What are the treatment options for adenomyosis?

Treatment Options for Adenomyosis

For symptomatic adenomyosis, initiate treatment with a levonorgestrel-releasing intrauterine device (LNG-IUD) as first-line therapy, which provides superior symptom control for both pain and bleeding compared to other medical options. 1, 2, 3

Medical Management Algorithm

First-Line Therapy

• Levonorgestrel-releasing IUD (LNG-IUD) is the preferred initial treatment for adenomyosis symptoms, demonstrating significant improvement in both pain and heavy menstrual bleeding through local hormonal action with minimal systemic effects 1, 2, 3
• A recent randomized controlled trial showed LNG-IUD superior to combined oral contraceptives for adenomyosis-related pain and bleeding 1
• This option is particularly effective for long-term management, reducing uterine volume and resolving abnormal bleeding 4

Second-Line Medical Options

• Combined oral contraceptives can reduce painful and heavy menstrual bleeding when LNG-IUD is not tolerated or contraindicated 1, 3
• GnRH antagonists are highly effective for heavy menstrual bleeding, with pooled analysis demonstrating efficacy even with concomitant adenomyosis 1, 3
• Dienogest and other progestins show antiproliferative and anti-inflammatory effects, particularly useful for pain control 4

Adjunctive Therapy

• NSAIDs serve as first-choice agents for pain control and are the only option for patients with immediate fertility plans 5

Interventional and Surgical Management

For Patients Desiring Uterine Preservation

Uterine artery embolization (UAE) is the preferred interventional option when medical management fails and fertility preservation is desired 1, 2, 3

UAE Outcomes:

• Short-term symptom improvement in 94% of patients (<12 months) 1, 2, 3
• Long-term improvement in 85% of patients (>12 months) 1, 2, 3
• Only 7-18% require subsequent hysterectomy for persistent symptoms 1, 2, 3
• Improvement in quality of life and symptom scores maintained up to 7 years 1

Important UAE Considerations:

• UAE is more effective when fibroids predominate over adenomyosis alone 2
• Successful pregnancy has been reported post-UAE, but comprehensive fertility data is lacking—counsel patients accordingly 1, 6, 2
• The ongoing QUESTA trial is comparing UAE versus hysterectomy outcomes 1

Conservative Surgical Options

• Cytoreductive surgery (adenomyomectomy) is effective for reducing abnormal uterine bleeding, pelvic pain, and uterine volume, but should only be performed by experienced surgeons in dedicated centers due to complexity and potential obstetric complications 7
• Success rates exceed 50% in selected patients, though long-term follow-up is limited to 3 years 8

Definitive Treatment

Hysterectomy remains the only definitive cure and should be considered when:

• Medical management and UAE have failed 1, 3
• Fertility preservation is not desired 1
• Symptoms severely impact quality of life despite conservative measures 3

Hysterectomy approach: Use the least invasive route possible—vaginal or laparoscopic approaches are associated with shorter hospital stays, faster recovery, and lower complication rates compared to abdominal hysterectomy 1

Special Clinical Scenarios

Adenomyosis with Concurrent Fibroids

• Medical management (LNG-IUD preferred) or UAE are both appropriate initial therapies 1
• Trial medical management before pursuing invasive therapies 1
• Myomectomy alone is unlikely to effectively address adenomyosis and should not be relied upon 1

Fertility Considerations

• For patients actively trying to conceive: NSAIDs only for symptom control, as hormonal therapies are incompatible with conception attempts 6, 5
• For infertility with adenomyosis: GnRH analogues before fertility treatments may improve pregnancy chances 4
• Progestin IUDs and oral contraceptives manage symptoms effectively but must be removed for conception 6

Common Pitfalls and Caveats

• Avoid relying on myomectomy for adenomyosis treatment—it does not effectively address the diffuse myometrial involvement 1
• Do not delay treatment in symptomatic patients; early diagnosis and intervention improve outcomes 8
• Counsel patients about recurrence: Symptoms frequently recur after medical therapy withdrawal, requiring long-term management strategies 5
• MRgFUS lacks evidence for adenomyosis treatment and should not be recommended 1
• Endometrial ablation has no supporting literature for adenomyosis and should be avoided 1

Follow-Up Protocol

• Reassess symptom improvement 3 months after initiating medical therapy 2
• For patients on LNG-IUD, expect maximal benefit within 6-12 months of placement 4
• Post-UAE patients require monitoring for persistent symptoms warranting hysterectomy 1