Adenomyosis: Diagnosis and Treatment
Diagnosis
Transvaginal ultrasound (TVUS) is the first-line imaging modality for diagnosing adenomyosis, with MRI reserved for cases where ultrasound is inconclusive or when detailed characterization is needed. 1, 2
Imaging Approach
- TVUS has a pooled sensitivity of 82.5% and specificity of 84.6% for adenomyosis diagnosis 1
- Perform combined transabdominal and transvaginal ultrasound to fully assess pelvic structures, as the transabdominal approach provides anatomic overview while transvaginal imaging offers superior spatial and contrast resolution 1
- MRI should be obtained when ultrasound findings are inconclusive, when the uterus is incompletely visualized, or when coexisting pathology (leiomyomas) obscures the diagnosis 1, 2
- MRI has sensitivity of approximately 78% and specificity of 93% for adenomyosis and can better differentiate it from leiomyomas 1
- Include gadolinium-based IV contrast and diffusion-weighted sequences when performing MRI 1
Diagnostic Pitfalls
- TVUS sensitivity drops dramatically from 97.8% to 33.3% when coexisting leiomyomas are present, making MRI particularly valuable in these cases 1
- Histological examination remains the gold standard, though imaging has largely replaced diagnostic laparoscopy for non-invasive diagnosis 3
- Endometrial biopsy is mandatory when presentation raises concern for malignancy, particularly in patients with risk factors like diabetes 4, 5
Medical Management Algorithm
The levonorgestrel-releasing intrauterine device (LNG-IUD 20 μg/day) is first-line therapy for adenomyosis, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 2, 4, 5, 6
First-Line Therapy
- LNG-IUD acts primarily at the endometrial level with minimal systemic progesterone absorption, providing long-term symptom control while preserving the uterus 2, 4
- Follow-up at 3 months to assess symptom improvement 2, 4
- Efficacy is maintained long-term with high patient satisfaction 2, 5
Second-Line Hormonal Options (when LNG-IUD fails or is contraindicated)
- Combined oral contraceptives reduce painful and heavy menstrual bleeding, though less effective than LNG-IUD 2, 4, 5
- GnRH antagonists are highly effective for heavy menstrual bleeding even with concomitant adenomyosis 2, 4, 5
- High-dose progestins provide effective symptom control as an alternative 2, 7
- Cyclic oral progestin reduces bleeding by 87%, often resulting in only light bleeding 4, 5
- GnRH agonists require add-back therapy with long-term use to prevent bone mineral loss 4, 7
- Danazol is equally effective to GnRH agonists but has more androgenic side effects 2, 7
Nonhormonal Options
- Tranexamic acid provides significant reduction in menstrual blood loss as a nonhormonal alternative 4, 6
- NSAIDs can reduce menstrual blood loss but should be avoided in women with cardiovascular disease 4
Critical Limitation
No medical therapy eradicates adenomyosis lesions—all provide only temporary symptom relief with rapid recurrence after discontinuation. 2, 4, 7
Management of Severe/Refractory Cases
Hemodynamically Unstable Patients
- High-dose oral or injectable progestin-only medications for short-term control of severe bleeding 4
- Concurrent iron supplementation is mandatory 4
- Consider hospital admission for monitoring and blood transfusion if needed 4
Interventional Options
Uterine artery embolization (UAE) should be considered for women who fail conservative measures and desire uterus preservation. 2, 4, 5, 6
- UAE provides symptom improvement in 94% of patients short-term and 85% long-term, with symptom control up to 7 years 2, 4, 5
- Only 7-18% of patients require hysterectomy for persistent symptoms after UAE 2
- Comprehensive data on fertility and pregnancy outcomes after UAE is lacking; patients must be counseled accordingly 2, 4
- UAE may be less effective when adenomyosis predominates compared to when fibroids predominate 2
Other Minimally Invasive Options
- Endometrial ablation offers greater long-term efficacy than oral medical treatment while reducing pregnancy risk 4, 6
- Radiofrequency ablation (RFA) and high-intensity focused ultrasound (HIFU) may be proposed when medical therapy is ineffective 8
Surgical Management
Hysterectomy should be offered when medical and interventional therapies fail, providing definitive resolution with patient satisfaction rates up to 90%. 4, 5, 6
Surgical Approach
- Vaginal or laparoscopic routes are strongly preferred over abdominal hysterectomy 2, 4
- Vaginal hysterectomy offers shorter operating times and faster return to normal activities 2
- Laparoscopic hysterectomy provides faster recovery, shorter hospital stays, and lower infection rates compared to abdominal approach 2
Conservative Surgery (Fertility Preservation)
- Cytoreductive surgery for adenomyosis is highly effective in ameliorating abnormal uterine bleeding and pelvic pain, but should only be performed by experienced surgeons in dedicated centers 8
- Surgical recurrence is common, with up to 44% of women experiencing symptom recurrence within one year after conservative surgery 2
- Conservative surgical treatment carries some postoperative risks and obstetric complications 8
Postoperative Considerations
- Hormone replacement therapy with estrogen is not contraindicated following hysterectomy and bilateral salpingo-oophorectomy for adenomyosis 2
Special Clinical Scenarios
Adenomyosis with Endometrioma
- Progestin IUD for adenomyosis symptoms combined with surgical excision of endometrioma if symptomatic or larger than 5 cm 2
- Surgical excision should preserve normal ovarian tissue and be performed by experienced surgeons 2
- Follow-up ultrasound in 8-12 weeks initially, then annually if stable 2
- If endometrioma shows enlargement, changing morphology, or developing vascular components, refer to specialist or obtain MRI 2
Perimenopausal Women
- LNG-IUD remains first-line therapy 4
- In women on antiplatelet therapy, hormonal therapy requires careful clinical judgment 4
- Consider that symptoms may resolve with menopause, potentially avoiding invasive interventions 4