Adenomyosis: Management When GnRH Agonist Therapy Has Not Achieved Adequate Symptom Control

This protocol applies to patients with adenomyosis who have completed a course of second-line medical therapy with a gonadotropin-releasing hormone (GnRH) agonist and have not reached the expected level of symptomatic improvement.

Previous Treatment — Targets Not Met

Second-line medical management with a GnRH agonist — triptorelin, leuprorelin, or goserelin — did not achieve significant improvement in heavy menstrual bleeding, dysmenorrhea, or pelvic pain, and did not produce the expected reduction in uterine volume by 16 weeks. This failure of response is the trigger for escalation to the current protocol.

Treatment Goals

Reduction in heavy menstrual bleeding and improvement in dysmenorrhea.

Next-Step Approach (Partial Preview)

When GnRH agonist therapy has not provided adequate control of adenomyosis, the next step involves interventional or surgical management. Which option is appropriate depends on individual clinical factors — the full protocol details the specific options and their selection criteria.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1016/j.jogc.2023.04.008

Uterine artery embolization is an effective treatment option for heavy bleeding and pain associated with adenomyosis; it can be offered to patients who have completed child-bearing and would like to preserve their uterus (strong, moderate).
Endometrial ablation (EA) is a minimally invasive option that has a faster recovery and lower rate of serious complications than hysterectomy.
Adenomyomectomy is an effective treatment option for symptomatic adenomyosis (strong, moderate).
Given the substantial risk of intraoperative hemorrhage, anemia (hemoglobin <120 g/L) should be corrected before adenomyomectomy (strong, low).
Given the potential for significant operative blood loss, anemia (hemoglobin <120 g/L) must be corrected preoperatively (i.e., with preoperative menstrual suppression and iron supplementation) to reduce morbidity and mortality.
Total hysterectomy is an effective treatment option for symptomatic adenomyosis and can be offered to women who have completed child-bearing after appropriate counselling regarding risks, benefits, and alternative treatments (strong, low).

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