What are the treatment options for a woman with adenomyosis?

Treatment Options for Adenomyosis

Start with a levonorgestrel-releasing intrauterine device (LNG-IUD 20 μg/d) as first-line therapy, which reduces menstrual blood loss by 71-95% and provides superior symptom control compared to all other medical options. 1

Medical Management Hierarchy

First-Line Therapy

• The LNG-IUD is the preferred initial treatment due to its local mechanism of action, minimal systemic hormone absorption, long duration after placement, and user independence. 1
• Recent randomized controlled trials demonstrate significant improvement in both pain and bleeding in women with adenomyosis treated with LNG-IUD versus combined oral contraceptives. 1
• The efficacy of LNG-IUD is comparable to endometrial ablation with 71-95% reduction in menstrual blood loss. 1
• Follow-up at 3 months is recommended to assess symptom improvement. 2

Second-Line Hormonal Options

• Combined oral contraceptives reduce painful and heavy menstrual bleeding in randomized controlled trials, though they are less effective than LNG-IUD. 1, 3
• Dienogest (2 mg) significantly reduces dysmenorrhea, dyspareunia, and heavy menstrual bleeding, with efficacy maintained over three years in most patients, though 49% require switching after the first year due to side effects or contraception needs. 4
• Oral GnRH antagonists (elagolix, linzagolix, relugolix) are highly effective for heavy menstrual bleeding, with a reduction in fibroid volume by 18-30%. 1
• Combination treatment with low-dose estrogen and progestin add-back therapy is mandatory when using GnRH antagonists to mitigate hypoestrogenic effects and prevent bone mineral loss. 1, 2
• High-dose progestins (including drospirenone 4 mg and desogestrel 75 mcg) are effective alternatives, with cyclic oral progestin reducing bleeding by 87%. 3, 2, 4

Nonhormonal Medical Options

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

Interventional Options

Uterine Artery Embolization (UAE)

• UAE should be considered for women with adenomyosis who fail conservative medical measures and desire uterus preservation. 3
• UAE provides short-term symptom improvement in 94% and long-term improvement in 85% of patients, with symptom control and quality of life improvement maintained up to 7 years. 1, 3, 2
• Long-term symptomatic relief (median follow-up 27.9 months) in patients with pure adenomyosis or adenomyosis with coexistent leiomyomas ranges from 65% to 82%. 5
• More recent retrospective studies (median follow-up ranging from 24 to 65 months) report symptomatic control in 73% to 88%. 5
• Only 7-18% of patients require hysterectomy for persistent symptoms after UAE. 3
• Important caveat: UAE may be less effective when adenomyosis is the predominant condition compared to when fibroids predominate, and comprehensive data on fertility and pregnancy outcomes after UAE is lacking. 5, 3

Endometrial Ablation

• Endometrial ablation offers greater long-term efficacy than oral medical treatment and reduces pregnancy risk while managing bleeding. 1, 2

Conservative Surgery

• Conservative surgical treatments (cytoreductive surgery, endomyometrial ablation, laparoscopic myometrial electrocoagulation or excision) are effective in ameliorating abnormal uterine bleeding and pelvic pain and in reducing uterine volume in >50% of patients. 6, 7
• Critical pitfall: Surgical recurrence is common, with up to 44% of women experiencing symptom recurrence within one year after conservative surgery. 3
• Cytoreductive surgery should be performed only by experienced surgeons in dedicated centers, especially with concomitant endometriosis. 6

Definitive Surgical Management

Hysterectomy

• Hysterectomy provides definitive resolution of all adenomyosis-related symptoms with patient satisfaction rates up to 90%, and is recommended when medical and interventional therapies fail. 1, 2
• The least invasive route should be chosen, with vaginal or laparoscopic approaches preferred over abdominal hysterectomy. 3
• Vaginal hysterectomy offers shorter operating times and faster return to normal activities. 3
• Laparoscopic hysterectomy provides faster recovery, shorter hospital stays, and lower infection rates compared to abdominal approach. 3
• Important consideration: Even with bilateral ovarian conservation, hysterectomy is associated with elevated cardiovascular disease risk, mood disorders, and potentially increased mortality when performed at a young age. 3

Critical Pitfalls and Caveats

• No medical therapy eradicates adenomyosis lesions; all provide only temporary symptom relief with rapid recurrence after discontinuation. 1, 3, 2
• Medical therapies will not treat bulk symptoms associated with fibroids. 1
• There is no evidence that medical treatment affects future fertility in women with adenomyosis. 3
• The flexibility in switching between different progestins or routes of administration may help optimize outcomes when initial therapy is inadequate. 4
• Fertility is suppressed during GnRH agonist/antagonist treatment. 2