From the Guidelines
Medical management or uterine artery embolization (UAE) is usually the appropriate initial therapy for a reproductive age patient with adenomyosis and uterine fibroids, symptomatic with heavy uterine bleeding or bulk symptoms, and no desire for future fertility. Adenomyosis is a condition where the endometrial tissue grows into the muscular wall of the uterus, causing heavy, painful periods, chronic pelvic pain, and an enlarged uterus. Treatment options depend on symptom severity and whether future fertility is desired. According to the American College of Radiology Appropriateness Criteria 1, in most cases, medical management should be trialed prior to pursuing more invasive therapies.
Key Considerations
- Medical management can include hormonal treatments, such as combined oral contraceptives or progesterone-only pills, which can help reduce symptoms.
- For patients with no desire for future fertility, UAE or medical management can be effective in managing symptoms.
- The goal of treatment is to alleviate symptoms, improve quality of life, and minimize morbidity and mortality.
Treatment Options
- Medical management: hormonal treatments, pain management, and other medications to reduce symptoms.
- UAE: a minimally invasive procedure that blocks blood flow to the uterus, reducing symptoms.
- Other options, such as hysterectomy or endometrial ablation, may be considered for patients who have completed childbearing or have severe symptoms that do not respond to medical management. As noted in the study published in the Journal of the American College of Radiology 1, medical management or UAE is usually appropriate for the initial therapy for a reproductive age patient with uterine fibroids and concurrent adenomyosis.
From the Research
Definition and Symptoms of Adenomyosis
- Adenomyosis is a commonly encountered estrogen-dependent disease in reproductive-age women, causing heavy menstrual bleeding, intense pelvic pain, and infertility 2.
- The disease can affect younger nulliparous women and may compromise their fertility potential 2.
- Symptoms of adenomyosis include dysmenorrhea, dyspareunia, abnormal uterine bleeding (AUB), and infertility 3.
Treatment Options for Adenomyosis
- Hysterectomy is the standard approach to definitively manage the disease, but it is not an option for patients wishing to preserve their fertility 2, 4.
- Conservative management of adenomyosis includes pharmacological and surgical approaches, such as hormonal drugs, radiological procedures, and conservative surgery 2, 4, 3.
- Levonorgestrel releasing intrauterine system (LNG-IUS) is a treatment option for adenomyosis, which can reduce the intensity of dysmenorrhea and improve quality of life 5.
- Conservative surgery, such as excision of adenomyosis, can be effective for symptom control and improving fertility outcomes 4.
Factors Affecting Treatment Outcomes
- Age at diagnosis and parity are factors that contribute to hysterectomy after conservative treatment 6.
- Patients who continue conservative treatment for approximately 5 years are more likely to have successful preservation of the uterus 6.
- The cumulative hysterectomy rate is 32.4%, and all women had hysterectomy within 63 months 6.
Efficacy and Safety of Treatment Options
- Combined GnRH-a and LNG-IUS treatment is more efficacious than LNG-IUS alone for patients with an enlarged uterus and moderate to severe dysmenorrhea 5.
- LNG-IUS seems to show potential long-term benefits in postoperative therapy, warranting further meta-analysis for confirmation 5.
- Conservative surgery for adenomyosis improves pelvic pain, abnormal uterine bleeding, and possibly fertility, but the best method of surgery is yet to be seen 4.