What are the treatment options for adenomyosis?

Treatment Options for Adenomyosis

Medical management should be the first-line treatment for adenomyosis, with progestin IUDs being clinically favored due to their local mechanism of action, lower systemic hormone levels, long duration, and user independence. 1

Medical Treatment Options

First-Line Options:

• Progestin IUD (Levonorgestrel-releasing intrauterine system)

  • Most effective hormonal option
  • A randomized controlled trial demonstrated significant improvement in pain and bleeding compared to combined oral contraceptives 1
  • Local action minimizes systemic side effects
  • Long-term management solution

• NSAIDs

  • First choice for pain control 2
  • Can reduce bleeding by 20-40% 3
  • Suitable for patients with recent fertility requirements

• Combined Oral Contraceptives

  • Effective for controlling bleeding symptoms
  • Less effective than progestin IUD based on recent evidence 1

• Tranexamic Acid

  • Non-hormonal option for heavy bleeding
  • Take only during menstruation
  • Contraindicated in women with active thromboembolic disease 3

Second-Line Options:

• GnRH Agonists/Antagonists with Add-back Therapy

  • Can reduce bleeding and adenomyosis volume by 40-50%
  • Pooled analysis shows effectiveness even with concomitant adenomyosis 1
  • Typically used temporarily or as bridge to definitive therapy 3

• Progestins (Norethindrone Acetate, Dienogest)

  • FDA-approved for endometriosis and abnormal uterine bleeding 4
  • Dosage: 5-15 mg daily for norethindrone acetate 4
  • Antiproliferative and anti-inflammatory effects 5

Interventional Options

• Uterine Artery Embolization (UAE)

  • Evidence from prospective cohort studies supports UAE for patients with adenomyosis who fail conservative measures 1
  • Improves symptom scores and quality of life for up to 7 years 1
  • Short-term (94%) and long-term (85%) symptom improvement 1
  • 18% hysterectomy rate for persistent symptoms 1
  • The American College of Radiology recommends UAE as a first-line treatment for patients with heavy menstrual bleeding who decline contraceptive management 3

• MR-Guided High-Intensity Focused Ultrasound (MRgFUS)

  • Limited evidence for adenomyosis specifically
  • Can achieve 18% decrease in adenomyosis volume 3

Surgical Options

• Conservative Surgical Approaches

  • Cytoreductive surgery (adenomyomectomy)
  • Should be performed by experienced surgeons in dedicated centers 6
  • Effective for improving abnormal uterine bleeding, pelvic pain, and reducing uterine volume 6
  • Consider for women desiring fertility preservation who have failed medical management

• Hysterectomy

  • Definitive treatment when other approaches fail
  • Only existing definitive treatment 6
  • Consider risks including cardiovascular disease, mood disorders when performed at young age 3

Treatment Algorithm

1. Initial Management:

   • Start with NSAIDs for pain control and progestin IUD for bleeding control
   • If IUD contraindicated or declined, use combined oral contraceptives or tranexamic acid

2. If inadequate response after 3-6 months:

   • Add or switch to GnRH agonists/antagonists with add-back therapy
   • Consider oral progestins (norethindrone acetate or dienogest)

3. For persistent symptoms despite medical management:

   • Consider UAE if uterine preservation desired
   • UAE particularly effective when fibroids predominate alongside adenomyosis 1

4. For women desiring fertility:

   • NSAIDs are the only choice for patients with immediate fertility requirements 2
   • GnRH analogues may improve chances of pregnancy in infertile women with adenomyosis 5
   • Consider conservative surgical approaches by experienced surgeons

5. When all else fails:

   • Hysterectomy offers definitive resolution

Special Considerations

• The QUESTA trial (Quality of Life after Embolization versus Hysterectomy in Adenomyosis) is ongoing and will provide comparison of UAE and hysterectomy outcomes 1

• Successful pregnancy has been reported after UAE for adenomyosis, but comprehensive data on fertility is lacking 1

• No specific drug is currently labeled specifically for adenomyosis, and symptoms often recur after drug withdrawal 2

• Treatment selection should be based on patient's age, symptoms, uterine size, fertility requirements, and economic conditions 2