Conservative Management of Uterine Adenomyosis: Medical vs. Surgical Approach

Abstract

Uterine adenomyosis is a commonly encountered estrogen-dependent disease in reproductive-age women, causing heavy menstrual bleeding, intense pelvic pain, and infertility. Although adenomyosis was previously considered a disease of multiparous women, it is becoming increasingly evident that it also affects younger nulliparous women and may compromise their fertility potential. It is clear that hysterectomy, the standard approach to definitively manage the disease, is not an option for patients wishing to preserve their fertility, so there is an urgent need to develop novel conservative strategies. We searched the current literature for available methods for conservative management of adenomyosis, including both pharmacological and surgical approaches. There is no existing drug that can cure adenomyosis at present, but some off-label treatment options may be used to tackle disease symptoms and improve fertility outcomes. Adenomyosis in patients wishing to conceive can be ‘treated’ by conservative surgery, though these procedures require highly experienced surgeons and pose a considerable risk of uterine rupture during subsequent pregnancies. While currently available options for conservative management of adenomyosis do have some capacity for alleviating symptoms and enhancing patient fertility perspectives, more effective new options are needed, with gonadotropin-releasing hormone antagonists showing encouraging results in preliminary studies.

Functional Implications of Estrogen and Progesterone Receptors Expression in Adenomyosis, Potential Targets for Endocrinological Therapy

“…Due to the lack of knowledge pertaining to the molecular bases of the pathogenesis of adenomyosis currently available, diagnostic and treatment options are limited [ 16 , 17 , 18 ]. Recent studies have shown similarities with deep endometriosis at the histological level [ 19 ].…”

Characterization of patients that can continue conservative treatment for adenomyosis

“…The success of conservative treatment requires a combination of long-term medical therapy or surgical therapy. In addition to the treatments used in this study, new GnRH antagonists are available [ 30 – 32 ], but as with GnRH agonists, the problem of side effects such as loss of bone density due to long-term administration remains. There are also some reports that uterine artery embolization and high-intensity focused ultrasound therapy are useful and safe as alternative therapies [ 33 ], but there is no randomized controlled trial, and the prognosis of pregnancy is unclear, so further verification is needed.…”

Nonsurgical management of adenomyosis: an overview of current evidence

“…They have a favourable therapeutic profile because of their water-soluble properties, oral absorption and lower side effects if supplied in low doses [26 ▪ ]. Recent studies have demonstrated promising effectiveness in uterine volume reduction through lesion regression and associated adenomyosis symptoms decline [45 ▪▪ ,46 ▪ ].…”

“…European Society of Human Reproduction and Embryology (ESHRE) guidelines recommend concomitant use of aromatase inhibitors and oral contraceptives, progestogens or GnRH agonists in patients with pain associated with drug-resistant and surgery-resistant rectovaginal endometriosis [51]. However, there is neither current evidence nor an international consensus on the use of aromatase inhibitors for adenomyosis management [46 ▪ ]. Nevertheless, an older prospective study of 32 patients that compared effectiveness of letrozole to GnRH agonists for adenomyosis management has shown significant reduction in uterine volume posttreatment in both groups [52].…”