Adenomyosis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

future fertility desired

1st line – levonorgestrel intrauterine device (IUD)

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1st line –

levonorgestrel intrauterine device (IUD)

A levonorgestrel IUD is a first-line treatment for women with symptomatic adenomyosis.[2][3][89]

Medical management can often provide effective symptom control for patients with adenomyosis and is an especially important option for women who have a wish to preserve their fertility.[2] Note that the recommendations provided in this algorithm for management of adenomyosis apply to adults only; consult a specialist for management options and medication dosages in adolescents with adenomyosis.

Levonorgestrel is a progestin. The exact mechanism of action of the levonorgestrel IUD in adenomyosis remains unclear. The improvement in heavy menstrual bleeding has been attributed to the reduction of prostaglandin I2, downregulation of estrogen receptors, and the decidualization and atrophy of the endometrium due to progestin.[94] Additionally, the levonorgestrel IUD may relieve dysmenorrhea by modulating neuropathologic and non-neuropathologic pain mediators, specifically by reducing the expression of nerve growth factor and its receptors.[95]

The levonorgestrel IUD has been shown in studies of patients with heavy menstrual bleeding from various causes to reduce menorrhagia and dysmenorrhea, and improve quality of life.[89][90][91] One study noted that patient satisfaction at 3 years post levonorgestrel IUD insertion for the treatment of adenomyosis was 72%.[92] One randomized controlled trial demonstrated that the levonorgestrel IUD was superior to the combined oral contraceptive in reducing pain and bleeding frequency among 62 patients with adenomyosis.[97] The study observed an average decrease in pain scores (measured using a visual analog scale) from 6.23 to 1.68 in the levonorgestrel IUD group, compared with 6.55 to 3.90 in the combined oral contraceptive group. The mean number of bleeding days per month decreased from 9.81 to 2.63 in the levonorgestrel IUD group, compared with 9.97 to 5.52 in the combined oral contraceptive group.[97]

Primary options

levonorgestrel intrauterine device: insert device as directed by manufacturer depending on the brand used

Consider – nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

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Consider –

nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

Treatment recommended for SOME patients in selected patient group

An NSAID (e.g., mefenamic acid, ibuprofen, naproxen) or the antifibrinolytic agent tranexamic acid can be used in addition to hormonal treatment if symptoms persist or recur.[109]

For dysmenorrhea, NSAIDs are typically started at onset of menses or 1-2 days prior to onset, depending on severity. The usual duration of treatment is up to 5 days. Long-term use of NSAIDs can be associated with gastrointestinal adverse effects (bleeding, perforation, or ulceration), cardiovascular thrombotic events, and renal disease. Use the lowest effective dose for the shortest effective treatment duration.

Primary options

mefenamic acid: 500 mg orally as a single dose initially, followed by 250 mg every 6 hours when required for up to 3 days

ibuprofen: 400 mg orally every 4 hours when required, maximum 3200 mg/day

naproxen: 250-500 mg orally every 12 hours when required, maximum 1250 mg/day

tranexamic acid: 1300 mg orally three times daily for up to 5 days during menstruation

2nd line – oral hormonal therapy

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2nd line –

oral hormonal therapy

Consider the use of oral hormonal treatments for the management of dysmenorrhea and heavy menstrual bleeding in women with adenomyosis who decline or are not suitable for management with a levonorgestrel IUD.[2][3] Options include a combined oral contraceptive, or an oral progestin such as norethindrone or dienogest.

Medical management can often provide effective symptom control for patients with adenomyosis and is an especially important option for women who have a wish to preserve their fertility.[2]

Oral hormonal treatments can result in a progestin-mediated inhibition of cellular proliferation and stimulation of apoptosis of adenomyotic cells.[100] Consistently elevated levels of steroids causes thinning of the endometrium and a decrease in the amount of endometrial shedding, leading to reduction in menstrual bleeding.[98] Progestins have the potential to address the progesterone resistance observed in both ectopic and eutopic endometrium in adenomyosis and consequently reduce symptoms. However, this resistance may also limit their effectiveness.[101]

Due to the scarcity of high-quality evidence on combined oral contraceptives for the treatment of adenomyosis, most data are extrapolated from studies using these agents to treat endometriosis or leiomyomas (fibroids).[98][99] Combined oral contraceptives have been found to improve dysmenorrhea and menstrual bleeding in patients with adenomyosis.[97] They are commonly used for cycle control and to suppress ovulation; if pain is strictly related to the menstrual cycle, continuous use of a combined oral contraceptive may be useful as women may become amenorrheic and therefore have less cyclic pain.[102] Adverse effects are generally mild and time-limited; however, the patient should be informed that continuous use of combined oral contraceptives is associated with breakthrough bleeding. Use is contraindicated in patients who are at high risk of arterial or venous thrombotic diseases; consult your local drug information source for a full list of contraindications before prescribing. There are numerous oral contraceptive formulations available; consult your local drug information source for guidance on choice of formulation and dose.

