What is adenomyosis and how is it treated?

Adenomyosis: Definition and Treatment

What is Adenomyosis?

Adenomyosis is a benign uterine disorder where endometrial glands and stroma are pathologically present within the myometrium, causing inflammation and fibrosis, commonly presenting with heavy menstrual bleeding, dysmenorrhea, and infertility. 1, 2

• The condition involves invasion of endometrium into the myometrium, causing alterations in the junctional zone visible on imaging 3, 4
• Adenomyosis can present as diffuse disease throughout the myometrium or focal lesions (adenomyomas) 2
• Many women are asymptomatic, while others experience severe symptoms that disrupt daily activities 5, 1
• The disease frequently coexists with endometriosis and uterine fibroids, complicating diagnosis and treatment 1, 2

Diagnosis

Transvaginal ultrasound is the first-line imaging modality, with MRI reserved for inconclusive cases or detailed characterization. 6

• Diagnosis no longer requires hysterectomy; non-invasive imaging techniques allow identification in reproductive-age women 1, 2
• 3D transvaginal ultrasound is superior to 2D ultrasound for diagnosis and may detect early-stage disease 4
• Endometrial biopsy should be performed if presentation raises concern for other pathology 7

Treatment Algorithm

First-Line Medical Management

The levonorgestrel-releasing intrauterine device (LNG-IUD) is the first-line treatment, reducing menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation. 6, 7

• The LNG-IUD acts primarily at the endometrial level with minimal systemic absorption, providing long-term symptom control 7
• Follow-up at 3 months to assess symptom improvement 5, 7
• A recent randomized controlled trial demonstrated significant improvement in pain and bleeding with progestin IUD versus combined oral contraceptives 8

Second-Line Medical Options

Combined oral contraceptives reduce painful and heavy menstrual bleeding, though less effective than LNG-IUD. 5, 6

• GnRH antagonists are highly effective for heavy menstrual bleeding even with concomitant adenomyosis 8, 5, 6
• High-dose progestins provide an effective alternative for symptom control 6, 3
• Tranexamic acid offers significant reduction in menstrual blood loss as a nonhormonal alternative 7

Critical Caveat About Medical Therapy

No medical therapy eradicates adenomyosis lesions; all treatments provide only temporary symptom relief with rapid recurrence after discontinuation. 6, 7

• Medical therapies suppress symptoms but do not cure the underlying disease 3
• There is no evidence that medical treatment affects future fertility 6

Interventional Options for Refractory Cases

Uterine artery embolization (UAE) should be considered for women who fail conservative measures and desire uterus preservation, providing short-term improvement in 94% and long-term improvement in 85% of patients. 5, 6, 7

• UAE results in symptom control for up to 7 years 5, 6
• Only 7-18% of women eventually require hysterectomy for persistent symptoms after UAE 5, 6
• UAE is most effective when fibroids predominate over adenomyosis 6
• Comprehensive data on fertility and pregnancy outcomes after UAE is lacking; patients must be counseled accordingly 6

Surgical Management

Hysterectomy is the only definitive treatment and should be offered when medical and interventional therapies fail, providing patient satisfaction rates up to 90%. 7, 9, 4

• The least invasive route should be chosen: vaginal or laparoscopic approaches are preferred over abdominal hysterectomy 6, 7
• Vaginal hysterectomy offers shorter operating times and faster return to normal activities 6
• Laparoscopic hysterectomy provides faster recovery, shorter hospital stays, and lower infection rates compared to abdominal approach 6
• Conservative surgical excision (cytoreductive surgery) may be considered for uterus preservation but has high recurrence rates (up to 44% within one year) and should only be performed by experienced surgeons in dedicated centers 6, 9

Management of Severe Bleeding

For hemodynamically unstable patients with severe perimenopausal bleeding, high-dose oral or injectable progestin-only medications provide short-term control. 7

• Bleeding saturating a large pad/tampon hourly for ≥4 hours warrants urgent evaluation 7
• Immediate assessment of hemodynamic stability, pregnancy status, and hemoglobin levels is required 7
• Concurrent iron supplementation is recommended 7
• Consider hospital admission for monitoring and blood transfusion if needed 7

Important Pitfalls and Caveats

• Hysterectomy, even with ovarian conservation, is associated with elevated risk of cardiovascular disease, mood disorders, osteoporosis, bone fracture, and dementia 8
• GnRH agonists require add-back therapy with long-term use to prevent bone mineral loss 6, 7
• Surgical recurrence is common with conservative surgery, limiting its utility 6
• Adenomyosis often coexists with endometriosis and fibroids, requiring comprehensive evaluation 1, 2
• Myomectomy alone (hysteroscopic or laparoscopic) is unlikely to effectively address adenomyosis 8