What are the treatment options for adenomyosis?

Treatment Options for Adenomyosis

Medical management should be the first-line treatment for adenomyosis, with uterine artery embolization (UAE) as an effective second-line option for those who fail conservative measures and desire uterus preservation. 1, 2, 3

First-Line Medical Treatments

• Levonorgestrel-releasing intrauterine system (LNG-IUD) is the preferred first-line treatment, providing significant improvement in pain and bleeding associated with adenomyosis 1, 2, 3
• Combined oral contraceptives effectively reduce painful and heavy menstrual bleeding in women with adenomyosis 1, 2, 3
• GnRH antagonists are effective for heavy menstrual bleeding even with concomitant adenomyosis 1, 2, 3
• Non-steroidal anti-inflammatory drugs (NSAIDs) are helpful for controlling pain and are the only option for patients with immediate fertility requirements 4

Second-Line Interventional Options

• Uterine Artery Embolization (UAE) should be considered for women who fail conservative measures and desire uterus preservation 1, 2, 3
  • UAE provides short-term symptom improvement in 94% and long-term improvement in 85% of patients 1, 2, 3
  • Only 7-18% of patients require hysterectomy for persistent symptoms after UAE 1, 2, 3
  • UAE may be less effective when adenomyosis is the predominant condition compared to when fibroids predominate 2
  • While successful pregnancies have been reported after UAE, comprehensive data on fertility outcomes is lacking 1, 5

Surgical Options

• Hysterectomy remains the definitive treatment for adenomyosis when other treatments fail and fertility preservation is not desired 3, 6
  • The least invasive route for hysterectomy should be performed 1
  • Vaginal hysterectomy is associated with shorter operating times and faster recovery 1
  • Laparoscopic hysterectomy offers faster return to normal activities and lower rates of wound infection compared to abdominal approach 1
• Conservative surgical treatments (cytoreductive surgery, endomyometrial ablation) can be effective in >50% of patients but should be performed by experienced surgeons in dedicated centers 6, 7

Special Considerations for Fertility

• Medical treatments like progestin IUDs and combined oral contraceptives effectively manage symptoms but are not compatible with conception attempts 5
• GnRH analogues may be indicated before fertility treatments to improve pregnancy chances in infertile women with adenomyosis 8
• NSAIDs are the only medical option for patients with immediate fertility requirements 4

Treatment Algorithm

1. Initial approach: Start with medical management using LNG-IUD (first choice) or combined oral contraceptives 1, 2, 3
2. If inadequate response: Consider GnRH antagonists or other hormonal options 1, 2, 3
3. If medical management fails: Consider UAE for patients desiring uterus preservation 1, 2, 3
4. Last resort: Hysterectomy when other treatments fail and fertility preservation is not desired 3, 6

Monitoring and Follow-up

• After initiating medical therapy, follow-up in 3 months to assess symptom improvement 2
• For patients undergoing UAE, long-term follow-up is necessary as symptoms may recur 1, 2

Pitfalls and Caveats

• No drug is currently FDA-approved specifically for adenomyosis treatment 8
• Symptoms often recur after discontinuation of medical therapy 4
• The presence of concurrent conditions like endometriosis may complicate diagnosis and treatment 5
• Conservative surgical treatments require expertise and carry risks of obstetric complications 6