Adenomyosis Definitive Treatment
A 45-year-old woman, para 6, reports chronic pelvic pain and heavy menstrual bleeding for 2 years. Her uterus is diffusely enlarged, boggy and tender, and the pregnancy test is negative. Pelvic MRI shows a diffusely thickened myometrium with a junctional zone of 16 mm. She has completed childbearing and hormonal therapy has failed. Which of the following is the most definitive treatment?
- A.Total hysterectomyCorrect
- B.Levonorgestrel intrauterine system
- C.Combined oral contraceptive pills
- D.Dilatation and curettage
Explanation
A diffusely enlarged, boggy, tender uterus with chronic pelvic pain and menorrhagia, together with a junctional zone thicker than 12 mm on MRI, establishes adenomyosis, in which endometrial glands and stroma invade the myometrium and cause hypertrophy and cyclical bleeding within the muscle. Because the disease is diffuse and embedded within the uterine wall, no conservative procedure can reliably remove it, and hysterectomy is the only definitive cure. It is appropriate here because she has completed childbearing, has failed hormonal therapy and has symptoms that impair her quality of life. Histology of the specimen confirms the diagnosis and simultaneously excludes coexisting endometrial pathology, which should nonetheless be sampled preoperatively given her age and bleeding pattern. Fertility-sparing options are tried first in younger women: the levonorgestrel intrauterine system is the most effective of these, reducing both bleeding and dysmenorrhoea, while combined oral contraceptives, continuous progestins, GnRH analogues and uterine artery embolization all give partial and temporary control. Adenomyomectomy is technically difficult with high recurrence. Dilatation and curettage has no therapeutic role because the disease lies within the myometrium rather than the cavity, and it serves only to obtain endometrial tissue. Note that adenomyosis and endometriosis frequently coexist.
Why each option
- A.
- Correct. Hysterectomy removes the diffusely affected myometrium and is the only definitive cure for adenomyosis in a woman who has completed childbearing.
- B.
- The levonorgestrel intrauterine system is the most effective conservative option and reduces bleeding and pain, but it controls rather than cures the disease.
- C.
- Combined oral contraceptives provide symptomatic relief only, and this patient has already failed hormonal therapy.
- D.
- Curettage removes endometrium from the cavity and cannot reach the intramyometrial disease, so it offers diagnostic tissue but no lasting treatment.
Reference: UpToDate 2025, Uterine adenomyosis; Berek and Novak's Gynecology, 17th ed., 2024
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