What are the key investigations and management options for adenomyosis, including medications and non-medical management?

Adenomyosis: Key Investigations and Management

Diagnostic Investigations

First-Line Imaging

• Transvaginal ultrasound (TVUS) is the initial imaging modality of choice to confirm adenomyosis, showing diffuse or focal thickening of the junctional zone 1, 2, 3
• Look for Doppler findings: resistive index >0.7 and pulsatility index >1.2 support adenomyosis diagnosis 2

Advanced Imaging

• MRI should be performed when ultrasound findings are inconclusive or to better characterize disease extent and exclude other pathologies 1
• MRI shows diffuse or focal thickening of the junctional zone as the characteristic finding 2

Histologic Confirmation

• Tissue diagnosis is not routinely required for typical presentations 4
• Consider biopsy only for atypical lesions or when malignancy cannot be excluded 5

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Medical Management

First-Line Treatment

• Levonorgestrel-releasing intrauterine system (LNG-IUD) is the first-line medical therapy, providing significant improvement in both pain and bleeding 1, 2, 3
• A recent randomized trial demonstrated superior outcomes with progestin IUD versus combined oral contraceptives for adenomyosis 5

Second-Line Hormonal Options

• Combined oral contraceptives reduce painful and heavy menstrual bleeding, though less effective than LNG-IUD 5, 1, 3
• Continuous oral contraceptive use (skipping placebo weeks) may provide better symptom control 4
• High-dose progestins (oral or depot medroxyprogesterone acetate) are effective alternatives 5, 4

Third-Line Hormonal Options

• GnRH antagonists are highly effective for heavy menstrual bleeding, even with concomitant adenomyosis 5, 1, 2
• GnRH agonists (for at least 3 months) provide equivalent pain relief to danazol but with better tolerability 5
• Add-back therapy must be used with long-term GnRH agonist therapy to prevent bone mineral loss (~1% per month without add-back), without reducing pain relief efficacy 5, 2
• Danazol (for at least 6 months) is equally effective to GnRH agonists but has more androgenic side effects 5

Emerging Medical Therapies

• Dienogest shows promise but requires further data 6
• Aromatase inhibitors, selective progesterone receptor modulators, and prolactin/oxytocin modulators are under investigation 4, 6

Follow-Up After Medical Therapy

• Reassess symptom improvement at 3 months after initiating medical therapy 1

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Non-Medical Management

Minimally Invasive Procedures

Uterine Artery Embolization (UAE)

• UAE should be considered for women who fail conservative medical measures and desire uterus preservation 1, 2, 3
• UAE provides symptom improvement in 94% of patients short-term (<12 months) and 85% long-term (>12 months) 1, 3
• Only 7-18% of patients require subsequent hysterectomy for persistent symptoms 1, 3
• Quality of life and symptom scores improve for up to 7 years post-procedure 5, 3
• UAE is less effective when adenomyosis predominates compared to when fibroids are the primary pathology 1
• UAE is not recommended as first-line for women actively seeking pregnancy due to increased risks: 35% miscarriage rate, 66% cesarean section rate, and 13.9% postpartum hemorrhage rate 2

High-Intensity Focused Ultrasound (HIFU)

• HIFU may be considered as an alternative minimally invasive option, though data are limited 7, 8

Radiofrequency Ablation (RFA)

• RFA may be proposed when medical therapy is ineffective, though evidence is limited 7

Conservative Surgical Options

Hysteroscopic Procedures

• Hysteroscopic endometrial resection or ablation may be considered for focal adenomyosis or when medical therapy fails 7, 8
• Endometrial ablation has limited data specifically for adenomyosis 8

Laparoscopic Cytoreductive Surgery

• Cytoreductive surgery (adenomyomectomy) is highly effective for reducing abnormal uterine bleeding, pelvic pain, and uterine volume 7
• This surgery should only be performed by experienced surgeons in dedicated centers, especially with concomitant endometriosis 7
• Post-operative obstetric complications may occur; counsel patients accordingly 7

Definitive Surgical Treatment

Hysterectomy

• Hysterectomy remains the only definitive cure for adenomyosis 7, 4, 9
• The least invasive route should be chosen: vaginal or laparoscopic approaches are preferred over abdominal hysterectomy 5
• Vaginal hysterectomy offers shorter operating times and faster return to normal activities 5
• Laparoscopic hysterectomy provides faster recovery, shorter hospital stays, and lower infection rates compared to abdominal approach 5
• Hormone replacement therapy with estrogen is not contraindicated following hysterectomy and bilateral salpingo-oophorectomy for adenomyosis 5

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Management Algorithm by Clinical Scenario

Symptomatic Adenomyosis (Desire for Fertility Preservation)

1. Start with LNG-IUD as first-line 1, 2, 3
2. If ineffective or not tolerated, try combined oral contraceptives or high-dose progestins 5, 1
3. If still symptomatic, consider GnRH antagonists (with add-back therapy if prolonged use) 5, 1, 2
4. For refractory cases, consider cytoreductive surgery by experienced surgeon 7
5. UAE may be considered but counsel regarding pregnancy risks 2

Symptomatic Adenomyosis (Fertility Not Desired)

1. Start with LNG-IUD as first-line 1, 2, 3
2. If ineffective, try GnRH agonists/antagonists with add-back therapy 5, 1
3. For refractory cases, consider UAE (94% short-term success rate) 1, 3
4. Hysterectomy for definitive treatment when other options fail 3, 7

Severe Adenomyosis

• Medical treatment alone may not be sufficient for severe disease 5
• Consider combination of medical therapy followed by surgical intervention 5

Asymptomatic Adenomyosis

• Expectant management is appropriate as adenomyosis may regress spontaneously 5

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Key Pitfalls and Caveats

• No medical therapy has been proven to eradicate adenomyosis lesions; all treatments provide temporary symptom relief only 5, 4
• There is no evidence that medical treatment affects future fertility in women with adenomyosis 5
• Surgical recurrence is common: up to 44% of women experience symptom recurrence within one year after conservative surgery 5
• UAE has 40-50% recurrence rates at 2 years 2
• Comprehensive data on fertility and pregnancy outcomes after UAE is lacking; patients must be counseled accordingly 5, 1
• Long-term GnRH therapy without add-back causes significant bone loss 5, 2
• Myomectomy alone does not effectively address adenomyosis 5