Approach Considerations

The most important factor when considering treatment of a patient with adenomyosis is her desire for future fertility. The only definitive treatment for symptoms associated with adenomyosis is hysterectomy; however, this is not an option for patients who desire future fertility and may not be an option for patients who are poor surgical candidates. Additionally, because adenomyosis is still rarely definitively diagnosed before hysterectomy, treatment relies on a presumptive diagnosis. Surveillance for improvement is based on clinical presentation, with little ability for surveillance through imaging studies.

Medical Care

The medications most commonly used to treat symptoms of adenomyosis are anti-inflammatory medications and hormonal therapies. The most common class of anti-inflammatory medications used to treat menorrhagia are non-steroidal antiinflammatory drugs. These inhibit formation of prostaglandins, which are considered the primary mechanism of action in uterine pain. Hormonal therapies cause ovarian suppression, mainly through negative feedback on the hypothalamic-pituitary-ovarian axis. By suppressing ovarian function, hormonal stimualtion of adenomyotic tissue is suppressed.

Surgical Care

High Intensity Focused Ultrasound (HIFU)

HIFU is a conservative surgical method which allows patients to preserve their uterus. MRI or ultrasound imaging is used to visualize the uterus and direct high-intensity ultrasound beams at a targeted area within the myometrial tissue. These argeted ultrasound beams cause thermal ablation and necrosis. HIFU can be used on both focal and diffuse adenomyosis.^{[37, 38]}Patients treated with MRI-guided FUS have shown improvement in menorrhagia and dysmenorrhea, with a decrease in uterine size.^{[39, 40, 41]}

Uterine Artery Embolization (UAE)

Uterine artery embolization (UAE) has long been used as conservative treatment for women with symptomatic uterine fibroids. More recently, it has been considered as a treatment for symptomatic adenomyosis for women who are not candidates for surgical management. After UAE, patients with adenomyosis have reported significant improvement in dysmenorrhea, pelvic heaviness and urinary frequency.^[42]Mean uterine volume has consistently been shown to have a significant decrease after UAE.^{[43, 42]}Resolution of symptoms may last from 17 months to >4 years; however, the overall efficacy of UAE for adenomyosis remains unknown.^{[44, 43, 45]}

Adenomyomectomy

Although adenomyomas are focal areas of adenomyosis surrounded by myometrial hypertrophy, there is no well-defined plane between an adenomyoma and normal myometrium. Adenomyomectomy is a surgical option for adenomyomas and is performed in the same manner as a myomectomy. After the location of the adenomyoma has been identified as well as possible using imaging techniques, the adenomyoma can be removed via laparotomy or laparoscopy.^{[46, 47, 48]}For larger, more severe cases of adenomyoma and adenomyosis, wedge resection of the uterus can be performed.^[49]Multiple different techniques exist for uterine reconstruction after resection of diffuse adenomyosis or adenomyoma;^[50]however, few studies have been performed evaluating fertility after reconstruction.

Hysterectomy

Hysterectomy is currently considered the only definitive management for adenomyosis, and is still the recommended method if desired future fertility is not a factor. In many instances, adenomyosis is incidentally noted on histologic exam.

Consultations

Typically, because adenomyosis is confined to the uterus, diagnosis and management can be managed by an OB/GYN. For patients desiring surgical management, a gynecologist adept in hysterectomy should be involved. If a patient prefers management with a uterine artery embolization, Interventional Radiology must be consulted for evaluation and management. If a patient desires future fertility, she should be referred to a Reproductive Endocrinologist for counseling regarding expectations of future fertility and for discussion of fertility options.

Diet

Although a healthy diet is always recommended, no diet has been found to cause or prevent the development of adenomyosis. However, obesity has been identified as an independent risk factor associated with the presence of adenomyosis and endometriosis, possibly due to exposure to elevated estrogen levels^[51]. A healthy diet, therefore, may reduce the risk of obesity.

Activity

There are no known physical activities which may cause or prevent the development of adenomyosis. However, as mentioned previously, obesity has been identified as an independent risk factor associated with adenomyosis^[51]and may be prevented with appropriate diet and physical activity.

Prevention

By avoiding potential risk factors, the risk of developing adenomyosis may be reduced. Minimizing unnecessary estrogen exposure and uterine trauma may prevent the occurrence of inciting events. Suppression of ovulation may additionally prevent further maturation of existent adenomyotic implants and may prevent the initial development of adenomyosis.

Long-Term Monitoring

Long-term monitoring is not typically indicated. Conservative management can be continued without scheduled surveillance, and future management can be dictated by the patient's symptoms.

Medication

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Media Gallery

MRI of fundal adenomyoma.
Photo of an adenomyoma dissecting through the uterine wall.
Ultrasound of an adenomyoma dissecting through the anterior uterine wall separate from the endometrial cavity.
Adenomyosis noted within thickened myometrium.