Norethindrone is an oral progestin approved for the treatment of endometriosis. It has been found to improve menstrual bleeding in adenomyosis patients.[103] When taken for 3 weeks followed by a 1-week break, it has also been found to improve patient-reported pain scores.[103]

Dienogest is an oral progestin approved for the treatment of endometriosis in many regions outside the US; however, it is currently only available in the US (and some other countries) in combination with estradiol. It has shown prolonged improvement in dysmenorrhea in patients with adenomyosis after 8 weeks' use, with a sustained effect at up to 52 weeks of use.[104][105][106] Prolonged use of dienogest exerts a hypoestrogenic effect without decreasing serum estradiol levels.[107] Some patients report repeated bleeding and hot flashes after long-term use; these adverse effects are tolerable for most patients and make long-term use of dienogest a suitable alternative to avoid hysterectomy.[106]

Primary options

norethindrone acetate: 5 mg orally once daily for 2 weeks, increase by 2.5 mg/day every 2 weeks, maximum 15 mg/day

estradiol valerate/dienogest: 1 tablet once daily according to product literature

Consider – nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

Back

Consider –

nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

Treatment recommended for SOME patients in selected patient group

An NSAID (e.g., mefenamic acid, ibuprofen, naproxen) or the antifibrinolytic agent tranexamic acid can be used in addition to hormonal treatment if symptoms persist or recur.[109]

Primary options

mefenamic acid: 500 mg orally as a single dose initially, followed by 250 mg every 6 hours when required for up to 3 days

ibuprofen: 400 mg orally every 4 hours when required, maximum 3200 mg/day

naproxen: 250-500 mg orally every 12 hours when required, maximum 1250 mg/day

tranexamic acid: 1300 mg orally three times daily for up to 5 days during menstruation

2nd line – nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

Back

2nd line –

nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

Consider the use of an NSAID (e.g., mefenamic acid, ibuprofen, naproxen) or the antifibrinolytic agent tranexamic acid as a nonhormonal treatment option in patients with symptomatic adenomyosis who have abnormal uterine bleeding with or without dysmenorrhea and who decline or are unsuitable for a levonorgestrel IUD or oral hormonal therapy.[3][88][108]

There is a lack of specific studies examining the use of NSAIDs and tranexamic acid in the context of adenomyosis.[2] NSAIDs have shown effectiveness in treating dysmenorrhea and also provide analgesia.[108] Although NSAIDs are effective for reduction of heavy menstrual bleeding, one meta-analysis of 19 randomized controlled trials found that NSAIDs were not as effective as tranexamic acid or the levonorgestrel IUD.[110] Note, however, that the cause of heavy menstrual bleeding in trial participants in this meta-analysis was not specified, and participants with pathologic causes of heavy menstrual bleeding were excluded from the study.

Tranexamic acid is commonly used in the management of heavy menstrual bleeding.[88] The role of tranexamic acid in conditions associated with heavy menstrual bleeding may be related to correlation of increased levels of plasminogen activators in the endometrium of women affected by heavy menstrual bleeding.[111] One systematic review and meta-analysis of 85 studies covering 9950 participants concluded that tranexamic acid was the second most effective intervention (after the levonorgestrel IUD) for reducing heavy menstrual blood loss.[89]

Primary options

mefenamic acid: 500 mg orally as a single dose initially, followed by 250 mg every 6 hours when required for up to 3 days

ibuprofen: 400 mg orally every 4 hours when required, maximum 3200 mg/day

naproxen: 250-500 mg orally every 12 hours when required, maximum 1250 mg/day

tranexamic acid: 1300 mg orally three times daily for up to 5 days during menstruation

2nd line – gonadotropin-releasing hormone (GnRH) agonist

Back

2nd line –

gonadotropin-releasing hormone (GnRH) agonist

Consider a GnRH agonist (e.g., goserelin, triptorelin, leuprolide) as a second-line option for short-term treatment of dysmenorrhea and heavy menstrual bleeding associated with adenomyosis.[2]

Medical management can often provide effective symptom control for patients with adenomyosis and is an especially important option for women who have a wish to preserve their fertility.[2]

GnRH agonists have the potential to alleviate symptoms associated with adenomyosis through both systemic and local effects.[112][113] Systemically, GnRH agonists induce a state of hypoestrogenemia by downregulating pituitary GnRH receptors. Locally, GnRH agonists exhibit anti-inflammatory and antiangiogenic properties, along with a direct antiproliferative effect on adenomyotic tissue.

