What is the recommended initial treatment approach for uterine adenomyosis?

From the Guidelines

The recommended initial treatment approach for uterine adenomyosis is typically medical management, which may include hormonal therapy or uterine artery embolization (UAE), depending on the patient's symptoms, desire for future fertility, and overall health status. According to the most recent guidelines, medical management or UAE is usually appropriate for the initial therapy for a reproductive age patient with uterine fibroids and concurrent adenomyosis, symptomatic with heavy uterine bleeding or bulk symptoms, and no desire for future fertility 1.

Key Considerations

• Medical management should be trialed prior to pursuing more invasive therapies, as it is often effective in managing symptoms and improving quality of life 1.
• Hormonal therapy, such as combined hormonal contraceptives or the levonorgestrel-releasing intrauterine system, can be used to suppress menstruation and reduce symptoms.
• UAE is a viable option for patients who fail conservative measures and desire uterus-preserving therapy, with evidence showing improvement in quality of life and symptom scores, especially when fibroids predominate 1.
• Treatment choice depends on symptom severity, desire for future fertility, and side effect profiles, and should be individualized to each patient's needs.

Additional Options

• Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can be used for pain management.
• GnRH agonists like leuprolide may be used for severe symptoms, but are limited to 6-12 months due to bone density concerns.
• Progestins such as norethindrone acetate or medroxyprogesterone acetate are also effective options for managing symptoms.
• Surgical options, including hysterectomy, may be considered for women who have completed childbearing and have failed other treatments.

From the Research

Uterine Adenomyosis Treatment Approaches

The recommended initial treatment approach for uterine adenomyosis varies depending on the symptoms and the patient's desire to preserve fertility.

• Medical treatments are effective in improving symptoms such as pain, abnormal uterine bleeding, and infertility 2.
• The use of nonhormonal and hormonal treatments, including nonsteroidal anti-inflammatory drugs, progestins, oral contraceptives, and gonadotropin-releasing hormone analogues, can help control pain symptoms and abnormal uterine bleeding 2, 3.
• The levonorgestrel-releasing intrauterine system has been shown to be effective in resolving abnormal uterine bleeding and reducing uterine volume in the long-term management of adenomyosis 2, 4, 5.

Treatment Options

Treatment options for adenomyosis include:

• Medical options: non-steroidal anti-inflammatory drugs, tranexamic acid, combined oral contraceptives, levonorgestrel intrauterine system, dienogest, other progestins, gonadotropin-releasing analogues 3.
• Interventional options: uterine artery embolization 3.
• Surgical options: endometrial ablation, excision of adenomyosis, hysterectomy 3, 4.
• Conservative surgery for patients wishing to conceive, which requires highly experienced surgeons and poses a risk of uterine rupture during subsequent pregnancies 6.

Emerging Therapies

Emerging therapies for adenomyosis include:

• Gonadotropin-releasing hormone antagonists, which have shown promising results in preliminary studies 5, 6.
• Other treatments such as dienogest, prolactin, and oxytocin modulators, which require further data to establish their efficacy definitively 5.