What are the recommended treatment options for a woman with adenomyosis presenting with dysmenorrhea, menorrhagia, and pelvic pain who wishes to preserve fertility?

Treatment of Adenomyosis with Fertility Preservation

For women with adenomyosis presenting with dysmenorrhea, menorrhagia, and pelvic pain who wish to preserve fertility, start with a levonorgestrel-releasing intrauterine system (LNG-IUS) as first-line therapy, as it provides superior symptom control compared to combined oral contraceptives while maintaining fertility potential. 1

First-Line Medical Management

The progestin IUD (LNG-IUS) is clinically favored over other hormonal options due to its local mechanism of action, lower systemic hormone levels, long duration after placement, and user independence 1. A recent randomized controlled trial demonstrated significant improvement in both pain and bleeding in women with adenomyosis treated with progestin IUD versus combined oral contraceptives 1.

Alternative First-Line Options:

• Combined oral contraceptives: Effective for reducing painful and heavy menstrual bleeding, though less effective than LNG-IUS 1
• NSAIDs: For dysmenorrhea management
• Tranexamic acid: Nonhormonal option for menorrhagia control

Second-Line Medical Management

If first-line therapy fails after 3-6 months:

• Oral GnRH antagonist combinations: Pooled analysis of 2 randomized controlled trials showed concomitant adenomyosis does not decrease effectiveness in treating heavy menstrual bleeding 1
• Dienogest or other progestins: Oral or depot medroxyprogesterone acetate are effective compared to placebo 2
• GnRH agonists: Use for at least 3 months with add-back therapy to prevent bone mineral loss 2

Critical caveat: All medical therapies temporarily suppress symptoms but do not eradicate adenomyosis lesions and must be discontinued when attempting conception 2.

Minimally Invasive Options for Medical Therapy Failures

Uterine Artery Embolization (UAE)

UAE should be considered for patients who fail conservative medical measures and desire uterus-preserving therapy 1, 3, 1. Evidence shows:

• Short-term (<12 months) symptom improvement in 94% of patients
• Long-term (>12 months) symptom improvement in 85% of patients
• 7% hysterectomy rate for persistent symptoms 1
• Up to 7-year follow-up demonstrates sustained quality of life improvement 1

Fertility considerations: Successful pregnancy has been reported after UAE for adenomyosis, but comprehensive data on fertility and pregnancy outcomes are lacking—patients must be counseled accordingly 1. The ongoing QUESTA trial will provide better comparative data 1.

High-Intensity Focused Ultrasound (HIFU/MRgFUS)

Limited evidence exists for adenomyosis treatment specifically 1. While emerging as a non-invasive option, comprehensive fertility data are lacking 4.

Surgical Options

Conservative Surgery (Adenomyomectomy)

Consider only when:

• Medical and minimally invasive options have failed
• Localized adenomyosis is present (focal adenomyoma)
• Patient accepts increased risk of uterine rupture in future pregnancy

Important warning: Conservative surgical treatment carries significant obstetric risks including uterine rupture, and the optimal surgical technique to minimize this risk remains unknown 5, 6. Surgery should only be performed by experienced surgeons in dedicated centers 5.

Hysterectomy

Not appropriate for patients desiring fertility preservation, though it remains the only definitive treatment 1.

Treatment Algorithm Based on Symptom Severity

Mild-to-moderate symptoms:

1. LNG-IUS first-line
2. If inadequate response at 3-6 months → add NSAIDs or switch to oral GnRH antagonist
3. If still inadequate → consider UAE

Severe symptoms interfering with daily activities:

1. Short-term GnRH agonist (3-6 months) with add-back therapy for rapid symptom control
2. Transition to LNG-IUS for maintenance
3. If inadequate → UAE
4. Conservative surgery only as last resort before hysterectomy

Key Clinical Pitfalls

• Do not delay fertility attempts indefinitely: Medical therapies only temporize symptoms and must be stopped for conception
• Avoid myomectomy alone: Adenomyosis is unlikely to be effectively addressed with myomectomy techniques designed for fibroids 1
• Counsel about UAE fertility risks: While pregnancy is possible post-UAE, comprehensive safety data are lacking 1, 3, 1
• Recognize treatment limitations: No medical therapy eradicates adenomyosis lesions; symptoms typically recur after discontinuation 2
• Consider concurrent endometriosis: This commonly coexists and may require simultaneous management 3