What are the management options for a patient with adenomyosis?

Management of Adenomyosis

For symptomatic adenomyosis, initiate a levonorgestrel-releasing intrauterine device (LNG-IUD) as first-line therapy, which reduces menstrual blood loss by 71-95% and provides superior symptom control compared to combined oral contraceptives. 1

First-Line Medical Management

The LNG-IUD is the preferred initial treatment due to its local mechanism of action, lower systemic hormone levels, long duration after placement, and user independence. 2 A recent randomized controlled trial demonstrated significant improvement in both pain and bleeding in women with adenomyosis treated with LNG-IUD versus combined oral contraceptives. 2, 1

Key Clinical Considerations:

• The LNG-IUD provides efficacy comparable to endometrial ablation with 71-95% reduction in menstrual blood loss 1
• This approach is particularly advantageous for women not desiring pregnancy while managing symptoms, as it provides contraception 3
• Critical caveat: No medical therapy eradicates adenomyosis lesions; all provide only temporary symptom relief with rapid recurrence after discontinuation 1

Second-Line Medical Options

If LNG-IUD is contraindicated or ineffective, proceed with the following hierarchy:

Hormonal Alternatives:

• GnRH antagonists (elagolix, linzagolix, relugolix) are highly effective for heavy menstrual bleeding, even with concomitant adenomyosis, with reduction in fibroid volume by 18-30% 1, 4

  • Mandatory requirement: Combination treatment with low-dose estrogen and progestin add-back therapy to mitigate hypoestrogenic effects (hot flushes, headaches, bone mineral density loss) 1, 4
  • Pooled analysis of 2 randomized controlled trials confirms effectiveness is not decreased by presence of adenomyosis 2

• Combined oral contraceptives reduce painful and heavy menstrual bleeding in randomized controlled trials, though less effective than LNG-IUD 2, 1, 4

• Cyclic oral progestins reduce bleeding by 87%, often resulting in only light bleeding 3

Nonhormonal 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, 4
• NSAIDs reduce menstrual blood loss and bleeding symptoms, but should be avoided in women with cardiovascular disease 1

Important limitation: Medical therapies will not treat bulk symptoms associated with adenomyosis 2, 1

Interventional Options for Uterus-Preserving Therapy

Uterine artery embolization (UAE) is recommended for patients who fail conservative medical measures and desire uterus-preserving therapy:

• Provides short-term (<12 months) symptom improvement in 94% and long-term (>12 months) improvement in 85% of patients 2, 1, 3
• Symptom control and quality of life improvement maintained up to 7 years follow-up 2, 1
• Long-term symptomatic relief (median follow-up 27.9 months) ranges from 65% to 82% in patients with pure adenomyosis or adenomyosis with coexistent leiomyomas 1
• More recent retrospective studies (median follow-up 24 to 65 months) report symptomatic control in 73% to 88% of patients 1
• 7-18% rate of subsequent hysterectomy for persistent symptoms 2, 1

Fertility considerations: Successful pregnancy has been reported after UAE for adenomyosis; however, comprehensive data on fertility and pregnancy is lacking, and patients should be counseled accordingly. 2

Surgical Management

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, 3

Route Selection Algorithm:

When hysterectomy is indicated, the least invasive route should be performed: 2, 4

1. Vaginal hysterectomy (preferred when feasible): Shorter operating times, faster return to normal activities, better quality of life compared to abdominal approach 2

2. Laparoscopic hysterectomy: Faster return to normal activities, shorter hospital stays, lower rates of wound infection compared to abdominal approach 2

3. Robotic-assisted hysterectomy: Similar outcomes to traditional laparoscopy in terms of operative time, hospital stay, and postoperative complications 2, 4

4. Abdominal hysterectomy (last resort): Associated with longer hospital stay, recovery time, greater pain and risk of infection 2

Important Safety Considerations:

• Randomized studies demonstrate increased rate of severe complications, longer hospitalization, and longer return to regular activities with hysterectomy compared to UAE despite similar symptom relief 2
• Long-term effects of hysterectomy include increased risk of cardiovascular disease, osteoporosis and bone fracture, and dementia 2, 4
• Ovaries should be left in place to avoid precipitating menopause and associated cardiovascular risks, unless there is an indication for removal 4

Ineffective or Limited-Evidence Treatments

Avoid the following approaches for adenomyosis:

• Myomectomy (hysteroscopic, laparoscopic, or open): Adenomyosis is unlikely to be effectively addressed with this technique, and there is no relevant literature supporting its use 2, 4
• Endometrial ablation: Has high failure rates in the presence of adenomyosis 4
• MR-guided high-frequency focused ultrasound ablation: No relevant literature regarding use in adenomyosis 2
• Laparoscopic uterine artery occlusion: No relevant literature regarding use in adenomyosis 2

Critical Pitfalls to Avoid

• Do not assume medical therapy will cure adenomyosis—it only temporizes symptoms, with rapid recurrence after discontinuation 1, 4
• Ensure endometrial biopsy has been performed to rule out endometrial cancer or hyperplasia, especially in perimenopausal women with adenomyosis 4, 3
• Recognize that symptom recurrence after conservative surgery is common, with up to 44% experiencing recurrence within one year 4
• Medical management should be attempted first in most cases unless there are other indications for hysterectomy, such as malignancy concerns, prolapse, or cervical dysplasia 4