What are the treatment options for adenomyosis?

Treatment Options for Adenomyosis

Medical management should be trialed as first-line therapy for adenomyosis before pursuing more invasive treatments. 1, 2

Medical Treatment Options

First-Line Options:

• Non-hormonal treatments:

  • NSAIDs: First choice for pain control, can reduce bleeding by 20-40% 2, 3
  • Tranexamic acid: First-line non-hormonal medication for heavy menstrual bleeding, taken only during menstruation 2
    • Contraindicated in women with active thromboembolic disease or history of thrombosis

• Hormonal treatments:

  • Progestin-containing IUDs (Levonorgestrel IUD/Mirena): Most effective hormonal option for bleeding control and pain relief 2, 3, 4
  • Combined oral contraceptives: Effective for controlling bleeding symptoms, especially with smaller lesions 2, 3
  • Progestins (e.g., dienogest, norethindrone acetate): Provide antiproliferative and anti-inflammatory effects, mainly for pain control 5, 3

Second-Line Options:

• GnRH agonists: Effective for short-term use (3-6 months)

  • Reduces bleeding and lesion volume by 40-50% 2
  • Particularly indicated before fertility treatments to improve pregnancy chances in infertile women 5
  • Caution: Chronic use causes trabecular bone loss; add-back therapy recommended for extended use 2

• Selective progesterone receptor modulators (SPRMs): Emerging treatment option 5, 4

• Aromatase inhibitors: Under investigation for adenomyosis treatment 5, 4

Minimally Invasive Procedures

When medical management fails or is contraindicated:

• Uterine Artery Embolization (UAE): Usually appropriate for reproductive-age patients with concurrent adenomyosis and fibroids who have no desire for future fertility 1

  • Improves symptom scores and quality of life
  • Shorter hospital stay compared to hysterectomy
  • Note: 20-25% incidence of symptom recurrence at 5-7 years 2

• MR-guided Focused Ultrasound (MRgFUS): Uses high-intensity ultrasound waves to thermally ablate lesions 2, 6

• Radiofrequency Ablation (RFA): May be proposed when medical therapy is ineffective 6

• Hysteroscopic procedures: May be considered in selected cases 6

Surgical Management

When other treatments fail or for definitive treatment:

• Conservative surgical approaches:

  • Cytoreductive surgery (adenomyomectomy)
  • Effective for improving abnormal uterine bleeding, pelvic pain, and reducing uterine volume
  • Caution: Should be performed by experienced surgeons in dedicated centers 6
  • Note: Associated with post-operative risks and potential obstetric complications

• Hysterectomy: The only definitive treatment for adenomyosis 6, 7

  • Very high patient satisfaction (90% reporting at least moderate satisfaction 2 years after procedure) 2
  • Completely eliminates risk of recurrence

Treatment Algorithm

1. Initial presentation: Start with medical management

   • For pain predominant: NSAIDs → hormonal options
   • For bleeding predominant: Tranexamic acid → hormonal options
   • Levonorgestrel IUD is particularly effective for long-term management

2. If medical management fails:

   • For patients desiring fertility: Consider GnRH agonists (short-term)
   • For patients not desiring fertility: Consider UAE or other minimally invasive procedures

3. If minimally invasive procedures fail:

   • For patients desiring fertility: Conservative surgical approaches by experienced surgeons
   • For patients not desiring fertility: Hysterectomy for definitive treatment

Important Considerations

• No drug is currently FDA-approved specifically for adenomyosis 5
• Symptoms often recur after discontinuation of medical therapy 3
• Treatment selection should consider:
  • Symptom severity (pain vs. bleeding)
  • Patient's age
  • Fertility desires
  • Uterine size
  • Economic considerations 3
• Conservative surgical treatments require specialized expertise and carry risks of complications 6