Medical treatment of adenomyosis ranges from local treatment with the release of medications by a intrauterine device (IUD) to systemically administered treatment.

IUD-released progestogens are used to reduce heavy menstrual bleedings in women with adenomyosis. These medications cause the decidualisation of the endometrium and consequently atrophic changes to reduce the amount of bleeding as in women with symptomatic adenomyosis (Fedele et al. 1997).

Medications available for systemic administration include gonadotropin-releasing hormone (GnRH) agonists. Adenomyosis is an oestrogen-dependent disease. GnRH agonists induce menopause by reducing the release of pituitary gonadotropins. The levels of oestrogen are lowered, producing atrophy and reduced volume of the uterus. If the therapy is interrupted, the effect is reversible (Faquhar and Brosens 2006).

Excision or enucleation is usually the preferred surgical approach for focal adenomyosis, but the type of treatment is heavily dependent on the type of lesion and the extent of myometrial involvement (Faquhar and Brosens 2006). Hysterectomy is the preferred surgical option for women with symptomatic adenomyosis if there is deep involvement of the myometrium. In cases of diffuse adenomyosis in which hysterectomy is considered, trans-vaginal access is preferable to trans-abdominal access due to the lower morbidity and shorter hospital stay of the former. Regarding the complications of trans-vaginal hysterectomy, a study on two groups of patients, one with fibroids and the other with adenomyosis reported a higher risk of lesions to the urinary bladder in patients from the latter group (Furuhashy et al. 1998). The reason is probably the greater complexity in identifying the vesico-vaginal septum due to the presence of adhesions. This is explained by the fact that adenomyosis and endometriosis may coexist in the same patient with pelvic adherences very frequently present in the latter (Valentini et al. 2011).

Hysterectomy is usually indicated as a definitive treatment. Rates of complication after hysterectomy range between 1.5 and 29.3 %. Hysterectomy is associated with complications such as blood loss, bowel and general uro-genital injury, pain, and infection. Recovery time is reported to range between 6 and 8 weeks (Faquhar and Brosens 2006; Meyers and Steege 1998; Dembek et al. 2007), and health care-related expenses and lost time at work (Volkers et al. 2008) render hysterectomy an option associated with high costs.

MR-HIFU is a new, image-guided, non-invasive technique which enables treatment of tumours by thermoablation by ultrasound waves. The treatment is completely guided by MRI, which offers advantages for therapy planning, monitoring and visualisation of the treatment result. MR-HIFU has a broad spectrum of applications, including ablation of uterine fibroids (Voogt et al. 2011). Most of these applications are still under research. The advantage of the non-invasive character of the treatment is that it can be performed on an outpatient basis and that recovery is fast. MR-HIFU has been used in adenomyosis with varying results. Therefore, although the technique seems to be a useful alternative, further studies are needed to clarify its effective role (Rabinovici and Stewart 2006).

In 1995, Ravina published the first report of women treated by uterine artery embolization (UAE) for symptomatic uterine fibroids (Ravina et al. 1995). UAE has emerged as an effective therapy in the treatment of uterine fibroids. The clinical success rate of UAE for uterine fibroids with respect to symptomatic improvement of associated menorrhagia and pelvic pain ranges from 85–95 % to 80–90 % (Katsumori et al. 2007; Goodwin and Spies 2009). There is about 25 % chance of failure of symptom control or recurrence after UAE for uterine fibroids at a 5 year follow-up (Spies et al. 2005a, b; Lohle et al. 2008). This minimally invasive therapeutic alternative to surgery has been reported to be associated with high patient satisfaction rates (Goodwin et al. 1997; Worthington-Kirsch et al. 1998; Spies et al. 2002; Goodwin et al. 2008; Hehenkamp et al. 2008; Hirst et al. 2008).

Based on the similarity of symptoms caused by uterine fibroids and adenomyosis and the positive results after UAE for fibroids, this interventional procedure has been investigated as a possible option to treat adenomyosis. Successful infarction of symptomatic fibroids with UAE may also be achievable in women suffering from focal or diffuse adenomyosis with or without fibroids.

In 1995, the first report was published of women treated by UAE for symptomatic uterine fibroids (Ravina et al. 1995). The UAE catheterisation technique for symptomatic adenomyosis is no different from the technique for symptomatic fibroids, apart may be from the angiographic embolization endpoint and maybe the embolic agent particle size. It is reported by some authors that the angiographic embolization endpoint should be when there is complete stasis at the level of the ascending distal part of both uterine arteries in case of adenomyosis (Lohle et al. 2007; Smeets et al. 2011). Embolization is performed by using a particulate embolic agent. The most widely used embolic agent is non-spherical polyvinyl alcohol particles ranging from 255 to 900 microns in size (Popovic et al. 2011). Others prefer the use of spherical embolics, calibrated microspheres, ranged in size from 500 to 700 microns, in order to facilitate deep penetration into the small afferent arterioles of adenomyosis. In contrast to the perifibroid vascularization pattern of uterine fibroids, adenomyosis has a deep and more diffuse distribution of parallel afferent arterioles throughout the myometrium (Dundr et al.2006). The difference in vascularisation might explain the reported higher failure rate after UAE in women with adenomyosis compared with UAE for fibroids. The currently available data do not seem to indicate a preferred embolic agent for use in women with symptomatic adenomyosis. Although in part based on speculation, to my experience, deep penetration with the embolic agent seems to be needed for optimal infarction of areas with adenomyosis. Calibrated microspheres are able to selectively occlude the tiny arterial branches of the adenomatous tissue deep in the uterine stroma and thus create adequate tissue infarction (Fig. 4). It has been demonstrated that calibrated microspheres have a predictable behaviour. Their uniform size and shape, their constant compressibility and elasticity results in deeper penetration into the small arterioles than non-spherical polyvinyl alcohol particles (Chua et al. 2005; Lohle et al. 2007; Smeets et al. 2011).