What are the treatment options for a female of reproductive age diagnosed with adenomyosis?

Treatment Options for Adenomyosis in Reproductive-Age Women

For reproductive-age women with adenomyosis, the levonorgestrel-releasing intrauterine device (LNG-IUD) is the first-line treatment, demonstrating significant improvement in both pain and bleeding symptoms while preserving fertility. 1, 2

First-Line Medical Management

Hormonal Intrauterine Device

• The progestin IUD is the preferred initial therapy due to its local mechanism of action, lower systemic hormone levels, long duration after placement, and user independence 1
• A randomized controlled trial demonstrated that progestin IUDs provide significantly better improvement in pain and bleeding compared to combined oral contraceptives in women with adenomyosis 1
• The LNG-IUD offers temporary symptom relief but does not cure the underlying disease or eradicate adenomyotic lesions—it provides only symptomatic management 2

Alternative Hormonal Options

• Combined oral contraceptives reduce painful and heavy menstrual bleeding but are less effective than hormonal IUDs and do not cure the underlying disease 2
• Oral GnRH antagonist combinations effectively treat heavy menstrual bleeding in adenomyosis, with pooled analysis showing that concomitant adenomyosis does not decrease effectiveness 1
• NSAIDs and tranexamic acid (a nonhormonal alternative) may reduce bleeding symptoms 3

Second-Line Medical Management

GnRH Agonists

• GnRH agonists should be considered if first-line therapies prove ineffective, are poorly tolerated, or contraindicated 4
• Treatment should continue for at least three months 4
• Add-back therapy must be implemented to reduce or eliminate GnRH-induced bone mineral loss without reducing pain relief efficacy 4

Other Hormonal Agents

• Dienogest and other progestins (medroxyprogesterone acetate, megestrol acetate) reduce the size of endometriotic lesions and are considered first-line pharmacological options due to favorable safety profile, tolerability, and cost-effectiveness 4, 3
• Danazol for at least six months is equally effective to GnRH agonists for pain relief in most women 4

Interventional Options for Uterus-Preserving Therapy

Uterine Artery Embolization (UAE)

• UAE should be considered for patients who fail conservative medical measures and desire uterus-preserving therapy 1, 2
• Prospective cohort studies demonstrate improvement in quality of life and symptom scores, especially when fibroids coexist with adenomyosis 1
• Meta-analysis reports 94% short-term (<12 months) and 85% long-term (>12 months) symptom improvement, with only 7% requiring hysterectomy for persistent symptoms 1, 2
• At 7-year follow-up, 18% of patients underwent hysterectomy for persistent symptoms 1
• Successful pregnancy has been reported after UAE for adenomyosis, though comprehensive fertility data is lacking and patients require appropriate counseling 1

Conservative Surgical Options

• Cytoreductive surgery (excision of adenomyosis) is very effective in ameliorating abnormal uterine bleeding and pelvic pain and reducing uterine volume 5
• This approach should only be performed by experienced surgeons in dedicated centers, particularly when concomitant endometriosis is present 5
• Critical caveat: Up to 44% of women experience symptom recurrence within one year after conservative surgery 4, 2

Endometrial Ablation

• Endometrial ablation may be considered, though treatment failure has been associated with the presence of adenomyosis 1
• This option is only appropriate for women who have completed childbearing 3

Definitive Surgical Management

Hysterectomy

• Hysterectomy provides definitive resolution of all adenomyosis-related symptoms for patients who do not desire future pregnancy 1, 2
• When hysterectomy is performed, the least invasive approach should be chosen: vaginal or laparoscopic hysterectomy is preferred over abdominal approach 2
• Vaginal hysterectomy offers shorter operating times, faster return to normal activities, and better quality of life compared to abdominal hysterectomy 1
• Laparoscopic hysterectomy provides faster return to normal activities, shorter hospital stays, and lower rates of wound infection compared to abdominal approach 1
• Robotic-assisted hysterectomy shows similar outcomes to traditional laparoscopy in terms of operative time, hospital stay, and postoperative complications 1, 2

Important Considerations for Hysterectomy

• Ovaries should be left in place to avoid precipitating menopause and associated cardiovascular risks, unless there is a specific indication for removal 2
• Even with ovarian conservation, hysterectomy carries significant long-term risks including cardiovascular disease, mood disorders, osteoporosis, bone fracture, and potentially increased dementia risk 1, 2
• Short-term complications include abscess, venous thromboembolism, damage to ureter/bowel/bladder, bleeding requiring transfusion, and vaginal cuff complications 1
• Some studies report increased mortality, especially when performed at a young age 1

Treatment Algorithm Based on Fertility Desires

For Women Desiring Future Fertility

1. Start with LNG-IUD as first-line therapy 1, 2
2. If ineffective or not tolerated, trial combined oral contraceptives or dienogest 1, 2
3. Consider GnRH agonists with add-back therapy for refractory cases 4
4. UAE may be considered for severe symptoms unresponsive to medical management, though fertility data is limited 1, 2
5. Conservative surgical excision only in specialized centers, with counseling about high recurrence rates 5, 2

For Women Not Desiring Future Fertility

1. Start with LNG-IUD as first-line therapy 1, 2
2. If medical management fails, consider UAE (85% long-term symptom improvement) 1, 2
3. Hysterectomy via least invasive route for definitive treatment when other options fail or are contraindicated 1, 2

Critical Pitfalls to Avoid

• Do not assume medical therapy will cure adenomyosis—it only temporizes symptoms 2
• Do not perform myomectomy alone for adenomyosis—it does not address the disease and is ineffective 2
• Ensure endometrial biopsy has been performed to rule out endometrial cancer or hyperplasia, especially in perimenopausal women 2
• Do not recommend hysterectomy as initial therapy when less invasive procedures with similar symptom relief are available 1
• Counsel patients that surgical recurrence after conservative surgery is common, with up to 44% experiencing symptom recurrence within one year 4, 2

Monitoring and Follow-Up

• Clinical evaluation every 6 months is recommended to assess treatment response and potential side effects 4
• Because adenomyosis may regress unpredictably, expectant management may be appropriate if the patient becomes asymptomatic 4
• Imaging follow-up with transvaginal ultrasound should be performed to monitor disease progression and treatment response 4