What are the management options for adenomyosis?

Adenomyosis Management

First-Line Medical Management

The levonorgestrel-releasing intrauterine device (LNG-IUD 20 μg/d) is the first-line therapy for adenomyosis, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 1, 2

• The LNG-IUD acts primarily at the endometrial level with minimal systemic progesterone absorption, providing long-term symptom control while preserving the uterus 1
• Follow-up at 3 months is recommended to assess symptom improvement 1, 2
• This approach is particularly effective for heavy menstrual bleeding and dysmenorrhea 3, 4

Alternative Hormonal Options When LNG-IUD Fails or Is Contraindicated

Second-Line Hormonal Therapies

• GnRH antagonists are highly effective for heavy menstrual bleeding even with concomitant adenomyosis 1, 2, 5
• Cyclic oral progestin reduces bleeding by 87%, often resulting in only light bleeding 1
• Combined oral contraceptives reduce painful and heavy menstrual bleeding, though less effective than LNG-IUD 1, 2, 5
• Dienogest and other progestins show antiproliferative and anti-inflammatory effects, particularly effective for pain control 3

Critical Caveat for GnRH Therapy

• GnRH agonists require add-back therapy with long-term use to prevent bone mineral loss 1, 2
• Fertility is suppressed during GnRH agonist/antagonist treatment 1

Nonhormonal Medical Options

• Tranexamic acid provides significant reduction in menstrual blood loss as a nonhormonal alternative 1, 4
• NSAIDs can reduce menstrual blood loss and are the first choice for pain control, particularly for patients with recent fertility requirements 1, 6, 4
• NSAIDs should be avoided in women with cardiovascular disease 1

Management of Severe/Hemodynamically Unstable Bleeding

When patients present with severe bleeding (saturating a large pad/tampon hourly for ≥4 hours):

• High-dose oral or injectable progestin-only medications for short-term control of severe bleeding with hemodynamic instability 1
• Concurrent iron supplementation is mandatory 1
• Consider hospital admission for monitoring and blood transfusion if needed 1
• Immediate assessment of hemodynamic stability, pregnancy status, and hemoglobin levels to quantify anemia 1

Interventional Options When Medical Management Fails

Uterine Artery Embolization (UAE)

UAE is the preferred interventional option for women desiring uterus preservation who fail conservative medical measures. 7, 2

• UAE provides short-term improvement in 94% of patients and long-term improvement in 85% of patients with symptom control up to 7 years 1, 2, 5
• Only 7-18% of patients require hysterectomy for persistent symptoms after UAE 2
• Important limitation: Comprehensive data on fertility and pregnancy outcomes after UAE is lacking; patients must be counseled accordingly 2
• UAE may be less effective when adenomyosis is the predominant condition compared to when fibroids predominate 2

Endometrial Ablation

• Endometrial ablation offers greater long-term efficacy than oral medical treatment, reducing pregnancy risk while managing bleeding 1

Definitive Surgical Management

Hysterectomy should be offered when medical and interventional therapies fail, providing definitive resolution with patient satisfaction rates up to 90%. 1, 5

Surgical Approach Algorithm

• Vaginal or laparoscopic routes are strongly preferred over abdominal hysterectomy 1, 2
• 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 Surgical Options

• Cytoreductive surgery (adenomyosis excision) may be considered for fertility preservation but should only be performed by experienced surgeons in dedicated centers 8
• Major caveat: Surgical recurrence is common, with up to 44% of women experiencing symptom recurrence within one year after conservative surgery 2

Critical Pitfalls and Caveats

Fundamental Limitations of Medical Therapy

• No medical therapy eradicates adenomyosis lesions; all provide only temporary symptom relief with rapid recurrence after discontinuation 1, 2, 3
• There is no evidence that medical treatment affects future fertility in women with adenomyosis 2
• No drug is currently FDA-labeled specifically for adenomyosis 3

Special Population Considerations

• In perimenopausal women on antiplatelet therapy, hormonal therapy requires careful clinical judgment 1
• Endometrial biopsy is recommended if presentation raises concern for other pathology, particularly in diabetic patients with increased endometrial cancer risk 1, 5
• Hormone replacement therapy with estrogen is not contraindicated following hysterectomy and bilateral salpingo-oophorectomy for adenomyosis 2

Concurrent Adenomyosis and Fibroids

• For patients with concurrent adenomyosis and fibroids, medical management or UAE is usually appropriate as initial therapy 7
• Medical management should be trialed prior to pursuing more invasive therapies in most cases 7