What are the treatment options for uterus adenomyosis?

Treatment Options for Uterine Adenomyosis

For patients with adenomyosis, a progestin IUD is the preferred first-line medical therapy due to its superior effectiveness in reducing pain and bleeding symptoms while minimizing systemic side effects. 1

Medical Treatment Options

First-Line Treatments

1. Progestin IUDs (Levonorgestrel-releasing intrauterine systems)

   • Most effective medical therapy with significant improvement in pain and bleeding 1
   • Advantages:
     • Local mechanism of action
     • Lower levels of systemic hormones
     • Long duration of action
     • User independence
   • A randomized controlled trial demonstrated superior effectiveness compared to combined oral contraceptives 1

2. Combined Oral Contraceptives

   • Effective for reducing painful and heavy menstrual bleeding 1, 2
   • Less effective than progestin IUDs based on direct comparison 1
   • Can be used continuously to suppress menstruation

3. NSAIDs

   • Helpful for managing pain symptoms 3
   • Limited effectiveness for heavy bleeding
   • Best used as adjunctive therapy

Second-Line Treatments

1. GnRH Agonists and Antagonists

   • Highly effective for symptom relief 1, 3, 2
   • Pooled analysis shows effectiveness in treating heavy menstrual bleeding even with concomitant adenomyosis 1
   • Limitations:
     • Hypoestrogenic side effects (hot flashes, bone mineral density loss)
     • Not suitable for long-term use without add-back therapy
     • Suppresses fertility during treatment
   • Particularly useful before fertility treatments to improve pregnancy chances 3

2. Other Progestins (e.g., dienogest)

   • Effective for pain control through antiproliferative and anti-inflammatory effects 3
   • May be used when IUD insertion is not feasible

Interventional Options

Uterine-Preserving Procedures

1. Uterine Artery Embolization (UAE)

   • Strong evidence from prospective cohort studies 1
   • Outcomes:
     • Short-term (<12 months) symptom improvement: 94%
     • Long-term (>12 months) symptom improvement: 85%
     • Hysterectomy rate for persistent symptoms: 7-18% 1
   • Follow-up data available for up to 7 years showing sustained improvement 1
   • Suitable for patients who:
     • Have failed conservative measures
     • Desire uterus-preserving therapy
     • Have completed childbearing (fertility data limited) 1

2. Other Minimally Invasive Options (limited evidence)

   • Radiofrequency ablation (RFA)
   • High-intensity focused ultrasound (HIFU)
   • Percutaneous microwave ablation (PMWA) 4
   • Note: Many of these treatments have limited availability and are often off-label in the US 4

Definitive Treatment

1. Hysterectomy
   • Most common and definitive treatment 1, 5
   • Consider when:
     • Medical therapy fails
     • Patient has completed childbearing
     • Symptoms significantly impact quality of life
   • Important considerations:
     • Choose least invasive approach (vaginal or laparoscopic preferred over abdominal) 1
     • Potential long-term risks include increased cardiovascular disease, osteoporosis, bone fracture, and dementia 1
     • Higher complication rates, longer hospitalization, and longer recovery compared to UAE 1

Treatment Algorithm

1. Initial Assessment

   • Confirm diagnosis with transvaginal ultrasound or MRI
   • Assess symptom severity (bleeding, pain, bulk symptoms)
   • Determine fertility desires

2. Treatment Pathway

   • For patients with mild-moderate symptoms:

     • Start with progestin IUD (first choice) 1
     • Alternative: Combined oral contraceptives or NSAIDs

   • For patients with severe symptoms or failure of first-line therapy:

     • Consider GnRH agonists/antagonists (short-term use)
     • Evaluate for UAE if uterine preservation desired 1
     • Consider hysterectomy if definitive treatment preferred and fertility not desired

   • For patients desiring fertility:

     • Consider GnRH agonists before fertility treatments 3
     • Avoid treatments that may compromise future fertility

Important Considerations

• No drug is currently FDA-approved specifically for adenomyosis 3
• Medical therapies primarily address symptoms rather than cure the condition 2
• Combination therapy may be more effective than monotherapy 4
• The ongoing QUESTA trial will provide direct comparison between UAE and hysterectomy outcomes 1
• Treatment should be guided by symptom severity, fertility desires, and patient preferences
• Myomectomy alone is unlikely to effectively address adenomyosis 1