Several studies have demonstrated a reduction of menstrual bleeding, pelvic pain, and adenomyoma volume in women with adenomyosis. In one small study evaluating the use of goserelin for 12 weeks, 92.8% of women self-reported improvement in chronic pelvic pain and 100% reported improvement in dysmenorrhea and menorrhagia.[114] Another study comparing triptorelin with dienogest demonstrated improvement in dyspareunia and chronic pelvic pain, with no significant difference between the two groups.[104] However, triptorelin was found to be superior to dienogest in relieving dysmenorrhea after 16 weeks.[104] The study also noted 100% improvement in irregular bleeding among patients who received triptorelin, with amenorrhea occurring in 94.4% of patients.[104]

Long-term treatment with a GnRH agonist beyond 6 months is typically not feasible due to the adverse effects associated with antiestrogen therapy, such as vasomotor syndrome, mood instability, reduced bone mineral density, and genital atrophy.[115] As a result, the use of "add-back" hormone replacement therapy may be considered when GnRH agonists are used for longer than 6 months.[2] There is currently no specific guidance for when and which type of add-back therapy should be used, particularly in cases involving severe vasomotor symptoms or to prevent bone loss.[116] In practice, add-back therapy options such as low-dose norethindrone or conjugated estrogens/medroxyprogesterone may be used. Nonhormonal treatments such as selective serotonin-reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) may also be considered for vasomotor symptoms.

Studies investigating the administration of GnRH agonists before IVF cycles have found conflicting results. One systematic review concluded that treatment with GnRH agonists could be beneficial in improving the clinical pregnancy rate in both symptomatic and asymptomatic patients with adenomyosis.[120] However, another systematic review confirmed the detrimental effects of adenomyosis on infertility and did not show significant benefits of using GnRH agonists to improve IVF outcomes.[121] It is challenging to separate confounding factors such as advanced maternal age and coexistence of endometriosis, which is frequently associated with adenomyosis. Further studies are needed to differentiate focal from diffuse adenomyosis and to design more standardized IVF protocols, reducing bias and evaluating the potential benefits of GnRH agonists in IVF treatment.

Primary options

goserelin: 3.6 mg subcutaneously every 28 days

triptorelin: 3.75 mg intramuscularly every 4-6 weeks; 11.25 mg intramuscularly every 12 weeks

leuprolide: 3.75 mg intramuscularly once monthly; 11.25 mg intramuscularly every 3 months

3rd line – uterine-sparing focal excision surgery

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3rd line –

uterine-sparing focal excision surgery

Uterine-sparing focal excision procedures (adenomyomectomy) may be considered in patients with focal adenomyotic disease who desire preservation of fertility, who have been counseled about risks during subsequent pregnancy, and in whom medical management has failed to resolve symptoms.[2] The aim is to resect diseased tissue to decrease uterine size while preserving fertility and improving symptoms.[126]

Adenomyomectomy is a challenging surgical procedure due to unclear surgical planes between healthy myometrium and adenomyotic tissue.[141] There are significant perioperative risks, and the procedure must be performed by an experienced surgeon.[2] Several different resection techniques are available for surgical excision of adenomyosis, such as the H-incision, double-flap, and triple-flap adenomyomectomy.[141][142][143][144] Laparoscopic focal excision has been shown to be noninferior to the abdominal approach in one study; however, strong evidence regarding perioperative and long-term outcomes of each route is lacking.[145] Data regarding outcomes related to quality of life, dysmenorrhea, and abnormal bleeding are limited to case series; while these series suggest an improvement, regardless of approach, they are too heterogeneous to recommend one surgical approach over another.[126]

Improvement of heavy bleeding has been reported up to 6 years after surgery, irrespective of the approach used, with a low rate of persistent abnormal bleeding (8% to 10% of patients).[145][146][147][148] In one study, 94% of women who had dysmenorrhea as a primary symptom reported complete pain resolution at 6 months following excisional procedures; the remaining 6% experienced partial improvement.[148]

