What is the treatment for adenomyosis?

Treatment for Adenomyosis

The levonorgestrel-releasing intrauterine system (LNG-IUD) is the first-line medical treatment for adenomyosis, providing significant improvement in pain and bleeding symptoms. 1, 2

Initial Medical Management

First-Line Therapy

• LNG-IUD (Mirena) is the preferred initial treatment, offering superior efficacy for both heavy menstrual bleeding and dysmenorrhea compared to other hormonal options 1, 2
• NSAIDs can be used for pain control, particularly in patients with near-term fertility plans 3
• Follow-up should occur at 3 months to assess symptom improvement 1

Second-Line Medical Options

When LNG-IUD is ineffective or not tolerated:

• Combined oral contraceptives reduce painful and heavy menstrual bleeding, though less effective than LNG-IUD 1, 4
• GnRH antagonists (relugolix, elagolix, linzagolix) are highly effective for heavy menstrual bleeding, even with concomitant adenomyosis 5, 1, 4
• High-dose progestins (dienogest, norethindrone acetate) provide effective symptom control through antiproliferative and anti-inflammatory effects 1, 6
• GnRH agonists (leuprolide) provide equivalent pain relief to danazol with better tolerability, but require add-back therapy to prevent bone mineral loss 1

Uterine-Preserving Interventional Options

For patients who fail medical management but desire uterus preservation:

Uterine Artery Embolization (UAE)

• UAE is the preferred interventional option for refractory cases in women desiring uterus preservation 1, 4
• Provides symptom improvement in 94% of patients short-term (<12 months) and 85% long-term (>12 months) 5, 1, 4
• Only 7-18% require subsequent hysterectomy for persistent symptoms 5, 1, 4
• Improves quality of life and symptom scores for up to 7 years 1, 4
• Critical caveat: Comprehensive fertility and pregnancy outcome data is lacking; counsel patients accordingly 5, 1, 2

Conservative Surgical Options

• Cytoreductive surgery may be effective for reducing uterine volume and improving symptoms, but should only be performed by experienced surgeons in dedicated centers 7
• Surgical recurrence is common, with up to 44% experiencing symptom recurrence within one year 1, 2

Definitive Surgical Management

Hysterectomy

When conservative measures fail and fertility is not desired:

• Choose the least invasive route: vaginal or laparoscopic approaches preferred over abdominal 5, 1
• Vaginal hysterectomy offers shorter operating times and faster return to normal activities 1
• Laparoscopic hysterectomy provides faster recovery, shorter hospital stays, and lower infection rates compared to abdominal approach 5, 1
• Provides definitive resolution of all symptoms 5
• Ovaries should be preserved when possible to avoid precipitating menopause and associated cardiovascular risks 5

Special Considerations for Concurrent Conditions

Adenomyosis with Fibroids

• Medical management or UAE is appropriate initial therapy 5
• Medical management should be trialed before invasive therapies 5
• GnRH antagonists remain effective even with concomitant adenomyosis 5

Adenomyosis with Endometrioma

• LNG-IUD for adenomyosis symptoms combined with surgical excision of endometrioma if symptomatic or >5 cm 1
• Surgical excision should preserve normal ovarian tissue and be performed by experienced surgeons 1

Critical Pitfalls and Caveats

• No medical therapy eradicates adenomyosis lesions—all provide only temporary symptom relief 1, 2
• Symptoms rapidly recur after cessation of hormonal therapy 2
• Fertility is suppressed during GnRH antagonist treatment 2
• No evidence that medical treatment affects future fertility in women with adenomyosis 1
• UAE may be less effective when adenomyosis predominates compared to when fibroids predominate 1
• Endometrial ablation has higher failure rates in the presence of adenomyosis 5