies have shown effectiveness for symptomatic fibroids, but as yet the literature on adenomyosis is limited. The data to date are limited by small numbers of patients and short-interval follow-ups [2, 3]. To further complicate the issue, adenomyosis can coexist with fibroids in 10–20% of patients [3], and imaging techniques vary in their accuracy in detecting adenomyosis. We do not routinely perform biopsy for this diagnosis.
The literature supports MRI as the best non-invasive method of detecting adenomyosis [4]. Furthermore, we all recognize that aside from its invasive nature, biopsy is limited by the often patchy distribution of adenomyosis. Also, although endometrial biopsy can be used to assess the presence or absence of adenomyosis, it may not be helpful to assess the depth and thus the severity of involvement of the myometrium, which is seen as a thickened junctional zone on MRI.
Most of the patients in our recent study [1] had both fibroids and adenomyosis. The patients had a mean junctional zone thickness of 32 mm. We attempted to include only patients who clearly had a junctional zone thickness greater than 13 mm and excluded all patients who are borderline. Our goal was to describe both the changes in imaging in these patients and the short-term clinical response. In a follow-up article, we will explore the MRI and clinical response of patients with adenomyosis only. We hope this will provide greater clarity regarding the usefulness of uterine artery embolization in patients with adenomyosis.
From a practical perspective, these patients often have few definitive treatment options available apart from hysterectomy, which many women refuse as treatment for a benign condition. I support the approach of my colleagues in being cautious in proclaiming uterine artery embolization as the treatment of choice for all benign pelvic disease. To understand the disease processes, we need to continue to investigate the options and follow up these patients clinically and with imaging. Most important, we need to look at the disease response over time before we can claim a significant advance in promoting women's health with uterine artery embolization.
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