What is the best management approach for a woman in her 40s with adenomyosis and anemia (low hemoglobin level)?

Management of Adenomyosis with Anemia in a Woman in Her 40s

Start with a levonorgestrel-releasing intrauterine system (LNG-IUS) as first-line therapy for both the adenomyosis symptoms and bleeding control, while simultaneously initiating oral iron supplementation with ferrous sulfate 200 mg three times daily to correct the anemia. 1, 2

Immediate Dual Treatment Strategy

Iron Supplementation Protocol

• Begin ferrous sulfate 200 mg three times daily immediately as the most cost-effective first-line option to address the hemoglobin of 100 mg/dL (10 g/dL) 2, 3
• Expect hemoglobin to rise by 2 g/dL after 3-4 weeks of treatment 3
• Continue iron therapy for three months after hemoglobin normalizes to ensure adequate replenishment of iron stores 2, 3
• If ferrous sulfate is not tolerated, switch to ferrous gluconate or ferrous fumarate, which are equally effective alternatives 2, 3
• Add ascorbic acid (vitamin C) to enhance iron absorption if response is poor 2, 3

Hormonal Management for Adenomyosis

• The levonorgestrel-releasing IUD is clinically favored due to local mechanism of action, lower systemic hormone levels, long duration of action, and user independence 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 1
• Alternative medical options include combined oral contraceptives, though less effective than LNG-IUS for adenomyosis 1, 4
• GnRH antagonist combinations have also shown effectiveness in treating heavy menstrual bleeding associated with adenomyosis 1

Monitoring and Follow-Up Protocol

Short-Term Monitoring

• Monitor hemoglobin concentration and red cell indices at three-month intervals for one year, then after another year 2, 3
• Check ferritin levels if hemoglobin or MCV falls below normal during follow-up 2, 3
• Assess symptom improvement (bleeding patterns, pain) at each visit 5

When to Escalate Iron Therapy

• Reserve intravenous iron only for intolerance to at least two different oral iron preparations or documented non-compliance 2, 3
• Parenteral iron should not be used as first-line therapy 2

Interventional Options if Medical Management Fails

Uterine Artery Embolization (UAE)

• UAE should be considered for patients who fail conservative medical measures and desire uterus-preserving therapy 1
• Long-term symptomatic relief (median follow-up 27.9 months) ranges from 65% to 82% in patients with adenomyosis 1
• More recent retrospective studies (median follow-up 24-65 months) report symptomatic control in 73% to 88% 1
• A prospective study demonstrated significant symptom relief with 83% showing complete adenomyosis necrosis 1
• Approximately 7-18% of patients may ultimately require hysterectomy for persistent symptoms 1

Surgical Management

• Hysterectomy remains definitive treatment if symptoms are not controlled with medical therapy and the patient has completed childbearing 6, 5
• If hysterectomy is indicated, the least invasive route should be performed (vaginal or laparoscopic preferred over abdominal) 1
• Hysterectomy is associated with increased risk of cardiovascular disease, osteoporosis, bone fracture, and dementia, so should be avoided if less invasive procedures are available 1
• Myomectomy alone is unlikely to effectively address adenomyosis 1

Critical Pitfalls to Avoid

Iron Therapy Pitfalls

• Discontinuing iron therapy prematurely when hemoglobin normalizes but before iron stores are replenished leads to recurrence 2
• Poor compliance is the most common cause of treatment failure 3
• Not monitoring hemoglobin and iron indices at appropriate intervals to detect recurrence 2
• Using intravenous iron as first-line therapy rather than reserving it for oral iron intolerance 2, 3

Adenomyosis Management Pitfalls

• Treating iron deficiency alone without addressing the underlying adenomyosis will result in treatment failure as continued blood loss will exceed iron replacement 3
• Medical therapies will not treat bulk symptoms if present 1
• Given the patient's age (40s), consider that adenomyosis often coexists with endometriosis and fibroids, which may require additional evaluation 7, 5

Additional Considerations

Gastrointestinal Evaluation

• Women over 45 years with iron deficiency anemia require gastrointestinal evaluation even when adenomyosis is present, as GI blood loss is the most common cause of IDA in this age group 1, 3
• Upper gastrointestinal endoscopy with small bowel biopsy and colonoscopy should be performed to exclude GI malignancy if no obvious gynecologic cause explains the severity of anemia 1

Fertility Considerations

• If the patient desires future fertility, this significantly alters the treatment algorithm, as hysterectomy would be contraindicated and medical management or fertility-preserving surgical options would be prioritized 5
• However, given the patient is in her 40s, fertility preservation may not be a primary concern unless specifically stated 6