What are the treatment options for managing pain associated with adenomyosis?

Pain Management for Adenomyosis

Start with NSAIDs for immediate pain relief, then advance to a levonorgestrel-releasing intrauterine system (progestin IUD) as the most effective first-line hormonal therapy for adenomyosis-related pain. 1, 2

First-Line Pharmacologic Management

NSAIDs

• Use NSAIDs as the initial approach for immediate pain control in adenomyosis-related dysmenorrhea 3, 2
• NSAIDs are the only appropriate choice for patients with near-term fertility plans 3
• These agents address pain but do not reduce uterine volume or treat the underlying disease process 3

Progestin IUD (Levonorgestrel-Releasing Intrauterine System)

• The progestin IUD is clinically favored over combined oral contraceptives due to its local mechanism of action, lower systemic hormone levels, long duration after placement, and user independence 1
• A randomized controlled trial demonstrated significant improvement in both pain and bleeding in women with adenomyosis treated with progestin IUD versus combined oral contraceptives 1
• This option has shown effectiveness specifically for adenomyosis symptoms 2

Second-Line Hormonal Therapies

Combined Oral Contraceptives

• Oral contraceptives can effectively relieve pain and control uterine bleeding, though they are less effective than progestin IUDs 1, 3
• These remain a reasonable alternative when progestin IUD is not feasible or desired 3

GnRH Agonists

• GnRH agonists effectively relieve pain and control uterine bleeding in adenomyosis 3, 4
• These agents induce suppression of adenomyosis but must be used for short duration due to side effects 5
• When using GnRH agonists, implement add-back therapy to prevent bone mineral loss without reducing pain relief efficacy 6

Oral GnRH Antagonist Combinations

• Pooled analysis of two randomized controlled trials demonstrated that concomitant adenomyosis does not decrease the effectiveness of oral GnRH antagonist combinations in treating heavy menstrual bleeding 1
• These represent a newer option with potentially better tolerability than GnRH agonists 1

Other Hormonal Options

• Dienogest is more effective and commonly used in clinical practice 3
• Aromatase inhibitors represent an effective therapeutic option 4
• Mifepristone can effectively relieve pain and control uterine bleeding 3

Important Limitations of Medical Therapy

A critical pitfall: No medical therapy is proven to eradicate adenomyosis lesions completely, and symptoms frequently recur after drug withdrawal 3, 5

• Hormonal menstrual suppression treats symptoms but does not cure the underlying disease 2
• Exogenous progestogenic agents alone are ineffective for treating adenomyosis despite the hormone-sensitive nature of adenomyotic endometrial glands 5
• Long-term drug use strategies require further study due to symptom recurrence after discontinuation 3

Interventional and Surgical Options for Refractory Pain

Uterine Artery Embolization (UAE)

• UAE is appropriate for patients who fail conservative measures and desire uterus-preserving therapy 1
• Meta-analysis shows 94% short-term (<12 months) and 85% long-term (>12 months) symptom improvement 1
• UAE improved symptom scores and quality of life at up to 7 years follow-up, though 18% of patients required hysterectomy for persistent symptoms 1
• This option is particularly effective when fibroids predominate alongside adenomyosis 1

Conservative Surgical Treatment

• Cytoreductive surgery for adenomyosis is very effective in ameliorating abnormal uterine bleeding and pelvic pain and reducing uterine volume 7
• This surgery is complex and should be performed only by experienced surgeons in dedicated centers 7
• Consider this option for patients desiring uterine preservation who have failed medical therapy 7

Hysterectomy

• Hysterectomy provides definitive resolution of all adenomyosis-related symptoms 1, 2
• Patients may ultimately require hysterectomy if symptoms are not controlled with medical therapy 2
• This remains the only definitive cure for adenomyosis 3, 5

Treatment Selection Algorithm

Base drug selection on the patient's age, symptom severity, uterine size, fertility requirements, and economic considerations 3

1. Immediate pain control: Start NSAIDs for all patients with adenomyosis-related pain 3, 2

2. First-line hormonal therapy: Advance to progestin IUD for sustained symptom control, as it outperforms oral contraceptives 1

3. Alternative hormonal options: Use combined oral contraceptives, dienogest, or oral GnRH antagonist combinations if progestin IUD is not suitable 1, 3

4. Refractory symptoms: Consider GnRH agonists with add-back therapy for short-term use, or advance to interventional options like UAE 1, 4

5. Definitive treatment: Proceed to hysterectomy when medical and interventional therapies fail to control symptoms adequately 2, 5

Common Pitfalls to Avoid

• Do not expect medical therapy to cure adenomyosis—it only manages symptoms 3, 5
• Do not use progestogenic agents alone without other hormonal strategies, as they are ineffective 5
• Do not continue GnRH agonists long-term without add-back therapy due to bone mineral density loss 6, 5
• Do not assume symptom control will persist after stopping hormonal therapy—recurrence is common 3
• Do not attempt cytoreductive surgery without appropriate surgical expertise and center resources 7