What are the surgical management options for a woman with adenomyosis, considering her desire to preserve fertility and severity of symptoms?

Surgical Management of Adenomyosis

For women desiring fertility preservation, conservative surgical excision of focal adenomyosis or adenomyoma is the preferred surgical approach, achieving symptom relief in over 75% of patients and enabling conception in approximately 75% of cases, though recurrence rates approach 50% depending on follow-up duration. 1

Fertility-Sparing Surgical Options

Conservative Surgical Excision

• Surgical excision of focal adenomyosis or adenomyoma is effective for symptom control (menorrhagia and dysmenorrhea) and likely improves adenomyosis-related infertility. 1
• Approximately 75% of women experience symptom relief after conservative surgery, with similar conception rates (75%) achieved with or without adjuvant medical treatment. 1
• This approach requires highly experienced surgeons due to technical complexity and poses considerable risk of uterine rupture during subsequent pregnancies. 2
• Recurrence rates vary from zero to nearly 50% depending on follow-up duration, making this a temporizing rather than definitive solution. 1

Minimally Invasive Procedures

• Laparoscopic myometrial electrocoagulation can manage both focal and diffuse disease while preserving fertility, though recurrence risk exists. 3
• Endomyometrial ablation is effective for lesions deeper than the endometrial-myometrial junction, whereas hysteroscopic ablation efficacy is limited to foci 2-3 mm deep. 3
• These procedures should be reserved for patients refractory to medical management or those with focal adenomyoma unsuitable for long-term hormonal therapy. 1

Uterine Artery Embolization (UAE)

• UAE should be considered for women with adenomyosis who fail conservative measures and desire uterus preservation, providing short-term improvement in 94% and long-term improvement in 85% of patients. 4, 5
• Symptom control extends up to 7 years, with only 7-18% requiring subsequent hysterectomy for persistent symptoms. 4, 6, 5
• Critical caveat: Comprehensive data on fertility and pregnancy outcomes after UAE is lacking; patients must be counseled accordingly before proceeding. 4, 6
• UAE may be less effective when adenomyosis predominates compared to when fibroids are the primary pathology. 4

Definitive Surgical Management

Hysterectomy

• Hysterectomy remains the definitive treatment for women who have completed childbearing or when conservative measures fail, providing patient satisfaction rates up to 90%. 6, 7
• The least invasive route should be chosen: vaginal or laparoscopic approaches are preferred over abdominal hysterectomy. 8, 4
• Vaginal hysterectomy offers shorter operating times, faster return to normal activities, and better quality of life compared to abdominal approach. 8, 4
• Laparoscopic hysterectomy provides faster recovery, shorter hospital stays, and lower infection rates compared to abdominal hysterectomy. 8, 4
• Abdominal hysterectomy should be avoided unless anatomical constraints preclude minimally invasive approaches, as it is associated with longer hospitalization, greater pain, and higher infection risk. 8

Surgical Decision Algorithm

For Women Desiring Fertility:

1. First-line: Medical management with LNG-IUD (20 μg/d), reducing menstrual blood loss by 71-95%. 4, 6
2. Second-line: Conservative surgical excision if focal adenomyoma present or refractory to medical therapy after 3-month trial. 4, 1
3. Consider UAE only after thorough counseling regarding unknown fertility outcomes. 4, 6

For Women Not Desiring Fertility:

1. First-line: Medical management with LNG-IUD or GnRH antagonists. 4, 6, 5
2. Second-line: UAE for those desiring uterus preservation despite failed medical therapy. 4, 6, 5
3. Definitive: Hysterectomy (vaginal or laparoscopic route) when medical and interventional therapies fail. 8, 4, 6

Critical Pitfalls and Caveats

• No medical or surgical therapy (except hysterectomy) eradicates adenomyosis lesions; all conservative approaches provide only temporary symptom relief with potential for recurrence. 6, 2
• Conservative surgery requires referral to specialized centers with surgeons experienced in complex uterine reconstruction. 4
• Surgical recurrence is common, with up to 44% experiencing symptom recurrence within one year after conservative surgery. 4
• Patients undergoing fertility-sparing surgery must be counseled about uterine rupture risk in subsequent pregnancies. 2
• Even with bilateral ovarian conservation, hysterectomy is associated with elevated cardiovascular disease risk, mood disorders, and potentially increased mortality when performed at young age. 8
• Hormone replacement therapy with estrogen is not contraindicated following hysterectomy with bilateral salpingo-oophorectomy for adenomyosis. 4