What are the next steps for a patient diagnosed with adenomyosis on ultrasound?

Management of Adenomyosis Diagnosed on Ultrasound

The next step after ultrasound diagnosis of adenomyosis is to initiate a levonorgestrel-releasing intrauterine device (LNG-IUD) as first-line medical therapy for symptomatic patients, while asymptomatic patients require no treatment beyond routine surveillance. 1, 2, 3

Initial Assessment and Symptom Characterization

After ultrasound confirms adenomyosis, determine whether the patient is symptomatic:

• Asymptomatic patients (approximately one-third) require no treatment and can return to routine gynecologic care 4
• Symptomatic patients most commonly present with heavy menstrual bleeding, followed by pelvic pain (dysmenorrhea, dyspareunia, chronic pelvic pain), or infertility 5, 4
• Document specific symptoms as this guides treatment selection 5

Role of Additional Imaging

MRI should be obtained when:

• Ultrasound findings are inconclusive or equivocal 2
• Surgical intervention is being considered to better characterize disease extent 2
• Coexisting pathology (fibroids, endometriosis, malignancy) needs exclusion 1, 2

MRI has 78% sensitivity and 93% specificity for adenomyosis diagnosis and provides superior anatomic detail for surgical planning 1

First-Line Medical Management Algorithm

For symptomatic adenomyosis, initiate treatment in this order:

Primary Option: LNG-IUD

• Reduces menstrual blood loss by 71-95% with efficacy comparable to endometrial ablation 3
• Provides significant improvement in both pain and bleeding symptoms 1
• Acts primarily at the endometrial level with minimal systemic absorption 3
• Superior to combined oral contraceptives in randomized trials 1
• Follow-up at 3 months to assess symptom improvement 2

Second-Line Medical Options (if LNG-IUD fails or is contraindicated):

• Combined oral contraceptives reduce painful and heavy menstrual bleeding, though less effective than LNG-IUD 1, 2, 3
• GnRH antagonists (oral combinations) are highly effective for heavy menstrual bleeding even with concomitant adenomyosis 1, 2, 3, 6
• High-dose progestins serve as effective alternatives 2

Critical Caveat About Medical Therapy

No medical therapy eradicates adenomyosis lesions—all provide only temporary symptom relief. 2, 6 Symptoms recur rapidly after cessation of therapy, and there is no evidence that medical treatment affects future fertility 2

When to Consider Interventional or Surgical Options

Uterine Artery Embolization (UAE) should be considered for:

• Patients who fail conservative medical measures 1, 2
• Those desiring uterus preservation 1, 2
• Provides 94% short-term and 85% long-term symptom improvement 1, 2, 3
• Only 7-18% require subsequent hysterectomy for persistent symptoms 1, 2
• Important limitation: Comprehensive data on fertility and pregnancy outcomes after UAE is lacking; counsel patients accordingly 1, 2, 6

Hysterectomy is definitive treatment when:

• Medical and interventional therapies fail 3
• Patient has completed childbearing 4
• Provides definitive resolution with up to 90% patient satisfaction 3
• Choose least invasive route (vaginal or laparoscopic preferred over abdominal) 2

Special Populations and Considerations

Reproductive-Age Women Desiring Fertility

• Medical management does not affect future fertility 2
• Surgical recurrence is common, with up to 44% experiencing symptom recurrence within one year after conservative surgery 2, 6
• Adenomyomectomy is investigational with limited data 7

Coexisting Conditions

If adenomyosis coexists with fibroids:

• UAE remains effective, with better outcomes when fibroids predominate 1
• Surgical options can address both conditions simultaneously 1

If adenomyosis coexists with endometrioma:

• LNG-IUD for adenomyosis symptoms combined with surgical excision of endometrioma if symptomatic or >5 cm 2

Common Pitfalls to Avoid

• Do not perform endometrial biopsy routinely unless there are concerning features (postmenopausal bleeding, thickened endometrium in amenorrhea, diabetes with secretory endometrium) 3
• Avoid hysteroscopic or laparoscopic myomectomy alone for adenomyosis—these techniques do not effectively address the diffuse myometrial disease 1
• Do not assume infertility is solely due to adenomyosis—complete fertility evaluation is warranted 5
• Counsel patients that GnRH antagonists suppress fertility during treatment and symptoms recur after cessation 6

Follow-Up Protocol

• After initiating LNG-IUD: Reassess at 3 months for symptom improvement 2
• If symptoms persist despite medical therapy: Consider MRI to reassess disease extent and exclude other pathology 1, 2
• If considering UAE or surgery: Obtain MRI for procedural planning 2