Surgical versus hormonal treatment of focal uterine adenomyosis: open-label patient preference trial

Study Objective: To assess the efficacy of hormonal therapy and surgery in the treatment of focal adenomyosis. Design: Open-label patient preference trial. Setting: University hospital. Patients: 31 women of reproductive age with diagnosis of focal adenomyosis at MRI suffering pain symptoms and/or heavy menstrual bleeding who wish to preserve the uterus. Exclusion criteria for the study were: desire to conceive, previous uterine surgery, hormonal therapies at the time of inclusion in the study, uterine leiomyomas, surgical diagnosis of endometriosis. Intervention: Patients received one of the following treatments on the basis of their preference: letrozole (2.5 mg/day) and gonadotropin-releasing hormone agonist (triptorelin 11.25 mg) for 3 months followed by laparoscopic excision of adenomyosis (group A) or letrozole (2.5 mg/day) and norethindrone acetate (2.5 mg/day) for 9 months (group B). Intensity of pain symptoms was measured by using a VAS scale. Patients’ satisfaction was estimated by using a Likert scale. The SF-36 was used to evaluate quality of life. Measurements and Main Results: 13 patients were included in group A and 18 in group B. Laparoscopic excision of focal adenomyosis was successfully performed in 11 patients (84.9%; 95% C.I., 54.6%-98.1%), conversion to laparotomy was required in 2 patients. At the completion of the 9-month hormonal therapy, pain symptoms were significantly improved in group B; however, 7 patients included in group B (38.9%; 95% C.I., 17.3%-64.3%) had at least one adverse effect related to the hormonal treatment. At 1-year follow-up, patients included in group A had higher improvement of dysmenorrhea, chronic pelvic pain, dyspareunia and menorrhagia compared with those included in group B. Similarly, patients’ satisfaction and quality of life were significantly higher in group A than in group B. Conclusion: Surgical excision of uterine focal adenomyosis is more efficacious than hormonal therapy in causing a long-term improvement of symptoms and in ameliorating quality of life.