What are the treatment options for adenomyosis?

Treatment Options for Adenomyosis

For patients with adenomyosis, a Levonorgestrel-releasing intrauterine system (LNG-IUD) should be considered first-line medical therapy due to significant improvement in pain and bleeding symptoms. 1

Medical Management Options

First-Line Treatments

• Progestin intrauterine devices (LNG-IUD) provide significant improvement in pain and bleeding through local hormone delivery with minimal systemic effects 1, 2
• Combined oral contraceptives effectively reduce painful and heavy menstrual bleeding in women with adenomyosis 3, 2
• NSAIDs and tranexamic acid can help manage pain and reduce bleeding symptoms as non-hormonal alternatives 3

Second-Line Treatments

• GnRH antagonists (elagolix, linzagolix, relugolix) are effective for heavy menstrual bleeding even with concomitant adenomyosis 3, 1, 2
• GnRH agonists (leuprolide acetate) can significantly reduce symptoms and uterine volume but are associated with hypoestrogenic side effects including bone mineral density loss 3, 4
• Progestins such as dienogest show antiproliferative and anti-inflammatory effects, making them useful for pain management 4
• Aromatase inhibitors may be considered for refractory cases based on pathogenetic mechanisms 4, 5

Interventional Treatments

Uterine Artery Embolization (UAE)

• UAE is recommended for patients who fail conservative measures and desire uterus preservation 3, 1, 2
• Prospective cohort studies demonstrate improvement in quality of life and symptom scores for up to 7 years follow-up 3, 2
• Short-term (<12 months) symptom improvement occurs in 94% of patients and long-term (>12 months) improvement in 85% 3, 1
• Only 7-18% of patients require hysterectomy for persistent symptoms after UAE 1, 2
• UAE may be more effective when fibroids predominate rather than pure adenomyosis 3, 1
• While successful pregnancy has been reported after UAE, comprehensive fertility data is lacking 3, 6

Other Interventional Options

• High-intensity focused ultrasound (HIFU) and radiofrequency ablation (RFA) may be considered when medical therapy is ineffective 7, 5
• Endometrial ablation has limited evidence for adenomyosis but may help with bleeding symptoms in select cases 5

Surgical Management

Conservative Surgical Approaches

• Conservative surgical treatments (adenomyomectomy, cytoreductive surgery) can improve abnormal uterine bleeding, pelvic pain, and reduce uterine volume 7
• These procedures should be performed by experienced surgeons in dedicated centers, especially with concomitant endometriosis 7
• Hysteroscopic approaches may be used for focal adenomyosis but have limited efficacy for diffuse disease 5

Definitive Treatment

• Hysterectomy remains the definitive treatment for adenomyosis when other treatments fail and fertility preservation is not desired 3, 2
• If hysterectomy is indicated, the least invasive approach should be used (vaginal or laparoscopic preferred over abdominal) 3
• Hysterectomy is associated with longer hospitalization, recovery time, and higher complication rates compared to less invasive procedures 3
• Long-term effects of hysterectomy may include increased risk of cardiovascular disease, osteoporosis, and mood disorders 3

Treatment Algorithm Based on Patient Goals

For Symptom Management with Fertility Preservation

1. Start with LNG-IUD or combined oral contraceptives for symptom control 1, 2
2. Add NSAIDs for breakthrough pain as needed 3
3. Consider GnRH antagonists with add-back therapy for refractory symptoms 3, 1
4. For patients who fail medical management, consider UAE with appropriate counseling about fertility implications 3, 1

For Patients with Completed Family Planning

1. Begin with LNG-IUD for symptom control 1, 2
2. Consider UAE for persistent symptoms with desire for uterine preservation 3, 2
3. Hysterectomy should be considered when other treatments fail 3, 2

Clinical Pitfalls and Considerations

• Adenomyosis often coexists with other gynecological conditions like endometriosis or fibroids, complicating diagnosis and treatment 8, 5
• Medical therapies can control symptoms but do not cure the underlying condition 9, 4
• Hormonal treatments used for symptom control are not compatible with conception attempts 6
• Conservative surgical treatments carry risks of post-operative complications and potential obstetric complications 7
• The ongoing QUESTA trial (Quality of Life after Embolization versus Hysterectomy in Adenomyosis) will provide important comparative data between UAE and hysterectomy 3