What are the step-by-step management options for a female patient of reproductive age with adenomyosis experiencing pain?

Management of Adenomyosis Pain: Step-by-Step Approach

Start with NSAIDs for immediate pain relief, then advance to a levonorgestrel-releasing intrauterine system (progestin IUD) as the most effective first-line hormonal therapy, reserving uterine artery embolization for patients who fail conservative measures and desire uterus preservation, with hysterectomy as the definitive option for refractory cases. 1

Step 1: Immediate Pain Control with NSAIDs

• Begin with naproxen 500 mg twice daily or 250 mg every 6-8 hours as the first-line agent for acute pain relief. 1, 2
• NSAIDs work by controlling the inflammatory component of adenomyosis pain and are the only appropriate choice for patients with immediate fertility plans. 3
• Onset of pain relief typically begins within 1 hour with naproxen. 2
• For acute pain crises, consider starting with naproxen 500 mg followed by 500 mg every 12 hours, with a maximum initial daily dose of 1250 mg, then reducing to no more than 1000 mg daily thereafter. 2

Step 2: First-Line Hormonal Therapy - Progestin IUD

• The levonorgestrel-releasing intrauterine system (progestin IUD) is the preferred first-line hormonal therapy over all other options. 1
• The progestin IUD is clinically favored due to its local mechanism of action, lower systemic hormone levels, long duration after placement, and user independence. 4, 1
• A recent randomized controlled trial demonstrated significant improvement in both pain and bleeding in women with adenomyosis treated with progestin IUD versus combined oral contraceptives. 4
• This option effectively addresses both pain and heavy menstrual bleeding while preserving fertility potential. 5

Step 3: Alternative Hormonal Therapies

If the progestin IUD is not tolerated, contraindicated, or ineffective:

• Combined oral contraceptives can effectively relieve pain and control uterine bleeding, though they are less effective than progestin IUDs. 4, 1
• Consider oral GnRH antagonist combinations, as pooled analysis of two randomized controlled trials showed that concomitant adenomyosis does not decrease their effectiveness in treating heavy menstrual bleeding. 4, 1
• When using GnRH agonists for chronic pain, implement add-back therapy (such as norethindrone acetate 5 mg daily with or without low-dose estrogen) to prevent bone mineral loss without reducing pain relief efficacy. 1, 6
• GnRH agonists should be used for at least three months to achieve significant pain relief. 7

Important caveat: No medical therapy eradicates adenomyosis lesions; all hormonal treatments only provide symptomatic relief through hormonal suppression. 6

Step 4: Interventional Option - Uterine Artery Embolization

For patients who fail conservative medical measures and desire uterus-preserving therapy:

• Uterine Artery Embolization (UAE) is appropriate with 94% short-term and 85% long-term symptom improvement. 1
• UAE improved symptom scores and quality of life at up to 7 years follow-up in prospective cohort studies. 1
• Evidence from prospective cohort studies supports UAE for patients with adenomyosis (with or without fibroids) who fail conservative measures. 4
• Critical limitation: 18% of patients required hysterectomy for persistent symptoms after UAE. 1
• Long-term symptomatic relief (median follow-up 27.9 months) ranged from 65% to 82%, with more recent studies showing symptom control in 73% to 88%. 4

Step 5: Definitive Surgical Management - Hysterectomy

• Hysterectomy provides definitive resolution of all adenomyosis-related symptoms. 1
• If hysterectomy is indicated, the least invasive route should be performed: vaginal or laparoscopic approaches are associated with shorter hospital stays, faster recovery, and lower complication rates compared to abdominal hysterectomy. 4
• Ovaries should be left in place to avoid precipitating menopause and associated cardiovascular risks, unless there is another indication for removal. 4

Critical pitfall: Hysterectomy is associated with elevated risk of subsequent cardiovascular disease, mood disorders, osteoporosis, bone fracture, and dementia, with increased mortality especially when performed at a young age. 4 Randomized studies demonstrated increased rates of severe complications, longer hospitalization, and longer return to regular activities with hysterectomy compared to UAE despite similar symptom relief. 4

Treatments to Avoid

• Myomectomy (hysteroscopic, laparoscopic, or open) is unlikely to effectively address adenomyosis and should not be used as primary treatment. 4
• MR-guided focused ultrasound ablation lacks sufficient evidence for adenomyosis treatment. 4

Adjunctive Non-Pharmacologic Measures

• Heat application to the abdomen or back may reduce cramping pain. 7
• Acupressure on Large Intestine-4 (LI4) or Spleen-6 (SP6) points may help reduce cramping pain. 7
• Aromatherapy with lavender may increase satisfaction and reduce pain or anxiety. 7