From the Guidelines
Adenomyosis should be managed with uterine artery embolization (UAE) as the preferred treatment option for patients with severe symptoms who have failed conservative measures and desire uterus-preserving therapy, as it has been shown to improve quality of life and symptom scores in up to 85% of patients at long-term follow-up 1.
Treatment Options
The treatment of adenomyosis depends on the severity of symptoms and whether future fertility is desired. For mild symptoms, over-the-counter pain medications like ibuprofen (400-600mg every 6-8 hours) or naproxen (500mg twice daily) can help manage pain. Hormonal treatments such as combined oral contraceptives, progestin-only pills, or the levonorgestrel intrauterine device (Mirena) can reduce bleeding and pain by suppressing the growth of endometrial tissue.
Surgical Options
For severe cases unresponsive to medication, surgical options include:
- Endometrial ablation
- Uterine artery embolization (UAE)
- Hysterectomy for definitive treatment when fertility is no longer desired According to a recent meta-analysis, UAE has been shown to improve symptoms in 94% of patients at short-term follow-up and 85% at long-term follow-up, with a 7% rate of hysterectomy for persistent symptoms 1.
Diagnosis and Classification
Adenomyosis is a condition where the tissue that normally lines the uterus (endometrial tissue) grows into the muscular wall of the uterus, causing the uterus to enlarge and leading to symptoms including heavy or prolonged menstrual bleeding, severe menstrual cramps, pelvic pain, and pain during intercourse. The PALM-COEIN classification system is used to describe uterine bleeding abnormalities in women of reproductive age, including structural causes such as adenomyosis and nonstructural causes such as coagulopathy and ovulatory dysfunction 1.
From the Research
Definition and Symptoms of Adenomyosis
- Adenomyosis is a heterogeneous gynaecologic condition with a range of clinical presentations, the most common being heavy menstrual bleeding and dysmenorrhoea 2
- Patients can also be asymptomatic, and the condition is common in reproductive-aged women 3
- Adenomyosis is characterized by the infiltration of the myometrium by ectopic endometrial islets, causing dysmenorrhea, abnormal uterine bleeding, and infertility 4
Diagnosis of Adenomyosis
- Diagnostic options include transvaginal sonography and magnetic resonance imaging 3
- Imaging studies, such as transvaginal ultrasound and magnetic resonance imaging, can show alterations in the junctional zone, which are commonly seen in adenomyosis 2
Treatment Options for Adenomyosis
- Medical options include non-steroidal anti-inflammatory drugs (NSAIDs), tranexamic acid, combined oral contraceptives, levonorgestrel intrauterine system, dienogest, other progestins, and gonadotropin-releasing analogues 3, 5
- NSAIDs are the first choice to control pain associated with adenomyosis, and are the only choice for patients with recent fertility requirements 6
- Hormonal treatments, such as progestins, oral contraceptives, and gonadotropin-releasing hormone analogues, can effectively relieve pain and control uterine bleeding 6, 5
- Surgical options include endometrial ablation, excision of adenomyosis, and hysterectomy, which is the standard treatment for adenomyosis but does not allow for future pregnancy 2, 3
Management of Adenomyosis
- The management of adenomyosis is still controversial, and there are no specific guidelines to follow for the best management 5
- Medical treatments are effective in improving symptoms, such as pain, abnormal uterine bleeding, and infertility 5
- The rationale for using medical treatment is based on the pathogenetic mechanisms of adenomyosis, including sex steroid hormones aberrations, impaired apoptosis, and increased inflammation 5
- New drugs are under development for the treatment of adenomyosis, such as selective progesterone receptor modulators, aromatase inhibitors, valproic acid, and anti-platelets therapy 5