Guideline No. 437: Diagnosis and Management of Adenomyosis

ObjectiveTo describe the current evidence-based diagnosis and management of adenomyosis.Target PopulationAll patients with a uterus of reproductive age.OptionsDiagnostic options include transvaginal sonography and magnetic resonance imaging. Treatment options should be tailored to symptoms (heavy menstrual bleeding, pain, and/or infertility) and include medical options (non-steroidal anti-inflammatory drugs, tranexamic acid, combined oral contraceptives, levonorgestrel intrauterine system, dienogest, other progestins, gonadotropin-releasing analogues), interventional options (uterine artery embolization), and surgical options (endometrial ablation, excision of adenomyosis, hysterectomy).OutcomesOutcomes of interest include reduction in heavy menstrual bleeding, reduction in pelvic pain (dysmenorrhea, dyspareunia, chronic pelvic pain), and improvement in reproductive outcomes (fertility, miscarriage, adverse pregnancy outcomes).Benefits, Harms, and CostsThis guideline will benefit patients with gynaecological complaints that may be caused by adenomyosis, especially those patients who wish to preserve their fertility, by presenting diagnostic methods and management options. It will also benefit practitioners by improving their knowledge of various options.EvidenceDatabases searched were MEDLINE Reviews, MEDLINE ALL, Cochrane, PubMed, EMBASE. The initial search was completed in 2021 and updated with relevant articles in 2022. Search terms included adenomyosis, adenomyoses, endometritis (used/indexed as adenomyosis before 2012), (endometrium AND myometrium) uterine adenomyosis/es, symptom/s/matic adenomyosis] AND [diagnosis, symptoms, treatment, guideline, outcome, management, imaging, sonography, pathogenesis, fertility, infertility, therapy, histology, ultrasound, review, meta-analysis, evaluation]. Articles included randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Articles in all languages were searched and reviewed.Validation MethodsThe authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Table A1 for definitions and Table A2 for interpretations of strong and conditional [weak] recommendations).Intended AudienceObstetrician-gynaecologists, radiologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, residents, and fellows.Tweetable AbstractAdenomyosis is common in reproductive-aged women. There are diagnostic and management options that preserve fertility available.SUMMARY STATEMENTS

• 1.Providers should be aware that adenomyosis has been associated with heavy menstrual bleeding, pelvic pain, infertility, miscarriage, and adverse pregnancy outcomes (moderate).

RECOMMENDATIONS

• 1.Transvaginal sonography should be the first-line modality for imaging of suspected adenomyosis in patients presenting with heavy menstrual bleeding, pelvic pain, infertility, miscarriage, and adverse pregnancy outcomes (strong, high).
• 2.Transvaginal sonography in patients presenting with symptoms suggestive of adenomyosis should be assessed by radiologists for the following: presence of features typical of adenomyosis, location, focal or diffuse disease, cystic or non-cystic disease, uterine layer involvement, extent of disease, and the size of the largest lesion or affected area (strong, high).
• 3.Magnetic resonance imaging should be considered by clinicians if there is inconclusive sonographic evaluation of adenomyosis or suspicion of significant concomitant pelvic pathology (conditional, moderate).
• 4.Oral contraceptives, levonorgestrel-releasing intrauterine system, and dienogest should be used as first-line medical options for pain and heavy menstrual bleeding from adenomyosis (strong, moderate).
• 5.Gonadotropin-releasing hormone (GnRH) agonists can be considered as a second-line agent for management of pain and heavy menstrual bleeding from adenomyosis; add-back hormones should be initiated if GnRH agonists are used longer than 6 months (strong, low).
• 6.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).
• 7.Minimally invasive thermal ablation procedures, such as high-intensity focused ultrasound, radiofrequency ablation, and percutaneous microwave ablation, might be used for the treatment of symptomatic adenomyosis in the future, but more data are needed before they are used outside of a research context (conditional, low).
• 8.Adenomyomectomy is an effective treatment option for symptomatic adenomyosis (strong, moderate).
• 9.Adenomyomectomy can be a challenging surgical procedure, with the potential for significant perioperative morbidity, and should be performed by an experienced surgeon (strong, low).
• 10.Focal adenomyosis may be amenable to surgical excision using minimally invasive routes (laparoscopy, robotic); however, diffuse adenomyosis is best approached using an open technique (conditional, low).
• 11.Given the substantial risk of intraoperative hemorrhage, anemia (hemoglobin <120 g/L) should be corrected before adenomyomectomy (strong, low).
• 12.Patients undergoing adenomyomectomy should be counselled about the uncertain impact of these procedures on fertility and pregnancy. They should be specifically informed about the increased risk of uterine rupture during pregnancy, and the need for pre-labour cesarean delivery (strong, low).
• 13.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).
• 14.Patients with dysmenorrhea undergoing surgical management of adenomyosis should be counselled to have concurrent excision of any coexisting endometriosis during surgery, for more complete relief of their symptoms (strong, low).
• 15.The impact of adenomyosis on pregnancy outcomes in patients undergoing fertility treatments is uncertain (conditional, low).
• 16.For patients with adenomyosis undergoing in vitro fertilization, gonadotropin-releasing hormone agonist downregulation for a period of 2 to 4 months may be considered before transferring fresh or frozen embryos (weak, low).