What are the treatment options for patients with endometriosis, adenomyosis, hydrosalpinx, and uterine myoma (fibroids)?

Treatment of Complex Gynecologic Pathology: Endometriosis, Adenomyosis, Hydrosalpinx, and Myoma

For patients presenting with this complex combination of pathologies, surgical intervention addressing all conditions simultaneously is the most appropriate approach, with the specific surgical plan determined by fertility desires, symptom severity, and disease extent. 1

Treatment Algorithm Based on Fertility Desires and Symptom Severity

For Patients Desiring Future Fertility

Surgical excision of endometriosis combined with myomectomy should be performed simultaneously, as surgical methods for fibroids and endometriosis can be done together and surgery may be more appropriate in this population. 1

• Hydrosalpinx requires salpingectomy prior to any fertility treatment, as the presence of hydrosalpinx significantly impairs fertility outcomes and increases risk of ectopic pregnancy
• Adenomyosis presents the greatest challenge for fertility preservation, as no medical therapy eradicates adenomyosis lesions—all provide only temporary symptom relief with rapid recurrence after discontinuation 2
• Conservative surgical treatment (cytoreductive surgery) for adenomyosis may be considered but should only be performed by experienced surgeons in dedicated centers, particularly with concomitant endometriosis 3
• Myomectomy (laparoscopic or open) provides equivalent quality of life improvement while preserving fertility 4

For Patients Not Desiring Future Fertility

Hysterectomy with bilateral salpingo-oophorectomy provides definitive resolution of all pathologies and should be strongly considered, as it accounts for three-quarters of fibroid treatment in the United States and provides patient satisfaction rates up to 90%. 5, 2

• Vaginal or laparoscopic routes are preferred over abdominal approach 2
• Hysterectomy remains the only existing definitive treatment for adenomyosis 3
• Complete excision of endometriosis should be performed at the same surgery 6, 7

For Patients Seeking Uterine Preservation Without Fertility Concerns

A stepwise approach beginning with medical management, followed by interventional procedures if medical therapy fails, represents the optimal strategy:

First-Line Medical Management

• Levonorgestrel-releasing intrauterine device (LNG-IUD 20 μg/d) is first-line therapy, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation 2
• The LNG-IUD acts primarily at the endometrial level with minimal systemic absorption, providing long-term symptom control for both adenomyosis and myoma-related bleeding 2
• GnRH antagonists (elagolix, relugolix) are highly effective for heavy menstrual bleeding even with concomitant adenomyosis and can reduce fibroid volume by 18-30% 5, 2
• Mandatory add-back therapy with low-dose estrogen and progestin is required with GnRH agonists/antagonists to mitigate hypoestrogenic side effects while maintaining efficacy 5
• Tranexamic acid provides significant reduction in menstrual blood loss as a nonhormonal alternative 5, 2
• Combined oral contraceptives reduce painful and heavy menstrual bleeding, though less effective than LNG-IUD 2

Second-Line Interventional Options

Uterine artery embolization (UAE) should be considered for patients with symptomatic adenomyosis or concomitant adenomyosis and uterine leiomyomata, as recent data shows durability in symptom control with 73-88% symptomatic control at median follow-up of 24-65 months. 1

• UAE provides short-term improvement in 94% of patients and long-term improvement in 85% of patients with symptom control up to 7 years 2
• Long-term symptomatic relief (median follow-up 27.9 months) in patients with pure adenomyosis or adenomyosis with coexistent leiomyomas ranged from 65-82% 1
• Critical caveat: Calcified fibroids do not respond to UAE and require surgical intervention 4
• Hydrosalpinx is not addressed by UAE and requires separate surgical management

Critical Management Considerations

Diagnostic Workup Requirements

• Endometrial biopsy is mandatory in postmenopausal patients prior to any intervention to rule out endometrial neoplasia and diagnose potential sarcoma 5
• MRI pelvis provides optimal preoperative assessment of adenomyosis extent and fibroid characteristics 1, 8
• Saline infusion sonohysterography shows good agreement (kappa 0.80) with diagnostic hysteroscopy for classifying submucosal fibroids 5
• CT pelvis is superior for calcified fibroids as it better delineates calcification compared to ultrasound and MRI, directly impacting treatment planning 4

Disease-Specific Pitfalls

Endometriosis requires definitive surgical excision for cure, as medical therapy is suppressive rather than curative with rapid recurrence when discontinued. 7

• The time interval between first symptoms and diagnosis averages 7 years due to non-specific symptoms and lack of awareness 6
• Recurrence rates among treated patients range from 5% to >60%, highly dependent on surgical skills and integrated management 6
• Deep infiltrating endometriosis should be managed in specialized centers with multidisciplinary teams 6, 9

Adenomyosis has no curative medical therapy—all treatments provide only temporary symptom relief. 2

• Recurrence rates at 2 years after UAE for adenomyosis are approximately 40-50% 1
• Hormonal drugs represent first-line therapy, highly effective on symptoms and uterine volume reduction 3

Hydrosalpinx significantly impairs fertility and increases infection risk:

• Salpingectomy is required before any assisted reproductive technology
• Cannot be managed medically or with UAE

Surgical Approach Hierarchy

For patients with all four pathologies requiring surgery, the recommended sequence is:

1. Bilateral salpingectomy for hydrosalpinx (addresses infection risk and fertility impairment)
2. Complete excision of endometriosis lesions (provides definitive treatment)
3. Myomectomy or hysterectomy depending on fertility desires (addresses fibroids and adenomyosis)

This combined approach is superior to staged procedures as it reduces anesthesia exposure, recovery time, and overall morbidity. 1

Special Considerations for Severe Bleeding

For hemodynamically unstable patients with severe bleeding:

• High-dose oral or injectable progestin-only medications provide short-term control 2
• Concurrent iron supplementation is mandatory 2
• Hospital admission for monitoring and potential blood transfusion should be considered 2
• Assess hemoglobin levels to quantify anemia, with bleeding saturating a large pad/tampon hourly for ≥4 hours warranting urgent evaluation 2