What are the primary medical management options for a woman with adenomyosis?

Medical Management of Adenomyosis

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

First-Line Medical Therapy

Levonorgestrel-Releasing Intrauterine System (LNG-IUD)

• The 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 in patients with adenomyosis 1
• Acts primarily at the endometrial level with minimal systemic progesterone absorption 3
• Offers the advantage of long-term management with contraceptive benefit 4
• Critical caveat: The LNG-IUD provides only temporary symptom relief and does not cure or eradicate adenomyosis lesions 1, 5

Second-Line Medical Options

Combined Oral Contraceptives (COCs)

• Reduce painful and heavy menstrual bleeding, though less effective than the LNG-IUD 1, 2, 3
• Provide contraception for women not desiring pregnancy 3
• Do not cure the underlying disease 1

Dienogest

• Appears superior to combined oral contraceptives where marketed 4
• A recent 2024 randomized trial demonstrated significant VAS score reduction from 6.41 to 3.12 after 12 weeks (p<0.001) 6
• May provide greater improvement in quality of life scores compared to LNG-IUD (48.26 vs 28.76, p=0.04) 6
• Effective for pain control through antiproliferative and anti-inflammatory effects 7

Other Progestins

• High-dose progestins (such as norethindrone acetate) are effective alternatives 3, 5
• Cyclic oral progestin reduces bleeding by 87% 3
• Work through antiproliferative and anti-inflammatory mechanisms 7

Third-Line Medical Options

GnRH Antagonists

• Highly effective for heavy menstrual bleeding, even with concomitant adenomyosis 8, 2, 3
• Should be considered second-line therapy but limited by hypoestrogenic effects 4
• Combination treatment with low-dose estrogen and progestin mitigates side effects including hot flushes, headaches, and bone mineral density loss 8
• Fertility is suppressed during treatment, and cessation leads to rapid symptom recurrence 8

GnRH Agonists

• Effective at reducing both bleeding and bulk symptoms 8
• Require add-back therapy with long-term use to prevent bone mineral loss 2
• Indicated before fertility treatments to improve pregnancy chances in infertile women with adenomyosis 7

Non-Hormonal Medical Options

NSAIDs and Tranexamic Acid

• NSAIDs are first-line for pain management 9
• Tranexamic acid is a nonhormonal alternative that may reduce bleeding symptoms 8, 9

Treatment Algorithm

1. Start with LNG-IUD for most patients with symptomatic adenomyosis (pain and/or bleeding) 1, 2, 4
2. If LNG-IUD fails or is not tolerated, consider dienogest or other progestins 4, 6
3. If hormonal contraception is contraindicated, use NSAIDs and tranexamic acid for symptom control 9
4. For refractory cases, consider GnRH antagonists with add-back therapy 8, 4
5. Follow-up at 3 months to assess symptom improvement 2

Critical Pitfalls to Avoid

• Do not assume medical therapy will cure adenomyosis—it only temporizes symptoms 1, 2, 5
• Surgical recurrence is common, with up to 44% experiencing symptom recurrence within one year after conservative surgery 1, 2
• Endometrial ablation has high failure rates in the presence of adenomyosis 8
• Always perform endometrial biopsy to rule out endometrial cancer or hyperplasia, especially in perimenopausal women, before initiating treatment 1, 3
• Myomectomy alone does not address adenomyosis and is ineffective for this condition 1

When Medical Management Fails

Uterine Artery Embolization (UAE)

• Consider for women who fail conservative measures and desire uterus preservation 2, 3
• Provides 94% short-term and 85% long-term symptom improvement 1, 2, 3
• Only 7-18% require subsequent hysterectomy for persistent symptoms 2
• Important limitation: Comprehensive data on fertility and pregnancy outcomes after UAE is lacking; counsel patients accordingly 8, 2

Hysterectomy

• Provides definitive resolution when medical and interventional therapies fail 3
• Choose the least invasive route: vaginal or laparoscopic preferred over abdominal approach 1, 2
• Major caveat: Even with ovarian conservation, hysterectomy carries risks including cardiovascular disease, mood disorders, osteoporosis, and potentially increased dementia risk 1, 2