From the Guidelines
Treatment for adenomyosis with menorrhagia should prioritize medical management, such as hormonal medications, as the initial therapy, with uterine artery embolization (UAE) considered for patients with symptomatic adenomyosis or concomitant adenomyosis and uterine leiomyomata, as it has shown durability in symptom control 1.
Treatment Options
- Medical management: hormonal medications, such as combined oral contraceptives, the levonorgestrel intrauterine system (Mirena), or GnRH agonists like leuprolide, to reduce bleeding and pain
- Minimally invasive procedures: endometrial ablation techniques to destroy the uterine lining and reduce bleeding
- Uterine artery embolization (UAE): to decrease blood flow to adenomyosis tissue and reduce symptoms
- Surgery: hysterectomy for women who have completed childbearing and have severe symptoms unresponsive to other treatments
Considerations
- Symptom severity: treatment choice should be individualized based on symptom severity
- Desire for future fertility: medical management and minimally invasive procedures may be preferred for women who desire future fertility
- Patient preferences: treatment choice should take into account patient preferences and values
Evidence
- A recent study published in 2024 found that medical management or UAE is usually appropriate for the initial therapy for a reproductive age patient with uterine fibroids and concurrent adenomyosis, symptomatic with heavy uterine bleeding or bulk symptoms 1
- Another study published in 2018 found that UAE has shown early success in controlling the symptoms of bleeding with adenomyosis, with long-term durability of symptom control ranging from 65% to 82% 1
From the FDA Drug Label
Therapy with norethindrone acetate tablets must be adapted to the specific indications and therapeutic response of the individual patient. Secondary amenorrhea, abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology 2. 5 to 10 mg norethindrone acetate tablets may be given daily for 5 to 10 days to produce secretory transformation of an endometrium that has been adequately primed with either endogenous or exogenous estrogen. Patients with a past history of recurrent episodes of abnormal uterine bleeding may benefit from planned menstrual cycling with norethindrone acetate tablets. INDICATIONS AND USAGE Norethindrone Acetate Tablets, USP are indicated for the treatment of secondary amenorrhea, endometriosis, and abnormal uterine bleeding due to hormonal imbalance in the absence of organic pathology, such as submucous fibroids or uterine cancer.
Treatment of menorrhagia due to adenomyosis with norethindrone acetate (PO) may be considered, as the drug label indicates it can be used for abnormal uterine bleeding due to hormonal imbalance.
- The dosage for this condition is not explicitly stated, but the label suggests 2.5 to 10 mg daily for 5 to 10 days to produce secretory transformation of the endometrium.
- Planned menstrual cycling with norethindrone acetate tablets may also be beneficial for patients with a history of recurrent abnormal uterine bleeding 2. However, it is essential to note that adenomyosis is not explicitly mentioned in the drug label, and the treatment should be adapted to the individual patient's response 2.
From the Research
Adenomyosis Treatment with Menorrhagia
- Adenomyosis is a clinical condition where endometrial glands are found in the myometrium of the uterus, often presenting with heavy menstrual bleeding, pelvic pain, or infertility 3.
- Treatment of adenomyosis typically starts with hormonal menstrual suppression, with levonorgestrel-releasing intrauterine systems showing some effectiveness 3, 4.
- A study found that a levonorgestrel-releasing intrauterine device (IUD) can provide marked and safe relief from adenomyosis-associated menorrhagia, with significant increases in hemoglobin, hematocrit, and serum ferritin 4.
- Another study compared the efficacy of dienogest and levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of intrinsic and extrinsic subtypes of adenomyosis, finding that dienogest demonstrates greater advantages over LNG-IUS in terms of complete relief of dysmenorrhea and the degree of symptom alleviation 5.
- The levonorgestrel-releasing intrauterine system appears to be the most effective first-line therapy for adenomyosis, based on efficacy compared with oral agents, maintenance of steady-state hormonal levels, and contraceptive benefit 6.
Treatment Options
- Medical options for adenomyosis include non-steroidal anti-inflammatory drugs, tranexamic acid, combined oral contraceptives, levonorgestrel intrauterine system, dienogest, other progestins, and gonadotropin-releasing analogues 7.
- Interventional options include uterine artery embolization, and surgical options include endometrial ablation, excision of adenomyosis, and hysterectomy 7.
- Long-acting gonadotropin-releasing hormone agonists are effective and should be considered second-line therapy, but are limited by hypogonadal effects 6.
Considerations
- The incidence of irregular vaginal bleeding in patients with intrinsic adenomyosis is higher than in those with extrinsic adenomyosis, and a more cautious approach is required when selecting progestin therapy for these patients 5.
- For patients with extrinsic adenomyosis, particularly those with prominent dysmenorrhea symptoms, dienogest treatment offers greater benefits 5.