Adenomyosis is a gynecological condition characterized by the presence of endometrial tissue, which normally lines the uterus, growing into the muscular wall of the uterus, known as the myometrium. This misplaced tissue continues to behave like normal endometrial tissue, thickening, breaking down, and bleeding with each menstrual cycle. This internal bleeding and tissue buildup within the uterine wall can lead to significant discomfort, including severe pain and heavy menstrual bleeding. While some individuals with adenomyosis may experience no symptoms, for many, the condition can disrupt daily life.
Targeting Adenomyosis with Ablation
Ablation for adenomyosis uses various forms of energy to destroy or reduce adenomyotic tissue within the uterine wall. Its main objective is to alleviate symptoms like chronic pelvic pain and heavy menstrual bleeding, while preserving the uterus. This less invasive approach is an alternative to hysterectomy and is considered when medical treatments, such as hormonal therapies, have not provided sufficient relief. Ablation selectively targets abnormal tissue, leaving healthy uterine muscle intact, a significant consideration for individuals wishing to retain fertility or avoid major surgery.
Ablation’s suitability depends on whether the adenomyosis is focal or diffuse. Focal adenomyosis involves localized endometrial tissue within the myometrium, sometimes forming distinct masses called adenomyomas. Diffuse adenomyosis involves a more widespread infiltration of the uterine wall.
Ablation techniques are generally more effective for focal adenomyosis, where affected areas are clearly defined and precisely targeted. For diffuse cases, ablation’s effectiveness can be limited due to the widespread nature of the disease, making it challenging to ablate all affected tissue. In such instances, other treatment modalities or combined approaches might be considered.
Specific Ablation Techniques
Radiofrequency ablation (RFA) uses heat generated by a high-frequency electrical current to destroy adenomyotic tissue. A thin probe is inserted into the adenomyoma, and the electrical current heats the surrounding tissue, causing cell death. This method is typically guided by ultrasound imaging for precise placement within the focal lesion.
As a uterus-preserving treatment, RFA has shown that it can reduce adenomyosis lesion volume by approximately 61.1% and total uterine volume by about 46% within 12 months. Patients report a significant decrease in dysmenorrhea (painful periods), with an average reduction of around 63.4% in pain scores at 12 months.
Microwave ablation (MWA) uses microwave energy to generate heat within targeted tissue. A specialized probe emits microwaves, causing water molecules to vibrate and induce cell death. Like RFA, MWA is guided by imaging for accurate targeting.
As a minimally invasive, uterus-preserving option, research indicates MWA can reduce adenomyosis volume by around 71.7% and uterine volume by approximately 64.9% at 12 months post-procedure, showing comparable or slightly better reductions than RFA in some studies. This technique is recognized for its efficacy and efficiency.
Uterine Artery Embolization (UAE) achieves tissue destruction by blocking the blood supply to adenomyotic areas. An interventional radiologist inserts a catheter, usually into an artery in the groin or wrist, guiding it to the uterine arteries. Tiny, biocompatible particles, known as embolic agents, are then injected to block these blood vessels.
Depriving the tissue of oxygen and nutrients leads to its shrinkage and death. UAE is applicable for both focal and diffuse adenomyosis, as it targets blood vessels supplying the uterus. This minimally invasive alternative preserves the uterus and often leads to significant symptom improvement within three to six months.
Patient Suitability and Outcomes
Selecting suitable candidates for ablation procedures involves considering several factors, including the patient’s desire for uterine preservation, the intensity of their symptoms, and the specific characteristics of their adenomyosis. Ablation is often considered when medical management, such as hormonal therapies, has been ineffective or is not preferred. Patients who wish to avoid a hysterectomy are also strong candidates for these uterus-sparing interventions.
The efficacy of ablation in providing symptom relief, particularly for pain and heavy bleeding, varies depending on the specific technique and the individual patient’s condition. For instance, radiofrequency ablation has been shown to result in a mean decrease in dysmenorrhea pain scores by approximately 63.4% at 12 months. Microwave ablation has also demonstrated significant improvement in dysmenorrhea symptoms, with reported improvement rates ranging from 50% to 81.3%, and menorrhagia improvement rates from 20.9% to 69.6%.
Uterine artery embolization has demonstrated success in improving symptoms in a majority of patients, with one study showing symptomatic improvement in 92.3% of patients at a three-month follow-up. While these procedures aim for long-term relief, the durability can vary, and in some cases, symptoms may recur, potentially requiring further treatment.
Potential risks and complications associated with ablation procedures can include pain, infection, and bleeding. There is also a possibility of damage to surrounding organs, though this is rare. A recognized, albeit rare, complication of endometrial ablation, which can be part of an ablation strategy for adenomyosis, is post-ablation syndrome (PAS). This syndrome involves delayed onset cyclical pelvic pain due to continued bleeding trapped within the uterus, often in conjunction with intrauterine scarring.
Recovery periods after ablation procedures are generally shorter than those for more invasive surgeries. Most patients can resume normal activities within a few days to about a week, though full recovery may take longer. Common post-procedure symptoms can include mild to moderate pain, cramping, and vaginal discharge, which typically resolve within a few weeks.
For patients desiring future fertility, the impact of ablation on pregnancy outcomes is a complex consideration. While uterus-preserving treatments are chosen to maintain reproductive potential, some studies suggest that adenomyosis itself can negatively affect fertility and pregnancy outcomes, including reduced clinical pregnancy rates and increased risks of preterm delivery and pre-eclampsia.
Conservative surgical treatments for adenomyosis, including some ablation techniques, aim to improve fertility outcomes. However, the risk of uterine rupture during subsequent pregnancies remains a concern, and more research is needed to determine the safest and most effective approaches for fertility preservation. Patients considering ablation who desire future pregnancy should receive comprehensive counseling regarding these potential risks and variable outcomes.