What are the treatment options for diffuse uterine adenomyosis?

Treatment Options for Diffuse Uterine Adenomyosis

Treatment for diffuse uterine adenomyosis should follow a stepwise approach, starting with medical management, followed by minimally invasive procedures, and finally surgical options, with uterine artery embolization (UAE) showing 85-94% symptom improvement for adenomyosis, particularly when fibroids predominate alongside the condition. 1

Medical Management (First-Line)

Medical therapy should be the initial approach for managing adenomyosis symptoms:

• Hormonal Options:

  • Levonorgestrel-releasing intrauterine system (LNG-IUS): Most effective hormonal option for controlling bleeding and reducing uterine volume 1, 2
  • Combined oral contraceptives: Effective for bleeding control but less effective than progestin IUDs 1
  • GnRH agonists/antagonists with add-back therapy: Can reduce bleeding and adenomyosis volume by 40-50%, typically used temporarily (3-6 months) or as a bridge to definitive therapy 1, 2
  • Progestins (e.g., dienogest): Effective for pain symptoms due to antiproliferative and anti-inflammatory effects 2

• Non-hormonal Options:

  • Tranexamic acid: First-line non-hormonal medication for heavy menstrual bleeding (take only during menstruation) 1
  • NSAIDs: Can reduce bleeding by 20-40% and help with pain 1

Minimally Invasive Procedures (Second-Line)

When medical management fails to control symptoms:

• Uterine Artery Embolization (UAE):

  • Provides short-term (94%) and long-term (85%) symptom improvement 1
  • Particularly effective when fibroids predominate alongside adenomyosis 1
  • Recent studies show durability in symptom control (73-88% at 24-65 months follow-up) 3
  • Consider that recurrence rates at 2 years may be approximately 40-50% 3

• High-Intensity Focused Ultrasound (HIFU/MRgFUS):

  • Uses high-intensity ultrasound waves to thermally ablate adenomyotic tissue 1
  • May be proposed when medical therapy is ineffective 4

Surgical Options (Third-Line)

For patients with persistent symptoms despite medical and minimally invasive approaches:

• Conservative Surgical Approaches (for fertility preservation):

  • Adenomyomectomy: Surgical removal of adenomyotic tissue while preserving the uterus
  • Effective in improving abnormal uterine bleeding and pelvic pain 4, 5
  • At 7-month follow-up, can improve dysmenorrhea (100%) and menorrhagia (89%) 5
  • Should be performed by experienced surgeons in dedicated centers 4
  • Carries risk of uterine rupture during subsequent pregnancies 6

• Definitive Treatment:

  • Hysterectomy: Only definitive treatment for adenomyosis 4, 7
  • Consider for women who have completed childbearing and have failed other treatments

Treatment Algorithm Based on Patient Goals

1. For symptom control with no immediate fertility desires:

   • Start with medical management (LNG-IUS preferred)
   • If inadequate response, consider UAE or HIFU
   • Consider hysterectomy if all other options fail and fertility is not desired

2. For patients desiring future fertility:

   • Short-term GnRH analogues may improve chances of pregnancy 1
   • Conservative surgery (adenomyomectomy) may be considered despite risks 6, 5
   • Avoid UAE if immediate pregnancy is desired

Important Considerations

• Diagnosis confirmation: Transvaginal ultrasound or MRI should confirm adenomyosis before treatment 7
• Combined pathologies: When adenomyosis coexists with endometriosis or fibroids, treatment approach may need modification 3, 4
• Surgical expertise: Conservative surgical treatments require highly experienced surgeons 4
• Monitoring: Follow hemoglobin levels and adenomyosis size with imaging before and after treatment 1

Pitfalls to Avoid

• Prolonged use of GnRH agonists/antagonists beyond 3-6 months without add-back therapy due to bone mineral density loss 1
• Underestimating the complexity of conservative surgery for diffuse adenomyosis 4
• Inadequate counseling about fertility expectations after treatment 1
• Overlooking the risk of uterine rupture during pregnancy after conservative surgery 6