Careful counseling is needed about the uncertain impact of adenomyomectomy on fertility and pregnancy outcomes as well as the increased risk of serious pregnancy-related complications including uterine rupture.[2][149] Many experts recommend prelabor cesarean delivery because of this risk.[126] There are insufficient strong data to support performing surgery for the express purpose of enhancing fertility as evidence is mixed.[2]

Several small studies have highlighted adverse pregnancy outcomes associated with uterine-sparing surgeries for adenomyosis. Significant risks may include placenta accreta spectrum and uterine rupture, which are thought to occur due to adenomyosis-induced changes in myometrial strength and perfusion, further aggravated by surgical trauma that potentially hampers uterine healing.[143][149][152][153] In one large series, a 4% rate of uterine rupture was reported.[149] However, a meta-analysis of 12 studies involving 364 women who had partial or complete excision of adenomyosis reported that 35% successfully conceived and, of that group, 74% delivered at full term with a uterine rupture rate of 0.8%.[153]

future fertility not desired

uterine preservation desired or unsuitable for hysterectomy

1st line – levonorgestrel intrauterine device (IUD)

Back

1st line –

levonorgestrel intrauterine device (IUD)

A levonorgestrel IUD is a first-line treatment for women with symptomatic adenomyosis.[2][3][89]

Medical management can often provide effective symptom control for patients with adenomyosis.[2]

A prospective randomized clinical trial comparing the levonorgestrel IUD with hysterectomy in women with adenomyosis reported comparable effects on menorrhagia, with a significant improvement in hemoglobin levels after 1 year.[96] Additionally, although both treatment options improved quality of life, the levonorgestrel IUD showed slightly superior effects on psychological and social aspects of life as measured by quality of life scores.[96]

One randomized controlled trial demonstrated that the levonorgestrel IUD was superior to the combined oral contraceptive in reducing pain and bleeding frequency among 62 patients with adenomyosis.[97] The study observed an average decrease in pain scores (measured using a visual analog scale) from 6.23 to 1.68 in the levonorgestrel IUD group, compared with 6.55 to 3.90 in the combined oral contraceptive group. The mean number of bleeding days per month decreased from 9.81 to 2.63 in the levonorgestrel IUD group, compared with 9.97 to 5.52 in the combined oral contraceptive group.[97]

Primary options

levonorgestrel intrauterine device: insert device as directed by manufacturer depending on the brand used

Consider – nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

Back

Consider –

nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

Treatment recommended for SOME patients in selected patient group

An NSAID (e.g., mefenamic acid, ibuprofen, naproxen) or the antifibrinolytic agent tranexamic acid can be used in addition to hormonal treatment if symptoms persist or recur.[109]

Primary options

mefenamic acid: 500 mg orally as a single dose initially, followed by 250 mg every 6 hours when required for up to 3 days

ibuprofen: 400 mg orally every 4 hours when required, maximum 3200 mg/day

naproxen: 250-500 mg orally every 12 hours when required, maximum 1250 mg/day

tranexamic acid: 1300 mg orally three times daily for up to 5 days during menstruation

2nd line – oral hormonal therapy

Back

2nd line –

oral hormonal therapy

Medical management can often provide effective symptom control for patients with adenomyosis and is an especially important option for women who have a wish to preserve their fertility.[2]

Primary options

norethindrone acetate: 5 mg orally once daily for 2 weeks, increase by 2.5 mg/day every 2 weeks, maximum 15 mg/day

estradiol valerate/dienogest: 1 tablet once daily according to product literature

Consider – nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

Back

Consider –

nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

Treatment recommended for SOME patients in selected patient group

An NSAID (e.g., mefenamic acid, ibuprofen, naproxen) or the antifibrinolytic agent tranexamic acid can be used in addition to hormonal treatment if symptoms persist or recur.[109]

Primary options

mefenamic acid: 500 mg orally as a single dose initially, followed by 250 mg every 6 hours when required for up to 3 days

ibuprofen: 400 mg orally every 4 hours when required, maximum 3200 mg/day

naproxen: 250-500 mg orally every 12 hours when required, maximum 1250 mg/day

tranexamic acid: 1300 mg orally three times daily for up to 5 days during menstruation

