What is the recommended management for severe perimenopausal bleeding with adenomyosis?

Management of Severe Perimenopausal Bleeding with Adenomyosis

For severe perimenopausal bleeding with adenomyosis, initiate treatment with a levonorgestrel-releasing intrauterine device (LNG-IUD 20 μg/d) as first-line therapy, which reduces menstrual blood loss by 71-95% and is comparable in efficacy to endometrial ablation. 1, 2

Initial Assessment and Stabilization

When evaluating severe bleeding, immediately assess:

• Hemodynamic stability (bleeding saturating a large pad/tampon hourly for ≥4 hours warrants urgent evaluation) 3
• Pregnancy status (mandatory testing in all reproductive-age women) 3
• Hemoglobin levels to quantify anemia 3
• Endometrial biopsy if presentation raises concern for other pathology 3

First-Line Medical Management Algorithm

Primary Option: Levonorgestrel IUD

• The LNG-IUD (20 μg/d) is the most effective medical therapy, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation 1, 2
• Acts primarily at the endometrial level with minimal systemic progesterone absorption 3
• Provides long-term symptom control while preserving the uterus 1
• Follow-up at 3 months to assess symptom improvement 2

Alternative Hormonal Options (if LNG-IUD contraindicated or declined):

• Combined oral contraceptives reduce painful and heavy menstrual bleeding, though less effective than LNG-IUD 1, 2
• GnRH antagonists are highly effective for heavy menstrual bleeding even with concomitant adenomyosis 1, 2
• High-dose progestins (dienogest, norethindrone acetate) provide antiproliferative and anti-inflammatory effects 4, 5
• Cyclic oral progestin reduces bleeding by 87%, often resulting in only light bleeding 3

Nonhormonal Options:

• Tranexamic acid provides significant reduction in menstrual blood loss as a nonhormonal alternative 6, 7
• NSAIDs can reduce menstrual blood loss 6, 7

Management of Hemodynamically Unstable Patients

For severe bleeding with hemodynamic instability:

• High-dose oral or injectable progestin-only medications for short-term control 3
• Concurrent iron supplementation 6
• Consider hospital admission for monitoring and blood transfusion if needed 3

Second-Line Interventional Options

Uterine Artery Embolization (UAE)

For women who fail conservative medical management and desire uterus preservation, UAE provides:

• Short-term improvement in 94% of patients 1, 2
• Long-term improvement in 85% of patients with symptom control up to 7 years 1, 2
• Only 7-18% require subsequent hysterectomy for persistent symptoms 1, 2

Important caveat: UAE may be less effective when adenomyosis predominates compared to when fibroids are the primary pathology 2

Endometrial Ablation

• Second-generation techniques (thermal balloon, microwave, radiofrequency) offer greater long-term efficacy than oral medical treatment 3
• Reduces pregnancy risk while managing bleeding 3
• Particularly useful in perimenopausal women not desiring future fertility 7

Definitive Surgical Management

Hysterectomy Indications:

Hysterectomy should be offered when medical and interventional therapies fail, providing definitive resolution with patient satisfaction rates up to 90% 6, 7

Surgical approach selection:

• Vaginal or laparoscopic routes preferred over abdominal approach 2
• Vaginal hysterectomy offers shorter operating times and faster return to activities 2
• Laparoscopic hysterectomy provides faster recovery, shorter hospital stays, and lower infection rates 2

Critical Pitfalls and Caveats

• No medical therapy eradicates adenomyosis lesions; all provide only temporary symptom relief with rapid recurrence after discontinuation 2, 4
• In perimenopausal women on antiplatelet therapy (if concurrent cardiovascular disease), hormonal therapy requires careful clinical judgment as it may be relatively contraindicated 3
• Avoid NSAIDs and tranexamic acid in women with cardiovascular disease given association with MI and thrombosis 3
• GnRH agonists require add-back therapy with long-term use to prevent bone mineral loss 2
• Fertility is suppressed during GnRH agonist/antagonist treatment 6
• Comprehensive data on fertility and pregnancy outcomes after UAE is lacking 2

Perimenopausal-Specific Considerations

Given the perimenopausal context:

• Hysterectomy becomes increasingly appropriate as definitive management since fertility preservation is not a concern 7, 5
• Symptoms may naturally resolve with menopause, making temporizing medical management reasonable if bleeding is controllable 5
• Endometrial ablation is particularly suitable in this population as pregnancy avoidance is desired 3, 7