What are the management options for a woman with adenomyosis experiencing pain and heavy menstrual bleeding?

Management of Pain from Adenomyosis

The levonorgestrel-releasing intrauterine device (LNG-IUD 20 μg/d) is the first-line treatment for adenomyosis-related pain, providing superior symptom control compared to all other medical options. 1

First-Line Medical Management

• Start with LNG-IUD (20 μg/d) as initial therapy, which reduces menstrual blood loss by 71-95% and provides significant improvement in both pain and bleeding symptoms. 2, 1
• The LNG-IUD works through local endometrial suppression with minimal systemic hormone absorption, offering long-term symptom control while preserving the uterus. 2
• A recent randomized controlled trial demonstrated that LNG-IUD is superior to combined oral contraceptives for both pain and bleeding control in adenomyosis patients. 1
• Reassess at 3 months to evaluate symptom improvement and determine if additional interventions are needed. 2

Second-Line Hormonal Options (When LNG-IUD Fails or Is Contraindicated)

• Combined oral contraceptives reduce painful and heavy menstrual bleeding but are less effective than LNG-IUD. 2, 1
• High-dose progestins (oral or injectable) provide effective symptom control and can be used continuously to suppress menstruation. 3, 4
• GnRH antagonists (elagolix, linzagolix, relugolix) are highly effective for heavy menstrual bleeding and pain, even with concomitant adenomyosis. 2, 1
  • Mandatory add-back therapy with low-dose estrogen and progestin must be used to prevent bone mineral loss and mitigate hypoestrogenic effects. 1, 3
  • These agents suppress fertility during treatment. 2

Nonhormonal Options

• Tranexamic acid provides significant reduction in menstrual blood loss for patients who cannot or prefer not to use hormonal therapy. 2, 1
• NSAIDs reduce menstrual blood loss and pain but should be avoided in women with cardiovascular disease. 2, 1

Interventional Options for Refractory Cases

When medical management fails and the patient desires uterine preservation:

• Uterine artery embolization (UAE) provides short-term symptom improvement in 94% of patients and long-term improvement in 85%, with symptom control maintained up to 7 years. 2, 1, 3
• Only 7-18% of patients require subsequent hysterectomy for persistent symptoms after UAE. 3
• Endometrial ablation offers greater long-term efficacy than oral medical treatment while reducing pregnancy risk. 2, 1

Conservative Surgical Excision

• Cytoreductive surgery (adenomyomectomy) improves pelvic pain and abnormal uterine bleeding in over three-fourths of women, with approximately three-fourths conceiving after surgery. 5
• This should only be performed by experienced surgeons in dedicated centers, particularly when concomitant endometriosis is present. 6, 5
• Surgical recurrence is common, with up to 44% experiencing symptom recurrence within one year, and recurrence rates approaching one-half of patients with longer follow-up. 3, 5

Definitive Surgical Management

When all conservative measures fail:

• Hysterectomy provides definitive resolution with patient satisfaction rates up to 90%. 2, 1
• Vaginal or laparoscopic routes are strongly preferred over abdominal hysterectomy, offering shorter operating times, faster recovery, shorter hospital stays, and lower infection rates. 2, 3
• Abdominal hysterectomy should be avoided unless anatomical constraints preclude minimally invasive approaches. 3

Critical Pitfalls and Caveats

• No medical therapy eradicates adenomyosis lesions—all treatments provide only temporary symptom relief with rapid recurrence after discontinuation. 2, 1, 4
• Medical therapies will not treat bulk symptoms if present. 1
• Even with bilateral ovarian conservation, hysterectomy performed at a young age is associated with elevated cardiovascular disease risk, mood disorders, and potentially increased mortality. 3
• Comprehensive data on fertility and pregnancy outcomes after UAE is lacking; counsel patients accordingly before proceeding. 3
• GnRH agonists provide equivalent pain relief to danazol but with better tolerability, though danazol has more androgenic side effects. 3