Laparoscopic adenomyomectomy combined with levonorgestrel-releasing intrauterine system is effective for long-term management of adenomyosis

(2024) 24:28 Jiang et al. BMC Women’s Health https://doi.org/10.1186/s12905-023-02795-1 RESEARCH ARTICLE BMC Women’s Health Open Access Laparoscopic adenomyomectomy combined with levonorgestrel‑releasing intrauterine system is effective for long‑term management of adenomyosis Jilan Jiang1,2,3†, Yilian Pan1,2,3†, Jin Yu1,2,3, Ye Zhang1,2,3, Yeping Yang1,2,3, Hong Xu1,2,3*   and Feng Sun1,2,3* Abstract Backgroud Laparoscopic adenomyomectomy combined with intraoperative placement of levonorgestrel-releasing intrauterine device (LNG-IUS) is a novel conservative surgical procedure for adenomyosis. Our study aimed to compare the efficacy of surgery with or without intraoperative placement of LNG-IUS treatment in adenomyosis. Methods We retrospectively reviewed the medical records of adenomyosis patients who received laparoscopic adenomyomectomy from January 2014 to April 2020, finally including 70 patients undergoing surgery-LNG-IUS as group A and 69 patients undegoing surgery only as group B. Risk factors for three-year relapse were analyzed using Cox’s multivariate proportional hazard analysis. Results Visual analog scale and Mansfield-Voda-Jorgensen Menstrual Bleeding Scale scores of group A at 3, 6, 12, 24, and 36 months were significantly lower than those of group B at the corresponding points (P < .001 for both scales). Individuals in both groups showed statistically significant symptom relief. The recurrence rate in group A was significantly lower than that in group B at 36 months after the surgery (2.94% vs. 32.84%, P < .001). A cox proportional hazard model showed that relapse was significantly associated with coexisting ovarian endometriosis (adjusted hazard ratio [aHR], 2.94; 95% confidence interval [CI], 1.33–7.02, P = .015). Patients who received surgery-LNG-IUS had a lower risk of recurrence than those with surgery-alone (aHR, 0.07; 95% CI, 0.016–0.31, P < .001). Conclusions Conservative surgery with intraoperative placement of LNG-IUS is effective and well-accepted for longterm therapy with a lower recurrence rate for adenomyosis. Coexistent ovarian endometriosis is a major factor for adenomyosis relapse. Keywords Adenomyosis, Laparoscopic adenomyomectomy, Levonorgestrel-releasing intrauterine system, Recurrence † Jilan Jiang and Yilian Pan contributed equally to this work and should be considered co-first authors. *Correspondence: Hong Xu Feng Sun Full list of author information is available at the end of the article © The Author(s) 2024. 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The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Jiang et al. BMC Women’s Health (2024) 24:28 Background Uterine adenomyosis is described as a benign gynecological disease featured by aberrant development of endometrial glands and stroma within the myometrium [1]. Diffuse and/ or focal lesions can occur in the internal or external layers of the myometrium [2]. Clinical symptoms associated with adenomyosis include menorrhagia, dysmenorrhea, and an enlarged uterus [3]. Because an increasing number of women choose to preserve their uteri, conventional hysterectomy has become less acceptable as treatment for adenomyosis. Various treatment strategies can be used for adenomyosis [4]. Drug therapy, such as nonsteroidal anti-inflammatory drugs, oral contraceptives, gonadotropin-releasing hormone agonists (GnRH-a), and progestins can all be used for symptom relief. However, once these treatments stop, symptoms will soon reoccur. A surgical approach for adenomyosis may be considered when medical management fails, either due to breakthrough of pain or intolerable side effects from drug therapy or the patient wants a definitive diagnosis [5]. Laparoscopic adenomyomectomy has been increasingly performed worldwide and has been demonstrated to be a safe and effective therapeutic modality [6]. It is reported that, after conservative surgery, over three-fourths of patients achieved complete relief, and the recurrence rate of symptoms is about 9% after the complete excision [7]. As conservative surgery for adenomyosis cannot remove adenomyotic focus thoroughly, even if adenomyosis is characterized by focal lesions, adenomyosis recurrence is unavoidable thus the efficacy of adenomyomectomy decreases over time after surgery. There are still some patients suffering from symptoms relapsed within 1 year of surgery. By releasing levonorgestrel locally, LNG-IUS exerts progesterone-like effect on the endometrium, which then relieves dysmenorrhea and reduces menstrual flow [8]. The LNG-IUS is a suitable alternative to surgery for the management of dysmenorrhea. However, in patients with large adenomyosis, the LNG-IUS has a high expulsion rate (37.5%) [9]. Lee et al. reported the LNG-IUD expulsion rate increased significantly when the uterine volume was greater than 150 ml [10]. Laparoscopic adenomyomectomy reduces the size of the uterus by removing the lesions, thus creating appropriate conditions for LNGIUS placement. Previously, we reported that the combination of laparoscopic adenomyomectomy with LNG-IUS is an effective and novel conservative surgical procedure for adenomyosis [11]. However, the symptom recurrence rate associated with this modality has not yet been reported. Therefore, we conducted this retrospective study to compare the efficacy of surgery alone with combined Page 2 of 7 surgical-LNG-IUS treatment in adenomyosis and to explore the risk factors for symptom recurrence. Methods Study design and population This retrospectively study between January 2014 and April 2020 has been approved by the ethic committee of the International Peace Maternity and Child Health Hospital of the China Welfare Institute (GKLW 2017-71). For the adenomyosis patients who wanted uterus-sparing sugery without fertility desire, LNG-IUS placement was recommended in the surgery. The enrollment criteria included: (1) age between 20 and 48 years, (2) severe dysmenorrhea and/or menorrhagia, (3) availability for transvaginal ultrasound examination data, a (...truncated)