Diffuse adenomyosis as seen on transvaginal ultrasound
Adenomyosis is a benign condition in which the glands that normally line the inner cavity of the uterus grow within its muscular walls, causing uterine enlargement, heavy, painful menses and anemia. Adenomyosis can be likened to endometriosis within the uterus and, in fact, often co-exists with pelvic endometriosis.
Not all women with adenomyosis have symptoms, and those with mild symptoms can find relief with oral contraceptives or Depo Provera. But for women with more extensive disease whose quality of life and health are threatened by heavy bleeding and pain, and for whom these hormonal interventions fail, the best treatment until now has been hysterectomy.
Researchers in Turkey randomly assigned women with strictly-diagnosed adenomyosis to treatment with either hysterectomy or insertion of a levonorgestrel IUD (Mirena). At baseline, all the women had heavy menses for at least 6 months, in addition to other symptoms such as dysmenorrhea and painful intercourse. The mean hemoglobin in the groups was 10 gm/dL, indicating significant anemia.
At one year post treatment, both hysterectomy and IUD groups had normal hemoglobin levels and improved quality of life as measured by the World Health Organizations Quality of Life Questionnaire. The study authors state that the IUD group had a greater improvement in psychological and social measures, but I suspect this was because the IUD group has lower scores in these domains at baseline.
Complications of hysterectomy were limited to post op wound infection in one patient. IUD users experienced headache (11%) , acne (5%) , breast tenderness (7%) and transient mood issues (1 subject), but no woman requested removal of her IUD due to side effects. One woman expelled her IUD and went on to hysterectomy.
The Study Has Important Limitations
The authors do not tell us what treatments women had tried before entering this study, so I am a bit wary that they may not have adequately sampled the group of women with adenomyosis who are most likely to warrant hysterectomy – those women who have tried and failed hormonal treatments such as birth control pills. One would never proceed to hysterectomy without at least trying these interventions. If the group studied here included all comers with adenomyosis, and if Mirena was their first attempt at treating the condition, than of course the IUD would prove to be effective (and hysterectomy potentially unnecessary). In the same way, oral contraceptives could be said to be an effective hysterectomy alternative for adenomyosis.
Not all adenomyosis needs to be treated. But if adenomyosis is causing significant symptoms, the Mirena IUD can be added to the list of treatment options, and may prevent the need for hysterectomy in women with the more severe forms of the condition. Although this particular study is only one year, previous research on Mirena use in adenomyosis has found that it remains effective for at least 3 years, although side effects reduce satisfaction a bit over time.
For any given women, if Mirena’s benefits don’t persist, or if its side effects become intolerable, hysterectomy is still there as an effective and definitive solution to the problem.
Of note, Mirena has also proven to be effective in treating endometriosis.
Image from Geneva Foundation for Medical Education and Research (I believe these images are royalty free…)