What are the treatment options for a patient with adenomyosis?

Treatment Options for Adenomyosis

First-Line Medical Management

The levonorgestrel-releasing intrauterine system (LNG-IUD) is the first-line medical treatment for adenomyosis, providing significant improvement in pain and bleeding symptoms. 1, 2

Hormonal Therapies (Stepwise Approach)

• Progestin IUD (LNG-IUS): Most effective hormonal option with significant improvement in both pain and bleeding, though it provides only temporary symptom relief without eradicating adenomyosis lesions 1, 3

• Combined oral contraceptives: Second-line option that reduces painful and heavy menstrual bleeding, though less effective than LNG-IUD 1, 2

• High-dose progestins: Effective alternative for symptom management when IUD is not tolerated or desired 2

• GnRH antagonists: Highly effective for heavy menstrual bleeding even with concomitant adenomyosis 1, 2

• GnRH agonists: Provide equivalent pain relief to danazol with better tolerability, but require add-back therapy with long-term use to prevent bone mineral loss 2

• Danazol: Equally effective to GnRH agonists but limited by androgenic side effects 2

Critical caveat: No medical therapy eradicates adenomyosis lesions—all provide only temporary symptom relief, and there is no evidence that medical treatment affects future fertility 2, 4

Uterine-Preserving Interventional Options

When Medical Management Fails

Uterine Artery Embolization (UAE) should be considered for women who fail conservative medical measures and desire uterus preservation. 1, 2

• UAE effectiveness: Provides short-term improvement in 94% and long-term improvement in 85% of patients, with quality of life improvement lasting up to 7 years 1, 2

• Hysterectomy rate post-UAE: Only 7-18% of women eventually require hysterectomy for persistent symptoms 1, 2

• Important limitation: Comprehensive data on fertility and pregnancy outcomes after UAE is lacking, and patients must be counseled accordingly 2

• UAE may be less effective when adenomyosis predominates compared to when fibroids are the primary pathology 2

Conservative Surgical Options

• Cytoreductive surgery: May be effective for ameliorating abnormal uterine bleeding and pelvic pain, but should only be performed by experienced surgeons in dedicated centers 5

• Surgical recurrence is common: Up to 44% of women experience symptom recurrence within one year after conservative surgery 2, 3

• Myomectomy alone does not address adenomyosis and is ineffective for this condition 3

Definitive Surgical Management

Hysterectomy Indications

Hysterectomy should be considered when other treatments fail and fertility preservation is not desired, or when there are other indications such as malignancy concerns, prolapse, or cervical dysplasia. 1, 3

Surgical Approach Selection

The least invasive route should be chosen, with vaginal or laparoscopic approaches strongly preferred over abdominal hysterectomy. 2, 3

• Vaginal hysterectomy: Offers shorter operating times and faster return to normal activities 2

• Laparoscopic hysterectomy: Provides faster recovery, shorter hospital stays, and lower infection rates compared to abdominal approach 2, 3

• Robotic-assisted hysterectomy: Shows similar outcomes to traditional laparoscopy 3

• Abdominal hysterectomy should be avoided unless anatomical constraints preclude minimally invasive approaches 2

Ovarian Conservation

Ovaries should be left in place to avoid precipitating menopause and associated cardiovascular risks, unless there is a specific indication for removal. 3

• Even with ovarian conservation, hysterectomy carries risks including elevated cardiovascular disease risk, mood disorders, osteoporosis, potentially increased dementia risk, and potentially increased mortality when performed at a young age 2, 3

• Hormone replacement therapy with estrogen is not contraindicated following hysterectomy and bilateral salpingo-oophorectomy for adenomyosis 2

Pre-Treatment Evaluation

Ensure endometrial biopsy has been performed to rule out endometrial cancer or hyperplasia, especially in perimenopausal women, before initiating treatment. 3

Common Pitfalls to Avoid

• Do not assume medical therapy will cure adenomyosis—it only temporizes symptoms 3

• Do not perform myomectomy alone for adenomyosis—it is ineffective for this condition 3

• Do not choose abdominal hysterectomy when minimally invasive options are feasible—it results in longer recovery and higher complication rates 2, 3

• Do not remove ovaries routinely at hysterectomy—preservation reduces cardiovascular and other long-term health risks 3