2nd line – nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

Back

2nd line –

nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

Tranexamic acid is commonly used in the management of heavy menstrual bleeding.[88] The role of tranexamic acid in conditions associated with heavy menstrual bleeding may be related to correlation of increased levels of plasminogen activators in the endometrium of women affected by heavy menstrual bleeding.[111] A systematic review and meta-analysis of 85 studies covering 9950 participants concluded that tranexamic acid was the second most effective intervention (after the levonorgestrel IUD) for reducing heavy menstrual blood loss.[89]

Primary options

mefenamic acid: 500 mg orally as a single dose initially, followed by 250 mg every 6 hours when required for up to 3 days

ibuprofen: 400 mg orally every 4 hours when required, maximum 3200 mg/day

naproxen: 250-500 mg orally every 12 hours when required, maximum 1250 mg/day

tranexamic acid: 1300 mg orally three times daily for up to 5 days during menstruation

2nd line – gonadotropin-releasing hormone (GnRH) agonist

Back

2nd line –

gonadotropin-releasing hormone (GnRH) agonist

Consider a GnRH agonist (e.g., goserelin, triptorelin, leuprolide) as a second-line option for short-term treatment of dysmenorrhea and heavy menstrual bleeding associated with adenomyosis.[2]

Medical management can often provide effective symptom control for patients with adenomyosis and is an especially important option for women who have a wish to preserve their fertility.[2]

Primary options

goserelin: 3.6 mg subcutaneously every 28 days

triptorelin: 3.75 mg intramuscularly every 4-6 weeks; 11.25 mg intramuscularly every 12 weeks

leuprolide: 3.75 mg intramuscularly once monthly; 11.25 mg intramuscularly every 3 months

2nd line – endometrial ablation or uterine artery embolization

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2nd line –

endometrial ablation or uterine artery embolization

Consider second-generation endometrial ablation or uterine artery embolization (UAE) for management of pain and heavy bleeding associated with adenomyosis in women who do not wish to have future pregnancies but wish to retain their uterus and in whom pharmacologic interventions have been unsuccessful, are contraindicated, or have been declined.[2][3][134] These interventional procedures may also be considered for women who are a high-risk group for major surgery and therefore not candidates for hysterectomy (e.g., because of cardiac or pulmonary dysfunction).

Various techniques may be performed to ablate the endometrial lining, with an aim to hinder regeneration and reduce abnormal bleeding. The available evidence suggests that second-generation endometrial ablation techniques are associated with greater satisfaction with treatment and a reduction in blood loss compared with first-generation techniques; therefore, second-generation options are usually preferred.[3] Second-generation minimally invasive approaches involve non-resectoscopic thermal endometrial ablation, which utilizes a disposable device inserted into the uterine cavity to deliver energy to uniformly eliminate the endometrial lining. Such methods include bipolar radiofrequency, hot liquid-filled balloon, cryotherapy, circulating hot water, and microwave techniques.[127] First-generation techniques entail endometrial resection or ablation via hysteroscopy, utilizing electrosurgical instruments such as a rollerball, wire loop, vaporizing electrode, or laser.[127]

Endometrial ablation is not an appropriate option for women who have a desire for future childbearing.[3][126] Advise women to use effective contraception to avoid subsequent pregnancy after endometrial ablation.[3] A desire for future childbearing is an absolute contraindication for first-generation ablation techniques.[126] Data on fertility outcomes and pregnancy complications (including the risk of uterine rupture) remain scarce with regard to second-generation techniques; hence, great caution is required.[2]

Radiofrequency (RF) thermal ablation is a minimally invasive thermal ablation technique that has received Food and Drug Administration (FDA) approval for the treatment of leiomyomata (uterine fibroids) in the US, using either a laparoscopic or transcervical ultrasound-guided system. RF thermal ablation results in volumetric tissue reduction and destruction, which provides the observed symptomatic relief.[126] A meta-analysis of thermal ablation for treatment of adenomyosis reported a reduction in uterine volume after RF ablation of 44.0% (95% CI 36.0% to 52.0%; two studies), and adenomyosis volume reduction of 61.3% (95% CI 52.5% to 70.2%; three studies).[128] The results from two further studies indicate a significant decrease (71% to 72%) in dysmenorrhea measured using a visual analog scale (VAS).[129][130] In one study of 87 women with symptomatic adenomyosis, symptom severity scores were reported to decrease by 73% at 12 months after treatment. However, most cases of diffuse adenomyosis showed no improvement and required additional treatments, with the majority of these cases proceeding to hysterectomy.[130]

