Diffuse Adenomyosis: Symptoms and Management
Primary Symptoms
Diffuse adenomyosis most commonly presents with heavy menstrual bleeding and dysmenorrhea, though one-third of patients remain asymptomatic. 1
The cardinal symptoms include:
- Heavy or prolonged menstrual bleeding that disrupts daily activities is the most frequent presentation 2, 3, 1
- Dysmenorrhea (painful menstruation) occurs commonly alongside bleeding symptoms 4, 5, 3
- Dyspareunia (painful intercourse) may be present 4
- Chronic pelvic pain independent of menstruation 5, 3
- Infertility or subfertility in women of reproductive age 4, 5
Important caveat: Up to one-third of patients with adenomyosis are completely asymptomatic, making incidental imaging findings common 1. Additionally, adenomyosis frequently coexists with endometriosis and uterine fibroids, which can complicate the clinical picture and make it difficult to attribute specific symptoms to adenomyosis alone 5, 3, 6.
Management Algorithm
First-Line Medical Management
Start with a levonorgestrel-releasing intrauterine system (LNG-IUD) as first-line therapy for symptomatic adenomyosis. 7, 8
- The LNG-IUD provides significant improvement in both pain and bleeding symptoms 7, 2, 8
- This approach offers temporary symptom relief but does not cure or eradicate adenomyosis lesions 7, 8
- Follow-up at 3 months to assess symptom improvement 8
Second-Line Medical Options
If LNG-IUD is ineffective or not tolerated:
- Combined oral contraceptives reduce painful and heavy menstrual bleeding, though they are less effective than the LNG-IUD 7, 2, 8
- High-dose progestins serve as an effective alternative 8
- GnRH antagonists are highly effective for heavy menstrual bleeding, even with concomitant adenomyosis 2, 8
- GnRH agonists provide equivalent pain relief to danazol with better tolerability, but require add-back therapy to prevent bone mineral loss with long-term use 8
Critical pitfall: No medical therapy eradicates adenomyosis lesions—all treatments only temporize symptoms 7, 8. Patients must understand this is lifelong management, not cure.
Interventional Options for Uterine Preservation
For women who fail medical management but desire uterine preservation, uterine artery embolization (UAE) should be considered. 7, 2, 8
- UAE provides 94% short-term and 85% long-term symptom improvement 7, 2, 8
- Quality of life improvements can last up to 7 years 2
- Only 7-18% of patients eventually require hysterectomy for persistent symptoms 2, 8
- However, long-term durability shows recurrence rates of approximately 40-50% at 2 years, though more recent data suggests 73-88% symptomatic control with median follow-up of 24-65 months 9
Important consideration: Comprehensive data on fertility and pregnancy outcomes after UAE is lacking, and patients must be counseled accordingly 8. UAE may be less effective when adenomyosis predominates compared to when fibroids are the primary pathology 8.
Surgical Management
Hysterectomy remains the only definitive cure for adenomyosis and should be considered when medical management fails and fertility preservation is not desired. 7, 2, 3, 1
When performing hysterectomy:
- Choose the least invasive approach: vaginal or laparoscopic hysterectomy is preferred over abdominal approach 7, 8
- Vaginal hysterectomy offers shorter operating times and faster return to normal activities 8
- Laparoscopic hysterectomy provides faster recovery, shorter hospital stays, and lower infection rates 8
- Robotic-assisted hysterectomy shows similar outcomes to traditional laparoscopy 7
Ovarian management: Leave ovaries in place to avoid precipitating menopause and associated cardiovascular risks, unless there is a specific indication for removal 7. Even with ovarian conservation, hysterectomy carries risks including cardiovascular disease, mood disorders, osteoporosis, and potentially increased dementia risk 7.
Conservative Surgical Options
Cytoreductive surgery (adenomyomectomy) may be considered in select cases but has significant limitations. 4
- This approach is very effective in ameliorating abnormal uterine bleeding and pelvic pain and reducing uterine volume 4
- However, surgical recurrence is common, with up to 44% of women experiencing symptom recurrence within one year after conservative surgery 7, 8
- This surgery should only be performed by experienced surgeons in dedicated centers, especially with concomitant endometriosis 4
Critical pitfall: Myomectomy alone does not address adenomyosis and is ineffective for this condition 7.
Essential Diagnostic Considerations
Before initiating treatment:
- Perform endometrial biopsy to rule out endometrial cancer or hyperplasia, especially in perimenopausal women with abnormal bleeding 7
- Confirm diagnosis with transvaginal ultrasound as first-line imaging 8, 6
- Use MRI to better characterize disease extent when ultrasound is inconclusive 8, 6
When to Escalate Care
Refer to specialist or consider more aggressive management when: