What are the treatment options for a patient with adenomyosis?

Treatment Options for Adenomyosis

First-Line Medical Management

Start with a levonorgestrel-releasing intrauterine device (LNG-IUD) as first-line therapy for adenomyosis, which provides significant improvement in pain and heavy menstrual bleeding, though it only temporizes symptoms and does not cure the disease. 1, 2, 3

Hormonal IUD Considerations

• The LNG-IUD demonstrates the most favorable risk-benefit profile among medical therapies, with substantial reduction in dysmenorrhea and abnormal uterine bleeding 1, 3
• Critical caveat: No medical therapy eradicates adenomyosis lesions—all treatments provide only symptomatic management, not cure 1
• Reassess symptom control at 3 months after IUD insertion 3

Second-Line Medical Options

When LNG-IUD fails or is contraindicated, proceed algorithmically:

For Contraception-Seeking Patients

• Combined oral contraceptives (COCs) reduce painful and heavy menstrual bleeding, though they are less effective than the LNG-IUD 1, 3
• COCs can be used continuously to suppress menstruation 1

For Severe Bleeding or Pain

• GnRH antagonists are highly effective for heavy menstrual bleeding even with concomitant adenomyosis and should be considered second-line therapy 1, 2
• Combine with low-dose estrogen and progestin add-back therapy to mitigate hypoestrogenic effects including hot flushes, headaches, and bone mineral density loss 1
• GnRH agonists provide equivalent efficacy but require add-back therapy with long-term use to prevent bone loss 1, 3

Alternative Hormonal Options

• High-dose progestins serve as effective alternatives when IUD placement is not feasible 3, 4
• Dienogest shows promise but lacks robust evidence for standardized recommendations 5
• Danazol provides equivalent efficacy to GnRH agonists but carries significant androgenic side effects (acne, hirsutism, voice deepening), limiting its use 1, 3

Non-Hormonal Option

• Tranexamic acid may reduce bleeding symptoms for patients who cannot tolerate or refuse hormonal therapy 1

Surgical Management Algorithm

When Medical Therapy Fails

For patients who fail medical management and do not desire fertility preservation, hysterectomy is the only definitive cure, with minimally invasive approaches (vaginal or laparoscopic) strongly preferred over abdominal hysterectomy. 1, 2, 3

Hysterectomy Approach Selection

• Vaginal or laparoscopic hysterectomy offers shorter operating times, faster return to activities, lower infection rates, and improved quality of life compared to abdominal approach 1, 3
• Robotic-assisted hysterectomy shows similar outcomes to traditional laparoscopy 1
• Reserve abdominal hysterectomy only when anatomical constraints preclude minimally invasive approaches 3

Ovarian Conservation

• Preserve ovaries to avoid precipitating premature menopause with associated cardiovascular risks, mood disorders, osteoporosis, and potentially increased dementia risk 1
• Remove ovaries only when specific indications exist (malignancy concern, family history of ovarian cancer) 1
• Even with ovarian conservation, counsel patients that hysterectomy carries cardiovascular and metabolic risks, particularly when performed at young age 3

For Fertility Preservation or Uterus-Sparing Desire

Uterine artery embolization (UAE) should be offered to patients who fail conservative medical management but desire uterus preservation, providing 94% short-term and 85% long-term symptom improvement. 1, 2, 3

UAE Outcomes and Counseling

• Only 7-18% of patients require subsequent hysterectomy for persistent symptoms 2, 3
• UAE maintains quality of life improvements for up to 7 years 2
• Critical limitation: Comprehensive data on fertility and pregnancy outcomes after UAE is lacking—counsel patients accordingly before proceeding 3
• UAE may be less effective when adenomyosis predominates compared to when fibroids are the primary pathology 3

Conservative Surgical Options

• Cytoreductive surgery (adenomyomectomy) is very effective for reducing abnormal uterine bleeding, pelvic pain, and uterine volume 6
• This procedure should only be performed by experienced surgeons in dedicated centers due to technical complexity and risk of complications 6
• Warning: Surgical recurrence is common, with up to 44% of patients experiencing symptom recurrence within one year after conservative surgery 1, 3

Ineffective or Contraindicated Approaches

Procedures to Avoid

• Endometrial ablation has high failure rates in the presence of adenomyosis and should not be performed 1
• Myomectomy alone does not address adenomyosis and is ineffective for this condition 1

Essential Pre-Surgical Workup

• Always perform endometrial biopsy before surgical intervention to rule out endometrial cancer or hyperplasia, especially in perimenopausal women 1

Special Clinical Scenarios

Adenomyosis with Concurrent Endometrioma

• Use LNG-IUD for adenomyosis symptoms combined with surgical excision of endometrioma if symptomatic or ≥5 cm 3
• Preserve normal ovarian tissue during endometrioma excision to maintain ovarian reserve 3

Refractory Cases

• Aromatase inhibitors show promise for alleviating bleeding and pelvic pain in refractory patients but should be limited to trial settings due to safety concerns requiring further exploration 5

Post-Treatment Considerations

After Hysterectomy with Bilateral Oophorectomy

• Hormone replacement therapy with estrogen is not contraindicated following hysterectomy and bilateral salpingo-oophorectomy for adenomyosis 3

Fertility Counseling

• No evidence suggests that medical treatment affects future fertility in women with adenomyosis 3
• However, adenomyosis itself may impact fertility outcomes 5