What’s the best treatment approach?

The definitive treatment for adenomyosis is hysterectomy.

Unlike fibroids, where a myomectomy is a surgical option, adenomyosis cannot be easily excised. Until a screening test exists that has acceptable sensitivity and specificity, safety profile, and cost, it appears that adenomyosis can only be accurately diagnosed and treated if a hysterectomy is simultaneously performed. Given that patients with symptoms suggestive of adenomyosis probably have other pathologies contributing to their symptoms, we suggest that treatment be targeted to the patient’s symptoms or other conditions. The physician needs to consider each patient’s individual situation, and make decisions based on what is appropriate for the woman’s age, parity, and plans for future reproduction.

IF A PATIENT IS NOT a candidate for hysterectomy, or doesn’t want one, you can attempt medical management of the symptoms. Adenomyosis is known to have both estrogen and progesterone receptors present, which is why hormone therapy has been investigated as an option. Since researchers have proposed that estrogen may be involved in the disease’s pathophysiology, suppressing the estrogenic environment improves the symptoms.

Investigators have also reported that GnRH-agonists can relieve adenomyosis. They have been shown to reduce uterine size, alleviate pelvic symptoms, and decrease the JZ on MRI. This may be a good option for women who temporarily want to delay surgery or who desire children in the future. Pregnancies have been reported after treatment cessation, in histologically confirmed cases of adeno-myosis, after treatment with a GnRH-agonist. It is likely that when depot preparations of GnRH antagonists become available that they would be more efficacious than GnRH agonists since they will not cause an initial gonadotropin flare. The downside, however, is that antagonists should not be used for more than 6 months because the subsequent hypoestrogenism can compromise bone density. The levonorgestrel-releasing intrauterine device has also been used successfully in women with adenomyosis. It has been observed to decrease uterine size, improve anemia, and relieve menorrhagia. Advantages of this is that it can be used on a long-term basis, and fertility is retained.

While adenomyosis may in fact be more common that we previously thought, its presence may not be clinically significant since it is often asymptomatic and frequently concurrent with other symptom producing conditions. As more controlled studies are done, we may be able to determine the significance of the diagnosis, if any.

DR. MASEELALL is a Fellow, Reproductive Endocrinology and Infertility, at UMDNJ-New Jersey Medical School, Newark, NJ. DR. WEISS is Professor and Chair, Department of Obstetrics, Gynecology and Women’s Health, UMDNJ-New Jersey Medical School, Newark, NJ.

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Publish date: Feb 1, 2008
By: Priya Maseelall, MD, Gerson Weiss, MD
source: Contemporary OB/GYN