Microwave ablation involves the percutaneous insertion under ultrasound guidance of a 15-gauge needle antenna with an exposed tip, generating 40 to 60 W of energy into the lesion.[131] Several studies have reported a significant reduction in uterine volume and an improvement in adenomyosis symptoms, including dysmenorrhea and bleeding.[131][132][133] One study of microwave ablation in 107 patients with focal and nonfocal adenomyosis found no significant difference between focal and nonfocal ablation over a 12-month follow-up, with uterine volume decreased by 61.1% (±13.6%) versus 59.4% (±10.2%), respectively.[132] Dysmenorrhea and heavy bleeding showed significant or complete remission at 12 months, with no significant difference between focal and nonfocal ablation (77.7% vs. 81.1%, respectively).[132]

Outcomes of UAE in patients with adenomyosis may vary according to specific characteristics, although data are conflicting. Patients with hypervascular, focal adenomyotic lesions seem to respond better to treatment.[2] Patients should be made aware that symptoms may not resolve following the procedure, or may recur.[134]

There is a paucity of high-quality evidence regarding the use of UAE for the treatment of adenomyosis.[58] Pelvic pain, nausea, and fever caused by ischemic necrosis are among the adverse effects of UAE frequently reported after treatment.[135]

Studies have demonstrated a reduction of uterine volume by approximately 25% following UAE correlating to improvement of symptoms.[136][137] Several investigations have demonstrated marked improvement in abnormal or heavy menstrual bleeding following UAE, with 88% and 70% of patients reporting significant improvement after 6 and 12 months, respectively.[138][139] UAE appears to have a positive impact on dysmenorrhea and pelvic pain in patients with adenomyosis; one study found that 74% of patients reported improvement in dysmenorrhea at 12 months and 70.4% at 5 years.[139] However, after 5 years, 47.2% of women experienced recurrence of at least one symptom.[139] The vascularity pattern of the adenomyotic lesion on MRI was identified as a predictor of UAE outcomes, with highly vascularized, focal lesions being associated with better short- and long-term pain relief than diffuse disease.[139] The rate of long-term recurrence of symptoms was 36% in one study and 35% in another study, with a time to recurrence ranging from 4 to 48 months.[136][140]

Rates of subsequent hysterectomy following initial UAE range from 10% to 18%.[136][140]

uterine preservation not desired and suitable for surgery

1st line – hysterectomy

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1st line –

hysterectomy

Consider referral for hysterectomy as a definitive treatment option in patients with abnormal uterine bleeding, dysmenorrhea, or bulk symptoms secondary to adenomyosis who do not desire future fertility or uterine preservation.[2][88]

Hysterectomy may be considered in women who: decline or have contraindications to medical management; have failed to adequately respond to medical management; are unsuitable for endometrial ablation; have severe symptoms and a preference for hysterectomy as a first-line treatment option.

While hysterectomy is highly effective for the treatment of benign uterine diseases such as adenomyosis, patients should be counseled regarding both benefits and risks of the procedure.[2][3] This should include discussion of emerging data suggestive of potential long-term health risks associated with hysterectomy, even with conservation of both ovaries.[122]

For noncancerous uterine conditions such as adenomyosis, minimally invasive surgical approaches (vaginal or laparoscopic) are recommended in preference to open abdominal hysterectomy, if feasible.[123] Vaginal hysterectomy is the preferred minimally invasive intervention due to faster recovery rates and lower rates of ureteral injury.[123]

Endometriosis is a common coexisting condition in women with adenomyosis who undergo hysterectomy. One study of 76 such women found that 26% had a history of endometriosis.[124] In such cases, total laparoscopic hysterectomy, diagnostic laparoscopy followed by vaginal hysterectomy, or natural orifice transluminal endoscopy (vNOTES) may be considered; these options allow visualization of the peritoneal cavity and treatment of concomitant endometriosis through complete excision during the surgery.[125]

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Adenomyosis

Treatment algorithm

future fertility desired

levonorgestrel intrauterine device (IUD)

Primary options

nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

Primary options

oral hormonal therapy

Primary options

nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

Primary options

nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

Primary options

gonadotropin-releasing hormone (GnRH) agonist

Primary options

uterine-sparing focal excision surgery

future fertility not desired

levonorgestrel intrauterine device (IUD)

Primary options

nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

Primary options

oral hormonal therapy

Primary options

nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

Primary options

nonsteroidal anti-inflammatory drug (NSAID) or tranexamic acid

Primary options

gonadotropin-releasing hormone (GnRH) agonist

Primary options

endometrial ablation or uterine artery embolization

hysterectomy