Current and Future Surgical and Interventional Management Options for Adenomyosis

Abstract

Historically, hysterectomy has been the recommended treatment for patients with adenomyosis. However, in the past two decades, various uterine-sparing treatment methods have emerged. These range from excisional techniques such as adenomyomectomy or wedge resection to uterine artery embolization, radiofrequency thermal ablation, hysteroscopic excision, endometrial ablation, and high-intensity focused ultrasound. While largely investigative for the treatment of adenomyosis, these procedures have demonstrated improvement in symptoms including abnormal uterine bleeding, dysmenorrhea, pelvic pain, and overall quality of life. However, long-term data including fertility and obstetric outcomes are needed. Future research is needed to better understand the impact of these uterine-preserving techniques to expand our armamentarium for the treatment of adenomyosis.

Diagnosis, Evaluation, and Treatment of Adenomyosis

“…Although future fertility is often desired by women choosing these options, data regarding reproductive outcomes remain limited. Uterine artery embolization is the most well-studied intervention for adenomyosis and effectively decreases heavy menstrual bleeding and dysmenorrhea; however, approximately 25% of patients will undergo subsequent hysterectomy due to persistent symptoms . Pregnancy after uterine artery embolization is not generally recommended based on studies that demonstrated higher rates of obstetric complications, including miscarriage and postpartum hemorrhage.…”

“…Similarly, endometrial ablation, which seeks to destroy the endometrium, diminishes bleeding and pain, but subsequent pregnancy is not recommended. Excisional procedures, such as adenomyomectomy, uterine wedge resection, and hysteroscopic excision, have shown promise in improving symptoms to varying degrees, with up to 60% of women achieving subsequent pregnancy . These techniques of focal excision of both diffuse and focal adenomyosis are not commonly used, but show promise over more global uterine procedures for women seeking to preserve fertility.…”

“…Uterine artery embolization is the most well-studied intervention for adenomyosis and effectively decreases heavy menstrual bleeding and dysmenorrhea; however, approximately 25% of patients will undergo subsequent hysterectomy due to persistent symptoms. 10 Pregnancy after uterine artery embolization is not generally recommended based on studies that demonstrated higher rates of obstetric complications, including miscarriage and postpartum hemorrhage. Similarly, endometrial ablation, which seeks to destroy the endometrium, diminishes bleeding and pain, but subsequent pregnancy is not recommended.…”

“…Excisional procedures, such as adenomyomectomy, uterine wedge resection, and hysteroscopic excision, have shown promise in improving symptoms to varying degrees, with up to 60% of women achievingsubsequentpregnancy. 10 Thesetechniquesoffocalexcisionofboth diffuseandfocaladenomyosisarenotcommonlyused,butshowpromiseovermoreglobaluterineproceduresforwomenseekingtopreserve fertility. For all these interventions, more data are needed regarding the potential benefits on quality of life, fertility, and pregnancy, specifically inpatientswithadenomyosisratherthanmixedgroupsofpatientswith symptoms attributable to other etiologies.…”

Image-guided thermal ablation in the management of symptomatic adenomyosis: a systematic review and meta-analysis

“…One of the minimally invasive therapies is image-guided thermal ablation that destroys the lesions by a rapid temperature rise. Currently, there are several thermal energy sources used in clinical practice, involving high-intensity focused ultrasound (HIFU), percutaneous microwave ablation (PMWA) and radiofrequency ablation (RFA) [8]. HIFU ablation is performed under the guidance of ultrasound or magnetic resonance imaging (MRI) without the use of an antenna or electrode.…”