What are the treatment options for adenomyosis?

Treatment Options for Adenomyosis

For symptomatic adenomyosis, start with a levonorgestrel-releasing intrauterine system (LNG-IUD) as first-line therapy, escalate to GnRH antagonists or combined oral contraceptives if symptoms persist, and reserve uterine artery embolization for patients who fail medical management but desire uterus preservation. 1, 2, 3

Medical Management Algorithm

First-Line Therapy

• Levonorgestrel-releasing intrauterine system (LNG-IUD) is the preferred initial treatment for adenomyosis-related heavy menstrual bleeding and pain, providing significant symptom improvement and uterine volume reduction with long-term efficacy 1, 2, 3
• Follow-up at 3 months to assess symptom response 2

Second-Line Medical Options

• Combined oral contraceptives reduce painful and heavy menstrual bleeding, though they are less effective than LNG-IUD 2
• GnRH antagonists (elagolix, linzagolix, relugolix) are highly effective for heavy menstrual bleeding, even with concomitant adenomyosis, and work by reducing estrogen levels 1, 2, 3
• High-dose progestins (dienogest, norethindrone acetate) provide antiproliferative and anti-inflammatory effects, particularly effective for pain control 2, 4
• Tranexamic acid and NSAIDs can be used as nonhormonal alternatives for bleeding and pain symptoms 5

Important Medical Therapy Caveats

• No medical therapy eradicates adenomyosis lesions—all treatments provide only temporary symptom relief 2, 3
• GnRH agonists require add-back therapy to prevent bone mineral loss with long-term use 2
• Fertility is suppressed during GnRH antagonist treatment, and symptoms rapidly recur after cessation 3
• Medical treatments are not compatible with active conception attempts 6

Interventional Management

Uterine Artery Embolization (UAE)

• UAE should be considered for women who fail conservative medical measures and desire uterus preservation 1, 2
• Provides symptom improvement in 94% of patients short-term (<12 months) and 85% long-term (>12 months) 1, 2
• Only 7-18% of patients require subsequent hysterectomy for persistent symptoms 1, 2
• Critical caveat: Comprehensive data on fertility and pregnancy outcomes after UAE is lacking—counsel patients accordingly before proceeding 1, 6, 2, 3
• UAE may be less effective when adenomyosis predominates compared to when fibroids are the primary pathology 2

Surgical Management

Conservative Surgery

• Cytoreductive surgery (adenomyosis excision) can be effective for symptom relief and uterine volume reduction but should only be performed by experienced surgeons in dedicated centers 7
• Surgical recurrence is common, with up to 44% of women experiencing symptom recurrence within one year 2, 3
• Poses considerable risk of uterine rupture in subsequent pregnancies 8

Definitive Surgery

• Hysterectomy remains the only definitive cure for adenomyosis and is appropriate for patients with completed childbearing who have failed conservative measures 1, 5
• Choose the least invasive route: vaginal or laparoscopic approaches are preferred over abdominal hysterectomy, offering shorter operating times, faster recovery, and lower infection rates 2
• Hormone replacement therapy with estrogen is not contraindicated following hysterectomy and bilateral salpingo-oophorectomy for adenomyosis 2

Fertility Considerations

For Patients Desiring Pregnancy

• Medical management with GnRH agonists before fertility treatments may improve pregnancy chances in infertile women with adenomyosis 4
• Progestin IUDs and combined oral contraceptives manage symptoms but are incompatible with conception attempts 6
• There is no evidence that medical treatment affects future fertility outcomes in women with adenomyosis 2
• Successful pregnancy has been reported after UAE, but comprehensive fertility data is lacking 1, 6

Common Pitfalls to Avoid

• Do not expect medical therapy to cure adenomyosis—set realistic expectations for symptom management only 2, 3
• Avoid recommending UAE without thorough counseling about limited fertility outcome data 1, 6, 2, 3
• Do not perform conservative surgery without warning patients about high recurrence rates (44% within one year) 2, 3
• Remember that adenomyosis often coexists with endometriosis, complicating both diagnosis and treatment planning 6