What are the treatment options for adenomyosis versus adenomyoma?

Treatment Options for Adenomyosis vs. Adenomyoma

For patients with adenomyosis, a combination of medical management with progestin IUDs is the most effective first-line treatment for symptom control, while hysterectomy remains the only definitive treatment for those with completed childbearing. 1

Understanding the Difference

• Adenomyosis: Diffuse invasion of endometrial tissue into the myometrium
• Adenomyoma: Focal, nodular form of adenomyosis that can resemble uterine fibroids

Medical Management Options

First-Line Treatments

1. Progestin-containing IUDs (Levonorgestrel/Mirena)

   • Most effective hormonal option for bleeding control and pain relief 1
   • Significantly improves pain and bleeding compared to combined oral contraceptives 2
   • Local mechanism of action with lower systemic hormone levels 2

2. Non-hormonal options

   • NSAIDs: Reduce bleeding by 20-40% 1
   • Tranexamic acid: First-line non-hormonal medication for heavy menstrual bleeding, taken only during menstruation 1
     • Caution: Contraindicated in women with active thromboembolic disease or history of thrombosis

Second-Line Treatments

1. Combined oral contraceptives

   • Effective for controlling bleeding symptoms, especially with smaller lesions 1
   • Less effective than progestin IUDs for adenomyosis 2, 1

2. GnRH agonists/antagonists

   • Reduce bleeding and lesion volume by 40-50% 1
   • Oral GnRH antagonist combinations maintain effectiveness even with concomitant adenomyosis 2
   • Limitation: Effective only for short-term use (3-6 months) due to bone loss 1, 3
   • Add-back therapy can minimize side effects while maintaining efficacy 1

3. Other progestins (dienogest, danazol, norethindrone acetate)

   • Antiproliferative and anti-inflammatory effects 3
   • Primarily control pain symptoms 3

4. Selective progesterone receptor modulators (SPRMs)

   • Emerging treatment option 1, 4
   • Ulipristal acetate (UPA) achieves amenorrhea in 70-83% of patients 1

Interventional Procedures

1. Uterine Artery Embolization (UAE)

   • Supported by prospective cohort studies for patients who fail conservative measures 2, 1
   • Improves quality of life and symptom scores at up to 7 years follow-up 1
   • Short-term and long-term symptom improvement in 94% and 85% of patients, respectively 1
   • Only 18% of patients require subsequent hysterectomy for persistent symptoms 1

2. MR-guided Focused Ultrasound (MRgFUS)

   • Uses high-intensity ultrasound waves to thermally ablate lesions 1
   • Results in 18% decrease in lesion diameter 1

3. Laparoscopic uterine artery occlusion (LUAO)

   • Less effective than UAE (39% vs. 53% diameter reduction) 1

Surgical Management

Conservative Surgical Approaches

1. Cytoreductive surgery (adenomyomectomy)

   • Effective for improving abnormal uterine bleeding, pelvic pain, and reducing uterine volume 1, 5
   • Should be performed by experienced surgeons in dedicated centers 5
   • Higher risk of complications, including uterine rupture in subsequent pregnancies 6, 7

2. Hysteroscopic procedures

   • May be proposed when medical therapy is ineffective 5
   • Limited efficacy for diffuse adenomyosis 2

Definitive Treatment

1. Hysterectomy
   • Only definitive treatment for adenomyosis 2, 6, 7
   • Very high patient satisfaction 1
   • Completely eliminates risk of recurrence 1
   • Should use least invasive route possible 2:
     • Vaginal approach: Shorter operating times, faster recovery
     • Laparoscopic approach: Faster return to normal activities, shorter hospital stays
     • Robotic-assisted: Similar outcomes to traditional laparoscopy

Treatment Algorithm Based on Patient Needs

For Patients with Symptom Control as Primary Goal

1. Start with progestin IUD (most effective) or non-hormonal options (NSAIDs, tranexamic acid)
2. If inadequate response, add or switch to combined oral contraceptives or other hormonal options
3. For persistent symptoms, consider UAE or MRgFUS
4. Hysterectomy as definitive treatment when other options fail and fertility is not desired

For Patients Desiring Fertility Preservation

1. Short-term GnRH analogues before fertility treatments to improve pregnancy chances 3
2. Conservative surgical approaches (adenomyomectomy) in selected cases
3. Caution: Increased risk of uterine rupture during subsequent pregnancies 6

Important Clinical Considerations

• Treatment selection should consider:

  • Symptom severity (pain vs. bleeding)
  • Patient's age and fertility desires
  • Uterine size
  • Economic considerations 1

• Regular monitoring:

  • Hemoglobin levels
  • Lesion size with imaging (ultrasound) before and after treatment 1

• Adenomyosis often coexists with other conditions like endometriosis or fibroids, which may influence treatment approach 5