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, levonorgestrel-releasing intrauterine devices (LNG-IUD) should be first-line therapy, demonstrating superior efficacy over combined oral contraceptives for both pain and bleeding symptoms while preserving fertility. 1, 2

First-Line Medical Management

Hormonal Intrauterine Device (Preferred)

• Progestin IUDs are the most effective first-line option due to their local mechanism of action, lower systemic hormone levels, long duration after placement, and user independence 1
• A randomized controlled trial demonstrated significant improvement in both pain and bleeding in women with adenomyosis treated with progestin IUD versus combined oral contraceptives 1
• However, LNG-IUD provides only temporary symptom relief and does not cure the disease or eradicate adenomyotic lesions—it is purely symptomatic management 2

Alternative First-Line 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
• NSAIDs and tranexamic acid (a nonhormonal alternative) may reduce bleeding symptoms in patients with adenomyosis 1, 3

Second-Line Medical Management

GnRH Therapy

• Oral GnRH antagonist combinations should be considered if first-line therapies prove ineffective, are poorly tolerated, or contraindicated 1, 4
• Pooled analysis of randomized controlled trials demonstrated that concomitant adenomyosis does not decrease the effectiveness of oral GnRH antagonist combinations for heavy menstrual bleeding 1
• GnRH agonists (such as leuprolide acetate) for at least three months should be used with add-back therapy to reduce or eliminate GnRH-induced bone mineral loss without reducing pain relief efficacy 4
• Dienogest and other progestins are additional options for second-line management 3

Interventional Options for Fertility Preservation

Uterine Artery Embolization (UAE)

• UAE is the preferred uterus-preserving intervention when medical management fails, with prospective cohort studies demonstrating improvement in quality of life and symptom scores 1
• Meta-analysis reported 94% short-term (<12 months) and 85% long-term (>12 months) symptom improvement, with only 7% requiring hysterectomy for persistent symptoms 1, 2
• UAE improved symptom scores and quality of life at up to 7 years follow-up, though 18% of patients underwent hysterectomy for persistent symptoms 1
• Successful pregnancy has been reported after UAE for adenomyosis, though comprehensive fertility and pregnancy data is lacking and patients should be counseled accordingly 1

Other Interventional Approaches

• Endometrial ablation has been associated with treatment failure in the presence of adenomyosis and should generally be avoided 1
• Radiofrequency ablation (RFA) and high-intensity focused ultrasound (HIFU) may be proposed when medical therapy is ineffective 5

Conservative Surgical Options

Cytoreductive Surgery

• Conservative surgical treatment (excision/resection 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
• Surgical recurrence is common, with up to 44% of women experiencing symptom recurrence within one year after conservative surgery 4, 2

Hysteroscopic Approaches

• Hysteroscopy may be proposed in cases where medical therapy is ineffective 5
• Myomectomy alone does not address adenomyosis and is ineffective for this condition 2

Definitive Surgical Management

Hysterectomy

• Hysterectomy provides definitive resolution of all adenomyosis-related symptoms for patients who do not desire future pregnancy 1
• When hysterectomy is performed, the least invasive approach should be chosen: vaginal or laparoscopic hysterectomy is preferred over abdominal approach, offering shorter operating times, faster return to activities, and lower infection rates 2
• Robotic-assisted hysterectomy shows similar outcomes to traditional laparoscopy 2
• Ovaries should be left in place to avoid precipitating menopause and associated cardiovascular risks unless there is an indication for removal 2
• Critical caveat: Even with ovarian conservation, hysterectomy carries risks including cardiovascular disease, mood disorders, osteoporosis, bone fracture, and potentially increased dementia risk 1, 2

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, advance to oral GnRH antagonists or dienogest 1, 4
3. If medical management fails, consider UAE for uterus preservation 1, 2
4. Reserve conservative surgical excision for refractory cases in experienced centers 5

For Women Not Desiring Future Fertility:

1. Trial LNG-IUD or other hormonal management first 1, 2
2. Consider UAE if medical management fails and patient wishes to avoid hysterectomy 1
3. Proceed to hysterectomy (least invasive route) for definitive treatment when conservative measures fail or patient preference 1, 2

Critical Pitfalls to Avoid

• Do not assume medical therapy will cure adenomyosis—it only temporizes symptoms 2
• Ensure endometrial biopsy has been performed to rule out endometrial cancer or hyperplasia, especially in perimenopausal women 2
• Do not perform myomectomy alone expecting to treat adenomyosis—it is ineffective 2
• Recognize that adenomyosis often coexists with endometriosis and fibroids, complicating diagnosis and treatment response evaluation 3, 6, 7
• Be aware that symptom recurrence after conservative surgery is high (up to 44% within one year) 4, 2