Your adenomyosis treatment options depend on your symptoms and your past treatments. Sydney Fibroid Clinic offers medical therapies, Mirena IUD, uterine artery embolisation, and hysterectomy as a last resort.
Medical Therapy for Adenomyosis
Nonsteroidal anti-inflammatory drugs (NSAIDs) can be used for period pain. There are many different NSAIDs and you might need to try a few to find the one most effective for you. For best result, remember to taking just before your period or pain occur. Some people might get stomach irritation as side effect.
Tranexamic acid (Cyklokapron) reduces heavy periods by enhancing the body’s clotting ability. The tablets are taken 4 times a day when the bleeding is heavy. Women who has had history of deep venous thrombosis (DVT), pulmonary embolism (clots in the lung), heart attacks or strokes should avoid Tranexamic acid.
Combined birth control pills or progesten only pills (or injection) an be used to damp oestrogen surges and might ease heavy menstrual bleeding and pain. However, the effectiveness has not been proven in the setting of adenomyosis. Taking these pills continuously might avoid having periods and associated heavy bleeding and pain, but some women does not like the idea of not having regular periods whilst other does not like taking hormone pills.
Gonadotropin-releasing hormone agonists (GnRHa), such as Zoladex or Synarel, is used to achieve medical menopause by removing oestrogen stimulation. GnRHa is especially useful for women who desire pregnancy. Due its common side effects such as hot flashes, mood changes and osteoporosis , GnRHa use is generally limited to six months.
Mirena IUD for Adenomyosis
Mirena is an Intrauterine Device (IUD) that slowly releases tiny doses of sex hormone Progestrone over 5 years.
Mirena is effective in many women for reducing heavy menstrual bleeding. A Turkish study showed Mirena could be as effective as a hysterectomy for controlling heavy menstrual bleeding.
Mirena could also be effective for reducing period pain. However patient satisfaction was only achieved in 56.3% of women at 12 month. The suboptimal patient satisfaction is probably due to the side effects, such as prolonged light bleeding (25%), irregular bleeding (14%), and less commonly, weight gain, ovarian cyst, lower abdominal pain and acne.
When the uterus is enlarged ( >150ml), the adenomyosis is likely to be extensive and Mirena is less effective. Discontinuation rate of 70% is noted in women with uterine volume larger than 314ml.
Uterine Artery Embolisation for Adenomyosis
Uterine artery embolisation (UAE) is a safe, minimally invasive, non-surgical alternative to a hysterectomy. Reducing heavy periods and relieving pain, the procedure has been shown to be effective in 90% of women suffering from adenomyosis. Having had UAE, 95% of women are able to avoid a hysterectomy.
UAE is for women who have failed or considered not suitable for conservative medical therapies, but keen to avoid a hysterectomy.
The procedure and its benefits can be summarised as follows:
- Local anaesthetic only
- Proven to be safe and effective
- 90% patient satisfaction rate
- No surgical cuts, no general anaesthesia
- 1 – 2 nights hospital stay
- 1-week recovery
- Keep your uterus and pelvic floor intact
Uterine artery embolisation (UAE) means blocking of the arteries supplying the uterus. UAE is performed by an interventional radiologist. Only a tiny nick on the skin is needed to allow insertion of a small 1 – 2mm diameter tube called a catheter into the femoral artery in the groin. The catheter is navigated to the uterine artery under X-ray guidance. Tiny particles are then injected inside the uterine arteries to block the blood flow, thereby starving and killing the adenomyosis tissue. Normal uterine tissue has immense capacity to recruit dormant vessels and therefore remains unharmed.
The procedure is suitable for women who wish to avoid a hysterectomy, keep their uterus and achieve quicker recovery.
Endometrial Ablation for Adenomyosis
Endometrial ablation uses heat energy to destroy the inner lining of the uterus, so bleeding will be reduced.
However, glands in the muscle (adeno= glands; myosis in the muscle) will be trapped. Some have described this as “sealing off the juice on the BBQ hot plate”. Period pain and prementrual bloating can get worse following ablation. Even with modern technology, adenomyosis deeper than 2.5mm cannot be treated by ablation, according to a 2015 study.
If MRI is used for diagnosis, the minimal depth is 12mm . Therefore, adenomyosis diagnosed on MRI should not be treated with ablation.
In the past, when ablation failed to treat adenomyosis or if pain is worse after ablation, hysterectomy is to follow.
Today, there is an alternative to a hysterectomy.
If you had ablation and the pain has become worse, UAE might help to kill off adenomyosis tissue and alleviate pain.UAE
Hysterectomy for Adenomyosis
A hysterectomy is a surgical operation in which all or part of the uterus is removed.
Hysterectomy is a major operation that requires general anaesthetic, several days in hospital and up to 4 to 6 weeks of recovery.
Surgical risks include anaesthetic complications, blood transfusion, infection, wound issues, and rarely injuries to the bowel, bladder and ureter (the tube connecting the kidney to the bladder). The overall risks of severe complications from hysterectomy is 3.5 to 11% and hysterectomy mortality rate can be as high as 0.15%.
Long term side effects of a hysterectomy are prolapse and urinary incontinence, early menopause and higher risk of cardiovascular disease (even with ovaries left behind), change of sexual feeling and constipation, and so called post hysterectomy syndrome with depression and lethargy.
If you have uterine cancer, your only choice may be to remove the uterus. However, an overwhelming number of hysterectomies in developed countries – like Australia and the United States – are performed for benign conditions such as fibroids and adenomyosis.
In the past, when conservative treatments failed or were deemed unsuitable, women were faced with the difficult decision to putting up with symptoms or having a hysterectomy.
Today, there are now many effective, non-surgical forms of adenomyosis treatment, hysterectomies for adenomyosis should be considered as a last resort, if all other less invasive methods have failed. Depending on your specific situation, medical therapy, Mirena IUD (56% patient satisfaction) or uterine artery embolisation (90% patient satisfaction) should be considered before embarking on hysterectomy.
Surgical Removal of Adenomyosis
Generally speaking, adenomyosis is not suitable for surgical removal. Adenomyosis is often a diffuse infiltrative process. Unlike fibroids, which can be easily separated from the normal uterine wall, adenomyotic tissue does not have a clear boundary with the normal myometrium.
Surgeons often find it difficult to determine where adenomyosis stops and where normal myometrium starts. The removal is either incomplete, leaving behind adenomyotic tissue which can continue to grow and cause problems, or a larger than necessary amount of normal myometrium around the adenomyosis might have to be removed.
Surgeons might have been misled by an incorrect ultrasound diagnosis and inadvertently went ahead with surgery, with the intention of removing a “fibroid”. Half way through the surgery, it is then realized that the “fibroid” cannot be separated out from uterus and in fact it was adenomyosis that they are dealing with, and that surgery might need to be abandoned.